Anabela Marinho

Prevalence and characteristics of sleep apnoea in patients with stable heart failure: Results from a heart failure clinic

BackgroundHeart failure (HF) and sleep apnoea (SA) association has been recognized but whether it results from confounding factors (hypertension, ischaemia, obesity) remains unclear.We aimed to determine the prevalence of SA in HF and to identify potential risk factors for SA in HF population.MethodsWe prospectively evaluated 103 patients with stable HF on optimized therapy. In-laboratory polysomnography was performed. Type and severity of SA were defined according international criteria. Demographic, anthropometric and clinical characteristics were collected. Continuous data are expressed as median and interquartile range.ResultsSA was found in 72.8%, moderate to severe in a significant proportion (apnoea-hypopnoea index ≥ 15- 44.7% of all patients) and predominantly obstructive (60.0% of patients with SA). Most patients were non-sleepy (Epworth < 10- 66%). SA patients were predominantly men (85.3 vs 60.7%, p-0.015), had larger neck (38.0 (35.0-42.0) vs 35.0 (33.2-38.0) cm, p-0.003), severe systolic dysfunction, (63.9 vs 33.3%, p-0.018), left ventricle (LV) hypertrophy (16.2 vs 0.0%, p-0.03), LV and left atria (LA) dilatation (49.0 (44.0-52.0) vs 42.0 (38.0-48.0) mm, p < 0.001; 60.0 (54.0-65.0) vs 56.0 (52.0-59.0) mm, p-0.01). However, only LA diameter was an independent predictor of SA. Higher body-mass index (BMI) was associated with moderate to severe SA. Patients with obstructive SA had larger neck and a trend for higher BMI, snoring and sleepiness. Hypocapnia was not associated with central SA.ConclusionsIn our HF population, SA was prevalent, frequently asymptomatic and without characteristic risk factors. Unlike previously reported, obstructive SA was the predominant type. These results suggest that SA is underdiagnosed in HF and there is a possible correlation between them, independent of confounding factors. Recent advances in HF therapy might influence prevalence and type of SA in this population.

Indications and Compliance of Home Mechanical Insufflation-Exsufflation in Patients with Neuromuscular Diseases

Introduction: Neuromuscular disease (NMD) patients frequently have impaired cough. Mechanical insufflation-exsufflation (MI-E) has proven efficacy in improving airway clearance, however data related to its long-term home use is lacking. The purpose of this study was to describe indications, safety and compliance of home MI-E in NMD patients. Methods: Four years observational analysis of 21 NMD patients on home MI-E. Diagnosis included bulbar and non-bulbar Amyotrophic Lateral Sclerosis (ALS) and other NMD. Median age was 58 years. Only cooperative patients with unassisted baseline Peak Cough Flow (PCF) < 270 L/min were included. All patients were under continuous mechanical ventilation (6 by tracheostomy). Pulmonary function before initiation of MI-E (median): FVC = 0.81 L, MIP = 28 cmH2O, MEP = 22 cmH2O and PCF = 60 L/min. MI-E was performed by previously trained non-professional caregivers, with an on-call support of a trained health care professional. Patients had pulse oximetry monitorization and applied MI-E whenever SpO2 < 95 %. Median follow-up was 12 months (3-41 months). Results: Ten patients (9 ALS) used MI-E daily. Eleven patients used MI-E intermittently, during exacerbations, and in 8 patients early application of MI-E (guided by oximetry feed-back) avoided hospitalization. All tracheostomized patients used MI-E daily and more times a day than patients under NIV. Four patients (3 bulbar ALS), were hospitalized due to secretion encumbrance. MI-E was well-tolerated and there were no complications. In general, caregivers considered MI-E effective. During this period, 4 patients died, related to disease progression. Conclusions: Home MI-E is well tolerated, effective and safe if used by well trained caregivers. MI-E should be considered as a complement to mechanical ventilation.

Indicaciones y cumplimiento con la insuflación-exuflación mecánica domiciliaria en pacientes con enfermedades neuromusculares

INTRODUCTION Neuromuscular disease (NMD) patients frequently have impaired cough. Mechanical insufflation-exsufflation (MI-E) has proven efficacy in improving airway clearance, however data related to its long-term home use is lacking. The purpose of this study was to describe indications, safety and compliance of home MI-E in NMD patients. METHODS Four years observational analysis of 21 NMD patients on home MI-E. Diagnosis included bulbar and non-bulbar Amyotrophic Lateral Sclerosis (ALS) and other NMD. Median age was 58 years. Only cooperative patients with unassisted baseline Peak Cough Flow (PCF) <270 L/min were included. All patients were under continuous mechanical ventilation (6 by tracheostomy). Pulmonary function before initiation of MI-E (median): FVC=0.81 L, MIP=28cmH(2)O, MEP=22 cmH(2)O and PCF=60 L/min. MI-E was performed by previously trained non-professional caregivers, with an on-call support of a trained health care professional. Patients had pulse oximetry monitorization and applied MI-E whenever SpO(2)<95%. Median follow-up was 12 months (3-41 months). RESULTS Ten patients (9 ALS) used MI-E daily. Eleven patients used MI-E intermittently, during exacerbations, and in 8 patients early application of MI-E (guided by oximetry feed-back) avoided hospitalization. All tracheostomized patients used MI-E daily and more times a day than patients under NIV. Four patients (3 bulbar ALS), were hospitalized due to secretion encumbrance. MI-E was well-tolerated and there were no complications. In general, caregivers considered MI-E effective. During this period, 4 patients died, related to disease progression. CONCLUSIONS Home MI-E is well tolerated, effective and safe if used by well trained caregivers. MI-E should be considered as a complement to mechanical ventilation.

Non-invasive ventilation in acute respiratory failure related to 2009 pandemic Influenza A/H1N1 virus infection

Non-invasive ventilation (NIV) is considered first-line intervention for different causes of acute respiratory failure [1]. However, Rello and colleagues [2] show high rates of NIV failure in pandemic Influenza A/H1N1 virus infection (PH1N1). We describe a patient with PH1N1 in whom NIV was effective. A 53-year-old male was admitted in November 2009 with cough, dyspnea, and hemoptysis. His temperature was 38.9°C, he was tachypneic, with diffuse rhonchi and bilateral crackles, and oxygen saturation was 96% (4 L/min oxygen). Arterial partial pressure of oxygen (PaO2) and arterial partial pressure of carbon dioxide (PaCO2) were 76 and 23 mm Hg, respectively. Creatine kinase (2,278 U/L) and brain natriuretic peptide (3,544 pg/mL) were increased. Acute myocardial infarction was excluded. Chest x-ray showed bilateral interstitial infiltrates and cardiomegaly. Echocardiogram showed severe left ventricular systolic dysfunction. PH1N1 pneumonia was suspected, and oseltamivir was administered in association with antibiotics and diuretics. On day 2, a nasopharyngeal swab was positive for PH1N1. The patient was subsequently transferred to a negative-pressure ward. He was still tachypneic, with basal crackles and a PaO2/fraction of inspired oxygen (FiO2) ratio of 246. NIV (BiPAP Vision; Philips Respironics, Murrysville, PA, USA) through an oro-nasal mask inbilevel positive airway pressure mode (inspiratory positive airway pressure [IPAP] = 16 cm H2O, expiratory positive airway pressure [EPAP] = 8 cm H2O) was started. Due to patient preference, the mode was changed to continuous positive airway pressure (CPAP) at 10 cm H2O and an FiO2 of 25%. After 1 hour, PaO2/FiO2 increased to 364, and CPAP was stopped after 12 hours. Recently, Djibre and colleagues [3] demonstrated the effectiveness of NIV in acute respiratory distress syndrome related to PH1N1 pneumonia. Our case further supports its role in a hypoxemic patient with cardiogenic pulmonary edema and PH1N1 pneumonitis.

Nontuberculous mycobacteria in respiratory specimens: clinical significance at a tertiary care hospital in the north of Portugal

1. Intern in the Department of Pulmonology, Sao Joao Hospital Center, EPE, Porto, Portugal. 2. Attending Physician. Department of Pulmonology, Sao Joao Hospital Center, EPE, Porto, Portugal. 3. Attending Physician. Department of Clinical Pathology, Sao Joao Hospital Center, EPE, Porto, Portugal. Nontuberculous mycobacteria (NTM) are ubiquitous in the human environment, and more than 150 NTM species have been described to date.(1) When inhaled by susceptible individuals, such as those with chronic lung disease, NTM can lead to chronic, progressive, and sometimes fatal respiratory symptoms. Over the last three decades, the incidence of NTM laboratory isolation and related lung disease has been increasing, surpassing that of tuberculosis in some areas.(1,2) However, the isolation of NTM from respiratory specimens might be due to contamination of specimens or colonization of patients that is transient, not necessarily indicating disease.(1) Here, we report the incidence of NTM isolation in the Pulmonology Department of the Sao Joao Hospital Center, a tertiary care university hospital located in Porto, the second most populous city in Portugal. It is the largest hospital in the northern region and one of the three largest in the country. We retrospectively analyzed patients who were seronegative for HIV and for whom NTM had been isolated in at least one respiratory specimen between January of 2008 and December of 2012. The samples were decontaminated with the N-acetyl-L-cysteine-sodium hydroxide method and inoculated into Middlebrook 7H9 broth medium (BBL Mycobacteria Growth Indicator Tube [MGIT]; Becton Dickinson, Franklin Lakes, NJ, USA), in accordance with the manufacturer instructions. Positive cultures, incubated and monitored in an automated culture system (BACTEC MGIT 960; Becton Dickinson), were examined by smear microscopy with Kinyoun staining for AFB. In the presence of AFB, we used a molecular assay for common mycobacteria and additional species (GenoType Mycobacterium CM/ AS; Hain Lifescience GmbH, Nehren, Germany), in accordance with the manufacturer instructions, to determine the species of the isolates. Demographic, clinical, radiological, and microbiological data were collected. The clinical relevance of the isolation in the respiratory sample was defined in accordance with the current American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) criteria.(3) Two hundred and two patients were included in this study. Of those, 118 (58%) were male. The mean age was 64 years (range, 23-89 years). The main risk factors identified were the underlying structural lung disease, such as COPD, in 73 patients (36%), bronchiectasis, in 62 (31%), and tuberculosis sequelae, in 40 (20%); and nonpulmonary conditions, such as diabetes mellitus, in 18 patients (9%), gastroesophageal reflux disease, in 16 (8%), and receiving immunosuppression therapy, in 12 (6%). Data on environmental exposure were not available. A total of 407 isolates were obtained, and the species were identified in 378 (93%). Of the 407 isolates, 237 (58%) were identified as being within the Mycobacterium avium complex (MAC) group and 141 (35%) were identified as belonging to one of 11 other Mycobacterium species, the remaining 29 (7%) being identified as mycobacteria but not down to the species level (Table 1). These isolates were obtained from sputum samples in 192 (95%) of the patients, bronchial lavage fluid samples in 13 (6%), BAL fluid samples in 7 (4%), a lung biopsy sample in 1 (0.5%), and a gastric aspirate sample in 1

Aspergilosis pulmonar nodular, ¿todavía supone un desafío?

te do y pequeñas bronquiectasias cilíndricas en el lóbulo medio del pulmón derecho. La broncoscopia fue normal, la citología y los cultivos del líquido del lavado bronquial fueron negativos y la arteriografía bronquial no mostró cambios. La biopsia por aspiración transtorácica (BAT) reveló unas estructuras fúngicas, que se identificaron como Aspergillus fumigatus (AF) (fig. 1E). Las serologías de AF y VIH-1 y 2 fueron negativas y las poblaciones linfocitarias y las concentraciones de inmunoglobulinas séricas resultaron normales. Se inició tratamiento con voriconazol (200 mg, 2 veces al día), pero se suspendió unos 2 meses más tarde porque se detectó toxicidad hepática en la paciente. La TAC practicada en aquel momento (fig. 1B) mostró una reducción del tamaño del nódulo (17 mm). Tras la resolución de la toxicidad hepática (al cabo de un mes), la paciente inició tratamiento antifúngico con itraconazol (200 mg, 2 veces al día). Dos meses más tarde, el nódulo había aumentado de tamaño (27 mm) y se había cavitado (fig. 1C). La repetición de la broncoscopia con lavado broncoalveolar y la BAT no aportaron más información. El voriconazol se reintrodujo gradualmente y, cinco meses más tarde, la TAC solamente mostraba cambios fibróticos (fig. 1D), pero las enzimas hepáticas habían aumentado de nuevo y 2. Bawa P, Soontarapornchai K, Perenyi A, Goldfisher R, Amodio J. Developm of localized pulmonary interstitial emphysema in a late preterm infant with mechanical ventilation. Case Rep Pediatr. 2014;2014:429797. 3. Barcia SM, Kukreja J, Jones KD. Pulmonary interstitial emphysema in adults clinicopathologic study of 53 lung explants. Am J Surg Pathol. 2014;38:339–4 4. Sherren PB, Jovaisa T. Pulmonary interstitial emphysema presenting in a wom on the intensive care unit: Case report and review of literature. J Med Case R 2011;5:236.