A case of idiopathic multicentric Castleman disease with pulmonary hyalinizing granuloma-like multiple pulmonary nodules

A 41-year-old man presented with chronic cough and chest pain. Laboratory tests revealed anemia, inflammation, hypoalbuminemia, polyclonal hypergammaglobulinemia, and elevated interleukin-6 levels. Computed tomography revealed diffuse bilateral pulmonary nodules and multicentric lymphadenopathy. Histopathology of the pulmonary nodule resembled pulmonary hyalinizing granuloma (PHG), whereas lymph node histopathology was consistent with idiopathic multicentric Castleman disease (iMCD). The patient was diagnosed with iMCD involving PHG-like pulmonary nodules. Little is known about the association between these two diseases, and the present case provides insights regarding the relationship between PHG and iMCD.

Clinical usefulness of end-tidal CO2 measured using a portable capnometer in patients with respiratory disease

INTRODUCTION

This study aimed to evaluate the correlation and agreement between end-tidal CO₂ (EtCO₂ ) measured with the novel portable capnometer (CapnoEye®) and partial pressure of arterial carbon dioxide (PaCO₂ ) levels in patients with respiratory diseases and to compare the efficacy of EtCO₂ and PvCO₂ in predicting PaCO₂ levels.

METHODS

We analyzed the correlation and the agreement between EtCO₂ and PaCO₂ and between PvCO₂ and PaCO₂ using Pearson's moment correlation coefficient in patients with type 1 and type 2 respiratory failure and both groups overall.

RESULTS

A total of 100 samples were included that comprised 67 men (67%). The mean age of the subjects was 77 ± 13 years. Chronic obstructive pulmonary disease (COPD) (43%) was the most common disease. There was a high correlation between EtCO₂ and PaCO₂ (r = 0.88; p < 0.0001). Sixty-six PvCO₂ samples were obtained, and there was a high correlation between PvCO₂ and PaCO₂ (r = 0.81; p < 0.0001). Regarding type 2 respiratory failure, there was a high correlation between EtCO₂ and PaCO₂ (r = 0.81). The Bland-Altman analysis between PaCO₂ and EtCO₂ revealed a bias of 5.7 mmHg, with limits of agreement ranging from -5.1 mmHg to 16.5 mmHg. In contrast, the analysis between PaCO₂ and PvCO₂ revealed a bias of -6.8 mmHg, and the limits of agreement ranged from -22.13 mmHg to 8.53 mmHg.

CONCLUSION

EtCO₂ measured by CapnoEye® was significantly correlated to PaCO₂ levels in patients with respiratory diseases. Moreover, CapnoEye® may be more useful for predicting hypercapnia conditions in which respiratory diseases are compared with measure PvCO₂ .

Short- and long-term efficacy of bronchial artery embolization using a gelatin sponge for the treatment of cryptogenic hemoptysis

Bronchial artery embolization (BAE) is the first choice treatment for hemoptysis. With advances in endovascular treatment, various embolic materials have become available. However, the optimal embolic material for the treatment of cryptogenic hemoptysis has not been determined. This study aimed to investigate the short-and long-term efficacy of BAE using a gelatin sponge in the treatment of patients with cryptogenic hemoptysis. The clinical characteristics, angiographic findings, and short- and long-term outcomes of BAE were retrospectively analyzed in 22 consecutive patients who underwent BAE for control of cryptogenic hemoptysis between January 2010 and September 2018. Selective angiography and super-selective BAE were successfully performed for all patients. A gelatin sponge was used in all patients. Further, polyvinyl alcohol was mixed with the gelatin sponge in 11 patients (50%). Angiography showed that the bronchial artery was responsible for hemoptysis in all patients, along with the intercostal artery in one patient (4.5%) and the inferior phrenic artery in one patient (4.5%). Immediate hemostasis was achieved in all patients. The recurrence-free rate was 100% for 1 month, 94.1% for 3 months, 94.1% for 12 months, and 87.4% for 24 months. Of two patients with recurrent hemoptysis, one underwent bronchoscopic hemoptysis and the other received intravenous hemostatic agents. No patient underwent BAE for recurrence. No severe complications occurred. In conclusion, BAE using a gelatin sponge has short- and long-term hemostatic efficacy for treating cryptogenic hemoptysis without any severe complications. A gelatin sponge is a suitable embolic material for patients with cryptogenic hemoptysis.

Effect of asthma, COPD, and ACO on COVID-19: A systematic review and meta-analysis

Introduction

The prevalence of asthma, chronic obstructive pulmonary disease (COPD), and asthma-COPD overlap (ACO) in patients with COVID-19 varies, as well as their risks of mortality. The present study aimed to assess the prevalence of asthma, COPD, and ACO as comorbidities, and to determine their risks of mortality in patients with COVID-19 using a systematic review and meta-analysis.

Methods

We systematically reviewed clinical studies that reported the comorbidities of asthma, COPD, and ACO in patients with COVID-19. We searched various databases including PubMed (from inception to 27 September 2021) for eligible studies written in English. A meta-analysis was performed using the random-effect model for measuring the prevalence of asthma, COPD, and ACO as comorbidities, and the mortality risk of asthma, COPD, and ACO in patients with COVID-19 was estimated. A stratified analysis was conducted according to country.

Results

One hundred one studies were eligible, and 1,229,434 patients with COVID-19 were identified. Among them, the estimated prevalence of asthma, COPD, and ACO using a meta-analysis was 10.04% (95% confidence interval [CI], 8.79–11.30), 8.18% (95% CI, 7.01–9.35), and 3.70% (95% CI, 2.40–5.00), respectively. The odds ratio for mortality of pre-existing asthma in COVID-19 patients was 0.89 (95% CI, 0.55–1.4; p = 0.630), while that in pre-existing COPD in COVID-19 patients was 3.79 (95% CI, 2.74–5.24; p<0.001). France showed the highest prevalence of asthma followed by the UK, while that of COPD was highest in the Netherlands followed by India.

Conclusion

Pre-existing asthma and COPD are associated with the incidence of COVID-19. Having COPD significantly increases the risk of mortality in patients with COVID-19. These differences appear to be influenced by the difference of locations of disease pathophysiology and by the daily diagnosis and treatment policy of each country.

Infectious Pulmonary Artery Pseudoaneurysm That Resolved with Conservative Treatment

Pulmonary artery pseudoaneurysms (PAPs) are rare but can cause massive hemoptysis if they rupture. Infectious PAPs are often treated by surgery or transcatheter embolization and are rarely treated conservatively with antibiotics. We herein report a case of PAP treated conservatively in a 21-year-old woman with lung abscess. Except for one massive hemoptysis early in the course, the patient responded well to the empirical therapy with ampicillin/sulbactam and systemic hemostatic agents. After six weeks of antibiotics, the pseudoaneurysm disappeared. Conservative therapy with careful observation can be considered in small infectious PAPs when there is a good clinical response to initial conservative therapy.

Unexpected Complications 25 Years after Coil Embolization for Pulmonary Arteriovenous Fistula

An 87-year-old woman who had undergone coil embolization 25 years ago for pulmonary arteriovenous fistula, which was diagnosed following repeated cerebral infarction, presented with massive hemoptysis. The coils migrated and were excreted in stool following hemoptysis during long-term follow-up. Although the technical success rate of coil embolization for pulmonary arteriovenous malformations is extremely high, and coil embolization-related complications are rare, little is known about the long-term complications. We herein report the clinical course of our case, review previous reports related to coil migration as a long-term complication, and discuss the associated mechanism.

A rare case of docetaxel-induced myositis in a patient with a lung adenocarcinoma

Docetaxel is a cytotoxic taxane frequently used to treat patients with various cancers, including non‐small cell lung cancer (NSCLC). Docetaxel is known to cause acute myalgias, arthralgias, and neuropathy, but there have been few published case reports of myositis. Here, we describe a rare case of docetaxel‐induced myositis diagnosed based on laboratory data, thigh magnetic resonance imaging (MRI), and electromyography (EEG). A 66‐year‐old male was admitted for thigh pain and fatigue that onset 1 week prior. He had been diagnosed with stage IVA (cT4N0M1a) NSCLC 3 years ago and had been started on docetaxel (60 mg/m² intravenously every 3 weeks; fourth‐line chemotherapy) 1 month earlier. After the second cycle, he developed both thigh pain and fatigue. On admission, his creatinine phosphokinase (CPK) level was elevated, thigh MRI revealed diffuse muscle edema, and EEG showed myogenic changes. We found no plausible cause for myositis except docetaxel. He was diagnosed with myositis and treated with oral prednisolone. His symptoms were relieved and the CPK level declined. Although rare, this case indicates that clinicians should consider the possibility of myositis as a complication in patients on docetaxel.

COVID-19 mRNA vaccine-related interstitial lung disease: Two case reports and literature review

The Pfizer-BioNTech mRNA vaccine (BNT162b2) is an effective and well-tolerated coronavirus disease 2019 (COVID-19) vaccine. However, rare adverse events have been reported. We report two cases of COVID-19 mRNA vaccine-related interstitial lung disease (ILD). A 67-year-old man and a 70-year-old man with underlying ILD presented to our hospital with a few days of fever and respiratory symptoms after receiving the BNT162b2 vaccine. Drug-related pneumonitis due to the COVID-19 mRNA vaccine was diagnosed. One case was diagnosed with lymphocytic alveolitis by bronchoalveolar lavage fluid and transbronchial lung cryobiopsy. Both patients were successfully treated with corticosteroids, and they attended outpatient clinics thereafter. Although the safety and efficacy of COVID-19 vaccines have been established, further studies are needed to estimate long-term data and reports of rare adverse reactions. We present the clinical course of two cases, review previously published case reports on COVID-19 mRNA vaccine-related ILD and discuss the relevant findings.

Findings of in vitro Analyses of Basophil Functions May Help Us Better Understand Drug Desensitization

Drug hypersensitivity can be an important problem during pharmacological management of various diseases. Patients diagnosed as having a drug allergy usually need to avoid the offending drug, either temporarily or for life. Another way of overcoming a drug allergy is to establish desensitization using the allergen drug itself. We previously investigated in vitro desensitization of human basophils using a subthreshold dose of an IgE-crosslinking reagent. We found that basophil desensitization occurred in a dose-dependent manner over a period of one to several hours. We think that inducible basophil desensitization occurring without histamine release may explain, at least in part, the clinical features of drug desensitization in type 1 drug allergy.

Effectiveness of bronchial thermoplasty for severe persistent bronchial asthma accompanied by Pseudomonas aeruginosa infection

Bronchial thermoplasty (BT) is a type of bronchoscopic treatment specifically used for patients with severe asthma. Most severe asthmatics receive systemic steroids and are at risk of being immunocompromised. This raises the clinical question of whether or not BT can be effectively and safely performed in such patients. Herein, we report a case highlighting the effectiveness and safety of BT in a patient with severe persistent bronchial asthma and Pseudomonas aeruginosa infection. We performed BT on a 46-year-old woman undergoing treatment for severe persistent asthma with inhaled steroids and 20 mg prednisolone orally. Although she was deemed to be infection-free before the procedure, culture of endobronchial secretions obtained during the first BT procedure grew Pseudomonas aeruginosa. After the first BT, she was given clarithromycin 400 mg orally daily. The amount of sputum decreased with each BT session, and sputum culture for Pseudomonas aeruginosa turned negative by the third BT session. Respiratory function tests showed 23.7% improvement in % post-bronchodilator forced expiratory volume in 1.0 s (%FEV_1.0) and the asthma quality of life questionnaire (AQLQ) score increased by 2.41 points after the third BT. Bronchial wall thickness decreased and infiltrative shadows on CT disappeared after the three BT sessions, along with decrease in the amount of purulent sputum. Improvement in her asthma symptoms, after three BT sessions allowed decrease in the prednisolone dose.

We report the effectiveness of BT and infection control in a severe asthmatic with Pseudomonas aeruginosa infection.

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Bronchial thermoplasty (BT) is a type of bronchoscopic treatment specifically used for patients with severe asthma.

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There is a clinical question that whether we can perform the BT effectively and safely on immunocompromised patients.

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We report the effectiveness of BT and infection control in a severe asthmatic with Pseudomonas aeruginosa infection.

Usefulness of Jackson mask ventilation during bronchoscopy in patients with acute respiratory failure: A retrospective review

Bronchoscopy is a procedure for diagnosis and treatment decision-making in patients with lung disease, especially those with acute respiratory failure. However, the optimal bronchoscopic method for patients with acute respiratory failure is not known. Therefore, in the real world, we sometimes hesitate to perform bronchoscopy in such patients because of safety and have experienced treating patients without bronchoscopy. To address this problem, we evaluated the usefulness and safety of Jackson mask ventilation, a novel noninvasive method of bronchoscopy performed under mask ventilation using the Jackson Rees circuit, in patients with acute respiratory failure.We retrospectively reviewed patients with acute respiratory failure who underwent bronchoscopy at our institution between January 2015 and May 2018. We compared patients who received Jackson mask ventilation (Jackson group) and those who received conventional oxygen administration (conventional group). Mean percutaneous oxygen saturation (SpO2) and mean oxygen flow rate were compared between the groups by the Wilcoxon signed-rank test. We excluded patients who were intubated and those without acute respiratory failure who received Jackson mask ventilation preventively.Of 1262 patients who underwent bronchoscopy, 12 were classified into the Jackson group and 13 into the conventional group. Proper oxygenation was maintained in the Jackson group, with SpO2 increasing after Jackson mask ventilation (89.4% to 96.8%, P = .03). Mean SpO2 was significantly higher in the Jackson group than in the conventional group (96.8% vs 95.2%, P = .03). Mean oxygen flow rate was significantly lower in the Jackson group (4.0 L/min vs 7.9 L/min, P < .001). There was no significant difference in safety.Our findings suggest that Jackson mask ventilation is safe and effective when performing bronchoscopy in patients with acute respiratory failure. Jackson mask ventilation maintained proper oxygenation and decreased the oxygen flow rate compared with the conventional method. Using Jackson mask ventilation, we could perform bronchoscopy safely and effectively in patients with acute respiratory failure, including some who had unstable respiratory status. (UMIN000038481).

Refractory Hemoptysis Caused by Severe Pulmonary Vein Stenosis after Multiple Catheter Ablations

We herein report a 48-year-old man with a history of chronic atrial fibrillation (AF) and repeated hemoptysis after radiofrequency ablation. Contrast tomography showed soft tissue thickening of the left hilar region and left pulmonary vein stenosis. We performed bronchial artery embolization, but the hemoptysis did not disappear, and AF was not controlled. We performed left lung lobectomy and maze procedures since we considered surgical removal necessary as radical treatment. After the surgery, hemoptysis and atrial fibrillation did not recur. Refractory hemoptysis after catheter ablation is rare, but occasionally occurs in patients with severe pulmonary vein stenosis.

Cost-effectiveness of bronchial thermoplasty for severe asthmatic patients in Japan

Bronchial thermoplasty (BT) is an interventional endoscopic treatment for severe bronchial asthma. Some studies have shown the clinical efficacy of this intervention, but its cost-effectiveness is unclear. The aim of this study was to evaluate the cost-effectiveness of BT. We collected data from the medical records of 16 Japanese patients who were treated with BT between February 2015 and April 2017, and compared asthma-related medical expenses between the year preceding and the year following BT. Four patients were Global Initiative for Asthma (GINA) treatment step 4, and 12 were step 5. In 8 patients who had a successful response to BT, the annual asthma-related medical expenses decreased because of a reduction in hospitalization and emergency outpatient visits due to asthma attacks, and termination of the use of biologics. Most patients in the non-responder group had increased asthma-related medical costs postoperatively. The main reason for the increase in medical costs was the add-on treatment of biologics. BT was cost-effective in the responder group. If its effects continue for more than 10 years, BT will be a cost-effective treatment. Medical costs will be reduced if those who respond to BT can be identified prior to commencement of treatment.

A case of diffuse pulmonary lymphangiomatosis with a venous anomaly presenting with acute respiratory failure and hemoptysis

Diffuse pulmonary lymphangiomatosis (DPL) is a rare lymphatic disease that can cause diverse respiratory symptoms. A 22-year-old man, whose chest CT had shown an abnormality for years, presented with acute respiratory failure due to the abrupt onset of hemoptysis. The diagnosis of DPL was confirmed by surgical lung biopsy and lymphangiography. Histopathological investigation showed dilated vascular and lymphatic vessels. DPL can cause acute and life-threatening symptoms during its chronic clinical course. A coexisting anomaly in the venous system may be present in DPL patients with hemoptysis.

Evaluation of the efficacy and safety of a new flex-rigid pleuroscope

Objective

New flex‐rigid pleuroscope enables observations with a maximum angle of curvature of 180^°, allowing visualization of the area near the insertion site of the pleuroscope. And, it improved the image quality and channel inner diameter. The aim of this study was to evaluate the clinical effectiveness and safety of a new flex‐rigid pleuroscope.

Methods

A retrospective analysis of patients who were examined with a new flex‐rigid pleuroscope under local anesthesia at our institution was conducted.

Pleuroscopy was performed in 33 patients with undiagnosed exudative pleural effusions from December 2016 to March 2019.

Results

A total of 33 patients (10 women, 23 men); their median age 74 years (range 24‐90) were investigated. Pleuroscopy showed that 18 had malignant pleural disease (54%), and 15 had benign pleural diseases (46%). The top three most frequent causes of pleural disease were pleural metastases of lung carcinoma (30.3%), pyothorax (15.1%), and malignant pleural mesothelioma (12.1%). In 32 cases (97%), observation at the introducer insertion site was possible. It was not possible in one case due to hard adhesions. The diagnostic rate was 100%, and the complication rate was 6.1%. There were no major complications, and minor complications included mild pain (one case) and minor bleeding (one case) that was stanched spontaneously.

Conclusions

The new flex‐rigid pleuroscope is effective and safe for diagnosing pleural effusions. The improved bending angle is likely to minimize the blind area. The new pleuroscopy fiberscope may improve the diagnostic rate.

Pembrolizumab-induced pancytopenia in a patient with squamous cell lung cancer

Immune checkpoint inhibitors (ICIs) are reportedly effective against many kinds of neoplasm, but may be responsible for several kinds of immune‐related adverse events (irAEs). Among these irAEs, the incidence of myelosuppression due to ICIs is relatively low. Corticosteroids are needed to control most cases of myelosuppression. Here, we report an 88‐year‐old woman with squamous cell lung cancer who was administered pembrolizumab. After five cycles of pembrolizumab, she developed severe pancytopenia. The pancytopenia improved under observation without steroid administration after cessation of pembrolizumab. During recovery from this irAE, the patient also maintained long‐term antitumor efficacy.

Key points

Significant findings of the study

There are several kinds of immune‐related adverse events. We encountered a case of pembrolizumab‐induced pancytopenia with squamous cell lung cancer.

What this study adds

Corticosteroids are needed to control most cases of myelosuppression induced by ICIs, but pancytopenia induced by pembrolizumab in our case improved without steroids.

Mucor pulmonary embolism in a patient with myelodysplastic syndrome

Mucormycosis is a life-threatening infectious disease that occurs most commonly in immunocompromised patients such as those with hematological malignancies. Its clinical symptoms and associated radiological findings vary and specific biomarkers and culture characteristics have not been defined. An 85-year-old man who had been treated for myelodysplastic syndrome and tuberculosis for several months presented with subacute fever and worsening left-side chest pain. Contrast-enhanced computed tomography images depicted massive tumor-like consolidation without enhancement, expanding from the left lower lobe. Emboli that did not respond to anticoagulants were detected in the left descending pulmonary artery. Despite intensive treatment he developed multiple organ failure and died 47 days after hospitalization. Gross pathology of a lung autopsy specimen revealed left lower pulmonary arterial emboli and pulmonary infarction, which was concluded to be the direct cause of death. The emboli were histopathologically identified as invasive mycelia in vessels. Mucor sp. was detected via real-time polymerase chain reaction and immunohistopathological analyses revealed that the mold in the blood vessels of lung tissue was partially positive for the mucor antigen. In the present case of Mucor sp. pulmonary emboli in a patient with myelodysplastic syndrome, radiographic findings were hard to distinguish from those typical of a lung abscess.

Treatment for intractable asthma: bronchial thermoplasty

Bronchial Thermoplasty (BT) is an epoch-making treatment that reduces bronchial smooth muscle by using a bronchoscope to reach the basket catheter to the bronchus and directing high-frequency current directly into the bronchi. In GINA Guidelines 2019, BT is considered to be additional treatment at Step V (the most severe), and the evidence level is B. The Japanese guidelines (JGL) also added BT as a treatment for Step 4, but it is reserved because there are still unclear points regarding long-term efficacy and safety. In Japan, as of April 1, 2019, 672 treatments were performed at 123 institutions nationwide. The average age of patients was 54.1 years, but 84 cases were over 70 years old. The average value of %FEV1 was 78.2%, but there were 94 cases less than 60%. There were 32 cases that underwent BT treatment at our institution. Of them, 12 cases with progress up to one year later could be observed. The average age was 56.1 years old, and each of 6 men and women had a %FEV1 of 70.5%. One year later, AQLQ and %FEV1 improved, and the number of exacerbations decreased, but exhaled NO values increased. %FEV1 improvement might be due to poorer lung function (70.5% vs. 77.8%) and more BT activation (average 1.28 times AIR2) compared to the AIR2 trial. In terms of improvement in %FEV1, patients with moderate obstructive disorder from 50 to 80% responded well after BT treatment. In the near future, various new antibody preparations such as IL-4 / 13 antibody and anti-TSLP antibody are expected to be promoted. Therefore, we first consider whether these antibody preparations can be applied to patients with refractory asthma. We consider that BT is indicated only when there is no indication or no expected effect of antibody preparations. In other words, BT treatment is the last resort of intractable asthma, and it is the duty of medical professionals involved in BT treatment to be able to advocate when it is best to give BT to such patients.

Refractory Chylothorax and Lymphedema Caused by Advanced Gastric Cancer

Chylothorax is the accumulation of lipid pleural effusion. Few reports have described chylothorax caused by gastric cancer. A 45-year-old woman presented with progressive lymphedema and bilateral chylothorax. Although repetitive thoracentesis was performed to relieve her dyspnea, swelling of her axillary lymph nodes became significant. Positron emission tomography/computed tomography demonstrated the accumulation of ¹⁸F-fluorodeoxyglucose in these nodes, and a lymph node biopsy showed signet ring cell carcinoma. The primary site was a 0-IIc type lesion in the gastric body that was only detected by upper gastrointestinal endoscopy. The patient was diagnosed with advanced gastric cancer 3.5 months after presentation for chylothorax.

Cough related to swallowing in asthma patients

Background

Occurrence of cough during swallowing is common among asthma patients, but has not been investigated in detail.

Objective

We conducted an observational study to determine the prevalence of swallowing-related cough (SRC) and its characteristics in asthma patients.

Methods

Asthma patients attending our outpatient department between May 2005 and April 2007 were interviewed to investigate if they had ever experienced SRC, as well as postnasal drip or heartburn and cough related to these conditions.

Results

Among 417 patients who completed the questionnaire, 121 patients (29.0%) had experienced SRC. Spicy and sour foods were the most frequent tussigenic foods, causing cough in 76.0% and 53.7% of the 121 patients, respectively. In patients without SRC, the prevalence rates of postnasal drip and postnasal drip-induced cough were 35.8% (106 of 296) and 7.8% (23 of 296), respectively. The corresponding prevalence rates in patients with SRC were 50.4% (61 of 121) and 37.2% (45 of 121), which were both significantly higher than in patients without cough (p = 0.006 and p < 0.001 respectively). In patients without SRC, the prevalence rates of heartburn and heartburn-induced cough were 22.2% (66 of 296) and 2.4% (7 of 296), respectively. The corresponding prevalence rates in patients with SRC were 45.5% (55 of 121) and 16.5% (20 of 121), with both being significantly higher than in patients without cough (p = 0.002 and p < 0.001, respectively).

Conclusion

SRC was frequent in asthma patients, and was closely related to postnasal drip and heartburn. Irritable larynx is one of the possible underlying mechanisms of SRC. This study was registered with the University Hospital Medical Information Network clinical trials registry (registration number: UMIN000017426).

Comparison of End-Tidal, Arterial, Venous, and Transcutaneous PCO2

BACKGROUND

We investigated the measurement of end-tidal partial pressure of carbon dioxide (P_ETCO2 ) with a capnometer in patients with respiratory failure, and we determined whether this technique could provide an alternative to measurement of P_aCO2 using arterial blood gas analysis in the clinical setting.

METHODS

We measured P_ETCO2 in subjects with hypoxemic and hypercarbic respiratory failure using a capnometer. We simultaneously measured P_aCO2 , venous partial pressure of carbon dioxide (P_v̄CO2 ), and transcutaneously measured partial pressure P_CO2 (P_tcCO2 ). We analyzed agreements among these parameters with Bland-Altman analysis. We obtained 30 samples from subjects with hypoxemic respiratory failure and 30 samples from subjects with hypercarbic respiratory failure.

RESULTS

Thirty subjects with hypoxemic respiratory failure and 18 subjects with hypercarbic respiratory failure participated in this study. Significant relationships were found between P_ETCO2 and P_aCO2 , between P_tcCO2 and P_aCO2 , and between P_v̄CO2 and P_aCO2 . Bland-Altman analysis of P_ETCO2 and P_aCO2 in all subjects revealed a bias of 6.48 mm Hg (95% CI 4.93-8.03, P < .001) with a precision of 6.01 mm Hg. Bland-Altman analysis of P_ETCO2 and P_aCO2 with hypoxemic respiratory failure revealed a bias of 5.14 mm Hg (95% CI 3.35-6.93, P < .001) with a precision of 4.80 mm Hg. Bland-Altman analysis of P_ETCO2 and P_aCO2 in subjects with hypercarbic respiratory failure revealed a bias of 7.83 mm Hg (95% CI 5.27-10.38, P < .001) with a precision of 6.83 mm Hg.

CONCLUSIONS

P_ETCO2 can be measured simply using a capnometer, and P_ETCO2 measurements can estimate P_aCO2 . However, the limits of agreement were wide. Therefore, care providers must pay attention to the characteristics and errors of these devices. These results suggest that measurement of P_ETCO2 might be useful for screening for hypercarbic respiratory failure in the clinical setting.

Bronchial Thermoplasty for Severe Asthma with Mucus Hypersecretion

Bronchial thermoplasty (BT), which delivers thermal radiofrequency to the bronchial wall, is an effective therapy for patients with severe persistent uncontrolled asthma. We herein report the case of a 47-year-old man who underwent BT for uncontrolled severe asthma. After BT, his asthma control, asthma-related quality of life, and pulmonary function improved. Furthermore, a histologic examination of transbronchial biopsy specimens revealed a decrease in goblet cell hyperplasia and the smooth muscle mass as well as in the subepithelial basement membrane thickness. BT can be effective for patients with severe uncontrolled asthma and mucus hypersecretion.

A case of recurrent hemoptysis caused by pulmonary actinomycosis diagnosed using transbronchial lung biopsy after bronchial artery embolism and a brief review of the literature

A 60-year-old man was admitted to our hospital because of massive hemoptysis with acute respiratory failure. Since six months ago, he noticed gradual worsening of hemoptysis and was transferred to our hospital. Chest computed tomography showed a nodular lesion with cavitation in the left upper lobe and surrounding ground-glass opacification. Initially, a hemostatic agent was administered, but we eventually performed bronchial artery embolization (BAE) by ourselves due to persistent hemoptysis. After achieving good hemostasis with BAE bronchoscopy was performed, which gave a diagnosis of pulmonary actinomycosis on histopathologic examination of the transbronchial biopsy specimen without the need for lung resection.

A case of Aspergillus and Nocardia infections after bronchial thermoplasty

Bronchial thermoplasty (BT) is a bronchoscopic treatment for severe asthma. A 35-year-old woman with uncontrolled severe asthma despite maximal pharmacological treatment underwent BT and started coughing after the first procedure. One month later, during the second BT procedure, there were white ulcerous lesions on the right B9 bronchus. Culture of the bronchial brushing specimen showed Aspergillus fumigatus, for which voriconazole was started for treatment. On the third BT procedure, endobronchial mucus sampling demonstrated Nocardia spp., for which trimethoprim-sulfamethoxazole was given for three months. Seven months after the third BT procedure, no particular endobronchial lesions were found, and no abnormal pathogens were obtained by culture. The resulting bronchial infection in this case may be attributed to the use of systemic steroids, which rendered the patient immunocompromised, and to tissue fragility that was caused by the thermal energy from the BT procedure. Culture of endobronchial mucus should be considered during BT.

Evaluation of expiratory capacity with severe asthma following bronchial thermoplasty

Bronchial thermoplasty (BT) is a bronchoscopic treatment to reduce the amount of smooth muscle in the bronchial wall in patients with severe asthma. Reducing smooth muscle in the airway wall reportedly alleviates air trapping and decreases expiratory volume. In the current study, expiratory computed tomography (CT) was performed in 10 patients who underwent BT at our facility, and their expiratory volume was evaluated. We observed an improvement in the expiratory volume on CT in nine of the 10 patients. Total expiratory lung volume decreased from 1693 ± 907 to 1426 ± 853 mL, indicating an improvement of approximately 15%. Use of CT for evaluation of expiratory volume may be a method for assessing the effectiveness of BT.

A successful treatment of rheumatoid arthritis-related interstitial pneumonia with nintedanib

Rheumatoid arthritis-related interstitial pneumonia with a usual interstitial pneumonia (RA-UIP) has a poor prognosis and a new treatment strategy is required. The antifibrotic agent nintedanib reduces the annual rate of decline in forced vital capacity (FVC) in idiopathic pulmonary fibrosis (IPF) patients. Recently, the potential efficacy of antifibrotic agents against chronic progressive fibrotic diseases including RA-UIP has been attracting attention. A 74-year-old man diagnosed with IPF on high-resolution computed tomography (HRCT). His FVC was decreasing over time, and his exertional dyspnea and cough had progressed with progression of reticulation on imaging. He was treated with nintedanib, which resulted in decreased coughing together with a reduction in FVC decline, from -11.6%/year to -5.2%/year. A swollen joint appeared eight months after this intervention, and he was diagnosed with rheumatoid arthritis. In this patient, nintedanib was effective against RA-UIP. This is the first case in which nintedanib was shown to be effective for RA-UIP.

Effectiveness of clarithromycin in patients with yellow nail syndrome

BACKGROUND

Yellow nail syndrome (YNS) is a rare disease characterized by the triad of thickened, slow-growing yellow nails, lymphedema, and chronic respiratory manifestations. The cause of YNS is not known; however, it is suggested to be due to a congenital lymph abnormality. Since YNS is accompanied by chronic bronchial infection in more than half of patients, we hypothesized that treatment with clarithromycin (CAM) could be effective. We therefore evaluated the effectiveness of CAM against nail discoloration and respiratory manifestation in patients with YNS.

METHODS

We conducted an observational study involving 5 patients with YNS who were treated at our institution between January 2005 and January 2016. CAM was prescribed for every patient. Patient demographic information, comorbidities, medications, chest radiographs, and clinical data such as nail color were extracted to evaluate clinical outcome.

RESULTS

Mean patient age was 71.6 years, and 2 patients (40%) were male. Four patients had sinusitis, and 2 had rheumatoid arthritis. Regarding respiratory manifestations, 4 patients had sinobronchial syndrome and 2 had pleural effusion. Nail discoloration improved in every patient after CAM treatment. Four patients also experienced improvement in their respiratory manifestations.

CONCLUSIONS

In patients with YNS, the anti-inflammatory activity of macrolides might improve their systemic inflammation. This improvement could help to reduce lymphedema and promote nail growth.

TRIAL REGISTRATION

Ethical approval was provided by the institutional review board of the National Center of Global Health and Medicine (NCGM-G-002143-00), in January 2017. This study is retrospectively registered for UMIN Clinical Trial Registry ( UMIN000028514 ) in August 4th, 2017.

Patient-oriented optimal depth of conscious sedation using midazolam during flexible bronchoscopy: A prospective open-labeled single-arm trial

BACKGROUND

The British Thoracic Society guidelines for diagnostic flexible bronchoscopy (FB) in adults recommend that intravenous sedation should be offered to patients undergoing bronchoscopy. However, it is difficult to determine the adequate depth of sedation for each patient because of inter-individual variability.

METHODS

This prospective, open-label, single-arm study was conducted in patients undergoing routine bronchus examination with FB. All patients underwent FB under local anesthesia and conscious sedation, with initial administration of 0.03 mg/kg midazolam. The sedation level during FB was objectively assessed using the Ramsay sedation score (RSS). Two hours after the procedure, patients completed a questionnaire about its efficacy and adverse effects using a visual analog scale (VAS). Receiver operating characteristic (ROC) curve analyses were performed to determine the optimal RSS that could improve the subjective efficacy indicated by the VAS.

RESULTS

This study enrolled 110 consecutive patients between September 2008 and February 2012. The median total amount of midazolam administered was 1.65 mg per patient. In an analysis of ROC curves between RSS and VAS, the area under the ROC curve for an RSS of 4 against the others was 0.66 (95% CI: 0.54 to 0.77, p = 0.014). The area under the ROC curve was not shown to be statistically significant for RSSs other than 4.

CONCLUSIONS

The optimal depth of conscious sedation during FB for conventional examination was achieved at an RSS of 4. The patients' subjective evaluations indicated that a deep level of conscious sedation does not seem necessary for FB.

Identification of patterns of factors preceding severe or life-threatening asthma exacerbations in a nationwide study

BACKGROUND

Reducing near-fatal asthma exacerbations is a critical problem in asthma management.

OBJECTIVES

To determine patterns of factors preceding asthma exacerbations in a real-world setting.

METHODS

In a nationwide prospective study of 190 patients who had experienced near-fatal asthma exacerbation, cluster analysis was performed using asthma symptoms over the 2-week period before admission.

RESULTS

Three distinct clusters of symptoms were defined employing the self-reporting of a visual analogue scale. Cluster A (42.1%): rapid worsening within 7.4 hours from moderate attack to admission, young to middle-aged patients with low Body mass index and tendency to depression who had stopped anti-asthma medications, smoked, and hypersensitive to environmental triggers and furred pets. Cluster B (40.0%): fairly rapid worsening within 48 hours, mostly middle-aged and older, relatively good inhaled corticosteroid (ICS) or ICS/long-acting beta-agonist (LABA) compliance, and low perception of dyspnea. Cluster C (17.9%): slow worsening over 10 days before admission, high perception of dyspnea, smokers, and chronic daily mild-moderate symptoms. There were no differences in overuse of short-acting beta-agonists, baseline asthma severity, or outcomes after admission for patients in these 3 clusters.

CONCLUSION

To reduce severe or life-threatening asthma exacerbation, personalized asthma management plans should be considered for each cluster. Improvement of ICS and ICS/LABA compliance and cessation of smoking are important in cluster A. To compensate for low perception of dyspnea, asthma monitoring of peak expiratory flow rate and/or exhaled nitric oxide would be useful for patients in cluster B. Avoidance of environmental triggers, increase usual therapy, or new anti-type 2 response-targeted therapies should be considered for cluster C.

Mechanism of Periostin Production in Human Bronchial Smooth Muscle Cells

BACKGROUND

Asthma is a chronic airway inflammatory disease characterized by airway remodeling, in which the bronchial smooth muscle (BSM) cells play an important role. Periostin, a biomarker that reflects Th2-driven inflammatory diseases such as asthma, may play an important role in the asthmatic airway. Although periostin is mainly produced in airway epithelial cells and fibroblasts after interleukin (IL)-13 stimulation, whether BSM cells produce periostin remains unclear. Therefore, we investigated periostin production in BSM cells and the mechanisms involved.

METHODS

Human BSM cells were cultured, and the effect of IL-13 stimulation on periostin production was evaluated using quantitative polymerase chain reaction and enzyme-linked immunosorbent assay (ELISA). We evaluated the phosphorylation of signal transducer and activator of transcription factor 6 (STAT6), extracellular signal-regulated kinase (ERK)1/2, and Akt after IL-13 stimulation. Furthermore, using ELISA, we evaluated the influence of several phosphorylation inhibitors on periostin production.

RESULTS

Periostin mRNA expression increased in a dose- and time-dependent manner after IL-13 stimulation; periostin production was induced 24 and 48 h after stimulation. IL-13 stimulation induced the phosphorylation of STAT6, ERK1/2, and Akt. IL-13-induced periostin production was attenuated by inhibiting STAT6 phosphorylation and strongly suppressed by inhibiting mitogen-activated protein kinase kinase 1/2 phosphorylation or phosphatidylinositol 3-kinase (PI3K) phosphorylation.

CONCLUSIONS

BSM cells produced periostin after IL-13 stimulation, via the JAK/STAT6, ERK1/2, and PI3K/Akt pathways. Understanding the mechanism of periostin production in BSM cells may help to clarify asthma pathogenesis.

A case of pulmonary cyst and pneumothorax after bronchial thermoplasty

Bronchial thermoplasty (BT) is a bronchoscopic treatment for severe asthma using thermal energy to reduce smooth muscle in the bronchial wall. A 47‐year‐old man underwent BT for uncontrolled severe asthma despite maximal pharmacological treatment. After a third procedure, he experienced hypoxaemia because of complete bilateral upper lobe atelectasis. A pulmonary cyst suddenly emerged in to the right middle lobe, associated with the pneumothorax on postoperative day 6, and a chest drainage tube was inserted. As atelectasis of the right upper lung suddenly improved on postoperative day 12, pneumothorax and the cyst improved. Excess stress on the middle lobe due to upper lobe collapse, and check valve due to airway oedema and phlegm, might be related to pulmonary cyst formation. Tissue fragility related to systemic steroid usage and pressure load during pulmonary function testing might influence the occurrence of pneumothorax. Severe adverse events under complete atelectasis after BT require careful attention.

A prospective, multicenter phase II trial of low-dose erlotinib as maintenance treatment after platinum doublet chemotherapy for advanced non-small cell lung cancer harboring EGFR mutation

BACKGROUND

Maintenance therapy with full-dose erlotinib for patients with advanced non-small cell lung cancer (NSCLC) has demonstrated a significant overall survival (OS) benefit. However, 150 mg/day of erlotinib seems too toxic as maintenance therapy. This study aimed to evaluate the efficacy and safety of low-dose erlotinib (25 mg/day) as maintenance treatment after platinum doublet chemotherapy in NSCLC harboring epidermal growth factor receptor (EGFR) mutation.

METHODS

Activated EGFR-mutation-positive NSCLC patients who did not progress after first-line platinum-doublet chemotherapy, ≥20 and ≤85 years old, with performance status (PS) 0-3 were included in this study. Low-dose erlotinib (25 mg/day) was administered until disease progression. The primary endpoint was overall response rate (ORR). Secondary endpoints included progression-free survival (PFS), OS, and safety. The required sample size was 40 patients.

RESULTS

The study was stopped early, after achieving only 28% of planned enrollment, due to poor accrual. Between April 2011 and May 2014, 11 patients (male/female, 5/6; median age, 72 years; PS 0/1, 8/3; stage IV/relapse after surgery, 9/2; exon 19 deletions/L858R, 7/4) were enrolled and accessible in this study. Partial response (PR) was observed in 6 patients (56%). Median PFS was 14.9 months [95% confidence interval (CI), 2.7-27.1 months] and median OS was not calculable. Toxicities were generally mild. Only one patient developed grade 3 aspartate aminotransferase (AST)/alanine aminotransferase (ALT) elevation. Eight patients developed grade 1 skin rash. No treatment-related deaths were observed. Eight patients progressed, and recurrences included brain metastases (n=3), local recurrence (n=2), local recurrence plus brain metastasis (n=1), bone metastasis (n=1), and pulmonary metastasis (n=1).

CONCLUSIONS

The study was stopped early due to poor accrual. However, our study suggests that maintenance therapy with low-dose erlotinib might be useful and tolerable in selected NSCLC patients harboring EGFR mutation.

Re-administration of abatacept for the control of articular symptoms of rheumatoid arthritis during anti-tuberculous therapy

This case report describes the re-administration of abatacept to successfully reduce the articularsymptoms of a patient with rheumatoid arthritisduring the intensive phase of anti-tuberculous therapy. A 75-year-old man developed active pulmonary tuberculosis during the administration of abatacept for rheumatoid arthritis. The patient experienced a paradoxical reaction and exacerbation of rheumatoid arthritis that caused us to discontinue the abatacept. Later re-administration of abatacept along with anti-tuberculosis treatment led to well-controlled rheumatoid arthritis without exacerbation of the tuberculosis. This case shows that re-administration of abatacept may be much safer than TNF inhibitor to treat patients who are infected with mycobacteria during thetreatment of immunological diseases such asrheumatoid arthritiswith biological agents.

TIM-3 is not essential for development of airway inflammation induced by house dust mite antigens

Background

T cell immunoglobulin domain and mucin domain-containing molecule 3 (TIM-3), which is preferentially expressed on Th1 cells rather than Th2 cells, is considered to be a negative regulator of Th1 cell function. This suggests that TIM-3 indirectly enhances Th2-type immune responses by suppressing Th1 cell function.

Methods

To investigate TIM-3's possible involvement in Th2-type acute and chronic airway inflammation, wild-type and TIM-3-deficient (TIM-3^−/−) mice were sensitized and challenged with a house dust mite (HDM) extract. Airway inflammation and the number of inflammatory cells in bronchoalveolar lavage fluids (BALFs) in the mice were determined by histological analysis and with a hemocytometer, respectively. Expression of mRNA in the lungs was determined by quantitative PCR, while the levels of cytokines in the BALFs and IgE in sera were determined by ELISA.

Results

Despite constitutive expression of TIM-3 mRNA in the lungs, the number of eosinophils in bronchoalveolar lavage fluids (BALFs) and the score of pulmonary inflammation were comparable between wild-type and TIM-3^−/− mice during both acute and chronic HDM-induced airway inflammation. On the other hand, the number of lymphocytes in the BALFs of TIM-3^−/− mice was significantly increased compared with wild-type mice during HDM-induced chronic, but not acute, airway inflammation, while the levels of Th2 cytokines in the BALFs and HDM-specific IgG1 and IgG2a and total IgE in the sera were comparable in both groups.

Conclusions

Our findings indicate that, in mice, TIM-3 is not essential for development of HDM-induced acute or chronic allergic airway inflammation, although it appears to be involved in reduced lymphocyte recruitment during HDM-induced chronic allergic airway inflammation.

Severe or life-threatening asthma exacerbation: patient heterogeneity identified by cluster analysis

BACKGROUND

Severe or life-threatening asthma exacerbation is one of the worst outcomes of asthma because of the risk of death. To date, few studies have explored the potential heterogeneity of this condition.

OBJECTIVES

To examine the clinical characteristics and heterogeneity of patients with severe or life-threatening asthma exacerbation.

METHODS

This was a multicentre, prospective study of patients with severe or life-threatening asthma exacerbation and pulse oxygen saturation < 90% who were admitted to 17 institutions across Japan. Cluster analysis was performed using variables from patient- and physician-orientated structured questionnaires.

RESULTS

Analysis of data from 175 patients with severe or life-threatening asthma exacerbation revealed five distinct clusters. Cluster 1 (n = 27) was younger-onset asthma with severe symptoms at baseline, including limitation of activities, a higher frequency of treatment with oral corticosteroids and short-acting beta-agonists, and a higher frequency of asthma hospitalizations in the past year. Cluster 2 (n = 35) was predominantly composed of elderly females, with the highest frequency of comorbid, chronic hyperplastic rhinosinusitis/nasal polyposis, and a long disease duration. Cluster 3 (n = 40) was allergic asthma without inhaled corticosteroid use at baseline. Patients in this cluster had a higher frequency of atopy, including allergic rhinitis and furred pet hypersensitivity, and a better prognosis during hospitalization compared with the other clusters. Cluster 4 (n = 34) was characterized by elderly males with concomitant chronic obstructive pulmonary disease (COPD). Although cluster 5 (n = 39) had very mild symptoms at baseline according to the patient questionnaires, 41% had previously been hospitalized for asthma.

CONCLUSIONS & CLINICAL RELEVANCE

This study demonstrated that significant heterogeneity exists among patients with severe or life-threatening asthma exacerbation. Differences were observed in the severity of asthma symptoms and use of inhaled corticosteroids at baseline, and the presence of comorbid COPD. These findings may contribute to a deeper understanding and better management of this patient population.

Asthmatic Attack Complicated with Takotsubo Cardiomyopathy after Frequent Inhalation of Inhaled Corticosteroids/Long-Acting Beta2-Adrenoceptor Agonists

A 63-year-old man was transferred to our hospital because of an exacerbation of asthma. His symptoms deteriorated even after increasing the dose of inhaled corticosteroids/long-acting beta2-adrenoceptor agonists (ICS/LABA). He had no chest pain and an electrocardiogram revealed ST elevation. A coronary angiogram revealed a reduced left ventricular function with an apical ballooning pattern without coronary stenosis. He was diagnosed with Takotsubo cardiomyopathy. Catecholamine elevation due to acute asthma and an overdose of ICS/LABA may be triggers of this disease. We should remember that Takotsubo cardiomyopathy is a complication of asthma and that catecholamine plays an important role in its onset, although it is essential for asthma treatment.

An Interleukin-33-Mast Cell-Interleukin-2 Axis Suppresses Papain-Induced Allergic Inflammation by Promoting Regulatory T Cell Numbers

House dust mite-derived proteases contribute to allergic disorders in part by disrupting epithelial barrier function. Interleukin-33 (IL-33), produced by lung cells after exposure to protease allergens, can induce innate-type airway eosinophilia by activating natural helper (NH) cells, a member of group 2 innate lymphoid cells (ILC2), to secrete Th2 type-cytokines. Because IL-33 also can induce mast cells (MCs) to secrete Th2 type-cytokines, MCs are thought to cooperate with NH cells in enhancing protease or IL-33-mediated innate-type airway eosinophilia. However, we found that MC-deficient Kit(W-sh/W-sh) mice exhibited exacerbated protease-induced lung inflammation associated with reduced numbers of regulatory T (Treg) cells. Moreover, IL-2 produced by IL-33-stimulated MCs promoted expansion of numbers of Treg cells, thereby suppressing development of papain- or IL-33-induced airway eosinophilia. We have thus identified a unique anti-inflammatory pathway that can limit induction of innate-type allergic airway inflammation mediated by NH cells.

The importance of bacterial and viral infections associated with adult asthma exacerbations in clinical practice

BACKGROUND

Viral infection is one of the risk factors for asthma exacerbation. However, which pathogens are related to asthma exacerbation in adults remains unclear.

OBJECTIVE

The relation between various infections and adult asthma exacerbations was investigated in clinical practice.

METHODS

The study subjects included 50 adult inpatients due to asthma exacerbations and 20 stable outpatients for comparison. The pathogens from a nasopharyngeal swab were measured by multiplex PCR analysis.

RESULTS

Asthma exacerbations occurred after a common cold in 48 inpatients. The numbers of patients with viral, bacterial, or both infections were 16, 9, and 9, respectively. The dominant viruses were rhinoviruses, respiratory syncytial virus, influenza virus, and metapneumovirus. The major bacteria were S. pneumoniae and H. influenzae. Compared to pathogen-free patients, the patients with pathogens were older and non-atopic and had later onset of disease, lower FeNO levels, lower IgE titers, and a higher incidence of comorbid sinusitis, COPD, or pneumonia. Compared to stable outpatients, asthma exacerbation inpatients had a higher incidence of smoking and comorbid sinusitis, COPD, or pneumonia. Viruses were detected in 50% of stable outpatients, but a higher incidence of rhinovirus, respiratory syncytial virus, and metapneumovirus infections was observed in asthma exacerbation inpatients. H. influenzae was observed in stable asthmatic patients. Other bacteria, especially S. pneumoniae, were important in asthma exacerbation inpatients.

CONCLUSION

Viral or bacterial infections were observed in 70% of inpatients with an asthma exacerbation in clinical practice. Infection with S. pneumoniae was related to adult asthma exacerbation.

Diffuse Liver Metastasis of Small-Cell Lung Cancer Presenting as Acute Liver Failure and Diagnosed by Transjugular Liver Biopsy: A Rare Case in Whom Nodular Lesions Were Detected by Enhanced CT Examination

Small-cell lung cancer (SCLC) is a subgroup of lung cancer with a high frequency of liver metastasis, which is a predictor of poor prognosis. Diffuse liver metastases of SCLC with no visible nodular lesions in the liver when examined using computed tomography (CT) are relatively rare; however, a few cases with rapid progression to acute liver failure that were diagnosed after death have been reported. In this paper, we report a 63-year-old man with diffuse liver metastases of SCLC that were histologically diagnosed using a transjugular liver biopsy while the patient was alive, even though no lesions were visible during a contrast-enhanced CT examination.

Asthma Control Can Be Maintained after Fixed-Dose, Budesonide/Formoterol Combination Inhaler Therapy is Stepped Down from Medium to Low Dose

BACKGROUND

In cases using a budesonide/formoterol combination inhaler, many patients are started on fixed-dose treatment at 640/18 μg (4 puffs) daily, but there are no guidelines yet regarding the step-down method when control has been maintained.

METHODS

Patients with moderate asthma treated with either budesonide 400 μg and salmeterol 100 μg (GINA step3 group) or salmeterol/fluticasone 250 at 2 puffs (GINA step4 group) were enrolled and started on therapy of budesonide/formoterol 4 puffs. Thereafter, step-down to 2 puffs was performed if either of the following criteria was met at 8-week intervals: fractional exhaled nitric oxide (FeNO)≤28 ppb plus asthma control test (ACT) score≥22, or ACT score≥24 at 3 consecutive visits regardless of FeNO level. Thereafter, changes in ACT score, the number of acute exacerbations and reliever use, and FeNO level were monitored through 48^th week.

RESULTS

Fifty-one patients, 27 in step3 group and 24 in step4 group, underwent step-down. ACT scores and the number of reliever use remained stable in both groups even after step-down. In contrast, FeNO levels increased gradually in step4 group, whereas in the step3 group they increased immediately after step-down. Step-down was considered to be safely performed because the numbers of reliever use and those of moderate or more severe exacerbations during the 48-week period has not changed significantly compared to before step-down.

CONCLUSIONS

If complete control of asthma, not only of clinical symptoms but also airway inflammation, is achieved by 3-6 months of fixed-dose budesonide/formoterol 4 puffs/day, it should be possible to safely perform step-down to 2 puffs/day.

Clinical usefulness of a guideline-based screening tool for the diagnosis of allergic rhinitis in asthmatics: the Self Assessment of Allergic Rhinitis and Asthma questionnaire

BACKGROUND AND OBJECTIVE

Allergic rhinitis (AR) is common in asthmatic patients and may impair asthma control. However, this comorbidity is frequently missed. A simple test is needed to enable physicians to diagnose and evaluate the severity of both diseases. The Self Assessment of Allergic Rhinitis and Asthma (SACRA) questionnaire, which GINA and ARIA Japan committees developed in 2011, consist of questionnaires based on GINA and ARIA guidelines for the diagnosis and severity of AR and asthma, and a visual analogue scale (VAS) to evaluate the severity of both diseases. Our objective was to investigate the clinical usefulness of SACRA as a patient-based screening tool for identifying asthmatic patients with AR.

METHODS

SACRA, ACT (Asthma Control Test) and serum IgE RAST were performed in asthmatic patients. The correlation between SACRA and other parameters were analyzed.

RESULTS

Four hundred twenty asthmatic patients were enrolled. Among 168 subjects who self-reported no concomitant AR, 76 asthmatics scored one or more symptoms on SACRA. Eventually, 32 of these 76 subjects were diagnosed with AR by physicians based on laboratory data or physical examinations by ear, nose and throat specialists. The sensitivity and specificity of SACRA for the diagnosis of AR were 92% and 66%, respectively. The estimated prevalence of AR among asthmatics was 66%, almost identical to that of the previous nationwide study in Japan. The level of asthma control assessed by the VAS on SACRA and the ACT score showed a strong correlation (r = -0.700, P < 0.001).

CONCLUSIONS

SACRA may be a clinically useful tool for identifying bronchial asthma patients with AR.

A comparison of long-term anti-inflammatory effect of two ICS/LABA combination inhalers; fix-dosed maintenance therapy with budesonide/formoterol and salmeterol/fluticasone

BACKGROUND

The clinical usefulness of fixed-dose maintenance therapy with salmeterol/fluticasone (SFC) and budesonide/formoterol combination inhaler (BUD/FM) has been established, though evidence of the long-term anti-inflammatory effects of these 2 inhalers are limited.

METHODS

Patients with moderate persistent adult asthma who had received SFC 50/250μg bid with well-control status were recruited. After switching to 8-week therapy with fixed-dose BUD/FM 4 puffs (640/18μg) (phase-1), patients chose either SFC or BUD/FM. FeNO and ACT score were evaluated every 8 weeks until the end of the 52-week treatment period for both treatment groups (phase-2).

RESULTS

In total, 103 patients were examined: BUD/FM was chosen by 34 patients (BUD/FM group), while SFC was chosen by 23 (SFC group). Thirty-six received SFC consistently from the beginning of the study (control). Patients in the BUD/FM and SFC groups showed significant improvements in ACT scores and FeNO levels in phase-1; these beneficial effects persisted for 52 weeks in the BUD/FM group. On the other hand, in the SFC group, although the FeNO level decreased from 54.3 ± 26.4 ppb to 41.9 ± 18.3 ppb in phase-1, it increased to 54.5 ± 26.2 ppb, a level similar to the baseline prior to the beginning of BUD/FM therapy, at 8 weeks in phase-2, and remained at 50-odd ppb thereafter.

CONCLUSIONS

These results suggest that maintenance therapy with fixed-dose BUD/FM is a useful treatment option exerting an airway anti-inflammatory effect for a period as long as 1 year, even for asthmatics who could not accomplish total control with SFC.