Exacerbation Of Respiratory Symptoms Research Articles

A Case Report and Literature Review of a Triple-Vaccinated, Rituximab-Treated Systemic Lupus Erythematosus patient with COVID-19 pneumonia

Introduction: Patients being on immunosuppressive treatment of any reason, along with other risk factors such as smoking and obesity, are vulnerable to be infected from SARS-CoV2. Aim of this report is to describe a case of a female patient under Rituximab therapy who experienced episodes of lung infection due to Severe Acute Coronavirus 2 (SARS-CoV-2) invasion although fully vaccinated. Case report: A 50-year-old woman, with a past medical history of lupus nephritis on rituximab was diagnosed with lung infection due to SARS-CoV-2. Eight months later, following her last infusion of Rituximab (RTX), she developed moderate Coronavirus Disease 2019 (COVID-19). After a partial recovery, she exhibited exacerbation of respiratory symptoms leading to readmission and invasive oxygenation. She was eventually discharged home after 31 days. Her monthly neurological evaluation did not reveal evidence of disease activity. She later received intravenous immunoglobulin and a decision was made to restart rituximab. Conclusions: This case raises the possibility of persistent virus shedding and reactivation of severe acute respiratory syndrome coronavirus in a patient with SLE and Rituximab therapy. We emphasize a precise consideration of management of patients with autoimmune disorders during the COVID-19 pandemic.

First report of SAVI syndrome in Panama due to a variant of the STING1 gene in patient with emphysema and idiopathic pulmonary fibrosis

Introduction: The STING gene (Stimulator of Interferon Genes) emerges as a key element in the understanding and management of hyperinflammation and autoimmune conditions. Case: We report an adolescent patient with a history of asthma since early childhood, who after a SARS-CoV-2 infection, presented an exacerbation of respiratory symptoms, detecting emphysema, bronchiectasis and pulmonary fibrosis and in whom a pathogenic variant with gain of function of the STING gene was detected, allowing the diagnosis of SAVI (Sting-Associated Vasculopathy with onset in Infancy), which is the first case reported in Panama. Conclusions: JAK protein inhibitors and other innovative strategies constitute a therapeutic option in these cases, as well as other innovative strategies still under development, in which interferon inhibitors such as Zeatin, a cytokinin present in plants, as well as other natural products, may play a role.

Frequency of Occurrence of Leukocytosis in Patients with Acute Exacerbation of Copd at a Tertiary Centre

COPD is a major cause of chronic morbidity and mortality; it is currently the fourth highest cause of death in the world, and is predicted to be the third leading cause of mortality worldwide by the year 2020 [1-2]. COPD is identified mainly according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines; [post bronchodilator forced expiratory volume in 1 s (FEV1)/forced vital capacity ratio less than 0.7; severity determined by FEV1 alone] combined with a history of exposure to risk factors [2]. Exacerbations of respiratory symptoms in COPD are of major importance because of their profound and long lasting adverse effects on patients [3]. Frequent episodes accelerate loss of lung function, affect the quality of life of patients, and are associated with poor survival. There are some specific blood biomarkers for predicting lung function decline, acute exacerbation, or even mortality from big longitudinal cohort studies. However, their performance is depressing [4] . Peripheral blood leukocytosis has already been well investigated in the aspect of inflammatory biomarkers for COPD. The level of leukocytes is a key parameter in the clinical assessment of patients with COPD exacerbation, with and without fever. The presentation of high WBC count makes it important to distinguish the effect of the glucocorticosteroid from the effect of the possible infection [5-7].

Management of Severe Persistent Asthma Stage 4 Gina Associated with Multiple Pulmonary Complications

Abstract We present the case of a 42-year-old female patient, known with the diagnosis of severe persistent l asthma stage 3 Gina since 2012, for which she is on treatment with Formoterol/Budesonid (Symbicort) 160mcg/4.5 mcg 1 puff/12 h, inhaler, daily and Salbutamol (Ventolin) 100 mcg, 2 puffs as needed, maximum 6 puffs/24 h, inhaler, who is being treated for exacerbation of respiratory symptoms. It is important to mention the onset of asthma - at the age of 1 year, with rapidly progressive evolution towards the severe stage and association of multiple pulmonary complications. In order to determine the evolutionary stage of the disease and the therapeutic management, spirometry, DLCO examination and native thoraco-pulmonary CT was performed, the patient presenting an important atopic field: multiallergy-environmental factors and iodine. After the establishment of the therapeutic step and the degree of severity, a complex, multimodal treatment was initiated, with a relatively good evolution and prognosis, provided the patient's compliance.

Rare primary pulmonary mucosa-associated lymphoid tissue lymphoma misdiagnosed with tuberculosis: A case report.

Primary pulmonary mucosa-associated lymphoid tissue lymphoma (MALToma) is a rare subtype of non-Hodgkin lymphoma with a relatively low incidence rate clinically. Atypical clinical symptoms and nonspecific chest computed tomography features of the disease make it difficult to determine and treatment is delayed. We discuss the diagnosis and treatment of a patient with primary pulmonary MALToma to raise clinicians' awareness of this condition. A 66-year-old male patient with a medical history of tuberculosis has been experiencing progressive exacerbation of respiratory symptoms and nonresponsive treatment without an unclear diagnosis for 5 years. He was transferred to our hospital because a nonspecific soft tissue mass in the right upper lobe of the lung was found on his chest computed tomography. Laboratory results with serum immunofixation electrophoresis showed polyclonal immunoglobulin (Ig) G, IgM, IgA, and λ-light chain on admission. Pathological examination and immunohistochemical staining of lung biopsy revealed a definitive diagnosis of pulmonary MALToma with stage IV. The patient received immunotherapy with anti-CD20 monoclonal antibody (rituximab), and showed significant clinical improvement at the 6-month follow-up. Diagnosis of primary pulmonary MALToma mainly relies on histopathological examination, and comprehensive laboratory examinations are also necessary. Clinicians should combine laboratory tests (such as immunofixation electrophoresis in our case) to assist in medical diagnosis in cases of atypical clinical manifestations and imaging characteristics. Immunotherapy appears to be the main treatment protocol for advanced patients.

The Possible Role of Food and Diet in the Quality of Life in Patients with COPD-A State-of-the-Art Review.

Diet has been described as a modifiable risk factor for the development and progression of chronic diseases, and emerging evidence increasingly points to its preventive and therapeutic role in chronic obstructive pulmonary disease (COPD). While the relationship between the underlying disease and diet is natural in conditions such as metabolic disorders, obesity, diabetes, etc., the direct effect is not so evident in chronic obstructive pulmonary disease. Poor diet quality and the development of nutrient deficiencies in respiratory diseases, including COPD, can be associated with disease-specific factors such as the exacerbation of respiratory symptoms. These symptoms can be improved by dietary interventions, leading to positive changes in the pathogenesis of the disease and the quality of life of patients. Therefore, our aim was to review the latest randomized controlled trials (RCTs) of dietary interventions in chronic respiratory patients and describe their effects on respiratory function, physical activity, systemic inflammatory parameters, and quality of life. We conducted a literature search on dietary interventions for COPD patients in the PubMed, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials (CENTRAL) databases, focusing on publications from 1 July 2018 to 1 July 2023. We used specific keywords and MESH terms, focusing on RCTs. A total of 26 articles and 1811 COPD patients were included in this review. On the basis of our findings, dietary interventions, in particular components of the Mediterranean diet such as protein, omega-3 polyunsaturated fatty acids, and vegetables, appear to have beneficial effects in patients with chronic respiratory diseases, and their application is beneficial. However, long-term follow-up studies are still needed to examine the effects of dietary interventions in this patient population.

Comparison of the clinical outcomes of patients with NSAID-exacerbated respiratory disease receiving aspirin or biologicals

Objective NSAID-exacerbated respiratory disease (NERD) is characterized by exacerbation of respiratory symptoms after NSAID intake. While research for specific treatment options continues in patients who cannot tolerate or are unresponsive to aspirin treatment after aspirin desensitization (ATAD), biologicals have emerged as a new therapeutic option in NERD patients. The aim of this study was to compare the quality of life, and the sinonasal and respiratory outcomes of NERD patients treated with ATAD or biologicals. Methods Patients who have been followed up at a tertiary care allergy center and who have been receiving at least one of ATAD, mepolizumab or omalizumab for at least six months were included. Evaluations were made using sinonasal outcome test (SNOT-22), asthma control test (ACT), short form-36 (SF-36), blood eosinophil counts, need for recurrent functional endoscopic sinus surgeries (FESS), and asthma or rhinitis exacerbations requiring oral corticosteroids (OCS). Results A total of 59 patients comprised of 35 (59%) females and 24 (41%) males with a mean age of 46.1 (min-max, 20–70) years were included. The baseline blood eosinophil count was higher, and a significant decrease in blood eosinophil counts was observed in the mepolizumab group compared to ATAD group (p = 0.001, p < 0.001, respectively). At follow-up, the rate of recurrent FESS was lower in the group that received mepolizumab (p = 0.02). Conclusions In NERD patients, mepolizumab significantly decreased blood eosinophil counts and recurrent FESS. There was no significant difference between the patients receiving ATAD or mepolizumab regarding other clinical parameters.

Clinical Profile and Quality of Life of Patients With Post-pulmonary Tuberculosis Sequelae Presenting to a Tertiary Care Hospital.

Background and objective There is a dearth of studies on the clinical presentation of patients with post-pulmonary tuberculosis (PTB) sequelae and its impact on their quality of life (QoL). In light of this, we conducted this study to analyze the clinical profile and QoL in patients with post-PTB sequelae. Methods Patients with a history of treated PTB and evidence of radiological damage were enrolled prospectively from November 2018 till June 2020 to study their clinical profile and QoL as per the eligibility criteria. A detailed clinical history was taken along with posteroanterior-view chest X-rays and CT scans of the thorax with bronchial angiography in patients with hemoptysis. QoL was assessed using theHindi version of St. George's Respiratory Questionnaire (SGRQ) for which permission was obtained from the St. George's University of London. SGRQ scores were calculated using score calculation algorithms (Microsoft Excel-based) and missing data imputation as recommended by its developer. Results A total of174 patients were included in the analysis. The analyzed population was relatively younger (mean age: 44.27 years) with BMIs leaning toward the lower side of normal (median: 19.6 kg/m²); the majority of the patients were males (59%) and non-smokers (77%). PTB had been diagnosed clinico-radiologically in the majority (68%) of patients with non-compliance to antitubercular treatment (ATT) being reported by only 9% of patients. Multiple courses of ATT were received by about one-third of patients, mainly on a clinico-radiologic basis. Systemic hypertension (HTN) (11%) and diabetes mellitus (DM) (9%) were the most common comorbidities. The most common symptom complex found was cough, expectoration, and dyspnea (n=102, 59%). At least one incidence of massive hemoptysis was reported by 20% of patients. Bronchial artery embolization (BAE) was performed for moderate to massive hemoptysis in 26% of patients with a success rate of >90%. One-fifth of the study participants required hospitalization for exacerbation of respiratory symptoms with more than half of these (59%) requiring ventilatory support. Health-related QoL was significantly impaired as reflected by amedian SGRQ total score of 45.53. The most affected domain of QoLwas the activity domain (mean score: 45.47). Females had worse QoL as compared to males (p=0.0062), and so did underweight patients (p=0.048). The prolonged duration of the illness also significantly impaired the QoL (p<0.001, r=0.313). Conclusion The sequelae of PTB are under-recognized even among physicians and are frequently misdiagnosed as active PTB. The QoL is more severely affecteddue to residual damage. This study highlights the clinical profile of this patient population and underscores the need to recognize post-PTB sequelae as a separate entity. An important remedy to mitigate its long-term consequences is its inclusion and recognition in national and international TB guidelines to facilitate its early identification and promote further research to address its evidence-based management.

Incidence of acute exacerbation in patients with interstitial lung disease after COVID-19 vaccination

Acute exacerbations due to COVID-19 vaccination in patients with interstitial lung disease (ILD) have been reported, but their incidence is unknown. We investigated the incidence of exacerbations of ILD and respiratory symptoms due to the mRNA COVID-19 vaccines. A questionnaire survey was conducted on adverse reactions to the mRNA COVID-19 vaccination in 545 patients with ILD attending our hospital and retrospectively examined whether the eligible patients actually developed acute exacerbations of ILD induced by the vaccine. Of the 545 patients, 17 (3.1%) patients were aware of the exacerbation of respiratory symptoms, and four (0.7%) patients developed an acute ILD exacerbation after vaccination. Of the four patients who experienced exacerbations, two had collagen vascular disease-associated ILD, one had nonspecific interstitial pneumonia, another had unclassifiable idiopathic pneumonia, and none had idiopathic pulmonary fibrosis. Four patients were treated using steroid pulse therapy with a steroid taper, and two of the four also received intravenous cyclophosphamide pulse therapy. Tacrolimus was started in one patient with myositis-associated interstitial lung disease. Eventually, all patients exhibited improvement with immunosuppressive treatment and were discharged. COVID-19 vaccination for patients with ILD should be noted for developing acute exacerbations of ILD with low incidence, although manageable with early diagnosis and treatment.

Etiology of Emergency Visit and In-Hospital Outcomes of Patients with COPD.

Backgrounds Patients with COPD often visit the emergency department (ED) due to exacerbation of respiratory symptoms (dyspnea, cough, and sputum production). Because manifestations of acute exacerbation of COPD (AECOPD) are nonspecific, differential diagnosis is critical in this acute setting. The causes for emergency visiting and the in-hospital outcomes are varied in patients with COPD. This study aimed to investigate the distributions of etiologies and the in-hospital outcomes of patients with COPD who presented to the ED because of exacerbation of respiratory symptoms. Methods This was a retrospective study on COPD patients who had visited the ED and been hospitalized in a tertiary hospital because of worsening respiratory symptoms including cough, sputum production, and dyspnea from January 2017 to April 2020. Demographics, clinical manifestations, and laboratory studies in the ED were collected as the baseline data. The primary diagnosis at discharge or death was recorded. The hospitalization settings (general wards and ICU), the in-hospital outcomes, and associated factors were analyzed. Results During the study period, 392 patients with COPD (male 302 (77.0%)), with a median age of 78 years, visited the ED and hospitalized in this hospital. The first 3 causes for emergency visit were AECOPD (n = 314, 80.1%), acute coronary artery syndrome with or without congestive heart failure (n = 24, 6.1%), and pulmonary embolism (n = 13, 3.3%). For patients with AECOPD (n = 314), 51.6% (n = 162) was admitted to ICU, and 6.4% (n = 20) died. Multivariate logistic analysis showed that age, atrial fibrillation, NT-pro BNP ≥300 pg/ml, and blood pH <7.3 were independent risk factors for ICU admission. Age, comorbid malignancy, NT-pro BNP ≥1800 pg/ml, and pneumonia on CT scan were independent risk factors for hospital mortality in patients with AECOPD. Conclusion In COPD patients visiting the ED because of worsening respiratory symptoms, nearly 20% were due to non-AECOPD causes. For those with AECOPD, age, atrial fibrillation, NT-pro BNP ≥300 pg/ml, and blood pH <7.3 were independent risk factors for ICU admission, while advanced age, underlying malignancy, elevated NT-pro BNP, and pneumonia on CT scan were risk factors for hospital mortality.

Birch pollen, air pollution and their interactive effects on airway symptoms and peak expiratory flow in allergic asthma during pollen season – a panel study in Northern and Southern Sweden

BackgroundEvidence of the role of interactions between air pollution and pollen exposure in subjects with allergic asthma is limited and need further exploration to promote adequate preventive measures. The objective of this study was to assess effects of exposure to ambient air pollution and birch pollen on exacerbation of respiratory symptoms in subjects with asthma and allergy to birch.MethodsThirty-seven subjects from two Swedish cities (Gothenburg and Umeå) with large variation in exposure to both birch-pollen and air pollutants, participated in the study. All subjects had confirmed allergy to birch and self-reported physician-diagnosed asthma. The subjects recorded respiratory symptoms such as rhinitis or eye irritation, dry cough, dyspnoea, the use of any asthma or allergy medication and peak respiratory flow (PEF), daily for five consecutive weeks during two separate pollen seasons and a control season without pollen. Nitrogen oxides (NOx), ozone (O3), particulate matter (PM2.5), birch pollen counts, and meteorological data were obtained from an urban background monitoring stations in the study city centres. The data were analysed using linear mixed effects models.ResultsDuring pollen seasons all symptoms and medication use were higher, and PEF was reduced in the subjects. In regression analysis, exposure to pollen at lags 0 to 2 days, and lags 0 to 6 days was associated with increased ORs of symptoms and decreased RRs for PEF. Pollen and air pollution interacted in some cases; during low pollen exposure, there were no associations between air pollution and symptoms, but during high pollen exposure, O3 concentrations were associated with increased OR of rhinitis or eye irritation, and PM2.5 concentrations were associated with increased ORs of rhinitis or eye irritation, dyspnea and increased use of allergy medication.ConclusionsPollen and air pollutants interacted to increase the effect of air pollution on respiratory symptoms in allergic asthma. Implementing the results from this study, advisories for individuals with allergic asthma could be improved, minimizing the morbidities associated with the condition.

Treatment of Pulmonary Sarcoidosis Using Allogenic Bone Marrow-Derived Mesenchymal Stem Cell Therapy is Safe: A Case Report

Mesenchymal stem cells have a proven potent immunomodulatory effect both in vitro and in vivo. We report a case of a 67-year-old male patient, first diagnosed with sarcoidosis in 2005, that responded well clinically and biologically to ImmunoARTTM (developed by Educell Ltd.) allogenic, HLA-incompatible, and non-related bone marrow-derived MSCs in a dose of 106/kg. The patient presented to St. Catherine Specialty Hospital in 2021 with an exacerbation of respiratory symptoms. After a clinical and radiological examination with laboratory workup, radiological findings were consistent with pulmonary sarcoidosis, while laboratory work revealed increased leucocytes at 14.2 g/L, CRP at 51.2 mg/L, and lymphocytes at 4.25 g/L. The patient was then administered intravenous application of MSCs on three occasions in the out-patient clinic. MSC doses were prepared from a young, healthy donor who agreed to donate bone marrow for allogeneic treatment and who was negative for viral markers (HBs Ag, HBc Ab, HCV Ab, HIV 1-2 Ab, TPHA, HBV NAT, HCV NAT, HIV NAT) according to EU legislation. Cells were prepared in a controlled and verified laboratory for “Hospital exemption” cell preparation in the cleanroom facility in safety cabinet class A and expressed CD105, CD 73, and CD 90 but lacked the expression of CD45 and CD34. Before the treatment, standard print and detailed verbal information were provided to patients undergoing treatment. Immediately after the informed consent form (ICF) was signed by the patient. Throughout MSC therapy, the patient showed an improvement clinically and biologically with a decrease in inflammatory parameters. Laboratory values were assessed on days 2, 5, and 7. On day 7, leucocytes were 11.2 g/L, CRP 5.1 mg/L, and lymphocytes 4.0 g/L. In the follow-up period, the patient felt subjectively better, without any side effects of the MSC therapy. Unfortunately, the patient dropped out from follow-up, therefore, the prolonged effects of this therapy were not able to be assessed. Therefore, systemic MSC therapy presents an opportunity to treat sarcoidosis that needs to be further researched.

Effect of comprehensive yoga therapy on pulmonary function among various groups with chronic obstructive pulmonary disease

Introduction and Aim: COPD is a disease with involvement of multiple organ system. Our previous study has proved yoga to be useful in improving the lung function. The current study assesses the effect of yoga on lung function with respect to age, duration of illness and severity of disease due to COPD. Materials and Methods: Thirty cases of COPD were recruited in this study. Cases were assessed for lung function, peripheral oxygen saturation and exercise tolerance by 6MWT. Patients were exposed to yoga within their capacity of feasibility, and assessed for above parameters at the end of each month for about three months. A comparison study of various parameters following yoga based on age, duration of illness and severity of disease was done applying independent t test. Variables were expressed as Mean±SD. P&lt;0.05 was considered the threshold for statistical significance. Results: there was an average increase in FEV1% by 5.2 in &lt;65 years, compared to FEVI% by11.4 in &gt;65yrs (p&lt;0.05). FEV1/FVC (%) in both the age groups showed similar response following yoga intervention (p&lt; 0.01 level). We did not get any significant results with duration of illness and severity of disease. Conclusion: Regular yoga practice improves the lung parameters and also the respiratory muscle strength. In this study, COPD patients falling under higher age groups showed more of benefit with yoga. We could not elucidate any response in lung function following yoga based on duration of illness and disease severity. Yoga practice is useful in improving lung parameters in higher age groups. Regular practice of yoga has helped patients with relief from frequent exacerbation of respiratory symptoms.

Activation of platelet-adherent basophils in chronic rhinosinusitis with alcohol hypersensitivity

BackgroundAlcohol hypersensitivity (AH), an exacerbation of respiratory symptoms in response to alcohol consumption, is common in aspirin-exacerbated respiratory disease and other forms of chronic rhinosinusitis (CRS). We speculated that these reactions relate to the activation of innate immune cells including basophils and, in particular, platelet-adherent basophils by polyphenolic compounds contained within eliciting alcoholic beverages. ObjectiveWe investigated the absolute numbers of these cells in patients with AH and the ability of relevant polyphenolic compounds to cause cellular activation. MethodsData were collected from 412 consecutive adults presenting to a tertiary care sinonasal clinic in whom the presence of AH was elicited. The CRS phenotype was determined and results from complete blood cell count and differential were analyzed. A subset of patients was invited to donate blood samples that were used to explore the ability of relevant compounds associated with alcohol consumption to activate platelet-nonadherent and platelet-adherent basophils. Activation was quantified by flow cytometry as up-regulated expression of CD63 and as secretion of lipid metabolites. ResultsOf the 412 patients enrolled, 69 (16.7%) endorsed having AH. Significantly higher platelet counts were seen in patients reporting AH. Red wine extract and several polyphenolic compounds produced basophil activation and this was primarily observed among platelet-adherent basophils. Platelet activation was further established as the release of thromboxane B2. ConclusionThe presence of AH is associated with significantly higher platelet levels and compounds present in alcoholic beverages can directly mediate both their activation and the activation of platelet-adherent basophils.

Lung function and side effects of Aspirin desensitization: a real world study

ABSTRACT Introduction: NSAID-exacerbated respiratory disease (N-ERD) is mainly treated with topical and oral corticosteroids, as well as acetylsalicylic acid (ASA) treatment after desensitization (ATAD). During desensitization and ATAD, it is common to experience an exacerbation of respiratory symptoms and other side effects, which may lead to cessation of treatment. Objectives: The aim of this retrospective follow-up study was to evaluate the effect of ATAD on lung functions and respiratory symptoms, and to clarify the occurrence of adverse events. Methods: We analysed the patient data of 67 patients treated with ASA desensitization between 2006 and 2016 in three hospitals, concerning adverse events, respiratory symptoms, lung function tests, and reasons for discontinuation. Results: 26 patients discontinued AD or ATAD. The most common reasons for discontinuation were lack of response (9%) and side effects (18%). ATAD did not affect lung function values in the follow-up of up to 5 years. Upper respiratory symptoms improved in 31 (52%) and lower respiratory symptoms (LRS) in 7 (10%) cases. Side effects occurred in 42 (63%) cases, the most common being dyspepsia and lower respiratory symptoms. Conclusion: Our study suggests that ATAD has little effect on lower airway functions. Side effects were common, and discontinuation rates high.

Anxiety sensitivity and respiratory disease outcomes among individuals with chronic obstructive pulmonary disease

ObjectiveChronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Depression and anxiety worsen COPD and lead to greater respiratory symptom severity and health care utilization. Fear of physical sensations of anxiety (AS-P) is known to exacerbate respiratory symptoms. The current study investigated the unique contribution of AS-P in respiratory symptom exacerbations, emergency department visits, hospitalizations, and COPD-related functional health status, controlling for medical characteristics, depression, and anxiety. MethodThe sample included 535 adults with COPD (Mage = 56.57; 58.1% male). Participants were recruited from a web-based panel of adults with chronic respiratory disease and completed an online battery of self-report measures. ResultsConsistent with hypotheses, AS-P significantly increased the likelihood of acute symptom exacerbations by 12% and respiratory-related emergency department visits and hospitalizations by 7% during the prior 12 month period. Additionally, AS-P demonstrated a unique, large effect (f2 = 0.37) on COPD-related functional health status. ConclusionFear of physical sensations contributed to worse respiratory outcomes and health care utilization among adults with COPD. Screening for AS-P may effectively identify at-risk COPD patients, while reducing AS-P through targeted interventions may result in decreased symptom severity, functional limitations, and burden on the health care system.

Heart Failure is Highly Prevalent and Difficult to Diagnose in Severe Exacerbations of COPD Presenting to the Emergency Department.

Background: Some 20% of patients with stable Chronic Obstructive Pulmonary Disease (COPD) might have heart failure (HF). HF contribution to acute exacerbations of COPD (AECOPD) presenting to the emergency department (ED) is not well established. Aims: To assess (1) the HF incidence in patients presenting to the ED with AECOPD; (2) the concordance between ED and respiratory ward (RW) diagnosis; (3) the factors associated with risk of death after hospital discharge. Methods: Retrospective chart review of 119 COPD patients presenting to ED for acute exacerbation of respiratory symptoms and then admitted to RW where a final diagnosis of AECOPD, AECOPD and HF and AECOPD and OD (other diagnosis), was obtained. ED and RW diagnosis were then compared. Factors affecting survival at follow-up were investigated. Results: At RW, 40.3% of cases were diagnosed of AECOPD, 40.3% of AECOPD and HF and 19.4% of AECOPD and OD, with ED diagnosis coinciding with RW’s in 67%, 23%, and 57% of cases respectively. At RW, 60% of patients in GOLD1 had HF, of which 43% were diagnosed at ED, while 40% in GOLD4 had HF that was never diagnosed at ED. Lack of inclusion in a COPD care program, HF, and early readmission for AECOPD were associated with mortality. Conclusions: HF is highly prevalent and difficult to diagnose in patients in all GOLD stages presenting to the ED with severe AECOPD, and along with lack of inclusion in a COPD care program, confers a high risk for mortality.

Recommendations for respiratory rehabilitation in adults with coronavirus disease 2019.

Coronavirus disease-2019 (COVID-19) is a highly infectious respiratory disease that leads to respiratory, physical, and psychological dysfunction in patients. Respiratory rehabilitation is an important intervention as well as cure for clinical patients. With increased understanding of COVID-19 and the accumulation of clinical experience, we proposed recommendations for respiratory rehabilitation in adults with COVID-19 based on the opinions of frontline clinical experts involved in the management of this epidemic and a review of the relevant literature and evidence. Our recommendations are as follows: 1. for inpatients with COVID-19, respiratory rehabilitation would relieve the symptoms of dyspnea, anxiety, and depression and eventually improve physical functions and the quality of life; 2. for severe/critical inpatients, early respiratory rehabilitation is not suggested; 3. for patients in isolation, respiratory rehabilitation guidance should be conducted through educational videos, instruction manuals, or remote consultation; 4. assessment and monitoring should be performed throughout the respiratory rehabilitation process; 5. proper grade protection should be used following the present guidelines. These recommendations can guide clinical practice and form the basis for respiratory rehabilitation in COVID-19 patients.

Physiological Adaptations During the Acclimatization To‐ and Deacclimatization From‐Chronic Hypercapnia

Respiratory disturbances, such as chronic obstructive pulmonary disease (COPD), are often associated with chronically elevated arterial CO2 (PaCO2 &gt;45mmHg), which has been linked to an increase risk of all‐cause mortality. Additionally, acute exacerbations of respiratory symptoms may lead to greater levels of PaCO2 that require mechanical intervention to restore PaCO2 to control levels.Many physiological effects of chronic hypercapnia have been previously reported, and include robust adaptations in acid/base, and respiratory control mechanisms. However, the effects of restoring PaCO2 to control levels following chronically elevated PaCO2 are largely unknown. Thus, the goal of my project is to gain insight into the physiological and ventilatory control adaptations during the acclimatization to‐ and deacclimatization from‐chronic hypercapnia. Based on studies focusing on the deacclimatization from chronic hypoxia, I hypothesize that deacclimatization from chronic hypercapnia would not be completed within 24 hours of return to normoxia.To assess the effects of deacclimatization from chronic hypercapnia, I measured the temporal pattern of ventilation, ventilatory CO2/[H+] chemoreflex, and acid‐base status during acclimatization to‐ and deacclimatization from‐chronic exposure to elevated inspired CO2 (InCO2) in goats. Goats were chronically housed in environmental chambers that allowed for modification of ambient CO2 levels. Following a room air control period, goats were exposed to an InCO2 of 6% for 30 days, followed by returned to room air for 24 hours (hrs). Within 1 hour of 6% InCO2, VI increased to 322% above control, but decreased slightly to 293% above control after 24 hours. By Day 2 of exposure, PaCO2 increased 15 Torr and changed minimally thereafter. pH decreased by 0.06 units upon initial exposure but was partially compensated by Day 5 due to an 8mEq/L increase in arterial [HCO3−]. Within 4hrs of deacclimatization, VI decreased to 123% above control, and continued to decrease to near control levels by 24hrs. PaCO2 decreased 13mmHg by 24hrs, while pH increased 0.04 units. The CO2/[H+] chemoreflex was assessed by increasing InCO2 to 3, 5, and 7% at 4 and 24 hours of deacclimatization. The chemoreflex was above control at 4 and 24 hours of deacclimatization. The steady‐state ventilation/[H+] relationship was also slightly elevated at 4 and 24hrs.Taken together, these data suggest that deacclimatization from chronic hypercapnia is nearly complete by 24 hours. Further studies will extend the recovery time to 5 days to see if the deacclimatization is complete. Additional studies will aim to use western blotting to investigate neurological adaptations underlying the deacclimatization processSupport or Funding InformationDepartment of Veteran Affairs

Determinants of Exercise Capacity Assessed With the Modified Shuttle Test in Individuals With Cystic Fibrosis.

Patients with cystic fibrosis develop decreased exercise capacity. However, the main factors responsible for this decline are still unclear. Thus, the objective of this study was to evaluate the factors influencing exercise capacity assessed with the modified shuttle test (MST) in individuals with cystic fibrosis. A cross-sectional study was carried out in subjects with a diagnosis of cystic fibrosis who were 6-26 y old and were regularly monitored at 2 cystic fibrosis reference centers in Brazil. Individuals who were unable to perform the tests or who exhibited hemodynamic instability and exacerbation of respiratory symptoms were excluded. Anthropometric, clinical, and genotype data were collected. In addition, lung function and exercise capacity were evaluated with the MST. 73 subjects (mean age 12.2 ± 4.9 y and FEV1 76.8 ± 23.3%) were included. The mean distance achieved in the MST was 765 ± 258 m (71.6% of predicted). The distance achieved on the MST correlated significantly with age (r = 0.49, P < .001), body mass index (r = 0.41, P < .001), resting heart rate (r = -0.51, P < .001), and FEV1 (r = 0.24, P = .042). Subjects with FEV1 > 67% of predicted (P = .02) and those with resting heart rate < 100 beats/min (P = .01) had a greater exercise capacity. Resting heart rate, age, and FEV1 (%) were found as significant variables to explain the distance achieved on the MST (R2 = 0.48, standard error = 191.0 m). The main determinants of exercise capacity assessed with the MST in individuals with cystic fibrosis were resting heart rate, age, and lung function.