be advanced by studying whether pleural fluid maintained in a nonheparinized syringe will avoid clotting in settings where pH determination is delayed.
Lawrence S. Goldstein, MD Alejandro C. Arroliga, MD Department of Pulrrwnary and Critical Care Medicine Cleveland Clinic Cleveland, OH
REFERENCES 1 Light RW, MacGregor MI, Ball WC Jr, et a!. Diagnostic significance of pleural fluid pH and Pco 2 . Chest 1973; 64:591-596 2 Light RW. Pleural diseases. 3rd ed. Baltimore: Williams & Wilkins, 1995.
over-the-counter (OTC) medications from an appropriately large and representative database (compared with the limited population that can be accessed by the authors' methodology). In contrast to Kuschner and colleagues' finding that OTC asthma medication use is not restricted to persons with mild disease, our studies showed that the typical user of inhaled epinephrine had infrequent episodes, experienced little interruption of daily activities, and rarely required nonroutine medical care, that is, the user had mild asthma 7 Physician diagnosis had been obtained by 87% of all past-year nonprescription users. Among subjects who used both prescription and nonprescription asthma medications, prescription medications were the predominant medications used. Use of OTC drugs was intermittent relative to prescription drugs, and rarely were the two used simultaneously (6% of respondents). In summary, these data demonstrate that inhaled epinephrine is used by an appropriate population and in accordance with the label directions.
Nonprescription Bronchodilator Use in Asthma
Christine M. Redman, PhD Howard M. Druce, MD Whitehall-Robins Healthcare Madison, New Jersey
To the Editor: We read with interest the recent study by Kuschner and colleagues (October 1997).1 Prospective survey methods have gained an accepted place in the medical literature to provide databases to study patients with chronic diseases. 2 •3 .4 Using these methods, we collected data5.6 (Table 1) that characterize users of
Table !-Characteristics of Users of Inhaled Epinephrine* 4 ,5 No. of respondents who used epinephrine in the ~~
Mean frequency of episodes per year per respondent
Assessment Medication use Used prescription within last year Used prescription and over-the-counter medication On different occasions At the same time Frequency of sleep interruption < 1/month Once/month 2-3 times/month Once/week Few times/week Daily No. of times missed school or work because of asthma 0 1-5 5-10 11+
No. of times required urgent care last year 0 1-3 4+
%of Respondents 40 65 59 6 57 9
12 5 ll 6
84 13 2
74 16 8
*Inhaled epinephrine is the medication used by most persons who purchase nonprescription asthma products.
Correspondence to: Christine M. Redman, PhD, Whitehall-Robins Healthcare, 5 Giralda Farms, Madison, NJ 07940
REFERENCES 1 Kuschner WG, Hankinson TC, Wong HH, et al. Nonprescription bronchodilator medication use in asthma. Chest 1997; 112:987-993 2 Storms W, Meltzer EO, Nathan RA, et a!. Allergic rhinitis: The patient's perspective. J Allergy Clin lmmunol 1997; 99:S825-S828 3 Nathan RA, Meltzer EO, Selner JC, et a!. Prevalence of allergic rhinitis in the United States. J Allergy Clin Immunol 1997; 99:S808-S814 4 Malone DC, Lawson KA, Smith DH, et al. A cost of illness study of allergic rhinitis in the United States. J Allergy Clin Immunol 1997; 99:22-27 5 Profile of asthma sufferers and users of non-prescription epinephrine (mist) and ephedrine combination (tablets). Submitted to FDA Docket No. 94N-0232, 1994 6 Druce H, Furey SA, Kalfus MD, et al. Patterns of use of inhaled epinephrine. Ann Allergy Clin Immunol1997; 78:110 7 Expert Panel Report. Guidelines for the diagnosis and management of asthma. US Department of Health and Human Services Publication NIH 91-3042. Bethesda, MD: National Asthma Education Program, 1991
To the Editor: We welcome the survey data on inhaled epinephrine use provided by Drs. Redman and Druce, particularly as so little information on this important topic has been available in the peer-reviewed literature. As with our study, 1 the authors found considerable overlap with prescription asthma medication use among epinephrine self-medicators. Data by gender were not provided, which makes it difficult to know whether the male predominance that we observed was also a factor in their population. vVe have recently published an analysis of over-the-counter (OTC) asthma medication use in another cohort and once again found an association between inhaled epinephrine use and male gender. 2 In that study, 6% of adults with subspecialist-treated asthma reported OTC asthma medication use in the previous 12 months, double the prevalence reported by the Whitehall group in their household survey. 3 CHEST I 114 I 2 I AUGUST, 1998
Drs. Redman and Druce infer from their survey data that inhaled epinephrine self-treatment is limited to mild asthma only. We do not come to the same conclusion on the basis of our own data from two independent studies or, indeed, on the basis of the data that they themselves provide: 24% of those that they surveyed required urgent care for their asthma during the prior year; of these, more than a third appeared to have quite poorly controlled disease, which led to frequent urgent care visits. Data on hospitalization and on therapies that would serve as markers of more severe disease (eg, systemic corticosteroid administration) were not provided. Perhaps most importantly, survey data examining delays in the institution of more specific sympathomimetic medication as well as anti-inflammatory therapy. although of considerable interest, remain to be reported. Ware Kuschner, MD Division of Respiratory and Critical Care Medicine Stanford University School of Medicine Veterans Affairs Palo Alto Health Care System Palo Alto, California Paul D. Blanc, MD, MSPH, FCCP Division of Occupational and Environmental Medicine and Division of Respiratory and Critical Care Medicine University of California, San Francisco
REFERENCES 1 Kuschner WG, Hankinson T, Wong H, et al. Nonprescription bronchodilator medication use in asthma. Chest 1997; 112: 987-993 2 Blanc PD, Kuschner WG, Katz PP, et a!. Use of herbal products, coffee or black tea, and over-the-counter medications as self-treatments among adults with asthma. J Allergy Clin Immunol 1997; 100:789-791 3 Druce HM, Furey SA, Kalfus MD, et al. Patterns of use of inhaled epinephrine [abstract]. Ann Allergy Asthma Immunol 1997; 78 :110
Significance of Airway Colonization by Burkholderia gladioli in Lung Transplant Candidates To the Editor:
We read with interest the article by Kanj and colleagues in CHEST (October 1997)1 on the role of airway colonization by multidrug-resistant organisms in causing invasive infection following lung transplantation in patients with cystic fibrosis (CF). The authors report two cases of lung transplant recipients who developed bacteremia and sternal wound infection by Burkholderia gladioli and mention that these were the first reported cases of B gladioli infection in human lung transplant recipients. They also suggest that infection with B gladioli at the time of pretransplant evaluation should not be considered a contraindication to transplantation. We want to point out that we recently reported a case 2 of a 25-year-old lung transplant recipient with CF who developed recurrent chest wall abscesses and empyema from B gladioli infection. In contrast to the patients reported by Kanj and colleagues, our patient had a progressive, deteriorating course, and despite appropriate antibiotic therapy, eventually died from widespread infection. Although earlier reports suggest that B gladioli is a benign colonizer in CF patients,2 •3 its pathogenicity in an immunocompromised host should not be underestimated. We recommend a 658
cautious approach in selecting patients for lung transplant evaluation if their pretransplant evaluation shows airway colonization by B gladioli. Saeed U. Khan, MD Alejandro C. Arroliga, MD Department of Pulmonary and Critical Care Medicine Steven M. Gordon, MD Department of Infectious Diseases The Cleveland Clinic Foundation Cleveland
REFERENCES 1 Kanj SS, Tapson V, Davis RD, et a!. Infections in patients with cystic fibrosis following lung transplantation. Chest 1997; 112:924-930 2 Khan SU, Gordon SM , Stillwell PC , Empyema and bloodstream infection caused by Burkholderia gladioli in a patient with cystic fibrosis after lung transplantation. Ped Infect Dis J 1996; 15:637-639 3 Christenson JC, Welch DF, Mukwaya G, et a!. Recovery of Pseudomonas gladioli from respiratory tract specimens of patients with cystic fibrosis . J Clin Microbial 1989; 27:270-73 4 Mortensen JE, Schidlow DV, Stahl EM. Pseudomonas gladioli (morginata) isolated from a patient with cystic fibrosis. Clin Microbial 1988; 10:429-430
Parapneumonic Effusion Does Not Equal Empyema To the Editor:
The randomized trial of empyema therapy published recently in CHEST (June 1997)1 is an important first step in attempting to introduce science into the study of empyema and parapneumonic effusions. The authors chose an unfortunate title for their study, however, since most clinicians would label their cases as parapneumonic effusions, rather than empyema. Although the definition of empyema is controversial, Light prefers "thick, purulent-appearing pleural fluid."2 Indeed, most clinicians think of empyema as a thick, soupy material in the pleural space-often resembling pea soup-with many WBCs and associated with a high percentage of positive Gram's stains and cultures. This soupy material is incompatible with the blood gas machines generally used to measure pH, so this study on pH of the pleural fluid is clearly of parapneumonic effusions and not of empyema.3 While pH is well known to decline with more aggressive infections, the 7.20±0.12 pH range of Wait et al's video-assisted thorascopic surgery group is not sufficiently low to warrant invasive treatment, in general. Similarly, their chest tube/streptokinase group had a pH of7.26±0.15. The fact that half of these patients failed drainage with #36 chest tubes plus streptokinase is of interest and is difficult to understand. Radiographic shadows do, however, often increase due to pleural reaction in this context while the WBC and fever are declining. I have been treating this kind of patient for many years with antibiotics and repeated thoracentesis, using a #14 F catheter, and very rarely have I resorted to tube thoracostomy or any surgical procedure;• most of these patients were discharged on oral antibiotics, returned to work, and were clinically well, although some required several months for the radiograph to normalize. As the authors mentioned in their discussion, "it is difficult to recommend one type of treatment as routine" because of the diversity of the patients. However, their data is consistent with a Communications to the Editor