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Heliox-Driven Vs. Air-Driven Nebulized Bronchodilator (BD) Therapy and Pulmonary Function Tests (PFT) in Patients With Obstructive Lung Diseases.

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PURPOSE: To compare the effect of heliox-driven (Helium 80%: Oxygen 20%) to air-driven (Nitrogen 79%; Oxygen 21%) BD therapy on PFTs in patients with different levels of severity of airway obstructions.

METHODS: 150 patients undergoing their first pre- and post-bronchodilator PFT measurements were included in the study. Pregnant women and morbidly obese patients were excluded. Each patient was studied on two consecutive days with random assignment to receive either air-driven nebulization of 2.5mg of albuterol sulfate on day one and heliox-driven nebulization of same drug on day two or vice versa. After baseline PFT on day one, each patient received the nebulized bronchodilator treatment for 10 minutes at a flow rate of 8L/min with the randomized driving gas for day one. Post bronchodilator PFT was repeated after 30 minutes. The next day, the exact protocol was performed except that the other driving gas was used to nebulize the drug. The patients and the staff conducting the PFTs were blinded to the driving gas. Patients were sub-grouped and analyzed according to their baseline FEV1 on day one: 100%>FEV1≥80%; 80%>FEV1>50%; FEV1≤50%. Changes from baseline in PFT variables were compared with heliox-driven versus air-driven bronchodilation therapy.

RESULTS: The percentages of patients who showed >12% increases in FEV1 with either heliox-driven or air-driven bronchodilation were not different in patients with 100%>FEV1≥80% (20% vs. 20%) and 80%>FEV1>50% (38% vs. 28%) but significantly greater in patients with FEV1≤50% (58% vs. 18%). Only in patients with FEV1≤50%, changes from baseline in FVC, FEV1, FEV1/FVC, FEF25-75%, FEFmax, FEF25%, FEF50%, and FEF75% were larger with heliox-driven versus air-driven bronchodilation.

CONCLUSIONS: PFT variables improvements are more frequent and larger with heliox-driven compared to air-driven bronchodilator therapy only in patients with FEV1≤50%.

CLINICAL IMPLICATIONS: In patients with severe airway obstructions heliox-driven should replace air-driven bronchodilation for identifying patients who will exhibit positive response to bronchodilator therapy. Physicians should consider heliox-driven bronchodilator therapy when seeking improvements in PFT variables in patients with severe obstructive airway diseases.

DISCLOSURE: The following authors have nothing to disclose: Mohamad El Khatib, Ghassan Jamaleddine, Nadim Kanj, Juliette Jibrail, Marwan Alawieh, Salah Zeineddine, Imad BouAkl, Ahmad Husari, Hassan Chami, Pierre BouKhalilNo Product/Research Disclosure Information.

New Treatments for COPD in the Elderly.

In elderly people the respiratory function is affected by anatomical and physiological modifications caused by aging. Elderly COPD patients are characterized by a complexity due to an increasing prevalence of comorbidities related to the age that suggest peculiar care in prescribing the therapy in those patients, also considering other disabilities that are not related with respiratory disorders as physical and mental limitations.

Nowadays a therapy that allows modifying the long-term decline in lung function of patients suffering from COPD does not yet exist and, therefore, the treatment of this disease is mainly focused on the administration of bronchodilators and the use of inhaled glucocorticoids. As for younger subjects, also in elderly patients the main classes of bronchodilators used in the treatment of COPD include β2-agonists, anticholinergics and methylxanthines.

The inflammatory response suppression represents another mechanistic approach for treating COPD in the elderly, although the use of inhaled corticosteroids is limited to specific indications. Indeed, nowadays there is a strong medical need for novel treatments of COPD in the elderly. These are mainly represented by agents that reduce the spillover of inflammatory mediators from the lung and by compounds that inhibit the chronic systemic inflammatory syndrome.

The therapeutic approach of COPD in elderly patients remains a topic of increasing interest, however the development of novel compounds for preventing the COPD progression in the elderly, other than bronchodilators and corticosteroids, remains a challenge.

Air pollution and subclinical airway inflammation in the SALIA cohort study.

The association between long-term exposure to air pollution and local inflammation in the lung has rarely been investigated in the general population of elderly subjects before. We investigated this association in a population-based cohort of elderly women from Germany.

METHODS: In a follow-up examination of the SALIA cohort study in 2008/2009, 402 women aged 68 to 79 years from the Ruhr Area and Borken (Germany) were clinically examined. Inflammatory markers were determined in exhaled breath condensate (EBC) and in induced sputum (IS). We used traffic indicators and measured air pollutants at single monitoring stations in the study area to assess individual traffic exposure and long-term air pollution background exposure. Additionally long-term residential exposure to air pollution was estimated using land-use regression (LUR) models. We applied multiple logistic and linear regression analyses adjusted for age, indoor mould, smoking, passive smoking and socio-economic status and additionally conducted sensitivity analyses.

RESULTS: Inflammatory markers showed a high variability between the individuals and were higher with higher exposure to air pollution. NO derivatives, leukotriene (LT) B4 and tumour necrosis factor-alpha (TNF-alpha) showed the strongest associations. An increase of 9.42 mug/m3 (interquartile range) in LUR modelled NO2 was associated with measureable LTB4 level (level with values above the detection limit) in EBC (odds ratio: 1.38, 95% CI: 1.02 -1.86) as well as with LTB4 in IS (%-change: 19%, 95% CI: 7% - 32%). The results remained consistent after exclusion of subpopulations with risk factors for inflammation (smoking, respiratory diseases, mould infestation) and after extension of models with additional adjustment for season of examination, mass of IS and urban/rural living as sensitivity analyses.

CONCLUSIONS: In this analysis of the SALIA study we found that long-term exposure to air pollutants from traffic and industrial sources was associated with an increase of several inflammatory markers in EBC and in IS. We conclude that long-term exposure to air pollution might lead to changes in the inflammatory marker profile in the lower airways in an elderly female population.

Perspectives about spirometry and knowledge of spirometric diagnostic criteria among primary care physicians.

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Perspectives about spirometry and knowledge of spirometric diagnostic criteria among primary care physicians.

Chest. 2014 Mar 1;145(3 Suppl):458A

Authors: Sehgal P, D'Urzo A

Abstract
SESSION TITLE: Physiology/PFTs/Rehabilitation PostersSESSION TYPE: Poster PresentationsPRESENTED ON: Saturday, March 22, 2014 at 01:15 PM - 02:15 PMPURPOSE: The reasons why spirometry remains underutilized in primary care are poorly understood. The aim of this study was to gather information related to perspectives about spirometry among family physicians as well as their knowledge of current spirometric diagnostic criteria (SDC) about asthma (CTS 2012) and COPD (GOLD 2013).
METHODS: Participants included 88 family physicians who attended 4 standardized, accredited workshops in Canada between 2011 and 2013. Remote data capture devices were used to obtain (real-time) responses to 10 questions (component 1) regarding physician perspectives on spirometry including 4 questions relating to knowledge about SDC for asthma/COPD. Following a 25-minute didactic session (component 2) on spirometry interpretation strategies and SDC, responses to the 4 knowledge questions (component 3) asked in component 1 were obtained to assess the learning effect of workshop participation. Descriptive analysis was performed for component 1 while linear regression analysis was used to determine how well physician perspectives correlated with physician knowledge on SDC.
RESULTS: Component 1 analysis showed that 61% of physicians were not very or not at all comfortable with administrating a spirometry test. Only 9% of physicians were 'very' or 'extremely confident' in their ability to interpret a spirometry test. Linear regression analysis revealed that these variables were not strongly correlated to physician knowledge about SDC (p=0.36). Only 36% and 23% of physicians correctly answered knowledge questions about SDC for asthma and COPD, respectively. Physician knowledge of SDC improved significantly following the didactic training session using 2 metrics: 1) Number of physicians who answered at least ¾ of the questions correctly (p=0.02) and 2) Mean number of correct answers (p=0.008).
CONCLUSIONS: Family physicians appear to be uncomfortable in performing spirometry tests, lack confidence in spirometry interpretation, and demonstrated knowledge gaps relating to awareness of SDC for asthma and COPD. Workshop participation significantly improved physician knowledge.
CLINICAL IMPLICATIONS: Strategies to improve confidence and knowledge related to spirometry principles should be studied in primary care in an effort to improve spirometry utilization
DISCLOSURE: The following authors have nothing to disclose: Prateek Sehgal, Anthony D'UrzoNo Product/Research Disclosure Information.

PMID: 24638615 [PubMed - in process]

The role of a positive exhaled nitric oxide in evaluating the pulmonary patient: exhaled nitric oxide versus methacholine challenge?

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The role of a positive exhaled nitric oxide in evaluating the pulmonary patient: exhaled nitric oxide versus methacholine challenge?

Chest. 2014 Mar 1;145(3 Suppl):467A

Authors: Nickels A, Parker K, Scanlon P, Lim K

Abstract
SESSION TITLE: Pulmonary Function TestingSESSION TYPE: Slide PresentationsPRESENTED ON: Sunday, March 23, 2014 at 04:15 PM - 05:15 PMPURPOSE: Exhaled nitric oxide (FeNO) and Methacholine challenge (MCH) are both utilized in the detection and management of numerous pulmonary diseases. MCH is a measure of direct airway hyperresponsiveness. FeNO measures bronchial epithelial damage from eosinophilic bronchitis whether asthma or non-asthma related. FeNO has an attractive performance profile, as it is a cheaper and less invasive test. We hypothesize that FeNO can decrease the need for MCH testing.
METHODS: Retrospective chart review of patients ≥ 18 years presenting to a tertiary referral center seen between 11/01/2009 - 8/31/2013 who received FeNO and MCH within 2 weeks. Fischer exact test and diagnostic testing evaluations were used for analysis.
RESULTS: 1322 patients were identified. Demographics: 843 (63.7%) females and 479 (36.2%) males; 1288 (97.4%) Caucasian, 21 (1.6%) Black, 13 (1%) Asian. Average age was 54.1 years (SD +/- 15.5 years). Mean BMI 29.5 (SD +/-6.7). 89 patients were positive for both MCH and FeNO, 178 patients had a positive MCH but negative FeNO, 160 patients had a negative MCH but positive FeNO, and 895 patients had both a negative (p<0.01). Directly comparing FeNO to MCH yielded: sensitivity 33.33% (95% CI: 27.71 % to 39.34 %), specificity 84.83% (95% CI: 82.53 % to 86.95 %), positive likelihood ratio 2.2 (95% CI: 1.76 to 2.74), negative likelihood ratio 0.79 (95% CI: 0.72 to 0.86), positive predictive value 35.74% (95% CI: 29.79 % to 42.04 %), and negative predictive value 83.41% (95% CI: 81.05 % to 85.59 %).
CONCLUSIONS: In this large cohort of pulmonary patients, a strategy of FeNO at the point-of-care may reduce but does not eliminate the need for MCH testing. Likely this represents that FeNO and methacholine responsiveness measure different biological phenomenon. Further subgroup analysis is needed to determine if FeNO is more predicative in certain patient groups, such as steroid naïve patients.
CLINICAL IMPLICATIONS: Exhaled nitric oxide seems to represent a different biologic phenomena from methacholine challenge. Despite exhaled nitric oxide being non-invasive and having an attractive cost profile, it can not be used to replace methacholine challenge in the evaluation of the pulmonary patient.
DISCLOSURE: The following authors have nothing to disclose: Andrew Nickels, Kenneth Parker, Paul Scanlon, Kaiser LimNo Product/Research Disclosure Information.

PMID: 24638624 [PubMed - in process]

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