Pulmonary & Respiratory Medicine

Chronic dyspnea is a frequent cause of applications to pulmonology clinics. Cardiopulmonary diseases represent the most frequent etiological causes of dyspnea. However, studies on this subject are limited. The purpose of this study is to determine the etiological causes in patients who admitted to outpatient clinic with the complaint of chronic dyspnea via specific diagnostic procedures. This prospectively planned study was performed with patients referred to chest disease clinic of Recep Tayyip Erdogan University, Turkey, between 1 July 2012 and 31 May 2013. Patients with a history of shortness of breath that was ongoing more than 1 month were included to study. Causes of dyspnea were investigated by using a 3-stage diagnostic procedure. Four hundred seventy-one patients were enrolled. Specific etiology of dyspnea was identified in 462 patients. The other nine patients could not be diagnosed. Respiratory disease was determined in 101 (22%) patients and non-respiratory disease was found in 361 (78%). Non-respiratory reasons of chronic dyspnea were identified as cardiac disease in 184 (51%), psychiatric diseases in 142 (39%) and other causes in 35 (10%) individuals. The etiology was considerably different between male and female groups. The most common cause of chronic dyspnea was found as respiratory disease (43%) in male group and cardiovascular disease (45%) in female group.

Objective: Endotoxin-induced acute respiratory distress syndrome (ARDS) is characterized by diffuse dysfunction of the microvasculature including increased permeability with oedema formation and apoptosis or necrosis of endothelial- and epithelial cells. Concomitantly, an increased concentration of circulating endothelial progenitor cells (EPC) was found in septic patients, which seem to be involved in pulmonary regeneration. The number of circulating EPC correlated inversely to disease severity and mortality. Since bone marrow-derived endothelial progenitor cells (BMDPC) were found homing to damaged lung tissue, a reparative process seems to be initiated right after the initiation of vessel damage or degeneration. In the present study we investigated the potential of BMDPC as a treatment strategy in lipopolysaccharide (LPS)-induced ARDS.

Methods: Male Wistar rats received lipopolysaccharide (LPS) (25 μg/kg) systemically and directly after LPS injection, the animals were administered 1x106 suspension of CD133+-cells dissolved in 1 ml of sodium chloride 0.9% or only 1 ml sodium chloride 0.9% for the control group. Mortality, macroscopic changes in lung tissue, disease symptoms, blood gas analyses, serum cytokine concentration, wet/dry weight and long-term results were analyzed.

Results: Rats treated with BMDPC showed a significantly improved pulmonary gas exchange, an inhibition of proinflammatory cytokine synthesis, an improved clinical course and a reduced mortality (p<0.024) compared to rats treated with LPS alone.

Conclusions: These findings suggest that the application of exogenous BMDPC can reduce the severity of septic organ damage. Cell therapy with BMDPC might therefore become a novel option in ARDS therapy.

Background: In India, 15% of pulmonary tuberculosis cases have been estimated to be attributable to DM. Clinical presentation of Tuberculosis and Diabetes is overlapping many times, difficult to differentiate one from other. Although DM has been associated with increased risk of TB treatment failure or relapse, and diminished 2-month and 6-month culture conversion rates, neither international guidelines nor India’s Revised National TB Control Programme (RNTCP) currently recommend active screening of TB patients for detection of DM.

Methods: Prospective study conducted at MIMSR Medical College Latur, India during Jan. 2011 to Nov. 2013 included 200 cases of TB with Diabetes Mellitus (DM), compared with 200 cases of TB without DM. Objectives of study were to correlate impact of DM on sputum conversion rate and on clinic-radiological pattern.

Results: PTB was observed in 141 (70.5%) cases with DM as compared to 173 (86.5%) cases without DM, while EPTB was observed in 59 (29.5%) cases with DM as compared to 27 (13.5%) cases without DM (p<0.0002). Lower Lung fields involvement in 34 (24.11%) cases with DM and 11 (6.35%) cases without DM cases. Pulmonary Cavities were observed in 55 (39.00%) cases with DM and 49 (28.32%) cases without DM (p<0.0001). Sputum conversion at intensive phase completion was observed in 76.53% and 92.70% cases of PTB with and without DM respectively (p<0.003). Out of 5.2% cases which were failed to show sputum conversion in diabetic group, 2.8% cases were found to have MDR.

Conclusion: DM affects the clinical, bacteriological and radiological presentation of PTB. Failure of sputum conversion after intensive phase completion should be interpreted cautiously, as many cases were showing sputum conversion after one month therapy of completion of intensive phase and only 2.8% cases found to have MDR.

A former smoker 85-year-old man with a history of emphysematous COPD was admitted to hospital with a mild COPD exacerbation. He also reported a costal trauma 48 hours before. The following day the patient began to complain that he was "swelling up"; a physical examination was performed without findings at the time.

Within two days of admission and after a fit of coughing, the patient experienced a large and fast increase of volume of soft tissue on the face, neck, chest and upper extremities, with crackling to the touch. Chest CT was performed in which fractures in several ribs and significant subcutaneous emphysema, pneumomediastinum and a small pneumothorax were observed. A drainage tube was placed with full resolution of emphysema and the patient was discharged two weeks later, without further treatment.

This case report shows how a good physical examination can help to diagnose a serious condition in advance. As such, this paper should be of interest to a broad readership including those interested in respiratory medicine, thoracic surgery or general internal medicine.

Tracheobronchomegaly (TBM) or Mounier - Kuhn syndrome is a rare disorder of uncertain aetiology characterized by marked dilatation of trachea and bronchi and recurrent lower respiratory tract infection. We report a case in a 20 year old male presenting with recurrent lower respiratory tract infection.

Rationale: Impulse Oscillometry (IOS) is a noninvasive method to measure respiratory impedance. The use of IOS as an indirect measure of airflow obstruction compared to spirometry in the evaluation of Exercise-Induced Bronchoconstriction (EIB) has not been fully explored in children. In this study we aim to describe the IOS values, resistance at 5 Hz (R5rs) in subjects with EIB and without EIB. We also aim to compare whether IOS variables correlate with spirometry variables following exercise challenge test in asthmatic subjects.

Methods: We designed a cross sectional study involving subjects between 6-18 years old with a diagnosis of asthma who were referred to the pediatric pulmonary function lab for an exercise challenge test to rule out EIB. Spirometry and IOS were performed at baseline and at 5 minute intervals up to 20 minutes post exercise and again post bronchodilator.

Results: 43 subjects were enrolled. Of the 43 subjects, 15 had a 10% fall in FEV1 after exercise significant for EIB. Demographic characteristics (gender, age and ethnicity) were not different comparing subjects with EIB to those without EIB. There was a significant correlation between spirometry and IOS measurements at baseline, 1 minute, 5 minutes, 10 minutes, 15 minutes, 20 minutes and post bronchodilator after exercise (r= -0.75, -0.72, -0.72, -0.76, -0.75, -0.72 and -0.75 respectively, p<0.01) in asthmatic subjects without EIB. In asthmatic subjects with EIB, there was a significant correlation between spirometry and IOS measurements at baseline, 1 minute, and post bronchodilator after exercise (r=-0.55, -0.79 and -0.63 respectively p<0.05). There was weak correlation between spirometry and IOS measurements at 5 minutes, 10 minutes, 15 minutes and 20 minutes after exercise for asthmatic subjects with EIB.

Conclusion: A significant correlation was found between spirometry and IOS measurements of change in airway function in asthmatic patients both with EIB and without EIB.

Background: Patients with obstructive sleep apnea are more likely to have a non-dipping blood pressure profile than hypertensive patients without sleep apnea. The study of clinical factors and biomarkers affecting the nocturnal dip of blood pressure is of practical value.

Aim: To determine the role of glucometabolic, sleep study parameters and biomarkers in the detection of dipper and non-dipper obstructive sleep apnea patients.

Materials and Methods: A total of 87 patients participated in the study. Obstructive sleep apnea was verified by a standard polysomnography. Metabolic syndrome was diagnosed according to IDF, 2005. Anthropological parameters, glucmetabolic and sleep study characteristics were assessed. An ambulatory 24-hour blood pressure monitoring was performed. Resistin and free fatty acids plasma levels were measured. Urinary 8-isoprostanes were determined.

Results: Nondippers did not differ significantly from dippers regarding the anthromopetric measurements. From the sleep study parameters only the duration of sleep at SaO2<90% was longer in non-dippers (63.17 ± 30.32 vs 39.92 ± 34.89). Glucometabolic markers could not differentiate dippers from non-dippers, except for HbA1C (5.9 ± 0.5 vs 6.4 ± 1.05; p=0.006). The biomarkers – resistin, free fatty acids and isoprostanes were of similar range in both groups. The multivariate regression analysis, however showed that HbA1C lost its value as an independent predictor of non-dipping after adjustment for duration of sleep at SaO2<90%.

Conclusions: According to our study the average duration of sleep with SatO2<90% could be of clinical value in the prediction of the non-dipping phenomenon in patients with obstructive sleep apnea and metabolic syndrome.

Background: Obstructive Sleep Apnea Syndrome (OSAS) is recognized as a serious health problem that impairs quality of life. Although, optimal treatment of OSAS with continuous positive airway pressure (CPAP) reduce the number of respiratory events during sleep, and thus improve quality of life, a large number of patients do not tolerate CPAP. In the last decade, there has been an explosion of interest in the using of oral appliances to treat OSAS; however, in severe OSAS there is only scanty evidence available indicating that dental appliances are effective.

Objectives: This study aimed at evaluating the efficacy of the mandibular advancing appliance (MAA) in the treatment of severe OSAS patients.

Material and Methods: Thirty three polysomnography (PSG) diagnosed cases of severe OSAS patients were included. The mean apnea/hypopnea index (AHI) was 42.36 ± 7.92. The cases were subjectively assessed by the Epworth Sleepiness Scale (ESS). Outcome measurements included sleep study, sleepiness; side-effects and compliance were assessed.

Results: The polysomnographic variables and clinical assessments revealed a significant improvement in the patients.

Conclusion: Mandibular Advancement Appliance therapy can be an actual alternative treatment for severe OSAS patients who cannot tolerate CPAP. The better compliance seen with the MAA may be advantageous.