Current Respiratory Medicine Reviews - Volume 13, Issue 2, 2017

Objective: This review discusses available clinical data regarding PDE4-inhibitors in the treatment of Chronic Obstructive Pulmonary Disease (COPD). Background: COPD is an inflammatory disease characterized by progressive decline of lung function with periods of acute exacerbations. Cigarette smoking is strongly associated with the development of COPD. Current therapies are not optimal and few COPD-specific medications exist. Furthermore, clinical trials specifically designed to assess candidate drugs are difficult and expensive to perform given the chronic and slowly progressive nature of the disease. These issues, among others, are significant barriers towards the development of effective management strategies. Phosphodiesterase 4 (PDE4), a member of a class of important inflammatory mediators, is an important modulator of lung inflammation. Inhibition of PDE4 with small, orally available molecules is a novel treatment strategy that has shown promise in the treatment of COPD. Conclusion: PDE-4 inhibitors are a novel class of orally bioavailable medications that have shown clinical promise in patients with COPD. Roflumilast is the first drug of this class approved for the use in a specific subset of COPD patients.

Background: For decades there were no significant advances in the development of diagnostic procedures for drug resistant TB (DR-TB), or the availability of new, effective drugs specifically developed for DR-TB. Now, we have witnessed during the last decade, the arrival of several new diagnostic techniques and new drugs, already available for clinical use. This review aims to critically analyze evidence-based recommendations on the most recent developments in the diagnosis and treatment of multidrug-resistant tuberculosis (MDR.TB). Methods: PubMed search for papers describing innovative diagnostic techniques and newer drugs and treatment regimens for MDR-TB. All World Health Organization (WHO) evidence-based guidelines on the subject of diagnostic techniques and new drugs and treatment regimens were also reviewed. Results: 21 papers, 10 WHO guidelines and one Global Tuberculosis Report (2016) were included in the review. Nineteen were original papers on diagnostic techniques or newer drugs and 2 were editorials on the global burden of MDR-TB. One WHO global report dealt with the burden of MDRTB, 6 guidelines had evidence-based recommendations on newer diagnostic techniques for MDR-TB and 4 had evidence based recommendations on new drugs and treatment regimens for MDR-TB. Conclusion: The findings of this review confirm that genotypic diagnostic methods have revolutionized the diagnosis of MDR-TB, from a process that used to take months to one that now takes just a few hours. Also, for the first time in more than 50 years, two new antituberculosis drugs, delamanid and bedaquiline, are now added to the armamentarium, a greatly needed alternative for the treatment of MDR-TB.

Background: Noninvasive ventilation (NIV) is a method of positive pressure ventilation that does not require an endotracheal tube. NIV is used in pediatrics in numerous clinical conditions, but it is necessary to systematize the available knowledge to better understand its application and effectiveness in disease management. Objective: To discuss the scientific evidence published in the last five years (2011 to 2016) regarding the use of NIV in children and adolescents. Methods: A systematic review was performed in the databases PEDro and MEDLINE using the descriptors: noninvasive ventilation, pediatrics, children and adolescent. We selected articles with participants aged from zero to 20 years, regardless of pathology, who were submitted to NIV in the hospital or at home. We excluded studies that did not have the assessment of NIV as the main objective. Results: Initially, 377 articles were identified, of these, 123 articles were excluded because of the title, year or duplicity, 147 because of the abstract, and 73 after full reading. Thus, 34 articles were included in the review. Of the 34 articles evaluated, only two reported side effects for NIV, but the benefits outweigh the side effects mentioned. Conclusion: NIV has become a reality well established and studied in pediatrics in numerous diseases. In the review, we demonstrated that NIV is safe, viable and effective for the treatment of acute respiratory failure, obstructive sleep apnea syndrome, nocturnal alveolar hypoventilation, acute viral bronchiolitis, neuromuscular disease, asthma and cystic fibrosis, and that it can be used as therapy at home.

Background: The use of cryosurgery for the treatment of airway diseases has recently gained popularity. Cryotherapy can be applied through a flexible or rigid bronchoscope and delivered via cryotherapy probe or cryospray. Cryosurgical techniques can be used to freeze tissue to approximately negative 80 degrees Celsius, resulting in cell death and tissue necrosis. Treatment of malignant airway obstructions can be accomplished through cellular necrosis by utilizing repeated freeze/thaw cycles and subsequent removal of sloughing tissue. Additionally, immediate airway recanalization can be achieved through cryodebridement, a technique by which tissue adheres to the freezing cryoprobe and is then quickly withdrawn to debulk tumor. Cryosurgical techniques have also been used in benign diseases, including foreign body removal and treatment of airway stenosis. The cryotherapy probe can also be used to obtain large transbronchial tissue biopsies. The safety profile of cryotherapy within the airways is favorable, with bleeding and pneumothorax being the main risks. As cryosurgical interventions within the airway evolve, the additional applications will continue to grow. Methods: A peer-reviewed literature search was conducted to obtain published literature for this review. The following bibliographic databases were searched: Ovid MEDLINE with in-process records and daily updates through Ovid (1970 to present), including clinical trials and reviews. Search results included 87 publications. If objective data were not available, expert opinion was used. Keywords included airway and cryotherapy. Results: Twenty-five articles were used to develop this review, of which 12 articles were review articles themselves. Based on these findings, this review article was able to show that airway cryotherapy is an effective tool for the treatment of malignant and benign airway disease. Conclusion: The use of airway cryotherapy is an effective and safe approach for the treatment of both malignant and benign airway diseases.

Background: The use of natural products, especially from plant origin is antique. Undoubtedly, a type of plant-derived product, essential oils have gained much attention, due to their promising biological activities and diverse applicability. Diterpenes, the family members of essential oils are reported for various important biological activities. This revision aimed to sketch a current scenario on diterpenes acting on the respiratory system. Methods: A search was made in the electronic databases (PubMed, Science Direct, Medline, Scopus, Medline, Atlantics, Web of Science, Springer, American Chemical Society, SciFinder, and Google scholar) as published articles. To date (December 2016), a total 2583 articles were found on the search topics, among them only 49 were included in this study. Results: Findings suggest that diterpenes may act through various pathways in the respiratory system, such as airway constriction/relaxation, anti-inflammatory and cytogenotoxic/cytoprotective mechanisms, molecular signals and so on. Conclusion: Diterpenes may be one of the most promising sources of respiratory medicine. More researches are highly appreciated on diterpenic lung protective traits.

Introduction: Phenotypic characterization of COPD subjects may rely on clinical and physiological manifestations, imaging, assessment of patient-related outcomes (health related quality of life), COPD comorbidities, COPD exacerbations and systemic inflammation. The aim of the study was to evaluate and to analyze the health-related quality of life (HRQL) in COPD patients classified into different phenotypes. Methods: 395 consecutive COPD patients were enrolled into the study. Spirometric data were analyzed (FEV1, FVC, FEV1/FVC). HRQL was assessed by the St. George Respiratory Questionnaire (SGRQ), COPD Assessment Test (CAT) and Clinical COPD Questionnaire (CCQ). Results: The cohort consisted of 395 COPD patients with mean age 62.7 ± 9.4 years, 79 % were males. Patients were divided in 4 groups according to phenotypes: 44% of the patients were nonexacerbators, 35% frequent exacerbators with chronic bronchitis (CB), 12% frequent exacerbators without CB, and 8% were patients with asthma-COPD overlap syndrome (ACOS). There were statistically significant differences in HRQL and lung function between COPD phenotypes. Frequent exacerbators with chronic CB and without CB had the similar total SGRQ scores, CCQ scores and CAT, and these scores were worse in comparison with HRQL of non-exacerbators and patients with ACOS. Conclusion: Frequent exacerbators with chronic CB and without CB have a more severe deterioration of the HRQL and worse lung function then non-exacerbators and patients with ACOS.

Background and Aims: In late November 2015 and early February 2016, an outbreak of H1N1 influenza A virus infection occurred in the north of Iran. The aim of this study was to describe the incidence of mortality due to H1N1 influenza among patients admitted in hospitals affiliated to Mazandaran University of Medical Sciences in north of Iran. Material and Methods: A descriptive cross-sectional study was done using the medical records of mortality cases of influenza A, whose result of RT-PCR (reverse transcriptase polymerase chain reaction assay) confirmed H1N1. Demographic data, symptoms and signs of disease, clinical backgrounds, radiographic evidences, laboratory findings, treatment procedure and outcome of these patients were recorded. Results: Out of the 428 confirmed cases of influenza A (H1N1) in Mazandaran province between 21st March 2015 and 19th March 2016, 23 (5.3%) deaths (10 males and 13 females) were reported. Death occurred between outbreak in late November 2015 and early February 2016. The average age of deceased patients was 46.9±21.4 years old (range 14-95 years). The most prevalent symptoms and signs were: fever (91.3%), cough (82.6%), dyspnea (73.9%), and headache (69.5%). The most underlying conditions among decedent patients were: heart failure (47.8%), diabetes mellitus (30.4%), and BMI≥40 (30.4%). Conclusion: The association between underlying risk factors and mortality rate, emphasizes the priority of vaccination in high risk groups.

Background: For several years, surgical therapies have been the mainstay for treatment of pulmonary tuberculosis. However, due to higher complication rates and the advent of potent antituberculosis (anti-TB) medications, the use of surgical therapies has declined. With the increase in the incidence of drug-resistant tuberculosis and failure to achieve satisfactory cure rates with anti-TB medications, surgical treatment might be resurging. Case Report: We recently encountered a patient who had a successful plombage therapy for the treatment of pulmonary tuberculosis. Thereby, different surgical approaches and supporting evidence for their role in the treatment of pulmonary tuberculosis in recent years has been reviewed. Conclusion: Clinicians need to be aware of this therapy, when encountering plombage on the routine x-ray chest.

Mediastinal abscess is an uncommon medical condition usually secondary to infection elsewhere. This study reports a case of a young male with fever, dry cough, reduced appetite and weight loss for one month presenting radiologically as a mediastinal mass. Flexible video-bronchoscopy with trans-tracheal needle aspiration revealed thick pus which was sterile on microscopy and culture. The patient was hospitalized and broad spectrum intravenous antibiotics were started. After few days, the patient developed worsening of symptoms. CT-guided percutaneous aspiration of abscess was done with immediate relief in compressive but persistence of constitutional symptoms. Anti-tubercular therapy was initiated and patient showed marked clinical improvement on follow-up visits.