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- Predictors of Hospital Admission Two Months after Emergency Department Evaluation of COPD Exacerbation. [JOURNAL ARTICLE]
- Respiration 2014 Sep 10.
Background: Limited information is available regarding the factors related to short-term hospital admission following an exacerbation of chronic obstructive pulmonary disease (eCOPD). Objectives: The aim of this study was to identify variables related to short-term admission in patients with an eCOPD. Methods: This was a prospective cohort study of patients with an eCOPD who attended an emergency department (ED) at 1 of 16 hospitals. Information on possible predictor variables was recorded during the ED stay, 24 h after admission to the hospital or after ED discharge home, and at hospital discharge or 1 week later if discharged home from the ED. An admission after an eCOPD within 2 months was the outcome of interest. Multivariate models were employed for patients admitted to the hospital or discharged home from the ED. Results: For patients discharged home from the ED, eCOPD-related hospital admissions in the previous year [odds ratio (OR) 1.98 and 2.33], pCO2 at ED admission (ORs 2.02 and 2.90), the number of ED visits within 1 week of the index ED visit (OR 5.14) and dyspnea level 1 week after the index ED visit (ORs 2.66 and 1.40) were predictors of short-term admission [area under the curve (AUC) 0.82]. For patients admitted to the hospital during the index ED visit, baseline FEV1% (ORs 1.32 and 1.88), eCOPD-related hospital admissions in the previous year (ORs 1.28 and 2.51), severe baseline dyspnea (OR 2.57) and dyspnea level 1 week after the index ED visit (ORs 2.15 and 1.74) were predictors of short-term readmission (AUC 0.73). Conclusions: Just a few easily recorded parameters may allow clinicians to identify patients at a higher risk of short-term readmission and establish preventive strategies. © 2014 S. Karger AG, Basel.
- Disability and Recovery of Independent Function in Obstructive Lung Disease: The Cardiovascular Health Study. [JOURNAL ARTICLE]
- Respiration 2014 Sep 9.
Background: Chronic obstructive lung disease frequently leads to disability. Older patients may experience transitions between states of disability and independence over time. Objective: To identify factors associated with transition between states of disability and independent function in obstructive lung disease. Methods: We analyzed data on 4,394 participants in the Cardiovascular Health Study who completed prebronchodilator spirometry. We calculated the 1-year probability of developing and resolving impairment in ≥1 instrumental activity of daily living (IADL) or ≥1 activity of daily living (ADL) using transition probability analysis. We identified factors associated with resolving disability using relative risk (RR) regression. Results: The prevalence of IADL impairment was higher with moderate (23.9%) and severe (36.9%) airflow obstruction compared to normal spirometry (22.5%; p < 0.001). Among participants with severe airflow obstruction, 23.5% recovered independence in IADLs and 40.5% recovered independence in ADLs. In the adjusted analyses, airflow obstruction predicted the development of IADL, but not ADL impairment. Participants with severe airflow obstruction were less likely to resolve IADL impairment [RR 0.67 and 95% confidence interval (CI) 0.49-0.94]. Compared to the most active individuals (i.e. who walked ≥28 blocks per week), walking less was associated with a decreased likelihood of resolving IADL impairment (7-27 blocks: RR 0.81 and 95% CI 0.69-0.86 and <7 blocks: RR 0.73 and 95% CI 0.61-0.86). Increased strength (RR 1.16 and 95% CI 1.05-1.29) was associated with resolving IADL impairment. Conclusions: Disability is common in older people, especially in those with severe airflow obstruction. Increased physical activity and muscle strength are associated with recovery. Research is needed on interventions to improve these factors among patients with obstructive lung disease and disability. © 2014 S. Karger AG, Basel.
- One- to Four-Year Follow-Up of Endobronchial Lung Volume Reduction in Alpha-1-Antitrypsin Deficiency Patients: A Case Series. [JOURNAL ARTICLE]
- Respiration 2014 Sep 11.
Background: Lung volume reduction surgery can improve lung function and working capacity in severe heterogeneous emphysema. Endobronchial lung volume reduction (ELVR) performed by one-way valves inserted via a flexible bronchoscope can result in a moderate but significant improvement in lung function and exercise tolerance, eliminating the surgical risks. Objectives: Most studies of this method have excluded patients with α1-antitrypsin (AAT) deficiency, but small series of cases with positive short-term outcome have been reported. The sustainability of results has been questioned and we here present our experience in AAT-deficient patients treated with ELVR followed up for up to 4 years. Methods: From August 2008 to January 2012, 15 patients were treated with ELVR. Inclusion criteria were homozygotic AAT deficiency, age <80 years, residual volume of 140% or more, forced expiratory volume in 1 s (FEV1) 15-45% of predicted, severe heterogeneous emphysema, symptoms severely restricting daily life, informed consent and absence of other serious diseases. Results: One patient coughed up valves after 2 months, 1 developed pneumothorax and had valve displacement and subsequent removal, and 1 improved from an FEV1 of 0.62 to 0.84 liters, but after 4 months developed repeated and severe pneumonia and the valves had to be removed. Thus, 12 patients remained and were followed up for at least 1 year. In these patients, FEV1 increased (mean: 54%), the quality of life was much improved, and 2 patients could be taken off oxygen therapy. During the 4-year follow-up, patients demonstrated no significant deterioration in lung function. Conclusion: In carefully selected AAT deficiency patients with severe emphysema, ELVR can be safely performed with encouraging long-lasting results. © 2014 S. Karger AG, Basel.
- Cardiopulmonary and Gas-Exchange Responses during the Six-Minute Walk Test in Patients with Chronic Obstructive Pulmonary Disease. [JOURNAL ARTICLE]
- Respiration 2014 Sep 9.
Background: The 6-min walk test (6MWT) is representative of daily life activities and reflects the functional capacity of patients with chronic obstructive pulmonary disease (COPD). Information on the cardiopulmonary and gas exchange responses to the 6MWT is limited. Objectives: We aimed to analyze the breath-by-breath cardiopulmonary and gas exchange responses of patients with COPD during the 6MWT. We also investigated the extent to which parameters reflecting cardiopulmonary and gas exchange function are associated with exercise capacity. Methods: The oxygen uptake (VO2) kinetics of patients were obtained using mobile telemetric cardiopulmonary monitoring during a 6MWT. A new mean response time (MRT) index was developed to quantify VO2 on-kinetics by correcting MRT for work rate (wMRT). Multiple linear regression analysis was performed to assess the association between variables reflecting cardiopulmonary and gas exchange function and exercise capacity [6-min walking distance (6MWD) and VO2 at steady state (VO2SS)]. Results: In 72 COPD patients (29 females) with a mean (SD) age of 65 (10) years, FEV1 44 (14) % predicted exercise capacity as assessed by VO2SS (p = 0.003) was significantly reduced across the stages of COPD. The criteria for maximal effort during the 6MWT were fulfilled by 82% of the patients. After adjustment for covariates, wMRT was independently associated with 6MWD (p = 9.7 × 10(-5)) and VO2SS (p = 5.5 × 10(-10)). Conclusions: As wMRT mostly depends on the rate of increase of pulmonary blood flow, our results underline the fact that cardiocirculatory function may play a significant role in exercise tolerance in patients with COPD. Our findings imply that modification of cardiocirculatory function may be beneficial in the treatment of COPD patients and improve their outcome more than anticipated previously. © 2014 S. Karger AG, Basel.
- Never Change a Winning Team: Patient and Inhalation Device. [JOURNAL ARTICLE]
- Respiration 2014 Sep 4.
- Diagnosis of Pulmonary Embolism: Conventional Ventilation/Perfusion SPECT Is Superior to the Combination of Perfusion SPECT and Nonenhanced CT. [JOURNAL ARTICLE]
- Respiration 2014 Aug 30.
Background: Ventilation/perfusion single-emission photon CT (V/P-SPECT) is widely used to detect pulmonary embolism (PE). Any pathological deficit on P-SPECT with a corresponding unremarkable V-SPECT is considered an embolism. This means that a deficit on P-SPECT with a corresponding deficit on the ventilation scan correlates with other lung pathologies such as pneumonia, bullous emphysema or tumor. In principle, it is possible to identify any of these lung pathologies on nonenhanced chest CT and so this technique has the potential to replace V-SPECT in the diagnosis of PE. Today, SPECT/CT hybrid imaging systems are increasingly applied in clinical routines. Objectives: We investigated whether embolism can be diagnosed using a combined P-SPECT/CT hybrid imaging approach without V-SPECT. Methods: Ninety-three patients with clinically suspected embolism were investigated with standard V/P-SPECT and a nonenhanced CT scan on a combined SPECT/CT system. A diagnosis of embolism was based on V/P-SPECT (gold standard). P-SPECT/CT datasets were blinded and analyzed without any knowledge of the V-SPECT data. The accuracy of P-SPECT/CT was compared to the gold standard. Results: Embolism was diagnosed in 24/93 patients using V/P-SPECT. In total, 57 lung lobes were affected. P-SPECT/CT significantly (p < 0.01) overdiagnosed embolism in nonaffected patients. In total, 36 cases with 88 affected lung lobes were shown. The sensitivity was 95.8%, the specificity 82.6%, the false-negative rate 4.2% and the false-positive rate 17.3%. Conclusions: Our results demonstrate that a nonenhanced CT scan in a novel hybrid imaging system cannot replace V-SPECT in the scintigraphy-based diagnosis of PE. V-SPECT increases specificity and reduces the number of false-positive results when compared to 'perfusion-only' SPECT/CT. © 2014 S. Karger AG, Basel.
- The Importance of Continuity in Inhaler Device Choice for Asthma and Chronic Obstructive Pulmonary Disease. [JOURNAL ARTICLE]
- Respiration 2014 Aug 29.
Inhaled therapies are central to the treatment of asthma and chronic obstructive pulmonary disease. Physicians consider many factors when selecting the most appropriate inhaler device, including device efficacy and the cost to the health care system. This review aims to discuss the factors that are important when considering inhaler devices and the importance of continuity in the choice of inhaler device. A large number of factors can contribute to therapeutic outcomes with inhalation devices. The inhalation technique is critical to treatment success and differs substantially between inhaler devices. Misuse of an inhaler is common, and thorough training of patients and physicians is important to ensure correct utilization. Patient satisfaction is an important consideration because it is significantly correlated with compliance and better outcomes. Financial pressures contribute to decision making: although selecting the less expensive inhaler device might reduce direct treatment costs, it can have a large impact on disease control and the patient's well-being. Switching may be associated with a poor inhalation technique, reduced disease control and quality of life, increased use of other treatments and health care resources, and a greater chance of unsuccessful treatment. Nonconsensual switches can result in patient discontent, reduced confidence in the medication, and uncertainty regarding the degree of disease control. It is recommended that patients with stable disease remain on their current device. If a switch is considered, the patient should be consulted and the physician should take into account the patient's preference, their ability to correctly use the device, and the availability of the preferred drug in the preferred device. © 2014 S. Karger AG, Basel.
- Sniff Nasal Inspiratory Pressure in Patients with Moderate-to-Severe Chronic Obstructive Pulmonary Disease: Learning Effect and Short-Term Between-Session Repeatability. [JOURNAL ARTICLE]
- Respiration 2014 Aug 30.
Background: Sniff nasal inspiratory pressure (SNIP) is a non-invasive measure of inspiratory muscle function often used as an outcome measure in clinical studies. An initial period of familiarisation with the test is recommended to minimise the learning effect. The repeatability of SNIP in patients with chronic obstructive pulmonary disease (COPD) is currently unknown. Objectives: The aim of this study was to assess the between-session repeatability of SNIP over a 3-week period in moderate-to-severe COPD patients and compare it with that of maximal inspiratory (PImax) and expiratory pressure (PEmax). Methods: Twenty-one patients (13 males) with a mean forced expiratory volume in 1 s (FEV1) of 38% of predicted (SD: 15) and FEV1/forced vital capacity of 34.3% (SD: 10.4) performed SNIP and PImax and PEmax manoeuvres on 3 different sessions (S1, S2 and S3) 3-7 days apart. SNIP was performed at functional residual capacity (FRC), and PImax was performed at FRC and at residual volume (RV) to explore volume-dependent differences in the learning effect between sessions and PEmax from total lung capacity. Results: The intra-class correlation coefficient (ICC) for SNIP was the highest of the three measures: S1-S3 ICC (95% CI) SNIP: 0.96 (0.88-0.94); PImax at FRC 0.82 (0.63-0.92); PImax at RV: 0.89 (0.78-0.95), and PEmax: 0.96 (0.92-0.98), and had the lowest mean change between sessions [mean S2 - S1: 2.1(p = 0.4) and S3 - S2: -0.3 (p = 0.9)]. Conclusions: SNIP is repeatable over a period of 3 weeks in medically stable, moderate-to-severe COPD patients. In our study, 2 sessions were adequate to learn how to perform the test. © 2014 S. Karger AG, Basel.
- Leukotriene Receptor Blockade as a Life-Saving Treatment in Severe Bronchopulmonary Dysplasia. [JOURNAL ARTICLE]
- Respiration 2014 Aug 30.
Background: Bronchopulmonary dysplasia (BPD) is a major cause of mortality and morbidity in infants with an extremely low birth weight. Because there is no effective therapy, the mortality of this condition in severely affected patients is high. Therapeutic blocking of the leukotriene system seems to be a logical approach due to the known pathophysiology of BPD. Objectives: The aim of this study was to examine the therapeutic effect of montelukast in preterm children suffering from severe BPD. Methods: We performed an unblinded, prospective trial including infants born between 23 and 27 weeks of gestation suffering from severe BPD. The study drug was montelukast (1 mg/kg of body weight as a single dose daily in the 1st week of therapy, increasing to 1.5 mg/kg of body weight in the 2nd week and finally to 2 mg/kg of body weight in the 3rd week). Treatment was continued until the radiological signs and the clinical symptoms of BPD disappeared or the patient was discharged from the hospital. Each patient included in this study was matched for gestational age, birth weight, and pulmonary severity score to a control. Results: Until March 2014, a total of 22 infants were enrolled into the study. The rates of the primary outcome differed significantly between the montelukast-treated group and the control group. All but 1 of the children in the treatment group survived (91%), whereas 7 of the 11 children in the control group died (survival rate 36%; p = 0.002 using Fisher's exact test). The mean mechanical ventilation time (41.2 ± 25.3 vs. 103.7 ± 90.6 days) was significantly shorter and the mean preterm complication score (3.0 ± 1.7 vs. 5.6 ± 1.4) was significantly lower in treated patients compared to the control group. (p = 0.05 for both items; Wilcoxon's matched-pairs test). Conclusion: Based on the clinical observations, the statistical results, and the relatively low risk of the study drug montelukast, we recommend using this treatment in severe cases of BPD for infants facing a high risk of death. © 2014 S. Karger AG, Basel.