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Sulaiman I, Wu BG, Chung M, Isaacs B, Tsay JCJ, Holub M, Barnett CR, Kwok B, Kugler MC, Natalini JG, Singh S, Li Y, Schluger R, Carpenito J, Collazo D, Perez L, Kyeremateng Y, Chang M, Campbell CD, Hansbro PM, Oppenheimer BW, Berger KI, Goldring RM, Koralov SB, Weiden MD, Xiao R, D’Armiento J, Clemente JC, Ghedin E, Segal LN. Lower Airway Dysbiosis Augments Lung Inflammatory Injury in Mild-to-Moderate Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2023; 208:1101-1114. [PMID: 37677136 PMCID: PMC10867925 DOI: 10.1164/rccm.202210-1865oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 09/07/2023] [Indexed: 09/09/2023] Open
Abstract
Rationale: Chronic obstructive pulmonary disease (COPD) is associated with high morbidity, mortality, and healthcare costs. Cigarette smoke is a causative factor; however, not all heavy smokers develop COPD. Microbial colonization and infections are contributing factors to disease progression in advanced stages. Objectives: We investigated whether lower airway dysbiosis occurs in mild-to-moderate COPD and analyzed possible mechanistic contributions to COPD pathogenesis. Methods: We recruited 57 patients with a >10 pack-year smoking history: 26 had physiological evidence of COPD, and 31 had normal lung function (smoker control subjects). Bronchoscopy sampled the upper airways, lower airways, and environmental background. Samples were analyzed by 16S rRNA gene sequencing, whole genome, RNA metatranscriptome, and host RNA transcriptome. A preclinical mouse model was used to evaluate the contributions of cigarette smoke and dysbiosis on lower airway inflammatory injury. Measurements and Main Results: Compared with smoker control subjects, microbiome analyses showed that the lower airways of subjects with COPD were enriched with common oral commensals. The lower airway host transcriptomics demonstrated differences in markers of inflammation and tumorigenesis, such as upregulation of IL-17, IL-6, ERK/MAPK, PI3K, MUC1, and MUC4 in mild-to-moderate COPD. Finally, in a preclinical murine model exposed to cigarette smoke, lower airway dysbiosis with common oral commensals augments the inflammatory injury, revealing transcriptomic signatures similar to those observed in human subjects with COPD. Conclusions: Lower airway dysbiosis in the setting of smoke exposure contributes to inflammatory injury early in COPD. Targeting the lower airway microbiome in combination with smoking cessation may be of potential therapeutic relevance.
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Affiliation(s)
- Imran Sulaiman
- Division of Pulmonary and Critical Care Medicine
- Department of Medicine
- Department of Respiratory Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Respiratory Medicine, Beaumont Hospital, Dublin, Ireland
| | - Benjamin G. Wu
- Division of Pulmonary and Critical Care Medicine
- Department of Medicine
- Division of Pulmonary and Critical Care Medicine, Veterans Affairs (VA) New York Harbor Healthcare System, New York, New York
| | - Matthew Chung
- Systems Genomics Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Bradley Isaacs
- Division of Pulmonary and Critical Care Medicine
- Department of Medicine
| | - Jun-Chieh J. Tsay
- Division of Pulmonary and Critical Care Medicine
- Department of Medicine
- Division of Pulmonary and Critical Care Medicine, Veterans Affairs (VA) New York Harbor Healthcare System, New York, New York
| | - Meredith Holub
- Division of Pulmonary and Critical Care Medicine
- Department of Medicine
- Division of Pulmonary and Critical Care Medicine, Hartford Health Care, Hartford, Connecticut
| | - Clea R. Barnett
- Division of Pulmonary and Critical Care Medicine
- Department of Medicine
| | - Benjamin Kwok
- Division of Pulmonary and Critical Care Medicine
- Department of Medicine
| | | | - Jake G. Natalini
- Division of Pulmonary and Critical Care Medicine
- Department of Medicine
| | - Shivani Singh
- Division of Pulmonary and Critical Care Medicine
- Department of Medicine
| | - Yonghua Li
- Division of Pulmonary and Critical Care Medicine
- Department of Medicine
| | - Rosemary Schluger
- Division of Pulmonary and Critical Care Medicine
- Department of Medicine
| | - Joseph Carpenito
- Division of Pulmonary and Critical Care Medicine
- Department of Medicine
| | - Destiny Collazo
- Division of Pulmonary and Critical Care Medicine
- Department of Medicine
| | - Luisanny Perez
- Division of Pulmonary and Critical Care Medicine
- Department of Medicine
| | - Yaa Kyeremateng
- Division of Pulmonary and Critical Care Medicine
- Department of Medicine
| | - Miao Chang
- Division of Pulmonary and Critical Care Medicine
- Department of Medicine
| | - Christina D. Campbell
- Department of Respiratory Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Respiratory Medicine, Beaumont Hospital, Dublin, Ireland
| | - Philip M. Hansbro
- Centre for Inflammation, Centenary Institute and University of Technology Sydney, School of Life Sciences, Sydney, New South Wales, Australia
| | | | - Kenneth I. Berger
- Division of Pulmonary and Critical Care Medicine
- Department of Medicine
| | | | | | - Michael D. Weiden
- Division of Pulmonary and Critical Care Medicine
- Department of Medicine
| | - Rui Xiao
- Department of Physiology and Cellular Biophysics, Columbia University School of Medicine, New York, New York; and
| | - Jeanine D’Armiento
- Department of Physiology and Cellular Biophysics, Columbia University School of Medicine, New York, New York; and
| | - Jose C. Clemente
- Department of Genetics and Genomic Sciences and Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Elodie Ghedin
- Systems Genomics Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Leopoldo N. Segal
- Division of Pulmonary and Critical Care Medicine
- Department of Medicine
- Laura and Isaac Perlmutter Cancer Center, New York University Grossman School of Medicine, New York University (NYU) Langone Health, New York, New York
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Sharpe AL, Reibman J, Oppenheimer BW, Goldring RM, Liu M, Shao Y, Bohart I, Kwok B, Weinstein T, Addrizzo-Harris D, Sterman DH, Berger KI. Role of small airway dysfunction in unexplained exertional dyspnoea. ERJ Open Res 2023; 9:00603-2022. [PMID: 37284422 PMCID: PMC10240305 DOI: 10.1183/23120541.00603-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 03/01/2023] [Indexed: 06/08/2023] Open
Abstract
Background Isolated small airway abnormalities may be demonstrable at rest in patients with normal spirometry; however, the relationship of these abnormalities to exertional symptoms remains uncertain. This study uses an augmented cardiopulmonary exercise test (CPET) to include evaluation of small airway function during and following exercise to unmask abnormalities not evident with standard testing in individuals with dyspnoea and normal spirometry. Methods Three groups of subjects were studied: 1) World Trade Center (WTC) dust exposure (n=20); 2) Clinical Referral (n=15); and Control (n=13). Baseline evaluation included respiratory oscillometry. Airway function during an incremental workload CPET was assessed by: 1) tidal flow versus volume curves during exercise to assess for dynamic hyperinflation and expiratory flow limitation; and 2) post-exercise spirometry and oscillometry to evaluate for airway hyperreactivity. Results All subjects demonstrated normal baseline forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC). Dyspnoea was reproduced during CPET in WTC and Clinical Referral groups versus Control without abnormality in respiratory pattern and minute ventilation. Tidal flow-volume curves uncovered expiratory flow limitation and/or dynamic hyperinflation with increased prevalence in WTC and Clinical Referral versus Control (55%, 87% versus 15%; p<0.001). Post-exercise oscillometry uncovered small airway hyperreactivity with increased prevalence in WTC and Clinical Referral versus Control (40%, 47% versus 0%, p<0.05). Conclusions We uncovered mechanisms for exertional dyspnoea in subject with normal spirometry that was attributable to either small airway dysfunction during exercise and/or small airway hyperreactivity following exercise. The similarity of findings in WTC environmentally exposed and clinically referred cohorts suggests broad relevance for these evaluations.
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Affiliation(s)
- Alexis L. Sharpe
- Department of Medicine, Division of Pulmonary Critical Care and Sleep Medicine, NYU Grossman School of Medicine, New York, NY, USA
- André Cournand Pulmonary Physiology Laboratory, Bellevue Hospital, New York, NY, USA
| | - Joan Reibman
- Department of Medicine, Division of Pulmonary Critical Care and Sleep Medicine, NYU Grossman School of Medicine, New York, NY, USA
- Department of Environmental Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Beno W. Oppenheimer
- Department of Medicine, Division of Pulmonary Critical Care and Sleep Medicine, NYU Grossman School of Medicine, New York, NY, USA
- André Cournand Pulmonary Physiology Laboratory, Bellevue Hospital, New York, NY, USA
| | - Roberta M. Goldring
- Department of Medicine, Division of Pulmonary Critical Care and Sleep Medicine, NYU Grossman School of Medicine, New York, NY, USA
- André Cournand Pulmonary Physiology Laboratory, Bellevue Hospital, New York, NY, USA
| | - Mengling Liu
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Yongzhao Shao
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Isaac Bohart
- Department of Medicine, Division of Pulmonary Critical Care and Sleep Medicine, NYU Grossman School of Medicine, New York, NY, USA
- André Cournand Pulmonary Physiology Laboratory, Bellevue Hospital, New York, NY, USA
| | - Benjamin Kwok
- Department of Medicine, Division of Pulmonary Critical Care and Sleep Medicine, NYU Grossman School of Medicine, New York, NY, USA
- André Cournand Pulmonary Physiology Laboratory, Bellevue Hospital, New York, NY, USA
| | - Tatiana Weinstein
- Department of Medicine, Division of Pulmonary Critical Care and Sleep Medicine, NYU Grossman School of Medicine, New York, NY, USA
- André Cournand Pulmonary Physiology Laboratory, Bellevue Hospital, New York, NY, USA
| | - Doreen Addrizzo-Harris
- Department of Medicine, Division of Pulmonary Critical Care and Sleep Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Daniel H. Sterman
- Department of Medicine, Division of Pulmonary Critical Care and Sleep Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Kenneth I. Berger
- Department of Medicine, Division of Pulmonary Critical Care and Sleep Medicine, NYU Grossman School of Medicine, New York, NY, USA
- André Cournand Pulmonary Physiology Laboratory, Bellevue Hospital, New York, NY, USA
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3
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Wang Y, Berger KI, Zhang Y, Shao Y, Goldring RM, Reibman J, Liu M. Novel approach to studying effects of inhalational exposure on lung function in civilians exposed to the World Trade Center disaster. Sci Rep 2023; 13:3218. [PMID: 36828851 PMCID: PMC9958097 DOI: 10.1038/s41598-023-30030-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 02/14/2023] [Indexed: 02/26/2023] Open
Abstract
It is increasingly important to study the impact of environmental inhalation exposures on human health in natural or man-made disasters in civilian populations. The members of the World Trade Center Environmental Health Center (WTC EHC; WTC Survivors) had complex exposures to environmental disaster from the destruction of WTC towers and can serve to reveal the effects of WTC exposure on the entire spectrum of lung functions. We aimed to investigate the associations between complex WTC exposures and measures of spirometry and oscillometry in WTC Survivors and included 3605 patients enrolled between Oct 1, 2009 and Mar 31, 2018. We performed latent class analysis and identified five latent exposure groups. We applied linear and quantile regressions to estimate the exposure effects on the means and various quantiles of pre-bronchodilator (BD) % predicted forced expiratory volume in one second (FEV1), forced vital capacity (FVC) and FEV1/FVC ratio, as well as the resistance at an oscillating frequency of 5 Hz (R5), frequency dependence of resistance R5-20, and reactance area (AX). Compared with Group 5, which had low or unknown exposure and was treated as the reference group, Group 1, the local workers with both acute and chronic exposures, had a lower median of % predicted FVC (-3.6; 95% CI: -5.4, -1.7) and higher (more abnormal) measures of AX at 10th quantile (0.77 cmH2O L-1 s; 95% CI: 0.41, 1.13) and 25th quantile (0.80 cmH2O L-1 s; 95% CI: 0.41, 1.20). Results suggested heterogeneous exposures to the WTC disaster had differential effects on the distributions of lung functions in the WTC Survivors. These findings could provide insights for future investigation of environmental disaster exposures.
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Affiliation(s)
- Yuyan Wang
- Department of Population Health, New York University Grossman School of Medicine, 180 Madison Avenue, New York, NY, 10016, USA
| | - Kenneth I Berger
- Department of Medicine, New York University Grossman School of Medicine, 550 1st Avenue, New York, NY, 10016, USA
| | - Yian Zhang
- Department of Population Health, New York University Grossman School of Medicine, 180 Madison Avenue, New York, NY, 10016, USA
| | - Yongzhao Shao
- Department of Population Health, New York University Grossman School of Medicine, 180 Madison Avenue, New York, NY, 10016, USA
- Department of Environmental Medicine, New York University Grossman School of Medicine, 550 1st Avenue, New York, NY, 10016, USA
| | - Roberta M Goldring
- Department of Medicine, New York University Grossman School of Medicine, 550 1st Avenue, New York, NY, 10016, USA
| | - Joan Reibman
- Department of Medicine, New York University Grossman School of Medicine, 550 1st Avenue, New York, NY, 10016, USA.
- Department of Environmental Medicine, New York University Grossman School of Medicine, 550 1st Avenue, New York, NY, 10016, USA.
| | - Mengling Liu
- Department of Population Health, New York University Grossman School of Medicine, 180 Madison Avenue, New York, NY, 10016, USA.
- Department of Environmental Medicine, New York University Grossman School of Medicine, 550 1st Avenue, New York, NY, 10016, USA.
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4
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Morris AH, Horvat C, Stagg B, Grainger DW, Lanspa M, Orme J, Clemmer TP, Weaver LK, Thomas FO, Grissom CK, Hirshberg E, East TD, Wallace CJ, Young MP, Sittig DF, Suchyta M, Pearl JE, Pesenti A, Bombino M, Beck E, Sward KA, Weir C, Phansalkar S, Bernard GR, Thompson BT, Brower R, Truwit J, Steingrub J, Hiten RD, Willson DF, Zimmerman JJ, Nadkarni V, Randolph AG, Curley MAQ, Newth CJL, Lacroix J, Agus MSD, Lee KH, deBoisblanc BP, Moore FA, Evans RS, Sorenson DK, Wong A, Boland MV, Dere WH, Crandall A, Facelli J, Huff SM, Haug PJ, Pielmeier U, Rees SE, Karbing DS, Andreassen S, Fan E, Goldring RM, Berger KI, Oppenheimer BW, Ely EW, Pickering BW, Schoenfeld DA, Tocino I, Gonnering RS, Pronovost PJ, Savitz LA, Dreyfuss D, Slutsky AS, Crapo JD, Pinsky MR, James B, Berwick DM. Computer clinical decision support that automates personalized clinical care: a challenging but needed healthcare delivery strategy. J Am Med Inform Assoc 2022; 30:178-194. [PMID: 36125018 PMCID: PMC9748596 DOI: 10.1093/jamia/ocac143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 07/27/2022] [Accepted: 08/22/2022] [Indexed: 12/15/2022] Open
Abstract
How to deliver best care in various clinical settings remains a vexing problem. All pertinent healthcare-related questions have not, cannot, and will not be addressable with costly time- and resource-consuming controlled clinical trials. At present, evidence-based guidelines can address only a small fraction of the types of care that clinicians deliver. Furthermore, underserved areas rarely can access state-of-the-art evidence-based guidelines in real-time, and often lack the wherewithal to implement advanced guidelines. Care providers in such settings frequently do not have sufficient training to undertake advanced guideline implementation. Nevertheless, in advanced modern healthcare delivery environments, use of eActions (validated clinical decision support systems) could help overcome the cognitive limitations of overburdened clinicians. Widespread use of eActions will require surmounting current healthcare technical and cultural barriers and installing clinical evidence/data curation systems. The authors expect that increased numbers of evidence-based guidelines will result from future comparative effectiveness clinical research carried out during routine healthcare delivery within learning healthcare systems.
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Affiliation(s)
- Alan H Morris
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
- Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Christopher Horvat
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Brian Stagg
- Department of Ophthalmology and Visual Sciences, Moran Eye Center, University of Utah, Salt Lake City, Utah, USA
| | - David W Grainger
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah, USA
| | - Michael Lanspa
- Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - James Orme
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
- Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Terry P Clemmer
- Department of Internal Medicine (Critical Care), Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Lindell K Weaver
- Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Frank O Thomas
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Colin K Grissom
- Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Ellie Hirshberg
- Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Thomas D East
- SYNCRONYS - Chief Executive Officer, Albuquerque, New Mexico, USA
| | - Carrie Jane Wallace
- Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Michael P Young
- Department of Critical Care, Renown Regional Medical Center, Reno, Nevada, USA
| | - Dean F Sittig
- School of Biomedical Informatics, University of Texas Health Science Center, Houston, Texas, USA
| | - Mary Suchyta
- Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - James E Pearl
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
- Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Antinio Pesenti
- Faculty of Medicine and Surgery—Anesthesiology, University of Milan, Milano, Lombardia, Italy
| | - Michela Bombino
- Department of Emergency and Intensive Care, San Gerardo Hospital, Monza (MB), Italy
| | - Eduardo Beck
- Faculty of Medicine and Surgery - Anesthesiology, University of Milan, Ospedale di Desio, Desio, Lombardia, Italy
| | - Katherine A Sward
- Department of Biomedical Informatics, College of Nursing, University of Utah, Salt Lake City, Utah, USA
| | - Charlene Weir
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Shobha Phansalkar
- Wolters Kluwer Health—Clinical Solutions—Medical Informatics, Wolters Kluwer Health, Newton, Massachusetts, USA
| | - Gordon R Bernard
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - B Taylor Thompson
- Pulmonary and Critical Care Division, Department of Internal Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Roy Brower
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jonathon Truwit
- Department of Internal Medicine, Pulmonary and Critical Care, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jay Steingrub
- Department of Internal Medicine, Pulmonary and Critical Care, University of Massachusetts Medical School, Baystate Campus, Springfield, Massachusetts, USA
| | - R Duncan Hiten
- Department of Internal Medicine, Pulmonary and Critical Care, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Douglas F Willson
- Pediatric Critical Care, Department of Pediatrics, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jerry J Zimmerman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Martha A Q Curley
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Christopher J L Newth
- Childrens Hospital Los Angeles, Department of Anesthesiology and Critical Care, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Université de Montréal Faculté de Médecine, Montreal, Quebec, Canada
| | - Michael S D Agus
- Division of Medical Pediatric Critical Care, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kang Hoe Lee
- Department of Intensive Care Medicine, Ng Teng Fong Hospital and National University Centre of Transplantation, National University Singapore Yong Loo Lin School of Medicine, Singapore
| | - Bennett P deBoisblanc
- Department of Internal Medicine, Pulmonary and Critical Care, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
| | - Frederick Alan Moore
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - R Scott Evans
- Department of Medical Informatics, Intermountain Healthcare, and Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Dean K Sorenson
- Department of Medical Informatics, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Anthony Wong
- Department of Data Science Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Michael V Boland
- Department of Ophthalmology, Massachusetts Ear and Eye Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Willard H Dere
- Endocrinology and Metabolism Division, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Alan Crandall
- Department of Ophthalmology and Visual Sciences, Moran Eye Center, University of Utah, Salt Lake City, Utah, USA
- Posthumous
| | - Julio Facelli
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Stanley M Huff
- Department of Medical Informatics, Intermountain Healthcare, Department of Biomedical Informatics, University of Utah, and Graphite Health, Salt Lake City, Utah, USA
| | - Peter J Haug
- Department of Medical Informatics, Intermountain Healthcare, and Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Ulrike Pielmeier
- Aalborg University Faculty of Engineering and Science - Department of Health Science and Technology, Respiratory and Critical Care Group, Aalborg, Nordjylland, Denmark
| | - Stephen E Rees
- Aalborg University Faculty of Engineering and Science - Department of Health Science and Technology, Respiratory and Critical Care Group, Aalborg, Nordjylland, Denmark
| | - Dan S Karbing
- Aalborg University Faculty of Engineering and Science - Department of Health Science and Technology, Respiratory and Critical Care Group, Aalborg, Nordjylland, Denmark
| | - Steen Andreassen
- Aalborg University Faculty of Engineering and Science - Department of Health Science and Technology, Respiratory and Critical Care Group, Aalborg, Nordjylland, Denmark
| | - Eddy Fan
- Internal Medicine, Pulmonary and Critical Care Division, Institute of Health Policy, Management and Evaluation, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Roberta M Goldring
- Department of Internal Medicine, Pulmonary and Critical Care, New York University School of Medicine, New York, New York, USA
| | - Kenneth I Berger
- Department of Internal Medicine, Pulmonary and Critical Care, New York University School of Medicine, New York, New York, USA
| | - Beno W Oppenheimer
- Department of Internal Medicine, Pulmonary and Critical Care, New York University School of Medicine, New York, New York, USA
| | - E Wesley Ely
- Internal Medicine, Pulmonary and Critical Care, Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Tennessee Valley Veteran’s Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, Tennessee, USA
| | - Brian W Pickering
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, USA
| | - David A Schoenfeld
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Irena Tocino
- Department of Radiology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Russell S Gonnering
- Department of Ophthalmology and Visual Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Peter J Pronovost
- Department of Anesthesiology and Critical Care Medicine, University Hospitals, Highland Hills, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Lucy A Savitz
- Northwest Center for Health Research, Kaiser Permanente, Oakland, California, USA
| | - Didier Dreyfuss
- Assistance Publique—Hôpitaux de Paris, Université de Paris, Sorbonne Université - INSERM unit UMR S_1155 (Common and Rare Kidney Diseases), Paris, France
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, Keenan Research Center, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - James D Crapo
- Department of Internal Medicine, National Jewish Health, Denver, Colorado, USA
| | - Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Brent James
- Department of Internal Medicine, Clinical Excellence Research Center (CERC), Stanford University School of Medicine, Stanford, California, USA
| | - Donald M Berwick
- Institute for Healthcare Improvement, Cambridge, Massachusetts, USA
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5
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Baba RY, Zhang Y, Shao Y, Berger KI, Goldring RM, Liu M, Kazeros A, Rosen R, Reibman J. COPD in Smoking and Non-Smoking Community Members Exposed to the World Trade Center Dust and Fumes. Int J Environ Res Public Health 2022; 19:ijerph19074249. [PMID: 35409931 PMCID: PMC8999000 DOI: 10.3390/ijerph19074249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/23/2022] [Accepted: 03/28/2022] [Indexed: 01/18/2023]
Abstract
Background: The characteristics of community members exposed to World Trade Center (WTC) dust and fumes with Chronic Obstructive Pulmonary Disease (COPD) can provide insight into mechanisms of airflow obstruction in response to an environmental insult, with potential implications for interventions. Methods: We performed a baseline assessment of respiratory symptoms, spirometry, small airway lung function measures using respiratory impulse oscillometry (IOS), and blood biomarkers. COPD was defined by the 2019 GOLD criteria for COPD. Patients in the WTC Environmental Health Center with <5 or ≥5 pack year smoking history were classified as nonsmoker-COPD (ns-COPD) or smoker-COPD (sm-COPD), respectively. Main Results: Between August 2005 and March 2018, 467 of the 3430 evaluated patients (13.6%) fit criteria for COPD. Among patients with COPD, 248 (53.1%) were ns-COPD. Patients with ns-COPD had measures of large airway function (FEV1) and small airway measures (R5−20, AX) that were less abnormal than those with sm-COPD. More ns-COPD compared to sm-COPD had a bronchodilator (BD) response measured by spirometry (24 vs. 14%, p = 0.008) or by IOS (36 vs. 21%, p = 0.002). Blood eosinophils did not differ between ns-COPD and sm-COPD, but blood neutrophils were higher in sm-COPD compared to ns-COPD (p < 0.001). Those with sm-COPD were more likely to be WTC local residents than ns-COPD (p = 0.007). Conclusions: Spirometry findings and small airway measures, as well as inflammatory markers, differed between patients with ns-COPD and sm-COPD. These findings suggest potential for differing mechanisms of airway injury in patients with WTC environmental exposures and have potential therapeutic implications.
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Affiliation(s)
- Ridhwan Y. Baba
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA; (R.Y.B.); (K.I.B.); (R.M.G.); (A.K.)
| | - Yian Zhang
- Division of Biostatistics, Department of Population Health and Environmental Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA; (Y.Z.); (Y.S.); (M.L.)
| | - Yongzhao Shao
- Division of Biostatistics, Department of Population Health and Environmental Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA; (Y.Z.); (Y.S.); (M.L.)
| | - Kenneth I. Berger
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA; (R.Y.B.); (K.I.B.); (R.M.G.); (A.K.)
| | - Roberta M. Goldring
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA; (R.Y.B.); (K.I.B.); (R.M.G.); (A.K.)
| | - Mengling Liu
- Division of Biostatistics, Department of Population Health and Environmental Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA; (Y.Z.); (Y.S.); (M.L.)
| | - Angeliki Kazeros
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA; (R.Y.B.); (K.I.B.); (R.M.G.); (A.K.)
| | - Rebecca Rosen
- Department of Psychiatry, New York University Grossman School of Medicine, New York, NY 10016, USA;
| | - Joan Reibman
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA; (R.Y.B.); (K.I.B.); (R.M.G.); (A.K.)
- Department of Environmental Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
- Correspondence:
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6
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Norweg AM, Skamai A, Kwon SC, Whiteson J, MacDonald K, Haas F, Collins EG, Goldring RM, Reibman J, Wu Y, Sweeney G, Pierre A, Troxel AB, Ehrlich-Jones L, Simon NM. Acceptability of capnography-assisted respiratory therapy: a new mind-body intervention for COPD. ERJ Open Res 2021; 7:00256-2021. [PMID: 34938800 PMCID: PMC8685511 DOI: 10.1183/23120541.00256-2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 08/03/2021] [Indexed: 11/11/2022] Open
Abstract
Dyspnoea self-management is often suboptimal for patients with COPD. Many patients with COPD experience chronic dyspnoea as distressing and disabling, especially during physical activities. Breathing therapy is a behavioural intervention that targets reducing the distress and impact of dyspnoea on exertion in daily living. Using a qualitative design, we conducted interviews with 14 patients after they participated in a novel mind-body breathing therapy intervention adjunct, capnography-assisted respiratory therapy (CART), combined with outpatient pulmonary rehabilitation. Comprehensive CART consisted of patient-centred biofeedback, tailored breathing exercises, a home exercise programme and motivational interviewing counselling. We assessed participants' perceptions and reported experiences to gauge the acceptability of CART and refine CART based on feedback. Constant comparative analysis was used to identify commonalities and themes. We identified three main themes relating to the acceptability and reported benefits of CART: (1) self-regulating breathing; (2) impact on health; and (3) patient satisfaction. Our findings were used to refine and optimise CART (i.e. its intensity, timing and format) for COPD. By addressing dysfunctional breathing behaviours and dysregulated interoception, CART offers a promising new paradigm for relieving dyspnoea and related anxiety in patients with COPD.
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Affiliation(s)
- Anna Migliore Norweg
- Rehabilitation Medicine, New York University (NYU) Grossman School of Medicine, New York, NY, USA
| | - Anne Skamai
- Phelps Family Medicine Residency Program, Hofstra/Northwell Zucker School of Medicine, New York, NY, USA
| | - Simona C. Kwon
- Dept of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Jonathan Whiteson
- Rehabilitation Medicine, New York University (NYU) Grossman School of Medicine, New York, NY, USA
| | - Kyle MacDonald
- Rehabilitation Medicine, New York University (NYU) Grossman School of Medicine, New York, NY, USA
| | - Francois Haas
- Rehabilitation Medicine, New York University (NYU) Grossman School of Medicine, New York, NY, USA
| | - Eileen G. Collins
- College of Nursing, University of Illinois at Chicago, Chicago, IL, USA
| | | | | | - Yinxiang Wu
- Dept of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Greg Sweeney
- Rehabilitation Medicine, New York University (NYU) Grossman School of Medicine, New York, NY, USA
| | - Alicia Pierre
- Rehabilitation Medicine, New York University (NYU) Grossman School of Medicine, New York, NY, USA
| | - Andrea B. Troxel
- Dept of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | | | - Naomi M. Simon
- Dept of Psychiatry, NYU Grossman School of Medicine, New York, NY, USA
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7
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Morris AH, Stagg B, Lanspa M, Orme J, Clemmer TP, Weaver LK, Thomas F, Grissom CK, Hirshberg E, East TD, Wallace CJ, Young MP, Sittig DF, Pesenti A, Bombino M, Beck E, Sward KA, Weir C, Phansalkar SS, Bernard GR, Taylor Thompson B, Brower R, Truwit JD, Steingrub J, Duncan Hite R, Willson DF, Zimmerman JJ, Nadkarni VM, Randolph A, Curley MAQ, Newth CJL, Lacroix J, Agus MSD, Lee KH, deBoisblanc BP, Scott Evans R, Sorenson DK, Wong A, Boland MV, Grainger DW, Dere WH, Crandall AS, Facelli JC, Huff SM, Haug PJ, Pielmeier U, Rees SE, Karbing DS, Andreassen S, Fan E, Goldring RM, Berger KI, Oppenheimer BW, Wesley Ely E, Gajic O, Pickering B, Schoenfeld DA, Tocino I, Gonnering RS, Pronovost PJ, Savitz LA, Dreyfuss D, Slutsky AS, Crapo JD, Angus D, Pinsky MR, James B, Berwick D. Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. J Am Med Inform Assoc 2021; 28:1330-1344. [PMID: 33594410 PMCID: PMC8661391 DOI: 10.1093/jamia/ocaa294] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 11/10/2020] [Indexed: 02/05/2023] Open
Abstract
Clinical decision-making is based on knowledge, expertise, and authority, with clinicians approving almost every intervention-the starting point for delivery of "All the right care, but only the right care," an unachieved healthcare quality improvement goal. Unaided clinicians suffer from human cognitive limitations and biases when decisions are based only on their training, expertise, and experience. Electronic health records (EHRs) could improve healthcare with robust decision-support tools that reduce unwarranted variation of clinician decisions and actions. Current EHRs, focused on results review, documentation, and accounting, are awkward, time-consuming, and contribute to clinician stress and burnout. Decision-support tools could reduce clinician burden and enable replicable clinician decisions and actions that personalize patient care. Most current clinical decision-support tools or aids lack detail and neither reduce burden nor enable replicable actions. Clinicians must provide subjective interpretation and missing logic, thus introducing personal biases and mindless, unwarranted, variation from evidence-based practice. Replicability occurs when different clinicians, with the same patient information and context, come to the same decision and action. We propose a feasible subset of therapeutic decision-support tools based on credible clinical outcome evidence: computer protocols leading to replicable clinician actions (eActions). eActions enable different clinicians to make consistent decisions and actions when faced with the same patient input data. eActions embrace good everyday decision-making informed by evidence, experience, EHR data, and individual patient status. eActions can reduce unwarranted variation, increase quality of clinical care and research, reduce EHR noise, and could enable a learning healthcare system.
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Affiliation(s)
- Alan H Morris
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine
- Department of Biomedical Informatics
| | - Brian Stagg
- Department of Ophthalmology and Visual Sciences and John Moran Eye Center
| | - Michael Lanspa
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - James Orme
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine
- Department of Biomedical Informatics
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Terry P Clemmer
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine
- Department of Biomedical Informatics
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
- Emeritus
| | - Lindell K Weaver
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine
- Department of Biomedical Informatics
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Frank Thomas
- Department of Value Engineering, University of Utah Hospitals and Clinics, Salt Lake City, Utah, USA
- Emeritus
| | - Colin K Grissom
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine
- Department of Biomedical Informatics
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Ellie Hirshberg
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Thomas D East
- SYNCRONYS, and University of New Mexico Health Sciences Library & Informatics, Albuquerque, New Mexico, USA
| | - Carrie Jane Wallace
- Department of Ophthalmology and Visual Sciences and John Moran Eye Center
- Emeritus
| | - Michael P Young
- Critical Care Division, Renown Medical Center, School of Medicine, University of Nevada, Reno, Nevada, USA
| | - Dean F Sittig
- School of Biomedical Informatics, University of Texas Health Science Center, Houston, Texas, USA
| | - Antonio Pesenti
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Michela Bombino
- Department of Emergency and Intensive Care Medicine, ASST-Monza San Gerardo Hospital, Milan, Italy
| | - Eduardo Beck
- Ospedale di Desio—ASST Monza, UOC Anestesia e Rianimazione, Milan, Italy
| | | | - Charlene Weir
- Department of Biomedical Informatics
- School of Nursing
| | | | - Gordon R Bernard
- Pulmonary, Critical Care, and Allergy Division, Department of Internal Medicine
| | - B Taylor Thompson
- Pulmonary, Critical Care, and Sleep Division , Department of Internal Medicine
| | - Roy Brower
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jonathon D Truwit
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jay Steingrub
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts, USA
| | - R Duncan Hite
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Douglas F Willson
- Division of Pediatric Critical Care, Department of Pediatrics, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jerry J Zimmerman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Vinay M Nadkarni
- Department of Anesthesia and Critical Care Medicine
- Department of Pediatrics, Perelman School of Medicine
| | | | - Martha A. Q Curley
- Department of Pediatrics, Perelman School of Medicine
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christopher J. L Newth
- Department of Pediatrics, University of Southern California, Los Angeles, California, USA
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine and Université de Montréal, Montréal, Canada
| | | | - Kang H Lee
- Asian American Liver Centre, Gleneagles Hospital, Singapore, Singapore
| | - Bennett P deBoisblanc
- Section of Pulmonary/Critical Care & Allergy/Immunology, Louisiana State University School of Medicine, New Orleans, Louisiana, USA
| | | | | | - Anthony Wong
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | | | - David W Grainger
- Department of Biomedical Engineering and Department of Pharmaceutics and Pharmaceutical Chemistry, University of Utah
| | - Willard H Dere
- Department of Biomedical Engineering and Department of Pharmaceutics and Pharmaceutical Chemistry, University of Utah
| | - Alan S Crandall
- Department of Ophthalmology and Visual Sciences and John Moran Eye Center
| | - Julio C Facelli
- Department of Biomedical Informatics
- Center for Clinical and Translational Science, School of Medicine
| | | | | | - Ulrike Pielmeier
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Stephen E Rees
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Dan S Karbing
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Steen Andreassen
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Eddy Fan
- Institute of Health Policy, Management and Evaluation
| | - Roberta M Goldring
- Pulmonary, Critical Care, and Sleep Division, NYU School of Medicine, New York, New York, USA
| | - Kenneth I Berger
- Pulmonary, Critical Care, and Sleep Division, NYU School of Medicine, New York, New York, USA
| | - Beno W Oppenheimer
- Pulmonary, Critical Care, and Sleep Division, NYU School of Medicine, New York, New York, USA
| | - E Wesley Ely
- Pulmonary, Critical Care, and Allergy Division, Department of Internal Medicine
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center
- Tennessee Valley Veterans Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, Tennessee, USA
| | - Ognjen Gajic
- Pulmonary , Critical Care, and Sleep Division, Department of Internal Medicine
| | - Brian Pickering
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - David A Schoenfeld
- Department of Biostatistics, T.H. Chan School of Public Health, Harvard Medical School, Boston, Massachusetts, USA
| | - Irena Tocino
- Department of Radiology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Russell S Gonnering
- Department of Ophthalmology and Visual Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Peter J Pronovost
- Critical Care, Department of Anesthesia, Chief Clinical Transformation Officer, University Hospitals, Highland Hills, Case Western Reserve University, Cleveland, OH, USA
| | - Lucy A Savitz
- Kaiser Permanente Northwest Center for Health Research, Portland, OR, USA
| | - Didier Dreyfuss
- Assistance Publique – Hôpitaux de Paris, Université de Paris, INSERM unit UMR S_1155 (Common and Rare Kidney Diseases), Sorbonne Université, Paris, France
| | - Arthur S Slutsky
- Keenan Research Center, Li Ka Shing Knowledge Institute / ST. Michaels' Hospital and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - James D Crapo
- Department of Internal Medicine, National Jewish Health, Denver, Colorado, USA
| | - Derek Angus
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Brent James
- Clinical Excellence Research Center (CERC), Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Donald Berwick
- Institute for Healthcare Improvement, Boston, Massachusetts, USA
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8
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Berger KI, Wohlleber M, Goldring RM, Reibman J, Farfel MR, Friedman SM, Oppenheimer BW, Stellman SD, Cone JE, Shao Y. Respiratory impedance measured using impulse oscillometry in a healthy urban population. ERJ Open Res 2021; 7:00560-2020. [PMID: 33816605 PMCID: PMC8005688 DOI: 10.1183/23120541.00560-2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 12/02/2020] [Indexed: 11/12/2022] Open
Abstract
This study derives normative prediction equations for respiratory impedance in a healthy asymptomatic urban population using an impulse oscillation system (IOS). In addition, this study uses body mass index (BMI) in the equations to describe the effect of obesity on respiratory impedance. Data from an urban population comprising 472 healthy asymptomatic subjects that resided or worked in lower Manhattan, New York City were retrospectively analysed. This population was the control group from a previously completed case–control study of the health effects of exposure to World Trade Center dust. Since all subjects underwent spirometry and oscillometry, these previously collected data allowed a unique opportunity to derive normative prediction equations for oscillometry in an urban, lifetime non-smoking, asymptomatic population without underlying respiratory disease. Normative prediction equations for men and women were successfully developed for a broad range of respiratory oscillometry variables with narrow confidence bands. Models that used BMI as an independent predictor of oscillometry variables (in addition to age and height) demonstrated equivalent or better fit when compared with models that used weight. With increasing BMI, resistance and reactance increased compatible with lung and airway compression from mass loading. This study represents the largest cohort of healthy urban subjects assessed with an IOS device. Normative prediction equations were derived that should facilitate application of IOS in the clinical setting. In addition, the data suggest that modelling of lung function may be best performed using height and BMI as independent variables rather than the traditional approach of using height and weight. Prediction equations for respiratory impedance were derived in an urban cohort incorporating the effects of mass loading from obesity. Urban exposures had minimal effect on impedance allowing application of the equations to a broad range of populations.https://bit.ly/3a3zZvd
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Affiliation(s)
- Kenneth I Berger
- Dept of Medicine, NYU Grossman School of Medicine, New York, NY, USA.,André Cournand Pulmonary Physiology Laboratory, Bellevue Hospital, New York, NY, USA
| | - Margaret Wohlleber
- Dept of Medicine, NYU Grossman School of Medicine, New York, NY, USA.,André Cournand Pulmonary Physiology Laboratory, Bellevue Hospital, New York, NY, USA
| | - Roberta M Goldring
- Dept of Medicine, NYU Grossman School of Medicine, New York, NY, USA.,André Cournand Pulmonary Physiology Laboratory, Bellevue Hospital, New York, NY, USA
| | - Joan Reibman
- Dept of Medicine, NYU Grossman School of Medicine, New York, NY, USA.,Dept of Environmental Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Mark R Farfel
- World Trade Center Health Registry, New York City Department of Health and Mental Hygiene, New York, NY, USA
| | - Stephen M Friedman
- World Trade Center Health Registry, New York City Department of Health and Mental Hygiene, New York, NY, USA
| | - Beno W Oppenheimer
- Dept of Medicine, NYU Grossman School of Medicine, New York, NY, USA.,André Cournand Pulmonary Physiology Laboratory, Bellevue Hospital, New York, NY, USA
| | - Steven D Stellman
- World Trade Center Health Registry, New York City Department of Health and Mental Hygiene, New York, NY, USA.,Mailman School of Public Health, Columbia University, New York, NY, USA
| | - James E Cone
- World Trade Center Health Registry, New York City Department of Health and Mental Hygiene, New York, NY, USA
| | - Yongzhao Shao
- Dept of Population Health, NYU Grossman School of Medicine, New York, NY, USA
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9
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Miller A, Goldring RM, Berger KI. Airway Disease Presenting as Restrictive Impairment. Am J Respir Crit Care Med 2020; 202:1194-1195. [PMID: 32755377 PMCID: PMC7560794 DOI: 10.1164/rccm.202005-1904le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Albert Miller
- Mount Sinai School of Medicine New York, New York and
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10
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Reibman J, Caplan-Shaw C, Wu Y, Liu M, Amin MR, Berger KI, Cotrina-Vidal ML, Kazeros A, Durmus N, Fernandez-Beros ME, Goldring RM, Rosen R, Shao Y. Characterization of Persistent Uncontrolled Asthma Symptoms in Community Members Exposed to World Trade Center Dust and Fumes. Int J Environ Res Public Health 2020; 17:ijerph17186645. [PMID: 32933057 PMCID: PMC7558705 DOI: 10.3390/ijerph17186645] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 08/26/2020] [Accepted: 09/01/2020] [Indexed: 12/22/2022]
Abstract
The destruction of the World Trade Center (WTC) towers on the 11th of September, 2001 released a vast amount of aerosolized dust and smoke resulting in acute and chronic exposures to community members as well as responders. The WTC Environmental Health Center (WTC EHC) is a surveillance and treatment program for a diverse population of community members, including local residents and local workers with WTC dust exposure. Many of these patients have reported persistent lower respiratory symptoms (LRS) despite treatment for presumed asthma. Our goal was to identify conditions associated with persistent uncontrolled LRS despite standard asthma management. We recruited 60 patients who were uncontrolled at enrollment and, after a three-month run-in period on high-dose inhaled corticosteroid and long acting bronchodilator, reassessed their status as Uncontrolled or Controlled based on a score from the Asthma Control Test (ACT). Despite this treatment, only 11 participants (18%) gained Controlled status as defined by the ACT. We compared conditions associated with Uncontrolled and Controlled status. Those with Uncontrolled symptoms had higher rates of upper airway symptoms. Many patients had persistent bronchial hyper-reactivity (BHR) and upper airway hyper-reactivity as measured by paradoxical vocal fold movement (PVFM). We found a significant increasing trend in the percentage of Controlled with respect to the presence of BHR and PVFM. We were unable to identify significant differences in lung function or inflammatory markers in this small group. Our findings suggest persistent upper and lower airway hyper-reactivity that may respond to standard asthma treatment, whereas others with persistent LRS necessitate additional diagnostic evaluation, including a focus on the upper airway.
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Affiliation(s)
- Joan Reibman
- Department of Medicine, NYU Grossman School of Medicine, New York, NY 10016, USA; (C.C.-S.); (K.I.B.); (A.K.); (N.D.); (M.-E.F.-B.); (R.M.G.)
- Department of Population Health, NYU Grossman School of Medicine, New York, NY 10016, USA; (Y.W.); (M.L.); (Y.S.)
- Department of Environmental Medicine, NYU Grossman School of Medicine, New York, NY 10016, USA
- World Trade Center Environmental Health Center, NYC H+HC, New York, NY 10016, USA; (M.L.C.-V.); (R.R.)
- Correspondence: ; Tel.: +1-212-263-6479
| | - Caralee Caplan-Shaw
- Department of Medicine, NYU Grossman School of Medicine, New York, NY 10016, USA; (C.C.-S.); (K.I.B.); (A.K.); (N.D.); (M.-E.F.-B.); (R.M.G.)
- Department of Population Health, NYU Grossman School of Medicine, New York, NY 10016, USA; (Y.W.); (M.L.); (Y.S.)
- Department of Environmental Medicine, NYU Grossman School of Medicine, New York, NY 10016, USA
- World Trade Center Environmental Health Center, NYC H+HC, New York, NY 10016, USA; (M.L.C.-V.); (R.R.)
| | - Yinxiang Wu
- Department of Population Health, NYU Grossman School of Medicine, New York, NY 10016, USA; (Y.W.); (M.L.); (Y.S.)
| | - Mengling Liu
- Department of Population Health, NYU Grossman School of Medicine, New York, NY 10016, USA; (Y.W.); (M.L.); (Y.S.)
- Department of Environmental Medicine, NYU Grossman School of Medicine, New York, NY 10016, USA
- World Trade Center Environmental Health Center, NYC H+HC, New York, NY 10016, USA; (M.L.C.-V.); (R.R.)
| | - Milan R. Amin
- Department of Otolaryngology-Head and Neck Surgery, NYU Grossman School of Medicine, New York, NY 10016, USA;
| | - Kenneth I. Berger
- Department of Medicine, NYU Grossman School of Medicine, New York, NY 10016, USA; (C.C.-S.); (K.I.B.); (A.K.); (N.D.); (M.-E.F.-B.); (R.M.G.)
- Department of Population Health, NYU Grossman School of Medicine, New York, NY 10016, USA; (Y.W.); (M.L.); (Y.S.)
- World Trade Center Environmental Health Center, NYC H+HC, New York, NY 10016, USA; (M.L.C.-V.); (R.R.)
| | - Maria L. Cotrina-Vidal
- World Trade Center Environmental Health Center, NYC H+HC, New York, NY 10016, USA; (M.L.C.-V.); (R.R.)
| | - Angeliki Kazeros
- Department of Medicine, NYU Grossman School of Medicine, New York, NY 10016, USA; (C.C.-S.); (K.I.B.); (A.K.); (N.D.); (M.-E.F.-B.); (R.M.G.)
- Department of Population Health, NYU Grossman School of Medicine, New York, NY 10016, USA; (Y.W.); (M.L.); (Y.S.)
- World Trade Center Environmental Health Center, NYC H+HC, New York, NY 10016, USA; (M.L.C.-V.); (R.R.)
| | - Nedim Durmus
- Department of Medicine, NYU Grossman School of Medicine, New York, NY 10016, USA; (C.C.-S.); (K.I.B.); (A.K.); (N.D.); (M.-E.F.-B.); (R.M.G.)
| | - Maria-Elena Fernandez-Beros
- Department of Medicine, NYU Grossman School of Medicine, New York, NY 10016, USA; (C.C.-S.); (K.I.B.); (A.K.); (N.D.); (M.-E.F.-B.); (R.M.G.)
- World Trade Center Environmental Health Center, NYC H+HC, New York, NY 10016, USA; (M.L.C.-V.); (R.R.)
| | - Roberta M. Goldring
- Department of Medicine, NYU Grossman School of Medicine, New York, NY 10016, USA; (C.C.-S.); (K.I.B.); (A.K.); (N.D.); (M.-E.F.-B.); (R.M.G.)
- Department of Population Health, NYU Grossman School of Medicine, New York, NY 10016, USA; (Y.W.); (M.L.); (Y.S.)
- World Trade Center Environmental Health Center, NYC H+HC, New York, NY 10016, USA; (M.L.C.-V.); (R.R.)
| | - Rebecca Rosen
- World Trade Center Environmental Health Center, NYC H+HC, New York, NY 10016, USA; (M.L.C.-V.); (R.R.)
- Department of Psychiatry, NYU Grossman School of Medicine, New York, NY 10016, USA
| | - Yongzhao Shao
- Department of Population Health, NYU Grossman School of Medicine, New York, NY 10016, USA; (Y.W.); (M.L.); (Y.S.)
- Department of Environmental Medicine, NYU Grossman School of Medicine, New York, NY 10016, USA
- World Trade Center Environmental Health Center, NYC H+HC, New York, NY 10016, USA; (M.L.C.-V.); (R.R.)
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11
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Oppenheimer BW, Goldring RM, Soghier I, Smith D, Parikh M, Berger KI. Small airway function in obese individuals with self-reported asthma. ERJ Open Res 2020; 6:00371-2019. [PMID: 32714957 PMCID: PMC7369433 DOI: 10.1183/23120541.00371-2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 04/22/2020] [Indexed: 11/05/2022] Open
Abstract
Diagnosis of asthma in obese individuals frequently relies on clinical history, as airflow by spirometry may remain normal. This study hypothesised that obese subjects with self-reported asthma and normal spirometry will demonstrate distinct clinical characteristics, metabolic comorbidities and enhanced small airway dysfunction as compared with healthy obese subjects. Spirometry, plethysmography and oscillometry data pre/post-bronchodilator were obtained in 357 obese subjects in three groups as follows: no asthma group (n=180), self-reported asthma normal spirometry group (n=126), and asthma obstructed spirometry group (n=51). To assess the effects of obesity related to reduced lung volume, oscillometry measurements were repeated during a voluntary inflation to predicted functional residual capacity (FRC). Dyspnoea was equally prevalent in all groups. In contrast, cough, wheeze and metabolic comorbidities were more frequent in the asthma normal spirometry and asthma obstructed spirometry groups versus the no asthma group (p<0.05). Despite similar body size, oscillometry measurements demonstrated elevated R 5-20 (difference between resistance at 5 and 20 Hz) in the no asthma and asthma normal spirometry groups (0.19±0.12; 0.23±0.13 kPa/(L·s-1), p<0.05) but to a lesser degree than the asthma obstructed spirometry group (0.34±0.20 kPa/(L·s-1), p<0.05). Differences between groups persisted post-bronchodilator (p<0.05). Following voluntary inflation to predicted FRC, R 5-20 in the no asthma and asthma normal spirometry groups fell to similar values, indicating a reversible process (0.11±0.07; 0.12±0.08 kPa/(L·s-1), p=NS). Persistently elevated R 5-20 was seen in the asthma obstructed spirometry group, suggesting chronic inflammation and/or remodelling (0.17±0.11 kPa/(L·s-1), p<0.05). Thus, small airway abnormalities of greater magnitude than observations in healthy obese people may be an early marker of asthma in obese subjects with self-reported disease despite normal airflow. Increased metabolic comorbidities in these subjects may have provided a milieu that impacted airway function.
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Affiliation(s)
- Beno W Oppenheimer
- André Cournand Pulmonary Physiology Laboratory, Division of Pulmonary, Critical Care and Sleep, Dept of Medicine, Bellevue Hospital/New York University School of Medicine, New York, NY, USA
| | - Roberta M Goldring
- André Cournand Pulmonary Physiology Laboratory, Division of Pulmonary, Critical Care and Sleep, Dept of Medicine, Bellevue Hospital/New York University School of Medicine, New York, NY, USA
| | - Israa Soghier
- Jacobi Medical Center, Dept of Medicine, Division of Pulmonary Medicine, Albert Einstein College of Medicine, New York, NY, USA
| | - David Smith
- André Cournand Pulmonary Physiology Laboratory, Division of Pulmonary, Critical Care and Sleep, Dept of Medicine, Bellevue Hospital/New York University School of Medicine, New York, NY, USA
| | - Manish Parikh
- Bellevue Hospital Bariatric Center, Dept of Surgery, New York University School of Medicine, New York, NY, USA
| | - Kenneth I Berger
- André Cournand Pulmonary Physiology Laboratory, Division of Pulmonary, Critical Care and Sleep, Dept of Medicine, Bellevue Hospital/New York University School of Medicine, New York, NY, USA
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Gaylord A, Berger KI, Naidu M, Attina TM, Gilbert J, Koshy TT, Han X, Marmor M, Shao Y, Giusti R, Goldring RM, Kannan K, Trasande L. Serum perfluoroalkyl substances and lung function in adolescents exposed to the World Trade Center disaster. Environ Res 2019; 172:266-272. [PMID: 30822559 PMCID: PMC8336627 DOI: 10.1016/j.envres.2019.02.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 05/04/2023]
Abstract
The effects of childhood exposure to perfluoroalkyl substances (PFASs) on lung function remain mostly unknown. Previous research indicates that children living or going to school near the World Trade Center (WTC) disaster were exposed to high levels of PFASs, among other toxic chemicals. To explore the effects of PFAS exposure on lung function, we measured serum PFASs in a cohort of children from the WTC Health Registry and a matched control group. Perfluorooctanesulfonate had the highest median concentrations in both groups (WTCHR = 3.72 ng/mL, Comparison = 2.75 ng/mL), while the lowest median concentrations were seen for perfluoroundecanoic acid (WTCHR = 0.12 ng/mL, Comparison = 0.01 ng/mL). Lung function outcomes were measured by spirometry, plethysmography, and oscillometry. Asthma diagnosis and serum eosinophil count were also recorded. We examined the relationships of each PFAS with lung function parameters and eosinophil count using linear regressions. Odds ratios for asthma were obtained for each PFAS using logistic regression. The effect of total PFASs on these outcomes was also assessed. All regression models were adjusted for sex, race/ethnicity, age, body mass index (BMI) and tobacco smoke exposure. We found that serum PFASs were not statistically associated with the measured lung function parameters, asthma diagnosis, or eosinophil count in this cohort (p < 0.05). These findings highlight the need for more longitudinal studies to explore the long-term effects of childhood PFAS exposure on lung function past adolescence and early adulthood.
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Affiliation(s)
- Abigail Gaylord
- Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - Kenneth I Berger
- Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Mrudula Naidu
- Departments of Pediatrics, New York University School of Medicine, New York, NY, USA
| | - Teresa M Attina
- Departments of Pediatrics, New York University School of Medicine, New York, NY, USA
| | - Joseph Gilbert
- Departments of Pediatrics, New York University School of Medicine, New York, NY, USA
| | - Tony T Koshy
- Departments of Pediatrics, New York University School of Medicine, New York, NY, USA
| | - Xiaoxia Han
- Public Health Sciences Department, Henry Ford Health System, Detroit, MI, USA
| | - Michael Marmor
- Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - Yongzhao Shao
- Department of Population Health, New York University School of Medicine, New York, NY, USA; Department of Environmental Medicine, New York University School of Medicine, New York, NY, USA
| | - Robert Giusti
- Departments of Pediatrics, New York University School of Medicine, New York, NY, USA
| | - Roberta M Goldring
- Department of Medicine, New York University School of Medicine, New York, NY, USA
| | | | - Leonardo Trasande
- Department of Population Health, New York University School of Medicine, New York, NY, USA; Department of Medicine, New York University School of Medicine, New York, NY, USA; Departments of Pediatrics, New York University School of Medicine, New York, NY, USA; Department of Environmental Medicine, New York University School of Medicine, New York, NY, USA; NYU Wagner School of Public Service, New York, NY, USA; NYU College of Global Public Health, New York, NY, USA.
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13
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Pradhan D, Xu N, Reibman J, Goldring RM, Shao Y, Liu M, Berger KI. Bronchodilator Response Predicts Longitudinal Improvement in Small Airway Function in World Trade Center Dust Exposed Community Members. Int J Environ Res Public Health 2019; 16:ijerph16081421. [PMID: 31009988 PMCID: PMC6517979 DOI: 10.3390/ijerph16081421] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 04/04/2019] [Accepted: 04/17/2019] [Indexed: 01/16/2023]
Abstract
The evolution of lung function, including assessment of small airways, was assessed in individuals enrolled in the World Trade Center Environmental Health Center (WTC-EHC). We hypothesized that a bronchodilator response at initial evaluation shown by spirometry or in small airways, as measured by forced oscillation technique (FOT), would be associated with improvement in large and small airway function over time. Standardized longitudinal assessment included pre and post bronchodilator (BD) spirometry (forced vital capacity, FVC; forced expiratory volume in 1 second, FEV1) and FOT (resistance at 5 Hz, R5; resistance at 5 minus 20 Hz, R5–20). Longitudinal changes were assessed using linear mixed-effects modelling with adjustment for potential confounders (median follow-up 2.86 years; 95% measurements within 4.9 years). Data demonstrated: (1) parallel improvement in airflow and volume measured by spirometry and small airway function (R5 and R5–20) measured by FOT; (2) the magnitude of longitudinal improvement was tightly linked to the initial BD response; and (3) longitudinal values for small airway function on FOT were similar to residual abnormality observed post BD at initial visit. These findings suggest presence of reversible and irreversible components of small airway injury that are identifiable at initial presentation. These results have implications for treatment of isolated small airway abnormalities that can be identified by non-invasive effort independent FOT particularly in symptomatic individuals with normal spirometry indices. This study underscores the need to study small airway function to understand physiologic changes over time following environmental and occupational lung injury.
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Affiliation(s)
- Deepak Pradhan
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, NY 10016, USA.
| | - Ning Xu
- Department of Population Health, New York University School of Medicine, New York, NY 10016, USA.
| | - Joan Reibman
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, NY 10016, USA.
| | - Roberta M Goldring
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, NY 10016, USA.
- André Cournand Pulmonary Physiology Laboratory, Bellevue Hospital, New York, NY 10016, USA.
| | - Yongzhao Shao
- Department of Population Health, New York University School of Medicine, New York, NY 10016, USA.
| | - Mengling Liu
- Department of Population Health, New York University School of Medicine, New York, NY 10016, USA.
| | - Kenneth I Berger
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, NY 10016, USA.
- André Cournand Pulmonary Physiology Laboratory, Bellevue Hospital, New York, NY 10016, USA.
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Trye A, Berger KI, Naidu M, Attina TM, Gilbert J, Koshy TT, Han X, Marmor M, Shao Y, Giusti R, Goldring RM, Trasande L. Respiratory Health and Lung Function in Children Exposed to the World Trade Center Disaster. J Pediatr 2018; 201:134-140.e6. [PMID: 30029866 PMCID: PMC8336626 DOI: 10.1016/j.jpeds.2018.06.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 05/09/2018] [Accepted: 06/01/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES To compare lung function in a representative sample of World Trade Center (WTC)-exposed children with matched comparisons, and examine relationships with reported exposures. STUDY DESIGN Study population consisted of 402 participants. Oscillometry, spirometry, and plethysmography were performed on WTC Health Registry (WTCHR) respondents who were ≤8 years of age on September 11, 2001 (n = 180) and a sociodemographically matched group of New York City residents (n = 222). We compared lung function by study arm (WTCHR and comparison group) as well as dust cloud (acute); home dust (subchronic); and other traumatic, nondust exposures. RESULTS In multivariable models, post-9/11 risk of incident asthma was higher in the WTCHR participants than in the comparison group (OR 1.109, 95% CI 1.021, 1.206; P = .015). Comparing by exposure rather than by group, dust cloud (OR 1.223, 95% CI 1.095, 1.365; P < .001) and home dust (OR 1.123, 95% CI 1.029, 1.226; P = .009) exposures were also associated with a greater risk of incidence of post-9/11 asthma. No differences were identified for lung function measures. CONCLUSIONS Although we cannot exclude an alternative explanation to the null findings, these results may provide some measure of reassurance to exposed children and their families regarding long-term consequences. Further study with bronchodilation and/or methacholine challenge may be needed to identify and further evaluate effects of WTC exposure. Biomarker studies may also be more informative in delineating exposure-outcome relationships. TRIAL REGISTRATION ClinicalTrials.gov: NCT02068183.
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Affiliation(s)
- Alice Trye
- Department of Pediatrics, New York University School of Medicine
| | | | - Mrudula Naidu
- Department of Pediatrics, New York University School of Medicine
| | - Teresa M. Attina
- Department of Pediatrics, New York University School of Medicine
| | - Joseph Gilbert
- Department of Pediatrics, New York University School of Medicine
| | - Tony T. Koshy
- Department of Pediatrics, New York University School of Medicine
| | - Xiaoxia Han
- Department of Population Health, New York University School of Medicine
| | - Michael Marmor
- Department of Population Health, New York University School of Medicine
| | - Yongzhao Shao
- Department of Population Health, New York University School of Medicine;,Department of Environmental Medicine, New York University School of Medicine
| | - Robert Giusti
- Department of Pediatrics, New York University School of Medicine
| | | | - Leonardo Trasande
- Department of Pediatrics, New York University School of Medicine, New York, NY; Department of Population Health, New York University School of Medicine, New York, NY; Department of Environmental Medicine, New York University School of Medicine, New York, NY; New York University Wagner School of Public Service, New York, NY; New York University College of Global Public Health, New York, NY.
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15
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Jordan HT, Friedman SM, Reibman J, Goldring RM, Miller Archie SA, Ortega F, Alper H, Shao Y, Maslow CB, Cone JE, Farfel MR, Berger KI. Risk factors for persistence of lower respiratory symptoms among community members exposed to the 2001 World Trade Center terrorist attacks. Occup Environ Med 2017; 74:449-455. [PMID: 28341697 PMCID: PMC5520238 DOI: 10.1136/oemed-2016-104157] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 02/09/2017] [Accepted: 02/15/2017] [Indexed: 11/15/2022]
Abstract
Objectives We studied the course of lower respiratory symptoms (LRS; cough, wheeze or dyspnoea) among community members exposed to the 9/11/2001 World Trade Center (WTC) attacks during a period of 12–13 years following the attacks, and evaluated risk factors for LRS persistence, including peripheral airway dysfunction and post-traumatic stress disorder (PTSD). Methods Non-smoking adult participants in a case-control study of post-9/11-onset LRS (exam 1, 2008–2010) were recruited for follow-up (exam 2, 2013–2014). Peripheral airway function was assessed with impulse oscillometry measures of R5 and R5-20. Probable PTSD was a PTSD checklist score ≥44 on a 2006–2007 questionnaire. Results Of 785 exam 1 participants, 545 (69%) completed exam 2. Most (321, 59%) were asymptomatic at all assessments. Among 192 participants with initial LRS, symptoms resolved for 110 (57%) by exam 2, 55 (29%) had persistent LRS and 27 (14%) had other patterns. The proportion with normal spirometry increased from 65% at exam 1 to 85% at exam 2 in the persistent LRS group (p<0.01) and was stable among asymptomatic participants and those with resolved LRS. By exam 2, spirometry results did not differ across symptom groups; however, R5 and R5-20 abnormalities were more common among participants with persistent LRS (56% and 46%, respectively) than among participants with resolved LRS (30%, p<0.01; 27%, p=0.03) or asymptomatic participants (20%, p<0.001; 8.2%, p<0.001). PTSD, R5 at exam 1, and R5-20 at exam 1 were each independently associated with persistent LRS. Conclusions Peripheral airway dysfunction and PTSD may contribute to LRS persistence. Assessment of peripheral airway function detected pulmonary damage not evident on spirometry. Mental and physical healthcare for survivors of complex environmental disasters should be coordinated carefully.
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Affiliation(s)
- Hannah T Jordan
- World Trade Center Health Registry, New York City Department of Health and Mental Hygiene, New York, New York, USA
| | - Stephen M Friedman
- World Trade Center Health Registry, New York City Department of Health and Mental Hygiene, New York, New York, USA
| | - Joan Reibman
- Department of Medicine, New York University School of Medicine, New York, New York, USA
| | - Roberta M Goldring
- Department of Medicine, New York University School of Medicine, New York, New York, USA
| | - Sara A Miller Archie
- World Trade Center Health Registry, New York City Department of Health and Mental Hygiene, New York, New York, USA
| | - Felix Ortega
- World Trade Center Health Registry, New York City Department of Health and Mental Hygiene, New York, New York, USA
| | - Howard Alper
- World Trade Center Health Registry, New York City Department of Health and Mental Hygiene, New York, New York, USA
| | - Yongzhao Shao
- Department of Medicine, New York University School of Medicine, New York, New York, USA
| | - Carey B Maslow
- World Trade Center Health Registry, New York City Department of Health and Mental Hygiene, New York, New York, USA
| | - James E Cone
- World Trade Center Health Registry, New York City Department of Health and Mental Hygiene, New York, New York, USA
| | - Mark R Farfel
- World Trade Center Health Registry, New York City Department of Health and Mental Hygiene, New York, New York, USA
| | - Kenneth I Berger
- Department of Medicine, New York University School of Medicine, New York, New York, USA
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Berger KI, Pradhan DR, Goldring RM, Oppenheimer BW, Rom WN, Segal LN. Distal airway dysfunction identifies pulmonary inflammation in asymptomatic smokers. ERJ Open Res 2016; 2:00066-2016. [PMID: 27995132 PMCID: PMC5165724 DOI: 10.1183/23120541.00066-2016] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 10/10/2016] [Indexed: 12/30/2022] Open
Abstract
Smoking induced inflammation leads to distal airway destruction. However, the relationship between distal airway dysfunction and inflammation remains unclear, particularly in smokers prior to the development of airway obstruction. Seven normal controls and 16 smokers without chronic obstructive pulmonary disease (COPD) were studied. Respiratory function was assessed using the forced oscillation technique (FOT). Abnormal FOT was defined as elevated resistance at 5 Hz (R5). Parameters reflecting distal lung function included frequency dependence of resistance (R5–20) and dynamic elastance (X5). Inflammation was quantified in concentrated bronchoalveolar lavage utilising cell count differential and cytokines expressed as concentration per mL epithelial lining fluid. All control subjects and seven smokers had normal R5. Nine smokers had elevated R5 with abnormal R5–20 and X5, indicating distal lung dysfunction. The presence of abnormal FOT was associated with two-fold higher lymphocyte and neutrophil counts (p<0.025) and with higher interleukin (IL)-8, eotaxin and fractalkine levels (p<0.01). Reactivity of R5–20 and X5 correlated with levels of IL-8, eotaxin, fractalkine, IL-12p70 and transforming growth factor-α (r>0.47, p<0.01). Distal airway dysfunction in smokers without COPD identifies the presence of distal lung inflammation that parallel reported observations in established COPD. These findings were not evident on routine pulmonary function testing and may allow the identification of smokers at risk of progression to COPD. Isolated dysfunction in distal airways identifies pulmonary inflammation in asymptomatic smokers with normal airflowhttp://ow.ly/8bVk305aVkj
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Affiliation(s)
- Kenneth I Berger
- André Cournand Pulmonary Laboratory, Bellevue Hospital Center, New York, NY, USA; Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Medicine, New York University School of Medicine, New York, NY, USA
| | - Deepak R Pradhan
- André Cournand Pulmonary Laboratory, Bellevue Hospital Center, New York, NY, USA; Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Medicine, New York University School of Medicine, New York, NY, USA
| | - Roberta M Goldring
- André Cournand Pulmonary Laboratory, Bellevue Hospital Center, New York, NY, USA; Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Medicine, New York University School of Medicine, New York, NY, USA
| | - Beno W Oppenheimer
- André Cournand Pulmonary Laboratory, Bellevue Hospital Center, New York, NY, USA; Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Medicine, New York University School of Medicine, New York, NY, USA
| | - William N Rom
- Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Medicine, New York University School of Medicine, New York, NY, USA
| | - Leopoldo N Segal
- André Cournand Pulmonary Laboratory, Bellevue Hospital Center, New York, NY, USA; Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Medicine, New York University School of Medicine, New York, NY, USA
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17
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Berger KI, Kalish S, Shao Y, Marmor M, Kazeros A, Oppenheimer BW, Chan Y, Reibman J, Goldring RM. Isolated small airway reactivity during bronchoprovocation as a mechanism for respiratory symptoms in WTC dust-exposed community members. Am J Ind Med 2016; 59:767-76. [PMID: 27582479 DOI: 10.1002/ajim.22639] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2016] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Small airway dysfunction occurs following WTC dust exposure, but its role in producing symptoms is unclear. METHODS Methacholine challenge (MCT) was used to assess the relationship between onset of respiratory symptoms and small airway abnormalities in 166 symptomatic WTC dust-exposed patients. Forced oscillation testing (FOT) and respiratory symptoms were assessed during MCT. FOT parameters included resistance at 5 and 20 Hz (R5 and R20 ) and the R5 minus R20 (R5-20 ). RESULTS Baseline spirometry was normal in all (mean FEV1 100 + 13% predicted, mean FEV1 /FVC 80 + 4%). MCT revealed bronchial hyperreactivity by spirometry in 67 patients. An additional 24 patients became symptomatic despite minimal FEV1 change (<5%); symptom onset coincided with increased R5 and R5-20 (P > 0.001 vs. baseline). The dose-response of FOT (reactivity) was greater compared with subjects that remained asymptomatic (P < 0.05). CONCLUSIONS FOT during MCT uncovered reactivity in small airways as a mechanism for respiratory symptoms in subjects with inhalational lung injury. Am. J. Ind. Med. 59:767-776, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Kenneth I. Berger
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine; NYU School of Medicine; New York New York
- Andre Cournand Pulmonary Physiology Laboratory; Bellevue Hospital; New York New York
| | - Samantha Kalish
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine; NYU School of Medicine; New York New York
| | - Yongzhao Shao
- Department of Population Health; NYU School of Medicine; New York New York
| | - Michael Marmor
- Department of Population Health; NYU School of Medicine; New York New York
| | - Angeliki Kazeros
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine; NYU School of Medicine; New York New York
| | - Beno W. Oppenheimer
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine; NYU School of Medicine; New York New York
- Andre Cournand Pulmonary Physiology Laboratory; Bellevue Hospital; New York New York
| | - Yinny Chan
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine; NYU School of Medicine; New York New York
- Andre Cournand Pulmonary Physiology Laboratory; Bellevue Hospital; New York New York
| | - Joan Reibman
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine; NYU School of Medicine; New York New York
| | - Roberta M. Goldring
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine; NYU School of Medicine; New York New York
- Andre Cournand Pulmonary Physiology Laboratory; Bellevue Hospital; New York New York
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18
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Berger KI, Goldring RM, Oppenheimer BW. Rebuttal From Dr Berger et al. Chest 2016; 148:1137-1138. [PMID: 26020419 DOI: 10.1378/chest.15-1037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Kenneth I Berger
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine; André Cournand Pulmonary Physiology Laboratory, Bellevue Hospital, New York, NY.
| | - Roberta M Goldring
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine; André Cournand Pulmonary Physiology Laboratory, Bellevue Hospital, New York, NY
| | - Beno W Oppenheimer
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine; André Cournand Pulmonary Physiology Laboratory, Bellevue Hospital, New York, NY
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19
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Berger KI, Turetz M, Liu M, Shao Y, Kazeros A, Parsia S, Caplan-Shaw C, Friedman SM, Maslow CB, Marmor M, Goldring RM, Reibman J. Oscillometry complements spirometry in evaluation of subjects following toxic inhalation. ERJ Open Res 2015; 1:00043-2015. [PMID: 27730155 PMCID: PMC5005120 DOI: 10.1183/23120541.00043-2015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 10/12/2015] [Indexed: 01/02/2023] Open
Abstract
The World Trade Center (WTC) destruction released dust and fumes into the environment. Although many community members developed respiratory symptoms, screening spirometry was usually normal. We hypothesised that forced oscillation testing would identify functional abnormalities undetected by spirometry and that symptom severity would relate to magnitude of abnormalities measured by oscillometry. A symptomatic cohort (n=848) from the Bellevue Hospital WTC Environmental Health Center was evaluated and compared to an asymptomatic cohort (n=475) from the New York City Department of Health WTC Health Registry. Spirometry and oscillometry were performed. Oscillometry measurements included resistance (R5) and frequency dependence of resistance (R5-20). Spirometry was normal for the majority of subjects (73.2% symptomatic versus 87.6% asymptomatic, p<0.0001). In subjects with normal spirometry, R5 and R5-20 were higher in symptomatic versus asymptomatic subjects (median (interquartile range) R5 0.436 (0.206) versus 0.314 (0.129) kPa·L-1·s-1, p<0.001; R5-20 0.075 (0.085) versus 0.004 (0.042) kPa·L-1·s-1, p<0.0001). In symptomatic subjects, R5 and R5-20 increased with increasing severity and frequency of wheeze (p<0.05). Measurement of R5-20 correlated with the presence and severity of symptoms even when spirometry was within normal limits. These findings are in accord with small airway abnormalities as a potential explanation of the respiratory symptoms.
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Affiliation(s)
- Kenneth I Berger
- Dept of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, NY, USA; André Cournand Pulmonary Physiology Laboratory, Bellevue Hospital, New York, NY, USA; These authors contributed equally to this manuscript
| | - Meredith Turetz
- Dept of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, NY, USA; These authors contributed equally to this manuscript
| | - Mengling Liu
- Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - Yongzhao Shao
- Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - Angeliki Kazeros
- Dept of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, NY, USA
| | - Sam Parsia
- Dept of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, NY, USA
| | - Caralee Caplan-Shaw
- Dept of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, NY, USA
| | - Stephen M Friedman
- New York City Department of Health and Mental Hygiene, New York, NY, USA
| | - Carey B Maslow
- New York City Department of Health and Mental Hygiene, New York, NY, USA
| | - Michael Marmor
- Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - Roberta M Goldring
- Dept of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, NY, USA; André Cournand Pulmonary Physiology Laboratory, Bellevue Hospital, New York, NY, USA
| | - Joan Reibman
- Dept of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, NY, USA
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Oppenheimer BW, Berger KI, Segal LN, Stabile A, Coles KD, Parikh M, Goldring RM. Airway dysfunction in obesity: response to voluntary restoration of end expiratory lung volume. PLoS One 2014; 9:e88015. [PMID: 24505355 PMCID: PMC3913722 DOI: 10.1371/journal.pone.0088015] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 01/02/2014] [Indexed: 11/18/2022] Open
Abstract
Introduction Abnormality in distal lung function may occur in obesity due to reduction in resting lung volume; however, airway inflammation, vascular congestion and/or concomitant intrinsic airway disease may also be present. The goal of this study is to 1) describe the phenotype of lung function in obese subjects utilizing spirometry, plethysmography and oscillometry; and 2) evaluate residual abnormality when the effect of mass loading is removed by voluntary elevation of end expiratory lung volume (EELV) to predicted FRC. Methods 100 non-smoking obese subjects without cardio-pulmonary disease and with normal airflow on spirometry underwent impulse oscillometry (IOS) at baseline and at the elevated EELV. Results FRC and ERV were reduced (44±22, 62±14% predicted) with normal RV/TLC (29±9%). IOS demonstrated elevated resistance at 20 Hz (R20, 4.65±1.07 cmH2O/L/s); however, specific conductance was normal (0.14±0.04). Resistance at 5–20 Hz (R5−20, 1.86±1.11 cmH2O/L/s) and reactance at 5 Hz (X5, −2.70±1.44 cmH2O/L/s) were abnormal. During elevation of EELV, IOS abnormalities reversed to or towards normal. Residual abnormality in R5−20 was observed in some subjects despite elevation of EELV (1.16±0.8 cmH2O/L/s). R5−20 responded to bronchodilator at baseline but not during elevation of EELV. Conclusions This study describes the phenotype of lung dysfunction in obesity as reduction in FRC with airway narrowing, distal respiratory dysfunction and bronchodilator responsiveness. When R5−20 normalized during voluntary inflation, mass loading was considered the predominant mechanism. In contrast, when residual abnormality in R5−20 was demonstrable despite return of EELV to predicted FRC, mechanisms for airway dysfunction in addition to mass loading could be invoked.
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Affiliation(s)
- Beno W. Oppenheimer
- André Cournand Pulmonary Physiology Laboratory, Division of Pulmonary, Critical Care and Sleep, Department of Medicine, Bellevue Hospital/New York University School of Medicine, New York, New York, United States of America
- * E-mail:
| | - Kenneth I. Berger
- André Cournand Pulmonary Physiology Laboratory, Division of Pulmonary, Critical Care and Sleep, Department of Medicine, Bellevue Hospital/New York University School of Medicine, New York, New York, United States of America
| | - Leopoldo N. Segal
- André Cournand Pulmonary Physiology Laboratory, Division of Pulmonary, Critical Care and Sleep, Department of Medicine, Bellevue Hospital/New York University School of Medicine, New York, New York, United States of America
| | - Alexandra Stabile
- André Cournand Pulmonary Physiology Laboratory, Division of Pulmonary, Critical Care and Sleep, Department of Medicine, Bellevue Hospital/New York University School of Medicine, New York, New York, United States of America
| | - Katherine D. Coles
- André Cournand Pulmonary Physiology Laboratory, Division of Pulmonary, Critical Care and Sleep, Department of Medicine, Bellevue Hospital/New York University School of Medicine, New York, New York, United States of America
| | - Manish Parikh
- Bellevue Hospital Bariatric Center, Department of Surgery, New York University School of Medicine, New York, New York, United States of America
| | - Roberta M. Goldring
- André Cournand Pulmonary Physiology Laboratory, Division of Pulmonary, Critical Care and Sleep, Department of Medicine, Bellevue Hospital/New York University School of Medicine, New York, New York, United States of America
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Berger KI, Goldring RM. Airways Disease Presenting as Restrictive Impairment: Response. Chest 2013; 144:1978-1979. [DOI: 10.1378/chest.13-1961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Berger KI, Reibman J, Oppenheimer BW, Vlahos I, Harrison D, Goldring RM. Lessons from the World Trade Center disaster: airway disease presenting as restrictive dysfunction. Chest 2013; 144:249-257. [PMID: 23392588 DOI: 10.1378/chest.12-1411] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The present study (1) characterizes a physiologic phenotype of restrictive dysfunction due to airway injury and (2) compares this phenotype to the phenotype of interstitial lung disease (ILD). METHODS This is a retrospective study of 54 persistently symptomatic subjects following World Trade Center (WTC) dust exposure. Inclusion criteria were reduced vital capacity (VC), FEV1/VC>77%, and normal chest roentgenogram. Measurements included spirometry, plethysmography, diffusing capacity of lung for carbon monoxide (Dlco), impulse oscillometry (IOS), inspiratory/expiratory CT scan, and lung compliance (n=16). RESULTS VC was reduced (46% to 83% predicted) because of the reduction of expiratory reserve volume (43%±26% predicted) with preservation of inspiratory capacity (IC) (85%±16% predicted). Total lung capacity (TLC) was reduced, confirming restriction (73%±8% predicted); however, elevated residual volume to TLC ratio (0.35±0.08) suggested air trapping (AT). Dlco was reduced (78%±15% predicted) with elevated Dlco/alveolar volume (5.3±0.8 [mL/mm Hg/min]/L). IOS demonstrated abnormalities in resistance and/or reactance in 50 of 54 subjects. CT scan demonstrated bronchial wall thickening and/or AT in 40 of 54 subjects; parenchymal disease was not evident in any subject. Specific compliance at functional residual capacity (FRC) (0.07±0.02 [L/cm H2O]/L) and recoil pressure (Pel) at TLC (27±7 cm H2O) were normal. In contrast to patients with ILD, lung expansion was not limited, since IC, Pel, and inspiratory muscle pressure were normal. Reduced TLC was attributable to reduced FRC, compatible with airway closure in the tidal range. CONCLUSIONS This study describes a distinct physiologic phenotype of restriction due to airway dysfunction. This pattern was observed following WTC dust exposure, has been reported in other clinical settings (eg, asthma), and should be incorporated into the definition of restrictive dysfunction.
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Affiliation(s)
- Kenneth I Berger
- André Cournand Pulmonary Physiology Laboratory, New York University School of Medicine, New York, NY; World Trade Center Environmental Health Center, Bellevue Hospital, New York University School of Medicine, New York, NY; Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, NY.
| | - Joan Reibman
- World Trade Center Environmental Health Center, Bellevue Hospital, New York University School of Medicine, New York, NY; Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, NY
| | - Beno W Oppenheimer
- André Cournand Pulmonary Physiology Laboratory, New York University School of Medicine, New York, NY; Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, NY
| | - Ioannis Vlahos
- Department of Radiology, St. George's Healthcare National Health Service Trust, London, England
| | - Denise Harrison
- Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, NY; New York University World Trade Center Health Program Clinical Center of Excellence, New York, NY
| | - Roberta M Goldring
- André Cournand Pulmonary Physiology Laboratory, New York University School of Medicine, New York, NY; World Trade Center Environmental Health Center, Bellevue Hospital, New York University School of Medicine, New York, NY; Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, NY
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Segal LN, Alekseyenko AV, Clemente JC, Kulkarni R, Wu B, Chen H, Berger KI, Goldring RM, Rom WN, Blaser MJ, Weiden MD. Enrichment of lung microbiome with supraglottic taxa is associated with increased pulmonary inflammation. Microbiome 2013; 1:19. [PMID: 24450871 PMCID: PMC3971609 DOI: 10.1186/2049-2618-1-19] [Citation(s) in RCA: 303] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Accepted: 06/21/2013] [Indexed: 05/07/2023]
Abstract
BACKGROUND The lung microbiome of healthy individuals frequently harbors oral organisms. Despite evidence that microaspiration is commonly associated with smoking-related lung diseases, the effects of lung microbiome enrichment with upper airway taxa on inflammation has not been studied. We hypothesize that the presence of oral microorganisms in the lung microbiome is associated with enhanced pulmonary inflammation. To test this, we sampled bronchoalveolar lavage (BAL) from the lower airways of 29 asymptomatic subjects (nine never-smokers, 14 former-smokers, and six current-smokers). We quantified, amplified, and sequenced 16S rRNA genes from BAL samples by qPCR and 454 sequencing. Pulmonary inflammation was assessed by exhaled nitric oxide (eNO), BAL lymphocytes, and neutrophils. RESULTS BAL had lower total 16S than supraglottic samples and higher than saline background. Bacterial communities in the lower airway clustered in two distinct groups that we designated as pneumotypes. The rRNA gene concentration and microbial community of the first pneumotype was similar to that of the saline background. The second pneumotype had higher rRNA gene concentration and higher relative abundance of supraglottic-characteristic taxa (SCT), such as Veillonella and Prevotella, and we called it pneumotypeSCT. Smoking had no effect on pneumotype allocation, α, or β diversity. PneumotypeSCT was associated with higher BAL lymphocyte-count (P= 0.007), BAL neutrophil-count (P= 0.034), and eNO (P= 0.022). CONCLUSION A pneumotype with high relative abundance of supraglottic-characteristic taxa is associated with enhanced subclinical lung inflammation.
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Affiliation(s)
- Leopoldo N Segal
- André Cournand Pulmonary Research Laboratory, Bellevue Hospital Center/New York University School of Medicine, New York, NY, USA
- Division of Pulmonary and Critical Care Medicine, New York University School of Medicine, New York, NY, USA
- Department of Medicine, New York University School of Medicine, 462 First Ave 7 W54, New York 10016, NY, USA
| | - Alexander V Alekseyenko
- Department of Medicine, New York University School of Medicine, 462 First Ave 7 W54, New York 10016, NY, USA
- Center for Health Informatics and Bioinformatics, New York University School of Medicine, New York, NY, USA
| | - Jose C Clemente
- Division of Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY, USA
| | - Rohan Kulkarni
- Division of Pulmonary and Critical Care Medicine, New York University School of Medicine, New York, NY, USA
| | - Benjamin Wu
- Division of Pulmonary and Critical Care Medicine, New York University School of Medicine, New York, NY, USA
| | - Hao Chen
- Center for Health Informatics and Bioinformatics, New York University School of Medicine, New York, NY, USA
| | - Kenneth I Berger
- André Cournand Pulmonary Research Laboratory, Bellevue Hospital Center/New York University School of Medicine, New York, NY, USA
- Division of Pulmonary and Critical Care Medicine, New York University School of Medicine, New York, NY, USA
- Department of Medicine, New York University School of Medicine, 462 First Ave 7 W54, New York 10016, NY, USA
| | - Roberta M Goldring
- André Cournand Pulmonary Research Laboratory, Bellevue Hospital Center/New York University School of Medicine, New York, NY, USA
- Division of Pulmonary and Critical Care Medicine, New York University School of Medicine, New York, NY, USA
- Department of Medicine, New York University School of Medicine, 462 First Ave 7 W54, New York 10016, NY, USA
| | - William N Rom
- Division of Pulmonary and Critical Care Medicine, New York University School of Medicine, New York, NY, USA
- Department of Medicine, New York University School of Medicine, 462 First Ave 7 W54, New York 10016, NY, USA
| | - Martin J Blaser
- Department of Medicine, New York University School of Medicine, 462 First Ave 7 W54, New York 10016, NY, USA
| | - Michael D Weiden
- Division of Pulmonary and Critical Care Medicine, New York University School of Medicine, New York, NY, USA
- Department of Medicine, New York University School of Medicine, 462 First Ave 7 W54, New York 10016, NY, USA
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Friedman SM, Maslow CB, Reibman J, Pillai PS, Goldring RM, Farfel MR, Stellman SD, Berger KI. Case-control study of lung function in World Trade Center Health Registry area residents and workers. Am J Respir Crit Care Med 2011; 184:582-9. [PMID: 21642248 DOI: 10.1164/rccm.201011-1909oc] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Residents and area workers who inhaled dust and fumes from the World Trade Center disaster reported lower respiratory symptoms in two World Trade Center Health Registry surveys (2003-2004 and 2006-2007), but lung function data were lacking. OBJECTIVES To examine the relationship between persistent respiratory symptoms and pulmonary function in a nested case-control study of exposed adult residents and area workers 7-8 years after September 11, 2001. METHODS Registrants reporting post September 11th onset of a lower respiratory symptom in the first survey and the same symptom in the second survey were solicited as potential cases. Registrants without lower respiratory symptoms in either Registry survey were solicited as potential control subjects. Final case-control status was determined by lower respiratory symptoms at a third interview (the study), when spirometry and impulse oscillometry were also performed. MEASUREMENTS AND MAIN RESULTS We identified 180 cases and 473 control subjects. Cases were more likely than control subjects to have abnormal spirometry (19% vs. 11%; P < 0.05), and impulse oscillometry measurements of elevated airway resistance (R5; 68% vs. 27%; P < 0.0001) and frequency dependence of resistance (R₅₋₂₀; 36% vs. 7%; P < 0.0001). When spirometry was normal, cases were more likely than control subjects to have elevated R₅ and R₅₋₂₀ (62% vs. 25% and 27% vs. 6%, respectively; both P < 0.0001). Associations between symptoms and oscillometry held when factors significant in bivariate comparisons (body mass index, spirometry, and exposures) were analyzed using logistic regression. CONCLUSIONS This study links persistent respiratory symptoms and oscillometric abnormalities in World Trade Center-exposed residents and area workers. Elevated R₅ and R₅₋₂₀ in cases despite normal spirometry suggested distal airway dysfunction as a mechanism for symptoms.
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Affiliation(s)
- Stephen M Friedman
- New York City Department of Health and Mental Hygiene, New York, New York 11101, USA.
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Segal LN, Goldring RM, Oppenheimer BW, Stabile A, Reibman J, Rom WN, Weiden MD, Berger KI. Disparity between proximal and distal airway reactivity during methacholine challenge. COPD 2011; 8:145-52. [PMID: 21513433 DOI: 10.3109/15412555.2011.560127] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
There is an increasing awareness of the role of distal airways in the pathophysiology of obstructive lung diseases including asthma and chronic obstructive pulmonary disease. We hypothesize that during induced bronchoconstriction: 1) disparity between distal and proximal airway reactivity may occur; and 2) changes in distal airway function may explain symptom onset in subjects with minimal FEV(1) change. 185 subjects underwent methacholine challenge testing (MCT). In addition to spirometry, oscillometry was performed at baseline and after maximum dose of methacholine; 33/185 also underwent oscillometry after each dose. Oscillometric parameters included resistance at 5 and 20 Hz (R(5), R(20)) and heterogeneity of distal airway mechanics assessed by frequency dependence of resistance 5-20 Hz (R(5-20)) and reactance area (AX). R(5) varied widely during MCT (range -0.8 - 11.3 cmH(2)O/L/s) and correlated poorly with change in FEV(1) (r = 0.17). Changes in R(5) reflected changes in both R(20) and R(5-20) (r = 0.59, p<0.05; r = 0.87, p<0.0001). However, R(20) increased only 0.3 cmH(2)O/L/s, while R(5-20) increased 0.7 cmH(2)O/L/s for every 1cmH(2)O/L/s change in R(5,) indicating predominant effect of distal airway mechanics. 9/33 subjects developed symptoms despite minimal FEV(1) change (<5%), while R(5) increased 42% due to increased distal airway heterogeneity. These data indicate disparate behavior of proximal airway resistance (FEV(1) and R(20)) and distal airway heterogeneity (R(5-20) and AX). Distal airway reactivity may be associated with methacholine-induced symptoms despite absence of change in FEV(1). This study highlights the importance of disparity between proximal and distal airway behavior, which has implications in understanding pathophysiology of obstructive pulmonary diseases and their response to treatment.
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Affiliation(s)
- Leopoldo N Segal
- André Cournand Pulmonary Physiology Laboratory, New York University School of Medicine, New York, New York 10016, USA.
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Abstract
This study examined the ventilatory adjustment to chronic metabolic alkalosis induced under controlled conditions in normal human volunteers. Metabolic alkalosis induced by buffers (sodium bicarbonate, trishydroxymethylamine methane) or ethacrynic acid was associated with alveolar hypoventilation, as evidenced by a rise in arterial Pco(2), a fall in arterial Po(2), a reduced resting tidal volume, and a diminished ventilatory response to CO(2) inhalation. Alveolar hypoventilation did not occur when metabolic alkalosis was induced in the same subjects by thiazide diuretics or aldosterone despite comparable elevations of the arterial blood pH and bicarbonate concentration.The different ventilatory responses of the two groups could not be ascribed to differences among individuals comprising each group, pharmacological effects of the alkalinizing agents, differences in the composition of the lumber spinal fluid, changes in extracellular fluid volume, or sodium and chloride balance.The differences in ventilatory adjustments were associated with differences in the patterns of hydrogen and potassium ion balance during the induction of alkalosis. Alveolar hypoventilation occurred when hydrogen ions were buffered (sodium bicarbonate, trishydroxymethylamine methane) or when renal hydrogen ion excretion was increased (ethacrynic acid). Alveolar hypoventilation did not occur when induction of similar degrees of extracellular alkalosis was accompanied by marked potassium loss and no demonstrable increase in external hydrogen loss (thiazides and aldosterone).These observations suggest that respiratory depression does not necessarily accompany extracellular alkalosis but depends on the effect of the mode of induction of the alkalosis on the tissues involved in the control of ventilation.
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Affiliation(s)
- R M Goldring
- Department of Medicine, Presbyterian Hospital, College of Physicians and Surgeons, Columbia University, New York
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Parikh M, Berger KI, Goldring RM, Schwartz M, Kim A, Oppenheimer BW. P-156: Detection of airway dysfunction BY oscillometry in morbid obesity despite normal spirometry. Surg Obes Relat Dis 2010. [DOI: 10.1016/j.soard.2010.03.200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Oppenheimer BW, Goldring RM, Berger KI. Distal airway function assessed by oscillometry at varying respiratory rate: comparison with dynamic compliance. COPD 2010; 6:162-70. [PMID: 19811371 DOI: 10.1080/15412550902918410] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Distal airways disease causes significant morbidity yet remains insufficiently identified. We hypothesize that: ( [1] ) when spirometry is normal impulse oscillometry may provide information about mechanical properties of the distal airways in a manner comparable to dynamic compliance and ( [2] ) variation of breathing frequency will influence oscillometric measurements similar to effects of breathing frequency on dynamic compliance. Fifty-three symptomatic subjects with normal large airway function (spirometry) were studied; distal airway dysfunction was identified by presence of frequency dependence of compliance (FDC). Oscillometric parameters evaluated were resistance at 20 Hz (R20) and 5-20 Hz (R(5-20)), reactance at 5 Hz (X5), and reactance area (AX). R20 correlated with airway resistance by esophageal manometry (r = 0.74, p < 0.001); X5 correlated with dynamic compliance at a respiratory rate of 60 bpm (r = 0.61, p < 0.001); R(5-20) and AX correlated with FDC (r = 0.48, p < 0.001; r = 0.53, p < 0.01). IOS indices were further evaluated at increased respiratory rate (RR40). Oscillometric parameters changed minimally at RR40 in normal subjects DeltaR20 = 0.20 +/- 0.08 cmH2O/L/s, DeltaR(5-20) = 0.10 +/- 0.03 cmH2O/L/s, DeltaAX = 0.33 +/- 0.19 cmH2O/L). However, in symptomatic subjects, while R20 increased minimally at RR40 (DeltaR20 = 0.37 +/- 0.10 cmH2O/L/s), R(5-20) and AX increased markedly (DeltaR(5-20) = 0.54 +/- 0.06 cmH2O/L/s, DeltaAX = 4.28 +/- 0.67 cmH2O/L) and reversed post bronchodilator. IOS evaluates physiology of the distal airways in a manner comparable to dynamic compliance. Elevated respiratory rate influences oscillometric parameters and must be considered when interpreting oscillometric data. IOS provides a non-invasive tool for assessment of distal airway function when spirometry is normal, which can be applied to various clinical settings including early diagnosis of COPD (GOLD stage 0), asthma in clinical remission and occupational/ environmental irritant exposure.
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Affiliation(s)
- Beno W Oppenheimer
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, New York University School of Medicine/Bellevue Medical Center, New York, NY, USA.
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Segal LN, Oei E, Oppenheimer BW, Goldring RM, Bustami RT, Ruggiero S, Berger KI, Fiel SB. Evolution of pattern of breathing during a spontaneous breathing trial predicts successful extubation. Intensive Care Med 2009; 36:487-95. [PMID: 19946770 DOI: 10.1007/s00134-009-1735-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2009] [Accepted: 11/04/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE Rapid shallow breathing may occur at any time during spontaneous breathing trials (SBT), questioning the utility of a single determination of the rapid shallow breathing index (RSBI). We hypothesize that change in RSBI during SBT may more accurately predict successful extubation than a single determination. METHODS Prospective observational study. Seventy-two subjects were extubated. At 24 h, 63/72 remained extubated (Extubation Success), and 9 were re-intubated (Extubation Failure). Respiratory rate (RR), tidal volume (VT) and RSBI were measured every 30 min during 2-h T-piece SBT. Change in respiratory parameters was assessed as percent change from baseline. RESULTS Initial RSBI was similar in Extubation Success and Extubation Failure groups (77.0 +/- 4.8, 77.0 +/- 4.8, p = ns). Nevertheless, RSBI tended to remain unchanged or decreased in the Extubation Success group; in contrast RSBI tended to increase in the Extubation Failure group because of either increased RR and/or decreased VT (p < 0.001 for mean percent change RSBI over time), indicating worsening of the respiratory pattern. Quantitatively, only 7/63 subjects of the Extubation Success group demonstrated increased RSBI >or=20% at any time during the SBT. In contrast, in the Extubation Failure group, RSBI increased in all subjects during the SBT, and eight of nine subjects demonstrated an increase greater than 20%. Thus, with a 2-h SBT the optimal threshold was a 20% increase (sensitivity = 89%, specificity = 89%). Similar results were obtained at 30 min (threshold = 5% increase). Percent change of RSBI predicted successful extubation even when initial values were >or=105. CONCLUSION Percent change of RSBI during an SBT is a better predictor of successful extubation than a single determination of RSBI.
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Affiliation(s)
- Leopoldo N Segal
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, New York University School of Medicine, 462 First Ave 7W54, New York, NY 10016, USA.
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Weiden MD, Ferrier N, Nolan A, Rom WN, Comfort A, Gustave J, Zeig-Owens R, Zheng S, Goldring RM, Berger KI, Cosenza K, Lee R, Webber MP, Kelly KJ, Aldrich TK, Prezant DJ. Obstructive airways disease with air trapping among firefighters exposed to World Trade Center dust. Chest 2009; 137:566-74. [PMID: 19820077 DOI: 10.1378/chest.09-1580] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The World Trade Center (WTC) collapse produced a massive exposure to respirable particulates in New York City Fire Department (FDNY) rescue workers. This group had spirometry examinations pre-September 11, 2001, and post-September 11, 2001, demonstrating declines in lung function with parallel declines in FEV(1) and FVC. To date, the underlying pathophysiologic cause for this has been open to question. METHODS Of 13,234 participants in the FDNY-WTC Monitoring Program, 1,720 (13%) were referred for pulmonary subspecialty evaluation at a single institution. Evaluation included 919 full pulmonary function tests, 1,219 methacholine challenge tests, and 982 high-resolution chest CT scans. RESULTS At pulmonary evaluation (median 34 months post-September 11, 2001), median values were FEV(1) 93% predicted (interquartile range [IQR], 83%-101%), FVC 98% predicted (IQR, 89%-106%), and FEV(1)/FVC 0.78 (IQR, 0.72-0.82). The residual volume (RV) was 123% predicted (IQR, 106%-147%) with nearly all participants having normal total lung capacity, functional residual capacity, and diffusing capacity of carbon monoxide. Also, 1,051/1,720 (59%) had obstructive airways disease based on at least one of the following: FEV(1)/FVC, bronchodilator responsiveness, hyperreactivity, or elevated RV. After adjusting for age, gender, race, height and weight, and tobacco use, the decline in FEV(1) post-September 11, 2001, was significantly correlated with increased RV percent predicted (P < .0001), increased bronchodilator responsiveness (P < .0001), and increased hyperreactivity (P = .0056). CT scans demonstrated bronchial wall thickening that was significantly associated with the decline in FEV(1) post-September 11, 2001 (P = .024), increases in hyperreactivity (P < .0001), and increases in RV (P < .0001). Few had evidence for interstitial disease. CONCLUSIONS Airways obstruction was the predominant physiologic finding underlying the reduction in lung function post-September 11, 2001, in FDNY WTC rescue workers presenting for pulmonary evaluation.
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Affiliation(s)
- Michael D Weiden
- Division of Pulmonary/Critical Care, New York University, New York, NY, USA
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Abstract
The term obesity hypoventilation syndrome (OHS) refers to the combination of obesity and chronic hypercapnia that cannot be directly attributed to underlying cardiorespiratory disease. Despite a plethora of potential pathophysiological mechanisms for gas exchange and respiratory control abnormalities that have been described in the obese, the etiology of hypercapnia in OHS has been only partially elucidated. Of particular note, obesity and coincident hypercapnia are often associated with some form of sleep disordered breathing (apnea/hypopnea or sustained periods of hypoventilation). From a conceptual point of view, even transient reductions of ventilation from individual sleep disordered breathing events must produce acute hypercapnia during the period of low ventilation. What is less clear, however, is the link between these transient episodes of acute hypercapnia and the development of chronic sustained hypercapnia persisting into wakefulness. A unifying view of how this comes about is presented in the following review. In brief, our concept is that chronic sustained hypercapnia (as in obesity hypoventilation) occurs when the disorder of ventilation that produces acute hypercapnia interacts with inadequate compensation (both during sleep and during the periods of wakefulness); neither alone is sufficient to fully explain the final result. The following discussion will amplify on both the potential reasons for acute hypercapnia in the obese and on what is known about the failure of compensation that must occur in these subjects.
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Affiliation(s)
- Kenneth I Berger
- Department of Medicine, New York University School of Medicine, NYU/Bellevue Medical Center, New York, USA.
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Oppenheimer BW, Goldring RM, Herberg ME, Hofer IS, Reyfman PA, Liautaud S, Rom WN, Reibman J, Berger KI. Distal airway function in symptomatic subjects with normal spirometry following World Trade Center dust exposure. Chest 2007; 132:1275-82. [PMID: 17890470 DOI: 10.1378/chest.07-0913] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
RATIONALE Following collapse of the World Trade Center (WTC), individuals reported new-onset respiratory symptoms. Despite symptoms, spirometry often revealed normal airway function. However, bronchial wall thickening and air trapping were seen radiographically in some subjects. We hypothesized that symptomatic individuals following exposure to WTC dust may have functional abnormalities in distal airways not detectable with routine spirometry. METHODS One hundred seventy-four subjects with respiratory symptoms and normal spirometry results were evaluated. Impedance oscillometry (IOS) was performed to determine resistance at 5 Hz, 5 to 20 Hz, and reactance area. Forty-three subjects were also tested for frequency dependence of compliance (FDC). Testing was repeated after bronchodilation. RESULTS Predominant symptoms included cough (67%) and dyspnea (65%). Despite normal spirometry results, mean resistance at 5 Hz, 5 to 20 Hz, and reactance area were elevated (4.36 +/- 0.12 cm H(2)O/L/s, 0.86 +/- 0.05 cm H(2)O/L/s, and 6.12 +/- 0.50 cm H(2)O/L, respectively) [mean +/- SE]. Resistance and reactance normalized after bronchodilation. FDC was present in 37 of 43 individuals with improvement after bronchodilation. CONCLUSIONS Symptomatic individuals with presumed WTC dust/fume exposure and normal spirometry results displayed airway dysfunction based on the following: (1) elevated airway resistance and frequency dependence of resistance determined by IOS; (2) heterogeneity of distal airway function demonstrated by elevated reactance area on oscillometry and FDC; and (3) reversibility of these functional abnormalities to or toward normal following administration of a bronchodilator. Since spirometry results were normal in all subjects, these abnormalities likely reflect dysfunction in airways more distal to those evaluated by spirometry. Examination of distal airway function when spirometry results are normal may be important in the evaluation of subjects exposed to occupational and environmental hazards.
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Affiliation(s)
- Beno W Oppenheimer
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, New York University School of Medicine, New York, NY 10016, USA
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Oppenheimer BW, Berger KI, Rennert DA, Pierson RN, Norman RG, Rapoport DM, Kral JG, Goldring RM. Effect of circulatory congestion on the components of pulmonary diffusing capacity in morbid obesity. Obesity (Silver Spring) 2006; 14:1172-80. [PMID: 16899798 DOI: 10.1038/oby.2006.134] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Obese patients without clinically apparent heart disease may have a high output state and elevated total and central blood volumes. Central circulatory congestion should result in elevated pulmonary diffusing capacity (DLCO) and capillary blood volume (Vc) reflecting pulmonary capillary recruitment; however, the effect on membrane diffusion (Dm) is uncertain. We examined DLCO and its partition into Vc and Dm in 13 severely obese subjects (BMI = 51 +/- 14 kg/m2) without manifest cardiopulmonary disease before and after surgically induced weight loss. RESEARCH METHODS AND PROCEDURES DLCO and its partition into Vc and Dm [referenced to alveolar volume (VA)] as described by Roughton and Forster, total body water by tritiated water, and fat distribution by waist-to-hip ratio were performed. RESULTS Despite normal DLCO (mean 98 +/- 16% predicted), Vc/VA was increased (mean 118 +/- 30% predicted), and Dm/VA was reduced (mean 77 +/- 34% predicted). Nine of 13 subjects were restudied after weight loss (mean 52 +/- 43 kg); Vc/VA decreased to 89 +/- 18% predicted (p = 0.01), and Dm/VA increased to 139 +/- 30% predicted (p < 0.01). Increasing total body water was associated with both increasing Vc (r = 0.74, p = 0.01) and increasing waist-to-hip ratio (r = 0.65, p = 0.02), indicating that circulatory congestion increases with increasing central obesity. DISCUSSION Severely obese subjects without manifest cardiopulmonary disease may have increased Vc indicating central circulatory congestion and reduced Dm suggesting associated alveolar capillary leak, despite normal DLCO. Reversibility with weight loss is in accord with reversibility of the hemodynamic abnormalities of obesity.
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Affiliation(s)
- Beno W Oppenheimer
- Division of Pulmonary and Critical Care Medicine and Bellevue Hospital Chest Service, Department of Medicine, New York University School of Medicine, New York, NY 10016, USA.
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Oppenheimer BW, Berger KI, Hadjiangelis NP, Norman RG, Rapoport DM, Goldring RM. Membrane diffusion in diseases of the pulmonary vasculature. Respir Med 2006; 100:1247-53. [PMID: 16376536 DOI: 10.1016/j.rmed.2005.10.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2005] [Revised: 10/07/2005] [Accepted: 10/16/2005] [Indexed: 11/23/2022]
Abstract
INTRODUCTION We examined pulmonary diffusing capacity (D(LCO)) and its partition in pulmonary vascular diseases without evident parenchymal disease to assess the pattern and proportionality of change in membrane diffusion (D(m)) and capillary blood volume (V(c)). Disproportionate reduction in D(m) relative to V(c) (low D(m)/V(c)) in these diseases has been attributed to associated alveolar membrane/parenchymal disease, thus providing a potentially important diagnostic tool. METHODS Diseases included: idiopathic pulmonary arterial hypertension (n=6), chronic thromboembolic disease (n=5), and intravenous drug use (n=14), providing a spectrum of pulmonary vascular diseases. V(c) and D(m) were determined as described by Roughton and Forster. RESULTS All diseases showed a reduced V(c) (59+/-10, 69+/-14, 71+/-21 % predicted, respectively) and D(m) (76+/-22, 53+/-19, 63+/-16 % predicted, respectively) with no differences between groups (p>0.05). Disproportionate reduction of D(m) (D(m)/V(c) % predicted <1) was seen in all diseases (range 0.36-1.89). A mathematical analysis is presented to illustrate that changes in vascular geometry may additionally influence the proportionality of changes in D(m) and V(c). The mathematical analysis suggests that when reduction in patency of some vessels co-exits with compensatory dilatation of the remaining vasculature, a disproportionate reduction in D(m) relative to V(c) may result. CONCLUSIONS The balance between vascular curtailment and compensatory dilatation may contribute to the variability of the D(m)/V(c) relationship seen in pulmonary vascular disease. Disproportionate reduction in D(m) relative to V(c) may result from this imbalance and need not imply subclinical alveolar membrane and/or parenchymal disease.
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Affiliation(s)
- Beno W Oppenheimer
- Division of Pulmonary and Critical Care Medicine, Bellevue Hospital Chest Service, Department of Medicine, New York University School of Medicine, 462 First Ave 7W54, New York, NY 10016, USA.
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Abstract
In this work MRI-based spirometry is presented as a method for noninvasively assessing pulmonary mechanical function on a regional basis. A SPAMM tagging sequence was modified to allow continuous dynamic imaging of the lungs during respiration. A motion-tracking algorithm was developed to track material regions from time-resolved grid-tagged images. Experiments were performed to image the lungs during quiet breathing and volumetric strain was calculated from the measured displacement maps. Regional volume calculations, derived from volumetric strain, were integrated over the entire lung and compared to segmented volume calculations with good agreement. Results from this work demonstrate that MRI spirometry has the potential to become a clinically useful tool for measuring regional ventilation and assessing pulmonary diseases that regionally affect the mechanical function of the lung.
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Affiliation(s)
- Abram Voorhees
- Department of Radiology, New York University School of Medicine, New York 10016-3240, USA.
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Norman RG, Goldring RM, Clain JM, Oppenheimer BW, Charney AN, Rapoport DM, Berger KI. Transition from acute to chronic hypercapnia in patients with periodic breathing: predictions from a computer model. J Appl Physiol (1985) 2005; 100:1733-41. [PMID: 16384839 DOI: 10.1152/japplphysiol.00502.2005] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Acute hypercapnia may develop during periodic breathing from an imbalance between abnormal ventilatory patterns during apnea and/or hypopnea and compensatory ventilatory response in the interevent periods. However, transition of this acute hypercapnia into chronic sustained hypercapnia during wakefulness remains unexplained. We hypothesized that respiratory-renal interactions would play a critical role in this transition. Because this transition cannot be readily addressed clinically, we modified a previously published model of whole-body CO2 kinetics by adding respiratory control and renal bicarbonate kinetics. We enforced a pattern of 8 h of periodic breathing (sleep) and 16 h of regular ventilation (wakefulness) repeated for 20 days. Interventions included varying the initial awake respiratory CO2 response and varying the rate of renal bicarbonate excretion within the physiological range. The results showed that acute hypercapnia during periodic breathing could transition into chronic sustained hypercapnia during wakefulness. Although acute hypercapnia could be attributed to periodic breathing alone, transition from acute to chronic hypercapnia required either slowing of renal bicarbonate kinetics, reduction of ventilatory CO2 responsiveness, or both. Thus the model showed that the interaction between the time constant for bicarbonate excretion and respiratory control results in both failure of bicarbonate concentration to fully normalize before the next period of sleep and persistence of hypercapnia through blunting of ventilatory drive. These respiratory-renal interactions create a cumulative effect over subsequent periods of sleep that eventually results in a self-perpetuating state of chronic hypercapnia.
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Affiliation(s)
- Robert G Norman
- Divisions of Pulmonary and Critical Care Medicine, Department of Medicine, New York University School of Medicine/Bellevue Medical Center, New York, NY 10016, USA.
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Rogers L, Cassino C, Berger KI, Goldring RM, Norman RG, Klugh T, Reibman J. Asthma in the elderly: cockroach sensitization and severity of airway obstruction in elderly nonsmokers. Chest 2002; 122:1580-6. [PMID: 12426256 DOI: 10.1378/chest.122.5.1580] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES To test the hypothesis that the presence of sensitization to indoor allergens is associated with increased severity of airway obstruction in elderly subjects with asthma. DESIGN Cohort study of subjects enrolled in a public hospital asthma clinic. SETTING Asthma clinic in a municipal public hospital serving an indigent population in New York City. PATIENTS Subjects aged > or = 60 years with asthma who were enrolled in the Bellevue Hospital Asthma Clinic. Total serum IgE and allergen-specific IgE measurements were performed in a cohort of elderly never-smokers who had asthma (45 patients) who had undergone spirometry before and after bronchodilator (BD) therapy. MEASUREMENTS AND RESULTS The results of radioallergosorbent tests demonstrated that most subjects (ie, 60%) were sensitized to at least one allergen, with many sensitized to at least one indoor allergen. Cockroach (CR) was the most common allergen to which subjects were sensitized, with 47% displaying an elevated serum-specific IgE level. Fewer subjects were sensitized to dust mite, cat, dog, or ragweed. Subjects sensitized to CR (CR+) had greater reductions in airflow compared to subjects not sensitized to CR (CR-) [64 +/- 4.4% predicted vs 77.1 +/- 4.1% predicted FEV(1), respectively; p < 0.05]. Following BD administration, only 29% of CR+ subjects achieved a normal post-BD FEV(1) compared to 58% of CR- subjects. Lung volume measurements differed between CR+ and CR- subjects, with a greater elevation of functional residual capacity in CR+ subjects. CONCLUSION In a population of elderly urban patients with asthma, the presence of CR-specific serum IgE is associated with more severe asthma, as reflected by an increase in airway obstruction and hyperinflation.
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Affiliation(s)
- Linda Rogers
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York University School of Medicine, Bellevue Hospital Center, New York, NY 10016, USA
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Ayappa I, Berger KI, Norman RG, Oppenheimer BW, Rapoport DM, Goldring RM. Hypercapnia and ventilatory periodicity in obstructive sleep apnea syndrome. Am J Respir Crit Care Med 2002; 166:1112-5. [PMID: 12379556 DOI: 10.1164/rccm.200203-212oc] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Prevention of acute hypercapnia during obstructive events in obstructive sleep apnea requires a balance between carbon dioxide (CO(2)) loading during the event and CO(2) unloading in the interevent period. Earlier studies have demonstrated that acute CO(2) retention may occur despite high interevent ventilation when the interevent duration is short relative to the duration of the preceding event. The present study examines the relationship between apnea and interapnea durations and relates this assessment of ventilatory periodicity to the degree of chronic hypercapnia in subjects with severe sleep apnea. A total of 18 subjects with sleep apnea (> 40 apnea/hour; chronic awake Pa(CO2) 36-62 mm Hg) and without underlying lung disease underwent polysomnography. For each event, apnea duration, interapnea duration, and apnea/interapnea duration ratio were determined. No relationship was observed between chronic Pa(CO2) and mean apnea or interapnea duration (p > 0.1). However, Pa(CO2) was directly related to apnea/interapnea duration ratio (r = 0.48; p < 0.05) such that with increasing chronic hypercapnia the interapnea duration shortens relative to the apnea duration. The present study suggests that control of the interapnea ventilatory duration relative to the duration of the preceding apnea, is an important component of the integrated ventilatory response to CO(2) loading during apnea and may contribute toward the development and/or maintenance of chronic hypercapnia in obstructive sleep apnea/hypopnea syndrome.
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Affiliation(s)
- Indu Ayappa
- Division of Pulmonary and Critical Care Medicine and Bellevue Hospital Chest Service, Department of Medicine, New York University School of Medicine, New York, New York 10016, USA.
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Berger KI, Ayappa I, Sorkin IB, Norman RG, Rapoport DM, Goldring RM. Postevent ventilation as a function of CO(2) load during respiratory events in obstructive sleep apnea. J Appl Physiol (1985) 2002; 93:917-24. [PMID: 12183486 DOI: 10.1152/japplphysiol.01082.2001] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Maintenance of eucapnia during sleep in obstructive sleep apnea (OSA) requires a balance between CO(2) loading during apnea and CO(2) elimination. This study examines individual respiratory events and relates magnitude of postevent ventilation to CO(2) load during the preceding respiratory event in 14 patients with OSA (arterial PCO(2) 42-56 Torr). Ventilation and expiratory CO(2) and O(2) fractions were measured on a breath-by-breath basis during daytime sleep. Calculations included CO(2) load during each event (metabolic CO(2) production - exhaled CO(2)) and postevent ventilation in the 10 s after an event. In 12 of 14 patients, a direct relationship existed between postevent ventilation and CO(2) load during the preceding event (P < 0.05); the slope of this relationship varied across subjects. Thus the postevent ventilation is tightly linked to CO(2) loading during each respiratory event and may be an important mechanism that defends against development of acute hypercapnia in OSA. An inverse relationship was noted between this postevent ventilatory response slope and the chronic awake arterial PCO(2) (r = 0.90, P < 0.001), suggesting that this mechanism is impaired in patients with chronic hypercapnia. The link between development of acute hypercapnia during respiratory events asleep and maintenance of chronic awake hypercapnia in OSA remains to be further investigated.
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Affiliation(s)
- Kenneth I Berger
- Division of Pulmonary and Critical Care Medicine and Bellevue Hospital Chest Service, Department of Medicine, New York University School of Medicine, New York, New York 10016, USA.
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Berger KI, Ayappa I, Chatr-Amontri B, Marfatia A, Sorkin IB, Rapoport DM, Goldring RM. Obesity hypoventilation syndrome as a spectrum of respiratory disturbances during sleep. Chest 2001; 120:1231-8. [PMID: 11591566 DOI: 10.1378/chest.120.4.1231] [Citation(s) in RCA: 147] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE To identify the spectrum of respiratory disturbances during sleep in patients with obesity hypoventilation syndrome (OHS) and to examine the response of hypercapnia to treatment of the specific ventilatory sleep disturbances. DESIGNS AND METHODS Twenty-three patients with chronic awake hypercapnia (mean [+/- SD] PaCO(2), 55 +/- 6 mm Hg) and a respiratory sleep disorder were retrospectively identified. Nocturnal polysomnography testing was performed, and flow limitation (FL) was identified from the inspiratory flow-time contour. Obstructive hypoventilation was inferred from sustained FL coupled with O(2) desaturation that was corrected with treatment of the upper airway obstruction. Central hypoventilation was inferred from sustained O(2) desaturation that persisted after the correction of the upper airway obstruction. Treatment was initiated, and follow-up awake PaCO(2) measurements were obtained (follow-up range, 4 days to 7 years). RESULTS A variable number of obstructive sleep apneas/hypopneas (ie, obstructive sleep apnea-hypopnea syndrome [OSAHS]) were noted (range, 9 to 167 events per hour of sleep). Of 23 patients, 11 demonstrated upper airway obstruction alone (apnea-hypopnea/FL) and 12 demonstrated central sleep hypoventilation syndrome (SHVS) in addition to a variable number of OSAHS. Treatment aimed at correcting the specific ventilatory abnormalities resulted in correction of the chronic hypercapnia in all compliant patients (compliant patients: pretreatment, 57 +/- 6 mm Hg vs post-treatment, 41 +/- 4 mm Hg [p < 0.001]; noncompliant patients: pretreatment, 52 +/- 6 mm Hg vs post-treatment, 51 +/- 3 mm Hg; [difference not significant]). CONCLUSIONS This study demonstrates that OHS encompasses a variety of distinct pathophysiologic disturbances that cannot be distinguished clinically at presentation. Sustained obstructive hypoventilation due to partial upper airway obstruction was demonstrated as an additional mechanism for OHS that is not easily classified as SHVS or OSAHS.
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Affiliation(s)
- K I Berger
- Department of Medicine, New York University School of Medicine, New York, NY 10016, USA.
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Cassino C, Berger KI, Goldring RM, Norman RG, Kammerman S, Ciotoli C, Reibman J. Duration of asthma and physiologic outcomes in elderly nonsmokers. Am J Respir Crit Care Med 2000; 162:1423-8. [PMID: 11029356 DOI: 10.1164/ajrccm.162.4.9912140] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Airway and alveolar inflammation have been described in asthma. Prolonged inflammation may lead to airway remodeling, which can result in physiologic abnormalities. Elderly lifetime nonsmokers are an ideal population in which to examine the consequences of longstanding asthma. To test the hypothesis that airflow limitation and hyperinflation are associated with the duration of asthma, we evaluated airflow and lung volumes in a cohort of elderly asthmatic individuals. All subjects were > 60 yr of age and were lifetime nonsmokers (n = 75). Patients with asthma of long duration (LDA; n = 38) had asthma for >/= 26 yr (median = 40.0 yr); patients with asthma of short duration (SDA; n = 37) had asthma for < 26 yr (median = 9 yr). Patients with LDA had a significantly lower FEV(1)% predicted than did those with SDA (59.5 +/- 2.6% versus 73.8 +/- 3.1% [mean +/- SEM], respectively; p < 0.007). Regression analysis demonstrated that duration of asthma was inversely associated with FEV(1)% predicted (r = 0.264, p < 0.03). After bronchodilator administration, the patients with LDA continued to show airflow obstruction (FEV(1)% predicted = 65.4 +/- 2.9). Only 18% of patients with LDA attained a normal postbronchodilator FEV(1), whereas 50% of those with SDA were able to do so (p < 0.003). The FRC% predicted was significantly higher in subjects with LDA than in those with SDA (142.9 +/- 5.6 versus 124.1 +/- 4.4, respectively, p < 0.01). Multiple regression analysis revealed an association between FRC and duration of asthma that was independent of the degree of airflow limitation. These data suggest that the duration of asthma is associated with the degree of airflow limitation and hyperinflation. Moreover, these abnormalities can become irreversible over time, and may reflect distal airway and/or parenchymal changes as well as proximal airway remodeling.
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Affiliation(s)
- C Cassino
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, New York University School of Medicine, New York, New York, USA
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de la Hoz RE, Berger KI, Klugh TT, Friedman-Jiménez G, Goldring RM. Frequency dependence of compliance in the evaluation of patients with unexplained respiratory symptoms. Respir Med 2000; 94:221-7. [PMID: 10783932 DOI: 10.1053/rmed.1999.0719] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Frequency dependence of compliance (FDC) reflects non-homogeneous ventilatory distribution and, in the presence of a normal measured airway resistance, suggests peripheral airways dysfunction. This study evaluated peripheral airway function and bronchial reactivity in irritant exposed or non-exposed individuals with normal routine pulmonary function tests (PFTs) who had persistent unexplained lower respiratory symptoms. Twenty-two patients were identified with persistent respiratory symptoms and with normal chest X-ray and PFTs. Twenty were non-smokers; two had stopped smoking more than 10 years before evaluation. Twelve patients had been exposed to irritants in their workplaces or at home. Non-specific bronchial hyper-reactivity (nsBHR) and FDC, pre- and post-bronchodilator, were measured in all patients. Studies were repeated in 6/12 irritant-exposed subjects after exposure removal and inhaled corticosteroid treatment. Whereas 12/22 patients had nsBHR, all 22 subjects demonstrated FDC [dynamic lung compliance/static lung compliance Cdyn,1 / Cst,1 at respiratory frequency 60 min(-1) (f60), mean 46%, range 27-67%]. After bronchodilator administration, a 15% improvement Cdyn,1 was observed most consistently at f60 (mean% improvement 26%, 95% CI 14-38%) and in subjects without nsBHR. However, Cdyn,1 at f60 did not return to normal after inhaled bronchodilator. Irritant-exposed and unexposed individuals appeared similar in results of testing for FDC and nsBHR. FDC and its response to bronchodilators provide objective physiological measures of an airway abnormality which may provide a basis for clinical symptoms in patients with normal routine pulmonary function studies. The presence of persistently abnormal FDC after bronchodilator (BD) and on follow up studies may reflect chronic inflammatory and/or structural changes in the airways in addition to bronchoconstriction.
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Affiliation(s)
- R E de la Hoz
- New York University School of Medicine, Department of Medicine, Bellevue Hospital Center, NY, USA.
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Berger KI, Ayappa I, Sorkin IB, Norman RG, Rapoport DM, Goldring RM. CO(2) homeostasis during periodic breathing in obstructive sleep apnea. J Appl Physiol (1985) 2000; 88:257-64. [PMID: 10642388 DOI: 10.1152/jappl.2000.88.1.257] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The contribution of apnea to chronic hypercapnia in obstructive sleep apnea (OSA) has not been clarified. Using a model (D. M. Rapoport, R. G. Norman, and R. M. Goldring. J. Appl. Physiol. 75: 2302-2309, 1993), we previously illustrated failure of CO(2) homeostasis during periodic breathing resulting from temporal dissociation between ventilation and perfusion ("temporal V/Q mismatch"). This study measures acute kinetics of CO(2) during periodic breathing and addresses interapnea ventilatory compensation for maintenance of CO(2) homeostasis in 11 patients with OSA during daytime sleep (37-171 min). Ventilation and expiratory CO(2) and O(2) fractions were measured on a breath-by-breath basis by means of a tight-fitting full facemask. Calculations included CO(2) excretion, metabolic CO(2) production, and CO(2) balance (metabolic CO(2) production - exhaled CO(2)). CO(2) balance was tabulated for each apnea/hypopnea event-interevent cycle and as a cumulative value during sleep. Cumulative CO(2) balance varied (-3,570 to +1,388 ml). Positive cumulative CO(2) balance occurred in the absence of overall hypoventilation during sleep. For each cycle, positive CO(2) balance occurred despite increased interevent ventilation to rates as high as 45 l/min. This failure of CO(2) homeostasis was dependent on the event-to-interevent duration ratio. The results demonstrate that 1) periodic breathing provides a mechanism for acute hypercapnia in OSA, 2) acute hypercapnia during periodic breathing may occur without a decrease in average minute ventilation, supporting the presence of temporal V/Q mismatch, as predicted from our model, and 3) compensation for CO(2) accumulation during apnea/hypopnea may be limited by the duration of the interevent interval. The relationship of this acute hypercapnia to sustained chronic hypercapnia in OSA remains to be further explored.
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Affiliation(s)
- K I Berger
- Division of Pulmonary and Critical Care Medicine and Bellevue Hospital Chest Service, Department of Medicine, New York University School of Medicine, New York, New York 10016, USA.
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Abstract
Pressure support ventilation (PSV) provides a range of ventilatory support from partial respiratory muscle unloading, where inspiratory work is shared between the patient and the mechanical ventilator, to total respiratory muscle unloading, where inspiratory work is performed solely by the ventilator. This study is designed to determine if minimizing work fully accounts for relief of tachypnea during PSV. We examined respiratory parameters over a range of PSV that includes the crossover from partial to total respiratory muscle unloading. Eight studies were obtained on seven intubated patients in respiratory failure. Ventilation, occlusion pressure (P0.1), and patient inspiratory work (WOBinsp) were measured while PSV was varied. In all patients, WOBinsp decreased as PSV increased. The level of PSV where WOBinsp was minimized was identified; this marked the crossover from partial to total respiratory muscle unloading. Frequency decreased with increasing PSV but remained elevated (range, 22 to 38 breaths/min) at the crossover. Frequency was normalized only at PSV levels 131 to 193% of the levels of pressure at the crossover. Tidal volume (VT) changed little during partial support and averaged 5.9 mL/kg at the crossover. VT increased only on PSV providing total unloading. Six of seven patients exhibited increasing static compliance with increasing VT suggesting alveolar recruitment. P0.1 tracked WOBinsp over the entire range of PSV (r = 0.95, p < 0.001). The normalization of frequency observed above the crossover coincided with increasing VT rather than decreasing work. These observations suggest that reflexes resulting from increased VT and/or alveolar recruitment may have contributed to the normalization of frequency.
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Affiliation(s)
- K I Berger
- Division of Pulmonary and Critical Care Medicine, New York University Medical Center, NY 10016, USA
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Condos R, Norman RG, Krishnasamy I, Peduzzi N, Goldring RM, Rapoport DM. Flow limitation as a noninvasive assessment of residual upper-airway resistance during continuous positive airway pressure therapy of obstructive sleep apnea. Am J Respir Crit Care Med 1994; 150:475-80. [PMID: 8049832 DOI: 10.1164/ajrccm.150.2.8049832] [Citation(s) in RCA: 177] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Many patients with obstructive sleep apnea syndrome (OSAS), despite therapy with nasal continuous positive airway pressure (CPAP), have persisting daytime somnolence that may be due to a persistently elevated upper-airway resistance associated with electroencephalographic (EEG) arousals. We tested the hypothesis that elevated upper-airway resistance can be inferred from the contour of the inspiratory flow tracing obtained from a conventional CPAP circuit. This may provide a noninvasive method for determining optimal CPAP. Data were collected during a CPAP titration of an upper-airway model and in eight patients with OSAS. Estimated inspiratory resistance was calculated from esophageal pressure, CPAP mask pressure, and inspiratory flow. At high CPAP, resistance was low and inspiratory flow contour was found to be rounded. At low CPAP, resistance was high and flow contour developed a plateau suggesting flow limitation. We also noted that the CPAP pressure at which high resistance developed, and at which flow limitation appeared, showed hysteresis. We conclude that when respiration is stable, the contour of inspiratory flow tracing from a CPAP system can be used to infer the presence of elevated upper-airway resistance and flow limitation. Optimizing flow contour may be an alternative to eliminating apneas in evaluation of the optimal therapeutic level of CPAP in OSAS.
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Affiliation(s)
- R Condos
- Department of Medicine, New York University Medical Center, New York 10016
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Abstract
The Bohr/Riley model of CO2 homeostasis describes the relationship between CO2 production, ventilation, and arterial PCO2 and assumes that ventilation and CO2 delivery to the lung are both anatomically and temporally well matched. In contrast to normal breathing, periodic patterns of ventilation show temporal mismatch of ventilation to CO2 delivery. We developed a computer model of lung CO2 clearance that uses CO2 transfer equations to generate iterative solutions for PCO2 in multiple body compartments as a function of time. During continuous ventilatory patterns our model predicts steady-state arterial PCO2 identical to that of the Bohr model. During periodic ventilation, we predict mean PCO2 will be elevated unless mean ventilation is increased above that required by the Bohr model. Waxing and waning tidal volumes, low functional residual capacity, and low capillary blood volume potentiate the hypercapnia. However, if cardiac output oscillates in phase with breathing, hypercapnia is minimized. This analysis suggests a new mechanism for the development of sustained hypercapnia, separate from absolute hypoventilation or the presence of lung disease.
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Affiliation(s)
- D M Rapoport
- Department of Medicine, New York University Medical Center, New York 10016
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48
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D'Alonzo GE, Barst RJ, Ayres SM, Bergofsky EH, Brundage BH, Detre KM, Fishman AP, Goldring RM, Groves BM, Kernis JT. Survival in patients with primary pulmonary hypertension. Results from a national prospective registry. Ann Intern Med 1991; 115:343-9. [PMID: 1863023 DOI: 10.7326/0003-4819-115-5-343] [Citation(s) in RCA: 2333] [Impact Index Per Article: 70.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To characterize mortality in persons diagnosed with primary pulmonary hypertension and to investigate factors associated with survival. DESIGN Registry with prospective follow-up. SETTING Thirty-two clinical centers in the United States participating in the Patient Registry for the Characterization of Primary Pulmonary Hypertension supported by the National Heart, Lung, and Blood Institute. PATIENTS Patients (194) diagnosed at clinical centers between 1 July 1981 and 31 December 1985 and followed through 8 August 1988. MEASUREMENTS At diagnosis, measurements of hemodynamic variables, pulmonary function, and gas exchange variables were taken in addition to information on demographic variables, medical history, and life-style. Patients were followed for survival at 6-month intervals. MAIN RESULTS The estimated median survival of these patients was 2.8 years (95% Cl, 1.9 to 3.7 years). Estimated single-year survival rates were as follows: at 1 year, 68% (Cl, 61% to 75%); at 3 years, 48% (Cl, 41% to 55%); and at 5 years, 34% (Cl, 24% to 44%). Variables associated with poor survival included a New York Heart Association (NYHA) functional class of III or IV, presence of Raynaud phenomenon, elevated mean right atrial pressure, elevated mean pulmonary artery pressure, decreased cardiac index, and decreased diffusing capacity for carbon monoxide (DLCO). Drug therapy at entry or discharge was not associated with survival duration. CONCLUSIONS Mortality was most closely associated with right ventricular hemodynamic function and can be characterized by means of an equation using three variables: mean pulmonary artery pressure, mean right atrial pressure, and cardiac index. Such an equation, once validated prospectively, could be used as an adjunct in planning treatment strategies and allocating medical resources.
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Affiliation(s)
- G E D'Alonzo
- Division of Lung Diseases, National Heart, Lung, and Blood Institute, Bethesda, MD 20892
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Abramson SB, Dobro J, Eberle MA, Benton M, Reibman J, Epstein H, Rapoport DM, Belmont HM, Goldring RM. Acute reversible hypoxemia in systemic lupus erythematosus. Ann Intern Med 1991; 114:941-7. [PMID: 2024861 DOI: 10.7326/0003-4819-114-11-941] [Citation(s) in RCA: 74] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To determine the frequency of unexplained reversible hypoxemia in patients with systemic lupus erythematosus and to assess the relation between hypoxemia and elevated plasma levels of complement split products. DESIGN Cohort study. SETTING Inpatient and outpatient facilities of the New York University Medical Center/Bellevue Hospital and the Hospital for Joint Diseases. PATIENTS Case patients were 22 patients hospitalized with disease exacerbation and no evidence of parenchymal lung disease on chest roentgenogram. Four patients with stable disease were followed in the outpatient clinic, and five healthy normal volunteers served as controls. MEASUREMENTS Plasma levels of complement split products (C3a, factor Bb fragment), alveolar-arterial (A-a) Po2 gradients, and pulmonary function were measured. MAIN RESULTS Nine episodes of hypoxemia or hypocapnia (mean A-a gradient, 30.4 +/- 4.8 mm Hg) or both (despite normal chest roentgenogram results) were noted in six hospitalized patients (group 1). Gas exchange improved within 72 hours of steroid therapy (mean A-a gradient, 11.6 +/- 4.3 mm Hg; P less than 0.01). These patients had an elevated initial mean C3a level (938.4 +/- 246.8 ng/mL) that decreased within 72 hours (407.8 +/- 80.9 ng/mL; P less than 0.01), concomitant with improved oxygenation. Ventilation-perfusion scans, obtained for four of six group 1 patients, excluded pulmonary emboli. Four hospitalized patients (group 2) had a normal A-a gradient (mean, 7.5 +/- 2.7 mm Hg). The mean C3a level of this group (358.3 +/- 39.2 ng/mL) was lower than that of group 1 (P less than 0.05). Four patients with stable disease (group 3) had a mean A-a gradient and a mean C3a level of 3.3 +/- 2.7 mm Hg and 237.8 +/- 105.7 ng/mL, respectively, similar to values found in five normal volunteers, in whom the mean A-a gradient was 3.7 +/- 1.7 mm Hg and the mean C3a level was 124.8 +/- 9.2 ng/mL. CONCLUSION A syndrome of reversible hypoxemia, unassociated with parenchymal lung disease, is unexpectedly common in acutely ill, hospitalized patients with systemic lupus erythematosus. The pathogenesis of this syndrome is unclear, although the data are compatible with the hypothesis that hypoxemia may be related to pulmonary leukoaggregation.
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Greenberg HE, Rapoport DM, Rothenberg SA, Kanengiser LA, Norman RG, Goldring RM. Endogenous opiates modulate the postapnea ventilatory response in the obstructive sleep apnea syndrome. Am Rev Respir Dis 1991; 143:1282-7. [PMID: 2048814 DOI: 10.1164/ajrccm/143.6.1282] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Defense of ventilatory homeostasis against recurrent hypercapnia, hypoxia, and acidosis resulting from apnea in obstructive sleep apnea syndrome (OSAS) is dependent on compensatory mechanisms operative between episodes of airway obstruction. This investigation was designed to examine whether endogenous opiate activity modulates the compensatory ventilatory response to apnea in OSAS. Polysomnography and quantitative measurement of tidal volume was performed in 12 patients with moderate to severe OSAS during a morning nap study before and after intravenous administration of 10 mg of naloxone. Apnea index was not significantly altered. There was a small but significant shortening of apneas (postnaloxone apnea duration, 91.2% of prenaloxone; p = 0.002 by ANOVA). Tidal volume of the first postapnea breath and minute ventilation extrapolated from the first two postapnea breaths, but not frequency, increased significantly after naloxone (postnaloxone first breath volume, 112.7% of prenaloxone value [p = 0.03], with a similar increase for minute ventilation, 115.1% [p = 0.007]). The volume of the first postapnea breath was correlated with the duration of the previous apnea, both before (r = 0.59, p = 0.0001) and after naloxone. Despite this, analysis of covariance with apnea duration as the covariate confirmed a significant independent increase in postapnea breath volume after naloxone (p = 0.001). Naloxone also altered sleep architecture, increasing percent time awake during the study period (prenaloxone, 36.3 +/- 15.6%; postnaloxone, 56.7 +/- 22.4%; p = 0.0003) and decreasing total sleep time and percent time in Stage 1. Furthermore, naloxone increased continuity of awake periods (mean length of awake periods increased from 27.0 +/- 8.4 to 66.0 +/- 66.6 s after naloxone, p = 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- H E Greenberg
- Department of Medicine, New York University Medical Center, New York 10016
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