Aggravation Of Dyspnea Research Articles

Resolution of daytime and night-time respiratory symptoms but persistent sleep apnea in severe asthma with the add-on of benralizumab.

IntroductionThe relationship between asthma and obstructive sleep apnea (OSA) is a widely debated topic in the scientific literature with the controversy surrounding the bi-directional nature of the correlation.Case presentationWe report the case of a 59-year-old male being affected by severe allergic eosinophilic asthma and severe OSA (apnea-hypopnea index [AHI] 32 ev·hr-1). Due to a clinical worsening of asthma (aggravation of dyspnea, chest constriction and night-time respiratory symptoms), despite the optimal therapy for asthma and recurrent administration of systemic corticosteroids, we have added-on treatment with benralizumab (monoclonal anti-interleukin 5 antibody). After eight months, the patient reported an improvement in asthma control (asthma control test [ACT]= 25 points), in pulmonary function and a good control of nocturnal symptoms of both diseases (i.e., wheezing, snoring, etc.). Then, the follow up polysomnography (PSG) was performed resulting in a high reduction of OSA severity (~18% AHI) even if obstructive events persisted and almost resolution of nocturnal hypoxemia. So, a trial with positive airway pressure (PAP) was proposed to the patient, who declined.ConclusionsIn consideration of our experience, we suggest that the nocturnal profile of patients with severe asthma should be always studied by a sleep investigation to prevent the negative effects of interaction with OSA. However, further studies on larger samples are needed to better understand the pathophysiological mechanisms underlying the beneficial effects of benralizumab on obstructive events during sleep.

Serum Procalcitonin in Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide. One of the most important events in the course of COPD is acute exacerbation. Acute exacerbation of COPD (AECOPD) is characterized by the aggravation of dyspnea, cough, and sputum. Chronic obstructive pulmonary disease exacerbation leads to respiratory failure, hospitalization, morbidity, and mortality. During and after the COPD attack, lung function dramatically decreased. Bacterial pneumonia is an important and serious risk factor for AECOPD. However, there are other inflammatory and non-inflammatory causes of AECOPD. Antibiotic treatment is usually challenging in AECOPD. Procalcitonin is a non-hormone active protein and precursor to calcitonin that consists of 116 amino acids, and 13 kDa weight is produced by the neuroendocrine cells of the thyroid gland. However, procalcitonin is secreted in septic shock, metastatic cancers, bacterial and fungal infections; therefore, serum procalcitonin is increased in bacterial pneumonia of AECOPD. Some studies recommended procalcitonin serum measurement as a guide for antibiotic initiation in AECOPD.

031. Amiodarone induced pulmonary toxicity (APT).

Male patient aged 68 was transferred to ED due to aggravation of dyspnea that started 10 days before. According to the medical history, he is a coronary patient and an active smoker (40 p/y) who was subject to Coronary artery bypass surgery (CABG) 12 months ago. His medication has included since one year acetylsalicylic acid (100 mg), clopidogrel (75 mg) and amiodarone (200 mg) on a daily basis. The clinical examination detected crackles on both lungs, desaturation (sat 78%, FiO2: 21%), pH: 7.42, pCO2=34.6 mmHg, pO2=45.6 mmHg, HCO3−: 23 mmol/L, bilateral diffuse infiltrates on the chest X-ray and restrictive pattern on PFTs (FVC: 67%, FEV1: 71%, FEV1%: 86.8%, DLCO: 59%). The patient was afebrile with negative markers of infection and we decided immediate discontinuation of amiodarone. The chest HRCT showed patchy loci of organizing pneumonia, traction bronchiectases and extended interstitial fibrosis, imaging compatible with NSIP. Bronchoscopy with BAL revealed a high percentage of lymphocytes (52%), specifically T cytotoxic lymphocytes (CD3+,CD8+), a relatively large percentage of neutrophils (48%) and a very low (0.23) TH/TC ratio in BAL, almost seven times lower than the blood ratio (1.56). We prescribed Oxygen therapy (LTOT) until follow up 20 days later. At follow up there was clear improvement in SpO2, infiltrates and clinical symptoms. The APT is severe and potentially life-threatening while the percentages of incidence ranging between 5% and 13%. Risk factors include a daily dose >400 mg, treatment longer than two months, age over 60 years, antecedent lung disease or surgery and prior angiographic investigations. The most common clinical presentation of chronic APT is a subacute illness characterized by progressive dyspnea on exertion, nonproductive cough and occasionally malaise, weight loss and low-grade fever. HRCT findings include ground glass opacities, interstitial, alveolar or mixed infiltrates, lung nodules or ‘masses’ and pleural thickening. Pulmonary function tests usually reveal low volumes and a restrictive pattern, with a reduction in DLCO of 15-20%. Classic findings on histopathological examination of lung tissues are: foamy macrophages, reactive type II pneumocytes, and endothelial cells with cytoplasmic lamellar inclusions containing phospholipids. Regarding the treatment, if disease extent is limited, discontinuation of amiodarone may be sufficient. Corticosteroids should be given to patients who show substantial involvement on imaging or hypoxemia. Mortality is approximately 10% for those who develop pneumonitis, 20-30% for those admitted to hospital, and 50% for those who develop ARDS.

Exacerbations in Idiopathic Pulmonary Fibrosis Triggered by Pulmonary and Nonpulmonary Surgery: A Case Series and Comprehensive Review of the Literature

Acute exacerbations (AE) of idiopathic pulmonary fibrosis (IPF) are well recognized in the progression of this uniformly fatal disease. Surgical lung biopsy and lung resection may initiate these acute events leading to a rapid deterioration and permanent decline in lung function. Our aim is to discuss the role of pulmonary and nonpulmonary surgery as a precipitating factor and to review the literature on the nature, course, and outcomes of acute exacerbations in the context of surgical interventions. This study consisted of a retrospective case series of patients at the Johns Hopkins Hospital who experienced acute exacerbation following a surgical procedure. Patients included in the case series suffered from aggravation of dyspnea within 1 month after surgical intervention, with new infiltrates on imaging. There was no other more likely cause after diagnostic evaluation. A comprehensive review of the current literature pertaining to AEs of IPF in the context of a surgical intervention was performed. In a series of four patients from Johns Hopkins Hospital with AE in IPF, two of three patients who underwent video-assisted thoracoscopic surgery (VATS) lung biopsy had a fatal outcome. The fourth patient survived an AE after a total knee replacement but had a fatal outcome after a subsequent coronary artery bypass graft surgery. We found no report in the literature of AE in an IPF patient who underwent nonpulmonary surgery. Acute exacerbations of IPF can occur postoperatively after both pulmonary and nonpulmonary surgery and are associated with a high mortality rate. As a next step, a prospective multicenter clinical study of patients with IPF undergoing both pulmonary and nonpulmonary surgeries would allow the identification of perioperative risk factors in the development of AE of IPF.

Four Cases of Mumps with Laryngeal Edema

Mumps virus infections primarily involve the parotid glands and most frequently affect school-aged children. Mumps has many complications, such as meningitis, but laryngeal edema is not a common one. We present four cases of mumps with laryngeal edema. The patients were a 39-year-old male, 23-year-old female, 29-year-old female and 31-year-old female. They came to our hospital complaining of submandibular and subaural regional swelling and dyspnea. In every case, fiberscopic findings revealed edema of the arytenoid. Laboratory examination showed normal WBC, slightly high CRP and high serum amylase. Their mumps titers were positive for immunoglobulin M and G. The patients were admitted to our hospital and were started on intravenous steroids. In one case, because of progressive dyspnea, a tracheotomy was needed. All symptoms of laryngeal edema improved within 3 days. In previous reports in the literature, there were four cases of mumps with laryngeal edema which required a tracheotomy because of aggravation of dyspnea. If a patient with mumps complains of dyspnea, examination of the respiratory airway is important.

An approach to mitral valve surgery by a T-shaped mini-sternotomy with functioning bilateral internal thoracic artery grafts

We herein report successful surgical treatment of mitral valve regurgitation in a 49-year-old man. He was admitted to our hospital due to acute aggravation of dyspnea on effort. He had a surgical history of coronary artery bypass grafting with bilateral internal thoracic artery grafts. A transthoracic echocardiogram showed severely decreased cardiac function and severe mitral regurgitation due to anterolateral mitral valve leaflet prolapse. Computed tomography showed the right internal thoracic artery running over the front of the aorta to the left circumflex artery. To avoid injury to the functioning grafts during median sternotomy, we chose to perform an inferior T-shaped mini-sternotomy. The surgical field was sufficient to perform mitral valve replacement with a mechanical prosthetic valve under fibrillatory arrest. The grafts were neither dissected nor clamped, and access to the aorta and mitral valve was excellent.

Aggravation of dyspnea in stage I non-small cell lung cancer patients following stereotactic body radiotherapy: Is there a dose-volume dependency?

In SBRT for NSCLC, highly potent radiation doses are delivered to patients with frequent pre-irradiatory compromise of pulmonary function. For the risk of pulmonary toxicity to be minimized during SBRT planning, data on its dose-volume dependency is needed. In the present study, we analyse the association of dose-volume histogram parameters with changes in dyspnea. The study concerns 28 medically inoperable stage I NSCLC patients that received SBRT at our department between 2000 and 2003. A central dose of 45 Gy/3 fractions was delivered in 5–8 days. WHO toxicity scoring of dyspnea was prospectively performed at baseline and during a 6-month follow-up post-SBRT. DVH parameters for pulmonary tissue were retrieved from the 3-D dose distributions.Aggravated dyspnea was registered in 11 patients (40%). We found no association between DVH parameters and changes in dyspnea. Nor did we find any consistent temporal variations of dyspnea after SBRT. We identified COPD as the factor showing the closest association with aggravation of dyspnea. The observed aggravation of dyspnea following SBRT reflects habitual exacerbations of COPD rather than treatment-related toxicity. Concern about pulmonary toxicity should not be prohibitive for future studies targeting limitations to dose and volume.

Clinical Experience of Photodynamic Therapy in Five Patients with Advanced Lung Cancer

Background : A tracheobronchial obstruction in lung cancer is associated with significant morbidity and mortality due to dyspnea, cough, hemoptysis, and recurrent respiratory infection. It is well known that one of standard treatments is photodynamic therapy (PDT) in tracheobronchial obstruction after radiotherapy, chemotherapy, and/or surgery. We reported here the role of PDT in airway obstruction in patients advanced lung cancer. Method : Pre-treatment protocol consisted of clinical, radiologic, and bronchoscopic examination, pulmonary function test, and assessment of Karnofsky performance status. A 2 mg/kg of porfimer sodium was injected intravenously, and then followed by cylindrical and/or interstitial irradiation with 630 nm of laser after 48 hours. The repeated bronchoscopy for debridement of necrotic tissue and re-illumination was performed after 48 hours. Result : Improved airway obstruction and selective tumor necrosis were achieved by photodynamic therapy in all cases. Dyspnea and performance status were improved in three cases. A purulent sputum, fever and hemoptysis were improved in one of five cases. After PDT, all patients showed temporarily aggravation of dyspnea, two of five showed febrile reaction for a few days and nobody presented photosensitivity reaction, hemoptysis and respiratory failure. Conclusion : Our experiences of PDT are effective in palliation of inoperable advanced lung cancer in terms of tracheobronchial obstruction. (Tuberc Respir Dis 2004; 57:72-77)