Kaiser G. Lim

Use of Exhaled Nitric Oxide in Predicting Response to Inhaled Corticosteroids for Chronic Cough

OBJECTIVE To evaluate our experience with patients who presented with chronic cough and how exhaled nitric oxide predicted response to inhaled corticosteroid (ICS) therapy. PATIENTS AND METHODS This retrospective observational study of 114 patients evaluated for chronic cough with measured exhaled nitric oxide and methacholine challenge testing was conducted from December 1, 2004, through November 30, 2005. Clinical records were extracted. Patients with no documented follow-up were contacted by telephone and administered a questionnaire. RESULTS In 64 patients, ICS therapy was started or the current ICS dose increased. Forty-one patients had elevated exhaled nitric oxide levels (defined as >or=35 ppb), 36 (88%) of whom had significant improvement in their chronic cough (likelihood ratio of a positive response, 4.9; 95% confidence interval, 2.2-10.9). Twenty-three patients with exhaled nitric oxide levels in the reference range were also prescribed ICS, and only 2 had cough improvement (likelihood ratio of a negative response, 0.07; 95% confidence interval, 0.02-0.25). Patients had documented follow-up that ranged from 4 weeks to 16 months. A cutoff of 38 ppb was found to best differentiate ICS responders and nonresponders. CONCLUSIONS Measurement of exhaled nitric oxide accurately predicted response to ICS therapy for chronic cough. Patients with a positive exhaled nitric oxide test result had a strong likelihood of response to ICS, whereas a negative exhaled nitric oxide test result indicated an unlikely response to ICS. This finding may potentially have an impact on how patients with chronic cough are evaluated and treated.

B-Mode Ultrasound Assessment of Diaphragm Structure and Function in Patients With COPD

BACKGROUND Electromyographic evaluation of diaphragmatic neuromuscular disease in patients with COPD is technically difficult and potentially high risk. Defining standard values for diaphragm thickness and thickening ratio using B-mode ultrasound may provide a simpler, safer means of evaluating these patients. METHODS Fifty patients with a diagnosis of COPD and FEV₁ < 70% underwent B-mode ultrasound. Three images were captured both at end expiration (Tmin) and at maximal inspiration (Tmax). The thickening ratio was calculated as (Tmax/Tmin), and each set of values was averaged. Findings were compared with a database of 150 healthy control subjects. RESULTS There was no significant difference in diaphragm thickness or thickening ratio between sides within groups (control subjects or patients with COPD) or between groups, with the exception of the subgroup with severe air trapping (residual volume > 200%), in which the only difference was that the thickening ratio was higher on the left (P = .0045). CONCLUSIONS In patients with COPD presenting for evaluation of coexisting neuromuscular respiratory weakness, the same values established for healthy control subjects serve as the baseline for comparison. This knowledge expands the role of ultrasound in evaluating neuromuscular disease in patients with COPD.

Formulating an effective and efficient written asthma action plan.

Written asthma action plans (WAAPs) are recommended by national and international guidelines to help patients recognize and manage asthma exacerbations. Despite this recommendation, many patients with asthma do not have a WAAP. In addition, WAAPs vary widely in their readability and usability. To promote issuance and patient use, the WAAP should clearly define the decision (action) points, expected response, and expected time of response. The WAAP should also be easily integrated into a physicians busy practice. Herein, we describe the key elements of an effective WAAP, including concise, detailed recommendations regarding asthma exacerbation recognition (patient self-monitoring) and treatment.

The impact of asthma medication guidelines on asthma controller use and on asthma exacerbation rates comparing 1997–1998 and 2004–2005

BACKGROUND The relationship between asthma controller medication use and exacerbation rates over time is unclear at the population level. OBJECTIVE To estimate the change in asthma controller medication use between 2 time periods as measured by the controller-to-total asthma medication ratio and its association with changes in asthma exacerbation rates between 1997-1998 and 2004-2005. METHODS The study design was a cross-sectional population-level comparison between individuals from 1997-1998 and 2004-2005. Study participants were individuals aged 5 to 56 years identified as having asthma in the Medical Expenditure Panel Survey (MEPS). The main outcome measures were a controller-to-total asthma medication ratio greater than 0.5 and asthma exacerbation rates (dispensing of systemic corticosteroid or emergency department visit/hospitalization for asthma) in 1997-1998 compared with 2004-2005. RESULTS The proportion of individuals with a controller-to-total asthma medication ratio greater than 0.5, when adjusted for other demographic factors, has improved by 16.1% (95% CI: 10.8%, 21.3%) for all individuals from 1997-1998 to 2004-2005. Annual asthma exacerbation rates did not change significantly in any group from 1997-1998 to 2004-2005 (0.27/year to 0.23/year). African American and Hispanic individuals with asthma had higher asthma exacerbation rates and a lower proportion with a controller-to-total asthma medication ratio greater than 0.5 than whites in both 1997-1998 and 2004-2005; however, these differences were not statistically significant. CONCLUSIONS An increase in asthma controller-to-total medication ratio in a sample reflective of the US population was not associated with a decreased asthma exacerbation rate comparing 1997-1998 and 2004-2005.

How Well Does Patient Self-Report Predict Asthma Medication Possession? Implications for Medication Reconciliation and Adherence Assessment

Background. Self-report is the most commonly used method for collecting information regarding asthma medication possession and adherence in clinical practice. Objective. To determine the agreement between self-report and pharmacy claims data for asthma medication possession. Methods. This is a retrospective study that examined pharmacy claims data 12 months before and after participants completed a structured asthma survey. This study was performed in a sample of health care workers and dependents >17 years old in a large, self-insured Midwestern United States health care center. The main outcome measure was agreement (kappa calculation) between self-report and pharmacy claims data of asthma medication possession. Results. Self-report of asthma medication use agreed moderately with pharmacy claims data for short-acting albuterol (κ = 0.47 ± 0.03), salmeterol (κ = 0.79 ± 0.04), and montelukast (κ = 0.69 ± 0.03) but only slightly for inhaled corticosteroids (κ = 0.18 ± 0.03) and prednisone (κ = 0.10 ± 0.03) (n = 1050 respondents). Both under self-reporting and over self-reporting were common with inhaled corticosteroids (14.4% and 23.1%, respectively) and varied significantly by specific drug type. Conclusions. Self-report moderately agrees with asthma medication possession for most adult asthma patients, though the agreement differs considerably between and within asthma medication classes.

Selected ReportsChyloptysis in Adults: Presentation, Recognition, and Differential Diagnosis

Chyloptysis is a rare finding, and the accompanying respiratory symptoms are usually nonspecific. The recognition of the chylous nature of the sputum is requisite for proper diagnosis, especially if chyloptysis is not accompanied by chylous pleural effusion. The key to the differential diagnosis of chyloptysis is to consider illnesses that can induce reflux of chyle into the bronchial tree. There are two mechanisms postulated: the first requires the presence of an abnormal communication between the bronchial tree and the lymphatic channels, and the second requires a bronchopleural fistula in the context of a chylous pleural effusion. Chyloptysis in adults should prompt assessment for evidence of lymphatic obstruction from trauma, radiation, and malignancy, and to exclude diseases with known association with chyloptysis, ie, lymphangioleiomyomatosis, yellow nail syndrome, or thoracic lymphangiectasis. A lymphangiogram is recommended to define the abnormality. In the case of lymphangiectasis, patients respond to either dietary modification and/or ligation of the thoracic duct.

The ABCs of Asthma Control

The new asthma guidelines have introduced impairment and risk assessments into the management of asthma. Impairment assessment is based on symptom frequency and pulmonary function, whereas risk assessment is based on exacerbation frequency and severity. These 2 measures determine the initial severity of asthma in the untreated patient as well as the degree of control in asthma once treatment has been initiated. The focus on asthma control is important because the attainment of control correlates with a better quality of life and reduction in health care use. We describe 4 easy steps to achieving asthma control in the ambulatory practice setting: (1) a standardized assessment of asthma symptoms using a 5-question assessment tool called the Asthma Control Test, (2) a simple mnemonic that provides a systematic review of the comorbidities and clinical variables that contribute to uncontrolled asthma, (3) directed patient education, and (4) a schedule for ongoing care. Most if not all patients can achieve good control of their asthma with optimal care through an active partnership with their health care professionals.

Chronic Cough: An Update

Cough persisting beyond 8 weeks (ie, chronic cough) is one of the most common reasons for an outpatient visit. A protracted cough can negatively affect ones quality of life by causing anxiety, physical discomfort, social isolation, and personal embarrassment. Herein, the anatomy and physiology of the cough reflex are reviewed. Upper airway cough syndrome, asthma, eosinophilic bronchitis, and gastroesophageal reflux disease account for most chronic cough after excluding smoking, angiotensin-converting enzyme inhibitor use, and chronic bronchitis. Many patients have more than one reason for chronic cough. Treating the underlying cause(s) resolves cough in most instances. There are some coughs that seem refractory despite an extensive work-up. The possibility of a hypersensitive cough reflex response has been proposed to explain these cases. Several clinical algorithms to evaluate chronic cough are presented.

Temozolomide-Associated Organizing Pneumonitis

Temozolomide is an oral alkylating agent recently approved for the treatment of glioblastoma multiforme. It has a favorable side effect profile and is generally well tolerated. Although mild respiratory symptoms have been described, pulmonary toxicity that requires discontinuation of therapy is rare. To our knowledge, this is the first case of temozolomide-associated organizing pneumonitis.

Long-term Safety of Nebulized Lidocaine for Adults With Difficult-to-Control Chronic Cough: A Case Series

BACKGROUND The long-term safety of patient-administered nebulized lidocaine for control of chronic cough has not been established. METHODS We performed a retrospective study of adults who received a prescription and nurse education for nebulized lidocaine for chronic cough between 2002 and 2007. A survey questionnaire inquiring about adverse reactions and the effectiveness of nebulized lidocaine was developed and administered to these individuals after the nebulized lidocaine trial. We conducted two mailings and a postmailing phone follow-up to nonresponders. When adverse events were reported in the questionnaire response, a structured phone interview was conducted to obtain additional details. RESULTS Of 165 eligible patients, 99 (60%) responded to the survey. Responders were a median age of 62 years (range, 29-87 years); 77 (79%) were women, and 80 (82%) were white. The median duration of cough was 5 years before treatment with nebulized lidocaine. Of the patients who used nebulized lidocaine (93% of survey responders), 43% reported an adverse event. However, none of these events required an emergency visit, hospitalization, or antibiotic therapy for aspiration pneumonia. The mean (SD) of the pretreatment cough severity score was 8.4 (1.6) and posttreatment was 5.9 (3.4) (P < .001). Of the patients reporting improvement in cough symptoms (49%), 80% reported improvement within the first 2 weeks. CONCLUSIONS Adults tolerated self-administration of nebulized lidocaine for difficult-to-control chronic cough. No serious adverse effects occurred while providing symptomatic control in 49% of patients.