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Electromagnetic navigation bronchoscopy (ENB): Increasing diagnostic yield

Objectives : To determine factors associated with diagnostic yield of ENB.

Methods : In 112 consecutive patients referred to our department between March 2010 and December 2010 the diagnostic work-up for solitary pulmonary lesions included a FDG-PET-CT scan, and ENB in combination with ROSE. The final diagnosis was confirmed by histopathological evaluation of specimen obtained either by ENB, or – if ENB was not diagnostic – by CT-guided fine needle aspiration or surgery.

Results : Thirty-seven (33%) subjects were female, mean age was 66.7 (±1.04) years. The mean diameter of lesions was 27mm (range: 6–46mm). In 83.9% the combination of PET-CT, ENB, and ROSE established a correct diagnosis, as defined by the definite histopathological result. 15.2% (17/112) of lesions were benign, and 84.8% (95/112) were malignant. For 112 procedures we observed a steep learning curve with a diagnostic yield of 80% and 87.5% for the first 30 and last 30 procedures, respectively. The diagnostic yield in lesions ≤20mm and >20mm in diameter was 75.6% and 89.6% (p =0.06), respectively. No significant difference in diagnostic yield was seen depending on lung function, and the localization of the lesions. Two cases (1.8%) of pneumothorax were seen during and up to 24h after bronchoscopy, none of them required a chest tube.

Conclusion : Diagnostic yield increased with experience but was independent from the size of the lesion, the localisation in the lungs, and lung function. The diagnostic yield of ENB can be as high as for CT-guided transthoracic biopsies but carries a significantly lower complication rate.

Air trapping is a major determinant of persistent airway obstruction in asthmatics

Chronic persistent airway obstruction has been observed in moderate-to-severe asthmatics despite treatment with inhaled corticosteroids.

We investigated which airway changes were associated with this obstruction. High-resolution computed tomography (HRCT) was performed at study entry and reexamined at the time of follow-up when the FEV1 reached a maximally constant level after treatment for 1 year or more with inhaled corticosteroids. Bronchial wall area and air trapping extent were compared in the recovered group (n = 18) and the persistent airway obstruction group (n = 14). Bronchial wall area and air trapping of the initial HRCT were similar between the two groups.

On follow-up HRCT, air trapping was markedly decreased in the recovered group compared with that on initial HRCT (P = 0.017), whereas bronchial wall area did not change. In the persistent-airway-obstruction group, these two parameters did not change during follow-up. When follow-up HRCT was compared, air trapping was significantly greater in the persistent-airway-obstruction group than in the recovered group (P = 0.003). Difference post-bronchodilator FEV1 value between at initial and 2nd HRCT exam was correlated with difference air trapping value between at initial and 2nd HRCT exam(%) on the follow-up HRCT (P = 0.017).

The presence of persistent airflow obstruction were significantly associated with the air trapping % difference between initial and 2nd time (RR = 1.70, P = 0.018). Persistence of AT could be a main contributing factor to chronic persistent airflow obstruction in asthma.

Dose effect of once-daily fluticasone furoate in persistent asthma: A randomized trial

This randomized, double-blind, multicenter study was designed to evaluate the efficacy of inhaled once-daily fluticasone furoate (FF) administered in the evening in patients with persistent asthma not controlled by short-acting beta2 agonists, and to determine the dose(s) suitable for further development.

Methods : Of 1459 patients screened, 598 received one of six treatments: placebo, FF (25 μg, 50 μg, 100 μg or 200 μg) once daily each evening, or fluticasone propionate (FP) 100 μg twice daily for 8 weeks. The primary endpoint was change from baseline in pre-dose evening forced expiratory volume in 1 s (FEV1).

Results : A dose–response effect was observed for once-daily FF 25–200 μg including (p < 0.001) and excluding placebo (p = 0.03). FF 50–200 μg once daily significantly increased FEV1 from baseline (p < 0.05 vs placebo), by >200 mL for FF 100 μg and 200 μg. Significant improvements were also achieved for peak expiratory flow, and percentage symptom-free and rescue-free 24 h periods. The magnitude of effect was at least as good as twice-daily FP. Overall, once-daily FF was well tolerated with no systemic corticosteroid effects.

Conclusion : FF 50–200 μg/day once daily in the evening demonstrated dose-related efficacy in asthma with 100–200 μg appearing to be the optimal doses for further evaluation.

COPD among non-smokers – Report from the Obstructive Lung Disease in Northern Sweden (OLIN) studies

In westernized countries smoking and increasing age are the most important risk factors for COPD. Prevalence and risk factors of COPD among non-smokers are not well studied.

Aim : To study the prevalence and risk factors of COPD among non-smokers and to determine the proportion of non-smokers among subjects with COPD.

Methods : A random sample of 2470 subjects drawn from a population-based postal survey of 10,040 (85–88% participation) adults (aged 20–77) in Norrbotten, Sweden, were invited to structured interviews and lung function tests, and 1897 participated. COPD was classified using the fixed ratio (GOLD) definition and for comparison the lower limit of normal (LLN).

Results : The prevalence of airway obstruction was 6.9% among non-smokers and strongly age related. The prevalence of GOLD stage ≥II among non-smokers was 3.5%. Both among subjects with airway obstruction and among subjects with GOLD stage ≥II, the proportions of non-smokers were 20%. Of men with airway obstruction, 14.1% were non-smokers versus 26.8% among women. Non-smokers with GOLD stage ≥II had significantly more symptoms and higher co-morbidity than non-smokers without airway obstruction. Sex, area of domicile and exposure to environmental tobacco smoke was not significantly associated to airway obstruction among non-smokers. Using LLN for defining airway obstruction yielded a similar prevalence.

Conclusion : The prevalence of airway obstruction among non-smokers was close to 7% and was associated with increasing age. One out of seven men with airway obstruction, defined using the fixed ratio, versus one out of four women had never smoked.

Severe pneumonia in intensive care: cause, diagnosis, treatment and management: a review of the literature

Severe pneumonia is a common disease that intensive care physicians have to face. The review highlights recent findings about microbiology, diagnosis and treatment, including the management of critically ill patients with severe respiratory failure.

Recent findings: Epidemiological and clinical risk factors strongly influence microbiological cause in patients with severe pneumonia. In addition to typical respiratory pathogens, less common microrganisms and multidrug-resistant (MDR) germs may cause severe lung infections. New molecular diagnostic techniques appear promising for early detection of microbes involved in severe pneumonia. Antimicrobials remain the mainstay of causative severe pneumonia treatment and the optimization of antibiotic therapy may be obtained by applying their pharmacodynamic/pharmacokinetic properties. Several new strategies have been implemented for the management of acute respiratory failure (ARF) due to severe pneumonia; however, their extensive clinical application is limited by the need for well trained physicians and adequate hospital centers.

Summary: Despite advancements in antibiotic and life-supportive treatments, severe pneumonia remains a leading cause of intensive care unit (ICU) admission and death. Prompt and appropriate antimicrobial therapy is essential. The use of new nonconventional strategies for ARF management might be effective in more severe patients.

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