Bronchial Secretions Research Articles

Non-invasive Ventilation in Children With Neuromuscular Disease.

The respiratory muscles are rarely spared in children with neuromuscular diseases (NMD) which puts them at risk of alveolar hypoventilation. The role of non-invasive ventilation (NIV) is then to assist or “replace” the weakened respiratory muscles in order to correct alveolar hypoventilation by maintaining a sufficient tidal volume and minute ventilation. As breathing is physiologically less efficient during sleep, NIV will be initially used at night but, with the progression of respiratory muscle weakness, NIV can be extended during daytime, preferentially by means of a mouthpiece in order to allow speech and eating. Although children with NMD represent the largest group of children requiring long term NIV, there is a lack of validated criteria to start NIV. There is an agreement to start long term NIV in case of isolated nocturnal hypoventilation, before the appearance of daytime hypercapnia, and/or in case of acute respiratory failure requiring any type of ventilatory support. NIV is associated with a correction in night- and daytime gas exchange, an increase in sleep efficiency and an increase in survival. NIV and/or intermittent positive pressure breathing (IPPB) have been shown to prevent thoracic deformities and consequent thoracic and lung hypoplasia in young children with NMD. NIV should be performed with a life support ventilator appropriate for the child's weight, with adequate alarms, and an integrated (±additional) battery. Humidification is recommended to improve respiratory comfort and prevent drying of bronchial secretions. A nasal interface (or nasal canula) is the preferred interface, a nasobuccal interface can be used with caution in case of mouth breathing. The efficacy of NIV should be assessed on the correction of alveolar ventilation. Patient ventilator synchrony and the absence of leaks can be assessed on a sleep study with NIV or on the analysis of the ventilator's in-built software. The ventilator settings and the interface should be adapted to the child's growth and progression of respiratory muscle weakness. NIV should be associated with an efficient clearance of bronchial secretions by a specific program on the ventilator, IPPB, or mechanical insufflation-exsufflation. Finally, these children should be managed by an expert pediatric multi-disciplinary team.

Deoxynucleoside therapy for respiratory involvement in adult patients with thymidine kinase 2-deficient myopathy

BackgroundRecessive mutations in the thymidinekinase 2 (TK2) gene cause a rare mitochondrial myopathy, frequently with severe respiratory involvement. Deoxynucleoside therapy is currently under investigation.Research questionWhat is the impact of nucleosides...

Раціональний вибір мукоактивних фітопрепаратів у педіатрії: комплексна фармакологічна дія, ефективність, безпечність

Cough is one of the most common symptoms of acute respiratory viral infections in childhood. In the treatment of acute respiratory infections accompanied by cough in children, the main task is to stop the cough by improving the rheological properties of bronchial secretions for their early withdrawal. Cough can be effectively treated only by improving the discharge of mucus from the respiratory tract. For this purpose, mucoactive drugs are used: secretolytics, capable of thinning mucus (mucolytic action), and secretomotor drugs, which improve its output (expectorant effect). Among the many mucoactive drugs in pediatrics, preference is given to herbal drugs, which have a milder expectorant effect compared to synthetic drugs, and are better tolerated. On the Ukrainian pharmaceutical market there is Gederin Ivy Syrup, a preparation with ivy extract. Among the complex of effects of the ivy leaf extract (expectorant, secretolytic, anti-inflammatory), the unique action that distinguishes it from other herbal and synthetic drugs is bronchospasmolytic one. Taking this into account, preparations with ivy extract can be recommended for respiratory infections accompanied by obstruction. These can be both acute and chronic conditions occurring with reversible narrowing of the airways. Due to its natural composition, the drug is safe. Side effects from Gederin Ivy syrup are very rare. In patients with hypersensitivity to the components of the drug some allergic reactions (mainly rash), as well as gastrointestinal disorders are possible. It should not be administered to patients suffering from fructose intolerance. Sorbitol, which is a component of the syrup, can cause a slight laxative effect. Thus, the combination of such effects of ivy extract in the preparation Gederin Ivy – expectorant (mucokinetic and secretolytic), bronchospasmolytic and anti-inflammatory – predetermines its expressive clinical efficacy in the treatment of cough, as well as good tolerance. And this allows it to be widely used in the complex therapy of bronchitis in pediatric practice. No conflict of interest was declared by the authors. Key words: Mucoactive phytopreparations, children, treatment, ivy extract, efficacy, safety.

COVID-19 and myeloid cells: complex interplay correlates with lung severity.

COVID-19 spans a wide range of symptoms, sometimes with profound immune system involvement. How immune cell subsets change during the disease course and with disease severity needs further study. While myeloid cells have been shown to initiate and maintain responses to pneumonia and lung inflammation, often playing a role in resolution, their involvement with COVID-19 remains unknown. In this issue of the JCI, Sánchez-Cerrillo and Landete et al. investigated DCs and monocytes from blood and bronchial secretions of patients with varying COVID-19 severity and with healthy controls. The authors conclude that circulating monocytes and DCs migrate from the blood into the inflamed lungs. While sampling differences in sex, collection timing, bacteria/fungal infection, and corticosteroid treatment limit interpretation, we believe that reprogramming monocyte or macrophages by targeting immunometabolism, epigenetics, or the cytokine milieu holds promise in resolving lung inflammation associated with COVID-19.

Two Sites - One Major Problem

The authors present the case of a 36-year-old woman with disseminated tuberculosis shown by pulmonary nodules and urogenital involvement. Positive cultures for Mycobacterium tuberculosis in urine and bronchial secretions made the diagnosis. After three months of multidrug treatment, there was a clinical and radiologic improvement. This case highlights an uncommon case of an immunocompetent patient with disseminated tuberculosis. A delay in the diagnosis of pulmonary tuberculosis can result in serious public health problems with disease spread.

Use of Hyaluronic Acid (HA) in Chronic Airway Diseases

Hyaluronic acid (HA) is a key component of the extracellular matrix of the lungs. A unique attribute of HA is its water-retaining properties, so HA has a major role in the regulation of fluid balance in the lung interstitium. Hyaluronic acid has been widely used in the treatment of eyes, ears, joints and skin disorders, but in the last years, it has been also proposed in the treatment of certain lung diseases, including airway diseases, due to its anti-inflammatory and water-binding capacities. Hyaluronic acid aerosol decreases the severity of elastase-induced emphysema in murine models, prevents bronchoconstriction in asthmatics and improves some functional parameters in chronic obstructive pulmonary disease (COPD) patients. Due to the protection of HA against bronchoconstriction and its hydration properties, inhaled HA would increase the volume of airway surface liquid, resulting in mucus hydration, increased mucous transport and less mucous plugging of the airways. In addition, it has been seen in human studies that the treatment with nebulised HA improves the tolerability of nebulised hypertonic saline (even at 6% or 7% of concentration), which has been demonstrated to be an effective treatment in bronchial secretion management in patients with cystic fibrosis and bronchiectasis. Our objective is to review the role of HA treatment in the management of chronic airway diseases.

Cryptolepine, the major alkaloid of Cryptolepis sanguinolenta (Lindl.) Schlechter (Apocynaceae), attenuates early and late-phase symptoms of asthma

Aqueous root extract of Cryptolepis sanguinolenta has been used traditionally to treat many upper respiratory tract disorders. Besides its well-known broad spectrum antimicrobial activity, we had reasoned that cryptolepine can directly attenuate the symptoms of asthma. Therefore, this study evaluates cryptolepine, the main compound of the aqueous extract of Cryptolepis sanguinolenta, on early and late-phase symptoms of asthma attack. In the early phase study, isolated cryptolepine was evaluated on its ability to reverse histamine-induced bronchoconstriction and reduce histamine release from mast cells and bronchial mucus secretion. In the late phase study, cryptolepine was evaluated on its ability to affect airway inflammation and hypersensitivity as well as its ability to attenuate airway remodeling induced by ovalbumin. In the early asthma phase study, Cryptolepine (10–100 mg/kg) significantly and dose dependently inhibited Histamine-induced bronchoconstriction in guinea pigs. The protection lasted beyond 24 h. It also decreased the volume and optical density of bronchial secretions in mice. Cryptolepine (10–100 µg /mL) stabilized mesentery mast cells in vitro against Compound 48/80 -induced degranulation. In the late phase study, cryptolepine (10–100 mg/kg) prevented ovalbumin-induced airway obstruction and basal membrane smooth muscle hypertrophy. It significantly reduced systemic leukocytosis and inflammatory cell infiltration into airways in antigen-sensitized animals. Using the skin prick test, cryptolepine reduced the hypersensitivity to allergen challenge in antigen-sensitized animals. Cryptolepine's effects in the late phase was similar to dexamethasone (1 mg/kg) used as standard drug. Cryptolepine attenuates both early and late phase symptoms of asthma. It reduces bronchospasms, bronchial secretions, airway remodeling and hypersensitivity. This gives scientific credence to the traditional usage of cryptolepis extracts in upper respiratory tract disorders.

E-cigarette, or Vaping, Associated Lung and Hepatic Injury.

E-cigarette, or Vaping, Associated Lung and Hepatic Injury.

How palliative care professionals deal with predicting life expectancy at the end of life: predictors and accuracy

To assess the accuracy of hospice staff in predicting survival of subjects admitted to hospice, exploring the factors considered most helpful by the hospice staff to accurately predict survival. Five physicians and 11 nurses were asked to predict survival at admission of 827 patients. Actual and predicted survival times were divided into ≤ 1week, 2-3weeks, 4-8weeks, and ≥ 2months and the accuracy of the estimates was calculated. The staff members were each asked to score 17 clinical variables that guided them in predicting survival and we analyzed how these variables impacted the accuracy. Physicians' and nurses' accuracy of survival of the patients was 46% and 40% respectively. Survival was underestimated in 20% and 12% and overestimated in 34% and 48% of subjects. Both physicians and nurses considered metastases, comorbidities, dyspnea, disability, tumor site, neurological symptoms, and confusion very important in predicting patients' survival with nurses assigning more importance to intestinal symptoms and pain too. All these factors, with the addition of cough and/or bronchial secretions, were associated with physicians' greater accuracy. In the multivariable models, intestinal symptoms and confusion continued to be associated with greater predictive accuracy. No factors appreciably raised nurses' accuracy. Some clinical symptoms rated as relevant by the hospice staff could be important for predicting survival. However, only intestinal symptoms and confusion significantly improved the accuracy of physicians' predictions, despite the high prevalence of overestimated survival.

Efeitos da supressão da aspiração endotraqueal na incidência de complicações pulmonares no pós operatório de cirurgia cardíaca

INTRODUÇÃO: Aspiração traqueal é utilizada rotineiramente após cirurgia cardíaca para garantir adequada ventilação. OBJETIVO: Verificar se a ausência da aspiração traqueal antes da extubação em pacientes sem sinais de secreção brônquica influencia na incidência de complicações pulmonares, além de repercussões hemodinâmicas e ventilatórias do procedimento e custos. MÉTODOS: Pacientes foram avaliados entre agosto/2012 e julho/2014, divididos igualmente em Grupo ASP (aspiração traqueal prévia à extubação) e NASP (sem aspiração prévia). Foram incluídos indivíduos com: primeira cirurgia cardíaca, idade entre 18 e 75 anos, IMC ? 30 kg/m² e sem doença pulmonar prévia. Foram excluídos indivíduos com tempo de CEC > 120 minutos, necessidade de assistência circulatória mecânica, relação PaO2/FiO2 < 200, SpO2 < 92%, tempo de intubação > 12 horas, PAM < 60 mmHg e sinais de secreção pulmonar. Variáveis hemodinâmicas, ventilatórias, complicações pulmonares e custos hospitalares foram avaliados. RESULTADOS: Foram analisados 228 pacientes (ASP= 114 NASP= 114). FC, PAS, PAD e PAM elevaram-se após aspiração e pós extubação nos grupos, retornando aos valores basais no decorrer do tempo. Não houve diferença estatística na FR e SpO2. Complicações pulmonares representaram 7,8%, sem diferença entre os grupos. CONCLUSÃO: A supressão da aspiração traqueal nos pacientes em pós-operatório imediato de cirurgia cardíaca não influenciou na incidência de complicações pulmonares e evolução clínica pós-operatória. Durante aspiração, houve alterações hemodinâmicas e respiratórias, sem repercussões clínicas, porém estas mesmas alterações ocorreram no grupo NASP após extubação, em menor intensidade. Aspiração endotraqueal sem indicação mostrou-se custosa e com desperdício de tempo dos profissionais.

Approaches to the Treatment of Cough in Acute Bronchitis in an Outpatient Setting

The objective: to determine the therapeutic efficacy and dynamics of clinical and instrumental indicators on the background of comprehensive treatment of patients with acute bronchitis with the use of the drug Ascoril in an outpatient setting.Materials and methods. To establish the diagnosis and prescribe basic treatment, the recommendations of the Unified Clinical Protocol of Primary Care for Adults and Children “Acute Respiratory Infections” were used – Order of the Ministry of Health of Ukraine dated 11.02.2016 № 85. Using the BSS scale (Bronchitis Severity Score). The study involved 40 patients with acute bronchitis aged 23–48 years. Patients were divided into two groups using the “closed envelopes” method. Patients in group I (n = 30) were prescribed a combined drug Asсoril (manufactured by Glenmark Pharmaceuticals Ltd.), which contains salbutamol 2 mg, bromhexine 8 mg, guaifenesin 100 mg (1 tablet 3 times per day). Ten patients of group II (comparison) were prescribed a combined mucolytic drug containing ambroxol hydrochloride 30 mg and acetylcysteine 200 mg (1 tablet 3 times a day). Patients took the drugs for 7 days. Observations were performed on the first and eighth day. A diary was recommended for all patients for 2–7 days. On the first and eighth day were conducted on the background of clinical and instrumental studies: of FEV1, PSV, SpO2, evaluated the maintenance of the diary.Results. It is established that the classic manifestation of acute bronchitis is a combination of catarrhal and inflammatory syndromes. According to the indicators of the scale of severity of bronchitis (BSS), the most pronounced sign was cough, and the most regressive signs – chest pain when coughing (0.72 ± 0.21 – group I and 0.56 – group II in the acute period, up to 0.00 –during convalescence in both groups); wheezing on auscultation and difficulty breathing. It was determined that the most stable on the BSS scale is a symptom of cough (a significant decrease in group I from 2.84 ± 0.11 – in the acute period, up to 1.22 ± 0.16 – in the period of convalescence and from 2.67 ± 0.15 to 1.94 ± 0.12, respectively – in group II). It was found that in group I (against the background of complex therapy with Ascoril) the dynamics of the cough symptom had a significant difference from this indicator in the second group of comparison on the 8th day of control. Therefore, the reduction of cough as the main symptom of acute bronchitis was significantly faster with Ascoril. During the therapy with the drug Ascoril it was recorded a significant decrease (p <0.001) from 9.58 ± 0.12 to 3.96 ± 0.42 of the total score on the BSS scale in the convalescence period compared to the acute period. This indicator was significantly better compared to the result in group II – from 9.47 ± 0.75 to 6.05 ± 0.56 (p <0.05). Observed the absence of symptoms of intoxication, improvement of general condition, increased strength and energy for homework, and hence the quality of life on a modified questionnaire “SF-36 Health Status Surve”, which during convalescence was more pronounced in group I, which can be explained by synergistic action of the components that are part of the combined drug Ascoril. The results of treatment according to the adapted integrated IMOS scale were assessed as a significant improvement in 20% of patients and a moderate improvement in 80 % of group I on the third day of treatment, while in group II a slight improvement was observed in 60 % of patients and 40 without changes, indicating a faster localization of symptoms of acute bronchitis on the background of complex therapy with Ascoril. The effect of Ascoril on the number of cough attacks in group I patients was effective, as the frequency of attacks on the 8th day of control was 75.92 % lower compared to the first day respectively. During the follow-up, no side effects and adverse reactions were registered in patients of both groups on the background of the use of drugs.Conclusion. A short, 7-day follow-up of complex therapy with Ascoril (group I) and a preparation containing a combination of ambroxol hydrochloride and acetylcysteine (comparison group II) showed a comparative effect of the drugs on the components of acute bronchitis (BSS scale). At the same time, promoting a faster effect on the cough symptom on the third day when using the drug Ascoril compared with the other group. All components of the drug Ascoril created a synergistic effect, improving mucociliary clearance, regulating the secretion of bronchial mucus and its rheological properties, reducing excessive bronchial tone. As a result, there was a rapid clearing of the bronchi from the altered bronchial secretion, reduction or cessation of cough, improvement of bronchial patency and general condition of the patients.

The Respiratory Microbiome in Cystic Fibrosis: Compartment Patterns and Clinical Relationships in Early Stage Disease.

We compared the bacterial microbiomes lodged in the bronchial tree, oropharynx and nose of patients with early stage cystic fibrosis (CF) not using chronic antibiotics, determining their relationships with lung function and exacerbation frequency. CF patients were enrolled in a cohort study during stability and were checked regularly over the following 9 months. Upper respiratory samples (sputum [S], oropharyngeal swab [OP] and nasal washing [N]) were collected at the first visit and every 3 months. 16S rRNA gene amplification and sequencing was performed and analyzed with QIIME. Seventeen CF patients were enrolled (16.6 SD 9.6 years). Alpha-diversity of bacterial communities between samples was significantly higher in S than in OP (Shannon index median 4.6 [IQR: 4.1–4.9] vs. 3.7 [IQR: 3-1-4.1], p = 0.003/Chao 1 richness estimator median 97.75 [IQR: 85.1–110.9] vs. 43.9 [IQR: 31.7–59.9], p = 0.003) and beta-diversity analysis also showed significant differences in the microbial composition of both respiratory compartments (Adonis test of Bray Curtis dissimilarity matrix, p = 0.001). Dominant taxa were found at baseline in five patients (29.4%), who showed lower forced expiratory volume in the first second (FEV1%, mean 74.8 [SD 19] vs. 97.2 [SD 17.8], p = 0.035, Student t test). The Staphylococcus genus had low RAs in most samples (median 0.26% [IQR 0.01–0.69%]), but patients with RA > 0.26% of Staphylococcus in bronchial secretions suffered more exacerbations during follow-up (median 2 [IQR 1–2.25] vs. 0 [0–1], p = 0.026. Mann–Whitney U test), due to S. aureus in more than a half of the cases, microorganism that often persists as bronchial colonized in these patients (9/10 [90%] vs. 2/7 [28.6%], p = 0.034, Fisher’s exact test). In conclusion, the bronchial microbiome had significantly higher diversity than the microbial flora lodged in the oropharynx in early stage CF. Although the RA of the Staphylococcus genus was low in bronchial secretions and did not reach a dominance pattern, slight overrepresentations of this genus was associated with higher exacerbation frequencies in these patients.

Comparison of four commercially available chromogenic media to identify Candida albicans and other medically relevant Candida species.

The number of invasive Candida infections has significantly increased in recent decades. For the successful treatment of fungal infections, rapid identification at the species level, particularly in polyfungal infections, is a key factor. In this study, four commercially available chromogenic media, CandiSelect™ 4 (CS4), chromID™ Candida Agar (CCA), BBL™ CHROMagar™ Candida Medium (BBL) and Brilliance™ Candida Agar (BCA) were evaluated for Candida identification. Overall, 181 bronchial secretion samples from intensive care patients were analysed prospectively. In addition, 18 primarily sterile materials, previously tested positive for Candida, were investigated retrospectively. All samples were cultured as recommended by the manufacturer and visually inspected after 24 and 48hours by three independent investigators. As a control, colonies were identified by MALDI-TOF MS. Specificity and sensitivity were determined for Calbicans identification prospectively. CS4 and BCA showed the best overall consensus with the identification results reached by MALDI-TOF MS for Candidaalbicans and species. A clear differentiation between the species could be ascertained via easily identifiable, species-specific coloration in contrast to BBL and CCA. Sensitivity for Calbicans (n=73) identification varied between 32% (BCA) and 69% (CS4 and CCA) after 24hours and 68% (BBL) and 82% (BCA) after 48hours incubation, while specificity ranged between 62% (BBL) and 81% (CCA) after 24hours and 82% (BBL) and 85% (CS4) after 48hours. CS4 and BCA are recommended for routine identification of Candida species in human samples.

Day and Night Control of COPD and Role of Pharmacotherapy: A Review.

The topic of 24-hour management of COPD is related to day-to-night symptoms management, specific follow-up and patients’ adherence to therapy. COPD symptoms strongly vary during day and night, being worse in the night and early morning. This variability is not always adequately considered in the trials. Night-time symptoms are predictive of higher mortality and more frequent exacerbations; therefore, they should be a target of therapy. During night-time, in COPD patients the supine position is responsible for a different thoracic physiology; moreover, during some sleep phases the vagal stimulation determines increased bronchial secretions, increased blood flow in the bronchial circulation (enhancing inflammation) and increased airway resistance (broncho-motor tone). Moreover, in COPD patients the circadian rhythm may be impaired. The role of pharmacotherapy in this regard is still poorly investigated. Symptoms can be grossly differentiated according to the different phenotypes of the disease: wheezing recalls asthma, while dyspnea is strongly related to emphysema (dynamic hyperinflation) or obstructive bronchiolitis (secretions). Those symptoms may be different targets of therapy. In this regard, GOLD recommendations for the first time introduced the concept of phenotype distinction suggesting the use of inhaled corticosteroids (ICS) particularly when an asthmatic pattern or eosiophilic inflammations are present, and hypothesized different approaches to target symptoms (ie, dyspnea) or exacerbations. Pharmacotherapy should be evaluated and possibly directed on the basis of circadian variations, for instance, supporting the use of twice-daily rapid-action bronchodilators and evening dose of ICS. Recommendations on day and night symptoms monitoring strategies and choice of the specific drug according to patient’s profile are still not systematically investigated or established. This review is the summary of an advisory board on the topic “24-hour control of COPD and role of pharmacotherapy”, held by five pulmonologists, experts in respiratory pathophysiology, pharmacology and sleep medicine.

THU0616-HPR EXPIRATORY FLOW ACCELERATOR (EFA) IN SYSTEMIC SCLEROSIS PATIENTS WITH MUCUS HYPERSECRETION, PRODUCTIVE COUGH AND DYSPNOEA: PRELIMINARY RESULTS FROM A HOME-BASED AIRWAY CLEARANCE TECHNIQUE DAILY PROGRAM

Background:Systemic sclerosis (SSc) is a chronic disease with frequent lung involvement. As mucociliary clearance is impaired, mucus retention and frequent pulmonary infections, increase morbidity and mortality (1).Airway clearance techniques (ACT) enhance removal of mucus from the airways. Expiratory flow accelerator (EFA) is a new technology that promotes deep and gentle drainage of the bronchial secretions, through the Venturi effect. No respiratory effort is required and no negative pressure is generated, avoiding risk of bronchial collapse (2).Objectives:The aim of this study was to describe the effectiveness of EFA in improving pulmonary symptoms in SSc patients.Methods:SSc patients with daily productive cough, frequent pulmonary exacerbations, exertional dyspnea and/or reduced physical activity were selected. All of them underwent a home-based ACT program with EFA. A Respiratory Physiotherapist (RT) trained each patient to use the device 3 times a day, 15 minutes each session. Every subject compiled the Saint George’s Respiratory Questionnaire (SGRQ) and scleroderma Health Assessment Questionnaire (SHAQ) at baseline, 30, 90 and 180 days from the beginning. Statistical analysis has been carried out with General linear model for repeated measures. A value of p<0.05 was considered statistically significant.Results:8 patients were enrolled (M:F=1:7), median age 54 (IC95% 46-69) years. Interstitial lung disease affected the majority of them (7/8). SGRQ total score and SHAQ domain for respiratory symptoms decreased over time (p= 0.003 and p= 0.005). In particular, there was an improvement in two SGRQ domains: activities (p= 0.013) and symptoms (p= 0.005) (fig.1).Figure 1Conclusion:This is the first study to investigate the effect of EFA technology on airway clearance in SSc patients. The observations suggest the importance of a daily ACT program with EFA in improving respiratory symptoms. This technology appear to be extremely promising in SS patient management as it is well tolerated and it has the potential to slow down the pulmonary disease progression by limiting bronchial infections.

MON-437 False Positive I-131 Uptake

BackgroundIodine has high specificity for thyroid tissue hence it plays very important role is management for differentiated thyroid cancer. Despite its high specificity and sensitivity, false-positive I-131 uptake could be seen on whole body scan (WBS).We are presenting a case of false positive intense uptake in lung due to bronchiectasis.Clinical casePatient is a 78-year-old Asian female who initially present with left sided 5.8 cm thyroid nodule. The fine needle aspiration was performed, and the cytology came back as Bethesda category III. Per our institute protocol a molecular mutation panel was sent, which came back with NRAS mutation.She underwent total thyroidectomy and the histology showed 6.2 cm Follicular carcinoma with extensive angioinvasion, oncocyte type. She received adjuvant 165.2 mci of RAI. Per protocol she had a one-week I-131whole body scan.There was intense abnormal uptake in left mid and upper chest. The stimulate thyroglobulin with a TSH of >100mcIU/ml was only 0.17 ng/dl with Tab negative.Patient subsequently had a PET CT which showed a faint diffuse FDG activity noted in the cystic bronchiectasis predominantly in the left apex, lingula, and right middle lobe. Patient informed us that she has history of pulmonary tuberculosis in 1970’s for which she was successfully treated in her home country. We had 10-year-old chest X-ray which showed stable cystic bronchiectasis lesion in the region of intense uptake.DiscussionAlthough I131 whole body scan has high specificity and sensitivity but physician should be aware of potential false positive uptake to avoid unnecessary intervention. In a retrospective evaluation i the most common non-thyroid conditions included were bronchiectasis, lung infection, subcutaneous injection into gluteal fatty tissue, aortic calcification, benign bone cyst, vertebral hemangioma, recent nonthyroidal surgical procedure site, rotator cuff injury, mature cystic teratoma and ovarian follicle cyst). The accumulation of the bronchial secretion is the proposed mechanism of the high false positive uptake in bronchiectasis.Endnotes i Mol Imaging Radionucl Ther 2018; 27:99–106 DOI:10.4274/mirt.37450

Ventilator-associated Events in Children: Controversies and Research Needs.

Ventilator-associated Events in Children: Controversies and Research Needs.

Swallowing Difficulties with Tracheostomy: A Neuro-Rehabilitation Perspective

Swallowing and breathing are complex and highly coordinated functions. These functions depend on well-coordinated work of many organs with larynx and nervous system playing a critical role. Disturbance in one of these functions negatively affects the other. Surgical airways like tracheostomies are required in a number of situations, including but not limited to major head and neck procedures, cases with decreased lung function, excessive bronchial secretions and cases requiring neuro-rehabilitation when prolonged airway is required for mechanical ventilation. Extensive neuro-rehabilitation is required since patients with surgical airway may develop swallowing difficulties including dysphagia and/or aspiration with a very high prevalence, which can pose a threat to life. This article reviews the current status of the diagnostic and therapeutic modalities for swallowing difficulties with special emphasis on current neuro-rehabilitative strategies. Electronic databases including Medline, Web-of-science, Cochrane Library, and Google scholar were used for literature search. Downloaded articles were subsequently assessed independently by two researchers to determine suitability for inclusion in the study.Key words: Neurorehabilitation, Tracheostomy, Transcranial direct current stimulation, Transcranial magnetic stimulation, swallowing difficulty

A case of toxic epidermal necrolysis with refractory acute respiratory distress syndrome

Toxic epidermal necrolysis (TEN) is a life-threatening cutaneous reaction with several complications. Although acute respiratory distress syndrome (ARDS) is rare, it can cause rapid and potentially fatal pulmonary dysfunction. Here, we present a case of TEN with ARDS attributed to acetaminophen. Toxic epidermal necrolysis (TEN) is a life-threatening cutaneous reaction with several complications. Although acute respiratory distress syndrome (ARDS) is rare, it can cause rapid and potentially fatal pulmonary dysfunction. Here, we present a case of TEN with ARDS attributed to acetaminophen. A 49-year-old woman with cerebral palsy was admitted to our hospital with a high fever and erythema of the face and trunk that developed 1 day earlier. She took acetaminophen twice at 4 and 1 day before admission. The erosion covered approximately 30% of the body surface area, and hemorrhagic erosions were observed on the lips (Figure 1A). TEN was diagnosed, with a severity-of-illness score (SCORTEN) of 3. Chest computed tomography (CT) revealed a bilateral infiltrative shadow in the lower lung fields (Figure 1B). Aspiration pneumonia was diagnosed. All medications were discontinued, and methylprednisolone pulse therapy (steroid pulse; 1000 mg/d for 3 days) was administered with antibiotics. On Day 2, she developed acute-onset dyspnea (SpO2: 70%-80%). Chest CT revealed spreading of the bilateral diffuse infiltrative shadow (Figure 1C). ARDS induced by TEN was diagnosed, and mechanical ventilation was initiated. Intravenous immunoglobulin therapy (IVIg; 400 mg/kg/d for 5 days) was administered after steroid pulse therapy, leading to rapid improvements in the skin and mucosal involvement. The prednisolone dosage was tapered to 30 mg/d, and re-epithelialization was completed on Day 19. Nevertheless, the ARDS responded poorly, and steroid pulse therapy was repeated on Days 19-21. Thereafter, the chest shadow and dyspnea gradually improved, and prednisolone was slowly tapered to 5 mg/d on Day 100. However, she developed an ARDS relapse a few days later and received steroid pulse therapy. The chest CT findings improved, although she could not be weaned from mechanical ventilation upon discharge at Day 150. A drug-induced lymphocyte stimulation test was positive for acetaminophen (stimulation index: 803%), and a patch test was negative. Reports describe an approximate respiratory complication rate of 40% during the acute phase of SJS/TEN.1 Prost et al reported that approximately 25% of SJS/TEN patients required mechanical ventilation (MV); of these cases, 57% had a fatal outcome.2 Lebargy et al reported that dyspnea, hypoxia, increased bronchial secretions, and normal chest X-rays within the first 3 days of illness indicated early bronchial involvement.3 To date, however, few case reports have described the features of SJS/TEN with ARDS. Three of 138 patients with SJS/TEN who were treated at our hospitals from 2000 to 2019 developed ARDS, of whom two (including the present case) survived. The third and fatal case did not begin treatment until more than 1 week postonset. Evidence regarding the effective treatment of pulmonary complications with SJS/TEN is lacking. Although antibiotics and steroids are commonly used,1 the effectiveness of systemic steroid therapy for ARDS remains controversial; some studies reported effectiveness,4, 5 while others reported no survival benefit.6, 7 Moreover, steroid-induced infections tend to worsen prognosis. We conclude that steroid initiation promptly after onset, followed by IVIg, may have contributed to our patient's survival. Additional case studies are needed to support future treatment development. The authors declare no conflict of interest.

Subphenotypes of nonsteroidal antiinflammatory disease-exacerbated respiratory disease identified by latent class analysis.

BackgroundInduced sputum (IS) allows to measure mediators of asthmatic inflammation in bronchial secretions. NSAID‐exacerbated respiratory disease (NERD) is recognized as a distinct asthma phenotype, usually with a severe course, eosinophilic airway inflammation, and increased production of pro‐inflammatory eicosanoids. A more insightful analysis of NERD patients has shown this phenotype to be nonhomogeneous.ObjectiveWe aimed to identify possible subphenotypes in a cohort of NERD patients with the means of latent class analysis (LCA).MethodsA total of 95 asthma patients with aspirin hypersensitivity underwent sputum induction. High‐performance liquid chromatography or gas chromatography coupled with mass spectrometry was used to profile eicosanoids in induced sputum supernatant (ISS). Sixteen variables covering clinical characteristics, IS inflammatory cells, and eicosanoids were considered in the LCA.ResultsThree classes (subphenotypes) were distinguished within the NERD cohort. Class 1 subjects had mild‐to‐moderate asthma, an almost equal distribution of inflammatory cell patterns, the lowest concentrations of eicosanoids, and logLTE4/logPGE2 ratio. Class 2 represented severe asthma with impaired lung function despite high doses of steroids. High sputum eosinophilia was in line with higher pro‐inflammatory LTE4 in ISS and the highest logLTE4/logPGE2 ratio. Class 3 subjects had mild‐to‐moderate asthma and were also characterized by eosinophilic airway inflammation, yet increased production of pro‐ (LTE4, PGD2 and 11‐dehydro‐TBX2) was balanced by anti‐inflammatory PGE2. The value of logLTE4/logPGE2 was between values calculated for classes 1 and 3, similarly to disease control and severity.ConclusionsLCA revealed three distinct NERD subphenotypes. Our results support a more complex pathobiology of aspirin hypersensitivity. Considering NERD heterogeneity, the relationship between inflammatory pathways and clinical manifestations of asthma may lead to more individualized treatment in difficult to treat patients in the future.