Jacek Nasiłowski

Incidence and aetiology of eosinophilic pleural effusion

Although eosinophilic pleural effusion (EPE) has been a subject of numerous studies, its clinical significance still remains unclear. The aim of our study was to evaluate: 1) the relative incidence and aetiology of EPE; 2) the predictors of malignancy in patients with EPE; and 3) the relationship between repeated thoracentesis and pleural fluid eosinophilia. A retrospective analysis of 2,205 pleural fluid samples from 1,868 patients treated between 1995 and 2007 was performed. We identified 135 patients with EPE (7.2% of all patients with pleural effusion) and 153 EPE samples. The most common condition associated with EPE was malignancy (34.8%) followed by infectious (19.2%), unknown (14.1%), post-traumatic (8.9%) and miscellaneous (23.0%) pleural effusions. The incidence of malignancy was significantly higher in patients with a lower (≤40%) pleural fluid eosinophil percentage. 40 patients with EPE underwent a second thoracentesis. In 16, eosinophilia was present in both pleural fluid samples, 14 revealed pleural fluid eosinophilia only after the second thoracentesis and 10 had eosinophilia only in the first pleural fluid sample. Pleural fluid eosinophilia should not be regarded as a predictor of nonmalignant aetiology. Probability of malignancy is lower in effusions with a high eosinophil percentage. The incidence of EPE in patients undergoing second thoracentesis is not different to that found during the first thoracentesis.

Comparing supplementary oxygen benefits from a portable oxygen concentrator and a liquid oxygen portable device during a walk test in COPD patients on long-term oxygen therapy

BACKGROUND Differences in oxygen delivery between portable oxygen concentrators (POC) and liquid oxygen (LO) portable units, pose a question if POCs are equally effective as LOs in reducing exercise-induced hypoxaemia. DESIGN Randomized, single-blind clinical trial. PATIENTS Thirteen COPD patients (means: age 66+/-11 year, FEV(1) 35.2+/-13.7% predicted) and respiratory failure (means: PaO2 52+/-5mmHg, PaCO2 51.3+/-7.5mmHg). METHODS All patients underwent a series of 6-min walk tests (6MWT) carried out in random order among one of the three devices: POC, LO cylinder and cylinder with compressed air (CA). Oxygen supplementation was 3lpm for LO and an equivalent to 3lpm in a pulse flow system for POC. RESULTS The mean SpO2 was equally improved at rest: 92.9+/-2.8% with POC and 91.7+/-2.0% with LO compared to CA-87.8+/-2.7% (POC and LO vs. CA p<0.05). POC and LO significantly improved oxygenation during 6MWT (mean SpO(2) was 84.3+/-5% and 83.8+/-4.2%, respectively) compared to breathing CA-77.6+/-7.4%, p<0.05. Mean 6MWT distance increased with LO (350+/-83m) and POC (342+/-96m) when compared to CA (317+/-84m), however, these differences were not statistically significant. Dyspnoea score assessed at the end of the exercise (Borg scale) was significantly lower when breathing oxygen (4.2+/-1.2 with POC and 4.1+/-1.7 with LO vs. 5.4+/-1.9 with CA, p<0.05). CONCLUSIONS Effectiveness of oxygen supplementation from a POC did not differ from the LO source during 6MWT in COPD patients with respiratory failure. Oxygen at 3lpm flow was not sufficient to prevent hypoxaemia during strenuous exercise.

Indoor air quality, ventilation and respiratory health in elderly residents living in nursing homes in Europe

Few data exist on respiratory effects of indoor air quality and comfort parameters in the elderly. In the context of the GERIE study, we investigated for the first time the relationships of these factors to respiratory morbidity among elderly people permanently living in nursing homes in seven European countries. 600 elderly people from 50 nursing homes underwent a medical examination and completed a standardised questionnaire. Air quality and comfort parameters were objectively assessed in situ in the nursing home. Mean concentrations of air pollutants did not exceed the existing standards. Forced expiratory volume in 1 s/forced vital capacity ratio was highly significantly related to elevated levels of particles with a 50% cut-off aerodynamic diameter of <0.1 µm (PM0.1) (adjusted OR 8.16, 95% CI 2.24–29.3) and nitrogen dioxide (aOR 3.74, 95% CI 1.06–13.1). Excess risks for usual breathlessness and cough were found with elevated PM10 (aOR 1.53 (95% CI 1.15–2.07) and aOR 1.73 (95% CI 1.17–10.3), respectively) and nitrogen dioxide (aOR 1.58 (95% CI 1.15–2.20) and aOR 1.56 (95% CI 1.03–2.41), respectively). Excess risks for wheeze in the past year were found with PM0.1 (aOR 2.82, 95% CI 1.15–7.02) and for chronic obstructive pulmonary disease and exhaled carbon monoxide with formaldehyde (aOR 3.49 (95% CI 1.17–10.3) and aOR 1.25 (95% CI 1.02–1.55), respectively). Breathlessness and cough were associated with higher carbon dioxide. Relative humidity was inversely related to wheeze in the past year and usual cough. Elderly subjects aged ≥80 years were at higher risk. Pollutant effects were more pronounced in the case of poor ventilation. Even at low levels, indoor air quality affected respiratory health in elderly people permanently living in nursing homes, with frailty increasing with age. The effects were modulated by ventilation. Poor air quality in European nursing homes impairs respiratory health in the elderly permanently living in them http://ow.ly/Es8VQ

DIAGNOSTIC UTILITY OF PLEURAL FLUID AND SERUM MARKERS IN DIFFERENTIATION BETWEEN MALIGNANT AND NON-MALIGNANT PLEURAL EFFUSIONS

Study objectiveTo evaluate the diagnostic value of four different tumor markers: cancer antigen 125 (CA-125), carcinoembryonic antigen (CEA), cytokeratin 19 fragment (CYFRA 21-1) and neuron specific enolase (NSE) in patients with malignant and non-malignant pleural effusion.Material and methodsOne hundred and two patients with pleural effusion treated in the University Hospital in Warsaw between 2001 and 2003 were studied. They underwent an extensive, diagnostic work-up in order to determine the pleural effusion etiology. Patients with known pleural fluid etiology were labeled as the study group and submitted for further analysis. Pleural fluid and serum samples for CA-125, CEA, CYFRA 21-1 and NSE measurements were collected during the first thoracentesis, centrifuged, and frozen until further use. Pleural fluid and serum concentration of tumor markers were assessed by electrochemiluminescence methods using commercial kits.Results74 patients (32 M, 42 F; mean age 65 ± 14 years) composed the final study group. Exudative pleural effusion was found in 62 patients; of these 36 were malignant (48.6% of all effusions), 20 parapneumonic (or pleural empyema), and 6 tuberculous. In 12 patients, pleural transudate was diagnosed. The highest diagnostic sensitivity for malignant pleural effusion was found for NSE (94.4% and 80.6% in the pleural fluid and serum, respectively). However, the specificity of NSE measurement was relatively low (36.1% and 47.4% in pleural fluid and serum, respectively). The most specific markers of malignant pleural fluid etiology were pleural fluid CYFRA 21-1 and CEA levels (92.1% and 92.1%, respectively). CA-125 was found to be the most specific serum marker of pleural malignancies (78.9%). The AUC for combined pleural markers was 0.89, combined serum markers 0.82, combined ratio pleural/serum markers 0.88.ConclusionsThere are significant differences between the diagnostic value of various pleural fluid and serum markers. Overall, pleural fluid markers are superior to serum markers in determining the pleural fluid etiology. A combination of two or more tumor markers may help improve their diagnostic accuracy. Pleural fluid and serum measurements of different tumor markers play a limited role in the differentiation between malignant and non-malignant pleural effusions.

The Evolution of Home Mechanical Ventilation in Poland Between 2000 and 2010

BACKGROUND: Home mechanical ventilation (HMV) is a routine method of treatment for patients with chronic ventilatory failure. Over the last 20 y, a marked development in HMV has been noted in terms of its prevalence and the changing proportion of patients with various indications. However, data on HMV come exclusively from the developed countries of Europe and North America. Nowadays, we can see the emergence of HMV in less developed countries. This study aimed to describe the development of HMV in Poland. METHODS: Data from the largest HMV centers were retrospectively evaluated with regard to cause of respiratory failure, ventilation technique, and characteristics of the HMV-implementing institution. RESULTS: The number of subjects treated with HMV increased from 8 in 2000 to 928 in 2010. Neuromuscular diseases remained the main indication. However, their relative contribution decreased from 100 to 51% in favor of pulmonary diseases (an increase from 0 to 21%) and hypoventilation syndromes (0% in 2000 and 11% in 2010). The majority of the HMV population treated between 2000 between 2008 was ventilated by tracheostomy; however, since 2007, the percentage of subjects on noninvasive ventilation significantly increased and was equal to the number of tracheostomized subjects. HMV was initiated mainly in ICUs. However, their role systematically diminished, and an increasing number of subjects were recruited in respiratory departments. CONCLUSIONS: The prescription pattern of HMV in Poland has evolved, and there is a clear shift from neuromuscular to respiratory diseases. The prevalence of ventilation via tracheostomy still remains very high in comparison with other European countries. The Polish experience could be useful for countries with emerging HMV care systems.

Inspiratory pressure during noninvasive ventilation in stable COPD: help the lungs, but do not forget the heart

To the Editor : The disappointing results of the randomised trials on the use of noninvasive ventilation (NIV) in stable hypercapnic chronic obstructive pulmonary disease (COPD) patients [1] necessitates a search for the reasons for NIV inefficiency in long term treatment. Windisch et al. [2] suggested that NIV aimed at increasing maximum-tolerated inspiratory positive airway pressure and taking over patients breathing rhythm by a ventilator is a key factor in the success of NIV. The new idea proposed by Windisch et al. [3], called high intensity noninvasive positive pressure ventilation (Hi-NPPV), seems to be attractive, but requires verification. Therefore, we would like to congratulate Lukacsovits et al. [4] on their excellent physiological study of the short-term effects of Hi-NPPV published in the April 2012 issue of the European Respiratory Journal . However, we believe that some aspects of this study need to be critically discussed. Firstly, Lukacsovits et al. [4] …

How should we monitor patients with acute respiratory failure treated with noninvasive ventilation

Noninvasive ventilation (NIV) is currently one of the most commonly used support methods in hypoxaemic and hypercapnic acute respiratory failure (ARF). With advancing technology and increasing experience, not only are indications for NIV getting broader, but more severe patients are treated with NIV. Depending on disease type and clinical status, NIV can be applied both in the general ward and in high-dependency/intensive care unit settings with different environmental opportunities. However, it is important to remember that patients with ARF are always very fragile with possible high mortality risk. The delay in recognition of unresponsiveness to NIV, progression of respiratory failure or new-onset complications may result in devastating and fatal outcomes. Therefore, it is crucial to understand that timely action taken according to monitoring variables is one of the key elements for NIV success. The purpose of this review is to outline basic and advanced monitoring techniques for NIV during an ARF episode. Adequate monitoring during NIV is one of the key elements for NIV success http://ow.ly/bNID30hBmDk

Uneven use of noninvasive ventilation in acute respiratory failure in Europe.

To the Editors: We read with great interest the paper by Crimi et al. [1], recently published in the European Respiratory Journal , on routine use of noninvasive ventilation (NIV) in Europe. Application of NIV during acute respiratory failure in exacerbated chronic obstructive pulmonary disease patients is recognised as one of the few procedures that can reduce mortality [2]. We congratulate Crimi et al. [1] on the important idea of exploring current use and methodology of treatment of acute respiratory failure with NIV throughout Europe. Until now, most of the data about NIV in the medical literature have originated from clinical trials performed in well-equipped and experienced medical centres, and little was known about its use in general clinical practice. However, it would be difficult to agree with the …

Noninvasive Ventilation: Factors Influencing Carbon Dioxide Rebreathing – Key Practical Implications

Noninvasive ventilation (NIV) may increase the risk of carbon dioxide (CO2) rebreathing for two reasons: firstly, the single-limb circuit that is preferentially used for NIV causes patients to exhale into the same space from which they inhale, and, secondly, the interfaces used for NIV increase dead space.