Persistent Airway Obstruction Research Articles

Do Different Amounts of Exogenous Surfactant Differently Influence Cerebrovascular Instability in a Consecutive Group of Preterm Babies? Preliminary Results from a Single-Center Experience

Background: Thirty years ago, the first attempt by Saliba and colleagues was made to reduce the negative effects (hypercarbia) of exogenous surfactant (ES) by slowing its administration. Sixteen years later, we observed the first less invasive surfactant administration (LISA) attempt by Kribs and colleagues. Many studies, since that time, have tried to minimize the invasiveness of ES and subsequent cerebral blood flow perturbations through studies using near-infrared spectroscopy (NIRS). We sought to address this medical challenge by identifying a less problematic modality of ES administration by delivering multiple aliquots of ES instead of a single one, as typically performed. The aim of this study was to test the hypothesis that a different way of administering ES using more aliquots could be a safe alternative that should be assessed in further studies. Methods: Patients between 26 + 0 and 35 + 6 weeks of gestational age (GA) requiring ES administration were enrolled (April 2023–February 2024). Differently fractioned doses were delivered according to an arbitrary standard dosage (0.3 mL per aliquot in babies < 29 weeks; 0.6 mL in babies ≥ 29 weeks), while NIRS and transcutaneous CO2 (tCO2) monitoring were always performed. ES’s effectiveness was assessed based on the reduction in the Oxygen Saturation Index (OSI) after administration. Persistent desaturation, bradycardia, and airway obstruction were defined as adverse effects and used to evaluate safety during ES administration, as well as variability in NIRS-rSO2 values and tCO2. Results: Twenty-four patients were enrolled with a median GA of 29 weeks (IQR 4.5) and BW of 1223 ± 560 g. In addition, 50% of the cohort received fewer than three aliquots, whereas the other 50% received more than three. Monitoring was started before the procedure and continued 30′ after the last ES aliquot administration. The variability in NIRS-SpO2 values was significantly higher in the group (p = 0.007) with a lower number of aliquots administered. Similarly, increased NIRS-rSO2 values (p = 0.003) and increased tCO2 levels (p = 0.005) were observed in infants who underwent an ES split after the administration of a low number of aliquots. Conclusions: Our data obtained from the group with > 3 fractionated doses of ES seem to justify the preparation of a more robust study, as the combination of reduced NIRS variability and reduced tCO2 maximum levels is consistent with more stable cerebral blood flow during the challenging time of ES administration.

Update in postinfectious bronchiolitis obliterans.

Postinfectious bronchiolitis obliterans (PiBO) is a rare and severe form of chronic obstructive lung disease caused by an infectious injury to the lower respiratory tract. The most commonly recognized inciting stimuli leading to PiBO are airway pathogens, such as adenovirus and Mycoplasma. PiBO is characterized by persistent and nonreversible airway obstruction, with functional and radiological evidence of small airway involvement. The literature has limited information on the aetiology, clinical profile, treatment, and outcome of PiBO.

Serum Levels of Urokinase Plasminogen Activator Receptor (suPAR) Discriminate Moderate Uncontrolled from Severe Asthma

The most clinically useful concept in asthma is based on the intensity of treatment required to achieve good asthma control. Biomarkers to guide therapy are needed. To investigate the role of circulating levels of soluble urokinase plasminogen activator receptor suPAR as a marker for asthma severity. We recruited patients evaluated at the Asthma Clinic, University of Thessaly, Greece. Asthma severity and control were defined according to the GINA strategy and Asthma Contro Test (ACT). Anthropometrics, spirometry, fractional exhaled nitric oxide (FeNO), suPAR, blood cell count, c-reactive protein (CRP), and analyses of kidney and liver function were obtained. Patients with a history of inflammatory, infectious, or malignant disease or other lung disease, more than 5 pack years of smoking history, or corticosteroid therapy were excluded. We evaluated 74 asthma patients (69% female, mean age 57 ± 17 years, mean body mass index (BMI) 29 ± 6 kg/m2). In total, 24%, 13%, 6%, 5%, 29% and 23% of the participants had mild well-controlled, mild uncontrolled, moderate well-controlled, moderate uncontrolled, severe well-controlled, and severe uncontrolled asthma, respectively. Overall, 67% had T2-high asthma, 26% received biologics (15% and 85% received omalizumab and mepolizumab, respectively), and 34% had persistent airway obstruction. suPAR levels were significantly lower in asthmatics with moderate uncontrolled asthma than in patients with severe uncontrolled asthma without (2.1 ± 0.4 vs. 3.3 ± 0.7 ng/mL, p = 0.023) or with biologics (2.1 ± 0.4 vs. 3.6 ± 0.8 ng/mL, p = 0.029). No correlations were found between suPAR levels and age, BMI, T2 biomarkers, CRP, or spirometric parameters. suPAR levels were higher in asthmatics with severe disease than in those with moderate uncontrolled asthma.

Clusters based on immune markers in a Lithuanian asthma cohort study

Objective Asthma is divided into various distinct phenotypes on the basis of clinical characteristics, physiological findings, and triggers, and phenotyping is usually performed in a hypothesis-driven univariate manner. However, phenotyping can also be performed using computer algorithms to evaluate hypotheses-free relationships among many clinical and biological characteristics. We aimed to identify asthma phenotypes based on multiple demographic, clinical, and immunological characteristics. Methods Cluster analysis in R v3.5.0 was performed using asthma patient data. A total of 170 adult patients with asthma (diagnosed according to the GINA recommendations) were recruited to the study. All patients completed questionnaires about their smoking history and underwent physical examination, spirometry, skin-prick test, blood sample collection to evaluate peripheral blood cell counts and serum IgE, periostin, and interleukin (IL)-33 levels, as well as body mass index measurements. Data normality was checked with histograms and QQ plots. Hierarchical clustering was performed using Ward’s linkage with Ward’s clustering criterion. The optimal number of clusters was validated using the Dunn criterion as well as by comparing different clustering algorithms using the clValid package. Results Three clusters characterizing asthma phenotypes were identified: (1) early-onset, highly atopic, and eosinophilic asthma associated with male sex and high levels of IL-33 and periostin; (2) late-onset, eosinophilic asthma associated with female sex and low levels of IL-33 and periostin; and (3) late-onset, obese, neutrophilic asthma associated with female sex, persistent airway obstruction, and very low IL-33 and periostin levels.

Severe Neutrophilic Asthma: Pathogenesis and Treatment

Asthma is a common chronic airway disease affecting about 358 million people worldwide, and an estimated 7 million children globally. Approximately 10% of patients with asthma have severe refractory disease, which is difficult to control on high doses of inhaled corticosteroids and other modifiers. Among these, are patients with severe neutrophilic asthma. Neutrophilic asthma is a severe phenotype of asthma, characterized by frequent exacerbations, persistent airway obstruction, and poor lung function. Immunopathologically, it is characterized by the presence of high levels of neutrophils in the airways and lungs. Interleukin-17 produced by Th17 cells, plays a key role in the pathogenesis of neutrophilic asthma by expressing the secretion of chemoattractant cytokines and chemokines for the recruitment, and activation of neutrophils. Interleukin-8 is a powerful chemoattractant and activator of neutrophils. Activated neutrophils produce an oxidative burst, releasing multiple reactive oxygen species, proteinases, cytokines, which cause airway epithelial cell injury, inflammation, airway hyperresponsiveness, and remodeling. Furthermore, exasperated neutrophils due to viral, bacterial or fungal infections, and chemical irritants can release extracellular nucleic acids (DNA), designated as NETs (neutrophil extracellular traps), which are more toxic to the airway epithelial cells, and orchestrate airway inflammation, and release alarmin cytokines. Dysregulated NETs formation is associated with severe asthma. Most patients with neutrophilic asthma are unresponsive to the standard of care, including high dose inhaled corticosteroids, and to targeted biologics, such as mepolizumab, and dupilumab, which are very effective in treating eosinophilic asthma. There is unmet need to explore for novel biologics for the treatment of neutrophilic asthma, and in refining therapies, such as bronchial thermoplasty.

Postinfectious Bronchiolitis Obliterans

Childhood bronchiolitis obliterans (BO) is an uncommon complication that is characterized clinically by persistent and continuous obstructive respiratory symptoms, and has been described secondary to various etiologic factors, including drugs, exposure to toxic fumes, allergic reactions, collagen vascular disease or infections. BO occurs most commonly in children after an episode of acute bronchiolitis and is considered a long-term sequela of viral infection.Postinfectious Bronchiolitis Obliterans (PIBO) is characterized by persistent airway obstruction with functional and radiological evidence of small airway involvement that is in general unresponsive to bronchodilator treatment.Although the condition is relatively rare, and its exact incidence is unknown, it is important to keep it in mind. PIBO is complication of lower respiratory tract epithelial injury, and is often misdiagnosed, delaying recognition and potential treatment. A PIBO diagnosis is usually based on a few factors, including a good medical history, positive clinical findings, and lung function test and imaging results, although biopsy and histopathology remain as the optimum diagnostic approach. There have to date been few studies proposing treatments for the condition, and no accepted protocol exists in literature. There is usually a fixed airway obstruction in PIBO. Various treatment approaches have been extrapolated from studies of post bone marrow transplantations and lung transplant BO. The clinical course is variable, and good supportive therapy is essential, with anti-inflammatory therapy often being employed.

Spirometry for the diagnosis of airway obstruction in patients with risk factors for COPD: the GOLD and lower limit of normal criteria.

ABSTRACTObjective:The identification of persistent airway obstruction is key to making a diagnosis of COPD. The GOLD guidelines suggest a fixed criterion-a post-bronchodilator FEV1/FVC ratio < 70%-to define obstruction, although other guidelines suggest that a post-bronchodilator FEV1/FVC ratio < the lower limit of normal (LLN) is the most accurate criterion. Methods:This was an observational study of individuals ≥ 40 years of age with risk factors for COPD who were referred to our pulmonary function laboratory for spirometry. Respiratory symptoms were also recorded. We calculated the prevalence of airway obstruction and of no airway obstruction, according to the GOLD criterion (GOLD+ and GOLD−, respectively) and according to the LLN criterion (LLN+ and LLN−, respectively). We also evaluated the level of agreement between the two criteria. Results:A total of 241 individuals were included. Airway obstruction was identified according to the GOLD criterion in 42 individuals (17.4%) and according to the LLN criterion in 23 (9.5%). The overall level of agreement between the two criteria was good (k = 0.67; 95% CI: 0.52-0.81), although it was lower among the individuals ≥ 70 years of age (k = 0.42; 95% CI: 0.12-0.72). The proportion of obese individuals was lower in the GOLD+/LLN+ category than in the GOLD+/LLN− category (p = 0.03), as was the median DLCO (p = 0.04). Conclusions:The use of the GOLD criterion appears to be associated with a higher prevalence of COPD. The agreement between the GOLD and LLN criteria also appears to be good, albeit weaker in older individuals. The use of different criteria to define airway obstruction seems to identify individuals with different characteristics. It is essential to understand the clinical meaning of discordance between such criteria. Until more data are available, we recommend a holistic, individualized approach to, as well as close follow-up of, patients with discordant results for airway obstruction.

Clusters of Severe Eosinophilic Asthma in a Korean Asthma Cohort

Background: Targeted therapies have broadened the available treatment options for patients with severe eosinophilic asthma (SEA). However, differences in the magnitude of treatment responses among patients indicate the presence of various underlying pathophysiological processes and patient subgroups. Objectives: We aimed to describe the characteristics of SEA and identify its patient subgroups. Methods: Clinical data from the Cohort for Reality and Evolution of Adult Asthma in Korea were analyzed. Cluster analysis was performed among those with SEA using 5 variables, namely, prebronchodilator forced expiratory volume in 1 s, body mass index, age at symptom onset, smoking amount, and blood eosinophil counts. Results: Patients with SEA showed prevalent sensitization to aeroallergens, decreased lung function, and poor asthma control status. Cluster analysis revealed 3 distinctive subgroups among patients with SEA. Cluster 1 (n = 177) consisted of patients reporting the lowest blood eosinophils (median, 346.8 cells/μL) and modest severe asthma with preserved lung function during the 12-month treatment period. Cluster 2 (n = 42) predominantly included smoking males with severe persistent airway obstruction and moderate eosinophilia (median, 451.8 cells/μL). Lastly, cluster 3 (n = 95) included patients with the most severe asthma, the highest eosinophil levels (median, 817.5 cells/μL), and good treatment response in terms of improved lung function and control status. Conclusions: Three subgroups were identified in SEA through the cluster analysis. The distinctive features of each cluster may help physicians predict patients who will respond to biologics with greater magnitude of clinical improvement. Further research regarding the underlying pathophysiology and clinical importance of each subgroup is warranted.

Creation and Implementation of a Hospitalist-Run Propofol Sedation Program.

Pediatric hospitalists increasingly provide sedation outside the operating room. Given the large body of safety data available, propofol was identified as a beneficial addition to our hospitalist-run sedation service's medication repertoire. Currently, the training required for hospitalists to provide sedation is defined and determined locally by individual institutions. We convened a task force to develop and implement training for hospitalists in the use of propofol for deep sedation. After implementing training, we analyzed the outcome of patients receiving propofol for deep sedation for MRI, including the adverse event rate and successful completion rate. An adverse event was defined as a significant desaturation, persistent upper airway obstruction, laryngospasm, administration of neuromuscular blockade, conversion to anesthesia, call for additional backup, or if the procedure was not able to be completed. Successful completion was defined as any patient being able to complete the imaging study or procedure with sedation performed by a hospitalist physician. Between September 2015 and September 2018, sedation services sedated 12 979 patients, 3929 of whom were deeply sedated with propofol. During this period, the trained hospitalists had an adverse event rate of 3.6% and a 98.9% rate of successful completion of all studies or procedures when using propofol for deep sedation. With a comprehensive training program for hospitalists in the administration of propofol, we provided effective sedation for a selective population of patients. We now have a standard approach that uses credentialed hospitalists to train new faculty for propofol administration.

Predicting Failure of Conservative Airway Management in Robin Sequence

PURPOSE: While initial management of upper airway obstruction in Robin sequence is traditionally conservative, early identification of patients who failed in this approach would avoid the deleterious effects of prolonged upper airway obstruction and hospitalization. The purpose of the current study was to evaluate patient factors, clinical data, and polysomnographic (PSG) results in hospitalized infants with Robin sequence who were either discharged after successful conservative airway measures (Group 1) or required surgical airway intervention after a protracted hospital course (Group 2). We hypothesized that differences between these two groups may expedite early operative airway procedures in appropriate patients without an initial prolonged and, ultimately, unsuccessful period of conservative management. METHODS: A retrospective review was conducted among infants diagnosed with RS who underwent primary airway management at a single institution from 1994 to 2020. Patient demographics, nutritional and respiratory status, laboratory values, and PSG results were recorded. Airway management was classified as conservative or surgical, and recorded variables were compared between the groups. Unpaired t-test/Wilcoxon-Mann-Whitney test was used to compare continuous data and Chi square test/Fisher exact test for categorical data. To assess the ability of PSG variables to predict failure of conservative management, we performed receiver operator characteristic (ROC) curve analysis. Accuracy was graded based on the area under the curve (AUC) defined as “poor” (AUC 0.60–0.70), “fair” (AUC 0.70–0.80), “good” (AUC 0.80–0.90), and “excellent” (AUC 0.90–1.00). Optimal cut-points were calculated using the Youden index (J) method. RESULTS: In total, 122 infants with Robin sequence were analyzed. Conservative airway measures were successful in 61 patients (Group 1), while 61 infants failed this approach after a mean period of 23 days and required a surgical airway procedure (Group 2). Lower 5-minute Apgar scores and associated pulmonary, CNS, and reflux disease were seen more frequently in Group 2 patients. A significantly smaller proportion of patients in Group 2 also demonstrated adequate oral intake compared with Group 1 patients (5% versus 28%, P < 0.001). The surgically managed patients required greater respiratory support or intubation, as well as higher levels of maximum CO2 (67.8 versus 51.4 mm Hg, P < 0.001) and maximum HCO3 (32.7 versus 28 mmol/L, P = 0.001). PSG results in Group 2 patients documented a higher percentage of time with O2 saturation < 90% (10.4% versus 1.1%, P = 0.005) and overall higher apnea-hypopnea index (AHI) (59.7 versus 20.6 events/hour, P < 0.001). Good predictors for failure of conservative airway management (AUC range: 0.80–0.85) included AHI, obstructive AHI (OAHI) REM, OAHI non-REM, and maximum ETCO2 (asleep). Cut points most predictive for failure of conservative management by ROC curve analysis included: AHI > 16.9, OAHI REM > 25.9, OAHI non-REM > 23.6, and maximum ETCO2 > 49 mm Hg. CONCLUSIONS: The current study identified patient factors and PSG results in infants with RS that were associated with persistent upper airway obstruction despite weeks of conservative airway management. Our data may expedite earlier definitive treatment of these critical patients that is essential to reducing risk for known complications such as hypertension, metabolic syndrome, and neurocognitive dysfunction.

Occupation and subcategories of asthma: a population-based incident case–control study

BackgroundWe hypothesised that occupational exposures differently affect subtypes of adult-onset asthma.ObjectiveWe investigated potential relations between occupation and three subtypes of adult asthma, namely atopic asthma, non-atopic asthma and asthma–COPD overlap...

Upregulation of neuropeptides and obstructive airway disorder in infancy: A review with focus on post-RSV wheezing and NEHI.

Obstructive airway disorders, common in infancy and early childhood, include some entities that are recognized to have neuro immune mediators as their underlying pathogenetic mechanisms. The best characterized example amongst post-viral wheezing phenotypes is the disorder that follows respiratory syncytial virus (RSV) infection and leads to intermittent, long-term wheezing. The underlying mechanisms of the airway reactivity related to RSV infection have been extensively studies and are associated with dysregulation of the nonadrenergic-noncholinergic (NANC) system, via upregulation of neurotransmitters, typically Substance P. Neuroendocrine hyperplasia of infancy (NEHI), while a less common entity, is a disorder characterized by more severe and long-term obstructive airway disease. NEHI is pathophysiologically characterized by abundance of neuroendocrine cells in the airways containing the neuroimmune mediator bombesin, the release of which is presumed to be the driver of the persistent small airway obstruction and functional air-trapping. Here we review the NANC and neuroendocrine cells, the neurotransmitter systems and their studied roles in pulmonary diseases with a focus on their role in lung development, and subsequent various pediatric lung diseases. We focus on the juxtaposition of the separate neuroimmune mechanisms underlying the pathogenesis of post-RSV recurrent wheezing and NEHI's persistent small airway obstruction. We finally propose a unifying concept of neuropeptides in obstructive disorders that may encompass these two entities and possibly others.

Will the asthma revolution fostered by biologics also benefit adult ICU patients?

Asthma exacerbations are inflammatory events that rarely result in full hospitalization following an ER visit. Unfortunately, certain patients require prolonged support, including occasional external lung support through ECMO or ECCOR (with subsequent further exposure to other life-threatening issues), and some die. In parallel, biologics are revolutionizing severe asthma management, mostly in T2 high patients. We extensively reviewed the current unmet needs surrounding ICU-admitted asthma exacerbations, with a focus on currently available drugs and the underlying biological processes involved. We explored whether currently available T2-targeting drugs can reasonably be seen as potential players not only for relapse prevention but also as candidate drugs for a faster resolution of such episodes. The patient's perspective was also sought. About 30% of asthma exacerbations admitted to the ICU do not resolve within five days. Persistent severe airway obstruction despite massive doses of corticosteroids and maximal pharmacologically induced bronchodilation is the main cause of treatment failure. Previous ICU admission is the main risk factor for such episodes and may eventually be considered as a T2 surrogate marker. Fatal asthma cases are hallmarked by poorly steroid-sensitive T2-inflammation associated with severe mucus plugging. New, fast-acting T2-targeting biologics (already used for preventing asthma exacerbations) have the potential to circumvent steroid sensitivity pathways and decrease mucus plugging. This unmet need was confirmed by patients who reported highly negative, traumatizing experiences. There is room for improvement in the management of ICU-admitted severe asthma episodes. Clinical trials assessing how biologics might improve ICU outcomes are direly needed.

Tidal Breathing Measurements in Former Preterm Infants: A Retrospective Longitudinal Study

To investigate, in infants born preterm with or without bronchopulmonary dysplasia (BPD), the trajectory of tidal breathing flow-volume (TBFV) parameters in the first 2years of life; the association between TBFV parameters and perinatal risk factors; and the predictive value of TBFV parameters for rehospitalizations due to respiratory infections and wheeze. We retrospectively analyzed TBFV measurements performed at 0-6, 6-12, and 12-24months of corrected age in 97 infants <32weeks of gestation and <1500g. We assessed the association between TBFV parameters and perinatal risk-factors using linear regressions and the predictive capacity for subsequent respiratory morbidity using logistic regressions. We used the area under the curve and likelihood ratio test (LRT) to compare nested models. Time to peak tidal expiratory flow/expiratory time ratio (tPTEF/tE) was lower than normal for the first 2years of corrected age. Longer duration of oxygen supplementation, intubation, and respiratory support were associated with reduced tPTEF/tE at all time points. For each z-score increase in tPTEF/tE, the OR for rehospitalizations decreased by 0.70. tPTEF/tE added significantly to BPD classifications alone in predicting rehospitalizations (area under the receiver operating characteristic curve=0.81 vs 0.76, P value for LRT=.0012), and wheeze (area under the receiver operating characteristic curve=0.76 vs 0.71, P value for LRT <.001). Infants born preterm, with and without BPD, display persistent airway obstruction during the first 2years of life. tPTEF/tE may identify infants at greater risk of severe respiratory morbidity.

The Effect of Thymoquinone on Interleukin-8 Levels, %FEV1 and CAT Scores in Chronic Obstructive Pulmonary Disease

Background: Chronic obstructive pulmonary disease (COPD) is a characterized by respiratory symptoms and persistent airway obstruction due to alveoli and/or airway abnormalities caused by continuous exposure to harmful particles or gases. Airway inflammation plays an important role in the pathogenesis of COPD. Nigella sativa, known as habbatusauda, contains thymoquinone, which has an anti-inflammatory effect. Airway inflamation improvement was measured based on decreased plasma IL-8 level, maintain the optimization of %FEV1 value and clinical improvement based on the decreased CAT score.&#x0D; Methods: The pretest and posttest experimental clinical trial was carried out in 40 patients with stable COPD in the pulmonology outpatient clinics of Dr. Moewardi Surakarta and dr. Soehadi Prijonegoro Sragen Hospital from 29 June to 3 August 2019. Subjects were grouped into treatment group (n=20) receiving standard therapy along with thymoquinone oil capsules 500 mg/day and placebo group (n=20) receiving standard therapy only for 30 days.&#x0D; Results: The study revealed statistically insignificant decreases of IL-8 level (P=0.052) and %FEV1 value (P=0.943) in the treatment group, while CAT score showed significant decreases in the treatment group (P=0.0005).&#x0D; Conclusion: Thymoquinone administration reduce inflammation as it can lower IL-8 level and improves the clinical condition of patients with stable COPD based on a decrease in CAT score.

Long-Term Functional Outcomes Following Septal Extension Grafting in Open Rhinoplasty

BACKGROUND: Septal extension grafts in rhinoplasty can successfully support tip projection/position, tension the lower lateral cartilages, and thereby open the nasal airway. Since long cartilage grafts under tension may warp or collapse over time, long-term outcomes must be evaluated in these patients. We aimed to assess long-term functional outcomes in a large series of patients who underwent septal extension grafting. METHODS: Retrospective chart review was performed on all patients who underwent an open rhinoplasty approach that included use of a septal extension graft performed by a single surgeon from February 2013 through December 2018. Patients with a minimum 12-month postoperative follow-up were included. Pre- and postoperative functional outcomes including history of nasal obstruction, snoring, sleep apnea, sinus congestion, and sinus headaches were recorded. Patient demographics, types of grafts used, patient complaints, readmission, and reoperation rates were recorded. Statistical analysis was performed using McNemar’s test. RESULTS: Of the 385 patients who underwent open rhinoplasty with septal extension grafting during the study period, 127 with adequate follow-up were included; 72% females, 28% males, mean age 28 (range: 5–72) years. 83.5% primary rhinoplasty, 16.5% secondary rhinoplasty. Mean follow-up was 24.2 (range: 11.2–74.0) months. 10.2% had history of cleft lip, 49.6% had history of nasal trauma. Other graft types used included tip/infratip (92.9%), dorsal onlay (90.6%), spreader graft/flap (92.1%), and columellar strut/onlay (7.9%). 85.0% underwent a turbinate outfracture/coblation. Patients reported an improvement in (pre- versus postoperative) nasal airway obstruction (89.8% versus 11.8%; P < 0.001), snoring (55.1% versus 1.6%; P < 0.001), sleep apnea (5.5% versus 0.0%; P = 0.016), sinus congestion (45.7% versus 15.7%; P < 0.001), and sinus headaches (6.3% versus 0.0%; P = 0.008). All patients reported an improvement in aesthetic appearance, with 7.9% undergoing touch-up procedures such as filler or fat injection to smooth a minor contour deformity. 6.5% of patients in this cohort required reoperation; the most common reasons for reoperation were for nasal deformity/deviation (72.0%), persistent airway obstruction (20.0%), and scar revision/dermabrasion (8.0%). Only 3.1% of noncleft, nontrauma patients required revision. No patients reported worsening of nasal airway patency. CONCLUSIONS: Septal extension grafts, when applied in open rhinoplasty patients, can reliably and significantly improve functional outcomes in addition to the aesthetic benefits to tip projection and rotation. Quantitative analysis of nasal airway changes following septal extension grafting will be presented.

The Global Usability Score Short-Form for the simplified assessment of dry powder inhalers (DPIs) usability.

BackgroundThe choice of the Dry Powder Inhaler (DPI) to prescribe is a critical issue. The estimation of DPIs usability depends on the objective assessment of several indices related to both subjective and objective determinants. The Global Usability Score (GUS) Questionnaire is a comprehensive tool usable for checking, comparing, and ranking inhalers’ usability objectively in real life, but it takes some time to fill.AimThe aim of this study was to favour the quicker check of DPIs usability in clinical practice by means of a simplified short-form GUS (S-GUS) Questionnaire, while maintaining the high specificity and sensitivity of the original, extended version of the Questionnaire (O-GUS questionnaire).MethodsThe usability of the six most prescribed DPIs was assessed in 222 patients with persistent airway obstruction and needing long-term inhalation treatments. LASSO regression and multicollinearity test were used to select the subset of questions of the O-GUS questionnaire, with the highest information power. Each item was then scored using the corresponding coefficient in the linear regression (normalized at 50 as the O-GUS score). Agreement between the original and the short-form questionnaire was evaluated using the Cohen’s kappa statistic (κ). The overall S-GUS values obtained for each DPI were then compared to those from the O-GUS, in the same patients, using a Bayesian indirect comparison (IC) model.ResultsAfter the statistical selection of the items mostly contributing to the overall score, the novel S-GUS questionnaire consists of twelve items only. Nine items are related to patients’ opinion before DPIs handling, and three to the nurse’s assessment after DPIs practicality. O-GUS and S-GUS score were strongly correlated (R2=0.9843, p<0.0001) and the usability score calculated for each DPI by means of the O- and of S- GUS overlapped almost completely (κ=84.5%, 95% CI 81.3% to 89.2%). Furthermore, S-GUS was much faster to complete than O-GUS (mean time 6.1 vs 23.4 minutes, p<0.001). Estimates of S-GUS, obtained from the IC model, allowed to propose a simple classification of usability: “good” by GUS values >25; “pretty good” by values ≤25≥15, and “insufficient” by values <15.ConclusionsThe S-GUS proves as much specific and suitable as the extended O-GUS questionnaire in measuring DPIs usability, while maintaining the same high sensitivity. As the time required for its use is quite shorter, S-GUS is also particularly suitable and helpful in current clinical practice.

Treating Symptomatic Midvault Soft Tissue Collapse in Revision Rhinoplasty with a Nasal Wall Implant.

Summary:Persistent nasal airway obstruction (NAO) due to midvault soft tissue collapse in patients following rhinoplasty or nasal surgery is a clinical challenge for surgeons. An absorbable lateral nasal wall implant is one option available to help treat midvault soft tissue collapse and to improve NAO symptoms. Previous studies have not investigated its use in complex revision functional rhinoplasty with respect to patient-reported outcomes. Data were collected on all patients with a history of previous nasal procedures who underwent Latera implant placement in conjunction with functional rhinoplasty from January to December 2018. The Nasal Obstructive Symptom Evaluation and Visual Analogue Scale were used to evaluate functional outcomes. Eight implants were placed in 6 revision functional rhinoplasty patients with midvault collapse. All patients responded to the survey. Mean follow-up was 16 ± 4 months. There were no implant-related adverse events. Mean Nasal Obstructive Symptom Evaluation score was 33 ± 33, and mean Visual Analogue Scale score was 20 ± 9. In total, 1 patient reported complete resolution of NAO, whereas 2 patients reported mild, 1 reported moderate, 1 reported severe, and 1 reported extreme symptoms. Four of the 6 patients reported nasal obstruction improvement, with all reporting improvement in midvault soft tissue collapse. Apart from being used in nasal valve collapse treatment, a lateral nasal wall implant is a potentially useful solution that may help surgeons improve patients’ NAO symptoms in complex functional rhinoplasty cases. However, in certain cases, a patient’s nasal obstructive symptoms may continue to be multifactorial.

Assessment of Medication Adherence Barriers in COPD Patients in A Secondary Care Teaching Hospital

Background: COPD is characterised by persistent airway obstruction in which better clinical outcome can be attained by appropriate management of disease. Adherence to COPD medication is poorly understood due to chronic nature of the disease. It is crucial to identify the barriers of non-adherence to build up and execute policies and interventions to upgrade medication adherence. Objective: To identify the predisposing barriers of medication adherence and to find the association between medication adherence and variables. Methods: A descriptive analytical study was conducted and data was collected from COPD outpatients. The Morisky Medication Adherence Scale was used to measure adherence and self-assessed questionnaire was employed to identify the predictors of poor adherence. Chi square test was carried out to find the relationship between medication adherence and variables such as age, gender, literacy, socioeconomic class, polypharmacy, delivery device and climate. Results: A total of 403 patients were involved in the study where 68% reported lower adherence. The most common adherence barriers found were forgetfulness (88%), intentional stoppage of medicines when symptoms improve (83%) and negligence towards medication (82%).A significant association was found between gender, literacy, socioeconomic class, polypharmacy, delivery device and climate. Conclusion: Adherence to medication regimen in COPD patients is poor, even though it is a preventable and a treatable disease. Well-structured education, training, counseling is required to overcome medication adherence particularly among illiterate and low socioeconomic class patients. The combined interventions should be used such as video clips demonstrations of inhaler technique should be given.&#x0D; Keywords: COPD, Morisky medication adherence scale, Chi square test.

Distinct profile of inflammatory and remodelling biomarkers in sputum of severe asthmatic patients with or without persistent airway obstruction

BackgroundBoth inflammatory and remodelling processes are associated with irreversible airway obstruction observed in severe asthma. Our aim was to characterize a group of severe asthmatic patients with or without persistent airway obstruction in relation to specific sputum inflammatory and remodelling biomarkers. MethodsForty-five patients under regular high-dose inhaled corticosteroid/ß-2agonist treatment were studied, after a follow-up period of at least 2 years, with a minimum of 4 visits. Periostin, TGF-ß, RANTES, IL-8, GM-CSF, FGF-2, and cell counts were measured in induced sputum. Serum periostin was also measured. ResultsSputum induction was successfully performed in all but 5 patients. There were no significant differences in demographic and clinical data between patients with non-persistent obstruction (NO: FEV1/VC>88%pred.) and those with persistent obstruction (O: a not completely reversible obstruction with FEV1/VC<88%pred. at each visit before the study visit). Patients with persistent obstruction had significantly higher sputum periostin and TGF-ß concentrations than NO patients and a trend of higher serum periostin levels. GM-CSF and FGF-2 were significantly increased in NO compared to O patients. No differences between groups were found for RANTES, IL-8 and differential cell counts. Sputum periostin inversely correlated with functional parameters (prebronch. FEV1: rho = −0.36, p < 0.05; postbronch. FEV1: rho = −0.33, p = 0.05). Patients with high sputum periostin concentration (>103.3 pg/ml: median value) showed an absolute number of sputum eosinophils significantly higher than patients with low sputum periostin; this behavior was unobserved when serum periostin was considered. ConclusionsOnly periostin and TGF-ß identified a subgroup of severe asthmatic patients with persistent airway obstruction. Sputum periostin was also inversely associated with FEV1 and proved to be a more sensitive biomarker than serum periostin to identify severe asthmatics with higher sputum eosinophilia.