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Intensive care unit admission in chronic obstructive pulmonary disease: patient information and the physician's decision-making process.

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Intensive_Care_Unit-2ICU admission is required in more than 25% of patients with chronic obstructive pulmonary disease (COPD) at some time during the course of the disease. However, only limited information is available on how physicians communicate with COPD patients about ICU admission.

METHODS: COPD patients and relatives from 19 French ICUs were interviewed at ICU discharge about their knowledge of COPD. French pulmonologists self-reported their practices for informing and discussing intensive care treatment preferences with COPD patients. Finally, pulmonologists and ICU physicians reported barriers and facilitators for transfer of COPD patients to the ICU and to propose invasive mechanical ventilation.

RESULTS: Self-report questionnaires were filled in by 126 COPD patients and 102 relatives, and 173 pulmonologists and 135 ICU physicians were interviewed. For 41% (n = 39) of patients and 54% (n = 51) of relatives, ICU admission had never been expected prior to admission. One half of patients were not routinely informed by their pulmonologist about possible ICU admission at some time during the course of COPD. Moreover, treatment options (that is, noninvasive ventilation, intubation and mechanical ventilation or tracheotomy) were not explained to COPD patients during regular pulmonologist visits. Pulmonologists and ICU physician have different perceptions of the decision-making process pertaining ICU admission and intubation.

CONCLUSIONS: The information provided by pulmonologists to patients and families concerning the prognosis of COPD, the risks of ICU admission and specific care could be improved in order to deliver ICU care in accordance with the patient's personal values and preferences. Given the discrepancies in the decision-making process between pulmonologists and intensivists, a more collaborative approach should probably be discussed.

Pharmacological Treatment of Depression in Older Patients with Chronic Obstructive Pulmonary Disease: Impact on the Course of the Disease and Health Outcomes.

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Over 40 % of older chronic obstructive pulmonary disease (COPD) patients suffer from clinically significant depressive symptoms, which may interfere with their daily activities. Untreated depression may increase physical disability, social isolation, hopelessness and healthcare utilization.

This review examined the impact of depression on the course of COPD, and the efficacy of antidepressant drug therapy and its implications for clinical practice. The efficacy of antidepressants in published trials in patients with COPD has been inconclusive. Specifically, there has been no clear evidence that antidepressants can induce remission of depression or ameliorate dyspnoea or physiological indices of COPD. Both selective serotonin reuptake inhibitor (SSRI) and tricyclic antidepressant (TCA) studies conducted in depressed COPD patients have been significantly limited by methodological weaknesses including small sample size, sample heterogeneity and variability in the scales used to diagnose and monitor the treatment of depression. For this reason, it remains unclear which SSRIs or TCAs should be favoured in the treatment of depressed COPD patients and what are appropriate dosages and duration ranges. Simply offering antidepressant drugs to older depressed COPD patients is unlikely to improve their condition.

Promising treatment strategies such as a collaborative treatment approach and cognitive behavioural therapy should be considered for depressed COPD patients, with or without antidepressant drug therapy.

Further studies are needed, including large, randomized, controlled trials with long-term follow-up, to examine the efficacy of antidepressants in patients with COPD.

Lung Volume Reduction Coil Treatment in Chronic Obstructive Pulmonary Disease Patients with Homogeneous Emphysema: A Prospective Feasibility Trial.

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32232aqwIn patients with heterogeneous emphysema, surgical and bronchoscopic lung volume reduction (LVR) treatments are available. However, for patients with homogeneous emphysema these treatments are hardly investigated and seem less effective. Bronchoscopic LVR coil treatment has been shown to be effective in patients with heterogeneous emphysema, but this treatment has not been exclusively investigated in homogeneous emphysema.

Objectives: The aim of this study was to investigate the safety and efficacy of LVR coil treatment in patients with homogeneous emphysema.

Methods: In this single-arm, open-label study, patients received a maximum of 12 LVR coils (PneumRx Inc., Mountain View, Calif., USA) in each upper lobe in two sequential procedures. Tests were performed at baseline and at 6 months. The primary endpoint was the improvement from baseline in 6-min walking distance (6MWD) after treatment.

Results: Ten patients with severe airway obstruction and hyperinflation were treated. A median of 11 (range 10-12) coils were placed in each lung. Two chronic obstructive pulmonary disease exacerbations and one small pneumothorax were recorded as serious adverse events. At 6 months, 6MWD had improved from 289 to 350 m (p = 0.005); forced vital capacity from 2.17 to 2.55 liters (p = 0.047); residual volume from 5.04 to 4.44 liters (p = 0.007) and St. George's Respiratory Questionnaire from 63 to 48 points (p = 0.028).

Conclusion: LVR coil treatment in homogeneous patients improves hyperinflation, airway resistance, exercise capacity and quality of life with an acceptable safety profile. The benefit of LVR coil treatment is not limited to patients with heterogeneous emphysema, and patients with homogenous emphysema can benefit as well. © 2014 S. Karger AG, Basel.

β2-Adrenoceptor Involved in Smoking-Induced Airway Mucus Hypersecretion through β-Arrestin-Dependent Signaling.

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Progression of chronic obstructive pulmonary disease is associated with small airway obstruction by accumulation of inflammatory mucous exudates. However, the mechanism of mucin hypersecretion after exposure to cigarette smoke (CS) is still not clear.

In this study, we explored the contribution of β2-adrenoceptor (β2-AR) signaling to CS extract (CSE)-induced mucus hypersecretion in vitro and examined the effect of a β-blocker on airway mucin hypersecretion in vivo. NCI-H292 epithelial cell line was used to determine the contribution of β2-AR signaling to CSE-induced MUC5AC production by treatment with β2-AR antagonists propranolol and ICI118551 and β2-AR-targeted small interfering RNA. The effect of propranolol on airway mucus hypersecretion was examined in a rat model exposed to CS. MUC5AC expression was assayed by real-time PCR, immunohistochemistry and ELISA. β2-AR and its downstream signaling were detected by western blot analysis. We found that pretreating NCI-H292 cells with propranolol, ICI118551 for 30 min or β2AR-targeted siRNA for 48 h reduced MUC5AC mRNA and protein levels stimulated by CSE. However,inhibiting the classical β2AR-cAMP-PKA pathway didn't attenuate CSE-induced MUC5AC production, while silencing β-arretin2 expression significantly decreased ERK and p38MAPK phosphorylation, thus reduced the CSE-stimulated MUC5AC production. In vivo, we found that administration of propranolol (25 mg kg-1d-1) for 28 days significantly attenuated the airway goblet cell metaplasia, mucus hypersecretion and MUC5AC expression of rats exposed to CS. From the study, β2-AR-β-arrestin2-ERK1/2 signaling was required for CS-induced airway MUC5AC expression.

Chronic propranolol administration ameliorated airway mucus hypersecretion and MUC5AC expression in smoking rats. The exploration of these mechanisms may contribute to the optimization of β2-AR target therapy in chronic obstructive pulmonary disease.

TBNA with and without EBUS: a comparative efficacy study for the diagnosis and staging of lung cancer.

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TBNAConventional transbronchial needle aspiration (TBNA) has been around for over 30 years with sensitivities approaching 70-90%. Recent development of endobronchial ultrasound (EBUS) TBNA demonstrated even higher sensitivities among experts. However EBUS-TBNA is more costly and less available worldwide than conventional TBNA. A comparison study to determine the efficacy of TBNA with and without EBUS in the diagnosis and staging of lung cancer is described.

METHODS: A total of 287 patients with mediastinal and hilar lymphadenopathy presenting for diagnosis and/or staging of lung cancer at enrolling institutions were included. Equal numbers of punctures were performed at the target lymph node stations using conventional TBNA techniques followed by EBUS-TBNA at the same sites. Patients and puncture sites that were biopsied by both methods and were positive for lung cancer were compared to establish efficacy of each technique on the same patients.

RESULTS: In 253 patients at least one pair of specimens were obtained by conventional TBNA and EBUS-TBNA. In 83 of these patients malignancy was diagnosed. Among the 83 patients with a diagnosis of a malignancy there was no significant difference in the diagnostic yield of conventional TBNA versus EBUS-TBNA. When comparing diagnosis of malignancy for each lymph node sampled, there were a significantly greater number of positive (diagnostic for malignancy) lymph nodes sampled by EBUS-TBNA.

CONCLUSIONS: Recommendations for current practice depend on individual centers and bronchoscopist comfort level with TBNA (with or without EBUS). In our study, no significant difference was seen between the techniques for the diagnosis and staging of individual patients.

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