Educational intervention in farmers with occupational asthma: long-term effect on exhaled nitric oxide

BACKGROUND

The fraction of exhaled nitric oxide (FE(NO)) has been found reduced 4 to 6 weeks after an educational intervention in farmers with occupational asthma.

OBJECTIVE

To reveal whether long-term changes in FE(NO) would still be detectable a year after the intervention.

METHODS

We evaluated airway inflammation and obstruction at baseline and after 1 year in animal farmers with occupational asthma (n = 43, 16 women, mean [SD] age, 46.5 [8.9] years) who participated in a 1-day educational program, and in a control group of farmers without intervention (n = 15, 3 women, mean age, 44.1 [10.7] years). FE(NO), spirometry results, and questionnaire data were compared between measurements and between the intervention and control group.

RESULTS

In the intervention group, geometric mean (SEM) FE(NO) decreased from 31.5 (1.1) to 25.0 (1.1) parts per billion (ppb) (P = .001), whereas in the control group there was a slight but not statistically significant increase from 27.2 (1.2) to 30.7 (1.2) ppb. Spirometric values remained unchanged in both groups.

CONCLUSIONS

We found that FE(NO) was still decreased 1 year after an educational intervention in farmers with occupational asthma. It would thus seem that FE(NO), a noninvasive marker of airway inflammation that can be easily assessed in occupational field work, may be suitable for the evaluation of both short-term and long-term effects of preventive measures in occupational asthma.

Serum leptin and adiponectin levels and their association with allergic sensitization

BACKGROUND

Obesity and respiratory allergies have increased in parallel in industrialized countries. We have recently shown an association between obesity and allergic sensitization whereby obesity diminished the protective effect of childhood farm contact.

OBJECTIVE

To assess whether taking obesity into account allergic sensitization is associated with adipokine levels in blood and whether this effect is modified by childhood farm contact.

METHODS

Serum samples of 231 adult participants (age 18-45 years) of the Lower Saxony Lung Study were analysed for leptin and adiponectin by ELISA. Subjects were elected to represent equal-sized groups with respect to obesity (<30 vs> or =30 kg/m(2)), childhood farm contact, specific IgE to ubiquitous allergens and sex. Multiple logistic regression models were adjusted for potential confounders.

RESULTS

Leptin levels were positively related to the prevalence of sensitization (highest vs lowest quartile odds ratio 6.7, 95% confidence interval 2.0-22.4). For adiponectin levels, a weak, not statistically significant inverse association with sensitization was shown (highest vs lowest quartile 0.4, 0.2-1.1). The association between leptin and sensitization appeared to be more pronounced in subjects with farm contact; however, the effect modification was not statistically significant.

CONCLUSION

These findings suggest that adipokines might be involved in the causal pathway between obesity and allergic sensitization.

Educational intervention decreases exhaled nitric oxide in farmers with occupational asthma

Allergic occupational asthma is frequent in farming populations. As educational interventions can improve disease management, the short-term effect of an educational intervention in asthmatic farmers was evaluated on the basis of spirometric indices and exhaled nitric oxide fraction (F(eNO)). Farmers with occupational asthma (n = 81), mostly sensitised against cow dander and storage mites, participated in a 1-day educational programme. Outcome measures were assessed at baseline and after 4-6 weeks, using F(eNO), lung function and a questionnaire. Results were compared with those of a control group without intervention (n = 24). In the educational group, the proportion of subjects reporting work-related symptoms was reduced after the intervention. The F(eNO) decreased from a geometric mean of 28.2 to 25.7 ppb, and, in subjects with an elevated (>35 ppb) baseline F(eNO) (n = 32), from 59.7 to 49.2 ppb. The corresponding changes in the control group were 25.6 versus 27.7 ppb and 49.5 versus 48.1 ppb. Spirometric results were unaltered in the two groups. Thus exhaled nitric oxide fraction, a marker of allergic airway inflammation, indicated a beneficial effect of a short-term educational intervention in farmers with occupational asthma. This suggests a potential for exhaled nitric oxide fraction in assessing the efficacy of preventive measures within a short time with higher sensitivity than spirometry.

Impact of noninvasive home ventilation on long-term survival in chronic hypercapnic COPD: a prospective observational study

AIMS

The long-term benefit from noninvasive ventilation (NIV) in chronic hypercapnic chronic obstructive pulmonary disease (COPD) remains uncertain.

METHODS

Within a prospective observational design, we compared the long-term survival of 140 patients with severe persistent hypercapnic COPD (FEV(1) 28.7 +/- 8.7% predicted; PaCO(2) 60.1 +/- 9.2 mmHg) with (n = 99) or without (n = 41) NIV. End-point was all-cause mortality, determined up to 4 years by Kaplan-Meier analysis. Additionally, Cox's proportional hazards regression and stratification by risk factors was performed. Patients were characterised by anthropometric and functional parameters, comorbidities and medical therapy.

RESULTS

Adherence in patients with NIV was high (88.9%), daily ventilator use being 6.4 +/- 2.6 h/day and inspiratory pressures 21.0 +/- 4.0 cmH(2)O. One- and 2-year survival rates were 87.7% and 71.8%, respectively, in patients with NIV vs. 56.7% and 42.0% in patients without NIV. Survival rates were significantly higher in patients with NIV compared to those without this therapy (p = 0.001; hazard ratio 0.380; 95% confidence interval 0.138-0.606). The difference between groups was still significant after adjustment for differences in baseline characteristics. Moreover, stratification by risk factors revealed beneficial effects, particularly in patients with high base excess (BE; > 8.9 mmol/l), low pH (< 7.41), FEV(1) (< 27.5%) haemoglobin (< 13.8 g/dl) or large hyperinflation (residual volume-to-total lung capacity > 189% predicted) upon inclusion (p < 0.05 each).

CONCLUSION

In patients with severe chronic hypercapnic COPD receiving NIV at high inspiratory pressure levels and showing high adherence to this therapy, long-term survival was significantly higher than in non-ventilated patients. Patients displaying more severe disease according to known risk factors seemed to benefit most from long-term NIV.

Efficacy of the combination of fluticasone propionate and salmeterol in patients with moderate persistent asthma within a "real-life" setting

There are only few data on the effectiveness of recommended drug therapies in asthma under "real-life" conditions without targeted intervention. The study aimed at analyzing the efficacy of the fixed combination of the inhaled corticosteroid fluticasone propionate and the long-acting beta2-agonist salmeterol (FS) for maintenance treatment of moderate persistent asthma (GINA stage 3) within an observational design, mimicking "real-life" as closely as possible. The fixed combination was compared with other forms of treatment that were in accordance with treatment guidelines (pooled comparison (PC) group). Patients kept a diary during a 12-month observation period and routine visits were taken for surveillance. Among 596 patients, 371 patients belonged to the FS and 225 patients to the PC group. The proportion of symptom-free days (SFD) was higher in the FS than PC group (median, 76 vs 67%; p=0.002). Furthermore, the change in asthma control score (p<0.0001) and the percent increase in FEV1 (p<0.05) after 12 months were greater. There was a lower percentage of patients with hospital stays (p<0.05). The proportions of episode-free or sick-leave days and the number of routine or emergency visits did not significantly differ between groups. Direct costs of treatment per SFD were lower in the FS than PC group (median, 3.78 vs 4.41 Euro; p<0.05). We conclude that in a setup close to clinical practice treatment of patients with moderate persistent asthma with the fixed combination of fluticasone propionate and salmeterol has beneficial effects compared to other forms of therapy and can improve cost-efficiency.

Mortality and prognostic factors in patients with obesity-hypoventilation syndrome undergoing noninvasive ventilation

OBJECTIVES

The incidence of obesity-hypoventilation syndrome (OHS) has greatly increased over time, but data on long-term outcome are limited. We investigated survival and prognostic factors in these patients undergoing noninvasive positive pressure ventilation (NPPV).

DESIGN

Retrospective descriptive analysis of patients with OHS and NPPV up to 10 years.

METHODS

Long-term mortality and predictors of survival were assessed. Additionally, we evaluated changes in lung function, blood gas and laboratory parameters 5.7 +/- 2.5 months after initiation of NPPV.

RESULTS

126 patients (BMI 44.6 +/- 7.8 kg m(-2); PaCO(2) 55.5 +/- 7.7 mmHg) were followed for 41.3 +/- 27.6 months. Upon follow-up, blood gases (daytime and nighttime), as well as pulmonary function improved, whilst haemoglobin and BMI decreased (P < 0.001 each). Adherence to NPPV was high (94.5% continuing NPPV 6.5 +/- 2.3 h day(-1)). All-cause mortality was 12.7%, with 1-, 2- and 5-year survival of 97.1%, 92.0% and 70.2%, respectively. In univariate analysis, patients with PaO(2) <50 mmHg, C-reactive protein > or = 5.1 mg L(-1), leucocytes > or = 7.8 x 10(3) microl(-1), or pH > or = 7.44 at baseline had poor prognosis (P < 0.05 each). In Cox multivariate analysis, PaO(2), pH and leucocytes were independent predictors of mortality. Reduction in nocturnal PaCO(2) by > or =23.0% and haemoglobin at follow-up was associated with improved survival (P < 0.05 each) whilst a decrease in pH was a predictor of increased mortality. In contrast, neither baseline BMI nor its change was linked to survival.

CONCLUSION

Gas exchange and lung function in OHS were improved after initiation of NPPV. Hypoxemia, high pH and elevated inflammation markers predicted poor survival. Overall, NPPV was well tolerated and survival was excellent when compared with data from historical matched controls.

Nutritional depletion and its relationship to respiratory impairment in patients with chronic respiratory failure due to COPD or restrictive thoracic diseases

OBJECTIVE

While malnutrition, especially fat-free mass index (FFMI), is a predictor for mortality in chronic obstructive pulmonary disease (COPD), less information on prevalence and mechanisms is available in patients with chronic respiratory failure (CRF) due to restrictive thoracic diseases (RTD).

DESIGN AND SETTING

Cross-sectional study of patients consecutively admitted to an in-patient primary pulmonary centre.

SUBJECTS

One hundred and thirty-two patients (30% RTD; 70% COPD) with CRF and intermittent non-invasive positive pressure ventilation.

INTERVENTIONS

Malnutrition was quantified by bioelectrical impedance analysis or body mass index (BMI), and its relationship to laboratory, lung function, inspiratory muscle and blood gas parameters and 6-min walking distance (6-MWD) was assessed.

RESULTS

Malnutrition in terms of BMI<20 kg/m(2) occurred in 16.1% of patients with COPD but none of those with RTD. FFMI<17.4 (<15.0 in female patients) kg/m(2) was found in 35.4 and 30.7%, respectively. FFMI was correlated with airway obstruction (sR(aw), r = -0.50; FEV(1)/VC, r = -0.28; P< or = 0.01 each) and lung hyperinflation (intrathoracic gas volume, r = -0.41; total lung capacity (TLC), r = -0.50; P< or = 0.001 each) in COPD, and with lung restriction in RTD (TLC, r=0.40; P=0.011). Furthermore, malnourished patients showed a higher inspiratory load (P (0.1)) and reduced 6-MWD in both groups. In COPD, only hyperinflation and P (0.1) were independently related to FFMI.

CONCLUSIONS

Malnutrition as indicated by low FFMI was similarly prevalent in patients with CRF and COPD or RTD, but inadequately represented by BMI. The correlations between lung function impairments specific for the disease and FFMI emphasized the link between malnutrition and respiratory mechanical load irrespective of its aetiology.

Cytological diagnosis of malignant mesothelioma—improvement by additional analysis of hyaluronic acid in pleural effusions

Cytology allows the diagnosis of malignant mesothelioma (MM) from effusions with high specificity but low sensitivity. Conversely, elevated levels of hyaluronic acid (HA) in effusions are sensitive indicators of MM, although specificity is insufficient. We studied whether the cytological diagnosis of MM could be improved by HA analysis. HA was analysed in patients with histologically confirmed MM (n=162), adenocarcinoma or other malignant tumours (n=100) and in 90 patients with benign pleural diseases. In 77 out of 162 effusions, all, and in 33 some, cytological criteria of MM were satisfied. The cut-off value of HA showing maximum diagnostic reliability (86%) regarding MM was 30 mg/l (sensitivity 87%, specificity 86%). A HA value of 100 mg/l yielded 39 and 98%, respectively. Seventy three out of 77 patients with cytological findings indicative of MM showed HA levels greater than 30 mg/l as well as 27 of 33 patients with suspicious lesions. These 100 patients were correctly recognised as having MM. The addition of HA analysis to cytology, requiring all or some criteria of MM as positive, increased sensitivity for MM from 48 to 71-91%, whereas specificity only slightly decreased to 94-96%. We conclude that the combined cytological and HA analysis of pleural effusions had the potential to improve the diagnosis of MM.