Unilateral pulmonary agenesis with ipsilateral facial congenital anomalies in an adult with obstructive airway disease

Pulmonary agenesis is a rare congenital anomaly which can be isolated or co-exist with other developmental defects. Boyden et al has described three degrees of mal development of lung which include agenesis, hypoplasia and aplasia. Almost all the reported cases are in paediatric age group patients while, adults with pulmonary developmental abnormalities are sparsely documented in the literature. Interestingly, adult with coexisting hemifacial anomaly and pulmonary agenesis has not been reported in the medical literature. Here, we describe a middle-aged female who initially presented with bronchial asthma and her chest radiography showed absent left lung which was later confirmed with enhanced CT imaging. Furthermore, she had ipsilateral hemi facial microsomia, microtia, facial nerve palsy and mixed sensory loss, left side large café au lait patch, splenicule and hemangioma in segment V/VI of the liver.

The Acute Effects of the Use of Salbutamol and Ipratropium on the Heart Rates of Patients With Obstructive Airway Disease

Background The cornerstone of pharmaceutical therapy for obstructive airway illnesses involves inhalation of bronchodilators, such as ipratropium bromide (IP) and salbutamol (SB). The heart rate regulation may be changed by β-2 agonists and anticholinergic medications. Investigating the impact of inhaled SB and IP on the heart rate was the goal of this study. Methods A total of 304 patients were enrolled in this investigation. Baseline demographic characteristics, medical history, and adverse events were documented. Their heart rates were monitored before and after bronchodilator administration. SB and IP were selected based on historical usage. Blood pressure readings were also taken before and after each session. Results There was a significant increase in heart rates after SB from a mean of 106.69 to 117.20. Similarly, the heart rate of the patients in the IP group increased to a mean of 106.95 from 93.44, with a statistically significant p-value. Moreover, tremors were the most common adverse effect, accounting for 85.3% of the patients in the IP group and 75% in the SB group. In contrast, palpitation was more common in the SB group 25% vs. 14.7% with a significant p-value. Conclusion Frequently administered dosages of SB and IP caused a considerable increase in heart rates, as well as tremors and palpitation.

From the infant to the geriatric patient-Strategies for inhalation therapy in asthma and chronic obstructive pulmonary disease

Inhalation therapy represents the standard of care in children, adolescents as well as in young, middle-aged and geriatric adults with asthma or chronic obstructive pulmonary disease. However, there are only few recommendations for the choice of inhalation devices, which consider both, age-specific limitations in young and geriatric patients. Transition concepts are lacking. In this narrative review, the available device technologies and the evidence for age-specific problems are discussed. Pressurized metered-dose inhalers may be favoured in patients who fulfill all cognitive, coordinative and manual power requirements. Breath-actuated metered-dose inhalers, soft-mist inhalers or the use of add-on devices such as spacers, face masks and valved holding chambers may be suitable for patients with mild to moderate impairments of these variables. In these cases, available resources of personal assistance by educated family members or caregivers should be used to allow metered-dose inhaler therapy. Dry powder inhalers may be reserved for patients with a sufficient peak inspiratory flow and good cognitive and manual abilities. Nebulizers may be indicated in persons who are either unwilling or unable to use handheld inhaler devices. After initiation of a specific inhalation therapy, close monitoring is essential to reduce handling mistakes. An algorithm is developed that considers age and relevant comorbidities to support the decision-making process for the choice of an inhaler device.

Comparing self-reported obstructive airway disease in firefighters with and without World Trade Center exposure

BACKGROUND

The degree to which routine, non-World Trade Center (WTC) firefighting exposures contribute to the WTC exposure-obstructive airway disease (OAD) relationship is unknown. Our objective was to compare the frequency of self-reported OAD diagnoses in WTC-exposed firefighters from the Fire Department of the City of New York (FDNY) compared with non-WTC-exposed firefighters from other cities and the general population.

METHODS

A total of 9792 WTC-exposed male FDNY firefighters and 3138 non-WTC-exposed male firefighters from Chicago, Philadelphia, and San Francisco who were actively employed on 9/11/01 and completed a health questionnaire were included. Logistic regression estimated odds ratios of self-reported asthma and COPD diagnoses in firefighters (WTC-exposed vs. non-WTC-exposed; all firefighters vs. general population), adjusting for age, race, smoking status, and last medical visit.

RESULTS

WTC-exposed firefighters were, on average, younger on 9/11 (mean ± SD = 40.2 ± 7.4 vs. 44.1 ± 9.1) and less likely to report ever-smoking (32.9% vs. 41.8%) than non-WTC-exposed firefighters. Odds of any OAD and asthma were 4.5 and 6.3 times greater, respectively, in WTC-exposed versus non-WTC-exposed. Odds of COPD were also greater in WTC-exposed versus non-WTC-exposed, particularly among never-smokers. Compared with the general population, WTC-exposed firefighters had greater odds of both asthma and COPD, while the nonexposed had lower odds of asthma and greater odds of COPD.

CONCLUSIONS

Odds ratios for OAD diagnoses were greater in WTC-exposed firefighters versus both non-WTC-exposed and the general population after adjusting for covariates. While asthma and other OADs are known occupational hazards of firefighting, WTC exposure significantly compounded these adverse respiratory effects.

The i-gel supraglottic airway device improves airway management during endobronchial ablative therapy under general anesthesia: a case report

Endobronchial ablative therapy (EAT) in patients with preexisting obstructive airway disease can cause hypoxemia because bronchoscope insertion interferes with ventilation and a low fraction of inspired oxygen (FiO₂) is essential to avoid airway fire. A man in his early 50s with moderately severe obstructive airway disease was scheduled for EAT for treatment of tracheal papillomatosis. Ventilation and oxygenation would have been difficult because of narrowing of the endotracheal tube by bronchoscopic insertion and a low FiO₂; therefore, an i-gel supraglottic airway device with a larger inner diameter was inserted. All visible intratracheal papillomas were ablated by a potassium titanyl phosphate laser through the bronchoscopic port that passed through the lumen of the i-gel at an FiO₂ of 0.3. During anesthesia for EAT, the i-gel supraglottic airway device provided a wider lumen for ventilation. We were thus able to provide stable ventilation at an FiO₂ of 0.3 during EAT in this patient with obstructive airway disease, avoiding airway fire and hypoxemia.

Roles of phosphatidyl inositol 3 kinase gamma (PI3Kγ) in respiratory diseases

Phosphatidyl inositol 3 kinase gamma (PI3Kγ) is expressed in all the cell types that are involved in airway inflammation and disease, including not only leukocytes, but also structural cells, where it is expressed at very low levels under physiological conditions, while is significantly upregulated after stress. In the airways, PI3Kγ behaves as a trigger or a controller, depending on the pathological context. In this review, the contribution of PI3Kγ in a plethora of respiratory diseases, spanning from acute lung injury, pulmonary fibrosis, asthma, cystic fibrosis and response to both bacterial and viral pathogens, will be commented.

Resting Dead Space Fraction as Related to Clinical Characteristics, Lung Function, and Gas Exchange in Male Patients with Chronic Obstructive Pulmonary Disease

Background

Measures of forced expired volume in one second % predicted (FEV₁%), residual volume to total lung capacity ratio (RV/TLC) and diffusing capacity for carbon monoxide measurements (D_LCO) are the standard lung function test for evaluating patients with chronic obstructive pulmonary disease (COPD). The dead space fraction (V_D/V_T) has been shown to be a robust marker of gas exchange abnormality. However, the use of V_D/V_T has gradually become less common. As V_D/V_T measured at rest (V_D/V_TR) has been successfully used in non-COPD conditions, it was hypothesized that in COPD the V_D/V_TR was more sensitive than the standard lung function test in correlation with clinical characteristics and gas exchange. This study aimed to test the hypothesis and to identify the variables relevant to V_D/V_TR.

Methods

A total of 46 male subjects with COPD were enrolled. Clinical characteristics included demographic data, oxygen-cost diagram (OCD), and image studies for pulmonary hypertension. The standard lung function was obtained. To calculate V_D/V_T, invasive arterial blood gas and pulmonary gas exchange (PGX) were measured. The variables relevant to V_D/V_TR were analyzed by multiple linear regression.

Results

Compared to lung function, V_D/V_TR was more frequently and significantly related to smoking, carboxyhemoglobin level, pulmonary hypertension and P_aCO₂ (all p <0.05) whereas FEV₁% was more related to lung function test, P_aO₂ and OCD score. V_D/V_TR and FEV₁% were highly related to resting gas exchange but RV/TLC and D_LCO% were not. Cigarette consumption, the equivalent for CO₂ output, arterial oxyhemoglobin saturation, and the product of tidal volume and inspiratory duty cycle were identified as the parameters relevant to V_D/V_TR with a power of 0.72.

Conclusion

Compared to lung function test, V_D/V_TR is more related to clinical characteristics and is a comprehensive marker of resting gas exchange. Further studies are warranted to provide a noninvasive measurement of V_D/V_TR.

Registration Number

MOST 106-2314-B-040-025 and CSH-2019-C-30.

The first state-level public health program for obstructive airway disease in India: An early field-level evaluation

Background:

Chronic obstructive pulmonary disease (COPD) is the second leading cause of mortality in India; however, there are no programs for COPD in India at primary care level. Kerala became the first state in India to implement a program at primary care for COPD, called the Step Wise Approach to Airway Syndrome program.

Objective:

The objective of the study was to evaluate and document the implementation status of a program for obstructive airway disease (OAD) in Trivandrum district of Kerala state in India and compare the treatment characteristics of patients with OAD seeking care from the centers implementing and not implementing this program for OADs.

Methods:

A cross-sectional study was done as early evaluation of a program for OAD implemented in Kerala state, India, from October 2018 to February 2019.

Results:

A reflection of the health-seeking behavior due to better facilities at the FHCs. There was no difference in the hospital visits or emergency department visits between the two groups. However, there was a statistically significant difference in the average number of visits per patient to health center for taking injectable drugs and visits for nebulization. Forty-nine (94%) of the COPD and 36 (100%) of the asthma patients underwent spirometry from implementing center itself. A higher proportion of patients receiving care from implementing centers (30.9%) never had to buy inhalers from outside.

Conclusion:

This is the first time that a public health programme for chronic respiratory disease management at primary care level was evaluated in India. The study has provided valuable insights on the need for strengthening the training for health care providers as well as patient education in bringing about a change in patient attitudes.

High-frequency oscillatory ventilation as a rescue for severe asthma crisis in a child

Mechanical ventilation in the asthmatic child may be complicated by dynamic air trapping leading to hemodynamic compromise and cardiac arrest. High-frequency oscillatory ventilation is relatively contraindicated because it may cause hyperinflation compared to conventional mechanical ventilation. A 2-year-old girl (weight, 11 kg) with a history of asthma was admitted because of status asthmaticus. Despite treatment with intravenous methylprednisolone, continuous albuterol, terbutaline, aminophylline, and magnesium sulfate, she had persistent respiratory distress. She required endotracheal intubation and mechanical ventilation because of worsening respiratory fatigue and hypercarbia ((PCO₂), 96 mm Hg). Severe airflow obstruction persisted, and the hypercarbia worsened despite conventional mechanical ventilation (PCO₂ > 134 mm Hg). It was judged that the patient was at risk for dynamic air trapping leading to hemodynamic compromise and cardiac arrest. High-frequency oscillatory ventilation was started to overcome airflow obstruction, and a decrease in arterial PCO₂ to 87 mm Hg was observed within 2 h. High-frequency oscillatory ventilation was discontinued after 5 h, and conventional mechanical ventilation resumed. The patient was extubated after 5 days without further complications. In summary, this case shows that high-frequency oscillatory ventilation may be considered as a rescue treatment in children who have severe status asthmaticus with persistent airflow obstruction and hypercarbia unresponsive to pharmacological therapy and conventional mechanical ventilation.

Tracheobronchomalacia/excessive dynamic airway collapse in patients with chronic obstructive pulmonary disease with persistent expiratory wheeze: A pilot study

BACKGROUND

Tracheobronchomalacia (TBM) refers to a condition in which structural integrity of cartilaginous wall of trachea is lost. Excessive dynamic airway collapse (EDAC) is characterized by excessive invagination of posterior wall of trachea. In both these conditions, airway lumen gets compromised, especially during expiration, which can lead to symptoms such as breathlessness, cough, and wheezing. Both these conditions can be present in obstructive lung diseases; TBM due to chronic airway inflammation and EDAC due to dynamic compressive forces during expiration. The present study was planned with the hypothesis that TBM/EDAC could also produce expiratory wheeze in patients with obstructive airway disorders. Hence, prevalence and factors affecting presence of this entity in patients with obstructive airway diseases were the aims and objectives of this study.

MATERIALS AND METHODS

Twenty-five patients with obstructive airway disorders (chronic obstructive pulmonary disease [COPD] or bronchial asthma), who were stable on medical management, but having persistent expiratory wheezing, were included in the study. They were evaluated for TBM/EDAC by bronchoscopy and computed tomographic scan of chest. The presence of TBM/EDAC was correlated with variables including age, sex, body mass index (BMI), smoking index, level of dyspnea, and severity of disease.

RESULTS

Mean age of the patients was 62.7 ± 7.81 years. Out of 25 patients, 14 were males. TBM/EDAC was found in 40% of study subjects. Age, sex, BMI, severity of disease, frequency of exacerbations and radiological findings etc., were not found to have any association with presence of TBM/EDAC.

CONCLUSION

TBM/EDAC is common in patients with obstructive airway disorders and should be evaluated in these patients, especially with persistent expiratory wheezing as diagnosis of this entity could provide another treatment option in these patients with persistent symptoms despite medical management.

Impulse oscillometry: The state-of-art for lung function testing

Impulse oscillometry (IOS) is a variant of forced oscillation technique, described by Dubois over 50 years ago, which permits passive measurement of lung mechanics. In this method, sound waves are superimposed on normal tidal breathing, and the disturbances in flow and pressure caused by the external waves are used to calculate parameters describing the resistance to airflow and reactive parameters that mostly relate to efficient storage and return of energy by the lung. It requires minimal patient cooperation and can be done easily in subjects who are unable to perform spirometry. Importantly, IOS can differentiate small airway obstruction from large airway obstruction and is more sensitive than spirometry for peripheral airway disease. It has been used to study various respiratory disorders, especially asthma and is suitable for measuring bronchodilatory response as well as bronchoprovocation testing. IOS parameters seem to be able to pick up early changes in lung functon such that they are superior to spirometry in predicting loss of control in asthmatic patients and possibly in identifying early airway disease in smokers. Such comparisons, especially for chronic obstructive pulmonary disease, are made difficult by widespread use of spirometric parameters as the diagnostic gold standard. Here, we discuss the principles and technique of IOS and review its application in obstructive airway diseases.

Sleep Apnea and Obstructive Airway Disease in Older Men: Outcomes of Sleep Disorders in Older Men Study

STUDY OBJECTIVES

To evaluate the association between obstructive airway disease (OAD) and sleep apnea in older men.

METHODS

A community-based cross-sectional study of 853 community-dwelling older men (mean age 80.7 ± 4.1 years [range 73 to 90]) across 6 centers in the United States from the Outcomes of Sleep Disorders in Older Men Study. Sleep was objectively measured using full in-home polysomnography and lung function was objectively measured using spirometry. The association of OAD (pre-bronchodilator FEV1/FVC ratio < 0.7 and FEV1 < 80% predicted) and sleep apnea (apnea-hypopnea index [AHI] ≥ 15 events/hour) was assessed using logistic regression.

RESULTS

OAD and sleep apnea were identified in 111 (13.0%) and 247 (29.0%) men, respectively. In univariate analysis, participants with OAD had a lower AHI (mean ± SD; 8.7 ± 11.7 vs. 12.7 ± 13.8, P = 0.0009) and a lower prevalence of sleep apnea (14.4 vs. 31.1%, P = 0.0003) compared to participants without OAD. OAD remained independently associated with a lower odds of sleep apnea (odds ratio 0.30, 95% CI 0.16 to 0.55, P = 0.0001) after adjustment for demographics, body composition, smoking, and potential mediators (arousal index, time spent in rapid eye movement sleep). Individuals with OAD and sleep apnea (n = 16) had an increased arousal index and lower oxygen saturation level as compared to individuals with OAD alone (P values < 0.05).

CONCLUSIONS

Obstructive airway disease was associated with a lower prevalence of sleep apnea in a cohort of community-dwelling elderly men, and unexplained by differences in adiposity or sleep architecture. Although uncommon in this cohort, coexisting sleep apnea and OAD was associated with increased sleep fragmentation and nocturnal oxygen desaturation compared to OAD alone.

Chronic obstructive pulmonary disease associated with increased risk of bipolar disorder

Epidemiological studies have identified a trend in the development of depressive and anxiety disorders following a diagnosis of chronic obstructive pulmonary disease (COPD). However, the relationship between COPD and subsequent bipolar disorder remains unclear. From January 1, 2000, we identified adult patients with COPD from the Taiwan National Health Insurance Research Database. A nationwide population-based study was conducted; 46,778 COPD patients and 46,778 age-, sex-, and comorbidity-matched subjects between 2000 and 2011 were enrolled. The two cohorts were followed up till December 31, 2011 and observed for occurrence of bipolar disorder. We observed the COPD and comparison cohorts for 263,020 and 267,895 person-years, respectively, from 2000 to 2011. The incidence rate for bipolar disorder was 1.6/1000 person-years in the COPD cohort and 1.2/1000 person-years in the comparison cohort ( p < 0.001). After multivariate adjustment, the hazard ratio (HR) for subsequent bipolar disorder among the COPD patients was 1.42 (95% confidence interval [CI], 1.22-1.64; p < 0.001). In the COPD patients, short-acting beta-agonists (SABAs) was associated with a significantly increased risk of bipolar disorder development (HR = 1.83, 95% CI = 1.25-2.69, p = 0.002). Other COPD medications were not associated with the risk of bipolar disorder development. The study results indicate that COPD may be an independent risk factor for the development of bipolar disorder. The regular use of SABAs might increase the risk of bipolar disorder in COPD patients.

Asthma-COPD overlap syndrome (ACOS): A diagnostic challenge

Asthma-chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS) is characterized by persistent airflow limitation with several features usually associated with asthma and several features usually associated with COPD. ACOS may be a special phenotype of a spectrum of chronic obstructive airway diseases, in which asthma and COPD are at the two opposite ends. The prevalence of ACOS varies considerably due to differing criteria being applied for diagnosis. Patients with ACOS utilize a large proportion of medical resources. They are associated with more frequent adverse outcomes than those with asthma or COPD alone. ACOS is currently a diagnostic challenge for physicians because there are no specific biomarkers to differentiate ACOS from asthma or COPD. The approach to diagnosing ACOS depends on the population from which the patient originated. The management of ACOS should be individualized to ensure the most effective treatment with minimal side effects. In this paper, we review the diagnostic criteria of ACOS used in previous studies, propose practical approaches to diagnosing and managing ACOS and raise some research questions related to ACOS.

Pulmonary function testing in infants with tetralogy of Fallot and absent pulmonary valve syndrome

Aim:

Absent pulmonary valve syndrome (APVS) is found in 3-6% of patients with Tetralogy of Fallot (TOF). Along with findings of TOF, absence of pulmonary valve tissue results in aneurysmal dilatation of the main and branch pulmonary arteries compressing the trachea, main-stem, and intrapulmonary bronchi leading to obstructive airways disease. Our objective was to review pulmonary function tests (PFT) in TOF-APVS patients.

Materials and Methods:

Eight PFT were performed on five mechanically ventilated TOF-APVS patients in the intensive care unit. Tidal volume, forced vital capacity (FVC), maximal expiratory flow 25%, resistance and compliance of the respiratory system were measured.

Results:

Pre-operative PFTs showed markedly elevated airways resistance (R_RS) (median 0.45 cmH₂O/mL/sec, range 0.17-0.66) and marked variability of the static compliance of the respiratory system (C_RS) (median 0.6 mL/cmH₂O/kg, range 0.25-2.6). Flow-volume loops measured by forced deflation showed flow limitation within the medium to small airways. Post-operative FVC was reduced in four of the five patients (median 46 mL/kg, IQR 42.9 - 48.8 mL/kg). Patients studied with various levels of positive end expiratory pressure (PEEP) showed improvement in tidal volume and reduced obstruction with PEEP greater than 10 cmH₂O. For three patients with pre-operative data available, surgical correction resulted in near-normal post-operative C_RS and improved, but still elevated R_RS (median 0.14 cmH₂O/mL/sec, interquartile range [IQR] 0.11-0.31).

Conclusion:

For our patients with TOF-APVS, airway resistance was elevated. Flow limitation was seen in the medium to small airways with a mild reduction of FVC. PFTs may help guide management of mechanical ventilation for TOF-APVS patients.

Comparison of in-hospital mortality in patients with COPD, asthma and asthma-COPD overlap exacerbations

BACKGROUND AND OBJECTIVE

Obstructive airway diseases, such as asthma and chronic obstructive pulmonary disease (COPD), have airflow limitation associated with chronic inflammation. Using a national inpatient database in Japan, we aimed to evaluate factors affecting in-hospital mortality in patients with asthma, COPD or asthma-COPD overlap (ACO).

METHODS

We retrospectively collected data for inpatients (age >40 years) with exacerbation of COPD and/or asthma in 1073 hospitals across Japan between July 2010 and May 2013. We performed multivariable logistic regression analysis to examine the association of various factors with all-cause in-hospital mortality, including diagnosis of ACO, asthma alone and COPD alone.

RESULTS

Of 30 405 eligible patients, in-hospital mortality in patients with ACO, asthma alone and COPD alone was 2.3%, 1.2% and 9.7%, respectively. COPD patients had a significantly higher mortality than ACO patients (odds ratio 1.96; 95% confidence interval: 1.38-2.79); patients with asthma alone showed lower mortality (0.70; 0.50-0.97). Higher mortality was also significantly associated with older age, male gender, lower body mass index, more severe dyspnoea, lower level of consciousness, worse activities of daily life and higher daily dose of corticosteroids.

CONCLUSION

Asthma alone was associated with lower mortality, but COPD alone was associated with higher mortality than ACO.

Estimating the time interval between exposure to the World Trade Center disaster and incident diagnoses of obstructive airway disease

Respiratory disorders are associated with occupational and environmental exposures. The latency period between exposure and disease onset remains uncertain. The World Trade Center (WTC) disaster presents a unique opportunity to describe the latency period for obstructive airway disease (OAD) diagnoses. This prospective cohort study of New York City firefighters compared the timing and incidence of physician-diagnosed OAD relative to WTC exposure. Exposure was categorized by WTC arrival time as high (on the morning of September 11, 2001), moderate (after noon on September 11, 2001, or on September 12, 2001), or low (during September 13–24, 2001). We modeled relative rates and 95% confidence intervals of OAD incidence by exposure over the first 5 years after September 11, 2001, estimating the times of change in the relative rate with change point models. We observed a change point at 15 months after September 11, 2001. Before 15 months, the relative rate for the high- versus low-exposure group was 3.96 (95% confidence interval: 2.51, 6.26) and thereafter, it was 1.76 (95% confidence interval: 1.26, 2.46). Incident OAD was associated with WTC exposure for at least 5 years after September 11, 2001. There were higher rates of new-onset OAD among the high-exposure group during the first 15 months and, to a lesser extent, throughout follow-up. This difference in relative rate by exposure occurred despite full and free access to health care for all WTC-exposed firefighters, demonstrating the persistence of WTC-associated OAD risk.

Systemic Inflammation in Older Adults With Asthma-COPD Overlap Syndrome

PURPOSE

The role of systemic inflammation on asthma-COPD overlap syndrome is unknown. This study aimed to examine systemic inflammation in asthma-COPD overlap syndrome, and to identify associations between clinical characteristics and inflammatory mediators in asthma-COPD overlap syndrome.

METHODS

In 108 adults older than 55 years comprising healthy controls (n=29), asthma (n=16), COPD (n=21) and asthma-COPD overlap syndrome (n=42), serum high sensitivity C-reactive protein and Interleukin 6 (IL-6) were assayed. Spirometry, induced sputum, quality of life, comorbidities and medications were assessed, and their associations with asthma-COPD overlap syndrome were analyzed using logistic regression. Associations between systemic inflammatory mediators and clinical characteristics were tested in multivariate linear regression models.

RESULTS

Patients with asthma-COPD overlap syndrome had significantly elevated IL-6 levels compared with healthy controls and asthmatics. Age, comorbidity index and IL-6 level were independently associated with asthma-COPD overlap syndrome. FEV1% predicted was inversely associated with IL-6 level, and cardiovascular disease was associated with an increased IL-6 level. Systemic markers were not associated with airway inflammation.

CONCLUSIONS

Systemic inflammation is commonly present in asthma-COPD overlap syndrome, and asthma-COPD overlap syndrome resembled COPD in terms of systemic inflammation. IL-6 is a pivotal inflammatory mediator that may be involved in airflow obstruction and cardiovascular disease and may be an independent treatment target.

Obliterative lower airway lesions in childhood: bronchoscopic diagnosis and clinical spectrum

Previous reports have described structural airway abnormalities in children with non-cystic fibrosis chronic supportive lung disease as well as obliterative membranes in the major bronchi of cystic fibrosis patients. The putative paradigm proposed in the evolution of these membranes invokes intense inflammation resulting in granulation tissue and neovascularization with the formation of pyogenic granuloma and eventually fibrosis. Our series of four cases widens the spectrum of conditions that may be conducive to large airway obliteration to include non-suppurative chronic infections and possibly immunosuppression. Obliteration of lumina in proximal and distal airways was visualized on bronchoscopy, the latter by the use of the ultrathin bronchoscopes. An attempt at invasive intervention by transbronchial breaching of the obstruction was unsuccessful in three cases, and in one case, the obliterative process resolved spontaneously and without any radiologic trace, presumably by resorption or rupture or through development of collateral ventilation. This series highlights the use of bronchoscopy for diagnosis and occasionally for therapeutic intervention in hitherto little recognized obliterative airway lesions. These acquired obliterative lesions should be considered in the evaluation of patients with isolated non-resolving pulmonary infiltrates or other conditions in which bronchial and bronchiolar patency may be impaired.

Incidence of restless legs syndrome and its correlates

BACKGROUND

Restless legs syndrome (RLS) is a common sensorimotor disorder whose incidence is not known. The aim of the study was to determine the incidence and correlates of RLS in a population-based sample.

METHODS

We obtained data from the Tucson Cohort of the Sleep Heart Health Study, a prospective multicenter study. This cohort included 535 participants aged ≥ 40 years, who answered questions regarding RLS on the 2002 and 2006 sleep surveys. For this study, RLS was defined as the presence of all 4 International RLS Study Group criteria, with symptoms occurring ≥ 5 days/month and associated with at least moderate distress.

RESULTS

Mean age of the predominantly Caucasian (90.8%) participants on the 2002 survey was 59.8 ± 9.7 years; 52.2% were women. RLS prevalence was 4.1% in 2002 and 7.7% in 2006. The yearly incidence of RLS was 1.7% (6.6% over 4 years). Multivariate analyses demonstrated that estrogen use (OR = 2.5, 95% CI: 1.17-5.10) and self-reported obstructive lung disease (OR = 2.8, 95% CI: 1.37-5.83) were independent risk factors predicting incident RLS. Incident RLS was associated with higher prevalence of insomnia (26.5% vs. 7.6%, p = 0.001), increased sleepiness (38.2% vs. 22%, p = 0.036); and higher sleeping pill use in 2006 (23.5% vs. 9.7%, p = 0.019).

CONCLUSION

The incidence of RLS in this population sample was 1.7% per year. Use of estrogen and history of obstructive lung disease were associated with a significantly higher incidence of RLS. RLS, in turn, was associated with insomnia and increased sleepiness.

FEV(6) as screening tool in spirometric diagnosis of obstructive airway disease

Context:

The use of spirometry is currently limited to the diagnosis of obstructive airway disease for tertiary centers mainly because of the unmet need for technical expertise and funding. Use in primary care asks for a simpler and cost-effective screening tool for obstructive airway disease.

Aim:

To estimate the efficacy of FEV₆ against the current standard of FVC in the spirometric diagnosis of obstructive airway disease.

Setting and Design:

The Pulmonary Function Laboratory of a tertiary care hospital in Coastal South India. It was a descriptive study.

Materials and Methods:

We analyzed 150 serial patients on ATS standardized spirometers. The patients were classified into normal subjects and those with airway obstruction, further categorized as mild, moderate and severe and those with mixed defect. Those with obstruction were also classified as having reversible and irreversible defects.

Statistical Analysis:

Data was analyzed using SPSS Software (v.11.5), statistical test ANOVA and Pearson correlation was done and P less than 0.05 considered statistically significant.

Results:

FVC and FEV₆ showed a linear correlation in all subjects. The difference in means was statistically significant in all subjects. The sensitivity and specificity of FEV₁/FEV₆ in comparison to FEV₁/FVC were both found to be 100%.

Conclusion:

FEV₆ is an excellent screening tool in the diagnosis of airway obstruction but, there is a necessity for further research to confirm our findings. There is also a need for reference values in an Indian setting to find out the efficiency of this new parameter. Our sample size is relatively small and comprises of a very high proportion (70%) of subjects with airway obstruction and so our results may not be applicable for use in general population.

Pesticide spraying for West Nile virus control and emergency department asthma visits in New York City, 2000

Pyrethroid pesticides were applied via ground spraying to residential neighborhoods in New York City during July-September 2000 to control mosquito vectors of West Nile virus (WNV). Case reports link pyrethroid exposure to asthma exacerbations, but population-level effects on asthma from large-scale mosquito control programs have not been assessed. We conducted this analysis to determine whether widespread urban pyrethroid pesticide use was associated with increased rates of emergency department (ED) visits for asthma. We recorded the dates and locations of pyrethroid spraying during the 2000 WNV season in New York City and tabulated all ED visits for asthma to public hospitals from October 1999 through November 2000 by date and ZIP code of patients' residences. The association between pesticide application and asthma-related emergency visits was evaluated across date and ZIP code, adjusting for season, day of week, and daily temperature, precipitation, particulate, and ozone levels. There were 62,827 ED visits for asthma during the 14-month study period, across 162 ZIP codes. The number of asthma visits was similar in the 3-day periods before and after spraying (510 vs. 501, p = 0.78). In multivariate analyses, daily rates of asthma visits were not associated with pesticide spraying (rate ratio = 0.92; 95% confidence interval, 0.80-1.07). Secondary analyses among children and for chronic obstructive pulmonary disease yielded similar null results. This analysis shows that spraying pyrethroids for WNV control in New York City was not followed by population-level increases in public hospital ED visit rates for asthma.

Effect of obstructive airway disease in patients with non-cystic fibrosis bronchiectasis

BACKGROUND

Extensive research has been devoted to cystic fibrosis-related brochiectasis, compared with non-cystic fibrosis bronchiectasis but the latter is more common and results in significant morbidity and mortality. We assessed the relationship between pulmonary function test (PFT) findings and sputum bacteriology, blood gases, number of hospital admissions and mortality in patients with non-cystic fibrosis bonchiectasis (NCFB).

METHODS

We conducted a retrospective review of 88 consecutive patients admitted with exacerbation of bronchiectasis over 5 years from 1996 to 2001. Demographic and clinical data collected included gender, age, pulmonary functions, arterial blood gases, sputum bacteriology during stable and exacerbation periods, and number of hospital admissions due to exacerbation of bronchiectasis. A comparison was made between patients having obstructive airway disease (OAD group) and patients with normal or restrictive pulmonary functions (non-OAD group).

RESULTS

OAD in patients with NCFB adversely affected clinical outcome. There was a significant increase in Pseudomonas colonization (60.3% vs. 16%; P<0.0003), hypercapnic respiratory failure (63.4% vs. 20%; P<0.0003), and mean number of admissions due to exacerbation (6 vs. 2; P<0.0001) in the OAD group as compared with the non-OAD group. Although mortality was increased in the OAD group, the difference was not statistically significant.

CONCLUSION

Patients with NCFB who have OAD have a significantly higher rate of colonization with Pseudomonas aeruginosa (PSA), hypercapnic respiratory failure, a greater number of hospital admissions due to exacerbation of bronchiectasis, and a higher mortality compared with patients with restrictive or normal pulmonary functions.