Prapaporn Pornsuriyasak

Indicator dilution measurements of extravascular lung water: basic assumptions and observations.

Since they were introduced more than five decades ago, a variety of single-pass indicator, thermal, and osmotic dilution approaches have been developed for detecting and measuring excess fluid in the lungs. This brief review discusses why studies of the extravascular lung water (EVLW) continue to intrigue physiologists and clinicians and the likelihood that they will become sufficiently reliable for more widespread use. Emphasis is placed on the basic assumptions that underlie these measurements and limitations imposed by the nature of the data that are collected. A distinction is made between approaches that are based on compartmental models of solute and water exchange and those that represent extensions of more conventional washout procedures, which have been utilized extensively for measurements of gas volumes in the lungs. Although the compartmental approach has been used to simplify indicator dilution studies by eliminating the need for a vascular indicator, it is based on assumptions that may not be realistic. Early recirculation inevitably limits the period in which observations can be made and impairs detection of those portions of the lungs with decreased perfusion. These general principles are also used to develop a new method of analyzing osmotic transient studies. A short account is given of EVLW observations that have been made in animals and humans. Both the sensitivity and specificity of EVLW measurements in humans are uncertain, and the normal clinical range of EVLW remains in doubt.

Pseudomembranous aspergillus tracheobronchitis superimposed on post-tuberculosis tracheal stenosis.

Pseudomembranous aspergillus tracheobronchitis superimposed on post‐tuberculosis tracheal stenosis has not been previously reported. In the patient described in this case report, the airway obstruction was worsened by aspergillus infection which responded to antifungal therapy and debridement of pseudomembranous tissues by rigid bronchoscopic procedures. A silicone stent was successfully placed in the trachea to restore airway patency when there was no more evidence of tracheobronchial aspergillosis. This case raises the questions of whether, how and when to restore airway patency in patients with tracheal stenosis and concurrent aspergillus tracheobronchitis.

Interleukin-2 levels in exhaled breath condensates, asthma severity, and asthma control in nonallergic asthma.

There was evidence that interleukin (IL)-2 and IL-10 in the airways play roles in regulating the asthmatic inflammatory response. The purpose of this study was to measure the levels of these cytokines in exhaled breath condensates (EBCs) from asthmatic airways and their correlation with a clinical assessment of asthma severity. The levels of IL-2 and IL-10 in EBC, Asthma Control Test (ACT) score, and the forced expiratory volume in 1 second (FEV1) were studied in 28 steroid-free asthmatic patients and 10 healthy volunteers. The results were analyzed according to their allergic status, asthma severity, and body weight. The correlations between IL-2 and IL-10 levels, percent predicted FEV1, ACT score, and body mass index were also determined. Both IL-2 and IL-10 levels in EBC significantly increased in asthmatic patients, especially in patients with moderate-to-severe persistent asthma, compared with those in normal controls. However, the signification correlations between IL-2 levels and ACT (r = -0.684; p = 0.007), as well as with percent predicted FEV1 (r = -0.671; p = 0.009), were established only in patients with nonallergic asthma. The elevation of IL-2 levels in EBC in obese subjects was observed but was probably related to asthma severity. The levels of IL-2 and IL-10 in EBC increase in asthmatic patients but only IL-2 levels significantly correlate with the ACT score and percent predicted FEV1 in nonallergic asthma. Additional studies should be explored to confirm the reliability of ACT score as a predictor of inflammatory response in asthmatic airways. Clinical trial NCT01246414, http://www.clinicaltrials.gov.

Inhaled corticosteroid for persistent cough following upper respiratory tract infection

Objective:  The aim of this study was to determine the clinical effect of inhaled corticosteroid treatment for persistent cough, post upper respiratory tract infection (URTI) in previously healthy individuals, and on bronchial hyperresponsiveness (BHR).

Work- and Travel-related Physical Activity and Alcohol Consumption: Relationship With Bone Mineral Density and Calcaneal Quantitative Ultrasonometry

A number of healthy workers rarely exercise because of a lack of time or resources. Physical activity related to work and everyday travel may be more feasible, but evidence of its beneficial effect on bone health is scarce. We assessed if this form of physical activity was associated with higher bone mineral density (BMD) and stiffness index (SI) when adjusted for recreational physical activity, age, body mass index, smoking, alcohol consumption, education, and serum level of 25-hydroxyvitamin D. Healthy workers, aged 25-54 yr, of the Electricity Generating Authority of Thailand were surveyed. The outcomes were BMD (lumbar spine, femoral neck, and total hip) and calcaneal SI. Physical activity was estimated using the global physical activity questionnaire and considered active when >600 metabolic equivalent tasks (min). Of 2268 subjects, 74% were men. Active male subjects had significantly higher BMD at the femoral neck and total hip (p<0.005). However, the association was not significant with male lumbar spine BMD, male SI, or any bone parameters in women (p>0.05). In men, work and travel physical activity seems beneficial to male bone health; hence, it should be encouraged. Furthermore, smoking appeared harmful while moderate alcohol consumption was beneficial.

Acute respiratory failure secondary to eosinophilic pneumonia following influenza vaccination in an elderly man with chronic obstructive pulmonary disease

Summary Acute respiratory failure with diffuse pulmonary opacities is an unusual manifestation following influenza vaccination. We report herein a patient with chronic obstructive pulmonary disease who developed fever with worsening of respiratory symptoms and severe hypoxemia requiring ventilatory support shortly after influenza vaccination. Bronchoalveolar lavage was compatible with acute eosinophilic pneumonia. Rapid clinical improvement was observed 2 weeks after systemic corticosteroid treatment, followed by radiographic improvement at 4 weeks. No disease recurrence was observed at the 6-month follow-up.

Heterogeneous properties of intermediate- and low-density lipoprotein subpopulations.

OBJECTIVE Intermediate-density lipoprotein (IDL) and low-density lipoprotein (LDL) consist of heterogeneous particles whose subpopulations may have different atherogenic characteristics. This study investigated the associations between these subpopulations and other lipids, lipoproteins and atherosclerosis-related markers. DESIGN AND METHODS A total of 416 subjects (124 males and 292 females, mean age: 50.8 years) were enrolled in this study. Using polyacrylamide gel electrophoresis, serum lipoproteins were separated according to their specific electrophoretic mobility based on particle size. The IDL particles were separated into three midbands (MID-A to C), and the LDL particles were separated into seven subfractions (LDL1 to 7). RESULTS MID-B, MID-C, LDL2 and LDL3 to 6 (as a small LDL fraction) were significantly and positively correlated with very LDL (VLDL), while MID-A and LDL1 were significantly and inversely correlated with VLDL. MID-A and LDL1 were significantly and positively correlated with high-density lipoprotein (HDL). The correlation patterns between MID-A or LDL1 and triglycerides, apolipoprotein A-I, glucose, the insulin resistance index, creatinine and the mean LDL particle size had similar trends to those between HDL and these parameters. CONCLUSIONS The respective subpopulations of IDL and LDL particles can vary in their ability to predict cardiovascular disease risks. These variations may partially explain why quantitative assessments using LDL-cholesterol concentrations, as typically performed in conventional practice, are not perfect predictors of cardiovascular disease. Further studies are required to determine the clinical relevance of analyzing the IDL and LDL subpopulations.

Peak inspiratory flow rate measurement by using In-Check DIAL for the different inhaler devices in elderly with obstructive airway diseases

Background Inhaler device technique is a common cause of treatment failure in patients with asthma and chronic obstructive pulmonary disease. Dry powder inhaler (DPI) requires optimal peak inspiratory flow rate (PIFR) for drug delivery. Low PIFR generation is common in the elderly. Patient lung function and intrinsic inhaler resistance are factors for determining generated PIFR and drug delivery from DPI. Objectives We aimed to identify the PIFR of the older (aged >60 years) and the younger (aged ≤60 years) patients with obstructive airway diseases for the different inhaler devices (Turbuhaler® and Accuhaler). Patients and methods A cross-sectional study was conducted from January to December 2014. Patients with obstructive airway diseases were recruited. Spirometry was performed. PIFR was measured by using an In-Check DIAL device. Individual PIFR values for each inhaler device were obtained for three consecutive measurements and then averaged. Results A total of 139 patients diagnosed with obstructive lung diseases (asthma, n = 109; chronic obstructive pulmonary disease, n = 30) were recruited. Of these, 71 patients (51%) were >60 years. The PIFR generated by the patients who were ≤60 years for nonresistance mode was not different from that generated by those aged >60 years (115.0 ± 15.2 L/min vs 115.4 ± 13.3 L/min, p = 0.86). Regarding the DPI, PIFR generated from the older group was significantly lower than that generated from the younger group for Turbuhaler (72.5 ± 18.8 L/min vs 82.4 ± 21.1 L/min, p = 0.01), but the PIFR generated was not significantly different between the older and the younger groups for the Accuhaler (93.8 ± 22.9 L/min vs 99.4 ± 24.2 L/min, p = 0.86). The low peak expiratory flow rate and PIFR from spirometry were associated with the suboptimal PIFR measured by using In-Check DIAL. Discussion Optimal PIFR is critical for DPI use in the elderly; appropriate DPI selection is essential for management. In-Check DIAL may be useful for detecting inhaler device problem among the elderly. Conclusion Lower PIFR generated from Turbuhaler was noted in patients with airway diseases who were older than 60 years, when compared to the younger patients.

Validity and reliability of the Thai version of the leicester cough questionnaire in chronic cough

BACKGROUND Chronic cough is a common problem potentially disturbing the quality of life (QoL) of coughers. The Leicester Cough Questionnaire (LCQ), previously developed in England, is a validated, self-completed QoL instrument for assessment of chronic cough. This study aimed to develop a Thai version of the LCQ (LCQ-T) and assess its validity and reliability among adult Thai patients with subacute to chronic cough. METHODS A total of 146 patients with a cough lasting for more than 3 weeks consented to participate in this study and self-administered the LCQ-T, together with the following 3 instruments: Borg Cough Scale (BCS), Short Form-36 (SF-36), and Hospital Anxiety Depression Scale (Thai-HADS). The LCQ-T was developed by applying a forward-backward translation approach. The LCQ-T comprises 19 items divided into 3 domains: physical (8 items), psychological (7 items), and social (4 items). To validate the LCQ-T, concurrent validity, internal consistency reliability, and test-retest reliability were assessed. RESULTS Participants included 96 women and 50 men with a mean (SD) age of 59.6 (14.4) years. The concurrent validity comparing LCQ-T to BCS yielded statistically significant Pearson correlation coefficients (r= -0.74, P<0.05). The correlation coefficients for SF-36 and Thai-HADS were also significant. The LCQ-T demonstrated very good internal consistency in all domains and the overall scale, with the Cronbachs alpha coefficients ranging from 0.89 to 0.94. The 3-day repeatability of the LCQ-T in 25 clinically stable patients was high with the intra-class correlation coefficients ranging between 0.81 and 0.90. CONCLUSION LCQ-T is a valid and reliable cough-specific instrument for assessing symptoms and QoL of adult Thai patients with subacute to chronic cough.

Postgraduate Education Corner: Contemporary Reviews in Critical Care MedicineA 76-Year-Old Man With Anemia, Bone Pain, and Progressive Dyspnea

76-year-old man presented with left-sided hip pain radiating to the leg and foot for 4 weeks. He was a former smoker. The patient’s medical history included coronary artery disease, benign prostatic hypertrophy, and mild chronic renal impairment (serum creatinine, 1.5 mg/dL). Other previous blood chemistry tests and chest radiographs obtained 6 months earlier were unremarkable. The plain radiographs of the lumbosacral spine revealed only mild degenerative changes. Two weeks later, the patient developed progressive dyspnea and dry cough without fever, orthopnea, or paroxysmal nocturnal dyspnea. On examination, he looked distressed and was tachypneic. Fine crepitations were heard bilaterally in the lower lungs. Both legs were edematous. There was a hard, nonpainful palpable mass at the sternum. Other physical examinations and neurologic signs were normal.