Karan Singh

A Lifestyle Physical Activity Intervention for Patients with Chronic Obstructive Pulmonary Disease. A Randomized Controlled Trial

RATIONALEnPhysical inactivity is associated with poor outcomes among patients with chronic obstructive pulmonary disease (COPD).nnnOBJECTIVESnTo determine effectiveness of a behavioral intervention intended to increase daily physical activity with the goal of improving health-related quality of life and functional performance.nnnMETHODSnWe conducted a randomized trial among patients with COPD cared for in primary care and pulmonary clinics. The patients were at least 45 years of age and eligible for pulmonary rehabilitation. All patients received self-management education during a 6-week run-in period. Subsequently, patients were randomized to usual care or the intervention delivered over 20 weeks.nnnMEASUREMENTS AND MAIN RESULTSnCo-primary outcomes were change from baseline in Chronic Respiratory Questionnaire dyspnea domain score and 6-minute-walk distance measured at 6, 12, and 18 months after randomization. A total of 325 patients were enrolled, with 156 randomized to receive usual care and 149 to receive the intervention. At 18 months, there was no overall statistical or clinically significant change in the dyspnea domain in either group. However, for 6-minute-walk distance, there were statistically significant declines in both groups. In contrast, 6-minute-walk distance remained stable (5.3 m; Pu2009=u20090.54) among patients in the intervention group with moderate spirometric impairment, but it was associated with clinically and statistically significant declines (-28.7 m; Pu2009=u20090.0001) among usual care patients with moderate spirometric impairment. Overall, there was no increase in adverse events associated with the intervention, which was associated with a lower prevalence of hospitalization for COPD exacerbations (28.3%) compared with usual care (49.5%).nnnCONCLUSIONSnDuring this 18-month trial among outpatients with COPD, a health coach-based behavioral intervention did not improve scores in the dyspnea domain of the Chronic Respiratory Questionnaire or 6-minute-walk test distance. However, subgroup analyses suggested that there may be differential effects for specific outcomes that vary with severity of COPD. Specifically, benefits of this low-intensity intervention may be limited to 6-minute walk distance among patients with moderate spirometric impairment. Clinical trial registered with www.clinicaltrials.gov (NCT1108991).

Domain-Specific Self-Efficacy Is Associated with Measures of Functional Capacity and Quality of Life among Patients with Moderate to Severe Chronic Obstructive Pulmonary Disease

RATIONALEnThe relationship between self-efficacy and health behaviors is well established. However, little is known about the relationship between self-efficacy and health-related indicators among patients with chronic obstructive pulmonary disease (COPD).nnnOBJECTIVESnThe purpose of this cross-sectional cohort study was to test the hypothesis that the total score and specific subdomain scores of the COPD Self-Efficacy Scale (CSES) are associated with functional capacity and quality of life in a group of patients with moderate to severe COPD.nnnMETHODSnRelationships were examined in a cross-sectional study of baseline data collected as part of a randomized trial. Self-efficacy was measured using the five domains of the CSES: negative affect, emotional arousal, physical exertion, weather/environment, and behavioral. Measures of quality of life and functional capacity included SF-12: physical and mental composite scores, Chronic Respiratory Questionnaire dyspnea domain, and the 6-minute-walk test. Statistical analyses included Spearman correlation and categorical analyses of self-efficacy (confident vs. not confident) using general linear models adjusting for potential confounders.nnnMEASUREMENTS AND MAIN RESULTSnThere were 325 patients enrolled with a mean age (standard deviation) of 68.5 (9.48) years, 49.5% male, and 91.69% non-Hispanic white. The negative affect, emotional arousal, and physical exertion domains were moderately correlated (range, 0.3-0.7) with the SF-12 mental composite score and Chronic Respiratory Questionnaire dyspnea domain. In models exploring each CSES domain as confident versus not confident and adjusting for age, sex, race, pack-years, and airflow obstruction severity, there were multiple clinically and statistically significant associations between the negative affect, emotional arousal, and physical exertion domains with functional capacity and quality of life.nnnCONCLUSIONSnThe aggregated total CSES score was associated with better quality of life and functional capacity. Our analysis of subdomains revealed that the physical exertion, negative affect, and emotional arousal subdomains had the largest associations with functional capacity and quality of life indicators. These findings suggest that interventions to enhance self-efficacy may improve the functional capacity and quality of life of patients with moderate to severe COPD.

Feasibility, Safety, and Utility of Advanced Critical Care Transesophageal Echocardiography Performed by Pulmonary/Critical Care Fellows in a Medical ICU

BACKGROUND: Competence in advanced critical care transesophageal echocardiography allows the intensivist to diagnose and manage cardiopulmonary failure when transthoracic echocardiography is not sufficient to answer the clinical question. This report describes the feasibility, safety, and utility of transesophageal echocardiography performed by pulmonary and critical care fellows in a medical ICU in critically ill patients who were mechanically ventilated. METHODS: This longitudinal descriptive study of advanced transesophageal echocardiography was performed in patients who were mechanically ventilated. The complications and clinical utility of the examinations were abstracted from review of the image set, the written report, and the patient chart. Influence on diagnosis was classified as confirming the initial clinical diagnosis or identification of a new or unanticipated finding. Therapeutic impact was categorized as no change in therapy resulting from the study findings or as change in therapy resulting from the study findings. RESULTS: The examination was feasible in all patients in whom it was attempted, and there were no complications of the procedure. New or actionable findings were identified in 43 (28%) studies, and 109 (72%) studies confirmed the initial clinical diagnosis. The findings resulted in a change in clinical management in 58 (38%) patients. CONCLUSIONS: Critical care transesophageal echocardiography is feasible, safe, and has clinical utility. It can be safely and effectively performed by fellows within the context of their critical care training with faculty supervision. Pulmonary critical care fellowship training programs should consider introducing critical care transesophageal echocardiography as a useful clinical tool.

Serial Diaphragm Ultrasonography to Predict Successful Discontinuation of Mechanical Ventilation

IntroductionDiaphragm excursion and contraction velocity measured using ultrasonography have been used to assess diaphragm function. We aimed to evaluate the performance of diaphragm ultrasonography during weaning from mechanical ventilation (MV).MethodsDiaphragm ultrasonography was performed on 73 mechanically ventilated patients who were being considered for extubation on three separate occasions: (1) on assist control mode (A/C) during consistent patient triggered ventilation, (2) following 30xa0min during a spontaneous breathing trial (SBT), (3) 4–24xa0h following extubation. Right hemidiaphragm excursion and contraction velocity were measured on A/C, during SBT, and following extubation. These measurements were correlated with the outcome of extubation.ResultsTwenty patients failed extubation: 6 of whom required re-intubation and 14 of whom required non-invasive ventilatory support. During SBT, the mean diaphragm excursions were 1.7u2009±u20090.82xa0cm in the group who failed extubation compared to 2.1u2009±u20090.9xa0cm in the group who were successfully extubated (pu2009=u20090.06). To predict successful extubation, a decrease in diaphragm excursion of <u200916.4% between A/C and SBT had a sensitivity of 84.9% and a specificity of 65%. The area under curve (AUC) for receiver operative characteristics for above cut-off was 0.75. Diaphragm contraction velocity performed poorly in predicting weaning outcome.ConclusionsDiaphragm excursion measured during SBT is an imperfect predictor of the outcome of extubation. Maintenance of diaphragm excursion between A/C and SBT has good performance characteristics by AUC analysis. Diaphragm contraction velocity has poor ability to predict outcome of extubation.

Diaphragm Excursion-Time Index: A New Parameter Using Ultrasonography to Predict Extubation Outcome

Background The diaphragmatic response to increased mechanical load following withdrawal of mechanical ventilation is critical in determining the outcome of extubation. Using ultrasonography, we aimed to evaluate the performance of the excursion‐time (E‐T) index—a product of diaphragm excursion and inspiratory time, to predict the outcome of extubation. Methods Right hemidiaphragm excursion, inspiratory time, and E‐T index were measured by ultrasonography during mechanical ventilation: (1) on assist‐control (A/C) mode during consistent patient‐triggered ventilation, (2) following 30 min during a spontaneous breathing trial (SBT), and (3) between 4 and 24 h following extubation. These measurements were correlated with the outcome of extubation. Patients in the “failure” group required reintubation or noninvasive ventilation within 48 h of extubation. Results Of the 73 patients studied, 20 patients failed extubation. During SBT, diaphragm excursion was 1.65 ± 0.82 and 2.1 ± 0.9 cm (P = .06), inspiratory time was 0.89 ± 0.30 and 1.11 ± 0.39 s (P = .03), and the E‐T index was 1.64 ± 1.19 and 2.42 ± 1.55 cm‐s (P < .03) in the “failure” and “success” groups, respectively. The mean change in E‐T index between A/C and SBT was –3.9 ± 57.8% in the failure group and 59.4 ± 74.6% in the success group (P < .01). A decrease in diaphragmatic E‐T index less than 3.8% between A/C and SBT had a sensitivity of 79.2% and a specificity of 75%, to predict successful extubation. Conclusions Diaphragm E‐T index measured during SBT may help predict the outcome of extubation. Maintenance or increase in diaphragm E‐T index between A/C and SBT increases the likelihood of successful extubation.

Light to moderate drinking and therapeutic doses of acetaminophen: An assessment of risks for renal dysfunction

This study investigated the potential effect of therapeutic doses of acetaminophen (APAP) in combination with light-moderate amounts of alcohol on kidney functions controlling for factors such as hypertension, diabetes and obesity that may predispose the kidney to APAP and/or alcohol toxicity. Secondary analysis of the 2003–2004 National Health and Nutrition Examination Survey data was performed using SAS 9.4. Odds ratios (OR) and 95% confidence intervals (CI) comparing the likelihood that individuals who ingested therapeutic doses of APAP and light-moderate amount of alcohol, compared to those who did not, would have kidney dysfunction were generated from multiple logistics regression models by further controlling for potential predisposing factors namely hypertension, diabetes and obesity. Kidney dysfunction was defined based on self-reports and laboratory examination of serum creatinine (SCr), blood urea nitrogen (BUN), glomerular filtration rate (GFR) and albumin creatinine ratio (ABCR). Statistically significant increased odds of renal dysfunction were noted among respondents who reported use of therapeutic doses of APAP and light-moderate amount of alcohol [OR(95% CI)u202f=u202f1.64(1.28–2.10) self-report, 2.18(1.81–2.63) SCr, 4.60(3.03–7.00) BUN, 3.14(2.42–4.07) GFR, and 1.71(1.36–2.14) ALBCR)] even after adjusting for hypertension, diabetes and obesity [Adjusted OR (95% CI)u202f=u202f1.78 (1.22–2.58) self-report, 2.05 (1.07–3.92) GFR]. The toxic effects of APAP and alcohol on the kidney were hypothesized. The threshold doses at which these effects begin to occur are unknown. The findings of this study suggest that even therapeutic doses of APAP and light-moderate amount of alcohol could be health problematic if consumed concomitantly.

Pseudomembranous tracheitis caused by Aspergillus fumigatus in the setting of high grade T-cell lymphoma

Pseudomembranous tracheitis (PMT) is a rare condition most commonly caused by fungal or bacterial infection that is characterized by a pseudomembrane that partially or completely covers the tracheobronchial tree. PMT is most commonly found in immunocompromised patient populations, such as post-chemotherapy, AIDS, post-transplant and hematological malignancies. Due to its rarity, PMT is often not included in the differential diagnosis. This case describes a 65 year old male with persistent fever and refractory cough despite high dose empiric antibiotics. Subsequent bronchoscopy with biopsy revealed pseudomembranous tracheitis due to Aspergillus fumigatus in the setting of T-cell lymphoma. PMT should be considered in the differential diagnosis of refractory cough in the immunocompromised population. However, it has been described in patients with nonspecific respiratory symptoms such as dyspnea, cough, and other airway issues.