Purulent Sputum Research Articles

Vancomycin-resistant Enterococcus faecium pneumonia in a uremic patient on hemodialysis: a case report and review of the literature

BackgroundEven though enterococci can cause serious infections in multiple sites, they are a rare cause of pneumonia. We reported a uremic patient with vancomycin-resistant E. faecium (VRE-fm) pneumonia, possibly related to epileptic seizures.Case presentationA 57-year old man with uremia on hemodialysis was admitted to the hospital with complaint of recurrent epileptic seizures, followed by a two-week history of recurrent fever and cough with purulent sputum. Chest CT demonstrated multiple exudation of both lungs. He was diagnosed as community acquired pneumonia. Despite antibiotic combination therapy, abnormal chest shadows aggravated. Sputum and blood cultures were initially negative, but later blood culture grew VRE-fm. We suspected aspiration of gastrointestinal content induced by epilepsy as the most likely mechanism. The patient was successfully treated with a four-week course of linezolid according to the antibiotic susceptibility testing.ConclusionsPhysicians should consider multi-drug resistant organisms such as VRE in uremic patients with pneumonia that fails to resolve with broad-spectrum antibiotics, especially in the cases with aspiration induced by epilepsy, immunocompromised conditions, and repeated or prolonged hospitalizations.

Unilateral antibiotic-induced acute eosinophilic pneumonia on the operative side after surgery for primary lung cancer: a case report

BackgroundAcute eosinophilic pneumonia (AEP) is a rare idiopathic lung disease characterized by pulmonary eosinophilia. The epidemiology of AEP remains understudied; however, past reports have reported that AEP can be caused by an allergic reaction to medications, such as antibiotics or inhaled antigens, such as tobacco smoke. AEP usually occurs bilaterally. However, we encountered an unusual case of antibiotic-induced eosinophilic pneumonia showing unilateral consolidation just on the operative side, which was initially diagnosed as postoperative bacterial pneumonia and treated with antibiotic therapy. The prescribed antibiotics paradoxically provoked AEP and worsened the patient’s condition. Here, we report this antibiotic-induced AEP case showing unilateral consolidation only on the operative side which could be triggered by surgery for primary lung cancer.Case presentationA 74-year-old man underwent right upper lobectomy for lung adenocarcinoma. On postoperative day (POD) 9, an interstitial shadow appeared in the right lower lung field of the chest radiographs, along with a fever of 38.5 °C, dyspnea needing oxygen supplementation, and increased purulent sputum production, suggesting postoperative bacterial pneumonia. Despite administration of the broad-spectrum antibiotic, meropenem, the fever did not improve, and pulmonary opacity gradually worsened. Blood analysis showed increased peripheral eosinophils at 1182/mm3. The meropenem treatment was discontinued and bronchoscopy was performed for further evaluation, and the bronchoalveolar lavage fluid assessment showed a remarkable increase in the eosinophil population (51%). The drug lymphocyte stimulation test (DLST) for meropenem was positive. We diagnosed the patient with antibiotic-induced unilateral AEP, after which corticosteroid treatment was initiated. The patient subsequently improved and the infiltration in the right lower lung field completely disappeared. The patient was discharged on POD 43 without oxygen supplementation and is doing well without tumor recurrence 16 months after the surgery.ConclusionsUnilateral drug-induced AEP is rare. Nonetheless, it should be recognized as a differential diagnosis of postoperative pneumonia even in cases of a unilateral radiographic infiltration, because the lung operation itself could trigger this type of AEP.

Bronchial Infection and Temporal Evolution of Bronchiectasis in Patients With Chronic Obstructive Pulmonary Disease.

Bronchiectasis (BE) impact the clinical course and prognosis of patients with chronic obstructive pulmonary disease (COPD). Yet, the temporal evolution of BE in these patients is unknown. This study seeks to assess the temporal evolution of BE in persons with COPD. 201 moderate-to-severe patients were recruited between 2004 and 2007 and followed up at least every 6 monts (median of 102 months). To investigate the temporal evolution of BE, in 2015 a second high-resolution computed tomography scan (HRCT) was obtained in survivors and compared with the one obtained at recruitment. 99 (49.3%) died during follow-up. The second HRCT could be obtained in 77 patients and showed that (1) in 27.3% of patients BE never developed, in 36.4% they remained stable, in 16.9% they increased in size and/or extension, and in 19.5% new BE emerged; and that (2) the presence of chronic purulent sputum (hazard ratio [HR], 2.8 [95% confidence interval {CI}, 1.3-5.8]), number of hospitalizations due to exacerbatons (HR, 1.2 [95% CI, 1.1-1.5]), and number of pathogenic microorganism (PPM) isolations (HR, 1.1 [95% CI, 1.02-1.3]) were independent risk factors for the progression or development of BE. The presence of chronic purulent sputum production, number of PPMs isolated in sputum, and number of hospitalizations due to exacerbations of COPD are independent risk factors of BE progression in patients with COPD.

Organizing pneumonia secondary to Exophiala dermatitidis in cystic fibrosis: A case report

A 51-year-old Caucasian male with cystic fibrosis (CF) (homozygous ΔF508) and mild obstructive lung disease (baseline forced expiratory volume in 1 second (FEV1) was 2.59L, 70% predicted), presented to our clinic with a history of recurrent fevers, cough with purulent sputum, and dyspnea on exertion. Comorbidities included chronic infection with Pseudomonas aeruginosa, intermittent colonization with Exophiala dermatitidis, pancreatic insufficiency, adenomatous colon polyps (resected), osteopenia and CF-related diabetes.

Accidental inhalation of scarf pin: Presentation and management.

Background:The accidental aspiration of foreign bodies (FBs) is a rare occurrence in adults. However, inhalation of scarf pin is a phenomenon more and more common in the context of Muslim nations. The aim of our study was to describe the characteristics of this particular FB and illustrate the circumstances and consequences of inhalation.Methods:This retrospective study involved patients with a history of scarf pin aspiration admitted to the Thoracic Surgery Department of Mohammed VI University Hospital Center, Oujda, Morocco, over a period of 10 years. Their main presentation, diagnosis, treatment, and outcome were analyzed.Results:The average age of the 30 cases was 18 years (13–43). No antecedent was found in all cases. The penetration syndrome was found in all cases, with a transient moment of suffocation in 19 cases (63.33%), a dry cough in 15 cases (50%), minimal hemoptysis in 4 cases (13.33%), and purulent sputum in 3 cases (10%). The clinical examination was normal in all cases. The chest X-ray showed the FB in the form of linear right sided opacity in 14 cases (46.66%), left sided in 8 cases (26.66%), and in the trachea in 8 cases (26.66). Rigid bronchoscopy visualized the scarf pin at the level of the right basal pyramid in 5 cases (16.66%) and on the left side in 2 cases (6.66%), at the level of the main right and intermediate trunk in 7 cases (23.33%), at the level of the left main bronchus in 4 cases (13.33%) and in the trachea in 5 cases (16.66%). The pin was extracted by rigid bronchoscopy in 23 cases (76.66%) and was expelled spontaneously in 5 cases (16.66%). Thoracotomy was required in 2 cases (6.66%). Medical treatment, including antibiotic therapy and short-course oral corticosteroids, was administered in all cases.Conclusion:Scarf pin inhalation is common in women who wear the Islamic headscarf. Bronchoscopy is an important tool to manage these FBs, but the best prevention treatment is careful handling of these potentially sharp objects away from the mouth.

Nontuberculous mycobacterium as a hidden cause of noncystic fibrosis bronchiectasis

Background The incidence of lung colonization and infection owing to nontuberculous mycobacteria (NTM) in patients with cystic fibrosis (CF) and non-CF bronchiectasis is increasing worldwide, which may play a role in pathogensis of bronchiectasis. Aim The aim of this study is to search about NTM as a hidden cause of non-CF bronchiectasis. Patients and methods This is an observational cohort study done at Chest Department of Menoufia University Hospital on 40 patients with non-CF bronchiectasis more than 18 years of age between June 2017 and June 2018. All patients underwent spirometry, chest radiograph, high-resolution computed tomography, and sputum examination for tuberculous and NTM. The sputum samples were assessed by PCR, and positive cases did another PCR after 2 months. Results A total of 40 (21 females and 19 males) patients were included in the study, with mean age of 55.2±6.5 years, mean BMI of 21.4±2.1, and mean height of 163.7±7.3 cm. There were 7.5% of non-CF bronchiectasis cases with NTM (n=3). Mycobacterium avium complex (MAC) was the most common mycobacteria (66.6%) of positive patients. NTM isolation was significantly higher in elderly, tall, low BMI, and female patients (66%). High-resolution computed tomography of patients with NTM especially MAC has shown mucous plugging, peripheral nodules, and ectatic changes in bronchi, and also sputum purulence was less in patients positive for NTM. Conclusion NTM, especially MAC, may be a hidden cause in non-CF bronchiectasis and must be treated properly.

Change in Inhaler Use, Lung Function, and Oxygenation in Association with Symptoms in COPD.

Despite clinical guidelines for chronic obstructive pulmonary disease (COPD) patients to self-treat worsening respiratory symptoms with supplemental inhaler/nebulizer use, few studies have investigated if symptom changes are associated with differences in oxygenation, lung function, or self-treatment. A total of 26 former smokers (mean age 72.7 ±7.5 years; 57.7% female) with COPD (≥ Global Initiative for Chronic Obstructive Lung Disease Stage 2) were followed for up to 4 months, during which they recorded daily oxygenation, lung function, and inhaler/nebulizer use. Differences in these health measures were assessed in association with self-reported worsening symptoms and COPD exacerbations, as defined by validated questionnaire. We collected 2451 observations with spirometry and questionnaire data and identified 253 symptom days (10.3%) and 47 (1.92%) exacerbation days. In linear mixed effects models adjusted for age, sex, race, height, weight, and season, each respiratory symptom reported worse than baseline was associated with a 0.19 percentage point (95% CI -0.31 to -0.07) lower daily oxygen saturation (p=0.002). On major symptom days (defined as worse-than-baseline dyspnea, sputum purulence or sputum amount), oxygen saturation was 0.56 percentage points lower (95% CI -0.89 to -0.23, p=0.001) than days without increased major symptoms. We found no association of symptom days or exacerbations with forced expiratory volume in 1 second. There were 8 reports of increased inhaler/nebulizer use from baseline on symptom days (1.5% of 253). In this moderate-to-severe COPD population, worsening respiratory symptoms were common and associated with lower oxygenation. However, participants did not self-treat symptoms with increased inhaler/nebulizer use, which may suggest poor perceived clinical benefit from short-acting bronchodilators and a potential target for patient education.

The portrayal of microbes in respiratory medicine

Respiratory diseases caused by a number of infectious agents including Streptococcal pneumonia, streptococcal pyogenes, Klebsiella pneumonia H. influenzae, Legionella pneumophilia, Mycoplasma pneumonia, Coxiella Bunetii, chlamydia pisittaci. These microbes enter into the lungs and cause primary cases of pneumonia. The whole respiratory epithelium down to the internal bronchioles is ciliated. The cilia and the thin film of mucus covering them have the critical function of trapping foreign particles, including bacteria, and propelling them toward the pharynx. They contribute to the prevention of respiratory infection as they do the macrophages utilizing their secretory, phagocytic, and bactericidal activity. Despite the wonderful defense, the bacterium escapes and settles in the lungs to produce diseases. Pneumonia is the term used to describe inflammation of the lung. Pneumococcal pneumonia is characterized by homologous consolidation of one or more lobes or segments. Pneumococcal pneumonia occurs at all ages but most frequently in early and middle adult life. Pneumonia is characterized with the rise in body temperature 39-40oC, remain associated with painful cough initially dry, but later patient develops production of tenacious sputum, which is often rusty and occasionally bloodstained. Staphylococcal pneumonia is caused due to Streptococcus aureus, which may occur either as a primary respiratory infection or as a blood-borne infection from a staphylococcal lesion elsewhere in the body. Klebsiella pneumonia is caused due to K. pneumoniae, a rare disease with high mortality. There is usually massive consolidation and excavation of one or more lobes, with the upper lobes being most often involved and with large amounts of purulent sputum, sometimes characteristic red currant jelly sputum. Legionella pneumonia is caused by Gram-negative bacillus L. pneumophila, which is usually transmitted in water droplets from infected cisterns used to provide water for showers, particularly in warm climates. It is often a serious and occasionally a fatal illness. C. psittaci causes psittacosis (ornithosis), a systemic illness contracted from infected birds. Pneumonia associated with it may be extensive, with severe toxemia. M. pneumoniae is a pleomorphic bacterium; symptoms of mycoplasma pneumonia are mild compared to other cases of pneumonia (walking pneumonia). On the other hand, liver function test derangements and dyselectrolytemia are more common. It is susceptible to tetracyclines though a few strains are sensitive only to erythromycin.

Living with Alpha-1 Antitrypsin Deficiency: Empowering Patients and Healthcare Professionals

Exacerbations in chronic obstructive pulmonary disease (COPD) impose a substantial healthcare burden and are key drivers of negative clinical outcomes and reduced patient quality of life. Prof Stockley highlighted the main differences in exacerbations between alpha-1 antitrypsin deficiency (AATD) and non-AATD-related COPD and considered potential implications for patient management. Early treatment of exacerbations with purulent sputum is known to be associated with improved patient outcomes. Emerging evidence from clinical studies also suggests that alpha-1 antitrypsin (AAT) therapy can have a positive impact on the nature and course of exacerbations in AATD. Dr Zanichelli outlined how self-administration of intravenous drugs, which is a routine procedure that patients safely implement in other indications, has the potential to be successfully used by carefully selected AATD patients. Reflecting the current trend towards a more personalised approach to AATD therapy, self-administration can empower patients to assume an increasingly active role in their own disease management, thereby bringing improvements in treatment satisfaction, disease control, clinical outcomes, and quality of life. A unique patient’s perspective on AAT self-administration was provided by Karen Skålvoll, who highlighted the key benefits offered by self-infusion, such as reduced localised trauma and increased freedom to travel and enjoy life. Photographs from Karen’s many global travels illustrate the unparalleled freedom that self-administration has afforded her as an AATD patient. From the physician’s standpoint, Prof Sandhaus summarised his experience of how patients can be empowered to self-administer AAT therapy independently with minimal training. Among motivated individuals, self-administration can provide a successful long-term treatment solution for their AATD. The drive towards self-treatment also delivers the dual benefits of reduced healthcare burden and enhanced convenience and flexibility for patients. Prof Koczulla reported that, overall, the available evidence indicates pulmonary rehabilitation as a successful strategy in AATD, which can significantly enhance a patients’ physical performance. Although the most effective training algorithm still needs to be prospectively validated, this approach may prove particularly advantageous in patients with anxiety, dyspnoea, and fear of physical activity. In order to achieve maximum benefit, therapy and goals of pulmonary rehabilitation must always be tailored to the individual patient in a personalised approach to care. The meeting concluded with the compelling ‘AATD Strongman Contest,’ which pitted Prof Koczulla against AATD patient Karen Skålvoll in a physical test of endurance (the so called ‘farmer’s walk’ involving carrying a heavy obstacle) and strength (dumbbell raises). Notwithstanding the expected impairment in aerobic ability, the domination of Karen in the strength test clearly demonstrates the physical gains that patients with AATD can achieve with physical training.

Acute lower respiratory tract infections: Symptoms, findings and management in Danish general practice

Background Acute lower respiratory tract infections (LRTIs) are among the most common infections managed in general practice. Objectives To describe differences in reported symptoms, findings and management of patients diagnosed with acute LRTIs, and to explore possible associations between these findings and being diagnosed with pneumonia. Methods During one winter season (2017 or 2018), a prospective registration of patients diagnosed with either acute bronchitis (ICPC-2: R78) or pneumonia (ICPC-2: R81) was conducted in Danish general practice for 20 days. A 42 item registration chart was filled in for each patient. Descriptive statistics, Pearson's chi-square test and multiple logistic regressions were used for data analysis. Results In total, 70 general practices participated with 1384 patients registered. Patients diagnosed with pneumonia were more often reported as having a fever, dyspnoea, increased purulent sputum, abnormal pulmonary auscultation/chest retractions, and were more often assessed as unwell by the healthcare professional, than those diagnosed with acute bronchitis. Very few patients had a chest X-ray. Contrary, most patients had a C-reactive protein (CRP) test performed (pneumonia: 83%; acute bronchitis: 71%). Respectively, 93% and 20% of patients were treated with antibiotics. Having a fever, an abnormal pulmonary auscultation/chest retractions or being assessed as unwell increased the likelihood of the diagnosis pneumonia at least fivefold. Even a slightly elevated CRP (≥11 mg/L) was positively associated with being diagnosed with pneumonia. Conclusion Danish healthcare professionals are highly influenced by symptoms, signs and CRP tests when diagnosing patients with acute LRTIs in general practice.

Evaluation of active neutrophil elastase in sputum of bronchiectasis and cystic fibrosis patients: A comparison among different techniques

Neutrophil elastase (NE) is a crucial marker of neutrophilic inflammation. We aimed to compare different techniques to detect active NE in sputum samples of 50 Bronchiectasis (BE) and 50 Cystic Fibrosis (CF) patients. Three methods including a ProteaseTag® Active NE Immunoassay (ELISA) and two enzymatic digestion assays (chromogenic –CS- and fluorogenic –FS- substrate) were compared. Results of active NE were also correlated with clinical data. The three methods provided statistically different values for NE activity in the same sputum samples in both cohorts. In the BE cohort, the highest correlations between NE activity and Bronchiectasis Severity Index (rho = 0.40, P < 0.0001), sputum purulence (AUC = 0.79), and chronic infections due to any pathogen (AUC = 0.76) and P. aeruginosa (AUC = 0.80) were found when NE was measured through the activity-based immunoassay. In the CF cohort, the highest correlations between NE activity and sputum quantity (rho = 0.71) and FEV1% (rho = 0.42, P = 0.03) were observed when the FS method was used, while similar correlations with chronic P. aeruginosa infection were identified with the FS and ELISA methods. NE activity in sputum correlates with clinical variables in both diseases. However, different methods to evaluate active NE in sputum lead to significantly different results, also in terms of correlation with clinical data.

CRP testing may help guide antibiotic use for COPD exacerbations

C-reactive protein (CRP)-guided prescribing of antibiotics in patients with an acute exacerbation of COPD resulted in fewer patients receiving antibiotics during the initial consultation and over the first 4 weeks of follow-up compared with those receiving usual care, according to results of the PACE study published in the New England Journal of Medicine.1Butler CC et al.N Engl J Med. 2019; 281: 111-120Crossref Scopus (91) Google Scholar In addition, the two groups had similar clinical outcomes. The cause of acute exacerbations of COPD may vary, with some triggered by bacterial respiratory infections and others by viruses. Unfortunately, it is difficult to determine which patients may benefit from antibiotics (i.e., those with bacterial infections) and which do not need them. Therefore, having a reliable biomarker that can be assessed in the clinic would be beneficial in reducing unnecessary antibiotic use in these patients. The PACE study was a multicenter trial in which 653 patients with an acute exacerbation of COPD (mean age 68.1 y, 51.6% male) were randomized to point-of-care CRP testing to help guide antibiotic prescribing (n = 325) or to usual care (n = 324).1Butler CC et al.N Engl J Med. 2019; 281: 111-120Crossref Scopus (91) Google Scholar The patients were enrolled from 86 general medical practices in the United Kingdom from January 2015 to February 2017. In the CRP-guided group, the guidance stated that for patients with a CRP level lower than 20 mg/L, antibiotics are unlikely to be beneficial and usually should not be prescribed. For those with a CRP level from 20 mg/L to 40 mg/L, antibiotics may be beneficial, mainly if purulent sputum is present; and for those with a CRP level higher than 40 mg/L, antibiotics are likely to be beneficial. Fewer patients in the CRP-guided group reported receiving antibiotics compared with those receiving usual care (57% vs. 77.4%), with comparable clinical outcomes between the two groups, according to the clinical COPD questionnaire given at 2 weeks. Overall, fewer patients in the CRP-guided group received antibiotics at the initial consultation (47.7% vs. 69.7%) or over the first 4 weeks of follow-up (59.1% vs. 79.7%). The 2019 GOLD (Global Initiative for Chronic Obstructive Lung Disease) guidelines comment on the use of CRP to help guide antibiotic prescribing during COPD exacerbations.2https://goldcopd.org/wp-content/up-loads/2018/11/GOLD-2019-v1.7-FINAL-14Nov2018-WMS.pdfGoogle Scholar The organization noted that study data on this biomarker have been contradictory, and CRP is elevated in both bacterial and viral infections, making it difficult to determine if antibiotics should be used. Therefore, GOLD stated that CRP should not be used to guide antibiotic use in patients with COPD exacerbations. Instead, GOLD highlighted data on use of procalcitonin, suggesting that this biomarker is more specific for bacterial infections and may be of greater value to help determine if antibiotics should be given to those with COPD exacerbations. Several studies have suggested that procalcitonin-guided antibiotic treatment reduced antibiotic exposure and adverse effects without affecting clinical outcomes. However, the majority of data is of low to moderate quality, and additional well-designed studies are needed to confirm the utility of this biomarker. GOLD recommends that antibiotics be given to patients with COPD exacerbations who meet any of these criteria: Patient has the three cardinal symptoms (increase in dyspnea, sputum volume, and sputum purulence); patient has two of the cardinal symptoms if increased sputum purulence is one of them; or patient requires mechanical ventilation. Antibiotics are recommended to be given for 5 to 7 days, and the choice of therapy should be based on local bacterial resistance patterns. The organization noted that appropriately used antibiotics for COPD exacerbations can help shorten recovery time and reduce the risk of early relapse and hospitalization duration. In an accompanying editorial on the findings of the PACE study, the authors wrote, “In our view, the findings from this study are compelling enough to support CRP testing as an adjunctive measure to guide antibiotic use in patients with acute exacerbations of COPD. Whether primary care practices in the United States would embrace point-of-care CRP testing is another matter, given the regulatory requirements for in-office laboratory testing and uncertainty about reimbursement.”3Brett AS et al.N Engl J Med. 2019; 281: 174-175Crossref Scopus (6) Google Scholar The PACE results need to be considered along with the GOLD guidelines. For now, symptomatic patients with COPD exacerbations should be treated appropriately until further studies can confirm the utility of CRP or procalcitonin.

The role of bacterial and viral infection in exacerbation of bronchiectasis: a prospective study

BackgroundExacerbations are crucial events in the progression of bronchiectasis. Previous studies have documented associations between viral or bacterial infection and bronchiectasis exacerbations, but assays for viral or bacterial infection were conducted separately. No study has yet revealed an association between bacteria and viruses in bronchiectasis exacerbations. Moreover, the clinical correlates of bacterial with or without viral detections are unclear. We sought to explore associations between bacterial infection, viral infection and co-infection, and exacerbation of bronchiectasis. MethodsIn this prospective cohort study, we enrolled 108 patients from the outpatient clinics of The First Affiliated Hospital of Guangzhou Medical University (Guangzhou, China). The participants were followed up every 3–6 months and at exacerbation episodes, between March, 2017, and November, 2018. Each sputum sample was split into two for detection of bacteria (routine culture) and viruses (quantitative PCR). Clinical characteristics were assessed during exacerbation episodes. FindingsThe median exacerbation rate was 2·0 (interquartile range 1·0–2·5) per patient per year. Viral infection was correlated with significantly higher risks of exacerbation (29% [22 of 76] of exacerbation episodes; OR 3·28, 95% CI 1·76–6·12) than non-viral infection. Similarly, new occurrence of bacterial infection was correlated with significantly higher risks of exacerbation (eg, Haemophilus influenza was associated with 11% [eight of 26] of exacerbation episodes; 2·52, 1·35–4·71) than no new occurrence of bacterial infection, and likewise co-infection (2·24, 1·11–4·55) than all of the other groups combined. A positive bacterial culture alone was not correlated with exacerbations (p>0·778). Although coryza seemed to be more common in viral exacerbation than in unexplained and new bacterial exacerbation (p=0·053), lower airway symptoms were more severe in new bacterial exacerbation (visual analogue scale for cough, p=0·030; sputum volume, p=0·006; sputum purulence, p=0·025). Airway interleukin-1β levels were consistently higher in new bacterial exacerbation than in unexplained and viral exacerbation (p=0·007). A significantly greater number of coryza was correlated with co-infection at exacerbation (p=0·019). However, co-infection did not differ from bacterial or viral infection alone in lower airway symptoms (p=0·063), lung function decline (forced expiratory volume in one second, p=0·278; forced vital capacity, p=0·230), and sputum cytokine levels (interleukin-1β, p=0·445; CXC motif chmokine-8, p=0·279; tumour necrosis factor-α, p=0·055; and interferon-γ, p=0·555). InterpretationViral infection, new occurrence of bacterial infection and co-infection are associated with exacerbation of bronchiectasis. The clinical characteristics of bronchiectasis exacerbation might inform clinicians of the possible underlying pathogens. FundingThis work was supported by the National Natural Science Foundation (no. 81870003), Pearl River S&T Nova Program of Guangzhou (no. 201710010097) and Guangdong Province Universities and Colleges Pearl River Scholar Funded Scheme 2017 (to W-JG), and the Impact and Mechanisms of Physical, Chemical and Biological Interventions on the Development and Outcome of Acute Lung Injury (no. 81490534, to N-SZ).

MORTALITY PREDICTORS IN PATIENTS WITH ACUTE EXACERBATION OF CHRONIC OBSTRUCTIVE PULMONRY DISEASES

INTRODUCTION: COPD is a chronic disease which involves the airways, lung parenchyma, and pulmonary vasculature and also has considerable systemic manifestations. This disease is progressive and there is gene–environment interaction and hence can be prevented by avoiding exposure to the noxious particles. Commonest attributing risk factor is cigarette smoking in any form or air pollution.The in-hospital mortality rate for acute exacerbation of COPD may range from 2.5% - 25%; readmission rates from 25% to 55% for those who survived, and 25% -50% of these patients may die within one year. Most important single most crucial parameter to determine the risk of mortality in patients experiencing acute exacerbation of COPD is the forced expiratory volume in one second (FEV1). This DACF score can be useful in severely ill patients to predict mortality. This study was carried out to evaluate the DACF score as a clinical prediction of mortality for patients with acute exacerbation of COPD.&#x0D; MATERIAL AND METHODS: All patients admitted for an acute exacerbation of COPD during study period were included in the study. All included patients were cases of COPD confirmed with pulmonary function test i.e. forced expiratory volume in one second/forced vital capacity &lt;0.7 and irreversible airway obstruction and were treated with a combination of various bronchodilators. The study included patients aged 40 years or older and who were admitted in the hospital and had a primary clinical diagnosis of AECOPD. Sociodemographic data was recorded which includes age, gender, comorbidities, and number of previous AECOPD. Plain chest x-ray, spirometry, electrocardiogram was carried out. Relevant tests such as ABG analysis, complete blood count, kidney function test, liver function test, and serum electrolytes were done. DACF score was calculated.&#x0D; RESULTS: A total of 124 patients were included in the study, out of which 104 (83.88%) survived and were placed in group 2 and 20 (16.12%) patients died during the hospital stay were placed in group 1. Hence, the overall in hospital mortality rate for AECOPD was 16.12%.FEV1 in non-survivors group was 38 ± 12.98 while in survivor group it was 45 ± 11.55. Long-term oxygen therapy was given to 11 (55%) in non-survival group while it was given to 20 (19.23%) in survivors group.DACF score was calculated, most common score was 3 (48, 39%). On DACF score 1 there were 2(10%) non survivors and 34 (33%) survivors.35% mortality was seen in score 4, while no survivor was found on same score, this was statistically significant (P&lt;0.0001). on DACF score three, 25% patients died while 41% survived. Purulent sputum was observed in 90% of non survivors and 49% of survivors. Respiratory rate/min in Non-survivors (n=20) was 29.2±5.4 and in Survivors (n=104) was 25.4±3.8. Arterial blood gases analysis pH in Non-survivors (n=20) was 7.29±0.04 and in Survivors (n=104) was 7.45±0.08. paCO2 (mm Hg) in Non-survivors was 50.78±13.44 and in Survivors was 43.11±11.49. Body mass index (kg/m2) in Non-survivors was 21.65±7.4 and in Survivors was 26.97±8.9.63.&#x0D; CONCLUSION: DACF score can predicts mortality and effectively stratifies COPD patients admitted with acute exacerbations into survivors and non-survivor’s category and clinical tests such as PaCO2, arterial pH, purulent sputum can be used to predict the mortality in AECOPD.

Systemic inflammation and the effects of short-term antibiotic treatment for PPM positive patients with stable COPD.

ObjectiveTo evaluate patients with stable COPD for the presence of potentially pathogenic microorganisms (PPM), systemic inflammation and the effects of short-term antibiotic therapy in PPM positive patients.MethodsFrom January 2016 to June 2017, we enrolled 96 stable COPD patients. Bacterial cultures from sputum collections were quantitated, along with markers for systemic inflammation including serum C-reactive protein (CRP), interleukin-8 (IL-8) and plasma fibrinogen (FIB) in all patients. All enrolled patients were followed for 12 months. Forty patients were identified as PPM positive and were randomly divided into an antibiotic group and a control group. The antibiotic group was treated with moxifloxacin orally for 6 days. Lung function and markers for systemic inflammation were repeatedly measured at 30 days and 6 months in PPM positive subjects.ResultsBinary logistic regression analysis showed that risk factors for PPM positive are bronchiectasis (OR 4.18, 95% CI 1.20–14.59; P=0.025), COPD assessment test (CAT) ≥20 (OR 17.55, 95% CI 2.82–109.18; P=0.002), spontaneous sputum (OR 15.09, 95% CI 1.36–168.02; P=0.027) and sputum purulence (OR 38.43, 95% CI 5.39–274.21; P=0.000). CRP and IL-8 were higher in PPM positive group than those in PPM negative group (P=0.001, P=0.007, respectively), but there were no differences of FIB between the two groups (P=0.086). Compared to the PPM negative group, the rate of acute exacerbation of COPD was higher (P=0.029) and time to next acute exacerbation was shorter (P=0.030) in PPM positive group. There were no differences in lung function and systemic inflammatory markers either in the control group or the antibiotic group at different time points of follow-up.ConclusionPPM exists in stable COPD patients and can cause systemic inflammation and is associated with acute exacerbation of COPD. Short-term antibiotic therapy had no effect on systemic inflammation nor on acute exacerbation of COPD.China Clinical Trials Registry: ChiCTR-IOR-15006769

Mucolytic agents versus placebo for chronic bronchitis or chronic obstructive pulmonary disease.

Background Individuals with chronic bronchitis or chronic obstructive pulmonary disease (COPD) may suffer recurrent exacerbations with an increase in volume or purulence of sputum, or both. Personal and healthcare costs associated with exacerbations indicate that any therapy that reduces the occurrence of exacerbations is useful. A marked difference among countries in terms of prescribing of mucolytics reflects variation in perceptions of their effectiveness. Objectives Primary objective • To determine whether treatment with mucolytics reduces frequency of exacerbations and/or days of disability in patients with chronic bronchitis or chronic obstructive pulmonary disease. Secondary objectives • To assess whether mucolytics lead to improvement in lung function or quality of life. • To determine frequency of adverse effects associated with use of mucolytics. Search methods We searched the Cochrane Airways Group Specialised Register and reference lists of articles on 10 separate occasions, most recently in July 2014. Selection criteria We included randomised studies that compared oral mucolytic therapy versus placebo for at least two months in adults with chronic bronchitis or COPD. We excluded studies of people with asthma and cystic fibrosis. Data collection and analysis This review analysed summary data only, most derived from published studies. For earlier versions, one review author extracted data, which were rechecked in subsequent updates. In later versions, review authors double-checked extracted data and then entered data into RevMan for analysis. Main results We added four studies for the 2014 update. The review now includes 34 trials, recruiting a total of 9367 participants. Many studies did not clearly describe allocation concealment; hence selection bias may have inflated the results, which reduces our confidence in the findings. Results of 26 studies with 6233 participants show that the likelihood that a patient could be exacerbation-free during the study period was greater among mucolytic groups (Peto odds ratio (OR) 1.75, 95% confidence interval (CI) 1.57 to 1.94). However, more recent studies show less benefit of treatment than was reported in earlier studies in this review. The overall number needed to treat with mucolytics for an additional beneficial outcome for an average of 10 months - to keep an additional participant free from exacerbations - was eight (NNTB 8, 95% CI 7 to 10). Use of mucolytics was associated with a reduction of 0.03 exacerbations per participant per month (mean difference (MD) -0.03, 95% CI -0.04 to -0.03; participants = 7164; studies = 28; I2 = 85%) compared with placebo, that is, about 0.36 per year, or one exacerbation every three years. Very high heterogeneity was noted for this outcome, so results need to be interpreted with caution. The type or dose of mucolytic did not seem to alter the effect size, nor did the severity of COPD, including exacerbation history. Longer studies showed smaller effects of mucolytics than were reported in shorter studies. Mucolytic use was associated with a reduction of 0.43 days of disability per participant per month compared with placebo (95% CI -0.56 to -0.30; studies = 13; I2 = 61%). With mucolytics, the number of people with one or more hospitalisations was reduced, but study results were not consistent (Peto OR 0.68, 95% CI 0.52 to 0.89; participants = 1788; studies = 4; I2 = 58%). Investigators reported improved quality of life with mucolytics (MD -2.64, 95% CI -5.21 to -0.08; participants = 2231; studies = 5; I2 = 51%). Although this mean difference did not reach the minimal clinically important difference of -4 units, we cannot assess the population impact, as we do not have the data needed to carry out a responder analysis. Mucolytic treatment was not associated with any significant increase in the total number of adverse effects, including mortality (Peto OR 1.03, 95% CI 0.52 to 2.03; participants = 2931; studies = 8; I2 = 0%), but the confidence interval is too wide to confirm that the treatment has no effect on mortality. Authors' conclusions In participants with chronic bronchitis or COPD, we are moderately confident that treatment with mucolytics may produce a small reduction in acute exacerbations and a small effect on overall quality of life. Our confidence in the results is reduced by the fact that effects on exacerbations shown in early trials were larger than those reported by more recent studies, possibly because the earlier smaller trials were at greater risk of selection or publication bias, thus benefits of treatment may not be as great as was suggested by previous evidence.

Non Cystic Fibrosis Bronchiectasis-new clinical approach, management of treatment and pulmonary rehabilitation

Abstract Non-Cystic Fibrosis Bronchiectasis (NCFB) are characterised by abnormal, permanently damaged and dilated bronchi due to the innapropiate clearence of various microorganisms and recurrent chronic infections.The diagnosis is suggested by the clinical presentation and is confirmed by multiple investigations. There are some comorbidities associated with bronhciectasis, such as chronic obstructive pulmonary disease (COPD), cardiovascular disorders, gastro-esophageal reflux disease (GERD), psychological illnesses, pulmonary hypertension, obstructive apnea syndrome(OSA). The condition has a substantial socioeconomic impact because it requests a multidisciplinary management and periods of exacerbations are common. The aims of the management of bronchiectasis are to reduce symptoms (such as sputum volume and purulence, cough and dyspnea), reduce the frequency and severity of exacerbations, preserve lung function and improve health-related quality of life. The multidisciplinary approach of bronchiectasis patients require along with the medical treatment, a specific plan of nonphamarcological strategies, including balneological intervention. There are a lot of techniques improving the airway clearence, such as: active cycle of breathing techniques (which include breathing control, thoracic expansion exercises, forced expiratory technique), oscilatting possitive expiratory pressure, autogenic drainage, gravity-assisted-positioning, modified postural drainage. Together with specific medication, these techniques can diminuate symptoms and improve the quality of life. Key words: NCFB, airway clearence, physiotherapy,

SUN-LB066 Assessing the Need for Individualized Sick Day Protocol in a Patient with Secondary Adrenal Insufficiency and Pneumonia

Introduction: Secondary Adrenal Insufficiency (SAI) has a prevalence of 280 per million [1]. Most patients with chronic SAI are on daily glucocorticoid replacement therapy. However, due to underlying inability to mount cortisol response to illness, it is critical to implement a Sick Day Protocol (SDP). We present the case of septic shock due to pneumonia, in a patient with secondary hypocortisolism following meningeal tumor resection. Case Presentation: A 60 year old Caucasian female presented to ED with fever and progressively worsening cough with purulent sputum for four days. She had hypertension, hypothyroidism, Type 2 diabetes, and secondary hypocortisolism following resection of meningotheliomatous meningioma. At presentation she was febrile and in septic shock with elevated WBC with left shift [14 (4.5 -11 K/microL)], lactic acid [7.2 (0.7-2.0 mmol/L)] and procalcitonin [41 (<0.5 ng/ml)]. Despite bolus IV fluids, stress dose steroids and broad-spectrum antibiotics, patient continued to be encephalopathic and hypotensive (MAP <65 mm Hg). She thus required pressor support (Norepinephrine) in ICU. Chest X-ray and CT confirmed pneumonia in left lower lobe and lingula. Home regimen of hydrocortisone comprised 17.5 mg at 0900 and 7.5 mg at 1700. Within 12 hours of stress dose hydrocortisone (250 mg) she was successfully weaned off norepinephrine with resolution of encephalopathy, and WBC normalized. She was given stress dose hydrocortisone (200 mg/day) for four days. She was then discharged home with instruction to finish oral course of antibiotics, continue home dosing of hydrocortisone and to further discuss SDP with primary healthcare provider. Discussion: In times of severe physiological stress, cortisol levels can raise up to tenfold normal levels. Cortisol plays key role in maintaining vascular integrity, potentiating vasoconstrictor effects of catecholamines and mediating anti-inflammatory effects on immune system [2]. Patients with chronic adrenal insufficiency require hydrocortisone dosing of 10-12 mg/m2 body surface area (15-25mg/day) in two doses with two-thirds of the dose optimally administered in AM to mimic physiological cycling [1]. This patient had symptoms of pneumonia for four days and had only been taking her regular hydrocortisone doses. This case emphasizes the need for individualized counselling for early SDP in patients with SAI.

Chronic Bacterial Infection Prevalence, Risk Factors, and Characteristics: A Bronchiectasis Population-Based Prospective Study.

Background: Few data are available on chronic bacterial infections (CBI) in bronchiectasis patients. Given that CBI seems to trigger longer hospital stays, worse outcomes, and morbimortality, this study was undertaken to assess CBI prevalence, characteristics, and risk factors in outpatients with bronchiectasis. Methods: A total of 186 patients followed in a bronchiectasis tertiary referral centre in Portugal were included. Demographic data and information on aetiology, smoking history, mMRC score, Bronchiectasis Severity Index (BSI) score, sputum characteristics, lung function, exacerbations, and radiological involvement degree were collected. Results: Patients included (mean age 54.7 ± 16.2 years; 60.8% females) were followed up for a period of 3.8 ± 1.7 years. The most common cause of bronchiectasis was infection (31.7%) followed by immune deficiencies (11.8%), whereas in 29% of cases, no cause was identified. Haemophilus influenzae (32.3%) and Pseudomonas aeruginosa (30.1%) were the most common CBI-associated possible pathogenic microorganisms. CBI patients presented a higher follow-up time than no-CBI patients (p = 0.003), worse lung function, BSI (p < 0.001), and radiological (p < 0.001) scores, and more prominent daily sputum production (p = 0.002), estimated mean volume (p < 0.001), and purulent sputum (p < 0.001). The number of exacerbations/year (p = 0.001), including those requiring hospital admission (p = 0.009), were also higher in the CBI group. Independent CBI predictors were BSI score (OR 3.577, 95% CI 1.233–10.378), sputum characteristics (OR 3.306, 95% CI 1.107–9.874), and radiological score (OR 1.052, 95% CI 1.004–1.102). Conclusion: According to the CBI status, two different sub-groups of patients were found on the basis of several clinical outcomes, emphasizing the importance of routine sputum microbiological monitoring. Further studies are needed to better characterize CBI profiles and to define the individual clinical impact of the most prevalent pathogenic microorganisms.

Development of a Nomogram to Predict the Risk of 30-Day Re-Exacerbation for Patients Hospitalized for Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Acute exacerbation (AE) is the main cause of increased disability and mortality for patients with Chronic Obstructive Pulmonary Disease (COPD). Short-term re-exacerbation after discharge is common for in-hospital patients with AECOPD. Thus, we aimed to design a scoring system to effectively predict the 30-day re-exacerbation using simple and easily accessible variables. We retrospectively enrolled 686 cases hospitalized for AECOPD in two Chinese hospitals from 2005 to 2017. A variety of parameters were collected like demographics, clinical manifestations and treatments in stable and AE period. The optimal subset of covariates in the multivariate logistic analysis was identified by the smallest Akaike Information Criterion (AIC) and was further used to develop a practical and reliable nomogram to predict the 30-day re-exacerbation. The efficacy of the nomogram was internally validated by concordance index (C-index) and a calibration plot. The incidence of 30-day re-exacerbation was 15.8%. Based on the smallest AIC, eight easily-accessible parameters were included in the nomogram, including sex, COPD assessment test (CAT) scores, AE with respiratory failure in the previous year, new purulent sputum, new cardiovascular events, combined antibiotic therapy, theophylline therapy for AE and ICU admission. Our nomogram revealed good discriminative ability with the C-index of 0.702. The calibration curve showed good agreement between nomogram-predicted probability and actual observation. Incorporating eight common variables, a nomogram for 30-day re-exacerbation after discharge with high predictive performance was constructed for patients with AECOPD, which was helpful in predicting individualized risk of re-exacerbation and offering individualized post-discharge support.