Improvement In Dyspnea Research Articles

Efficacy and Safety of Opioids in Treating Cancer-Related Dyspnea: A Systematic Review and Meta-Analysis Based on Randomized Controlled Trials

BackgroundDyspnea is one of the most distressing symptoms encountered by advanced cancer patients. In this study, we aimed to evaluate the role of opioids in the management of cancer-related dyspnea. MethodsA systematic review and meta-analysis based on Randomized Controlled Trials was conducted in the databases PUBMED, EMBASE, and Cochrane Central Register of Controlled Trials testing the effect of opioids in relieving cancer-related dyspnea. Subgroup and sensitivity analyses were performed to evaluate various types of opioids in dyspnea management and stabilization of the study respectively. ResultsEleven RCTs fulfilled the eligibility criteria and had a total of 290 participants. Nine of these studies were included in meta-analyses. Compared with control, opioid therapy showed a small positive effect in dyspnea, SMD-0.82 (95%CI = −1.54 to -0.10) and Borg score, WMD-0.95 (95%CI = −1.83 to -0.06); Opioid therapy did not increase the risk of somnolence, OR0.93 (95%CI = 0.34 to 2.58), whereas a negative effect on respiratory rate was observed,WMD-1.89 (95%CI = −3.36 to -0.43); Also, there was no evidence to suggest improved performance of the 6MWT test, WMD6.49 (95%CI = −34.23 to 47.21), or the level of peripheral oxygen saturation, WMD0.33 (95%CI = −0.59 to 1.24) after opioid therapy. Subgroup analysis yielded a small positive effect for morphine on dyspnea, SMD-0.78 (95%CI = −1.45 to −0.10), whereas fentanyl showed no improvement in dyspnea, SMD-0.44 (95%CI = −0.89 to 0.02). Sensitivity analysis showed no changes in the direction of effect when any one study was excluded from the meta-analyses. ConclusionsOur systematic review and meta-analysis indicated low quality evidence for a small positive effect of opioids in cancer-related dyspnea. Evidence for safety is insufficient as comprehensive adverse events were not adequately reported in studies.

Transoral management of adult benign laryngeal stenosis

PurposeManagement of benign laryngeal stenosis (BLS) remains challenging even though transoral treatments in selected cases have shown satisfactory results, at least comparable to open-neck approaches, with reduced invasiveness. To date, no overall consensus has been reached on many issues. The aim of this study is to assess the effectiveness of a purely transoral treatment in a cohort of patients affected by BLS.MethodsWe evaluated 40 patients affected by BLS, treated by transoral surgery between 2013 and 2017. The European Laryngological Society classification for laryngotracheal stenosis was applied for the staging. Improvement in airway patency and quality of life was assessed by decannulation rate, Airway-Dyspnea-Voice-Swallowing (ADVS) score, Voice handicap index (VHI)-30, and Eating assessment tool (EAT)-10 questionnaires.ResultsMean age was 61 years and M:F ratio was 1.4:1. Previous laryngeal surgery was the most common cause of stenosis (50%), followed by radiotherapy (20%), idiopathic etiology (12%), granulomatosis with polyangiitis (10%), and prolonged intubation (8%). Transoral treatment entailed an improvement in quality of life with a significant decrease in the VHI score (p < 0.0001) and improvement in Airway (p = 0.008), Dyspnea (p < 0.0001), and Voice (p < 0.0001) scores. No major perioperative complications were observed. The decannulation rate among patients with a tracheostomy in place (N = 16) was 63%.ConclusionsTransoral treatment of selected BLS managed by a team with high-level expertise in surgery and anesthesiology is associated with significant improvement of quality of life, especially with regard to voice and breathing functions.

Penatalaksanaan Fisioterapi Pada Kasus Bronchitis Chronic Di BBKPM Surakarta

Background : Chronic bronchitis is inflammation of the bronchi of continuous and progressive improvement in productive cough and dyspnea that can not be attributed to specific causes that have a productive cough throughout the day for at least 3 consecutive months. Modality given in these conditions in the form of Infra Red, Chest Therapy and Nebulizer Purpose : Scientific Writing aims to determine the benefits, the cause, the cause and effect as well as the management and the influence of infra red, chest therapy and nebulizer in patients with chronic bronchitis and how the signs and symptoms of the disease. Methods :In the case studies, conducted by the physiotherapy management of infra-red method, chest therapy and nebulizer after therapy as much as 6x obtained results. Result : An increase in the thorax expansion during therapy to 1 (T1) the result is the axilla showed inspiration: 87 cm, 86 cm expiration by a margin of 1 cm, and at the end of therapy (T6) in the axilla is obtained inspiration: 90 cm, expiration: 87,4 cm by a margin of 2,6 cm. At proc. Xypoideus when therapy to 1 (T1) is obtained inspiration: 89 cm, 88 cm expiration by a margin of 1 cm, and at the end of therapy (T6) on proc. RESULTS inspiration Xypoideus 92 cm, 89,6 cm by a margin expiratory 2,4 cm. Their frequency decreased shortness of breath that at the time of treatment to 1 (T1) obtained the value of asphyxiation 4 (slightly heavy) and at the end of therapy to 6 showed breathlessness value of 0 (not at all feel shortness of breath). A decrease in chest pain during therapy to 1 (T1) is obtained by using the value of chest pain VAS (4.2) that at the end of therapy (T6) is obtained VAS value (2.3). Conclusions :Management of physiotherapy in the condition of Chronic Bronchitis with infra red modalities, chest therapy, and used Nebulizer shows the increase certainly better direction. Showed an increase in thoracic expansion, a decrease shortness of breath and chest pain decrease.

VANISHING LUNG SYNDROME OR GIANT BULLOUS EMPHYSEMA

TYPE: Abstract Publication TOPIC: Obstructive Lung Diseases PURPOSE: We report a case of Giant Bullous Emphysema (Vanishing Lung Syndrome) that presented with pneumothorax in a smoker/COPD case. METHODS: A 40 years old female, current smoker, presented with pleuritic chest pain and dyspnoea. A chest x-ray showed a large right pneumothorax that was managed with a chest drain. However, pneumothorax recurred post-discharge and required another chest drain. Due to recurrence, a CT chest was performed, that showed bilateral giant bullae that occupied more than one-third of the lungs, located predominantly in upper lobes. The remaining lung parenchyma appeared normal except minor/early centrilobular emphysema. Alpha 1-antitrypsin levels were normal. RESULTS: CT Chest findings were consistent with giant bullous emphysema. She successfully managed to quit smoking and had a right-sided thoracoscopic bullectomy with resolution in her symptoms. CONCLUSIONS: A major complication of giant bullous emphysema is pneumothorax, that may pose a diagnostic challenge on a chest -x-ray in the presence of a giant bulla. A CT thorax remains an important tool to define the extent/distribution of bullous disease, pneumothorax, associated emphysema, and to assist immediate (chest drain) and long-term management (pre-operative planning). Smoking cessation and surgical resection of giant bullae (if occupy >1/3rd of lung) remain an effective strategy with improvement in dyspnoea, lung functions and exercise capacity. CLINICAL IMPLICATIONS: Vanishing Lung Syndrome is a rare clinical entity, that tends to be progressive, however, there appear to be no guidelines on its management or follow-up. The role of new interventions such as endoscopic lung volume reduction (ELVRS) remains undefined in the management of Giant Bullous Emphysema. DISCLOSURE: No significant relationships. KEYWORDS: Emphysema, Giant Bullae, Vanishing Lung

The effects of a respiratory rehabilitation programme on body composition

Abstract Objective Analysis of the respiratory rehabilitation effects on body composition, performed for 10 patients with respiratory pathology. Materials and method In our pilot study were included patients with respiratory disease, for which bioelectrical impedance analysis was performed before and after an outpatient respiratory rehabilitation (RR) programme. The RR programme consisted of 20 sessions of exercise for lower limb (cycling and walking on a treadmill) and upper limb (weights). Results Ten patients followed the rehabilitation programme (five patients with chronic obstructive pulmonary disease, two with bronchiectasis, one with cystic fibrosis, one with lung cancer and one with idiopathic pulmonary fibrosis). Following the rehabilitation, they presented an important decrease in total body fat distribution (average total body fat distribution before RR – 31.38% and after RR – 27.09%, p = 0.000) and also segmental body fat distribution; we found an increase of total muscle mass after RR programme (average total muscle mass distribution before RR – 53.03 kg and after the RR – 56.84 kg, p = 0.000) and segmental muscle mass. The average body weight of the patients measured before and after the rehabilitation programme remained relatively constant in absolute value (81.8 kg and 81.3 kg after RR), probably by decreasing fat mass and increasing muscle mass. The RR programme had also a positive effect on increasing exercise tolerance (with 88.5 m at 6-min walk test) and dyspnoea improvement (decrease of mMRC scale with 1.5 points). Conclusion The RR programme has modified the body composition by increasing muscle mass and decreasing fat mass in the respiratory patients, with positive effects on symptoms and exercise tolerance.

Treatment With Mycophenolate and Cyclophosphamide Leads to Clinically Meaningful Improvements in Patient-Reported Outcomes in Scleroderma Lung Disease: Results of Scleroderma Lung Study II.

ObjectiveOur objective was to determine if treatment with cyclophosphamide (CYC) and mycophenolate mofetil (MMF) improves patient‐reported outcomes (PROs) among patients with systemic sclerosis‐related interstitial lung disease (SSc‐ILD).MethodsThis study examined PROs in patients with SSc‐ILD (N = 142) who participated in the Scleroderma Lung Study II, a randomized controlled trial comparing MMF for 2 years with oral CYC for 1 year followed by 1 year of a placebo. Joint models were created to evaluate the course of PROs over 2 years. The difference in PRO scores from baseline to 24 months was measured, and the percentage of patients meeting the minimum clinically important difference (MCID) was calculated. Correlations between PROs and SSc‐ILD disease severity measures were also examined.ResultsTreatment with CYC and MMF led to improvements in several PROs with no between‐treatment differences. Scores for the Transitional Dyspnea Index (TDI) and St. George’s Respiratory Questionnaire (SGRQ) improved significantly over 2 years, and 29%/24% and 28%/25% of participants in the CYC/MMF groups met or exceeded the MCID estimates for TDI and SGRQ, respectively. At baseline, the forced vital capacity (FVC) percentage predicted (FVC%‐predicted) did not correlate with the Baseline Dyspnea Index or SGRQ. However, improvements in the FVC%‐predicted were weakly associated with improvements in dyspnea (assessed by the TDI) and SGRQ scores.ConclusionTreatment with CYC and MMF improved overall health‐related quality of life in patients with SSc‐ILD. The relationship between PRO measures and the FVC was relatively weak, suggesting that PROs provide complementary information about treatment efficacy not captured by changes in the FVC alone in this patient population.

Tepotinib in patients (pts) with NSCLC with MET exon 14 (METex14) skipping: Health-related quality of life (HRQoL).

9575 Background: In the phase II VISION study (NCT02864992) tepotinib had promising efficacy (response rate of 40–50% &amp; median duration of response &gt;1 y) and tolerable safety in pts with advanced NSCLC with METex14 skipping (3–4% of NSCLC), who are typically elderly with poor prognosis. Pt reported outcomes (PROs) of HRQoL are described here. Methods: Pts with advanced NSCLC positive for METex14 skipping by tissue or liquid biopsy received oral tepotinib 500 mg once daily; PROs were assessed using QLQ-LC13 (lung cancer symptoms), EORTC QLQ-C30 (Global health status [GHS] &amp; 5 functional scales), and EQ-5D-5L (VAS). Questionnaires were completed at baseline (BL) and every 6 weeks (Wk); results were scored from 0–100 (minimal clinically important difference [MCID] ≥10 points). Mean change from BL was analyzed at Wk 12 (predefined analyses). Results: By 19 Jul 19 cut-off, 130 pts across treatment lines were enrolled (median age 74.2 y), with PROs available for 129. Questionnaire completion rates were 90.1% at Wk 12. Symptom burden at BL was moderate for advanced NSCLC; mean change from BL for PROs are shown in the table (better functioning: lower QLQ-LC13 or higher QLQ-C30 scores). For the QLQ-LC13 symptoms, mean changes from BL indicated a meaningful improvement in coughing, with a median time to improvement (2.8 months) paralleling the onset of objective response (within first 3 months), and a numerical improvement in dyspnea (–2.3 at Wk 12) and chest pain (–4.2 at Wk 12). QLQ-C30 values remained stable over treatment as did EQ-5D-5L scores (higher=better): mean (standard deviation, SD) change from BL score (60 [20.4]) was 6 (18.6) at Wk 6 and 5 (20.9) at Wk 12. Conclusions: In this first analysis of PROs in pts with advanced NSCLC with METex14 skipping with a moderate symptom burden, treatment with tepotinib led to a clinically meaningful improvement in coughing symptoms, while maintaining HRQoL. Coupled with the efficacy and safety profile, the predefined HRQoL analysis from the VISION study supports tepotinib as a promising treatment option for this elderly population with METex14+ NSCLC. Clinical trial information: NCT02864992 . [Table: see text]

Effectiveness of Nebulized Magnesium Sulphate as an Adjuvant Therapy (With Salbutamol) in the Management of Acute Asthma

Background: Although the treatment of acute asthma in the emergency department varies, the administration of magnesium sulfate (MgSO4) is usually recommended adjacent to corticosteroids and bronchodilators. This study aims to ascertain the influence of inhaled MgSO4 as complement treatment with salbutamol regarding treatment of urgent asthma exacerbations. Methods: A single-blind randomized control study was carried out, from 1st January 2017 to 30th June 2017, involving asthmatic patients presenting to Ziauddin Hospital and Jinnah Hospital in Karachi, with severe acute asthma exacerbations. The Sealed Envelope calculator was used to calculate a sample size of 84 patients, and data was collected through non-probability consecutive sampling. Both batches were administered salbutamol and ipratropium, with Batch A patients also receiving nebulization with MgSO4. Dyspnea, respiratory rate, pulse, peak expiratory flow rate, and oxygen saturation were recorded for each participant. An independent sample t-test was used to assess the effectiveness of MgSO4, as a significant means of improving asthma treatment, with a p&lt;0.05 interpreted as significant. Results: A sum of 115 patients was included in the research, out of which 63.5% had a family history of asthma. Treatment with MgSO4 was seen as significant (p&lt;0.01). MgSO4 administration showed significant improvement in mean pulse rate (p = 0.001), peak expiratory flow rate (p = 0.004) and mean respiratory rate (p = 0.003), as compared to treatment with salbutamol only. Conclusion: Treatment outcomes between the two groups differed significantly. Intervention with MgSO4 showed significant improvement in pulse rate, respiratory rate, dyspnea, and peak flow, without any observed side effects.

Efficacy and Safety of Once-Daily Inhaled Umeclidinium in Asian Patients with COPD: Results from a Randomized, Placebo-Controlled Study.

PurposePrevious studies demonstrating efficacy and safety of once-daily umeclidinium (UMEC) in patients with chronic obstructive pulmonary disease (COPD) have included few Asian patients. This study evaluated efficacy and safety of UMEC 62.5 mcg versus placebo in Asian patients with COPD.Patients and MethodsA Phase III, randomized, double-blind, parallel-group study. Patients (aged ≥40 years with COPD, pre-, and post-albuterol forced expiratory volume in 1 s [FEV1]/forced vital capacity ratio <0.70 and low risk of exacerbations) were randomized 2:1 to once-daily UMEC 62.5 mcg or placebo via the ELLIPTA inhaler for 24 weeks. Primary endpoint was change from baseline (CFB) in trough FEV1 on Day 169. Secondary endpoints were weighted mean FEV1 over 0–6 hrs post-dose on Day 1 and CFB in Transition Dyspnea Index (TDI) focal score on Day 168.ResultsA total of 306 patients were included in the modified intent-to-treat population (UMEC: 205; placebo: 101). UMEC versus placebo provided a statistically significant improvement in least squares (LS) mean trough FEV1 between baseline and Day 169 (154 mL [95% confidence interval (CI): 113, 194]; p<0.001). A clinically meaningful difference of 125 mL in favor of UMEC (95% CI: 103, 147; p<0.001) was also seen in LS weighted mean FEV1 0–6 hrs post-dose on Day 1. A LS mean treatment difference in TDI focal score of 0.9 units in favor of UMEC was seen on Day 168 (95% CI: 0.3, 1.5; p=0.004). Incidence of on-treatment adverse events (AEs) was lower in the placebo (55%) versus UMEC arm (60%); non-fatal serious AEs, drug-related AEs, and AEs leading to withdrawal were similar with UMEC and placebo.ConclusionOnce-daily UMEC 62.5 mcg resulted in statistically significant and clinically meaningful improvements in lung function and dyspnea, compared with placebo, in Asian patients with COPD, with no new safety concerns observed.

Inspiratory Muscle Training in COPD.

The benefits of inspiratory muscle training (IMT) for patients with COPD are documented in the literature, but its isolated effect or association with other interventions, the best training methods, and what type of patient benefits the most are not clear. We sought to assess the effects of IMT on respiratory muscle strength, pulmonary function, dyspnea, functional capacity, and quality of life for subjects with COPD, considering IMT isolated or association with other interventions, presence of inspiratory muscle weakness, training load, and intervention time. We searched the MEDLINE, EMBASE, PEDro, Cochrane CENTRAL, and LILACS databases in June 2018. We also performed a manual search of references in the studies found in the database search and included in this analysis. We included randomized controlled trials that investigated the above-mentioned outcomes and assessed IMT, either isolated or associated with other interventions, in comparison with a control group, placebo, or other interventions, in subjects with COPD. We used the GRADE approach to evaluate the quality of the evidence. Of 1,230 search results, 48 were included (N = 1,996 subjects). Isolated IMT increased PImax (10.64cm H2O, 95% CI 7.61-13.66), distance walked in 6-min-walk test (34.28 m; 95% CI 29.43-39.14), and FEV1 (0.08, 95% CI 0.02-0.13). However, there was no improvement in dyspnea and quality of life. The presence of inspiratory muscle weakness did not change the results; higher loads (60-80% of PImax) promoted a greater improvement in these outcomes, and a shorter intervention time (4 weeks) improved PImax, but longer intervention times (6-8 weeks) are required to improve functional capacity. IMT associated with other interventions only showed an increase in PImax (8.44cm H2O; 95% CI 4.98-11.91), and the presence of inspiratory muscle weakness did not change this result. Isolated IMT improved inspiratory muscle strength, functional capacity, and pulmonary function, without changing dyspnea and quality of life. Associated IMT only increased inspiratory muscle strength. These results indicate that isolated IMT can be considered as an adjuvant intervention in patients with COPD.

Percutaneous Closure of PFO in Patients with Reduced Oxygen Saturation at Rest and during Exercise: Short- and Long-Term Results.

Background A patent foramen ovale (PFO) is a rare cause of hypoxemia and clinical symptoms of dyspnea. Due to a right-to-left shunt, desaturated blood enters the systemic circulation in a subset of patients resulting in dyspnea and a subsequent reduction in quality of life (QoL). Percutaneous closure of PFO is the treatment of choice. Objectives This retrospective multicentre study evaluates short- and long-term results of percutaneous closure of PFO in patients with dyspnea and/or reduced oxygen saturation. Methods Patients with respiratory symptoms were selected from databases containing all patients percutaneously closed between January 2000 and September 2018. Improvement in dyspnea, oxygenation, and QoL was investigated using pre- and postprocedural lung function parameters and two postprocedural questionnaires (SF-36 and PFSDQ-M). Results The average follow-up period was 36 [12–43] months, ranging from 0 months to 14 years. Percutaneous closure was successful in 15 of the 16 patients. All patients reported subjective improvement in dyspnea immediately after device deployment, consistent with their improvement in oxygen saturation (from 90 ± 6% to 94 [92–97%] on room air and in upright position) (p < 0.05). Both questionnaires also indicated an improvement of dyspnea and QoL after closure. The two early and two late deaths were unrelated to the procedure. Conclusion PFO-related dyspnea and/or hypoxemia can be treated successfully with a percutaneous intervention with long-lasting benefits on oxygen saturation, dyspnea, and QoL.

Exercise training increases respiratory muscle strength and exercise capacity in patients with chronic obstructive pulmonary disease and respiratory muscle weakness

BackgroundHow respiratory muscle strength influences the effectiveness of pulmonary rehabilitation (PR) in patients with chronic obstructive pulmonary disease (COPD) is unclear. ObjectiveTo investigate the benefits of PR in subjects with COPD according to respiratory muscle strength. MethodsNinety-seven subjects with COPD were evaluated using maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), pulmonary function tests, the cardiopulmonary exercise test (CPET), and the St. George's Respiratory Questionnaire (SGRQ). Subjects were divided into four groups: 1 (normal MIP and MEP); 2 (low MIP); 3 (low MEP); and 4 (low MIP and MEP). Subjects underwent PR for 3 months; MIP, MEP, SGRQ, and CPET were evaluated post-PR. ResultsSubjects with both poor MIP and MEP had the highest dyspnea score, lowest exercise capacity, and poorest health-related quality of life (HRQoL). PR improved exercise capacity and HRQoL in all groups, with more improvement in MIP, MEP, tidal volume (on exercise), and dyspnea (at rest) in subjects with both low MIP and MEP. ConclusionsPatients with respiratory muscle weakness had worse dyspnea, lower exercise capacity, and poorer HRQoL at baseline. Exercise training improved respiratory muscle strength with concurrent improvement of exercise capacity, HRQoL, and dyspnea score. Subjects with both poor baseline MIP and MEP showed greater benefits of PR.

Opioid utility for dyspnea in chronic obstructive pulmonary disease: a complicated and controversial story.

Chronic obstructive pulmonary disease (COPD) is common chronic respiratory disorder, predominantly caused by exposure to cigarette smoke or biomass fuels, and it usually affects older adults. Dyspnea in COPD that is unresponsive to traditional management is a challenging disease complication for both the patient and the health care professional. Off-label use of opioids has been advocated as a pharmacotherapy strategy for refractory dyspnea. However, negative respiratory outcomes are a potential concern with opioids drugs, especially among individuals with COPD. In this review, randomized controlled trials evaluating opioid efficacy among individuals with COPD are reviewed and critically analyzed, and data from observational drug safety studies is also presented. In summary, the evidence in support of using opioids for refractory dyspnea in COPD is minimal and weak, and there is mounting data demonstrating that opioids are associated with increased respiratory-related morbidity and mortality in this population. Therefore, current evidence does not support the broad application of opioids for refractory dyspnea among individuals with COPD. However, there may be subsets of individuals that experience modest improvement in dyspnea with opioids, and better understanding predictors and mechanisms of such opioid responsiveness should be a focus of future research endeavours.

A Comparison of Hospitalized Patients With Heart Failure and Cancer Referred to Palliative Care

Growing evidence shows that palliative care (PC) improves treatment outcomes in patients with heart failure (HF), but few large-scale studies have prospectively evaluated the processes and outcomes associated with PC consultation for such patients in the real world. To characterize processes and outcomes of PC consultations for hospitalized patients with HF compared with patients with cancer. This cohort study of inpatient encounters at community and academic hospitals in the Palliative Care Quality Network enrolled participants between 2013 and 2017. Of a total of 135 197 patients, 57 272 adults with a primary diagnosis of HF or cancer receiving PC consultation were enrolled. Data analysis was performed from April 2018 to December 2019. Primary diagnosis of HF or cancer. Symptom improvement and changes in care planning documentation after PC consultation. At the time of consultation, patients with HF were older (mean age, 75.3 years [95% CI, 75.0-75.5 years] vs 65.2 years [95% CI, 65.0-65.3 years]; P < .001), had lower Palliative Performance Scale scores (mean, 35.6% [95% CI, 35.3%-35.9%] vs 42.4% [95% CI, 42.2%-42.6%]; P < .001), and were more likely to be in a critical care unit (5808 of 16 741 patients [35.3%] vs 4985 of 40 531 patients [12.5%]; P < .001) or a telemetry or step-down unit (5802 of 16 741 patients [35.2%] vs 7651 of 40 531 patients [19.2%]; P < .001) compared with patients with cancer. Patients with HF were less likely than patients with cancer to be referred to PC within 24 hours of admission (6773 of 16 741 patients [41.2%] vs 19 348 of 40 531 patients [49.0%]; P < .001) and had longer hospitalizations before receiving PC consultation requests (mean, 4.6 days [95% CI, 4.4-4.8 days] vs 3.9 days [95% CI, 3.8-4.0 days]; P < .001). Patients with HF were referred less frequently for symptoms other than pain (1686 of 16 488 patients [10.2%] vs 8587 of 39 609 patients [21.7%]; P < .001), but were equally likely to report improvements in anxiety (odds ratio, 0.85; 95% CI, 0.71-1.02; P = .08) and more likely to report improvements in dyspnea (odds ratio, 2.17; 95% CI, 1.83-2.57; P < .001) compared with patients with cancer. Patients with HF were less likely than those with cancer to be discharged alive (odds ratio, 0.78; 95% CI, 0.64-0.96; P = .02) or to be referred to hospice (odds ratio, 0.50; 95% CI, 0.47-0.53; P < .001). These findings suggest that PC referral comes late for patients with HF and is used primarily to discuss care planning. Practitioners caring for patients with HF should consider involving PC experts earlier for symptom management.

Persistent unexplained chest pain and dyspnea in a patient with coronary artery disease: a case report

BackgroundNeurogenic orthostatic hypotension, a sustained decrease in blood pressure upon standing, is caused by autonomic nervous system failure and characterized by an insufficient increase in heart rate needed to maintain blood pressure upon standing. In this case, neurogenic orthostatic hypotension symptoms preceded a diagnosis of Parkinson disease. A diagnosis of underlying neurogenic orthostatic hypotension significantly changed the course of treatment for this patient.Case presentationAn 84-year-old woman was referred to a cardiologist by her primary care practitioner for evaluation of exertional dyspnea and chest pain upon walking a few feet. Her medical history included hypertension, hypothyroidism, and osteoarthritis. Based on her continued symptoms, the patient underwent 2 cardiac catheterizations for coronary artery stenosis. After the catheterizations, exertional dyspnea and chest pain continued, and subsequently, dysphagia to solid foods and episodic dizziness developed. Orthostatic evaluation showed a supine blood pressure of 150/80 mmHg with a heart rate of 70 beats per min. Upon standing for 3 min, the patient’s blood pressure decreased to 110/74 mmHg with a heart rate of 76 beats per min. The diagnostic criteria for orthostatic hypotension were met, and the lack of an adequate compensatory heart rate increase upon standing was consistent with a neurogenic cause (ie, neurogenic orthostatic hypotension), which was supported by tilt-table testing results. Although nonpharmacologic treatments were initially successful, episodes of lightheadedness, chest pain, and dyspnea upon standing became more frequent, and the patient was prescribed droxidopa (200 mg; 3 times daily). Droxidopa significantly improved her symptoms, with the patient reporting resolution of her chest pain and significant improvement of dyspnea and dizziness. She was diagnosed with Parkinson disease approximately 6 months later.ConclusionsThis case highlights the importance of evaluating and identifying potential causes of symptoms of cardiovascular disease when persistent symptoms do not improve after cardiac interventions. This case complements findings demonstrating that signs of autonomic failure, such as neurogenic orthostatic hypotension, may precede the motor symptoms of Parkinson disease. Importantly, this case provides real-world evidence for the efficacy of droxidopa to treat the symptoms of neurogenic orthostatic hypotension, after an appropriate diagnosis.

Benefits of Pulmonary Rehabilitation in Patients with COPD with Use and without the Use of Supplemental Oxygen During Exercise

Objective:To determine the effects of a pulmonary rehabilitation program in patients with COPD who use and do not use supplemental oxygen during exercise.Materials and Methods:Prospective longitudinal descriptive study on 59 patients with COPD who were part of a pulmonary rehabilitation program and who were classified into two groups: a group that required supplemental oxygen during rehabilitation and another that did not.Results:31 patients were linked to the group that used oxygen during rehabilitation and 28 patients who did not use it. The average age was 69.1 ± 10.6 years old. The mMRC dyspnea decreased 0.7 ± 0.2 (p = 0.000) in the group that used oxygen and 0.8 ± 0.1 (p = 0.000) in the group that did not use it. The distance increased 45.9 meters ± 7.2 (p = 0.000) in the group that used oxygen and 65.2 meters ± 16.3 (p = 0.001) in the group that did not use it.Conclusion:Both groups showed significant improvements in dyspnea and aerobic capacity, however, there was a greater increase in the group that did not use oxygen.

Comparison between thoracoscopic pleurodesis results by talc, doxycycline poudrage, and silver nitrate slurry in patients with malignant pleural effusion

Background It is known that malignant pleural effusion (MPE) is one of the most deleterious hazards of cancers from which most patients become annoyed mainly from the discomfort of dyspnea that can interfere with life quality and compel the affected persons to repeatedly seek medical advice asking mainly about how to get rid of the effusion permanently and to prevent the recurrence. Aims The target of the discipline is comparing the effectiveness and safety of thoracoscopic pleurodesis by talc, doxycycline poudrage, and silver nitrate (SN) slurry in patients with MPE. Patients and methods Forty-five patients with MPE eligible for pleurodesis were randomly chosen and divided into three groups, with 15 patients each, for 1-g doxycycline poudrage (group I) or 4–5 g of sterilized medical talc powder (group II) or 50 ml SN 1% (group III) through thoracoscopy using spraying catheter. The results were compared among the three groups. Results A total of 20 patients had bronchogenic carcinoma in groups I, II, and III (53.3, 46.7, and 33.3%, respectively) and breast cancer was seen in nine patients (26.6% of both groups I and II and 33.3% of group III). Conclusion Talc, doxycycline poudrage, and SN slurry are approximately equal regarding the improvement of dyspnea and postthoracoscopic hospital stay.

Value of pulmonary rehabilitation in interstitial lung diseases

Background Interstitial lung diseases (ILDs) are restrictive pulmonary disorders that make lungs unable to expand on inhalation. Persistent symptoms and/or limitation in usual efforties make pulmonary rehabilitation (PR) very helpful. Aim To assess the purpose of PR in improvement of dyspnea, quality of life, and functional capacity in patients with ILDs. Patients and methods A total of 20 adult patients with ILDs were selected from the ward of the Chest Diseases Department at Al-Maamora Chest Hospital. They were subjected to PR program (three sessions per week for 6 weeks). The program is composed of endurance, strengthening, and breathing exercises. Spirometry, arterial blood gas analysis, 6-min walking distance, aerobic capacity (VO2 peak) using Rockport formula, peripheral muscle strength assessment, dyspnea assessment (modified Medical Research Council), and health-related quality of life (HRQL) score using St George’s Respiratory Questionnaire were assessed before and after the sixth week of the program. Results There was crucial influence in modified Medical Research Council (P=0.001), 6-min walk test (P≤0.001), maximal inspiratory pressure (P=0.003), maximal expiratory pressure (P=0.003), VO2 peak (P=0.005), and HRQL (P≤0.001). However, arterial blood gas and spirometry showed no important advancement after the program. Conclusion PR improves exercise capacity, dyspnea, peripheral muscle strength, and HRQL in patients with ILD.

Assessment of respiratory muscle functions before and after exercise training in stable chronic obstructive pulmonary disease patients

Background Respiratory muscle dysfunction and dynamic hyperinflation are considered important factors leading to exercise intolerance in chronic obstructive pulmonary disease (COPD) patients. Aim We hypothesized that respiratory muscle functions would improve after an exercise training program in COPD patients. Patients and methods The study included 24 stable COPD patients, their mean value of forced expiratory volume in the first second (%) was 44.5±15%. The training program was performed three times weekly for 4 weeks. Patients underwent ultrasonographic assessment of diaphragmatic excursion. Maximal inspiratory and expiratory pressures were detected by a handheld manometer. Exercise capacity was assessed using 6-min walking distance. Dyspnea was rated using modified Medical Research Council. Assessment of all parameters was done at baseline and after 4 weeks. Results Maximal diaphragmatic excursion mean value demonstrated a significant increase (from 3.6±1.6 to 4.5±1.2 cm with P=0.006). PImax mean value illustrated a significant increase (from −40.2±13.8 to −43.8±12.1 cmH2O with P=0.010). PEmax mean value showed a statistically significant increase (from 93.9 to 105 cmH2O). There was a significant increase of exercise capacity presented by an increase of 6-min walking distance mean value (from 185.4±68.5 to 358.5±103 m with P Conclusion Exercise can result in significant improvements of respiratory muscle functions in stable COPD patients. This could be an important factor in the improvement of dyspnea and exercise capacity.

Isolated Right Pulmonary Agenesis in a 2-Month-Old Infant in the Pediatric Ward of Hospital of Mali

Introduction: Pulmonary agenesis is a rare congenital abnormality defined by the absence of parenchyma, bronchi and pulmonary vessels, frequently associated with other malformations. We describe a case of isolated right pulmonary agenesis diagnosed in the pediatric ward of the Mali Hospital. Clinical case: He was a month-old baby boy, born at term by cesarean section of a well-followed pregnancy. He was not resuscitated. He developed dyspnea after a cold. An emergency chest X-ray revealed a right opaque lung. He was referred to the hospital for the exploration of this opacity. At the entrance, it weighed 3910 g, size: 54 cm and the temperature was 36.9°C. He had a polypnea, an intercostal print. The sounds of the heart were diverted to the right. The rest of the clinical examination was without much particularity. The chest CT scan confirmed the right pulmonary agenesis. Abdominal and cardiac ultrasound was normal. A healing includes oxygenotherapy, serum glucose 10% minding 100 ml/ Kg/day and amoxicillin minding 100 mg/ Kg/day at 3 times by oral way. After 24 hours of treatment, we observed an improvement in dyspnea. On D2, he was weaned off oxygen and resumed feeding. Conclusion: Pulmonary agenesis is a rare congenital anomaly that is frequently associated with other malformations, thus making its prognosis poor. The search for malformative abnormalities should be systematic in right pulmonary agenesis.