Hypercapnic respiratory failure - review.

This review summarizes the issue of acute hypercapnic respiratory failure. Acute respiratory failure is a condition in which the respiratory system is unable to fulfill its basic function, i.e. enriching the blood with oxygen and excreting carbon dioxide. Chronologically, we divide it into acute and chronic, and according to the manifestation into hypoxemic or hypoxemic with hypercapnia. Multiple factors, such as reduced ventilation and increased dead space, contribute to the development of hypoxemic-hypercapnic (global) respiratory failure. Both the patient's clinical presentation and laboratory examination of blood gases and acid-base balance (preferably from arterial blood) are used for diagnosis. In the absence of contraindications, non-invasive ventilation is used to establish normocapnia.

The use of extracorporeal membrane oxygenation in the treatment of critical course of pneumonia.

Extracorporeal membrane oxygenation is the highest form of resuscitation care in management of patients with respiratory failure. In the case of acute respiratory distress syndrome, the veno-venous setting is more often used. ECMO support enables, in case of lung function failure, to obtain the necessary time for the onset of the causal treatment effect or is used as a bridge to transplantation Mortality of the patients varies according to the underlying cause and presence of risk factors (e.g., age, complications or comorbid diseases). The onset of the COVID-19 pandemic has led to a significant increase in the need for ECMO. The quality of life of patients after ECMO is significantly reduced, but most patients do not experience permanent disability.

[Respiratory manifestations of post-COVID syndrome].

Overcoming infection with coronavirus disease 2019 (COVID-19) can lead to the persistence of various symptoms in some patients. The complex of symptoms causally related to severe acute respiratory coronavirus 2 infection is called post-COVID syndrome. One of the most common respiratory complications is pulmonary fibrosis, especially after critical course of the disease. In some patients, however, only the peripheral airways are affected by the air-trapping seen on high-resolution computed tomography scans. Less common respiratory complications include sarcoidosis and pneumatoceles. This narrative review summarizes current knowledge about pulmonary involvement as part of post-COVID syndrome.

Non-Invasive Positive Pressure Ventilation Use-Practice Recommendations of the Slovak Society of Pulmonology and Phthisiology.

Non-invasive positive pressure ventilation (NIPPV) is increasingly used as a treatment method for patients with respiratory failure. The first recommendations for the use of NIPPV in Slovakia were developed by the Slovak Society of Pulmonology and Phthisiology in 2007 and were partially revised in 2015. New scientific evidence prompted the present update, which is based on widely accepted international guidelines and was adapted to address local needs. Important features of the present update include a classification of acute indications for NIPPV into three categories based on the level of supporting evidence, namely 1. definite indications for in-hospital use of NIPPV; 2. possible indications for in-hospital use of NIPPV; and 3. disorders and states in which in-hospital use of NIPPV is not recommended. The current update also reflects the importance of comorbid sleep-related breathing disorders and other chronic respiratory conditions, as well as the use and limitations of continuous positive airway pressure therapy. Since oxygen therapy is often administered along with NIPPV, guidance on the safe use of oxygen in NIPPV-treated patients has also been included. Also, the present update extends the range of its users, addressing the needs of specialists in pediatric respiratory medicine as a novelty.

The effectiveness of glucocorticoid treatment in post-COVID-19 pulmonary involvement.

RATIONALE: Persistent respiratory symptoms following Coronavirus Disease 2019 (COVID-19) are associated with residual radiological changes in lung parenchyma, with a risk of development into lung fibrosis, and with impaired pulmonary function. Previous studies hinted at the possible efficacy of corticosteroids (CS) in facilitating the resolution of post-COVID residual changes in the lungs, but the available data is limited. AIM: To evaluate the effects of CS treatment in post-COVID respiratory syndrome patients. PATIENTS AND METHODS: Post-COVID patients were recruited into a prospective single-center observational study and scheduled for an initial (V1) and follow-up visit (V2) at the Department of Respiratory Medicine and Tuberculosis, University Hospital Olomouc, comprising of pulmonary function testing, chest x-ray, and complex clinical examination. The decision to administer CS or maintain watchful waiting (WW) was in line with Czech national guidelines. RESULTS: The study involved 2729 COVID-19 survivors (45.7% male; mean age: 54.6). From 2026 patients with complete V1 data, 131 patients were indicated for CS therapy. These patients showed significantly worse radiological and functional impairment at V1. Mean initial dose was 27.6 mg (SD ± 10,64), and the mean duration of CS therapy was 13.3 weeks (SD ± 10,06). Following therapy, significantly better improvement of static lung volumes and transfer factor for carbon monoxide (DLCO), and significantly better rates of good or complete radiological and subjective improvement were observed in the CS group compared to controls with available follow-up data (n = 894). CONCLUSION: Better improvement of pulmonary function, radiological findings and subjective symptoms were observed in patients CS compared to watchful waiting. Our findings suggest that glucocorticoid therapy could benefit selected patients with persistent dyspnea, significant radiological changes, and decreased DLCO.

ERS International Congress 2023: highlights from the Airway Diseases Assembly.

In this review, early career and senior members of Assembly 5 (Airway Diseases, Asthma, COPD and Chronic Cough) present key recent findings pertinent to airway diseases that were presented during the European Respiratory Society International Congress 2023 in Milan, Italy, with a particular focus on asthma, COPD, chronic cough and bronchiectasis. During the congress, an increased number of symposia, workshops and abstract presentations were organised. In total, 739 abstracts were submitted for Assembly 5 and the majority of these were presented by early career members. These data highlight the increased interest in this group of respiratory diseases.

Sleep Disturbance and Immunological Consequences of COVID-19.

The overarching importance of sleep was further emphasized during the pandemic of COVID-19. The subjects infected by COVID-19 frequently experience sleep disturbances; some are long-lasting problems and decrease the quality of life. Insomnia is the most studied sleep disorder associated with COVID-19. Insomnia affects patients who have experienced an infection and the general population. Good sleep is important in maintaining mental and physical health, including immune system functions. The interconnections between insomnia, the immune system, and COVID-19 are complex. Insomnia triggers numerous immune system dysregulations and makes individuals more vulnerable to respiratory infections. This narrative review overviews the influence of the COVID-19 pandemic on the immune system through sleep disorders.

Pupillography in contemporary sleep medicine - A narrative review.

Excessive daytime sleepiness (EDS) is a common symptom of sleep disorders such as narcolepsy, obstructive sleep apnea, and hypersomnia. The most common tools for assessing EDS are various specialized questionnaires such as Epworth Sleepiness Scale (ESS) and Stanford Sleepiness Scale (SSS). However, the scores obtained from self-rating questionnaires do not seem to measure physiological sleepiness but rather a more complex phenomenon of subjective sleepiness modulated by other factors such as motivation, expectation, and capability of self-perception. The golden standard for measuring physiological sleepiness and assessing EDS is the Multiple Sleep Latency Test (MSLT). However, MSLT is very time consuming and requires trained personnel and expensive equipment. Different method modifications are employed in various medical and industrial fields for different purposes. The infrared pupillography in darkness has the potential to measure objective physiological sleepiness, especially the Pupillographic Sleepiness Test (PST), which is the method of choice for pupillographic measurement of daytime sleepiness. The method has also been employed in several specific sleep disorders, outlining possible future usage. This narrative review summarizes the current state of knowledge on the relevance and usefulness of pupillography in sleep medicine.

Clinical presentation and pulmonary function tests in post-acute COVID-19 patients.

AIMS: The study analysed post-acute COVID-19 symptoms and the pulmonary function test (PFT) results in patients surviving the native strain of the virus. METHODS: The study was prospective; the inclusion criteria were positive PCR test for SARS-CoV-2 and age 18-100. Exclusion criteria were active respiratory infection, known or suspicious pre-existing pulmonary disease, cardiac failure, recent or acute pulmonary embolism, anaemia, and neuromuscular diseases. The recruitment period was 1st March 2020 - 25th December 2020. The initial examination was performed 4-12 weeks after the disease onset. All subjects underwent physical examination, anamnesis, chest x-ray and PFT. RESULTS: The study involved 785 subjects (345 male) mean age 53.8 (SD 14.6). The disease severity groups were: mild (G1), moderate (G2) and severe/critical (G3). Anosmia was present in the acute disease phase in 45.2% of G1 patients, but only in 4.5% of G3 patients. Dyspnoea occurred frequently in more severe groups (40%, 51.8% and 63.7% for G1, G2 and G3 respectively), while cough and fatigue showed no relationship to disease severity. Females were more likely to experience persistent symptoms. PFT results were significantly decreased in more severe groups compared to the mild COVID-19 patients, diffusing capacity was 86.3%, 79% and 68% of predicted values in G1, G2 and G3 respectively. CONCLUSION: Anosmia during the acute phase was associated with mild disease, persisting dyspnoea was more frequent after more severe COVID-19. Females tended to have persisting symptoms in post-acute phase more frequently. PFT results showed decrease with disease severity.

Long-Term Follow-Up of Patients Needing Extracorporeal Membrane Oxygenation Following a Critical Course of COVID-19.

INTRODUCTION: Severe respiratory failure is one of the most serious complications of coronavirus disease 2019 (COVID-19). In a small proportion of patients, mechanical ventilation fails to provide adequate oxygenation and extracorporeal membrane oxygenation (ECMO) is needed. The surviving individuals need long-term follow-up as it is not clear what their prognosis is. AIM: To provide a complex clinical picture of patients during follow-up exceeding one year after the ECMO therapy due to severe COVID-19. METHODS: All subjects involved in the study required ECMO in the acute stage of COVID-19. The survivors were followed-up for over one year at a specialized respiratory medical center. RESULTS: Of the 41 patients indicated for ECMO, 17 patients (64.7% males) survived. The average age of survivors was 47.8 years, and the average BMI was 34.7 kg·m-2. The duration of ECMO support was 9.4 days. A mild decrease in vital capacity (VC) and transfer factor (DLCO) was observed on the initial follow-up visit (82.1% and 60%, respectively). VC improved by 6.2% and by an additional 7.5% after 6 months and 1 year, respectively. DLCO improved by 21.1% after 6 months and remained stable after 1 year. Post-intensive care consequences included psychological problems and neurological impairment in 29% of patients; 64.7% of the survivors got vaccinated against SARS-CoV-2 within 12 months of hospitalization and 17.6% experienced reinfection with a mild course. CONCLUSION: The COVID-19 pandemic has significantly increased the need for ECMO. Patients' quality of life after ECMO is temporarily significantly reduced but most patients do not experience permanent disability.

Obstruction sleep apnoea and panic disorder.

OBJECTIVE: Both panic disorder (PD) and obstructive sleep apnea (OSA) are frequent conditions that can be comorbid. This article reviews the current state of knowledge about the comorbidity of PD and OSA and the effectiveness of therapy in patients with this comorbidity. METHOD: Articles obtained via PubMed and Web of Science search were selected; the publishing date was between January 1990 and December 2022. The applied search terms were: obstructive sleep apnea; panic disorder; CPAP; antidepressants; anxiolytics; antipsychotics. Eighty-one articles were chosen by primary search via keywords. After a complete assessment of the full texts, 60 papers were chosen. Secondary papers from the references of the primary documents were investigated, evaluated for suitability, and included in the list of documents (n = 18). Thus, seventy-eight papers were incorporated into the review article. RESULTS: Studies describe a greater prevalence of panic disorder in OSA patients. So far, there is no data on the prevalence of OSA in PD patients. Limited evidence is found regarding the influence of CPAP treatment on PD, and this evidence suggests that CPAP can partially alleviate PD symptoms. Medication used in PD treatment can significantly impact comorbid OSA, as explored in several studies. CONCLUSIONS: The relationship between the two conditions seems bidirectional, and it is necessary to assess OSA patients for comorbid panic disorder and vice versa. Both disorders can worsen the other and must be treated with a complex approach to ensure improvement in patients' physical health and psychological well-being.

ERS International Congress 2022: highlights from the Airway Diseases Assembly.

The European Respiratory Society (ERS) celebrated the return of an in-person meeting in Barcelona, Spain, after 2 years of virtual congresses. The ERS Congress 2022 programme was replete with symposia, skills workshops and abstract presentations from all 14 assemblies, encompassing over 3000 abstracts presented in the form of thematic poster discussion and oral presentations. In this article, highlights from the ERS Congress 2022 (including from thematic poster sessions, oral presentations and symposia from keynote speakers), presented by Assembly 5 (Airway diseases, asthma, COPD and chronic cough), are reviewed by Early Career Members and experts in the field, with the aim of presenting key recent findings in the field.

Large Thoracic Lymphadenopathy and Pulmonary Nodules in Young Man.

CASE PRESENTATION: A 33-year-old man with obesity, systemic arterial hypertension, and psoriasis who had been treated previously with little success by a pulmonologist for chronic unproductive irritant cough came to the outpatient pulmonary department because of profuse cough and short syncope (probably cough-induced). Chest radiography revealed widened mediastinum with lobular, polycyclic contours that was suspected to be a large mediastinal lymphadenopathy or mediastinal mass.

Increased adipose tissue expression of proinflammatory CD40, MKK4 and JNK in patients with very severe chronic obstructive pulmonary disease.

BACKGROUND: CD40, a transmembrane receptor of the tumor necrosis factor gene superfamily, is activated in response to cellular stress, including hypoxia, and orchestrates the process of inflammation via secondary messengers such as mitogen-activated protein kinase kinase 4 (MKK4) and c-Jun NH(2)-terminal kinases (JNK). OBJECTIVES: We hypothesized that CD40, MKK4 and JNK expression is increased in the adipose tissue of patients with very severe chronic obstructive pulmonary disease (COPD). METHODS: In 20 patients with stable COPD, lung function was assessed using body plethysmography, and samples of subcutaneous adipose tissue were analyzed using real-time PCR. Body composition, including fat mass index (FMI), was assessed by bioelectrical impedance. RESULTS: 12 patients in GOLD stage I-III (age 61.6 ± 8.6 years, 4 females, mean partial pressure of oxygen in arterial blood, PaO(2), 9.38 ± 0.21 kPa) were compared to 8 patients in GOLD stage IV (age 62.6 ± 6.3 years, all male, mean PaO(2) 7.70 ± 0.37 kPa). Compared to patients in GOLD stage I-III, patients in GOLD stage IV had lower FMI (p = 0.004), being associated with significantly higher adipose tissue expression of CD40, MKK4 and JNK [ΔΔCt: 2.55 (1.99, 4.40) vs. 1.87 (1.63, 2.23), p = 0.013; 5.19 (3.13, 5.96) vs. 2.98 (2.82, 3.86), p = 0.002; 9.01 (5.12, 11.41) vs. 4.65 (4.42, 6.26), p = 0.001, respectively]. Log-transformed CD40, MKK4 and JNK expression was significantly inversely related to PaO(2), respectively. CONCLUSIONS: Upregulation of proinflammatory CD40, MKK4 and JNK gene expression in adipose tissue in very severe COPD raises the possibility of a role of chronic systemic hypoxia in the pathogenesis of adipose tissue inflammation in COPD.

Metabolic phenotype and adipose tissue inflammation in patients with chronic obstructive pulmonary disease.

Potential links between metabolic derangements and adipose tissue (AT) inflammation in patients with chronic obstructive pulmonary disease (COPD) are unexplored. We investigated AT expressions of interleukin (IL)-6, tumor necrosis factor (TNF)-α, CD68 (macrophage cell surface receptor), caspase-3, and Bax, and their relationships to the metabolic phenotype in nine cachectic, 12 normal-weight, 12 overweight, and 11 obese patients with COPD (age 62.3 ± 7.2 years). With increasing body mass index, increases in AT expressions of IL-6, TNF-α, and CD68 were observed (P < .001; P = .005; P < .001, resp.), in association with reduced insulin sensitivity (P < .001). No differences were observed between cachectic and normal-weight patients in AT expressions of inflammatory or proapoptotic markers. Adipose tissue CD68 and TNF-α expressions predicted insulin sensitivity independently of known confounders (P = .005; P = .025; R(2) = 0.840). Our results suggest that AT inflammation in obese COPD patients relates to insulin resistance. Cachectic patients remain insulin sensitive, with no AT upregulation of inflammatory or proapoptotic markers.

Relationship Between the Apolipoprotein E Genotype and LDL Particle Size in Patients With Obstructive Sleep Apnea.

Obstructive sleep apnea (OSA) is associated with dyslipidemia and increased cardiovascular risk. We assessed the effects of apolipoprotein E ( APOE) genotype on low-density lipoprotein (LDL) and high-density lipoprotein (HDL) particle size and lipid subclasses (separated by gradient gel electrophoresis) in patients with OSA. Stable patients (n = 181) prospectively recruited underwent full polysomnography. Both LDL particle size and LDL I proportion were reduced from ∊3∊3 homozygotes to ∊2 carriers and to ∊4 carriers (analysis of variance: P = .024; P = .040, respectively); carriers of the ∊4 allele of the APOE genotype had significantly lower LDL particle size and LDL I proportion compared to ∊3∊3 homozygotes ( P < .05 for both comparisons). Insulin resistance increased from patients with no OSA to those with mild-moderate and to those with severe OSA ( P < .001). In multivariate analysis, LDL size was independently predicted by APOE genotype, male gender, and the presence of metabolic syndrome (MetS; P = .001, P = .020, P = .027, respectively). The HDL particle size was not affected by APOE genotype. Our data demonstrate that both the ∊4 APOE genotype and MetS are independently related to smaller LDL size in patients with OSA.

Circulatory osteoprotegerin is related to osteoporosis of the hip in patients with COPD.

BACKGROUND: Osteoprotegerin (OPG), a potent inhibitor of osteoclastogenesis, decreases bone resorption and has protective effects on bone mineral density (BMD). Recently we have shown that the adipose-tissue derived OPG relates to BMD in patients with chronic obstructive pulmonary disease (COPD), a condition associated with increased risk of osteoporosis. OBJECTIVE: Here we aimed to investigate the potential of circulatory OPG to reflect hip BMD in patients with COPD. PATIENTS AND METHODS: In 56 subjects with COPD [age, 61.7 ± 6.7 years; forced expiratory volume in 1 s (FEV1), 53.6 ± 19.2% predicted], total femur BMD was assessed by dual energy X-ray absorptiometry, serum OPG and ß-crosslaps, a marker of increased bone resorption, by commercially available assays. RESULTS: From patients with normal hip BMD (n = 32, T-score 0.1 ± 0.8) to those with osteopenia (n = 14, T-score -1.6 ± 0.4) and osteoporosis (n = 10, T-score -3.4 ± 0.7) serum OPG levels significantly increased (6.6 ± 1.8 versus 7.2 ± 2.9 and versus 8.6 ± 1.5 pmol/l, p = 0.036). In addition, hip T-scores were directly related to FEV1, and inversely to ß-crosslaps (R = 0.40, p = 0.002; R = 0.38, p = 0.01, respectively). In multivariate analysis, OPG independently predicted hip T-scores after adjustments for age, gender, FEV1, and ß-crosslaps (p = 0.011, adjusted R(2) = 0.354). Area under receiver operator curve for OPG as a discriminator of osteoporosis was 0.787 (95% CI, 0.653-0.921) (p = 0.005). CONCLUSIONS: Present results suggest that osteoporosis of the hip is associated with increased circulatory levels of OPG in patients with COPD. OPG might serve as a biomarker of this COPD-related comorbidity.

Relationship between osteoporosis and adipose tissue leptin and osteoprotegerin in patients with chronic obstructive pulmonary disease.

INTRODUCTION: The role of fat-bone interactions in the pathogenesis of osteoporosis in chronic obstructive pulmonary disease (COPD) is poorly understood. Our aim was to investigate expressions of leptin and osteoprotegerin (OPG) in the adipose tissue, and their relationships to osteoporosis in patients with COPD. METHODS: In 39 patients with stable COPD, bone mineral density (BMD) and body composition was assessed by Dual Energy X-Ray Absorptiometry. Serum leptin was determined by the enzyme-linked immunosorbent assay, and bone turnover markers osteocalcin and ß-crosslaps by the electrochemiluminiscence immunoassays. Subcutaneous adipose tissue samples were analyzed using real-time PCR. RESULTS: Twenty-one patients without, and 18 with osteoporosis were enrolled (35 men; age 62.2 ± 7.3years). Compared to patients without osteoporosis, those with the disease had significantly lower serum levels and adipose tissue expressions of leptin, in association with increased serum ß-crosslaps (p=0.028, p=0.034, p=0.022, respectively). Log adipose tissue leptin was inversely related to serum ß-crosslaps (p=0.015), and directly to serum leptin (p<0.001) and to the total, femoral, and lumbar BMD and T-score (p<0.02 for all relationships). Adipose tissue OPG expression was related to all variables of bone density except for lumbar BMD and T-score (p<0.05 for all relationships). Log adipose tissue leptin and OPG expressions predicted femoral T-score independently of age, gender and pulmonary function (p<0.001, adjusted R(2)=0.383; p=0.008, adjusted R(2)=0.301, respectively). Introducing body mass (or fat mass) index into these models eliminated independent predictive value of leptin and OPG expressions. CONCLUSION: Our results suggest that adipose tissue leptin and OPG expressions are related to osteoporosis in patients with COPD, and appear to act as mediators between fat mass and BMD.