Acute Respiratory Events Research Articles

Obstructive respiratory events and premature atrial contractions after cardioversion

Recurrence of atrial fibrillation (AF) after electrical cardioversion (ECV) is increased in patients with obstructive sleep apnoea (OSA). In patients with persistent AF, with (n=40) and without (n=32) obstructive respiratory events (OREs) during sedation for ECV, we determined the occurrence of premature atrial contractions (PACs) before and after insertion of a nasopharyngeal tube. The influence of acute obstructive respiratory events on atrial electrophysiology after termination of AF was studied in pigs. Incidence of PACs directly after ECV was higher in patients with OREs compared to those without OREs (7±2 versus 1±1 per 10 s, respectively; p<0.01). Occurrence of PACs could be reduced by 79% by insertion of a nasopharyngeal tube. In a subsequent sleeping study, patients with OREs had higher apnoea-hypopnoea indices and more PACs during night. 16 patient with and four patients without OREs had a relapse of AF during 1 week after ECV (p<0.01). In pigs, acute OREs after 30 min of AF increased occurrence of PACs and vulnerability for reinduction of AF, which could be attenuated by atropine, beta-blockers and renal denervation. OREs are associated with increased occurrence of PACs and more early relapse of AF. OREs increase occurrence of PACs and vulnerability for reinduction of AF by sympathovagal imbalance.

Long-acting muscarinic antagonist use in adults with asthma: real-life prescribing and outcomes of add-on therapy with tiotropium bromide.

BackgroundRandomized controlled trials indicate that addition of a long-acting muscarinic antagonist (LAMA) such as tiotropium may improve asthma control and reduce exacerbation risk in patients with poorly controlled asthma, but broader clinical studies are needed to investigate the effectiveness of LAMA in real-life asthma care.MethodsMedical records of adults with asthma (aged ≥18 years) prescribed tiotropium were obtained from the UK Optimum Patient Care Research Database for the period 2001–2013. Patients diagnosed with chronic obstructive pulmonary disease were excluded, but no other clinical exclusions were applied. Two primary outcomes were compared in the year before (baseline) and the year after (outcome) addition of tiotropium: exacerbations (asthma-related hospital emergency department attendance or inpatient admission, or acute oral corticosteroid course) and acute respiratory events (exacerbation or antibiotic prescription with lower respiratory consultation). Secondary outcomes included lung function test results and short-acting β2 agonist usage. The Wilcoxon signed-rank test was used for variables measured on the interval scale, the marginal homogeneity test for categorized variables, and the paired t-test for lung function indices.ResultsOf the 2,042 study patients, 83% were prescribed an inhaled corticosteroid and 68% a long-acting β2 agonist during the baseline year; 67% were prescribed both. Comparing baseline and outcome years, the percentage of patients having at least one exacerbation decreased from 37% to 27% (P<0.001) and the percentage having at least one acute respiratory event decreased from 58% to 47% (P<0.001). There were no significant changes in lung function, and usage of short-acting β2 agonists (in salbutamol/albuterol equivalents) increased from a median (interquartile range) of 274 (110, 548) to 329 (110, 603) μg/day (P=0.01).ConclusionIn this real-life asthma population, addition of LAMA therapy was associated with significant decreases in the incidence of exacerbations and antibiotic prescriptions for lower respiratory tract infections in the following year.

Comparative outcomes of peripheral nerve blocks versus general anesthesia for hip fractures in geriatric Chinese patients.

BackgroundGeriatric patients undergoing hemiarthroplasty for hip fractures have unacceptably high rates of postoperative complications and mortality. Whether anesthesia type can affect the outcomes has still been inconclusive.ObjectivesWe compared general anesthesia (GA) and peripheral nerve blocks (PNBs) on postoperative complications and mortality in elderly patients with femoral neck fractures (FNF) undergoing hemiarthroplasty.Materials and methodsThis retrospective study involved data collection from an electronic database. Two hundred and seventeen patients underwent hemiarthroplasty for FNF between January 2008 and December 2012 at the Chinese People’s Liberation Army General Hospital. Data on mortality within in-hospital, 30-day, and 1-year, complications, comorbidities, blood loss and transfusion, operative time, postoperative hospital length of stay, intensive care unit admission, and hospital charge were collected and analyzed. Univariate and multivariate Cox regression analyses of all variables were used for 30-day and 1-year mortality.ResultsSeventy-two patients receiving GA and 145 receiving PNBs were eventually submitted and analyzed. Mortality was 6.9%, 14.7%, and 23.5% at in-hospital, 30-day, and 1-year, respectively postoperatively, while mortality and cardiovascular complications did not differ between the two anesthetic techniques. Preoperative comorbidities and intraoperative parameters were not statistically different except that patients receiving GA were more likely to have dementia (χ2=10.45, P=0.001). The most common complications were acute cardiovascular events, electrolyte disturbances, and delirium. Postoperative acute respiratory events and hypoxemia both were also common, but no differences were found between groups (χ2=0.68, P=0.410; χ2=3.42, P=0.065, respectively). Key factors negatively influencing mortality included: age, male gender, American Society of Anesthesiologists status, dementia, perioperative cardiovascular events and respiratory events, postoperative stroke, myocardial infarction, and hypoxia.ConclusionMortality and postoperative complications are not statistically significantly different between PNBs and GA among eldery patients undergoing hemiarthroplasty for FNF.

Motilidad Espermática, Bronquiectasias y Sinusitis en el Diagnóstico de la Disquinesia Ciliar Primaria

0bjetivos: Valorar la relación entre inmovilidad espermática y antecedente de si-nusitis y bronquiectasias, con el fin de asociar una alteración ciliar común. Material y métodos: El estudio se llevó a cabo en 17 pacientes (promedio de edad 23 años) con diagnóstico de sinusitis y bronquiectasias, a quienes se les realizó un espermatograma para evaluar inmovilidad espermática. Resultados: 10 pacientes (58,83%) presentaron inmovilidad espermática, siendo uno de los casos diagnosticado de azoospermia. Estos pacientes presentaron mayores episodios de infecciones respiratorias, así como bronquiectasias difusas. Por otro lado, los pacientes con movilidad espermática conservada presentaron episodios agudos. Conclusiones: La inmovilidad ciliar de las vías respiratorias, que condiciona infecciones frecuentes, puede estar relacionada con la inmovilidad ciliar espermática, ya que los cilios del organismo son estructuralmente iguales.

Survey of postoperative residual curarization, acute respiratory events and approach of anesthesiologists

Background and objectivesresidual paralysis following the use of neuromuscular blocking drugs (NMBDs) without neuromuscular monitoring remains a clinical problem, even when NMBDs are used. This study surveys postoperative residual curarization and critical respiratory events in the recovery room, as well as the clinical approach to PORC of anesthesiologists in our institution. MethodsThis observational study included 415 patients who received general anesthesia with intermediate-acting NMBDs. Anesthesia was maintained by non-participating anesthesiologists who were blinded to the study. Neuromuscular monitoring was performed upon arrival in the recovery room. A CRE was defined as requiring airway support, peripheral oxygen saturation <90% and 90–93% despite receiving 3L/min nasal O2, respiratory rate >20breaths/min, accessory muscle usage, difficulty with swallowing or speaking, and requiring reintubation. The clinical approach of our anesthesiologists toward reversal agents was examined using an 8-question mini-survey shortly after the study. ResultsThe incidence of PORC was 43% (n=179) for TOFR <0.9, and 15% (n=61) for TOFR <0.7. The incidence of TOFR <0.9 was significantly higher in women, in those with ASA physical status 3, and with anesthesia of short duration (p<0.05). In addition, 66% (n=272) of the 415 patients arriving at the recovery room had received neostigmine. A TOFR <0.9 was found in 46% (n=126) of the patients receiving neostigmine. ConclusionsWhen routine objective neuromuscular monitoring is not available, PORC remains a clinical problem despite the use of NMBDs. The timing and optimal antagonism of the neuromuscular blockade, and routine objective neuromuscular monitoring is recommended to enhance patient safety.

Erratum to: Early postoperative prophylactic noninvasive ventilation after major lung resection in COPD patients: a randomized controlled trial

To investigate whether prophylactic postoperative NIV prevents respiratory complications following lung resection surgery in COPD patients. In seven thoracic surgery departments, 360 COPD patients undergoing lung resection surgery were randomly assigned to two groups: conventional postoperative treatment without (n = 179) or with (n = 181) prophylactic NIV, applied intermittently during 6 h per day for 48 h following surgery. The primary endpoint was the rate of acute respiratory events (ARE) at 30 days postoperatively (ITT analysis). Secondary endpoints were acute respiratory failure (ARF), intubation rate, mortality rate, infectious and non-infectious complications, and duration of ICU and hospital stay. ARE rates did not differ between the prophylactic NIV and control groups (57/181, 31.5 vs. 55/179, 30.7 %, p = 0.93). ARF rate was 18.8 % in the prophylactic NIV group and 24.5 % in controls (p = 0.20). Re-intubation rates were similar in the prophylactic NIV and control group [10/181 (5.5 %) and 13/179 (7.2 %), respectively, p = 0.53]. Mortality rates were 5 and 2.2 % in the control and prophylactic NIV groups, respectively (p = 0.16). Infectious and non-infectious complication rates, and duration of ICU and hospital stays were similar between groups. Prophylactic postoperative NIV did not reduce the rate of ARE in COPD patients undergoing lung resection surgery and did not influence other postoperative complications rates, mortality rates, and duration of ICU and hospital stay.

Early postoperative prophylactic noninvasive ventilation after major lung resection in COPD patients: a randomized controlled trial

To investigate whether prophylactic postoperative NIV prevents respiratory complications following lung resection surgery in COPD patients. In seven thoracic surgery departments, 360 COPD patients undergoing lung resection surgery were randomly assigned to two groups: conventional postoperative treatment without (n = 179) or with (n = 181) prophylactic NIV, applied intermittently during 6 h per day for 48 h following surgery. The primary endpoint was the rate of acute respiratory events (ARE) at 30 days postoperatively (ITT analysis). Secondary endpoints were acute respiratory failure (ARF), intubation rate, mortality rate, infectious and non-infectious complications, and duration of ICU and hospital stay. ARE rates did not differ between the prophylactic NIV and control groups (57/181, 31.5 vs. 55/179, 30.7%, p = 0.93). ARF rate was 18.8% in the prophylactic NIV group and 24.5% in controls (p = 0.20). Re-intubation rates were similar in the prophylactic NIV and control group [10/181 (5.5%) and 13/179 (7.2%), respectively, p = 0.53]. Mortality rates were 5 and 2.2% in the control and prophylactic NIV groups, respectively (p = 0.16). Infectious and non-infectious complication rates, and duration of ICU and hospital stays were similar between groups. Prophylactic postoperative NIV did not reduce the rate of ARE in COPD patients undergoing lung resection surgery and did not influence other postoperative complications rates, mortality rates, and duration of ICU and hospital stay.

Burden of respiratory viruses in patients with acute respiratory failure

Respiratory viruses (RVs) are ubiquitous pathogens that represent a major cause of community‐acquired pneumonia and chronic pulmonary diseases exacerbations. However, their contribution to acute respiratory failure events requiring intensive care unit admission in the era of rapid multiplex molecular assay deserves further evaluation. This study investigated the burden of viral infections in non immunocompromised patients admitted to the intensive care unit for acute respiratory failure using a multiplex molecular assay. Patients were investigated for RVs using immunofluoresence testing and a commercial multiplex molecular assay, and for bacteria using conventional culture. Half the patients (34/70, 49%) had a documented RVs infection. No other pathogen was found in 24 (71%) patients. Viral infection was detected more frequently in patients with obstructive respiratory diseases (64% vs. 29%; P = 0.0075). Multiplex molecular assay should be considered as an usefull diagnostic tool in patients admitted to the intensive care unit with acute respiratory failure, especially those with acute exacerbations of chronic obstructive pulmonary disease and asthma. J. Med. Virol. 86:1198–1202, 2014. © 2013 Wiley Periodicals, Inc.

Early Double Switch With Lecompte Maneuver for Life-Threatening Airway Obstruction

A 6-month-old boy with congenitally corrected transposition of the great arteries, ventricular septal defect, and mild pulmonary valve stenosis presented with acute obstructive respiratory life-threatening events. Airways obstruction was caused by aneurysmal dilation of the branch pulmonary arteries compressing the carina and bronchi. The child was ventilator dependent. A double switch operation with Lecompte maneuver was performed, bringing the pulmonary arteries forward and relieving the airway compression. The child made a complete recovery and remains well 9 months later with no clinical or radiologic signs of airway compression.

G193 The Role of Acute Respiratory Events in Child Deaths Due to Neurological Conditions and Congenital Anomalies

AimsTo determine the role of acute respiratory events mentioned on death certificates of children dying of a neurological condition or a congenital anomaly in the UK.MethodsData on causes of death,...

Predictors and Clinical Outcomes from Failed Laryngeal Mask Airway Unique™

Although the estimated risk of life-threatening adverse respiratory events during supraglottic airway device use is rare, the reported rate of events leading to failure of the airway device is 0.2-8%. Little is known about the risk-adjusted prediction of Laryngeal Mask Airway failure requiring rescue tracheal intubation and its impact on patient outcomes. All adult patients in whom a laryngeal mask airway (LMA Unique™, uLMA™; LMA North America, Inc., San Diego, CA) was used in ambulatory and nonambulatory anesthesia settings were included. The primary outcome was uLMA™ failure, defined as an airway event requiring uLMA™ removal and tracheal intubation. The secondary outcomes were the incidence of difficult mask ventilation and unplanned hospital admissions. Of the 15,795 cases included in our study, 170 (1.1%) experienced the primary outcome of uLMA™ failure. More than 60% of patients with uLMA™ failure experienced significant hypoxia, hypercapnia, or airway obstruction, whereas 42% presented with inadequate ventilation related to leak. Four independent risk factors for failed uLMA™ were identified: surgical table rotation, male sex, poor dentition, and increased body mass index. A 3-fold increased incidence of difficult mask ventilation was observed in patients with uLMA™ failure. Among outpatients with uLMA™ failure, 13.7% had unplanned hospital admission, 5.6% of whom needed intensive care for persistent hypoxemia. The study supports the use of the uLMA™ as an effective supraglottic airway device with a relatively low failure rate. However, there are clinically relevant consequences of uLMA™ failure, as evidenced by the high rate of acute respiratory events and need for unplanned hospital admissions.

Safety of indacaterol in the treatment of patients with COPD

PurposePooled data were analyzed to evaluate the safety and tolerability of indacaterol, a once-daily inhaled long-acting β2-agonist for chronic obstructive pulmonary disease (COPD).Patients and methodsData were pooled from clinical studies of 3–12 months’ duration in patients with moderate-to-severe COPD receiving double-blind indacaterol 75 μg (n = 449), 150 μg (n = 2611), 300 μg (n = 1157), or 600 μg once daily (n = 547); formoterol 12 μg twice daily (n = 556); salmeterol 50 μg twice daily (n = 895); placebo (n = 2012); or tiotropium 18 μg once daily, given open label or blinded (n = 1214). Outcomes were adverse events, serious adverse events and deaths, plasma potassium, blood glucose, and QTc interval and vital signs.ResultsThe commonest adverse events with indacaterol were COPD worsening, nasopharyngitis, and headache; most cases were mild or moderate and incidence was generally similar to placebo and other active treatments. The risk of acute respiratory serious adverse events (leading to hospitalization, intubation, or death) was not significantly increased with any of the active treatments compared with placebo. COPD exacerbation rates (analyzed in the intent-to-treat population) were significantly reduced with all active treatments versus placebo. Hazard ratios versus placebo for major cardiovascular adverse events were <1 for all indacaterol doses. Notable values for vital signs and measures of systemic β2-adrenoceptor activity were rare with indacaterol. The number of deaths adjusted per patient-year was lower with indacaterol (all doses combined) than with placebo (relative risk 0.21 [95% confidence interval 0.07–0.660], P = 0.008).ConclusionIndacaterol has a good profile of safety and tolerability that is appropriate for the maintenance treatment of patients with COPD.

Residual Neuromuscular Block

In this review, we summarize the clinical implications of residual neuromuscular block. Data suggest that residual neuromuscular block is a common complication in the postanesthesia care unit, with approximately 40% of patients exhibiting a train-of-four ratio <0.9. Volunteer studies have demonstrated that small degrees of residual paralysis (train-of-four ratios 0.7-0.9) are associated with impaired pharyngeal function and increased risk of aspiration, weakness of upper airway muscles and airway obstruction, attenuation of the hypoxic ventilatory response (approximately 30%), and unpleasant symptoms of muscle weakness. Clinical studies have also identified adverse postoperative events associated with intraoperative neuromuscular management. Large databased investigations have identified intraoperative use of muscle relaxants and residual neuromuscular block as important risk factors in anesthetic-related morbidity and mortality. Furthermore, observational and randomized clinical trials have demonstrated that incomplete neuromuscular recovery during the early postoperative period may result in acute respiratory events (hypoxemia and airway obstruction), unpleasant symptoms of muscle weakness, longer postanesthesia care unit stays, delays in tracheal extubation, and an increased risk of postoperative pulmonary complications. These recent data suggest that residual neuromuscular block is an important patient safety issue and that neuromuscular management affects postoperative outcomes.

The effects of allergens in outdoor air on both atopic and nonatopic subjects with airway disease

Reports on air pollution and asthma exacerbations have been inconsistent, although effects of airborne allergen can be spectacular. With no generalized test for allergen in air, it is not known how far allergen is responsible for nonepidemic exacerbations of the disease. Two hundred and ninety-seven patients using bronchodilators aged 18-64 years attending a London practice provided serum samples and were asked to report any acute respiratory events over the coming months. Small particles with a mean aerodynamic diameter <10 microm (PM(10)) were collected using a high volume sampler on the roof of the practice. The ability of airborne particles to bind IgE from the patients was compared for particles sampled on the weekend before their reported exacerbation with particles sampled on the weekend 2 weeks before or after. Exacerbations were associated with a 25% increase in IgE binding to particles collected on the previous weekend compared with the control weekends (95% confidence interval: 10-43%; P = 0.00089). This increase was not higher in patients with positive skin tests or in those sensitized to grass or tree pollens. Airborne allergen is an important cause of exacerbations even in those with 'intrinsic' asthma. It is important to identify the allergens responsible, as some of these may be controllable. Interpretation of associations of asthma exacerbations with other air pollutants is difficult in the light of these findings.

Empyema and pleural effusion in children

Pleural empyema (PE) is a serious complication of community-acquired pneumonia (CAP). To describe the clinical profile of hospitalized patients with PE in the pediatric ward of the Catholic University Hospital between 2000-2005. Retrospectively, all pediatric admission due to CAP and pleural effusion (86 children) were identified. In 59 (70%) children > 1 thoracocentesis were performed. We considered PE as the presence in the pleural effusion of pus, and/or a positive gram strain and/ or positive culture, and/or a pH < 7.10. Children with effusions not meeting any criteria were used as controls. Twenty four PE and 25 controls were identified, with a global mean age of 2.9 years (range: 8 months to 14.3 years); 78% were < 5 years, with a significant difference between PE and controls [1.6 vs 3.3 years (p = 0.01)]. The mean duration of symptoms in PE patients before admission was 7 days (range: 2-21), and the most frequent symptoms were fever (100%) and cough (96%). In 15/24 cases a microorganism was identified being Streptococcus pneumoniae (n = 9) the most common. In 48 patients management was conservative and in 4 surgical procedures were required. The mean duration of hospitalization was significantly higher in the PE group vs controls group: 15 (range: 5-38) vs 9 days (range 3-16) (p < 0.01). A chest tube was inserted in 83% of children with EP compared with 36% in the control group (p = 0.002). There were no difference in number of days of oxygen use [6 vs 4.5 (p = 0.36)] or number of chest tubes per child [3 vs 2.5 (p = 0.29)]. No deaths were reported. PE in children represented an acute respiratory event associated with more prolonged hospitalization especially at younger ages; the majority of cases did not require surgical intervention.

Five-year results of a non-randomised study evaluating spiral computed tomography (sCT) for early detection of lung cancer (LC)

7210 Background: In high-risk subjects low-dose sCT showed a 4-fold increase in the detection rate of neoplastic nodules in comparison with chest-X-ray. However, among studies there is a considerable discrepancy in the % of lung nodules, overall lung cancer and stage I detection rate as well as of the additional diagnostic work up. Subjects &amp; Methods: From April to December 2001, 520 asymptomatic volunteers aged ≥ 55 years with a history of cigarette smoking ≥ 20 packs-year and of no previous cancer received annually chest sCT for 5 consecutive years. Results: At baseline 73% were male, median age was 59 years and 91% current smokers. At baseline sCT 127 subjects (24.5%) had nodules &lt;5 mm while nodules ≥5 mm were detected in 114 (22%); the size of lung nodules ranged from 5 to 9.9 mm in 81.5% of the cases. The % of nodules worth of additional investigation varied over time (2 yr: 6%; 3 yr: 5%; 4 yr: 11%). Five (1%) cases of LC were detected during the 1st year (3 stage I) and in two additional resections an atypical adenomatous hyperplasia was found. Three new cases of thoracic cancers were detected in the 2nd, 3rd and 4th year of the study. Drop-out rate in the first year was 5% (2 yr 4,5%, 3 yr 2.3% and 4 yr 3%). One interval case was detected during the 3rd year. Subjects who quitted smoking in the 1st year were 13% and the % decreased over years (6% at the end of 3rd yr and 3% at 4th and 5th yr) and among quitters failure rate was 1–2%/year. In 3% of cases quitting was related to an acute cardiovascular or respiratory event. Fifty % of subjects showed some radiological signs of emphysema. Conclusions: Evidence from ongoing randomised trials is needed to support the routine use of sCT for early detection of LC. A program of smoking cessation is strongly recommended for further studies. Currently a conservative attitude should be encouraged. No significant financial relationships to disclose.

Does End‐tidal Carbon Dioxide Monitoring Detect Respiratory Events Prior to Current Sedation Monitoring Practices?

The value of ventilation monitoring with end-tidal carbon dioxide (ETCO2) to anticipate acute respiratory events during emergency department (ED) procedural sedation and analgesia (PSA) is unclear. The authors sought to determine if ETCO2 monitoring would reveal findings indicating an acute respiratory event earlier than indicated by current monitoring practices. The study included a prospective convenience sample of ED patients undergoing PSA. Clinicians performed ED PSA procedures with generally accepted patient monitoring, including oxygen saturation (SpO2), and clinical ventilation assessment. A study investigator recorded ETCO2 levels and respiratory events during each PSA procedure, with clinical providers blinded to ETCO(2) levels. Acute respiratory events were defined as SpO2 < or =92%, increases in the amount of supplemental oxygen provided, use of bag-valve mask or oral/nasal airway for ventilatory assistance, repositioning or airway alignment maneuvers, and use of physical or verbal means to stimulate patients with depressed ventilation or apnea, and reversal agent administration. Enrollment was stopped after independent review of 20 acute respiratory events in 60 patient sedation encounters (33%). Abnormal ETCO2 findings were documented in 36 patients (60%). Seventeen patients (85%) with acute respiratory events demonstrated ETCO2 findings indicative of hypoventilation or apnea during PSA. Abnormal ETCO2 findings were documented before changes in SpO2 or clinically observed hypoventilation in 14 patients (70%) with acute respiratory events. Abnormal ETCO2 findings were observed with many acute respiratory events. A majority of patients with acute respiratory events had ETCO2 abnormalities that occurred before oxygen desaturation or observed hypoventilation.

Ambient Woodsmoke and Associated Respiratory Emergency Department Visits in Spokane, Washington

Three multivariate receptor algorithms were applied to seven years of chemical speciation data to apportion fine particulate matter to various sources in Spokane, Washington. Source marker compounds were used to assess the associations between atmospheric concentration of these compounds and daily cardiac hospital admissions and/or respiratory emergency department visits. Total carbon and arsenic had high correlations with two different vegetative burning sources and were selected as vegetative burning markers, while zinc and silicon were selected as markers for the motor vehicle and airborne soil sources, respectively. The rate of respiratory emergency department visits increased 2% for a 3.0 microg/m3 interquartile range change in a vegetative burning source marker (1.023, 95% CI 1.009-1.038) at a lag of one day. The other source markers studied were not associated with the health outcomes investigated. Results suggest vegetative burning is associated with acute respiratory events.

Simulating Public Health Response to a Severe Acute Respiratory Syndrome (SARS) Event

In response to recent public health threats and disasters, greater emphasis has been placed on the use of exercises and drills to improve individual performance and enhance capacity of the public health workforce. However, despite the increased application of these exercises, rigorous research regarding their appropriate development and relative effectiveness in improving public health preparedness is limited. The present study attempted to fill this void by presenting a detailed account of a comprehensive and integrated approach to developing, implementing, and evaluating a tabletop exercise designed to enhance emergency preparedness and response of public health workers. Following a comprehensive training systems model, a tabletop exercise was developed to simulate worker recognition and response to a Severe Acute Respiratory Syndrome event among public health workers in Arkansas. Forty-nine individuals participated in the tabletop exercise, including public health workers and their external partners. Results demonstrated the effectiveness of this tabletop exercise in increasing participants' competency-related knowledge and skills. The flexibility afforded by creating a standardized competency-based process can extend to other state and local health departments and provides evidence of the reciprocal relationship between research and practice needed to advance the areas of emergency preparedness training and workforce development initiatives in public health.

Reducing airways inflammation to prevent exacerbations in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is amajor cause of handicap, mortality and health careexpenses (1). Altered quality of life (QOL) is a hallmarkof the disease, and relates mainly to dyspnoea andexacerbations: both QOL at steady-state and its rate ofdecline over time correlate to the frequency of acuterespiratory events (2, 3). In parallel, hospitalizations forexacerbations in the most severe patients are importantdeterminants of health care costs (4). Thus, preventingexacerbations is a major goal of care for COPD patients,both from an individual and collective point of view.Inflammation and COPD exacerbationsIn most cases, COPD occurs in smokers and ex-smokers,in whom airflow limitation is the consequence of variousdegrees of emphysema, chronic bronchiolitis and mucusplugging (5). These components of the disease have beenlinked to inflammatory and remodelling processes in theairways and lung parenchyma, involved inflammatorycells being mainly neutrophils, B and T lymphocytes andmacrophages (5, 6). Airways inflammation is moreintense during exacerbations, as shown by increases inthe levels of (i) expression of neutrophil elastase, CXCL-5, CXCL-8 and CXCR1/2 in biopsies (7), (ii) exhaledLTB4 and 8-isoprostane in breath condensates (8), (iii)interleukin (IL)-8 and tumour necrosis factor (TNF)-a insputum (9).Infections are a leading cause of exacerbations andfurther amplify airway inflammation (10). However,about one half of exacerbations occur in the absence ofany detectable infective pathogen, which may not preventinflammation from increasing (11). Besides, higher levelsof inflammatory markers in the airways of patients atsteady-state are also associated with more frequentexacerbations (12). Studies of the East London COPDcohort even suggest the existence of a particular subgroupof COPD patients called frequent exacerbators, whoconsistently have more than 2–3 exacerbations per year(13). In these patients, QOL is more altered, forcedexpiratory volume at 1 s (FEV