Medicina Pulmonar e Respiratória

Background: Repeated observations suggest that the incidence and/or severity of the Acute Respiratory Distress Syndrome (ARDS) is lower in mildly obese humans compared to lean subjects, phenomenon called the Obesity-ARDS Paradox. A reduced lung nitrosative stress could contribute to this unexplained protection. We measured levels of nitrate, the most oxidized nitric oxide (NO) metabolite, and other related metabolites in the exhaled breath condensate (EBC) of obese (composed of both overweight or mildly obese) and normal weight patients.

Methods: We studied patients without respiratory disease immediately after starting mechanical ventilation for elective surgery. We performed targeted metabolomics analyses of EBC and blood samples. We measured concentrations of arginine, asymmetrical dimethylarginine (ADMA), symmetrical dimethylarginine (SDMA), nitrite, and nitrate and then analyzed their relationship to body mass index (BMI). We compared patients classified as BMI<25 (normal) or 25-34.9 (obese).

Results: 21 patients were included in the analysis: 5 with a BMI<25 and 16 with a BMI 25-34.9. Concentrations of nitrate in EBC, but not in plasma, inversely correlated with BMI. EBC nitrate levels positively correlated with EBC nitrite but not with plasma nitrate levels. EBC nitrite levels inversely correlated with plasma nitrite levels. Patients with a BMI 25-34.9 had significantly lower EBC nitrate levels than patients with a BMI<25.

Conclusion: Our results suggest a lower nitrosative stress in the lungs of overweight and mildly obese patients compared to normal weight patients. This observation deserves further evaluation as a possible contributing factor to the Obesity ARDS Paradox.

Lipoid pneumonia (LP) is due to the accumulation of either endogenous or exogenous lipids in the alveoli. The exogenous LP (ELP) results from the chronic aspiration or inhalation of animal, vegetable, or mineral oils or fatty substances that by reaching the pulmonary alveoli cause a foreign body-type inflammatory reaction of lung parenchyma, associated with fibrosis, necrosis, and possible cavitation. Pulmonary reaction is characterised by symptoms and radiological findings that are common to other pulmonary diseases. The radiologic presentation of ELP includes lung consolidations and ground-glass opacities, with predominant involvement of the lower lobes. Thickening of interlobular septa, adipose or not adipose single mass, and poorly marginated nodules may also occur. Cavitation, when present, is mainly associated with infection by non-tuberculous mycobacteria or fungi. Thus in patients exposed to lipoid aspiration presenting with cavitated mass on CT scan, possible infection should be thoroughly ascertained, and adequate treatment promptly initiated. Hereby, we report three cases of non-infectious cavitary exogenous lipoid pneumonia. In all three patients, one with acute onset and two with chronic recurrent form, the ELP diagnosis was confirmed by both cytological and histological findings, whereas microbiological examination gave negative results. Moving from these three cases, we review the pathogenesis, clinical and radiological manifestation of ELP.

Background: The molecular mechanisms governing right atrial (RA) and ventricular (RV) hypertrophy and failure in chronic pulmonary hypertension (CPH) remain unclear. The purpose of this investigation was to characterize RA and RV protein changes in CPH and determine their adaptive versus maladaptive role on hypertrophic development.

Methods: Nine dogs underwent sternotomy and RA injection with 3 mg/kg dehydromonocrotaline (DMCT) to induce CPH (n=5) or sternotomy without DMCT (n=4). At 8-10 weeks, RA and RV proteomic analyses were completed after trypsinization of cut 2-D gel electrophoresis spots and peptide sequencing using mass spectrometry.

Results: In the RV, 13 protein spots were significantly altered with DMCT compared to Sham. Downregulated RV proteins included contractile elements: troponin T and C (-1.6 fold change), myosin regulatory light chain 2 (-1.9), cellular energetics modifier: fatty-acid binding protein (-1.5), and (3) ROS scavenger: superoxide dismutase 1 (-1.7). Conversely, beta-myosin heavy chain was upregulated (+1.7). In the RA, 22 proteins spots were altered including the following downregulated proteins contractile elements: tropomyosin 1 alpha chain (-1.9), cellular energetic proteins: ATP synthase (-1.5), fatty-acid binding protein (-2.5), and (3) polyubiquitin (-3.5). Crystallin alpha B (hypertrophy inhibitor) was upregulated in both the RV (+2.2) and RA (+2.6).

Conclusions: In early stage hypertrophy there is adaptive upregulation of major RA and RV contractile substituents and attenuation of the hypertrophic response. However, there are multiple indices of maladaptive pathology including considerable cellular stress associated with aberrancy of actin machinery activity, decreased efficiency of energy utilization, and potentially decreased protein quality control.

The ventilation associated pneumonia is one the biggest challenge in the critical care team. It has a high mortality rate and an increase cost of the management. The use of the antibiotics did not show a great improvement in the survival rate. On the other hand, the prevention of ventilation associated pneumonia shows promising results, it improves the survival rate, decease both days of antibiotic use and days in the critical care unit. In the last 10 years, different methods used for the prevention of ventilator associated pneumonia. Some of those methods show a promising results while others need do not. We reviewed different methods of prevention including oral hygiene, probiotics, cuff pressure control, subglottic secretion drainage, endotracheal cuff, coated endotracheal tube, and the multisystem approach. We review the papers and the data supplement online, and we compared between the different methods in the short outcome, long outcome, length of stay in the ICU, and the cost of the management.

Aim: The optimum number of revolutions (back and forth movement of the needle inside the lymph node) during endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) remains to be determined. This study aimed to compare the performance of number of revolutions during EBUS-TBNA of mediastinal and hilar lymph nodes.

Methods: Prospective analysis of consecutive patients with mediastinal and hilar lymphadenopathy who underwent EBUS-TBNA over a 3-month period was done. Cytological or histological results from the specimen obtained using two revolutions were compared with 16 revolutions.

Results: Twenty four patients underwent sampling of 37 lymph node stations. No difference in the detection rate of the malignancy was noted between lymph node aspiration using 2 versus 16 revolutions (p=0.058). This lack of difference was maintained whether the “worm like” string of core tissue was obtained or not (p=0.08). Although the “worm like” string of core tissue was obtained significantly more frequently with 16 revolutions (p=0.0104), this did not influence the detection rate of malignancy. The average time taken from the start of the procedure to the completion of two revolutions was 11.8 ± 5.6 minutes.

Conclusion: More than two revolutions or “worm like” string of aspirate does not add value in diagnosing malignancy via EBUS-TBNA. In patients with high pre-test probability of lung cancer, adequacy of two revolutions may confer greater safety and efficiency to the procedure. However, in case of high suspicion of a benign disease, it may be preferable to seek “worm like” material to aid establishment of diagnosis.

Background: Chronic Obstructive Pulmonary Disease (COPD) is a common disease and equally affecting rural population. Majority of COPD exacerbations are infective and facilities of bacterial culture are not available at peripheral health institutions. Acute exacerbations can contribute to irreversible progression of disease.

Objective: To find out the bacteria predominantly causing the AECOPD in our region, its relation with severity of the diseases and antibiotic most effective against these organisms.

Material and Methods: Previously diagnosed patients presented with acute exacerbation were investigated for sputum characteristics, culture and drug sensitivity.

Results: Culture was positive in 41 (82%) patients. Streptococcus pneumoniae (32%) was the most common pathogen isolated followed by Streptococcus pyogens (16%) and Pseudomonas (12%). Piperacillin+tazobactum was the most effective antibiotic against all organisms. Quinolones were less effective.

Discussion: Sputum culture was positive in 82% of patients with AECOPD which was higher as compare to other studies. On the contrary positive growth in 97% of samples has also been found. This difference may be because of the fact that culture positivity depends on nature of sputum, time of collection sputum and previous antibiotic use.

Conclusion: Streptococcus pneumoniae is still the most common pathogen in patients with AECOPD of this area. Piperacillin+tazobactum should be the first choice empirical antibiotic. Quinolones should be used cautiously in area where prevalence of tuberculosis is high. However more studies with larger population required which also includes bronchoscopic sampling along with sputum.

Background and objective: It is imperative that the clinical workforce in the health sciences professions has the right qualifications, skills and approaches to provide safe and high-quality health-care. The reduction of variability and improved consistency of practice are key goal of professional practice across the health science professions, particularly with regard to evidence-based techniques. The objective of this study was to develop a performance standard and assessment tool for the assessment of competency in the performance of ventilator hyperinflation by physiotherapists.

Method and results: Development of the performance standard was facilitated by an allied health professional with expertise in competency-based training and coupled with a subject matter expert. Key components of the performance standard developed included the elements and the performance criteria which are based on the required skills and knowledge to perform a selected task (in this case ventilator hyperinflation) independently. The performance standard was successfully implemented as part of the training program within the department.

Conclusions: An assessment tool based on the development of a performance standard can be used to assess competency in the performance of clinical tasks, such as ventilator hyperinflation by physiotherapists, for the primary purposes of reducing practice variability, optimizing evidence-based practice, evaluation of training efficacy and in research. External validation of the performance standard and assessment tool is required and future research should focus on evaluating these in the context of Kirkpatrick’s hierarchy including healthcare delivery and patient outcomes.

Introduction: Breathlessness or dyspnoea is a complex subjective sensation that is an important feature of cardio-respiratory disease which is difficult to quantify. An objective measure would be useful as it would allow patients symptoms and response to therapy to be summarized and compared.

Objectives: This study aims to investigate whether a new approach could be used to quantify resistive load detection in participants with healthy lungs or obstructive lung disease with breathlessness.

Methods: Sixteen participants (five with chest disease, MRC dyspnoea score 4) were variously tested using three respiratory loading protocols, and applying a resistance between 0.2 to 1.5 kPa.L.sec-1 .

Results: In a healthy group (n=11) a sigmoidal relationship between load detection and applied load was observed with the 50% detection rate being 0.5 kPa.L.sec-1 and a minimal load detection between 0.2 and 0.3 kPa.L.sec-1 whereas in the group with chest disease (n=5) a threshold response was seen instead and a load below 0.75 kPa.L.sec-1 was undetectable.

Conclusions: In health there is a graded response to extrathoracic resistive respiratory loading, with the perceptual sensitivity independent of the method of load delivery. In lung disease the perceptual sensitivity is lost and load detection is reported (all or nothing) only above a threshold (0.75 kPa.L.sec-1). This approach provides a simple method for quantifying resistive load detection.

Introduction: The aim of our study was to describe the characteristics and clinical outcomes of pulmonary hypertension (PH) patients who underwent their follow-up at a single centre.

Methods: We included patients who fulfilled the criteria for the diagnosis of PH by right heart catheterisation. A detailed clinical history and complete physical examination were recorded for each patient. Demographic data, laboratory testing, hemodynamic values and treatment records were also collected. A 6-minute walk test was used to evaluate exercise capacity. Survival analysis was performed using the Kaplan-Meier method, and a log-rank test was used to compare survival curves among groups. A multivariate Cox’s proportional hazards model was used in order to identify independent predictors of mortality in the overall PH population.

Results: A total of 93 patients (64 women and 29 men) were studied. The patients were distributed across the groups as follows: 50.5% in group 1, 20.4% in group 2, 9.7% in group 3, 14% in group 4 and 5.4% in group 5. The most common type of PH in our population was portopulmonary hypertension followed by PH associated with leftheart disease, and idiopathic and chronic thromboembolic disease. Nineteen deaths, constituting 20.5% of the sample population, were reported. The Kaplan-Meier estimates of the 1-, 2-, and 3-year survival rates were 91%, 89%, and 85%, respectively. There were no statistically significant differences in survival among the groups (p=0.18). A multivariate analysis revealed that the cardiac index (CI) was an independent predictor of death.

Conclusions: The survival rates of PH patients are higher than previously reported. In our study, the largest number of deaths occurred in groups 1 and 2, and CI was found to be an independent predictor of mortality.

Chronic respiratory failure (CRF) should be considered a syndrome defined by arterial blood gas abnormalities. Domiciliary non-invasive ventilation (NIV) is an increasingly used intervention to curtail the detrimental effects of CRF in individuals with a broad range of cardiorespiratory disorders. Progress in the provision, monitoring and improvement in patient centred outcomes with NIV has simply been staggering over the last decade. Despite this, questions still remain in terms of the ideal mode of delivery, the most efficient techniques to monitor its effectiveness, and the timing of NIV initiation for several of the more common diseases which can require NIV support. There are a number of mechanisms accounting for the reduced ventilation that is apparent during sleep, even in normal subjects. This represents a particularly unique physiological state whereby changes in upper airway resistance control of respiration and changes in lung mechanics have an impact on the adequacy of tidal volume breathing. Abnormal respiratory events tend to occur specifically during sleep, and so NIV which is appropriate for the awake patient may not be suitable when asleep at night. These factors need to be kept in mind both for the optimal timing of NIV, and the manner in which it should be monitored. This article aims to provide an overview of current concepts in the appropriate mode of delivery of NIV, discusses the patient groups who benefit from its application, highlights challenges with interface design, and aspects that need to be kept in mind in terms of the optimal monitoring of NIV

Background: Majority of women living in rural areas use biomass fuels for production of domestic energy. Biomass fuel combustion causes indoor air pollution when used inside the dwellings. Combustion products may induce various effects on lung function.

Objective: Objective of this study was to compare the pulmonary functions in healthy non smoking rural women using biomass for cooking to those obtained in control group who were not exposed to biomass.

Methods: One hundred healthy non-smoking women were randomly selected within the age of 20-35 years for this study. The study group comprised of 50 subjects who cooked solely in biomass and 50 age matched subjects who were not exposed to biomass served as controls. A standardized respiratory questionnaire was administered to all the subjects and pulmonary function tests were evaluated by using Medspiror.

Results: The lung function parameters were significantly lesser in the study group, exposed to biomass fuel, than the controls FVC (p<0.01), FEF25-75%, (p<0.01), FEV1, (p<0.001), PEFR (p<0.01), FEV1/FVC% (p>0.05). The evaluation of PFT suggested both restrictive and early small airway obstructive type of pulmonary disease.

Conclusion: The reduction in the pulmonary function in the biomass exposed women could be due to high exposure of biomass pollutants with inadequate ventilation in cooking area leading to chronic pulmonary disease.

Pulmonary tuberculosis is one disease that has created, nurtured & modified thoracic surgery.With the invention of effective antitubercular drugs, role of surgery in pulmonary TB declined over decades, but with appearance of MDR/XDR TB – role of surgery is again becoming important.

Background: Ample evidence suggests a dose-response relationship between increasing weight and level of asthma risk or reduced asthma control. To establish reversibility, several randomized controlled trials (RCTs) have recently been published to investigate the impact of weight management on asthma. This systematic review synthesizes evidence from these RCTs on the effects of weight management (weight loss, weight maintenance, maintenance of lost weight, or weight gain prevention) interventions on asthma outcomes in both adult and pediatric populations.

Methods: We searched Medline, CINAHL, PsychInfo, and Cochrane for studies published between 1950 and November 2014. Two researchers independently rated the included studies using the quality assessment tool for RCTs as outlined in the 2013 Obesity Treatment Guideline. Discrepancies were resolved by consensus after discussion between the raters and, if needed, with the senior author.

Results: Four RCTs in adults and 3 in children and adolescents were included. The adult studies seem to consistently support the benefit of substantial weight loss, but a threshold effect may exist such that only weight loss beyond a minimal amount will likely lead to clinically important improvement in asthma outcomes. Three of them suggest that the threshold may lie between 5-10% of weight loss. RCTs in youth suggest that modest calorie reductions alone or combined with increased physical activity, or even a healthy normocaloric diet, may lead to improved asthma outcomes. However, most RCTs reviewed were limited by small sample size, short intervention durations, and short follow-up periods.

Conclusion: Trial evidence shows the promise of weight loss interventions for asthma control in adults and youth. More adequately-powered, long-term RCTs are needed to elucidate the role of weight loss and other weight management interventions in asthma control and prevention. Definitive data are needed to guide clinical and public health practice to effectively address the dual epidemic of obesity and asthma.

Background: This study was conceived to determine the ventilatory pattern of patients with diabetes as well as the effect of body mass index, age, glycosylated haemoglobin, duration of diabetes and blood glucose levels on their pulmonary functions.

Method: Two hundred persons with type 2 DM who consented and met inclusion criteria were recruited. The pulmonary function test was carried out using the Spirotrac intuitive version V spirometer made by Vitalograph. This was done according to standard guidelines. Statistic tests employed include Students’ test, correlation coefficient analysis and binary logistic regression.

Result: Mean age of the Study participants was 59.6 ± 11.30 years, with more than half 114(57%) of the Diabetics having abnormal ventilatory pattern with 76(38%) having restrictive defect. We noted significant associations between Age (r= -28, p=000), duration of DM (r=-15, p=034) and lung function. A possible predictor of abnormal pulmonary function test was the presence of hypertension (Odds ratio=0.39, p= 0.009).

Conclusion: We have reported that Restrictive lung function defect is common among patients with diabetes mellitus and non-modifiable clinical parameters are associated with lung function abnormalities in this group of patients.

The significant findings of this study: Restrictive lung function defect is the predominant abnormality of pulmonary function in persons with type 2 DM.

This Study adds: Hypertension in the presence of type 2 DM is a potential risk factor for the development of abnormal lung function in this group of patients.

Background: The variation of blood pressure indicates the status of cardiovascular circulation. The spectral analysis of blood pressure variability (BPV) provides a way to quantitatively assess the variations by specific fixed frequency band. Blood pressure contains various non-stationary fluctuations and varies individually. It is hard to assess the non-stationary characteristics based on stationary method.

Method: Recently, a novel adaptive extraction method, called empirical mode decomposition (EMD), was proposed and is capable to extract the non-stationary intrinsic trends from blood pressure waveform. Results: The results showed that the non-stationary intrinsic trends extracted by EMD are high correlated to the power in conventional fixed frequency band (r>0.7).

Conclusions: This study examined the potential usage of EMD on BPV measurement and provided the reliable estimation of BPV based on adaptive frequency band. Moreover, the main frequency of the non-stationary trend can be evaluated by this method. It helps for cardiovascular studies and the optimal frequency band exploration.

Objectives: Published data on gender differences in the effect of smoking on pulmonary function have been controversial. The study was designed to investigate the gender differences in effects of smoking on pulmonary function.

Methods: Female smokers were chosen among individuals older than 40 yrs, living in home for the aged. Male smokers were chosen from among office workers older than 40 yrs in MCI (machine chemical industry). Total 215 female smokers and 283 male smokers included the study. The individuals were interrogated with a questionnaire concerning respiratory symptoms, smoking status and other characteristics. Chronic airway obstruction was defined by FEV1/FVC <70%.

Results: The prevalence of chronic bronchitis in male smokers was similar to those of female smokers. The prevalence of airflow obstruction was higher in male smokers than female smokers [11.0% vs 3.7%, OR=3.1 (95%CI 1.4 to 7.0), p=0.003, respectively]. The man smokers compared to women smokers had lower values of the ratio forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC) (81.1 ± 8.3 vs 86.9 ± 7.9, p=0.0001, respectively) and lower the dyspnea score. FEV1/FVC was an important predictor for magnitude of dyspnea, after adjusting for confounding factors in all subjects in regression analysis.

Conclusions: Male smokers have more severe airway obstruction and lower perception of dyspnea than female smokers with similar age and smoking burden. The males are particularly prone than females to the negative effects of smoking. Individuals' perceptions of airway obstruction and response to cigarette smoke vary depending on gender.

Nasal congestion is the fourth most common minor ailment presented in primary care and as such, a method to quantify the meaning of nasal congestion in order to enable evaluation of medicines catered to specific congestion levels can prove important. The Airflow Perturbation Device (APD) is a noninvasive respiratory diagnostic device that evaluates the respiratory resistance in humans. It measures the total respiratory resistance under normal breathing in less than one minute. This study involved using the APD to determine the influence of nasal congestion on respiratory resistance in a laboratory setting. A total of 25 volunteers volunteered for this study and it employed a standard subjective categorical scale for nasal congestion (i.e. No Congestion, Mild Congestion, Moderate Congestion, and Severe Congestion). The results show that resistance values increased with increased congestion levels. However, resistance values of the groups of volunteers for the various congestion categories overlapped, and there were no statistically significant values differentiating no congestion and mild congestion or moderate congestion and severe congestion.

A middle aged female presented with symptoms of chronic cough, breathlessness, fatigue and weight loss of 4 months duration. Chest X-ray (CXR) was suggestive of bilateral upper lobe mass lesion with a differential diagnosis in favour of malignancy. Contrast enhanced computed tomography (CECT) chest showed collapse of right upper lobe and left upper lobe. Bronchoscopy showed thick gelatinous globular plugs occluding both upper lobes and guided biopsy showed granular necrotic debris and dense eosinophilic infiltrates. Her serum immunoglobulin-E (IgE) levels were very high (18,887 IU/ml) and Gomori Methenamine Silver staining was suggestive of Aspergillus sps. She was diagnosed to have Primary pulmonary aspergillosis and treated with itraconazole for 2 months. She responded very well and lung lesions cleared drastically on follow up.

Bronchiectasis in Chronic obstructive pulmonary disease (COPD) has been recognized as a potential new phenotype of COPD in recent years due to different clinical presentation, prognosis and treatment response. Broad application of CT scan significantly increased identification of bronchiectasis in COPDpatients. Although the exact mechanism of bronchiectasis development in COPD is lacking, the chronic airway inflammation, colonization of particular bacteria strain such as P. aeruginosa and continuous airway reconstruction may proceed to airway damage and following bronchiectasis. The significance of identifying bronchiectasis in COPD patients is to improve patients’ management through more individualized treatment regimen. Given the poor prognosis in COPD patients with bronchiectasis and limited evidenced based clinical experience, it is therefore essential to have high quality clinical trials conducted in this group of patients.

With early diagnosis of pulmonary tuberculosis and availability of effective antituberculosis chemotherapy, prevalence of laryngeal tuberculosis had decreased significantly. Because of similar clinical presentation and risk factors, laryngeal tuberculosis is often confused with laryngeal carcinoma and diagnosis was usually made while work-up for malignancy. Here we are presenting one such case of 55 years old male, initially suspected as laryngeal carcinoma was diagnosed to have secondary laryngeal tuberculosis.