Current Respiratory Medicine Reviews - Volume 13, Issue 3, 2017

Background: Pulmonary hypertension (PH) is a potentially life-threatening condition with an increased global awareness. Although PH can be long-time asymptomatic in the early stages, it may participate in cardiac remodelling, leading to heart failure and death. Generally, physical exercise is not recommended for safety concerns, but nowadays, evidences in scientific literature are proving its efficacy as complementary treatment in PH. Methods: An increasing number of studies are focusing on how exercise can improve the cardiopulmonary function and the quality of life overall. We briefly examined and summarized the benefit of exercise training in patients with PH, analyzing the evidence-based recommendations about exercise training in these patients. Results: Throughout the analysis of the physiological mechanisms that may be the basis for the amelioration of the symptoms and provided evidence-based recommendations about frequency, type, intensity and setting of exercise training, we consistently verified that increasing physical activity could help to better manage the pulmonary hypertension. Conclusion: An exponential number of studies show the potential role of exercise as additional treatment in PH, with significant effects in several clinical and haemodynamic parameters as endurance, peak oxygen consumption, cardiovascular, respiratory and musculo-skeletal function. In terms of activity of daily living, the improvement in 6-minute walking distance is similar to that achieved with optimal use of medication. Longer and larger studies are needed to determine whether exercise training benefits on exercise capacity, cardiorespiratory fitness and quality of life are maintained in the long-term and also include an improvement in clinical outcomes.

Background: Chronic obstructive pulmonary disease (COPD) is a complex disease that requires multiple care providers working together closely. Recent advances in telemedicine technologies have generated enormous potential benefits for COPD management and care. This review aims to explore the clinical, economic, organizational and patient-quality-of-life impact from using telemedicine systems for COPD and to provide a comprehensive description of these methodologies. Methods: We conducted a structured search of bibliographic databases for peer-reviewed research literature using a focused review question. We include quantitative and qualitative studies. Data extraction and quality assessment of the reviewed studies were done with standardized forms and checklists. Results: The support of evidence from studies points to beneficial results of telemedicine in its various manifestations. Benefits include the reduction of emergency department attendances and hospitalizations, but little evidence has been found to make a strong case for telemedicine regarding the quality of life or economic improvements. Internal organizational consequences of telemedicine are frequent and efficient use of the technology requires organizational changes. Telemedicine modifies traditional practices and can help patients better engage in managing their health. Nevertheless, telemedicine must be integrated into a care process and within a care model. Conclusion: COPD telemedicine interventions could significantly reduce the risk of emergency department attendance and hospitalization. It is an important area of research, and further studies of the effect of telemedicine for patients with COPD would be beneficial.

Background: Volumetric capnography (VCap) is an alternative tool in the search for connections between structural damage and early pulmonary functional changes in chronic respiratory diseases. Thus, numerous markers obtained in VCap, including the inclination curve of phase III (Slp3), have been studied to detect early changes in the airways. Objective: To present the use of Slp3 in different outpatient clinic situations, seeking its better understanding. Method: We performed searches in electronic databases (LILACS, MEDLINE-PubMed, PEDro, and SciELO) for the descriptor “volumetric capnography”. We considered the presence of the descriptors in the title or abstract as a criterion for initial inclusion. All publications until June 2017 were included. Results: In total, 130 studies that addressed the use of Slp3 in clinical practice were identified (109 in PubMed, 10 in LILACS, 10 in SciELO, and one in PEDro). 21 were excluded because of duplicity between databases, and 100 because of the absence of the descriptor in the title and/or abstract or for considering only Slp3 in the invasive mechanical ventilation. Conclusion: In the literature, there is evidence that the evaluation of non-homogeneity of ventilation by Slp3 can identify early lung changes, more specifically of peripheral airways, in individuals with lung disease.

Background: Patients with COPD experience a consistent disability which leads to a deterioration in their Health related quality of life (HRQL). In Tunisia, this topic has not yet been studied. Objective: This study aims to assess the HRQL of patients with COPD in Tunisia and to identify possible predictors of HRQL. Methods: A cross-sectional study was carried out in the two main primary care centers in Sousse over a period of three months. HRQL was assessed by the Medical Outcomes Study Short form 36 (SF- 36). Clinic and socio demographic data were collected from patients' records. The population was divided into four subgroups, high and low components' scores. Univariable analysis and multivariable analysis were used to identify predictive factors of HRQL. Results: A total of 335 patients have participated with a mean age of 66.70±11.60. Physical component's median was 37.08 and that of mental component was 40.70. compared to age 40-49, the age groups associated independently to impaired PQL and MQL were 70-79 (OR=19; 95% CI: 4-89 and OR=6; 95% CI: 1.20-17, respectively), and ≥80 (OR=19; 95% CI: 4-99 and OR=6.04; 95% CI: 1.30-26, respectively). Age group 60-69 was associated only to impaired PQL (OR=9; 95% CI: 2-40). Analysis of associations between PQL and the severity of the disease showed that the ORs of severe stage of COPD (OR= 3.70; 95% CI: 1.20-11) and very severe stage (OR=31.50; 95% CI: 9.20-90 and) were significant. While in MQL, ORs of moderate (OR=11.40; 95% CI: 1.40-90), severe (OR=44.50; 95% CI: 5-357), and very severe stages of COPD (OR=233; 95% CI: 28-280) were significant. The ORs of stages 4 and 5 of dyspnea were significant only in PQL (OR= 15; 95% CI: 1-135 and OR=17; 95% CI: 8-180, respectively). In addition, compared to having no comorbidities, the OR of two co-morbidities or more (OR=2.80; 95% CI: 1.30-5 and OR=3.40; 95% CI: 1.70-7) was significantly higher (OR=1.18; 95% CI: 0.50-2 and OR=1.20; 95% CI: 0.60-2.40). Dyspnea was independently associated with only PQL. Conclusion: Patients with COPD had an impaired HRQL associated independently with age, disease severity and co-morbidity. Health care professionals should take into account these predictive factors in order to improve the general health condition of COPD patients.

Objective: Chronic Obstructive Pulmonary Disease (COPD) has become a global health concern. The data indicate that only 20-25% of smokers develop COPD. The prevalence of bronchial hyperresponsiveness (BHR) among smokers that develop into COPD is presumed higher than smokers who do not develop COPD. Methods: Samples from lung clinics in three government hospitals in Surabaya were examined. The samples had to meet the inclusion criteria and were willing to participate in the research. The samples were divided into two groups: COPD (group A and group B) and healthy smokers. Samples with asthma, allergies, Asthma COPD Overlap Syndrome (ACOS), tuberculosis, post-tuberculosis, Forced Expiratory Volume in 1 second (FEV1) <50% predicted, FEV1 <1 liter, exacerbation ≥1 times that need hospital admission in a previous year were excluded from the study. The values of Provocation Concentration causing fall of 20% in FEV1 (PC20) with Methacholine Challenge Test on both groups samples were evaluated, the average was assessed and differences were compared. Results: There were 182 samples and only 23 samples were analyzed from each group; COPD and healthy smokers. BHR in COPD group were 47.83%, higher than healthy smoker (16 vs. 7) with significance PC20 average (3.77±3.74 vs. 10.20±3.73) mg.mL-1, p = 0.001. An analysis on BHR on COPD group indicated that group B had more BHR compared to group A (73.3% vs. 62.5%) with an average (3.55±2.96 vs. 4.26±5.49) mg.mL-1, but no statistically significant difference (p = 0.738). Conclusion: There were samples with more BHR in COPD group compared to healthy smokers. Smokers with BHR were at a risk of getting COPD.

Background: Thoracic surgeries have been safely applied to the surgical treatment of different thoracic conditions in our center since its introduction in September 2013. Our center is a small private center, with cardiothoracic unit as its main component, with only 20 beds, including 4 beds for the ICU. The ICU is well staffed and equipped. The hospital is supported with two operation rooms (OR), Clinical laboratory, Spirometry, Ultrasonography, Echocardiography, bronchoscopes and conventional X-Ray. The hospital doesn't have CT facility but it's done in a nearby diagnostic center when needed. This article summarizes and reflects our experience with thoracic surgery, highlighting the salient challenges and outcome. Methods: Retrospective description of cases, over a 3-year period (September 2013 to September 2016). All challenges and difficulties experienced during the course of patient care as well as complications and outcomes were recorded and analyzed. Results: Out of the 101 surgical operations performed in our hospital, during the study period, 87 (86%) were open thoracic surgeries. Patients were between the ages of 11 years and 67 years with a mean of 39 ± 9 years (95% confidence interval (CI)). Infective thoracic conditions were the most common indication for thoracic surgery in 45 patients (51.7%). Decortication for complicated pleural effusion was the most common thoracic surgery and was performed in 49 (59.5%) patients. Tumor resection was performed in 20 (22.9%) patients (Carcinoid tumors; 11 patients, Aspergillomas; in 5 patients and bronchial cancer; in 4 patients: 3 lobectomies & and 1 wedge resection). In 11 (12.6%) patient surgery was done to remove foreign bodies from different sites of the bronchial tree when removal with rigid bronchoscope was not possible. Penetrating chest stab wounds were repaired in 7 (8%) patients without complications. Major challenges experienced were patient late presentation to the hospital, non-availability of video assisted thoracic surgery (VATS) and positron emission tomography (PET) scan for proper staging and treatment of bronchial carcinoma. Complications included 5 deaths, 2 cases of post-operative bleeding and 2 cases of post-operative sepsis following decortication for empyema thoracic, hence the morbidity and mortality rates in our series of patients were 4.5% and 5.7%, respectively. Overall, 82 (94%) patients in our study experienced a positive outcome. Conclusion: This study highlighted the main obstacles which thoracic surgery service deals with in our hospital, as an example of a new private center in a resource-constrained setting. However, thoracic surgery is still safer in spite of the difficulties faced and complications are significantly low as compared to similar centers in the region.

Background: Bronchomediastinal fistula is an anomalous communication between the bronchial tree and mediastinum. It is a rare condition that occurs in the course of severe respiratory diseases such as rupture of bronchogenic cyst, descending necrotizing mediastinitis, tuberculous lymphadenitis, post-transplant lung infections and as a complication of treatment with chemotherapy or radiotherapy in bronchogenic tumours. Methods: We report the case of a 54-year-old male diagnosed with lung cancer four years ago, initially treated with surgery (lower left lobectomy), radiotherapy and chemotherapy, presenting recurrence and tumour progression in the last year. He came to the emergency department due to progressive dyspnoea in recent months. Chest computed tomography angiography was performed in which, besides progression of his neoplastic disease, an adenopathic mass-conglomerate was observed at the right parahilar mediastinal and subcarinal level, along with a fistula which communicated the necrotic subcarinal lymphadenopathy with the bronchus intermedius. Results: Flexible fibrobronchoscopy was performed, which confirmed the neoplastic disease (distal tracheal infiltration and in both main bronchi), with the existence of the aforementioned fistula, in the posterior wall of the bronchus intermedius, after bronchus exit from the right upper lobe, of 1.5 millimetres. The patient was scheduled for sealing the fistula with Bioglue® (surgical adhesive), a procedure proposed for ten days later. However, on the day of the operation spontaneous closure of the fistula was observed. The patient was discharged after clinical stabilization, dying at his home two months later due to overall deterioration secondary to the evolution of the neoplastic disease. Conclusion: This clinical case highlights, besides the appearance of a bronchomediastinal fistula (a rare entity), the fact that it had spontaneous resolution. This could be related to local adenopathic conglomerate tumour growth, which triggered the closure of the fistulous tract by compression. We did not find similar cases of respiratory fistula resolution without the need for specific treatment in the literature.

Background: Combined pulmonary fibrosis and emphysema (CPFE) is defined by imaging findings and is characterized by the coexistence of both upper lobe emphysema and lower lobe pulmonary fibrosis. The natural course of CPFE is frequently complicated by pulmonary arterial hypertension (PAH), which identifies the most severe CPFE phenotype with a particularly poor prognosis. Case Report: In June 2013, a 78-year-old white male was admitted to the pulmonary rehabilitation program because of exertional dyspnea. In 2007, he was diagnosed as CPFE due to imaging findings. After diagnosis, the patient remained stable until 2011, when he started to get short of breath with exertion. From September 2011, disease progression and worsening of the patient's clinical condition increased at a faster rate. During the hospitalization, a trans-thoracic two-dimensional echocardiography showed the left ventricular chamber slightly dilated with an ejection fraction of 40% and systolic/diastolic/mean pulmonary arterial pressures on the right heart catheterization were 71/24/44 mmHg. Upon progressive clinical worsening, not due to worsening of lung function tests but to the increase in PAH, an off-label use of ambrisentan was initiated as monotherapy and, then, tadalafil was added. This therapy obtained an improvement in both clinical condition and exercise capacity. Despite the advanced stage of lung disease, the patient survived for about 2 years after the start of treatment with ambrisentan and tadalafil. Conclusion: Some of the patients affected by CPFE complicated by PAH could benefit from the addition of pulmonary vasodilator agents to conventional treatment.