Pulmonary & Respiratory Medicine

Idiopathic pulmonary hypertension (PH) is a diagnosis of exclusion for any patient presenting with pulmonary hypertension (PH). Patient with PH may present with thrombocytopenia along with other signs of PH. We report a case of PH who presented with thrombocytopenia and breathlessness. The possible causes of thrombocytopenia were evaluated and excluded prior to concluding that her thrombocytopenia is due to PH. Various pathogenic mechanisms have been described for thrombocytopenia associated with PH.

We report the case of an 18 year old Japanese girl who suddenly started coughing after eating a piece of bread. Chest radiography revealed an aspirated marking pin used for sewing located in the right main bronchus. Using a flexible bronchoscope and a shortened endotracheal tube, we successfully removed the foreign body without any complications. Our case shows that a flexible bronchoscope can be used after intubation with an endotracheal tube cut to one-third its length to safely remove an aspirated pin.

Background: Noninvasive positive pressure ventilation (NPPV) has been used to treat acute respiratory failure in intensive care units (ICU), while some patients need tracheal intubation because of not only underlying diseases but also delirium. Delirium in patients being mechanically ventilated via endotracheal tubes has been subject to concern and investigated in numerous studies, however in patients receiving NPPV has been little studied. The aim of the study was to discover the incidence of delirium in NPPV patients.

Methods: Adult patients who received NPPV were enrolled. Basic profiles of patients, underlying diseases, indication of NPPV, duration of NPPV, length of stay in ICU, NPPV settings, administration of sedative agents and outcome were collected. Delirium was diagnosed with the Confusion Assessment Method for the ICU (CAM-ICU) by attending nurses.

Results: Forty-three adult patients who received NPPV were enrolled. For all patients, NPPV was applied via full face mask. The diagnosis of 30 patients (69%) was cardiogenic pulmonary edema. Delirium was observed in 16 patients (37%). Patients with delirium were older than those without (78.4 vs. 69.5 years old, p = 0.031). Thirty-one patients (72%) were successfully weaned from NPPV. NPPV failure rate was 38% for patients with delirium and 22% for patients without (p = 0.313). Dexmedetomidine was administered to 26 (61%) patients during NPPV.

A few studies reported the incidence of delirium during NPPV for hypercapnic respiratory failure. We found an incidence of delirium similar to patients with hypercapnic respiratory failure. Dexmedetomidine was most frequently administered because it carried minimal risk of respiratory depression, while we are unable to unconditionally rely on the safety of dexmedetomidine during NPPV.

Conclusions: The incidence of delirium in patients who received NPPV for normocapnic respiratory failure was as high as NPPV for hypercapnic patients. While it was lower than for patients receiving invasive mechanical ventilation.

Background: Illicit drug and substance use exacerbates tuberculosis (TB) pandemic and complicates management of the disease. Cytokines play a crucial role in TB infection, and recreational drugs of abuse present a confounder in the understanding of immunology of TB. Therefore, this review presents an updated summary describing the immunological link between illicit drug use and TB.

Methods: Information was obtained from previous research findings via Medline search (1990-2015) using the headings tuberculosis, drug interactions, cytokine alterations, prevalence of TB and illicit drug use. In addition, Google scholarly articles and PubMed citations were included in our search.

Discussion: Recreational drug induced immunosuppression hastens TB progression among habitual substance users. Additionally, substance consumption in the context of TB infection alters cytokine production and the ensuing immune responses. In this regard, understanding these interactions forms an integral component in improving clinical outcomes among this cohort.

Conclusions: Drug and substance abuse aggravates TB pandemic and remains a hindrance to effective TB diagnostic and therapeutic strategies. As such, poor adherence to TB treatment and interactions with drugs of abuse remain a hallmark for drug resistance that poses a unique setback in the fight against the world epidemic. In addition, substance consumption promotes derangement in inflammatory responses implicated in TB immunopathogenesis. This review necessitates clear identification on contribution of each substance towards TB predisposition and cytokine dysregulation while adjusting for confounders.

Chronic thromboembolic pulmonary hypertension (CTEPH) is one of the leading causes of severe pulmonary hypertension (PH) curable by pulmonary endarterectomy (PEA) necessarily made in the reference centers.

We report the case of a 30-year-old woman with a history of antiphospholipid syndrome diagnosed after a thromboembolic event responsible of her first pregnancy abortion. Two years after this event, she presented a massive and bilateral pulmonary embolism after the delivery of his second pregnancy. She was hospitalized in the intensive care unit and she received thrombolytic treatment relayed by vitamin K antagonists. One year later, she developed progressive dyspnoea (class III NYHA) and hemoptysis.

Ultrasonic cardiography showed severe pulmonary hypertension (Systolic arterial pulmonary pressure at 120 mmHg) and at the right cardiac catheterization (mean arterial pulmonary pressure at 90 mmHg). Computed tomography pulmonary angiogram and ventilation-perfusion lung scan concluded on CTEPH. Blood gases showed a moderate hypoxemia (58 mmHg); conventional treatment was prescribed (oxygen, vitamine K antagonists and diuretics). The patient was referred to the reference surgical center in Paris and a pulmonary endarterectomy was done. After the surgery, the patient reports an improvement of the class of dsypnea and of the sub-maximal aerobic capacity. The systolic pulmonary pressure decreased at 50 mmHg in the ultrasonic cardiography. The patient actually has a better quality of life and rapidly resumed work.

Background: Hypoxemia is the most common complication during one-lung ventilation (OLV). Inverse ratio ventilation (IRV) may lead to intrinsic positive end-expiratory pressure (PEEP) and improve oxygenation in acute respiratory distress syndrome, so we investigated whether volume-controlled IRV with external PEEP could improve hypoxemia, reduce the risk of acute lung injury during OLV.

Methods: Sixty patients undergoing one-lung ventilation for open thoracoctomy were randomly divided into IRV group and control group (n = 30). All patients were initially ventilated with a tidal volume of 8 mL/kg, an inspiratory: expiratory (I:E) ratio of 1:2 and a respiratory rate of 12 breaths/min in 100% oxygen without PEEP. During OLV, lungs were ventilated either with I:E of 2:1 (IRV group) or 1:2 (control group) with an actual tidal volume (VT) 7 mL/kg, respiratory rate 12 breaths/min, external PEEP of 5 cm H₂O. Arterial blood was collected respectively to analyze blood gas before and during OLV. Meanwhile, hemodynamic and respiratory mechanics were monitored. The concentrations of IL-1β, IL-6 and IL-8 in bronchoalveolar lavage fluid (BALF) were measured before and during OLV.

Results: Compared to the control group, partial pressure of arterial oxygen (PaO₂ ), mean airway pressure and dynamic compliance (CL) were significantly higher in IRV group during OLV (P < 0.05). However, plateau pressure (Pplat) and levels of IL-1β, IL-6 and IL-8 in BALF were lower in IRV group than those in control group (P < 0.05).

Conclusion: IRV (I:E = 2:1) applying PEEP could improve hypoxemia, promote oxygenation, and improve dynamic compliance of respiratory system, moreover reduce Pplat and the release of inflammatory cytokines in patients during one-lung ventilation. It is superior to conventional ventilation with PEEP during one-lung ventilation.

Background: The study is aimed at assessing the knowledge level of pneumonia and 23-valent pneumococcal polysaccharide vaccine (PPV23) and attitude toward PPV23 immunization among the elderly people residing in Shanghai, exploring related factors to improve the inoculation of PPV23, and providing evidence for effective intervention strategy to PPV23 uptake.

Methods: A cross-sectional study was conducted in Shanghai. Approximately 12000 household elderly aged 60 years and above from 12 neighborhoods (township) were chosen randomly to complete the questionnaires.

Results: A total of 11972 participants completed the questionnaires, 7414 (61.9%) of the participants knew about pneumonia, 8156 (68.1%) participants knew about PPV23. Of whom, 3649 people were responding to the question about PPV23 vaccination, 1315 (35.6%) were willing to receive PPV23. The awareness rate of PPV23 declined with age increase, and increased with education level and economic income increase. However, the willingness to accept the inoculation of PPV23 reduced by the education level and economic income increase. Over 80% of participants learned about PPV23 through television, posters, informed consents, people they know and physicians. Participants who didn’t know about PPV23 were willing to gain information about PPV23 through physicians, television, people they know, staff in vaccination clinic and informed consents.

Conclusions: The willing to inoculate with vaccine was based on the knowledge. 73.6% of the informants heard about pneumonia and 68.1% of them heard about its vaccine. But they needed further information through physicians, television, people they know and so on. The healthcare providers were the key to promote vaccination, and should be encouraged to play even more important role in the program of inoculation with PPV23 for olders in Shanghai.

Cardiac tamponade after lung resection is a very rare but life-threatening complication. The present case illustrates another of this uncommon complication, wherein the exact mechanism of injury remained undefined. Hemorrhagic cardiac tamponade occurred few hours after left lower lung lobectomy and re-thoracotomy surprisingly revealed that a left coronary artery branch rupture was the cause.

Pulmonary oedema is a common problem seen at emergency treatment unit. Although cardiac causes of pulmonary oedema are so common, noncardiogenic causes are not rare. Sepsis with acute respiratory distress syndrome, fluid overload, expansion pulmonary oedema, hypoalbuminemia and neurogenic are the causes of pulmonary oedema. Here we present a rare homicidal case of pulmonary oedema. We considered presenting this case as many of us may not think or look for it unless we are aware of it.

Background: Patients with severe chronic obstructive pulmonary disease (COPD) are becoming one of the main risk factors for invasive pulmonary aspergillosis (IPA). Furthermore, COPD patients are at a high risk for pulmonary embolism (PE). Both these two conditions, when COPD is concomitant with IPA or PE, carry a poor prognosis. The coexistence of these three fatal diseases is rare.

Case presentation: We report a case of recurrent IPA concomitant with PE in a 76-year-old male with GOLD 4 COPD, who presented as non-specific hypoxemia and dyspnea and did not respond to the antifungal therapy. This case shows that patients should be treated until resolution of all clinical and radiographic manifestations in case of reactivation and that 10 weeks of antifungal therapy may be inadequate. For the treatment failure of antifungals, we presume PE would aggravate ischemia and hypoxia in the fungal-infected tissue, thus limiting the access of antifungal drugs. It deserves further research to improve the efficacy of antifugals in IPA patients concurrent with PE.

Conclusion: A diagnosis of PE should be considered in COPD patients resistant to appropriate therapy such as bronchodilators and antibiotics. On the other hand, physicians should be alert for the relapse of IPA in COPD patients with prior IPA presented as fever and dyspnea not respond to appropriate therapy, and conduct diagnostic procedures promptly.

A case is presented where focus of all investigations centred around a lung cavity which in association hoarseness appeared in all probability a lung cancer after no response to anti tuberculosis chemotherapy. Oxygen desaturation on few steps of walk lead to further work up concluding with diagnosis of pulmonary thromboembolism with cavitary infract and cardiovocal syndrome.

Propionibacterium acnes (P. acnes) have been reported to have an etiologic link with sarcoidosis. A 45-year-old Japanese woman complaining of cough for 1 month presented to our hospital. Chest computed tomography showed an irregular nodular shadow in the right upper pulmonary lobe, a finding suggestive of either pulmonary sarcoidosis or tuberculosis. Biopsy specimens from the pulmonary shadow showed necrotizing granulomas, and there were no other findings from the initial laboratory examinations that could provide a definitive diagnosis. However, immunohistochemical staining using a P. acnes-specific monoclonal antibody revealed small round bodies within the granulomas. Based on these results, we diagnosed the patient clinically with sarcoidosis, and orally inhaled ciclesonide was administered. At a 7-month follow up, the patient had improved clinically and radiologically. The outcome of this case indicates that immunohistochemical evaluation using a P. acnes antibody may be useful for diagnosing necrotizing granuloma.

Auto-titrating positive airway pressure (APAP) devices are an effective treatment alternative for certain patients with obstructive sleep apnea (OSA). In patients with positional sleep apnea and sleep stage dependent OSA, APAP devices may be more preferable than continuous positive airway pressure (CPAP). The myriad of APAP machines currently available employ increasingly sophisticated mathematical algorithms to identify and ameliorate respiratory disturbances. The cardiovascular benefits accrued from consistent CPAP usage still remain to be proven with APAP use. Although a reasonable alternative to CPAP, APAP titration or treatment should not be used in patients in whom OSA coexists with risk factors for central sleep apnea and hypoventilation syndromes.

Aim: Update on efficacy and safety of non-antibiotic therapy for stable non-cystic fibrosis (CF) bronchiectasis.

Methods: Systematic review based on the PRISMA-guidelines.

Results: Fifteen studies (1278 patients) fulfilled the inclusion criteria. Studies (n = 3) suggest that inhaled hypertonic saline may be beneficial in patients with non-CF BE, although possibly not superior to isotonic saline. The effect of hypertonic saline on QoL, lung function, and exacerbation rate has, at best, been inconsistent. Inhaled mannitol (n = 6) affects sputum characteristics, but with no significant effect on exacerbation rate, lung function, or sputum, although it may have an effect on QoL and time to first exacerbation. High-dose inhaled corticosteroids (ICS) (n = 4) reduce sputum volume and eosinophils, possibly due to concomitant asthma, but with no effect on sputum purulence and bacteriology, lung function and exacerbation rate, although it seems to have positive impact on QoL and respiratory symptoms. One study investigating add-on long-acting beta2-agonist to ICS (n = 40) reported an effect on QoL, but no effect on lung function or exacerbation rate.

Conclusion: Airway clearing techniques, including hypertonic saline and mannitol, and asthma controller medication may have beneficial effects in patients with non-CF BE, but only limited evidence suggests an effect on lung function and exacerbation rate.

Pneumonia is the single largest infectious cause of death in children worldwide and a major cause of mortality in the elderly. Tuberculosis (TB) is the leading cause of mortality due to respiratory infection worldwide, killing approximately 1.5 million people each year. It is perhaps not surprising that the bulk of applied research on these high burden diseases has focussed on the development of new vaccines, diagnostic tools, and therapeutic interventions. However, in recent years, it has become apparent that both transmissible diseases contribute to the development of a major non-communicable disease, namely, chronic obstructive pulmonary disease (COPD). The latter chronic illness is emerging as the third largest cause of human mortality worldwide after heart disease and stroke and hence, there is acute interest in understanding its genesis and development. In this review, we examine the evidence that previous lower respiratory tract infectious disease is a contributory factor in the development of COPD. Based on the available data, there is an apparent epidemiological association between pneumonia, TB and COPD in later life. In addition, elements of COPD treatment place patients at a higher risk of presenting with pneumonia or TB. There is now a need to generate a deeper understanding of the interactions between bacterial lung disease and COPD from which new, complementary preventive and co-management strategies can be designed.

New endoscopic technology has advanced the field of bronchoscopy. With these innovations comes the increased price of maintenance and repair, and the current literature offers few interventions for reducing such costs. We identified increased maintenance costs despite standard physician and technician endoscopic training, which warranted further intervention. An on-site visit by an industry provided endoscopy support specialist team provided direct observation and feedback regarding daily operating procedures as well as bronchoscope handling, processing, and storage. Our intervention resulted in subsequent reduction of maintenance costs by 67%. The use of endoscopy support specialists may help identify and implement daily practices that can reduce bronchoscopy maintenance and repair costs when endoscopy units are faced with unexpectedly high maintenance expenditures.