நுரையீரல் & சுவாச மருத்துவம்

Invasive mechanical ventilation is known to be detrimental to patients with respiratory failure due to acute exacerbation of chronic obstructive pulmonary disease (AECOPD). If hypercapnic respiratory failure and acidosis cannot be controlled by noninvasive mechanical ventilation, extracorporeal carbon dioxide removal (ECCO2 R) serves as an alternative option. Currently applied systems like extracorporeal membrane oxygenation (ECMO) or pumpless extracorporeal lung assist (PECLA) are associated with potentially significant bleeding complications and require a very high nursing standard. We report a case of AECOPD with hypercapnic coma and failure of noninvasive ventilation for which we used a novel low-flow ECCO2 R device, called the Hemolung Respiratory Assist System. This device requires only a single 15.5 French double-lumen venous catheter and operates at blood flows of 350 mL/min to 550 mL/min. Use of this device enabled the patient to avoid general anesthesia and invasive mechanical ventilation without adverse events. In addition, weaning from noninvasive mechanical ventilation, early mobilization, communication and nutrition were facilitated. CO2 removal with low extracorporeal blood flow avoided intubation in the treatment of hypercapnic coma with failure of non-invasive ventilation.

The aim of this study was to investigate the effect of inspiratory muscle training at high altitude on peripheral capillary oxygen saturation and performance among endurance runners. Twelve endurance male runners (age: 24 yrs ± 3 yrs, height: 180.5 cm ± 4.2 cm, weight: 66.7 kg ± 3 kg, Body mass index: 20.5 ± 1.0) among Iranian national team were randomly divided into case and control group in hypoxic condition. Exhaustive testing free 1500 m, strength Index and arterial oxygen saturation tests were taken before and 24 h after training period. Training program include same continues, interval, aerobic and resistance training for two groups. Runners performed 16 training session per week in high altitude within four weeks. Data were analyzed by analysis of variance (P ≤ 0.05). Inspiratory muscle training at hypoxia due to significant decrease in 1500 m running performance, inspiratory muscle strength and peak inspiratory flow in both group, but the differences in volume and peripheral capillary oxygen saturation were not significant (P ≤ 0.05).

This study suggests that using inspiratory muscle training along with specified training in hypoxia increases inspiratory muscle strength and peak inspiratory flow pressure meanwhile it decreases ventilation and 1500 m running time in lower altitude.

We report a case of idiopathic chylothorax refractory to surgical management, where the leak was due to a spontaneously ruptured cisterna chyli. Surgical management was unsuccessful, including a left-sided pleuroscopy/pleurodesis and a right-sided thoracic duct ligation. After a prolonged period of hospitalization, lymphangiography ultimately demonstrated the site of the chyle leak as a spontaneously disrupted cisterna chyli. Due to the degree of disruption, it was not amenable to cannulation and embolization. However, lipiodol injection was sufficient in itself to lead to resolution of the chylothorax. Lymphangiography is a useful modality that can be potentially therapeutic in persistent chylothorax.

Objective: The lung clearance index (LCI), an index of ventilation homogeneity derived from the multiple breath wash out (MBW) of an inert gas, is a lung function test to monitor pulmonary disease. The aim of this study was to investigate whether LCI measurements are suitable for the daily routine in patients with COPD in comparison to young and healthy controls.

Methods: MBW measurements were performed successfully in 23 patients (out of 42) patients with COPD (FEV1 %, 40.41 ± 14.65). As controls we selected 30 healthy and young volunteers. All subjects used the EasyOne ProLab™ (ndd, Switzerland).

Results: 18 patients were not able to finish measurements successfully because of significant leaks, cough and irregular breathing (GOLD I n=1 (5.6%); GOLD II n=6 (33.3%); GOLD III n=5 (27.7%); GOLD IV n=6 (33.3%). The mean LCI was significantly higher in COPD patients as compared to young and healthy volunteers (12.55 ± 3.50 vs 7.00 ± 1.02, p<0.05). Although LCI correlated with FEV1 %of predicted (r²=-0.540, p<0.01) and Rtot (% pred.) (r²=0.504, p<0.01) the method failed to discriminate between GOLD II-IV classes. LCI correlated with the volume of trapped gas in elderly patients with COPD and young and healthy controls [FRC (% pred.) (r²=0.191, p<0.01), ITGV (% pred.) (r²=0.478, p<0.01), and RV (% pred.) (r²=0.462, p<0.01)]. Moreover, the results did not correlate with the 6-MWT, a validated clinical outcome parameter.

Conclusions: Although measurement of LCI was capable to detect inhomogeneous ventilation (airway obstruction and hyperinflation), this method did not discriminate between GOLD II-IV and did not correlate with 6-MWT. More than 43% of the patients with COPD did not complete the study because of difficulties with the method. Nevertheless, the LCI might be a tool to gain insight into lung pathophysiology in younger patients e.g. children. Our preliminary study encourages further investigations for the future.

Our study evaluated relationships between two surrogate measured vital capacity and aerobic capacity of predict Anthropometric Characteristics Determine the Cardiorespiratory Fitness among Soccer Players. Whereas our background confirms that weight-for-height as a relationship, were not considered in the kinematics analysis during the match. For the propose a total of 163 male soccer players under 17 years from the Algerian football championship participated in the present study. There VO2 max were estimated based on the formula Test Cooper (VO2 max =22.351 d (km)-11.288 (ml/min/kg)) where Vital capacity was calculating based on formula (vital capacity (ml)=(27.63-0.112 × age) × height(cm)). Based on the statistical applied. Our results confirm: 1) There is a strong positive relationship between maximal aerobic capacity and the Vital capacity, 2) Height is the most predictor of Vital capacity, 3) Height is the most predictor of the maximal aerobic capacity in the case of our sample.

We present a case of a 26 year with history of HIV/AIDS who presented with a pleural effusion. Serial radiography, pleural fluid analysis as well as clinical symptoms revealed development of Kaposi Sarcoma related immune reconstitution inflammatory syndrome (KS-IRIS) in the setting of initiation of effective anti- retroviral therapy.

A 5 year old boy was admitted to the emergency ward. Physical examination revealed a heart murmur and fever. During his stay on the emergency ward oxygen saturation progressively worsened. A cardiac ultrasound showed an occlusion of the right pulmonic artery and severe narrowing of the left pulmonic artery. Computed Tomography Angiography (CTA) confirmed the diagnosis. Pathology examination of the retrieved thrombus during emergency thoracotomy revealed a fungus cast from Zygomycete; Rhizopus microsporus. The patient was treated with Posaconazole and high dose of liposomal Amphotericin B. The patient was fully recovered forty-five days after admittance to the emergency ward.

Pulmonary arterial hypertension associated with congenital heart disease (PAH-CHD) is one of the most common forms of pulmonary arterial hypertension (PAH). Unlike the other forms, PAH-CHD can be treated surgically closing the extra- or intracardiac shunt if the shunt is left-to-right and the pulmonary vascular resistance (PVR) is low enough (<2,3-operable, 2,3-4,6 WU-borderline operable). If the PAH postoperatively persists the prognosis is even worse than for non-operated patients. Due to the previously mentioned fact the criteria for operability in such cases are often discussed. We report a case of a 54-year-old man who suffers from coronary artery disease (SYNTAX score-23,5) and PAH-CHD. As the patient required coronary artery bypass grafting (CABG) surgery, the atrial septal defect (ASD) was closed (surgically with a patch followed by transcatheter closure with an occluder) as well despite the fact that according to the current guidelines his pulmonary vascular resistance (4,7 WU) was considered too high for the defect to be operable. The patient was given PAH-specific treatment preoperatively in order to lower his PVR. This article describes the case and discusses the disease, its history, the new classification, diagnostics and treatment options.

Chest-tube placement is one of the most common procedures performed to evacuate pleural effusion. Several types and sizes of chest tubes are available. Although chest-tube placement is straightforward, it may be associated with significant morbidity and mortality. We describe here a hemothorax in a patient with Veno-venous extra corporeal membrane oxygenator (VV-ECMO) which was treated with chest-tube placements by Seldinger technique.

VV-ECMO is increasingly being used as a bridge to recovery or transplantation in patients with severe pulmonary disease. Unexpected complications, like a hemothorax can cause severe hemodynamic derangement. Treatment of this complication remains challenging for several reasons in patients assisted by VV-ECMO. Introduction of a chesttube should therefore be regarded as a high risk intervention in VV-ECMO patients.

Global TB control efforts have been severely hampered by the lack of diagnostic tests that are accurate, simple to use and can be applied at the point of clinical care. This has been further compounded by the widespread inability to test for drug resistance. We estimated the performance Characteristics of GenXpert MTB/rif of an active case finding program in Armenia where TB notifications is high. Armenia remains in the top ten out of the 27 high multidrug-resistant (MDR) TB burden countries in the world. According to the latest representative 2007 Drug Resistance Survey (DRS) 9.4% of new cases and 43.2% of previously treated cases were multi-drug resistant. Of these, 4% were extensively-drug-resistant tuberculosis (XDR/TB) cases. Detection of MDR-TB in Armenia remains at 37%. Despite of the fact that in 2013 all detected MDR-TB cases were enrolled in MDR-TB treatment, treatment success rate among 2011 MDR-TB cohort remains 51%, with 26% of patients defaulted therapy mostly due to labour migration, as the main reason of poor outcomes. Moreover, this can be accomplished using unprocessed sputum samples as well as clinical specimens from extrapulmonary sites. We review the development of this assay, its evaluation within the laboratory, its utility among adult and pediatric TB suspects, its use as a screening tool for HIV-associated TB and studies of its implementation at the central level. The Xpert® MTB/RIF assay is a rapid molecular assay that can be used close to the point of care by operators with minimal technical expertise, enabling diagnosis of TB and simultaneous assessment of rifampicin resistance to be completed within 2 h.

Objective: Cost-effectiveness analysis of the major tobacco control tools medium long term.

Method: This is a retrospective, descriptive study of the results obtained after analyzing the sample of all patients who attended the Unit Specialized Treatment Smoking during two years. Without drug treatment: the costs and effectiveness of the four options used in our Unit for smoking cessation compared: 1) Bupropion+ NRT, 2) Varenicline, 3) Varenicline and NRT and 4) No pharmacology treatment.

Costs and efficiency: Efficiencies rates for comparison are the result of our study for the 4 options. All costs are expressed in euros, both costs and an effect beyond the first year rate of 3.5% per annum is deducted.

Results: Of the 559 patients, 32.7% received no treatment. 34.5% (n=194) of patients was treated with NRT (gum, patches or in combination with varenicline). Varenicline is the second most frequently used drug with 22.9% and, finally, bupropion (9.8%). The analysis results show that the greater efficacy of varenicline is a better cost/effectiveness (C/E) in the treatment of smoking medium to long term that comes to fully offset the higher cost of treatment compared to the other options. So both varenicline monotherapy as associated with TSN have average costs of € 2.491,21 and € 2.432,22 per patient who quit smoking compared to the other options with Bupropion and TSN 4.136,55 € or drug treatment to 5.783,88 € in a perspective of two years.

Conclusion: The option of giving Varenicline is a better cost/effectiveness (C/E) in the treatment of smoking-half longer than the other options.

Background: Insertion of a chest tube is a potentially dangerous procedure in cases of pneumothorax. Different chest tube insertion techniques have been described. In a trauma setting, surgical approach should be aimed at diminishing the number of complications. Even though simulation-based training has facilitated enhanced performance of this procedure, no assessment scale has been published to date.

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Objective: The objective of this study was to design and validate a performance assessment scale for surgical chest tube insertion in traumatic pneumothorax.

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Methods: The scale content (8 steps, 20 items with a total over 20) was designed by three experts on the basis of international recommendations and Advanced Trauma Life Support courses, and adjusted after testing on 9 senior physicians. 104 participants were included for psychometric analysis of the scale. The model employed was a previously developed surgical chest tube insertion simulator. Assessment was carried out by two independent observers chosen from among a group of 6.

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Results: Mean score of participants registered to the university course was 13.51 ± 3.36 (n=104). Cronbach alpha was 0.747 and intraclass coefficient was 0.966 reflecting respectively good coherence and excellent interobserver reproducibility. The score was able to conclusively discriminate between success and failure of insertion (p<0.0001). Both assessment scores and success rates were found to correlate with level of training (Rho=0.76 and 0.66 respectively, p<0.0001).

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Conclusion: This performance assessment scale was found to be consistent and reliable for surgical chest tube insertion procedure in traumatic pneumothorax. It may constitute a useful tool for assessment of the performance of participants in simulation-based education setting.

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Bevacizumab is an emerging therapy with widespread use in the treatment of advanced malignancies. We describe a young female with metastatic breast cancer that underwent stereotactic body radiation during treatment with bevacizumab after the discovery of a new metastatic focus within the lung parenchyma. Approximately one year later she presented with a progressive foul smelling cough and dyspnea. Bronchoscopy revealed extensive necrotic destruction of the bronchus intermedius. Airway necrosis may be a rare adverse event associated with the use of bevacizumab, especially with concomitant radiotherapy.

Amiodarone, a common and efficacious antiarrhythmic agent, carries with it an array of serious side effects, most notably, amiodarone induced pulmonary toxicity, or APT. Patients typically present with dyspnea, and chest X-rays will show interstitial infiltrates. In severe cases, toxicity can lead to fibrosis and even respiratory failure. In this report, such effects are demonstrated based on the case of an 85 year old female who presented with multiple hospital admissions for multilobar pulmonary infiltrates and acute hypoxic respiratory failure, which did not respond to antibiotic therapy. She had, at the time of admission, been on amiodarone for over 2 years. The patient’s amiodarone was discontinued, and she was started on prednisone. The patient displayed a significant clinical and radiographic improvement within 4 weeks. In patients with pulmonary infiltrates of unclear etiology who are on amiodarone, APT should be considered in the differential diagnosis. At this time, no specific diagnostic test for APT exists, and therefore clinical management must rely on a combination of clues gleaned from the medical history, diagnostic imaging, and a systematic exclusion of other differential diagnoses. A high index of suspicion is required to make the diagnosis of amiodarone pulmonary toxicity.

Sleep disturbances are common in patients with chronic pain syndrome, and coexistent obstructive sleep apnea (OSA) in such patients could further compromise the quality of sleep and increase sleep fragmentation. Here we present an unusual case of profound increase in slow wave sleep as noted during the sleep study and discuss the potential causes for this observed polysomnograhic phenomenon.

Background and objectives: Sarcoidosis is an inflammatory disease that affects multiple organs including the muscles which may lead to physical intolerance. The 6 minute walking test (6MWT) is a method that is frequently used to assess physical capacity in these patients. The aim of this study is to investigate 6MWT results in sarcoidosis patients with different radiographic stages, medication therapy, and spirometric parameters.

Materials and methods: We assessed 6MWD and oxygen desaturation as outcome measure of 6MWT in 71 sarcoidosis patients categorized into four groups according to Scadding criteria .we also compared 6MWD among 30 patients based on the medication therapy in three groups 1) prednisolone 2) prednisolone plus methotrexate 3) hydroxychloroquine plus prednisolone). Also, correlation between 6MWD and spirometric parameters results including FEV1, FEV1/FVC were investigated in 24 patients.

Results: There was statically significant correlation between oxygen desaturation and sarcoidosis severity; but, in spite of finding a tendency in more severe sarcoidosis stages to walk shorter distance the correlation between 6MWD and sarcoidosis severity was not significant. In exploring 6MWD among different medication groups it turned out that patients who were taking methotrexate and prednisolone tended to walk shorter distance in comparison to patients were taking prednisolone alone.

Conclusion: Oxygen desaturation during 6MWT is another measure outcome of this test which would be recommended to be considered in assessing sarcoidosis severity. 6MWT can be considered not only to help assess sarcoidosis expansion in body but also help in better medication choose in these patients.

Purpose: Lung cancer is the most common incident cancer worldwide, accounting for 13% of all cancers. With decreasing burden of infectious diseases and increasing life expectancy in Africa, this study sought to identify risk factors for lung cancer and suggest mitigation strategies for implementation.

Methods: Lung cancer incidence rates for the different regions of Africa were determined using data from GLOBOCAN (2012) and risk factors were determined through an extensive literature review.

Results: Males have higher lung cancer incidence rates than females in all regions of Africa. The combined male and female incidence rates for Middle, Eastern, and Western Africa, were lower than those observed in Southern and Northern Africa. The incidence rates of lung cancer were highest in Southern Africa (18.5 per 100,000) followed by France La Reunion (17.6 per 100,000). Smoking was the most common risk factor studied followed by occupational/ environmental risk factors, and infectious agents (e.g., HIV). A limited number of candidate gene studies have evaluated the genetic susceptibility to lung cancer in these populations. Not all regions of Africa have had research studies published on the etiologic risk factors of lung cancer.

Conclusions: The lung cancer incidence rates are lower in Africa compared to incidence rates elsewhere, possibly due to a true lack of cases or detection biases. There is limited data on lung cancer (particularly risk factors) in Africa, especially Central, Eastern and Western Africa, pointing out the need for more research, prior to considering targeted mitigation policies.