Chronic Obstructive Bronchopulmonary Disease Research Articles

Internações por Condições Sensíveis à Atenção Primária de um município do interior de Minas Gerais, Brasil

Objetivo: caracterizar as internações por condições sensíveis à atenção primária de um município do interior de Minas Gerais, Brasil. Método: estudo transversal, descritivo, com coleta de dados secundários de prontuários, provenientes de internações hospitalares. Foi elaborado um formulário de coleta estruturado em três blocos: sociodemográficos; relacionados à anamnese; e relacionados a internação. Foram realizadas as frequências absolutas e relativas das variáveis e utilização do Qui-quadrado de Pearson e o Exato de Fisher, considerando o nível de significância de 5%. Resultados: Foram identificados 663 prontuários, com predomínio de pacientes ≥ 60 anos (70.7%), sexo feminino (54,1%), raça/cor parda e preta (69,5%) e sem registro referente a presença ou ausência de fatores de risco (28,5%). Predominaram os diagnósticos de acidentes vasculares e insuficiência cardíaca congestiva ambos com 13,3%, pneumonia (11,0%), angina (9,5%) e doença bronco pulmonar obstrutiva crônica com 8,4% dos casos. Entre os 45 casos (6,8%) de óbito, 19 (42,2%) foram pacientes que não pertenciam à área com cobertura da equipe de Estratégia de Saúde da Família do município. Conclusão: Os resultados contribuirão para uma adequação e qualificação da gestão dos serviços de saúde e melhor planejamento dos cuidados prestados, assim como, a definição de indicadores de desempenho para atenção primária à saúde da região para que sejam controladas e reduzidas as taxas de hospitalizações evitáveis.

Mortality risk factors in lobectomies: Single-institution study

Abstract The need to identify the risk factors (RFs) predictive of mortality after pulmonary lobectomy has fuelled several single- or multi-institution studies, without establishing a prediction model of the generally accepted risk. Each single-institution study offers its own RFs, which corroborated with the RFs published in other multicentric studies may allow a better prediction of postoperative mortality for specific categories of patients. The aim of our study was to identify the 30-day mortality RFs in our lobectomy patients and to compare our results with those published in literature. We therefore analysed the influence of 49 perioperative parameters on postoperative mortality of consecutive lobectomy patients. The 192 lobectomy patients enrolled had malignant (81.25%) and infectious conditions (12.5%) and a 2.6% mortality rate. The results of our study support the following perioperative RF associated with a high mortality rate: thrombocytosis, chronic obstructive bronchopulmonary disease (COPD), digestive and hepatic comorbidities, neoadjuvant chemotherapy, tuberculosis, the American Society of Anesthesiologists rating and the characteristics of postoperative drainage. In conclusion, these RFs may serve as the factors to consider when calculating the mortality rate after lobectomy, in preoperative selection as well as in instruments for the assessment of postoperative results.

Cardiovascular events in patients with chronic obstructive bronchopulmonary disease.

Chronic obstructive bronchopulmonary disease: a multiorgan conditionChronic obstructive bronchopulmonary disease (COPD) is a chronic pulmonary disorder affecting small airway and pulmonary parenchyma. It is associated with excessive inflammatory response to cigarette smoking and other polluting agen

Kluyvera ascorbata infection in Cystic Fibrosis airway disease

Bacilli belonged to genus Kluyvera are Gram negative non-fermentative microorganisms described in the Enterobacteriaceae family, generally considered as saprophytes of the digestive tract.Their role in pathogenesis of infectious disease is unclear, but recently, they are emerged as a cause of clinically significant disease in no-CFpopulation and several anatomic sites are involved as urinary, respiratory and gastrointestinal tracts. In the present note, we describe the identification of Kluyvera ascorbata isolates, obtained from sputum samples of one CF patient (male, 10 years old). The note concerns a patient suffering from chronic obstructive bronchopulmonary disease and chronic Pseudomonas aeruginosa infection. Isolates showed a good growth on MacConkey agar and BCSA, after incubation at 37°C for 24-48 h and they were sensitive to several antibiotics, as cephalosporins, carbapenems, quinolones and trimethoprim-sulfamethoxazole. Clinical observation and the spirometric parameters early before and after isolation of microrganism did not show any worsening status in our patient. The selective pressure given by intensive use of antibiotics in CF patients increases susceptibility to infections by opportunistic microrganisms. Our report underlines the importance of careful bacterial identification and antimicrobial susceptibility study in defining the potential role of new pathogen bacteria in CF lung and to address possible therapeutic strategies that may help to guide antibiotic therapy regimes in CF patients.

A prospective study of febrile neutropenia in lung cancer patients

BACKGROUND There are few data on microbiology of febrile neutropenia (FN) in lung cancer patients. The primary objective of this study was to evaluate the epidemiology of FN in this population. PATIENTS AND METHODS All patients with lung cancer treated with chemotherapy in the Institut Jules Bordet (a cancer hospital) and who developed FN (PMN <500/mm3) were included in the present prospective study. Febrile neutropenia was defined as any febrile episode (38.5°C once or 38.0°C twice) occurring during neutropenia (neutrophil count <500/mm3). RESULTS Ninety five patients, 62 with non-small cell and 33 with small cell lung carcinoma developed FN. A total of 102 FN episodes were observed. Of these, 46 were microbiologically and 14 clinically documented. The most frequent site of infection was the lung (31%). Gram-negative bacteria, mainly Escherichia coli and Haemophilus influenzae, were most commonly observed. In bacteremic patients, Gram-positive bacteria, essentially Streptococcus sp, Enterococcus sp and Staphylococcus aureus, accounted for 39% of the micro-organisms. CONCLUSION Lung constitutes the predominant site of infection in febrile neutropenic lung cancer patients. In these patients, E. coli and H. influenzae are the most commonly documented pathogens, except in case of bacteremia where Streptococcus sp and S. aureus as well as E. coli are the principal pathogens. I N T R O D U C T I O N Infection is one of the commonest complications associated with cancer. Different factors are contributing: immunosuppression related to cancer or its treatment, visceral neoplastic obstruction, use of implantable devices and invasive procedures, disruption of physiological barriers or blood product transfusion [1]. In lung cancer patients neutropenia, chronic obstructive bronchopulmonary disease (COPD) and bronchial obstruction are probably the main causes favouring infection. Epidemiological data on infections in lung cancer patients are scarce. We have previously reported a prospective epidemiological study demonstrating that the majority of lung infections were predominantly due to Gram negative bacteria [2]. Few other studies have assessed the respective frequency of the infection types and microbiology in these patients, also demonstrating that infections occur essentially in the lung. Chemotherapy is now generally accepted as part of the treatment of patients with lung cancer, whatever stage or histology are considered [3-5]. Chemotherapy is ORIGINAL ARTICLE HOSPITAL CHRONICLES 2007, 2(1): 38–43 Address for correspondence: Dr T. Berghmans Institut Jules Bordet Rue Hιger-Bordet, 1 1000 Bruxelles Belgium Tιl: +322.5413191 Fax: +322.5343756 e-mail: thierry.berghmans@bordet.be KEy-wORDS: febrile neutropenia, microbiology, non-small cell lung cancer, small cell lung cancer, epidemiology, risk

Sigmoid capnometry in abdominal aortic aneurysm surgery

A reply EDITOR: We thank Dr Björck for his interest in our work [1] and for giving us the opportunity both to re-emphasize points made in our paper and to correct a reference mistake in the published version. We first apologize to Dr Björck for the reference error in the third paragraph of the discussion part where reference 10 should in fact be reference 19. Furthermore, we share Dr Björck's point of view that sigmoid tonometry monitoring in surgery for aortic aneurysm is best indicated in high-risk patients. In our study, patients included were at high risk with a Parsonnet score ≥4; six of our patients had a combined history of myocardial necrosis and severe chronic obstructive bronchopulmonary disease. The surgical procedure was also particularly difficult as attested by long surgical and clamping times. All these factors explain our high frequency of ischaemic colitis. These patients were selected voluntarily because the main objective of our study was to compare the sigmoid-to-arterial PCO2 gap with the mucosal aspect as assessed by colonoscopy, which is the reference diagnostic tool of ischaemic colitis. It was interesting to observe that patients with the highest PCO2 gap were those who developed the most severe postoperative ischaemic colitis. However, our study was not powerful enough to determine the limits of the PCO2 gap, thus not allowing us to distinguish a normal from an ischaemic intestinal mucosa. In our practice, we do not argue about the sole regional PCO2 but we compare it with arterial PCO2 since tissue PCO2 concentration is dependent on the PCO2 of the perfusing arterial blood. A regional-to-arterial PCO2 gap >4 kPa provides sufficient information suggesting bowel mucosal low flow associated with O2 uptake-to-supply dependency [2], a state known as dysoxia. In this study [1], endoscopically proven ischaemic colitis was shown for PCO2 gaps >6-8 kPa. This leads us to think that a sigmoid PCO2 >15 kPa, an upper technical limit with the Tonocap® as emphasized by Björck [3], is so high, that the intestinal mucosa obviously suffers from dysoxia, preventing any doubt or interpretation. We emphasize furthermore that in our hands PrCO2 rarely goes beyond 10-12 kPa [1]. We would like to point out that trends - rather than absolute PCO2 or pHi - much better reflect any underlying regional PCO2. Therefore, a high PCO2 gap, which persists after aortic declamping without any improvement in the initial postoperative period, will alert the clinicians to perform a colonoscopy. For this reason, automatic measurements of PCO2 are certainly of great help. We agree with Dr Björck that sigmoid capnometry in aortic surgery will be mostly valuable in high-risk patients, whereas further prospective and multicentre studies are required to determine the lower limit of the PCO2 gap associated with colitis dysoxia and the influence of therapeutic correction of a high PCO2 gap on the incidence of bowel injury. G. Lebuffe B. Vallet Department of Anaesthesia and Intensive Care Medicine; University Hospital; Claude Huriez Hospital; Lille, France

Facteurs de risque de mortalité après chirurgie de l’aorte abdominale

Objective: To analyse pre and peroperative variables for predicting mortality after abdominal aortic surgery. Study design: Prospective study. Patients: We prospectively included 658 consecutive patients undergoing abdominal aortic surgery from January 1993 to July 1997. Methods: Age, gender, hypertension, history of myocardial infarction or coronary revascularization, angina pectoris, diabetes, arrhythmia, cardiac insufficiency, serum creatinine > 150 μmol·L –1, beta-blockers therapy, calcium channel inhibitors, angiotensin converting enzyme inhibitors were preoperative analysed variable. Type of aortic disease (anevrysms versus aortic occlusion), duration of surgery, blood loss, type of laparotomy (medium versus lombotomy) were peroperative analysed variables. Haemoglobinemia was monitored during surgery and patients were transfused if haemoglobinaemia < 80 g·L –1. Results: Thirty-three patients died after aortic surgery (5%). In multivariate analysis, angina pectoris (OR = 5.47, P < 0.001), chronic obstructive bronchopulmonary disease (OR = 2.27, P = 0.05) and duration of surgery (OR = 1.60, P < 0.001) were the independent predictive factors of mortality. Age, blood loss were predictive factors only in univariate analysis. Conclusion: Angina pectoris and COBP were the two independent preoperative factors of mortality. The duration of surgery was the only peroperative factor. Well monitored blood loss was not a predictive factor.

膿胸症例98例の分析

Ninety-eight cases of empyema thoracis admitted to Juntendo University Hospital between 1979 and 1990 were reviewed. Males accounted for 78 cases and females 20 cases. Thirteen pediatric patients ranged in age from 17 days to 4 years, while the 85 adult cases ranged from 16 to 89 years (mean: 58.4 years). The mortality rate increased with age. Fifty-three cases of community-acquired empyema thoracis consisted of 24 with no underlying disease (including 13 pediatric cases), and 29 with diabetes mellitus, alcoholic liver damage or chronic obstructive bronchopulmonary disease. Forty-five nosocomial empyema cases occurred after chest operation or thoracocentesis, or due to a subdiaphragmatic pathogenic condition or congestive heart failure complicated with aspiration pneumonia. In this series, 63 patients (64.3%) had para- or post-pneumonic empyema. Compared with the community-acquired infection cases, the mortality rate of the nosocomial infection cases was very high. Seventy-eight cases were culture-positive, including 3 positive for Mycobacterium tuberculosis. The remaining 20 cases were culture-negative. In 75 cases of culture-positive pleural fluid, aerobic bacteria were isolated from 31 cases (mortality rate: 22.6%), anaerobes mixed with aerobes from 21 cases (mortality rate: 52.4%), and anaerobes only from 23 cases (mortality rate: 21.7%). Thus, the mortality rate of mixed infected cases was highest. Anaerobes were frequently isolated from the community-acquired empyema cases, and were often found in para- or postpneumonic lesions, including aspiration pneumonia. The most commonly encountered aerobe was Staphylococcus aureus. Among the anaerobes, Bacteroides spp., microaerophilic streptococcus, Peptostreptococcus and Fusobacterium spp. were most common. A single organism was isolated in pure culture from 39 cases. Single organisms isolated from fluids were more frequently aerobes (25) than anaerobes (14). The cases harboring Bacteroides spp. showed the worst outcome, with 11 deaths in 25 such cases.

Pulmonary Concerns and the Exercise Prescription

When writing an exercise prescription, the contributions of the pulmonary system are commonly forgotten. The lung has a tremendous potential to improve its work output, and its contributions are only realized when pulmonary disease or environmental stresses of altitude limit pulmonary performance. At altitudes of 5000 feet above sea level, hypoxia is significant in limiting aerobic capacity, and the exercise prescription should follow relative percentages of VO2max guided by the training heart rate rather than actual work output. Training at altitude will improve performance at altitude, but training at altitude does not always improve sea level performance. Suggestions of using longer recovery intervals, sojourns back and forth from sea level to altitude, and shorter-duration, high-intensity exercise sessions may help improve sea level performance, but more research is needed. The limitations of reactive airway disease and exercise-induced asthma can be minimized with proper attention to training techniques, environmental modifications, and pharmacologic treatment. In the 1984 Olympics, 41 medals were won by athletes with the diagnosis of reactive airway disease. Finally, the crippling limitations of chronic obstructive bronchopulmonary disease can be improved by a proper exercise rehabilitation program that uses an accurate and thorough assessment procedure prior to beginning an exercise program. Also, careful follow-up and continual monitoring of cardiac rhythm, oximetry, and exercise intensity of the pulmonary impaired patient will result in optimal improvement in the patient's sense of well-being, tolerance to dyspnea, and increased ability to do aerobic work, as well as an enhanced quality of life.

Tracheal Hamartoma

We present the findings in a man with longstanding airway obstruction attributed to chronic obstructive bronchopulmonary disease. After hospitalization, a tracheal hamartoma was found and resected, without complications. Symptoms of chronic airway obstruction can cause the physician to treat medically a surgically curable lesion.

Pulmonary emphysema and alpha1-antitrypsin deficiency.

A literature review is presented of a deficiency of the major serum alpha1-globulin, alpha1-antitrypsin, a rare inherited autosomal recessive trait which is associated with development of chronic obstructive bronchopulmonary disease, especially emphysema. The serum level of alpha1-antitrypsin has a trimodal distribution among family members which consists of a severe deficiency or homozygous state, an intermediate deficiency or heterozygous state, and the normal state. The unique characteristics of pulmonary emphysema in each state are discussed and the methods for measuring the serum level of alpha1-antitrypsin are described. A mechanism is proposed, as speculated by several authors, by which this serum protein deficiency might produce pulmonary lesions. Implications for the future are presented should further research define clearly the relationship between alpha1-antitrypsin deficiency and pulmonary emphysema.

Right ventricular function and pulmonary hemodynamics during exercise in patients with chronic obstructive bronchopulmonary disease.

Central hemodynamics were examined in 50 patients with chronic obstructive bronchopulmonary disease at rest and during mild steady-state supine exercise. The cardiac output rose proportionally to increased oxygen uptake in most cases; there was no difference between the patients with and without chronic right heart failure (RHF). The mean pulmonary arterial pressure in exercise increased disproportionally to cardiac output in about half of the compensated patients and in all cases with RHF. The pulmonary vascular resistance did not change significantly. The right ventricular end-diastolic pressure (RVEDP) at rest was significantly higher in the patients with RHF than in the other but the individual variations were large. Thus, the resting RVEDP cannot be considered as a reliable sign of RV functional abnormality in individual cases. Better agreement with clinical classification of the patients was obtained when considering the exercise values of RVEDP and particularly the relation of RVEDP to stroke volume during exercise.

Management of chronic bronchitis.

It has been estimated that respiratory conditions account for 25 % of all illness in general practice. One of the commonest of these conditions is chronic obstructive broncho-pulmonary disease. This term has been coined because of the difficulty in separating the various components of the group chronic bronchitis, emphysema, asthma and bronchiectasis. All may be present in one individual or one disease may present in a relatively pure state. This article is concerned with the treatment of those patients in whom chronic bronchitis is the dominant condition.

Morphometric study in chronic obstructive bronchopulmonary disease. Pathologic, clinical, and physiologic correlations.

Morphometric study in chronic obstructive bronchopulmonary disease. Pathologic, clinical, and physiologic correlations.

Peripheral neuropathy in chronic disease of the respiratory tract

Eight patients with chronic obstructive bronchopulmonary disease were studied. In seven who had wasting associated with chronic respiratory tract disease, evidence of peripheral neuropathy was found on clinical and electromyographic examinations. Histologic changes were also present in muscle and sural nerve biopsy specimens from these patients. Biochemical analysis of these sural nerve specimens showed them to differ from those in normal control subjects and patients with alcoholic neuropathy. It is suggested that the neuropathy in chronic obstructive bronchopulmonary disease might be due to abnormalities in the metabolism of Schwann cells.

The Many Faces of Emphysema

To the Editor:— Will we ever agree on a single term to describe the diffuse lung damage associated with cigarette smoking? Here are some terms in current use: Emphysema Chronic emphysema Pulmonary emphysema Destructive emphysema Chronic emphysema and bronchitis Chronic nonspecific lung disease Chronic obstructive lung disease Chronic obstructive airway disease Chronic obstructive pulmonary disease Chronic obstructive ventilatory disease Chronic obstructive bronchopulmonary disease Irreversible general obstructive lung disease Obstructive ventilatory disease of the lung Some authors will use one of these terms for one disease and a second term for another disease. If so, it is difficult to find uniformity among the workers in this field as to where the line is drawn. This disease, whatever we choose to call it, is most certainly important. Let us hope that authors and editors will come to some sort of agreement on naming it. Emphysema, alone, will certainly not do. There are

Chronic obstructive bronchopulmonary disease: II. Oxygen transport in two clinical types

Two contrasting types of patients with chronic airway obstruction were distinguished by purely clinical criteria: the emphysematous type (herein referred to as PP patients) and the bronchial type (BB patients). In the autopsy cases there was somewhat more extensive emphysematous destruction of the lungs and much less evidence of active bronchial mucous gland hyperplasia in the former type than in the latter. These two types of patients were studied physiologically and were found to have equivalent degrees of ventilatory impairment. However, PP patients had larger lungs, more uniform distribution of inert gas (helium) and hyperventilated both at rest and during exercise. BB patients had higher carbon dioxide tensions and much lower arterial oxygen saturations than did PP patients. The severe hypoxemia in BB patients was not caused by alveolar hypoventilation per se nor could it be satisfactorily explained by calculations of gas and blood flow distribution in the lungs. The most consistent measured difference relevant to pulmonary oxygen transport in the two types was in pulmonary blood flow: PP patients had subnormal and BB patients normal cardiac outputs both at rest and during exercise. The higher ratio of total ventilation to total blood flow in PP patients probably accounted for the nearly normal arterial oxygenation. The hypoxemia in BB patients is considered to be a form of diffusion impairment resulting from too rapid flow of red blood cells through hypoventilated alveoli. The most consistent measured difference relevant to tissue oxygenation in the two types was in the systemic oxygen transport (product of total blood flow and arterial blood oxygen content). Because of their low cardiac outputs, PP patients, although their arterial blood had a higher oxygen pressure, delivered less oxygen to their tissues than BB patients, who maintained a normal cardiac output despite a greater degree of pulmonary hypertension. These findings may account for the cachexia of the former and the cor pulmonale of the latter patients.

Peptic Ulcer and Chronic Obstructive Bronchopulmonary Disease: A Prospective Clinical Study of Prevalence

Peptic Ulcer and Chronic Obstructive Bronchopulmonary Disease: A Prospective Clinical Study of Prevalence

Heparin in the treatment of chronic obstructive bronchopulmonary disease

Intravenous heparin has been evaluated by a double-blind technic in the treatment of obstructive bronchopulmonary disease. Release of bronchospasm and elimination of obstructing mucous secretions was observed in 11 of 19 patients (58%) treated with intravenous heparin. Marked improvement was observed in an additional patient and failure was observed in only 6 patients (22%) so treated. Fourteen (77%) of 18 control patients demonstrated little or no response to an injected placebo, while 2 patients (11%) demonstrated an apparently beneficial effect from the placebo. The mechanism of this antiinflammatory and antiallergic effect of heparin is not presently known. Additional observations suggest that heparin enhances the antibacterial activity of certain antibiotics, namely, Coly-Mycin and neomycin, in the treatment of resistant Pseudomonas aeruginosa infection. Finally, in 2 patients, heparin appeared to prevent or reduce toxic side effects of Coly-Mycin without interfering with its antibacterial activity.