Warren J. Davidson

Obesity negatively impacts lung function in children and adolescents.

To investigate the relationship between weight status (body mass index [BMI] percentile and BMI z‐score) and lung volumes in healthy children and adolescents.

Effect of incremental exercise on airway and systemic inflammation in patients with COPD

Airway and systemic inflammation are features of chronic obstructive pulmonary disease (COPD), and there is growing interest in clarifying the inflammatory processes. Strenuous exercise induces an intensified systemic inflammatory response in patients with COPD, but no study has investigated the airway inflammatory and anti-inflammatory responses to exercise. Twenty steroid-naïve, ex-smokers with diagnosed COPD (forced expired volume in 1 s = 66 ± 12%) underwent baseline collection of venous blood and induced sputum followed by an incremental exercise test to symptom limitation 48 h later. Additional venous blood samples were collected following exercise at 0, 2, and 24 h, while induced sputum was collected 2 and 24 h after exercise. Sputum and blood samples were analyzed for differential cell count, CD4(+) and CD8(+) T lymphocytes (serum only), interleukin (IL)-6, IL-8, IL-10, chemokine (C-C motif) ligand 5 (CCL5), and high sensitivity C-reactive protein (serum only). There was an increase in the number of sputum eosinophils (cells/gram, P = 0.012) and a reduction in sputum IL-6 (P = 0.01) 24 h postexercise. Sputum IL-8 and CCL5 were also persistently decreased after exercise (P = 0.0098 and P = 0.0012, respectively), but sputum IL-10 did not change. There was a decrease in serum eosinophils 2 h after exercise (P = 0.0014) and a reduction in serum CCL5 immediately following and 2 h postexercise (P < 0.0001). Both serum eosinophils and CCL5 returned to baseline levels within 24 h. An acute bout of exercise resulted in a significant increase in the number of sputum eosinophils, which may be mediated by serum CCL5. However, there was also a reduction in sputum proinflammatory cytokines, suggesting some anti-inflammatory effect of exercise in the lungs of steroid-naïve patients with COPD.

Cryptococcus gattii pneumonia

A 27-year-old previously healthy woman presented to the emergency department in Calgary, Alberta, with shortness of breath, muscle aches and a nonproductive cough that had lasted for 48 hours. During the previous two weeks, the patient had experienced a loss of appetite, fatigue, fever and chills.

Airway inflammation, cough and athlete quality of life in elite female cross‐country skiers: A longitudinal study

The aim of this study was to investigate the effect of a season of cross‐country training and racing on airway inflammation, cough symptoms, and athlete quality of life in female skiers. Eighteen elite female skiers performed sputum induction and completed the Leicester Cough Questionnaire (LCQ) and the Recovery‐Stress Questionnaire (REST‐Q) at three time points (T1 – May/Jun, T2 – Oct/Nov, T3 – Jan–Mar) during the year. No changes were observed between T1 and T2. However, an increase in sputum eosinophils and lymphocytes (P < 0.05) and a significant change in all three domains of the LCQ were observed between T1 and T3 (P < 0.05). A significant association was found between the total yearly hours of training and the change in the total cell count (r2 = 0.74; P = 0.006), and a number of other sputum cell counts between T1 and T3. No changes were observed for any domain of the REST‐Q. The results of this study demonstrate that airway inflammation and cough symptoms are significantly increased in elite female cross‐country skiers across a year of training and racing. The increase in airway inflammation is related to the total amount of training and is worse during the winter months when athletes are training and racing in cold, dry air.

Identification and validation of nebulized aerosol devices for sputum induction

BACKGROUND Induced sputum cell counts are a noninvasive and reliable method for evaluating the presence, type and degree of airway inflammation in patients with asthma. Currently, standard nebulizer devices used for sputum induction in multiple patients are labelled as single-patient devices by the manufacturer, which conflicts with infection prevention and control requirements. As such, these devices cannot feasibly be used in a clinical sputum induction program. Therefore, there is a need to identify alternative nebulizer devices that are either disposable or labelled for multipatient use. OBJECTIVE To apply validated rigorous, scientific testing methods to identify and validate commercially available nebulizer devices appropriate for use in a clinical sputum induction program. METHODS Measurement of nebulized aerosol output and size for the selected nebulizer designs followed robust International Organization for Standardization methods. Sputum induction using two of these nebulizers was successfully performed on 10 healthy adult subjects. The cytotechnologist performing sputum cell counts was blinded to the type of nebulizer used. RESULTS The studied nebulizers had variable aerosol outputs. The AeroNeb Solo (Aerogen, Ireland), Omron NE-U17 (Omron, Japan) and EASYneb II (Flaem Nuova, Italy) systems were found to have similar measurements of aerosol size. There was no significant difference in induced sputum cell results between the AeroNeb Solo and EASYneb II devices. DISCUSSION There is a need for rigorous, scientific evaluation of nebulizer devices for clinical applications, including sputum induction, for measurement of cell counts. CONCLUSION The present study was the most comprehensive analysis of different nebulizer devices for sputum induction to measure cell counts, and provides a framework for appropriate evaluation of nebulizer devices for induced sputum testing.

Establishing a Normal Range for Induced Sputum Cell Counts in Western Canada

BACKGROUND Induced sputum cell counts are a noninvasive, reliable method for evaluating the presence, type and degree of airway inflammation. Whether current reference values for induced sputum cell counts are applicable in other induced-sputum laboratories, particularly those in Western Canada or at elevated altitude, is not clear. OBJECTIVES To describe the normal range of induced sputum cell counts in healthy adults in Western Canada. METHODS A total of 105 healthy nonsmoking adults with normal bronchial responsiveness and no history of lung disease proceeded with sputum induction. Sputum samples were fixed in formalin. RESULTS Sixty-nine subjects were included in the final analyses. The mean ± SD and median (interquartile range) of the cell counts, respectively, were: total cell count 2.453 ± 2.108, 2.000 (2.512); neutrophils 1.212 ± 1.491, 0.721 (1.016); eosinophils 0.034 ± 0.069, 0.005 (0.043); macrophages 1.050 ± 1.213, 0.696 (1.005); lymphocytes 0.057 ± 0.161, 0.001 (0.049); and bronchial epithelial cells 0.041 ± 0.126, 0.000 (0.027). The respective differential cell percentages were: neutrophils 50.3 ± 23.5, 51.9 (32); eosinophils 1.4 ± 2.3, 0.3 (2); macrophages 43 ± 22.8, 39.3 (32); lymphocytes 2.6 ± 5.2, 0.4 (2.5); and bronchial epithelial cells 2.2 ± 4.8, 0.0 (2.9). Bland-Altman analysis and intraclass correlation coefficients revealed excellent interobserver agreement for measurement of sputum cell types. DISCUSSION The range of induced sputum cell counts performed in a laboratory in Western Canada in healthy nonsmoking adult subjects was described; cellular distributions were similar to previous studies. This was also the first description of normal values for formalin-fixed induced sputum samples. CONCLUSIONS These results confirm that current reference values for induced sputum are generalizable across different laboratories, including those in Western Canada and those at elevated altitude, and are also generalizable to formalin-fixed samples, allowing use in the broader Canadian asthma population.

Flow-volume loop abnormality detecting a previously unrecognized right upper lobe tracheal bronchus.

Tracheal bronchus is a rare anatomic variant in which a bronchus originates from the trachea. Patients may be asymptomatic or present with a variety of respiratory symptoms. We present a case of a patient who presented with a history of poorly controlled asthma and a persistent abnormality of the flow-volume loop. Bronchoscopy revealed a tracheal bronchus with narrowed right-sided bronchial orifices. An unrecognized tracheal bronchus may result in serious complications during elective or emergent endotracheal intubation. Spirometry testing may reveal abnormalities of the flow-volume loop associated with altered airflow. Relying on spirometric values without assessing the shape of the flow-volume loop may lead to misdiagnosis and inappropriate management of lung pathology.

Using Operational Analysis to Improve Access to Pulmonary Function Testing

Background. Timely pulmonary function testing is crucial to improving diagnosis and treatment of pulmonary diseases. Perceptions of poor access at an academic pulmonary function laboratory prompted analysis of system demand and capacity to identify factors contributing to poor access. Methods. Surveys and interviews identified stakeholder perspectives on operational processes and access challenges. Retrospective data on testing demand and resource capacity was analyzed to understand utilization of testing resources. Results. Qualitative analysis demonstrated that stakeholder groups had discrepant views on access and capacity in the laboratory. Mean daily resource utilization was 0.64 (SD 0.15), with monthly average utilization consistently less than 0.75. Reserved testing slots for subspecialty clinics were poorly utilized, leaving many testing slots unfilled. When subspecialty demand exceeded number of reserved slots, there was sufficient capacity in the pulmonary function schedule to accommodate added demand. Findings were shared with stakeholders and influenced scheduling process improvements. Conclusion. This study highlights the importance of operational data to identify causes of poor access, guide system decision-making, and determine effects of improvement initiatives in a variety of healthcare settings. Importantly, simple operational analysis can help to improve efficiency of health systems with little or no added financial investment.

Evidence-based risk assessment and recommendations for physical activity clearance: respiratory disease1This paper is one of a selection of papers published in the Special Issue entitled Evidence-based risk assessment and recommendations for physical activity clearance, and has undergone the Journal’s usual peer-review process.

The 2 most common respiratory diseases are chronic obstructive pulmonary disease (COPD) and asthma. Growing evidence supports the benefits of exercise for all patients with these diseases. Due to the etiology of COPD and the pathophysiology of asthma, there may be some additional risks of exercise for these patients, and hence accurate risk assessment and clearance is needed before patients start exercising. The purpose of this review was to evaluate the available literature regarding the risks of exercise for patients with respiratory disease and provide evidence-based recommendations to guide the screening process. A systematic review of 4 databases was performed. The literature was searched to identify adverse events specific to exercise. For COPD, 102 randomized controlled trials that involved an exercise intervention were included (n = 6938). No study directly assessed the risk of exercise, and only 15 commented on exercise-related adverse events. For asthma, 30 studies of mixed methodologies were included (n = 1278). One study directly assessed the risk of exercise, and 15 commented on exercise-related adverse events. No exercise-related fatalities were reported. The majority of adverse events in COPD patients were musculoskeletal or cardiovascular in nature. In asthma patients, exercise-induced bronchoconstriction and (or) asthma symptoms were the primary adverse events. There is no direct evidence regarding the risk of exercise for patients with COPD or asthma. However, based on the available literature, it would appear that with adequate screening and optimal medical therapy, the risk of exercise for these respiratory patients is low.