Underlying Lung Pathology Research Articles

Endobronchial Valves: considerations for general anaesthesia

SummaryWe present the case of a patient with advanced bullous emphysema and an in‐situ endobronchial valve who successfully underwent general anaesthesia for emergency laparotomy and Hartmann's procedure. No published recommendations exist for the anaesthetic management of patients with endobronchial valves. In the absence of consensus guidelines, we suggest that ventilatory management in such patients is best dictated by the underlying lung pathology and a high index of suspicion should be maintained for complications associated with endobronchial valves, particularly pneumothorax and valve migration.

Pleural Effusions and Pneumothoraces.

1. Katherine Cashen, DO* 2. Tara L. Petersen, MD† 1. *Department of Pediatrics, Children's Hospital of Michigan/Wayne State University School of Medicine, Detroit, MI 2. †Division of Critical Care, Department of Pediatrics, The Children’s Hospital of Wisconsin/The Medical College of Wisconsin, Milwaukee, WI * Abbreviations: BTS: : British Thoracic Society CHF: : congestive heart failure CT: : computed tomography VATS: : video-assisted thoracoscopic surgery 1. Clinicians should be aware of the causes and clinical presentation of pleural effusions and pneumothoraces. 2. Clinicians should understand the current role of diagnostic tests, imaging modalities, and timing of minimally invasive treatments. After completing this article, readers should be able to: 1. Describe the pathogenesis of pleural fluid accumulation. 2. Identify the most likely causes of pleural effusion and pneumothorax. 3. Understand the basic clinical presentation, diagnostic tests, and management of pleural effusions and pneumothoraces. 4. Differentiate between transudative and exudative pleural effusions. 5. Understand the natural history of spontaneous pneumothorax. The pleural space is created by the parietal and visceral pleura that line the chest wall and the lung surface, respectively. Normally, only a small amount (0.3 mL/kg) of hypotonic fluid is present within the pleural space due to homeostatic balances in physiologic fluid production and absorption. Various infectious and noninfectious processes can lead to pathologic filling of the pleural space with fluid (effusion) or air (pneumothorax). Such pathologic changes create a true space that can interfere with normal lung mechanics and, in severe cases, cardiac function. Although much less common in pediatric than adult populations, pleural effusions and pneumothoraces in both groups can lead to substantial complications, resulting in significant morbidity and mortality if unrecognized or untreated. Overall, the cause of pleural effusions and pneumothoraces differs in children compared to adults. In adults, congestive heart failure (CHF) and malignancy account for a substantial number of pleural effusions, but these are uncommon causes in children. Infectious pleural effusions in the setting of pneumonia (parapneumonic effusions) remain the most common cause of effusions in both children and adults. Unlike the adult population, children experience spontaneous …

Imaging of Pneumonia: An Overview

Pneumonia is one of the common causes of morbidity and mortality in general population. Imaging plays an important role in the management of pneumonia. In the current era, there has been an increase in the patients with extremes of age, immunocompromised status, underlying lung pathology, post-transplant status, and atypical infections. It is necessary to use cross-sectional imaging modalities like computed tomography (CT) due to atypical or non-specific chest radiograph findings in such cases. CT narrows down the differential diagnosis, for etiological agent. It helps in the evaluation of the causes of non-resolving pneumonia, pulmonary, and non-pulmonary complications of pneumonia. Pneumonia is classified into three main types as community-acquired pneumonia, hospital-acquired pneumonia, and aspiration pneumonia. It is important to differentiate these three types, since host factors and etiological organisms differ, thus changing the course and management in these patients. Knowing the clinical background and correlation with imaging findings may help in the early detection of pathogen and direct the physician toward appropriate management. Imaging also helps in follow-up of patients to look for response to therapy. Cross-sectional imaging can help in ruling out diseases mimicking pneumonia.

Identification of Mycobacterium avium subsp. hominissuis secreted proteins using an in vitro system mimicking the phagosomal environment.

Background Mycobacterium avium subsp. hominissuis is a common intracellular pathogen that infects patients with HIV/AIDS and cause lung infection in patients with underlying lung pathology. M.avium preferably infects macrophages and uses diverse mechanisms to alter phagosome maturation. Once in the macrophage, the pathogen can alter the host cellular defenses by secreting proteins into the cytosol of host cells, but despite considerable research, only a few secreted effector proteins have been identified. We hypothesized that the environmental cues inside the phagosome can trigger bacterial protein secretion. To identify M. avium secretome within the phagosome, we utilized a previously established in vitro system that mimics the metal ion concentrations and pH of the M. avium phagosome.Results M. avium was exposed to phagosome metal concentrations for different time points and exported proteins were profiled and analyzed against bacterial proteins secreted in the culture medium. Mass spectrometric analysis of the secreted proteome identified several proteins, of which 46 were unique to bacteria incubated in the metal mixture. Ten of potential effectors were selected and secretion of these proteins was monitored within M. avium infected mononuclear phagocytic cells using the beta-lactamase FRET-based reporter system. In addition, pull-down assay was performed for secreted calmodulin-like protein MAV_1356 protein to evaluate for eukaryotic target. All examined M. avium proteins were secreted into the macrophage cytosol, and gene expression analysis suggested that the metal environment likely stimulates secretion of pre-made proteins. Further investigation of bacterial secreted MAV_1356 protein, lead to the observation that the MAV_1356 interacts with the host proteins Annexin A1 and Protein S100-A8.ConclusionsWe established an in vitro system for the study if proteins secreted intracellularly, and revealed that the metal mixture mimicking the concentration of metals in the phagosome environment, triggers protein secretion.

Different Spirometry Pattern in Patient Attending Respiratory Medicine OPD for Diagnostic Evaluation

Pulmonary function testing has come into widespread use since the 1970s. This has been facilitated by several developments.1,2Pulmonary function tests are valuable investigations in the management of patients with suspected or previously diagnosed respiratory disease. They aid diagnosis, help monitor response to treatment and can guide decisions regarding further treatment and intervention. The interpretation of pulmonary functions tests requires knowledge of respiratory physiology. This study was carried out on patient attending pulmonary medicine OPD. Patient above 20 years of age was included in this study. The test group had 193 patients- comprising of 51 females and 142 males.Subjects were divided in six groups depending on their age and also on the basis of gender. The results showed that values of FVC, FEV 1 , FEF 2 5 - 7 5 % , PEFR were observed to be normal in the age group of 20 -30 years. Pulmonary function, as measured by spirometry is an important predictor in estimating the lung function of persons. Differences in the respiratory patterns of healthy adults and the elderly with no underlying airway and parenchymal pathology, suggesting that age also impacts on lung function. Patient with underlying lung pathology have shown to have poor lung function as compared with the normal individuals.

Monotherapy with minocycline or trimethoprim/sulfamethoxazole for treatment of Stenotrophomonas maltophilia infections.

Stenotrophomonas maltophilia is a Gram-negative bacillus intermittently isolated from hospitalized patients. Trimethoprim/sulfamethoxazole is considered the treatment of choice for S. maltophilia infections, though limited by toxicities. Minocycline is utilized at our institution for S. maltophilia infections due to its improved tolerability and in vitro susceptibility rates. Our objective was to evaluate the effectiveness of minocycline monotherapy compared with trimethoprim/sulfamethoxazole monotherapy for treatment of S. maltophilia infections. Patients were identified via microbiology laboratory data and those with at least one positive culture for S. maltophilia were cross-referenced with pharmacy data to detect patients who received trimethoprim/sulfamethoxazole or minocycline. Patients initially receiving combination therapy were excluded. Our primary outcome was treatment failure, defined as receipt of alternative antibiotics with in vitro activity against S. maltophilia, isolation of S. maltophilia on repeat culture or death within 30 days of treatment. Forty-five patients were evaluated. Overall mortality rate was 9% and equal between groups; 41% of patients (9/22) who received trimethoprim/sulfamethoxazole and 30% (7/23) of patients who received minocycline experienced treatment failure (P = 0.67). Patients who received minocycline were more likely to have had a recent acute kidney injury (AKI) (43.5% versus 9%; P = 0.017) or chronic lung disease (52% versus 9%; P = 0.003). Logistic regression showed consistent results of non-inferiority of the primary outcome when controlling for rates of underlying lung pathology and recent AKI (P = 0.728). Treatment failure did not differ between patients receiving trimethoprim/sulfamethoxazole or minocycline monotherapy for treatment of S. maltophilia infections.

Microfilaria in pleural effusion: An unusual association

Lymphatic filariasis is a major public health problem in tropical countries and India is endemic for it. However, lymphatic filariasis presenting as pleural effusion is an unusual manifestation and finding microfilaria in pleural effusion without any lung pathology is rare. We report a case of pleural effusion without any underlying lung pathology and normal blood picture. Clinical cure occurred after treatment with diethyl-carbamazepine. Filariasis should be kept in view while considering the differential diagnosis of idiopathic pleural effusion, especially in endemic countries.

Pulmonary hypertension in the course of diffuse parenchymal lung diseases - state of art and future considerations.

Lung diseases are one of the most frequent causes of pulmonary hypertension (PH). The development of PH influences the course of lung disease, worsening the clinical symptoms and prognosis. According to the most recent publications, PH in the course of lung diseases develops as a result of both "parenchymal" and vascular pathology, in the patients with genetic predisposition. Prolonged infection (especially viral one) may be an additional promoting factor. Right heart catheterization (RHC), which is an invasive procedure, is the only objective method of diagnosing PH. According to the latest recommendations, the management algorithm of PH and coexisting interstitial lung disease is based on RHC and the results of pulmonary function tests. Majority of the patients develop mild PH in the course of advanced lung disease. Best treatment of underlying lung pathology combined with long term oxygen treatment is recommended in this group. In case of severe PH (mean resting pulmonary artery pressure (mPAP) ≥ 35 mm Hg) the alternate cause of PH has to be sought. PAH-specific drugs use should be limited to patients with severe PH participating in clinical trials. In this review, the value of various non-invasive methods (echocardiography, radiological examination, exercise capacity and brain natriuretic peptides assessment) in the process of screening for PH is presented, and the results of recent randomized clinical trials with PAH-specific drugs in patients with diffuse parenchymal lung diseases are discussed.

Infection pulmonaire à Geotrichum capitatum à propos d’un cas et revue de la littérature

Pulmonary geotrichosis is a rare mycosis caused by an arthrospore filamentous fungi of the genus Geotrichum. It is an opportunistic infection that develops when underlying conditions are present, particularly immunosuppression including neutropenia. Pulmonary mycoses in non-neutropenic patients affect two main populations: the solid organ transplanted patients and patients whose local pulmonary defenses are altered by a chronic underlying lung pathology. We report a case of pulmonary infection Geotrichum capitatum in an old tuberculosis patient.

Frequency and intensive care related risk factors of pneumothorax in ventilated neonates.

Objectives. Relationships of mechanical ventilation to pneumothorax in neonates and care procedures in particular are rarely studied. We aimed to evaluate the relationship of selected ventilator variables and risk events to pneumothorax. Methods. Pneumothorax was defined as accumulation of air in pleural cavity as confirmed by chest radiograph. Relationship of ventilator mode, selected settings, and risk procedures prior to detection of pneumothorax was studied using matched controls. Results. Of 540 neonates receiving mechanical ventilation, 10 (1.85%) were found to have pneumothorax. Respiratory distress syndrome, meconium aspiration syndrome, and pneumonia were the underlying lung pathology. Pneumothorax mostly (80%) occurred within 48 hours of life. Among ventilated neonates, significantly higher percentage with pneumothorax received mandatory ventilation than controls (70% versus 20%; P < 0.01). Peak inspiratory pressure >20 cm H2O and overventilation were not significantly associated with pneumothorax. More cases than controls underwent care procedures in the preceding 3 hours of pneumothorax event. Mean airway pressure change (P = 0.052) and endotracheal suctioning (P = 0.05) were not significantly associated with pneumothorax. Reintubation (P = 0.003), and bagging (P = 0.015) were significantly associated with pneumothorax. Conclusion. Pneumothorax among ventilated neonates occurred at low frequency. Mandatory ventilation and selected care procedures in the preceding 3 hours had significant association.

Vaccine-Associated Enhanced Respiratory Disease Does Not Interfere with the Adaptive Immune Response Following Challenge with Pandemic A/H1N1 2009

The implications of sequential prime and challenge with mismatched influenza A viruses is a concern in mammals, including humans. We evaluated the ability of pigs affected with vaccine-associated enhanced respiratory disease (VAERD) to generate a humoral immune response against the heterologous challenge virus inciting the VAERD. Vaccinated and challenged (V/C) pigs were administered an inactivated swine δ-cluster H1N2 (MN08) vaccine with an HA similar to pre-2009 seasonal human viruses and challenged with heterologous A(H1N1) pandemic 2009 (H1N1pdm09). Vaccination induced MN08-specific hemagglutination inhibition (HI) antibody but not cross-reacting H1N1pdm09 HI antibody. However, vaccinated pigs demonstrated significantly higher post-challenge anti-H1N1pdm09 serum neutralizing (SN) antibodies at 14 and 21 days post inoculation (dpi) compared to nonvaccinated, challenged pigs (NV/C), indicating a priming effect of the vaccine. Serum and lung whole virus anti-H1N1pdm09 IgG ELISA antibodies in the vaccinated group were significantly higher than the challenge only pigs at all-time points evaluated. Lung IgA ELISA antibodies to both antigens were detected at 2, 5, and 21 dpi in vaccine-primed pigs, contrasted against mucosal ELISA antibody responses detected only at 21 dpi in the naïve-challenged group. Collectively, vaccine-primed pigs demonstrated a robust humoral immune response and elevated local adaptive cytokine levels, indicating VAERD does not adversely affect the induction of an immune response to challenge with heterologous virus despite the severe clinical disease and underlying lung pathology. Thus, original antigenic sin does not appear to be a component of VAERD.

En-bloc resection of a giant chest wall tumour and skeletal reconstruction with methyl methacrylate in a resource poor environment: case report

We describe a 42 year old man who presented to us with a left lateral chest wall mass of 2years duration. It has been increasing in size since it was noticed, initially painless but became painful 2 months prior to presentation. No history of trauma to the chest and no cough or haemoptysis. He is a known hypertensive regular on his medications. Examination revealed a left lateral chest wall mass, firm in consistency, non-tender, measuring 26x18x10cm. He had reduced air entry on the left middle and lower lung zones. Chest X-ray shows a left lateral soft tissue mass with homogenous opacity involving the left middle and lower lobes. Chest CT scan shows a left soft tissue mass with intrathoracic extension and destruction of the 4th and 5th ribs. There is also compressive atelectasis of the left middle and lower lobes. No features suggestive of underlying lung pathology. He had en-bloc resection of the chest wall tumour and skeletal reconstruction with methyl metacrylate” sandwich” in prolene mesh. Postoperative recovery was uneventful and was discharged on the 14th day post-op. Histology of the tumour revealed a neurofibroma. We still see patients with giant chest wall tumours in this part of the world presenting only when the tumours are symptomatic. Even though these tumours can be huge, curative resection and skeletal reconstruction can be offered with good outcome.

Clinical presentation, auscultation recordings, ultrasonographic findings and treatment response of 12 adult cattle with chronic suppurative pneumonia: case study

Auscultation is considered the critical component of the veterinary clinical examination for the diagnosis of bovine respiratory disease but the accuracy with which adventitious sounds reflect underlying lung pathology remains largely unproven. Modern portable ultrasound machines provide the veterinary practitioner with an inexpensive, non-invasive tool with which to examine the pleural surfaces and superficial lung parenchyma. Simultaneous recording of sounds overlying normal lung and defined pathology allows critical assessment of auscultated sounds in the same animal removing confounding factors such as respiratory rate and thickness of the chest wall (body condition). Twelve cows, referred to the University of Edinburgh Veterinary School, were diagnosed with chronic suppurative pneumonia and enrolled into this prospective study to record and monitor lung sounds, ultrasonographic findings, and response to a standardised antibiotic treatment regimen.Most cows (8/12) had a normal rectal temperature on presentation but all cows had received antibiotic therapy at some time in the previous two weeks and six animals were receiving antibiotic treatment upon admission. All cattle were tachypnoeic (>40 breaths per minute) with frequent and productive coughing, halitosis, and a purulent nasal discharge most noticeable when the head was lowered. Ultrasonographic examination of the chest readily identified pathological changes consistent with severe lung pathology subsequently confirmed as chronic suppurative pneumonia in four cows at necropsy; eight cows recovered well after antibiotic treatment and were discharged two to six weeks after admission. It proved difficult to differentiate increased audibility of normal lung sounds due to tachypnoea from wheezes; coarse crackles were not commonly heard. In general, sounds were reduced in volume over consolidated lung relative to normal lung tissue situated dorsally. Rumen contraction sounds were commonly transmitted over areas of lung pathology.Trueperella (formerly Arcanobacterium) pyogenes was isolated from three of four lung tissue samples at necrospy. Treatment with procaine penicillin for 42 consecutive days resulted in marked improvement with return to normal appetite and improvement in body condition in 8 of 12 cows (67%) where lesions did not extend more than 10-15 cm above the level of the olecranon on both sides of the chest.

Diaphragmatic paralysis following blunt neck trauma

A 25-year-old construction worker presented to the emergency department (ED) after the accidental fall of a metal bar on his neck. In the field, he was appropriately managed with a cervical collar for possible spine injury. On arrival at the ED, he was fully conscious with severe neck pain, hypotensive 80/50 mmHg and bradycardiac 48 beats/min. Physical examination revealed a flaccid paralysis and sensory loss in all four extremities. A chest X-ray study was unremarkable (Fig. 1, panel a). Two hours later, after examination revealed absent air entry over the right lung base, a repeat X-ray study showed an elevated right hemidiaphragm and an ipsilateral mediastinal shift (Fig. 1 panel b). Computed tomography (CT scan) of the neck showed a comminuted, posteriorly displaced fracture of the third cervical vertebrae (Fig. 1, panel c and d). In view of the established quadriplegia and neurogenic shock, this X-ray finding is suggestive of unilateral diaphragmatic paralysis. The delayed onset of diaphragmatic paralysis probably coincides with the evolving post-traumatic spinal cord edema. A few hours later, he developed respiratory distress with evident abdominal wall retraction during inspiration and protrusion during expiration in addition to hypoxia, hypercapnia and respiratory acidosis on blood gas analysis. The trachea was intubated and mechanical ventilation was started. This worsening respiratory status was concerning for the progression into bilateral diaphragmatic paralysis. Throughout the ICU course, his neurological status failed to improve requiring continued mechanical ventilation and subsequent tracheostomy. He was transferred to a subacute rehabilitation facility for further care. The diagnosis of diaphragmatic paralysis is suggested clinically by the presence of abdominal wall retraction during inspiration and protrusion during expiration. Whereas unilateral diaphragmatic paralysis is usually well tolerated in the absence of underlying lung pathology, bilateral paralysis requires long-term ventilatory support. In contrast to bilateral diaphragmatic paralysis, a chest X-ray study is more specific for diagnosing a unilateral paralysis. Fluoroscopy confirms the diagnosis when paradoxical inspiratory elevation of the paralyzed hemidiaphragm is evident.

The different treatment modalities of pyopneumothorax- Study of 50 cases

Background: Pyopneumothorax is defined as a collection of pus and air in the pleural cavity. It may be localised (encapsulated) or it may involve the entire pleural cavity. In India, Pyopneumothorax with pre-existing disease is treated with antimicrobial multiple antituberculous drugs and Intercostal drainage tube or surgery. Aims & Objective: (1) To know the age and sex incidence. (2) To study clinical presentation and characteristics of mode of onset (3) To obtain relationship with smoking. (4) To emphasise the importance of radiological and other investigations as an aid to diagnosis and management. (5) To find out the underlying lung pathology if any. (6) To decide the response to various modes of treatment. (7) To understand the complications of Pyopneumothorax. Material and Methods: This is a progressive study of 50 Indoor patients with pyopneumothorax admitted in the civil hospital, Ahmedabad in consecutive 3 years. Traumatic pyopneumothorax patients were excluded from the Study. The response to various modes of treatment and complications were noted. Results: The age incidences indicate that it was high in 21-30 years of age. Most common complaints were cough followed by dyspnoea and chest pain. The mycobacterium tuberculosis was the most common etiological factor. The best modality of treatment was intercostal drainage by tube with antibiotic coverage. Conclusion: Tuberculosis is main etiology in country like India. Intercostal drainage with under water seal was the treatment of choice in most of the patients. The commonest complication following ICD was surgical emphysema.

Legionella jordanis in hematopoietic SCT patients radiographically mimicking invasive mold infection

Opportunistic pulmonary infections are a major cause of post-transplant morbidity and mortality. Among these infections, Aspergillus is a common cause of fatal pneumonia. Owing to the precarious clinical condition of many patients who acquire invasive mold infections, clinicians often treat them on the basis of radiographic findings, such as the halo sign. However, in patients who do not respond to treatment or who have uncommon presentations, bronchoscopy or lung biopsy looking for other pathogens should be considered. This study describes two cases in which the radiographic halo signs characteristic of Aspergillus were in fact due to Legionella jordanis, a pathogen that has been culture proven only in two patients previously (both of whom had underlying lung pathology) and diagnosed by serologic evidence in several other patients. In immunocompromised patients, Legionella can present as a cavitary lesion. Thus, presumptive treatment for this organism should be considered in post-transplant patients who do not have a classic presentation for invasive fungal infection and/or who fail to respond to conventional treatment. These cases illustrate the importance of obtaining tissue cultures to differentiate among the wide variety of pathogens present in this patient population.

Clinical profile and surgical outcome for pulmonary aspergilloma: Nine year retrospective observational study in a tertiary care hospital

Background The indications and the outcome of surgery for pulmonary aspergilloma remain highly controversial. This retrospective observational study was conducted to study the clinical profile, indications, post-operative complications and long term outcome of patients having pulmonary aspergilloma. Methods From January 2000 to October 2008, 52 patients underwent surgery for pulmonary aspergilloma at our tertiary care institute. Results The group consisted of 32 males and 20 females with a mean age of 39.3 ± 11.2 years. The most common indication for surgery was hemoptysis (96.15%). The underlying lung diseases were tuberculosis (75%), bronchiectasis (5.76%), and lung abscess (5.76%). In one patient (2%), concomitant ruptured lung hydatid cyst and an aspergilloma was present. The procedures performed were lobectomy ( n = 43), bilobectomy ( n = 3). pneumonectomy ( n = 3), segmental resection ( n = 3). The post-operative mortality was 1.92% (one patient). Overall complications occurred in 12 (23.07%) patients. The complications included prolonged air leak ( n = 6), bleeding ( n = 3), empyema ( n = 1), repeated pneumothorax ( n = 1), and wound dehiscence ( n = 1). The mean follow-up period was 38 ± 18.6 months. There was no recurrence of disease or hemoptysis. Conclusion Pulmonary aspergilloma is common in developing countries like India in which there is high prevalence of pulmonary tuberculosis. Surgical resection of pulmonary aspergilloma is effective in preventing recurrence of symptoms including hemoptysis. We recommend early surgical resection of symptomatic aspergilloma with reasonable complications. Pre-operative preparation of the patients, meticulous surgical technique and post-operative chest physiotherapy reduces the rate of complications. Complications may still occur and are largely related to the underlying lung pathology; however, the long term outcome is good.

Index of Suspicion in the Nursery

A 2,435-g male infant is born at 38 weeks gestational age to a 22-year-old G2P1001 woman who is blood group O+ and negative for group B Streptococcus. Labor had been induced for intrauterine growth restriction. Rupture of membranes with clear fluid occurred 3 hours before delivery, and the baby is delivered by emergency cesarean section for fetal bradycardia. Apgar scores are 8 at 1 minute and 8 at 5 minutes. The baby is suctioned by bulb and nasogastric tube. At 8 minutes of age, the baby's lungs sound wet, with a pulse oximetry reading of 68%, and 40% blow-by oxygen is started. By 15 minutes of age, he is breathing room air with a pulse oximetry reading of 98%. Physical examination in the newborn nursery yields normal results, with a Ballard score of 39 weeks, weight between the 10th and 25th percentiles, length at the 75th percentile, and head circumference at the 25th percentile. He has one low temperature of 35.4°C initially, but the capillary blood glucose measurements are 59 mg/dL (3.3 mmol/L) or more. He does well on formula feedings, with a weight loss of 15 g at 12 hours and 40 g at 36 hours. At 45 hours of age, after an uneventful hospital stay, the baby develops tachypnea and moderate intercostal and subcostal retractions. His pulse oximetry reading is 85% to 89%. He is placed on oxygen by nasal cannula, and an evaluation is undertaken that reveals the source of his respiratory distress. A 23-day-old male infant presents to the clinic because of persistent crying. Yesterday, he was seen in the emergency department, where colic was diagnosed. Today, his mother appears overwhelmed, stating that the baby cries throughout the day and night. She is concerned that the infant has abdominal pain or pain in his left …

Treatment of COPD: from pharmacological to instrumental therapies

The two main goals of the current management of chronic obstructive pulmonary disease (COPD) are: 1) to reduce the impact of the disease on daily activities; and 2) to reduce the risk of future events (exacerbations, lung function decline and death) [1]. The first measure is obviously smoking cessation; however, we will not discuss this. Treatment guidelines are mainly based on randomised clinical trials that include a small and highly selected fraction of the COPD population [2]. Therefore, it is questionable as to whether these evidence-based guidelines can be extrapolated to the overall COPD population in the everyday practice. Indeed, less than one in five or 10 patients with COPD could fit into inclusion or exclusion criteria commonly used in clinical trials evaluating efficacy of pharmacological treatments [2, 3]. In addition, COPD is a heterogeneous disease and patients with similar forced expiratory volume in 1 s (FEV1) may show very different functional status, underlying lung pathology and comorbidities. For most treatments, differences in the responsiveness of COPD subgroups are not yet established and large, long clinical trials, along with high-quality meta-analyses, remain the basis of the current treatment guidelines and the evaluation of the benefit/risk ratio of the main therapeutic classes used in COPD management. However, even the large therapeutic trials may suffer from methodological limitations in the design or analysis [4]. The most important outcomes in clinical trials are patient-centred outcomes. Exacerbations, health-related quality of life and mortality are logical major outcomes in COPD trials [4]. In addition, exercise performance and lung function decline are other important targets for therapeutic intervention in COPD [5]. Lung function and biological markers reliably predicting individual response to treatments would be useful. ### Bronchodilators Bronchodilators are the mainstay of the current pharmacological …

Management of Spontaneous Pneumothorax in a Developing Caribbean Nation: A Clinical Practice Audit

A five year clinical audit was conducted between January 1, 2000 and January 1, 2005 to evaluate the management of patients with spontaneous pneumothoraces at three tertiary referral centres across Kingston, the capital city of Jamaica. Secondary pneumothoraces (SSP) were considered present if there was underlying lung pathology, otherwise patients were considered to have primary pneumothoraces (PSP). Data retrospectively extracted from hospital records, including patient demographics, clinical details and therapeutic outcomes, were analyzed using SPSS Version 12.0. Of the 81 cases identified, 58 patients with a mean age of 41.3 +/-18.2 years (SD) had PSP. The remaining 23 patients at a mean age of 51.8 +/-17.7 years were diagnosed with SSP from COPD (11), tuberculosis (6), asthma (3), PCP (1), endometriosis (1) and sarcoidosis (1). Recurrent SSP was present in 13/81 (16.1%) cases. One patient had a clinically diagnosed tension pneumothorax while the remaining cases were diagnosed on chest radiographs. Most cases were unilateral: 52 right sided (64.2%); 28 left sided (34.6%); 1 bilateral (1.2%). Of this, 80 patients had tube thoracostomy and 1 had aspiration as the definitive therapeutic maneouvre. Prophylactic second procedures (chemical pleurodesis in 3; open gauze pleurodeses in 5) were offered to 8/81 (9.9%) patients, all with recurrent SSP. The remaining patients had ongoing surveillance. There were no recurrences recorded during the study period. Needle aspiration and prophylactic procedures were under-utilized in this setting in contravention of evidence-based guidelines. Educational programmes and early referral to thoracic surgeons may increase the compliance with the standardized guidelines.