Acute Exacerbation Of Bronchiectasis Research Articles

Effect of sputum bacteriology on the prognosis of patients with acute exacerbations of bronchiectasis in the intensive care unit

OBJECTIVE: In bronchiectasis cases, isolation of the bacterial infection agent is related with disease severity. The purpose of the study was to find the impact of bacterial infections on the prognosis of bronchiectasis exacerbations in patients hospitalized in the Intensive Care Unit (ICU). MATERIALS AND METHODS: A retrospective, single-center, clinical study was performed on 48 patients who were diagnosed as having bronchiectasis exacerbation in the ICU. Sputum cultures of the patients were collected at the time of ICU admission. Clinical characteristics, treatment with noninvasive ventilation, IV requirement, and mortality were recorded. RESULTS: The bacteriologic sputum examination was positive in 24 patients. The bacteriologic analysis of sputum cultures revealed Pseudomonas aeruginosa in 12 patients, Streptococcus pneumoniae in 4, Haemophilus influenzae in 3, Acinetobacter baumannii in 3, and Escherichia coli in 2 patients. Seventeen patients needed IV during ICU follow-up, 7 of whom died. Bacterial proliferation in sputum culture was correlated to IV treatment need (P = 0.005). The radiologic disease extent was greater in patients with culture proliferation (P = 0.028). The patients who needed IV treatment had a greater radiologic disease extent (P = 0.007), pulmonary artery systolic pressure pulmonary arterial pressure (PAP) (P = 0.004), C-reactive protein (P = 0.014), and number of hospital admissions (P = 0.017). A multiple regression analysis for treatment success involving the variables of PAP, culture results, and radiologic disease extent revealed that bacterial proliferation was the most important factor for treatment success (odds ratio: 2.05; confidential interval: [0.87–3.23]; P = 0.04). CONCLUSION: Positive bacterial examination of sputum is the most important prognostic factor for patients with bronchiectasis exacerbation admitted to the ICU.

Effect of sputum bacteriology on the prognosis of patients with acute exacerbations of bronchiectasis in the intensive care unit

Effect of sputum bacteriology on the prognosis of patients with acute exacerbations of bronchiectasis in the intensive care unit

Positive expiratory pressure therapy versus other airway clearance techniques for bronchiectasis

People with bronchiectasis experience chronic cough and sputum production and require the prescription of airway clearance techniques (ACTs). A common type of ACT prescribed is positive expiratory pressure (PEP) therapy. A previous review has suggested that ACTs including PEP therapy are beneficial compared to no treatment in people with bronchiectasis. However, the efficacy of PEP therapy in a stable clinical state or during an acute exacerbation compared to other ACTs in bronchiectasis is unknown. The primary aim of this review was to determine the effects of PEP therapy compared with other ACTs on health-related quality of life (HRQOL), rate of acute exacerbations, and incidence of hospitalisation in individuals with stable or an acute exacerbation of bronchiectasis.Secondary aims included determining the effects of PEP therapy upon physiological outcomes and clinical signs and symptoms compared with other ACTs in individuals with stable or an acute exacerbation of bronchiectasis. We searched the Cochrane Airways Group Specialised Register of Trials, PEDro and clinical trials registries from inception to February 2017 and we handsearched relevant journals. Randomised controlled parallel and cross-over trials that compared PEP therapy versus other ACTs in participants with bronchiectasis. We used standard methodological procedures as outlined by Cochrane. Nine studies involving 213 participants met the inclusion criteria, of which seven were cross-over in design. All studies included adults with bronchiectasis, with eight including participants in a stable clinical state and one including participants experiencing an acute exacerbation. Eight studies used oscillatory PEP therapy, using either a Flutter or Acapella device and one study used Minimal PEP therapy. The comparison intervention differed between studies. The methodological quality of studies was poor, with cross-over studies including suboptimal or no washout period, and a lack of blinding of participants, therapists or personnel for outcome measure assessment in most studies. Clinical heterogeneity between studies limited meta-analysis.Daily use of oscillatory PEP therapy for four weeks was associated with improved general health according to the Short-Form 36 questionnaire compared to the active cycle of breathing technique (ACBT). When applied for three sessions over one week, minimal PEP therapy resulted in similar improvement in cough-related quality of life as autogenic drainage (AD) and L'expiration Lente Totale Glotte Ouverte en Decubitus Lateral (ELTGOL). Oscillatory PEP therapy twice daily for four weeks had similar effects on disease-specific HRQOL (MD -0.09, 95% CI -0.37 to 0.19; low-quality evidence). Data were not available to determine the incidence of hospitalisation or rate of exacerbation in clinically stable participants.Two studies of a single session comparison of oscillatory PEP therapy and gravity-assisted drainage (GAD) with ACBT had contrasting findings. One study found a similar sputum weight produced with both techniques (SMD 0.54g (-0.38 to 1.46; 20 participants); the other found greater sputum expectoration with GAD and ACBT (SMD 5.6 g (95% CI 2.91 to 8.29: 36 participants). There was no difference in sputum weight yielded between oscillatory PEP therapy and ACBT with GAD when applied daily for four weeks or during an acute exacerbation. Although a single session of oscillatory PEP therapy was associated with less sputum compared to AD (median difference 3.1 g (95% CI 1.5 to 4.8 g; one study, 31 participants), no difference between oscillatory PEP therapy and seated ACBT was evident. PEP therapy had a similar effect on dynamic and static measures of lung volumes and gas exchange as all other ACTs. A single session of oscillatory PEP therapy (Flutter) generated a similar level of fatigue as ACBT with GAD, but greater fatigue was noted with oscillatory PEP therapy compared to ACBT alone. The degree of breathlessness experienced with PEP therapy did not differ from other techniques. Among studies exploring adverse events, only one study reported nausea with use of oscillatory PEP therapy. PEP therapy appears to have similar effects on HRQOL, symptoms of breathlessness, sputum expectoration, and lung volumes compared to other ACTs when prescribed within a stable clinical state or during an acute exacerbation. The number of studies and the overall quality of the evidence were both low. In view of the chronic nature of bronchiectasis, additional information is needed to establish the long-term clinical effects of PEP therapy over other ACTs for outcomes that are important to people with bronchiectasis and on clinical parameters which impact on disease progression and patient morbidity in individuals with stable bronchiectasis. In addition, the role of PEP therapy during an acute exacerbation requires further exploration. This information is necessary to provide further guidance for prescription of PEP therapy for people with bronchiectasis.

Expression of serum interleukin-13 and significance of gene polymorphism on the patients with bronchiectasis in acute exacerbation period

Objective: To explore the expression of serum interleukin-13 (IL-13) and significance of its gene polymorphism on the patients with acute exacerbation of bronchiectasis in acute exacerbation period. Methods: Forty-three patients with bronchiectasis in acute exacerbation period admitted into the respiratory ward of Fujian Provincial Hospital from December, 2014 to March, 2016 were included as bronchiectasis group. Thirty-three healthy controls from normal people of health examination were included as control group during the corresponding period. A total of 5 ml fasting peripheral blood sample was extracted from each individual. The IL-13 levels were determined by enzyme-linked immunosorbent assay (ELISA). IL-13 gene polymorphisms in+ 1923 C/T site and+ 2044 site were genotyped in these two groups by using polymerase chain reaction (PCR) combined with gene sequencing methods. About 7 days after admission, thirty patients with improved condition among the 43 patients were included as bronchiectasis improvement group, all had the extraction of 3 ml peripheral blood for IL-13 detection determined by ELISA. The expression of serum IL-13 and gene polymorphisms between bronchiectasis group and control group were analyzed statistically. The changes of serum IL-13 between bronchiectasis group and bronchiectasis improvement group were also analyzed statistically. Results: The serum IL-13 level was lower in the bronchiectasis group in acute exacerbation period than that of the healthy controls [(31.1±26.3) vs (70.6±53.6) μg/L, P<0.05]. There was no significant difference of the genotype distribution in + 1923C/T site of IL-13 gene between the two groups (χ(2)=0.915, P>0.05). In the bronchiectasis group, the C and T allele frequencies at+ 1923 site of IL-13 gene were 79.1% and 20.9%, respectively, and its single nucleotide polymorphism (SNP) was in strong linkage disequilibrium with the SNP IL-13+ 2044G/A site (R(2)=0.835, P<0.001). There was no significant difference of the serum IL-13 between allele T_ groups and allele CC group, and also no significant difference between allele A_ groups and allele GG group (P>0.05). Conclusion: The IL-13 levels decreased specifically in the bronchiectasis group in acute exacerbation period, but IL-13+ 1923C/T and+ 2044G/A polymorphisms are not significantly related to the susceptibility of bronchiectasis.

Impact of Air Pollutants on Outpatient Visits for Acute Respiratory Outcomes.

The air pollution in China is a severe problem. The aim of our study was to investigate the impact of air pollutants on acute respiratory outcomes in outpatients. Outpatient data from 2 December 2013 to 1 December 2014 were collected, as well as air pollutant data including ozone (O3), nitrogen dioxide (NO2), carbon monoxide (CO), sulfur dioxide (SO2), and particulate matter (PM2.5 and PM10). We screened six categories of acute respiratory outcomes and analyzed their associations with different air pollutant exposures, including upper respiratory tract infection (URTI), acute bronchitis (AB), community-acquired pneumonia (CAP), acute exacerbation of chronic obstructive pulmonary disease (AECOPD), acute exacerbation of asthma (AE-asthma), and acute exacerbation of bronchiectasis (AEBX). A case-crossover design with a bidirectional control sampling approach was used for statistical analysis. A total of 57,144 patients were enrolled for analysis. PM2.5, PM10, NO2, SO2, and CO exposures were positively associated with outpatient visits for URTI, AB, CAP, and AEBX. PM10, SO2, and CO exposures were positively associated with outpatient visits for AECOPD. Exposure to O3 was positively associated with outpatient visits for AE-asthma, but negatively associated with outpatient visits for URTI, CAP, and AEBX. In conclusion, air pollutants had acute effects on outpatient visits for acute respiratory outcomes, with specific outcomes associated with specific pollutants.

Airway clearance techniques for bronchiectasis.

People with non-cystic fibrosis bronchiectasis commonly experience chronic cough and sputum production, features that may be associated with progressive decline in clinical and functional status. Airway clearance techniques (ACTs) are often prescribed to facilitate expectoration of sputum from the lungs, but the efficacy of these techniques in a stable clinical state or during an acute exacerbation of bronchiectasis is unclear. Primary: to determine effects of ACTs on rates of acute exacerbation, incidence of hospitalisation and health-related quality of life (HRQoL) in individuals with acute and stable bronchiectasis. Secondary: to determine whether:• ACTs are safe for individuals with acute and stable bronchiectasis; and• ACTs have beneficial effects on physiology and symptoms in individuals with acute and stable bronchiectasis. We searched the Cochrane Airways Group Specialised Register of trials from inception to November 2015 and PEDro in March 2015, and we handsearched relevant journals. Randomised controlled parallel and cross-over trials that compared an ACT versus no treatment, sham ACT or directed coughing in participants with bronchiectasis. We used standard methodological procedures as expected by The Cochrane Collaboration. Seven studies involving 105 participants met the inclusion criteria of this review, six of which were cross-over in design. Six studies included adults with stable bronchiectasis; the other study examined clinically stable children with bronchiectasis. Three studies provided single treatment sessions, two lasted 15 to 21 days and two were longer-term studies. Interventions varied; some control groups received a sham intervention and others were inactive. The methodological quality of these studies was variable, with most studies failing to use concealed allocation for group assignment and with absence of blinding of participants and personnel for outcome measure assessment. Heterogeneity between studies precluded inclusion of these data in the meta-analysis; the review is therefore narrative.One study including 20 adults that compared an airway oscillatory device versus no treatment found no significant difference in the number of exacerbations at 12 weeks (low-quality evidence). Data were not available for assessment of the impact of ACTs on time to exacerbation, duration or incidence of hospitalisation or total number of hospitalised days. The same study reported clinically significant improvements in HRQoL on both disease-specific and cough-related measures. The median difference in the change in total St George's Respiratory Questionnaire (SGRQ) score over three months in this study was 7.5 units (P value = 0.005 (Wilcoxon)). Treatment consisting of high-frequency chest wall oscillation (HFCWO) or a mix of ACTs prescribed for 15 days significantly improved HRQoL when compared with no treatment (low-quality evidence). Two studies reported mean increases in sputum expectoration with airway oscillatory devices in the short term of 8.4 mL (95% confidence interval (CI) 3.4 to 13.4 mL) and in the long term of 3 mL (P value = 0.02). HFCWO improved forced expiratory volume in one second (FEV1) by 156 mL and forced vital capacity (FVC) by 229.1 mL when applied for 15 days, but other types of ACTs showed no effect on dynamic lung volumes. Two studies reported a reduction in pulmonary hyperinflation among adults with non-positive expiratory pressure (PEP) ACTs (difference in functional residual capacity (FRC) of 19%, P value < 0.05; difference in total lung capacity (TLC) of 703 mL, P value = 0.02) and with airway oscillatory devices (difference in FRC of 30%, P value < 0.05) compared with no ACTs. Low-quality evidence suggests that ACTs (HFCWO, airway oscillatory devices or a mix of ACTs) reduce symptoms of breathlessness and cough and improve ease of sputum expectoration compared with no treatment (P value < 0.05). ACTs had no effect on gas exchange, and no studies reported effects of antibiotic usage. Among studies exploring airway oscillating devices, investigators reported no adverse events. ACTs appear to be safe for individuals (adults and children) with stable bronchiectasis and may account for improvements in sputum expectoration, selected measures of lung function, symptoms and HRQoL. The role of these techniques in acute exacerbation of bronchiectasis is unknown. In view of the chronic nature of bronchiectasis, additional data are needed to establish the short-term and long-term clinical value of ACTs for patient-important outcomes and for long-term clinical parameters that impact disease progression in individuals with stable bronchiectasis, allowing further guidance on prescription of specific ACTs for people with bronchiectasis.

Pulmonary function abnormalities in adult patients with acute exacerbation of bronchiectasis: A retrospective risk factor analysis.

Lung function impairments, especially airflow obstruction, are important features during acute exacerbation in patients with bronchiectasis. Recognition of the risk factors associated with airflow obstruction is important in the management of these exacerbations. The medical records of adult patients admitted to the Peking University People's Hospital, Beijing, China, from 2004 to 2011 with a diagnosis of bronchiectasis were reviewed retrospectively. Univariate and multivariate analyses were used to evaluate the risk factors associated with airflow obstruction. Airflow obstruction was found in 55.6% of 156 patients hospitalized with acute exacerbation of bronchiectasis, and the risk factors associated with airflow obstruction included young age (≤14 years old) at diagnosis (odds ratio (OR) = 3.454, 95% confidence interval (CI) 1.709-6.982, p = 0.001) as well as the presence of chronic obstructive pulmonary disease (COPD; OR = 14.677, 95% CI 5.696-37.819, p = 0.001), asthma (OR = 3.063, 95% CI 1.403-6.690, p = 0.005), and wheezing on auscultation (OR = 3.279, 95% CI 1.495-7.194, p = 0.003). The C-reactive protein (13.9 mg/dl vs. 6.89 mg/dl, p = 0.005), partial pressure of arterial oxygen (66.7 ± 8.57 mmHg vs. 89.56 ± 12.80 mmHg, p < 0.001), and partial pressure of arterial carbon dioxide (40.52 ± 2.77 mmHg vs. 42.87 ± 5.39 mmHg, p = 0.02) profiles were different between patients with or without airflow obstruction. In addition, patients colonized with potential pathogenic microorganisms had a decreased diffusing capacity (56.0% vs. 64.7%, p = 0.04). Abnormal pulmonary function was common in hospitalized patients with bronchiectasis exacerbations. Airflow obstruction was correlated with the patient's age at diagnosis, as well as the presence of combined COPD and asthma, and wheezing on auscultation, which also resulted in more severe systemic inflammation and hypoxemia.

Risk factors for acute exacerbation in patients with bronchiectasis

To evaluate the risk factors for patients with an acute exacerbation of bronchiectasis. Retrospective analyses were conducted for 228 patients diagnosed with acute exacerbation of bronchiectasis at Affiliated Beijing Anzhen Hospital, Capital Medical University from January 2008 to December 2012. Depending on whether there were recurrences with exacerbation within one year after discharge, they were divided into two groups. Their basic profiles, clinical symptoms and signs, blood tests, sputum culture, dyspnea score (mMRC) and imaging data were analyzed. There were 110 males and 118 females with an average age of (64.5+14.5) years. The incidence of the recurrence of acute exacerbation was 55.7% (127/228) within one year after discharge. Multivariate Logistic regression analysis showed that age ≥ 60 years (OR = 2.583, 95%CI: 1.188-5.613), body mass index (BMI)<18.5 kg/m(2) (OR = 2.991, 95%CI: 1.112-8.042), high dyspnea score (OR = 7.905, 95%CI: 2.288-27.309), Pseudomonas aeruginosa in sputum culture (OR = 3.227, 95%CI: 1.041-10.004), chest high-resolution computed tomography (CT) displayed bronchiectasis involving ≥ 3 lobes (OR = 3.179, 95%CI: 1.449-6.976) and staying in intensive care unit (ICU) (OR = 2.499, 95%CI: 1.301-4.801) were associated with the acute exacerbation of bronchiectasis (all P < 0.05). There are multiple risk factors of acute exacerbation in patients with bronchiectasis. And their proper identification and management shall improve the prognosis of bronchiectasis patients.

Morbidity and Risk Factors for Mortality in Patients With Acute Exacerbation of Bronchiectasis

Morbidity and Risk Factors for Mortality in Patients With Acute Exacerbation of Bronchiectasis

Socioeconomic deprivation, readmissions, mortality and acute exacerbations of bronchiectasis

Bronchiectasis is known to cause significant morbidity in children in New Zealand. Little is known of the disease in adults. Our objective was to characterise a cohort of adults who presented to hospital with acute exacerbations of the disease. We retrospectively collected information on all exacerbations treated as inpatients from a single hospital in South Auckland, New Zealand during 2002. We collected information on 307 exacerbations in 152 patients. Twenty-seven per cent were of Maaori ethnic origin, and 44% Pacific. Seventy per cent lived in areas categorised as the 20% most deprived in New Zealand. Comorbid conditions were present in 80% of patients - most commonly chronic obstructive pulmonary disease, asthma, diabetes and cardiac disease. Seventy (46%) patients had at least one readmission and 32 patients (21%) died within 12 months of admission to hospital. Greater deprivation was associated with increased mortality at 12 months after admission after adjusting for other factors (OR 11, 95% CI 2.0-61, P= 0.006). In the subgroup who underwent high-resolution computed tomographic scanning (93), increasing severity of bronchiectasis (modified Bhalla score) was associated with readmission within 12 months (P= 0.004), but not mortality (P= 0.419). We have shown that exacerbations of bronchiectasis in South Auckland are more common in patients who are predominantly of Maaori or Pacific descent and are socioeconomically deprived. Admission to hospital for an exacerbation is associated with high readmission and mortality rates.

Guidelines for the management of adult lower respiratory tract infections - Full version

This document is an update of Guidelines published in 2005 and now includes scientific publications through to May 2010. It provides evidence-based recommendations for the most common management questions occurring in routine clinical practice in the management of adult patients with LRTI. Topics include management outside hospital, management inside hospital (including community-acquired pneumonia (CAP), acute exacerbations of COPD (AECOPD), acute exacerbations of bronchiectasis) and prevention. Background sections and graded evidence tables are also included. The target audience for the Guideline is thus all those whose routine practice includes the management of adult LRTI.

Guidelines for the management of adult lower respiratory tract infections - Summary

This document is an update of Guidelines published in 2005 and now includes scientific publications through to May 2010. It provides evidence-based recommendations for the most common management questions occurring in routine clinical practice in the management of adult patients with LRTI. Topics include management outside hospital, management inside hospital (including community-acquired pneumonia (CAP), acute exacerbations of COPD (AECOPD), acute exacerbations of bronchiectasis) and prevention. The target audience for the Guideline is thus all those whose routine practice includes the management of adult LRTI.

First experience of using nebulized tobramycin in patients with acute exacerbation of bronchiectasis

First experience of using nebulized tobramycin in patients with acute exacerbation of bronchiectasis.

Predictors of mortality in hospitalized patients with acute exacerbation of bronchiectasis

In-hospital and long term outcomes of patients admitted to the hospital for acute exacerbation of bronchiectasis (AEB) has been evaluated in only a limited fashion. The resulting debilitation after an AEB can increase mortality. This study aims to evaluate the factors associated with mortality in patients admitted with an acute exacerbation of bronchiectasis (AEB). All charts of the patients admitted between 2003 and 2006 with an AEB were reviewed through an electronic database. Demographics, sputum cultures, pulmonary functions tests and other factors associated with long-term mortality were examined. The social security death index was used to determine long term mortality (http://ssdi.genealogy.rootsweb.com). Forty-three patients (13 men and 30 women) with a mean age of 71.8+/-11.8 were studied. The hospital mortality was 9% and one-year mortality was 30% with a median survival of 46.6 months. Variables associated with mortality were male gender (female vs. male (HR), 0.36; (CI), 0.14-0.98; p=0.045), use of systemic steroids (with vs. without steroids HR, 3.12; CI 1.08-9.02; p=0.036), decreased FEV(1.0)% predicted (HR, 0.96; CI 0.92-0.999; p=0.042), elevated creatinine (HR, 2.36; CI 1.093-5.10; p=0.029), history of smoking (HR, 0.283; CI 0.097-0.825; p=0.021), and mechanical ventilation (HR, 66.011; CI 6.64-656.76; p=0.0004). Male gender, elevated creatinine, decreased FEV(1.0)% predicted, mechanical ventilation, history of smoking, and acute use of systemic steroids during the hospitalization were associated with an increased risk of mortality.

The addition of inhaled tobramycin to ciprofloxacin improves microbiological outcome in patients with acute exacerbations of bronchiectasis

The addition of inhaled tobramycin to ciprofloxacin improves microbiological outcome in patients with acute exacerbations of bronchiectasis

Lack of clinical efficacy of rituximab in the treatment of autoimmune neutropenia and pure red cell aplasia: implications for their pathophysiology

We describe 11 patients with severe refractory autoimmune cytopenias treated with the anti-CD20 monoclonal antibody rituximab. Six patients had autoimmune neutropenia (AIN), two had pure red cell aplasia (PRCA), one had AIN and autoimmune haemolytic anaemia, one had AIN and immune thrombocytopaenia purpura (ITP) and one had PRCA and ITP. Rituximab was administered at a dose of 375 mg/m(2) as an intravenous infusion weekly for 4 weeks. Six of eight patients with AIN and all three patients with PRCA did not respond. Two patients died: one with resistant AIN and autoimmune haemolytic anaemia died of pneumocytis pneumonia infection, and one with PRCA and ITP died of an acute exacerbation of bronchiectasis. Rituximab in AIN and PRCA appears to be less effective than Campath-1H when compared to historical data from our group. This supports the hypothesis that T cells may be important in the pathophysiology of AIN and PRCA.

Effect of Treatment with Rituximab in Patients with Refractory Autoimmune Cytopenias.

The autoimmune cytopenias encompass the disorders of immune thrombocytopenia purpura (ITP), autoimmune haemolytic anaemia (AIHA), autoimmune neutropenia (AIN), pure red cell aplasia (PRCA) and various combinations of these conditions. We describe 34 patients with severe autoimmune cytopenias resistant to standard immunosuppression treated with the anti-CD20 monoclonal antibody Rituximab. 17 patients had ITP, 6 AIN, 2 AIHA, 2 PRCA, 4 AIHA and ITP (Evan's syndrome), 1 AIHA and AIN, 1 PRCA and ITP, and 1 AIN and ITP. 28 patients had primary autoimmune cytopenias and in 6 patients, the cytopenia was secondary to an underlying disorder (3 B-NHL, 1 T-NHL, 1 B-CLL and 1 SLE).Rituximab was administered intravenously at a dose of 375mg/m2 weekly for 4 weeks. 33 of 34 patients completed treatment. In one patient treatment was discontinued after 3 infusions due to a hypotensive syncopal episode. No other major infusion related side effects were observed. Responses were seen in 9/17 patients with ITP, 2/2 patients with AIHA and 4/4 patients with AIHA and ITP. Responses were sustained in 8/9 ITP patients with median follow up of 25.8months (range 4–66 months). We observed a complete response in 5 of 7 ITP patients who were previously splenectomised.In contrast, there was no response in 5/6 patients with AIN and in 3/3 patients with PRCA.In two patients we observed severe neutropenia at 3 months post Rituximab which was associated with fatal infection in both patients, namely pnemocystis pneumoniae infection and acute exacerbation of bronchiectasis. Apart from these 2 cases no other infections were seen.In conclusion, Rituximab appears to be a an alternative and safe option in the treatment of patients with ITP, AIHA and Evan's syndrome inducing sustained clinical remissions in patients who have failed to respond to conventional immunosuppression and/or splenectomy. In contrast Rituximab does not seem to be effective in AIN and PRCA and this may reflect a different pathogenesis for these conditions.

Bronchiectasis in northern lraq clinical and bacteriological characteristics during acute exacerbation

Context: Bronchiectasis is a relatively common disease in developing countries, The pathogens responsible for its acute exacerbations vary from one area to another. Objectives: To study the characteristics of patients with bronchiectasis in Northern lraq, and to identify the types of pathogens responsible for the acute exacerbations. Design: Case series study. Setting: Respiratory Care Unit and general medical wards in lbn-Sina Teaching Hospital in Mosul, during the years 2002-2004. Patients and Methods: Fifty patients with bronchiectasis (16 males and 34 females) presenting during an acute exacerbation underwent clinical and radiological evaluation with sputum Gram (Gm)stain and culture. Results: The cause of the disease was readily identifiable in 367o of patients. Tuberculosis was the predominant aetiology. Streptococcus pneumoniae and klebsiella pneumoniae were the commonest pathogens. Gm negative bacilli were responsible for 36% of cases overall, and were especially important in those with long standing disease (≥15 years) Pseudomonas aeruginosa was related to more extensive disease. Most of the isolates were sensitive to ciprofloxacin and cefotaxime. conclusion: Gm negative bacilli should be considered in antibiotic selection during acute exacerbation of bronchiectasis, especially in long standing and extensive disease. Keywords: bronchiectasis, Gram negative bacilli

Postural Drainage or Flutter® Device in Conjunction with Breathing and Coughing Compared to Breathing and Coughing Alone in Improving Secretion Removal and Lung Function in Patients with Acute Exacerbation of Bronchiectasis: A Pilot Study

Maximizing normal coughing, the single best means for clearing pulmonary secretions and protecting the lung, is a primary focus of physiotherapy in patients with impaired mucociliary clearance. In busy Hong Kong hospitals, patients are often encouraged to use breathing and coughing (BC) manoeuvres, in conjunction with other techniques such as postural drainage (PD) and the use of the Flutter(r) device (FL), as self-treatment to mobilize secretions. This pilot study examined whether the effects of PD and FL on secretion clearance and lung function indices in patients with acute exacerbations of bronchiectasis were greater than that of BC alone. Fifteen patients admitted with bronchiectasis were randomly allocated to three groups: PD+BC, FL+BC and BC alone. Treatment was applied for 15 minutes daily in all groups, until the day of discharge. Variables measured included wet weight sputum production (during the 15-minute treatment time, during the subsequent 15-minute post-treatment period, and over 24 hours), forced vital capacity, forced expiratory volume in 1 second, and peak expiratory flow rate. Variables were recorded on Days 2 and 4 after admission and on the day of discharge. Patients were asked to allocate subjective ease and effectiveness scores for their treatment method. There was no difference in sputum production or lung function parameters among the three groups at any of the measurement points. Patients reported that all techniques were equally easy to use, but FL was perceived as being the most effective in clearing secretions. PD and FL do not appear to facilitate secretion removal beyond that achieved by BC alone.

Effect of antibiotics on sputum inflammatory contents in acute exacerbations of bronchiectasis

We studied the changes in sputum neutrophil chemotactic activity (NCA) and elastolytic activity (EA) in acute exacerbations of bronchiectasis before and after treatment with oral antibiotics. Twelve patients who chronically produced sputum were assessed in the stable state, and when they subsequently developed symptoms of acute exacerbations, prior to initiation of antibiotics, during 2 weeks of antibiotics, and at 2 and 6 weeks after stopping antibiotics. NCA was measured using modified Boyden's technique with multiwell chemotaxis chamber, and EA with N-succiny-trialanine- p-nitroanilide as elastase substrate. All 12 patients had NCA (49·3 ± 8·69% FMLP response) and EA (50·5 ± 17·1 mU per 100 μl) in their sputum in the stable state. At acute exacerbation, there was significant increase in NCA ( P < 0·001) and EA ( P < 0·05). All responded clinically after 1 week of antibiotics, and this was associated with a decrease in NCA and EA back to the levels in stable state. A further week of antibiotics did not result in further decline of NCA or EA. Three patients had another acute exacerbation clinically between 2–6 weeks after stopping antibiotics and their NCA and EA rose again. In the other nine patients, both NCA and EA at 2 and 6 weeks post-treatment were similar to pre-exacerbation levels. Our findings suggest that short course antibiotics effectively control the upsurge in inflammatory activity in acute axacerbations, but has little effect on chronic airway inflammation. This would challenge the validity of such a treatment strategy which is still the most common in clinical practice, when persistent airway inflammation is believed to lead to progressive lung destruction.