Respiratory Diseases

Abstract: The increase in cigarette smoking among women is now being reflected in an increased incidence of chronic obstructive pulmonary disease (COPD). Since 1985, the rate of COPD-related deaths in women has steadily risen, and it nearly tripled from 1980 to 2000. There continues to be debate about whether women are more susceptible than men to COPD. Women on average have airways that are 17% smaller, and further narrowing of the airways by COPD may make women more vulnerable to symptomatic airways obstruction. There also is some evidence of greater bronchial hyperreactivity in women, although conflicting findings have been reported. Gender bias appears to exist in the diagnosis and workup of COPD. For example, there is some evidence that clinicians are more likely to consider the diagnosis of COPD in men than in women. One study showed that women who had symptoms consistent with COPD were significantly less likely than men to undergo spirometric assessment. (J Respir Dis. 2006;27(2):70-74)

Physicians around the country are being bombarded with questions about avian flu. This brief review of the current status of the avian flu outbreak and its treatment and prevention provides the information you will need to answer the most pressing patient questions.

A number of inflammatory diseases have been associated with an increased risk of atherosclerosis. Knoflach and colleagues report findings that support a link between allergic diseases, such as allergic rhinitis and asthma, and atherosclerosis. Their findings came from 2 studies: the Bruneck study, which included 826 men and women aged 40 to 70 years, and the Atherosclerosis Risk Factors in Male Youngsters (ARMY) study, which included 141 male participants aged 17 or 18 years.

My patient has been hospitalized for pneumonia several times by different physicians. He has never received the pneumococcal vaccine. Can this vaccine begiven during the patient’s hospital stay?

Abstract: Although cystic fibrosis (CF) is typically diagnosed during infancy or childhood, it may escape detection until adulthood. Diagnostic accuracy can be sharpened by maintaining a high index of suspicion for CF in an adult who is pancreatic-sufficient but has unexplained recurrent respiratory infections, bronchiectasis, or nutritional deficiencies. The workup begins with the quantitative pilocarpine iontophoresis sweat test. If necessary, additional tests include mutation analysis, full-gene sequencing of CF transmembrane conductance regulator protein, and measurement of nasal transepithelial potential difference. Multidisciplinary care is essential and includes nutritional support, chest physiotherapy, exercise, appropriate antibiotics, and other pulmonary interventions. Dornase alpha, inhaled tobramycin, and azithromycin have been associated with improved outcomes and are considered to be the standard of care for patients with moderate lung involvement. (J Respir Dis. 2006;27(1):32-41)

The influenza vaccine has been used for many years to control outbreaks of influenza, and its role in reducing morbidity and mortality is widely appreciated among health care professionals and patients alike. The panic that occurred in 2004 after announcements of a vaccine shortage bears testimony to the importance placed on this approach to influenza prevention and control.

Abstract: Shortness of breath is a common complaint associated with a number of conditions. Although the results of the history and physical examination, chest radiography, and spirometry frequently identify the diagnosis, dyspnea that remains unexplained after the initial evaluation can be problematic. A stepwise approach that focuses further testing on the most likely diagnoses is most effective in younger patients. Early bronchoprovocation challenge testing is warranted in younger patients because of the high prevalence of asthma in this population. Older patients require more complete evaluation because of their increased risk of multiple cardiopulmonary abnormalities. For patients who have multiple contributing factors or no clear diagnosis, cardiopulmonary exercise testing can help prioritize treatment and focus further evaluation. (J Respir Dis. 2006;27(1):10-24)

A 45-year-old man was referred to our pulmonary clinic for progressive dyspnea and worsening asthma. His shortness of breath had been worsening over the past 2 years. He denied fever, weight loss, and other systemic complaints.

In the October 2004 issue of TheJournal of Respiratory Diseases,Morrison and Gupta1 reviewed theclinical and laboratory approachesto the diagnosis of communityacquiredpneumonia (CAP) causedby Legionella. They discussed theadvantages and limitations of culture,direct fluorescent antibody(DFA) staining, serology, polymerasechain reaction, and Legionellaurinary antigen assays. As the authorsnoted, DFA staining of respiratorysecretions is an underusedtest that has a high specificity in patientswith untreated Legionnairesdisease.

Abstract: The manifestations of indoor mold-related disease (IMRD) include irritant effects, such as conjunctivitis and rhinitis; nonspecific respiratory complaints, such as cough and wheeze; hypersensitivity pneumonitis; allergic fungal sinusitis; and mycotoxicosis. The diagnosis of IMRD depends on eliciting an accurate history and excluding preexisting pathology that would account for the patient's symptoms. Laboratory tests, imaging studies, and spirometry can play an important role in ruling out other diagnoses, such as allergic or nonallergic rhinitis, asthma, and pneumonia. The diagnosis of IMRD also involves integrating the results of immunologic, physiologic, and imaging studies with the results of indoor air-quality studies. (J Respir Dis. 2005;26(12):520-525)

Abstract: Spinal tuberculosis is the most common form of osteoarticular involvement in patients with tuberculosis. Localized pain is a common presenting symptom. In patients who do not present until vertebral wedging and collapse have occurred, a localized knuckle kyphosis is obvious, especially in the dorsal spine. In some patients, a retropharyngeal abscess develops, causing dysphagia, dyspnea, and/or hoarseness. Peripheral joint tuberculosis is characterized by an insidious onset of slowly progressive, painful, and swollen monoarthropathy, most commonly affecting the hip or knee. The radiologic features include juxta-articular osteoporosis, peripheral osseous erosion, and gradual narrowing of the interosseous space. Treatment involves antituberculosis drugs; the indications for surgery are relatively limited. (J Respir Dis. 2005; 26(12):543-546)

Templeton and colleagues report encouraging news about the use of polymerase chain reaction (PCR) in the diagnosis of community- acquired pneumonia (CAP). They found that real-time PCR was more sensitive than conventional techniques for detecting major respiratory viruses and atypical bacteria.

The diagnosis of cystic fibrosis (CF) is typically made in childhood. However, there is increasing evidence that a mild and atypical form of this disease can present in adulthood. The author describes a patient who received the diagnosis of CF when she was 74 years old.

The initial evaluation of a patient with community-acquired pneumonia (CAP) should include a careful search for comorbidities, according to a study by Falguera and associates.

Abstract: In addition to causing pulmonary disease, infection with Mycobacterium tuberculosis can result in a wide range of extrapulmonary manifestations, including abdominal involvement. Patients with acute tuberculous peritonitis typically present with fever, weight loss, night sweats, and abdominal pain and swelling. Intestinal tuberculosis is characterized by weight loss, anorexia, and abdominal pain (usually in the right lower quadrant). A palpable abdominal mass may be present. Patients with primary hepatic tuberculosis may have a hard, nodular liver or recurrent jaundice. The workup may involve tuberculin skin testing, imaging studies, fine-needle aspiration, colonoscopy, and peritoneal biopsy. Percutaneous liver biopsy and laparoscopy are the main methods of diagnosing primary hepatic tuberculosis. Treatment includes antituberculosis drug therapy and, in some cases, surgery. (J Respir Dis. 2005;26(11):485-488)

Although the National Asthma Education and Prevention Program's (NAEPP) guidelines for managing asthma have been widely disseminated, compliance has been less than impressive. Results of a study by Grant and associates in the Chicago area reveal a considerable discrepancy between the NAEPP's therapeutic goals and the asthma control level achieved.

The use of analgesics, specifically acetaminophen, has been proposed as one of the mechanisms for the rise in asthma prevalence in the last 30 to 40 years.1 Acetaminophen, approved by the FDA in 1951, is one of the most commonly used analgesics in adults and children. The association between asthma and acetaminophen has been reported in case reports, in the setting of oral challenge tests, and in larger clinical studies.2

Influenza vaccinationcontinues to be the primarymethod of preventinginfluenza and its lifethreateningcomplications.In preparation forthis year’s influenza season,the Advisory Committeeon ImmunizationPractices (ACIP) has publishedits recommendationsfor the preventionand control of influenza.1

Under what circumstances would asthma or chronic obstructive pulmonary disease (COPD) be a contraindication to scuba diving? What precautions should patients with either asthma or COPD take if they are determined to go diving?

Abstract: Although controller therapies are currently recommended for patients who have persistent asthma, a number of studies indicate that these therapies do not adequately control asthma in a substantial number of these patients. This observation, combined with the potential risk of adverse effects with corticosteroids, supports the conclusion that controller therapies are not appropriate for all patients. However, some patients who do not respond to one type of controller therapy will respond to another, which suggests that we might consider targeting specific medications to select patients. There is increasing evidence that certain biomarkers may be useful in guiding therapy. For example, levels of sputum eosinophils have been shown to predict which patients are at increased risk for deterioration of asthma when inhaled corticosteroids are withdrawn.

Abstract: There is convincing evidence that controller therapies, such as inhaled corticosteroids and leukotriene receptor antagonists, provide many benefits to patients with asthma. These benefits include decreased symptoms, improved lung function, reduced frequency of exacerbations, and improved quality of life. Even patients with mild asthma and normal lung function can benefit from controller therapy. A recent analysis of the burden of asthma suggests that the proportion of patients who have mild intermittent disease is much smaller than previously estimated and that many more patients have persistent asthma. This finding, in combination with the considerable variability of patient responses to therapy and the difficulty in predicting which patients will respond, underscores the importance of considering a trial of controller therapy in patients with asthma.

Abstract: Pulmonary function tests, such as the measurement of forced expiratory volume in 1 second (FEV1) and peak expiratory flow (PEF), provide an objective, standardized, and quantifiable method of patient assessment and can be essential in the evaluation of asthma. However, FEV1 and PEF are relatively insensitive for detecting changes in persons with good baseline pulmonary function, and they do not directly measure worsening airway inflammation. One way to deal with the shortcomings of these tests is to include multiple outcomes assessment. Evaluating patient-oriented variables, such as symptoms, need for rescue medication, nocturnal awakenings, and unscheduled medical care visits, can detect clinically relevant changes that pulmonary function tests do not identify. Composite outcomes provide a more comprehensive approach to patient follow-up. For example, a patient who is considered to be a "nonresponder" to a given therapy on the basis of pulmonary function criteria might, in fact, be responding favorably according to assessment of composite outcomes. Two patient-centric tools for measuring outcome are the asthma control questionnaire and the asthma control test.

Asthma is one of the most common chronic diseases worldwide, and its prevalence--particularly among children--is increasing in many countries.1,2 In 1997, an estimated 9.6% of persons in the United States had asthma (Table 1).3

Dr Storms: Given that a patient's asthma varies quite a bit from day to day, and that controller therapies can prevent exacerbations, is there any role for using a controller medication as-needed rather than using it regularly? Could exacerbations be prevented if the patient has been educated to start treatment as soon as symptoms occur or peak expiratory flow (PEF) falls?

Abstract: The coexistence of asthma and obstructive sleep apnea (OSA) in a given patient presents a number of diagnostic and treatment challenges. Although the relationship between these 2 diseases is complex, it is clear that risk factors such as obesity, rhinosinusitis, and gastroesophageal reflux disease (GERD) can complicate both asthma and OSA. In the evaluation of a patient with poorly controlled asthma, it is important to consider the possibility of OSA. The most obvious clues are daytime sleepiness and snoring, but the definitive diagnosis is made by polysomnography. Management of OSA may include weight loss and continuous positive airway pressure (CPAP). Surgical intervention, such as uvulopalatopharyngoplasty, may be an option for patients who cannot tolerate CPAP. Management may include specific therapies directed at GERD or upper airway disease as well as modification of the patient's asthma regimen. (J Respir Dis. 2005;26(10):423-435)

Tai Chi (also known as T'ai Chi Chuan, Taijiquan) is a form of mind-body exercise that has its roots in ancient Chinese martial arts. Throughout Asia, it is often practiced for preventive health, especially among the elderly. In recent years, Tai Chi has become popular in the West among all age groups and has been studied as a therapy for various medical conditions.

Abstract: Tuberculous meningitis has several different clinical presentations, including an acute meningitic syndrome simulating pyogenic meningitis, status epilepticus, stroke syndrome, and movement disorders. Cranial nerve palsies and seizures occur in about one third of patients, and vision loss is reported by almost 50%. The cerebrospinal fluid (CSF) typically shows moderately elevated levels of lymphocytes and protein and low levels of glucose. The demonstration of acid-fast bacilli in the CSF smear or Mycobacterium tuberculosis in culture confirms the diagnosis. CNS tuberculosis may also manifest as intracranial tuberculomas. The characteristic CT and MRI finding is a nodular enhancing lesion with a central hypointensity. Antituberculosis treatment should be initiated promptly when either tuberculous meningitis or tuberculoma is suspected. (J Respir Dis. 2005;26(9):392-400)

Studies have indicated that the use of acetaminophen is associated with an increased risk of asthma. Now there is evidence linking acetaminophen use to an increased risk of chronic obstructive pulmonary disease (COPD).

A 67-year-old woman was referred for evaluation of exertional dyspnea, with multiple episodes of fever, cough, and pneumonia. She had a long history of cough with sputum and had been admitted several times for exacerbations of chronic obstructive pulmonary disease and pneumonia. She received maintenance therapy with an ipratropium and albuterol combination, fluticasone, and salmeterol, but she continued to experience exertional dyspnea, with an average of 5 or 6 exacerbations and 2 hospital admissions a year.

Studies have indicated that depression occurs more frequently in adults with asthma than in the general population; however, few studies have investigated the relationship between depression and asthma outcomes. A recent study by Eisner and associates revealed noteworthy findings: depressive symptoms appear to be associated with poorer outcomes, including increased risk of hospitalization for asthma.