Increased E/A Ratio is a Risk Factor for the Formation of Pleural Effusion in Heart Failure.

PURPOSE: Pleural effusion is a common finding in patients with congestive heart failure (CHF). The pathogenesis of pleural effusion in heart failure is multifactorial. However, the role of right and left ventricular function assessed by ECHO cardiogram has not been studied. Therefore, we explored the association between right and left ventricular parameters on echocardiogram in patients with heart failure with and without pleural effusion diagnosed using CT scan of chest. METHODS: A case-control study was utilized to explore the objectives. Using strict exclusion criteria, patients admitted with a single diagnosis of acute CHF were stratified into those with and without pleural effusion using CT scan of chest done at admission. Multiple logistic regression analysis was used to identify significant factors associated with pleural effusion. RESULTS: Among the 70 patients, 36 (51%) had pleural effusions. The mean E/A ratio in patients with effusion (2.53 ± 1.1) was significantly higher than in patients without effusion (1.15 ± 0.9), p < 0.01. Multiple logistic regression analysis showed that elevated E/A ratio was significantly associated with pleural effusion, OR 3.26 (95% CI 1.57-6.77, p < 0.009). Left ventricular ejection fraction (LVEF), septal E', lateral E', and medial E/E' ratio were not significantly different in patients with and without pleural effusion. CONCLUSION: Elevated E/A ratio is a risk factor for the formation of pleural effusion in patients with heart failure.

The synergetic effect of ambient PM2.5 exposure and rhinovirus infection in airway dysfunction in asthma: a pilot observational study from the Central Valley of California.

BACKGROUND: Elevated levels of particulate matter PM2.5 and rhinovirus infection have been known to exacerbate asthma. However, the combined effect of rhinovirus infection and high PM2.5 has not been investigated. PURPOSE: To investigate the effect of PM2.5 and concomitant rhinovirus infection on airway function in asthma in an area with high PM2.5 concentration. METHODS: Asthmatics and their matched controls were monitored for lung function, exhaled nitric oxide (eNO) and respiratory symptoms on days with varying levels of PM2.5. As the study was a repeated measure design, repeated clinical findings, and laboratory data were used in the mixed model analysis. RESULTS: Wheezing and dyspnea in asthmatics were worsened with increasing ambient PM2.5. Increasing PM2.5 decreased FEV1% predicted (-0.51, -0.79 to -0.23) and FEF25-75% predicted (-0.66, -1.07 to -0.24) in subjects with asthma (all P < .01). Rhino viral infection reduced FEF25-75% predicted in subjects with asthma (-11.7, -20 to -2.9). The reductions in FEV25-75 and FEV1 per 10 µg/m(3) increase in ambient PM2.5 were 6% and 5% respectively. A significant interaction was observed between presence of rhinovirus infection and elevated PM2.5 in asthmatics causing a 4-fold decrease in FEF25-75 (P = .01) and a 2-fold decrease in FEV1% predicted values (P = .01) compared with asthmatics with no rhino viral infection. CONCLUSIONS: Increasing ambient PM2.5 and low temperature independently worsened airway function in asthma. The interaction between rhinovirus and PM2.5 significantly impairs airway function in asthma. A larger sample size study is suggested to investigate these observations.

Lung volume abnormalities and its correlation to spirometric and demographic variables in adult asthma.

BACKGROUND: Presence of airflow obstruction in asthma has been based on a fixed FEV1(forced expiratory volume at 1 second)/FVC (forced vital capacity) ratio abnormality. The accuracy of FEV1/FVC ratio in diagnosing airflow obstruction remains controversial. Lung volume abnormalities have been observed in severe asthma. We utilized simultaneously measured spirometry and lung volume to determine the utility of residual volume (RV)/total lung capacity (TLC) ratio in diagnosing airflow obstruction and to identify predictors of abnormal RV in asthmatic subjects. METHODS: Data from physician-diagnosed asthmatics referred for lung function tests were collected retrospectively. Patient demographics and lung function data were analyzed using general linear modeling. RESULTS: Of the 321 subjects, 221 were female (69%). The ethnicity was Caucasian in 157 (49%), Hispanic in 131 (41%), and African-American in 33 (10%). The percentage of subjects with FEV(1)/FVC ratio <70%, FEV(1)-predicted <80%, and FEF25-75% <65% were 25%, 25%, and 38%, respectively. Fifty-two and fifty-seven percent of the patients had abnormal residual volume and abnormal RV/TLC ratio, respectively. A significant bronchodilator response was observed in 32% of the patients. A positive correlation was observed between RV to age (r = 0.4) and height (r = 0.3). A negative correlation was observed between RV to FEF25-75% (r = 0.5) and body weight (r = 0.07). There was no significant correlation between FEV1 reversibility and residual volume (r = 0.1). RV correlated significantly better with FEF25-75% (r(2) = 0.25) than FEV(1) (r(2) = 0.16). CONCLUSION: A significant proportion of asthmatic patients have elevated residual volume and abnormal RV/TLC ratio in the presence of normal FEV1/FVC ratio and absence of significant bronchodilator response. The clinical significance of these findings in asthma needs further prospective study.

Residual Volume Responsiveness Testing May Improve the Detection of Reversible Airway Obstruction in Asthma.

BACKGROUND: Residual volume responsiveness to bronchodilator administration has been observed in subjects with chronic obstructive pulmonary disease. However, the prevalence of residual volume (RV) responsiveness has not been formally studied in asthma. OBJECTIVE: To identify the prevalence and magnitude of RV responsiveness in asthma. METHODS: Physician-diagnosed adult subjects with asthma on treatment for >12 months were prospectively recruited to perform spirometry and measurement of lung volumes using body plethysmography before and after administration of 360 µg of albuterol. RESULTS: Among 120 subjects, 76% were women. The ethnic composition was 64% Caucasian, 32% Hispanic, and 13% African American. The mean age was 52 ± 15 years. The mean duration of asthma was 16 ± 15 years. The mean RV% responsiveness was -7.74 ± 14. Whereas patients with the lowest baseline forced expiratory volume in 1 second (FEV1) value showed the highest mean responsiveness (P = .001), the baseline RV value had minimal influence on RV responsiveness. Using -7.74% to define significant RV responsiveness, and ≥12% and ≥200 mL to define significant FEV1 responsiveness, more subjects showed isolated RV responsiveness (37%) compared with 6% with isolated FEV1 responsiveness and 14% with both FEV1 and RV responsiveness (P = .04). There was a minimal correlation between FEV1 responsiveness and RV responsiveness (r = 0.17, P = .06). The RV responsiveness was significantly associated with the wheeze score (P = .006) and dyspnea score (P = .029). CONCLUSION: The addition of RV responsiveness testing to spirometry based responsiveness testing can improve the identification of reversible airway obstruction in asthma. RV responsiveness may be useful in monitoring symptoms associated with air trapping in asthma.

Air Trapping Correlates With Increased Frequency of Albuterol Use and Severity of Wheeze in Persistent Asthma.

BACKGROUND: Symptoms of asthma have been shown to correlate poorly with spirometric variables of obstruction. We hypothesized that lung volume measurements might correlate with symptoms and frequency of rescue inhaler use in asthma. METHODS: Patients with persistent asthma on treatment for ≥12 months were enrolled from university-based clinics. The association between lung volumes, spirometry, asthma symptoms, and rescue inhaler use were explored by using linear modeling. RESULTS: Among the 120 subjects, 76% were women. The mean age ± SD was 52 ± 15 y. With regard to ethnicity, 64% of the subjects were caucasian, 23% were Hispanic, and 13% were African-American. Twenty-one percent of the subjects reported chest pain. There was no significant correlation between asthma symptoms or rescue inhaler use to spirometry indices of obstruction. The residual volume percent of predicted showed a significant association with the wheeze score (r = 0.32, P = .001) and frequency of rescue inhaler use (r = 0.35, P ≤ .001). Linear contrast analysis showed that the mean wheeze score (P = .003) and frequency of rescue inhaler (P = .007) use increased linearly from the lowest to the highest quartiles of residual volume. Furthermore, multiple regression analysis showed an association only to the residual volume percent predicted value to the pressurized metered-dose inhaler score and the wheeze score. CONCLUSIONS: Frequent albuterol use and wheezing may be a sign of unrelieved air trapping. Chest pain is a unique symptom in persistent asthma, and the pathogenesis requires further studies. Lung volume measurement added to routine spirometry can help identify patients with asthma and with air trapping.

Grand rounds: asbestos-related pericarditis in a boiler operator.

CONTEXT: Occupational and environmental exposures to asbestos remain a public health problem even in developed countries. Because of the long latency in asbestos-related pathology, past asbestos exposure continues to contribute to incident disease. Asbestos most commonly produces pulmonary pathology, with asbestos-related pleural disease as the most common manifestation. Although the pleurae and pericardium share certain histologic characteristics, asbestos-related pericarditis is rarely reported. CASE PRESENTATION: We present a 59-year-old man who worked around boilers for almost 30 years and was eventually determined to have calcific, constrictive pericarditis. He initially presented with an infectious exacerbation of chronic bronchitis. Chest radiographs demonstrated pleural and pericardial calcifications. Further evaluation with cardiac catheterization showed a hemodynamic picture consistent with constrictive pericarditis. A high-resolution computerized tomography scan of the chest demonstrated dense calcification in the pericardium, right pleural thickening and nodularity, right pleural plaque without calcification, and density in the right middle lobe. Pulmonary function testing showed mild obstruction and borderline low diffusing capacity. DISCUSSION: Based on the patient's occupational history, the presence of pleural pathology consistent with asbestos, previous evidence that asbestos can affect the pericardium, and absence of other likely explanations, we concluded that his pericarditis was asbestos-related. RELEVANCE TO CLINICAL PRACTICE: Similar to pleural thickening and plaque formation, asbestos may cause progressive fibrosis of the pericardium.

Longer duration of asthma is significantly associated with increased RV/TLC ratio.

BACKGROUND: Although FEV1/FVC ratio has been shown to be negatively associated with longer duration of asthma; an association between RV/TLC ratio and longer duration of asthma has not been explored. MATERIAL AND METHODS: Patients with established asthma for more than a year and met inclusion and exclusion criteria were recruited. Data obtained by questionnaire after informed consent was obtained, Pulmonary function tests and laboratory results were collected through chart review. Correlation and multiple linear regressions were used to analyze the data. RESULTS: Among the 93 subjects, 61 were women. The mean age of patients was 58 ± 15 years, and the mean duration of asthma was 21 ± 18 years. The ethnic composition included: Caucasians 64%, Hispanics 28% and other groups 8%. The FEV1/FVC ratio was not significantly associated with duration of asthma (R2 = 0.15, p = 0.05). However, the RV/TLC ratio was significantly associated with duration of asthma (R2 = 0.46, p < 0.001). CONCLUSION: RV/TLC ratio may be a better indicator than FEV1/FVC ratio to detect airway obstruction related to longer duration of asthma. Lung volume measurements should be done in addition to spirometry to detect changes related to airway obstruction in patients with longer duration of asthma.

Patterns of pulmonary dysfunction in asbestos workers: a cross-sectional study.

BACKGROUND: Restrictive patterns of pulmonary function abnormalities associated with asbestos exposure are well described. Studies are less consistent, however, regarding the association of asbestos inhalation with airway dysfunction and obstructive impairment. METHODS: We compared pulmonary function test results between 277 chrysotile exposed workers (22% non-smokers) and 177 unexposed controls (50.3% non-smokers). Information on exposure and smoking were collected using a standardized questionnaire. Standardized spirometric and DCLO Measurement methods were utilized. CXRs were read based on ILO pneumoconiosis guidelines. RESULTS: Asbestos exposed subjects had significantly reduced FVC, FEV1, FEV1/FVC and DLCO. Restricting the analysis to non-smokers, asbestos workers still had about 3% lower FEV1/FVC ratio than controls, but this difference did not reach statistical significance. Among exposed workers, the presence of radiographic evidence of asbestosis further lowered FVC and DLCO but not FEV1/FVC compared to asbestos exposure without radiographic asbestosis. Additionally, smoking asbestos workers had significantly lower DLCO compared to non-smoking workers. CONCLUSION: Asbestos exposure, especially when radiographic evidence of interstitial fibrosis from asbestosis is present, leads to significant decreases in FVC, FEV1 and the DLCO. However, asbestos exposure alone is not significantly associated with a reduction of the FEV1/FVC. Smoking-asbestos workers had significantly lower DLCO than their non-smoking counterparts. Whether asbestos interacts with smoking additively or synergistically on DLCO needs further investigation. Similarly, further studies are needed to assess the progression and clinical significance of asbestos induced airway dysfunction.