The use of the Asthma Control Test in general practice and its correlation with asthma control according to the GINA guidelines.

BACKGROUND: The GINA guidelines have redefined the primary goal of asthma treatment as achieving optimum control. OBJECTIVES: To document the level of asthma control in Switzerland, the correlations between the international guidelines by GINA and the ACT's rating of asthma control, current treatment in adolescent and adult Swiss asthma patients and factors associated with asthma control. METHODS: General practitioners and specialists (pulmonologists, allergologists and paediatricians) were invited to participate in the cross-sectional survey. Asthma control was assessed in 1093 asthma patients using both the ACT and the GINA classification for asthma control. RESULTS: According to the GINA guidelines controlled asthma was found in 290 (27%) patients, when measured with the ACT 124 (11.5%) patients showed sufficient asthma control. Of the test results 65% were in accordance with each other, whereas in 85% of the non-matching results the ACT underestimated control according to GINA classification. An ACT cut-off score of ≤17 best identified uncontrolled asthma according to GINA guidelines. A total of 956 (87.7%) patients received controller medication and 849 (77.9%) patients received reliever medication. The following parameters were consistently identified to be significantly associated with insufficient asthma control in both GINA and ACT measurements: presence of exacerbation, use of reliever medication, switch of therapy and smoking. STUDY LIMITATION: For this study only the ACT version for adults was used. CONCLUSION: Asthma control remains insufficient in the majority of patients, despite prescription of regular controller medication. This survey confirms the validated ACT to be useful and important in everyday practice as an objective measure for asthma control according to GINA guidelines in order to monitor control and adjust treatment.

Combined airway and oesophageal stenting in malignant airway-oesophageal fistulas: a prospective study.

Malignant airway-oesophageal fistulas (AEF) are a serious complication of advance oesophageal or lung cancer. The aim of this study was to assess the quality of life before and after stent insertion, and to examine the role of treatment and location of AEF as factors influencing survival in AEF patients managed with airway and/or oesophageal stent insertion. 112 patients with AEF were included prospectively. 83 (74%) patients had advanced lung cancer and 29 (26%) patients had oesophageal cancers. Airway stents were inserted in 65 (58%) patients, oesophageal stents in 37 (33%) patients, and both airway and oesophageal stents in 10 (9%) patients. Seven (6%) patients developed respiratory failure and required transient ventilator support in the intensive care unit (four patients with airway stenting, two patients with double stents and one patient in the oesophageal stenting group). None of the patients developed stent migration or needed stent repositioning. Overall, mean survival was 236.6 days (airway stent 219.1 days, oesophageal stent 262.8 days and combined airway-oesophageal stent 252.9 days). Backward, stepwise regression revealed the site of stent placement (airway and/or oesophagus; p < 0.028), exact location of the fistula in airway (p = 0.011) and additional treatment with chemotherapy and/or radiation (p < 0.001) as independent risk factors predicting increased survival. The mean quality of life score (QoL) was 81 prior to stent insertion and 72 post-stent insertion (p < 0.001). Airway and/or oesophageal stent insertion provides an effective approach to improve the QoL in patients with malignant AEF.

Quality of spirometry in primary care for case finding of airway obstruction in smokers.

BACKGROUND: Diagnosis of chronic obstructive pulmonary disease (COPD) and its severity determination is based on spirometry. The quality of spirometry is crucial. OBJECTIVES: Our aim was to assess the quality of spirometry performed using a spirometer with automated feedback and quality control in a general practice setting in Switzerland and to determine the prevalence of airflow limitation in smokers aged > or =40 years. METHOD: Current smokers > or =40 years of age were consecutively recruited for spirometry testing by general practitioners. General practitioners received spirometry training and were provided with an EasyOne spirometer. Spirometry tests were assigned a quality grade from A to D and F, based on the criteria of the National Lung Health Education Program. Only spirometry tests graded A-C (reproducible measurements) were included in the analysis of airflow limitation. RESULTS: A total of 29,817 spirometries were analyzed. Quality grades A-D and F were assigned to 33.9, 7.1, 19.4, 27.8 and 11.8% of spirometries, respectively. 95% required < or =5 trials to achieve spirometries assigned grade A. The prevalence of mild, moderate, severe and very severe airway obstruction in individuals with spirometries graded A-C was 6, 15, 5 and 1%, respectively. CONCLUSION: Spirometries in general practice are of acceptable quality with reproducible spirometry in 60% of measurements. Airway obstruction was found in 27% of current smokers aged > or =40 years. Office spirometry provides a simple and quick means of detecting airflow limitation, allowing earlier diagnosis and intervention in many patients with early COPD.

Propofol versus combined sedation in flexible bronchoscopy: a randomised non-inferiority trial.

Combined sedation with a benzodiazepine and an opiate has been proposed as standard sedation for bronchoscopy. Propofol is a sedative-hypnotic with a rapid onset of action and fast recovery time, but carries the potential risk of respiratory failure. Consecutive patients (n = 200) were randomly allocated to receive either the combination midazolam and hydrocodone or intravenous propofol. The primary end-points were the mean lowest arterial oxygen saturation during bronchoscopy and the readiness-for-discharge score 1 h after the procedure. The mean lowest arterial oxygen saturation during bronchoscopy did not differ across treatment groups (p = 0.422), and the number of patients recording an arterial oxygen saturation of < or =90% on at least one occasion was similar in both groups (p = 0.273). The median (interquartile range) readiness-for-discharge score 1 h after the procedure was significantly higher in the propofol group than in the combined sedation group (8 (6-9) versus 7 (5-9); p = 0.035). Patients assigned propofol exhibited less tachycardia during bronchoscopy and for > or =1 h after the examination. Minor procedural complications were noted in 71 (35.5%) patients and exhibited a similar incidence in both treatment arms (p = 0.460). Propofol is as effective and safe as combined sedation in patients undergoing flexible bronchoscopy, thus representing an appealing option if timely discharge is a priority.

The value of transbronchial lung biopsy using jumbo forceps via rigid bronchoscope in diffuse lung disease.

BACKGROUND: Transbronchial lung biopsy (TBLB) is a valuable procedure used to obtain a parenchymal specimen in the evaluation of diffuse lung infiltrates. Large forceps are expected to result in larger specimens and improve diagnostic yield. AIM: The objective of this study was to evaluate diagnostic yield of TBLB using large modified flexible gastroenterological forceps ("Jumbo forceps") compared with 'normal' flexible forceps via rigid bronchoscopy in patients with diffuse parenchymal lung disease (DPLD). METHODS: The study was a prospective analysis of 95 patients who underwent fluoroscopy guided TBLB over a two year period. Patients with a lung mass or solitary lung nodule undergoing TBLB were excluded. The larger and small forceps were used in a random sequence to avoid a reduction in diagnostic yield of the second series of biopsies related to possible bleeding by first series of biopsies. To minimize the consequence of haemorrhage, we performed every rigid bronchoscopy, placing a non inflated Fogarty balloon and a rigid aspirator (diameter 4 mm) in lobar bronchus near the biopsy segment. The Fogarty balloon has been inflated in case of bleeding. After the bleeding was controlled we continued to operate up to the biopsy segment. RESULTS: Diagnostic yield of TBLB using Jumbo forceps was significantly higher than using normal flexible forceps via rigid bronchoscopy in patients with DPLD (p = 0.001). In 74 out of 95 patients (78%) the diagnosis was placed with Jumbo forcep while the smaller forcep was diagnostic in 62 out of 95 patients (65%). Large forceps obtained significantly more tissue than the small forceps; the biopsy specimen taken with normal forcep measured in average 1.4 x 1.0 mm and the larger biopsy taken with jumbo forcep measured in average 2.5 x 1.9 mm (p < 0.005). CONCLUSION: The use of large biopsy forceps to perform TBLB via rigid bronchoscope can significantly increase diagnostic yield in the pathological diagnosis of diffuse infiltrative lung disease.

Respiratory symptoms, atopy and bronchial hyperreactivity in professional firefighters.

The aim of the present study was to assess respiratory health in professional firefighters. A total of 101 male professional firefighters from Basel, Switzerland, were included in the study. A control group consisting of 735 male subjects of the general population was composed of the Basel sample of the Swiss Study on Air Pollution and Lung Diseases in Adults. All subjects were administered a standardised questionnaire, spirometry, skin-prick tests and bronchial challenge testing to methacholine. Respiratory symptoms at work were more frequent in firefighters compared with the control group, including burning eyes (21 versus 3%), running nose (19 versus 2%), itchy throat (26 versus 3%), cough (28 versus 3%), dyspnoea (7 versus 2%) and headache (25 versus 3%), respectively. Atopy was present in 51% of firefighters compared with 32% in the control group. The odds ratio for hyperreactivity to methacholine was 2.24 (95% confidence interval 1.12-4.48) for firefighters compared with the control group. Firefighters reported more respiratory symptoms at work and suffered more often from atopy compared with the control group. Bronchial hyperreactivity was more pronounced in firefighters, but it was not related to acute exposure or duration of employment. It remains unclear whether these findings were present at recruitment or developed after joining the workforce.

Long-term follow-up of thoracoscopic talc pleurodesis for primary spontaneous pneumothorax.

The aim of the present study was to evaluate the long-term outcome of patients with primary spontaneous pneumothorax treated with talc pleurodesis. A follow-up study was undertaken in all patients with primary spontaneous pneumothorax who underwent talc pleurodesis for prolonged air leak or recurrence using thoracoscopy. In total, 112 patients underwent pleurodesis and follow-up data was obtained in 63 (56%) patients: 45 patients were available for clinical follow-up, 14 for telephone follow-up and four were dead. The causes of death were unrelated to the pleurodesis. There were no episodes of acute respiratory failure following pleurodesis. A total of 56 (95%) out of the cohort of 59 patients had a successful pleurodesis. Surgical pleurectomy was required in three (5%) patients for persistent air leak. Median duration of follow-up after talc pleurodesis was 118 months. Long-term success was observed in 53 (95%) out of 56 patients. Recurrent pneumothorax was observed in three (5%) out of 56 patients. Patients with successful talc pleurodesis had a median forced vital capacity (FVC) of 102% and median total lung capacity of 99% at follow-up. Comparing smokers and nonsmokers, the forced expiratory volume in one second (FEV(1)) was significantly lower in smokers and there was a tendency for the FEV(1)/FVC ratio to be lower in smokers. Talc pleurodesis in patients with primary spontaneous pneumothorax via thoracoscopy is an effective procedure associated with normal lung function in patients who do not smoke.

Mesothelioma after lung transplantation.

The case history is presented of a lung transplant recipient who developed malignant mesothelioma. This is thought to be the first such report. Mesothelioma should be suspected in lung transplant recipients with a haemorrhagic pleural effusion in the native lung when there is no convincing evidence for bronchogenic carcinoma or post transplant lymphoproliferative disease, even in the absence of exposure to asbestos.

Measurement of combined oximetry and cutaneous capnography during flexible bronchoscopy.

The aim of the present study was to assess the feasibility of measuring combined arterial oxygen saturation measured by pulse oximetry (Sp,O2) and cutaneous carbon dioxide tension (Pc,CO2) to monitor ventilation and quantify change in Pc,CO2 during bronchoscopy. Combined Sp,O2 and Pc,CO2 were measured at the ear lobe in 114 patients. In four patients, the ear-clip slipped and they were excluded. In total, 11 patients had artefacts with Sp,O2 recordings, thus, Sp,O2 was analysed in 99 patients. Spirometry data were available in 77 patients. Multivariate analysis of covariance and logistic regression were used for statistical analyses. Mean baseline Pc,CO2 was 4.78+/-1.06 kPa (36+/-8 mmHg) and mean rise in the Pc,CO2 during bronchoscopy was 1.26+/-0.70 kPa (9.5+/-5.3 mmHg), while mean Pc,CO2 at the end of bronchoscopy was 5.85+/-1.19 kPa (44+/-9 mmHg) . Baseline Pc,CO2 and the lowest Sp,O2 were significantly associated with peak Pc,CO2 and the change in Pc,CO2 during bronchoscopy. Risk of significant hypoxaemia (Sp,O2

Combined transbronchial needle aspiration and positron emission tomography for mediastinal staging of NSCLC.

There are no data available combining transbronchial needle aspiration (TBNA) of mediastinal lymph nodes and positron emission tomography (PET) in the staging of nonsmall cell lung cancer (NSCLC). The aim of the current study was to determine if these two methods can enhance the negative predictive value of the individual modality alone, for a specific lymph node station, and if this integrated approach can reduce the number of mediastinoscopies. A total of 113 patients with enlarged mediastinal lymph nodes (> or = 1 cm), who underwent both TBNA and PET scanning, were included. In 51 patients, histopathology, confirmed by surgical lymph node dissection, was compared with PET results and TBNA. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy to detect malignant lymphadenopathy was 68 (13/19), 89 (119/134), 46 (13/28), 95 (119/125) and 86% (132/152) for PET, respectively; 54% (6/11), 100 (53/53), 100 (6/6), 91 (53/58) and 92% (59/64), respectively for TBNA; and 100 (11/11), 94 (50/53), 79 (11/14), 100 (50/50) and 95 (61/64) for combined TBNA and PET, respectively. Combination of transbronchial needle aspiration and positron emission tomography has the potential to allow adequate mediastinal staging of nonsmall cell lung cancer with enlarged lymph nodes in most patients without the need for mediastinoscopy.

Value of smear and PCR in bronchoalveolar lavage fluid in culture positive pulmonary tuberculosis.

At present, further investigations are needed in patients with suspected pulmonary tuberculosis (TB) and either negative sputum smear or without sputum. The aim of the present study was to analyse the yield of bronchoalveolar lavage fluid (BALF) smear and PCR in patients with confirmed pulmonary TB. Patients with a positive culture for Mycobacterium tuberculosis complex in sputum or BALF were analysed over 5 yrs. In total, 90 out of 230 (39%) patients with culture-positive pulmonary TB had a positive sputum smear, and 120 patients underwent bronchoscopy. BALF smear was positive in 56 (47%), BALF PCR in 93 (78%) patients, and BALF smear and/or PCR was positive in 83%. In total, 71 patients who underwent bronchoscopy and had complete clinical records were further analysed. BALF (smear or Mycobacterium tuberculosis complex-PCR) allowed a rapid diagnosis in 10 (59%) out of 17 patients who had a negative sputum smear, and 49 (91%) out of 54 patients without sputum production. Of these 71 patients, 12 (17%) were only culture positive. Rapid diagnosis of pulmonary TB by smear and/or PCR was made in 190 out of 210 patients (90%) in sputum or BALF. In conclusion, combined use of bronchoalveolar lavage fluid smear and Mycobacterium tuberculosis complex-PCR has a good diagnostic yield in patients with sputum smear-negative tuberculosis or without sputum production.

A comparison of video and autofluorescence bronchoscopy in patients at high risk of lung cancer.

The aim of this study was to compare the diagnostic yield of flexible video bronchoscopy (FVB) and autofluorescence bronchoscopy (i.e. lung imaging fluorescence endoscopy (LIFE)) in 151 patients at a high risk of lung cancer and with moderate dysplasia or worse on sputum cytology mass screening. Findings from FVB and LIFE were classified as either normal, abnormal or suspicious for cancer. Endobronchial biopsies (EBX) were obtained from abnormal or suspicious areas on FVB and/or LIFE, or randomly when FVB and LIFE were normal. Moderate dysplasia and worse were defined as pathologically positive. Overall, 83 out of 343 (24%) EBX were pathologically positive. The sensitivity of FVB was 72% and LIFE 96%. Relative sensitivity of LIFE over FVB was 1.33. Specificities of FVB and LIFE were 53 and 23%, respectively. The numbers of pathologically positive EBX from sites designated normal, abnormal or suspicious were: from FVB, 23 out of 162 (14%), 37 out of 151 (25%) and 23 out of 30 (77%); from LIFE, three out of 69 (4%), 44 out of 212 (21%) and 36 out of 62 (58%). In normal or abnormal areas at FVB, there was a significant increase in the yield of EBX guided by abnormal and suspicious sites noted at LIFE. In conclusion, endobronchial biopsies of suspicious findings from lung imaging fluorescence endoscopy and flexible video bronchoscopy have a good diagnostic yield. Lung imaging fluorescence endoscopy is more useful when flexible video bronchoscopy is either normal or abnormal.

Cough suppression during flexible bronchoscopy using combined sedation with midazolam and hydrocodone: a randomised, double blind, placebo controlled trial.

BACKGROUND: Current British Thoracic Society guidelines do not recommend routinely the combined use of a benzodiazepine and opiate during flexible bronchoscopy (FB). A randomised, placebo controlled, double blind study was undertaken to determine whether hydrocodone in combination with midazolan improves cough suppression during FB without increasing the risk of desaturation. METHODS: 120 patients were randomised to receive midazolam and 5 mg i.v. hydrocodone or midazolam and placebo with topical anaesthesia. Pulse oximetry was recorded continuously during FB. Bronchoscopists and nurses charted their perception of cough and the patients rated their discomfort during the procedure on a 10 cm visual analogue scale (VAS). RESULTS: There was no significant difference between the two groups with regard to the indication for FB, duration of procedure (21 (11) min v 22 (10) min, p = 0.570), doses of supplemental lignocaine (171 (60) mg v 173 (66) mg, p = 0.766) and midazolam (4.5 (2.3) mg v 4.9 (2.7) mg, p = 0.309), lowest oxygen saturation (94.8 (2.7) v 94.9 (2.7), p = 0.433), and desaturations < or =90%. Perception of cough by both the bronchoscopist and the nurse was significantly lower in the hydrocodone group (3 (0-10) and 3 (0-10)) than in the placebo group (6 (0-10) and 6 (0-10)), respectively (p = 0.001). According to the VAS scale, patients' tolerance was also significantly better with hydrocodone than with placebo (2 (0-8) v 3 (0-9), p = 0.043). CONCLUSION: The combination of midazolam and hydrocodone markedly reduces cough during FB without causing significant desaturation, especially when invasive diagnostic procedures are performed.

Advances in bronchoscopy--therapeutic bronchoscopy.

The common indications for therapeutic bronchoscopy include relief of benign and malignant airway stenosis, in the intensive care unit, foreign body removal and management of hemoptysis. Debulking of airway tumors may be undertaken using techniques such as laser photoresection, electrocautery, cryotherapy, argon plasma coagulation or mechanically using rigid bronchoscopy. These techniques are often used in combination. Balloon dilatation and insertion of silicone or metallic airway stents can be undertaken to treat benign and malignant strictures or bronchomalacia. Airway stents maintain luminal patency by opposing extrinsic compressive forces or by providing internal support. Certain stent types may also physically prevent (Silicone and covered metallic stents) the encroachment of tumor tissue into the airways. Covered metallic airway stents are safe and effective in the management of malignant tracheoesophageal fistulae, reduce the risk of recurrent aspiration and provide enhanced quality of life by allowing resumption of oral nutrition. In this article, we present an overview of application and the current methods available to perform therapeutic bronchoscopy.

Obstructive sleep apnea: therapies other than CPAP.

Nasal application of continuous positive airway pressure (CPAP) is the standard form of therapy for treating obstructive sleep apnea (OSA). Common difficulties associated with CPAP therapy include sense of dryness in the mouth, rhinorrhea, nasal congestion and dryness, mask discomfort, claustrophobia, irritation from device noise, aerophagy, chest discomfort and partner's intolerance. Therefore, many patients are unable to or unwilling to comply with the use of CPAP. This article discusses the various non-CPAP approaches that have been investigated in the management of OSA, which include behavioral therapy (weight loss and positional therapy), pharmacological treatment, mandibular advancement techniques and surgery. However, none of these has been shown to be superior to CPAP. In clinical practice, only selected patients will benefit from therapies other than CPAP.

Advances in bronchoscopy--new and upcoming bronchoscopic methods at the dawn of the 21st century.

The last decade has seen the increasing application of bronchoscopic methods such as transbronchial needle aspiration in the staging of lung cancer as well as in the diagnosis of peripheral lung cancer, balloon dilatation using flexible bronchoscopy, development of new tracheobronchial stents to manage central airway obstruction, autofluorescence bronchoscopy for the early diagnosis of lung cancer and pediatric flexible bronchoscopy. There is also a better understanding in the mechanisms and management of hypoxemia during bronchoscopy such as upper airway obstruction. Recent developments include direct endobronchial ultrasound to increase the yield of transbronchial needle aspiration, high magnification bronchoscopy to assist in the diagnosis of early lung cancer and bronchoscopic lung volume reduction to gain the effects lung volume reduction surgery without the need for surgery in patients with severe emphysema. In this article the new and upcoming bronchoscopic techniques are discussed, which we believe will find a broader clinical application in the near future to manage patients in a better way.

Bronchoscopic closure of bronchopleural fistula using gelfoam.

Management of a persistent bronchopleural fistula (BPF) can be a therapeutic challenge. The etiological factors responsible for BPF include pulmonary tuberculosis, post-thoracic resection surgeries, trauma, malignancy, necrotising infections and rupture of lung abscess. The immediate management of BPF is drainage of the pleural cavity with insertion of an intercostal drainage tube. Patients with BPF may also require surgical intervention in the form of a wedge resection or lobectomy or muscle flap surgery. We report a case of a peripheral BPF secondary to a bacterial infection, which was successfully managed by the instillation of gelfoam via flexible bronchoscopy.

Prophylactic nasopharyngeal tube insertion prevents acute hypoxaemia due to upper-airway obstruction during flexible bronchoscopy.

Insertion of a nasopharyngeal tube (NT) is a highly effective approach to the management of acute hypoxaemia during flexible bronchoscopy (FB) in lung -transplant recipients. We noted that lung transplant recipients undergoing FB who had been treated previously with NT insertion had further episodes of oxygen desaturation (<90%), despite supplemental oxygen therapy. Prophylactic NT insertion prevented acute hypoxaemia in the majority of lung transplant recipients, with previously documented FB-related oxygen desaturation secondary to UAO. Additional jaw support may be needed in some patients with severe upper-airway obstruction.