Pulmonology

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)

Cardiovascular disease is a leading cause of death in patients with chronic obstructive pulmonary disease (COPD). While some physicians may be reluctant to prescribe ß-blockers for these patients, because of concern about adverse effects on lung function, a study conducted by Au and associates indicates that ß-blockers may have an edge over other antihypertensive agents in reducing mortality risk.

A study in Finland confirms that many adults with asthma have gastroesophageal reflux disease (GERD) and that many of these persons do not have the classic GERD symptoms. However, the role of GERD as an asthma trigger has not been clearly defined.

ABSTRACT: Education can help improve compliance with inhaled corticosteroid therapy or correct faulty metered-dose inhaler (MDI) technique. Options for patients with poor MDI technique include use of a spacer or an alternative device, such as a nebulizer or a dry powder inhaler. If therapy is ineffective, consider alternative conditions that mimic asthma, especially vocal cord dysfunction and upper airway obstruction. Treatment of comorbid conditions, such as gastroesophageal reflux disease or rhinosinusitis, may improve control. In refractory asthma, it is crucial to identify allergic triggers and reduce exposure to allergens. If another medication needs to be added to the inhaled corticosteroid, consider a long- acting b-agonist, leukotriene modifier, or the recombinant monoclonal anti-IgE antibody omalizumab.

A 51-year-old patient asked me whether she should receive the influenza vaccine. She was last vaccinated in 1976; symptoms that resemble Guillain-Barré syndrome developed shortly afterwards. She has not received the vaccine since then; however, because she teaches schoolchildren, she wondered whether she should be vaccinated.

Several new drugs are being introduced-and more are on thehorizon.

Anxiety is a common and troubling symptom in many patients with chronic obstructive pulmonary disease (COPD), even when their degree of respiratory impairment is only mild to moderate. Anxiety may also accompany other chronic, progressive pulmonary disorders, such as interstitial fibrosis and cystic fibrosis, and a wide variety of other, less common diseases that are characterized by progressive dyspnea on exertion.

Bronchodilators, preferably inhaled, are recommended for all patients with chronic obstructive pulmonary disease; ipratropium, with a 6- to 8-hour duration of action, is effective maintenance therapy. Tiotropium is currently being reviewed by the FDA for release in the United States; its once-daily dosing schedule may facilitate adherence. Criteria for long-term oxygen therapy are severe hypoxemia (PaO2, 55 mm Hg or lower) or a PaO2 of 60 mm Hg or lower with signs of cor pulmonale or secondary polycythemia (hematocrit higher than 55%). When symptoms are disabling despite optimal medical management, referral for pulmonary rehabilitation is the next step. Patients with upper lobe-predominant emphysema and low exercise capacity may benefit most from lung volume reduction surgery. Consider transplantation if the patient has severe lung disease that is refractory to medical therapy and survival is expected to be less than 2 to 3 years.

The key factor in reducing morbidity and mortality in patients with chronic obstructive pulmonary disease (COPD) continues to be smoking cessation. Newer formulations of nicotine replacement therapy-a nasal spray and an inhaler-provide rapid delivery of nicotine and may be appropriate for highly dependent smokers. Bupropion has been shown to improve smoking cessation rates, either when used alone or with a nicotine patch. Both the influenza and pneumococcal vaccines are recommended to reduce the morbidity and mortality associated with respiratory infections in patients with COPD.

In general, asthma-related morbidity and mortality are greatest among members of ethnic minority groups who live in the inner cities; about 5000 deaths occur in these populations each year in the United States.

ABSTRACT: When influenza is present in the community, clinical symptoms are as accurate as rapid point-of-care tests for making the diagnosis; in this setting, the combination of cough and fever (temperature, 37.7°C [100°F] or higher) of acute onset has a positive predictive value of 77% to 79%. Accurate diagnosis ensures timely administration of antiviral agents and prevents unnecessary antibiotic use. In elderly persons, vaccination reduces illness severity, incidence of complications, and mortality. An intranasal vaccine is a new option for persons aged 5 to 49 years who are at risk for complications and refuse injection. Chemoprophylaxis with amantadine, rimantadine, or a neuraminidase inhibitor is a useful adjunct to vaccination in certain groups, such as nursing-home residents. Antiviral therapy started within 24 to 48 hours of symptom onset can reduce the duration of illness by 1 to 1.5 days and ameliorate symptoms in patients with uncomplicated influenza. However, treatment is expensive and does not prevent complications.

What is the optimal means of preventing exercise-inducedbronchospasm in children with asthma?

If your bedroom or other rooms in your home look a lot like this one,you may be living in an asthma "nightmare"-an environment full ofpotential causes of asthma attacks.

ABSTRACT: Many patients with presumed mild intermittent asthma have unrecognized persistent symptoms; these can be elicited with specific questioning about coughing, wheezing, shortness of breath, chest tightness, nighttime awakenings, and exercise intolerance. Asthma severity may vary with the season. For asthmatic patients with predictable seasonal allergies, prescribe inhaled corticosteroids for a few weeks or months beginning 2 to 3 weeks before usual symptom onset. Successful long-term management requires identification and control of asthma triggers, such as cigarette smoke, house dust mites, cockroaches, molds, and animal dander. Removing triggers or minimizing the patient's exposure to them may allow improved asthma control with lower dosages of corticosteroids.

ABSTRACT: Bronchodilators are central to COPD symptom management; current options include the anticholinergic ipratropium, short- and long-acting ß2-agonists, and theophylline. Tiotropium, which is not yet available in the United States, may become a useful addition to the armamentarium. Novel phosphodiesterase 4 inhibitors with both anti-inflammatory and bronchodilatory effects, including roflumilast, piclamilast, and cilomilast, are being investigated. Combination therapy with bronchodilators that have different mechanisms and durations of action may prove key in achieving the greatest symptom control with the fewest side effects. For example, prescribing a first-generation ß2-adrenergic agonist, such as albuterol, together with an antimuscarinic agent is reasonable from the standpoints of both efficacy and safety.

ABSTRACT: In addition to advanced age, factors such as comorbid illness and debility determine the risk of community- acquired pneumonia (CAP). Many elderly persons do not have the classic symptoms of CAP; instead, they may present with confusion, lethargy, tachypnea, anorexia, or abdominal pain. Even with thorough investigation, an infectious pathogen can be identified in only about half of patients. In addition to the causative organisms for pneumonia in younger adults, elderly persons are at risk for infection with organisms such as Haemophilus influenzae, Staphylococcus aureus, enteric gram-negative bacteria, and anaerobes, and for polymicrobial infection. Prompt empiric treatment is essential. Recommended initial therapy choices include a ß-lactam agent with a macrolide, or an antipneumococcal fluoroquinolone.

Sir William Osler once called pneumococcalpneumonia “the captain of themen of death.”1 Pneumonia is the sixthleading cause of death in the UnitedStates and the fourth leading causeamong Americans 80 years of age andolder.2

ABSTRACT: The emergence of drug-resistant pneumococci has changed the empiric treatment of community-acquired pneumonia. Newer fluoroquinolones with activity against Streptococcus pneumoniae offer an alternative in the treatment of infection with penicillin-resistant strains. These agents are not recommended as first-line therapy because of concerns about the development of resistance. Reserve the fluoroquinolones for patients who are allergic to macrolides and β-lactams, have failed to respond to a first-line agent, or have a documented infection with a highly resistant strain. The pneumococcal vaccine is recommended for all persons aged 65 years and older, adults with chronic car-diopulmonary diseases, and immunocompromised persons. Consider revaccination every 6 years in asplenic patients and immunocompromised persons. In addition, vaccination against influenza can help prevent secondary pneumonia and reduce the need for hospitalization.

Cutaneous lesions can develop in anumber of pulmonary diseases, suchas tuberculosis and sarcoidosis, as wellas in other diseases that may have pulmonaryinvolvement, such as Wegenergranulomatosis, collagen vasculardiseases, varicella, and pneumococcalinfections. In many cases, knowledgeof the clinical and histologic characteristicsof the skin lesions associatedwith these diseases can greatly facilitatediagnosis.

How critical-and cost-effective-is in-officepulmonary function equipment for the primarycare practitioner?