EDITORIAL
The aim of this study was to investigate a role of impulse oscillometry (IO) for detection of mild bronchial obstruction.
Methods. The study involved 87 patients with different respiratory diseases. Bronchial obstruction according to spirometry results was found in 50 patients (the study group). The control group patients did not demonstrate any abnormalities in spirometry, body plethysmography and lung diffusing test.
Results. An abnormal increase in frequency-dependent resistive component of respiratory impedance (Rrs) at the oscillation frequency of 5Hrz and 10 Hrz [both the relative oscillation frequency (Rrs5–Rrs20)/Rrs20 and the absolute oscillation frequency (Rrs5–Rrs20)] was found in patients with mild bronchial obstruction. The resonance frequency (fres) shifted towards higher frequency; reactance area (AX) increase and expiratory airflow (DXrs5) limitation were also found in those patients. Rrs5, Rrs20, and the reactive resistance (Xrs5) were within the normal range.
Conclusion. Rrs5 и Xrs5 could detect mild bronchial obstruction only in 32 % of the cases. AX is more useful parameter as it increased in 64% of the patients. The severity of bronchial obstruction diagnosed with IO or spirometry was not identical in some cases.
CLINICAL GUIDELINES
Adopted from: Fan E., Del Sorbo L., Goligher E.C., Hodgson C.L., Munshi L., Walkey A.J., Adhikari N.K.J., Amato M.B.P., Branson R., Brower R.G., Ferguson N.D., Gajic O., Gattinoni L., Hess D., Mancebo J., Meade M.O., McAuley D.F., Pesenti A., Ranieri V.M., Rubenfeld G.D., Rubin E., Seckel M., Slutsky A.S., Talmor D., Thompson B. T., Wunsch H., Uleryk E., Brozek J., Brochard L.J. An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome. Am. J. Respir. Crit. Care Med. 2017; 195 (9): 1253–1263. DOI: 10.1164/rccm.201703-0548ST
The aim of this guideline is to provide clinical recommendation on the use of mechanical ventilation in adult patients with acute respiratory distress
syndrome (ARDS).
Methods. This guideline is based on systematic review and metaanalysis of available literature on the use of mechanical ventilation in adult patients with ARDS.
Results. All patients with ARDS should be mechanically ventilated with the use of lower tidal volumes (4–8 ml/kg predicted bodyweight) and lower inspiratory pressures (plateau pressure, 30 cm H2O). In severe ARDS, the prone positioning for more than 12 h/d is strongly recommended. In patients with moderate to severe ARDS, routine use of high-frequency oscillatory ventilation is not recommended; a conditional recommendation has been developed for the use of higher positive end-expiratory pressure and recruitment maneuvers. CuОР – ently, there is not enough evidence for the use of extracorporeal membrane oxygenation in patients with severe ARDS.
Conclusions. Practical recommendations on selected methods to coОР – ect ventilation disturbances in adult patients with ARDS have been developed. Clinicians involved in the management of patients with ARDS should use personalized approach to the treatment of these patients.
ORIGINAL STUDIES
The objective of this study was to describe pharmacological management (including different schemes of glucocorticoid therapy) of patients with severe and very severe COPD, management of acute exacerbation of COPD (AECOPD) and causes of change in the therapy.
Methods. This was an observational multicenter descriptive study. The study involved 1,029 patients admitted to a hospital due to AECOPD. Demographic, social and economic data and patients’ distribution to clinical phenotypes according to the Czech classification, history of COPD, serious comorbidity, pharmacotherapy for COPD, smoking status, occupational history, health status and quality of life were analyzed.
Results. Phenotypes of chronic bronchitis and of frequent exacerbator were the most common. There were 795 patients (77.26%) with stage 3 COPD and 234 patients (22.66%) with stage 3 COPD in the population involved. About 95% patients were treated in line with GOLD, 2014. Three months after hospital discharge, therapy with inhaled corticosteroids (ICS) was changed in 89 patients (10.45%), mostly due to an acute exacerbation of COPD (about 29%), followed by a high cost of the drugs (25.4%) and non-reimbursable drugs (21%).
Conclusion. Pharmacological therapy was guideline-adherent in majority of patients with severe and very severe. ICS as single therapy or in fixed combinations with long-acting beta-agonists comprised a significant part of treatment in those patients. Therapy was change during 12 months after hospital discharge in 59% of patients.
The aim of this study was to analyze the possibility of inhaled drug substitutions.
Methods. The authors analyzed spontaneous reports from the Federal database of adverse events associated with switching a patient from the reference ipratropium bromide/fenoterol combination to a generic one.
Results. The drug substitution within one INN was reported in 15% of all reports about adverse events related to prescription of this INN. A great deal of these reports was related to drug substitution in elderly. Generally, the reference drug was well tolerated, but its substitution to a generic drug resulted in lower efficacy (18.8%) or development of adverse events, mostly respiratory (51.8% of all adverse events).
Conclusion. The inhaled drug substitution could be associated with a potential risk of adverse events or lower efficacy. The substitution of inhaled drugs within one INN should be made with caution.
This study was designed to compare results of pharmacoepidemiological analysis of antibacterial therapy in patients with community-acquired pneumonia (CAP) admitted to hospitals of Nizhniy Novgorod.
Methods. Data for analysis were obtained from medical records of all patients with CAP (n = 117; 51.3% were males) admitted to two city hospitals in 2015 and 2016. Therapy of CAP was in agreement with corresponding standards. We analyzed real drug utilization using the defined daily dose (DDD) and drug utilization accounting for 90% of the total amount of DDD prescribed (DU90%).
Results. Penicillinase-resistant penicillins, the 3rd generation cephalosporins and fluoroquinolones were the most often prescribed antibiotics in hospitals. The highest number of DDD was for ceftriaxone (376.0 g) in the hospital 1 and levofloxacin (468.16 g) in the hospital 2. The drugs constituting 90% of the prescription volume for inpatient therapy of CAP were ceftriaxone (46.09%), levofloxacin (20.0%), azythromycin (9.19%), and ciprofloxacin (9.19%) in the hospital 1 and ceftriaxone (16.50%), levofloxacin (71.19%), and ertapenem (4.70%) in the hospital 2. In the hospital 1, the cost of one DDD in DU10% segment (982.12 RUB) was 4-fold higher than that in DU90% segment (200.0 RUB); this suggests that inexpensive drugs were predominantly used in the hospital 1. In the hospital 2, DU10% consisted of two drugs accounting 24.56% of the total prescriptions. The cost of one DDD in DU90% segment (6 022.88 RUB) was 1.9-fold higher than that in DU10% segment (3 166.73 RUB); this suggests that more expensive antibiotics were widely used in the hospital 2.
Conclusion. The strategy used in the hospital 2 is recommended according to the study results. The initial therapy with a single antibiotic could significantly reduce the drug load for the patient. Addition of the second antibiotic to the treatment was needed in 15% only, though patients were admitted to a hospital after the treatment failure both in ambulatory settings and in other hospitals.
This was an observational prospective cohort study of safety and efficacy of mucolytic therapy with inhaled combination of 7% hypertonic saline (HS) and 0.1% hyaluronic acid (HA) in patients with cystic fibrosis (CF). The treatment duration was 4 weeks, the follow-up of patients was continued up to 8 weeks. Methods. The study involved 74 CF patients aged > 12 years. A comparative analysis of respiratory function, patients’ satisfaction with therapy, and efficacy and safety of 4-wk treatment was performed in groups of patients treated with 7% HS (n = 33) or HA (n = 41). Changes in patients’ status (n = 41) were assessed after 8 weeks. Results. The forced expiratory volume for 1 sec (FEV1) increased by 5.8% (p = 0.037) after 4-wk therapy with HA and additionally increased by 5.5% (p = 0.020) in 8 weeks after starting the treatment; the total growth in FEV1 during the study was 11.3% (p < 0.001). FEV1 did not improve in the HS group. Nasal and ear congestion, mucus in the throat or in the chest (62.9% vs 83.9%; p = 0.0014), appearance or worsening of cough (68.8% vs 93.8%; p < 0.0001), sore throat (43.8% vs 68.8%; p = 0.0006); unpleasant taste (29.4% vs 43.8%; p = 0.0398), and balance disorder (12.5% vs 3.1%; p = 0.0317) significantly differed between the groups. Conclusion. HA was better tolerated compared to HS in CF patients. One-month therapy with HA could decrease frequency and severity of sore throat, cough and nasal congestion in CF patients. Prolonged treatment with HA for 2 months was associated with improved tolerability of the drug and significant increase in FEV1.
The aim of this study was to identify predictors of poor outcomes in patients hospitalized for severe acute exacerbation of COPD (AECOPD).
Methods. This retrospective, observational cohort study was conducted in Pulmonology Department of a city hospital in 2015 – 2016 and involved patients hospitalized for severe AECOPD. Patients were divided according to outcomes. Poor outcomes included at least one of the followings: the need in invasive (IMV) or non-invasive (NIV) ventilation, admission to ICU, in-hospital death and COPD- related readmission during 2 months. Demographic, clinical, laboratory parameters, pulmonary function tests and blood gas analysis were analyzed; different multidimensional prognostic scores were also evaluated and compared.
Results. Of 121 patients included, a poor outcome had occurred in 45 patients (37%). Among them, NIV was required in 21 (17%), IMV in 8 (6%), and admission to ICU in 16 patients (13%); death was registered in 6 patients (5%) and readmission in 27 (22%) of the patients. Patients with poor outcomes were admitted more frequently by ambulance (62% vs 40%; p = 0.003), more often were admitted to a hospital for AECOPD in the previous year (69% vs 45%; p = 0.0006), and had lower pH (p = 0.001), lower PaO2 (p = 0.001), higher PaCO2 (p = 0.001), and a worse score on several prognostic scales such as APACHE II (13.9 ± 5.4 vs 7.8 ± 3.6; p = 0.001), DECAF (2.4 ± 0.6 vs 1.5 ± 0.6; p = 0.001), BODEx (5.6 ± 1.8 vs 3.9 ± 1.1; p = 0.001), DOSE (2.9 ± 1.5 vs 2.2 ± 1.2; p = 0.029), and ADO (4.9 ± 1.5 vs 4.3 ± 1.3; p = 0.015) at admission. They more frequently received O2 therapy (87% vs 46%; p = 0.001) and had longer hospital stay (19.2 ± 6.2 days vs 12.5 ± 1.8 days; p = 0.001).
Conclusions. Hypercapnia, hypoxemia and worse prognostic scores on admission predicted poor outcome in patients hospitalized for AECOPD during the previous year.
The aim of this study was to investigate body composition in patients with COPD using two methods, Quételet index and bioelectrical impedance analysis (BIA), and to compare their diagnostic values.
Methods. The study included 198 patients with COPD admitted to the Territorial Teaching hospital No.2, and 28 healthy volunteers. According to COPD severity, patients were divided into 4 groups; healthy volunteers (n = 28) were included in the control group. All groups were matched for sex and age. Anthropometry with body mass index (BMI) calculation and BIA were done in all participants.
Results. The lowest average BMI was found in patients with severe and very severe COPD. Patients with infrequent exacerbations without decreased BMI had reduction in fat-free mass (FFM) in 12.3% (n = 25); 14.1% patients (n = 28) had increased body fat mass and decreased FFM. According to BIA results, reduction of FFM was seen significantly more often than reduction of BMI (57.6% vs 30%; χ2= 58.71; p = 0.03). BIA parameters describing muscle tissue were significantly related to the severity of bronchial obstruction (FEV1).
Conclusion. Investigation of body composition using BIA method should be used as a tool for comprehensive examination of COPD patients, for personalized choice of treatment and in rehabilitation programs.
LECTIONS
Cough is one of the most common causes of seeking the primary medical care, especially during the autumn and the spring. This article is a review of literature aimed at differential diagnosis of possible causes of acute cough in children and adults. Given a vast majority of diseases associated with cough, differential diagnosis have to consider several issues. The key issue is cough duration and possible anatomical location of the pathological changes. An algorithm of differential diagnosis of acute cough in children and adults and description of most common diseases associated with acute cough are given in the review. Further diagnostic work-up should be driven by the duration of cough as soon as the acute cough could be first manifestation of a chronic disease.
REVIEW
Acute exacerbation of idiopathic pulmonary fibrosis (AE-IPF) is defined as an acute clinically significant respiratory deterioration characterized by evidence of new, widespread alveolar abnormalities, such as diffuse bilateral ground-glass opacification and/or consolidation, and the absence of other obvious clinical causes like fluid overload, left heart failure, or pulmonary embolism, etc. AE-IPF is subcategorized as “triggered” (where specific causes are identified, for example, infections, surgery procedures, drug toxicity, etc.) or “idiopathic” (where no specific causes are identified). In randomized trials, the annual incidence of AE-IPF is about 8%, in retrospective studies it reaches 19%. Severe forms of IPF are an important risk factor for the development of AE-IPF. In-hospital mortality from AE-IPF is more than 50%, and the average survival of patients with AE-IPF is 1–4 months. Currently, there remain no proven, effective therapies for AE-IPF. In real clinical practice patients with AE-IPF still receive high doses of systemic corticosteroids and antibiotics. Antifibrotic therapy can reduce the risk of exacerbations; it has been shown that therapy with nintedanib leads to a reduction in the number of confirmed/suspected AE-IPF by 68%. It is necessary to further study the potential methods of prevention and therapy of AE-IPF in future clinical trials.
Thiamphenicol glycinate acetylcysteinate (TGA) is a combination of thiamphenicol, a broad-spectrum antibiotic, and mucolytic drug N-acetylcysteine. This article is a review of pharmacological, microbiological, and clinical effects of this combined drug. Inhaled TGA could be considered as a worthy alternative for oral mucolytics and oral antibiotics in treatment of upper and lower airway diseases, such as acute and chronic rhinosinusitis, otitis media, tonsillitis, acute bronchitis, and acute exacerbation of chronic bronchitis and chronic obstructive pulmonary disease, in children and adults.
PRACTICAL NOTES
Interstitial changes in the lungs could be caused by vast majority of diseases including tuberculosis, sarcoidosis, hypersensitive pneumonitis, metastatic injury of the lungs, etc. Differential diagnosis of pulmonary dissemination remains an urgent and challenging clinical task. This article is a review of published literature and presentation of a clinical case of a patient with interstitial lung disease. The case demonstrates diagnostic difficulties in identification the cause of interstitial lung injuries. Interstitial lung injury was incidentally found in this patient and initially was considered as disseminated pulmonary tuberculosis. In-depth diagnostic work-up including lung tissue biopsy allowed diagnosis of lymphoid interstitial pneumonia associated with common variable immune deficiency. This case demonstrates common misdiagnosis of pulmonary tuberculosis in a patient with interstitial lung injury.
An autopsy case of a female patient of 65 years old was reported in the article. This case demonstrated clinical and anatomical features of chronic generalized sarcoidosis with predominant lesion of the lungs (extended bilateral fibrosis) and the kidneys (interstitial nephritis with segmental glomerulosclerosis). Long-term steroid therapy resulted in a significant slowing progression of the disease. This case was characterized by a prominent vasculitis which caused the misdiagnosis of ANCA- associated polyangiitis. Severe anemia and secondary immunodeficiency that were partially druginduced due to the long-term steroid therapy were other manifestations of this disease. The advanced disease was complicated by lower respiratory tract infection, acute respiratory distress-syndrome, and multiple organ dysfunction that caused the patient’s death. A comprehensive pathological investigation including immunohistochemistry had the crucial role for the final diagnosis.
CARRENT EVENTS. INFORMATION
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