American Thoracic Society Criteria Research Articles

Clinical, Radiological, and Microbiological Characteristics of Mycobacterium simiae Infection in 97 Patients.

Mycobacterium simiae is a rare species of slow-growing nontuberculous mycobacteria (NTM). From 2002 to 2017, we conducted a retrospective study that included all patients with NTM-positive respiratory samples detected in two university hospitals of the French overseas department of Reunion Island. We recorded the prevalence of M. simiae in this cohort, as well as the clinical, radiological, and microbiological features of patients with at least 1 sample positive for M. simiae In our cohort, 97 patients (15.1%) were positive for M. simiae Twenty-one patients (21.6%) met the American Thoracic Society (ATS) criteria for infection. M. simiae infection was associated with bronchiectasis, micronodular lesions, and weight loss. Antibiotic susceptibility testing was performed for 60 patients, and the isolates were found to have low susceptibility to antibiotics, except for amikacin, fluoroquinolones, and clarithromycin. Treatment failed for 4 of the 8 patients treated for M. simiae infection. Here, we describe a specific cluster corresponding to a large cohort of patients with M. simiae, a rare nontuberculous mycobacterium associated with low pathogenicity and poor susceptibility to antibiotics.

Exposure to cooking oil fumes and chronic bronchitis in nonsmoking women aged 40\xa0years and over: a health-care based study

BackgroundLittle is known about the effect of exposure to cooking oil fumes (COFs) on the development of non-malignant respiratory diseases in nonsmoking women. This study investigated the relationship between exposure to COFs and chronic bronchitis in female Taiwanese non-smokers.MethodsSearching the 1999 claims and registration records maintained by Taiwan’s National Health Insurance Program, we identified 1846 women aged 40 years or older diagnosed as having chronic bronchitis (ICD-9 code: 491) at least twice in 1999 as potential study cases and 4624 women who had no diagnosis of chronic bronchitis the same year as potential study controls. We visited randomly selected women from each group in their homes, interviewed to collect related data including cooking habits and kitchen characteristics, and them a spirometry to collect FEV1 and FVC data between 2000 and 2009.ResultsAfter the exclusion of thirty smokers, the women were classified those with chronic bronchitis (n = 53), probable chronic bronchitis (n = 285), and no pulmonary disease (n = 306) based on physician diagnosis and American Thoracic Society criteria. Women who had cooked ≥ 21 times per week between the ages of 20 and 40 years old had a 4.73-fold higher risk of chronic bronchitis than those cooking < 14 times per week (95% CI = 1.65–13.53). Perceived kitchen smokiness was significantly associated with decreased FEV1 (− 137 ml, p = 0.021) and FEV1/FVC ratio (− 7.67%, p = 0.008).ConclusionsExposure to COF may exacerbate the progression of chronic bronchitis in nonsmoking women.

Early Life Arsenic Exposure and Non-Malignant Respiratory Illnesses among Adolescents in Rural Bangladesh

Background/Aim: Evidence suggests that exposure to arsenic through drinking water increases the risk of non-malignant respiratory illnesses including impairment of lung function in adults. However, early life arsenic exposure and subsequent respiratory system effects in adolescents have not been reported so far. Methods: The study was conducted in rural Bangladesh, Matlab. A cohort of 200 children now aged 11-22 years were enrolled of which 107 had in utero and early childhood (first five years) exposure to drinking water arsenic concentration over 400µg/L (exposed group) and 93 had less than 10 µg/L (unexposed group). Histories of respiratory symptoms were collected through a validated structured questionnaire (ISAAC). Lung function (FEV1, FVC) was tested by EasyOne spirometry following the standard American Thoracic Society criteria. Water arsenic concentrations were measured by hydride generation atomic absorption spectrophotometry. Results: The mean age was 15 years. Chronic respiratory symptoms were evident in male participants in the exposed group. In an adjusted model, boys with in early life arsenic exposure (&gt;400 µg/L) were more likely to report wheezing attacks 1-3 times/week (Prevalence Odds Ratio (POR): 4.99, 95% Confidence Interval (CI): 1.00-24.9), wheezing after exercise (POR: 4.14, 95% CI: 1.05-16.4) and waking up with chest tightness (POR: 5.01, 95% CI: 1.00-25.0). Decrease in FEV1 (-117.3 ml, CI: -246.5, 11.8) and FVC (-135.2 ml, CI: -269.9, -0.37) were observed in male respondents in the exposed group compared to the unexposed. No respiratory impairment was observed among exposed girls. Conclusions: High exposure to arsenic in utero and early childhood may result in increased risk of chronic respiratory symptoms and decrements in lung function in adolescent males. We plan to follow this unique cohort further to see if early life arsenic exposure respiratory effects persist in males as they grow older, and remain absent in females.

Relationships between respiratory parameters, exercise capacity and psychosocial factors in people with chronic obstructive pulmonary disease

BackgroundChronic obstructive pulmonary disease (COPD) affects respiratory functioning and psychosocial factors. However, little is known about perceived ability of people with COPD to engage in a regular exercise program. This study assessed respiratory parameters, exercise capacity, psychosocial factors and their relations in people with COPD. MethodsThis cross-sectional study involved patients with COPD recruited from a Nigerian university teaching hospital. Respiratory parameters including forced expiratory volume in 1sec (FEV1) and forced vital capacity (FVC) were assessed by using a spirometer and FEV1/FVC ratio was calculated. Participants were sitting upright in a comfortable chair and wearing a nose clip for measurements. The procedure was performed in accordance with the American Thoracic Society criteria. Exercise capacity was assessed by the 6-min walk test (6MWT). Gait speed was assessed by the distance covered in 6min. Perceived exercise self-efficacy (PESE) and rating of perceived exertion (RPE) were assessed by exercise self-efficacy and Borg scales, respectively. Data were analysed using descriptive and inferential statistics. Alpha level was set at P<0.05. ResultsThe mean age of the 125 participants was 62.0±7.1years (60% male). The mean values for FEV1, FVC and FEV1/FVC were 1.8±0.6L, 2.4±0.5L and 58.0±8.8%, respectively, and the mean 6MWT and PESE values were 291.1±41.6m 63.1±11.2%. Exercise capacity was correlated with mean values for the respiratory parameters FEV1 (r=0.29; P=0.035), FVC (r=0.32; P=0.045) and FEV1/FVC ratio (r=0.37; P=0.007), and both exercise capacity and PESE were correlated with gait speed (r=0.96, P=0.001 and r=0.57; P=0.042) and RPE (r=0.42, P=0.050 and r=−0.44; P=0.032), but PESE was not correlated with respiratory parameter values (P>0.05). ConclusionParticipants with COPD demonstrated reduced respiratory parameter values and low exercise capacity but moderate PESE. We found significant correlations between exercise capacity and respiratory parameter values, but PESE was correlated with only gait speed and RPE. The study has implications for respiratory health promotion and exercise adherence.

Study of pulmonary function test in asymptomatic smokers and non-smokers between 30-50 years of age in a tertiary care hospital

Background: Tobacco smoking is widely prevalent all over the world and it continues to rise in developing countries. Smoking has a deleterious effect on pulmonary functions. Smoking is the single most significant risk factor contributing to the development of Chronic obstructive airway diseases (COPD). Spirometry by a trained health professional gives an indication of lung health by measuring airway abnormality. Objectives were to study pulmonary function test (PFT) in smokers and non-smokers between 30-50 years and to study the correlation of PFT with pack years.Methods: Apparently healthy subjects, 50 smokers and 50 non-smokers between 30-50 years without any symptoms were included as subjects. Patients with uncontrolled hypertension, recent myocardial infarction and pulmonary TB were excluded. Ex-smokers were excluded from the study. Patients with acute respiratory illness, severe systemic illness, chest trauma and dementia were also excluded. After proper history taking and clinical examination, measuring height and weight (vitals, pulse rate, respiratory rate, blood pressure) the selected individual was subjected to spirometry using ATS criteria (American Thoracic Society criteria). Spirometry was performed using UNI-EM spirometer. Collected data was analyzed using Statistical Package for the Social Service (SPSS) software version 17.Results: In this study 94 males and 6 females were enrolled as subjects. Maximum number of the patient 49 cases (49%) presented in the age group of 30-35 years, followed by 23 cases (23%) in 36-40 years age group. Of these 49 cases,15 were smokers while the rest 34 were non-smokers (P=0.0007). In 100 cases studied, 39% showed normal PFT and 61% shows abnormal PFT. Among smokers (out of total 50 cases) pulmonary function test (PFT) was abnormal in 36 cases (72%) while in non-smokers, 25 (50%) had abnormal PFT (P-value-0.024). This data indicates that smoking is highly associated with an abnormal PFT pattern. Out of 100 cases both smokers and non-smokers, 11 (73.33%) underweight cases with (BMI&lt;18.4) showed abnormal PFT. In 50 smokers, maximum cases 29 (58%) had normal BMI (18.5-22.9) (P value 0.0002). Abnormal PFT was observed in 25 (50%) non-smokers (P=0.001). Abnormal PFT was seen in 30 (69.77%) smokers with pack years &lt;15 and 6 smokers (85.6%) with pack years &gt;15 (P-value 0.383).Conclusions: Smoking is common in males between 30-35 years age group. Smoking is highly associated with an abnormal PFT. Cessation of smoking should be encouraged and PFTs from time to time in asymptomatic adults both smokers and non-smokers will be useful for early identification of abnormalities.

Species-Specific Risk Factors, Treatment Decisions, and Clinical Outcomes for Laboratory Isolates of Less Common Nontuberculous Mycobacteria in Washington State.

Nontuberculous mycobacteria (NTM) are a diverse group of environmental organisms that infrequently cause human disease. Understanding of the epidemiologic and clinical characteristics associated with NTM disease is needed to refine diagnostic and treatment strategies, particularly among the less commonly isolated species. To improve knowledge of geographic variance of NTM species, to correlate detailed clinical information with isolation of specific NTM, and to examine the decision to treat and outcomes for specific NTM. Mycobacterial cultures submitted to the University of Washington mycobacterial laboratory from 1998 to 2011 were examined. We report isolation frequency and demographic information from all samples with clinical variables. We also examined treatment decisions and outcomes in a subset of patients with Mycobacterium abscessus complex, Mycobacterium chelonae, Mycobacterium fortuitum, Mycobacterium gordonae, Mycobacterium kansasii, Mycobacterium lentiflavum, Mycobacterium porcinum, and Mycobacterium xenopi. Cultures of NTM were available from 3,470 patients, 937 of whom had clinical data available. When we compared patients born within or outside Washington State, we found that the mycobacterial species frequency varied. Among 168 patients with one of the studied environmental mycobacteria, 72% had major comorbid conditions. Bronchiectasis was common among patients with pulmonary isolation of any NTM, including those with nonpathogenic M. gordonae. Although mortality was high (37%), few deaths were directly attributable to mycobacterial infection. Among 56 patients who met American Thoracic Society criteria for NTM lung disease, 22 were treated, and 19 of those had M. abscessus complex and M. kansasii. The treatment regimens used tended to follow published guidelines. Isolation of NTM varied by geographic region of origin and location within Washington State. Several clinical risk factors were specific to individual species. Comorbid conditions were common in patients with and without mycobacterial disease. Among patients with one of the studied organisms, there was a high mortality rate more frequently related to comorbid conditions than to mycobacterial disease.

Refraining from smoking shortly before lobectomy has no influence on the risk of pulmonary complications: a case-control study on a matched population.

Whether or not smoking increases the risk of postoperative pulmonary complications (PPCs) in lung resection patients remains controversial. The objective of this study was to evaluate whether active smoking at the time of surgery increases the risk of PPCs compared to abstention shortly before the procedure. We conducted a case-control study on 378 patients who underwent non-extended lobectomy in our institution. Cases were active smokers at the time of surgery, and controls were patients who quit smoking at any time up to 16 weeks before surgery. All patients received the same perioperative care, including chest physiotherapy. The occurrence of PPCs was the considered outcome. PPCs were defined as pneumonia (American Thoracic Society criteria, 2004) or atelectasis requiring bronchoscopy. Cases and controls were matched according to age, body mass index, forced expiratory volume in the first second of expiration (FEV1%), FEV1/forced vital capacity, type of approach and diagnosis of non-small-cell lung cancer. We calculated the odds ratio (OR) with 95% confidence interval (CI) for PPCs. The overall prevalence of PPCs was 4.7% (18/378); 5.3% (13 out of 244) in the active smokers group and 3.7% (5 out of 134) in the ex-smokers group. After matching, two sets of 134 patients each were compared. The prevalence was 4.5% (6/134) in active and 3.7% (5/134) in ex-smokers (OR 1.21 95% CI: 0.29-5.13, P = 0.76). In this population of patients strictly matched according to risk criteria for PPCs, smoking at the time of surgery was not identified as a risk variable. Therefore, the practice of postponing surgery until tobacco abstention has been achieved does not seem to be justified.

Myositis-associated usual interstitial pneumonia has a better survival than idiopathic pulmonary fibrosis.

To compare the survival outcomes between myositis-associated usual interstitial pneumonia (MA-UIP) and idiopathic pulmonary fibrosis (IPF-UIP). Adult MA-UIP and IPF-UIP patients were identified using CTD and IPF registries. The MA-UIP cohort included myositis or anti-synthetase syndrome patients with interstitial lung disease while manifesting UIP on high-resolution CT chest and/or a lung biopsy revealing UIP histology. IPF subjects met American Thoracic Society criteria and similarly had UIP histopathology. Kaplan-Meier survival curves compared cumulative and pulmonary event-free survival (event = transplant or death) between (i) all MA-UIP and IPF-UIP subjects, (ii) MA-UIP with biopsy proven UIP (n = 25) vs IPF-UIP subjects matched for age, gender and baseline forced vital capacity (±10%). Cox proportional hazards ratios compared the survival controlling for co-variates. Eighty-one IPF-UIP and 43 MA-UIP subjects were identified. The median cumulative and event-free survival time in IPF vs MA-UIP was 5.25/1.8 years vs 16.2/10.8 years, respectively. Cumulative and event-free survival was significantly worse in IPF-UIP vs MA-UIP [hazards ratio of IPF-UIP was 2.9 (95% CI: 1.5, 5.6) and 5.0 (95% CI: 2.8, 8.7) (P < 0.001), respectively]. IPF-UIP event-free survival (but not cumulative) remained significantly worse than MA-UIP with a hazards ratio of 6.4 (95% CI: 3.0, 13.8) after controlling for age at interstitial lung disease diagnosis, gender, ethnicity and baseline forced vital capacity%. Respiratory failure was the most common cause of death in both groups. A sub-analysis of 25 biopsy-proven MA-UIP subjects showed similar results. MA-UIP patients demonstrated a significant survival advantage over a matched IPF cohort, suggesting that despite similar histological and radiographic findings at presentation, the prognosis of MA-UIP is superior to that of IPF-UIP.

Severe Lung Disease due to Mycobacterium kansasii: Report of a Case and Review of the Literature

Mycobacterium kansasii disease present epidemiological, clinical and radiological features similar to Mycobacterium tuberculosis. Mycobacterium kansasii is the second most frequent mycobacteria isolated in human immunodeficiency virus infected patients. Confirmed diagnosis is often difficult according with the American Thoracic Society criteria. Here we describe a patient with AIDS that developed a severe lung compromise due to Mycobacterium kansasii. Epidemiological, clinical, radiological and diagnosis methods are analyzed.

Clinical Utility of Testing for Legionella Pneumonia in Central Texas

Legionella pneumophila is an uncommon cause of community-acquired pneumonia in the south central region of the United States, and regular testing may not be cost effective in areas of low incidence. To evaluate the incidence of Legionella in central Texas and to determine the cost effectiveness of Legionella urinary antigen testing. We performed a single-center retrospective cohort study of patients admitted with pneumonia between January 2001 and December 2013. Patients were identified by Binax Legionella urinary antigen and International Classification of Disease, Ninth Revision codes. Demographic characteristics and clinical history of the confirmed Legionella pneumonia cases were obtained by chart review. Descriptive statistics were used to describe patient characteristics. Over 12 years, 5,807 patients with 11,377 admissions for pneumonia were tested for Legionella urinary antigen. A positive Legionella urinary antigen was found in 17 patients. Cumulative incidence during the study period was 0.23%. Among the Legionella-positive patients, intensive care unit admission and median length of stay were 58.8% and 8.5 days, respectively. Most patients (64.7%) met American Thoracic Society criteria for severe pneumonia. All patients empirically received either a macrolide or fluoroquinolone covering Legionella. There were two in-hospital and three total 90-day deaths in those with a positive urinary antigen. The estimated cost of screening this population with Legionella urinary antigen was $214,438 over 13 years. This study reveals the low incidence of Legionella pneumonia in central Texas. Use of guideline-concordant antibiotic treatment provides coverage for Legionella. We speculate that testing in a low-prevalence area would not influence outcomes or be cost effective.

Accuracy and Quality of Spirometry in Primary Care Offices.

Spirometry is necessary for the optimal management of patients with respiratory disease. The quality of spirometry performed in the primary care setting has been inconsistent. We aimed to evaluate spirometer accuracy, determine the clinical significance of inaccurate spirometers, and assess the quality of spirograms obtained in primary care offices. We tested 17 spirometers used in primary care offices with a waveform generator; accuracy and precision were assessed using American Thoracic Society criteria. The clinical significance of inaccurate instruments was determined by applying the FEV1/FVC error from an obstructed waveform to a clinical data set. Spirogram quality was determined by grading spirograms using acceptability and repeatability criteria. The relationship between the number of tests performed by a clinic and test quality was assessed. Only 1 of 17 spirometers met accuracy criteria, with mean errors for FVC, FEV1, and FEV1/FVC ranging from 1.7 to 3.1%. Applying the percentage error to a clinical data set resulted in 28% of tests being recategorized from obstructed to nonobstructed. Of the spirograms reviewed, 60% were considered acceptable for clinical use. There was no association between the number of tests performed by a clinic and spirometry quality. Most spirometers tested were not accurate. The magnitude of the errors resulted in significant changes in the categorization of patients with obstruction. Acceptable-quality tests were produced for only 60% of patients. Our results raise concerns regarding the utility of spirometry obtained in primary care offices without greater attention to quality assurance and training.

Infection pulmonaire à Mycobacterium malmoense. Difficultés diagnostiques et de thérapeutiques

Pulmonary infection due to Mycobacterium malmoense can be difficult to diagnose. These difficulties can be responsible for a delay in the implementation of optimal treatment. Moreover, the treatment is not standardized. We report the case of a 56-year-old patient who developed a Mycobacterium malmoense pulmonary infection whose diagnosis was delayed due to initial suspicion of pulmonary Mycobacterium tuberculosis infection. Once the diagnosis was confirmed, the patient was treated empirically with rifampicin, ethambutol, and clarithromycin for 12 months after culture conversion, giving a total of 15 months. The clinical and radiological outcomes were favorable. This clinical case highlights the difficulties of diagnosing pulmonary atypical mycobacterial infection according to the American Thoracic Society criteria, particularly Mycobacterium malmoense, a non-tuberculous mycobacterium (NTM) quite uncommon in France. Currently, there are new diagnostic techniques such as GenoType Mycobacteria Direct®. The second issue is the poorly standardized treatment of this NTM and many others, that are based on the recommendations of the British Thoracic Society. A national register has been set up by the MycoMed network, based essentially on the work of microbiologists but this register is unfortunately not exhaustive. A more systematic reporting strategy could allow cohort studies and therefore provide us with data on the most efficient drugs in the treatment of the rarest NTM infections.

Prevalence and factors associated with nontuberculous mycobacteria in non-cystic fibrosis bronchiectasis: a multicenter observational study.

BackgroundData on the prevalence of and factors associated with nontuberculous mycobacteria (NTM) in patients with non–cystic fibrosis (CF) bronchiectasis are limited. Our aim was to determine the prevalence and factors associated with isolation of NTM in this population.MethodsWe performed a multicenter observational study of historical cohorts comprising consecutive patients with non-CF bronchiectasis and at least 2 sputum samples cultured for mycobacteria over a period of 5 years.ResultsThe study population included 218 adult patients (61.9 % women) with a mean (SD) age of 55.7 (16) years and a mean (SD) of 5.1 (3.3) cultures/patient. NTM was isolated from sputum in 18 patients (8.3 %). Of these, 5 patients (28 %) met the American Thoracic Society criteria for NTM disease. Mycobacterium avium complex was the most frequently isolated microorganism (9 patients, 4.1 %). The variables independently associated with isolation of NTM were FVC ≥ 75 % predicted (OR, 4.84; 95 % CI 1.47 to 15.9; p < 0.05), age ≥ 50 years (OR, 4.74; 95 % CI 1.25 to 17.97; p < 0.05), and body mass index (BMI) ≤ 23 kg/m2 (OR, 2.97; 95 % CI 1.03-8.58; p < 0.05). Patients with these three characteristics had a 40 % probability of having at least one isolation of NMT.ConclusionsA significant number of patients with non-CF bronchiectasis are positive for the isolation of NTM. M. avium complex is the most frequently isolated mycobacteria. FVC ≥ 75 % predicted, age ≥ 50 years, and a BMI ≤ 23 kg/m2 were independently associated with the presence of NTM in patients with non-CF bronchiectasis.

CASE STUDY: Gender-Specific Impairment Rating Examples

Abstract Accurate pulmonary impairment ratings depend on a valid and reliable lung function test and appropriate application of the criteria provided in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition. The two lung function tests are dynamic and static; the principal dynamic test is the cardiopulmonary stress test [see sidebar, “Cardiopulmonary Exercise Testing,” in this issue of The Guides Newsletter]. To rate pulmonary impairment using Chapter 5 of the AMA Guides, Sixth Edition, a physician should obtain the spirometric results and the value for the diffusion of carbon monoxide across the alveolar capillary membrane of the lung (DLCO); the latter should be administered according to American Thoracic Society criteria. A six-minute walk test is a standard test of pulmonary reserve in lung disease patients and may be part of the individual's physical examination. Each diagnosis table in Chapter 5 is divided into variables or factors that determine the impairment rating. Each impairment class (except 0) has five grades (A through E). Once the evaluator uses objective test results to assign the impairment class, the non-key factors are considered to determine whether the impairment should be adjusted from the default value. To determine the adjustment, the evaluator subtracts the impairment class integer from each non-key factor integer, and the differences are summated for the net adjustment.

IgE mediated sensitisation to aeroallergens in an asthmatic cohort: relationship with inflammatory phenotypes and disease severity.

SummaryBackgroundAtopy is known to play an important role in the asthmatic disease. The main objective of this study was to evaluate the frequency of sensitisation to common aeroallergens in a cohort of asthmatics with different inflammatory phenotypes and disease severity.MethodsWe have conducted a retrospective cross‐sectional study including 772 asthmatics recruited between 2003 and 2014 in our Asthma Clinic. The patients were defined as asthmatics on the basis of respiratory symptoms together with a positive methacholine test (PC20M) < 16 mg/ml and/or a reversibility to short‐acting β2‐agonists (salbutamol) ≥ 12% and 200 ml. Sensitisation to house dust mites, grass and birch pollens, cats, dogs and moulds was assessed by RAST and a specific immunoglobulin E (IgE) > 0.35 kU/l was considered as significant. Inflammatory phenotypes were subdivided between pauci‐granulocytic (n = 309) (40%), eosinophilic (n = 311) (40%), neutrophilic (N = 134) (17%) and mixed‐granulocytic (N = 18) (3%) asthmatics. Severe asthmatics (n = 118) were defined according to the American Thoracic Society (ATS 2000) criteria and compared with mild‐to‐moderate asthmatics (N = 654).ResultsThe eosinophilic phenotype was associated with higher levels of total serum IgE compared with neutrophilic and pauci‐granulocytic asthma (p < 0.001 for both). Sensitisation rate to dogs and cats was higher in eosinophilic asthmatics (31% and 37%, respectively, p < 0.01 both) compared with neutrophilic (18% and 23% respectively) and pauci‐granulocytic asthmatics (20% and 24%, respectively), while sensitisation rate to house dust mites and moulds were rather similar between the groups (ranging from 33% to 40% and from 10% to 16%, respectively). Severe asthmatics had slightly increased total serum IgE compared with mild‐to‐moderate asthmatics (p < 0.05) without any difference in the sensitisation rate to common aeroallergens.ConclusionEosinophilic asthma exhibits higher total serum IgE and sensitisation rate towards animal dander while clinical severity, though also associated with higher total IgE, did not preferentially relate to any type of common aeroallergens.

A primary care-based asthma program improves recognition and treatment of persistent asthma in inner-city children compared to routine care

Objective: To examine whether a primary care-based asthma program that applies the Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-2007 criteria to classify asthma severity increases detection of persistent asthma in inner-city children and affects “step of care” compared to routine care. Methods: A retrospective chart review was conducted of 97 consecutive children referred to the asthma program from 2011–2013. Asthma severity documented during routine health care maintenance visits was compared to the asthma severity assessed during the asthma program visit using five standardized questions and spirometry. Medication plan “step of care” was compared pre- and post- the asthma program visit. Results: 79 children, ages 5–19 years old (mean = 9.6), had spirometry tracings meeting American Thoracic Society criteria and were included in this study. 53% were male. The majority of children were Latino (45.6%) or African American (35.4%). At the asthma program visit, more children were identified with moderate or severe persistent asthma based upon clinical questions (47.9%), spirometry (56.9%) or combined criteria (75.3%) than had been identified during routine care (15.2%); all p < .05. After the asthma program visit, more children were prescribed controller medications (82.3% vs 63.3%; p < .05) and 40.6% had their medication plan stepped up. Conclusions: In this population of inner-city children, asthma severity was under-recognized and undertreated during routine care. A primary care based asthma program, which formalized applying EPR-3 criteria, increased detection of persistent asthma and led to “step-ups” in treatment plans.

Nontuberculous mycobacteria in cystic fibrosis patients on the Island of Gran Canaria. A population study.

To determine the prevalence of nontuberculous mycobacteria (NTM) colonization and disease in cystic fibrosis (CF) patients. All the CF patients followed-up from 2002 to 2012 with three acid-fast bacilli (AFB) cultures were included. The American Thoracic Society (ATS) criteria for NTM lung disease were applied. Forty-four of the 53 patients being followed-up were included. The mean time of follow-up was 7.0 years. A total of 18 patients (40.9%) were NTM positive. The NTN mean annual prevalence was 14.1%. The risk of Mycobacterium abscessus complex was higher in the group of 10-14 years-old (p<0.001). Ten patients (22.7% of the entire cohort) met the ATS microbiological criteria. The mean annual prevalence of NTM disease was 10.4%. Seven patients (four with Mycobacterium simiae and three with M.abscessus complex) with multiple positive cultures, positive AFB smears and clinical worsening were treated. Three patients with M.simiae and none of those with M.abscessus were cured. Overall NTM prevalence of colonization and disease were high in our CF patients. Patients <15 years old had a higher risk of M.abscessus complex colonization. Multiple positive cultures or positive AFB smears were associated with disease.

A Prospective Randomized Study Comparing Manual and Wall Suction in the Performance of Bronchoalveolar Lavage

Background: Bronchoalveolar lavage (BAL) may be performed using a hand-held syringe or wall suction. Objectives: The aim was to study BAL volume and diagnostic yields based on BAL technique. Methods: A total of 220 consecutive patients undergoing BAL at our center were included. Manual aspiration was performed in 115 patients (group 1), and wall suction (<50 mm Hg of negative pressure) was used in 105 patients (group 2). All bronchoscopies were performed under conscious sedation applying topical anesthesia with lidocaine. Three 50-ml sterile saline aliquots were instilled in all patients. Results: The mean total amount of fluid recovered was 67 ± 20 ml in group 1 and 55 ± 22 ml in group 2 (p < 0.001). More patients in the manual aspiration group met American Thoracic Society criteria (recovery of ≥30% of instilled fluid) for an optimal BAL (81 vs. 59%; p < 0.001). The quantity of recovered fluid was also related to BAL location (p < 0.001) and radiologic findings (p = 0.002). Forty-eight (22%) BALs were diagnostic (23 in group 1 and 25 in group 2), including 37 positive bacterial cultures, 6 positive stains for Pneumocystis, and 5 cases of malignancy. No statistically significant difference in diagnostic yield was observed between the two groups. A BAL diagnosis was more likely in patients with certain radiologic (p = 0.033) and endoscopic findings (p = 0.001). When taking into account all bronchoscopic techniques performed during the procedure (e.g. biopsies, brushing, etc.), bronchoscopy was diagnostic in 37% of patients. Conclusions: Manual aspiration is superior to wall suction during BAL yielding a larger quantity of aspirate. Diagnostic yields are similar for both techniques.

Clinical Significance of Environmental Mycobacteria Isolated From Respiratory Specimens of Patients With and Without Silicosis

ObjectiveTo describe the clinical, functional and radiographic differences of respiratory disease caused by environmental mycobacteria in patients with and without silicosis. MethodRetrospective, observational study in patients with nontuberculous mycobacteria isolated in the Hospital Meixoeiro (University Hospital of Vigo) microbiology laboratory between January 2007 and December 2013. Patients were grouped according to the presence or absence of silicosis and mycobacterial lung disease, using American Thoracic Society criteria. ResultsIn 156 cases, at least one species of environmental mycobacteria had been isolated from the respiratory culture. A total of 71% were identified in men, 40 (25.6%) of whom had silicosis. Sixty patients (38.5%) met American Thoracic Society microbiological criteria: 62.5% of the silicosis group and 30.2% of the non-silicosis group. The most common species were Mycobacterium avium complex, Mycobacterium genavense and Mycobacterium chelonae. American Thoracic Society criteria for environmental mycobacterial disease were met in 34 (22.7%) patients: 14 in the silicosis group and 20 in the non-silicosis group. Treatment was administered in 24 cases, with better bacteriological eradication levels in the non-silicosis group. ConclusionsIn our series, a history of silicosis was related with a higher incidence of environmental mycobacterial disease. The causative species in the majority of cases in our setting was Mycobacterium avium complex, followed by Mycobacterium genavense. Patients with silicosis showed lower cure rates after treatment.

Relationship between the Asbestos Cumulative Exposure Index (ACEI) and the Latency Period of Asbestos Related Diseases (ARD) within an Italian Study Group of Ex-Asbestos Workers

Objectives: The association between asbestos exposure, measured by mean of Asbestos Cumulative Exposure Index (ACEI) and the latency period of non-malignant asbestos-related diseases (ARD) diagnosed according to the American Thoracic Society (ATS) criteria was studied. Methods: 306 exposed asbestos workers in Bari, Italy, were included in a health surveillance program. By means of a standardized questionnaire we assessed asbestos exposure through ACEI. Latency period of Asbestos Related Diseases (ARD) was also assessed. Results: We found a significant inverse correlation between latency and ACEI increasing with ARD severity. ACEI and 30-35 years of age at time of first exposure were inversely associated with the latency period. The risk of ARD increased from baseline to the 2nd follow-up and among subjects exposed for the first time before 1960. Conclusions: The most important factors that caused a reduction in the latency period were the year of first exposure and the ACEI score while smoking habits did not show to play a significant role.