Bronchoscopic interventions for chronic bronchitis

PURPOSE OF REVIEW

Chronic bronchitis is a phenotype of chronic obstructive pulmonary disease (COPD), characterized by chronic cough and sputum production, associated with an increased rate of COPD exacerbations and hospital admissions, a more rapid decline in lung function and reduced life expectancy. Despite optimal medical therapy, chronic bronchitis remains difficult to treat. Interventional bronchoscopic procedures offer novel therapeutic approaches to this highly symptomatic condition.

RECENT FINDINGS

A characteristic feature of chronic bronchitis is the presence of an abnormal epithelium with excessive mucus producing cells, parasympathetic overactivity, and airway inflammation. Metered cryospray and bronchial rheoplasty are designed to target this abnormal epithelium to reduce mucus production and inflammation. Targeted lung denervation aims to reduce parasympathetic overactivity, which may drive mucus hypersecretion. Here, we review the available evidence to determine the safety and efficacy across the bronchoscopic interventions.

SUMMARY

Interventional bronchoscopy is a rapidly expanding field and its application in the treatment of chronic bronchitis has been recognized by the Global initiative for chronic Obstructive Lung Disease (GOLD). The outcomes from the latest clinical trials will guide future treatment approaches in patients with difficult to treat chronic bronchitis.

Effects of spray cryotherapy on cough receptors and airway microenvironment in a canine model of chronic bronchitis

The aim of this study was to explore the effects of spray cryotherapy (SCT) on cough receptors and airway microenvironment in a canine model of chronic bronchitis. We examined the expression of transient receptor potential vanilloid 1/4 (TRPV1/4) and the neuropeptides substance P (SP) and calcitonin gene-related peptide (CGRP) at the gene and protein levels before and after SCT. In addition, we explored whether TRPV1/4 could regulate inflammatory factors via mediator adenosine triphosphate (ATP). The levels of ATP and cytokines in alveolar lavage fluid and cell supernatant were measured using ELISA. SCT effectively downregulated the expression of TRPV1/4 and SP/CGRP in canine airway tissues with chronic bronchitis and reduced the levels of inflammatory mediators and cytokines that affect cough receptor sensitivity, achieving cough relief. TRPV1/4 - ATP - inflammatory cytokines axis has been demonstrated at the cellular level, which in turn modulate the milieu of the airways and promote the formation of a cough feedback loop. Our study has fully revealed the specific mechanism of SCT in treating cough in a canine model of chronic bronchitis, providing a solid theoretical basis for future clinical treatment.

Airway Mucosal Remodeling: Mechanism of Action and Preclinical Data of Pulsed Electric Fields for Chronic Bronchitis and Mucus Hypersecretion

Patients living with chronic bronchitis (CB) suffer from physical limitations and poor quality of life. In general, treatment options that directly address the mucus hypersecretion component of CB are quite limited. Chronic airway inflammation and the associated hypersecretion and cough that are pathognomonic for CB generally result from long-term exposure to airway irritants such as tobacco use and other environmental insults. This, in turn, results in an increase in the quantity and change in composition of the airway mucosa as a consequence of altered goblet cells, club cells, and submucosal glands. Pulsed electric fields (PEFs) provide a method for eradicating the cellular constituents of tissue with limited impact on the stromal proteins. Preclinical evidence in porcine airways demonstrated that particular PEF waveforms allowed for salutary remodeling of the epithelial and submucosal airway tissue layers and appeared to foster rapid regeneration and recovery of the tissue. Therefore, a therapeutic opportunity might exist whereby the application of a specific form of PEF may result in a reduction of the cellular secretory constituents of the airway while also reducing airway mucosal inflammation. This review discusses the use of such PEF to address the underlying disease processes in CB including challenges around device design, dosing, and appropriate delivery methods. Further, we outline considerations for the transition to human airways along with a brief examination of the initial work treating CB patients, suggesting that the therapy is well tolerated with limited adverse events.

Effect of probiotics, prebiotics and synbiotics for chronic bronchitis or chronic obstructive pulmonary disease: A protocol for systematic review and meta-analysis

BACKGROUND

Probiotics, prebiotics and synbiotics have been widely used in the treatment of respiratory diseases, but their clinical efficacy for treating chronic bronchitis (CB) or chronic obstructive pulmonary disease (COPD) has not been well studied.

METHODS

The following electronic databases will be searched for eligible randomized controlled trials: the Cochrane Library, EMBASE, MEDLINE, PubMed, Scopus, the Web of Science, the China National Knowledge Infrastructure, the Wanfang database, and the China Science and Technology Journal database (VIP Information Network). We will search these electronic databases weekly and extract relevant data from their inception dates until September 30, 2020. Risk of publication bias will be evaluated by the Cochrane Handbook for Systematic Reviews of Interventions. Data synthesis will be conducted using Review Manager (RevMan) version 5.3 software. Sensitivity and quality of evidence analyses will be conducted.

RESULTS

This systematic review and meta-analysis will provide a high-quality synthesis from existing evidence for estimating the efficacy and safety of probiotics, prebiotics and synbiotics in the treatment of CB or COPD.

CONCLUSION

This systematic review and meta-analysis will provide reliable and accurate evidence to guide the use of probiotics, prebiotics and synbiotics in the treatment of CB or COPD.

REGISTRATION OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/SP35M.

Effect of acupuncture on chronic bronchitis: A protocol for systematic review and meta-analysis

INTRODUCTION

Chronic bronchitis (CB) is a clinically common and recurrent respiratory disease. However, many trials have shown that acupuncture can effectively treat CB. There is currently no systematic review of this therapy. The plan is to evaluate the effectiveness and safety of this treatment in patients with CB.

METHODS AND ANALYSIS

This systematic evaluation will entail an electronic and manual search of all acupuncture for CB from inception to December 31, 2020, regardless of the publication status or language. Databases include PubMed, Embase, Springer, Web of Science, the Cochrane Library, the World Health Organization International Clinical Trial Registration Platform, the Chinese Medicine Database, the China National Knowledge Infrastructure, the Chinese Biomedical Literature Database, the China Science Journal Database, and the Wanfang Database. Other sources of information, including bibliographies and meeting minutes for identified publications, will also be searched. A manual search for grey literature, including unpublished conference articles will be performed. Additionally, any clinical randomized controlled trials related to acupuncture for CB, regardless of the publication status and language limitations, will be included in the study. Study selection, data extraction, and research quality assessments will be conducted independently by 2 researchers. The main result was the Change in cystic fibrosis transmembrane conductance regulator function as measured by sweat chloride analysis or treatment effect. Secondary outcomes included Quality of life (eg, SF-36), change in Breathlessness, Cough, and Sputum Scale score, follow-up relapse rate, and adverse events. The system searches for randomized controlled trials of this therapy for CB. Implement the Cochrane RevMan V5.3 bias assessment tool to assess bias risk, data integration risk, meta-analysis risk, and subgroup analysis risk (if conditions are met). Mean difference, standard mean deviation, and binary data will be used to represent continuous results.

RESULTS

This study will provide a comprehensive review and evaluation of the available evidence for the treatment of CB using this therapy.

CONCLUSION

This study will provide new evidence to evaluate the effectiveness and side effects of acupuncture on CB. Because the data are not personalized, no formal ethical approval is required.

PROSPERO REGISTRATION NUMBER

CRD42020170287.

Canine Chronic Bronchitis: An Update

Chronic bronchitis is a syndrome defined by cough on most days for at least 2 months for which no specific cause can be identified. Older small breed dogs are most commonly affected, but bronchitis can also be documented in midsized and larger breed dogs. Diagnostic testing includes physical examination, laboratory testing, radiography, and airway evaluation via bronchoscopy, cytology, and culture. Treatment is directed at reducing exposure to irritants, reducing airway inflammation, and controlling cough.

The Effect of Pulmonary Rehabilitation in Mountain Environment on Exercise Capacity and Quality of Life in Patients with Chronic Obstructive Pulmonary Disease (COPD) and Chronic Bronchitis

BACKGROUND We aimed to test the effectiveness of the pulmonary rehabilitation in a mountain environment on the pulmonary function, physical performance, dyspnea, affective factors, and quality of life (QoL) in patients with chronic obstructive pulmonary disease (COPD) and chronic bronchitis (CB), as well as to determine predictors of clinical improvement. MATERIAL AND METHODS 128 consecutive patients (90 diagnosed with COPD and 38 diagnosed with CB) underwent comprehensive pulmonary rehabilitation for a duration of 3 weeks in one of 3 mountain health resorts in the High Tatras. The examination included spirometry (FEV1 and FEV1/FVC), 6-minute walk test (6MWT), Borg scale of dyspnea, and assessment of depression (Zung score), anxiety (Beck score), and QoL using the SF-36 scales. RESULTS After the study intervention, all patients in both monitored groups demonstrated significant improvements in objective measurements in which large treatment effect was achieved (for FEV1 η²=0.218, for 6MWT η²=0.771). Similarly, in subjective measurements a large effect was achieved (for the Beck score: η²=0.599, for the Zung score: η²=0.536). QoL improved after the intervention in all the monitored SF-36 scales in both groups (P<0.001 for all). In patients with COPD, the improvement of exercise capacity was positively correlated with baseline 6MWT and FEV1, and negatively with the Beck anxiety score and the Borg dyspnea score, whereas, only improvement in the mental summary component of QoL was negatively correlated with baseline 6MWT and FEV1 (P<0.05 for all). CONCLUSIONS Rehabilitation in a mountain environment has proven to be effective in both the reported diagnoses of COPD and CB. Improvements in both functional and subjective indicators were observed. These findings support the use of this treatment modality.

COPD: obstructed lungs

CHRONIC OBSTRUCTIVE pulmonary diseases (COPD) affect 14 per cent of the population over 40 years of age. With an ageing population, the number of those requiring care for COPD is expected to increase, having a significant effect on health-care resources. COPD is projected to become the third leading cause of death globally by 2020. This disease has a major impact on economic and social well-being, and on quality of life. It is regarded as largely preventable but, once developed, is a progressive and complex condition characterised by frequent exacerbations and co-morbidities. Smoking is the primary cause of COPD but up to 30 per cent of those with COPD have never smoked. It is increasingly recognised COPD may have its origins prenatally and in early childhood. Treating exacerbations, improving exercise capacity, and delaying progression of disease are key management strategies. No curative or disease modifying therapies are available. Nurses are essential in providing comprehensive care to patients in both acute care and for long-term management. They also have a vital role to play in preserving healthy lung function in the early years of life to reduce the risk of COPD in older age.

[Use of high-frequency chest wall oscillation in an exacerbation of chronic pyo-obstructive bronchitis in adult patients with cystic fibrosis]

AIM

To evaluate the efficiency of high-frequency chest wall oscillation in the treatment of an exacerbation of chronic pyo- obstructive bronchitis in adult patients with cystic fibrosis (CF).

SUBJECTS AND METHODS

A simple open-label comparative study enrolled 31 patients with CF. C-reactive protein (CRP), spirometric indicators (forced vital capacity (FVC), forced expiratory volume in one second (FEV1), peak expiratory flow), hemoglobin oxygen saturation, anthropometric data, six-minute walk test, and dyspnea rating by the MRC scale were assessed before treatment and on the last day of hospitalization. All the patients received conventional drug therapy; the study group patients (n=15) had the latter in combination with vibration-compression therapy for 15 minutes twice daily at a vibration frequency of 9-12 Hz and at an amplitude of 6-9 bars; the treatment cycle lasted 12-14 days.

RESULTS

Both groups showed significant changes in spirometric and pulsometric readings, 6-minute walk test results, and MRC score. Body mass index increased and CRP decreased in the majority of patients in both groups. There were significant group differences in functional and anthropometric changes: 10.0 ± 4.6 and 6.9 ± 3.6% for FEV1 (p = 0.04) and 9.5 ± 4.8 and 5.9 ± 3.8% for FVC (p = 0.03) in the study and control groups, respectively.

CONCLUSION

Incorporation of vibration-compression therapy (Vest vibro drainage) into the combination treatment of adult patients with CF results in significantly improved bronchial patency and more effective abolishment of an exacerbation.

[Phenotype specific therapy of COPD]

COPD is not a homogenous disease but consists of at least four different phenotypes: Emphysema, COPD with chronic bronchitis, asthma-COPD overlap syndrome (ACOS), and COPD with recurrent exacerbations. With differentiation, treatment can be designed phenotype-specific. Some modern drugs are not indicated in all phenotypes.

Canine chronic bronchitis

Chronic bronchitis is a syndrome defined by cough on most days for at least 2 months where no specific cause can be identified. Older small breed dogs are most commonly affected, but bronchitis is also documented in midsized and larger breed dogs. Diagnostic testing includes physical examination, laboratory testing, radiography, and airway evaluation via bronchoscopy, cytology, and culture. Treatment is directed at reducing exposure to irritants, reducing airway inflammation, and controlling cough.

Exacerbations among chronic bronchitis patients treated with maintenance medications from a US managed care population: an administrative claims data analysis

PURPOSE

Chronic obstructive pulmonary disease (COPD) exacerbations are the leading cause of hospital admission and death among chronic bronchitis (CB) patients. This study estimated annual COPD exacerbation rates, related costs, and their predictors among patients treated for CB.

METHODS

This was a retrospective study using claims data from the HealthCore Integrated Research Database (HIRD(SM)). The study sample included CB patients aged ≥ 40 years with at least one inpatient hospitalization or emergency department visit or at least two office visits with CB diagnosis from January 1, 2004 to May 31, 2011, at least two pharmacy fills for COPD medications during the follow-up year, and ≥2 years of continuous enrollment. COPD exacerbations were categorized as severe or moderate. Annual rates, costs, and predictors of exacerbations during follow-up were assessed.

RESULTS

A total of 17,382 individuals treated for CB met the selection criteria (50.6% female; mean ± standard deviation age 66.7 ± 11.4 years). During the follow-up year, the mean ± standard deviation number of COPD maintenance medication fills was 7.6 ± 6.3; 42.6% had at least one exacerbation and 69.5% of patients with two or more exacerbations during the 1 year prior to the index date (baseline period) had any exacerbation during the follow-up year. The mean ± standard deviation cost per any exacerbation was $269 ± $748 for moderate and $18,120 ± $31,592 for severe exacerbation. The number of baseline exacerbations was a significant predictor of the number of exacerbations and exacerbation costs during follow-up.

CONCLUSION

Exacerbation rates remained high among CB patients despite treatment with COPD maintenance medications. New treatment strategies, designed to reduce COPD exacerbations and associated costs, should focus on patients with high prior-year exacerbations.

Chronic bronchitis and chronic obstructive pulmonary disease

Chronic bronchitis (CB) is a common but variable phenomenon in chronic obstructive pulmonary disease (COPD). It has numerous clinical consequences, including an accelerated decline in lung function, greater risk of the development of airflow obstruction in smokers, a predisposition to lower respiratory tract infection, higher exacerbation frequency, and worse overall mortality. CB is caused by overproduction and hypersecretion of mucus by goblet cells, which leads to worsening airflow obstruction by luminal obstruction of small airways, epithelial remodeling, and alteration of airway surface tension predisposing to collapse. Despite its clinical sequelae, little is known about the pathophysiology of CB and goblet cell hyperplasia in COPD, and treatment options are limited. In addition, it is becoming increasingly apparent that in the classic COPD spectrum, with emphysema on one end and CB on the other, most patients lie somewhere in the middle. It is known now that many patients with severe emphysema can develop CB, and small airway pathology has been linked to worse clinical outcomes, such as increased mortality and lesser improvement in lung function after lung volume reduction surgery. However, in recent years, a greater understanding of the importance of CB as a phenotype to identify patients with a beneficial response to therapy has been described. Herein we review the epidemiology of CB, the evidence behind its clinical consequences, the current understanding of the pathophysiology of goblet cell hyperplasia in COPD, and current therapies for CB.

Patient characteristics, treatment patterns, and health outcomes among COPD phenotypes

BACKGROUND

Recent literature has suggested that emphysema and chronic bronchitis, traditionally considered to be entities overlapping within chronic obstructive pulmonary disease (COPD), may be distinct disorders. Few studies have examined the differences in patient characteristics and health outcomes between these conditions. This study examined whether COPD phenotypes represent distinct patient populations, in a large nationally representative US sample.

METHODS

Data were obtained from the 2010 US National Health and Wellness Survey (NHWS). NHWS respondents (n = 75,000) were categorized as a COPD phenotype based on their self-reported diagnosis of COPD only (n = 970), emphysema only (n = 399), or chronic bronchitis only (n = 2071). Phenotypes were compared on demographics, health characteristics, treatment patterns, health outcomes, work productivity, and resource use. Variables were compared using Chi-square and analysis of variance tests for categorical and continuous outcomes, respectively. Health outcomes were also examined using regression modeling, controlling for demographic and health characteristic covariates.

RESULTS

Patients with chronic bronchitis were significantly younger (51.38 years versus 63.24 years for COPD versus 63.30 years for emphysema, P < 0.05) and more likely to be employed (46.98% versus 23.81% for COPD versus 28.33% for emphysema, P < 0.05). Relative to the other phenotypes, patients with chronic bronchitis were also significantly more likely to be female, nonwhite, and to exercise currently (all P < 0.05), and were significantly less likely to be a current or former smoker (P < 0.05). Controlling for demographic and health characteristics, patients self-identified as having COPD only reported significantly worse physical quality of life (adjusted mean 36.69) and health utilities (adjusted mean 0.65) and significantly more absenteeism (adjusted mean 7.08%), presenteeism (adjusted mean 30.73%), overall work impairment (adjusted mean 34.06%), and activity impairment (adjusted mean 46.59%) than the other phenotypes (all P < 0.05).

CONCLUSION

These results suggest considerable heterogeneity among different COPD phenotypes with respect to demographics, health characteristics, disease characteristics, treatment patterns, and health outcomes. Research aimed at understanding the differences in patient characteristics and disease presentation of these phenotypes could be used to guide treatment recommendations.

Impact of exacerbations on health care cost and resource utilization in chronic obstructive pulmonary disease patients with chronic bronchitis from a predominantly Medicare population

BACKGROUND

Exacerbations of chronic obstructive pulmonary disease (COPD) lead to significant increases in resource utilization and cost to the health care system. COPD patients with chronic bronchitis and a history of exacerbations pose an additional burden to the system. This study examined health care utilization and cost among these patients.

METHODS

For this retrospective analysis, data were extracted from a large national health plan with a predominantly Medicare population. This study involved patients who were aged 40-89 years, had been enrolled continuously for 24 months or more, had at least two separate insurance claims for COPD with chronic bronchitis (International Classification of Diseases, Ninth Revision, Clinical Modification code 491.xx), and had pharmacy claims for COPD maintenance medications between January 1, 2007, and March 31, 2009. Two years of data were examined for each patient; the index date was defined as the first occurrence of COPD. Baseline characteristics were obtained from the first year of data, with health outcomes tracked in the second year. Severe exacerbation was defined by COPD-related hospitalization or death; moderate exacerbation was defined by oral or parenteral corticosteroid use. Adjusted numbers of exacerbations and COPD-related costs per patient were estimated controlling for demographic and clinical characteristics.

RESULTS

The final study sample involved 8554 patients; mean age was 70.1±8.6 years and 49.8% of the overall population had exacerbation, 13.9% had a severe exacerbation only, 29.1% had a moderate exacerbation only, and 6.8% had both a severe and moderate exacerbation. COPD-related mean annual costs were $4069 (all figures given in US dollars) for the overall population and $6381 for patients with two or more exacerbations. All-cause health care costs were $18,976 for the overall population and $23,901 for patients with history of two or more exacerbations. Severity of exacerbations, presence of cardiovascular disease, diabetes, and long-term oxygen use were associated with higher adjusted costs.

CONCLUSIONS

The results indicate that despite treatment with maintenance medications, COPD patients continue to have exacerbations resulting in higher costs. New medications and disease management interventions are warranted to reduce the severity and frequency of exacerbations and the related cost impact of the disease.

Occupational asthma and lower airway disease among World Trade Center workers and volunteers

The World Trade Center (WTC) disaster and its recovery work involved a range of hazardous occupational exposures that have not been fully characterized but can be reasonably assumed to have the potential to cause mucosal inflammation in the upper and lower airways. A high prevalence of lower airway disease (LAD) symptoms was reported by several early surveys. Clinical studies further categorized the diagnoses as irritant-induced asthma (of subacute onset), nonspecific chronic bronchitis, chronic bronchiolitis, or aggravated preexistent obstructive pulmonary disease in a substantial proportion of patients. Risk factors for WTC-related LAD included early (on September 11 or 12, 2001) arrival at the WTC site and work at the pile of the collapsed towers. Cigarette smoking (but not atopy) also seemed to be a risk factor for LAD. No data thus far suggest an increased incidence of neoplastic or interstitial lung disease, but ongoing surveillance is clearly necessary.

[Low-intensity laser radiation in the combined treatment of patients with chronic obstructive bronchitis]

This study included 89 patients with chronic obstructive bronchitis (COB) that were exposed to harmful occupational factors. The control group consisted of 30 healthy subjects. Chronic obstructive bronchitis is characterized by serious disturbances in the cardiorespiratory system that manifest themselves in the form of bronchogenic pneumosclerosis with moderate lung emphysema and pulmonary hypertension associated with impaired general resistance. Simultaneously, activity of lipid peroxidation reactions decreases. Application of low-intensity laser radiation in combination with other therapeutic modalities for the treatment of patients with chronic obstructive bronchitis accelerates elimination of clinical symptoms, increases its efficiency, promotes drainage function of the bronchi, facilitates normalization of the patient's immune status, and contributes to the optimization of lipid peroxidation processes.

[Effectiveness of hypoxic therapy in patients with chronic obstructive pulmonary disease]

The search for non-medicamentous therapeutic modalities for the treatment of patients with chronic obstructive pulmonary disease is a challenging problem in pulmonology. Properly adjusted adaptation to hypoxia in the course of normobaric interval hypoxic training (IHT) can be successfully applied to the prevention and the treatment of chronic obstructive pulmonary disease because it produces neither side effects nor complications. Better understanding of pathogenic mechanisms of action of interval hypoxic training will allow to more extensively exploit this method for the treatment of patients with chronic obstructive pulmonary disease and prevent the most undesirable complications of hypoxic therapy by choosing its most optimal variants.

[Intermittent hypoxic training in the sanatorium and spa treatment for patients with chronic obstructive pulmonary disease]

The combined examination and treatment in the course of normobaric interval hypoxic training of 550 patients with chronic obstructive pulmonary disease was performed. Characteristics of change of state of functional respiratory system, immunological reactivity, electroencephalography after adaptation to hypoxia in the course of interval hypoxic training were determined. Revealed improvement of oxygen supply on all stages of its transfer and increase of oxygen consumption in tissues resulted in normalization of electrobiological activity of cerebral cortex, correction of immunological reactivity. High efficiency of interval hypoxic training in the combined treatment for patients with chronic obstructive pulmonary disease was proved.

[End therapeutic nihilism towards COPD]

Prevention of COPD requires appropriate patient education, especially of adolescents, as well as the establishment of an effective national health policy. The new GOLD guidelines represent the current standard of knowledge on the management of chronic, progressive, obstructive pulmonary diseases. It points out that COPD is avoidable and treatable,and hence, there is no reason for therapeutic nihilism. Chronic bronchitis preceding a progressive respiratory obstruction cannot be improved with the presently available respiratory therapeutics. For this reason, therapeutic measures concentrate on the avoidance of exacerbations, which are primarily responsible for the severity of the course of COPD.

Chronic bronchitis and chronic obstructive pulmonary disease. The Finnish Action Programme, interim report

The Finnish National Prevention and Treatment Programme for Chronic Bronchitis and COPD, launched in 1998, has, to date, been running for 6 years (2003). The goals of this action programme were to reduce the incidence of COPD and the number of moderate and severe cases of the disease, and to reduce both the number of days of hospitalisation and treatment costs. A prevalent implementation of over 250 information and training events started. Health centres and pharmacies appointed a person in charge of COPD patients. In order to improve the cooperation between primary and specialised care, two thirds of hospital districts created local COPD treatment chains. The early diagnosis of COPD by spirometric examination was activated during the programme. Number of health centres with available spirometric services increased to 95%. Before the start of the programme, approximately 5-9% of the adult population had COPD. During the whole programme, the proportion of male and female smokers decreased from 30% to 26% and from 20% to 19%, respectively. The total number of hospitalisation periods and days due to COPD decreased by 15% and 18%, respectively. Both the number of pensioners and daily sickness days due to COPD also decreased by 18%. Registered COPD induced deaths remained at their previous levels during the monitoring period, i.e. around 1000 deaths out of 5.2 millions annually. The measures recommended by the programme have been widely introduced but they need to be still more effective.

Static pressure-volume curves and body posture in severe chronic bronchitis

Based on prior data, the current authors hypothesised that beneficial pronation effects on gas exchange and respiratory mechanics might be maximised in severely hyperinflated chronic bronchitis patients. The current authors also sought to elucidate underlying mechanisms and to determine whether pronation effects are reflected by postural changes in inspiratory pressure-volume (P-V) curve characteristics. A total of 16 mechanically ventilated patients (for 16-36 h) with chronic bronchitis exacerbation were studied in pre-prone semirecumbent (SREC), prone and post-prone SREC postures. Static respiratory system intrinsic positive end-expiratory pressure (PEEPi,rs) was >12 cmH2O. Haemodynamics, partitioned respiratory mechanics, gas exchange, and lung volumes were determined at zero external positive end-expiratory pressure. P-V curves were constructed from functional residual capacity. End-expiratory lung volume exceeded opening volume. Prone position versus pre-prone SREC resulted in 20% reduced pressure at the lower inflection point (LIP) and 17% increased volume at the upper inflection point of the lung P-V curve, improved lung mechanics and volumes, oxygenation, and carbon dioxide arterial tension (Pa,CO2). In multiple linear regression, postural decreases in PEEPi,rs and additional lung resistance independently predicted postural decreases in lung LIP pressure and Pa,CO2), respectively. In conclusion, in severely hyperinflated patients, pronation reduces lung lower inflection point pressure and increases lung upper inflection point volume. Pronation effects on ventilation homogeneity and carbon dioxide arterial tension are maximised, implying that pronation can be useful during early controlled ventilation.

Acute exacerbation of chronic bronchitis: Need for an evidence-based approach

Acute exacerbations of chronic bronchitis (AECB) can be classified into three levels according to severity: (1) home treatment sufficient; (2) hospitalisation required; (3) hospitalisation in the presence of respiratory failure. This evidence-based classification is useful in ranking the clinical relevance of the episode and its outcome, and makes it possible to define the clinical history, clinical evaluation and diagnostic procedures of an exacerbation. Treatment guidelines vary according to severity, but they are essentially based on appropriate bronchodilator therapy (beta(2) agonists and/or anticholinergics, corticosteroids and antibiotics selected according to the local bacterial resistance pattern). It is important that cases requiring management in an intermediate/special respiratory care unit or intensive care unit (ICU) be identified. This is the stage where oxygen therapy and ventilatory support become particularly important. As first choice, they should be non-invasive, saving intubation and invasive ventilatory support for most severe cases characterised by severe acidemia and hypercapnia. We identify the optimal criteria for hospital discharge and follow-up of patients with AECB. In view of the chronic nature of the underlying disease, a correct follow-up is essential to avoid frequent and repeated relapses.

Epidemiology and global impact of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease that causes a heavy health and increasing economic burden both in the United States and around the world. Most of the risk factors for COPD are well known and include smoking, occupational exposures, air pollution, airway hyperresponsiveness, asthma, and certain genetic variations, although many questions, such as why a minority of smokers develop significant airway obstruction, remain. Major medical organizations have agreed on a common definition of COPD, although newer measures, such as functional status or exercise capability, have emerged as important in determining the prognosis of COPD patients. In most of the world, COPD prevalence and mortality are still increasing and will likely continue to rise in response to increases in smoking, particularly by women and adolescents. Resources aimed at smoking cessation and prevention, COPD education and early detection, and better treatment will be of the most benefit in our continuing efforts against this important cause of morbidity and mortality.

[Chronic bronchitis, COPD]

Chronic bronchitis is part and precursor of COPD, a complex disease triggered mostly by exposure to cigarette smoke. However COPD develops only in patients with specific susceptibility probably determined by genetic factors or additional risk factors. A specific type of inflammation resides in the bronchial and bronchiolar walls, that infers damage not only to airway structure but also to surrounding alveolar attachments and thus to the lung parenchyma. Chronic bronchitis, fibrosing bronchiolitis and emphysema constitute the three main stems of pathology of the disease but may coexist with varying extent. The clinical picture is therefore quite variable. Treatment exists largely in bronchodilation combining different mechanisms and using long acting drugs usually applied by inhalation. Acute exacerbations promote progression of the disease, which must be counteracted by adaptation and intensification of therapy, in some cases including non invasive or invasive ventilation. Several non-pharmacologic measures such as smoking cessation, rehabilitation, nutritional support, long term oxygen therapy, lung volume reduction and possibly lung transplantation may be available for appropriate patients and have to be considered.

[Effect of the treatment of relapsing bronchitis in children with combined interferon preparations applicated by different methods]

The clinico-immunological effect and significance of the rectal and inhalation methods of the application of recombinant IFN-alpha2 with complex immunoglobulin preparation (CIP) in the treatment of relapsing bronchitis in children have been determined. The determination of the levels of interferon activity in buccal secretions and in venous blood permits the objective evaluation of the immune responsiveness of the body and the treatment effect. The immunocorrecting action of the combined immunobiological preparation (recombinant IFN-alpha2 and CIP) is manifested by an increased level of endogenic interferon and the stimulation of phagocytic activity.

[Naso-subcutaneous application of the polycomponent vaccine VP-4 for the treatment of patients with bronchial asthma and chronic obstructive bronchitis]

Bacterial polycomponent vaccine (VP-4) earlier developed at the Mechnikov Research Institute for Vaccines and Sera on the basis of antigenic complexes of Klebsiella pneumoniae, Proteus vulgaris, Escherichia coli, Staphylococcus aureus was used within the program of clinical trials, for the treatment of 30 patients aged 16-59 years with the atopic and mixed form of bronchial asthma and chronic obstructive bronchitis by the combined naso-subcutaneous application. A good therapeutic effect produced by the vaccine was registered in 83.3% of the patients. It was manifested by a lower frequency of acute respiratory diseases and bronchopulmonary diseases as well as decreased need in antibiotic therapy. In the group of comparison a good effect was noted in 40% of the patients during 6 months of observation (statistically significant difference). Side effects caused by the administration of the vaccine were transitory, had mainly local character and disappeared without any treatment. In 1 patient the development of anaphylactic shock was observed. The positive effect of vaccine VP-4 could be attributed to the improved indices of cell-mediated immunity, an increased synthesis of alpha- and gamma-interferon, a droped level of IgE and specific IgG antibodies to Staphylococcus sp., Klebsiella sp., Proteus sp., Escherichia coli.

Prophylaxis for acute exacerbations of chronic bronchitis using an antibacterial sublingual vaccine obtained through mechanical lysis: a clinical and pharmacoeconomic study

Chronic obstructive bronchitis (COB) complicated by acute exacerbations, or exacerbations, triggered by episodes of infection is the most demanding respiratory disease in our country today, to the extent that the implementation of every possible prevention strategy, in terms of both behaviour and prophylactic vaccination, is fully justified. From this point of view, in addition to the classic anti-viral vaccines, increasing importance is also being placed on antibacterial vaccines obtained by mechanically crushing pathogen bacteria (without the use of chemicals to denature the antigenic structures), which can be sublingually administered. In this study, conducted on 57 patients aged over 75 suffering from COB and affected by at least one exacerbation over the past 12 months, we evaluated the incidence of these exacerbations during a follow-up period, subsequent to prophylaxis with polyvalent bacterial mechanical lysate. As well as the absolute number of episodes, we also evaluated the seriousness of the episodes, the length of any antibiotic therapy and the overall cost of this therapy and of the prophylactic treatment. We then compared this data with that of the same period for the previous year, during which time no antibacterial prophylaxis had been administered. Both the absolute number of exacerbations, their length and seriousness were shown to be significantly reduced during the period of treatment compared to the control period. Similarly, the need to use antibiotic treatments, as well as the overall cost of the treatment of these patients, were shown to be reduced during the period of treatment compared to the control period.

Canadian guidelines for the management of acute exacerbations of chronic bronchitis

Acute exacerbations of chronic bronchitis (AECB) account for over 1.5 million physician visits annually in Canada and are a cause of significant morbidity and mortality. This document represents a joint effort between respirologists, microbiologists, infectious disease specialists and family physicians to update the Canadian AECB guidelines published in 1994. Treatment recommendations are graded on the strength of evidence in the published literature where possible. The role for oral corticosteroid therapy in preventing treatment failures, speeding up recovery and delaying the time to next exacerbation is discussed. Risk factors for treatment failure were used to stratify patients into risk groups to help guide antibiotic treatment recommendations. The importance of emerging antimicrobial resistance to current antibiotics is reviewed and strategies to prevent future AECB episodes are suggested.

[The study of partial tension of blood oxygen and forced expiration in patients with chronic obstructive bronchitis receiving inhalation of hypertonic salt solution]

To ascertain side effects of aerosol therapy which implies use of concentrated hypertensive salt solution (HSS), patients with chronic obstructive bronchitis (COB) and marked obstructive ventilation disturbances on HSS inhalation treatment were examined for PaO2 and bronchial patency. It was established that HSS inhalations do not affect PaO2 in COB patients. This expands opportunities for design of aerosol technology and its practical applications.

Positive pressure techniques for airway clearance

Positive airway pressure (PAP) has been used since the 1930s to improve oxygenation, increase lung volumes and reduce venous return. More recently, PAP has been identified as an effective method of splinting airway during expiration, improving collateral ventilation, increasing response to inhaled bronchodilators, and aiding secretion clearance in patients with cystic fibrosis and chronic bronchitis. A range of devices, administration techniques, and evidence supporting their clinical use is explored, suggesting that PAP is equivalent to postural drainage in the clearance of secretions. PAP produced by threshold and fixed orifice resistors generate different characteristic flow, and airway and esophageal pressure patterns that may contribute to different physiologic effects. Further clinical studies are required to better understand the effects of these differences.

[Inhalation therapy and laser therapy in chronic bronchitis]

Sixty five patients aged 24 to 68 years who had chronic bronchitis (with the rate of exacerbations of at least twice a year) in the phase of exacerbation were examined. They were 46 males and 19 females. As being examined and diagnosed, all the patients were divided into 3 groups and treated by different regimens. Sixty five took drug therapy, in 44 patients it was supplemented by endobronchial laser radiation, 22 of them also received halo therapy. Following 6-week therapy, signs of endobronchitis disappeared in a significantly larger number of patients undergone laser therapy. Moreover, there was an increase in the interval between exacerbations in patients who additionally received halo therapy.

[Efficacy of low intensity laser irradiation and sodium nedocromil in the complex treatment of patients with bronchial asthma]

AIM

To study efficiency of low-intensity laser radiation (LILR) and sodium nedokromil (tailed) in combined treatment of bronchial asthma (BA).

MATERIAL AND METHODS

The choice of the treatment depended on the activity of bronchial inflammation and the presence of contraindications. Laser was used on the skin in the area of the lung and great vessels projection, endobronchially. Tailed was given in inhalations and irrigations of the tracheobronchial tree during therapeutic fibrobronchoscopy. These methods were used in combined treatment of 220 BA patients.

RESULTS

Combined use of LILR and tailed proved highly effective and safe in BA. Cytological markers of cell reactions of the bronchopulmonary system on the action of LILR were revealed.

CONCLUSION

Availability, good reproducability, cost-effect efficacy and safety make LILR one of the most beneficial nonpharmacological treatments for bronchial asthma.

[Effects of plasmapheresis with transfusion solutions on blood biochemical parameters and central hemodynamics in patients with chronic obstructive bronchitis]

The impact of plasmapheresis (P) using 0.9% physiological solutions of sodium chloride solution and 5% lactoprotein on some blood biochemical and central hemodynamic parameters was studied in 20 patients with chronic obstructive bronchitis. No matter what hemocorrector was used, P was found to promote reductions in blood medium-weight molecules of peptides, overall blood proteolytic activity, alpha 1-proteinase inhibitor, ceruloplasmin, transferrin and to increase lipid peroxidation. At the same time curative P using lactoprotein favours better central hemodynamics, which indicates its ability to correct postexfusion plasma volume when used in a dosage of 10 ml/kg body weight).

[Ultraviolet irradiation of blood and peloid therapy (standard- and short-course) of patients with chronic bronchitis]

Clinical symptoms, clinico-biochemical picture, immunograms and external respiration function were studied in 43 patients with chronic bronchitis undergoing UV blood radiation and peloid therapy. This treatment had a corrective effect on chronic bronchitis pathogenesis. Short courses of photon-peloid therapy showed the same effectiveness as routine ones at lower risk of side effects and higher cost efficiency.