Letters to the Editor

Recommendation for Modified Metered-Dose Inhaler

TO THE EDITOR: Asthma and chronic obstructive pulmonary disease (COPD) are significant health problems in the United States, affecting over 20 million Americans.^1,2 Reactive airways disease is treated with the use of inhaled bronchodilators and steroids, which are most commonly administered via handheld metered-dose inhalers (MDIs).¹ MDIs are designed with a mouthpiece that maximizes deposition of the medication in the small airways when used properly. We report two cases of serious aspiration of foreign bodies that had been inadvertently entrapped within the mouthpiece of the inhaler.

One case occurred in a 46-year-old woman who experienced an acute asthma exacerbation while driving. She used the inhaler, which was in her purse, in the standard manner; however, she accidentally inhaled a golf ball marker that was entrapped within the mouthpiece of the inhaler. She coughed violently, dislodging the foreign body from the lungs, but then swallowed it. She required emergency upper endoscopy to retrieve the marker from the distal esophagus.

The other case occurred in a 58-year-old man with a COPD exacerbation while walking. He used his inhaler, which was in his pants pocket. The patient continued to have dyspnea over the next two weeks. Chest radiographs revealed a foreign body in the left mainstream bronchus. Subsequent bronchoscopy revealed a corroded coin (a dime) that was intermittently obstructing the bronchus.

Given the serious nature of these two cases, we believe standard MDIs should be modified to prevent entrapment of foreign bodies within the mouthpiece. External caps can be effective if patients consistently use them. Newer delivery technologies using propellants, disks, and spacers may minimize this risk. Patients, physicians, and pharmaceutical companies need to be informed of the risk of foreign-body inhalation with MDIs. We suggest that the mouthpiece be modified with a mesh screen that would allow for inhalation of the drug while preventing the entrapment of foreign bodies. This minor modification may prevent life-threatening complications caused by MDI-induced foreign-body inhalation.

SHAZIA AHMED, M.D.
NARESH T. GUNARATNAM, M.D.
WILLIAM F. PATTON, M.D.
St. Joseph Mercy Hospital
Michigan Center for Digestive Care
P.O. Box 981
Ann Arbor, MI 48106

REFERENCES

1. 1. Stoller JK. Clinical practice. Acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med 2002;346:988-94.
2. 2. Cochrane MG, Bala MV, Downs KE, Mauskopf J, Ben-Joseph RH. Inhaled corticosteroids for asthma therapy: patient compliance, devices, and inhalation technique. Chest 2000;117:542-50.

Treatment of Tobacco Dependence

TO THE EDITOR: Dr. Mallin's article, "Smoking Cessation: Integration of Behavioral and Drug Therapies,"¹ drew helpful attention to the importance of the behavioral aspect of addressing tobacco dependence. It is important to include users of smokeless tobacco, as they often have more difficulty quitting because of the sustained high nicotine levels. The recent national tobacco cessation guideline (surgeon general.gov/tobacco) underlined that physicians must focus not simply on smoking cessation, but also on treatment of tobacco dependence.

Tobacco dependence is a chronic relapsing condition that requires consistent efforts by the patient, physician, and the entire health care system. Physicians can help patients quit tobacco by encouraging them during phone calls regarding test results or scheduling, and by adding a notation to faxed prescription refill requests, such as "If still smoking, encourage to quit." Pharmacists should also encourage patients to quit tobacco, because tobacco use alters the blood levels of many medications.²

The national guidelines listed bupropion, clonidine, and nortriptyline as pharmacotherapies that reliably increase long-term smoking abstinence rates.³ Nicotine replacement therapy (NRT) often needs to be personalized, with many highly addicted tobacco users needing more than the standard dosages approved by the U.S. Food and Drug Administration (FDA). The Mayo Clinic Nicotine Dependence Center (www.mayoclinic.org/ndc-rst) pioneered the use of high-dose NRT, such as more than one 21-mg nicotine patch per day and combining the nicotine patch with nicotine gum, inhaler, and/or nasal spray. Inhaler users need to be advised to puff for mouth absorption rather than inhale to minimize the cough and sore throat that inhalation can cause. The common rhinitis caused by nasal spray usually resolves over several days. Nicotine lozenges and sublingual tablets are available in Europe and may eventually be available in the United States.

Many patients have access to the Internet and can find great support for quitting tobacco. Some helpful sites include the American Lung Association (www.ffsonline.org); the National Spit Tobacco Education Program (www.nstep.org); Nicotine Anonymous (www. nicotine-anonymous.org); the American Cancer Society (www.cancer.org); www.kick butt.org; www.tobaccofreekids.org; and www. quitnet.com. Many states have telephone quitlines that offer tobacco cessation counseling, quit kits, access to medications, information, and referrals, such as Washington state's 877-270-STOP (877-270-7867). The American Legacy Foundation's Great Start (www.americanlegacy.org/greatstart; 866-66-START [866-667-8278]) is a nationwide service designed for pregnant women trying to quit tobacco.

Worldwide efforts include International Quit&Win 2002 (www.quitandwin.org), which is a contest to encourage tobacco users to quit tobacco for the entire month of May with a $10,000 grand prize drawing; however, only four counties in the United States currently participate. World No Tobacco Day (www. worldnotobaccoday.com) is a similar one day promotion held on May 31.

The American Academy of Family Physicians (AAFP) Stop Smoking Kit, developed by family physicians, contains patient materials, a physician/office staff manual, and chart forms for use in a primary care office.

CHRIS COVERT-BOWLDS, M.D.
3015 Squalicum Parkway, #100
Bellingham, WA 98225

REFERENCES

1. Mallin R. Smoking cessation: integration of behavioral and drug therapies. Am Fam Physician 2002; 65:1107-14.
2. Goldstein MG, Niaura R. Methods to enhance smoking cessation after myocardial infarction. Med Clin North Am 2000;84:63-80.
3. Fiore MC, Bailey WC, Cohen SJ, Dorfman SF, Goldstein MG, Gritz ER, et al. Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians. Rockville, Md: U.S. Department of Health and Human Services, Public Health Service; 2000.

Dr. Covert-Bowlds received funding for tobacco cessation talks from GlaxoSmithKline.

Should Patients be Referred for Endoscopy?

TO THE EDITOR: Thank you for the fine article by Drs. Meurer and Bower entitled, "Management of Helicobacter pylori Infection."¹ My only comment would regard the recommendation for family physicians to refer their patients "to a gastroenterologist for endoscopy." Esophagogastroduodenoscopy is a primary care procedure that is taught in many of our residency programs and at our own annual scientific assembly (along with colonoscopy).

With the prevalence of H. pylori infection demonstrated to be as high as 52 percent in the United States,² it should be obvious that there are simply not enough gastroenterologists to see all of these patients (especially considering the primacy of screening colonoscopy over screening flexible sigmoidoscopy³). More family physicians need to step forward and accept the challenge of learning and providing these procedures for our patients.

CARY E. BICKEL, M.D.
611 Fifth Avenue West
Hendersonville, NC 28739

REFERENCES

1. Meurer LN, Bower DJ. Management of Helicobacter pylori infection. Am Fam Physician 2002;65:1327-36.
2. Graham DY, Malaty HM, Evans DG, Evans DJ Jr., Klein PD, Adam E. Epidemiology of Helicobacter pylori in an asymptomatic population in the United States. Effect of age, race, and socioeconomic status. Gastroenterology 1991;100:1495-501.
3. Lieberman DA, Weiss DG. One-time screening for colorectal cancer with combined fecal occult-blood testing and examination of the distal colon. N Engl J Med 2001;345:555-60.

Techniques and Tips for Lipoma Excision

TO THE EDITOR: I would like to compliment Dr. Salam on his lucid article, "Lipoma Excision."¹ I would add a few minor facts and modifications in surgical techniques that I have found useful.

Before excising a lipoma, it is important to delineate the plane of the tumor (subcutaneous, subfascial). Once that is defined, it is useful to incise through all the overlying tissues right to the pseudocapsule before attempting to dissect the tumor from the surrounding tissues. Also, as in other soft tissue tumors, I have found it easier to get to one edge of the swelling, free the base from the deeper tissues, and then tilt the tumor out of the wound. This minimizes dissection and trauma, hematoma formation, and surgical time.

Lipomas at the nape of the neck are better left alone, unless they are a significant problem. In general, lipomas of the neck and back are more poorly defined than in other areas and there is no clear delineation between the subcutaneous fat and the tumor.

I prefer not to excise the overlying skin initially as Dr. Salam has indicated; rather, I would save this step until redundancy is demonstrated at the end of the procedure. By tucking one edge of the skin over the other, the exact extent of excess skin can be defined and excised.

I would also like to mention a few techniques that may be advantageous. One is the "squeeze technique," in which a small incision is made over the tumor, which is literally squeezed out through the incision.² Fat, being fluid at body temperature, allows itself to be manipulated in this fashion. If multiple tumors need to be excised in one sitting, this is a useful technique to master. The other is the "pot-lid" technique, which is useful in cosmetically challenging areas such as the face.³ Using a punch to remove a circular piece of skin overlying the tumor, the lipoma is extruded through the hole. The piece of skin is then positioned over the defect and acts as a graft and minimizes scarring. Pereira and Schonauer⁴ suggest passing a gynecologic forceps through an incision placed in an aesthetically advantageous site to remove these fatty tumors to minimize unsightly scarring.

Dumbbell extensions (one tumor connected to another in a deeper plane through a defect in the deep fascia) are not uncommon in lipomas and should be actively sought to avoid incomplete excision and "recurrence."

KALYANAKRISHNAN RAMAKRISHNAN, M.D.
Family Medicine Clinic
900 NE 10th St.
Oklahoma City, OK 73104

REFERENCES

1. Salam GA. Lipoma excision. Am Fam Physician 2002;65:901-4.
2. Kenawi MM. "Squeeze delivery" excision of subcutaneous lipoma related to anatomic site. Br J Surg 1995;82:1649-50.
3. Gupta S, Pandhi R, Kumar B. "Pot-lid" technique for aesthetic removal of small lipoma on the face. Int J Dermatol 2001;40:420-4.
4. Pereira JA, Schonauer F. Lipoma extraction via small remote incisions. Br J Plast Surg 2001;54:25-7.

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