Pulmonary & Respiratory Medicine

Unified Airways Disease (UAD) encompasses distinct clinical entities including chronic rhinosinusitis and asthma and gives credence to the hypothesis that these are different facets of the same disease process. Macrolide antibiotics are derived from the prototypic macrolide erythromycin. This was discovered in the early 1950’s as an isolate from the soil bacteria Saccharopolyspora erythraea and it is known to be a primarily bacteriostatic agent. Macrolides are a commonly used class of antibiotic that are known to have actions beyond their primary bactericidal functions and have been shown to be of benefit in conditions affecting all constituents of the airway, including chronic rhinosinusitis, asthma, diffuse panbronchiolitis and cystic fibrosis. These properties include potent anti-inflammatory and immunomodulatory effects. Promising results that have been shown with the use of macrolide therapies in airways diseases gives hope that there may be a wider application for them in Unified Airways Disease (UAD). A key property that macrolides (and newer generation ketolides) possess is the ability to interfere with protein translation at the 50s subunit of the bacterial ribosome. It is feasible that this action allows macrolides to disrupt the cellular processes related to bacterial proliferation and influence the inflammatory response, decreasing the production of inflammatory proteins and cytokines and disrupting biofilm formation. Macrolides are well established drugs with a known side-effect profile and relatively low cost and therefore could provide a cost-effective alternative to other costly therapies or surgeries.

Objective: We evaluated changes in bronchoconstriction by a new approach based on respiratory inductive plethysmography (RIP) signal analysis.

Methods: Thoracic and abdominal motions were recorded (5 min) by uncalibrated RIP in 44 adult subjects with a diagnosis of moderate bronchial obstruction (Obstructive group) and 50 healthy adult controls (Healthy group). In the Obstructive group, two series of measurements were performed before (Obstructive PRE) and after (Obstructive POST) a bronchodilation protocol. Airway resistance (Raw) and lung function data (forced vital capacity (FVC), forced expiratory volume in one second (FEV1 ) and FEV1 /FVC) were measured with a body plethysmograph. A breath-bybreath analysis was performed to calculate distances between normalized thorax and abdomen RIP signals and a mean distance (D) was calculated for each recording.

Results: D and Raw were higher in the Obstructive group than in the Healthy group in both PRE and POST conditions. Both D and Raw significantly decreased after bronchodilation in the Obstructive group. D and Raw were also positively and significantly correlated in the Obstructive group in both PRE and POST conditions.

Conclusion: D, as calculated from signals recorded by RIP, appears to be a useful non-invasive parameter for continuous monitoring of changes in bronchoconstriction.

Solitary Fibrous Tumors (SFT), previously termed haemangiopericytoma, are rare soft tissue sarcomas (STS). They usually grow slowly and show indolent behaviour in terms of malignancy. Surgery in localized disease is the only curative approach. While metastatic disease occurs rarely, locally advanced SFT often require systemic treatment. Systemic treatment for inoperable SFT is not standardized, and chemotherapy displays only modest activity. Temozolomide plus bevacizumab is a relatively active treatment option. Its advantages are prolonged tumor stabilisation combined with an overall low toxicity profile. We report the first case of treatment related interstitial pulmonary toxicity caused by temozolomide in combination with bevacizumab during treatment of SFT.

We report a case of endobronchial ultrasound guided trans-bronchial needle aspiration (EBUS-TBNA) in the diagnosis and bronchoscopic decompression of a tubercular mediastinal lymphadenitis causing dysphagia due to oesophagus compression.

This study aimed to determine the feasibility of recording speech breathing patterns before and after a six week Pulmonary Rehabilitation programme (PR) for patients with Chronic Obstructive Pulmonary Disease (COPD) and bronchiectasis. Fourteen patients with COPD (age 69 ± 9.64) and 6 patients with bronchiectasis (age 71 ± 6.15) were recruited from a respiratory outpatients department, and breathing patterns were recorded using Respiratory Inductive Plethysmography (RIP) during periods of quiet breathing, reading, counting and conversational speech, before and after a six week PR programme. Nine parameters were extracted from the recorded RIP signals: respiratory rate (bpm), inspiration and expiration time (s), inspiration and expiration magnitude (arbitrary units representing volume) and the regional percentage contributions of the ribcage and abdomen during inspiration and expiration. Clinical data, modified Borg scores, and Incremental Shuttle Walk Test (ISWT) data were retrieved from medical notes. Functional exercise capacity (ISWT) significantly improved following PR by 89 m for the group (t=-4.11, df=16, p=0.00). No clinically or statistically significant changes in breathlessness (Borg), or speech breathing parameters, were detected following PR during any of the speech tasks. This study has demonstrated the feasibility of collecting speech breathing pattern data outside laboratory conditions. No firm conclusions can be drawn from the findings because of the uncontrolled nature of the study. It is therefore too soon to know if speech breathing patterns will be a useful tool for the remote monitoring of respiratory health in future.

Amiodarone is a widely used antiarrhythmic with well-known adverse effects, being pulmonary toxicity one of the most serious, occurring even with low doses. Amiodarone-induced organizing pneumonia (AIOP) is an infrequent histopathological presentation but a few cases have been reported in the literature.

A 78-year-old woman with atrial fibrillation doing amiodarone 200 mg once daily for two years was admitted to the Emergency Department with progressive dyspnea to rest, productive purulent cough, flulike symptoms and pleuritic chest pain. Blood tests revealed a hypoxemic respiratory failure and a systemic inflammatory response, and the chest radiography showed bilateral, multifocal pulmonary infiltrates. Microbiologic studies of urine, blood and sputum were sterile. The patient was initially treated for community acquired pneumonia, with clinical and radiological worsening despite multiple extended spectrum antibiotics. The complementary study excluded other etiologies, and a transthoracic pulmonary biopsy was performed, revealing histology consistent with organizative pneumonia.

AIOP is typically presented as a community acquired pneumonia that does not respond to antibiotics. The diagnosis depends on a high clinical suspicion, and compatible clinical and radiological pattern. Although it is not the most frequent, the presented case enforces the assumption that toxicity is present even with lower doses such as 200 mg once daily for 2 years.

Background: COPD affects skeletal muscle system. Less efficient muscles generates higher ventilatory demand, which promotes a vicious cycle of dynamic hyperinflation and cardiac constraints, reducing functional capacity.

Aim: To investigate the effects of a pulmonary rehabilitation program, based on physical exercise, on ventilatory and cardiac performances profile. Methods: 5 moderate to severe COPD patients were recruited. All patients were submitted to 8 week (5 times/ week) pulmonary rehabilitation program, composed by aerobic and resistance training. The patients performed a cardiopulmonary exercise test (CPET) before and after the program.

Results: Pulmonary rehabilitation changed ventilatory (10.53 ± 5.32 vs. 28.97 ± 12.07%, p<0.05) and cardiac consumption (10.04 ± 1.80 vs. 22.88 ± 10.36%, p<0.05) at 100% work rate. Pulmonary rehabilitation also increased ventilation (20.6 ± 3.3 vs. 27.1 ± 5.9 L/min, p<0.05) and oxygen pulse (5.4 ± 1.6 vs. 7.5 ± 1.9 ml/beat, p<0.05) at 100% work rate, VO2 (610 ± 110 vs. 880 ± 230 ml/min, p<0.05) and work rate (36.8 ± 9.8 vs. 55.6 ± 14.8 W, p<0.05).

Conclusion: A 8 week pulmonary rehabilitation program improved ventilatory and cardiac performances, probably as a result of dynamic hyperinflation reduction. Peripheral muscle improvement also contributed to ventilatory and cardiac performances profile changes.

Rationale: In asthma, airway inflammation, obstruction and reactivity may lead to ventilation heterogeneity; our understanding of this process is limited in asthmatic children.

Objectives and Methods: The study’s objective was to measure ventilation heterogeneity, by the lung clearance index (LCI), in children with well controlled asthma and assess the association of LCI with airway reactivity through methacholine challenge tests. LCI and spirometry were measured in 24 children with asthma and 21 healthy controls between 4 and 10 years of age. Sixteen children with asthma and 11 healthy controls also performed methacholine challenge tests.

Results: LCI was higher in children with asthma compared to healthy controls (7.58 vs 6.79, p=0.004); no differences in FEV1 or FEF25-75 were noted between groups. Ages were similar (p=0.54); however, the slope of LCI versus age differed between groups (p=0.001). The LCI slope increased with age in asthmatics. Further, higher LCI values were associated with decreasing PC20 (provocative concentration of methacholine to decrease baseline FEV1 by 20%) values in children with asthma (p=0.02), but not healthy controls (p=0.16).

Conclusions: Ventilation heterogeneity is present from preschool age in children with well controlled asthma. The relationship between ventilation heterogeneity and airway reactivity suggests that normalizing ventilation heterogeneity may be an important therapeutic target for treating children with asthma.