Multidisciplinary Respiratory Medicine最新文献

Background: Eosinophilia is rare but one of the important reasons to refer patients to pneumonological centers. Determining etiology of eosinophilia has practical implications for therapeutic intervention and disease prognosis. The study aimed to determine the role of peripheral eosinophilia in the diagnosis of lung disorders.

Methods: In this retrospective study were included 46 patients diagnosed with peripheral eosinophilia with coexisting respiratory symptoms and/or radiologically detected lung lesions. All patients underwent standard diagnostic procedures, including a detailed clinical history review, physical examination, routine laboratory tests with basal cardiological examinations, and serological tests to detect parasites and allergies. Other procedures carried out depended on the symptoms of each patient. The relation between eosinophil counts in the blood and patients' clinical manifestation was investigated to identify the degree of eosinophilia requiring immediate diagnostic procedures and treatment. Statistical analyses were performed using scientific computation libraries in the Python programming language, SciPy, v. 1.3.1. Briefly, the following tests were used: parametric Kruskal-Wallis H test, an independent t-test, ANOVA, the Shapiro- Wilk test, Fisher's and Chi-squared tests, and the Holm-Bonferroni method.

Results: Severe eosinophilia (≥5,000 cells/μl) was associated with extrapulmonary involvement and constitutional symptoms. Skin, heart, and pleural diseases were more frequent in these patients than in patients with mild or moderate eosinophilia (p=0.010, p=0.040, and p=0.007, respectively), and only these patients showed signs of kidney disease (p=0.006). Vasculitis was significantly more frequent in the severe eosinophilia group (p=0.048) than in the other two groups. In patients with moderate eosinophilia (1,500-5,000 cells/μl), extrapulmonary symptoms were less common, although signs of cardiac involvement were confirmed in 44% of subjects. In this group, vasculitis was the most commonly observed disease (42% of cases). Mild eosinophilia (<1,500 cells/μl) was mainly associated with airway disease. In this group, vasculitis and interstitial lung diseases were identified, but most were not typically connected with eosinophilia.

Conclusions: Identification of peripheral eosinophilia may essentially determine diagnostic procedures in patients with lung disorders and may be a useful indicator of disease etiology.

Background: To evaluate retinal morphological and vascular parameters in patients recently diagnosed with obstructive sleep apnea syndrome (OSAS) and determine the correlation between retinal vascular density and the severity of OSAS.

Methods: We performed a retrospective study on the retinal vasculature of patients with OSAS and age-match healthy controls. OSAS was confirmed by full-night cardiorespiratory polygraphy. Patients were divided into three groups according to disease severity given by apnea-hypopnea index (AHI) i.e., mild, moderate or severe. Retinal thicknesses and vascular density were compared among groups, for both the macula and optic disc. Correlation between vascular density and clinical features were also assessed.

Results: The study included 30 eyes of patients with OSAS and 12 controls. No differences were found regarding retinal thickness in both the macula and the optic disc between OSAS patients and controls. In contrast, significant differences were found in the peripapillary vessel density between groups versus control patients. The greatest difference being between severe OSAS and controls (49.4% ± 2.1 versus 40.4% ± 4.2 respectively, p=0.01). Peripapillary vessel density was found to significantly and negatively correlate with AHI (p=0.02; r= -0.74) and directly correlate with the lowest percutaneous oxygen saturation (p=0.02; r= 0.58).

Conclusions: This study indicates that OSAS is associated with retinal microvasculature impairment, that seems to mainly affect the optic disc. This suggests that microvascular damage increases with the increasing severity of OSAS. As such, prospective trials are needed to clarify if this vascular peripapillary damage precedes glaucomatous optic neuropathy in OSAS patients.

Background: Coronavirus disease 2019 (COVID-19) has become a pandemic. Bacterial superinfections seem to be associated with higher mortality in COVID-19 patients in intensive care units (ICUs). However, details on the prevalence and species distribution of secondary infections are limited. Moreover, the increasing use of dexamethasone may pose an additional risk of superinfections.

Methods: We performed a single-center retrospective study of the clinical and microbiological characteristics of 154 COVID-19 patients admitted to the ICU between March 2020 and January 2021, focusing on bacterial infections, use of antimicrobial agents and dexamethasone therapy.

Results: The median age was 68 years; 67.5% of the patients were men. Critically ill COVID-19 patients were treated with dexamethasone since July 2020 (second wave), which was not common during the first wave of the pandemic. In the dexamethasone group (n=90, 58.4%), respiratory pathogens were detected more frequently, as were multidrugresistant pathogens. The number of patients with polymicrobial detection of respiratory pathogens was significantly increased (p=0.013). The most frequently detected species were Enterobacterales, Staphylococcus aureus, and Aspergillus fumigatus. The rates of bloodstream infections did not differ between the groups. The use of dexamethasone in ICU COVID-19 patients was associated with higher rates of respiratory infectious complications.

Conclusions: Secondary infections are present in a substantial fraction of critically ill COVID-19 patients. Respiratory pathogens were detectable in the majority of COVID-19 ICU patients. The use of dexamethasone poses a potential risk of secondary pulmonary infections. Infectious complications in patients with dexamethasone therapy could be associated with worse outcomes.

Introduction: The aim of this study was to compare the number of the Pediatric Emergency Department (PED) visits for young allergic patients with respiratory or cutaneous symptoms during the first wave of the coronavirus disease 19 (COVID-19) pandemic in 2020 with the same period in 2019, evaluating the percentage of positive cases to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). We carried out a retrospective analysis using data from young patients who visited the PED with cutaneous or respiratory symptoms in the period from 20^th February to 12^th May of the years 2020 and 2019. Data on allergy and COVID-19 nasal swab were also collected. We observed eleven (28.2%) PED visits for allergic patients with respiratory or cutaneous symptoms for the period from 20^th February to 12^th May of the year 2020 and ninety-three (31.8%) PED visits for the same time frame of the year 2019 (p=0.645). Only a two-month-old child out of 39 patients with non-allergic respiratory or cutaneous symptoms resulted positive for SARS-CoV-2. Specifically, we found for all the PED visits: 21 (7.2%) in 2019 vs 2 (5.1%) in 2020 for patients with urticaria/angioedema or atopic dermatitis (p=0.634); 3 (1.0%) in 2019 vs 3 (7.7%) in 2020 for patients with anaphylaxis (p=0.003); 19 (6.5%) in 2019 vs 2 (5.1%) in 2020 for those with asthma (p=0.740); 11(3.8%) in 2019 vs 1(2.6%) in 2020 for those with lower respiratory diseases, excluding asthma (p=0.706); 39(13.4%) in 2019 vs 3 (7.7%) in 2020 for those with upper respiratory diseases (URDs) (p=0.318). We also showed a substantial decrease (~80%) in all PED visits compared with the same time frame in 2019 (absolute number 263 vs 1,211, respectively). Among all the PED visits a significant reduction was mostly found for URDs [155 (12.8%) in 2019 vs 17 (6.5%) in 2020; p=0.045)]. The total number of PED visits for allergic patients with respiratory or cutaneous symptoms dropped precipitously in 2020. It is very tricky to estimate whether it was a protective action of allergy or the fear of contagion or the lockdown or a reduction in air pollution that kept children with allergy from visiting the PED. Further studies are needed to better understand the impact of underlying allergies on COVID-19 susceptibility and disease severity.

Background: Biological drugs have been recognized as a breakthrough in the treatment of severe refractory asthma. This retrospective real-life observational study aims to evaluate the effect of add-on benralizumab on lung function, exacerbation rate, oral corticosteroids (OCS) reduction and asthma control questionnaire (ACQ) score after 52-weeks.

Methods: In this observational study, a cohort of 18 patients with severe eosinophilic asthma (SEA) according to the ERS / ATS and GINA 2020 classifications, with reference to the Pulmonology Unit of the Azienda USL - IRCCS, Reggio Emilia, Italy, were enrolled from 1 September 2019 to 31 August 2020. For each patient, the following data were collected: demographic data (age, sex, age of onset of asthma, history of smoking and atopy); comorbidity; clinical data (lung function, exacerbations, emergency room visits and hospitalizations); asthma control questionnaire (ACQ); biomarkers (blood eosinophil count and total serum IgE); asthma control drugs as high-dose inhaled corticosteroids / long-acting beta-adrenoceptor agonists (ICS / LABA), long-acting muscarinic antagonists (LAMA), leukotriene receptor antagonists (LTRA), theophylline, OCS. The benralizumab 30 mg treatment schedule was based on the currently recommended dosing regimen.

Results: After end-of-treatment (EOT), a complete weaning of all patients from OCS was confirmed. After 26 weeks, the number of exacerbations decreased from 2.90 to 0.05 (p<0.0001), hospitalizations and ACQ score decreased from 3.37 to 0.97 (p<0.0001). At EOT, the number of exacerbations was unchanged, while no hospitalizations had occurred. Overall, lung function markedly improved over the study period. After 52 weeks, the increase in FEV₁ from baseline was 26,8% (p=0.0002). The subset of patients with nasal polyposis (NP) had an increase of nearly 50% (1008 ml) and patients with blood eosinophils count (BEC) greater than 500 cells / μl showed an increase of 68% (1081 ml) in FEV₁ at EOT.

Conclusions: The notable improvement in respiratory function is a significant result in this study and it is much higher than what has emerged to date. This result, together with the OCS sparing effect and the excellent clinical control of asthma, makes benralizumab a reliable and safe therapeutic option for SEA.

Background: Chronic obstructive pulmonary disease (COPD) is a complex, progressive respiratory condition characterized by heterogeneous clinical presentations (phenotypes). The aim of this study was to assess the prevalence of the main COPD phenotypes and match of each phenotype to the most fitting clinical and lung function profile.

Methods: the CLIMA (Clinical Phenotypes in Actual Clinical Practice) study was an observational, cross-sectional investigation involving twenty-four sites evenly distributed throughout Italy. Patients were tentatively grouped based on their history and claimed prevailing symptoms at recruitment: chronic cough (CB, suggesting chronic bronchitis); dyspnoea (possible emphysema components, E); recurrent wheezing (presuming asthma components, A). Variables collected were: anagraphics; smoking habit; history of asthma; claim of >1 exacerbations in the previous year; blood eosinophil count; total blood IgE and alpha¹ anti-trypsin (α¹-AT) levels; complete lung function, and the chest X-ray report. mMRC, CAT, BCS, EQ5d-5L were also used. The association between variables and phenotypes were checked by Chi-square test and multinomial logistic regression.

Results: The CB phenotype was prevalent (48.3%), followed by the E and the A phenotypes (38.8% and 12.8%, respectively). When dyspnoea was the prevailing symptom, the probability of belonging to the COPD-E phenotype was 3.40 times higher. Recurrent wheezing was mostly related to the COPD-A phenotype. Lung function proved more preserved in the COPD-CB phenotype. Smoke; n. exacerbations/year; VR, and BODE index were positively correlated with the COPD-E phenotype, while SpO₂, FEV₁/FVC, FEV₁/VC, and FEV₁ reversibility were negatively correlated. Lower DLco values were highly probative for the COPD-E phenotype (p<0.001). Conversely, smoke, wheezing, plasma eosinophils, FEV₁ reversibility, and DLco were positively correlated with the COPD-A phenotype. The probability of belonging to the COPD-A phenotype raised by 2.71 times for any increase of one unit in % plasma eosinophils (p<0.001). Also multiparametrical scores contributed to discriminate the three phenotypes.

Conclusion: The recognition of the main phenotypes of COPD can be effectively pursued by means of a few clinical and instrumental parameters, easy to obtain also in current daily practice. The phenotypical approach is crucial in the management of COPD as it allows to individualize the therapeutic strategy and to obtain more effective clinical outcomes.

Background: In 2003, the JNC 7 reported obstructive sleep apnea (OSA) as a cause of secondary hypertension. The prevalence of OSA in hypertension ranges from 30-80%. There are limited data on the prevalence and risk factors of OSA in hypertensive patients. This study thus aimed to evaluate prevalence and clinical predictors of obstructive sleep apnea (OSA) in these patients.

Methods: This was a cross-sectional study and conducted at the hypertension clinic at Khon Kaen University's Srinagarind Hospital, Thailand. We enrolled patients with hypertension treated at the clinic. OSA was defined as apnea-hypopnea index of 5 events/hour or over according to cardiopulmonary monitoring. Patients whose hypertension was due to any other causes were excluded. The prevalence of OSA was calculated and risk factors for OSA were analyzed using multivariate logistic regression.

Results: There were 726 hypertensive patients treated at the clinic. Out of those, 253 (34.8%) were randomly studied and categorized as either non-OSA (147 patients, 58.1%) or OSA (106 patients, 41.9%). There were four independent factors associated with OSA-induced hypertension: age, sex, history of snoring, and history of headache. Headache had an adjusted odds ratio (95% confidence interval) of 3.564 (95% confidence interval of 1.510, 8.411).

Conclusion: Age, male sex, history of snoring, and headache were independent predictors of hypertension caused by OSA.

Supporting patients suffering from severe respiratory diseases with mechanical ventilation, obstacles are often encountered due to pulmonary and/or thoracic alterations, reductions in the ventilable lung parenchyma, increases in airway resistance, alterations in thoraco-pulmonary compliance, advanced age of the subjects. All this involves difficulties in finding the right ventilation parameters and an adequate driving pressure to guarantee sufficient ventilation. Therefrom, new mechanical ventilation techniques were sought that could help overcome the aforementioned obstacles. A new mode of mechanical ventilation is being presented, i.e., a Positive + Negative Synchronized Ventilation (PNSV), characterized by the association and integration of two pulmonary ventilators; one acting inside the chest with positive pressures and one externally with negative pressure. The peculiarity of this combination is the complete synchronization, which takes place with specific electronic modifications. The PNSV can be applied both in a completely non-invasive and invasive way and, therefore, be used both in acute care wards and in ICU. The most relevant effect found, due to the compensation of opposing pressures acting on the chest, is that, during the entire inspiratory act created by the ventilators, the pressure at the alveolar level is equal to zero even if adding together the two ventilators' pressures; thus, the transpulmonary pressure is doubled. The application of this pressure for 1 hour on elderly patients suffering from severe acute respiratory failure, resulted in a significant improvement in blood gas analytical and clinical parameters without any side effects. An increased pulmonary recruitment, including posterior lung areas, and a reduction in spontaneous ventilatory rate have also been demonstrated with PNSV. This also paves the way to the search for the best ventilatory treatment in critically ill or ARDS patients. The compensation of intrathoracic pressures should also lead, although not yet proven, to an improvement in venous return, systolic and cardiac output. In the analysis of the study in which this method was applied, the total transpulmonary pressure delivered was the sum of the individual pressures applied by the two ventilators. However, this does not exclude the possibility of reducing the pressures of the two machines to modulate a lower but balanced total transpulmonary pressure within the chest.

Background: In primary care, general practitioners (GPs) and pharmacists are at the frontline to identify, classify and manage patients suffering from allergic rhinitis (AR). The Allergic Rhinitis and its impact on Asthma (ARIA) guidelines aid clinicians in disease management by providing evidence-based recommendations. A recently published ASEAN primary care survey demonstrated that the awareness of ARIA guidelines was high among GPs but notably lower in pharmacists. Hence, this study seeks to evaluate the effectiveness of a Boot Camp education initiative in bridging the unmet needs in pharmacist awareness and education.

Methods: The boot camp was organised as a virtual event. The participants answered the same questionnaire before (pre-assessment) and immediately after (post-assessment) the boot camp session. Statistical analysis was performed on the data paired between the pre- and post- assessments using SPSS v. 25.0 software.

Results: The boot camp survey results showed that second-generation oral antihistamines and allergen avoidance are the most preferred options for AR treatment in pharmacy practice, irrespective of the disease severity. In both pre- and post-assessments, efficacy was ranked as the most important factor considered for choosing an antihistamine and which affects patient adherence. With the boot camp initiative, there was a statistically significant increase in awareness about the patient profiling tool (from 31.6% to 88.2%) and ARIA guidelines (from 40.4% to 91.2%) among the pharmacists (p<0.05). The proportion of pharmacists who were able to identify, classify and refer AR patients was significantly increased in post-assessment (p<0.05). Post the boot camp, among the proportion of pharmacists (91.2%) who were already aware of ARIA, a high percentage of them further agreed that ARIA guidelines were useful in identifying and treating patients with AR, as well as classifying AR, respectively (97.6%, 95.2%, and 93.5%).

Conclusions: Based on improvements in knowledge and understanding of disease management post assessment, the Allergic Rhinitis Boot Camp initiative is effective and relevant to pharmacy practice. Outreach programs like this reiterate the emphasis on patient compliance and importance of utilizing ARIA guidelines in pharmacy practice that facilitates better management of AR in primary care.