Current Respiratory Medicine Reviews - Volume 14, Issue 3, 2018

Background: An adequate vitamin D status is essential for normal immune function. Vitamin D sub-nutrition is widespread, especially in low sunlight regions and in certain high-risk groups. There is growing evidence that vitamin D supplementation can reduce the risk of infection of the respiratory tract. Objective: The aim was to review the mechanisms whereby vitamin D supports the chemistry of optimal innate and adaptive immunity, and to evaluate critically the current evidence for the use of vitamin D supplements to help to minimize respiratory infection risk, particularly in individuals with sub-optimal vitamin D plasma levels. Method: PUBMED and MEDLINE were searched using the terms: vitamin D; cholecalciferol; calcitriol; calcifediol; respiratory infections; influenza; pneumonia; respiratory syncytial virus, respiratory tract infection; chronic obstructive pulmonary disease (COPD); immunisation; vaccination; innate immunity; adaptive immunity. Papers for citation were selected by the authors on the basis of quality and relevance. Findings: Vitamin D is needed for optimal function of innate and adaptive immune systems. The evidence for a protective effect of vitamin supplementation is the strongest for viral infection, particularly in people with plasma calcifediol levels below 25 nmol/L. However, the role of vitamin D in influenza risk and as an adjunct to influenza immunization is not clear. There is some evidence that a sufficient vitamin D status reduces the risk of infective exacerbations of COPD, and probably helps in the defence against some bacterial infections of the respiratory tract. Conclusion: Individuals with vitamin D deficiency have enhanced protection against some respiratory infections when given supplements. There are also other benefits including improved bone and muscle function, and mood. Further research is needed to identify sub-groups most likely to benefit from supplements.

The aim of this mini-review is to highlight the current state of the problem of nosocomial pneumonia and nosocomial tracheobronchitis in critically ill patients. The important concepts for nosocomial tracheobronchitis, novel genetic and molecular biomarkers of nosocomial pneumonia and nosocomial tracheobronchitis and the role of inhaled antibiotics in the treatment of this condition and their ability to prevent the development of nosocomial pneumonia are discussed.

Lung cancer has been recognized as the most important reason for death and a lifethreatening disease. The late diagnosis of this disease usually limits treatment interventions. The lack of reliable noninvasive biomarkers and therapies results in low survival rates. The current review is designed to uncover the specific role of biomarker genes involved in the non-small cell lung cancer (NSCLC) and demonstrate their high discrimination power between NSCLC from the normal tissues. So, studying the gene expression differences associated with their network functionality extracted from the serum biomarkers will be a helpful approach in predicting them on small cell lung cancer. Nowadays, several analyses based on bioinformatics and computational methodologies have determined various genes influencing the healthy and diseased cells for achieving a better performance on treatment and prognosis of NSCLC. Although the existing treatments for all stages of lung cancer including surgery, chemotherapy, or radiation did not show reasonable results, achieving better outcomes in the future may be possible through genetic diagnosis as well as gene therapy techniques.

COPD affects all organ systems by inducing chronic systemic inflammation as well as metabolic alterations. Various pharmacological, medical & surgical approaches are available for management of COPD. We can’t ignore the importance of nutrition to promote the sound state of health in all COPD patients. Intake of essential micronutrients in adequate amount as per recommended dietary allowance (RDA) & maintenance of normal body-mass index (BMI) is the fundamental requirement for achieving beneficial effects. Here, in this review, we will discuss all the facts related to the scientific role nutrition plays in the pathogenesis of COPD as well as clinical implications referring to the supplemental benefits of nutrients.

Background: Asthma is a multifactorial genetic disease caused by the interaction between genetic and environmental factors. FokI is a polymorphic site in exon II at the 5’ end of the vitamin D receptor gene locus on chromosome 12q13 and can be identified using the FokI restriction enzyme. It has an extensive promoter region capable of generating multiple tissue-specific transcripts, and lies just downstream from the collagen type II alpha1 gene. Objective: The main aim of this study was evaluation of VDR FokI polymorphism as a biomarker for detection of high-risk persons to express clinical manifestation of asthma, after exposure to environmental triggers. Methods: In the present case-control study, we analyzed FokI polymorphism in 50 doctor confirmed asthmatic patients and 50 healthy controls by Polymerase Chain Reaction (PCR) amplification and Restriction Fragment Length Polymorphism (RFLP). The data were analyzed using SPSS software version 16. Results: The significant differences were observed for the FokI T>C (rs10735810) polymorphism in asthmatic patients in comparison with controls (p<0.001). This relationship exists without considering the sex and age of cases and controls. The significant association of asthma with FokI SNP (single nucleotide polymorphisms) compared with healthy controls, was presented for the first time in the Iranian population. Conclusion: The significant association of asthma with FokI SNP polymorphisms compared with healthy controls, was presented for the first time in the Iranian population. Introducing of this candidate gene can help the development of diagnostic and interventional strategies that are safe, effective, necessary and individualized for asthmatic patients.

Background: Troponin is a specific marker for myocardial necrotic injury. Troponin elevations can also occur in other diseases like chronic obstructive pulmonary disease (COPD) and may be useful to predict mortality. The purpose of the present study was to assess the association between circulating cTnI and prognosis among patients with COPD exacerbation without the overt cardiovascular disease. Methods: In descriptive-analytical cross-sectional study 180 patients admitted to Imam Khomeini hospital with acute exacerbation of COPD were included and cTnI was assayed. Demographic data, clinical symptoms and signs, arterial blood gas, electrocardiogram/ echocardiography, spirometry, hospitalization ward, length of hospital stay and patient’s status including discharge or death were recorded. Results: Among 180 patients, 135 (75%) were men and 45 (25%) were women. Cardiac troponin I was negative in 117 (65%) patients and positive in 63 (35%) patients. The median survival rate was 16±2.80 and 16±4.12 days for troponin positive and negative patients respectively, indicating no significant relationship between survival and the positive or negative of cardiac troponin I. Conclusion: cTnI can be used as a marker to identify high-risk patients during acute exacerbation of COPD.

Background: A shift of cardiac autonomic balance towards sympathetic marks a poor prognosis in several diseases and has also been reported in COPD. Bronchodilators, beta-2 adrenergic agonists and anticholinergic drugs, are the mainstay of treatment of COPD. We hypothesized that drugs belonging to these classes, respectively salbutamol and ipratropium, would cause a sympathetic shift in cardiac autonomic activity as a consequence of their pharmacological actions. Objective: To study the effect of ipratropium and salbutamol on Heart Rate variability in COPD. Methods: Thirty-three stable ex-smoker, inpatient-male COPD patients were included in a doubleblind, placebo-controlled single-dose randomized study. After baseline spirometry, cardiac autonomic activity was measured using Heart Rate Variability (HRV) that yields several measures of parasympathetic and sympathetic activity. The patients randomly received placebo, salbutamol (200μg) or ipratropium (80μg) by inhalation on three consecutive days. After half an hour, HRV measurements and spirometry were repeated. The average heart rate, and various time and frequency domain parameters were obtained using non-parametric Fast Fourier Transform (FFT) algorithm. Results: Ipratropium decreased the resting heart rate by 2.5% while salbutamol increases it by approximately 6%. Salbutamol resulted in a significant decrease in normalized high frequency variability (HFnu), a marker of parasympathetic activity, and increase in normalized low frequency variability (LFnu) that marks sympathetic activity, and the LF/HF ratio indicating a sympathetic shift of autonomic balance. Ipratropium had no effect on HRV parameters. The study shows that a single inhalation of 200 μg salbutamol shifts cardiac autonomic control towards increased sympathetic activity whereas ipratropium does not. Conclusion: Inhalation of salbutamol causes a sympathetic shift in the cardiac autonomic balance.

Background: Granulomatosis with polyangiitis (GPA) which also known as Wegener's Granulomatosis is a rare disease. GPA is a heterogeneous disease that involves different organs with variable severities and a relapsing course. Objective: This study aimed to investigate the demographic data, clinical and laboratory presentations, prevalence of involvement in various organs, therapeutic regimens, response to treatment and relapse rate in Granulomatosis with polyangiitis (GPA) patients in Yazd Province, central Iran. Method: This is a retrospective descriptive study, including 27 patients with definite diagnosis of GPA from 2005 to 2014. Mean duration of follow up was 5 years. Results: Patients mean age was 35.42 years and male/female ratio 1.45. Initially involved organs were lower respiratory tract (40.7%), musculoskeletal system (33.3%) and upper respiratory tract (25.9%). In course of disease upper respiratory tract (74.7%), renal system (66.7%) and lower respiratory tract (62.9%) were the most involved organs. Cytoplasmic anti-neutrophilic cytoplasmic antibodies (cANCA) was positive in 88.8% and perinuclear anti-neutrophilic cytoplasmic antibodies (pANCA) in 18.51% of patients. Erythrocyte sedimentation rate (ESR) was high in 88.8%. Therapeutic regimens included prednisolone and cyclophosphamide were prescribed for induction in most patients (88.8%). Three patients were treated with plasmapheresis due to diffuse alveolar hemorrhage (DAH), and three with Rituximab due to refractory to conventional treatment, successfully. Complete remission was seen in 44.4% and partial remission in 33.3% patients after three months, also in 74.07% and 14.81% of cases after 12 months. Relapse occurred in 66.7% of cases. There was no significant correlation between cANCA and clinical manifestation or outcome in this study. (P value>0.05). Conclusion: In our patients, the involvement of lower respiratory tract was more than the upper part as presentation. However, during the course of disease involvement of the upper respiratory tract was observed more. Administration of rituximab was successful in patients with refractory to conventional therapy.

Mediastinal fibrosis is a rare disease of diverse etiologies, but sometimes idiopathic. Its evolution is progressive and its complications depend on the structures it compresses. Vascular compressions may lead to superior vena cava syndrome, and pulmonary hypertension. Surgery and endovascular treatment may be effective, but often need to be repeated. Systemic treatments, including corticosteroids, have variable responses. We present an original case of mediastinal fibrosis, compressing the superior vena cava, the right pulmonary artery, and upper right pulmonary vein. For a 6 year follow up, the patient did not present pulmonary hypertension but only superior vena cava syndrome which was effectively treated by endovascular stenting. Systemic corticosteroids were not very effective for the improvement of symptoms. Later, the patient was treated with chemotherapy and immunosuppressive drugs for acute myeloid leukaemia. His respiratory, cardiovascular and imaging exams revealed stability which led us to reflect on the possible impact of the immunosuppressive therapy on the evolution of this mediastinal fibrosis.

Aspergillus is an organism responsible for aspergilloma. Massive hemoptysis, which is a life-threatening symptom in a patient with pulmonary aspergilloma, is difficult to treat. Options for definitive treatment include bronchial artery embolization and surgical removal by thoracotomy. We report a 40-year-old housewife with no past medical illness, who presented with recurrent hemoptysis caused by multiple bilateral pulmonary aspergilloma who underwent repeated embolization in combination with systemic antifungal therapy. Prompt diagnosis and bronchial artery embolization was successful in embolizing the feeding vessel; however, it failed to reduce morbidity and mortality caused by recurrent pulmonary hemorrhage.