Meng-Heng Hsieh

Flexible Bronchoscopy with Multiple Modalities for Foreign Body Removal in Adults

Objectives Aspiration of the lower airways due to foreign body is rare in adults. This study aimed to determine the outcome of patients who received flexible bronchoscopy with different modalities for foreign body removal in the lower airways. Patients and Methods Between January 2003 and January 2014, 94 patients diagnosed with foreign body in the lower airways underwent flexible bronchoscopy with different modalities, which included forceps, loop, basket, knife, electromagnet, and cryotherapy. The clinical presentation, foreign body location and characteristics, and applications of flexible bronchoscopy were analyzed. Results Forty (43%) patients had acute aspiration, which developed within one week of foreign body entry and 54 (57%) had chronic aspiration. The most common foreign bodies were teeth or bone. More patients with chronic aspiration than those with acute aspiration were referred from the out-patient clinic (48% vs. 28%), but more patients with acute aspiration were referred from the emergency room (35% vs. 6%) and intensive care unit (18% vs. 2%). Flexible bronchoscopy with different modalities was used to remove the foreign bodies (85/94, 90%). Electromagnet or cryotherapy was used in nine patients to eliminate the surrounding granulation tissue before foreign body removal. In the nine patients with failed flexible bronchoscopy, eight underwent rigid bronchoscopy instead and one had right lower lung lobectomy for lung abscess. Conclusions Flexible bronchoscopy with multiple modalities is effective for diagnosing and removing foreign bodies in the lower respiratory airways in adults, with a high success rate (90%) and no difference between acute and chronic aspirations.

The role of the high-sensitivity C-reactive protein in patients with stable non-cystic fibrosis bronchiectasis.

Study Objectives. The aim of this study is to investigate the correlation between serum high-sensitivity C-reactive protein (hs-CRP) and other clinical tools including high-resolution computed tomography (HRCT) in patients with stable non-CF bronchiectasis. Design. A within-subject correlational study of a group of patients with stable non-CF bronchiectasis, who were recruited from our outpatient clinic, was done over a two-year period. Measurements. Sixty-nine stable non-CF bronchiectasis patients were evaluated in terms of hs-CRP, 6-minute walk test, pulmonary function tests, and HRCT. Results. Circulating hs-CRP levels were significantly correlated with HRCT scores (n = 69, r = 0.473, P < 0.001) and resting oxygenation saturation (r = −0.269, P = 0.025). HRCT severity scores significantly increased in patients with hs-CRP level of 4.26 mg/L or higher (mean ± SD 28.1 ± 13.1) compared to those with hs-CRP level less than 4.26 mg/L (31.7 ± 9.8, P = 0.004). Oxygenation saturation at rest was lower in those with hs-CRP level of 4.26 mg/L or higher (93.5 ± 4.4%) compared to those with hs-CRP level less than 4.26 mg/L (96.4 ± 1.6%, P = 0.001). Conclusion. There was a good correlation between serum hs-CRP and HRCT scores in the patients with stable non-CF bronchiectasis.

Advanced primary pulmonary lymphoepithelioma-like carcinoma: clinical manifestations, treatment, and outcome.

BACKGROUND Primary pulmonary lymphoepithelioma-like carcinoma (LELC) is rare, with better clinical outcomes than other lung cancers. However, reports on advanced LELC characteristics and prognosis are lacking. METHODS This retrospective study included adults diagnosed with advanced LELC (at least stage IIIA) between January 2003 and December 2015. Clinical characteristics, treatment modalities, and outcomes were recorded. RESULTS Study population comprised 23 patients with a mean age of 63.7±10.6 years. The Eastern Cooperative Oncology Group status on diagnosis was 0 in five patients and 1 in the others. Most patients received multimodality treatment and all received cisplatin-based chemotherapy. Median follow-up duration was 28.8 months. The median progression free survival (PFS) was 14.6 months in patients received palliative chemotherapy. There were nine (39.1%) deaths. The median overall survival (OS) was not achieved. Until July 31, 2016, median OS was 54.1 months for stage IIIB and 27.6 months for stage IV. There was no significant difference in OS among all stages. No prognostic factors were found. CONCLUSIONS Advanced LELC responded well to cisplatin-based chemotherapy and/or radiotherapy. Main tumor resection is probably beneficial for advanced LELC. Long-term survival is possible for advanced LELC after multimodality treatment.

Prognostic implication of EGFR gene mutations and histological classification in patients with resected stage I lung adenocarcinoma

Introduction The prognostic value of epidermal growth factor receptor (EGFR) mutations and the correlation between EGFR mutations and the new International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society (IASLC/ATS/ERS) histological classification remain controversial. The current study aimed to investigate the pure prognostic role of EGFR mutations in treatment-naïve patients with resected stage I lung adenocarcinoma. Methods We retrospectively reviewed 373 patients with stage I pulmonary non-small-cell lung cancer who underwent complete surgical resection between January 2010 and May 2014. The tumors were classified according to IASLC/ATS/ERS criteria. EGFR mutation status was determined by established methods. Results A total of 120 patients were included for analysis; 87 had tumors with EGFR mutations and 33 had wild-type tumors. More low- and intermediate-grade tumors had EGFR mutations, and nearly half of the high-grade tumors were wild-type (75.7% versus 46.2%, p = 0.041). Patients with low-grade tumors had significantly greater median disease-free survival (DFS) (76.8 versus 13 months, p < 0.0001) and better overall survival (OS) (median OS not reached, p = 0.0003) than those with intermediate- and high-grade tumors. Tumor recurrence was 41.4% and 30.3% in mutant and wild-type patients. The 5-years survival rate was 54% and 71.2%. Multivariate analysis revealed that the new histological classification and the pathologic stage were independent predictors of both DFS and OS. EGFR mutation status had no prognostic implications. Conclusion Low grade tumors according to IASLC/ATS/ERS histological classification and the pathologic stage IA tumors of resected stage I lung adenocarcinomas independently predict better DFS and OS. EGFR mutations were frequently seen in histologically low- and intermediate-grade tumors but not a prognostic factor.

Distance-saturation product of the 6-minute walk test predicts mortality of patients with non-cystic fibrosis bronchiectasis

Background Previous surveillance methods to monitor the prognoses of patients with bronchiectasis are too complex for use in daily practice. The 6-minute walk test (6MWT) is a simple exercise test to predict the prognosis of chronic obstructive airway disease and numerous chronic lung diseases, including idiopathic pulmonary fibrosis. No studies have investigated exercise-induced oxygen desaturation (EID) and distance-saturation product (DSP) of 6MWT to predict the prognoses of patients with bronchiectasis. Methods This was a prospective study to identify correlations between variables of 6MWT and mortality in patients with bronchiectasis over a 6-year period. The study cohort included 69 patients with stable non-cystic fibrosis (non-CF) bronchiectasis who were regularly evaluated for functional status via 6-minute walk distance (6MWD), spirometry, BODE index, EID, and DSP. Results Of the 69 patients, 9 (13%) died and 60 (87%) survived during the 6-year follow-up period. The percentage of EID was higher [7 of 9 patients (78%) vs. 22 of 60 patients (27%), P=0.003] in the non-survivors group. The 6MWD (467.9±77.1 vs. 363.7±126.7 m, P=0.001) was higher in the survivors group. DSP was significantly lower in the non-survivors group (411.0±78.4 vs. 283.9±90.0 m%, P<0.001). Multivariate analysis showed that DSP (OR =0.983; 95% CI: 0.974-0.993, P=0.001) was the best parameter of 6MWT to predict mortality. Patients with a lower DSP of <280 m% were at a 66.5-fold greater risk (OR =66.5; 95% CI: 9.4-469.2) of 6-year mortality compared with those with DSP >280 m% (P<0.001). Conclusions DSP is a simple parameter to predict 6-year mortality in patients with non-CF bronchiectasis.

Different Asthma Phenotypes in Adult Asthma: Comparison of Allergic Asthma and Nonallergic Asthma

Background: Allergen sensitization is a risk factor for the development of bronchial asthma in adults. However, the relationship between allergen sensitization and lung function in asthma patients is not well understood. This study was conducted to evaluate the relationship between sensitized allergens, total serum immunoglobulin E (IgE) level, and lung function in adult asthmatic patients in northern Taiwan.Methods: A total of 266 adult Taiwanese patients diagnosed with asthma between January 2003 and December 2004 were enrolled. Age, sex, duration of asthma, pulmonary function tests, total IgE, eosinophilic cationic protein, and specific IgE of ImmunoCAP were recorded. Allergic was defined as the presence of a specific IgE to 1 or more allergens.Results: There were 161 (60.5%) male and 105 (39.5%) female patients, with a mean age of 60.46 ± 15.40 years. The mean duration of asthma was 13.64 ± 7.35 years. Mite allergens, Dermatophagoides pteronyssinus (48.46%) and Dermatophagoides farina (49.23%), were the most common indoor allergens. We divided the patients into allergic and nonallergic asthma groups: 164 (61.7%) patients had allergic asthma and 102 (38.3%), nonallergic asthma. Patients with allergic asthma were younger, and had a higher total IgE level and better lung function than the nonallergic asthmatics (p＜0.05, respectively). Total serum IgE was correlated to peak expiratory flow (PEF) variability (r=0.3395, p＜0.0001) in asthmatic patients. Among allergic asthmatics, the serum total IgE and PEF variability were higher as the number of positive allergen-specific IgE tests increased.Conclusions: Defining asthma phenotypes as allergic or nonallergic is essential. This study supports the difference between allergic and nonallergic asthma. Patients with allergic asthma were younger and had higher total IgE and better lung function than patients with nonallergic asthma.

The Association of Atopy, Total IgE, and Pulmonary Function in Bronchiectasis

Background: Bronchiectasis is characterized by irreversible airway dilation and destruction, but its clinical features relative to atopy and sensitized allergens remain unclear. Therefore, this study aimed to investigate the relationship between atopy, serum IgE level, and lung function in bronchiectasis patients.Method: The study included 114 adult patients with a clinical diagnosis of bronchiectasis between January 2001 and December 2009. They were all evaluated for allergen specific-IgE levels, serum total IgE and eosinophilic cationic protein (ECP) levels, spirometry values of the pulmonary function test, and high-sensitivity C-reactive protein (hs-CRP) levels. Atopy was defined as the presence of a specific IgE to 1 or more allergens.Results: Of the 114 adult bronchiectasis patients, 33 (28.9%) showed positive specific immunoglobulin E (IgE) levels to 1 or more allergens and were assessed as atopic. Atopic patients with bronchiectasis had worse pulmonary function parameters, in terms of forced expiratory volume in 1 second (FEV1) and FEV1/FVC (forced vital capacity) ratio, and higher levels of total serum IgE. There was a significant decrease in the pulmonary function test of atopic subjects with a positive specific-IgE response to more than 2 allergens, but not in those with only 1 or 2 positive allergens. There were higher serum total IgE levels in patients with more positive allergen-specific IgE tests. Bronchiectatic patients with a high total IgE level (≥100 kU/L) had significantly worse lung function (FEV1% predicted and FEV1/FVC ratio) and more sensitized allergens than those with a normal IgE level (＜100 kU/L).Conclusion: The existence of atopy with more sensitized allergens or higher total serum IgE levels may lead to a worse pulmonary function in patients with bronchiectasis. This may be due to IgE-mediated local and systemic inflammation.

Comparison of Somnologica 3 Computerized Polysomnographic Systems Analysis and Manual Assessment of Sleep Apnea

Sleep disorders are increasingly being recognized by physicians, raising demand at sleep laboratories, and prompting a search for user-friendly methods of data analysis. Computerized polysomnographic systems have become a commonly used tool in sleep laboratories in Taiwan and throughout the world. This study was designed to compare the accuracy of data analysis using computerized Somnologica 3 systems and manual interpretation. Twenty-three patients with suspected respiratory sleep disorders were referred to our department from outpatient clinics. Each individual underwent a full-night sleep study in our sleep laboratory. Recorded data were simultaneously analyzed using the computerized Somnologica 3 system (Version Ⅱ software) and interpreted by a pulmonologist thoroughly experienced in polysomnography, using the standard Rechtschaffen and Kales criteria. When comparing autoscoring and manual analysis, our results revealed that the computerized system produced more substantial errors with respect to the duration of each sleep stage (S1 sleep time: 34.9±5.7 vs. 74.2±10.4min; S2: 94.5±15.1 vs. 208.9±15.8min; S4: 36.4±5.4 vs. 14.5±4.1min; REM: 26.1±5.4 vs. 55.4±6.2min, respectively; all p＜0.05), thus leading to a reduction not only in estimated total sleep time (226.2±19.9 vs. 376.4±16.4 min; p＜0.05), but also a decrease in the number of hypopnea/apnea events (AHI 13.0±19.5 vs. 18.9±3.6, p＜0.05). Based on the evidence from this study, therefore, we suggest that polysomnographic records autoscored by Somnologica 3 systems are inaccurate and will underestimate the severity of sleep-related disorders. A thoroughly experienced polysomnographer is needed for all data interpretation in clinical practice.

Late-onset Central Alveolar Hypoventilation Syndrome in a Patient with Hemorrhagic Brainstem Lesion: Improvement after Medroxyprogesterone Treatment

Central hypoventilation syndrome, a rare condition, is defined as the failure of the automatic control of breathing. Secondary central hypoventilation syndrome should be distinguished from congenital central hypoventilation syndrome by the abnormalities in the brainstem, the place of respiratory control. Patients with this syndrome manifest hypoventilation during sleep, sometimes accompanied by hypoventilation during periods of wakefulness. Patients also lack a ventilatory response to hypercapnia and progressive hypoxia. We report the case of a 57-year-old woman who presented with chronic alveolar hypoventilation syndrome secondary to a brainstem lesion. The initial manifestation was a sense of dyspnea during sleep, and daytime sleepiness. The ventilatory response to CO2 was markedly decreased. She was treated successfully with a central stimulator (oral medroxyprogesterone 30 mg per day). We concluded that central alveolar hypoventilation should be highly suspected in patients with hypercapnia and a brainstem lesion, which can-be treated with a central stimulant.

Erythromycin Modulates β2-integrins (CD11b/CD18) Expression and Intracellular Oxidant Capacity in Airway Neutrophils of Patients with Bronchiectasis

Bronchiectasis is a chronic airway disease of diverse etiology, characterised by persistent becterial colonization, bronchial inflammation, and progressive tissue damage. A neutrophil influx with oxidants and pro-inflammatory cytokines production not only provides opsonophagocytic protection from microbes, but is also implicated in further airway inflammation. To investigate whether erythromycin (EM) can affect neutrophil-mediated antimicrobes and airway inflammation, a 2-week course of therapy with EM (250 mg, 4 times per day) or duracef (250 mg, twice per day) was administered. Twenty-three bronchiectasis patients in stable condition after adequate chest care and hydration were enrolled in a randomized fashion. Leukocyte adhesion molecules CD11b/CD18 and DCFH in induced sputum and blood samples were determined by flow cytometric assay, and the sputum IL-8 and TNF-α levels were measured using the ELISA method before and after treatment. EM significantly increased the expression of CD11b and CD18, from 296.6±31.0 [expressed as mean fluorescence intensity (M.F.I.) of 10000 cells] to 416.1±35.1, and from 265.3±23.0 to 350.4±21.1 (p＜0.05; respectively), but not in patients using duracef (308.2±19.8 to 325.9±19.8 and 280.2±19.3 to 277.6±14.9). There were significant correlations between the expressions of baseline CD11b and CD18 before antibiotic therapy (r=0.72, n=23, p＜0.0001) and between the changes in CD11b and CD18 either after treatment with erythromycin (r=0.77, n=13, p＜0.005) or in both groups (r=0.72, n=23, p=0.0001). The mean DCF fluorescence intensity of neutrophils in the induced sputum of patients receiving EM was significantly increased, from 400.8±49.1 to 811.3±129.2 (p＜0.01), whereas duracef did not change the mean DCF fluorescence intensity (from 495.6±141.0 to 531.2±129.9; p＞0.05). The TNF-α and IL-8 levels in the EM and duracef groups did not significantly change after treatment. In conclusion, EM upregulates the expression of CD11b/CD18 on neutrophils to increase the production of intracellular H2O2, for a microcidal effect.