Current Respiratory Medicine Reviews - Volume 12, Issue 4, 2016

The introduction of electronic patient data capture platforms has led to an increase in the use of systems designed to predict and react to clinical deterioration. These systems capture clinical observations to calculate either single parameter, or aggregate weighted, track and trigger scores (also referred to as early warning scores). In this article, we examine the impact of early warning scores on management of patients with respiratory disease. We also review the evidence in the literature and summarise current and potential future strategies for recognition of clinical risk in the acute hospital setting.

Background: Cryptogenic organising pneumonia (COP) is an idiopathic pneumonic process featured by a high sensitivity to steroids, but also by a fairly high relapse rate. Accordingly, treatment needs to be protracted more than expected, leading to occurrence of side effects and need for therapeutic changes in many patients. There is an increasing evidence that long-term macrolides can effectively control disease in such situations. Objective: Aim of this work was to ascertain the overall number of published cases of macrolidetreated COP, treatment regimens, effectiveness, and tolerability. Methods: Articles published from 1981 to 2015 were systematically searched through PUBMED, EMBASE, and other databases. All patients with proven diagnosis of COP and treated with longterm macrolides were included. Any information was extracted from each case and analysed, including disease presentation, previous treatments, dose and length of macrolide administration, clinical and radiological response, side effects, and relapses. Results: Twelve papers were found for a total of 35 patients. Macrolides were administered at low or full dose and as monotherapy or in association with steroids. No significant difference was detected between the therapeutic regimens (P>0.05). Overall, long-term macrolide therapy was effective in 86% of cases, albeit after a minimum period of 3-4 months treatment. No side effects or relapses were reported. Conclusion: Certain macrolide antibiotics seem to be a promising therapeutic option in COP due to their immunomodulatory properties. Long-term macrolides, even as monotherapy and at low doses, have been shown to be effective in COP patients with mild-to-moderate disease and/or steroidinduced toxicity.

Malignant Mesothelioma: Asbestos are naturally occurring fibrous silicate materials. It is well recognised that inhalation of asbestos fibres especially amphiboles is the most important risk factor for developing mesothelioma. The epidemiological models of association between the risks of asbestos and malignant mesothelioma take into consideration not only cumulative exposure but also time since first exposure. Current epidemiological estimates suggest that mesothelioma will remain a public health problem for a number of years with epidemiological studies suggesting that the peak incidence of mesothelioma has not been reached. In the global context, mesothelioma remains responsible for between 15,000 - 20,000 deaths annually. Malignant mesothelioma can be divided as per World Health Organization classification into epithelioid, sarcomatoid, desmoplastic and biphasic subtypes.

The care of beta-thalassemia has improved dramatically over the last few decades mostly because of: i) improved blood transfusion regimens; ii) wide-spread use of deferoxamine; iii) surgical advances; and iv) allogeneic hematopoietic stem cell transplantation. Advanced healthcare standards, improved life expectancy, and complications specific to beta-thalassemia necessitate a renewed approach to the pulmonary issues of this disease. While transfusion-related infections are expected, and Streptococcal, Staphylococcal, E. coli and Salmonella infections are common, a number of special problems are also reported. Mycoplasma pneumoniae infections associated with hemolytic anemia, Pneumocystis carinii pneumonia and necrotizing pneumonia caused by Klebsiella pneumoniae are indicative of the special susceptibility to infections in beta-thalassemia. The issue of immune function in the (non-transplanted) patient with thalassemia is brought up. Conditions associated with chronic airway inflammation, such as plastic bronchitis and allergic bronchopulmonary mycosis, are discussed as well as life-threatening complications. In an attempt to organize the diagnostic approach to pulmonary disease in beta-thalassemia, four working entities are delineated, which, almost invariably, tend to overlap and aggravate each other: i) disorders inherent to the beta-thalassemia hemoglobinopathy; ii) chronic lung disease and its complications; iii) immunological corollaries of the therapy of beta-thalassemia, i.e. chronic transfusion, splenectomy and bone marrow transplantation; and iv) airway inflammation.

Malignant pleural mesothelioma is an asbestos-linked cancer associated with a very poor prognosis. Surgical interventions form an important aspect of the management of this aggressive form of cancer. However, debate continues regarding the different treatment options available. Video assisted thoracoscopic surgery (VATS) has been the procedure of choice for the diagnosis of malignant pleural mesothelioma as big samples can be taken from multiple areas of the chest under direct vision. It may also be used as a palliative procedure to drain pleural effusion and perform pleurodesis. Other surgical options include extrapleural pneumonectomy, radical pleurectomy or extended pleurectomy decortication and pleurectomy and decortication. Frequently, these surgical procedures are performed in conjunction with chemotherapy and/or radiotherapy. In this review we will discuss the developments and remaining controversies of surgery in the context of malignant pleural mesothelioma.

Among the pulmonary manifestations of rheumatoid arthritis (RA), rheumatoid nodules (RN) are frequent even if mostly asymptomatic. They are generally peripheral and different for sizes (up to 8 centimeter in diameter) and number (one or more). RN can be a consequence of RA or of the drugs used for RA. In the first case, they usually appear in patients with more aggressive and seropositive longstanding RA and are often associated with cutaneous RN. Methotrexate, leflunomide, azathioprine among the disease-modifying anti-rheumatic drugs (DMARDS) and etanercept among “biological” ones are the more frequent responsible drugs. RN induced by drugs are histologically identical to non-drugsinduced RN. In these cases, drug withdrawal is the first therapeutic choice. Differential diagnosis with other causes of pulmonary nodule is imperative, especially when RN is the first clinical manifestation of RA and serum levels of rheumatoid factor (RF) and/or anti-citrullinated peptides antigens (ACPA) are in the normal ranges. Cancer (primitive or metastatic) and infectious diseases represent the main diagnostic dilemma. The exclusion of neoplastic or infectious causes is particularly important in the course of immunosuppressive therapy for RA. As highlighted by some authors, bronchogenic carcinoma can grow on RN and RN can be associated with metastatic nodules or infectious nodules in the lung, but these are outstanding events. Percutaneous biopsy or thoracotomy remain the gold standard for diagnosis especially when high-resolution computed tomography (HRCT) or positron emission tomography (PET) -CT features and laboratory tests are not conclusive.

Objective: Aging is associated with increased risk of obstructive sleep apnea (OSA) and treatment of OSA in elderly is of great interest but controversial. Pneumonia requiring invasive mechanical ventilation (IMV) is a leading cause of death in the elderly. The purpose of the study was to assess pneumonia-related mortality in elderly persons with OSA. Methods: The Nationwide Inpatient Sample (NIS) was investigated for discharges with a primary or secondary diagnosis of pneumonia between 2009 and 2011. Persons with OSA, aged 65 years and older, were compared to a cohort of patients without OSA. Primary outcomes were in-hospital mortality and non-routine discharge (discharge to nursing home or skilled facility). Logistic regression models were used to assess the risk of OSA on in-hospital mortality and discharge status. Results: In 1,768,185 hospital discharges, approximately 5% had OSA, and its prevalence was inversely proportional to age (65-74: 8.3%, 75-84: 4.8%, 85+: 1.8%). Pneumonia requiring IMV was more common in the OSA cohort (OSA: 4.3% vs. Non-OSA: 3.3% <0.0001). In-hospital mortality (OSA: 3.3% vs. Non-OSA 5.1% <0.0001) and non-routine discharges (OSA: 46.9% vs. Non-OSA: 55.4% <0.0001) were significantly lower in the OSA group. Conclusion: OSA was associated with reduced inpatient mortality risk in pneumonia related respiratory failure in elderly subjects. Sleep apnea may confer a survival benefit in older individuals; but further research is warranted.