Peter Spiegler

Results of an 8-week, outpatient pulmonary rehabilitation program on patients with and without chronic obstructive pulmonary disease.

PURPOSE To determine whether there is any difference in the effect of pulmonary rehabilitation (PR) on outcomes in patients with and without chronic obstructive pulmonary disease (COPD). METHODS Retrospective analysis of medical records of all patients enrolling in PR over a 5-year period. RESULTS A total of 422 patients enrolled in a multidisciplinary PR program from August 1999 to April 2004. Three hundred nine patients had COPD and 113 patients had diagnoses other than COPD. Three hundred seventy-nine patients completed the program. PR was conducted according to currently accepted guidelines. Measurements included the 6-minute walk distance (6MW) performed at the beginning and end of the program and quality of life as determined by the Chronic Respiratory Questionnaire (CRQ) at the beginning and end of the program. Both groups had significant improvements in the 6MW and all domains of the CRQ following PR. There was no significant difference in any of these outcomes between the 2 groups. The baseline forced expiratory volume in 1 second (FEV1) was not correlated with improvement in the 6MW in either group. CONCLUSIONS There is no significant difference in improvement in exercise tolerance or quality of life following PR in COPD versus non-COPD patients. Baseline lung function does not predict improvement in exercise tolerance. PR is effective for patients with disability due to any chronic respiratory disease and not just COPD.

Bronchiectasis: new findings in the pathogenesis and treatment of this disease.

Purpose of reviewBronchiectasis is an under-appreciated cause of chronic lung disease in the USA. We highlight developments in diagnosis and treatment of this debilitating disease. Recent findingsA possible link between gastroesophageal reflux and development of nontuberculous mycobacterial lung disease was highlighted. Reflux is more common in patients with nontuberculous mycobacterial lung disease, and among those with established bronchiectasis more extensive disease was observed in those patients who also had reflux. Long-term mortality in bronchiectasis was significantly associated with age, lower body mass index, dyspnea, lack of vaccination, hypoxemia, hypercapnia, and other functional parameters. In a large, randomized clinical trial, addition of inhaled tobramycin to ciprofloxacin for acute exacerbations of Pseudomonas infection produced microbiologic improvement correlating with clinical outcomes but not overall improvement. A review noted that five macrolide trials reported reduced sputum volume, improved lung function, and better symptom control. Finally, articles suggested benefit from inhaled hyperosmolar agents (e.g. hypertonic saline and inhaled mannitol). SummaryThe possible link between gastroesophageal reflux and nontuberculous mycobacterial lung disease, and the microbiology and resistance patterns of bacteria observed in these patients were clarified. A large study of inhaled tobramycin for exacerbations was inconclusive, but macrolide therapy and hyperosmolar agents hold promise.

Written disclosure therapy for patients with chronic lung disease undergoing pulmonary rehabilitation.

PURPOSE: Chronic lung diseases are typically associated with impaired quality of life, stress, and anxiety. Written disclosure therapy (WDT) reduces stress in patients with a variety of chronic illnesses. We sought to determine whether WDT benefits patients with chronic lung disease. METHODS: A prospective, randomized, controlled trial was performed to evaluate the effect of using WDT in patients (N = 66) participating in a pulmonary rehabilitation program. Patients were randomly assigned to write about a particularly traumatic life event (WDT group) or to write about an emotionally neutral subject (control group). Exercise capacity, dyspnea and quality of life, and values of spirometry were recorded at baseline, at the end of the program, and at 6 months. RESULTS: The 6-minute walk distance (6MWD) significantly improved in both groups at 2 months, from 278 to 327 m in WDT and from 269 to 314 m in control groups (P < .01 in both groups). There was no difference in improvement in 6MWD between groups (P = .88). At 6 months, the gains made in 6MWD were no longer present. Dyspnea severity, as well as most of the other domains of the Chronic Respiratory Disease Questionnaire and the St. Georges Respiratory Questionnaire, showed improvement within each group, but not between WDT and control groups. CONCLUSION: WDT did not add any additional benefit in patients with chronic obstructive pulmonary disease or idiopathic pulmonary fibrosis when included as a component of pulmonary rehabilitation. These results are in contrast to previously seen benefits in patients with asthma.

Eosinophilic Pneumonia Associated With Azacitidine in a Patient With Myelodysplastic Syndrome

Eosinophilic pneumonia is characterized by cough, lung infiltrates on imaging, and by the presence of eosinophils in the alveoli and pulmonary interstitium. Azacitidine, a pyramidine nucleoside analog of cytidine, is FDA approved for the treatment of various myelodysplastic syndromes. We present a case of a 76-year-old man with recently diagnosed myelodysplastic syndrome, who developed eosinophilic pneumonia after initiating therapy with azacitidine. There was clinical and radiographic improvement with cessation of the drug and treatment with prednisone. Diagnosis of drug-induced eosinophilic pneumonia is established by having a temporal relationship between onset of symptoms and initiation of therapy, bronchoalveolar lavage or lung biopsy evidence of pulmonary eosinophilia, no other explanation for the disease, and improvement upon cessation of the offending agent. Our case illustrates the need for a high index of suspicion to identify adverse pulmonary reactions associated with newly developed medications.

Pharmacological Treatment Options for Bronchiectasis : Focus on Antimicrobial and Anti-Inflammatory Agents

Patients with bronchiectasis experience tenacious mucus, recurrent infectious exacerbations, and progressive worsening of symptoms and obstruction over time. Treatment is aimed at trying to break the cycle of infection and progressive airway destruction. Antibacterial treatment is targeted towards likely organisms or tailored to the results of sputum culture. Inhaled antibacterial therapy may offer the advantage of increased local concentration of medication, while minimizing systemic adverse effects; however, to date, studies have been equivocal in this disorder. Macrolides, in addition to their antibacterial properties, have unique anti-inflammatory properties, which may make them useful in this disorder. Other mucoactive and anti-inflammatory agents, such as inhaled corticosteroids, mannitol and hypertonic saline, may also prove useful in this disease, but further studies are needed.

The Impact of Continuous Positive Airway Pressure on Insulin Resistance in Patients With Obstructive Sleep Apnea

Synopsis:Obstructive sleep apnea (OSA) may independently affect insulin sensitivity, and the use of continuous positive airway pressure (CPAP) for OSA may improve insulin sensitivity. This beneficial effect may be present after as little as 2 days of therapy, perhaps occurring through the mechanism of diminished sympathetic drive. Source:Harsch IA et al. Continuous positive airway pressure treatment rapidly improves insulin sensitivity in patients with obstructive sleep apnea. Am J Respir Crit Care Med. 2004;169:156–162.

Low-Dose Inhaled Nitric Oxide in Patients With Acute Lung Injury

Synopsis:Patients with moderately severe acute lung injury not due to sepsis and without any other organ failure treated with low-dose inhaled nitric oxide showed a short-term improvement in oxygenation without reduction in duration of ventilatory support or mortality. Source:Taylor R, et al. Low-dose inhaled nitric oxide in patients with acute lung injury. JAMA. 2004;291:1603-1609.

Nocturnal Noninvasive Ventilation for COPD

Synopsis: The addition of nocturnal noninvasive ventilation for patients with stable, hypercapneic chronic obstructive pulmonary disease improved long-term survival. Source: Kohnlein T, Windisch W, Koehler D, et al. Non-invasive positive pressure ventilation for the treatment of severe stable chronic obstructive pulmonary disease: a prospective, multicentre, randomised, controlled clinical trial. Lancet Respir Med. 2014;2:698–705.

Why It’s Important to Pay Attention to Sleep in a Sleep Study

Synopsis: Based on review of data from the Wisconsin Sleep Cohort Study, obstructive sleep apnea occurring during REM sleep is associated with the prevalence and incidence of hypertension even when the overall apnea-hypopnea index was normal. Source: Mokhlesi B, Finn LA, Hagen EW, et al. Obstructive sleep apnea during REM sleep and hypertension. Results of the Wisconsin Sleep Cohort. Am J Respir Crit Care Med. 2014;190:158-167.

Prophylactic Treatment of VAP in High-risk Patients

Ventilator-associated pneumonia (VAP) and ventilatorassociated tracheobronchitis (VAT) have been a significant problem in patients receiving prolonged mechanical ventilation. In the past, reported rates were as high as 1% per day of mechanical ventilation. More recently, with attention placed to common intensive care unit (ICU) practices such as the use of stress ulcer prophylaxis, minimization of changes in ventilator circuits, decreased use of sedation, and early weaning from mechanical ventilation, rates have fallen. In the United States, hospitals have been required to report rates of VAP with the threat of reimbursement tied to performance standards. Coincident with this, rates in most hospitals have fallen to near-zero, either by means of practices mentioned above or through other, less clearly defined means. Despite this, certain patients are at much higher risk of developing VAP or VAT. These include patients with trauma or neurologic injuries. Another population at higher risk is post–open heart surgery patients who require prolonged mechanical ventilation. In this study, at a busy cardiothoracic service, patients who remained on mechanical ventilation for >48 hours after open heart surgery were randomized to receive 3 days of meropenem and linezolid or vancomycin or to a control group. Tracheal aspirates were performed each of the 3 days. Standard Centers for Disease Control and Prevention criteria were used to diagnose VAP. VAT was diagnosed when the same signs and symptoms were present with the exception of pulmonary infiltrates. The investigators failed to reach their recruitment goal of 116 patients and randomized 78 patients. The primary endpoint was the reduction in VAP, VAT, or both. There was a significant decrease in the combined endpoint of VAP and VAT, from 64.78 to 31.79/1000 ventilator days. When considered separately, there was no significant decrease in VAP alone or VAT alone. The development of VAP or VAT was significantly delayed in the treatment group (9 vs. 4.5 d). There was no difference in ICU or hospital length of stay, days on mechanical ventilation, or need for tracheostomy. There was also no difference in the occurrence of other infections including Clostridium difficile infection. One concern of using prophylactic antibiotics is the development of resistant organisms in the ICU. The investigators retrospectively reviewed rates of resistant organisms in the 3 years before the study and prospectively for 3 years starting at the end of the first year of the study. There was no apparent increase in the incidence of resistant gram-negative infections and the rates of methicillin-sensitive Staphylococcus aureus and methicillin-resistant S. aureus decreased significantly. However, 21 patients with linezolid-resistant organisms either causing colonization or infection were detected, which had not previously been seen. Although causality cannot be determined with this observation, this is clearly concerning. This study was underpowered and only showed a benefit in the combined endpoint of VAP or VAT. Important surrogate endpoints of length of stay or need for tracheostomy were unchanged. The positive results of this study have to be viewed with caution. These patients were at very high risk of developing VAP or VAT. Before instituting this practice, practitioners will have to review local rates of infection in high-risk patients. They will also have to answer the difficult question of how to balance modest benefit to individual patients against the risk of promoting resistant organisms that can affect the entire ICU patient population.