A crossover study of short burst oxygen therapy (SBOT) for the relief of exercise-induced breathlessness in severe COPD.

BACKGROUND: Previous small studies suggested SBOT may be ineffective in relieving breathlessness after exercise in COPD. METHODS: 34 COPD patients with FEV1 <40% predicted and resting oxygen saturation ≥93% undertook an exercise step test 4 times. After exercise, patients were given 4 l/min of oxygen from a simple face mask, 4 l/min air from a face mask (single blind), air from a fan or no intervention. RESULTS: Average oxygen saturation fell from 95.0% to 91.3% after exercise. The mean time to subjective recovery was 3.3 minutes with no difference between treatments. The mean Borg breathlessness score was 1.5/10 at rest, rising to 5.1/10 at the end of exercise (No breathlessness = 0, worst possible breathlessness = 10). Oxygen therapy had no discernable effect on Borg scores even for 14 patients who desaturated below 90%. 15 patients had no preferred treatment, 7 preferred oxygen, 6 preferred the fan, 3 preferred air via a mask and 3 preferred room air. CONCLUSIONS: This study provides no support for the idea that COPD patients who are not hypoxaemic at rest derive noticeable benefit from oxygen therapy after exercise. Use of air from a mask or from a fan had no apparent physiological or placebo effect.

Survey of major complications of intercostal chest drain insertion in the UK.

BACKGROUND: Following reports from the National Patient Safety Agency of deaths and serious harm from intercostal chest drains (ICD) we conducted a national survey among chest physicians of their experience of harm associated with ICD. METHODS: A questionnaire was sent to 198 UK chest physicians at 148 acute hospital trusts, enquiring about current practice and any adverse incidents related to chest drains from 2003 to 2008. RESULTS: 101 of 148 trusts (68%) replied. 67 trusts reported at least one major incident involving ICD insertion. 31 Cases of ICD misplacement were reported with seven deaths. Misplaced drains were inserted in liver (10), peritoneal space (6), heart (5), spleen (5), subclavian vessels (2), colon (1), oesophagus (1) and inferior vena cava (1). 47 cases of serious lung or chest wall injuries with eight deaths and six cases of ICD placement on the wrong side with two deaths were reported. The guidewire was lost in the pleural cavity in three cases. 22 of 101 trusts required written patient consent before ICD insertion. 11 trusts had a training policy. 16 trusts had patient information literature for this procedure. The seniority of doctors permitted to insert ICDs was as follows: 30% any doctor; 27% at least 1 year post qualification; 32% at least 2 years, 11% at least 4 years. CONCLUSIONS: 67% of responding trusts had encountered major complications of ICD. The survey raised concerns about training and consent. The National Patient Safety Agency has made recommendations to address these risks which are also addressed in the 2009 update of the British Thoracic Society Pleural Disease Guideline.

Acceptance, effectiveness and safety of continuous positive airway pressure in acute stroke: a pilot study.

OBJECTIVES: To evaluate the acceptance, effectiveness in preventing upper airways obstruction, and haemodynamic effects of continuous positive airway pressure (CPAP) in acute stroke. METHODS: Twelve patients (4 M, and 8 F; mean (SD), 75.2 (5.5) years) within 48 h of acute stroke onset underwent: (1) sleep studies (1st night: auto-CPAP mode; 2nd night: diagnostic); (2) nocturnal non-invasive blood pressure studies (1st night during CPAP; 2nd night during spontaneous breathing (SB)); and (3) daytime cerebral blood flow velocity measurement in middle cerebral artery (FV) with transcranial Doppler during SB and with CPAP (5, 10, 15 cm H(2)O). RESULTS: Ninety percent, 60% and 50% of stroke patients had a respiratory disturbance index (RDI) of >or=5, >or=10 and >or=15 events per hour, respectively (18.2 (11.3)). CPAP acceptance was 84%; 42% used CPAP more than 6h and 42% between 1-3h with a mean use of CPAP of 5.2h (4.0). Compared to SB, CPAP reduced, though not significantly, RDI, time with SaO(2)<90%, mean blood pressure and mean blood pressure dips (10 mm Hg)/h. Compared with SB, any level of CPAP progressively and significantly reduced systolic and mean FV; drop in diastolic FV was significant at CPAP10 and CPAP15. The partial pressure of end-tidal CO(2) was significantly lowered by all levels of CPAP. CONCLUSIONS: According to this pilot study, CPAP is reasonably well tolerated by patients with acute stroke for at least one night. Despite its possible beneficial effect on obstructive sleep-disordered breathing and blood pressure variability, CPAP use in acute stroke should be still considered with caution due to possible harmful haemodynamic effects at higher pressures.

Anthracofibrosis, bronchial stenosis with overlying anthracotic mucosa: possibly a new occupational lung disorder: a series of seven cases From one UK hospital.

Anthracofibrosis, which was recently defined as bronchial stenosis with overlying anthracotic mucosa, has been infrequently reported in Asia as a complication of tuberculosis (TB). It has not been reported in the United Kingdom or the United States, or, to our knowledge, in non-Asian patients. We have identified seven cases of patients presenting to a single teaching hospital in the northwest of England over a 13-year period. Only one patient had a history of TB, but six of the seven patients had a history of occupational dust exposure, including one patient with pneumoconiosis. It is possible that anthracofibrosis is an exaggerated endobronchial form of the much more common condition of anthracosis in coal miners and other workers who have been exposed to mineral dusts. Our study suggests that this is essentially a benign condition, although it may progress very slowly, leading to gradually progressive bronchial stenosis. The diagnosis is important because most patients have clinical, radiologic, and bronchoscopic changes that are highly suspicious of malignancy.

Effect of upper airway obstruction on blood pressure variability after stroke.

Approx. 60% of acute stroke patients have periods of significant UAO (upper airway obstruction) and this is associated with a worse outcome. UAO is associated with repeated fluctuation in BP (blood pressure) and increased BP variability is also associated with a poor outcome in patients with acute stroke. UAO-induced changes in BP, at a time when regional cerebral perfusion is pressure-dependent in areas of critically ischaemic brain, could explain the detrimental effect of UAO on outcome in these patients. The aim of the present study was to examine the relationship between UAO and BP variability in patients with acute stroke. Twelve acute stroke patients and 12 age-, sex- and BMI (body mass index)-matched controls underwent a sleep study with non-invasive continuous monitoring of BP to assess the impact of UAO on BP control after stroke. Stroke patients had significantly more 15 mmHg dips in BP/h than the controls (51 compared with 6.7 respectively; P<0.004). Stroke patients also demonstrated significantly higher BP variability than the controls (26.8 compared with 14.4 mmHg; P<0.001). There were significantly more 15 mmHg dips in BP/h in stroke patients who had significant UAO than those who did not (85.7 compared with 29.5 respectively; P<0.032). Furthermore, stroke patients without UAO (RDI <10, where RDI is respiratory disturbance index) had significantly more 15 mmHg dips in BP/h than the controls (29.5 compared with 6.7 respectively; P<0.037). There was a positive correlation between the severity of UAO (RDI) and 15 mmHg dips in BP/h (r=0.574, P<0.005) in stroke patients. Our results suggest that UAO alone does not explain BP variation post-stroke, but it does play an important role, particularly in determining the severity of the BP fluctuation.