Successfully treated but not fit for purpose: paying attention to chronic lung impairment after TB treatment.

In 2013, 86% of patients with newly diagnosed tuberculosis (TB) successfully completed treatment and were discharged from care. However, long-term studies in industrialised and resource-poor countries all point to a higher risk of death in TB survivors than in the general population. The likely explanation is chronic restrictive and obstructive lung disease consequent to TB. We call for better linkages between TB control programmes and respiratory medicine services, a better understanding of the burden of respiratory disability at the end of anti-tuberculosis treatment, and political, programmatic, clinical and research action to improve the quality of life of affected patients.

Variables en el triage de urgencias que contribuyen a la correcta ubicación de los pacientes que consultan por disnea / Variables at the emergency department triage wich help the correct location of patients who present dyspnea

Objetivos: Determinar qué variables pueden ser útiles en el triage, para asignar los pacientes que consultan por disnea en el área adecuada de urgencias. Métodos: Estudio prospectivo de 112 pacientes que consultaron por disnea con una saturación arterial de oxígeno (SaO2) > 90 por ciento, ubicados inicialmente en el nivel I (pacientes leves). Se recogieron datos de filiación, SaO2 mediante pulsioxímetro, constantes vitales, antecedentes patológicos y evolución clínica. Resultados: Se detectaron 25 pacientes mal ubicados en el nivel I. Estos presentaban, respecto a los bien ubicados, una significativa menor SaO2 (95,6 ñ 2,36 por ciento vs 96,8 ñ 2,06 por ciento; p a 37,5°C.Conclusiones: La frecuencia respiratoria, la temperatura y el antecedente de EPOC, son herramientas útiles en el triage para la ubicación de los pacientes que consultan por disnea con una SaO2 > 90 por ciento (AU)

[Respiratory rehabilitation in patients with bronchial asthma and chronic obstructive pulmonary disease (COPD) in Kinshasa]. / La réadaptation respiratoire de patients atteints d'asthme bronchique et de broncho-pneumopathies obstructives chroniques (BPCO) à Kinshasa.

A number of studies in western countries have shown that respiratory and physical rehabilitation of patients with chronic obstructive pulmonary disease (COPD) only has a minimal effect on respiratory function but can significantly improve physical capacity. The aim of our study was to apply these methods to patients in Kinshasa, Democratic Republic of Congo. We treated 38 patients (20 women) who had bronchial asthma (n=14) or COPD (n=24). These ambulatory patients were treated in two different hospitals in Kinshasa, the university hospital and the general hospital, three times per week for twelve weeks. The patients were treated with kinestherapy and inhaled bronchodilator drugs (salbutamol, and/or ipratropium bromide with a boreal nebulizer) as well as bronchial hygiene and performed breathing exercises on a Bodyguard Ergometer 990 with walking, running and climbing steps until exhaustion. After the rehabilitation program FEV1 increased from 1.37 +/- 0.62 (50% expected) to 1.54 +/- 0.69 (56% expected) (p<0.01). The same trend was observed for walking distance (from 644 +/- 459 m to 1213 +/- 569 m, p<0.001) and for maximal power developed on the cycloergometer (from 45 +/- 20 w to 73 +/- 37 w, p<0.001). In contrast, the maximal work load performed during climbing steps (from 106 +/- 44 w to 115 +/- 23 w) did not improve significantly. COPD patients improved their FEV1 significantly compared with asthma patients. Our study show that pulmonary rehabilitaion increase the level of spontaneous physical activity. The pulmonary rehabilitation program changes the quality of life of COPD patients who are able to move about better for longer periods of time, have a longer walking distance, and improved physical activity level.

[The effectiveness of hyperbaric oxygenation in chronic obstructive bronchitis made in outpatient clinic]. / Effektivnost' giperbaricheskoi oksigenatsii pri khronicheskom obstruktivnom bronkhite na poliklinicheskom étape reabilitatsii.

General clinical examination, external respiratory function investigation, antrovent pharmacological tests were performed in 68 patients aged 28-52 years with chronic obstructive bronchitis (COB) admitted to the rehabilitation center after hospital treatment. Hyperbaric oxygenation improved general condition of the patients, normalized excessive free-radical lipid oxidation and antioxidant defense. It also improves the results of combined rehabilitation treatment, bronchial permeability, sensitivity of beta-2 bronchial receptors to sympathomimetics. This allows to reduce doses or discontinue sympathomimetics.

Manejo ambulatorio de la EPOC: informe de una Reunión de Consenso / Ambulatory management of chronic obstructive pulmonary disease COPD: a consensus report

Based on the Consensus of the Chilean Respiratory Society, this article summarizes the main topics of the ambulatory management of patients with COPD. The Consensus proposes operative definitions in order to prevent the most frequent conceptual errors, specially those related to the confusion between patients with chronic bronchitis without chronic obstruction and those with COPD. Among the diagnostic criteria, the consensus emphasizes the importance of demonstrating irreversible airway obstruction through spirometry, as well as strategies to the differential diagnosis between COPD and asthma. The Consensus summarizes the therapeutic interventions used in the ambulatory setting, including smoking cessation, bronchodilators, corticosteroids, antibiotics, vaccination, oxygen therapy, respiratory rehabilitation and environmental management. The Consensus emphasizes the importance of patient education in order to involve them in their own management. Some criteria for referral of patients are given and the role of exceptional therapeutical interventions, such as non invasive mechanical ventilation and lung reduction surgery are mentioned. The Consensus states that a significative improvement of the quality of life can be achieved with a proper combination of therapeutic interventions

Evidence for obstructive and restrictive lung pathology among tetra-ethyl lead handlers and petrol tanker fillers at a petrochemical industry in Nigeria.

Described here is a computer predicted and computer measured pulmonary function in a randomly selected population sample of 111 men. These consisted of 36 primary school teachers (control), 35 Tetra-ethyl Lead handlers (TEL) and 40 Tanker Loaders (TL) at a petrochemical industry in Warri, Delta State, Nigeria. Productive cough and headache were commoner among the TL (45%, 38%) and the TEL handlers (43%, 31%). TEL handlers were 5 times likely to develop insomnia and other sleep disturbances than the control group. TL were more than 3 1/2 times more likely to develop nervousness than the control group. Measured FEF25-75% was significantly lower than its predicted value among the TEL handlers (56%) and TL (55%) when compared with the control group (36%) (P < 0.05 respectively). Although there were distinct reductions in the measured values of FEF75-85% among the TEL handlers (41%) and the TL (40%) compared to the control group (28%), this difference did not reach a level of significance when the TEL or the TL were compared individually to the control group. Predicted and measured forced mid expiratory flow time (FMFT) was not significantly varied among the cases and the control. There was statistically significant disparities (P < 0.005) in the values of predicted and measured maximum voluntary ventilation (litres) of the TEL handlers (47%) and of the TL (46%) compared with that of the control group (29%). The data suggest obstruction of the big and small airways of those occupationally exposed at a petrochemical factory in Nigeria especially the tetra-ethyl lead handlers and the tanker loaders. This data also suggests that pulmonary impairment may lead to an increased respiratory absorption of lead in its organic form. Efforts should be made to ascertain the degree of impairment and to treat the affected workers.

The effectiveness of neuromuscular release massage therapy in five individuals with chronic obstructive lung disease.

The purpose was to examine neuromuscular release massage therapy (NRMT) as an intervention for individuals with chronic obstructive lung disease (COLD) to improve pulmonary function, respiratory muscle strength, and quality of life. Variables measured were thoracic gas volume, peak flow, oxygen saturation, blood pressure, heart rate, forced expiratory volume in one second (FEV1), forced vital capacity (FVC), FEV1/FVC, and quality of life to determine if improvement occurred with 24 weekly treatments of NRMT. Four of five participants had an increase in thoracic gas volume, peak flow, and FVC. Paired differences t test resulted in significant changes in heart rate, oxygen saturation, and time of breath hold. Repeated measured analysis of variance indicated a significant interaction between participant and time for heart rate, oxygen saturation, and systolic blood pressure. The results suggest that individuals with COLD do benefit from NRMT, but the exact physiological mechanism for the changes warrants additional study.

Yoga therapy in chronic bronchitis.

Fifteen patients of chronic bronchitis received yoga therapy in the form of pranayam and 8 types of 'asans' for a period of 4 weeks. They had a perceptible improvement in dyspnoea as was measured by visual analog. Lung function parameters (VC, FEV1, and PEFR) also improved after the practice of yoga. This preliminary study indicates that, yoga may be an useful adjunct to other conventional form of therapy for COPD.

O estado nutricional da vitamina A em pacientes portadores de de doença pulmonar obstrutiva / Vitamin A status of patients with chronic obstructive pulmonary disease

Um conjunto de dados epidemiológicos, clínicos e experimentais permitiram levantar a hipótese de que pacientes com DPOC apresentam deficiência de vitamin A. Nesta linha, o objetivo principal deste trabalho consistiu na avaliaçäo do estado nutricional da vitamina A em pacientes em DPOC. Para a avaliaçäo, analisamos as várias fases do metabolismo da vitamina A, desde a ingestäo até os órgäos alvo: ingestäo alimentar, digestäo, captaçäo hepática de quilomícrons, transporte de ésteres retilínicos e de retinol no soro e a captaçäo celular da vitamina. Os seguintes métodos foram utilizados para o estudo das fases descritas: inquérito alimentar pela técnica do questionário de freqüência; determinaçäo, no soro, de ésteres retilínicos e retinol (antes e após dose teste com vitamina A), a-caroteno, ß-caroteno, u-tocoferol, RBP e TTR; e os índices de obstruçäo pulmonar, antes e após suplementaçäo com vitamina A. Com objetivos secundários, analisou-se o estado da vitamina A em fumantes habituais, em fumantes com doença pulmonar obstrutiva leve e em pacientes com DPOC com exacerbaçäo do quadro respiratório. Procurou-se verificar a existência de associaçäo entre o estado da vitamina A e o grau de obstruçäo pulmonar e a atividade inflamatória. Por último, analisou-se a resposta das provas de funçäo pulmonar, nos pacientes com DPOC leve, à suplementaçäo de vitamina A. Para este objetivos, foram empregados os seguintes métodos, alé dos citados acima: questionário relacionado com o fumo e as provas laboratoriais relacionadas com a fase aguda. Para satisfazer os objetivos do trabalho, foram estudados na avaliaçäo transversal: um grupo de doentes com DPOC clínica e estável (GIV) (sexo masculino, n=7, idade 63,6 ñ 5,9 anos);...

Acute exacerbations of obstructive lung disease. What to do when immediate care is crucial.

Obstructive lung disease is a major cause of morbidity and mortality in the United States, and the mortality rate is rising. Successful treatment of acute exacerbations begins with appropriate assessment and intervention. Supplemental oxygen is appropriate for all patients with hypoxemia, and mechanical ventilation should be considered in those with clouded consciousness, profound acidosis, or severe hypoxemia. Inhaled beta 2 agonists are the first line of therapy in acute exacerbations. Anticholinergics, methylxanthines, and corticosteroids may also be useful. Alternative therapies (eg, magnesium, glucagon, calcium channel blockers, clonidine, helium) are receiving increased attention and are undergoing investigation.

Chronic obstructive pulmonary disease: current comprehensive care for emphysema and bronchitis.

Chronic obstructive pulmonary disease (COPD) is the fifth leading cause of mortality in the United States. Most clients are initially seen when symptomatic and significant lung damage has already occurred; most cases are preventable. There is no cure for COPD, but lifestyle changes (especially smoking cessation) and proper treatment can significantly impact quality of life. The diagnostic tools most commonly used include chest x-ray, arterial blood gases, and pulmonary function tests. Pharmacologic interventions include steroids, bronchodilators, mucolytics, and an armamentarium of antibiotics, which must be selected with careful discretion. Because the prognosis of COPD may be guarded, the practitioner is obligated to provide information on advance directives. A sensitive approach, holistic perspective, consistent follow-up, and clinical astuteness are essential ingredients in the management of clients with COPD.

Effect of nifedipine on physiologic shunting and oxygenation in chronic obstructive pulmonary disease.

PURPOSE: To assess changes in physiologic shunting and oxygenation following short-term treatment with nifedipine in patients with pulmonary hypertension secondary to chronic obstructive pulmonary disease. PATIENTS AND METHODS: Changes in pulmonary vascular pressure, pulmonary vascular resistance, venous admixture, and systemic arterial oxygen tension following sublingual administration of 20 mg of nifedipine were studied in 18 patients (13 men, 5 women; mean age of 59.7 [SD 7.2] years) using Swan-Ganz catheterization. These patients had a mean peak expiratory flow rate of 112 (SD 27) L/min (mean 22.2 [SD 12.2]% of predicted value), mean forced expiratory volume in 1 second (FEV1) of 0.84 (SD 0.23) L (mean 31.2 [SD 8.5]% of predicted value), mean FEV1/forced vital capacity ratio of 31.6 (SD 4.5), and mean carbon monoxide diffusing capacity of 6.8 (SD 1.96) mmol/min/kPa. RESULTS: There was a significant decrease in mean pulmonary vascular resistance (562 to 371 dyne sec.cm-5) and a significant reduction in the mean pulmonary arterial pressure (mean 32.8 to 23.6 mm Hg). Pulmonary venous admixture, however, increased significantly from the baseline mean of 44.6% (SD 16.1) to a mean of 56% (SD 15.6), and the mean arterial oxygen tension decreased from 5.8 (SD 1.3) kPa to 4.5 (SD 0.8) kPa at 60 minutes following drug administration (p < 0.001). CONCLUSION: The role of nifedipine in the treatment of pulmonary hypertension secondary to chronic bronchitis may be limited because of its deleterious effect on venous admixture.

Selection criteria for exercise training in pulmonary rehabilitation.

While exercise training appears to have no effect on resting respiratory function, and its effect on ventilation/perfusion relationships is uncertain, it can significantly reduce the rate of lactic acid production, carbon dioxide generated from buffering of acid and the hydrogen ion stimulus to breathe during exercise. We had two objectives in this study: 1) to determine if patients who might benefit from exercise training could be selected based on resting respiratory function measurements; 2) to determine if the work rate at which the metabolic acidosis starts to develop could be reliably determined, non-invasively, by a simple modification of the recently described V-slope method of Beaver et al. Patients with severe obstructive lung disease, all of whom experienced exertional dyspnoea, underwent incremental exercise testing to determine if they could exercise to a level causing metabolic acidosis. About two thirds of the patients with severe airflow obstruction developed a significant metabolic acidosis (arterial standard HCO3- decrease of more than 2 mEq.l-1 after two minutes recovery following an incremental exercise test to maximum). The oxygen uptake (VO2) at which the metabolic acidosis (directly measured) and that of which the increase in CO2 in the expired air attributable to buffering (V-slope method), were in close agreement. There was no significant correlation between the magnitude of the exercise metabolic acidosis and the forced expiratory volume in one second (FEV1) or the diffusing capacity for carbon monoxide (DLCO). Thus, it is necessary to perform exercise testing in order to select patients for exercise training, based on the benefits accrued from reducing the exercise metabolic acidosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Exercise training in patients with chronic airways obstruction.

Some studies concerning the effects of specific and non-specific techniques of respiratory muscle training and new strategies in exercise training of both skeletal and respiratory muscles, are reviewed. Breathing and exercise training show some evidence of improved gas exchange. Breathing through an inspiratory resistance has some advantages but also disadvantages. This technique has caused immediate hypoxaemia and pulmonary arterial hypertension in one third of the subjects studied. High intensity exercise with correspondingly high levels of ventilation may induce improvements in ventilatory muscle function. Two new techniques are described: the "above anaerobic threshold 40 min constant exercise" and the "45 min square-wave endurance exercise test" (SWEET), simulating an interval-training session. The effects on the cardiorespiratory, metabolic, arterial blood gases and acid base balance responses, were measured in normal subjects and in patients with chronic airway obstruction (CAO). After training, the magnitude of ventilation (VE) reduction was correlated with the reduction in end-exercise lactate. In addition, maximal ventilation and maximal oxygen consumption (VO2max) can increase after training. Finally, an interesting hypothesis is proposed about the use of arm-training.

Chronic obstructive pulmonary disease.

Morbidity and mortality associated with chronic airway disease are expected to continue to rise over the coming years. Accordingly, increased attention will need to be directed toward the diagnosis and treatment of COPD in the elderly population. Cessation of cigarette smoking should be pursued in all patients regardless of age. The goals of bronchodilator therapy are to reduce respiratory symptoms and to improve functional capacity without causing adverse effects. In addition, supplemental oxygen, phlebotomy for polycythemia, general exercise training, and specific respiratory muscle training may further augment exercise tolerance. Complications of COPD, such as upper respiratory infections and right heart failure, should be recognized early and treated appropriately. Implementation of a pulmonary rehabilitation program, as discussed in the next article, should complement medical therapy in the treatment of elderly patients with COPD.