Clinical Medicine Insights. Circulatory, Respiratory And Pulmonary Medicine[JOURNAL]
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141 papers
Pharmacotherapies for COPD.
Ejiofor S, Turner AM
Clin Med Insights Circ Respir Pulm Med · 2013 · PMID 23700381 · Full text
This review article summarizes the main treatments for chronic obstructive pulmonary disease, their mechanisms, and the key evidence from trials supporting their use. Drug classes covered were short acting beta agonists...
This review article summarizes the main treatments for chronic obstructive pulmonary disease, their mechanisms, and the key evidence from trials supporting their use. Drug classes covered were short acting beta agonists (SABA), short acting muscarinic antagonists (SAMA), long acting beta agonists (LABA), long acting antimuscarinics (LAMA), inhaled corticosteroids (ICS), LABA/ICS combinations, specific phosphodiesterase (PDE4) inhibitors, non-specific PDE inhibitors, mucolytics, and oxygen. Non-specific therapies, such as opiates for relief of dyspnoea and therapies for smoking cessation, are also covered briefly. For each class of drug, mechanisms of action are described, key clinical trial results are reported, and available agents compared. Finally, the place of each drug in therapy is compared between current worldwide guidelines.
Emerging Therapeutic Options for the Management of COPD.
Reid DJ, Pham NT
Clin Med Insights Circ Respir Pulm Med · 2013 · PMID 23641160 · Full text
Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death worldwide and is projected to be the third by 2020. COPD is characterized by chronic airflow limitation caused by airway inflammation and...
Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death worldwide and is projected to be the third by 2020. COPD is characterized by chronic airflow limitation caused by airway inflammation and parenchymal destruction that is usually progressive. Inhaled bronchodilators continue to be the mainstay of the current management of COPD. Safety and efficacy data of the recently approved medications including aclidinium, glycopyrronium, roflumilast, and indacaterol are reviewed here.
Limitations to the 6-minute walk test in dermatomyositis with interstitial lung disease in comparison with idiopathic interstitial pneumonia.
Someya F, Mugii N
Clin Med Insights Circ Respir Pulm Med · 2013 · PMID 23400027 · Full text
Although the relationship between muscle strength and exercise capacity has been demonstrated in dermatomyositis without lung dysfunction, little is known about the association between exercise capacity and interstitial...
Although the relationship between muscle strength and exercise capacity has been demonstrated in dermatomyositis without lung dysfunction, little is known about the association between exercise capacity and interstitial lung disease in dermatomyositis. Eleven patients with dermatomyositis with interstitial lung disease without the manifestation of muscle weakness and 12 patients with idiopathic interstitial pneumonia underwent the 6-minute walk test (6MWT). PaO(2), creatine kinase, percentage predicted 6MWT distance (6MWD%), and SpO(2) at rest were similar between patients. Percentage predicted vital capacity, carbon monoxide diffusing capacity (DL(CO)%), and SpO(2) after 6MWT were higher and exertional dyspnea was lower in patients with dermatomyositis than in patients with idiopathic interstitial pneumonia. SpO(2) after 6MWT was positively correlated with 6MWD% in patients with dermatomyositis, while DL(CO)% and PaO(2) were positively correlated with 6MWD% in patients with idiopathic interstitial pneumonia. Lung dysfunction in dermatomyositis might not be a major limitation factor in exercise capacity.
Clinical utility of treprostinil and its overall place in the treatment of pulmonary arterial hypertension.
Mirza S, Foley RJ
Clin Med Insights Circ Respir Pulm Med · 2012 · PMID 22872790 · Full text
Pulmonary arterial hypertension (PAH) is a disease that leads to characteristic vascular wall remodeling and hemodynamic alterations. Consequently, this pulmonary vascular disease contributes to substantial morbidity and...
Pulmonary arterial hypertension (PAH) is a disease that leads to characteristic vascular wall remodeling and hemodynamic alterations. Consequently, this pulmonary vascular disease contributes to substantial morbidity and mortality in afflicted patients. PAH may be idiopathic in nature or associated with connective tissue disease, chronic liver disease, human immunodeficiency virus, congenital heart disease, and a growing list of other conditions. There are currently nine Food and Drug Administration-approved therapies for specific PAH treatment. Therapeutic targets include prostacyclin replacement, endothelin-1 antagonism, and phosphodiesterase-5 inhibition. This article focuses on the prostanoid treprostinil and explores its role in the management of patients with PAH.
Omalizumab: clinical use for the management of asthma.
Thomson NC, Chaudhuri R
Clin Med Insights Circ Respir Pulm Med · 2012 · PMID 22745565 · Full text
Omalizumab, a humanized monoclonal antibody that binds circulating IgE antibody, is a treatment option for patients with moderate to severe allergic asthma whose asthma is poorly controlled with inhaled corticosteroids a...
Omalizumab, a humanized monoclonal antibody that binds circulating IgE antibody, is a treatment option for patients with moderate to severe allergic asthma whose asthma is poorly controlled with inhaled corticosteroids and inhaled long-acting β(2) agonist bronchodilators. This review considers the mechanism of action, pharmacokinetics, efficacy, safety and place in management of omalizumab in asthma and focuses particularly on key articles published over the last three years. Omalizumab reduces IgE mediated airway inflammation and its effect on airway remodeling is under investigation. Recent long-term clinical trials confirm the benefits of omalizumab in reducing exacerbations and symptoms in adults and in children with moderate to severe allergic asthma. No clinical or immunological factor consistently predicts a good therapeutic response to omalizumab in allergic asthma. In responders, the duration of treatment is unclear. The main adverse effect of omalizumab is anaphylaxis, although this occurs infrequently. Preliminary data from a five-year safety study has raised concerns about increased cardiovascular events and a final report is awaited. Clinical trials are in progress to determine whether omalizumab has efficacy in the treatment of non-allergic asthma.
Therapeutic options for the treatment of hypertension in children and adolescents.
Stephens MM, Fox BA, Maxwell L
Clin Med Insights Circ Respir Pulm Med · 2012 · PMID 22408373 · Full text
Primary hypertension in children is increasing in prevalence with many cases likely going undiagnosed. The prevalence is currently estimated at between 3%-5% in the United States and may be higher in certain ethnic group...
Primary hypertension in children is increasing in prevalence with many cases likely going undiagnosed. The prevalence is currently estimated at between 3%-5% in the United States and may be higher in certain ethnic groups. Primary hypertension, once felt to be rare in children, is now considered to be about five times more common than secondary hypertension. This review provides information to guide physicians through an organized approach to: 1) screening children and adolescents for hypertension during routine visits; 2) using normative percentile data for diagnosis and classification; 3) performing a clinical evaluation to identify the presence of co-morbidities; 4) initiating a plan of care including subsequent follow-up blood pressure measurements, therapeutic lifestyle changes and pharmacologic therapies.
Achieving symptom control in patients with moderate asthma.
Weir NA, Levine SJ
Clin Med Insights Circ Respir Pulm Med · 2012 · PMID 22259262 · Full text
Disease severity in asthma can be classified as mild, moderate or severe based upon the frequency of symptoms or the severity of airflow obstruction. This review will focus on the treatment of youths greater than 12 year...
Disease severity in asthma can be classified as mild, moderate or severe based upon the frequency of symptoms or the severity of airflow obstruction. This review will focus on the treatment of youths greater than 12 years of age and adults with moderate persistent asthma. Moderate asthmatics may have daily symptoms that cause some limitation with normal daily activities and require use of a rescue inhaled short-acting beta(2)-agonist inhaler or experience nocturnal awakenings secondary to asthma that occur more than once per week. Furthermore, spirometry may reveal airflow obstruction with a reduction in FEV(1) to between 60% and 80% of predicted. Although inhaled corticosteroids (ICS) are the primary controller medication used to modify symptoms in moderate asthmatics, additional controller medications, such as inhaled long-acting beta(2)-agonists (LABA), leukotriene receptor antagonists (LTRA) or theophylline, are often needed to obtain optimal disease control. While the addition of an inhaled LABA to an ICS is very effective at improving disease control in moderate asthma, concerns have arisen over the safety of LABAs, in particular the risk of asthma-related death. Therefore, consideration may be given to initially adding a LTRA, rather than a LABA, to ICS when asthma symptoms are not adequately controlled by ICS alone. Furthermore, individualization of medication regimens, treatment of co-morbid conditions, and patient education are crucial to optimizing compliance with therapy, improving disease control, and reducing the risk of exacerbations. Lastly, the development of new asthma treatments, perhaps based upon personalized medicine, may revolutionize the future treatment of moderate asthma.
An unusual cause of acute hypercapneic respiratory failure.
Wang J, Chichra A, Koenig S
Clin Med Insights Circ Respir Pulm Med · 2011 · PMID 22174594 · Full text
We present a rare cause of hypercapneic respiratory failure through this case report of a 72-year-old man presenting with progressive dyspnea and dysphagia over two years. Hypercapneic respiratory failure was acute on ch...
We present a rare cause of hypercapneic respiratory failure through this case report of a 72-year-old man presenting with progressive dyspnea and dysphagia over two years. Hypercapneic respiratory failure was acute on chronic in nature without an obvious etiology. Extensive workup for intrinsic pulmonary disease and neurologic causes were negative. Laryngoscopy and diagnostic imaging confirmed the diagnosis of diffuse idiopathic skeletal hyperostosis, also known as DISH, as the cause of upper airway obstruction leading to hypercapneic respiratory failure.
Sleep insufficiency, sleep health problems and performance in high school students.
Ming X, Koransky R, Kang V … +3 more , Buchman S, Sarris CE, Wagner GC
Clin Med Insights Circ Respir Pulm Med · 2011 · PMID 22084618 · Full text
A survey on sleep schedule, sleep health, school performance and school start times was conducted in 1,941 adolescents. A high level of early and circadian-disadvantaged sleep/wake schedules during weekdays was observed....
A survey on sleep schedule, sleep health, school performance and school start times was conducted in 1,941 adolescents. A high level of early and circadian-disadvantaged sleep/wake schedules during weekdays was observed. Shorter sleep duration on weekdays was reported, especially in upper classmen. Complaints of inadequate sleep and sleepiness during weekdays, alarm clock use, and napping were prevalent. Night awakening and prolonged sleep onset were common and associated with poor school performance. Students with a sleep length of less than 7 hours on both weekdays and weekends exhibited poorer performance, while those who made up this sleep loss on weekends did not. The total number of poor sleep factors in an individual also correlated with poor school performance. Earlier school start times were associated with a perception of poor sleep quality, shorter sleep duration and more sleep health problems. We conclude that sleep inadequacies and sleep health problems were prevalent in this population, especially in those who started school earlier in the morning, and that these poor sleep factors were associated with school performance.
Roflumilast, a Novel Phosphodiesterase 4 Inhibitor, for COPD Patients with a History of Exacerbations.
Field SK
Clin Med Insights Circ Respir Pulm Med · 2011 · PMID 22084617 · Full text
Acute exacerbations of COPD (AECOPD) are major clinical events. They are associated with a more rapid decline in lung function, poorer quality of life scores, and an increased risk of dying. Exacerbations that require ho...
Acute exacerbations of COPD (AECOPD) are major clinical events. They are associated with a more rapid decline in lung function, poorer quality of life scores, and an increased risk of dying. Exacerbations that require hospitalization have particular significance. Approximately 40% of the AECOPD patients who require hospitalization will die in the subsequent year. Since many AECOPD require hospitalization, they account for most of the expense of caring for COPD patients. Treatment with long-acting bronchodilators and combination inhaled corticosteroid/long-acting bronchodilator inhalers reduces but does not eliminate AECOPD. Roflumilast, a selective phosphodiesterase 4 (PDE4) inhibitor, is an anti-inflammatory medication that improves lung function in patients with COPD. In patients with more severe airway obstruction, clinical features of chronic bronchitis, and a history of AECOPD, roflumilast reduces the frequency of AECOPD when given in combination with short-acting bronchodilators, long-acting bronchodilators, or inhaled corticosteroids. It is generally well tolerated but the most common adverse effects include diarrhea, nausea, weight loss, and headaches. In clinical trials, patients treated with roflumilast experienced weight loss that averaged just over 2 kg but was primarily due to the loss of fat tissue. Weight loss was least in underweight patients and obese patients experienced the greatest weight loss. An unexpected benefit of treatment with roflumilast was that fasting blood glucose and hemoglobin A1c levels improved in patients with comorbid type 2 diabetes mellitus. Roflumilast, the first selective PDE4 inhibitor to be marketed, is a promising drug for the management of COPD patients with more severe disease.
Arterial stiffness in lower limb amputees.
Magalhães P, Capingana DP, Silva AB … +2 more , Capunge IR, Gonçalves MA
Clin Med Insights Circ Respir Pulm Med · 2011 · PMID 22084616 · Full text
BACKGROUND: A high carotid-femoral pulse wave velocity (PWV) has been related to increased cardiovascular morbidity and mortality, but has not been previously evaluated in amputees. The aim of this study was to compare P...
BACKGROUND: A high carotid-femoral pulse wave velocity (PWV) has been related to increased cardiovascular morbidity and mortality, but has not been previously evaluated in amputees. The aim of this study was to compare PWV between amputees and nonamputees. METHODS: In this cross-sectional study, data were collected from 60 male lower limb amputees and 86 male age-matched nonamputees. PWV was measured noninvasively using a Complior(®) device. All participants underwent laboratory investigations and anthropometry. The difference in PWV between amputee and nonamputees was estimated. Multivariate regression was used to adjust for differences between the groups as a result of potential confounders. RESULTS: PWV was higher in amputees than in nonamputees (10.8 ± 1.9 m/sec versus 9.9 ± 1.8 m/sec, P = 0.008, respectively). This difference remained even after adjusting for confounding factors. CONCLUSION: A higher PWV was demonstrated in lower limb amputees. Routine assessment of PWV may contribute to cardiovascular risk stratification in amputees.
Optimal management of severe/refractory asthma.
Pakhale S, Mulpuru S, Boyd M
Clin Med Insights Circ Respir Pulm Med · 2011 · PMID 21912491 · Full text
Asthma is a chronic inflammatory disease of the airways, affecting approximately 300 million people worldwide. Asthma results in airway hyperresponsiveness, leading to paroxysmal symptoms of wheeze, cough, shortness of b...
Asthma is a chronic inflammatory disease of the airways, affecting approximately 300 million people worldwide. Asthma results in airway hyperresponsiveness, leading to paroxysmal symptoms of wheeze, cough, shortness of breath, and chest tightness. When these symptoms remain uncontrolled, despite treatment with high doses of inhaled and ingested corticosteroids, asthmatic patients are predisposed to greater morbidity and require more health care support. Treating patients with severe asthma can be difficult and often poses a challenge to physicians when providing ongoing management. This clinical review aims to discuss the definition, prevalence and evaluation of severe asthmatics, and provides a review of the existing pharmacologic and non-pharmacologic treatment options.
Incidence and Symptoms of High Altitude Illness in South Pole Workers: Antarctic Study of Altitude Physiology (ASAP).
Anderson PJ, Miller AD, O'Malley KA … +7 more , Ceridon ML, Beck KC, Wood CM, Wiste HJ, Mueller JJ, Johnson JB, Johnson BD
Clin Med Insights Circ Respir Pulm Med · 2011 · PMID 21695160 · Full text
INTRODUCTION: Each year, the US Antarctic Program rapidly transports scientists and support personnel from sea level (SL) to the South Pole (SP, 2835 m) providing a unique natural laboratory to quantify the incidence of...
INTRODUCTION: Each year, the US Antarctic Program rapidly transports scientists and support personnel from sea level (SL) to the South Pole (SP, 2835 m) providing a unique natural laboratory to quantify the incidence of acute mountain sickness (AMS), patterns of altitude related symptoms and the field effectiveness of acetazolamide in a highly controlled setting. We hypothesized that the combination of rapid ascent (3 hr), accentuated hypobarism (relative to altitude), cold, and immediate exertion would increase altitude illness risk. METHODS: Medically screened adults (N = 246, age = 37 ± 11 yr, 30% female, BMI = 26 ± 4 kg/m(2)) were recruited. All underwent SL and SP physiological evaluation, completed Lake Louise symptom questionnaires (LLSQ, to define AMS), and answered additional symptom related questions (eg, exertional dyspnea, mental status, cough, edema and general health), during the 1st week at altitude. Acetazolamide, while not mandatory, was used by 40% of participants. RESULTS: At SP, the barometric pressure resulted in physiological altitudes that approached 3400 m, while T °C averaged -42, humidity 0.03%. Arterial oxygen saturation averaged 89% ± 3%. Overall, 52% developed LLSQ defined AMS. The most common symptoms reported were exertional dyspnea-(87%), sleeping difficulty-(74%), headache-(66%), fatigue-(65%), and dizziness/lightheadedness-(46%). Symptom severity peaked on days 1-2, yet in >20% exertional dyspnea, fatigue and sleep problems persisted through day 7. AMS incidence was similar between those using acetazolamide and those abstaining (51 vs. 52%, P = 0.87). Those who used acetazolamide tended to be older, have less altitude experience, worse symptoms on previous exposures, and less SP experience. CONCLUSION: The incidence of AMS at SP tended to be higher than previously reports in other geographic locations at similar altitudes. Thus, the SP constitutes a more intense altitude exposure than might be expected considering physical altitude alone. Many symptoms persist, possibly due to extremely cold, arid conditions and the benefits of acetazolamide appeared negligible, though it may have prevented more severe symptoms in higher risk subjects.
Survival in Patients Receiving Prolonged Ventilation: Factors that Influence Outcome.
Mamary AJ, Kondapaneni S, Vance GB … +3 more , Gaughan JP, Martin UJ, Criner GJ
Clin Med Insights Circ Respir Pulm Med · 2011 Apr · PMID 21573034 · Full text
BACKGROUND: Prolonged mechanical ventilation is increasingly common. It is expensive and associated with significant morbidity and mortality. Our objective is to comprehensively characterize patients admitted to a Ventil...
BACKGROUND: Prolonged mechanical ventilation is increasingly common. It is expensive and associated with significant morbidity and mortality. Our objective is to comprehensively characterize patients admitted to a Ventilator Rehabilitation Unit (VRU) for weaning and identify characteristics associated with survival. METHODS: 182 consecutive patients over 3.5 years admitted to Temple University Hospital (TUH) VRU were characterized. Data were derived from comprehensive chart review and a prospectively collected computerized database. Survival was determined by hospital records and social security death index and mailed questionnaires. RESULTS: Upon admission to the VRU, patients were hypoalbuminemic (albumin 2.3 ± 0.6 g/dL), anemic (hemoglobin 9.6 ± 1.4 g/dL), with moderate severity of illness (APACHE II score 10.7 + 4.1), and multiple comorbidities (Charlson index 4.3 + 2.3). In-hospital mortality (19%) was related to a higher Charlson Index score (P = 0.006; OR 1.08-1.6), and APACHE II score (P = 0.016; OR 1.03-1.29). In-hospital mortality was inversely related to admission albumin levels (P = 0.023; OR 0.17-0.9). The presence of COPD as a comorbid illness or primary determinant of respiratory failure and higher VRU admission APACHE II score predicted higher long-term mortality. Conversely, higher VRU admission hemoglobin was associated with better long term survival (OR 0.57-0.90; P = 0.0006). CONCLUSION: Patients receiving prolonged ventilation are hypoalbuminemic, anemic, have moderate severity of illness, and multiple comorbidities. Survival relates to these factors and the underlying illness precipitating respiratory failure, especially COPD.
Individual canine airway response variability to a deep inspiration.
Brown RH, Kaczka DW, Fallano K … +2 more , Shapiro S, Mitzner W
Clin Med Insights Circ Respir Pulm Med · 2011 Feb · PMID 21487453 · Full text
In healthy individuals, a DI can reverse (bronchodilation) or prevent (bronchoprotection) induced airway constriction. For individuals with asthma or COPD, these effects may be attenuated or absent. Previous work showed...
In healthy individuals, a DI can reverse (bronchodilation) or prevent (bronchoprotection) induced airway constriction. For individuals with asthma or COPD, these effects may be attenuated or absent. Previous work showed that the size and duration of a DI affected the subsequent response of the airways. Also, increased airway tone lead to increased airway size variability. The present study examined how a DI affected the temporal variability in individual airway baseline size and after methacholine challenge in dogs using High-Resolution Computed Tomography. Dogs were anesthetized and ventilated, and on 4 separate days, HRCT scans were acquired before and after a DI at baseline and during a continuous intravenous infusion of methacholine (Mch) at 3 dose rates (17, 67, and 200 μg/min). The Coefficient of Variation was used as an index of temporal variability in airway size.We found that at baseline and the lowest dose of Mch, variability decreased immediately and 5 minutes after the DI (P < 0.0001). In contrast, with higher doses of Mch, the DI caused a variable response. At a rate of 67 μg/min of Mch, the temporal variability increased after 5 minutes, while at a rate of 200 μg/min of Mch, the temporal variability increased immediately after the DI. Increased airway temporal variability has been shown to be associated with asthma. Although the mechanisms underlying this temporal variability are poorly understood, the beneficial effects of a DI to decrease airway temporal variability was eliminated when airway tone was increased. If this effect is absent in asthmatics, this may suggest a possible mechanism for the loss of bronchoprotective and bronchodilatory effects after a DI in asthma.
Pulmonary hypertension in patients with treated pulmonary tuberculosis: analysis of 14 consecutive cases.
Ahmed AE, Ibrahim AS, Elshafie SM
Clin Med Insights Circ Respir Pulm Med · 2011 Jan · PMID 21339885 · Full text
BACKGROUND: Pulmonary tuberculosis (PTB) is an increasing global health problem that continues to cause significant morbidity and mortality. The impact of PTB has been measured in terms morbidity and mortality and little...
BACKGROUND: Pulmonary tuberculosis (PTB) is an increasing global health problem that continues to cause significant morbidity and mortality. The impact of PTB has been measured in terms morbidity and mortality and little attention has been paid to continuing respiratory disability in those who were cured. Pulmonary hypertension (PHT) is a serious respiratory disability that results from structural lung damage and chronic hypoxia. This study was conducted to investigate the presence of PHT in a cohort of treated PTB patients who presented with shortness of breath. METHODS: This is a cross-sectional study that included 14 consecutive patients who were cured of PTB and presented with shortness of breath. Demographic and clinical data were recorded for all patients. PHT was diagnosed using Doppler echocardiography. RESULTS: Fourteen patients who were treated for PTB and were found to have PHT were studied. All patients were sputum smear negative at the time of the study. The mean age (SD) was 43.1 (13.6) and half of the patients were males. The mean number of years since PTB was diagnosed (SD) was 9.4 (10.9). All patients had abnormal chest x-rays. The commonest radiological abnormality was fibrocavitation which occurred in 50% of patients. Estimated pulmonary artery systolic pressure (PASP) of 51 to 80 mm/Hg was found in 9 patients (64.3%) whereas PASP of 40 to 50 mm/Hg was found in 4 patients (28.6%) and one patient had PASP more than 80 mm/Hg. CONCLUSIONS: Different grades of PHT occurred in this cohort of treated PTB patients on average about 9 years after cure. The findings of this study support implementation of strategies for early detection and prevention of PTB. For those who were cured from PTB, longer periods of disability should be implemented in assessment of disease burden.
Variability in measures of exhaled breath na, influence of pulmonary blood flow and salivary na.
Wheatley CM, Cassuto NA, Foxx-Lupo WT … +1 more , Snyder EM
Clin Med Insights Circ Respir Pulm Med · 2010 Aug · PMID 21157525 · Full text
The assessment of inflammatory markers and ions in exhaled breath condensate (EBC) is being utilized more frequently in diseases such as asthma and cystic fibrosis with marked variability in EBC measures, including those...
The assessment of inflammatory markers and ions in exhaled breath condensate (EBC) is being utilized more frequently in diseases such as asthma and cystic fibrosis with marked variability in EBC measures, including those of exhaled Na(+). We sought to determine if variability in exhaled Na(+) was due to differences in pulmonary blood flow (PBF) or Na(+) in the mouth (salivary Na(+)). We measured exhaled Na(+) three times with coinciding sampling of salivary Na(+) and assessment of PBF (using acetylene rebreathing) in 13 healthy subjects (54% female, age = 27 ± 7 yrs., ht. = 172 ± 10 cm, wt. = 70 ± 21 kg, BMI = 22 ± 7 kg/m(2) mean ± SD). Exhaled Na(+) averaged 2.7 ± 1.2 mmol/l, and salivary Na(+) averaged 5.51 ± 4.58 mmol/l. The coefficients of variation across all three measures in all 13 subjects averaged 30% for exhaled Na(+) and 83% for salivary Na(+), within subjects the variability across the three measures averaged 30% for exhaled Na(+) and 38% for salivary Na(+). Across all three measures in all 13 subjects the relationship between PBF and exhaled Na(+) averaged 0.027 (P = 0.87), and the relationship between salivary Na(+) and exhaled Na(+) concentrations averaged 0.59 (P = 0.001). Also, we sought to determine the relationship between exhaled Na(+) and serum Na(+) in an addition 20 subjects. There was a moderate and significant relationship between serum Na(+) and exhaled Na(+) (r = 0.37, P = 0.04). These findings suggest there that the variability in exhaled Na(+) is caused, at least in part, by droplet formation from within the mouth as turbulent air passes through and that there is a flux of ions from the pulmonary blood into the airways.
The DNR Order: What Does it Mean?
Tsang JY
Clin Med Insights Circ Respir Pulm Med · 2010 Jul · PMID 21157524
As medical science continues to advance, patients nowadays with progressive cardiopulmonary diseases live to older ages. However, they too will eventually reach their unsustainable physiological limit and many die in poo...
As medical science continues to advance, patients nowadays with progressive cardiopulmonary diseases live to older ages. However, they too will eventually reach their unsustainable physiological limit and many die in poor health and discomfort prior to their demise. Regrettably many physicians have not kept pace in dealing with the inevitable end-of- life issues, along with modern technological developments. Without proper guidance, ill-informed patients often face unnecessary anxiety, receive futile resuscitation at the expense of their dignity and public cost which has and will become increasingly overwhelming according to our current demographic trends. In any health care reform, experts often suggest that difficult questions will have to be asked but the solutions are at least partly in the logistical details. From time to time, we see an isolated "Do Not Resuscitate" or DNR order in the chart, which is not always followed by thoughtful discussion on the boundary of care, either simultaneously or known to be followed up soon. This paper attempts to begin asking some of these difficult questions, point out the fallacies of this order and expose the weaknesses in the present state of entitlement by public demand if physicians retreats more from the discussion. The solution does not lie in asking the questions but in changing the practice pattern in real life on a continuous basis, hopefully to be eventually accepted by most, if not all.
Number of biopsies in diagnosing pulmonary nodules.
Wehrschuetz M, Wehrschuetz E, Portugaller HR
Clin Med Insights Circ Respir Pulm Med · 2010 Jul · PMID 21157523 · Full text
PURPOSE: To determine the number of specimens to be obtained from pulmonary lesions to get the highest possible accuracy in histological work-up. MATERIALS AND METHODS: A retrospective evaluation (January 1999 to April 2...
PURPOSE: To determine the number of specimens to be obtained from pulmonary lesions to get the highest possible accuracy in histological work-up. MATERIALS AND METHODS: A retrospective evaluation (January 1999 to April 2004) covered 260 patients with thoracic lesions who underwent computer tomography (CT)-guided core-cut biopsy in coaxial technique. All biopsies were performed utilizing a 19 gauge introducer needle and a 20 gauge core-cut biopsy needle. In all, 669 usable biopsies were taken (from 1-5 biopsies in each setting). The specimens were marked sequentially and each biopsy was worked up histologicaly. The biopsy results were correlated to histology after surgery, clinical follow-up or autopsy. The number of biopsies was determined that is necessary to achieve the highest possible accuracy in diagnosing pulmonary lesions. RESULTS: In 591 of 669 biopsies (88.3%), there were correct positive results. The overall accuracy was 87.4%. In 193 of 260 (74.2%) patients, a suspected malignancy was confirmed. In 50 of 260 (19.2%) patients, a benign lesion was correctly diagnosed. Seventeen (6.5%) patients were lost to follow-up. The first, second and third biopsies had cumulative accuracies of 63.6%, 89.2% and 91.5%, respectively (P < 0.02). More biopsies did not show any higher impact on accuracy. CONCLUSION: For the highest possible accuracy in diagnosing pulmonary lesions by CT-guided core-cut biopsy, at least three usable specimens are recommended to be taken.
Empyema thoracis.
Ahmed AE, Yacoub TE
Clin Med Insights Circ Respir Pulm Med · 2010 Jun · PMID 21157522 · Full text
Epmyema thoracis is associated with high mortality ranging between 6% to 24%. The incidence of empyema is increasing in both children and adults; the cause of this surge is unknown. Most cases of empyema complicate commu...
Epmyema thoracis is associated with high mortality ranging between 6% to 24%. The incidence of empyema is increasing in both children and adults; the cause of this surge is unknown. Most cases of empyema complicate community- or hospital-acquired pneumonia but a proportion results from iatrogenic causes or develops without pneumonia. Parapneumonic effusions (PPE) develop in about one half of the patients hospitalized with pneumonia and their presence cause a four-fold increase in mortality. Three stages in the natural course of empyema have long been described: the exudative, fibrinopurulent, and organizing phases. Clinically, PPE are classified as simple PPE, complicated PPE, and frank empyema. Simple PPE are transudates with a pH > 7.20 whereas complicated PPE are exudates with glucose level <2.2 mmol/l and pH < 7.20. Two guidelines statements on the management of PPE in adults have been published by the American College of Chest Physicians (ACCP) and the British Thoracic Society (BTS). Although they differ in their approach on how to manage PPE, they agree on drainage of the pleural space in complicated PPE and frank empyema. They also recommend the use of intrapleural fibrinolysis and surgical intervention in those who do not show improvement, but the level of evidence for the use of intrapleural fibrinolysis is not high highlighting the need for more research in this area. A recently published large randomized trial has shown no survival advantage with the use of intrapleural streptokinase in patients with pleural infection. However, streptokinase enhances drainage of infected pleural fluid and may still be used in patients with large collection of infected pleural fluid causing breathlessness or ventilatory failure. There is emerging evidence that the combination of intrapleural tPA/DNase is significantly superior to tPA or DNase alone, or placebo in improving pleural fluid drainage in patients with pleural space infection. A guideline statement on the management of PPE in children has been published by the BTS. It recommends the use of antibiotics in all patients with PPE in addition to either video-assisted thoracoscopic surgery (VATS) or tube thoracostomy and intrapleural fibrinolysis. Prospective randomized trials have shown that intrapleural fibrinolysis is as effective as VATS for the treatment of childhood empyema and is a more economic treatment and therefore, should be the primary treatment of choice.
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