Thursday, March 23, 2017

Pneumonology Quiz – Case 5 (free article from 2017 Archives of Hellenic Medicine)

A 78-year-old male patient presented in the emergency department with a gradual deterioration of his general state of health during the preceding month. More specifically, he complained of progressive breathlessness, retrosternal pain radiating throughout his thoracic cavity, dizziness, syncopal episodes and cough, productive of small quantities of pink-tinted phlegm, mainly on exertion. At presentation, the patient appeared severely unwell. He was pale and he scored four in the modified Medical Research Council (mMRC) breathlessness score.
Pulmonary auscultation revealed bilateral coarse crackles throughout the lung fields. Heart sounds were rhythmic, characterized by a loud ejection systolic murmur clearly audible in all auscultation areas and diminished heart sounds in the aortic area. His heart rate was 80 beats per minute and his blood pressure was 100/60 mmHg.
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Previous cases:

Pneumonology Quiz - Case 1

Pneumonology Quiz - Case 2

Pneumonology Quiz – Case 3

Pneumonology Quiz – Case 4

Tuesday, March 21, 2017

@RespiratoryBMC channel for Respiratory updates

Dear friends we are happy to present you new twitter channel @RespiratoryBMC!
@RespiratoryBMC on twitter will present OpenAccess research from the world known BioMedCentral’s Respiratory medicine journals!

The account will be covering content from all BioMedCentral’s Respiratory medicine journals Respiratory Research, Multidisciplinary Respiratory Medicine, Pneumonia, Asthma Research and Practice and COPD Research and Practice.  
FOLLOW @RespiratoryBMC!!!

Sunday, March 19, 2017

Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline 2017 (Free full text)

This document provides clinical recommendations for treatment of chronic obstructive pulmonary disease (COPD) exacerbations.
Comprehensive evidence syntheses, including meta-analyses, were performed to summarise all available evidence relevant to the Task Force's questions. The evidence was appraised using the Grading of Recommendations, Assessment, Development and Evaluation approach and the results were summarised in evidence profiles. The evidence syntheses were discussed and recommendations formulated by a multidisciplinary Task Force of COPD experts.
After considering the balance of desirable and undesirable consequences, quality of evidence, feasibility, and acceptability of various interventions, the Task Force made: 1) a strong recommendation for noninvasive mechanical ventilation of patients with acute or acute-on-chronic respiratory failure; 2) conditional recommendations for oral corticosteroids in outpatients, oral rather than intravenous corticosteroids in hospitalised patients, antibiotic therapy, home-based management, and the initiation of pulmonary rehabilitation within 3 weeks after hospital discharge; and 3) a conditional recommendation against the initiation of pulmonary rehabilitation during hospitalisation.
The Task Force provided recommendations related to corticosteroid therapy, antibiotic therapy, noninvasive mechanical ventilation, home-based management, and early pulmonary rehabilitation in patients having a COPD exacerbation. These recommendations should be reconsidered as new evidence becomes available.
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Saturday, March 18, 2017

Interventions to improve inhaler technique for people with asthma (Free fulltext from 2017 The Cochrane Library)

Background to the question
Many asthma drugs are taken by an inhaler, which deposits the drug directly into the lungs. It is important that the inhaler is taken properly, so the patient gets the most benefit. Taken properly, asthma drugs can improve symptoms and reduce attacks.

Lots of people do not use their devices correctly. This means that the drug is not delivered properly to the lungs, and as a result, asthma may not be as well controlled as it should be. People also tell us that they can have more than one type of inhaler, so it is confusing to know what to do.
We wanted to find out whether teaching people with asthma how to use their inhalers works, and whether this leads to better control of symptoms and fewer attacks. It may seem obvious, but it is important that doctors and nurses know how best to help people with asthma.
Study characteristics
We found 29 studies involving 2210 people with asthma. Studies lasted between 2 and 26 weeks. Studies reported inhaler technique on a range of different checklists.
We grouped studies into three types: studies testing enhanced face-to-face training session(s), studies using multi-media to deliver inhaler training (e.g. a video, computer app or game) and studies testing devices that give people visual or audio feedback about technique.
Studies tested different types of training and used different measures to gauge success, meaning that we could not bring data together. This was particularly true when we tried to assess effects on asthma attacks, adverse events, visits to a healthcare provider and absences from work or school.
Key results
Both face-to-face and multi-media inhaler training improved inhaler technique in most studies, although results varied depending on how and when each technique was assessed.
Some studies reported the number of people who had correct or 'good enough' technique. More people had correct or 'good enough' technique after face-to-face training and with feedback devices. But the benefit of multi-media training for adults was uncertain.
Interventions that provide inhaler training may bring some benefit for quality of life and asthma control among adults and children, but results were varied and studies were small.
Children may receive some benefit but results tended to be less clear for children because fewer and smaller studies have included children as participants.
Quality of the evidence
For studies like these, it is not possible to blind people to their assigned group. This may bias how people behave or respond to questionnaires, which reduced our confidence in the findings. We were uncertain about other results because studies did not provide enough data to show clear benefit.
We cannot say for sure what is the best way to help people learn how to use their inhaler properly. It is important that patients understand how their inhaler works, so they should ask their doctor or nurse for help.
We also use Cochrane Reviews to make suggestions for future research. We suggest that trials should last longer than six months and should report adherence information. The most useful information reported was the number of people who had 'good enough' inhaler technique, so we urge future trials to report this as well.

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World Sleep Day 2017

World Sleep Day is an annual event sponsored by World Sleep Society (founded by WASM and WSF) to raise awareness of sleep disorders and highlight the burden that they place on society. The next World Sleep Day will be held on Friday, March 17, 2017.

Most sleep disorders are preventable or treatable, yet less than one-third of sufferers seek professional help. Sleep problems constitute a global epidemic that threatens health and quality of life for up to 45% of the world’s population. Better understanding of sleep conditions and more research into this area of medicine will help reduce the burden of sleep disorders on society.
World Sleep Day offers a world stage to interested parties to join forces and reach their audiences. Individuals and sleep centers around the world are invited to participate to teach about the importance of sleep and the preservation of high quality, sound and sufficient sleep.

Monday, March 6, 2017

Bronchoscopic lung volume reduction procedures for COPD in 2017 (Systemic review from The Cochrane Library)


In the recent years, a variety of bronchoscopic lung volume reduction (BLVR) procedures have emerged that may provide a treatment option to participants suffering from moderate to severe chronic obstructive pulmonary disease (COPD).


To assess the effects of BLVR on the short- and long-term health outcomes in participants with moderate to severe COPD and determine the effectiveness and cost-effectiveness of each individual technique.

Search methods

Studies were identified from the Cochrane Airways Group Specialised Register (CAGR) and by handsearching of respiratory journals and meeting abstracts. All searches are current until 07 December 2016.

Selection criteria

We included randomized controlled trials (RCTs). We included studies reported as full text, those published as abstract only and unpublished data, if available.

Data collection and analysis

Two independent review authors assessed studies for inclusion and extracted data. Where possible, data from more than one study were combined in a meta-analysis using RevMan 5 software.

Main results

One RCT of 95 participants found that AeriSeal compared to control led to a significant median improvement in forced expiratory volume in one second (FEV1) (18.9%, interquartile range (IQR) -0.7% to 41.9% versus 1.3%, IQR -8.2% to 12.9%), and higher quality of life, as measured by the St Georges Respiratory Questionnaire (SGRQ) (-12 units, IQR -22 units to -5 units, versus -3 units, IQR -5 units to 1 units), P = 0.043 and P = 0.0072 respectively. Although there was no significant difference in mortality (Odds Ratio (OR) 2.90, 95% CI 0.14 to 62.15), adverse events were more common for participants treated with AeriSeal (OR 3.71, 95% CI 1.34 to 10.24). The quality of evidence found in this prematurely terminated study was rated low to moderate.
Airway bypass stents
Treatment with airway bypass stents compared to control did not lead to significant between-group changes in FEV1 (0.95%, 95% CI -0.16% to 2.06%) or SGRQ scores (-2.00 units, 95% CI -5.58 units to 1.58 units), as found by one study comprising 315 participants. There was no significant difference in mortality (OR 0.76, 95% CI 0.21 to 2.77), nor were there significant differences in adverse events (OR 1.33, 95% CI 0.65 to 2.73) between the two groups. The quality of evidence was rated moderate to high.
Endobronchial coils
Three studies comprising 461 participants showed that treatment with endobronchial coils compared to control led to a significant between-group mean difference in FEV1 (10.88%, 95% CI 5.20% to 16.55%) and SGRQ (-9.14 units, 95% CI -11.59 units to -6.70 units). There were no significant differences in mortality (OR 1.49, 95% CI 0.67 to 3.29), but adverse events were significantly more common for participants treated with coils (OR 2.14, 95% CI 1.41 to 3.23). The quality of evidence ranged from low to high.
Endobronchial valves
Five studies comprising 703 participants found that endobronchial valves versus control led to significant improvements in FEV1 (standardized mean difference (SMD) 0.48, 95% CI 0.32 to 0.64) and scores on the SGRQ (-7.29 units, 95% CI -11.12 units to -3.45 units). There were no significant differences in mortality between the two groups (OR 1.07, 95% CI 0.47 to 2.43) but adverse events were more common in the endobronchial valve group (OR 5.85, 95% CI 2.16 to 15.84). Participant selection plays an important role as absence of collateral ventilation was associated with superior clinically significant improvements in health outcomes. The quality of evidence ranged from low to high.
Intrabronchial valves
In the comparison of partial bilateral placement of intrabronchial valves to control, one trial favoured control in FEV1 (-2.11% versus 0.04%, P = 0.001) and one trial found no difference between the groups (0.9 L versus 0.87 L, P = 0.065). There were no significant differences in SGRQ scores (MD 2.64 units, 95% CI -0.28 units to 5.56 units) or mortality rates (OR 4.95, 95% CI 0.85 to 28.94), but adverse events were more frequent (OR 3.41, 95% CI 1.48 to 7.84) in participants treated with intrabronchial valves. The lack of functional benefits may be explained by the procedural strategy used, as another study (22 participants) compared unilateral versus partial bilateral placement, finding significant improvements in FEV1 and SGRQ when using the unilateral approach. The quality of evidence ranged between moderate to high.
Vapour ablation
One study of 69 participants found significant mean between-group differences in FEV1 (14.70%, 95% CI 7.98% to 21.42%) and SGRQ (-9.70 units, 95% CI -15.62 units to -3.78 units), favouring vapour ablation over control. There was no significant between-group difference in mortality (OR 2.82, 95% CI 0.13 to 61.06), but vapour ablation led to significantly more adverse events (OR 3.86, 95% CI 1.00 to 14.97). The quality of evidence ranged from low to moderate.

Authors' conclusions

Results for selected BLVR procedures indicate they can provide significant and clinically meaningful short-term (up to one year) improvements in health outcomes, but this was at the expense of increased adverse events. The currently available evidence is not sufficient to assess the effect of BLVR procedures on mortality. These findings are limited by the lack of long-term follow-up data, limited availability of cost-effectiveness data, significant heterogeneity in results, presence of skew and high CIs, and the open-label character of a number of the studies.

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Friday, March 3, 2017

The rare cause of Severe Pulmonary Hypertension (free full text from 2017 Moldovan Journal of Health Sciences)

Female patient, aged 57, retired, non-smoking, presents dyspnea on exertion, at minimal effort, chronic severe fatigue, daytime sleepiness, insomnia, broken sleep associated with snoring and apneas, nocturia (2-3 times/night), morning headaches and xerostomia, periodic pain in the periumbilical region.

From history: juvenile obesity (100 kg), hypertensive since the age of 50, presents sleep disturbances and noisy snoring for over 10 years. The physical examination reveals dry skin, mild inferior limbs edema, acrocyanosis (lips, legs), obesity with the BMI = 47 kg/m2 (m=118 kg, h=154 cm), neck girth = 43 cm, abdominal circumference = 140 cm, umbilical hernia 3x4 cm, free nasal breathing, diminished vesicular sounds, stable hemodynamics (HR= 68/min; BP= 130/80 mmHg), Mallampati score III and17 points on the Epworth Sleepiness Scale.
Chest X-ray was normal, ECG revealed signs of right ventricular strain. The EcoCG revealed slight dilation of both atria (up to 56 mm) with the left ventricle of normal dimensions and preserved ejection fraction (50%), severe right ventricle (RV) dilatation (46 mm) and severe pulmonary hypertension (pulmonary artery systolic pressure 80 mm Hg). SpO2 at rest is 95%. Spirometric and blood gazes values are as follows FEV1-81%; FVC-80%; FEV1/FVC-109%, pH 7,43; PaO2 96 mm Hg; PaCO2 44 mm Hg.
  Considering the anamnestic data and the physical examination, which are the probable causes of pulmonary hypertension?
  What tests do you suggest for confirmation? treatment is the most suitable?
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