Aylin Ozsancak Ugurlu

Clinical, radiologic, and functional evaluation of 304 patients with bronchiectasis

BACKGROUND: Bronchiectasis continues to be one of the major causes of morbidity and mortality in developing countries, with a probably underestimated higher prevalence than in developed countries. OBJECTIVE: To assess the clinical profile of adult patients with bronchiectasis. METHODS: We retrospectively reviewed the clinical, radiologic, and physiologic findings of 304 patients with bronchiectasis confirmed by high-resolution computed tomography. RESULTS: Mean age of participants (45.7% males, 54.3% females) was 56 ± 25 years and 65.8% of them were lifetime non-smokers. Most common identified causes of bronchiectasis were childhood disease (22.7%), tuberculosis (15.5%), and pneumonia (11.5%). The predominant symptoms were productive cough (83.6%), dyspnea (72%), and hemoptysis (21.1%). The most common findings on chest examination were crackles (71.1%) and rhonchi (28.3%). Types of bronchiectasis were cylindrical in 47%, varicose in 9.9%, cystic in 45.1%, and multiple types in 24.3%. Involvement was multilobar in 75.3% and bilateral in 62.5%. Of 274 patients, 20.8% displayed normal pulmonary function test results, whereas 47.4%, 8% and 23.7% showed obstructive, restrictive, and mixed pattern, respectively. Patients with cystic disease had a higher frequency of hemoptysis (42%) and a greater degree of functional impairment, compared to other types. CONCLUSION: In patients with bronchiectasis from southern Turkey, generally presenting with recurrent productive cough, hemoptysis, dyspnea, and persistent bibasilar rales, the etiology remains mainly idiopathic. Post-infectious bronchial destruction is one of the major identified underlying pathological processes. The clinical picture and the deterioration of the pulmonary function test might be more severe in patients with cystic type bronchiectasis.

Use and outcomes of noninvasive positive pressure ventilation in acute care hospitals in Massachusetts.

BACKGROUND This study determined actual utilization rates and outcomes of noninvasive positive pressure ventilation (NIV) at selected hospitals that had participated in a prior survey on NIV use. METHODS This observational cohort study, based at eight acute care hospitals in Massachusetts, focused on all adult patients requiring ventilatory support for acute respiratory failure during predetermined time intervals. RESULTS Of 548 ventilator starts, 337 (61.5%) were for invasive mechanical ventilation and 211 (38.5%) were for NIV, with an overall NIV success rate of 73.9% (ie, avoidance of intubation or death while on NIV or within 48 h of discontinuation). Causal diagnoses for respiratory failure were classified as (I) acute-on-chronic lung disease (23.5%), (II) acute de novo respiratory failure (17.9%), (III) neurologic disorders (19%), (IV) cardiogenic pulmonary edema (16.8%), (V) cardiopulmonary arrest (12.2%), and (VI) others (10.6%). NIV use and success rates for each of the causal diagnoses were, respectively, (I) 76.7% and 75.8%, (II) 37.8% and 62.2%, (III) 1.9% and 100%, (IV) 68.5% and 79.4%, (V) none, and (VI) 17.2% and 60%. Hospital mortality rate was higher in patients with invasive mechanical ventilation than in patients with NIV (30.3% vs 16.6%, P < .001). CONCLUSIONS NIV occupies an important role in the management of acute respiratory failure in acute care hospitals in selected US hospitals and is being used for a large majority of patients with acute-on-chronic respiratory failure and acute cardiogenic pulmonary edema. NIV use appears to have increased substantially in selected US hospitals over the past decade. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT00458926; URL: www.clinicaltrials.gov.

Use and Outcomes of Noninvasive Ventilation for Acute Respiratory Failure in Different Age Groups.

BACKGROUND: The prevalence of chronic disease and do-not-intubate status increases with age. Thus, we aimed to determine characteristics and outcomes associated with noninvasive ventilation (NIV) use for acute respiratory failure (ARF) in different age groups. METHODS: A database comprising prospective data collected on site on all adult patients with ARF requiring ventilatory support from 8 acute care hospitals in Massachusetts was used. RESULTS: From a total of 1,225 ventilator starts, overall NIV utilization, success, and in-hospital mortality rates were 22, 54, and 18% in younger (18–44 y); 34, 65, and 13% in middle-aged (45–64 y); 49, 68, and 17% in elderly (65–79 y); and 47, 76, and 24% in aged (≥80 y) groups, respectively (P < .001, P = .08, and P = .11, respectively). NIV use for cardiogenic pulmonary edema and subjects with a do-not-intubate order increased significantly with advancing age (25, 57, 57, and 74% and 7, 12, 18, and 31%, respectively, in the 4 age groups [P < .001 and P = .046, respectively]). For subjects receiving NIV with a do-not-intubate order, success and in-hospital mortality rates were similar in different age groups (P = .27 and P = .98, respectively). CONCLUSIONS: NIV use and a do-not-intubate status are more frequent in subjects with ARF ≥65 y than in those <65 y, especially for subjects with cardiogenic pulmonary edema. However, NIV success and mortality rates were similar between age groups. (ClinicalTrials.gov registration NCT00458926.)

Cardiotoxicity following cyclophosphamide therapy: a case report

Introduction Cardiac toxicity is one of the life-threatening complications of cancer therapy. Systemic anticancer treatments may exert their own toxic effects or can aggravate adverse effects of other drugs. We report a case of cyclophosphamide-induced cardiotoxicity in a patient with normal cardiac functions before chemotherapy. Case presentation A 66-year-old Caucasian woman with a mediastinal mass diagnosed with Burkitt lymphoma underwent chemotherapy with rituximab-hyperfractionated-cyclophosphamide-vincristine-doxorubicin-dexamethasone. On the seventh day of chemotherapy, she developed dyspnea. An electrocardiogram demonstrated low voltage in the limb and precordial leads. It also showed diffusely increased myocardial echogenicity, mild pericardial and pleural effusion, generally impaired biventricular systolic functions with a left ventricular ejection fraction of 31%, and right ventricular mid-apical akinesia, even though she had normal biventricular functions before chemotherapy. Cyclophosphamide-induced cardiotoxicity was suspected and she was given treatment for congestive heart failure. Her dyspnea decreased and she was discharged on the tenth day with a left ventricular ejection fraction of 37% and normal right ventricular function. After 1 month, echocardiography showed normal biventricular functions with a left ventricular ejection fraction of 60%. Conclusions Drug-induced cardiotoxicity, therefore, should be taken into consideration when using cyclophosphamide therapy, especially when anthracyclines are co-administered. Close communication between hematologists and cardiologists is required.IntroductionCardiac toxicity is one of the life-threatening complications of cancer therapy. Systemic anticancer treatments may exert their own toxic effects or can aggravate adverse effects of other drugs. We report a case of cyclophosphamide-induced cardiotoxicity in a patient with normal cardiac functions before chemotherapy.Case presentationA 66-year-old Caucasian woman with a mediastinal mass diagnosed with Burkitt lymphoma underwent chemotherapy with rituximab-hyperfractionated-cyclophosphamide-vincristine-doxorubicin-dexamethasone. On the seventh day of chemotherapy, she developed dyspnea. An electrocardiogram demonstrated low voltage in the limb and precordial leads. It also showed diffusely increased myocardial echogenicity, mild pericardial and pleural effusion, generally impaired biventricular systolic functions with a left ventricular ejection fraction of 31%, and right ventricular mid-apical akinesia, even though she had normal biventricular functions before chemotherapy. Cyclophosphamide-induced cardiotoxicity was suspected and she was given treatment for congestive heart failure. Her dyspnea decreased and she was discharged on the tenth day with a left ventricular ejection fraction of 37% and normal right ventricular function. After 1 month, echocardiography showed normal biventricular functions with a left ventricular ejection fraction of 60%.ConclusionsDrug-induced cardiotoxicity, therefore, should be taken into consideration when using cyclophosphamide therapy, especially when anthracyclines are co-administered. Close communication between hematologists and cardiologists is required.

Home Noninvasive Ventilation to Reduce Readmissions for Chronic Obstructive Pulmonary Disease

The use of long-term noninvasive ventilation (NIV) to benefit patients with severe chronic obstructive pulmonary disease (COPD) has long been controversial. Dating back to the 1960s, clinicians speculated that intermittent respiratory muscle rest afforded by negative pressure ventilators might benefit daytime respiratory muscle performance of patients with severe COPD.1 However, use of this approach was generally abandoned in the early 1990s when a large randomized clinical trial using a “jacket” negative pressure ventilator nocturnally showed no improvement in exercise endurance or respiratory muscle strength in patients with severe COPD, and acceptance of the device by patients was poor.2 Subsequent studies have used noninvasive positive pressure ventilation (NPPV) because of portability and convenience advantages over negative pressure ventilation as well as elimination of the tendency to induce upper airway obstruction.3 Results of these studies have been conflicting; some have yielded negative findings,4,5 whereas others have demonstrated improvements in dyspnea and quality of life, a trend toward reduced hospitalization,6 and less mortality, but only after adjustment for confounders and in association with worse quality of life.7 A 2013 Cochrane review of long-term NIV for COPD concluded that there was no evidence of significant benefit in any of the measured indices, although study sample sizes were small.8 In 2014, 2 well-designed randomized clinical trials comparing NPPV with standard treatment were published, one reporting favorable findings and the other negative. Köhnlein et al9 reported a significant reduction in 12-month mortality from 33% in the standard therapy group to 12% in the NPPV group as well as improvements in daytime PaCO2, exercise capacity, and quality of life. Study participants were required to have stable hypercapnia (PaCO2 >51.9 mm Hg) and the enrollment of 196 patients took 7 years at 39 centers. The authors suggested that the favorable outcomes were related to their use of “increased ventilator pressures” (mean pressure, 21.6 cm H2O inspiratory and 4.8 cm H2O expiratory) targeted to achieve a 20% reduction in PaCO2 during an initial session. In the other study, Struik et al10 enrolled 201 patients with severe COPD who were hospitalized with respiratory failure and persistent hypercapnia (PaCO2 >45 mm Hg) after at least 48 hours without ventilation. After 1 year, readmission rates, deaths (approximately 30% in each group), frequency of exacerbations, lung function, and quality of life were not significantly different between the 2 groups. Ventilator pressures were similar to the study by Köhnlein et al9 and PaCO2 levels declined slightly more in the NPPV group to equivalent mild levels of hypercapnia. Into this background comes the home oxygen therapy plus home NIV study performed at 13 centers in the United Kingdom and reported by Murphy and colleagues11 in JAMA. The authors enrolled 116 patients based on resolution of acidosis (pH >7.30) and persistent hypercapnia (PaCO2 >53 mm Hg) and hypoxemia (PaO2 <55 mm Hg and >30% of sleep spent with <90% oxygen saturation as measured by pulse oximetry) for at least 2 weeks but not for more than 4 weeks after hospital admission for an episode of acutely decompensated COPD requiring NPPV. Noninvasive ventilation was initiated using a “high pressure strategy”12 with mean inspiratory pressure of 24 cm H2O and expiratory pressure of 4 cm H2O. The primary outcome of time to readmission or death within 12 months was significantly improved for the home oxygen therapy plus home NIV group, with median time to readmission or death of 4.3 months compared with 1.4 months in the home oxygen therapy alone group. The difference in the estimated 1-year risk of readmission or death was 17.0% (63.4% in the home oxygen plus home NIV group vs 80.4% in the home oxygen alone group), whereas 1-year mortality was not significantly different between the groups; 16 deaths (28%) in the home oxygen plus home NIV group and 19 deaths (32%) in home oxygen alone group. Other outcomes included reduced transcutaneous PaCO2 and exacerbations in the home oxygen plus home NIV group and a better quality-of-life score but only at the 3-month time point. The authors concluded that addition of home NIV to home oxygen “should be considered” if patients with severe COPD have persistent hypercapnia after a life-threatening exacerbation. Strengths of the trial by Murphy and colleagues11 are the randomized design and a well-specified ventilator regimen. In addition, adherence with the home NIV therapy was reasonably good (4.7 hours per night at 6 weeks and 7.6 hours per night at 12 months). Some concerns include the lack of blinding, which is a universal problem with NIV studies. As the authors point out, sham controls are problematic due to possible adverse effects on dead space and sleep quality and because the differences in mask pressures during NPPV use vs sham are obvious. The high number of crossovers (18 patients) from the home oxygen alone group to the home oxygen plus home NIV group is also a concern, but because 17 of these crossovers occurred after the primary outcome was Related article Opinion

Effects of biomass smoke on pulmonary functions: a case control study

Background Biomass smoke is the leading cause of COPD in developing countries such as Turkey. In rural areas of Turkey, females are more exposed to biomass smoke because of traditional lifestyles. Aim The aim of this study was to determine the adverse effects of biomass smoke on pulmonary functions and define the relationship between duration in years and an index (cumulative exposure index) with altered pulmonary function test results. Participants and methods A total of 115 females who lived in the village of Kağizman (a borough of Kars located in the eastern part of Turkey) and were exposed to biomass smoke were included in the study. The control group was generated with 73 individuals living in the same area who were never exposed to biomass smoke. Results Twenty-seven (23.8%) females in the study group and four (5.5%) in the control group had small airway disease (P=0.038). Twenty-two (19.1%) females in the study group and ten (13.7%) in the control group had obstruction (P=0.223). Twenty (17.3%) females in the study group who were exposed to biomass smoke had restriction compared with ten (13%) in the control group (P=0.189). The duration needed for the existence of small airway disease was 16 years, for obstructive airway disease was 17 years, and for restrictive airway disease was 17 years. The intensity of biomass smoke was defined in terms of cumulative exposure index; it was calculated by multiplying hours per day, weeks per month, and total years of smoke exposure and dividing the result by three. Conclusion Exposure to biomass smoke is a serious public health problem, especially in rural areas of developing countries, because of its negative effects on pulmonary functions. As the duration and the intensity of exposure increase, the probability of having altered pulmonary function test results is higher.

Epidemiology of NIV for Acute Respiratory Failure in COPD Patients: Results from the International Surveys vs. the “Real World”

ABSTRACT Non-invasive ventilation (NIV) has been recommended as the first-line ventilation modality for acute respiratory failure (ARF) due to acute exacerbation of chronic obstructive pulmonary disease (AECOPD) based on strong evidence. However, everyday clinical practice may differ from findings of multiple randomized controlled trials. Physicians and respiratory therapists involved in NIV management have been queried about its utilization and effectiveness. In addition to these estimates, cohort studies and analysis of large inpatient dataset of patients with AECOPD and ARF managed with NIV have been extensively published over the last two decades. This review summarizes the perception of medical staff vs. the “real life” data about NIV use for ARF in AECOPD patients.

Results of Polysomnographies and Treatment Strategies in Elderly Patients with Symptoms of Obstructive Sleep Apnea Syndrome

OBJECTIVES In this study, we evaluated data regarding the management of geriatric patients with symptoms of obstructive sleep apnea syndrome (age, >65 years) who were admitted to our sleep clinic. MATERIAL AND METHODS Symptoms and sleep data of the patients were retrospectively evaluated, and the patients were reevaluated after treatment. RESULTS A total of 85 patients with a median age of 69 years were included. Snoring and fatigue were the most common symptoms. Cardiovascular diseases were the most frequently listed comorbidity. The median Epworth sleepiness scale was 10, and based on Berlin sleep questionnaire findings, 63.5% of the participants were in the high-risk group. Eighty-seven percent were diagnosed with obstructive sleep apnea (2/3 of them were positional), and moderate-to-severe obstructive sleep apnea was observed more in women than in men. Only one patient was diagnosed with central sleep apnea. There were positive and linear correlations between increased age and the apnea-hypopnea index, arousal index, Epworth sleepiness scale, and being in a high-risk group according to the Berlin sleep scale; however, there was no correlation between increased age and the number of hypopnea and apnea events. There were also positive and linear correlations between the apnea-hypopnea index and the Epworth sleepiness scale, being in a high-risk group according to the Berlin sleep questionnaire, an increased number of known medical conditions, and increased body mass index. We were able to contact 72 of the 85 patients via phone calls. Patients who adjusted to treatment had positive feedbacks. CONCLUSION Sleep disorders are observed more in the elderly, and an increasing age is an independent factor for sleep disorders. Besides the usual signs and symptoms of sleep disorders, it should be considered in elderly who have cognitive dysfunction and dementia.

Telemonitoring of CPAP Compliance: Key Technical Topics and Clinical Implications

The use of telemonitoring to transmit digital data and, therefore, to assist in the provision of better care and adherence to management outside the hospital in patients with chronic respiratory diseases, seems feasible. This chapter reviews different clinical implications of telemonitoring for patients receiving noninvasive ventilation and outcomes in terms of patients’ compliance.

Sirolimus induced diffuse alveolar hemorrhage: A case report

Sirolimus, mammalian targets of the Rapamycin, is responsible for inhibition of T and B cell proliferation, and usually. Recently we treated a 33 year old renal transplant reciepent with sirolimus induced diffuse alveolar hemorrhage. She was first diagnosed with pneumonia and underwent antibiotic therapy. In her radiological images there was bilateral diffuse patchy infiltration. In the 48th hour of antibiotic treatment her fever and inflammatory markers were still high, and afterwards, bronchoscopy was performed. Pathology result of the patient was reported as hemosiderin-loaded macrophages, eosinophil predominancy and few lymphocytes . Our final diagnosis was diffuse alveolar hemorrhage due to sirolimus. We discontinued sirolimus and started pulse steroid (1 gr/day methylprednisolon) for three days. In the following period her oxygen supply declined immediately and clinical condition of the patient got better. After two weeks we disharged the patient, continued methylprednisolon treatment in 1mg/kg/day dosage. By tapering the dose slowly we planned 6 months of steroid treatment. During her follow ups, pulmonary symptoms and radiological images got better.