Pulmonology

Abstract: Pulmonary function tests, such as the measurement of forced expiratory volume in 1 second (FEV1) and peak expiratory flow (PEF), provide an objective, standardized, and quantifiable method of patient assessment and can be essential in the evaluation of asthma. However, FEV1 and PEF are relatively insensitive for detecting changes in persons with good baseline pulmonary function, and they do not directly measure worsening airway inflammation. One way to deal with the shortcomings of these tests is to include multiple outcomes assessment. Evaluating patient-oriented variables, such as symptoms, need for rescue medication, nocturnal awakenings, and unscheduled medical care visits, can detect clinically relevant changes that pulmonary function tests do not identify. Composite outcomes provide a more comprehensive approach to patient follow-up. For example, a patient who is considered to be a "nonresponder" to a given therapy on the basis of pulmonary function criteria might, in fact, be responding favorably according to assessment of composite outcomes. Two patient-centric tools for measuring outcome are the asthma control questionnaire and the asthma control test.

Asthma is one of the most common chronic diseases worldwide, and its prevalence--particularly among children--is increasing in many countries.1,2 In 1997, an estimated 9.6% of persons in the United States had asthma (Table 1).3

Dr Storms: Given that a patient's asthma varies quite a bit from day to day, and that controller therapies can prevent exacerbations, is there any role for using a controller medication as-needed rather than using it regularly? Could exacerbations be prevented if the patient has been educated to start treatment as soon as symptoms occur or peak expiratory flow (PEF) falls?

Abstract: The coexistence of asthma and obstructive sleep apnea (OSA) in a given patient presents a number of diagnostic and treatment challenges. Although the relationship between these 2 diseases is complex, it is clear that risk factors such as obesity, rhinosinusitis, and gastroesophageal reflux disease (GERD) can complicate both asthma and OSA. In the evaluation of a patient with poorly controlled asthma, it is important to consider the possibility of OSA. The most obvious clues are daytime sleepiness and snoring, but the definitive diagnosis is made by polysomnography. Management of OSA may include weight loss and continuous positive airway pressure (CPAP). Surgical intervention, such as uvulopalatopharyngoplasty, may be an option for patients who cannot tolerate CPAP. Management may include specific therapies directed at GERD or upper airway disease as well as modification of the patient's asthma regimen. (J Respir Dis. 2005;26(10):423-435)

Tai Chi (also known as T'ai Chi Chuan, Taijiquan) is a form of mind-body exercise that has its roots in ancient Chinese martial arts. Throughout Asia, it is often practiced for preventive health, especially among the elderly. In recent years, Tai Chi has become popular in the West among all age groups and has been studied as a therapy for various medical conditions.

Abstract: Tuberculous meningitis has several different clinical presentations, including an acute meningitic syndrome simulating pyogenic meningitis, status epilepticus, stroke syndrome, and movement disorders. Cranial nerve palsies and seizures occur in about one third of patients, and vision loss is reported by almost 50%. The cerebrospinal fluid (CSF) typically shows moderately elevated levels of lymphocytes and protein and low levels of glucose. The demonstration of acid-fast bacilli in the CSF smear or Mycobacterium tuberculosis in culture confirms the diagnosis. CNS tuberculosis may also manifest as intracranial tuberculomas. The characteristic CT and MRI finding is a nodular enhancing lesion with a central hypointensity. Antituberculosis treatment should be initiated promptly when either tuberculous meningitis or tuberculoma is suspected. (J Respir Dis. 2005;26(9):392-400)

Studies have indicated that the use of acetaminophen is associated with an increased risk of asthma. Now there is evidence linking acetaminophen use to an increased risk of chronic obstructive pulmonary disease (COPD).

A 67-year-old woman was referred for evaluation of exertional dyspnea, with multiple episodes of fever, cough, and pneumonia. She had a long history of cough with sputum and had been admitted several times for exacerbations of chronic obstructive pulmonary disease and pneumonia. She received maintenance therapy with an ipratropium and albuterol combination, fluticasone, and salmeterol, but she continued to experience exertional dyspnea, with an average of 5 or 6 exacerbations and 2 hospital admissions a year.

Studies have indicated that depression occurs more frequently in adults with asthma than in the general population; however, few studies have investigated the relationship between depression and asthma outcomes. A recent study by Eisner and associates revealed noteworthy findings: depressive symptoms appear to be associated with poorer outcomes, including increased risk of hospitalization for asthma.

A 51-year-old man with a 20-year history of asthma and seasonal allergies presented with low-grade fever, progressive dyspnea on exertion, and wheezing that had persisted for 2 weeks. Four days earlier, he had been seen by his primary care physician and had started levofloxacin therapy. However, his respiratory symptoms had worsened, warranting hospitalization. He also reported pain in the abdomen and left flank and pain and swelling in the right metacarpophalangeal and right shoulder joints.

As the incidence of asthma continues to increase worldwide, current studies have indicated that the most prevalent challenge to the alleviation of asthma symptoms is undertreatment. Results of a controlled study in Denmark suggest that a physician-managed Internet-based asthma monitoring system can help patients optimize control over their asthma.

Abstract: The standard therapies for acute exacerbations of chronic obstructive pulmonary disease include short-acting bronchodilators, supplemental oxygen, and systemic corticosteroids. For most patients, an oxygen saturation goal of 90% or greater is appropriate. Bilevel positive airway pressure (BiPAP) is usually beneficial in patients with progressive respiratory acidosis, impending respiratory failure, or markedly increased work of breathing. However, BiPAP should not be used in patients with respiratory failure associated with severe pneumonia, acute respiratory distress syndrome, or sepsis. Systemic corticosteroids are appropriate for moderate to severe acute exacerbations; many experts recommend relatively low doses of prednisone (30 to 40 mg) for 7 to 14 days. Antibiotic therapy is controversial, but evidence supports the use of antibiotics in patients who have at least 2 of the following symptoms: increased dyspnea, increased sputum production, and sputum purulence. (J Respir Dis. 2005;26(8):335-341)

The authors describe a case of acute eosinophilic pneumonia (AEP) that occurred in a previously healthy young man. The presentation was similar to that of acute respiratory distress syndrome (ARDS), and the diagnosis was established by bronchoalveolar lavage (BAL). The authors note that it is important to recognize the subset of patients with AEP who present with an ARDS-like picture, especially since corticosteroids are very effective in this setting.

Abstract: Pleural tuberculosis and lymph node involvement are the most common extrapulmonary manifestations of tuberculosis. Most patients with pleural involvement complain of pleuritic chest pain, nonproductive cough, and dyspnea. The pleural effusion is usually unilateral and small to moderate in size. The diagnosis depends on the demonstration of acid-fast bacilli in pleural fluid or biopsy specimens, or the presence of caseous granulomas in the pleura. The gold standard for the diagnosis of lymph node tuberculosis is the identification of mycobacteria in smears on fine-needle aspiration cytopathology, histopathology, or mycobacterial culture. On ultrasonography and CT, the lymph nodes show enlargement with hypoechoic/hypodense areas that demonstrate central necrosis and peripheral rim enhancement or calcification. Treatment involves the combination of 4 antituberculosis drugs for 2 months, followed by 2-drug therapy for 4 months. (J Respir Dis. 2005;26(8):326-332)

Abstract: All children with asthma should have periodic office visits, usually every 3 to 6 months, in which asthma action plans are updated. Periodic assessment of lung function by peak expiratory flow or office spirometry can help determine the appropriate treatment strategy. Low daily doses of inhaled corticosteroids remain the first and most effective choice of therapy for persistent asthma. If this approach is inadequate, adding a second medication, such as a leukotriene modifier or a long-acting ß2-agonist, is suggested. Short-acting ß2-agonists remain the most important therapy for intermittent asthma. For most children, the best route is via a metered-dose inhaler with either a spacer or valved holding chamber. If these agents are inadequate, a short course of oral corticosteroids may be required. (J Respir Dis. 2005;26(8):348-358)

How can repeated visits to the emergency department (ED) for asthma exacerbations best be avoided?

Abstract: Although smoking cessation is still the most impor- tant intervention in chronic obstructive pulmonary disease (COPD), a variety of pharmacologic therapies are available to help manage symptoms. Short-acting ß2-agonists and/or ipratropium should be taken as needed, and the use of additional therapies is based on the severity of disease. Patients with moderate or severe COPD should regularly take 1 or more long-acting bronchodilators. The long-acting ß2-agonists salmeterol and formoterol have been demonstrated to improve health-related quality of life. Newer therapies include the long-acting anticholinergic tiotropium and a salmeterol-fluticasone combination. These agents improve forced expiratory volume in 1 second and may reduce the rate of acute exacerbations. For patients with moderate to very severe COPD, participation in a pulmonary rehabilitation program can improve health status, quality of life, and exercise tolerance. (J Respir Dis. 2005;26(7):284-289)

The American Thoracic Society (ATS) and the Infectious Diseases Society of America recently published guidelines for the management of hospital-acquired pneumonia (HAP).1 These guidelines, which are an update of a 1996 ATS consensus statement,2 focus on bacterial HAP in immunocompetent adults. This includes ventilator-associated pneumonia (VAP) and health care-associated pneumonia (HCAP). Selected highlights are presented here.

In their Photoclinic case of a man with achalasia (CONSULTANT, February 2005, page 268), Drs Sonia Arunabh and Manjula Thopcherla did not mention the extensive abnormalities evident in the left lung on both radiograph and CT .Did the patient also have aspiration pneumonia?

Abstract: ß-Agonists, administered by metered-dose inhaleror nebulizer, are still the mainstay of therapy for asthma exacerbations.A trial of a subcutaneous ß-agonist should beconsidered in patients who fail to respond to inhaled medications.Levalbuterol may play a role in managing refractoryasthma, particularly in patients with ischemic heart disease orsevere tachycardia. Systemic corticosteroids should be administeredto all patients presenting to the hospital withasthma unless their peak expiratory flow rate (PEFR) orforced expiratory volume in 1 second (FEV1) is at least 80% ofpredicted after 1 hour of treatment; this therapy should be institutedwithin 1 hour of presentation. For patients with severeobstruction, the combined use of an anticholinergic and aß-agonist improves PEFR and FEV1 more than ß-agonistsalone and significantly decreases the risk of hospital admission.(J Respir Dis. 2005;26(6):238-249)

Just how effective are the national guidelines for the management of community-acquired pneumonia (CAP)? Pretty good, according to Mortensen and associates. They found that compliance with practice guidelines, such as those published by the Infectious Diseases Society of America and the American Thoracic Society, is associated with a reduced mortality in patients with CAP.

Although pneumonia caused by Legionella pneumophila continues to be associated with significant morbidity, recent studies indicate that the mortality rate has declined. Two studies from Spain support this observation and suggest that therapy with levofloxacin may be more effective than therapy with erythromycin or clarithromycin.

Abstract: In most patients, a life-threatening exacerbation of asthma is preceded by a gradual worsening of symptoms. However, some patients have a sudden onset of worsening symptoms, and these patients are at increased risk for respiratory failure and death. Risk factors for near-fatal asthma include a history of a life-threatening exacerbation, hospitalization for asthma within the past year, delay in time to evaluation after the onset of symptoms, and a history of psychosocial problems. Regularly monitoring peak expiratory flow rate (PEFR) is particularly important because it can identify a subset of high-risk patients--specifically, those with large fluctuations in PEFR and those who have severe obstruction but minimal symptoms. Signs of life-threatening asthma include inability to lie supine, difficulty in speaking in full sentences, diaphoresis, sternocleidomastoid muscle retraction, tachycardia, and tachypnea. (J Respir Dis. 2005;26(5):201-207)

The prevalence of asthma in the United States is estimated to be 5% to 8%. Asthma is responsible for approximately 5000 deaths annually in this country. It is a leading cause of emergency department visits, hospitalizations, and school and work absenteeism. The total estimated direct cost of the disease in the United States was $12.7 billion in 1998.

Abstract: The use of sputum studies and blood cultures in patients hospitalized with community-acquired pneumonia (CAP) is somewhat controversial, and recommendations continue to evolve. A reasonable approach is to attempt to obtain sputum cultures from all patients before initiating antibiotic therapy. If antibiotics have already been given, sputum studies can be reserved for patients who are severely ill or who are at risk for infection with a resistant organism or an organism that is not covered by the usual empiric therapy. The Infectious Diseases Society of America and the American Thoracic Society both recommend obtaining blood cultures from all patients. However, cost considerations have led to alternative strategies, such as reserving blood cultures for those with severe CAP. (J Respir Dis. 2005;26(4):143-148)