Quality of Life, Mental Health, and CPAP Compliance in Thai Patients with Obstructive Sleep Apnea during COVID-19 Pandemic

Background

This study is aimed at determining the quality of life, mental health, and adherence to continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea (OSA) among Thai OSA patients during the coronavirus disease 2019 (COVID-19) pandemic as this data has been lacking.

Methods

A cross-sectional study was conducted at a university hospital between September 2021 and April 2022. OSA patients aged 18 years or older who required home CPAP treatment were included. Sleep Apnea Quality of Life Index (SAQLI) and Depression Anxiety Stress Scales-21 (DASS-21) were used to assess quality of life and mental health, respectively.

Results

A total of 142 participants (62% male) were included, with a mean age of 54.4 ± 14.7 years and a body mass index of 29.9 ± 6.8 kg/m2. Polysomnographic data showed a mean apnea-hypopnea index of 48.0 ± 32.4 events/hour and a mean lowest oxygen saturation of 79.2 ± 12.2%. Severe OSA was observed in 66.9%. CPAP compliance was reported in 50.7%. The SAQLI score was 2.32 ± 1.12. Depression, anxiety, and stress scores in DASS-21 were 2.89 ± 3.31, 3.94 ± 3.67, and 4.82 ± 4.00, respectively. Compared to the CPAP compliance group, the CPAP noncompliance group had higher daily activity scores in SAQLI (2.98 ± 1.25 vs. 2.45 ± 1.33, P = 0.015).

Conclusions

The quality of life for Thai OSA patients during the COVID-19 era was moderate degree. Poor CPAP compliance was significantly associated with limited daily activity. Enhancing CPAP compliance could improve the quality of life in these patients. This trial is registered with TCTR20211104004.

Expert panel consensus recommendations on the utilization of nebulized budesonide for managing asthma and COPD in both stable and exacerbation stages in Thailand

OBJECTIVE

This study investigated the utilization of nebulized budesonide for acute asthma and COPD exacerbations as well as for maintenance therapy in adults.

DATA SOURCES

We conducted a search on PubMed for nebulized budesonide treatment.

SELECTED STUDIES

Selecting all English-language papers that utilize Mesh phrases "asthma," "COPD," "budesonide," "nebulized," "adult," "exacerbation," and "maintenance" without temporal restrictions, and narrowing down to clinical research such as RCTs, observational studies, and real-world studies.

RESULTS

Analysis of 25 studies was conducted to assess the effectiveness of nebulized budesonide in asthma (n = 10) and COPD (n = 15). The panel in Thailand recommended incorporating nebulized budesonide as an additional or alternative treatment option to the standard of care and systemic corticosteroids (SCS) based on the findings.

CONCLUSION

Nebulized budesonide is effective and well-tolerated in treating asthma and COPD, with less systemic adverse effects compared to systemic corticosteroids. High-dose nebulized budesonide can enhance clinical outcomes for severe and mild exacerbations with slow systemic corticosteroid response. Nebulized budesonide can substitute systemic corticosteroids in some situations.

dCROX and ROX Indices Predict Clinical Outcomes in Patients with COVID-19 Pneumonia Treated with High-Flow Nasal Cannula Oxygen Therapy

Background

High-flow nasal cannula (HFNC) therapy is a common respiratory support in patients with COVID-19 pneumonia. Predictive tools for the evaluation of successful weaning from HFNC therapy for COVID-19 pneumonia have been limited. This study aimed to develop a new predictor for weaning success from HFNC treatment in patients with COVID-19 pneumonia.

Methods

We conducted a retrospective cohort study at Thammasat University Hospital, Thailand. Patients with COVID-19 pneumonia requiring HFNC therapy from April 2020 to September 2021 were included. The ROX index was defined as the ratio of oxygen saturation (SpO2)/fraction of inspired oxygen (FiO2) to respiratory rate. The CROX index was defined as the ratio of C-reactive protein (CRP) to the ROX index. dCROX was defined as the difference in CROX index between 24 hours and 72 hours. Weaning success was defined as the ability to sustain spontaneous breathing after separation from HFNC without any invasive or noninvasive ventilatory support for ≥48 hours or death.

Results

A total of 106 patients (49.1% male) were included. The mean age was 62.1 ± 16.2 years. Baseline SpO2/FiO2 was 276.1 ± 124.8. The rate of HFNC weaning success within 14 days was 61.3%. The best cutoff value of the dCROX index to predict HFNC weaning success was 3.15 with 66.2% sensitivity, 70.7% specificity, and an area under the ROC curve (AUC) of 0.71 (95% CI: 0.59-0.81, p < 0.001). The best cutoff value of the ROX index was 9.13, with 75.4% sensitivity, 78.0% specificity, and an AUC of 0.79 (95% CI: 0.69-0.88, p < 0.001).

Conclusions

ROX index has the highest accuracy for predicting successful weaning from HFNC in patients with COVID-19 pneumonia. dCROX index is the alternative tool for this setting. However, a larger prospective cohort study is needed to verify these indices for determining separation from HFNC therapy. This trial is registered with TCTR20221107004.

Comparison of ROX, HROX, and delta-HR indices to predict successful weaning from high-flow oxygen therapy in hospitalized patients with COVID-19 pneumonia

BACKGROUND

High-flow nasal cannula (HFNC) therapy is commonly used to treat acute respiratory failure in patients with COVID-19 pneumonia. However, predictors of successful weaning from HFNC in these patients has not been investigated.

OBJECTIVE

To assess predictors of successful separation from HFNC in patients with COVID-19 pneumonia.

METHODS

We conducted a retrospective cohort study at a university hospital in Thailand. Patients with COVID-19 pneumonia requiring HFNC therapy between April 2020 and June 2022 were included. ROX index was defined as the ratio of oxygen saturation (SpO2) / fraction of inspired oxygen (FiO2) to respiratory rate. Heart-ROX (HROX) index was defined as ROX multiplied by heart rate (HR) improvement. HR improvement (delta-HR) was defined as a percentage of the difference between the baseline HR and the morning HR at HFNC weaning day 1 divided by the baseline HR. Weaning success was defined as ability to sustain spontaneous breathing after separation from HFNC without any invasive or non-invasive ventilatory support for ≥48 hours or death.

RESULTS

A total of 164 patients (54% male) were included. Mean age was 61.1±16.1 years. Baseline SpO2/FiO2 was 265.3±110.8. HFNC weaning success was 77.4%. The best cut-off value of ROX index to predict HFNC weaning success was 7.88 with 100% sensitivity, 97.3% specificity, and area under the ROC curve (AUC) of 0.98 (95% CI: 0.937-1.000, p<0.001). The best cut-off value of delta-HR 3.7 with 88.2% sensitivity, 75.7% specificity, and AUC of 0.83 (95% CI: 0.748-0.919, p<0.001). The best cut-off value of HROX index was 59.2 with 88.2% sensitivity, 81.1% specificity, and AUC of 0.89, (95% CI: 0.835-0.953, p<0.001).

CONCLUSIONS

The ROX index has the highest accuracy for predicting successful weaning off HFNC treatment in patients with COVID-19 pneumonia. While HROX and delta-HR indices can serve as alternative tools, it is recommended to verify these indices and determine the optimal cut-off value for determining separation from HFNC therapy through a large prospective cohort study.

TRIAL REGISTRATION

Clinicaltrials.in.th number: TCTR20221108004.

Allergic rhinitis and other comorbidities associated with asthma control in Thailand

Background

Asthma and allergic rhinitis (AR) can coexist and cause disabilities. This study aimed to assess the association between AR, asthma control, asthma-related quality of life, and other comorbidities.

Methods

A cross-sectional study was conducted in adults with asthma in six hospitals in Thailand. The outcomes were association of asthma control assessed by the asthma control test (ACT), AR, and asthma comorbidities. Not-well-controlled asthma was defined as ACT scores ≤22. The severity of AR was determined by visual analog scale (VAS). Severe AR was defined as VAS ≥5. Asthma-related quality of life (AQLQ), comorbidities, and total IgE were recorded.

Results

A total of 682 asthmatic patients were included. Median (IQR) age was 58.0 (47.0-64.0) years. 69.9% were female. Not-well-controlled asthma was present in 44.7%. The prevalence of AR was 86.1%. Moderate/severe persistent AR was diagnosed in 21.7% and severe AR was diagnosed in 30.2% of the patients. Inhaled corticosteroid-containing regimens were prescribed in 97.7% of patients. Intranasal corticosteroid and antihistamine were prescribed in 65.7 and 31.7%, respectively. Patients with not-well-controlled asthma had higher body mass index, VAS scores, proportions of pollution exposure, aeroallergen sensitization, severe AR, nasal polyp, urticaria, food allergy, gastroesophageal reflux disease, depression and anxiety, peptic ulcer, and asthma exacerbations, but younger age, lower AQLQ scores, and lower FEV1. Correlation was found between AR severity and ACT (r = -0.461, p < 0.001), AQLQ (r = -0.512, p < 0.001), and total IgE (r = 0.246, p < 0.023). Multiple regression analysis revealed that ACT, AQLQ, and percentage of FEV1/FVC were significantly associated with severe AR.

Conclusion

Allergic rhinitis is prevalent in Thai asthmatic patients. AR severity is associated with asthma control, quality of life, and pulmonary function. Comprehensive care is essential for patients with uncontrolled asthma, particularly when coexisting with conditions.

Optimizing the Yield of Abnormal Preoperative Chest Radiographs in Elective Non-cardiothoracic Surgery: Development of a Risk Prediction Score and External Validation

BACKGROUND

Guideline recommendations for preoperative chest radiographs vary to the extent that individual patient benefit is unclear. We developed and validated a prediction score for abnormal preoperative chest radiographs in adult patients undergoing elective non-cardiothoracic surgery.

METHODS

Our prospective observational study recruited 703 adult patients who underwent elective non-cardiothoracic surgery at Ramathibodi Hospital. We developed a risk prediction score for abnormal preoperative chest radiographs with external validation using data from 411 patients recruited from Thammasat University Hospital. The discriminative performance was assessed by receiver operating curve analysis. In addition, we assessed the contribution of abnormal chest radiographs to perioperative management.

RESULTS

Abnormal preoperative chest radiographs were found in 19.5% of the 703 patients. Age, pulmonary disease, cardiac disease, and diabetes were significant factors. The model showed good performance with a C-statistics of 0.739 (95% CI, 0.691-0.786). We classified patients into four groups based on risk scores. The posttest probabilities in the intermediate-, intermediate-high-, and high-risk groups were 33.2%, 59.8%, and 75.7%, respectively. The model fitted well with the external validation data with a C statistic of 0.731 (95% CI, 0.674-0.789). One (0.4%) abnormal chest radiograph from the low-risk group and three (2.4%) abnormal chest radiographs from the intermediate-to-high-risk group had a major impact on perioperative management.

CONCLUSIONS

Four predictors including age, pulmonary disease, cardiac disease, and diabetes were associated with abnormal preoperative chest radiographs. Our risk score demonstrated good performance and may help identify patients at higher risk of chest abnormalities.

Three-Month Variability of Commonly Evaluated Biomarkers in Clinically Stable COPD

Introduction

Clinical decisions in chronic obstructive pulmonary disease (COPD) treatment often utilize serially assessed physiologic parameters and biomarkers. To better understand the reliability of these tests, we evaluated changes in commonly assessed biomarkers over 3 months in patients with clinically stable COPD.

Methods

We performed an observational prospective cohort study of 89 individuals with clinically stable COPD, defined as no exacerbation history within 3 months of enrollment. Biomarkers included lung function and functional performance status, patient-reported outcomes of symptoms and health status, and blood markers of inflammation. The correlation between testing at baseline and at 3-month follow-up was reported as the intraclass correlation coefficient (ICC). "Outliers" had significant variability between tests, defined as >1.645 standard deviations between the two measurements. Differences in clinical features between outliers and others were compared.

Results

Participants with COPD (n = 89) were 70.5 ± 6.7 years old, 54 (61%) male, had a 40 pack-year smoking history with 24.7% being current smokers, and postbronchodilator forced expiratory volume in one second (FEV1) 62.3 ± 22.7% predicted. The biomarkers with excellent agreement between the initial and the follow-up measurements were FEV1 (ICC = 0.96), Saint George's Respiratory Questionnaire (SGRQ) (ICC = 0.98), COPD Assessment Test (CAT) (ICC = 0.93) and C-reactive protein (CRP) (ICC = 0.90). By contrast, parameters showing less robust agreement were 6-minute walking distance (ICC = 0.75), eosinophil count (ICC = 0.77), erythrocyte sedimentation rate (ICC = 0.75) and white blood cell count (ICC = 0.48). Individuals with greater variability in biomarkers reported chronic bronchitis more often and had higher baseline SGRQ and CAT scores.

Conclusion

Our study evaluated the stability of commonly assessed biomarkers in clinically stable COPD and showed excellent agreement between baseline and three-month follow-up values for FEV1, SGRQ, CAT and CRP. Individuals with chronic bronchitis and more symptomatic disease at baseline demonstrated greater variability in 3-month interval biomarkers.

Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

BACKGROUND

Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation.

METHODS

WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109.

FINDINGS

Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0-4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2-6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital.

INTERPRETATION

In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates.

FUNDING

European Society of Intensive Care Medicine, European Respiratory Society.

Factors influencing acceptance of influenza and pneumococcal vaccinations for patients with chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD), often complicated by influenza or pneumococcus, is a leading cause of mortality worldwide. Vaccinations against influenza and pneumococcus are, but vaccination coverage in Thailand has not been ascertained. This study aimed to determine the determinants of influenza and pneumococcal vaccination acceptance in COPD patients. A cross-sectional study of 210 COPD patients was conducted. Demographics, vaccinations, clinical outcomes (exacerbations and hospitalizations), and pulmonary functions were collected. A total of 134 COPD patients (91.0%male) were eligible for final analysis. Of these, 102 (76.1%) and 59 (44.0%) were vaccinated against influenza and pneumococcus, respectively. The influenza-vaccinated group had a higher rate of pneumococcal vaccination than the influenza-unvaccinated group (57.8% vs 0%, P < .001). Rates of influenza and pneumococcal vaccinations were higher in the pulmonologist group than in the non-pulmonologist group (71.6% vs 31.3%, P < .001 and 91.5% vs 38.7%, P < .001, respectively). By multivariable logistic regression analysis, influenza vaccination coverage was significantly higher among patients with bronchodilator response on pulmonary function testing. Pneumococcal vaccination coverage was significantly higher among patients who were seeing pulmonologists. Reasons for not getting influenza vaccination or pneumococcal vaccination were lack of recommendation, lack of knowledge, and misunderstanding, and in the case of pneumococcal vaccine, the expense. In conclusion, the influenza vaccination coverage in our COPD patients was considered high while the pneumococcal vaccination coverage was considered low. Physicians are advised to recommend and promote pneumococcal vaccination.

Guidelines for the management of asthma in adults: Evidence and recommendations

The multidisciplinary experts in Thailand developed an asthma management recommendation that was relevant to low-middle income countries (LMICS). Populations level consideration about asthma management is emphasized. The healthcare systems, access to and availability of treatments as well as the asthma populations vary from country to country in LMICS. The feasibility in clinical practice for implementation is also a major issue. For these reasons, the practice guidelines that are relevant to local contexts are essential to improve better asthma control. Furthermore, integrative and collaboration between asthma experts and the public health sector to implement and discriminate such guidelines will help to achieve these challenging goals. The topics covered include the current asthma situation in Thailand and the Asia-Pacific region, the definition of asthma, asthma diagnosis, assessment of asthma patients, asthma treatment - both pharmacological and non-pharmacological, management of asthma exacerbation, management of asthma comorbidities, treatment of asthma in special conditions, severe and uncontrolled asthma, Thai alternative medicine and asthma, and asthma and coronavirus disease-19 (COVID-19).

Handgrip strength cutoff value predicting successful extubation in mechanically ventilated patients

Background

Handgrip strength (HGS) is an alternative tool to evaluate respiratory muscle function. HGS cutoff value indicating extubation success or failure has not been investigated. This study aimed to determine HGS cutoff value to predict successful extubation.

Methods

A prospective study was conducted. Patients requiring intubated mechanical ventilation with intubation ≥ 48 hours in medical wards were recruited. HGS test was performed at 10 minutes before and 30 minutes after spontaneous breathing trial (SBT). Rapid shallow breathing index (RSBI) was measured at 10 minutes before SBT.

Results

Ninety-three patients (58% men) were included. Mean age was 71.6 ± 15.2 years. Weaning failure rate was 6.5%. The area under the ROC curve of 0.84 for the best HGS cutoff value at 10 minutes before SBT was 12.7 kg, with 75.9% sensitivity and 83.3% specificity (P = 0.005). The best HSG cutoff value at 30 minutes after SBT was 14.9 kg, with the area under the ROC curve of 0.82, with 58.6% sensitivity and 83.3% specificity (P = 0.009). The best RSBI cutoff value was 43.5 breaths/min/L, with the area under the ROC curve of 0.46, 33.3% sensitivity and 66.6% specificity (P = 0.737).

Conclusions

HGS may be a predictive tool to guide extubation with better sensitivity and specificity than RSBI. A prospective study is needed to verify HGS test as adjunctive to RSBI in ventilator weaning protocol.

Prediction of optimal continuous positive airway pressure in Thai patients with obstructive sleep apnea

Continuous positive airway pressure (CPAP) is simple and effective treatment for obstructive sleep apnea (OSA) patients. However, the CPAP prediction equation in each country is different. This study aimed to predict CPAP in Thai patients with OSA. A retrospective study was conducted in Thai patients, who OSA was confirmed by polysomnography and CPAP titration from January 2015 to December 2018. Demographics, body mass index (BMI), neck circumference (NC), Epworth sleepiness scale, apnea–hypopnea index (AHI), respiratory disturbance index (RDI), mean and lowest pulse oxygen saturation (SpO₂), and optimal pressure were recorded. A total of 180 subjects were included: 72.8% men, age 48.7 ± 12.7 years, BMI 31.0 ± 6.3 kg/m², NC 40.7 ± 4.1 cm, AHI 42.5 ± 33.0 per hour, RDI 47.1 ± 32.8 per hour, and lowest SpO₂ 77.1 ± 11.0%. Multiple linear regression analysis identified NC, BMI, RDI, and lowest SpO₂. A final CPAP predictive equation was: optimal CPAP (cmH₂O) = 4.614 + (0.173 × NC) + (0.067 × BMI) + (0.030 × RDI) − (0.076 × lowest SpO₂). This model accounted for 50.0% of the variance in the optimal pressure (R² = 0.50). In conclusion, a CPAP prediction equation can be used to explain a moderate proportion of the titrated CPAP in Thai patients with OSA. However, the CPAP predictive equation in each country may be different due to differences of ethnicity and physiology.

Trial registration: TCTR20200108003.

Interest of hand grip strength to predict outcome in mechanically ventilated patients

BACKGROUND

Weaning from mechanical ventilation is a crucial process for critically ill patients. Hand grip strength (HGS) is an assessment tool for respiratory muscle function to assist guidance of extubation.

OBJECTIVE

To evaluate HGS as a predictor for in-hospital clinical outcomes in mechanically ventilated patients.

METHODS

A prospective study was conducted. Patients requiring mechanical ventilation with tracheal intubation in medical wards and intensive care units were recruited. HGS, reintubation, number of ventilator-free days and mortality were recorded.

RESULTS

A total of 34 patients (52.9% men) were included. When compared to the non re-intubation group, the re-intubation group had significantly lower HGS at 10 min and 30 min after starting spontaneous breathing trial (7.6 ± 4.8 kg Vs 13.4 ± 6.5 kg, P = 0.045, and 8 ± 5.1 kg Vs 13.2 ± 5.7 kg, P = 0.047). Moreover, at 1 h and 48 h of post extubation, the re-intubation group had lower HGS than the non re-intubation group. HGS at 1 h of post extubation was positively correlated with ventilator-free day at 28 days (r = 0.34, P = 0.05). HGS did not differ between survival group and death group in hospital over time.

CONCLUSIONS

Hand grip strength may be a predictive tool for extubation failure in mechanically ventilated patients. Low strength corresponded to significantly increased re-intubation rate. Furthermore, this measurement could not predict in-hospital mortality.

Incidence and outcome of weaning from mechanical ventilation in medical wards at Thammasat University Hospital

BACKGROUND

Weaning from mechanical ventilation is classified as simple, difficult, or prolonged according to weaning process. Theoretically, simple weaning group usually has better clinical outcomes than non-simple group; however, the results of previous studies were still inconsistent.

OBJECTIVES

The purpose of the study was to determine the incidence, predictors, and outcomes of ventilator weaning and causes of weaning failure.

METHODS

A prospective observational study was performed between June and December 2013 in all patients (n = 164) who required mechanical ventilation with endotracheal intubation in medical wards at Thammasat University Hospital, Thailand. Duration of weaning, causes of weaning failure, extubation, reintubation, tracheostomy, number of ventilator-free days within 28 days, length of hospital stay, and hospital mortality were measured.

RESULTS

103 patients were eligible for final analysis. Mean ± SD age was 65.1±17.5 years and 55.3% were males. The incidences of simple, difficult and prolonged weaning were 46.6%, 36.9% and 16.5%, respectively. The mortality rates for simple, difficult, and prolonged weaning were 0%, 10.5% and 23.5% (p = 0.006), respectively. The 3 causes of weaning failure in non-simple weaning were bronchospasm, pneumonia, and malnutrition.

CONCLUSIONS

Non-simple weaning increased mortality. Bronchospasm, pneumonia, and malnutrition were key risk factors for weaning failure. Strategies are needed to minimize their effects.

ASSESSMENT OF A NEW SMOKING CESSATION PROGRAM AT THAMMASAT UNIVERSITY HOSPITAL, PATHUM THANI, THAILAND

The Smoking Cessation Clinic (SCC) at Thammasat University Hospital had only 27 patients from October 2013 to September 2014 and a quit rate of only 3.7%. A new smoking cessation program was implemented at the end of 2014 to improve success rates. This new program is an interdisciplinary program that includes several health care specialists. The study aimed to examine the characteristics of the smokers and the outcomes after implementing the new program with an interdisciplinary approach at the SCC in order to gain data to improve the efficacy of the SCC. This prospective descriptive study was conducted by the SCC from December 2014 to December 2015. During the study period 111 patients attended the SCC under the new program and all were included in the survey; 100 (90.1%) were men. The mean (±SD) age of these patients was 56.5±13.5 years. The mean (±SD) age of onset of smoking was 18.5±5.5 years. Smoking cessation in the program was checked by measuring the exhaled carbon monoxide levels at 6 months after reporting smoking cessation. A level less than 10 parts per million was considered not to be a smoker. Of the 111 patients, 14 (12.6%) had reported smoking cessation and had an exhaled carbon monoxide level less than 10 parts per million. The new smoking cessation program was attended by more patients and had a higher success rate than the previous smoking cessation program, although the smoking cessation success rate was still low. Further studies are needed to determine which factors improved cessation rates and to determine other factors associated with successful smoking cessation in the study population.

Anaesthetic Management for Caesarean Delivery Patient with Obstructed Superior Vena Cava by Mediastinal Mass

Maternal anatomical and physiological changes occur during pregnancy, particularly with cardiovascular and respiratory systems. Pregnant women with large mediastinal mass additionally have an increased risk of cardiopulmonary compromise. We report a 31-year-old patient at 30 weeks of gestation with a large anterior mediastinal tumour with superior vena cava obstruction. Her presenting symptom was progressive and severe dyspnea due to the large mediastinal mass. An ultrasound-guided biopsy was performed and the pathologic result was Hodgkin’s lymphoma. Termination of pregnancy and delivery of the neonate were performed using a Caesarean delivery under spinal anesthesia in the sitting position. The perioperative anaesthetic management was successful without any serious complications, and the postoperative outcomes were very impressive.

Diagnostic Value of Pleural Fluid Adenosine Deaminase in Tuberculous Pleuritis at Thammasat University Hospital

BACKGROUND

Pleural fluid adenosine deaminase (ADAPF) is a diagnostic test for diagnosing the early tuberculous pleuritis (TBP). However, cutoff values vary widely in many studies.

OBJECTIVE

To determine the optimal diagnostic value of ADAPF.

MATERIAL AND METHOD

A prospective study was performed between August 2012 and August 2014. One hundred seventyeight patients with pleural effusions; 29 TBPs, 63 malignant pleural effusions (MPEs), 40 parapneumonic effusions (PARAEs), 18 transudates, 5 empyemas, 19 other exudates, and 4 unknown causes, were investigated.

RESULTS

Mean + SD of ADAPF was 60.0+25.6 U/L with TBPs, 15.6+11.1 U/L with MPEs, 15.8+9.9 U/L with PARAEs, 6.6+5.7 U/L with transudates, 13.8+7.7 U/L with empyemas, 14.5+7.1 U/L with other exudates, and 17.8+4.6 U/L with unknown causes. The area under the ROC curve was 0.983 (95% CI: 0.969-0.998) for the best ADAPF cutoff value of 33.5 U/L, with 93.1% sensitivity, 94.6 % specificity, 77.1% positive predictive value, and 98.6% negative predictive. ADAPF level <30.5 U/L suggests that a TBP is highly unlikely.

CONCLUSION

Pleural fluid ADA assay is a helpful diagnostic tool with high sensitivity and specificity for the rapid diagnosis of TBP.

DIFFERENCES IN CLINICAL MANIFESTATIONS AND PLEURAL FLUID CHARATERISTICS BETWEEN TUBERCULOUS AND MALIGNANT PLEURAL EFFUSIONS

Tuberculous and malignant pleural effusions share similar clinical and radiographic findings and both may produce lymphocytic-predominant exudative effusions. This study aimed to determine distinguishing clinical features between the two diseases. We conducted a retrospective study among 47 patients with tuberculous pleural effusions (TBPE) and 73 with malignant pleural effusions (MPE). Demographic data, clinical features, pleural fluid characteristics, and radiographic findings were obtained for each patient and the 2 groups were compared. Sixty-nine (57.5%) patients were males. The mean (+/- SD, range) age was 60.2 (+/- 16.9, 19-94) years. Mean (+/- SD) symptom duration was 31.6 (+/- 51.6) days. Univariate analysis identified 20 clinical, pleural fluid and radiological differences between the two groups. Multivariate logistic regression analysis revealed 3 independent predictors of TBPE: fever (OR=8.2; 95% CI: 1.9 - 35.9; p=0.005), having a non-serosanguinous effusion (OR=6.1; 95% CI: 1.1 - 33.6; p=0.038), and a fluid adenosine deaminase level > 30 U/I (OR=86.7; 95% CI: 4.3 - 1735; p=0.004). Fever, non-serosanguinous pleural effusions and high adenosine deaminase levels were suggestive of a TBPE and could be clinically useful when evaluating a pleural effusion of unknown etiology.

Prevalence, clinical manifestations and mortality rate in patients with spontaneous pneumothorax in Thammasat University Hospital

BACKGROUND

Spontaneous pneumothorax (SP) can be a medical emergency requiring early diagnosis and treatment to prevent subsequent respiratory failure and death. SP epidemiologic and clinical data are limited in Thailand

OBJECTIVE

To study the prevalence, clinical manifestations, and mortality rate of SP in Thai patients.

MATERIAL AND METHOD

A retrospective case study was conducted between July 2004 and December 2010 in patients with a confirmed diagnosis of SP Demographic, etiologic, clinical, radiographic, and outcome data were collected.

RESULTS

One hundred patients with SP were identified (66 primary, 34 secondary SP), for a prevalence of 76.3 per 100,000 hospital admissions. Males numbered 83. Male to female ratios were 7.5:1 and 4.1:1 for primary and secondary SP respectively. Mean (+/- standard deviation) age and body mass index were 35.3 +/- 20.3 years and 18.0 +/- 2.2 kilogram/meter2. The common presenting symptoms were dyspnea (73%), chest pain or discomfort (68%), pleuritic pain (46%), cough (20%), and fever (13%). Causes of secondary SP were pulmonary tuberculosis (19/34, 55.9%), chronic obstructive pulmonary disease (14/34, 41.2%), and pneumonia (8/34, 23.5%). There were 12 deaths (12%), 11 with secondary SP CONCLUSION: Spontaneous pneumothorax was relatively common with typical clinicalfeatures. Almost all of mortality cases rate suffered secondary SP Prospective studies are needed to develop evidenced based algorithms, especially for secondary SP patients.