[Acute airway obstruction during chemotherapy-induced agranulocytosis with fever]

Acute airway obstruction caused by mucoid impaction can cause sometimes life-threatening respiratory distress. Bronchial plugging is usually observed in subjects with chronic diseases such as asthma, allergic bronchopulmonary aspergillosis, or cystic fibrosis. In children, it can be related to heart failure. Acute airway obstruction in a patient without a chronic respiratory disease is exceptional. We report the case of a patient who developed bronchial plugs obstructing the bronchi during a period of agranulocytosis induced by chemotherapy. The patient experienced acute respiratory distress with asphyxia. The plugs were composed of fibrin and required several fibroscopic procedures for clearance. To our knowledge, this is the first case report of acute airway obstruction by plugging during a period of agranulocytosis.

Relation between duration of smoking cessation and bronchial inflammation in COPD

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is associated with airway inflammation. Although smoking cessation improves symptoms and the decline in lung function in COPD, it is unknown whether bronchial inflammation in patients with established COPD varies with the duration of smoking cessation.

METHODS

114 patients (99 men) with COPD of mean (SD) age 62 (8) years, a median (IQR) smoking history of 42 (31-55) pack years, no inhaled or oral corticosteroids, all current or ex-smokers (n = 42, quit >1 month, median cessation duration 3.5 years), post-bronchodilator FEV(1) 63 (9)% predicted, and FEV(1)/IVC 48 (9)% were studied cross sectionally. The numbers of subepithelial T lymphocytes (CD3, CD4, CD8), neutrophils, macrophages, eosinophils, mast cells, and plasma cells were measured in bronchial biopsy specimens (median (IQR)/0.1 mm(2)) using fully automated image analysis.

RESULTS

Ex-smokers with COPD had higher CD3+, CD4+, and plasma cell numbers than current smokers with COPD (149 (88-225) v 108 (61-164), p = 0.036; 58 (32-90) v 40 (25-66), p = 0.023; and 9.0 (5.5-20) v 7.5 (3.1-14), p = 0.044, respectively), but no difference in other inflammatory cells. Short term ex-smokers (<3.5 years) had higher CD4+ and CD8+ cell numbers than current smokers (p = 0.017, p = 0.023; respectively). Conversely, long term ex-smokers (quit > or =3.5 years) had lower CD8+ cell numbers than short term ex-smokers (p = 0.009), lower CD8/CD3 ratios than both current smokers and short-term ex-smokers (p = 0.012, p = 0.003; respectively), and higher plasma cell numbers than current smokers (p = 0.003).

CONCLUSIONS

With longer duration of smoking cessation, CD8 cell numbers decrease and plasma cell numbers increase. This indicates that bronchial T lymphocyte and plasma cell counts, but not other inflammatory cells, are related to duration of smoking cessation in patients with COPD.

[Influence of bronchoscopy on nitric oxide in exhaled air]

Nitric oxide has been extensively studied as a noninvasive marker of airway inflammation, especially in asthma. Assuming, bronchoscopy can produced not only systemic but also local inflammatory response we hypothesized that bronchofiberoscopy can be responsible for an increase in nitric oxide synthesis with resulting increase in fractional concentration of exhaled nitric oxide (FE(NO)). Seventeen subjects (10 M, 7 F), at mean age of 53.8+/-14.1 yrs undergoing diagnostic bronchoscopy participated in the study. The indications for bronchoscopy were as follows: lung cancer (n=5; 29%), interstitial lung diseases (n=3; 18%), slowly resolving pneumonia (n=3; 18%), hemoptysis (n=3; 18%), differential diagnosis of asthma/ dyspnea (n=3; 18%). During bronchoscopy bronchial washing (n=7) and bronchoalveolar lavage (BAL) (n=10) has been performed. FE(NO) has been analyzed on-line with chemiluminescence analyzer (NIOX, Aerocrine, Sweden) according to American Thoracic Society guidelines, before and at 1, 2, 3 and 24 hours after bronchoscopy. Mean FE(NO) before bronchoscopy was 19.7+/-4.5 ppb (mean +/- SEM), post - bronchoscopy a decrease with a nadir at second hour (12.1+/-1.5 ppb, p<0.05) was observed, FE(NO) 24 hours after bronchoscopy was not different than baseline (18.4+/-2.5 ppb). There were no differences in the FE(NO) profile in BAL patients when compared to those in whom only the bronchial washing has been performed.

CONCLUSIONS

Bronchoscopy leads to a significant decrease in exhaled nitric oxide. The underlying mechanisms are unclear. Future studies including analysis of other inflammatory markers are needed to explain these changes.

[Allergic rhinitis. Coexistent diseases and complications. A review and analysis]

Allergic rhinitis (AR) is rarely found in isolation and needs to be considered in the context of systemic allergic disease associated with numerous comorbid disorders, including asthma, chronic middle ear effusions, sinusitis, and lymphoid hypertrophy with obstructive sleep apnea, disordered sleep, and consequent behavioral and educational effects. The coexistence of allergic rhinitis and asthma is complex. First, the diagnosis of asthma may be confused by symptoms of cough caused by rhinitis and postnasal drip. This may lead to either inaccurate diagnosis of asthma or inappropriate assessment of asthma severity with over treatment of the patient. The term "cough variant rhinitis" is therefore proposed to describe rhinitis that manifest itself primarily as cough that results from postnasal drip. Allergic rhinitis, however, has also a causal role in asthma; it appears both to be responsible for exacerbating asthma and to have a role in its pathogenesis. Postnasal drip with nasopharyngeal inflammation leads to a number of other conditions. Thus sinusitis is a frequent extension of rhinitis and is one of the most frequently missed diagnoses. Allergen exposure in the nasopharynx with release of histamine and other mediators can cause Eustachian tube obstruction possibly leading to middle ear effusions. Chronic allergic inflammation of the upper airway causes lymphoid hypertrophy with prominence of adenoidal and tonsillar tissue. This may be associated with poor appetite, poor growth, obstructive sleep apnea, mouth breathing, pharyngeal irritation and dental abnormalities. Allergic rhinitis is therefore part of a spectrum of allergic disorders that can profoundly affect the well being and quality of life of a child. Prospective cohort studies are required to assess the disease burden caused by allergic rhinitis in childhood, its consequences due to delay in diagnosis and treatment, and to further assess the potential educational impairment that may result. Because allergic rhinitis is part of a systemic disease process, its diagnosis and management require a coordinated approach by the specialist in allergy-immunology-rhinology rather than a fragmented, organ based approach. There are other clinical presentations such as recurrent infections of the upper respiratory tract, as well as pharyngeal and laryngeal disorders.

Pseudomembranous and obstructiveAspergillustracheobronchitis - optimal diagnostic strategy and outcome

Pseudomembranous and obstructive Aspergillus tracheobronchitis (PMATB/OATB) are still considered to be refractory to therapy and to have a fatal outcome. To evaluate the optimal diagnostic strategy and to describe factors affecting the outcome of PMATB and OATB. Retrospective analysis of four new cases of PMATB and OATB combined with 16 previously reported cases over a 10-year period (1995-2004). Among the four new cases reported and the 16 published cases, four patients survived their infection. The mortality rate was significantly higher in the group of ventilated patients [94% (15 of 16 patients)] than in the group of non-ventilated patients [25% (1 of 4 patients), P < 0.05, Fisher's exact test]. In all 20 patients, diagnosis was established by bronchoscopy. Culture examination of mucous plugs was positive in 8 of 10, culture of the tracheobronchial aspirate was positive in 8 of 12, and bronchoalveolar lavage was diagnostic in 7 of 13 patients. All bronchoscopic techniques were complementary in improving the yield of bronchoscopy. However, microscopy of mucous plugs and/or necrotic material was the best diagnostic modality [positive in 94% (17 of 18 patients)]. Prognosis of PMATB and OATB remains poor. Microscopy of respiratory specimens is the most sensitive tool to confirm the diagnosis. The characteristic appearance of the disease makes it possible to start antifungal therapy immediately.

Staged bilateral stereotactic pallidothalamotomy for life-threatening dystonia in a child with Hallervorden-Spatz disease

Hallervorden-Spatz disease (HSD) is a rare disorder characterized by progressive motor dysfunction and dementia. Dystonia is the most prominent and disabling symptom, responding only to a modest extent to pharmacological therapy. At the moment, only a few cases have been reported to improve dystonia and even fewer to resolve status dystonicus for a longer period in children. The authors present the case of a 10-year-old boy who had progressive generalized dystonia, resulting in spontaneous femur fracture and life-threatening swallowing and respiratory disability. As a rescue solution, staged bilateral pallidothalamotomy was performed. Postoperatively, Burke-Fahn-Marsden Dystonia Rating Scale and Dystonia Disability Rating Scale improved (from 116 and 30 points to 41 and 18 points, respectively) and painful dystonia was resolved, which was still continuous 4 years later (47 and 20 points). Stereotactic staged bilateral pallidothalamotomy should be considered as a potential treatment in the management of life-threatening generalized dystonia related to HSD.

The incidence of respiratory symptoms and diseases among pulp mill workers with peak exposures to ozone and other irritant gases

OBJECTIVES

Pulp mills in Sweden started to use ozone as a bleaching agent in the early 1990s. The goal of this study was to investigate whether the incidence of selected respiratory outcomes was associated with peak exposures to ozone or other irritant gases (ie, chlorine dioxide [ClO2] or sulfur dioxide [SO2]) used in these mills.

METHODS

Bleachery workers (n = 245) from three pulp mills where ozone was used participated in surveys in the mid- to late-1990s. Comparison workers (n = 80) were from two adjacent paper mills. The person-time at risk was calculated for each participant, covering the period of employment when ozone was used. Data were collected by questionnaire, and a peak exposure was defined as a self-reported exposure to an irritant gas resulting in acute respiratory symptoms. The outcomes analyzed were self-reports of physician-diagnosed asthma, attacks of wheeze, and chronic bronchitis (ie, chronic cough with phlegm). Participants also reported when the peak exposures and outcomes occurred.

RESULTS

Based on proportional hazards regression (controlling for gender, age, cigarette smoking, atopy, and peak irritant exposures that occurred before follow-up), workers who reported both ozone and ClO2/SO2 peak exposures had elevated hazard ratios (HRs) for all three outcomes. Those who reported only ozone peak exposures had elevated HRs of 6.5 (95% confidence interval [CI], 1.2 to 36.3) for asthma and 3.3 (95% CI, 1.1 to 10.2) for attacks of wheeze but no increase in risk for chronic bronchitis. Workers with only ClO2/SO2 peak exposures had elevated HRs for attacks of wheeze (HR, 7.5; 95% CI, 1.9 to 29.3) and chronic bronchitis (HR, 22.9; 95% CI, 4.5 to 118.2) but not for asthma.

CONCLUSIONS

These findings suggest the need for additional efforts to prevent peak exposures in pulp-bleaching operations.

Congenital bronchial atresia (CBA). A critical review of CBA as a disease entity and presentation of a case series

PURPOSE

To analyse the state of the art of diagnostic imaging in the rare disease entity known as congenital bronchial atresia (CBA) and to suggest new guidelines for diagnosis.

MATERIALS AND METHODS

From January 2002 to December 2003 we examined 6 patients, 4 males and 2 females. Four of them complained of relapsing bronchitis; one patient was admitted with a diagnosis of pulmonary abscess. All patients underwent chest X-ray and MDCT.

RESULTS

Five patients presented at chest x-ray the typical association of hilar mass and distal parenchymal hyperinflation that raised the suspicion of CBA; the remaining patient presented an area of parenchymal translucency that prompted us to perform MDCT, which showed severe stenosis of the segmental bronchus. CBA involved the left upper lobe (LUL) in 4 patients and the right upper lobe (RUL) in the remaining 2. In 50% of cases there were associated anomalies: distal bronchiectasis, bronchogenic cyst, anomaly of branching of bronchial tree and vascular structure.

CONCLUSIONS

CBA is a relatively rare, generally oligosymptomatic malformation. Knowledge of the signs present at chest X-ray can prompt the radiologist to perform a CT scan. MDCT with multiplanar reconstruction is fundamental for the characterisation, localisation and study of the distribution of the lesion, helping to make a precise diagnosis. Surgery is seldom required and at any rate only performed in case of complications.

[Basic spirometry measurements in workers on pig farmers]

INTRODUCTION

Many epidemiological and clinical studies have demonstrated an increased risk for the symptoms of respiratory disorders consistent with chronic bronchitis and asthma and alterations of pulmonary function tests in pig farmers.

AIM

The aim of this study was to determine basic pulmonary function values in workers in swine confinement buildings and to compare them with the same values in the control group of unexposed persons. The next aim was to examine the association between these values with duration of professional exposure, cigarette smoking, age, and sex of the examined persons.

METHODS

We randomly selected for examination 145 workers of both sex who had worked for at least 2 previous years in pig farms and spent at least 3 hours per day, 6 days per week in a swine confinement building. The farmers worked at 6 different farms with 12,383 pigs on average on each farms. The subject was eligible for the study if he had had no history of atopic disease nor any serious chronic disease, and no acute respiratory infection within 3 previous months. As control group we examined 156 subjects who had lived and/or worked in the same areas and had had no history of exposure to farming environment or any other known occupational air pollutants. In both groups the study comprised cigarette smokers and persons who had never smoked. Pulmonary function data were collected according to the standard protocol with a Micro Spirometer, (Micro Medical Ltd, England, UK). The registered parameters were FEV1 and FVC. At least three satisfactory forced maximal expirations were performed by each subject and the best value was accepted for analyses. The results were also expressed as a percentage of predicted values and FEV1/FVC x 100 was calculated.

RESULTS

There were no differences in the main demographic characteristics between two examined groups (Table 1). Mean duration of work in pig farming was 11.6 years (SD=8.5; range 2-40). The average values of examined pulmonary function tests are shown in table 2. The values of FEV1 and FVC in each groups were between 92% and 97% of predicted values, and FEV1/FVC x 100 was not lower than 82%. There were no differences in the average values of FEV1 (p=0.574) and FEV1 % predicted (p=0.653) between pig farmers and control subjects. Pearson coefficient of correlation and Spearman nonparametric correlation test revealed a high level of correlation of FEV1 values with sex and age and no correlation of pig farming exposure with cigarette smoking as predictor variables (Table 3). The analysis by linear regression method showed that all examined predictor variables had the effect on the value of FEV1 (Table 4). After the elimination of the two least significant predictor variables it was possible to make the equation for prediction of FEV1 values.

DISCUSSION

In the present study there are no significant alterations in the values of the basic pulmonary function tests in pig farmers. In the majority of previous similar studies the differences in the average values of FEV1 and FVC between pig farmers and control subjects were also not found. However, in some studies the alterations in several more specific lung function parameters were registered. The decreased values of FEV1 during workshift were also found and they are probably connected to the bronchial hyperreactivity registered in many studies in pig farmers. Longer exposure to swine confinement environment caused more decline in FEV1 and FVC and accelerated mean age-related annual decline in FEV1 was observed reaching to 44 ml/yrs more than expected. The correlations between values of FEV1 with pig farming exposure and cigarette smoking in this study were not found. However, the analysis by linear regression method showed that all examined predictor variables had the effect on the value of FEV1. In a few previous bronchoscopic, BAL and sputum studies some signs of inflammation and morphological changes of the respiratory tract were observed. The absence of important alterations in the basic spirometric measures in this and the majority of the previous studies suggests that early airway injuries may not be readily apparent using spirometric measures of lung function.

CONCLUSION

In contrast to other world studies, our study comprised an important number of women farmers, but alterations associated to sex were not found. To assess the lung function in these pig farmers after several years may be of great importance.

Plastic bronchitis; a serious complication of the Fontan operation

Plastic bronchitis is characterised by the formation of large bronchial casts, which develop in the tracheobronchial tree and can cause airway obstruction. It has been increasingly encountered in more recent years as a serious complication of the Fontan operation with a reported mortality of up to 50% [Am. J. Respir. Crit. Care Med. 155 (1997) 364]. We report a case of a 4-year-old girl with Fontan circulation who developed plastic bronchitis and was successfully treated.

Fenestration of the Fontan circuit as treatment for plastic bronchitis

Plastic bronchitis is a rare, potentially life-threatening condition in which protein casts form within and occlude the bronchus, resulting in pulmonary failure, and has been identified as a complication after the Fontan procedure. We present a case of a 5-year-old girl who had undergone an extracardiac fenestrated Fontan repair as a component of staged palliation for tricuspid atresia. Six weeks following surgery, the patient presented with airway obstruction, coughing a bronchial cast. Medical therapies to optimize heart function and attempt to control cast formation were implemented, with little clinical impact. Following cardiac catheterization to stent open the fenestration, the symptoms of plastic bronchitis resolved. Cast expectoration recurred following spontaneous closure of the stented fenestration and again resolved with recreation of the baffle defect. Fenestration of the Fontan circuit alters hemodynamics, thereby providing an additional therapeutic option for this devastating disorder.

IL-8 and airway neutrophilia in children with gastroesophageal reflux and asthma-like symptoms

Gastroesophageal reflux (GER) may induce respiratory symptoms (RS) through inhalation of acid gastric contents. To characterize the airway inflammation associated with this condition, 20 children [7.4 (0.9) yr old] with "difficult to treat" RS and a positive 24-h oesophageal pH monitoring (pHm) were studied and bronchoalveolar lavage (BAL) performed. The control group included 10 children [7.3 (1.3) yr], non-atopics, with a respiratory clinical history similar to the cases but no reflux, as demonstrated by a negative 24-h oesophageal pHm. On BAL samples, in addition to inflammatory indexes, the lipid-laden macrophage (LLM) index was determined as index of gastric content inhalation. As compared to controls, GER children had higher neutrophil proportion (P=0.002), higher LLM index (P=0.004) and higher concentrations of interleukin (IL)-8 (P=0.005), myeloperoxidase (MPO) (P=0.001) and elastase (P=0.045) in BAL fluid. In GER children, but not in controls, neutrophil proportion significantly correlated with LLM index (r=0.65, P=0.002), with IL-8 (r=0.62, P=0.003) and MPO levels (r=0.54, P=0.014) but not with elastase concentrations. These results suggest an active pathogenetic role of IL-8 in the recruitment and activation of neutrophils in the airways of children with GER, respiratory symptoms and BAL findings suggestive of gastric content aspiration.

Inflammatory basis of exercise-induced bronchoconstriction

RATIONALE

Exercise-induced bronchoconstriction (EIB) is a highly prevalent condition with unclear pathogenesis. Two competing theories of the pathogenesis of EIB differ regarding the inflammatory basis of this condition.

OBJECTIVES

Our goals were to establish whether epithelial cell and mast cell activation with release of inflammatory mediators occurs during EIB and how histamine and cysteinyl leukotriene antagonists alter the airway events occurring during EIB.

METHODS

Induced sputum was used to measure mast cell mediators and eicosanoids at baseline and 30 minutes after exercise challenge in 25 individuals with asthma with EIB. In a randomized, double-blind crossover study, the cysteinyl leukotriene antagonist montelukast and antihistamine loratadine or two matched placebos were administered for two doses before exercise challenge.

MAIN RESULTS

The percentage of columnar epithelial cells in induced sputum at baseline was associated with the severity of EIB. After exercise challenge, histamine, tryptase, and cysteinyl leukotrienes significantly increased and prostaglandin E(2) and thromboxane B(2) significantly decreased in the airways, and there was an increase in columnar epithelial cells in the airways. The concentration of columnar epithelial cells was associated with the levels of histamine and cysteinyl leukotrienes in the airways. Treatment with montelukast and loratadine inhibited the release of cysteinyl leukotrienes and histamine into the airways, but did not inhibit the release of columnar epithelial cells into the airways.

CONCLUSIONS

These data indicate that epithelial cells, mast cell mediators, and eicosanoids are released into the airways during EIB, supporting an inflammatory basis for EIB.

Reliability for Grading Acute Rejection and Airway Inflammation After Lung Transplantation

BACKGROUND

The Lung Rejection Study Group (LRSG) created a scheme for grading acute allograft rejection in 1990 and then revised it in 1996, but virtually no studies have evaluated the reliability of this formulation. This investigation assessed the reliability of the current LRSG system by determining inter- and intrareader agreement for grading transbronchial biopsy samples from lung transplant recipients.

METHODS

Biopsy samples from a cohort of 204 recipients were reviewed and classified by a single pathologist who was blinded to original interpretations. The "A" and "B" rejection grades from this contemporary review were compared with original grades by the kappa statistic.

RESULTS

For "A" grading, weighted kappa was 0.65 (95% confidence interval [CI] 0.60-0.70) for interreader agreement (n = 529 specimens) and 0.65 (95% CI 0.53-0.76) for intrareader agreement (n = 97 specimens). For "B" grading, weighted kappa was 0.26 (95% CI 0.14-0.39) for interreader agreement (n = 164 specimens) and 0.33 (95% CI 0.15-0.51) for intrareader agreement (n = 58 specimens).

CONCLUSIONS

On the basis of the analysis of the LRSG scheme, "A" grades exhibit very good reliability, but "B" grades have only fair reliability, and steps to improve this shortcoming should be taken.

Establishment of exposure-response functions of air particulate matter and adverse health outcomes in China and worldwide

OBJECTIVE

To obtain the exposure-response functions that could be used in health-based risk assessment of particulate air pollution in China.

METHODS

Meta analysis was conducted on the literatures on air particulate matter and its adverse health outcomes in China and worldwide.

RESULTS

For each health outcome from morbidity to mortality changes, the relative risks were estimated when the concentration of air particulate matter increased to some certain units.

CONCLUSION

The exposure-response functions recommended here can be further applied to health risk assessment of air particulate matter in China.

Decreased CCAAT/enhancer binding protein transcription factor activity in chronic bronchitis and COPD

BACKGROUND

CCAAT/enhancer binding proteins (C/EBPs) are key regulators of cell differentiation and linked processes such as proliferation, apoptosis, and gene expression in several organs. C/EBPs are also central for inflammatory responses and infectious defenses, but so far little is known of their role in lung diseases. Chronic bronchitis (CB) and COPD are common smoking-associated lung diseases involving the airway epithelium.

METHODS

Gelshifts were used to study C/EBP transcription factor activity in airway epithelial cells obtained by bronchial brush biopsy in four groups: healthy never-smokers (n = 10), asymptomatic smokers (n = 7), and smokers with CB and recurrent infectious exacerbations without COPD (n = 23) and with COPD (n = 13).

RESULTS

C/EBP-binding activity was increased 4.6-fold in airway epithelial cells of healthy smokers compared with never-smokers. In contrast, C/EBP binding activity was not increased in the epithelium of smokers with CB or COPD. C/EBP-beta was the dominant C/EBP in the airway epithelium in all groups.

CONCLUSIONS

We hypothesize that this lack of increase in C/EBP-beta activity renders the epithelium incompetent of efficient regeneration and more sensitive to infection, suggesting a previously unknown role for C/EBPs in the pathogenesis of CB and COPD.

Does ventilator-associated tracheobronchitis need antibiotic treatment?

It is difficult to define ventilator-associated tracheobronchitis (VAT). The most accepted definition includes fever (temperature > 38°C), new or increased sputum production, a microbiologically positive respiratory sample with counts above the accepted thresholds and absence of pulmonary infiltrates on chest X-ray. Although we have no doubt that this pathologic process exists, the main controversy lies on whether this entity has any impact on the outcome and, thus, a specific therapeutic approach is suitable. We will discuss the strengths and drawbacks of the article on this topic published in this issue by Nseir et al.

Fine particulate matter and wheezing illnesses in the first year of life

BACKGROUND

Recent evidence implicates fine particulate matter (PM2.5), principally from vehicular exhaust, as a major cause of increased mortality and morbidity. However, there are limited data on the impact of PM2.5 on infant respiratory illnesses.

METHODS

We conducted a cohort study of 504 infants recruited at 4 months of age from primary health care units in southeastern Santiago, Chile. Project physicians followed infants through the first year of life via monthly check-ups and by appointments on demand. We obtained data for fine particulate matter, sulfur dioxide (SO2), and nitrogen dioxide (NO2) from the governmental monitoring network.

RESULTS

The most frequent diagnosis during follow-up was wheezing bronchitis, occurring 19.5 times per 100 infants per month. After adjusting for sex, socioeconomic level, family history of asthma, minimum temperature, and number of older siblings, we found that an increase of 10 microg/m of PM2.5 24-hour average was related to a 5% increase (95% confidence interval 0-9%) in the risk for wheezing bronchitis (1-day lag). This association was present for different lags, with a maximum observed for a 9-day lag (9%; 6-12%). No consistent association was detected with NO2 or SO2 ambient levels. Lower socioeconomic status and having older siblings were also associated with the risk of wheezing bronchitis. The association of PM2.5 and wheezing bronchitis was stronger among infants with a family history of asthma than among infants without.

CONCLUSIONS

Air pollution in the form of fine particulates, mostly from vehicular exhaust, may adversely affect infants' respiratory health with potential for chronic effects later in life.

[Plastic bronchitis. A case report and review of the literature]

Plastic bronchitis is a rare complication in which bronchial casts of lymphatic origin develop in the tracheobronchial tree and cause airway obstruction. The main feature is expectoration of bronchial casts. This condition usually occurs in the postoperative period after the Fontan operation for congenital heart disease. Treatment modalities include mucolytics and chest physiotherapy, and in the most severe cases bronchoscopy to remove the casts and aerosolized urokinase or r-TPA. We describe a 12-year-old boy with pulmonary atresia with intact ventricular septum and severely hypoplastic right ventricle who underwent a modified Fontan operation at the age of 7 years. At the age of 12 years the patient started to present frequent episodes of coughing, dyspnea, and desaturation followed by difficult emission of white bronchial casts. An extracardiac Fontan conversion was performed to improve hemodynamics and symptoms. During the postoperative period frequent episodes of airway obstruction required bronchoscopy and finally improved with administration of aerosolized urokinase.

Effect of ventilator-associated tracheobronchitis on outcome in patients without chronic respiratory failure: a case-control study

Introduction

Our objective was to determine the effect of ventilator-associated tracheobronchitis (VAT) on outcome in patients without chronic respiratory failure.

Methods

This was a retrospective observational matched study, conducted in a 30-bed intensive care unit (ICU). All immunocompetent, nontrauma, ventilated patients without chronic respiratory failure admitted over a 6.5-year period were included. Data were collected prospectively. Patients with nosocomial pneumonia, either before or after VAT, were excluded. Only first episodes of VAT occurring more than 48 hours after initiation of mechanical ventilation were studied. Six criteria were used to match cases with controls, including duration of mechanical ventilation before VAT. Cases were compared with controls using McNemar's test and Wilcoxon signed-rank test for qualitative and quantitative variables, respectively. Variables associated with a duration of mechanical ventilation longer than median were identified using univariate and multivariate analyses.

Results

Using the six criteria, it was possible to match 55 (87%) of the VAT patients (cases) with non-VAT patients (controls). Pseudomonas aeruginosa was the most frequently isolated bacteria (34%). Although mortality rates were similar between cases and controls (29% versus 36%; P = 0.29), the median duration of mechanical ventilation (17 days [range 3–95 days] versus 8 [3–61 days]; P < 0.001) and ICU stay (24 days [range 5–95 days] versus 12 [4–74] days; P < 0.001) were longer in cases than in controls. Renal failure (odds ratio [OR] = 4.9, 95% confidence interval [CI] = 1.6–14.6; P = 0.004), tracheostomy (OR = 4, 95% CI = 1.1–14.5; P = 0.032), and VAT (OR = 3.5, 95% CI = 1.5–8.3; P = 0.004) were independently associated with duration of mechanical ventilation longer than median.

Conclusion

VAT is associated with longer durations of mechanical ventilation and ICU stay in patients not suffering from chronic respiratory failure.

Mild dehydration: a risk factor of broncho-pulmonary disorders?

Several expert committees recommend a high fluid intake in patients with chronic bronchitis and asthma. Is there a relationship between fluid intake or hydration status and broncho-pulmonary disorders like bronchitis and asthma? First, basic physiologic mechanisms like regulation of lung fluid balance and water transport at pulmonary surfaces were analyzed, in order to characterize the role of local hydration status in lung and airways. Second, making use of the computer-based literature searches (PubMed), evidence for a role of hydration status in complex physiological and pathophysiological conditions of lungs and airways like perinatal lung adaptation (PLA) (in prematures), mucociliary clearance(MC) and asthma was categorized. The movement of fluid between the airspaces, interstitium, and vascular compartments in the lungs plays an important physiological role in the maintenance of hydration and protection of the lung epithelium and significantly contributes to a proper airway clearance. PLA is characterized by a rapid change from fluid secretion to fluid absorption in the distal respiratory tract, with the literature data confirming a critical role of the epithelial sodium channel. Only few studies have investigated the effect of different fluid input regimens on PLA in prematures. MC relies on the interaction between epithelial water fluxes, mucus secretions, and ciliary activity. Whereas animal data show that drying of the airway epithelium decreases MC, few clinical studies investigating the effect of local or systemic hydration on MC have led to ambiguous results. Asthma (A) is characterized by chronic airway inflammation and episodic airway obstruction. Data in animals and humans indicate an association between exercise-induced-A and conditioning (humidity and heat exchange) of inspired air. However, epidemiological studies (children and adults), investigating the role of fluid (and salt) input in the etiology of the disease as well as studies analyzing different markers of hydration status during asthmatic attacks have so far led to conflicting results. Some expert groups recommend sufficient hydration as a complementary A-therapy. Analysis of basic physiological mechanisms in lungs and airways clearly demonstrates a critical role for water transport and local hydration status. In broncho-pulmonary diseases, however, analysis of the complex pathophysiological mechanisms is difficult. Thus, we still need more studies to confirm or refute mild dehydration or hypohydration as a risk factor of broncho-pulmonary disorders.

[Outdoor risk factors and adverse effects on respiratory health in childhood]

Several epidemiological studies have provided evidence that exposure to auto vehicular traffic increases the prevalence of bronchitis, cough and deficits in lung function and may exacerbate pre-existing asthma, especially in children. The aim of this study was to investigate the role of road traffic pollution on respiratory health in a large sample of Italian school children. Eighteen percent of the SIDRIA-2 sample reported high traffic density in the zone of residence; 60% and 20% of subjects reported a very frequent transit of cars and lorries, respectively on the street of residence. High frequency of lorry traffic in the street of residence was associated with significantly increased risks for chronic cough or phlegm and sinusitis symptoms. These results, confirming previous findings (SIDRIA, 1994-95), show that children living near streets with intense traffic of heavy vehicles are at higher risk for adverse respiratory effects, especially for productive cough.

[Parental smoking and respiratory disorders in childhood]

The present study shows associations between parental smoking and respiratory diseases in Italian children and adolescents participating in SIDRIA-2. We studied associations (odds ratios, ORs, and 95% confidence intervals, 95% CI) between exposure to mothers smoking fathers smoking, both parents' smoking, and three categories of cases: current asthma, current asthmatic symptoms, chronic bronchitis. At least one parent smoker was associated with a greater risk for asthmatic diseases compared to subjects not exposed. Our findings are in agreement with other published studies' results on the adverse effect of passive smoking on childhood respiratory health. The proportion of families with at least one parent smoker is very high (about 50%), confirming that measures aimed to reduce passive smoking in the community, and particularly in all places where children are present, are urgently needed in Italy.

[Effects of comprehensive interventions in community on smoking, chronic bronchitis, and asthma in rural areas of Beijing]

OBJECTIVE

To study the effects of comprehensive interventions in community on smoking, chronic bronchitis, and asthma in rural areas of Beijing.

METHODS

Twenty-three villages in rural areas of Beijing were randomly divided into interventional (13 villages) and control villages (10 villages) in 1992. Comprehensive interventions including education of former-smokers and improvement of living environment were carried out in the interventional villages, and none was done in the control villages. In April 2000, surveys on smoking, chronic bronchitis, and asthma were carried out among 34,436 participants aged 15 or more in the interventional and control villages. During the same period, knowledge on prevention from chronic obstructive pulmonary diseases (COPD), living environments, and smoking were assessed among 1658 high-risk individuals of COPD at baseline and following-up period.

RESULTS

The scores of knowledge and improvement on living environments in the interventional villages were significantly higher than those in control villages (P < 0.001). The decrease rate of smoking and current smoking rate in the interventional villages were significantly higher than in the control villages (0.4% vs -0.8%, P < 0.001; 2.4% vs 1.3%, P < 0.001) in men, while not different in women (P > 0.05). Among never smokers at baseline, the accumulated incidence of smoking among people aged 15 to 24 from 1993 to 2000 was significantly lower in the interventional villages than in the control villages in men (18.9% vs 23.7%, P = 0.005) and in women (0% vs 0.7%, P = 0.005). Daily cigarettes smoked by smokers in the interventional villages were less than in control villages in both men (14.8 +/- 7.0 vs 17.2 +/- 8.2 cigs daily, P < 0.001) and women (12.8 +/- 6.9 vs 13.4 +/- 7.2 cigs daily, P = 0.088). The increase of prevalence of chronic bronchitis in the interventional villages was less than in the control villages (men: 0.9% vs 1.3%, P = 0.012; women: 0.1% vs 0.3%, P = 0.003). After the age factor is adjusted, odds ratio (OR) for accumulated incidence of chronic bronchitis from 1993 to 2000 in the interventional villages were 0.80 (95%CI: 0.60-1.07) for men, 0.76 (95%CI: 0.45-1.28) in women. The OR for asthma was not significant in both men and women.

CONCLUSIONS

Comprehensive interventions in community may improve knowledge of COPD prevention and living environments, decrease the smoking rate, cigarettes smoked per day, and incidence of chronic bronchitis, but have no significant effects on asthma.

[Algorithm of preoperative preparation in surgical treatment of lung echinococcus complicated by a rupture into the bronchus]

The clinical material includes 10 years of observations of 289 patients with lung echinococcosis complicated by a rupture into the bronchus. Different operative interventions were performed in 278 cases. The indications for operation, their volume and preoperative preparation were based on clinico-rentgenological signs and divided into 4 groups: 1 - patients with a rentgenological sign of the folded chitin membrane, or a ring-shaped shadow; 2 - patients with non-homogeneous complicated cysts; 3 - patients with "floating chitin membrane"; 4 patients with a rupture of the cyst into the bronchus and pleural cavity simultaneously. The third group patients needed more intensive preoperative preparation while the fourth group patients had an indication to urgent drainage of the pleural cavity or urgent operations in the absence of the purulent discharge from the drains. So, the proposed algorithm of the preoperative preparation of lung echinococcosis patients complicated by a rupture into the bronchus facilitates the improvement of the management of this category of patients.

Safety Issues Concerning the Medical Use of Cannabis and Cannabinoids

Safety issues are a major barrier to the use of cannabis and cannabinoid medications for clinical purposes. Information on the safety of herbal cannabis may be derived from studies of recreational cannabis use, but cannabis exposure and effects may differ widely between medical and recreational cannabis users. Standardized, quality-controlled cannabinoid products are available in Canada, and safety profiles of approved medications are available through the Canadian formulary. In the present article, the evidence behind major safety issues related to cannabis use is summarized, with the aim of promoting informed dialogue between physicians and patients in whom cannabinoid therapy is being considered. Caution is advised in interpreting these data, because clinical experience with cannabinoid use is in the early stages. There is a need for long-term safety monitoring of patients using cannabinoids for a wide variety of conditions, to further guide therapeutic decisions and public policy.

Inflammatory events in severe acute asthma

Severe acute asthma can be induced by different triggers, allergens, irritants, viruses, etc., which induce inflammation and provoke acute bronchoconstriction. Inflammatory cells, such as activated eosinophils and neutrophils identified in sputum and bronchial lavages (BL) in severe acute asthma from children and adults are associated with increased levels of IL-5, IL-8, and of proinflammatory mediators. Viruses, but also endotoxin or allergen exposure, are able to recruit neutrophils, via an IL-8 production by activated macrophages or epithelial cells. Together, these inflammatory mediators are responsible for the diffuse bronchial inflammation, which involve large and small airways. Activated T cells may also be related to the pathogenesis of severe asthma. An aberrant CD8+ T lymphocyte response in bronchi, with a cytotoxic activity has been associated with fatal asthma. Moreover, the persistence of inflammatory cells in bronchi, particularly neutrophils, which respond poorly to corticosteroids, could be in part responsible for the epithelial damage, the extensive mucus plugging, and the abnormalities of epithelial and endothelial permeability which are associated with severe acute asthma. Further studies are necessary to better identify the implication of this increased bronchial permeability in the persistence of high levels of airway resistance, particularly in patients with status asthmaticus.

Changes in cellular and biochemical profiles of induced sputum after allergen-induced asthmatic response: method for studying occupational allergic airway inflammation

OBJECTIVES

The purpose of the study was to analyze morphological and biochemical changes in induced sputum after the provocation with occupational allergens (mixture of flours and grains) in subjects with diagnosed occupational asthma.

MATERIALS AND METHODS

Subjects with occupational asthma and healthy volunteers had physical examination, skin prick tests with common and occupational allergens, and spirometry. Specific IgE against common and occupational allergens was also measured. Bronchial inflammation was characterized by the percentage of cells, levels of eosinophil cationic protein (ECP), and changes in mucosal permeability index.

RESULTS

There was a significant increase in the proportion of eosinophils, basophils, lymphocytes, and in the ECP level in induced sputum of occupational allergics after the specific provocation.

CONCLUSION

Sputum induction is a reliable method for measuring allergen-induced airway inflammation.

[Effectiveness of treatment of bronchoobstruction in children with acute respiratory infections using home-made spacer]

A metered-dose inhaler (MDI) with spacer is the best way to deliver bronchodilator therapy for treatment of bronchoobstructive syndrome, especially in children. In developing countries, commercially produced spacers are generally unavailable or are too costly. Hence, a home-made spacer modified from a 500 ml plastic bottle, was compared with imported spacer (AeroChamber) in 80 children with spastic bronchitis. Clinical score, PEF and oximetry were recorded at baseline and 15 min after treatment. A beta-2- agonist (Ventolin) was given via MDI and two spacers (home-made and conventional spacers). PEF and oxygen saturation were significantly increased at 15 min after administration of the ventolin in both groups. No significant difference was observed between Aerochamber and the home-made spacer. In conclusion, ventolin delivered by MDI with AeroChamber was as effective in bronchodilatation as MDI with home-made spacer. The home-made spacer therefore offers a simple, inexpensive and effective method for delivering aerosol drug.

Supplementary oxygen in healthy subjects and those with COPD increases oxidative stress and airway inflammation

BACKGROUND

Hyperoxia increases oxidative stress through the generation of reactive oxygen species and may therefore enhance inflammation in the lungs. The aim of this study was to investigate whether short term supplementary oxygen (28%) increases oxidative stress and inflammation in the airways by measuring 8-isoprostane and interleukin 6 (IL-6) concentrations in exhaled breath condensate.

METHODS

Twenty three healthy subjects (12 men, mean (SD) age 48 (7) years) and 23 patients with chronic obstructive pulmonary disease (COPD; 15 men, mean (SD) age 56 (5) years) were studied. 8-isoprostane and IL-6 concentrations were measured by immunoassay.

RESULTS

Increased concentrations of 8-isoprostane and IL-6 were found in all subjects after breathing 28% oxygen for 1 hour. In healthy subjects the concentrations of 8-isoprostane and IL-6 were 10.9 (2.9) pg/ml and 4.9 (0.8) pg/ml, respectively, compared with baseline concentrations of 6.1 (1.3) pg/ml and 2.9 (0.6) pg/ml, and in patients with COPD the concentrations were 27.9 (3.1) pg/ml and 8.3 (1.2) pg/ml), respectively, compared with baseline concentrations of 18.9 (3.6) pg/ml and 6.3 (0.6) pg/ml. By contrast, breathing air through the same face mask for 1 hour had no significant effects on 8-isoprostane or IL-6 concentrations in normal subjects or those with COPD.

CONCLUSIONS

These findings suggest that short term supplementary oxygen may enhance oxidative stress and inflammation in the airways. Whether this happens with long term oxygen therapy needs to be determined.

Eosinophilic bronchitis in the workplace

PURPOSE OF REVIEW

The purpose of this review is to report that eosinophilic bronchitis without asthma may occur as an occupational airway disease. This condition is characterized by cough that is responsive to corticosteroids and eosinophilia detectable in the sputum, without variable airflow obstruction or airway hyperresponsiveness.

RECENT FINDINGS

Eosinophilic bronchitis can be regarded as an occupational respiratory disorder when it develops as a consequence of work exposures. Recently, exposure to certain occupational allergens or sensitizers, such as natural rubber latex, mushroom spores, acrylates and an epoxy resin hardener, have been reported to cause eosinophilic bronchitis without asthma. Several hypotheses have been put forward trying to explain why patients with eosinophilic bronchitis do not have airway hyperresponsiveness. It is unknown whether eosinophilic bronchitis may progress to typical occupational asthma, or if eosinophilic airway inflammation may persist when asthma symptoms and airway hyperresponsiveness have waned after the cessation of exposure to the occupational agent.

SUMMARY

Eosinophilic bronchitis, like asthma, may arise from occupational exposures. The examination of induced sputum should be added to the objective monitoring of lung function during periods at work and away from work, as well as before and after specific inhalation challenges with occupational agents.

Respiratory effects in workers processing dried tobacco leaves

OBJECTIVES

The aim of this study was to examine the pollution level of the occupational environment and to investigate the effects of occupational exposure to tobacco dust on the respiratory system of tobacco workers. No such study has previously been conducted in Greece, which is one of the main tobacco-producing countries.

METHODS

A total of 1,020 seasonal and permanent tobacco workers (188 men and 832 women) were studied in a factory in Thessaloniki. The study included: 1) completion of a questionnaire (British Medical Research Council 1986), 2) spirometry and 3) rhinomanometry. At the same time, tobacco dust levels in the working environment were measured. As controls, 469 workers (87 men and 382 women) at a Thessaloniki hospital were used. Seventy six workers with nasal symptoms underwent: 1) special nasal provocation test with tobacco dust antigen, 2) skin prick tests, and 3) measurement of total IgE, specific IgE and specific IgG against tobacco protein.

RESULTS

Very high levels of total suspended dust were found in work site air (45.3-54.4 mg/m3). The prevalence of chronic bronchitis was 8.7 % versus 20.6 % in controls. Chronic obstructive pulmonary disease was found in 13 workers (1.3 %) and in 16 controls (3.4 %). FEV1 %pred, FVC %pred and the FEV1/FVC ratio were lower in controls, whereas FEF25-75 % %pred was lower in workers. There were no workers with bronchial asthma or extrinsic allergic alveolitis. Rhinitis was reported by 27.3 % of the workers versus 17.9 % of controls, whereas nasal flows were 563+/-211 versus 645 +/- 321 ml/sec, respectively. According to the results of skin prick tests, six workers were sensitized to dried tobacco leaf dust.

CONCLUSIONS

The results of our study do not support an association between the development of chronic diseases of the lower respiratory system and pollutants associated with the processing of dried tobacco leaves. In contrast, an association between disorders of the upper airways and tobacco dust in work sites is postulated.

Airway inflammation in aluminium potroom asthma

AIMS

To examine whether asthma induced by exposure to aluminium potroom emissions (potroom asthma) is associated with inflammatory changes in the airways.

METHODS

Bronchial biopsy specimens from 20 asthmatic workers (8 non-smokers and 12 smokers), 15 healthy workers (8 non-smokers and 7 smokers), and 10 non-exposed controls (all non-smokers) were analysed. Immunohistofluorescent staining was performed to identify mucosal total leucocytes (CD45+ leucocytes), neutrophils, and mast cells.

RESULTS

Median RBM thickness was significantly increased in both asthmatic workers (8.2 microm) and healthy workers (7.4 microm) compared to non-exposed controls (6.7 microm). Non-smoking asthmatic workers had significantly increased median density of lamina propria CD45+ leucocytes (1519 cells/mm2 v 660 and 887 cells/mm2) and eosinophils (27 cells/mm2 v 10 and 3 cells/mm2) and significantly increased concentrations of exhaled NO (18.1 ppb v 6.5 and 5.1 ppb) compared to non-smoking healthy workers and non-exposed controls. Leucocyte counts and exhaled NO concentrations varied with smoking habits and fewer leucocytes were observed in asthmatic smokers than in non-smokers Asthmatic smokers had significantly increased numbers of eosinophils in lamina propria compared to non-exposed controls (10 v 3 cells/mm2). Both eosinophilic and non-eosinophilic phenotypes of asthma were recognised in the potroom workers and signs of airway inflammation were also observed in healthy workers.

CONCLUSIONS

Airway inflammation is a central feature of potroom asthma and exposure to potroom emissions induces pathological alterations similar to those described in other types of asthma. Cigarette smoking seems to affect the underlying mechanisms involved in asthma, as the cellular composition of airway mucosa appears different in asthmatic smokers and non-smokers.

Unusual absence of neurologic symptoms in a six-year old girl with ataxia-telangiectasia

Ataxia-telangiectasia (A-T) is a rare multisystem, neurodegenerative genetic disorder. We present a case of a 6-year-old girl who had a history of frequent respiratory infections and also had ocular and immunological features of this syndrome. The absence of neurological symptoms, which is very unusual for a patient of this age, raised many difficulties in the diagnosis of the disease. It is concluded that a normal neurological assessment must not exclude the diagnosis of A-T and delay the proper interventional measures.

[Acute myeloid leukemia with Aspergillus tracheobronchitis after allogeneic peripheral blood stem cell transplant]

A 51-year-old female with acute myeloid leukemia was admitted to our hospital in December 2001. Though she had undergone two courses of induction chemotherapy (idarubicin hydrochloride + cytarabine), she failed to achieve a complete remission. In April 2002, while in non-complete remission, she subsequently underwent total body irradiation (TBI) and treatment with cyclophosphamide (CY) and etoposide (VP-16) before receiving an allogeneic peripheral blood stem cell transplant from her HLA-identical brother. For graft-versus-host disease (GVHD) prophylaxis, she was given tacrolimus and methotrexate. The infused CD34 positive cells provided 8.1 x 10(6) cells per kg. Engraftment was obtained on post-transplant day 14, and there was no evidence of clinical acute GVHD. The use of tacrolimus was discontinued on post-transplant day 60. As there was no occurrence of clinical acute GVHD, the patient received a donor lymphocyte infusion (CD3 cells 0.57 X 10(7) cells per kg) on post-transplant day 105. On day 132, however, she complained of coughing and fever, and on day 135, she was admitted to our hospital again for dyspnea. A CT scan demonstrated ground-glass opacity in the right pulmonary lobe. After considering her clinical course, symptoms, blood gas, CT scans, etc., we suspected interstitial pneumonia. The dyspnea progressively worsened, however, and despite the use of mechanical ventilation from day 143, the patient died on day 149. From the day she was admitted till the day she was intubated, she was unable to produce sputum. Autopsy findings revealed yellow-white tracheal pseudomembranes, as well as Aspergillus hyphae in the trachea, bronchus, and bilateral lungs. These findings are characteristic of Aspergillus tracheobronchitis. The clinical course of Aspergillus tracheobronchitis in allogeneic stem cell transplant recipients is, however, different from that of the usual invasive Aspergillus infection, and although Aspergillus tracheobronchitis is a very rare disease, attention should be paid to the possibility of its occurrence.

Acute effects of cigarette smoke on inflammation and oxidative stress: a review

Compared with the effects of chronic smoke exposure on lung function and airway inflammation, there are few data on the acute effects of smoking. A review of the literature identified 123 studies investigating the acute effects of cigarette smoking on inflammation and oxidative stress in human, animal, and in vitro models. An acute smoking model is a relatively easy and sensitive method of investigating the specific effects of cigarette smoke on oxidative stress and inflammation. Acute smoke exposure can result in tissue damage, as suggested by increased products of lipid peroxidation and degradation products of extracellular matrix proteins. Acute cigarette smoke has a suppressive effect on the number of eosinophils and several inflammatory cytokines, possibly due to the anti-inflammatory effect of carbon monoxide. An acute smoking model can supplement other ways of studying the effects of smoking and is an as yet underinvestigated method for intervention studies in smoking related diseases.

The association between occupational factors and adverse health outcomes in chronic obstructive pulmonary disease

BACKGROUND AND AIMS

Despite recognition that occupational exposures may make a substantive contribution to the aetiology of COPD, little is known about the potential role of work related factors in COPD related health outcomes.

METHODS

Prospective cohort study using structured telephone interviews among a random sample of adults aged 55-75 reporting a COPD condition (emphysema, chronic bronchitis, or COPD). Using multivariate models adjusting for smoking and demographic factors, the separate and combined associations were estimated between occupational exposure to vapours, gas, dust, or fumes (VGDF) and leaving work due to lung disease (respiratory related work disability) with health outcomes and utilisation ascertained at one year follow up.

RESULTS

Of 234 subjects, 128 (55%) reported exposure to VGDF on their longest held jobs, 58 (25%) reported respiratory related work disability, and 38 (16%) subjects reported both. Combined exposure to VGDF and respiratory related work disability (rather than either factor alone) was associated with the greatest risk at follow up of frequent (everyday) restricted activity days attributed to a breathing or lung condition (OR 3.8; 95% CI 1.4 to 10.1), emergency department (ED) visit (OR 3.9; 95% CI 1.4 to 10.5), and hospitalisation (OR 7.6; 95% CI 1.8 to 32).

CONCLUSIONS

Among persons with COPD, past occupational exposures and work disability attributed to lung disease, particularly in combination, appear to be risk factors for adverse health related outcomes.

The influence of active and passive smoking on habitual snoring

The impact of active smoking, passive smoking, and obesity on habitual snoring in the population is mainly unknown. We aimed to study the relationship of habitual snoring with active and passive tobacco smoking in a population-based sample. A total of 15,555 of 21,802 (71%) randomly selected men and women aged 25-54 years from Iceland, Estonia, Denmark, Norway, and Sweden answered a postal questionnaire. Habitual snoring, defined as loud and disturbing snoring at least 3 nights a week, was more prevalent among current smokers (24.0%, p < 0.0001) and ex-smokers (20.3%, p < 0.0001) than in never-smokers (13.7%). Snoring was also more prevalent in never-smokers exposed to passive smoking at home on a daily basis than in never-smokers without this exposure (19.8% vs. 13.3%, p < 0.0001). The frequency of habitual snoring increased with the amount of tobacco smoked. Active smoking and passive smoking were related to snoring, independent of obesity, sex, center, and age. Ever smoking accounted for 17.1% of the attributable risk of habitual snoring, obesity (body mass index > or = 30 kg/m(2)) for 4.3%, and passive smoking for 2.2%. Smoking, both current and ex-smoking, is a major contributor to habitual snoring in the general population. Passive smoking is a previously unrecognized risk factor for snoring among adults.

Extraesophageal manifestations of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) may manifest as laryngitis, asthma, cough, or noncardiac chest pain. Diagnosing these extraesophageal manifestations may be difficult for primary care physicians because most patients do not have heartburn or regurgitation. Diagnostic tests have low specificity, and a cause-and-effect association between GERD and extraesophageal symptoms is difficult to establish. Response to aggressive acid suppression is often the best indication of GERD etiology in a patient with extraesophageal symptoms.