Respiratory Diseases

A 51-year-old man with a 20-year history of asthma and seasonal allergies presented with low-grade fever, progressive dyspnea on exertion, and wheezing that had persisted for 2 weeks. Four days earlier, he had been seen by his primary care physician and had started levofloxacin therapy. However, his respiratory symptoms had worsened, warranting hospitalization. He also reported pain in the abdomen and left flank and pain and swelling in the right metacarpophalangeal and right shoulder joints.

As the incidence of asthma continues to increase worldwide, current studies have indicated that the most prevalent challenge to the alleviation of asthma symptoms is undertreatment. Results of a controlled study in Denmark suggest that a physician-managed Internet-based asthma monitoring system can help patients optimize control over their asthma.

Abstract: The standard therapies for acute exacerbations of chronic obstructive pulmonary disease include short-acting bronchodilators, supplemental oxygen, and systemic corticosteroids. For most patients, an oxygen saturation goal of 90% or greater is appropriate. Bilevel positive airway pressure (BiPAP) is usually beneficial in patients with progressive respiratory acidosis, impending respiratory failure, or markedly increased work of breathing. However, BiPAP should not be used in patients with respiratory failure associated with severe pneumonia, acute respiratory distress syndrome, or sepsis. Systemic corticosteroids are appropriate for moderate to severe acute exacerbations; many experts recommend relatively low doses of prednisone (30 to 40 mg) for 7 to 14 days. Antibiotic therapy is controversial, but evidence supports the use of antibiotics in patients who have at least 2 of the following symptoms: increased dyspnea, increased sputum production, and sputum purulence. (J Respir Dis. 2005;26(8):335-341)

The authors describe a case of acute eosinophilic pneumonia (AEP) that occurred in a previously healthy young man. The presentation was similar to that of acute respiratory distress syndrome (ARDS), and the diagnosis was established by bronchoalveolar lavage (BAL). The authors note that it is important to recognize the subset of patients with AEP who present with an ARDS-like picture, especially since corticosteroids are very effective in this setting.

Abstract: Pleural tuberculosis and lymph node involvement are the most common extrapulmonary manifestations of tuberculosis. Most patients with pleural involvement complain of pleuritic chest pain, nonproductive cough, and dyspnea. The pleural effusion is usually unilateral and small to moderate in size. The diagnosis depends on the demonstration of acid-fast bacilli in pleural fluid or biopsy specimens, or the presence of caseous granulomas in the pleura. The gold standard for the diagnosis of lymph node tuberculosis is the identification of mycobacteria in smears on fine-needle aspiration cytopathology, histopathology, or mycobacterial culture. On ultrasonography and CT, the lymph nodes show enlargement with hypoechoic/hypodense areas that demonstrate central necrosis and peripheral rim enhancement or calcification. Treatment involves the combination of 4 antituberculosis drugs for 2 months, followed by 2-drug therapy for 4 months. (J Respir Dis. 2005;26(8):326-332)

Abstract: All children with asthma should have periodic office visits, usually every 3 to 6 months, in which asthma action plans are updated. Periodic assessment of lung function by peak expiratory flow or office spirometry can help determine the appropriate treatment strategy. Low daily doses of inhaled corticosteroids remain the first and most effective choice of therapy for persistent asthma. If this approach is inadequate, adding a second medication, such as a leukotriene modifier or a long-acting ß2-agonist, is suggested. Short-acting ß2-agonists remain the most important therapy for intermittent asthma. For most children, the best route is via a metered-dose inhaler with either a spacer or valved holding chamber. If these agents are inadequate, a short course of oral corticosteroids may be required. (J Respir Dis. 2005;26(8):348-358)

How can repeated visits to the emergency department (ED) for asthma exacerbations best be avoided?

Abstract: Although smoking cessation is still the most impor- tant intervention in chronic obstructive pulmonary disease (COPD), a variety of pharmacologic therapies are available to help manage symptoms. Short-acting ß2-agonists and/or ipratropium should be taken as needed, and the use of additional therapies is based on the severity of disease. Patients with moderate or severe COPD should regularly take 1 or more long-acting bronchodilators. The long-acting ß2-agonists salmeterol and formoterol have been demonstrated to improve health-related quality of life. Newer therapies include the long-acting anticholinergic tiotropium and a salmeterol-fluticasone combination. These agents improve forced expiratory volume in 1 second and may reduce the rate of acute exacerbations. For patients with moderate to very severe COPD, participation in a pulmonary rehabilitation program can improve health status, quality of life, and exercise tolerance. (J Respir Dis. 2005;26(7):284-289)

The American Thoracic Society (ATS) and the Infectious Diseases Society of America recently published guidelines for the management of hospital-acquired pneumonia (HAP).1 These guidelines, which are an update of a 1996 ATS consensus statement,2 focus on bacterial HAP in immunocompetent adults. This includes ventilator-associated pneumonia (VAP) and health care-associated pneumonia (HCAP). Selected highlights are presented here.

In their Photoclinic case of a man with achalasia (CONSULTANT, February 2005, page 268), Drs Sonia Arunabh and Manjula Thopcherla did not mention the extensive abnormalities evident in the left lung on both radiograph and CT .Did the patient also have aspiration pneumonia?

Abstract: ß-Agonists, administered by metered-dose inhaleror nebulizer, are still the mainstay of therapy for asthma exacerbations.A trial of a subcutaneous ß-agonist should beconsidered in patients who fail to respond to inhaled medications.Levalbuterol may play a role in managing refractoryasthma, particularly in patients with ischemic heart disease orsevere tachycardia. Systemic corticosteroids should be administeredto all patients presenting to the hospital withasthma unless their peak expiratory flow rate (PEFR) orforced expiratory volume in 1 second (FEV1) is at least 80% ofpredicted after 1 hour of treatment; this therapy should be institutedwithin 1 hour of presentation. For patients with severeobstruction, the combined use of an anticholinergic and aß-agonist improves PEFR and FEV1 more than ß-agonistsalone and significantly decreases the risk of hospital admission.(J Respir Dis. 2005;26(6):238-249)

Just how effective are the national guidelines for the management of community-acquired pneumonia (CAP)? Pretty good, according to Mortensen and associates. They found that compliance with practice guidelines, such as those published by the Infectious Diseases Society of America and the American Thoracic Society, is associated with a reduced mortality in patients with CAP.

Although pneumonia caused by Legionella pneumophila continues to be associated with significant morbidity, recent studies indicate that the mortality rate has declined. Two studies from Spain support this observation and suggest that therapy with levofloxacin may be more effective than therapy with erythromycin or clarithromycin.

Abstract: In most patients, a life-threatening exacerbation of asthma is preceded by a gradual worsening of symptoms. However, some patients have a sudden onset of worsening symptoms, and these patients are at increased risk for respiratory failure and death. Risk factors for near-fatal asthma include a history of a life-threatening exacerbation, hospitalization for asthma within the past year, delay in time to evaluation after the onset of symptoms, and a history of psychosocial problems. Regularly monitoring peak expiratory flow rate (PEFR) is particularly important because it can identify a subset of high-risk patients--specifically, those with large fluctuations in PEFR and those who have severe obstruction but minimal symptoms. Signs of life-threatening asthma include inability to lie supine, difficulty in speaking in full sentences, diaphoresis, sternocleidomastoid muscle retraction, tachycardia, and tachypnea. (J Respir Dis. 2005;26(5):201-207)

The prevalence of asthma in the United States is estimated to be 5% to 8%. Asthma is responsible for approximately 5000 deaths annually in this country. It is a leading cause of emergency department visits, hospitalizations, and school and work absenteeism. The total estimated direct cost of the disease in the United States was $12.7 billion in 1998.

Abstract: The use of sputum studies and blood cultures in patients hospitalized with community-acquired pneumonia (CAP) is somewhat controversial, and recommendations continue to evolve. A reasonable approach is to attempt to obtain sputum cultures from all patients before initiating antibiotic therapy. If antibiotics have already been given, sputum studies can be reserved for patients who are severely ill or who are at risk for infection with a resistant organism or an organism that is not covered by the usual empiric therapy. The Infectious Diseases Society of America and the American Thoracic Society both recommend obtaining blood cultures from all patients. However, cost considerations have led to alternative strategies, such as reserving blood cultures for those with severe CAP. (J Respir Dis. 2005;26(4):143-148)

Cardiovascular disease is a leading cause of death in patients with chronic obstructive pulmonary disease (COPD). While some physicians may be reluctant to prescribe ß-blockers for these patients, because of concern about adverse effects on lung function, a study conducted by Au and associates indicates that ß-blockers may have an edge over other antihypertensive agents in reducing mortality risk.

A study in Finland confirms that many adults with asthma have gastroesophageal reflux disease (GERD) and that many of these persons do not have the classic GERD symptoms. However, the role of GERD as an asthma trigger has not been clearly defined.

ABSTRACT: Education can help improve compliance with inhaled corticosteroid therapy or correct faulty metered-dose inhaler (MDI) technique. Options for patients with poor MDI technique include use of a spacer or an alternative device, such as a nebulizer or a dry powder inhaler. If therapy is ineffective, consider alternative conditions that mimic asthma, especially vocal cord dysfunction and upper airway obstruction. Treatment of comorbid conditions, such as gastroesophageal reflux disease or rhinosinusitis, may improve control. In refractory asthma, it is crucial to identify allergic triggers and reduce exposure to allergens. If another medication needs to be added to the inhaled corticosteroid, consider a long- acting b-agonist, leukotriene modifier, or the recombinant monoclonal anti-IgE antibody omalizumab.

A 51-year-old patient asked me whether she should receive the influenza vaccine. She was last vaccinated in 1976; symptoms that resemble Guillain-Barré syndrome developed shortly afterwards. She has not received the vaccine since then; however, because she teaches schoolchildren, she wondered whether she should be vaccinated.

Several new drugs are being introduced-and more are on thehorizon.

Anxiety is a common and troubling symptom in many patients with chronic obstructive pulmonary disease (COPD), even when their degree of respiratory impairment is only mild to moderate. Anxiety may also accompany other chronic, progressive pulmonary disorders, such as interstitial fibrosis and cystic fibrosis, and a wide variety of other, less common diseases that are characterized by progressive dyspnea on exertion.

Bronchodilators, preferably inhaled, are recommended for all patients with chronic obstructive pulmonary disease; ipratropium, with a 6- to 8-hour duration of action, is effective maintenance therapy. Tiotropium is currently being reviewed by the FDA for release in the United States; its once-daily dosing schedule may facilitate adherence. Criteria for long-term oxygen therapy are severe hypoxemia (PaO2, 55 mm Hg or lower) or a PaO2 of 60 mm Hg or lower with signs of cor pulmonale or secondary polycythemia (hematocrit higher than 55%). When symptoms are disabling despite optimal medical management, referral for pulmonary rehabilitation is the next step. Patients with upper lobe-predominant emphysema and low exercise capacity may benefit most from lung volume reduction surgery. Consider transplantation if the patient has severe lung disease that is refractory to medical therapy and survival is expected to be less than 2 to 3 years.

The key factor in reducing morbidity and mortality in patients with chronic obstructive pulmonary disease (COPD) continues to be smoking cessation. Newer formulations of nicotine replacement therapy-a nasal spray and an inhaler-provide rapid delivery of nicotine and may be appropriate for highly dependent smokers. Bupropion has been shown to improve smoking cessation rates, either when used alone or with a nicotine patch. Both the influenza and pneumococcal vaccines are recommended to reduce the morbidity and mortality associated with respiratory infections in patients with COPD.

In general, asthma-related morbidity and mortality are greatest among members of ethnic minority groups who live in the inner cities; about 5000 deaths occur in these populations each year in the United States.

ABSTRACT: When influenza is present in the community, clinical symptoms are as accurate as rapid point-of-care tests for making the diagnosis; in this setting, the combination of cough and fever (temperature, 37.7°C [100°F] or higher) of acute onset has a positive predictive value of 77% to 79%. Accurate diagnosis ensures timely administration of antiviral agents and prevents unnecessary antibiotic use. In elderly persons, vaccination reduces illness severity, incidence of complications, and mortality. An intranasal vaccine is a new option for persons aged 5 to 49 years who are at risk for complications and refuse injection. Chemoprophylaxis with amantadine, rimantadine, or a neuraminidase inhibitor is a useful adjunct to vaccination in certain groups, such as nursing-home residents. Antiviral therapy started within 24 to 48 hours of symptom onset can reduce the duration of illness by 1 to 1.5 days and ameliorate symptoms in patients with uncomplicated influenza. However, treatment is expensive and does not prevent complications.

What is the optimal means of preventing exercise-inducedbronchospasm in children with asthma?

If your bedroom or other rooms in your home look a lot like this one,you may be living in an asthma "nightmare"-an environment full ofpotential causes of asthma attacks.

ABSTRACT: Many patients with presumed mild intermittent asthma have unrecognized persistent symptoms; these can be elicited with specific questioning about coughing, wheezing, shortness of breath, chest tightness, nighttime awakenings, and exercise intolerance. Asthma severity may vary with the season. For asthmatic patients with predictable seasonal allergies, prescribe inhaled corticosteroids for a few weeks or months beginning 2 to 3 weeks before usual symptom onset. Successful long-term management requires identification and control of asthma triggers, such as cigarette smoke, house dust mites, cockroaches, molds, and animal dander. Removing triggers or minimizing the patient's exposure to them may allow improved asthma control with lower dosages of corticosteroids.

ABSTRACT: Bronchodilators are central to COPD symptom management; current options include the anticholinergic ipratropium, short- and long-acting ß2-agonists, and theophylline. Tiotropium, which is not yet available in the United States, may become a useful addition to the armamentarium. Novel phosphodiesterase 4 inhibitors with both anti-inflammatory and bronchodilatory effects, including roflumilast, piclamilast, and cilomilast, are being investigated. Combination therapy with bronchodilators that have different mechanisms and durations of action may prove key in achieving the greatest symptom control with the fewest side effects. For example, prescribing a first-generation ß2-adrenergic agonist, such as albuterol, together with an antimuscarinic agent is reasonable from the standpoints of both efficacy and safety.