Vichaya Arunthari

A prospective, comparative trial of standard and breath-actuated nebulizer: Efficacy, safety, and satisfaction

BACKGROUND: Nebulized drug delivery is a cornerstone of therapy for obstructive lung disease, but the ideal nebulizer design is uncertain. The breath-actuated nebulizer (BAN) may be superior to conventional nebulizers. This study compared the BAN to standard nebulizer with regard to efficacy, safety, and patient and respiratory therapist (RT) satisfaction. METHODS: Adults admitted to the hospital and for whom nebulizer therapy was prescribed were enrolled. Subjects were randomly assigned to either AeroEclipse II or standard nebulizer and were surveyed at the completion of each treatment. BAN delivered albuterol 2.5 mg or albuterol 2.5 mg plus ipratropium 0.25 mg. Standard nebulizer delivered albuterol 2.5 mg or albuterol plus ipratropium 0.5 mg. An RT assessed each subjects heart rate, respiratory rate, and peak expiratory flow rate prior to and following treatment. Treatment time and adverse events were recorded. Each RT was asked to assess his/her satisfaction with each of the nebulizers. RESULTS: Twenty-eight subjects were studied. The mean age was 69 years. Fifty-four percent of the subjects indicated that overall the BAN was superior to conventional nebulizer therapy; 68% indicated that duration was preferable with the BAN. RTs were more satisfied with the BAN, based on overall performance, treatment duration, and ease of use. There were no significant differences in heart rate, peak expiratory flow rate, or respiratory rate before or after nebulization therapy with either device. The duration of treatment was significantly lower with the BAN (4.1 min vs 9.9 min, P < .001). Additionally, the BAN was associated with a lower occurrence of adverse events. CONCLUSIONS: Patients and RTs expressed greater satisfaction with the BAN, compared with standard nebulizer. Pre- and post-treatment vital signs did not differ between groups, but use of the BAN was associated with a shorter duration and a lower occurrence of adverse events. Taken together, these data support the use of the BAN for nebulized medication delivery.

Prevalence of Restless Legs Syndrome in Blood Donors

Iron deficiency anemia has been linked to restless legs syndrome (RLS) and regular blood donation may lead to iron deficiency. It has been reported that blood donations may be associated with RLS. A recent study from Sweden found that 25% of the women donors were affected by RLS. However, this type of study has not been replicated in the United States. We conducted a study in our blood donation unit between September and October 2008. To identify those with RLS, we used the RLS diagnostic index questionnaire by Benes et al. The proportion of blood donors with RLS was estimated and the number of blood donations and hemoglobin levels were compared according to RLS status. One hundred and fifty one patients were interviewed; 7 patients who donated only platelets were excluded, leaving 144 patients for analysis. There were 13 (9.0%, 95% confidence interval [CI]: 4.9–14.9%) patients with RLS. Of these, 7 (4.9%, 95% CI: 2.0–9.8%) had possible RLS and 6 (4.2%, 95% CI: 1.5–8.9%) had major or clinically relevant RLS. There was no dramatic association between RLS and number of blood donations or hemoglobin level (all P ≥ 0.21). In our sample of blood donors in the United States, the prevalence of major RLS was 4%. We could not demonstrate an association between RLS and the frequency of blood donation or hemoglobin level in our relatively small sample; a larger sample is needed to better identify any associations.

Utility of D-Dimer in the Diagnosis of Patients with Chronic Thromboembolic Pulmonary Hypertension

Background: Chronic thromboembolic pulmonary hypertension (CTEPH) is an important cause of severe pulmonary hypertension (PH). D-dimer, a degradation product of fibrin, has been used as a marker for various diseases. In patients with idiopathic pulmonary arterial hypertension there is evidence to suggest that D-dimer levels are associated with disease severity; however, data regarding D-dimer in patients with CTEPH are lacking. Objective: To assess the significance of D-dimer in patients with CTEPH. Patients and Methods: Retrospective chart review of 618 patients seen at our PH clinic from 1991 to June 2008. Data collection focused on patients diagnosed with CTEPH, D-dimer levels, demographics, clinical, and hemodynamics. We compared D-dimer levels in CTEPH patients or World Health Organization (WHO) diagnostic group 4 with PH patients in WHO group 1. Results: Thirty-four patients with confirmed CTEPH were identified, of these 19 had D-dimer levels and 7 were positive. Of the 234 patients in WHO group 1 excluding patients with portopulmonary hypertension (n = 54) and pulmonary venoocclusive disease (n = 2) 97 had D-dimer levels and 52 were positive. We found an estimated sensitivity of the D-dimer test in diagnosing CTEPH was 37% while the estimated specificity was 46%. The positive predictive value and negative predictive value were 12% and 79% respectively. Conclusion: D-dimer is an insensitive and nonspecific test for the diagnosis of CTEPH. Despite a high negative predictive value D-dimer alone cannot be used to rule out CTEPH in patients with PH.

Correlation of pulmonary function variables with hemodynamic measurements in patients with pulmonary arterial hypertension

Introduction:  A reduced diffusing capacity of the lung for carbon monoxide (DLCO) measured during a pulmonary function test can suggest pulmonary arterial hypertension (PAH). The DLCO has been reported to weakly correlate with pulmonary hemodynamics.

Survey of restless legs syndrome in a pulmonary hypertension population

The prevalence of restless legs syndrome (RLS) varies from 5% to 24% in the general population and is associated with a variety of medical disorders. However, the association between RLS and pulmonary hypertension (PH) is unknown.

Prevalence of acute vasoresponsiveness in patients with pulmonary hypertension: treatment implications.

Objective: Pulmonary hypertension (PH) is a serious and often progressive disorder that results in right ventricular dysfunction. The general reported rate of patients who are responders is 10%–26%. More recently, using the current criteria, the rate of acute vasodilator response was as low as 6%. This study used the most current guidelines to assess the prevalence of acute vasoresponsiveness in patients with PH. Methods: A retrospective chart review of 618 patients seen in the PH clinic at the Mayo Clinic Jacksonville from 1991 to June 2008 was conducted. We assessed the prevalence of acute vasoresponsiveness in patients with PH who had undergone vasodilator trial with epoprostenol or nitric oxide, using the current accepted criteria. Results: One hundred and seventy-six patients who underwent a vasodilator trial that had complete hemodynamic data were identified. The average age was 61 ± 14 years and most were women (67%). The PH was severe with most patients in the World Health Organization (WHO) functional class III-IV (82%), and an average mean pulmonary artery pressure of 48 ± 11 mm Hg. Although the study group included all WHO diagnostic groups, 69% were diagnosed as Group I pulmonary arterial hypertension. We found an overall prevalence of response to acute vasodilator therapy to be 26%. Conclusion: Using the most current criteria to identify acute responders to vasodilator therapy in PH patients, we found a slightly higher rate of “responders” than previously reported. Acute vasodilator testing identifies a clinically important group who may benefit from calcium channel blockers (CCBs), and this study confirms that a significant percentage of PH patients are acutely vasoresponsive.

Catamenial pneumothorax with umbilical and diaphragmatic endometriosis: a case report and review of the literature.

A 44-year-old female presented with a history of recurrent right-sided pneumothoraces, uterine fibroids, and a palpable lump in her navel. Total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH-BSO) and resection of the umbilical nodule was performed. Intraoperative inspection of the right hemidiaphragm revealed adherent brownish-blue nodules without any associated diaphragmatic defects and a similar-appearing nodule at the umbilicus. She had no symptoms of pelvic endometriosis, nor did surgical exploration reveal any. Her postoperative course was uneventful and she denied recurrent pneumothorax at 12-month followup. Recurrent pneumothoraces in women of a reproductive age should raise the suspicion of thoracic endometriosis. Failure to establish the diagnosis prevents appropriate curative interventions.

A Retrospective Analysis of Patients with Pulmonary Hypertension to Assess the Role of Overnight Oximetry in the Diagnosis of Sleep Disordered Breathing

Background: In patients with Pulmonary Hypertension (PH), the role of overnight oximetry as means to screen for Sleep Disordered Breathing (SDB) has not been well established. The aim of this study was to assess whether overnight oximetry was additive to a standard sleep questionnaire in the diagnosis of SDB. Methods: This retrospective study included 94 PH patients seen at Mayo Clinic Florida PH Center from 1992 to 2006. Analysis was performed on the following information: age, gender, body mass index, presence of hypertension, right ventricular systolic pressure (RVSP), presence of SDB symptoms (i.e. snoring, excessive daytime sleepiness, witnessed sleep apneas), overnight oximetry results, and polysomnography results when available. The primary outcome measurement was the correlation between SBD symptoms (snoring, excessive daytime sleepiness, and witnessed sleep apnea) and results of overnight oximetry. Results: There is strong evidence showing a higher prevalence of abnormal overnight oximetry results as the number of SDB symptoms increases (P<0.001). Of patients who had no symptoms of SDB (17), all oximetry results were found to be normal. The clinical symptoms of SDB were 100% sensitive for an abnormal screening overnight oximetry. Other analysis revealed evidence of a higher prevalence of snoring in men (P=0.005) and in patients with a higher BMI (P=0.038). Conclusions: In PH patients who have a few or no symptoms of SDB, an overnight oximetry is not additive in screening for SDB. In those patients with SDB symptoms, an overnight oximetry will be predictably abnormal.