Therapeutic effects of nebulized verapamil on chronic obstructive pulmonary disease: A randomized and double-blind clinical trial.

OBJECTIVES: In this study, we assessed the clinical effect of inhaled verapamil on hospitalized COPD patients in a randomized and double-blind study. METHOD: COPD patients randomly received 10 mg of inhaled verapamil or 4 cc nebulized distilled water (DW) as placebo. RESULTS: Twenty patients enrolled in each group with no difference in baseline characteristics. Mean age was 64.95 ± 8.9 and 66.9 ± 10.74 years in verapamil and control group; respectively, (P > 0.05). The mean dyspnea score was 6.4 ± 1.2 and 6.2 ± 1.8 in the verapamil and control group, respectively and decreased to 4.9 ± 1.3 and 5.7 ± 1.8 after the intervention. The mean change in the verapamil group was significantly higher, (22.43% ± 10.6% vs 8.7% ± 12.1%), P = 0.00. Unlike the control group, the FEV1 value in the verapamil group significantly increased and reached to 1.17 ± 0.4 L from 1.03 ± 0.4. There was a significant decrease in airway resistance in both groups after intervention. However, neither total lung capacity and residual volume nor forced vital capacity changed significantly. Moreover, oxygen saturation in the verapamil group changed 4.8% ± 2.5% and this improvement in the control group was 1.8 ± 1 (P = 0.00). Smoker subjects, ones with PAP more than 35 mm Hg and obese patients benefit from verapamil. CONCLUSION: The beneficial impact of inhaled verapamil on the diminishing of dyspnea score along with its bronchodilatory effect would make this selective calcium blocker agent a therapeutic option in COPD.

Fluticasone propionate in clinically suspected asthma patients with negative methacholine challenge test.

INTRODUCTION: Despite reports of response to steroid inhaler in some clinically suspected asthma patients with negative methacholine challenge test (CSA/MCT-), treatment in these patients has not been prospectively studied. OBJECTIVE: We studied the role of a 12 week high dose inhaled fluticasone trial in CSA/MCT- patients. METHODS: After a 2 week run-in period, CSA/MCT-patients were treated with 12 weeks of Fluticasone propionate 1000 µg/day. The Asthma Control Test (ACT), numeric cough score (NCS) and bronchodilator use were compared with their pretreatment values. RESULTS: Thirty-four of 42 CSA/MCT-patients completed the study. Mean pretreatment ACT score (pACT) was significantly increased after treatment (14.7 ± 3.37 to 20.9 ± 3.1, P < 0.001). Posttreatment values of daytime (1.0 ± 1.0) and night-time (0.6 ± 0.9) NCS decreased compared to their pretreatment values (2.8 ± 1.1 and 1.9 ± 1.3, respectively; P < 0.001). ACT score change (ΔACT) were significantly greater in those with pACT < 15 than in those ≥15 (P < 0.001) . Fifteen of 21 patients with ΔACT > 5 did not need to use bronchodilator for their symptom relief. Wheeze disappeared in all six patients with ΔACT > 5 after the trial. Six months after the study, steroid inhaler continued to be used by 72.2% of patients. CONCLUSION: A significant portion of CSA/MCT- (especially those with pretreatment ACT score <15) respond to high dose fluticasone inhaler in terms of symptoms relief, disappearance of wheeze and need to bronchodilator use. ΔACT could not be predicted with any individual symptoms or signs before MCT, % FEV1 decline or symptoms during MCT and exhaled nitric oxide.

Long Term Follow-Up of Sulfur Mustard Related Bronchiolitis Obliterans Treatment.

Bronchiolitis obliterans (BO) is the most remarkable pulmonary sequels of war-related sulfur mustard inhalation. There is little if any data about long-term efficacy of associated BO treatment. Five years spirometric records of three groups of patients with obstructive pulmonary diseases (asthma, COPD, BO) and documented sulfur mustard inhalation were evaluated. The BO patients were treated with inhaled Seretide 125-250/25 (2 puffs BID), azithromycin (250 mg, three times/week) and N-acetylcysteine (1200-1800/day). Asthma and COPD patients were treated according to existing guidelines. Seventy-three (38 asthma, 16 COPD and 19 BO) patients completed the 5 years follow-up. Basal and final FEV1 in BO patients (2.69±0.81 and 2.39±0.65 respectively) were not significantly different from COPD patients (2.46±0.56 and 1.96±0.76 respectively). There was also no significant difference between the yearly FEV1 decline in BO patients compared to COPD patients (60±84 cc vs. 99±79 cc respectively, P=0.163). The non-significant difference of FEV1 decline in BO compared to COPD patients suggests the effectiveness of azithromycin, inhaled steroid and N-acetyl cysteine in BO patients. Considering safety and possible effectiveness, this treatment is recommended until more data is available from controlled clinical studies.

Correlation of cardiopulmonary exercise testing parameters with quality of life in stable COPD patients.

BACKGROUND: The precise head to head relationships between Cardio-pulmonary exercise testing (CPET) parameters and patients' daily symptoms/activities and the disease social/emotional impact are less well defined. In this study, the correlation of COPD daily symptoms and quality of life [assessed by St. George's Respiratory Questionnaire (SGRQ)] and COPD severity index (BODE-index) with CPET parameters were investigated. METHODS: Symptom-limited CPET was performed in 37 consecutive COPD (GOLD I-III) subjects during non-exacerbation phase. The SGRQ was also completed by each patient. RESULTS: SGRQ-score correlated negatively with FEV1 (r=-0.49, P<0.01), predicted maximal work-rate (%WR-max) (r=-0.44, P<0.01), V'O2/WR (r=-0.52, P<0.01) and breathing reserve (r=-0.50, P<0.01). However it did not correlate with Peak-V'O2% predicted (r=-0.27, P=0.10). In 20 (54.1%) subjects in which leg fatigue was the main cause for stopping the test, Peak-V'O2, %WR-max, HR-Reserve and Breathing reserve were higher (P=0.04, <0.01, 0.04 and <0.01 respectively) than the others. There was also a significant correlation between BODE-index and ∆VO2/∆WR (r=-0.64, P<0.001) and breathing-reserve (r=-0.38, P=0.018). CONCLUSIONS: The observed relationships between CPET parameter and daily subjective complaints in COPD were not strong. Those who discontinued the CPET because of leg fatigue were in the earlier stages of COPD. Significant negative correlation between ∆VO2/∆WR and BODE-index suggests that along with COPD progression, regardless of negative past history, other comorbidities such as cardiac/musculoskeletal problems should be sought.

Subsegmental pulmonary embolism: A narrative review.

Through the introduction of computed tomography pulmonary angiography (CTPA) for diagnosis of the pulmonary embolism (PE), the high sensitivity of this diagnostic tool led to detecting peripheral filling defects as small as 2-3mm, termed as subsegmental pulmonary embolism (SSPE). However, despite these substantial increases in diagnosis of small pulmonary embolism, there are minimal changes in mortality. Moreover, SSPE patients generally are hemodynamically stable with mild clinical presentation, lower serum level of biomarkers, lower incidence of associated proximal DVTs and less frequent echocardiographic changes compared to the patients with emboli located in more central pulmonary arteries. However, the pros and cons of anticoagulant therapy versus non-treating, monitoring protocol and exact long term outcome of these patients are still unclear. In this article we review existing evidence and provide an overview of what is known about the diagnosis and management of subsegmental pulmonary embolism.

Accuracy of a new rapid antigen detection test for pulmonary tuberculosis.

BACKGROUND AND OBJECTIVES: Tuberculosis (TB) is a major problem in the world. Treatment and control of TB needs detection of the Mycobacterium tuberculosis (MT) in the proper samples. While smear doesn't have enough sensitivity, culture and PCR are expensive, time consuming and unavailable in many centers. Recent development of a rapid TB antigen detection test (PrTBK) at Pasteur Institute of Iran could give a simple way for diagnosis of TB in about two hours. In this test the antigen-antibody complex will change color when gold conjugated mouse anti-rabbit antibody detects specific MT cell wall antigen in suspected samples. MATERIALS AND METHODS: We evaluated the diagnostic accuracy of PrTBK for diagnosis of pulmonary TB in comparison with smear, culture and PCR techniques in 56 consecutive samples (47 BAL and 13 sputum samples) obtained from patients with clinical suspicion of active TB. RESULTS: Twentynine patients (52%) were female and seven patients were HIV positive. PrTBK was positive in 17 culture positive and 4 culture negative samples (100% sensitivity, 89% specificity and 92% accuracy in comparison with culture method). In two out of four patients with negative culture who were positive for PrTBK, PCR and anti-tuberculosis drugs trial therapy responses were in favor of tuberculosis. If we take this finding into account, the accuracy of PrTBK will rise. CONCLUSION: High sensitivity and accuracy of PrTBK test enable us to initiate treatment on the basis of this convenient and rapid test.

Computed Tomography Pulmonary Angiography for Evaluation of Patients With Suspected Pulmonary Embolism: Use or Overuse.

BACKGROUND: The use of computed tomography pulmonary angiography (CTPA) has been increased during the last decade. OBJECTIVES: We studied the adherence to current diagnostic recommendations for evaluation of pulmonary embolism in a teaching hospital of Tehran University of Medical Sciences. PATIENTS AND METHODS: The registered medical records (Wells scores and serum D-dimer level) of all patients whose CTPA was performed with suspicion of pulmonary thromboembolism (PTE) were studied retrospectively. Modified Wells score of each patient was determined without being aware of the CTPA results. The patients were categorized to those with a high (likely) clinical probability (score > 4) and low (unlikely) clinical probability (score≤ 4) of PTE. RESULTS: During a 6-month period, 82 patients who underwent CTPA were included. The prevalence of PTE was 62.2% in the group of subjects with a likely clinical risk. In 45 (54.8%) of those patients whose CTPA was requested, the PTE was unlikely based on modified Wells criteria. In the clinically unlikely group, serum D-dimer assay was done in 15 out of 45 (33.3%), while it was inappropriately checked in 10 out of 37 (27.0%) with a clinically likely risk. General adherence rate to diagnostic algorithm of PTE was 43.9%. CONCLUSION: There is still excessive unjustified concern of PTE in less trained physicians leading to excessive diagnostic work-up. Loyalty to the existing guideline for management of suspected PTE in educational hospitals and supervision of attending physicians could prevent overuse of CTPA.

Effect of Sample Storage Temperature and Time Delay on Blood Gases, Bicarbonate and pH in Human Arterial Blood Samples.

BACKGROUND: Results of arterial blood gas analysis can be biased by pre-analytical factors, such as time interval before analysis, temperature during storage and syringe type. OBJECTIVES: To investigate the effects of samples storage temperature and time delay on blood gases, bicarbonate and PH results in human arterial blood samples. PATIENTS AND METHODS: 2.5 mL arterial blood samples were drawn from 45 patients via an indwelling Intraarterial catheter. Each sample was divided into five equal samples and stored in multipurpose tuberculin plastic syringes. Blood gas analysis was performed on one of five samples as soon as possible. Four other samples were divided into two groups stored at 22°C and 0°C. Blood gas analyses were repeated at 30 and 60 minutes after sampling. RESULTS: PaO2 of the samples stored at 0°C was increased significantly after 60 minutes (P = 0.007). The PaCO2 of the samples kept for 30 and 60 minutes at 22°C was significantly higher than primary result (P = 0.04, P < 0.001). In samples stored at 22°C, pH decreased significantly after 30 and 60 minutes (P = 0.017, P = 0.001). There were no significant differences in other results of samples stored at 0°C or 22°C after 30 or 60 minutes. CONCLUSIONS: In samples stored in plastic syringes, overestimation of PaO2 levels should be noted if samples cooled before analysis. In samples stored in plastic syringes, it is not necessary to store samples in iced water when analysis delayed up to one hour.

Accuracy of endotracheal tube cuff pressure adjustment by fingertip palpation after training of intensive care unit nurses.

BACKGROUND: Untrained fingertip palpation has been shown to be unable to adjust endotracheal tube (ET) cuff pressure in most intubated patients. OBJECTIVE: We determined the impact of a training course of ETT cuff adjustment by palpation in attaining a safe cuff inflation pressure. PATIENTS AND METHODS: Twenty-five nurses were asked to adjust the ETT cuff pressure to 25 cmH2O by palpation on three different patients in seven sessions (S1-S7): before training, two hours and two days after first training session, and two hours, two days, one week, and eight months after second training session. RESULTS: Before training, 41.3% of the cuff pressures were adjusted to the safe range of 21-35 cmH2O. The pressures obtained in S2-S7 were lower and less variable than S1 (P = 0.02 to < 0.0001). After the first training session, all the ETT cuff pressures in the high range (36-50 cmH2O) and 87.5% in the very high range (> 50 cmH2O) changed to the safe range. CONCLUSIONS: Using trained fingertip adjustment of the ETT cuff pressure throughout the nursing shift with protocols for the adjustment of out of range pressures at the beginning of each shift by cuff manometer could decrease the rate of ETT cuff over- and under-inflation.

Community acquired Pseudomonas pneumonia in an immune competent host.

Pseudomonas aeruginosa is an uncommon cause of community-acquired pneumonia in immune-competent hosts. It is commonly seen in patients with structural lung abnormality such as cystic fibrosis or in immune compromised hosts. Here, the authors report a case of community-acquired Pseudomonas pneumonia in a 26-year old healthy man who presented with 8-week history of malaise and cough.

Fistula formation between the right and left main bronchus caused by endobronchial tuberculosis.

The prevalence of endobronchial tuberculosis (EBTB) in patients with active tuberculosis is about 10% to 40%. The most common complication of EBTB is bronchial stenosis. Fistula formation by pulmonary tuberculosis is a very rare complication and is most commonly bronchopleural. The authors present a 53-year-old woman presented with chronic cough and abnormality in chest computed tomography scan. According to chest computed tomography scan finding, bronchoscopic study was done and bronchial lavage was obtained. Bronchial lavage was positive for acid fast bacilli. Bronchoscopy showed fistula formation between the right and left main bronchus, a rare manifestation of EBTB. The patient was treated with antituberculosis therapy, and her symptoms improved and radiological findings showed regression of pulmonary lesions.

[Comparison of hot versus cold biopsy forceps in the diagnosis of endobronchial lesions]. / Comparación de las pinzas de biopsia caliente frente a fría en el diagnóstico de lesiones endobronquiales.

INTRODUCTION: Traditionally cold biopsy forceps were used for endobronchial biopsy, and recently electrocautery (hot) bronchoscopy biopsy forceps are introduced. It is hypothesized that hot biopsy forceps may decrease procedure related bleeding and also may decrease the quality of obtained samples. PATIENTS AND METHODS: Patients with different indications for endobronchial biopsy during fiberoptic bronchoscopy underwent three hot and three cold biopsies with a random fashion. All biopsies were obtained with a single biopsy forceps with and without the application of an electrocoagulation current, set on soft coagulation mode (40W). A four point scale was used for quantification of bleeding. A single pathologist blinded to the patients' history was requested to review all samples. A three point scale was used to assess electrocoagulation damage. RESULTS: A total of 240 biopsies were obtained from 40 patients. Frequency of positive concordance between the two methods was 85%. The degree of electrocoagulation damage of the samples was as follows: grade 1=52.5%, grade 2=32.5%, and grade 3=15%. The average bleeding score following hot biopsy was significantly lower compared to the cold biopsy (P=.006). The concordance between diagnostic yield of hot and cold biopsies was 85%. There was no significant difference between the diagnostic yields of two biopsy methods (P=.687). CONCLUSIONS: Hot biopsy forceps significantly decreased the procedure related bleeding. The quality of samples was not impaired significantly. Regarding low prevalence of bleeding following endobronchial biopsy, routine use of hot bronchoscopy forceps is not reasonable. However, familiarity of bronchoscopists with this method may improve bronchoscopy safety.