To determine whether sputum clearance is increased by using nebulised saline or terbutaline as an adjunct to chest physiotherapy, a radioaerosol method (using technetium-99m labelled human albumin millimicrospheres) was employed in eight patients with stable bronchiectasis on four occasions, for comparison of sputum clearance with four different regimens. These were: control, with the patient resting in an upright position; chest physiotherapy, by the forced expiration technique with postural drainage; and chest physiotherapy following five minutes' inhalation of either nebulised normal saline or nebulised terbutaline 5 mg. Use of both nebulised saline and nebulised terbutaline immediately before chest physiotherapy gave a significantly greater yield of sputum than did physiotherapy alone, and terbutaline also significantly increased radioaerosol clearance from the whole lung and from regions of interest. The mechanism is unclear, but this method may provide a simple way of increasing the efficacy of conventional chest physiotherapy.Chest physiotherapy is widely used in hospital practice but there is little objective assessment of its value in different settings. A central function of chest physiotherapy in acute conditions is to mobilise excess secretions and enhance expectoration.' The use of an inhaled radio aerosol that is deposited on the tracheobronchial tree allows such secretions to be "labelled" and their subsequent clearance monitored. Use of this method has shown the contribution of cough,2 vibration, or percussion3 to clearance to be limited; greater clearance of airways secretions is obtained by the forced expiration technique in conjunction with postural drainage.45 We have evaluated the use of nebulised saline and nebulised terbutaline as an adjunct to this optimal chest physiotherapy to determine whether sputum clearance is increased further. MethodsWe studied eight patients (six of them women), aged 36-71 years, with stable bronchiectasis on four occasions. Their mean daily sputum production was 36 (range 10-120) g. The results of spirometry before Address for reprint requests: Dr P P Sutton, Hartlepool General Hospital, Hartlepool, Cleveland TS24 9RH. Accepted 10 July 1987 and after each of the four treatment days are shown in the table. No patient smoked, and bronchodilators and domiciliary physiotherapy were withheld on the morning of each study day. PHYSIOTHERAPYThe treatment schedules, given in randomised order, were: (1) control, patient resting upright; (2) chest physiotherapy; (3) chest physiotherapy following five minutes' inhalation of nebulised normal saline; (4) chest physiotherapy following five minutes' inhalation of nebulised terbutaline (5 mg).Chest physiotherapy included the forced expiration technique and postural drainage and lasted for 20 minutes. For treatment 3, 4 ml normal saline was nebulised for five minutes immediately before physiotherapy by a Unicorn jet nebuliser with a mouthpiece and driven by oxygen at 8 1 m-'. For treatment 4, terbutaline respirator solut...

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Radioaerosol measurements of mucociliary clearance have been assessed in relationship to depth of particle penetration into the lung. The tests analysed were performed with 5 microns diameter 99Tcm particles inhaled under standardised conditions but at varying inhalation flow rates. Aerosol lung penetration was assessed by (i) penetration index (PI), a ratio of outer to inner zone radioactivity determined from a gamma camera image; and (ii) alveolar deposition (AD), a measure of activity retained at 24 hours and taken to represent deposition distal to the ciliated airways. Clearance rates in 30 tests on 19 normal non-smokers under the age of 50 varied significantly with aerosol inhalation flow rate, PI and AD. A normal range varying with PI is proposed although normal inter-subject variability remains high even after allowance for PI. Nevertheless 8 out of 12 patients with stable asthma and 21 out of 24 patients with chronic bronchitis demonstrated slow clearance lying outside the PI-based normal range.

given intravenously. Continued administration may lead to hyponatraemia and hypokalaemia through excessive loss of sodium and potassium.We report these cases for two reasons; firstly, to re-emphasise the fact that the skin is not a completely impermeable barrier and, secondly, as a reminder that although urea itself is not a particularly toxic substance, other drugs that are used in the treatment of ichthyotic skin conditionsfor example, salicylates and retinoids-are potentially more toxic, especially when absorbed systemically.We thank Dr D Haigh and Dr P Dear for permission to report their patients. References