Thoracic ultrasound in guiding management of respiratory disease.

INTRODUCTION: Theuse of ultrasound in respiratory disease has evolved substantially over thepast two decades. From a test done to confirm the safe site of pleural fluiddrainage, thoracic ultrasound has become a point-of-care test that guides themanagement of patients on respiratory wards, in clinics and endoscopy. AREASCOVERED: This review overviews of process ofultrasound examination in the chest. It then delves into specific disease areas(pleural disease, lung disease, diaphragm disease, and invasive procedures) tohighlight how thoracic ultrasound is being used to refine management. Thereview concludes with discussion on the training curricula and assessment toolsfor competency in thoracic ultrasound. Being a scoping review, literaturesearches were conducted on PubMed using relevant search terms. EXPERT OPINION: Inaddition to its current uses, there are many avenues where thoracic ultrasound willsoon be beneficial. Recent studies show promising roles in areas such aspatient-tailored guidance of pleurodesis and non-invasively predicting lungre-expansion after pleural fluid drainage. In addition, auxiliary tools such ascontrast-enhanced ultrasound and elastography are proving useful in identifyingthe etiology and directing the successful sample of pleural and lung lesions. Studiesare also exploring the utility of sonographic biomarkers such as echogenicity andseptations to predict outcomes in pleural disease.

Deregulated expression of autophagy genes; PIK3C3 and RAB7A in COVID-19 patients.

BACKGROUND: The role of autophagy in coronaviruses infection and replication has a lot of debate. Autophagy involves the catalytic breakdown of intracellular components to be subsequently recycled by the lysosome. The aim of the study was to evaluate autophagy genes; PIK3C3 and RAB7A expressions in COVID-19 patients, and identify if PIK3C3 and RAB7A can be used as markers for monitoring COVID-19 patients. METHODS: A case-control study was carried out on 50 patients and 50 healthy controls. Genes expression was performed using quantitative real-time polymerase chain reaction. RESULTS: Compared to controls, PIK3C3 and RAB7A gene expression levels were significantly lower in patients (p < 0.001) with approximately with 9.4 and 2.3 decreased fold in PIK3C3 and RAB7A respectively. The ROC curve of PIK3C3 and RAB7A expressions showed sensitivity of 84 % and 74 % and specificity of 98 % and 78 % respectively. There was a positive correlation between PIK3C3 expression and WBCs, absolute neutrophil count, interleukin-6, D-dimer, and ALT among patients and between RAB7A expression and WBCs, CRP, IL-6, D-dimer and ALT in patients. CONCLUSIONS: The study showed reduction of PIK3C3 and RAB7A expressions in COVID-19 patients. However, further studies are recommended to clarify their roles in the disease pathogenies as autophagy genes.

The Short versus Long Antibiotic Course for Pleural Infection Management (SLIM) randomised controlled open-label trial.

Introduction: Based on expert opinion, the length of antibiotic treatment for pleural infection in adults is typically recommended to be a minimum of 4 weeks. This clinical trial aimed to assess whether shorter antibiotic courses lead to more treatment failures than standard longer courses. Methods: In an open-label randomised controlled trial, adult patients with pleural infection who were medically treated and stabilised within 14 days of admission were randomised to either a short antibiotic course (total course 14-21 days) or a long antibiotic course (total course 28-42 days). Patients were excluded if their baseline RAPID score was >4 (high-risk category). The primary outcome was the incidence of treatment failure by 6 weeks post-admission. Secondary outcomes were total length of antibiotic treatment, proportion of patients who resumed normal activity levels within 6 weeks post-admission, time from discharge to resuming normal activity levels and incidence of antibiotic-related adverse reactions. Results: Between September 2020 and October 2021, 50 patients (mean±sd age 46±13.7 years; 35 (70%) males) were recruited to the trial and randomly assigned to the short course group (n=25) or the long course group (n=25), with outcome data available for 24 patients in each study group. Treatment failure occurred in four (16.7%) patients in the short course group and three (12.5%) patients in the long course group. In the intention-to-treat analysis the OR for treatment failure in the long course group was 0.714 (95% CI 0.142-3.600; p=0.683). The median (interquartile range) duration of antibiotic treatment in the short course group was 20.5 (18-22.5) days compared with 34.5 (32-38) days in the long course group (p<0.001). There were no statistically significant differences in the other outcomes. Conclusions: In medically treated adult patients with pleural infection a long course of antimicrobial therapy did not lead to fewer treatment failures compared with a shorter course. These findings need to be confirmed in a larger multicentre trial.

Recent Insights into the Management of Pleural Infection.

Pleural infection in adults has considerable morbidity and continues to be a life-threatening condition. The term "pleural infection" encompasses complicated parapneumonic effusions and primary pleural infections, and includes but is not limited to empyema, which refers to collection of pus in the pleural cavity. The incidence of pleural infection in adults has been continuously increasing over the past two decades, particularly in older adults, and most of such patients have comorbidities. Management of pleural infection requires prolonged duration of hospitalization (average 14 days). There are recognized differences in microbial etiology of pleural infection depending on whether the infection was acquired in the community or in a health-care setting. Anaerobic bacteria are acknowledged as a major cause of pleural infection, and thus anaerobic coverage in antibiotic regimens for pleural infection is mandatory. The key components of managing pleural infection are appropriate antimicrobial therapy and chest-tube drainage. In patients who fail medical therapy by manifesting persistent sepsis despite standard measures, surgical intervention to clear the infected space or intrapleural fibrinolytic therapy (in poor surgical candidates) are recommended. Recent studies have explored the role of early intrapleural fibrinolytics or first-line surgery, but due to considerable costs of such interventions and the lack of convincing evidence of improved outcomes with early use, early intervention cannot be recommended, and further evidence is awaited from ongoing studies. Other areas of research include the role of routine molecular testing of infected pleural fluid in improving the rate of identification of causative organisms. Other research topics include the benefit of such interventions as medical thoracoscopy, high-volume pleural irrigation with saline/antiseptic solution, and repeated thoracentesis (as opposed to chest-tube drainage) in reducing morbidity and improving outcomes of pleural infection. This review summarizes current knowledge and practice in managing pleural infection and future research directions.

Reduced skeletal muscle endurance and ventilatory efficiency during exercise in adult smokers without airflow obstruction.

Smokers without airflow obstruction have reduced exercise capacity, but the underlying physiological mechanisms are not fully understood. We aimed to compare quadriceps function assessed using nonvolitional measures and ventilatory requirements during exercise, between smokers without airway obstruction and never-smoker controls. Adult smokers (n = 20) and never-smoker controls (n = 16) aged 25-50 yr with normal spirometry, underwent incremental cycle cardiopulmonary exercise testing to exhaustion with measurement of symptoms and dynamic lung volumes. Quadriceps strength and endurance were assessed nonvolitionally using single and repetitive magnetic stimulation. Quadriceps bulk was assessed using ultrasound, as rectus-femoris cross-sectional area. Physical activity level was quantified using the SenseWear armband worn for 5 days. Smokers had lower peak exercise workload, peak oxygen consumption, and anaerobic threshold than controls (170 ± 46 vs. 256 ± 57 W, 2.20 ± 0.56 vs. 3.18 ± 0.72 L/min, 1.38 ± 0.33 vs. 2.09 ± 0.7 L/min, respectively; P < 0.01 for all). Quadriceps endurance was lower in smokers (Δforce-time integral 54.9% ± 14.7% vs. 40.4% ± 14.7%; P = 0.007), but physical activity, quadriceps strength, and bulk were similar between groups. Smokers displayed higher ventilation (120 W: 52.6 ± 11.8 vs. 40.7 ± 6.0 L/min; P < 0.001), decreased ventilatory efficiency (higher V̇e/V̇co2), and were more breathless with greater leg fatigue at iso-workloads and iso-ventilation levels compared with never-smoker controls. Smokers showed no mechanical constraints on tidal volume expansion during exercise or ventilatory limitation at peak exercise. Adult smokers without airflow obstruction have reduced skeletal muscle endurance and ventilatory efficiency compared with never-smoker controls, despite similar daily physical activity levels, which contributed to reduced peak exercise capacity.NEW & NOTEWORTHY In adult smokers without airflow obstruction, the contributions of pulmonary and skeletal muscle functions to reduced exercise capacity are unclear. We found that non-COPD smokers had decreased exercise capacity and muscle endurance although strength was preserved compared with never-smoking controls. Exercise endurance was associated with quadriceps endurance and CO transfer factor. Despite similar physical activity levels, smokers developed leg fatigue, breathlessness, and displayed increased ventilation with reduced ventilatory efficiency at lower workloads, without exhibiting ventilatory constraint.

The prevalence and associated mortality of non-anaemic iron deficiency in older adults: a 14 years observational cohort study.

Iron is central to multiple biological pathways, and treatment of non-anaemic absolute iron deficiency (NAID) is beneficial in certain conditions. However, it is unknown if NAID is associated with increased mortality in older adults. A nationally representative sample of 4451 older adults from the English Longitudinal Study of Ageing was used. NAID was defined as serum ferritin < 30 µg/l and haemoglobin ≥ 120 g/l (women) or ≥ 130 g/l (men). Cumulative mortality was estimated by Kaplan-Meier method. Unadjusted and adjusted hazard ratios (HRs) of mortality were calculated using Cox proportional hazards regression models. Baseline NAID prevalence was 8·8% (95% confidence interval [CI] 8·0-9·7%); 10·9% (95% CI 9·7-12·3%) for women and 6·35% for men (95% CI 5·3-7·5%). The HR for mortality for individuals with NAID compared with non-anaemic individuals without iron deficiency over the 14-year follow-up was 1·58 (95% CI 1·29-1·93). This association was independent of all identified demographic, health-related and biological covariates, and robust in multiple sensitivity analyses. In older adults in England, NAID is common and associated with an increased mortality rate compared to non-anaemic individuals with normal serum ferritin. The association is principally driven by an excess mortality in women.

Exercise response to oxygen supplementation is not associated with survival in hypoxemic patients with obstructive lung disease.

Purpose: Hypoxemia is associated with more severe lung disease and worse outcomes. In some patients with chronic obstructive lung diseases who desaturate on exertion, supplemental oxygen improves exercise capacity. The clinical significance of this exercise response to oxygen supplementation is not known. Patients and methods: We identified chronic obstructive lung disease patients at our center who underwent a 6-minute walking test (6MWT) for ambulatory oxygen assessment and who desaturated breathing air and therefore had an additional walk test on supplemental oxygen, between August 2006 and June 2016. Responders were defined as walking ≥26 m further with oxygen. Survival was determined up to February 1, 2017. We compared survival in oxygen responders and nonresponders in patients with obstructive lung diseases. Results: One hundred and seventy-four patients were included in the study, median age 70 years. Seventy-seven (44.3%) of the patients were oxygen responders. Borg dyspnea score improved by 1.4 (±1.4) units (P<0.0005) on oxygen. Median survival was 66 months with death occurring in 84 (48.2%) patients. Kaplan-Meier analysis revealed no survival difference between both responders and nonresponders (P=0.571). Cox regression analysis showed that more 6MWT desaturation, lower 6-minute walking distance on room air, male gender, lower hemoglobin, and body mass index were associated with higher mortality risk. Conclusion: Acute exercise response to supplemental oxygen is not associated with long-term survival in patients with obstructive lung disease. This supports the use of ambulatory oxygen treatment for symptomatic purposes only.