Microbial yield from physiotherapy assisted sputum production in respiratory outpatients

BACKGROUND

Sputum is a key diagnostic sample for those with chronic chest conditions including chronic and allergic aspergillus-related disease, but often not obtained in clinic. The objective of this study was to evaluate physiotherapeutic interventions to obtain sputum from those not able to spontaneously produce and the subsequent microbiological result.

METHODS

Sputum samples were collected by physiotherapists from patients attending routine outpatient clinics managing their aspergillus-related diseases who were unable to spontaneously produce. Active Cycle of Breathing Techniques (ACBT) technique was applied first, for 10 min, followed by hypertonic saline induction using a Pari LC plus or Pari Sprint nebuliser, if necessary and deemed safe to do so. Samples processed in the laboratory using standard microbiological techniques for bacterial and fungal culture with the addition of Aspergillus real-time PCR.

RESULTS

Samples were procured from 353 of 364 (97%) patients, 231 (65%) by ACBT and 119 (34%) with administration of hypertonic saline. Three of 125 (2.4%) patients had significant bronchospasm during sputum induction. Sixteen patients' sputum tested positive for Aspergillus culture, contrasting with 82 whose Aspergillus PCR was positive, 59 with a strong signal. PCR improved detection of Aspergillus by 350%. Sputum from 124 (34%) patients cultured other potentially pathogenic organisms which justified specific therapy.

CONCLUSIONS

Physiotherapeutic interventions safely and effectively procured sputum from patients unable to spontaneously produce. The method for sputum induction was well-tolerated and time-efficient, with important microbiological results.

Randomized clinical trial of the efficacy and safety of insulin glargine vs. NPH insulin as basal insulin for the treatment of glucocorticoid induced hyperglycemia using continuous glucose monitoring in hospitalized patients with type 2 diabetes and respiratory disease

AIMS

To investigate the clinical efficacy and safety of insulin glargine compared with NPH insulin as basal insulin for the management of corticosteroid-induced hyperglycemia in hospitalized people with type 2 diabetes (T2DM) and respiratory disease.

MATERIALS AND METHODS

Randomized, two-arm parallel group, clinical trial undertaken from February 2011 to November 2012 on the pneumology ward of the Hospital Regional Universitario de Málaga (Spain), involving 53 participants with T2DM treated with medium/high doses of intermediate-acting corticosteroids. Participants were randomly assigned to receive one single dose of insulin glargine or NPH insulin in three equally divided doses before each meal as basal insulin within a basal-bolus insulin protocol. The intervention lasted six days or until discharge if earlier.

RESULTS

No significant differences were seen between groups during the study in mean blood glucose (11.43±3.44 mmol/l in glargine vs. 11.88±2.94 mmol/l in NPH, p=0.624), and measures of glucose variability (standard deviation 3.27±1.16 mmol/l vs. 3.61±0.99 mmol/l, p=0.273; coefficient of variation 1.55±0.33 mmol/l vs. 1.72±0.39 mmol/l, p=0.200). Results from CGM were concordant with those obtained with capillary blood glucose reading. The length of hospital stay was also similar between groups (8.2±2.8 days vs. 9.8±3.4 days, p=0.166) There was a non significant trend for lower episodes of mild (4 vs. 8, p=0.351) and severe hypoglycemia (0 vs. 3, p=0.13) in the glargine group.

CONCLUSIONS

The results of this study showed that insulin glargine and NPH insulin are equally effective in a basal-bolus insulin protocol to treat glucocorticoid-induced hyperglycemia in people with T2DM on a pneumology ward.

Long-term non-invasive ventilation therapies in children: a scoping review protocol

INTRODUCTION

Non-invasive ventilation (NIV) in children has become an increasingly common modality of breathing support where pressure support is delivered through a mask interface or less commonly through other non-invasive interfaces. At this time, NIV is considered a first-line option for ventilatory support of chronic respiratory insufficiency associated with a range of respiratory and sleep disorders. Previous reviews on the effectiveness, complications and adherence to NIV treatment have lacked systematic methods. The purpose of this scoping review is to provide an overview of the evidence for the use of long-term NIV in children.

METHODS AND ANALYSIS

We will use previously established scoping methodology. Ten electronic databases will be searched to identify studies in children using NIV for longer than 3 months outside an intensive care setting. Grey literature search will include conference proceedings, thesis and dissertations, unpublished trials, reports from regulatory agencies and manufacturers. Two reviewers will independently screen titles and abstracts for inclusion, followed by full-text screening of potentially relevant articles to determine final inclusion. Data synthesis will be performed at three levels: (1) an analysis of the number, publication type, publication year, and country of publication of the studies; (2) a summary of the study designs, outcomes measures used; (3) a thematic analysis of included studies by subgroups.

ETHICS AND DISSEMINATION

This study will provide a wide and rigorous overview of the evidence on the use of long-term NIV in children and provide critical information for healthcare professionals and policymakers to better care for this group of children. We will disseminate our findings through conference proceedings and publications, and evaluate the results for further systematic reviews and meta-analyses.

The Lung Immune Response to Nontypeable Haemophilus influenzae (Lung Immunity to NTHi)

Haemophilus influenzae is divided into typeable or nontypeable strains based on the presence or absence of a polysaccharide capsule. The typeable strains (such as type b) are an important cause of systemic infection, whilst the nontypeable strains (designated as NTHi) are predominantly respiratory mucosal pathogens. NTHi is present as part of the normal microbiome in the nasopharynx, from where it may spread down to the lower respiratory tract. In this context it is no longer a commensal and becomes an important respiratory pathogen associated with a range of common conditions including bronchitis, bronchiectasis, pneumonia, and particularly chronic obstructive pulmonary disease. NTHi induces a strong inflammatory response in the respiratory tract with activation of immune responses, which often fail to clear the bacteria from the lung. This results in recurrent/persistent infection and chronic inflammation with consequent lung pathology. This review will summarise the current literature about the lung immune response to nontypeable Haemophilus influenzae, a topic that has important implications for patient management.

Revised listings for growth disorders and weight loss in children. Final rule

This rule adopts, with one change, the rule for evaluating growth disorders in children we proposed in a notice of proposed rulemaking (NPRM) published in the Federal Register on May 22, 2013. Several body systems in the Listing of Impairments (listings) contain listings for children based on impairment of linear growth or weight loss. We are replacing those listings with new listings for low birth weight (LBW) and failure to thrive; a new listing for genitourinary impairments; and revised listings for growth failure in combination with a respiratory, cardiovascular, digestive, or immune system disorder. These revisions reflect our program experience, advances in medical knowledge, and comments we received from medical experts and the public.

Which clinical signs predict hypoxaemia in young Senegalese children with acute lower respiratory tract disease?

BACKGROUND

Acute lower respiratory tract diseases are an important cause of mortality in children in resource-limited settings. In the absence of pulse oximetry, clinicians rely on clinical signs to detect hypoxaemia.

OBJECTIVE

To assess the diagnostic value of clinical signs of hypoxaemia in children aged 2 months to 5 years with acute lower respiratory tract disease.

METHODS

Seventy children with a history of cough and signs of respiratory distress were enrolled. Three experienced physicians recorded clinical signs and oxygen saturation by pulse oximetry. Hypoxaemia was defined as oxygen saturation <90%. Clinical predictors of hypoxaemia were evaluated using adjusted diagnostic odds ratios (aDOR).

RESULTS

There was a 43% prevalence of hypoxaemia. An initial visual impression of poor general status [aDOR 20.0, 95% CI 3.8-106], severe chest-indrawing (aDOR 9.8, 95% CI 1.5-65), audible grunting (aDOR 6.9, 95% CI 1.4-25) and cyanosis (aDOR 26.5, 95% CI 1.1-677) were significant predictors of hypoxaemia.

CONCLUSION

In children under 5 years of age, several simple clinical signs are reliable predictors of hypoxaemia. These should be included in diagnostic guidelines.

Geriatric multidimensional assessment for elderly patients with acute respiratory diseases

The case of an 87-year-old woman who falls at home and is admitted to the Emergency Department of an acute hospital with delirium exemplify a common situation that physicians face in their everyday clinical practice. We describe the typical context of frailty in which acute illnesses frequently present in frail elderly patients and, in particular, the relationship between comorbidity, disability and frailty. We also report the current knowledge about frailty theories and we focus on the "atypical" presentation of many acute illnesses. Major attention is devoted on delirium and on mobility impairment, two of the most common atypical symptoms of elderly frail subjects. Finally we describe the evidence on the comprehensive geriatric assessment, i.e., the method that is required to identify and understand the ultimate needs of elderly complex subjects.

Current trends in the management of pulmonary hypertension associated with respiratory disease in institutions approved by the Japanese Respiratory Society

BACKGROUND

Pulmonary hypertension (PH) often correlates with respiratory disease severity. Right heart catheterization (RHC) is recommended for the definitive diagnosis of PH associated with respiratory disease (R-PH). However, no previous studies have evaluated the perceived necessity for pulmonologists to use RHC for R-PH diagnosis, or the management of R-PH in Japan.

METHODS

Questionnaires were mailed to 855 institutions, approved by the Japanese Respiratory Society. Questions included the prevalence and necessity of RHC and other methods in R-PH diagnosis, and current trends in the treatment of R-PH.

RESULTS

Questionnaires were returned from 289 institutions (34%). Patients with R-PH were examined by pulmonologists in 89% of institutions; some pulmonologists performed echocardiography (15%) and some RHC (13%). Echocardiography was used to diagnose R-PH in 99% of institutions and RHC was used in 36%. RHC was considered in cases of suspected PH in 49% of institutions and prior to initiation of pulmonary arterial hypertension (PAH)-specific therapy in 57%. Of patients diagnosed with R-PH, 47% were treated with ambulatory oxygen therapy. Furthermore, 98 of 145 institutions used PAH-specific therapy to treat R-PH. Of the 1355 patients who underwent RHC as a part of PH evaluation, 29% were confirmed to have PH, and 8% had severe PH with a mean pulmonary arterial pressure of ≥35mmHg.

CONCLUSIONS

The current diagnostic and treatment modalities for R-PH in Japan were evaluated. Although few pulmonologists perform RHC for R-PH diagnosis in Japan, more than half consider using RHC for patients before initiating PAH-specific therapy.

[Lung and pregnancy]

During pregnancy several adaptations develop in response to the enhanced maternal and fetal metabolic needs. This review summarizes the major cardiorespiratory modifications of pregnancy as well as their consequences in chronic respiratory diseases such as restrictive ventilatory defects (post-tuberculosis pneumonectomy, kyphoscoliosis, neuromuscular disorders), asthma, cystic fibrosis, and pulmonary hypertension. It is important to recognize early the cardiorespiratory situations for which pregnancy is contraindicated or associated with a high risk of respiratory complications. Clinical management by an expert and often pluridisciplinary team is recommended.

Chronic cough: an update

Cough persisting beyond 8 weeks (ie, chronic cough) is one of the most common reasons for an outpatient visit. A protracted cough can negatively affect one's quality of life by causing anxiety, physical discomfort, social isolation, and personal embarrassment. Herein, the anatomy and physiology of the cough reflex are reviewed. Upper airway cough syndrome, asthma, eosinophilic bronchitis, and gastroesophageal reflux disease account for most chronic cough after excluding smoking, angiotensin-converting enzyme inhibitor use, and chronic bronchitis. Many patients have more than one reason for chronic cough. Treating the underlying cause(s) resolves cough in most instances. There are some coughs that seem refractory despite an extensive work-up. The possibility of a hypersensitive cough reflex response has been proposed to explain these cases. Several clinical algorithms to evaluate chronic cough are presented.

Chart-confirmed guillain-barre syndrome after 2009 H1N1 influenza vaccination among the Medicare population, 2009-2010

Given the increased risk of Guillain-Barré Syndrome (GBS) found with the 1976 swine influenza vaccine, both active surveillance and end-of-season analyses on chart-confirmed cases were performed across multiple US vaccine safety monitoring systems, including the Medicare system, to evaluate the association of GBS after 2009 monovalent H1N1 influenza vaccination. Medically reviewed cases consisted of H1N1-vaccinated Medicare beneficiaries who were hospitalized for GBS. These cases were then classified by using Brighton Collaboration diagnostic criteria. Thirty-one persons had Brighton level 1, 2, or 3 GBS or Fisher Syndrome, with symptom onset 1-119 days after vaccination. Self-controlled risk interval analyses estimated GBS risk within the 6-week period immediately following H1N1 vaccination compared with a later control period, with additional adjustment for seasonality. Our results showed an elevated risk of GBS with 2009 monovalent H1N1 vaccination (incidence rate ratio = 2.41, 95% confidence interval: 1.14, 5.11; attributable risk = 2.84 per million doses administered, 95% confidence interval: 0.21, 5.48). This observed risk was slightly higher than that seen with previous seasonal influenza vaccines; however, additional results that used a stricter case definition (Brighton level 1 or 2) were not statistically significant, and our ability to account for preceding respiratory/gastrointestinal illness was limited. Furthermore, the observed risk was substantially lower than that seen with the 1976 swine influenza vaccine.

Total laparoscopic distal gastrectomy for elderly patients with gastric cancer

INTRODUCTION

This study evaluated the feasibility of totally laparoscopic distal gastrectomy (TLDG) in elderly patients with gastric cancer.

METHODS

We retrospectively analyzed the data from 138 patients who underwent TLDG from April 2005 to March 2009. Of these 138 patients, 20 were older than 75 years of age, and 118 were 75 years of age or younger.

RESULTS

The preoperative respiratory function and American Society of Anesthesiologists (ASA) -physical status were significantly worse in the elderly patients than in the younger patients (P = 0.013). Hypertension and respiratory disease were more common in the elderly patients than in the younger patients (P = 0.032 / P = 0.005). The findings for the following parameters were similar in the two groups: intraoperative blood loss, operation time, severe postoperative complication rate, time required to start a solid diet, and duration of postoperative hospital stay. The rate of major complications was not different between the two groups, although minor complications were more commonly observed in the elderly patients.

CONCLUSION

TLDG was found to be a safe procedure for elderly patients. This method can be used as one of the standard treatments for gastric cancer in elderly patients.

Laparoscopic cholecystectomy in patients with anesthetic problems

Laparoscopic cholecystectomy is a standard operation for benign gallbladder disease. As experience with laparoscopic cholecystectomy has increased, the procedure has become possible in patients with anesthetic problems. Patients with ankylosing spondylitis or severe kyphosis represent a challenging group to anesthesiologists and laparoscopic surgeons since these diseases are associated with difficult intubation, restrictive ventilatory defects, and cardiac problems. The relatively new approach of awake fiberoptic intubation is considered to be the safest option for patients with anticipated airway difficulties. Laparoscopic cholecystectomy is usually performed under general anesthesia but considerable difficulties in anesthetic management are encountered during laparoscopic surgery; for example, hemodynamic instability may develop in patients with cardiopulmonary dysfunction due to pneumoperitoneum and position changes during the operation. Nonetheless, regional anesthesia can be considered as a valid option for patients with gallbladder disease who are poor candidates for general anesthesia due to cardiopulmonary problems. We report three cases of laparoscopic cholecystectomy successfully performed in patients with anesthetic problems that included cardiopulmonary disease, severe kyphosis, and ankylosing spondylitis.

Trends in death associated with pediatric dental sedation and general anesthesia

BACKGROUND

Inadequate access to oral health care places children at risk of caries. Disease severity and inability to cooperate often result in treatment with general anesthesia (GA). Sedation is increasingly popular and viewed as lower risk than GA in community settings. Currently, few data are available to quantify pediatric morbidity and mortality related to dental anesthesia.

OBJECTIVE

Summarize dental anesthesia-related pediatric deaths described in media reports.

METHODS

Review of media reports in the Lexis-Nexis Academic database and a private foundation website.

SETTINGS

Dental offices, ambulatory surgery centers, and hospitals. Patients :US-based children (≤21 years old) who died subsequently receiving anesthesia for a dental procedure between 1980-2011.

RESULTS

Most deaths occurred among 2-5 year-olds (n = 21/44), in an office setting (n = 21/44), and with a general/pediatric dentist (n = 25/44) as the anesthesia provider. In this latter group, 17 of 25 deaths were linked with a sedation anesthetic.

CONCLUSIONS

This series of media reports likely represent only a fraction of the overall morbidity and mortality related to dental anesthesia. These data may indicate an association between mortality and pediatric dental procedures under sedation, particularly in office settings. However, these relationships are difficult to test in the absence of a database that could provide an estimate of incidence and prevalence of morbidity and mortality. With growing numbers of children receiving anesthesia for dental procedures from providers with variable training, it is imperative to be able to track anesthesia-related adverse outcomes. Creating a national database of adverse outcomes will enable future research to advance patient safety and quality.

Common lung conditions: acute dyspnea

Dyspnea is a subjective experience of breathing discomfort; patients experience qualitatively distinct sensations that vary in intensity. Acute dyspnea might be secondary to an acute problem, or it might be an exacerbation of an existing disease (eg, asthma, chronic obstructive pulmonary disease, heart failure). It also accompanies a variety of illnesses at the end of life. New information has changed differentiation between respiratory and cardiovascular etiologies of acute dyspnea, as well as rapid diagnosis of pulmonary embolism. Management of acute dyspnea from hypercapnic failure also has changed. Patients presenting with dyspnea most commonly have underlying cardiovascular and/or respiratory etiologies, and differentiating between the two can be challenging. B-type natriuretic peptide (BNP) and N-terminal proB-type natriuretic peptide (NT-proBNP) are elevated when ventricular wall tension increases (eg, during a heart failure exacerbation). BNP and NT-proBNP are most useful for identifying patients with dyspnea who do not have heart failure. A BNP level less than 50 pg/mL has a negative predictive value of 96%, effectively ruling out heart failure; a serum BNP level less than 100 pg/mL has a negative likelihood ratio of 0.11. Patients with pulmonary embolism often present with dyspnea, and this condition needs to be diagnosed and managed expeditiously. When pulmonary embolism is suspected, use a clinical decision rule (eg, the Wells rule, the Geneva rule) to establish the probability of this condition. For patients with a low probability, obtain a D-dimer test; if the D-dimer result is negative, monitor the patient. A positive D-dimer result requires further investigation. For patients with intermediate or high probability, obtain computed tomography pulmonary angiography for a definitive diagnosis. Patients who have dyspnea from a chronic obstructive pulmonary disease exacerbation can experience hypercapnic failure. As an adjunct to usual medical treatment, noninvasive positive pressure ventilation decreases the need for mechanical ventilation and is particularly useful in patients who have chosen not to be resuscitated with intubation.

[Respiratory support in anaesthetic management for thoracic surgery and their comparative characteristics: over 2000 anaesthesia experience]

The article deals with the first comparative study of haemodynamics, gas exchange, and metabolic lung finction in patients with underlying respiratory and cardiovascular diseases. Different anaesthesia and ventilation (conventional AVL, OLV differentiated ALV) techniques were used. Respiratory support methodology with the use of HFV or CPAP during the main phase of thoracic surgery in patients with severe associated cardio-respiratory diseases was developed. Indications for differentiated AL V in thoracic surgery were developed.

Association of periodontal disease with self-reported systemic disorders in Greece

PURPOSE

The aim of this retrospective investigation was to examine the occurrence of periodontal disease in patients referred to a specialist clinic for neurosurgery and to explore possible associations between common systemic disorders and periodontal disease in an adult population in Greece.

MATERIALS AND METHODS

The study sample consisted of 1,652 individuals, 760 males and 892 females, aged 40 to 68 years, with a mean age of 57.3 ± 4.7 years. Data were collected by means of an oral clinical examination and a self-administered questionnaire. Statistical analysis of questionnaire items was performed by using a multiple linear regression analysis model in order to estimate correlations between systemic disorders as independent variables, and the relative frequency of periodontal pockets of 5 mm or more and the frequency of clinical attachment loss of 6 mm or more as dependent variables.

RESULTS

The relative frequencies of periodontal pockets >= 5.0 mm and clinical attachment loss >= 6.0 mm as expressed in terms of mean values were 76% and 70.2%, respectively, for individuals who suffer from cardiovascular disease and 62.3% and 52.9% respectively, for those who suffer from respiratory disease. The depth of periodontal pockets was significantly and positively correlated to the presence of respiratory diseases (P = 0.0001) and diabetes mellitus (P = 0.0001) after adjustment for age, gender and smoking, whereas clinical attachment loss was significantly and positively correlated to the presence of diabetes mellitus (P = 0.0001) and cardiovascular diseases (P = 0.037).

CONCLUSION

Based on the clinical criteria for established periodontitis, the current study supports associations between periodontal disease and systemic disorders such as diabetes mellitus, cardiovascular and respiratory diseases.

Small airways involvement in patients with rheumatoid arthritis

OBJECTIVES

One of the common causes of morbidity in patients with RA is pulmonary involvement. Some studies have shown that the possible abnormal results of pulmonary function tests in rheumatoid disease are higher than usual. We aimed to evaluate the prevalence of spirometric abnormalities in patients with RA.

MATERIALS & METHODS

This case-control study was conducted on 99 patients with RA who referred to a rheumatology clinic in Qazvin, northwest Iran. Sixty five age- and sex-matched healthy controls were recruited as well. History taking, physical examination, laboratory tests and spirometry were performed for the participants. RA severity was assessed according to Disease Activity Score 28 (DAS28). The data were processed using SPSS software version 16. Chi square and student's t test and multiple logistic regressions were used as appropriated.

RESULTS

The mean (±SD) age of the patients was 46 (±10.5) years. The mean (±SD) duration of disease was 4.8 (±5.4) years, and the mean (±SD) DAS28 was 2.5 (±1.1). Dyspnea was the most common respiratory complaint (6.1%). Three (3%) patients had mild restrictive, 2 (2%) patients mild obstructive, and one (1%) patient moderate obstructive diseases. In the control group, only one participant had mild restrictive pulmonary disease (P<0.05). A significant decrease of FEF25 [OR=3.2; 95%CI (1.9-4.5)], FEF50 [OR=2.5; 95% CI (1.7-3.1)], FEF75 [OR=2.3; 95% CI (1.4-2.7)] and FEF25-75 [OR=2.7; 95% CI (1.7-3.5)] was observed in patients compared with the control group. We found no correlation between the patients' age, duration and severity of the disease, and laboratory tests with spirometric indices.

CONCLUSION

It is recommended that patients with RA be visited on a regular basis and PFT be done for them for the early diagnosis of pulmonary involvement.

Case report: cystic hygroma

BACKGROUND

Cystic hygroma (CH) is a congenital malformation of the lymphatic system. It most commonly presents in the neck, and aetiological factors include environmental and genetic factors.

CASE REPORT

A 13-year-old female presented with spontaneous dental pain affecting the maxillary left first and second permanent molar teeth. Medical history revealed a history of left sided cervico-facial-thoracic CH. She was diagnosed with periapical peridontitis and required extraction of both teeth. Clinical management was compromised by the CH involving the left face, neck, ear, tongue, larynx, oropharynx and mediastinum and circling the trachea and great vessels.

TREATMENT

Initial management included the placement of obtundant dressings for teeth number 26 and 27 with resolution of dental pain. Intensive prevention was instigated, and teeth number 16 and 17 were restored with composite resin under local analgesia (LA) without incident. Extraction of teeth number 26 and 27 was complicated by significant trismus and the unacceptably high risk associated with general anaesthesia, due to intubation difficulties. It proved impossible to achieve satisfactory local analgesia. Due to her difficult airway, it was decided to treat the patient with inhalational sedation, but administered in an operating theatre by a consultant anaesthetist, and teeth were extracted using articaine LA.

FOLLOW-UP

The patient coped well with this treatment, and was discharged home on the same day. Two year follow-up with intensive prevention showed improved oral health, with no new carious lesions detected.

CONCLUSION

This is the first report to our knowledge describing dental extractions in the immediate vicinity of a cystic hygroma. A potential management strategy and the difficulties of conventional methods in such patients are discussed.