Management of community-acquired pneumonia by trained family general practitioners

SETTING

Community-acquired pneumonia (CAP) is a respiratory health disease with a high prevalence in the general population. Family general practitioners (GPs) can play an important role in CAP management by reducing unnecessary hospital admissions and, consequently, national health costs.

OBJECTIVE

To assess CAP management by trained GPs.

DESIGN

A course in CAP management, including a risk classification method based only on clinical criteria, was developed within the framework of an educational programme. GPs who participated in the programme (n = 220) were asked to collect data on their CAP patients.

RESULTS

GPs (n = 94, response rate 42.7%) provided information on 370 patients (50% males, aged 18-93 years). The numbers of patients judged to be at low, moderate and high risk were 81%, 13% and 6%, respectively. The admission rate was 19.5%. All home-treated patients had good clinical outcomes. Home treatment was based on quinolones (62%), beta-lactams (23%) and macrolides (15%). The attributable economic mean cost of antibiotic home treatment was euro 96 per episode (standard deviation 71, range 17-445).

CONCLUSIONS

The good outcomes suggest that GPs managed their CAP patients well, adhering to the content of the CAP management course. The risk evaluation of patients admitted to hospital, based exclusively on clinical elements, was consistent with more complex classification.

Association between markers of emphysema and more severe chronic obstructive pulmonary disease

BACKGROUND

The predominant emphysema phenotype is associated with more severe airflow limitation in patients with chronic obstructive pulmonary disease (COPD). A study was undertaken to investigate whether COPD patients, with or without emphysema quantitatively confirmed by high resolution computed tomography (HRCT), have different COPD severity as assessed by the BODE index (body mass index, airflow obstruction, dyspnoea, exercise performance) and inspiratory capacity to total lung capacity ratio (IC/TLC), and by different biological markers of lung parenchymal destruction.

METHODS

Twenty six outpatients with COPD and eight healthy non-smokers were examined. Each subject underwent HRCT scanning, pulmonary function tests, cell counts, and measurements of neutrophil elastase, matrix metalloproteinase (MMP)-9 and tissue inhibitor of metalloproteinase (TIMP)-1 in induced sputum, as well as measurement of desmosine, a marker of elastin degradation in urine, plasma and sputum.

RESULTS

Patients with HRCT confirmed emphysema had a higher BODE index and lower IC/TLC ratio than subjects without HRCT confirmed emphysema and controls. Forced expiratory volume in 1 second (FEV(1)), FEV(1)/forced vital capacity ratio, and carbon monoxide transfer coefficient were lower, whereas the number of eosinophils, MMP-9, and the MMP-9/TIMP-1 ratio in sputum were higher in patients with emphysema. In COPD patients the number of sputum eosinophils was the biological variable that correlated positively with the HRCT score of emphysema (p = 0.04).

CONCLUSIONS

These results suggest that COPD associated with HRCT confirmed emphysema is characterised by more severe lung function impairment, more intense airway inflammation and, possibly, more serious systemic dysfunction than COPD not associated with HRCT confirmed emphysema.

[Occupational exposure to respiratory irritants and chronic obstructive pulmonary disease]

Cigarette smoking and occupational exposure to respiratory irritants are the major riskfactors for chronic obstructive pulmonary disease (COPD), which is characterized by small-airway obstruction and destruction of pulmonary parenchyma: emphysema. We studied two groups of subjects: one exposed and the other one not-exposed to respiratory irritants, to investigate the relationship, if any, between occupational exposure and COPD. Subjects underwent high-resolution computed tomography-density mask of the chest to quantify pulmonary emphysema, pulmonary function tests, sputum induction and analysis for cell counts and measurements of metalloproteinase (MMP)-9 and its tissue inhibitor TIMP-1. Subjects with occupational exposure to respiratory irritants had higher residual volume and functional residual capacity, higher total inflammatory cells and neutrophils in induced sputum. By contrast, sputum levels of MMP-9, TIMP-1 and MMP-91TIMP-1 ratio did not differ between the 2 groups. We conclude that sputum induction and analysis could be a useful and non-invasive tool to study and follow subjects with occupational exposure to respiratory irritants.

Quality of generated diagnosis related groups in Italian Respiratory Intermediate Care Units

BACKGROUND

To date we lack official data on tipology of Diagnosis Related Groups (DRGs) and their quality in Italian Respiratory Intermediate Care Units (RICUs).

AIM

The objective of the study was to collect data on the activity of 26 Italian RICUs and to evaluate the quality of the DRGs generated.

METHODS

The primary and secondary diseases, the procedures carried out and their coding using the ICD9 system (valid Italy until 2000) were collected from the discharge forms of patients admitted to RICUs. To obtain the DRG, these codes were automatically recoded in the ICD9-CM classification system by Grouper 10. Afterwards, the same diseases and procedures were directly processed by the ICD9-CM classification system. Finally, in order to evaluate the quality of care, the DRGs generated by the ICD9 classification system were compared to DRGs generated by the ICD9-CM classification system.

RESULTS

The average weight of the patients cared for in an Italian RICU was 2.05 using the ICD9 classification system and 2.53 using the ICD9-CM classification system. Some non-complicated DRGs (80-97) or non specific DRGs (101-102) were set to zero; others, like DRG 87 appear due to the ability of the ICD9-CM classification system to recognise and accept the fifth digit of the Respiratory Failure code (518.81). The difference in terms of DRG scores generated by the two codification systems was 360.5 DRG points in favour of ICD9-CM. More than 1 million Euro of reimbursements have been lost, as the average national reimbursement for each DRG score is Euro 2,943.80.

CONCLUSION

Severe pulmonary diseases determined the case mix of patients cared for in the Italian RICUs during the observed period. The Italian RICUs offer high quality assistance and are characterised by high mean weight per treated patient. However, the activity has been under-estimated due to the low sensitivity of the ICD9 classification system used in the recognition of the real disease and in the correct generation of relative DRG. The ICD9 classification system penalised the recognition of respiratory failure in particular.

Is it possible to predict the success of non-invasive positive pressure ventilation in acute respiratory failure due to COPD?

There is now sufficient evidence that non-invasive positive pressure ventilation (NIPPV) in selected patients with severe hypercapnic acute respiratory failure due to chronic obstructive pulmonary disease (COPD) is more effective than pharmacological therapy alone. The aim of this study was to identify prognostic factors to predict the success of this technique. Fifty-nine consecutive patients with COPD admitted to a respiratory ward for 75 episodes of acute respiratory failure treated with NIPPV were analysed: success (77%) or failure (23%) were evaluated by survival and the need for endotracheal intubation. There were no significant differences in age, sex, cause of relapse and lung function tests between the two groups. Patients in whom NIPPV was unsuccessful were significantly underweight, had an higher Acute Physiology and Chronic Health Evaluation (APACHE) II score, and a lower serum level of albumin in comparison with those in whom NIPPV was successful. They demonstrated significantly greater abnormalities in pH and PaCO2 at baseline and after 2h of NIPPV. The logistic regression analysis demonstrated that, when all the variables were tested together, a high APACHE II score and a low albumin level continued to have a significant predictive effect. This analysis could predict the outcome in 82% of patients. In conclusion, our study suggests that low albumin serum levels and a high APACHE II score may be important indices in predicting the success of NIPPV.

Patient satisfaction with conscious sedation for bronchoscopy

STUDY OBJECTIVE

Bronchoscopic technique is not standardized. Controversies exist with regard to premedication with sedatives before the test. To evaluate safety and efficacy of conscious sedation, we studied 100 randomized patients undergoing diagnostic bronchoscopy; patients received premedication with lidocaine spray and atropine sulfate i.m. (nonsedation group; 50 patients) or lidocaine spray, atropine i.m. and diazepam i.v. (sedation group; 50 patients).

METHODS AND RESULTS

Monitoring during flexible fiberoptic bronchoscopy included continuous ECG and pulse oximetry. The procedure could not be completed in six patients. None received premedication with diazepam; among the patients who ended the examination, tolerance to the examination (visual analogue scale, 0 to 100; 0 = excellent; 100 = unbearable) was better in the sedation group. Low anxiety, male sex, but not age were also associated with improved patient tolerance to the test. Oxygen desaturation occurred in 17% of patients, and it was not more frequent after diazepam treatment.

CONCLUSIONS

In our study, sedation had a beneficial effect on patient tolerance and rarely induced significant alterations in cardiorespiratory monitoring parameters.

Efficacy of noninvasive positive pressure ventilation by facial and nasal mask in hypercapnic acute respiratory failure: experience in a respiratory ward under usual care

Noninvasive intermittent positive pressure ventilation (NIPPV) via a nasal or facial mask is an effective treatment of hypercapnic acute respiratory failure (ARF) caused by various diseases preventing endotracheal intubation (ETI) in 60-90% of patients. The technique can even be effective for routine care, using simplified ventilators, after adequate personnel training. In this study, the effectiveness, in a general respiratory ward under usual care, of NIPPV delivered by simplified ventilators via facial or nasal mask was evaluated in 40 patients with hypercapnic ARF (NIPPV group) and compared to 30 matched historical patients under conventional treatment (Conv group). Compared to conventional treatment, NIPPV was associated with a reduction in negative events such as ETI and mortality together (17% versus 60%, p = 0.0002), but not mortality alone (5% versus 13.5%, NS) or in the mean (+/- SD) length of the hospital stay (27.31 +/- 16.2 versus 27.5 +/- 20.5 days, NS). Patients treated with NIPPV, but not those treated conventionally, showed significant and rapid changes in arterial carbon dioxide tension (Pa,CO2) and pH between baseline and subsequent evaluation after 6 h, 1, 3 and 7 days and upon the discharge from hospital; in fact, in the NIPPV group after 6 h the arterial pH had risen from 7.30 +/- 0.062 to 7.35 +/- 0.066 and Pa,CO2 had decreased from 9.4 +/- 1.5 to 8.5 +/- 1.1 kPa. In the Conv group pH was stable at 7.29 and Pa,CO2 had risen from 9.39 +/- 1.8 to 9.43 +/- 1.6 kPa. In the NIPPV group no differences were found in the admission characteristics between patients successfully and unsuccessfully ventilated, although a significant improvement was observed after 1 h, for pH from 7.31 +/- 0.058 to 7.36 +/- 0.57 and Pa,CO2 from 9.2 +/- 1.3 to 8.3 +/- 1.3 kPa in successfully ventilated patients. In patients who failed to be ventilated with NIPPV pH worsened, from 7.26 +/- 0.069 to 7.24 +/- 0.078 and Pa,CO2 from 10.0 +/- 2.1 to 11.3 +/- 2.5 kPa. In conclusion, addition of noninvasive positive pressure ventilation delivered by nasal or face mask to conventional therapy, reducing the need for endotracheal intubation, may improve the management of patients with hypercapnic acute respiratory failure as compared to conventional therapy alone, even when instituted in a respiratory ward under usual care with simplified ventilators.

Distribution of bronchial responsiveness in a general population: effect of sex, age, smoking, and level of pulmonary function

Bronchial responsiveness (BR) was assessed by the methacholine challenge test in 1,694 subjects from a sample of the general population (aged 8 to 73 yr) enrolled in a prospective epidemiologic study on the natural history of chronic obstructive pulmonary disease (COPD). Information on respiratory symptoms and risk factors for COPD were obtained with a standardized questionnaire. The provocative dose causing a 10%, 15%, and 20% decrease in FEV1 was reached in 939 (55%), 658 (39%), and 447 (26%) subjects, respectively, after the last cumulative dose of methacholine (i.e., 4.8 mg). The slope of the dose-response curve was also computed in order to attribute a parameter to subjects who did not reach the provocative dose. After natural log transformation, the slope (Ln Slope) of the curve showed a significant association with the degree of airway obstruction, as assessed by FEV1% predicted, FEV1/VC%, and FEV1/FVC%. Therefore, relationships between BR, sex, age, and smoking were evaluated after adjustments for the initial airway caliber (FEV1, FEV1 adjusted for height, and FEV1/VC%). Females showed significantly higher values of Ln Slope than did males after adjustments were made for baseline lung function. In males, higher BR was observed in childhood-adolescence age groups and at older ages, while in females a higher level of BR was observed during childhood. Significantly higher Ln Slope values were found for females who currently smoked than for non- and ex-smokers. No difference was observed in males in relation to smoking habit. (ABSTRACT TRUNCATED AT 250 WORDS)

Residual volume in a general population. Effects of body size, age, cigarette smoking, and respiratory symptoms

Residual volume (RV) was obtained by subtracting vital capacity from total lung capacity determined by the single breath helium dilution (TLCsb) to measure CO diffusing capacity in 2,680 subjects (8 to 64 years old) of a general population sample. There were 712 normal subjects (243 male and 469 female subjects) selected to evaluate the pattern of RV by age and to derive reference values for internal comparisons. From 8 to 20 years old, RV showed an increase because of the cross-sectional body size effect; after 20 to 30 years, RV was still increasing, however, at a lower level. Age and height coefficients were significantly related to RV in younger and older ages, both in male and female subjects. The RV percent predicted and RV/TLC percent were higher in smokers when compared to nonsmokers and exsmokers (the difference was significant in male subjects). A dose-response effect was observed between RV percent predicted, RV/TLC percent, and pack-years. The RV percent predicted and RV/TLC percent were significantly higher in smokers and nonsmokers with FEV1 percent predicted below the normal limit (the difference was significant in male subjects). Moreover, higher values of RV percent predicted and RV/TLC percent were observed in subjects with wheezy symptoms in male smokers and nonsmokers. A negative significant correlation was observed between RV/TLC percent and the diffusing capacity adjusted for lung volume (DL/VA) in smokers, exsmokers and nonsmokers of both sexes, confirming the hypothesis that the decrease in DL/VA may be ascribed to the enlargement of terminal air spaces. In conclusion, determination of RV by the single breath helium dilution method is suitable in epidemiology, and it allows additional important information for understanding the physiopathologic mechanisms related to the pathogenesis of chronic obstructive lung disease.

Effects of home environment on respiratory symptoms and lung function in a general population sample in north Italy

Effects of indoor pollution exposure were evaluated in a general population sample (n = 3,289) living in the Po River Delta area. Prevalence rates of chronic cough in men and dyspnoea in women were significantly higher in association with the use of bottled gas (propane) for cooking instead of natural gas (methane). Chronic cough and phlegm in men and dyspnoea in women were significantly associated with the use of a stove for heating. When combining type of heating and fuel used, in men a trend toward higher prevalence rates of chronic cough and phlegm was shown in those with stove or fan heating (regardless of the fuel); in women the trend reached statistical significance for dyspnoea. The relationship between stove (regardless of fuel) and decrease in forced expirograms was statistically significant only in women. In multiple logistic models, accounting for independent effects of age, smoking, pack-years, parents' smoking, socio-economic status, body mass index, significantly increased odds ratios were found in males for the associations of: bottled gas for cooking with cough (1.66) and dyspnoea (1.81); stove for heating with cough (1.44) and phlegm (1.39); stove fuelled by natural gas and fan or stove fuelled other than by natural gas with cough (1.54 and 1.66). In females, significantly increased odds ratios were found only for dyspnoea when associated with bottled gas for cooking (1.45), stove for heating (1.46), stove fuelled by natural gas (1.58), stove or fan fuelled other than by natural gas (1.73).(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of home environment on respiratory symptoms and lung function in a general population sample in north Italy

Effects of indoor pollution exposure were evaluated in a general population sample (n = 3,289) living in the Po River Delta area. Prevalence rates of chronic cough in men and dyspnoea in women were significantly higher in association with the use of bottled gas (propane) for cooking instead of natural gas (methane). Chronic cough and phlegm in men and dyspnoea in women were significantly associated with the use of a stove for heating. When combining type of heating and fuel used, in men a trend toward higher prevalence rates of chronic cough and phlegm was shown in those with stove or fan heating (regardless of the fuel); in women the trend reached statistical significance for dyspnoea. The relationship between stove (regardless of fuel) and decrease in forced expirograms was statistically significant only in women. In multiple logistic models, accounting for independent effects of age, smoking, pack-years, parents' smoking, socio-economic status, body mass index, significantly increased odds ratios were found in males for the associations of: bottled gas for cooking with cough (1.66) and dyspnoea (1.81); stove for heating with cough (1.44) and phlegm (1.39); stove fuelled by natural gas and fan or stove fuelled other than by natural gas with cough (1.54 and 1.66). In females, significantly increased odds ratios were found only for dyspnoea when associated with bottled gas for cooking (1.45), stove for heating (1.46), stove fuelled by natural gas (1.58), stove or fan fuelled other than by natural gas (1.73).(ABSTRACT TRUNCATED AT 250 WORDS)