Prevalence, risk factors, and recurrence risk of persistent air leak in patients with secondary spontaneous pneumothorax.

Background: Persistent air leak (PAL) is common in secondary spontaneous pneumothorax (SSP), with risk factors only been determined for post-pulmonary resection PAL. Information about its risk factors and long-term outcome is, however, necessary to enable selection of treatment modalities for elderly SSP patients with comorbid conditions. Methods: A retrospective observational study was performed on chest drain-treated SSP patients from 2009 to 2018. The risk factors, long-term recurrent pneumothorax, and mortality rates of those with and without PAL were evaluated. Results: Of 180 non-surgical SSP patients, PAL prevalence for >2 days and >7 days were 81.1% and 43.3%, respectively. Bulla was associated with PAL >7 days (OR: 2.32; P: 0.027) and serum albumin negatively associated (OR: 0.94; P: 0.028). PAL resulted in longer hospitalization in the index episode (P: <0.01). PAL >7 days was associated with a higher pneumothorax recurrence rate in three months (HR: 2.65; P: 0.041), one year (HR: 2.50; P: 0.040) and two-year post-discharge (HR: 2.40; P: 0.029). Patients treated with medical pleurodesis were significantly older (P: <0.01), had higher Charlson Co-morbidity index scores (P: <0.01), and 77.8% of those who had PAL >7 days were considered unfit for surgery. Of these, pneumothorax had not recurred in 69.4% after two years (HR: 0.47; P: 0.044). Conclusion: Bulla was positively associated with PAL over seven days in SSP patients while albumin was negatively associated. PAL over seven days increased future recurrent pneumothorax risks, while elderly SSP patients unfit for surgery had acceptable recurrence rates after medical pleurodesis.

Hospital Burden of Chronic Obstructive Pulmonary Disease in Hong Kong - The Trend from 2006 to 2014.

Background: Chronic obstructive pulmonary disease (COPD) is a common cause for hospital admission. This study aims to review the hospital burden of COPD in Hong Kong (HK) and the trend from year 2006 to 2014. Methods: A multi-center, retrospective study of the characteristics of COPD patients discharged from the public hospitals of HK from year 2006 to 2014. Anonymized data retrieval and analysis were performed. The demographic data of the subjects, use of health-care resources, ventilatory support, medications used and mortality of the subjects were analyzed. Results: Total patient headcount (HC) and admission number reduced from 10,425 and 23,362 in year 2006 to 9613 and 19,771, respectively, in 2014. There was a progressive reduction of female COPD HC from 2193 (21%) in year 2006 to 1517 (16%) in 2014. The utilization of non-invasive ventilation (NIV) increased rapidly and peaked in 2010 (29%) and decreased thereafter. There was a rapid increase in the prescription of long-acting bronchodilators (from 15% to 64%). COPD and pneumonia were the top causes of death, but death due to pneumonia was rapidly increasing while death due to COPD was progressively decreasing over the period. Conclusion: COPD HC and admission number (particularly in female patients) decreased progressively from year 2006 to 2014. There was also a decreasing trend of severity of disease as reflected by lower NIV use (after year 2010) and lower mortality rate due to COPD. Reduced smoking prevalence and tuberculosis (TB) notification rate in the community in the past might have reduced the incidence and severity of COPD and the hospital burden of disease. We observed an increasing trend of mortality due to pneumonia in COPD patients. Appropriate and timely vaccination programs are recommended for COPD patients as in the general elderly population.

Comorbidities, mortality, and management of chronic obstructive pulmonary disease patients who required admissions to public hospitals in Hong Kong - computerized data collection and analysis.

Background: COPD is a common cause for hospital admission. Conventional studies of the epidemiology of COPD involved large patient number and immense resources and were difficult to be repeated. The present study aimed at assessing the utilization of a computerized data management system in the collection and analysis of the epidemiological and clinical data of a large COPD cohort in Hong Kong (HK). Patients and methods: It was a computerized, multicenter, retrospective review of the characteristics of patients discharged from medical departments of the 16 participating hospitals with the primary discharge diagnosis of COPD in 1 year (2012). Comparison was made between the different subgroups in the use of medications, ventilatory support, and other health care resources. The mortality of the subjects in different subgroups was traced up to December 31, 2014. The top 10 causes of death were analyzed. Results: In total, 9,776 subjects (82.6% men, mean age = 78 years) were identified. Of the 1,918 subjects with lung function coding, 85 (4.4%), 488 (25.5%), 808 (42.1%), and 537 (28.0%) subjects had the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 1, 2, 3, and 4 classes, respectively. Patients with higher GOLD classes had higher number of hospital admissions, longer hospital stay, increased usage of noninvasive mechanical ventilation (NIV), combinations of long-acting bronchodilators, and higher mortality. Of the 9,776 subjects, 2,278 (23.3%) received NIV, but invasive mechanical ventilation was uncommon (134 of 9,776 subjects [1.4%]); 4,427 (45.3%) subjects had died by the end of 2014. The top causes of death were COPD, pneumonia, lung cancer, and other malignancies. Conclusion: Patients admitted to hospitals for COPD in HK had significant comorbidities, mortality, and imposed heavy burden on health care resources. It is possible to collect and analyze data of a large COPD cohort through a computerized system. Suboptimal coding of lung function results was observed, and underutilization of long-acting bronchodilators was common.

Coronary plaque instability in severe acute respiratory syndrome.

In his second week of severe acute respiratory syndrome (SARS) illness, a patient developed an unusually complicated course of acute coronary syndrome. One day after initial stabilization of a non-ST-elevated anterior myocardial infarction (MI), he sustained an ST-elevated anterior MI. Eight hours after emergency coronary intervention to the culprit lesion, he developed another ST-elevated MI in the inferior territory. Acute inflammation and cytokine storm in the immunopathological phase of SARS may play a role in coronary plaque instability. Physicians should be alert to this potentially fatal complication and adopt appropriate vigilant and aggressive management strategies.

Management of Critically Ill Patients with Severe Acute Respiratory Syndrome (SARS).

Severe acute respiratory syndrome (SARS) is frequently complicated with acute respiratory failure. In this article, we aim to focus on the management of the subgroup of SARS patients who are critically ill. Most SARS patients would require high flow oxygen supplementation, 20-30% required intensive care unit (ICU) or high dependency care, and 13-26% developed acute respiratory distress syndrome (ARDS). In some of these patients, the clinical course can progress relentlessly to septic shock and/or multiple organ dysfunction syndrome (MODS). The management of critically ill SARS patients requires timely institution of pharmacotherapy where applicable and supportive treatment (oxygen therapy, noninvasive and invasive ventilation). Superimposed bacterial and other opportunistic infections are common, especially in those treated with mechanical ventilation. Subcutaneous emphysema, pneumothoraces and pneumomediastinum may arise spontaneously or as a result of positive ventilatory assistance. Older age is a consistently a poor prognostic factor. Appropriate use of personal protection equipment and adherence to infection control measures is mandatory for effective infection control. Much of the knowledge about the clinical aspects of SARS is based on retrospective observational data and randomized-controlled trials are required for confirmation. Physicians and scientists all over the world should collaborate to study this condition which may potentially threaten human existence.

Outcome of coronavirus-associated severe acute respiratory syndrome using a standard treatment protocol.

OBJECTIVE: There is so far no consensus on the optimal treatment strategy for the coronavirus-associated severe acute respiratory syndrome (SARS). We aimed to analyse the outcomes of a standard treatment strategy comprising antibiotics, a combination of ribavirin, a 3-week step-down course of corticosteroids, and the possibility of pulsed methylprednisolone rescue in the event of deterioration. METHODOLOGY: This was a prospective cohort study performed at a major public-funded hospital in Hong Kong. Eighty-eight World Health Organisation/Centers for Disease Control and Prevention probable cases of SARS (97% laboratory-confirmed) were treated with a standard protocol previously reported. Seventy-one patients treated de novo were analysed in detail with regard to time to clinical stabilization after combination treatment, requirement of additional therapy (pulsed methylprednisolone; assisted ventilation); and final outcomes (recovery, mortality). RESULTS: The mean age was 42. Twenty-one patients (24%) had comorbidities. Three of 71 treated de novo recovered with antibiotics alone. The remaining 68 received combination treatment at a mean of 5.8 days after symptom onset, of whom 30 subsequently required pulsed methylprednisolone rescue (independent predictors: older age and higher LDH) and 18 required assisted ventilation (independent predictors: older age, higher oxygen requirement and creatinine level). Their median time to clinical stabilization was 8.0 days after combination treatment (independent predictor for longer time to stabilization: median age of 41 or above). Common complications were hyperglycaemia (58%), pneumo-mediastinum/thoraces (13%), psychiatric manifestations (7%) and ventilator-associated pneumonia (2%). One patient (1%) died of SARS-related respiratory failure. All-cause mortality was 3.4%, occurring in patients aged > 65 years only. None of the discharged survivors required continuation of oxygen therapy. CONCLUSIONS: This standard treatment protocol resulted in overall satisfactory outcomes. Randomized controlled trial is suggested to confirm its efficacy.