Role of FEF25-75 in characterizing outpatients with asthma in clinical practice

BACKGROUND

Asthma is characterized by variable airflow limitation. FEF25-75 has been proposed as a reliable marker for bronchial obstruction, especially when FEV1 and FEV1/FVC are normal.

OBJECTIVES

To investigate the role of FEF25-75 in patients with asthma seen in clinical settings.

MATERIALS AND METHODS

The cross-sectional study included 439 (181 females and 255 males; mean age 39 years) outpatients with asthma who consecutively visited an allergy clinic for a routine assessment. History, physical examination, asthma control, and spirometry were evaluated.

RESULTS

FEF25-75 was impaired (< 65% of predicted) in 136 (31%) outpatients. Considering only subjects with normal FEV1 and FEV1/FVC, FEF25-75 was impaired in 71 (19.6%) subjects. In this subset, impaired FEF25-75 was associated with low FEV1 and FEV1/FVC values (OR 0.91 and 0.85, respectively), and presence of asthma symptoms (OR 2.19).

CONCLUSION

FEF25-75 deserves adequate and careful consideration in patients with asthma and normal FEV1 and FEV1/FVC, as the presence of impaired FEF25-75 in this subset suggests a more specific approach.

Bronchial obstruction in osteogenesis imperfecta can be detected by forced oscillation technique

Introduction

Respiratory insufficiency is a leading cause of death in individuals with osteogenesis imperfecta (OI). However, evaluating pulmonary function in OI presents challenges. Commonly used pulmonary function tests such as spirometry and body plethysmography are sometimes difficult to perform for OI patients, and reference intervals are not always applicable. The forced oscillation technique (FOT) is a patient-friendly method for detecting respiratory abnormalities that requires no effort from the patient.

Objective

This study investigates the feasibility of FOT in the evaluation of respiratory function in the clinical management of OI patients.

Methods

Twelve OI patients, comprising eight with Sillence OI I, two with OI IV, and two with OI III, underwent spirometry, body plethysmography, and FOT, both pre-and post-administration of salbutamol.

Results

FOT measurements exhibited consistent trends that aligned with spirometry and body plethysmography findings. The resistance at 8 Hz decreased after the administration of salbutamol, indicating that FOT is able to detect bronchial obstruction and its alleviation by medication (p < 0.05). The resonant frequency during expiration was higher than during inspiration in nearly all patients, suggesting obstructive disease. The technique gives insight into both inspiratory and expiratory impairment of pulmonary ventilation. The main FOT parameters showed a relatively high repeatability in duplicate measurements.

Conclusion

Bronchial obstruction can be detected by FOT in patients with OI during quiet breathing, making it an easily executable alternative to other lung function measurements. The technique can detect the bronchodilator effect of sympathomimetic medication. It has the potential to provide information on expiratory flow limitation, pulmonary restriction, and reduced lung compliance.

Lobar Mucus Plugging Reflecting Central Bronchial Tumoral Obstruction: A Case Report

Early diagnosis of bronchopulmonary carcinoid tumors is crucial as the surgical excision is the main treatment and determines the prognosis. We present the case of a 66-year-old heavy-smoker man who had started to complain about a cough a few months ago. We diagnosed him with an endobronchial mass on a chest computed tomography scan and lobar bronchoceles resulting from mucus plugging distal to the tumor obstruction. These findings were retrospectively visible on the previous chest radiograph that had initially been interpreted as non-contributary.

Benign endobronchial lipoma causing repeated pneumonia

Endobronchial lipomas are rare; nonetheless, physicians should consider them as a differential diagnosis in patients with repeated pneumonia. Computed tomography and bronchoscopy are recommended for diagnosis. In this case, the patient's cough was ameliorated after undergoing a right basal segmentectomy.

Aerated Lobar Collapse

Teaching Point: Air trapping is a useful sign for early detection of worsening lobar collapse in the follow-up of obstructive atelectasis.

[The risk factors studying for chronic obstructive pulmonary disease development in non-smoking elderly patients.]

In 524 elderly patients with COPD, risk factors for the development of the underlying disease were assessed. It turned out that a significant proportion of elderly patients with COPD had never been exposed to tobacco smoke. A previous diagnosis of asthma in elderly patients is associated with an increased risk of developing COPD among never-smokers. Exposure to organic dust in the workplace and a history of severe childhood respiratory tract infections also increase the risk of an underlying disease. The data obtained determine the need for an integrated approach to the analysis of risk factors for the development of COPD in non-smoking patients in order to draw up individual preventive programs aimed at preventing the development and progression of the disease.

Assessment of bronchial obstruction and its reversibility by shape indexes of the flow-volume loop in asthmatic children

Asthma assessment by spirometry is challenging in children as forced expiratory volume in 1 s (FEV1) is frequently normal at baseline. Bronchodilator (BD) reversibility testing may reinforce asthma diagnosis but FEV1 sensitivity in children is controversial. Ventilation inhomogeneity, an early sign of airway obstruction, is described by the upward concavity of the descending limb of the forced expiratory flow-volume loop (FVL), not detected by FEV1. The aim was to test the sensitivity and specificity of FVL shape indexes as β-angle and forced expiratory flow at 50% of the forced vital capacity (FEF50)/peak expiratory flow (PEF) ratio, to identify asthmatics from healthy children in comparison to "usual" spirometric parameters. Seventy-two school-aged asthmatic children and 29 controls were prospectively included. Children performed forced spirometry at baseline and after BD inhalation. Parameters were expressed at baseline as z-scores and BD reversibility as percentage of change reported to baseline value (Δ%). Receiver operating characteristic curves were generated and sensitivity and specificity at respective thresholds reported. Asthmatics presented significantly smaller zβ-angle, zFEF50/PEF and zFEV1 (p ≤ .04) and higher BD reversibility, significant for Δ%FEF50/PEF (p = .02) with no difference for Δ%FEV1. zβ-angle and zFEF50/PEF exhibited better sensitivity (0.58, respectively 0.60) than zFEV1 (0.50), and similar specificity (0.72). Δ%β-angle showed higher sensitivity compared to Δ%FEV1 (0.72 vs. 0.42), but low specificity (0.52 vs. 0.86). Quantitative and qualitative assessment of FVL by adding shape indexes to spirometry interpretation may improve the ability to detect an airway obstruction, FEV1 reflecting more proximal while shape indexes peripheral bronchial obstruction.

Insights to correlations and discrepancies between impaired lung function and heart failure in Eisenmenger patients

Impaired lung function and spirometric signs of airway obstruction without common risk factors for chronic obstructive pulmonary disease could be found in patients with Eisenmenger syndrome. This study aimed to analyse the association between lung function parameters and disease severity (including heart failure markers, associated congenital heart defect) as well as the possible reasons for airflow obstruction in Eisenmenger syndrome. The data of 25 patients with Eisenmenger syndrome were retrospectively evaluated. The patients were divided into groups according to airflow obstruction and a type of congenital heart defect. Airflow obstruction was found in nearly third (32%) of our cases and was associated with older age and worse survival. No relation was found between airway obstruction, B-type natriuretic peptide level, complexity of congenital heart defect and bronchial compression. Most of the patients (88%) had gas diffusion abnormalities. A weak negative correlation was noticed between gas diffusion (diffusing capacity of the lung for carbon monoxide) and B-type natriuretic peptide level (r = −0.437, p = 0.033). Increased residual volume was associated with higher mortality (p = 0.047 and p = 0.021, respectively). A link between B-type natriuretic peptide and lung diffusion, but not airway obstruction, was found. Further research and larger multicentre studies are needed to evaluate the importance of pulmonary function parameters and mechanisms of airflow obstruction in Eisenmenger syndrome.

Whistling Lipoma: Bronchial Obstruction Caused by a Lipoma

Lipomas are extremely common benign tumors that occur in a variety of locations. However, lipomas in the bronchus are exceptionally rare and account for a very small number of all bronchial tumors. Diagnosis of an endobronchial lipoma can be challenging at times, as they may present with overlapping symptoms of central airway obstruction, pneumonia, or dyspnea.

We present an 82-year-old male with a 40-pack-year history of smoking who presented with recurrent pneumonia and signs of airway obstruction. Imaging studies showed an obstructive lesion. The biopsy sample revealed adipose cells. Eventually, the lesion was successfully resected. The surgical specimen ruled out malignancy and confirmed the diagnosis of lipoma.

Timely identification and differentiating a malignant lesion from benign lesions, like lipoma, is crucial to management.

[Possibilities of cardioselective beta - blocker bisoprolol therapy in patients having coronary artery disease and bronchial asthma]

AIM

to compare the antianginal and pulse slowing effects, the impact on the ectopic myocardial activity as well as the safety of the treatment with beta - adrenoblocker bisoprolol, calcium antagonist verapamil and the combination of bisoprolol with amlodipine in patients with stable angina (SA) and bronchial asthma (BA).

MATERIALS AND METHODS

The study included 90 patients with SA II-III functional class (FC) having concomitant persistent asthma of moderate severity, controlled, without exacerbation. The patients were divided into three groups with 30 individuals in each one depending on the main antianginal drug prescribed. Group 1 patients received a cardio - selective beta - adrenergic blocker bisoprolol (Concor) at the dose of 5 mg/day, patients of group 2 were treated by a calcium antagonist verapamil at the dose of 240 mg/day, patients of group 3 received combined therapy with bisoprolol at the dose of 5 mg/day and amlodipine at the dose of 5 mg/day given as a fixed combination (Concor AM 5/5). All the patients were investigated by the methods of daily ECG monitoring and respiratory function study (RFS) in addition to physical examination at baseline and after 4 weeks of treatment.

RESULTS

After 4 weeks of treatment, patients of group 1 and group 3 did not complain of angina attacks and did not use nitroglycerin unlike patients of group 2. The achieved heart rate (HR) in group 1 patients was 68.6±8.5 beats/min, in group 2 - 74.3±5.6 beats/min, in group 3 - 67.3±4.8 beats/min. A significant decrease in the number of supraventricular and ventricular extrasystoles occurred in patients of group 1 and group 3 only. Thus, the pulse slowing, antianginal, antiischemic and antiarrhythmic effect of the calcium antagonist verapamil, even at the dose of 240 mg/day, is not always sufficient for the patients with SA II-III FC and concomitant BA, unlike therapy with the inclusion of beta - blocker bisoprolol. During the study there was no registered deterioration in the indices of bronchial patency according to the RFS data in the patients of all three groups.

CONCLUSION

In patients with coronary artery disease and concomitant asthma, all three types of pulse slowing therapy do not have any negative effects on bronchial patency. Therapy with the inclusion of beta - blockers (bisoprolol or its combination with amlodipine), in contrast to verapamil, reliably reduces heart rate and the number of supraventricular and ventricular extrasystoles in addition to a good antianginal effect.

Bronchial Obstruction Caused by a Dilated Pulmonary Artery

Airway obstruction from an enlarged pulmonary artery (PA) is not a common occurrence. We present a rare case of respiratory failure secondary to right bronchus obstruction from a dilated right PA. A 54-year-old male with a known history of pulmonary hypertension (PH) and obstructive sleep apnea (OSA) presented with worsening dyspnea. He was found to have collapse of his right middle and lower lobes. Intubation was required for respiratory failure. To our knowledge, this is the first case to be reported in the literature where PH caused PA dilatation to such a degree as to cause bronchial obstruction and subsequent lobar collapse.

Case Report: Mucus plug in bronchus mimicking a bronchial solid foreign body obstruction

Bronchial foreign body obstruction is common in all clinical settings. Obstruction of the airway due to foreign bodies and foreign body aspiration are major causes of childhood mortality and morbidity, which are a big challenge to manage. Occasionally, bronchial obstruction may be due to mucus plugs or other endogenous factors. Here we describe a case of bronchial obstruction caused by mucus plug formation that was managed conservatively in a one-year old boy. The patient was suffering from a cough and noisy breathing for 2 days prior to coming to our hospital, when he experienced sudden onset of difficulty in breathing and a severe cough. At the time of presentation his vital sign readings were:- HR 186 bpm, RR 46/min, BP 78/40 MmHg, temp 36.9°C and SPO2 68%. He was given oxygen immediately and nebulization was started. Chest CT scan was performed that suggested the presence of a right bronchial foreign body with right sided obstructive emphysema. The patient was stable with oxygenation and nebulization with ipratropium bromide, albuterol, normal saline and budesonide before the CT scan. Therefore, we conclude that symptoms resembling foreign body obstruction are not always aspirated or inhaled, and sometimes secreted sputum forms a plug, which mimics the symptoms of foreign body obstruction.

The bronchial obstruction as a complication of endovascular repair of aortic pseudoaneurysm in Behçet's disease

Behçet's disease (BD) is an autoimmune disorder affecting multiple organs. Aortic pseudoaneurysm is the most catastrophic lesion in BD. This lesion type is considered as a complicated and challenging pathology by surgeons because of the technical operative difficulties and frequent recurrence. So, the endovascular repair of inflammatory aortic pseudoaneurysm has been used as an alternative to open surgical repair. It is particularly important in patients who are high-risk surgical candidates because of comorbidities. In this report, we present a case and treatment of bronchial obstruction, which caused progressive dyspnea after endovascular repair of aortic rupture, in patient with known history of BD.

Drop in lung function during asthma and COPD exacerbations - can it be assessed without spirometry?

BACKGROUND

When assessing patients with exacerbation of asthma or COPD, it may be useful to know the drop in forced expiratory volume in 1 second (FEV₁) compared with stable state, in particular when considering treatment with oral corticosteroids. The objective of the study was to identify indicators of drop in FEV₁ during exacerbations.

METHODS

In this prospective multicenter study from primary care, patients diagnosed with asthma or COPD were examined at stable state and during exacerbations the following year. Symptoms, chest findings, and pulse oximetry were recorded, and spirometry was performed. A fixed drop in FEV₁ (10% and ≥200 mL) and percentage change in FEV₁ were outcomes when possible indicators were evaluated.

RESULTS

Three hundred and eighty patients attended baseline examination, and 88 with a subsequent exacerbation were included in the analysis. Thirty (34%) had a significant drop in FEV₁ (10% and 200 mL). Increased wheezing was the only symptom associated with this drop with a likelihood ratio of 6.4 (95% confidence interval, 1.9-21.7). Crackles and any new auscultation finding were also associated with a significant drop in FEV₁, as was a ≥2% drop in oxygen saturation (SpO₂) to ≤92% in the subgroup diagnosed with COPD. Very bothersome wheezing and severe decrease in SpO₂ were also very strong predictors of change in FEV₁ in linear regression adjusted for age, gender, and baseline FEV₁% predicted.

CONCLUSION

Increased wheezing, as experienced by the patient, and a decreased SpO₂ value strongly indicated a drop in lung function during asthma and COPD exacerbations and should probably be taken into account when treatment with oral corticosteroids is considered.

Argon Plasma Coagulation Combined with a Flexible Electronic Bronchoscope for Treating Foreign Body Granulation Tissues in Children's Deep Bronchi: Nine Case Reports

Deep bronchial obstruction in children caused by foreign bodies is a medical emergency frequently accompanied by the formation of granulation tissue in the airway mucosa, which is resected during removal of the foreign body. Argon plasma coagulation (APC), initially developed to achieve hemostasis in gastrointestinal bleeding during endoscopic procedures, is also used for interventional bronchoscopic therapies of malignant airway tumors. In this pilot study, we describe successful alternative resections of granulation tissues during foreign body removal by flexible bronchoscopy through concomitant APC applications in 9 children aged from 16 months to 4 years old.

Photodynamic Therapy in Non-Gastrointestinal Thoracic Malignancies

Photodynamic therapy has a role in the management of early and late thoracic malignancies. It can be used to facilitate minimally-invasive treatment of early endobronchial tumours and also to palliate obstructive and bleeding effects of advanced endobronchial tumours. Photodynamic therapy has been used as a means of downsizing tumours to allow for resection, as well as reducing the extent of resection necessary. It has also been used successfully for minimally-invasive management of local recurrences, which is especially valuable for patients who are not eligible for radiation therapy. Photodynamic therapy has also shown promising results in mesothelioma and pleural-based metastatic disease. As new generation photosensitizers are being developed and tested and methodological issues continue to be addressed, the role of photodynamic therapy in thoracic malignancies continues to evolve.

Photodynamic Therapy (PDT) with Chemotherapy for Advanced Lung Cancer with Airway Stenosis

Intractable advanced lung cancer can be treated palliatively with photodynamic therapy (PDT) combined with chemotherapy to remove central and peripheral (lobar or segmental bronchi) bronchial stenosis and obstruction. We present data for 12 (eight men, four women) consecutive patients with 13 advanced non-small cell lung carcinomas in whom curative operations were contraindicated, who underwent PDT combined with chemotherapy for local control of the intraluminal lesions. The mean age was 73.3 years (range, 58-80 years), and the stages of cancer were IIA-IV. The median stenosis rates before treatment, one week post-treatment, and one month post-treatment were 60% (range, 30%-100%), 15% (range, 15%-99%), and 15% (range 15%-60%), respectively. The mean and median survival times were 9.3 and 5.9 months, respectively. The overall 1-year survival rate was 30.0%. No PDT-related morbidity or mortality occurred. In this single-institution study, all patients experienced improved symptoms and quality of life at one week after treatment; furthermore, an objective response was evidenced by the substantial increase in the openings of the bronchial lumen and prevention of obstructive pneumonia. Therefore, PDT with chemotherapy was useful and safe for the treatment of bronchial obstruction.

Perception of Asthma Symptoms as Assessed on the Visual Analog Scale in Subjects With Asthma: A Real-Life Study

BACKGROUND

The perception of symptoms is a cornerstone in asthma management, but studies concerning this aspect provide conflicting evidence. The visual analog scale has been proposed as a useful tool for assessing perception of respiratory symptoms. The present study investigated whether visual analog scale assessment of perception of asthma symptoms was correlated to lung function or clinical features.

METHODS

This cross-sectional study enrolled 388 subjects with asthma (159 males; mean age 39.7 y). Perception of asthma symptoms was assessed by the visual analog scale; lung function was measured by spirometry. Asthma control was evaluated by the asthma control test. Anxiety and depression were evaluated on the Hospital Anxiety and Depression Scale questionnaire.

RESULTS

Asthma was well controlled in 46.6% of subjects. Asthma symptoms in the prior month were reported by 59% of subjects; asthma signs were detected in 7.2%. The visual analog scale score was moderately correlated to FEV1 (r = 0.43). Subjects with bronchial obstruction had lower visual analog scale values than those without (P < .001). A visual analog scale score of 6 was a reliable cutoff point to discriminate subjects with bronchial obstruction (area under the curve = 0.71 at receiver operating characteristic curve; odds ratio [OR] = 7.58). Reported asthma symptoms (OR = 4.83), asthma signs (OR = 8.36), and anxiety (OR = 1.14) were predictive of a visual analog scale score of <6.

CONCLUSIONS

This real-life study found that assessment of asthma symptoms by the visual analog scale might be a reliable tool in managing patients with asthma.

Evaluation of C-Reactive Protein in Patients with Chronic Obstructive Pulmonary Disease

BACKGROUND:

Chronic Obstructive Pulmonary Disease (COPD) is associated with evidence of systemic oxidative stress, activation of circulating inflammatory cells and increased plasma level of proinflamatory cytokines which include C-reactive protein (CRP). CRP is one biomarker of extrapulmonary or systemic consequences of COPD that can be detected.

AIM:

The aim of this research is to determine whether the level of CRP statistically significantly correlates with the level of bronchial obstruction and the accompanying co-morbidities in patients with COPD.

MATERIAL AND METHODS:

This study included 80 patients with exacerbation of COPD, hospitalised at the Institute for Lung Diseases and Tuberculosis in Skopje. We measured the level of CRP in the blood in all of these patients in fasting conditions. The classification of COPD patients by the severity of airflow limitation was made according to the actual version of the Global initiative for chronic Obstructive Lung Disease (GOLD). The Student’s Independent Samples t-test was used for the statistic analysis of the data.

RESULTS:

In 52 (65%) of the patients with exacerbation of COPD we detected an increase of the mean value of CRP. The statistical analysis using the Student’s t-test showed statistically significant differences in the mean value of CRP in patients with different level of bronchial obstruction. Hypertension, heart failure, diabetes mellitus, hyperlipidemia, coronary disease, and CVI were confirmed as co-morbidities in 45 (73.1%) of the patients, hypertension being the most frequent one (40%). The statistical analysis using the Student’s t-test showed statistically significant difference of the mean value of CRP (p< 0.01) depending on the number of co-morbidities.

CONCLUSION:

In 52 (65%) of the patients with exacerbation of COPD, were detected an increase of the mean value of CRP. The mean values of CRP statistically significantly correlate with the level of bronchial obstruction and the number of co-morbidities in patients with COPD.

Successful treatment of bronchial obstruction by flexible bronchoscopy and isoniazid: A case report

Interventional bronchology techniques have been employed as an effective first-line treatment in patients with tracheobronchial obstruction. However, recurrent stenosis produced by granulation tissue requires repeated procedures. Previous studies have indicated that isoniazid regulates collagen deposition and decreases collagen content. Thus, isoniazid has been successfully administered to patients with lesions who exhibited a delay in the healing process. A case of a left mainstem obstruction managed by interventional bronchology is described in the present study. Repeated bronchial stenosis was observed even following numerous treatment procedures, however, administration of isoniazid resulted in the inhibition of hypertrophic scar formation and prevention of repeated stenosis. The suppressive effect of isoniazid on granulation formation and further observations are reported. Few studies have been conducted with regard to the function of isoniazid in suppressing scar hyperplasia, therefore, the mechanism requires further investigation.