Current Respiratory Medicine Reviews - Volume 14, Issue 2, 2018

Asthma is a heterogeneous chronic inflammatory airways disease that affects more than 325 million people worldwide. Of these, approximately 10% have severe asthma that is refractory to commonly available treatments. In the past 15 years, there have been substantial advances in the understanding of asthma pathophysiology that have allowed for the development of targeted biological treatments such as omalizumab and mepolizumab in patients with severe asthma. On the horizon, several new classes of asthma treatments, specifically biological modulators of interleukin-4 (IL)-4, IL-5, IL-13, IL-33, and thymic stromal lymphopoietin (TSLP), are in both early and late phases of development or going through regulatory approval. Successes have also been met with failures, namely in targeting IL-17 and neutrophil-high asthma. This likely reflects knowledge gaps in the pathophysiology of non-eosinophilic and corticosteroid insensitive asthma. New treatment options are vital to patients with severe asthma who fall outside the indications for new biologic therapies or for those that have failed to respond. This review article shall be limited to a discussion on available and emerging biological treatment options in severe asthma and bronchial thermoplasty.

Chronic Obstructive Pulmonary Disease (COPD) is a chronic illness with a long clinical course characterised by episodes of worsening respiratory signs and symptoms due to acute exacerbations leading to increased usage of health care resources and much disability in later part of the life. Gastroesophageal reflux disease (GERD) is a common problem of the general population and has been seen by many researchers throughout the world as a potential risk factor for exacerbations in COPD due to micro aspiration of the gastric contents. It is observed that the incidence of GERD in COPD is much more than its incidence in the general population. This may be due to gastroesophageal dysfunction, leading to decreased tone and pressure in the lower oesophageal sphincter and oesophageal dysmotility. Many medications used by patients with COPD or changes in respiratory mechanics with increased lung hyperinflation may lead to this gastroesophageal dysfunction. GERD is amenable to treatment by both medical and surgical methods. This should help in reducing the exacerbations and improving the quality of life in patients with COPD. Hence further studies are needed to understand the cause-effect relationship.

Rationale: Lung function tests are often underutilized in assessing children hospitalized with asthma prior to discharge. We hypothesized that children with status asthmaticus may have more airflow obstruction and air trapping on lung functions than is apparent by physical examination alone. Methods: We retrospectively reviewed pulmonary function tests (airflow and lung volumes) of children admitted to Norton Children's Hospital (a tertiary care center) with asthma over a two-year period. Patients performed pulmonary function testing, according to ATS criteria, when the treating physician felt the patient was ready for discharge based on clinical improvement and the respiratory assessment score. Patients (ages 6-17, mean 12 years) were included if they had an admitting diagnosis of asthma and were able to perform lung function testing (both spirometry pre- and postbronchodilator and lung volumes). Lung function tests were excluded if they showed poor to variable effort based on flow-volume loop or a purely restrictive pattern in airflows. Results: We analyzed one hundred sixty-three lung function tests obtained over a two-year period. The mean FEV1/FVC ratio measured 0.78 (range 0.46 to 1.0), while the mean RV/TLC ratio measured 0.32 (range 0.14-0.53). Lung function testing showed moderate to severe air trapping (RV/TLC >31) in 55% of tests. 44% of tests had FEV1 less than 80 percent predicted. 58% of tests showed FEV1/FVC ratio less than or equal to 0.8. A negative correlation was seen between FEV1 and RV/TLC as well as between age and RV/TLC. We observed no correlation between the FEV1/FVC and RV/TLC. The highest RV/TLC ratio (0.53) had a normal FEV1/FVC ratio (0.91). Conclusions: We found children admitted with asthma to have more severe airflow obstruction and air trapping on spirometry than was apparent on physical assessment. Assessment of lung volumes may provide physiologic information which is not evident by spirometry alone. Further study on its role in clinical inpatient care is warranted.

Background: Obesity is a major health problem in Jordan. It has a deteriorating effect on pulmonary function tests. This study evaluated the impact of obesity on pulmonary function tests on the Jordanian population. Methods: Nonsmoking adults that did not suffer from cardiopulmonary disease were selected in this cross-sectional study. The participants were divided into two groups. The first group was the tested group, obese group (BMI≥30 kg/m2), the other was matched normal weight participants (BMI=18.5- 24.9 kg/m2). Measurements of lung-function, height and weight were performed, statistical analysis was conducted using linear regression, independent t-test and Mann-Whitney Test. Results: Linear regression showed that obesity decreased natural logarithm of forced vital capacity log (FVC), log forced expiratory volume in the first second (FEV1) and log Peak Expiratory Flow Rate (PEFR) in males and decreased log (FVC) and log (FEV1) in females. Height was positively associated with log (FVC), log (FEV1) and log (PEFR) in both sexes, while age was negatively associated with log (FVC) and log (FEV1) in both sexes. Conclusion: Obesity was negatively associated with pulmonary function tests. The result of this study has further shown the importance of weight control programs among the Jordanian population.

Background: Manual Therapy has recently gained popularity and interests from health care providers in the field of Pulmonary Rehabilitation programs for COPD patients as it has proved to have great health and clinical benefits. Additional benefits in clinical outcomes may be obtained by adding therapeutic exercise to manual therapy. Objective: The aim of this research was to study the acute effect of combined myofascial release based-manual therapy for pectoralis minor muscle and therapeutic strengthening exercises for shoulder depressors and scapular adductors, compared to the effect of a single administration of shortacting bronchodilator in COPD patients. Method: Fifty four male patients with COPD were equally divided into two groups; group A (n=27) received one physiotherapy treatment session combining pectoralis minor muscle myofacial release and therapeutic strengthening exercises for shoulder depressors & scapular adductors, while group B (n=27) received an inhaled short-acting bronchodilator for one time. Measurement included ventilatory function as the main outcome, and chest expansion & Verbal Descriptor Scale (VDS) of muscle pain as secondary outcomes. Results: FEV1, FVC, MVV, chest expansion, and VDS of pectoralis minor muscle tightness pain significantly improved only in group A (P #130; 0.05). Nevertheless, there was no statistically significant difference between the two groups except for VDS. Conclusion: a single physiotherapy intervention of myofascial release-based manual therapy combined with therapeutic exercise has succeeded to induce some clinical benefits in patients with COPD. This protocol may represent an alternatively novel physiotherapy intervention that can be included in pulmonary rehabilitation programs for COPD patients.

Background: Sarcoidosis is a granulomatous inflammatory disorder with unknown etiology and its relation with Mycobacterium tuberculosis (M. tuberculosis) has been debated for years. In this study, we have investigated the presence of mycobacterial DNA in sarcoidosis tissue samples. Methods: Formalin-Fixed Paraffin-Embedded (FFPE) tissues of 33 patients with sarcoidosis were analyzed for the presence of mycobacterial DNA. Genomic DNA extraction was done by QIAamp DNA FFPE Tissue Kit. Polymerase chain reaction using insertion element IS6110 of M. tuberculosis complex (MTC) was applied by commercial kits (GeneProof) for all individuals. The results were compared with 27 patients with tuberculosis and 5 other patients associated with granulomatous disease of the lung. All cases had confirmed granulomatous inflammation in their histopathological examination. Results: In this study, the IS6110 repetitive DNA element of (MTC) was not detected in any of the tissue samples from the patients with sarcoidosis. Of the 33 sarcoidosis patients, 30 (90.1%) had negative results for IS6110 and despite the repeated attempts of DNA extraction for three patients (9.1%), strong inhibitor made constant negative outcomes. In contrast, in patients with tuberculosis, 22 (81.5%) had positive results, three had (11.1%) negative results and 2 patients (7.4%) showed negative results with strong inhibitor. IS6110 was not found in any of the control group patients. Discussion: This study does not support the presence of M. tuberculosis in tissues of patients with sarcoidosis as a microbial pathogen or trigger of the immune response. Due to difficulties in diagnosis of sarcoidosis and different methods for diagnosis of M. tuberculosis, the impact of M. tuberculosis as a possible aetiological agent in sarcoidosis has been the point of debate.

Background: Chronic Obstructive Pulmonary Disease (COPD) manifests with dyspnoea which causes restriction in movement, loss of independence and social isolation. Objectives: To assess physical health status, depression, activities of daily living (ADL) and its determinants among COPD patients. Methods: This cross-sectional study was done among out and in-patients at a government and private tertiary care hospital. All confirmed cases of COPD were interviewed using a semi-structured interview schedule. Results: The mean age of the 76 patients was 60.9 ± 13.3 years. The majority were males 61(80.3%) and were from urban area 48(63.2%). Duration of COPD was between 1 to 5 years among 43(56.6%) patients. Among the participants, 49(64.5%) were smokers and among them 17(34.7%) were current smokers. Physical health status was good among 23(30.3%), average among 49(64.4%) and poor among 4(5.3%) patients. Level of depression was nil, mild, moderate, moderately severe and severe among 30(39.5%), 18(23.7%), 20(26.3%), 6(7.9%) and 2(2.6%) participants respectively. ADL was poor, average and good among 4(5.3%), 17(22.3%) and 55(72.4%) participants respectively. Pack-years of smoking more than 5 years among current smokers (n=17) was significantly associated with poor to average physical health status (P=0.0063). Duration of COPD more than 5 years was associated each with poor to average ADL (P=0.05) and with the presence of depression (P=0.022) among participants. The correlation between physical health status scores and Barthel index scores was found to be significant (r = – 0.359, P=0.001). Conclusion: The study identified the number of patients having an impairment with physical health, ADL and the presence of depression. Therefore these parameters need to be screened periodically during the course of management. Further interventions such as smoking cessation measures, monitoring COPD symptom burden and tailoring treatment accordingly would help to improve the quality of life of the affected.

Background: Lung cancer is the most common cancer in men worldwide. The incidence continues to rise in both males and females with wide geographical variability. Lung cancer has a high fatality rate. Early detection of lung cancer has better treatment outcome as early lung cancers can be operated. But the diagnosis of lung cancer is delayed due to many factors. Aims and Objectives: The aim of this study was to analyze the current clinico-pathological profile and epidemiological trends in lung cancer patients from a single tertiary care centre with emphasis on given on gender association and delay in detection due to misdiagnosis as tuberculosis. Materials and Methods: A retrospective analysis of the data of in-patients diagnosed as Primary lung cancer in the department of pulmonary medicine at SDSTRC& Rajiv Gandhi institute of chest diseases, Bengaluru, Karnataka from August 2015 to September 2017. Results: Lung cancer study is still a disease predominant in old age males. Smoking is one of the major causative factors. In Non smokers, females and young age group (<40yrs) adenocarcinoma was commoner than squammous cell carcinoma.17 patients (16.5%) were mis-diagnosed as tuberculosis before the definitive diagnosis was made. Conclusion: Due to widespread prevalence of tuberculosis, lung cancer poses a diagnostic challenge. A significant number of lung cancer patients in our country still continue to be misdiagnosed as tuberculosis. Poor diagnostic resources and economic constraints along with low clinical suspicion lead to delay in diagnosis of lung cancer resulting in poor prognosis and survival.

Pleural lipoma is an extremely rare benign tumor. A lesion homogeneity with smooth borders is a suggestive criterion of lipoma in the chest radiology. Tissue biopsy is usually required for the diagnosis and exclusion of liposarcoma. In this case report, we described a female patient diagnosed with a pleural lipoma which was discovered accidentally during a metastatic work up of a previously diagnosed squamous cell carcinoma in the left ala nasi. The diagnosis of the pleural lipoma was histopathologically confirmed with tru cut biopsy.