The Role of Chitinases in Chronic Airway Inflammation Associated with Tobacco Smoke Exposure

Chitinases and chitinase-like proteins are thought to play a role in innate inflammatory responses. Our study aimed to assess whether chitinase concentration and activity in induced sputum (IS) of patients exposed to tobacco smoke are related to the level of airway inflammation including the level and activity of chitinases and chitinase-like proteins. The study included 22 patients with chronic obstructive pulmonary disease (COPD), 12 non-COPD smokers, and nine nonsmoking subjects. Sputum CHIT1 and YKL-40 levels and chitinolytic activity were compared with sputum IL-6, IL-8, IL-18, and MMP-9 levels. A hierarchical cluster analysis was also performed. Sputum YKL-40 was higher in COPD patients than in the control groups. Sputum CHIT1 and YKL-40 levels correlated with IS inflammatory cell count as well as with MMP-9 and IL-8 levels. Two main clusters were revealed: Cluster 1 had lower chitinase levels and activity, lower IS macrophage and neutrophil count, and lower IS IL-8, IL-18, and MMP-9 than Cluster 2. Comparison of COPD patients from both clusters revealed significant differences in the IS inflammatory profile despite comparable clinical and functional data. Our findings seem to confirm the involvement of chitinases in smoking-associated chronic airway inflammation and show that airway chitinases may be a potential novel marker in COPD phenotyping.

Therapeutic decisions in a cohort of patients with idiopathic pulmonary fibrosis: a multicenter, prospective survey from Poland

Background

Pirfenidone and nintedanib are considered as the standard of care in idiopathic pulmonary fibrosis (IPF), but there is no consensus as to which of these two agents should be regarded as first-line treatment.

Objective

To provide real-world data on therapeutic decisions of pulmonary specialists, particularly the choice of the antifibrotic drug in patients with IPF.

Methods

This was a multicenter, prospective survey collecting clinical data of patients with IPF considered as candidates for antifibrotic treatment between September 2019 and December 2020. Clinical characteristics and information on the therapeutic approach were retrieved. Statistical evaluation included multiple logistic regression analysis with stepwise model selection.

Results

Data on 188 patients [74.5% male, median age 73 (interquartile range, 68-78) years] considered for antifibrotic therapy were collected. Treatment was initiated in 138 patients, while 50 patients did not receive an antifibrotic, mainly due to the lack of consent for treatment and IPF severity. Seventy-two patients received pirfenidone and 66 received nintedanib. Dosing protocol (p < 0.01) and patient preference (p = 0.049) were more frequently associated with the choice of nintedanib, while comorbidity profile (p = 0.0003) and concomitant medication use (p = 0.03) were more frequently associated with the choice of pirfenidone. Age (p = 0.002), lung transfer factor for carbon monoxide (TL_CO) (p = 0.001), and gastrointestinal bleeding (p = 0.03) were significantly associated with the qualification for the antifibrotic treatment.

Conclusion

This real-world prospective study showed that dose protocol and patient preference were more frequently associated with the choice of nintedanib, while the comorbidity profile and concomitant medication use were more frequently associated with the choice of pirfenidone. Age, TL_CO, and history of gastrointestinal bleeding were significant factors influencing the decision to initiate antifibrotic therapy.

mRNA expression profile of bronchoalveolar lavage fluid cells from patients with idiopathic pulmonary fibrosis and sarcoidosis

BACKGROUND

Sarcoidosis and idiopathic pulmonary fibrosis (IPF) are two most frequent forms of interstitial lung diseases (ILDs). Cellular and biochemical composition of bronchoalveolar lavage fluid (BALf) was shown to reflect the fibrotic changes in the lung. However, the usefulness of BALf cellular profile evaluation in the diagnosis of ILDs is limited. The aim of the study was a multivariate, molecular analysis of BALf cells from IPF and sarcoidosis patients.

METHODS

Transcriptomic measurements were carried out using Affymetrix Human Gene 2.1 ST ArrayStrip in 21 samples: 9 IPF and 12 sarcoidosis. The mRNA expression for the most significantly differentiating genes was evaluated by real-time PCR in 32 samples (11 IPF and 21 sarcoidosis).

RESULTS

The number of genes differentially expressed between IPF and sarcoidosis groups was 4832 (13359 probesets). Cluster analysis indicated that sarcoidosis BALf cells are characterized by increased mRNA expression of genes associated with ribosome biogenesis. Clusters formed by genes with changed mRNA expression in IPF samples were implicated in the processes of cell adhesion and migration, metalloproteinase expression and negative regulation of cell proliferation. The GO analysis indicated that predominant biological processes associated with the differential mRNA gene expression of BALf cells were upregulation of neutrophils in IPF and lymphocytes in sarcoidosis.

CONCLUSIONS

Analysis of BALf from sarcoidosis and IPF showed highly different mRNA profile of cells. The most important biological processes observed at the molecular level in BALf cells were associated with ribosome biogenesis and proteasome apparatus in sarcoidosis and neutrophilic dysfunction in IPF.

Serum testosterone depression as a factor influencing the general condition in chronic obstructive pulmonary disease patients

BACKGROUND

Testosterone has been recognized for its anabolic properties. It has been documented that in patients with chronic obstructive pulmonary disease (COPD), chronic hypoxia, disease severity, smoking, and corticosteroid treatment may contribute to low testosterone levels.

OBJECTIVES

The aim of the study was to evaluate the incidence of decreased serum testosterone concentration in male COPD patients and its influence on their condition.

MATERIAL AND METHODS

The study group consisted of 90 male patients, aged 67.2 ±8.8 years in all stages of airflow limitation severity (mild n = 6, moderate n = 43, severe n = 28 and very severe n = 13) Serum testosterone concentration was evaluated using ELISA method (Testosterone ELISE LDN). Decreased serum testosterone level was defined as a value of less than 3 ng/mL. Testosterone levels were related clinical features of COPD.

RESULTS

Serum testosterone concentration did not differ in patients with different stages of airflow limitation severity (3.8 ±0.7 ng/mL for mild: 3.6 ±2.1 ng/mL for moderate; 3.4 ±1.2 ng/mL for severe and 3.7 ±1.7 ng/mL for very severe, respectively). Decreased serum testosterone was found in 30 patients (group A). There were no differences in age, the number of exacerbations or CRP concentration between patients with decreased and the normal serum testosterone group (group B). Group A was characterized by a lower FEV1, shorter 6-minute walking distance, longer smoking history and higher BMI, but no differences in body composition and densitometry results were found.

CONCLUSIONS

Serum testosterone depression may occur in as much as 30% of male COPD patients in all COPD stages of severity. The relationship between serum testosterone and negative COPD prognostic factors indicates its influence on the natural history of the disease.

Comorbidities in chronic obstructive pulmonary disease: Results of a national multicenter research project

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is associated with various comorbidities, which influence the course of COPD and worsen prognosis.

OBJECTIVES

The aim of this study was to analyze the comorbidities in a cohort of COPD patients in Poland during 12 months of observation.

MATERIAL AND METHODS

A total of 444 COPD patients (median age: 66.1 years) in all stages of airflow limitation severity were enrolled. Medical histories and a questionnaire concerning comorbidities were analyzed at baseline and after 12 months (data of 267 patients available). Anthropometric data, pulmonary function, and body mass index, airflow obstruction, dyspnea, and exercise capacity (BODE index) were assessed.

RESULTS

No comorbidities were reported in 9 patients (2.0%), 101 patients (22.7%) had 1-2 comorbidities, 243 (54.7%) had 3-5, and 91 (20.6%) had more than 5 comorbidities. Cardiovascular diseases (CVDs) were the most frequent ones, followed by peptic ulcer, obstructive sleep apnea (OSA), diabetes, gastroesophageal reflux disease (GERD), and osteoporosis; 11 patients had a history of lung cancer. Cachexia was observed in 11 cases, overweight in 136 cases and obesity in 139 cases. The incidence of CVDs increased with time. The number of comorbidities correlated with the body mass index (BMI) and the number of hospitalizations for extra-pulmonary causes, but not with airflow limitation. The BODE index score increased with the number of comorbidities.

CONCLUSIONS

In a cohort of Polish COPD patients, the most frequent comorbidities were CVDs. The number of comorbidities affected the BODE index, but not airflow limitation. The BODE index is better than forced expiratory volume in 1 s (FEV1) in the rating of COPD patients' condition. The BMI correlated with the number of comorbidities as well as the number of hospitalizations for extra-pulmonary causes.

Matrix metalloproteinase 9 in exhaled breath condensate in patients with stable chronic obstructive pulmonary disease: an observational study

Introduction Data on the measurement of matrix metalloproteinase 9 (MMP‑9) in exhaled breath condensate (EBC) from patients with chronic obstructive pulmonary disease (COPD) are scarce and inconsistent. Objectives We aimed to assess the usefulness of enzyme‑linked immunosorbent assay (ELISA) and immunoenzymatic assay (IEA) for the measurement of MMP‑9 in EBC, the agreement between the results of both methods, and the relationships between total and active MMP‑9 in EBC and clinical and functional COPD characteristics. Patients and methods Total (ELISA and IEA) and active (IEA) MMP‑9 levels were assessed in EBC from 70 patients with stable COPD and 21 controls and correlated with pulmonary function and COPD symptom severity. Results MMP‑9 levels did not reach the sensitivity threshold of the ELISA kit in any of the COPD patients and in 11 controls. Total and active MMP‑9 (IEA) levels did not differ between COPD patients and controls. In COPD patients, total MMP‑9 levels correlated positively with forced expiratory volume in 1 second (FEV1) and FEV1 to forced vital capacity ratio and inversely with residual volume to total lung capacity ratio. A weak positive correlation between active MMP‑9 concentrations and COPD Assessment Test (CAT) score was found (r = 0.31, P = 0.01). Conclusions The utility of ELISA in MMP‑9 assessment in EBC is limited in COPD patients, while MMP‑9 measurement in EBC by IEA is feasible. The positive correlation between active MMP‑9 and CAT score in our patients and the inverse relationship between total MMP‑9 concentration and the degree of airway obstruction reflect the complex role of MMP‑9 in COPD.

Łagodne Przerzutowe Mięśniaki z Zajęciem Płuc

Łagodne przerzutowe mięśniaki (BML) to schorzenie charakteryzujące się występowaniem guzów wywodzących się z komórek mięśni gładkich macicy w różnych narządach u kobiet, które przebyły leczenie chirurgiczne mięśniaków macicy. Występowanie zmian ogniskowych nasuwa podejrzenie rozsianej choroby nowotworowej, w związku z czym u chorych niejednokrotnie przeprowadza się szeroki panel badań w poszukiwaniu nowotworu złośliwego, a rozpoznanie ostateczne jest oparte na badaniu mikroskopowym ogniska BML. Autorzy prezentują przypadek 56-letniej chorej na BML z zajęciem płuc, u której na podstawie obrazu histopatologicznego guzka płuca usuniętego w czasie torakotomii diagnostycznej rozpoznano rozsiany nowotwór złośliwy z komórek pochodzenia mezenchymalnego. Wyniki licznych badań dodatkowych nie potwierdziły procesu nowotworowego. Ostateczne rozpoznanie BML było oparte na ponownej analizie histopatologicznej materiału pobranego w czasie biopsji chirurgicznej. Chora pozostała w obserwacji; do monitorowania zmian w płucach wykorzystano rezonans magnetyczny. Łagodne przerzutowe mięśniaki powinny być uwzględnione w diagnostyce różnicowej guzków płuc u kobiet. Chore na BML wymagają długoterminowej obserwacji, w związku z czym w wyborze metody obrazowania należy również wziąć pod uwagę efekt kumulacji dawki promieniowania jonizującego.

Metastasising leiomyoma of the uterus with pulmonary involvement - case report

Benign metastasising leiomyoma (BML) is characterised by extrauterine smooth muscle tumours in women after surgical treatment for uterine leiomyoma. Usually manifested as solitary or multiple focal lesions in various organs, it imposes a scrutinous diagnostic work-up to exclude a malignant disease and requires confirmation in microscopic examination of the extrauterine focus. The authors present a case of a 56-year-old woman with BML manifesting as bilateral multiple pulmonary nodules, with a tentative diagnosis of a disseminated malignant disease of mesenchymal origin. The patient underwent multiple diagnostic tests, which excluded malignancy. The definite diagnosis was established after the microscopic reevaluation of an excised pulmonary nodule. The patient is monitored with chest magnetic resonance. BML should be considered in the differential diagnosis of multiple pulmonary nodules in asymptomatic women. Patients with BML require long-term monitoring, therefore the selected imaging method should not carry the risk of cumulative side effects.

Diurnal and nocturnal serum melatonin concentrations after treatment with continuous positive airway pressure in patients with obstructive sleep apnea

INTRODUCTION Melatonin secretion, one of the main factors controlling the sleep-wake rhythm, may be disrupted in patients with sleep disorders. OBJECTIVES The aim of the study was to evaluate the profile of circadian melatonin secretion in patients with obstructive sleep apnea (OSA) and to assess the impact of 2-day and 3-month treatment with continuous airway pressure (CPAP) on diurnal and nocturnal serum melatonin levels. PATIENTS AND METHODS Serum melatonin levels were evaluated in 71 untreated patients with OSA and 18 healthy controls at 6 time points: 10 AM, 2 PM, 6 PM, 10 PM, 2 AM, and 6 AM. The measurements were repeated after 2 days and 3 months of CPAP treatment. RESULTS Melatonin secretion rhythm was altered in 25.4% of the patients with OSA. In patients with preserved secretion rhythm, the serum melatonin level was significantly lower at 2 AM and 6 AM, compared with healthy controls: 68.2 pg/ml (interquartile range [IQR], 30.1-109.8 pg/ml) vs 109.1 pg/ml (IQR, 63-167.9 pg/ml), P = 0.02 and 40.8 pg/ml (IQR, 20.8-73.2 pg/ml) vs 67.7 pg/ml (IQR, 32.7-131.7 pg/ml), P = 0.04, respectively. Melatonin levels did not change significantly after the 2-day and 3-month CPAP treatment. However, at 3 months, a shift of the peak melatonin concentration to 2 AM was observed in patients with an altered secretion rhythm. CONCLUSIONS OSA has a significant effect on serum melatonin levels. Neither short-term nor long-term CPAP treatment significantly changes melatonin concentrations; however, our results seem to indicate that a 3-month CPAP treatment may be helpful in restoring the physiological rhythm of melatonin secretion in patients with OSA.

Correlation between hyperinflation defined as an elevated RV/TLC ratio and body composition and cytokine profile in patients with chronic obstructive pulmonary disease

INTRODUCTION

Body composition is an important prognostic factor in patients with COPD. The decrease in fat free mass (FFM), muscle mass (MM) and increase in visceral fat is associated with an elevated secretion of cytokines which promote systemic inflammation. The aim of the study was to evaluate body composition and the cytokine profile in patients with COPD in relation with the presence of hyperinflation.

MATERIAL AND METHODS

The study group consisted of 149 patients (61F, 88M) with stable COPD in all stages of severity aged 68 ± 8.8 yrs. All the patients underwent spirometry and bodypletysmography with bronchial reversibility testing. Hyperinflation was defined as RV%TLC > 48% and > 126% predicted. Body composition was analyzed by bioimpedance. The following serum inflammatory markers were evaluated: C-reactive protein, IL-6, IL-8, TNF-a, CC16, adiponectin and resistin.

RESULTS

Hyperinflation was found in 96 patients (group A) and it was more frequent in women than men (49/61 vs. 47/88, p < 0.001). BMI and age in this group were comparable to those in patients without hyperinflation (group B). Patients with hyperinflation have lover FFM, FFM index, MM and MM index and total body water and higher fat mass and fat mass index. We found significantly higher serum concentrations of inflammatory markers in group A: IL-6 - 6.4 ± 10.9 vs. 3.6 ± 4.2 pg/ml, resistin - 9.3 ± 4.2 vs. 7.6 ± 2.4 ng/ml, CRP 4.1 ± 2.3 vs. 2.9±2.1 mg/l, respectively.

CONCLUSIONS

Patients with hyperinflation have a lower FFMI, TBW and MMI and a higher proportion of fat tissue. Hyperinflation is associated with elevated concentrations of inflammatory markers what may be associated with more severe disease. Body compositions abnormality and higher activity of systemic inflammation could therefore be a negative prognostic factor in COPD patients.

Acute Response to Cigarette Smoking Assessed in Exhaled Breath Condensate in Patients with Chronic Obstructive Pulmonary Disease and Healthy Smokers

The effect of acute exposure to cigarette smoke (CS) on the respiratory system has been less extensively studied than the long term effects of smoking. The aim of the present study was to evaluate the acute response to CS in smokers suffering from chronic obstructive pulmonary disease (COPD) and in healthy smokers. Nineteen stable COPD patients and 19 young healthy smokers were enrolled. Tumor necrosis factor alpha (TNF-α), IL-1β, and malondialdehyde (MDA) were measured in exhaled breath condensate (EBC) before and 60 min after smoking a cigarette. When pre- and post-CS levels of the evaluated biomarkers were compared, no differences were found in either group. However, the post-CS MDA was significantly greater in healthy smokers than that in COPD patients; 20.41 vs. 16.81 nmol/L, p = 0.01, respectively. Post-CS TNF-α correlated inversely with FEV1/FVC in healthy smokers. We conclude that CS does not acutely increase the EBC concentration of the inflammatory markers either in COPD patients or healthy smokers. The short term CS-induced oxidative stress is higher in young smokers than in COPD patients, which what may indicate a higher susceptibility to CS content of the former.

[Body composition analysis performed by bioimpedance in patients with chronic obstructive pulmonary disease]

Body composition disorders are observed in chronic obstructive pulmonary disease (COPD) patients and have a significant impact the general condition and outcome in this disease.

AIM

The aim of the study was to assess body composition in relation to airway obstruction severity in patients with COPD.

MATERIALS AND METHODS

The study group consisted of 143 patients (58F, 85M) in the middle age The group was divided to two groups: group A FEV1<50% predicted and group B FEV1 ≥50% predicted; both groups were compared. The following anthropometric parameters were assessed: body mass index (BMI), waist/hip ratio and shoulder circumference of the dominant upper limb. Body composition analysis was performed by bioimpedance (Tanita T5896, TANITA Corporation of America, Inc, Arlington Heights, USA).

RESULTS

The mean BMI for the whole group was 27.5±5.1 kg/m2. None of the patients was underweight, 47 (32.9%) had normal BMI, 55 (38.5%) overweight and 41 (28.6%) were obese. Patients in group A had lower BMI, FFMI and muscle mass index (MMI) than patients in group B. We found the correlation between BMI, FFMI, MMI and FEV1 in the studied group.

CONCLUSIONS

Our results confirm the relationship between airflow limitation and body compositions in COPD patients. We suggest that anthropometric measurements should be a part routine COPD management.

Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration as a New Diagnostic Tool for Invasive Pulmonary Mycoses

Early diagnosis of invasive pulmonary mycoses in immunocompromised patients is a major determinant of effective treatment. However, making a reliable diagnosis is challenging and often requires transbronchial or even surgical lung biopsy. We provide evidence that endobronchial ultrasound-guided transbronchial needle aspiration may be an attractive, less invasive diagnostic method. Endobronchial ultrasound-guided transbronchial needle aspiration was not only a diagnostic clue in the presented kidney transplant recipient with invasive pulmonary mycosis but was useful in assessment of treatment efficacy.

Validation of the Polish Version of the Chronic Cough Quality of Life Questionnaire (Leicester Cough Questionnaire)

BACKGROUND

The Leicester Cough Questionnaire (LCQ) is one of the few specific quality-of-life questionnaires (QOLQ) dedicated to measuring the impact of chronic cough on patients' health/condition.

OBJECTIVES

The aim of the study was to validate the Polish version of the LCQ.

MATERIAL AND METHODS

The LCQ was translated forward and backward. The Polish version of the LCQ was tested on 35 patients suffering from chronic cough (23 women, median age 60 years, nonor ex-smokers, median cough duration of 23 weeks). Its validity was tested by comparison to a visual analogue scale (VAS) of cough intensity and other health questionnaires (hospital anxiety and depression scale - HADS, Euro-Quality of Life Questionnaire - EQ5D, St. George's Respiratory Questionnaire - SGRQ). The internal reliability of the Polish version of the LCQ was determined using the Cronbach alpha coefficient and its repeatability by the intraclass consistency coefficient.

RESULTS

The translation of the LCQ into Polish was accepted by the author of the original LCQ. The Cronbach's alpha coefficient for total LCQ was 0.89, and reached 0.82, 0.86 and 0.78 for the physical, psychological and social domain, respectively. There were significant negative correlations between cough severity measured by VAS, the results of the EQ5D and SGRQ and the Polish version of the LCQ. The intraclass correlation coefficient of the test-retest reliability was significant (0.99).

CONCLUSIONS

The Polish version of the LCQ has been validated and is a reliable tool to measure the impact of chronic cough on quality of life of patients with chronic cough.

Left brachiocephalic vein stenosis and infectious aortitis: two unusual causes of Ortner's syndrome

Ortner's syndrome (also known as cardiovocal syndrome) is defined as hoarseness due to compression of the left recurrent laryngeal nerve by an enlarged left atrium or enlarged thoracic vessels. We describe two cases of Ortner's syndrome with an unusual underlying vascular pathology. In the first patient, Ortner's syndrome was a consequence of left brachiocephalic vein stenosis resulting in collateral circulation filling the aorto-pulmonary window. The second patient developed a thoracic aortic aneurysm due infectious aortitis. Both patients required careful scrutiny in differential diagnosis because of their complex past medical history and concomitant diseases.

Causes of Chronic Cough in Non-smoking Patients

Chronic cough is a common medical problem. The aim of the study was to analyze chronic cough causes in non-smoking patients and to search for demographic factors associated with different cough reasons. The etiology of cough was determined by medical history, diagnostic tests and response to specific treatment. Patients with significant abnormalities in the chest radiograph or spirometry were not included. The study included 131 non-smoking patients; median age 54 years, 77 % female. The most frequent causes of cough were gastroesophageal reflux disease (GERD) (62 %) and upper airway cough syndrome (UACS) (46 %). Cough variant asthma and non-asthmatic eosinophilic bronchitis (NAEB) were diagnosed in 32 (25 %) and 19 (15 %) patients, respectively. Other cough causes were found in 27 patients (21 %). Asthma was a significantly more common cause of chronic cough in women than in men (31 % vs. 3 %, p = 0.005). A reverse relationship was demonstrated for UACS (39 % vs. 67 %, p = 0.01). Patients with chronic cough aged >50 yrs were more likely to be diagnosed with less common cough causes. In conclusion, the most common chronic cough reasons are GERD and UACS. Asthma-related cough is diagnosed more frequently in females, while UACS-related cough is more frequent in males.

Comparative study of periostin expression in different respiratory samples in patients with asthma and chronic obstructive pulmonary disease

INTRODUCTION

Periostin is considered to be a marker of eosinophilic inflammation in patients with asthma. However, there are no literature data on periostin in patients with chronic obstructive pulmonary disease (COPD). OBJECTIVES The aim of the study was to evaluate periostin expression and to compare its concentrations in various materials in patients with mild-to-moderate asthma and COPD, as well as to evaluate the potential association between periostin and clinical features of both diseases.

PATIENTS AND METHODS

Using an enzyme-linked immunosorbent assay, we measured periostin concentrations in serum, induced sputum (IS), exhaled breath condensate (EBC), and bronchoalveolar lavage fluid (BALF) as well as periostin expression in bronchial biopsy samples in 24 patients with asthma, 36 patients with COPD, and 12 controls. Correlations between periostin levels in different materials were also analyzed and periostin concentrations were compared between patients with asthma and those with COPD.

RESULTS

Periostin levels were detectable in serum, IS, EBC, and BALF from patients with asthma, COPD, and controls. EBC periostin levels correlated with tissue periostin expression and were significantly higher in asthma than in COPD (P = 0.04). Periostin expression in bronchial mucosa was higher in asthma than in COPD (P <0.001), as well as in asthma and COPD patients compared with controls (P <0.001). No significant correlations between tissue periostin expression and BALF, IS, or serum periostin levels were found. There were no differences in serum, IS, BALF, or EBC periostin concentrations between patients with different phenotypes of both diseases.

CONCLUSIONS

Periostin may be detected not only in serum, IS, and airway tissue samples, but also in EBC and BALF. EBC periostin levels and tissue periostin expression are higher in patients with asthma than in those with COPD. EBC periostin levels may serve as a potential surrogate marker for tissue periostin expression.

[Patients with chronic obstructive pulmonary disease (COPD)--similarities and differences of the study group participating in the project of National Center for Research and Development project "Chronic obstructive pulmonary disease (COPD)--systemic disease, the biggest threat of XXI century"]

Chronic obstructive pulmonary disease (COPD) is a significant clinical problem wich is dependent on many environmental factors.

THE AIM

of the study was to present a characteristic of examined group in the moment of including into the project.

MATERIALS AND METHODS

Based on data obtained from studies conducted in six medical universities in Poland we present the characteristics of 445 patients (M-69%), median age 66.2 years, suffering from COPD with median disease duration 7.7 years. The analysis included: age, education, risk factors, exacerbations and hospitalizations, comorbidities, severity of the disease, drug use and the results of selected tests and the quality of life of patients in relation with their place of residence.

RESULTS

Some differences were found among the participating centers. The youngest patients came from Wrocław and the oldest from Katowice. The largest number of patients with higher education were from Warsaw, while the lowest number was noted in Poznań; patients with primary education were most numerous in Lublin. Patients from Warsaw had the highest number of pack-years, smoking history was least relevant in patients from Wrocław. The highest values of spirometrical parameters were observed in Gdańsk, while the lowest--in Poznań. COPD treatment mainly comprised of long-acting beta2 agonists, followed by anticholinergic agents, more than 50% of patients were treated with inhaled glucocorticosteroids. The most common comorbidities were cardiovascular diseases.

CONCLUSIONS

The study group showed characteristics similar to those of other cohorts of patients with COPD described in the literature, but we found some differences between patients from different centers which participated in the study.

Variability of Transcutaneous Oxygen and Carbon Dioxide Pressure Measurements Associated with Sensor Location

Transcutaneous measurement of oxygen and carbon dioxide pressure (PtcO2 and PtcCO2) is useful in gas exchange monitoring. However, the relationship between PtcO2, pulse oximetry (SaO2) and arterial blood gases (ABG) is unclear. The aim of the present study was to compare PtcO2 and PtcCO2 with SaO2 and ABG, to evaluate the effect of sensor location on the results and stability of PtcO2 and PtcCO2, and to assess the impact of body composition on PtcO2 and PtcCO2. PtcO2 and PtcCO2 were measured in 20 healthy volunteers at three locations: right second intercostal space, lateral surface of the abdomen, and the inner surface of the left arm. The results were recorded 10, 15, and 20 min after sensor fixation and compared with SaO2 and ABG measured 20 min after electrode placement on the chest. Body composition was evaluated by bioimpedance. The findings were that PtcO2 was stable on the chest; but on the arm and abdomen it increased and reached maximum at 20 min. Transcutaneous PCO2 stabilized at 10 min in all the three locations. No significant correlations between PtcO2 and SaO2 or PaO2 were found. Transcutaneous PCO2 correlated with PaCO2. Both PtcO2 and PtcCO2 were not influenced by body composition. We conclude that the value of PtcO2 in monitoring of blood oxygenation was not unequivocally confirmed; PtcCO2 reliably reflects PaCO2, irrespective of sensor location. Body composition does not affect PtcO2 and PtcCO2.

Chronic cough - assessment of treatment efficacy based on two questionnaires

INTRODUCTION

Efficacy of chronic cough treatment is ambiguous. The aim of the study was to analyze chronic cough alleviation after specific treatment and the relationship between cough etiology and treatment efficacy.

MATERIAL AND METHODS

A stepwise diagnostic approach was used to diagnose cough etiology in non-smoking adults with chronic cough. In all patients specific treatment was applied. Two different questionnaires - a visual analog scale and a 5-degree scale - were used to assess cough severity before and after 4-6 months of treatment.

RESULTS

A significant correlation between pre-treatment and post-treatment results of both questionnaires was found (Spearman coefficient 0.43, p = 0.0003 and 0.73, p < 0.0001, respectively). Baseline questionnaire analysis revealed no differences in cough severity between patients with different cough causes or multiple cough causes. Although specific treatment resulted in a significant decrease of cough severity in the entire group, only partial improvement was noted. According to the visual analogue scale, a decrease of cough severity by at least 50% was achieved only in 54.4% of patients (37/68). Similarly, satisfactory improvement was noted in only 54.4% (37/68) of patients when using the 5-point scale. There were three sub-groups of patients, in whom no relevant decrease of cough severity was observed despite treatment: patients with 1. three coexisting cough causes, 2. non-asthmatic eosinophilic bronchitis, and 3. chronic idiopathic cough.

CONCLUSIONS

Cough severity does not depend on its etiology. Efficacy of chronic cough treatment in non-smoking patients is only moderate.

Effect of exacerbation frequency on body composition and serum ghrelin and adiponectin concentrations in patients with chronic obstructive pulmonary disease

INTRODUCTION Exacerbations affect the natural history of chronic obstructive pulmonary disease (COPD).

OBJECTIVES

The aim of the study was to evaluate the effect of exacerbation frequency in COPD on body composition and systemic inflammation assessed by the measurement of serum adiponectin and ghrelin concentrations.

PATIENTS AND METHODS

The study group included 152 patients with COPD. Body composition was assessed by bioimpedance. Fasting serum adiponectin and ghrelin concentrations were evaluated by enzyme-linked immunosorbent assays.

RESULTS

Of the 152 patients, 60 did not report any exacerbation in the last 12 months, 53 had 1 exacerbation, and 39 had more than 1 exacerbation. The mean number of exacerbations in the whole group was 1.04 ±1.3 per patient per year and increased with the increasing degree of airway obstruction. Patients with exacerbations had a lower fat-free mass (FFM) index, lower total body water, and lower resting metabolic rate compared with patients without exacerbations (18.3 ±2.5 kg/m2 vs. 19.3 ±2.7 kg/m2; 36.9 ±8.1 kg vs. 40.2 ±8.0 kg; and 1482.8 ±301.1 kcal vs. 1616.0 ±322.0 kcal; respectively). The adiponectin concentration was higher in patients with more than 1 exacerbation than in those with 1 or no exacerbations (14.5 ±8.6 mg/l vs. 11.2 ±7.6 mg/l, P <0.05). We observed significant negative correlations between the number of exacerbations and the muscle mass index, FFM index, total body water, resting metabolic rate, and adiponectin concentration in the whole group.

CONCLUSIONS

Exacerbations affect body composition in patients with COPD. Patients with frequent exacerbations have more enhanced systemic inflammation. Assessment of the body composition and systemic inflammation should be part of the routine management of patients with COPD.

Highlights from the ERS Congress in Amsterdam, 24–28 September 2011

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Usefulness of Selected Tests in the Diagnosis of Exercise-Induced Bronchoconstriction

Introduction: Indirect airway challenge tests are commonly used in the diagnostics of exercise-induced bronchoconstriction (EIB), defined as a post-exercise decrease in FEV1 ≥ 10%. The aim of this study was to evaluate the diagnostic value of bronchial hyperreactivity tests in the diagnosis of EIB. Material and methods: Forty-two subjects were allocated into 3 groups: A—19 steroid-naive asthma patients; D—11 non-asthma patients reporting symptoms suggestive of EIB (dyspnoea, wheezing, and cough provoked by exercise); and K—12 healthy controls. Subjects filled a questionnaire regarding symptoms related to exercise and underwent: inhaled bronchial challenge to methacholine (Mch), adenosine 5’-monophosphate (AMP), and exercise challenge on a treadmill. With a cut-off of ≥ 10% and ≥ 15% decrease in FEV1, EIB was diagnosed in 47% and 37% of asthma patients, respectively. Exercise-induced bronchoconstriction was found in 27% of subjects in group D and in none of the controls, irrespectively of the FEV1 criterion. Results: The analysis of the questionnaire revealed that a single symptom cannot be used to predict EIB. Symptoms occurring after termination of exercise, but not during exercise, characterize EIB more precisely. The analysis showed that the most useful measure to diagnose EIB can be a combination of bronchial challenge to AMP and typical symptoms of exercise-induced bronchoconstriction (i.e., dyspnoea, wheezing, and coughing provoked by exercise) with a sensitivity of 70%, specificity of 94%, PPV of 78%, NPV of 91%, and LR of 11.2. Conclusions: Symptoms suggestive of EIB do not have acceptable sensitivity and specificity for the diagnosis of exercise-induced bronchoconstriction. The most useful measure to diagnose EIB is the combination of typical symptoms of EIB with a positive challenge to AMP.

Primary Immune Thrombocytopenia in a Patient with Sarcoidosis

Sarcoidosis is a disease characterised by a highly variable clinical course. While it may be accompanied by various immune disorders, it is rarely accompanied by disorders of the haematopoietic system. We report a case of sudden-onset primary immune thrombocytopenia co-existing with sarcoidosis. The prevalence of primary immune thrombocytopenia in patients with sarcoidosis is estimated at about 2% and about 1% of patients with thrombocytopenia are diagnosed with sarcoidosis. Three potential pathomechanisms leading to the development of thrombocytopenia in sarcoidosis have been described, namely: (1) the presence of antiplatelet antibodies, (2) presence of epithelioid cell granulomas in the bone marrow and (3) hypersplenism.

[Primary immune thrombocytopenia in a patient with sarcoidosis]

Sarcoidosis is a disease with a strongly variable clinical manifestation. It may be associated with various autoimmune diseases but hematological manifestations have rarely been observed. The prevalence of thrombocytopenia in patients with sarcoidosis has been estimated at 2%, about 1% of patients with thrombocytopenia have been diagnosed with sarcoidosis We present a case of sarcoidosis associated with primary immune thrombocytopenia of an abrupt and severe onset. Three potential patomechanisms of thrombocytopenia in sarcoidosis: 1) autoantibody related platelet destruction, 2) bone marrow involvement, and 3) hipersplenism are discussed.

[Usefulness of selected tests in the diagnosis of exercise induced bronchoconstriction]

INTRODUCTION

Indirect airway challenge tests are commonly used in the diagnosis of exercise-induced bronchoconstriction (EIB), defined as a post-exercise decrease in FEV(1) ≥ 10%. The aim of this study was to evaluate the diagnostic value of bronchial hyperreactivity tests in the diagnosis of EIB.

MATERIAL AND METHODS

Forty two subjects were allocated to 3 groups: A - 19 steroid naive asthma patients; D - 11 no-asthma patients reporting symptoms suggestive for EIB (dyspnea, wheeze and cough provoked by exercise) and K - 12 healthy controls. Subjects filled a questionnaire regarding symptoms related to exercise and underwent: inhaled bronchial challenge to methacholine (Mch), adenosine 5'-monophosphate (AMP) and exercise challenge on a treadmill. With a cutoff of ≥ 10% or ≥ 15% decrease in FEV1 post exercise EIB was diagnosed in 47% and 37% of asthma patients, respectively; 27% of subjects in group D and in none of controls, irrespectively of the ΔFEV(1) criterion.

RESULTS

The analysis of questionnaire revealed that a single symptom cannot be used to predict EIB. Symptoms occurring after termination of exercise, but not during exercise characterize EIB more precisely. The analysis showed that the most useful measure to diagnose EIB can be a combination of bronchial challenge to AMP and typical symptoms of exercise induced bronchoconstriction (i.e. dyspnea, wheezes and cough provoked by exercise) with a sensitivity of 70%, specifity of 94%, PPV of 78%, NPV of 91% and LR of 11.2.

CONCLUSIONS

Symptoms suggestive of EIB do not have acceptable sensitivity and specifity for the diagnosis of exercise-induced bronchoconstriction. The most useful measure to diagnose EIB is a combination of typical symptoms of EIB with positive challenge to AMP.

Analysis of Solitary Pulmonary Nodules Found in Chest Radiograms

Introduction: The detection of solitary pulmonary nodules (SPNs) has increased due to widespread use of computed tomography; nevertheless, chest radiographs still remain the basic routine examination. The aim of the study was to estimate the detection of SPNs in routine chest X-rays in hospitalized patients and to assess the incidence of malignancy in newly diagnosed SPNs. Material and methods: We analyzed 5726 routine chest radiographs of patients admitted to the Department of Internal Diseases, Pneumology and Allergology in 2004 and 2005. Most of the patients were admitted to hospital due to emergency reasons. The malignant nature of the nodules was confirmed by pathological examination. The nature of benign nodules was confirmed either by pathological examination or based on radiological criteria: no growth within 2 years of radiological follow up, regression in control radiograms or CT scans, benign pattern of calcification. Results: Among the 5726 radiograms we found 116 newly diagnosed SPNs (2.2%). Twenty-four nodules (21%) were malignant: NSCLC in 21 cases and metastases in 3 cases. Fifty-one nodules (44%) were benign. In 19 patients (16%) SPNs proved to be artefacts or erroneously interpreted extrathoracic lesions. In 22 cases (19%) there was no final diagnosis (lack of data, diagnostic procedure renunciation). Conclusion: The incidence of newly detected SPNs in chest X-rays was 2.2%. Most SPNs were benign. About 21% of SPNs were diagnosed as malignant.

Influence of Nasal Continuous Positive Airway Pressure on Response to Exercise in Patients with Obstructive Sleep Apnea Syndrome

Obstructive sleep apnea syndrome (OSAS) patients are at risk of cardiovascular complications. The aim of this study was to assess the effect of treatment with continuous positive airway pressure (CPAP) on the response to symptom limited exercise test. Methods: twenty nine OSAS patients (1 F, 28 M), mean age 50.7 ± 9.7 yrs with body mass index of 32.6 ± 4.5 kg/m2 participated in the study. OSAS was diagnosed by overnight polysomnography. Incremental cardiopulmonary exercise test (CPET) on a treadmill was performed twice: before and after 2–3 weeks of regular treatment with CPAP. Results: mean apnea + hypopnea index (AHI) before therapy was 57.6 ± 12 h−1. CPAP treatment did not change peak oxygen consumption (VO2max) (38.3 ± 9.0 vs. 38.9 ± 6.9 mlO2/kg/min, p = ns) or peak heart rate (153.4 ± 21 min−1 vs. 155.5 ± 22 min−1, p = ns). There were no significant changes in ventilation or gas exchange variables. However, a decrease in peak systolic blood pressure from 194.5 ± 24 mmHg to 186.7 ± 27.9 mmHg (p < 0.05) with CPAP treatment was found. During recovery a decrease in heart rate (at 1st minute and minutes 3–6) and mean arterial pressure (MAP) (minutes 4–7) with CPAP treatment was observed. Significant correlations between VO2max and AHI (r = −0.38, p < 0.05); MAP at peak exercise and: AHI, mean oxygen saturation (SaO2) during sleep, minutes of sleep with SaO2 < 90% (T90); MAP at recovery (minutes 3–8) and T90 before CPAP treatment were also noted. Conclusions: OSAS patients are not limited on exercise. Treatment with nasal CPAP attenuates circulatory response to incremental exercise on a treadmill.

Macrophage Phenotype in Induced Sputum in Asthma Subjects

Macrophages represent the most predominant immune effector cells in the alveolar spaces and conducting airways and are known to express activated phenotype. The study was aimed at assessing the differences in cellular profile and the expression of selected surface markers on sputum macrophages in asthma and healthy subjects. 17 healthy subjects (never smoked) and 10 mild asthma subjects treated with glucocorticosteroids were enrolled into the study. For macrophage phenotyping a immunocytochemistry method was used with commercially available antibodies anti: CD14, CD71, CD11b and CD54. The nonparametric Mann Whitney U test was applied for data comparison, p value < 0.05 being regarded as significant. The total number of cells were increased in asthma patients 4.81 ± 5.27 × 106/ml vs. healthy 2.8 ± 2.15 × 106/ml and it was statistically significant. Statistically significant increase in the percentage of eosinophils was observed in mild asthma subjects. No differences were found between the proportion in macrophages and lymphocytes. The macrophage phenothype in induced sputum differed in both groups. The expression of CD 11b was higher in asthma group and the difference was statistically significant. The proportion of macrophages with the expression of CD 14, CD 71 and CD54 was comparable in both groups. Macrophage phenotyping during glucocorticosteroid therapy is useful in the assessment of inflammatory process in asthma subject.

Exhaled Nitric Oxide in Patients with Obstructive Sleep Apnea Syndrome

Exhaled nitric oxide has been extensively investigated as a non-invasive marker of airway inflammation. Some authors have suggested that morning FENO in obstructive sleep apnea syndrome (OSAS) patients is elevated due to inflammation of upper airways, while others have not found any differences between patients and healthy subjects. The purpose of this study was to analyze concentration of exhaled nitric oxide (FENO) in OSAS patients. Methods: 119 (99 M, 20 F) consecutive patients of sleep laboratory participated in this study. Standard overnight sleep studies with polysomnography or portable screening device were carried out in the whole group: OSAS was diagnosed in 66 patients and 53 no-OSAS served as controls. FENO was measured on-line with a flow rate kept at 0.045–0.055 l/s, according to the recommendations of ATS using a chemiluminescence analyzer twice: before the sleep study (8–10 p.m.) and after termination of data collection (6–8 a.m.). There were no differences in age between patients and controls. Respiratory disturbance index (RDI) was 40.3 ± 24.9 in patients and 3.7 ± 2.8 in con-trols (p < 0.001). In OSAS patients both evening and morning FENO was significantly higher compared to controls(23.1 ± 14.8 ppb vs. 16.8 ± 9.8 ppb and 22.4 ± 13.2 ppb vs. 15.3 ± 8.1 ppb respectively, p < 0.05). Weak but statistically significant correlations for the whole group between morning FENO and mean and minimum arterial oxygen saturation (SaO2) during sleep and number of study minutes with SaO2 < 90% were observed. Lower evening FENO in OSAS patients with coexisting arterial hypertension when compared to normotensive OSAS patients was also noticed (19.1 ± 10.8 ppb vs. 27.1 ± 19.1 ppb; p < 0.05). Conclusions: The increase in FENO in OSAS patents may be caused by repetitive apneas and hypoxemia during sleep.

Maximal Respiratory Pressures and Exercise Tolerance in Patients with COPD

Many authors reported respiratory muscle function impairment in patients with chronic obstructive pulmonary disease (COPD). Impaired respiratory muscle function may contribute exercise intolerance which is frequently observed in this disease. Aim of the study: was to determine the influence of respiratory muscle function on exercise capacity in patients with COPD. Methods: 23 patients with stable COPD aged 62.7 ± 9.3 years (6F, 17M; mean post-bronchodilator FEV1 = 47.9 ± 12.4% value predicted) participated in the study. Exercise capacity was assessed by the six-minute walk test and the incremental cardiopulmonary exercise test (CPET) on a treadmill. Maximal respiratory pressures (PImax, PEmax) were evaluated before and directly after CPET. Results: The mean peak oxygen uptake (VO2max) was 27.2 ± 6.1 mlO2/min/kg and the mean distance walked during the 6 MWT was 569.4 ± 101.7 m. Both PImax and PEmax decreased significantly after maximal exercise (71.4 ± 23.0 vs. 63.6 ± 22.2 cm H2O, p = 0.001 and 124.9 ± 46.5 vs. 112.3 ± 46.6 cm H2O, p = 0.02 respectively). No correlation between VO2max and the 6-minute walk distance and the maximal respiratory pressures was found. We observed a negative correlation between the 6-minute walk distance and the difference between the pre- and post CPET maximal inspiratory pressure. Conclusions: respiratory muscle function is impaired in patients with COPD but this does not affect exercise performance. Exercise causes a decrease of the respiratory muscle strength.

Bronchial Obstruction Reversibility Test in the Assessment of COPD Severity—Controversies

The GOLD and ERS/ATS guidelines recommend the post-bronchodilator FEV1 (% predicted) to define the severity of chronic obstructive pulmonary disease (COPD). Yet in various publications authors analyze the pre-bronchodilator value or do not clearly state which value was used when the bronchial reversibility test was performed. The guidelines established by the Polish Respiratory Society (PRS) do not specify if performing the reversibility test is necessary to estimate the COPD severity and suggest a reversibility test evaluation which differs from that in the ERS/ ATS and GOLD recommendations. Aim: to assess the changes in the degree of severity of COPD in the classification based upon the pre- and post-bronchodilator FEV1 and to compare the interpretation of the reversibility test as suggested by GOLD and ATS/ ERS and the PRS. Methods: 145 COPD patients (67F, 78M, mean age 67.5 ± 8.9 yrs) with a negative bronchial obstruction reversibility test (salbutamol 400 μg) were enrolled to the study. For each patient the degree of COPD severity using the pre- and postbronchodilator FEV1 was established. The pre- and post-bronchodilator classifications were compared. Differences in the interpretation of the reversibility test according to the GOLD and ATS/ ERS and the Polish guidelines were analyzed. Results: In 22 subjects (15.2%) the degree of disease severity changed after salbutamol. The changes were most frequent in the group of severe and very severe COPD (77.3% of changes). In 1 patient (0.7%) post-bronchodilator severity was greater than before salbutamol intake. In 7 patients (4.8%) the post-bronchodilator FEV1/FVC exceeded 70%, thus excluding the diagnosis of COPD. Of all the 145 negative (according to the ATS/ ERS and GOLD criteria) reversibility tests in 24 cases (16.6%) the test was positive when the criteria recommended by PRS were applied. Conclusions: the bronchial obstruction reversibility test is essential in the diagnosis and assessment of severity of COPD. Despite poor obstruction reversibility in this disease the use of pre-bronchodilator FEV1 in the assessment of COPD severity may be misleading and is an obstacle in the comparative analysis of studies in the domain of this disease. Differences in the guidelines for the management of COPD may also hinder comparative studies and influence epidemiologic data.