Current Respiratory Medicine Reviews - Volume 15, Issue 4, 2019

Nosocomial pneumonia and nosocomial tracheobronchitis present a significant problem of anesthesiology and critical care medicine. This review presents the results of our own research on the usefulness of new molecular biomarkers in the early diagnosis of nosocomial pneumonia, as well as modern principles for its prevention. A promising direction for the early diagnosis of nosocomial pneumonia and its complications is the study of new molecular biomarkers, in particular, Club cell protein and surfactant proteins. Effective prevention of nosocomial pneumonia should be based on a complex of modern evidence-based methods.

Since 1980, continuous positive airway pressure technology (CPAP) has been one of the most effective treatment methods for obstructive airway disease. About 10 years later, Bi-level Positive Airway Pressure (BiPAP) had been developed with a more beneficial concept. CPAP and BiPAP are the most common forms of noninvasive positive pressure ventilation (NIPPV). CPAP administrates a single, constant, low-pressure air to maintain airway expansion throughout the respiratory cycle, while BiPAP gives high and low levels of pressure; one during inspiration (IPAP) and another during expiration (EPAP) to regulate breathing pattern and to keep airways expanded. Recently, much evidence suggests NIPPV in form of CPAP or BiPAP as a treatment option for Chronic Obstructive Pulmonary Disease (COPD) to improve blood gas abnormality and to reduce mortality rate, as well as to decrease the requirement of invasive mechanical ventilation and hospitalization. A guide for health care professionals released in 2019 has confirmed the use of NIPPV in COPD patients during exacerbation and if combined with obstructive sleep apnea. However, the treatment of stable COPD patients with hypercapnia or post-hospitalization COPD patients due to exacerbation with long term home NIPPV has not yet been adopted. Thus, COPD patient status and the timing of NIPPV delivery should be clearly evaluated. This mini review aims to show the role of NIPPV technology as an additional treatment option for patients suffering from COPD.

Background: Black dust deposited in the lungs is called anthracosis. By damaging bronchial mucosa, anthracosis can affect the mucociliary cleaning function. Initial reports indicate that there is a relationship between anthracosis and pulmonary tuberculosis. Due to obstructive effects of anthracosis on distal airways and disruption in a proper sampling of bronchoalveolar lavage (BAL), other diagnostic methods are necessary for estimating the tuberculosis prevalence in these patients. The aims of this study was to evaluate tissue samples adjacent to an anthracotic plaque for acid-fast bacilli smear and culture. Methods: This is a cross-sectional analysis study on 100 patients referred to Shahid Sadoughi Hospital who required bronchoscopy and anthracotic plaque based on bronchoscopy results. Bronchial fluid lavage, two biopsy samples for culture, and a smear of Mycobacterium tuberculosis from the surrounding of these plaques were prepared. Data analyses were carried out using SPSS (version 18). Results: One-hundred patients og the age range 46-91years were studied. The patients with tuberculosis diagnosis based on the smear of BAL and bronchial tissue samples and culture of BAL and bronchial tissue samples were 7%, 13%, 6% and 8% respectively. The presence of granuloma in histopathology was seen in 15 patients infected with tuberculosis. (Κ > 0.04, p-value <0.05). In patients with positive tuberculosis, culture of bronchoalveolar lavage was superior to other methods. Conclusion: Diagnostic value of BAL method and tissue biopsy in anthracosis patients with tuberculosis did not show a statistically significant difference. As compared with other methods, BAL culture was more positive. Therefore, tissue biopsy is not a good alternative to BAL.

Background: Mechanical ventilation is a life support for ICU patients and is indicated in case of acute or chronic respiratory failure. 75% of patients admitted to ICU require this support and most of them stay on prolonged MV. Tracheostomy plays a fundamental role in airway management, facilitating ventilator weaning and reducing the duration of MV. Early tracheostomy is defined when the procedure is conducted up to 10 days after the beginning of MV and late tracheostomy when the procedure is performed after this period. Controversy still exists over the ideal timing and classification of early and late tracheostomy. Objective: Evaluate the impact of timing of tracheostomy on ventilator weaning. Methods: Single-center retrospective study. Patients were divided into three groups: very early tracheostomy (VETrach), intermediate (ITrach) and late (LTrach): >10 days. Results: One hundred two patients were included: VETrach (n=21), ITrach (n=15), and LTrach (n=66). ITrach group had lower APACHE II (p=0.004) and SOFA (p≤0.001). Total ICU length of stay, and incidence of post-tracheostomy ventilator-associated pneumonia were significantly lower in the VETrach and ITrach groups. The GCS and RASS scores improved in all groups, while the maximal inspiratory pressure and rapid shallow breathing index showed a tendency towards improvement on discharge from the ICU. Conclusion: Very early tracheostomy did not reduce the duration of MV or length of ICU stay after the procedure when compared to late tracheostomy, but was associated with low rates of ventilator-associated pneumonia. Neurological patients benefitted more from tracheostomy, particularly very early and intermediate tracheostomy.

Objective: To determine the effects of a pulmonary rehabilitation program in patients with COPD who use and do not use supplemental oxygen during exercise. Materials and Methods: Prospective longitudinal descriptive study on 59 patients with COPD who were part of a pulmonary rehabilitation program and who were classified into two groups: a group that required supplemental oxygen during rehabilitation and another that did not. Results: 31 patients were linked to the group that used oxygen during rehabilitation and 28 patients who did not use it. The average age was 69.1 ± 10.6 years old. The mMRC dyspnea decreased 0.7 ± 0.2 (p = 0.000) in the group that used oxygen and 0.8 ± 0.1 (p = 0.000) in the group that did not use it. The distance increased 45.9 meters ± 7.2 (p = 0.000) in the group that used oxygen and 65.2 meters ± 16.3 (p = 0.001) in the group that did not use it. Conclusion: Both groups showed significant improvements in dyspnea and aerobic capacity, however, there was a greater increase in the group that did not use oxygen.

Background: Chronic Obstructive Pulmonary Disease is an important cause of morbidity and mortality globally. The onset of pulmonary hypertension and corpulmonale is associated with decreased survival in patients with COPD. Objective: To assess risk factors associated with the development of pulmonary hypertension and corpulmonale and to identify high-risk phenotypes who may need early evaluation and intervention. Methods: Consecutive adult patients with COPD were evaluated for factors influencing the development of pulmonary hypertension and corpulmonale which included symptomatology, hospitalization in the previous year, MMRC dyspnea grade, SGRQ score, 6 minute walk test, ABG, CRP, spirometry and echocardiography. Results: We found Pulmonary Hypertension in 36(30%) patients and 27(22.5%) had corpulmonale. On multivariate analysis, we found PaO2 ≤75 mm Hg and six minute walk test <80% predicted to be significantly associated with the development of Pulmonary hypertension and we found hospitalization in the previous year to be significantly and independently associated with the development of corpulmonale. Conclusion: We observed hospitalization in the previous year was an independent risk factor for the development of corpulmonale and six-minute walk test <80% predicted, PaO2 <75 mm Hg were independent risk factors for the development of pulmonary hypertension.

Objective: The study aimed to evaluate heart rate recovery in subjects with restrictive lung disease (RLD) and healthy age matched subjects before and after a rehabilitation program (RP). Methods: This is a cross-sectional study on subjects of both genders, with over 40 years old with and without any diagnosis of restrictive lung disease and who were able to perform physical tasks were included in the study. They were evaluated for sociodemographic profile, lifestyle (ILP), Framingham score, physical capacity (6MWT and treadmill incremental testing) and heart rate recovery before and after RP. Results: 65 subjects were assigned into either G1 (patients with RLD, n=26) or G2 (healthy subjects, n= 39). Initially, patients with RLD increased their heart rate (HR) from 79 to 120bpm, and after the recovery post-exercise, the first minute they reduced HR by nine beats. In the fifth minute after the exercise, HR returned to baseline values. After the RP, mean HR was 71bpm and 79bpm in G1 and G2, respectively. Increased mean 6MWT peak HR in both the groups was seen (110bpm and 120bpm, G1 and G2, respectively). In the first minute of resting, mean HR decreased to 86bpm (- 24bpm) and 72 (-48bpm) in G1 and G2, respectively. In the fifth minute after exercise, HR recovery in both the groups was complete. Conclusion: The RP was effective in improving the first-minute heart rate recovery in patients with restrictive lung disease and, there was an inverse correlation of heart rate recovery with disease severity.

Allergic Bronchopulmonary Aspergillosis (ABPA) is a common hypersensitivity to Aspergillus sp. that is well described in the literature. The populations most susceptible to developing this reaction are asthmatics and patients with cystic fibrosis (CF). The presenting symptoms can vary as ABPA is rarely described in otherwise normal individuals, however, in patients with an underlying familial predisposition to atopy, it can be seen. This case illustrates the importance of how ABPA can affect a patient who does not fit into a typical phenotypic profile.

Parapneumonic effusions occur commonly in patients hospitalised with pneumonia. Both complicated parapneumonic effusions and empyema are often managed initially with tube thoracostomy and intrapleural t-PA and DNase. If complete expansion of the lung is not achieved, surgical intervention is considered. We present three cases of patients with complicated parapneumonic effusions who experienced complete recovery despite declining surgical intervention and discuss the pitfalls in management. While very few patients have complete radiological resolution at the time of discharge, medical therapy is successful in at least 90% of cases. At 3-6 months from presentation, the radiological findings may improve significantly with antibiotic therapy. Surgery should be considered for patients with non-resolving sepsis markers including elevated temperature, C-reactive protein, and white blood cell count, in addition to non-improving imaging. Incomplete resolution of the parapneumonic effusion should not be considered a treatment failure, and attempts to normalise CT imaging may result in prolonged hospitalisation and unnecessary surgical intervention.