Joerg Leuppi

Asthma control in Switzerland: a general practitioner based survey

ABSTRACT Background: Achievement of optimal asthma control is the goal of the Global Initiative for Asthma (GINA) guidelines. Methods: In a survey involving 281 physicians, asthma control was assessed using the Juniper asthma control questionnaire (ACQ); physicians were also asked to judge patients’ asthma control subjectively. Results: In total, 2127 patients were included. Follow-up was available in 1893 (89%) patients (885 females). The mean time between visits was 62 ± 29.3 days; mean age was 45 years (± 19 years) and 30% were smokers. Well-controlled asthma was found in 298 patients (16%). Smokers were less likely to have well-controlled asthma (smokers 12% vs. non-smokers 18%). Physicians assessed asthma control to be good in 292 patients (15%), sufficient in 504 (27%), insufficient in 954 (50%) and poor in 137 (7%) patients. Of the 292 patients assessed by their physicians as ‘good asthma control’, only 142 (49%) were confirmed as ‘well-controlled’ by the ACQ. At the first visit, 1308 (69%) patients were pre-treated with any inhaled corticosteroids (ICS). Pre-treatment with leukotriene receptor antagonists (LTRAs) was reported in 127 patients (7%). Add-on therapy with the LTRA montelukast was the most frequent treatment adjustment at the first visit. Out of 1893 patients who had a follow-up visit, 298 (16%) were well controlled at the first visit and 1170 (62%) at the follow-up visit. Conclusion: Asthma control is insufficient in the majority of patients. Improvement of asthma control can be achieved by using objective measures such as the ACQ in regular clinical practice and adapting therapy.

ERS technical standard on bronchial challenge testing: General considerations and performance of methacholine challenge tests

This international task force report updates general considerations for bronchial challenge testing and the performance of the methacholine challenge test. There are notable changes from prior recommendations in order to accommodate newer delivery devices. Rather than basing the test result upon a methacholine concentration (provocative concentration (PC20) causing a 20% fall in forced expiratory volume in 1 s (FEV1)), the new recommendations base the result upon the delivered dose of methacholine causing a 20% fall in FEV1 (provocative dose (PD20)). This end-point allows comparable results from different devices or protocols, thus any suitable nebuliser or dosimeter may be used, so long as the delivery characteristics are known. Inhalation may be by tidal breathing using a breath-actuated or continuous nebuliser for 1 min (or more), or by a dosimeter with a suitable breath count. Tests requiring maximal inhalations to total lung capacity are not recommended because the bronchoprotective effect of a deep breath reduces the sensitivity of the test. The new ERS recommendation for methacholine challenge tests will be the provocative dose rather than concentration http://ow.ly/FBe5309yXn2

Therapeutic bronchoscopy for malignant airway stenoses: choice of modality and survival.

BACKGROUND There are no data regarding the factors influencing the choice of therapeutic bronchoscopic modality in the management of malignant airway stenoses. OBJECTIVES To assess the choice of therapeutic bronchoscopy modality and analyze factors influencing survival in patients with malignant central airway obstruction. MATERIALS AND METHODS We performed 167 procedures in 130 consecutive patients, for malignant central airway obstruction, over six years. RESULTS Laser was used either alone or in combination with stent insertion in 76% procedures. Laser only was used in 53% procedures for lesions below the main bronchi. Stents alone were used for extrinsic compression or stump insufficiency. Combined laser and stent insertion was most frequently used for lesions involving the trachea plus both main bronchi or only the main bronchi. The Dumon stent was preferred in lesions of the trachea and the right bronchial tree, the Ultraflex stent for lesions on the left side and stenoses below the main bronchi. Survival was better in patients with lung cancer, lesions restricted to one lung and when laser alone was used compared to esophageal cancer, metastases and tracheal involvement. CONCLUSION The choice of different airway stents can be made based on the nature and site of the lesion. Dumon stents are suited for lesions in trachea and right main bronchus and the Ultraflex stents on the left side and stenoses beyond the main bronchi. Survival can be estimated based on the diagnosis, site of the lesion and treatment modality used.

Comparison of combined oximetry and cutaneous capnography using a digital sensor with arterial blood gas analysis.

Abstract Background: Cutaneous carbon dioxide tension (PcCO2) is a promising non-invasive surrogate measure of arterial partial pressure of carbon dioxide (PaCO2). Objectives: To compare values of PcCO2 and oxygen saturation (SpO2) with arterial blood gas (ABG) analysis. Methods: SpO2 and PcCO2 were measured with a v-Sign™-sensor (Sentec AG, Therwil, Switzerland) and the values compared with simultaneously obtained SaO2 and PaCO2 obtained from ABG analysis (ABL 725, Radiometer, Copenhagen, Denmark) in 275 adult patients referred to the lung function laboratory. Results: Median of the PcCO2 was 4.7 kPa (interquartile range [IQR] 0.9 kPa). Median of the SpO2 was 97% (IQR 3%). Bland-Altman analysis for comparison of PcCO2 with PaCO2 showed a bias of −0.1 kPa with a precision of ± 0.9 kPa with 3.7% outlying values. Bland-Altman analysis for the comparison of SpO2 and SaO2 showed a bias of 20.1 % with a precision of ± 3.5%. There were no complications. Conclusion: There is a good agreement between combined cutaneous capnography and oximetry values with ABG analysis. Due to the excellent safety profile and the short time to get a continuous measurement, this technique should be examined in settings where it can complement repeated ABG analysis when ventilatory disturbances are suspected or non-invasive monitoring of ventilation is needed.

Response to Add-on Inhaled Corticosteroids in COPD Based on Airway Hyperresponsiveness to Mannitol

BACKGROUND The use of inhaled corticosteroids in mild to moderate COPD is controversial. The aim of this study was to determine whether airway hyperresponsiveness to mannitol might identify patients who are likely to respond to add-on inhaled corticosteroids. METHODS Ninety subjects with mild to moderate COPD were recruited and 68 subsequently randomized in a double-blind manner to receive inhaled budesonide (1,600 μg/d, n = 31) or placebo (n = 37) for 3 months. Thirty-eight subjects had airway hyperresponsiveness to mannitol (17 received budesonide, 21 placebo). All subjects received tiotropium throughout the study, including 4 weeks before randomization. Spirometry, quality of life (St. George Respiratory Questionnaire), degree of dyspnea, airway responsiveness to mannitol, and exhaled nitric oxide were assessed at week 0 (recruitment), week 4 (baseline prior to randomization), and week 16 (posttreatment). RESULTS Compared with placebo, budesonide was associated with improved quality of life in subjects showing airway hyperresponsiveness to mannitol (difference of changes in quality of life score between randomization and study completion, −9.1; 95% CI, −15.8 to −2.3; P < .01). Treatment with inhaled budesonide also led to a reduction in airway responsiveness to mannitol compared with placebo (difference in log10 response-dose ratio, −0.3; 95% CI, −0.6 to −0.04; P < .01). However, postrandomization changes in FEV1 % predicted, quality of life, and exhaled nitric oxide showed no difference between budesonide and placebo. CONCLUSIONS In subjects with mild to moderate COPD and airway hyperresponsiveness to mannitol, quality of life and airway responsiveness improved after treatment with inhaled corticosteroids added to long-acting bronchodilator therapy.

Endobronchial ultrasound-guided transbronchial needle aspiration: Safe as it sounds

Real‐time endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) has earned its place as a standard of care in the evaluation of mediastinal and hilar lymphadenopathy. It is a minimally invasive and a safe procedure with high diagnostic accuracy and efficacy. The increased usage of EBUS‐TBNA worldwide has thrown light on its possible complications including death. The complications range from minor to life threatening in few and may occur either early or later in the course after the procedure. The present review summarizes the reported complications from EBUS‐TBNA, their outcome and the modalities used for their management.

The ADO index as a predictor of two-year mortality in general practice-based chronic obstructive pulmonary disease cohorts.

Background: Existing prediction models for mortality in chronic obstructive pulmonary disease (COPD) patients have not yet been validated in primary care, which is where the majority of patients receive care. Objectives: Our aim was to validate the ADO (age, dyspnoea, airflow obstruction) index as a predictor of 2-year mortality in 2 general practice-based COPD cohorts. Methods: Six hundred and forty-six patients with COPD with GOLD (Global Initiative for Chronic Obstructive Lung Disease) stages I-IV were enrolled by their general practitioners and followed for 2 years. The ADO regression equation was used to predict a 2-year risk of all-cause mortality in each patient and this risk was compared with the observed 2-year mortality. Discrimination and calibration were assessed as well as the strength of association between the 15-point ADO score and the observed 2-year all-cause mortality. Results: Fifty-two (8.1%) patients died during the 2-year follow-up period. Discrimination with the ADO index was excellent with an area under the curve of 0.78 [95% confidence interval (CI) 0.71-0.84]. Overall, the predicted and observed risks matched well and visual inspection revealed no important differences between them across 10 risk classes (p = 0.68). The odds ratio for death per point increase according to the ADO index was 1.50 (95% CI 1.31-1.71). Conclusions: The ADO index showed excellent prediction properties in an out-of-population validation carried out in COPD patients from primary care settings.

Endobronchial ultrasound in hilar and conventional TBNA-negative/inconclusive mediastinal lymphadenopathy

OBJECTIVE Assess the diagnostic yield of real-time bronchoscopic ultrasound transbronchial needle aspiration (EBUS TBNA) in conventional TBNA-negative mediastinal lymphadenopathy and hilar lymphadenopathy. MATERIALS AND METHODS Sixty-two patients having either conventional TBNA-negative mediastinal lymphadenopathy or hilar lymphadenopathy underwent real-time EBUS TBNA. RESULTS EBUS TBNA was performed on 72 lymph nodes (mediastinal = 48; and hilar = 24). 31 of the 72 (43%) lymph node samples were positive for malignancy (29) or benign diagnosis (2), and 17 of the 72 (24%) lymph nodes were true negative at EBUS TBNA confirmed at surgery. Out of 48 mediastinal lymph nodes EBUS TBNA was diagnostic for malignancy in 19 (40%) and negative in 14 of which 12 (86%) were surgically confirmed true negative and 2 (14%) false negative. In 10 of the 24 (42%) hilar lymph nodes, EBUS TBNA was diagnostic for malignancy while 5 were true negative and 1 false negative. All false-negative lymph nodes were PET positive. Adequacy of EBUS TBNA based on positive aspiration and surgically confirmed true negative was 67% and in patients suspected for malignancy was 77%. CONCLUSIONS EBUS TBNA has a good diagnostic yield in hilar lymphadenopathy and in conventional TBNA-negative mediastinal lymphadenopathy.

The evolution of flexible bronchoscopy: From historical luxury to utter necessity!!

Lung India • Vol 32 • Issue 3 • May Jun 2015 After the newer classification of idiopathic interstitial pneumonias and the development of novel treatment options, it is important to subtype an interstitial lung disease to optimize the management. BAL, endobronchial and transbronchial lung biopsy (TBLB) can help subtype the interstitial lung disease when used in the correct clinical setting.[10] A differential and subset cytology of a bronchoalveolar lavage may help in diagnosing eosinophilic pneumonias and sarcoidosis.[8]

Infraclavicular sensor site: A new promising site for transcutaneous capnography

Background. Transcutaneous measurement of carbon dioxide is routinely done at the earlobe site. In patients receiving non invasive ventilation or in the intensive care setting with necklines, an alternate measurement site would be useful. We started to use the infraclavicular site for transcutaneous measurements of carbon dioxide using a new digital sensor. Aim. Comparison of transcutaneous carbon dioxide with arterial carbon dioxide at the infraclavicular site. Methods. We retrospectively compared transcutaneous carbon dioxide at the infraclavicular site with arterial carbon dioxide in 50 samples. The Sentec Digital Monitoring System (Sentec AG, Therwil, Switzerland) was used. The V-Sign digital sensor was placed on the infraclavicular site at the medial two third and one third point from the sternoclavicular joint and acromioclavicular joint. Results. When comparing PcCO2 with PaCO2 values, the Bland-Altman analysis revealed a bias of 0.02 kPa (95% CI: [− 0.1; 0.14]) with a precision of 0.42 kPa. Linear regression analysis describes the relationship between the two methods. The slope of the linear model was 0.85 ± 0.04 and the intercept was 0.77 ± 0.21 (RSE = 0.37 , R2 = 0.91). Conclusion. The measurement of transcutaneous carbon dioxide at the infraclavicular site is feasible with a digital sensor and has a good correlation with the carbon dioxide values obtained from the arterial blood gas. The findings of the current study form the basis for further clinical studies for its regular application in clinical use.