Timothy J. McDonnell

Effectiveness of pulmonary rehabilitation in restrictive lung disease.

BACKGROUND Pulmonary rehabilitation is effective in improving exercise endurance and quality of life in chronic obstructive pulmonary disease (COPD). However, the efficacy of pulmonary rehabilitation in restrictive lung disease has not been extensively studied. METHODS Forty-six patients with restrictive lung disease (35 interstitial lung diseases, 11 skeletal abnormalities) were admitted to a pulmonary rehabilitation program; 26 completed the 8-week program and 15 were followed to a 1-year reassessment. Fifteen noncompliant patients were excluded and 1 patient with interstitial lung disease died at 8 weeks. Pulmonary function tests, exercise endurance, quality of life (Chronic Respiratory Disease Questionnaire, St. Georges Respiratory Questionnaire, Hospital Anxiety and Depression scale and dyspnea) were measured at baseline, 8 weeks, and 1 year. RESULTS Exercise endurance (treadmill) improved at 8 weeks (mean improvement, 10.2 +/- 7.4 minutes) and at 1 year (mean improvement, 8.7 +/- 12.2 minutes). Shuttle test improved at 8 weeks (mean improvement, 27.2 +/- 75.9 m) but not at 1 year. Patients using long-term oxygen therapy (LTOT) had a better improvement in the treadmill test (P < .01) at 8 weeks compared with those not using LTOT. Thirty-three percent of patients failed to complete the program. There was significant improvement in dyspnea and quality of life in Chronic Respiratory Disease Questionnaire, St. Georges Respiratory Questionnaire, and Hospital Anxiety and Depression scale for depression at 8 weeks compared with baseline; there was a sustained significant reduction in hospital admission days noted at 1-year postrehabilitation (P < .05). CONCLUSIONS Pulmonary rehabilitation is effective in improving exercise endurance and the quality of life and in reducing hospital admissions in this small group of patients with significant restrictive lung disease. The relatively large dropout number suggests that a standard chronic obstructive pulmonary disease program may not be ideal for patients with restrictive lung disease.

Use of a care bundle in the emergency department for acute exacerbations of chronic obstructive pulmonary disease: a feasibility study.

Aim To determine the efficacy and usefulness of a chronic obstructive pulmonary disease (COPD) care bundle designed for the initial management of acute exacerbations of COPD and to assess whether it improves quality of care and provides better outcomes. Introduction The level of care provided in the emergency department (ED) for COPD exacerbations varies greatly, and there is a need for a more systematic, consistent, evidence-based quality improvement approach to improve outcomes and costs. Methods A prospective before and after study was carried out in a university teaching hospital. Fifty consecutive patients were identified in the ED with COPD exacerbations and their management was reviewed. Following the education of ED staff and the implementation of a COPD care bundle, the outcome for 51 consecutive patients was analyzed. This COPD care bundle consisted of ten elements considered essential to the management of COPD exacerbations and was scored 0–10 according to the number of items on the checklist implemented correctly. Results Following implementation, the mean bundle score out of 10 improved from 4.6 to 7 (P<0.001). There was a significant decrease in the unnecessary use of intravenous corticosteroids from 60% to 32% (P=0.003) and also a marked improvement in the use of oxygen therapy, with appropriate treatment increasing from 76% to 96% (P=0.003). Prophylaxis for venous thromboembolism also improved from 54% to 73% (P=0.054). The 30-day readmission rate did not significantly improve. Conclusion The use of a bundle improves the delivery of care for COPD exacerbations in the ED. There is more appropriate use of therapeutic interventions, especially oxygen therapy and intravenous corticosteroids.

Quinolone-associated tendonitis: a potential problem in COPD?

BackgroundQuinolones have traditionally had limited application in the area of community-acquired respiratory tract infections due to poor cover againstStreptococcus pneumoniae. This trend is changing with the broader spectrum of newer fluoroquinoiones. A rare serious side effect of fluoroquinolones is tendinopathy.AimsThis study describes two cases of levofloxacin-associated tendinopathy in patients with severe chronic obstructive pulmonary disease (COPD) and the implications and mechanisms involved are discussed.ConclusionsThe finding of two cases of levofloxacin-induced tendinopathy in our patients suggests that the problem may be more frequent than previously considered. Patients with COPD treated with fluoroquinolones may have other risk factors for tendinopathy such as advanced age, corticosteroid use and renal impairment and merit vigilance for signs of tendonitis.

Defining exacerbations in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease is a very common disease often punctuated by intermittent episodes of exacerbation. These exacerbations affect the natural history of the disease, accelerating a decline in lung function. They affect the individual in many ways and affect the health service caring for these patients. The definition of exacerbation varies and lacks clarity. The definitions used most are either symptom based, for example, breathlessness, sputum production and sputum purulence, or event driven, for example, an event causing a patient to seek healthcare input or change to medications. In this article, we discuss the importance of exacerbations, the clinical definitions, clinical trial definitions, physiological and biomarker evidence of exacerbations and the challenges associated with each of these. Application of a practical definition would aid in our clinical management of patients with chronic obstructive pulmonary disease and facilitate developments in future therapeutic advances through clinical trials.

Does prior treatment with fumaric acid esters predispose to tuberculosis in patients on etanercept

A 36-year-old had a 17-year history of chronic plaque psoriasis. He had had multiple admissions for topical treatment, and had completed a lifetime’s cumulative exposure with phototherapy. Fumaric acid esters (FAEs) were introduced, which resulted in significant improvement in his psoriasis. After 5 months of treatment, he complained of fatigue of increasing intensity, and after a further 2 months, the FAEs were discontinued. He had experienced persistent lymphopenia since the start of FAE treatment. Without FAEs, his psoriasis flared and the anti-tumour necrosis factor (TNF)-a agent, etanercept, was introduced at a dose of 25 mg twice weekly. Prior to etanercept, the patient’s tuberculin skin test (2 U) was negative and his chest X-ray was normal. Within 4 months, his psoriasis was clear but he was still fatigued. Two months later, he was found to have enlarged, nontender, cervical lymph nodes; lymphoma was suspected and etanercept was discontinued. Histology of a lymph gland showed granulomas with extensive caseous necrosis consistent with mycobacterial infection. Ziehl–Neelsen stain for acid-fast bacilli was negative. A diagnosis of tuberculous lymphadenitis was made and the patient was treated with triple therapy (rifampicin, isoniazid, pyrazinamide) for 2 months, followed by 4 months of rifampicin and isoniazid, under the supervision of a respiratory physician. At the end of the 6-month course, the fatigue had abated, and there was complete resolution of the lymph nodes. The patient has recommenced treatment with etanercept. Etanercept is a fusion protein that binds free TNF-a using the extracellular or soluble portion of the TNF receptors. TNF-a has a central role both in the host immune response to Mycobacterium tuberculosis and in the immunopathology of tuberculosis (TB). TNF-a production is a requirement for formation of granulomas, which sequester mycobacteria and prevent their dissemination. Reactivation of TB is a major concern during treatment with TNF inhibitors. Keane et al. reported 70 cases of TB treated with infliximab. Mohan et al. reported 25 cases of TB associated with etanercept therapy and 13 of these had extrapulmonary TB. The interval between the first dose of etanercept and the diagnosis of TB was 11.5 months, compared with 6 months in our patient. Our patient was at low risk for TB as he was Irish by birth, had received the bacille Calmette–Guérin (BCG) vaccination as a child, and had no personal or family history of TB. A tuberculin test had been negative. We consider that he was immunosuppressed from FAEs prior to etanercept, as he was extremely fatigued and had a persistent lymphopenia for several months. Lymphopenia occurs in the majority of patients on FAEs, which indicates a degree of immunosuppression. The mode of action of FAEs is considered to be inhibition of T-cell activity with a shift in cytokine profile from a predominantly T-helper cell (Th)1-type response to a Th2-type pattern. Lehman et al. reported immunosuppressive efficacy of FAEs in vivo in rat transplantation models. It is possible that our patient’s tuberculin test was negative because of immunosuppression by FAEs. In summary, we report a patient with extrapulmonary TB on etanercept in whom we consider that prior treatment with FAEs caused a degree of immunosuppression that predisposed to reactivation of TB. In patients who have failed on FAEs for whom biological agents are being considered, we advocate tuberculin testing when they are off FAEs for 3 months, in accordance with British Thoracic Society guidelines.

Case of coccidioidomycosis in Ireland.

Coccidioidal infection is a well-recognised cause of pulmonary disease in certain parts of the south-western USA, Central and South America; however, it is rarely encountered elsewhere in the world. We describe the case of a previously healthy man presenting to a Dublin hospital with fever, dry cough and chest pain, following a visit to the western USA. Despite treatment with broad-spectrum antimicrobials, the patient developed progressive bilateral pulmonary infiltrates and a large pleural effusion. After extensive investigations including CT, bronchoscopy and pleural fluid analysis, a diagnosis of pulmonary coccidioidomycosis was made. Following the initiation of appropriate antifungal therapy, the patient made a full recovery. This case was of interest due to the rarity of the disease outside its areas of endemicity and the unusual findings associated with its diagnosis.

Late onset tuberculosis infection in patients receiving anti-TNFα therapy

### Learning Point for Clinicians This report demonstrates that tuberculosis (TB) is a significant problem in patients receiving anti-tumor necrosis factor alpha (TNFα) therapy. TB may occur despite pre-treatment screening. The onset may be delayed and associated with significant morbidity and mortality. In particular, response to treatment may be slow and the disease may progress before coming under control. A 58-year-old male presented with a 4-week history of high-grade fevers, night sweats and malaise. He denied any respiratory symptoms. He had a history of psoriatic arthritis and had been treated with infliximab for 5 years and subsequently switched to adalimumab. Prior to institution of infliximab, a Mantoux test had been negative and chest X-ray normal. Examination was unremarkable apart from a fever of 39°C. Chest X-ray was normal, white cell count was 8.6, erythrocyte sedimentation rate was 20 and …

Recurrent pneumothoraces in a 65-year-old female: an unusual case of cystic lung disease.

A 65-year-old female presented to the emergency department with a 3-day history of dyspnoea and right-sided chest discomfort. She had been an inpatient 6 weeks earlier with right-sided pneumothorax treated with a computed tomography-guided chest drain. On this admission her chest radiograph demonstrated a recurrence of the pneumothorax (fig. 1). She was a life long nonsmoker. Figure 1. a) Chest radiograph showing a loculated right-sided pneumothorax. b) Histology of the lung tissue (from open lung biopsy) showed multiple …