Current Respiratory Medicine Reviews - Volume 18, Issue 1, 2022

Background: The transplant patients should be considered a main high-risk population during the COVID-19 outbreak due to the use of immunosuppressive regimens and comorbidities. Objective: This study aimed to evaluate the possibility of COVID-19 transmission by liver transplantation from a donor with a late complication of COVID-19 to the recipients. Methods: This descriptive study was conducted on all the recipients of liver transplantation who had an acute liver failure or were the models for the End-Stage Liver Disease (MELD) higher than 20. Results: In general, 36 liver transplantation was performed during the study period. Out of these patients, only 14 cases (deceased donors) had hemorrhagic cerebrovascular accidents, and other donors died of trauma (n=7) and anoxia (n=15). All patients showed negative results for polymerase chain reaction (PCR) (two negative 24 h PCR), whereas their high-resolution computed tomography (HRCT) test revealed that they had previously lung involvement with COVID-19 as the late complication of the disease. Conclusion: This study supports the safety of continuing donation and transplant process during the outbreak even the transplant donor be infected previously with the COVID-19, which is reinforced by other similar pieces of evidence.

Home non-invasive ventilation has become a well-established form of therapy over the last few decades. Many conditions benefit from home NIV, for instance, patients with motor neurone disease (MND) and chest wall deformities that lead to respiratory complications. Home NIV has been shown to increase survival and improve quality of life in many chest wall diseases and MND. There is also substantial evidence to indicate that NIV can palliate symptoms of Obesity Hypoventilation Syndrome (OHS). Also, Home NIV is a valuable tool in the management of patients with severe COPD and has been shown to reduce mortality and morbidity in patients with chronic respiratory failure. However, the usefulness of home NIV varies according to compliance. This review investigates the factors affecting compliance with home NIV. Compliance remains to be an incredibly complex matter. Yet, due to the importance of compliance and its effect on outcomes, investigating influencing variables is a priority.

Evaluation of patients with pectus excavatum has primarily been focused on, especially the pediatric population who undergoes surgical correction of sternal defects mainly for cosmetic reasons combined with exercise-limiting symptoms. The extent of cardiopulmonary improvement in this population based on cardiac imaging, pulmonary function testing, and cardiopulmonary exercise testing may be highly variable. There is no current consensus on the limitations of cardiopulmonary impairment or potential improvement from surgical repair in pediatric patients. Limited data have been published in the medical literature on the evaluation of adults with pectus excavatum who may also present with a variety of clinical symptoms. Adult patients with exercise limitation and pectus excavatum may present with exertional dyspnea, chest discomfort, palpitations/tachycardia, exercise-induced wheezing, and use of bronchodilators for asthma-like symptoms. While numerous published review articles outline clinical evaluation and surgical treatment for younger patients, comprehensive evaluation for these adult patients has not been fully elucidated. There is no current consensus on the underlying cause of cardiopulmonary impairment in adult patients or their potential improvement from surgical repair. This review focuses on the recommended evaluation of adult patients to discern the potential cardiopulmonary limitations to exercise due to pectus excavatum, especially in physically fit adults, such as active-duty military personnel. Two illustrative cases are presented to describe the complexity of the evaluation for adult patients and the potential need for surgical correction.

Background: Acute respiratory failure (ARF) in oncohematologic subjects is one of the most common causes of high mortality rates. Noninvasive mechanical ventilation (NIMV) has arisen as an accessory treatment in this clinical scenario. Objective: This study aimed to compare mortality rates and severity of illness associated with NIMV or invasive mechanical ventilation (IMV) in oncohematologic patients with ARF. Methods: A search was conducted in the PubMed, SCOPUS, Cochrane Library, LILACS, Web of Science, and gray literature databases, published between November 2007 and May 2021. Results: Eight studies with a total of 570 patients were included. Patients with good responses to NIMV showed lower values of the Simplified Acute Physiology Score III (SAPS 3) (range: 42±7 to 53±17) when compared to those intubated following NIMV failure (range: 50±11 to 63.3±17.4) and those who underwent IMV as the primary ventilator support (range: 64.9±17.5 to 66±17). Similarly, patients whose NIMV treatment failed and those that initially used IMV had higher baseline values of Sequential Organ Failure Assessment Score (SOFA) when compared to the group with a good response to NIMV. ICU mortality ranged from 40% to 68% in NIMV success, 54% to 79% in NIMV failure, and from 54% to 80% in the group treated with IMV. NIMV therapy had a significant protective effect on mortality (RR=0.71, 95% CI: 0.53-0.94, p=0.02). Conclusions: NIMV use in oncohematologic patients admitted to the intensive care units (ICU) with ARF was associated with lower mortality. Patients successfully treated in the NIMV group showed lower values of SOFA and SAPS 3 (Prospero Systematic Review -protocol number: 132770).

Background: Transcutaneous partial pressure of carbon dioxide (PtCO2) monitorization provides a continuous and non-invasive measurement of partial pressure of carbon dioxide (pCO2). In addition, peripheral oxygen saturation (SpO2) can also be measured and followed by this method. However, data regarding the correlation between PtCO2 and arterial pCO2 (PaCO2) measurements acquired from peripheric arterial blood gas is controversial. Objective: We aimed to determine the reliability of PtCO2 with PaCO2 based on its advantages, like non-invasiveness and continuous applicability. Methods: Thirty-five adult patients with hypercapnic respiratory failure admitted to our tertiary medical intensive care unit (ICU) were included. Then we compared PtCO2 and PaCO2 and both SpO2 measurements simultaneously. Thirty measurements from the deltoid zone and 26 measurements from the cheek zone were applied. Results: PtCO2 could not be measured from the deltoid region in 5 (14%) patients. SpO2 and pulse rate could not be detected at 8 (26.7%) of the deltoid zone measurements. Correlation coefficients between PtCO2 and PaCO2 from deltoid and the cheek region were r: 0,915 and r: 0,946 (p = 0,0001). In comparison with the Bland-Altman test, difference in deltoid measurements was -1,38 ± 1,18 mmHg (p = 0.252) and in cheek measurements it was -5,12 ± 0,92 mmHg (p = 0,0001). There was no statistically significant difference between SpO2 measurements in each region. Conclusion: Our results suggest that PtCO2 and SpO2 measurements from the deltoid region are reliable compared to the arterial blood gas analysis in hypercapnic ICU patients. More randomized controlled studies investigating the effects of different measurement areas, hemodynamic parameters, and hemoglobin levels are needed.

Background: Chronic obstructive pulmonary disease (COPD) is related to oxidant/antioxidant imbalance and systemic inflammation. Objective: This study was conducted to evaluate associations of serum levels of C-reactive protein (CRP) and malondialdehyde (MDA) with the severity and exacerbations of COPD. Methods: A matched case-control study was performed among 200 COPD patients (100 cases and 100 controls) who were referred to Masih Daneshvari Hospital in Tehran, Iran. Cases were exacerbators with equal to or greater than two ambulatory exacerbations or one hospitalization; controls were non-exacerbators who had one/no ambulatory exacerbation during the preceding 12 months. Blood samples were collected for CRP, MDA, and erythrocyte sedimentation rate (ESR) analysis. In addition, spirometry, the COPD assessment test (CAT) score, the modified Medical Research Council (mMRC) dyspnea scale, and the BODEx index were applied. Results: The mean (SD) age of the patients was 65.31 (8.46) years. Those with exacerbations had significantly lower FEV1 and higher CRP, MDA, ESR, BMI, BODEx index, CAT, and mMRC scores compared to non-exacerbators. There were significant differences in CRP, MDA, ESR, FVC, FEV1, FEV1/FVC, BMI, BODEx index, mMRC, and CAT scores between the GOLD group. Moreover, multivariate analysis showed that higher levels of CRP (OR=0.61, p=0.023), MDA (OR=0.28, p=0.001), ESR (OR=0.86, p=0.029), CAT score (OR=0.84, p=0.012), BODEx index (OR=0.89, p <0.001), BMI (OR=0.42, p <0.001), and lower FEV1% (OR=0.77, p <0.001) were independent risk factors for frequent exacerbations. Conclusion: In conclusion, elevated serum MDA and CRP levels in combination may serve as prognostic indicators of the severity and exacerbation of COPD.

Background: The shorter regimen was widely accepted and advocated for MDR-TB treatment compared tothe conventional longer regimen. Evaluating the performance of both regimens in a programmatic setting will help in tailoring the treatment regimen of MDR-TB. Objectives: To estimate the duration of sputum smear conversion in the shorter MDR-TB regimen. 2. To compare the treatment outcomes of the shorter MDR-TB regimen with that of the longer conventional MDR regimen in a programmatic set up in India. 3. To estimate the adverse drug reactions in the shorter MDR-TB regimen. Methods: A retrospective cross-sectional study was conducted on 320 patients enrolled under programmatic management of drug resistant tuberculosis (PMDT) from April 2017 to May 2019 at a nodal DRTB center and a tertiary care hospital in India. Demographic and clinical characteristics of those who received a shorter MDR-TB regimen were recorded. Treatment outcomes of both regimens were recorded. Treatment success is defined as ‘disease cured and treatment completed’, whereas treatment failure was considered when the treatment was either terminated or changed due to lack of bacteriological conversion at the end of an extended intensive phase or culture reversion in the continuation phase. Results: The treatment success observed in the shorter MDR-TB regimen was 61.25%, which was significantly higher than the conventional longer regimen (p=0.0007). Treatment failures were higher with a shorter MDR-TB regimen (p=0.0001). Conclusion: Treatment success with the shorter MDR-TB regimen though higher than the conventional regimen, is still way behind the target treatment success rate. Improving treatment adherence remains pivotal for achieving end TB targets.

Background: Estrogen receptor beta (ERβ) is a potential target for cancer therapy as a tumor suppressor. Malignant pleural mesothelioma (MPM) is a rare but fatal cancer. This study tries to estimate the incidence of ERβ expression in the various subtypes of MPM tumors. Methods and Materials: In a retrospective study performed at a pulmonary tertiary referral hospital, formalin-fixed paraffin-embedded human tissues of 46 definitive MPM were evaluated for expression of ERβ by immunohistochemistry. Results: ERβ was detected in 14 cases (30.4%) out of the total 46 patients with a mean age of 58.08±11.59 SD, including 33 (71.7%) males. There was no statistically significant difference in patients with positive ERβ staining versus negative cases in age and sex (P >0.05). MPM subtypes included 36 (78.2%) cases of epithelioid mesothelioma, 3 (6.5%) cases of sarcomatoid, 5 (10.8%) cases of biphasic, and 2 (4.3%) cases of desmoplastic subtype. ERβ expression was observed only in epithelioid (11 of total 36 cases) and biphasic (3 of total 5 cases) tumors. There was no significant difference in the incidence of ERβ expression in different subtypes of malignant pleural mesothelioma. Statistical analysis shows a significant difference in the expression of ERβ in the epithelioid subtype (with a more favorable prognosis) versus non-epithelioid subtypes (with poor prognosis, including sarcomatoid, desmoplastic, and biphasic) (P = 0.024). Discussion and Conclusion: Considering the higher proportion of the epithelioid type of MPM with ERβ expression, this highlights the role of ERβ in target therapy of MPM tumor, especially in the epithelioid subtype with a more favorable prognosis. A better understanding of the pathology of mesothelioma will eventually contribute to the development of therapies beyond the existing therapeutic platform.

Background: COVID-19 has been a major concern for people and healthcare systems since its emergence in China in December 2019. Patients with medical diseases are at a higher risk of severe disease development and mortality. Cancer patients are more vulnerable to infections. Several studies demonstrated that COVID-19 is associated with a greater risk of morbidity and mortality among cancer patients. However, the risk factors for mortality among these patients are still unknown. Objective: This study aimed to identify the risk factors associated with in-hospital death among cancer patients with COVID-19. Methods: In this cross-sectional study, we analyzed demographic data, clinical characteristics and laboratory parameters of cancer patients with COVID-19 who were hospitalized in three tertiary referral hospitals in Tehran, Iran from February to May 2020. Diagnosis of COVID-19 was confirmed using real-time polymerase chain reaction testing and computed tomography scan findings. Data analysis was performed using SPSS software, version 20. P-value less than 0.05 was considered significant. Results: Sixty-six cancer patients with COVID-19 were enrolled in this study. Among participants, 35 (53.03%) patients were discharged, and 31 (46.97%) patients died in the hospital. Thirty-two (48.4%) patients suffered from hematologic and 34 (51.6%) from non-hematologic cancers. The most common comorbidities were hypertension (68.18%) and diabetes (56.06%). The most common symptoms among patients were rhinorrhea (59.1%), fever (54.5%), and dyspnea (48.4%), respectively. Diabetes (p= 0.00), hypoxemia (p= 0.005), and receiving chemotherapy or radiotherapy during the last three months (p= 0.022) were associated with a significantly greater risk of in-hospital mortality. Conclusion: Hypoxemia, diabetes, and the time interval between chemotherapy/radiotherapy and hospitalization are associated with a higher risk of in-hospital mortality among cancer patients with COVID-19. These risk factors should be considered in the clinical management of hospitalized COVID19 patients who suffer from cancers. In-hospital mortality and poor outcomes can be minimized by addressing risk factors.

Background: COVID-19 is an infectious disease caused by SARS-CoV-2 and can lead to acute respiratory distress. Objective: We aimed to investigate the association between COVID-19 severity and serum apelin- 17 and inflammatory mediator levels. Methods: This cross-sectional study was conducted on patients with COVID-19. COVID-19 infection was confirmed by the RT-PCR test. The patients' data were extracted from their records. Venous blood samples were obtained from the patients to investigate the serum levels of apelin-17 and inflammatory mediators. Results: Eighty-six COVID-19 patients were studied. The mean age of the participants was 55.56±14.88, and 43 (50 %) were male. Clinical symptoms were dyspnea 77.6 %, fever 52.3 %, cough 48.8 %, gastrointestinal symptoms 15.1 %, and chest pain 7 %. The overall mortality rate was 7 %. No significant relationship was found between serum apelin-17 levels and COVID-19 severity (P= 0.48). However, there was a significant and direct relationship between COVID-19 severity and serum levels of CRP (P= 0.038) and D-dimer (P= 0.029). Conclusion: Serum apelin-17 levels were higher in recovered patients than those who died (4.90 vs. 3.19). Moreover, serum apelin-17 levels were higher in the patients admitted to the general ward than those admitted to the ICU (5.15 vs. 3.98). The difference was not statistically significant. However, there was a significant and direct relationship between serum apelin-17 levels and lymphocyte count (P= 0.022). Moreover, there was a significant and inverse relationship between lymphocyte count and COVID-19 severity (P= 0.004). Therefore, it can be interpreted that COVID-19 severity may decrease with an increase in serum apelin-17 levels. Therefore, to prove this hypothesis, a study with larger sample size is recommended.

Background: The incidence of Simultaneous Bilateral Secondary Pneumothorax (SBSP) occurring as a complication of neoplasm is rare, only <1%. The lungs can be the site for the spread of metastatic osteosarcoma. Methods: We investigated a 16-year-old female who was diagnosed with right distal femur osteosarcoma, pulmonary metastasis, and a rare SBSP complication. Pneumothorax was observed in both sites of pulmonary metastases and bronchopleural fistula on contrasting chest computed tomography. Case Presentation: This pneumothorax is the second one; the previous one was only on one side before chemotherapy. The patient died 12 months after osteosarcoma was diagnosed and four months after SBSP occurred. The progression of osteosarcoma lesions was the cause for the death of the patient. SBSP is the leading cause of severe complications in osteosarcoma. Conclusion: The clinician must perform diagnostic strategies for early detection of osteosarcoma and its proper management, which can reduce a patient’s suffering and impairment of the patient’s quality of life, thus decreasing morbidity and the risk of mortality.