Pulmonary functional parameters and blood cotinine level in chronic obstructive pulmonary disease.

INTRODUCTION: Smoking is the leading cause of chronic obstructive pulmonary disease (COPD) and cotinine is reliable marker of tobacco exposure. We aimed to investigate the relationship between pulmonary function tests (FVC%, FEV1, FEV1/FVC and FEF25-75%), smoking history and blood cotinine levels in healthy volunteers as a control and patients who have COPD in our study. MATERIALS AND METHODS: One hundred and two COPD patients and 106 healthy volunteers who admitted to our institution were included. Spirometric investigations of the patients and volunteers were performed. A simple, rapid and reliable gas chromatography-mass spectrometry (GC-MS) method was used for determination of cotinine levels in blood samples. RESULT: The cut-off value of cotinine was determined as 41.12 ng/mL (97.2% sensitivity and 100% specificity). A significant relationship was observed between average pack-year and cotinine level in current smoker group (p< 0.05). The mean cotinine levels were 6.1, 8.8, and 467.0 ng mL-1 in never smokers, ex-smokers and current smokers, respectively. No relationship was observed between cotinine level and FVC%, FEV1% and FEV1/FVC (p> 0.05). In patient group, there was also no relationship between FEF25-75% and cotinine level however, in control group-smokers a negative correlation was found (p< 0.05; r= -0.372). CONCLUSIONS: We observed once again with our study that cotinine is a reliable marker of tobacco exposure. The most obvious result is the negative correlation between FEF25-75% value and cotinine level and this result may be caused by the effect of smoking in the peripheral airways at early stages of COPD.

The factors affecting survival in patients with bronchiectasis.

BACKGROUND/AIM: There is limited information about the rate and modifiers of mortality in noncystic fibrosis bronchiectasis. MATERIALS AND METHODS: This study enrolled a total of 56 bronchiectasis patients. Patients' body mass index, smoking habit, previous therapies, comorbid disorders, history of vaccination, bronchiectasis type and radiological extent, arterial blood gas analysis, respiratory function tests, and laboratory results were recorded. RESULTS: After a follow-up of 65.38 ± 18.62 months the overall mortality rate was 35.7%. The mean survival duration was 46.42 ± 8.25 months. Advanced age significantly increased mortality (HR: 2.031; CI: 0.991-4.072, P = 0.035). A significant correlation was found between mortality rate and the partial oxygen pressure level (HR: 0.886 (CI: 0.817-0.960); P = 0.039). Pulmonary artery pressure was directly proportional to mortality rate (HR: 9.015 (CI: 3.272-94.036); P = 0.03). There was also a significant correlation between Pseudomonas aeruginosa proliferation in sputum and mortality (HR: 7.014 (CI: 2.812-17.962); P = 0.00). Comorbidities increased mortality (HR: 1.984 (CI: 0.972-2.996); P = 0.04). CONCLUSION: Bronchiectasis is a disease with high mortality. Advanced age, comorbid conditions, reduced partial oxygen pressure, pulmonary hypertension, and Pseudomonas aeruginosa proliferation in sputum increase its mortality rate.

[Smoking cessation in patients with cardiopulmonary diseases]. / Kardiyopulmoner hastaligi olanlarda sigaranin birakilmasi

OBJECTIVE: To determine the smoking cessation rates of outpatients with cardiopulmonary disease and the differences between non-cardiopulmonary diseases. METHODS: Two hundred and two active smokers with comorbid diseases were prospectively evaluated between September 2004 and January 2008 in this observational study. All of the patients answered Fagerstrom test for nicotine dependence with a regular questionnaire of general characteristics. Behavioral counseling therapies were administered to all of the subjects. Nicotine replacement therapy, bupropion or combination therapies were the pharmacological therapies after running the baseline spirometry and carbon monoxide oximetry tests. Subjects were classified as patients with cardiopulmonary disease (124) and non-cardiopulmonary diseases (78), based on medical history. Student t and Chi-square tests were used for statistical analyses. RESULTS: The age of smoking was similar but total amount of smoked tobacco was higher (p<0.05) in the cardiopulmonary diseases group. In this group, the main smoking cessation reason was the existing disease (51%) (p<0.05). There was no other significant difference between two groups including treatment protocols. The smoking cessation rates were less (40%) with high relapses (12%) in cardiopulmonary diseases group (p<0.01 and p=0.01 respectively). In the subgroup analysis, treatment procedures were equivalent (p>0.05). CONCLUSION: Results of this analysis confirm that, tobacco dependence is still a severe but necessary condition for the patients with cardiopulmonary diseases. Additionally neither of the treatment protocols was superior to the others.

Evaluation of the functional parameters in scleroderma cases with pulmonary involvement.

To evaluate the relationship between functional changes in the scleroderma patients with pulmonary involvement and the diagnostic tests and to identify the tests that may be helpful in early diagnosis. In this prospective study, 33 scleroderma patients with pulmonary involvement were included. Pulmonary function tests, echocardiography, arterial blood gases, six minute walk tests, thorax high resolution computed tomography were performed and all patients were classified according to MRC dyspnea scores and NYHA(WHO) functional classification. Patients were also asked to conclude Saints Georges Respiratory Questionnaire (SGRQ). DLCO% found to be the earliest deteriorated parameter in our patients. Sensitivity of FVC%/DLCO% ratio, for detecting pulmonary arterial hypertension as a noninvasive method, was found low. SGRQ was found to be correlated with all functional parameters used in scleroderma follow up. Patients with scleroderma should be evaluated for pulmonary involvement and must be followed up ever if they were asymptomatic. Pulmonary function tests, echocardiography, thorax high resolution computed tomography, six minute walk tests are valuable tools that should be used in diagnosis and follow up. NYHA (WHO) functional classification, MRC and Borg dyspnea scores are also helpful for early diagnosis. SGRQ can also be helpful to evaluate the patients functional capacity in diagnosis and follow up as a non invasive parameter.

Mycobacterium simiae infection in an immunocompetent patient, with DNA analyses verification.

Mycobacterium simiae is a non-tuberculosis mycobacterium that does commonly cause clinical disease in immunocompromised patients with or without AIDS. We describe a case of M. simiae pulmonary infection in a patient without immunodeficiency syndrome, who had a history of Mycobacterium tuberculosis infections.

[Update on pulmonary hypertension in chronic obstructive pulmonary disease]. / Güncel verilerle kronik obstrüktif akciger hastaliginda pulmoner hipertansiyon.

Secondary pulmonary hypertension (PH) is a well known possible feature in patients with chronic respiratory diseases. Owing to its frequency advanced chronic obstructive pulmonary disease (COPD) is the most common cause of PH. The studies that have focused on this topic have shown that PH is frequent during sleep, exacerbations or exercise but mean pulmonary artery pressure (PAP) is usually between 20 to 35 mmHg. Limited number of patients have severe PH, which is defined as >35 or 40 mmHg. Unfortunately, there is another subset of patients whom have minimal airway obstruction with greater PAP values called as 'out of proportion'. These two groups need special interest for further evaluation diagnosis and treatment strategy.

[Comparing the effectiveness of different treatment modalities on the smoking cessation rates]. / Farkli tedavi yöntemlerinin sigara birakma basarisi üzerine etkileri.

The social patterns of smoking have changed significantly in the past two decades but smoking is still as prevalent in the lowest socioeconomic groups as it was widespread. For the solution of this enormous problem many kinds of treatment modalities have been proposed but there is no single successful method for quitting. To determine the smoking cessation rates with behavioural treatment, behavioural + pharmacological treatments and compare the differences between each approaches. 371 smokers were prospectively evaluated between 2004 and 2008. At the beginning subjects were classified into two groups: behavioral treatment group (I) and pharmacological + behavioural treatment group (II). Numbers of patients per group were 88 and 283 respectively. According to pharmacological therapy group II was also divided into three subgroups: nicotine replacement treatment (NRT) (regardless of the type and dosage) (IIa), bupropion (IIb) and combination treatment modalities group (IIc). Numbers of patients per subgroups were 185, 70 and 28 respectively. All of the patients were attended the one year follow up visits. According to the baseline characteristics there was no significant difference between the groups and subgroups. At the end of the fist year, in group I smoking cessation rate was 41% and in group II 51% and this was not statistically significant (p< 0.05). In the sub group analysis the success rates for group IIa, IIb and IIc; 44.8%, 62.8% and 64% respectively and bupropion is significantly superior to the NRT (p= 0.01). In study subjects, smoking cessation rates were less with comorbid diseases (p= 0.004), baseline airway obstruction (p= 0.04) and high CO levels (p= 0.008). Results of this analysis confirm that, there is a significant difference between pharmacological treatment and behavioral treatments. Additionally, in the pharmacological approaches, bupropion seems to be superior. Besides, comorbid conditions have been a huge problem to solve.

Acute anuric renal failure with streptokinase therapy in a patient with acute venous thromboembolic disease and the review of renal side effects of streptokinase.

The benefits of thrombolytic therapy in acute myocardial infarction are now well established. However many uncertainties, such as adverse effects, are still remain in venous thromboembolic disease. We describe a unique patient who treated with streptokinase for the methylen tetrahydrofolate reductase mutation associated acute deep vein thrombosis and massive pulmonary embolism. After therapy patient developed acute anuric renal failure without an evidence of bleeding or immunologic reaction and we would like to review the renal side effects of streptokinase in patients with venous thromboembolic disease.

Evaluation of the relationship between radiological abnormalities and both pulmonary function and pulmonary hypertension in coal workers' pneumoconiosis.

OBJECTIVE: The aim of this study was to investigate the effect of the radiological evidence of emphysema, and the extent of interstitial involvement, on lung function and pulmonary arterial pressure (PAP) in patients with coal workers' pneumoconiosis (CWP). METHODS: The records of 48 patients with suspected CWP were evaluated retrospectively. Pulmonary function tests, arterial blood gas analyses and right heart catheterization were evaluated in all patients. Radiological scoring was according to International Labour Organization criteria, and emphysema was scored by CT scanning. Patients were grouped according to the mean PAP (> or =20 mm Hg or < or =19 mm Hg). RESULTS: All patients showed a mild decrease in FEV(1)/FVC and a mild increase in FRC. Forty-four per cent of patients developed mild to moderate pulmonary hypertension. Emphysema scores correlated significantly with airflow rates, including FEV(1)%, FEV(1)/FVC and FEF(25-75%), and with carbon monoxide diffusing capacity (DLCO)% predicted as well as FRC% predicted and the ratio RV/TLC, which are indices of air trapping. Additionally, profusion and global profusion scores showed significant correlation with FEV(1)/FVC, DLCO% predicted, specific airway conductance and smoking. Mean PAP showed a significant negative correlation with FEF(50%) predicted, DLCO% predicted and profusion score. CONCLUSIONS: The impairment of pulmonary function (mainly disturbance in airflow rates and air trapping) and pulmonary hypertension may be present, even in a simple form of CWP. The pulmonary function impairment in patients with CWP is likely to be attributable to the occurrence of emphysema. However, pulmonary hypertension was directly related to the profusion of pneumoconiotic nodules, which may result in obliteration of the vascular bed.

Analysis of the factors related to mortality in patients with bronchiectasis.

BACKGROUND: Bronchiectasis is a common disabling but rarely fatal disease. However the long-term prognosis and risk factors for mortality are not well known. OBJECTIVE: The aim of this study was to determine prospectively the survival and predictive factors of mortality in patients with bronchiectasis, during 4-year follow-up. PATIENTS AND METHODS: From September 2000 to January 2005 survival of bronchiectasis (as evaluated by computed tomography) and predictors of mortality were assessed in 98 outpatients. Fifty-one of the patients had self-reported history of pulmonary infection including tuberculosis. Baseline data, reevaluated in every single year according to scheduled visits. RESULTS: The mean age was 61+/-10 and 74% of the patients were female. In total, 16 patients (16.3%) died; mean survival time was 44.06+/-1.6 months. The survival rates were 97%, 89%, 76%, 58% at 1, 2, 3 and 4 years, respectively. Cox proportional hazard model revealed that long-term mortality was significantly associated with age, body mass index (BMI), Medical Research Council (MRC) dyspnea scale, vaccination, radiographic extent, hypoxemia, hypercapnia and functional parameters. However, MRC and BMI had more significant effects on the mortality than the functional parameters. CONCLUSIONS: These results suggest that high BMI, regular vaccination and scheduled visits may have beneficial effects on the survival of bronchiectasis. Besides, presence of hypoxemia, hypercapnia, dyspnea level and radiographic extent were more closely correlated with mortality.

Predictors of long-term survival in patients with chronic obstructive pulmonary disease.

OBJECTIVE: To analyze the factors affecting survival of patients with chronic obstructive pulmonary disease (COPD) during the follow-up period using a 4-year prospective study. METHODS: The study included 276 out-patients with COPD. The study took place in Ankara University, Cebeci Hospital, Ankara, Turkey between September 2000 and January 2005. We used cox proportional hazards model in investigating the effects of clinical variables on survival. Risk factors related with mortality were analyzed. RESULTS: Forty-nine patients (17.8%) died and the mean survival time was 43.40 +/- 0.65 months. The survival rates were 97% at one year, 89% at 2 years, 84% at 3 years, and 73% at 4 years. Cox proportional hazard model revealed that long-term mortality was significantly associated with age (relative risks [RR]: 1.13, 95% confidence interval: 1.09-1.17), the level of dyspnea (RR: 1.99, 95% confidence interval: 1.44-2.74), the number of hospital admission for acute exacerbation of COPD (RR: 1.33, 95% CI: 1.07-1.67) and the number of scheduled physician visits (RR: 0.75, 95% CI: 0.58-0.95). Also, the presence of hypoxemia was correlated with survival of COPD patients (RR: 0.99, 95% CI: 95-1.00). CONCLUSION: Patient's age, level of dyspnea, hypoxemia and the number of hospital admission were more closely correlated with mortality in COPD. The regular follow-up patients increased the survival of this disease. According to this study patients with COPD may be followed in the specialized out-patient COPD clinics to decrease their morbidity and mortality rates.

Is there any difference between effects of ipratropium bromide and formoterol on exercise capacity in moderate COPD patients?

The effects of anticholinergic agents or long acting beta(2)-agonists on exercise capacity in chronic obstructive pulmonary disease (COPD) improves various out come measures but there is not enough double-blind study which included comparison of different medications. The aim of this study was to compare the effect of ipratropium bromide and formoterol on exercise capacity and also to determine the relationship between this improvement in functional parameters and exercise capacity for each treatment in patients with COPD. This study was performed as randomized, double blind and two period crossover design. Ten volunteer stable COPD patients were recruited from outpatient COPD clinic. At the initial visit medical data were recorded. One week later baseline measurements; pulmonary function tests and cardiopulmonary exercise testing were performed, afterwards, patients received ipratropium bromide 40 microg four times a day or formoterol 12 microg two times a day for two weeks. After a washout period, medications were crossed for another two weeks. After each of treatment period, all tests were performed. Nine subjects were male and mean age was 51.1 +/- 5.45 years, all of them were heavy smokers, level of COPD was mild to moderate (FEV(1)= 69%, FEV(1)/FVC= 68%). While formoterol significantly improved FEV(1), FEV(1)/FVC %, ipratropium significantly improved FEV(1), FEF(25-75), peak oxygen uptake and minute ventilation. Moreover, both of the medications increased exercise time. There were no differences between effects of ipratropium bromide and formoterol on exercise capacity and functional parameters. We observed that ipratropium bromide and formoterol have similar improvement in exercise capacity in COPD patients. The improvement in exercise capacity also correlated with increase in FEV(1).

Inhaled iloprost as a long-term additional therapy to oral sildenafil in severe idiopathic pulmonary arterial hypertension.

Idiopathic pulmonary arterial hypertension (IPAH) is an uncommon and devastating disease which, if untreated, progresses rapidly and leads to right heart failure and death. The course of the disease has been altered by advances in medical therapies. However, the effects of long-term alternative therapies and responses to each treatment protocols are not definite. We want to define an IPAH case, which had long-term temporary responses to the conventional therapy plus calcium channel blockers treatment and moreover compared the long-term clinical and physiologic effects of oral sildenafil mono therapy and additional inhaled iloprost therapy. Patients with IPAH may have response to a short-term vasodilatation therapy but they have to follow for the long-term results and may be of benefit from combination treatments.

Exercise capacity in sarcoidosis. Study of 29 patients.

BACKGROUND AND OBJECTIVE: Sarcoidosis is a systemic granulomatous disease of unknown etiology. Aims of this prospective study are to evaluate degree of impairment in pulmonary function tests (PFT), arterial blood gas analysis (ABG), respiratory muscle strength, exercise capacity and correlation of these parameters with radiological stages; to further evaluate the use of cardiopulmonary exercise testing in assessment of extent of pulmonary disease; and to discuss the pathophysiologic mechanisms of limitation in exercise capacity in patients with sarcoidosis. PATIENTS AND METHOD: 29 patients with sarcoidosis were grouped according to their radiological stages (stage I: group 1; stage II, group 2; stage III, group 3). Groups 1, 2 and 3 included 11, 13 and 5 patients, respectively. PFT, cardiopulmonary exercise testing and ABG were performed for each patient. RESULTS: Evaluation of all patients showed a significant decrement in exercise capacity. Patients in stage III had decreased diffusing capacity and exercise capacity. There was limitation in exercise capacity in stage I patients who had completely normal spirometry and diffusing capacity. We also found a correlation between radiological stages of the disease and exercise capacity, diffusing capacity and ABG. CONCLUSIONS: Exercise capacity is impaired also in early stages of sarcoidosis and it was found to be the earliest impaired physiological parameter in sarcoid patients. Exercise intolerance, having mutifactorial basis, is correlated with radiological stages. Circulatory impairment and impaired heart rate response to exercise have effects on limitation in exercise capacity. Especially in advanced radiological stages of disease, ventilatory and gas exchange impairment also seems to be effective on limiting exercise in patients with sarcoidosis.

Pulmonary hypertension and acute pulmonary edema in a 23-year-old male with a history of an upper respiratory tract infection.

The pathophysiology of upper-airway obstruction (UAO) is complex. Possible causes of UAO that may lead to acute respiratory failure, are as follows: infections like acute epiglottitis and croup, obstructing tumors in the base of the tongue, larynx or hypopharynx, aspirated food or liquid contents, obesity and anatomical variations. Management changes according to the pathogenesis of the disorder. In patients with severe carbon dioxide retention or apnea, emergency endotracheal intubation must be carried out. Hereby, we describe a 23-year-old patient with susceptible upper-airway anatomy and UAO occurred following an upper respiratory infection and complicated with pulmonary hypertension and pulmonary edema. Our patient seems to be one of the complicated UAO cases, with an unusual but critical clinical presentation, evaluated in a wide spectrum and nicely returned to life.

[The importance of exercise testing for the functional assessment of lung resectional candidates]. / Akciger rezeksiyonu yapilacak hastalarin fonksiyonel degerlendirmesi için egzersiz testinin önemi.

UNLABELLED: Although there are a lot of physiologic tests to evaluate the preoperative cardio-pulmonary reserve in the patients who candidate lung resection, there is no a single gold standard test to suggest the postoperative pulmonary complications. In this study, we researched the importance of the exercise testing in the evaluation preoperative cardio-pulmonary reserve. We analyzed a series of 26 consecutive patients with a resectable lung disease [26 male patients, mean age 51.5 +/- 15.8 (13-78 years), 22 non-small cell lung carcinoma (NSCLC), 2 bronchectasis, 1 hydatid cyst, 1 empyema]. Patients were evaluated by pulmonary function testing (PFT), diffusing capacity of lung for carbonmonoxide (DLCO), and symptom-limited exercise testing. After the functional examination, 26 patients underwent pulmonary resections with standard thoracotomy: 4 segmental or wedge resection, 11 lobectomies, 5 pneumonectomies, and 1 cystotomia. The mean stay in the ICU was 2.6 days (+/- 3.5), the mean hospital stay was 11.9 days (+/- 8.0). Postoperative complications (within 30 days) occurred in 9 (34.6%) patients of whom one died (overall mortality rate was 3.8%). There was no relationship between the presence of complication and physiologic tests (PFT, DLCO). The patients were divided three groups according to peak oxygen consumption (VO(2)/kg peak) (mL/kg/min) (< 10, 10-20, > 20 mL/kg/min). There was no significantly difference among these groups and complication rates (p= 0.056), but the complication rate was higher in the group of VO(2)/kg peak < 10 mL/kg/min (75%). On the other hand, there was a significantly relationship between the presence of only pulmonary complication and VO2/kg peak (p= 0.034). CONCLUSION: We think that the preoperative functional evaluation in the patients with lung resection candidate is prominent to reduce the postoperative mortality and morbidity and especially cardiopulmonary exercise testing has an important role to suggest the postoperative pulmonary complications as a major complication.

[Evaluation of spirometric and pulmonary haemodynamic parameters in patients with COPD]. / KOAH'li olgularda pulmoner hemodinamik ve spirometrik parametrelerin degerlendirilmesi.

In this study we aimed to asses the association between the spirometric test which is known to be an indicator of severity of the disease and pulmonary artery pressure, in patient chronic obstructive pulmonary disease (COPD). Study population consisted of 51 patients with COPD. Severity of the disease was graded by the criteria of European Respiratory Society; mildly obstructive 5 patients (FEV1 > 70%), moderately obstructive 10 (FEV1= 50-69%), severely obstructive 36 patients (FEV1 < 50%). Measurement of pulmonary artery pressure was performed bt microcatheterisation method. Statistical analysis was performed between two groups; group I consisted of mildly and moderately obstructive patients, and group II severely obstructive patients. Pulmonary artery pressure of the group II patients was significantly higher than that of group I patients (27 +/- 4 mmHg vs 22 +/- 1.6 mmHg, respectively p< 0.001). There were also statistically significant difference between group I and group II in respect to FEV1% (63 +/- 7 vs 28 +/- 9 respectively p< 0.001), FEV1 L (1.84 +/- 0.46 vs 0.89 +/- 0.36 respectively p< 0.001), FEV1/FVC (71 +/- 10 vs 53 +/- 11 respectively p< 0.001), FVC% (73 +/- 8 vs 47 +/- 10 respectively p< 0.001), and MMF% (38 +/- 13 vs 15 +/- 6 respectively p< 0.001). Pulmonary artery pressure and diameter of right descending pulmonary artery on chest X-ray of the patients were negatively correlated with FEV1%, FEV1 L, FVC and MMF (p< 0.001 for all). We have shown pulmonary artery pressure of the patients with COPD was negatively correlated with the spirometric parameters such as FEV1%, FEV1 L, FVC and MMF. So FEV1 < 50% can be used as an indicator of increased pulmonary artery pressure in patients with COPD.

[The evaluation of dyspnea and quality of life in COPD]. / KOAH'da dispne ve yasam kalitesinin degerlendirilmesi.

Dyspnea defined as an uncomfortable sensation of breathing is the main cause of disability in chronic obstructive pulmonary disease (COPD) patients. There is evidence that the underlying mechanisms of dyspnea are multifactorial. The aim of this study was to investigate these mechanisms causing dyspnea in COPD patients and the relationship between functional parameters, dyspnea scales and quality of life questionnaire. For this purpose 56 patients (11 female, 45 male) were recruited. Pulmonary function tests including airflow rates, lung volumes, maximal respiratory muscle forces, diffusing capacity, breathing pattern, arterial blood gas analyses as well as dyspnea scales MRC, baseline dyspnea index (BDI) and The Saint George Respiratory Questionnaire (SGRQ) were performed. The overall group showed moderate obstructive disease (FEV1%= 59.02 +/- 3.30) and mild hypoxemia with some air trapping (RV/TLC%= 52.00 +/- 2.00). MRC scale did not show any significant correlation with pulmonary function parameters. There was significant positive correlation between BDI and airflow rates, PImax, DLCO and air trapping. Breathing pattern parameters (Ti/Ttot, VT/Ti) also correlated with BDI. There was positive correlation between PaO2 and BDI (p< 0.001). SGRQ scores correlated significantly with FEV1, PImax, RV/TLC and P 0.1. There was also strong correlation between BDI and SGRQ scores. In conclusion, dyspnea is the result of multiple factors such as airflow limitation, decreased respiratory muscle strength, changes breathing pattern, hypoxemia, and air trapping which in turn affects quality of life in patients with COPD.