Stepwise Approach in Asthma Revisited 2023: Expert Panel Opinion of Turkish Guideline of Asthma Diagnosis and Management Group.

Introduction of inhaled corticosteroids (ICS) has been the cornerstone of the long-term management of asthma. ICSs either alone or in combination with long-acting beta-2 agonists have been shown to be associated with favorable asthma outcomes. However, asthma control is still reported to be below expectations all around the world. Research in the last decades focusing on the use of ICS/formoterol both as maintenance and as needed (maintenance and reliever therapy approach) showed improved asthma outcomes. As a result of recent developments, Turkish Asthma Guidelines group aimed to revise asthma treatment recommendations. In general, we recommend physicians to consider the risk factors for poor asthma outcomes, patients' compliance and expectations and then to determine "a personalized treatment plan." Importantly, the use of short-acting beta-2 agonists alone as a symptom reliever in asthma patients not using regular ICS is no longer recommended. In stepwise treatment approach, we primarily recommend to use ICS-based controllers and initiate ICS as soon as possible. We define 2 different treatment tracks in stepwise approaches as maintenance and reliever therapy or fixed-dose therapy and equally recommend each track depending on the patient's risks as well as decision of physicians in a personalized manner. For both tracks, a strong recommendation was made in favor of using add-on treatments before initiating phenotype-specific treatment in step 5. A strong recommendation was also made in favor of using biologic agents and/or aspirin treatment after desensitization in severe asthma when indicated.

Risk factors for post-acute sequelae of COVID-19 in hospitalized patients: An observational study based on a survey in a tertiary care center in Türkiye.

Introduction: Long COVID is a multisystem disease with various symptoms and risk factors. We aim to investigate the post-acute sequelae of COVID-19 and related risk factors in a tertiary care center. Materials and Methods: In this observational study, based on a survey of 1.977 COVID-19 patients hospitalized from April 2020 to January 2021, a retrospective assessment was carried out on 1.050 individuals who were reachable via telephone to determine their eligibility for meeting the inclusion criteria. Results: The data of 256 patients who reported at least one persistent symptom were analyzed. Long COVID prevalence was 24.3%. Among 256 patients (median age 52.8; 52.7% female; 56.63% had at least one comorbidity), dyspnea, fatigue, arthralgia-myalgia, cough, and back pain were the most common post-acute sequelae of COVID-19 (42.4%; 28.29%; 16.33%; 13.15% and 7.17%, respectively). The risk factors for the persistence of dyspnea included having lung diseases such as chronic obstructive pulmonary disease, a history of intensive care support, the requirement for long-term oxygen therapy, and a history of cytokine storm (p= 0.024, p= 0.026, p< 0.001, p= 0.036, p= 0.005, respectively). The correlation between lung involvement with post-discharge cough (p= 0.041) and dizziness (p= 0.038) was significant. No correlation between the symptoms with the severity of acute infection, age, and gender was found. When a multivariate regression analysis was conducted on the most common long COVID-related symptoms, several independent risk factors were identified. These included having lung disease for dyspnea (OR 5.81, 95% CI 1.08-31.07, p= 0.04); length of hospital stay for myalgia (OR 1.034, 95% CI 1.004-1.065, p= 0.024); and pulmonary involvement of over 50% during COVID-19 infection for cough (OR 3.793, 95% CI 1.184-12.147, p= 0.025). Conclusion: COVID-19 survivors will require significant healthcare services due to their prolonged symptoms. We hope that our findings will guide the management of these patients in clinical settings towards best practices.

Picturing asthma in Turkey: results from the Turkish adult asthma registry.

INTRODUCTION: National data on asthma characteristics and the factors associated with uncontrolled asthma seem to be necessary for every country. For this purpose, we developed the Turkish Adult Asthma Registry for patients with asthma aiming to take a snapshot of our patients, thereby assigning the unmet needs and niche areas of intervention. METHODS: Case entries were performed between March 2018 and March 2022. A web-based application was used to record data. Study outcomes were demographic features, disease characteristics, asthma control levels, and phenotypes. RESULTS: The registry included 2053 patients from 36 study centers in Turkey. Female subjects dominated the group (n = 1535, 74.8%). The majority of the patients had allergic (n = 1158, 65.3%) and eosinophilic (n = 1174, 57.2%) asthma. Six hundred nineteen (32.2%) of the patients had obese asthma. Severe asthma existed in 670 (32.6%) patients. Majority of cases were on step 3-5 treatment (n: 1525; 88.1%). Uncontrolled asthma was associated with low educational level, severe asthma attacks in the last year, low FEV1, existence of chronic rhinosinusitis and living in particular regions. CONCLUSION: The picture of this registry showed a dominancy of middle-aged obese women with moderate-to-severe asthma. We also determined particular strategic targets such as low educational level, severe asthma attacks, low FEV1, and chronic rhinosinusitis to decrease uncontrolled asthma in our country. Moreover, some regional strategies may also be needed as uncontrolled asthma is higher in certain regions. We believe that these data will guide authorities to reestablish national asthma programs to improve asthma service delivery.

The association of antiviral drugs with COVID-19 morbidity: The retrospective analysis of a nationwide COVID-19 cohort.

Background and objectives: Although several repurposed antiviral drugs have been used for the treatment of COVID-19, only a few such as remdesivir and molnupiravir have shown promising effects. The objectives of our study were to investigate the association of repurposed antiviral drugs with COVID-19 morbidity. Methods: Patients admitted to 26 different hospitals located in 16 different provinces between March 11-July 18, 2020, were enrolled. Case definition was based on WHO criteria. Patients were managed according to the guidelines by Scientific Board of Ministry of Health of Turkey. Primary outcomes were length of hospitalization, intensive care unit (ICU) requirement, and intubation. Results: We retrospectively evaluated 1,472 COVID-19 adult patients; 57.1% were men (mean age = 51.9 ± 17.7years). A total of 210 (14.3%) had severe pneumonia, 115 (7.8%) were admitted to ICUs, and 69 (4.7%) were intubated during hospitalization. The median (interquartile range) of duration of hospitalization, including ICU admission, was 7 (5-12) days. Favipiravir (n = 328), lopinavir/ritonavir (n = 55), and oseltamivir (n = 761) were administered as antiviral agents, and hydroxychloroquine (HCQ, n = 1,382) and azithromycin (n = 738) were used for their immunomodulatory activity. Lopinavir/ritonavir (ß [95% CI]: 4.71 [2.31-7.11]; p = 0.001), favipiravir (ß [95% CI]: 3.55 [2.56-4.55]; p = 0.001) and HCQ (ß [95% CI]: 0.84 [0.02-1.67]; p = 0.046) were associated with increased risk of lengthy hospital stays. Furthermore, favipiravir was associated with increased risks of ICU admission (OR [95% CI]: 3.02 [1.70-5.35]; p = 0.001) and invasive mechanical ventilation requirement (OR [95% CI]: 2.94 [1.28-6.75]; p = 0.011). Conclusion: Our findings demonstrated that antiviral drugs including lopinavir, ritonavir, and favipiravir were associated with negative clinical outcomes such as increased risks for lengthy hospital stay, ICU admission, and invasive mechanical ventilation requirement. Therefore, repurposing such agents without proven clinical evidence might not be the best approach for COVID-19 treatment.

Country-based report: the safety of omalizumab treatment in pregnant patients with asthma

Background/aim: We aimed to report outcomes of pregnant patients with asthma under omalizumab treatment and their infants in our country. Materials and methods: Patients with asthma who received omalizumab for at least 6 months and at least one dose during their pregnancy were retrospectively evaluated using a questionnaire regarding their disease and therapy and the health of their infants. Results: Twenty pregnant patients and their 23 infant's data were analyzed. The mean delivery age was 31.8 ± 7.4 years. They received omalizumab for 28.9 ± 21.8 months. Eight (36.4%) patients showed exacerbation of the disease during pregnancy. Forced expiratory volume in 1 s (FEV1) and asthma control test (ACT) scores at the starting time of omalizumab administration, first month of the pregnancy, and after delivery were 71 ± 18%, 83.4 ± 10.5%, and 80.5 ± 13% (FEV1), and 11.9 ± 4.9, 20.2 ± 2.6, and 20.4 ± 2.2 (ACT), respectively. One patient gave birth to twin infants, two patients to two infants each in different years, and 17 to one infant each. Three (13%) infants had low birth weight and five (21.7%) were born prematurely. No congenital anomalies were detected. Seven (30.4%) infants presented atopic diseases during their life. Conclusion: Omalizumab treatment during pregnancy seems to be safe for both patients and their infants.

Beliefs and preferences regarding biological treatments for severe asthma.

BACKGROUND: Severe asthma is a serious condition with a significant burden on patients' morbidity, mortality, and quality of life. Some biological therapies targeting the IgE and interleukin-5 (IL5) mediated pathways are now available. Due to the lack of direct comparison studies, the choice of which medication to use varies. We aimed to explore the beliefs and practices in the use of biological therapies in severe asthma, hypothesizing that differences will occur depending on the prescribers' specialty and experience. METHODS: We conducted an online survey composed of 35 questions in English. The survey was circulated via the INterasma Scientific Network (INESNET) platform as well as through social media. Responses from allergists and pulmonologists, both those with experience of prescribing omalizumab with (OMA/IL5) and without (OMA) experience with anti-IL5 drugs, were compared. RESULTS: Two hundred eighty-five (285) valid questionnaires from 37 countries were analyzed. Seventy-on percent (71%) of respondents prescribed biologics instead of oral glucocorticoids and believed that their side effects are inferior to those of Prednisone 5 mg daily. Agreement with ATS/ERS guidelines for identifying severe asthma patients was less than 50%. Specifically, significant differences were found comparing responses between allergists and pulmonologists (Chi-square test, p < 0.05) and between OMA/IL5 and OMA groups (p < 0.05). CONCLUSIONS: Uncertainties and inconsistencies regarding the use of biological medications have been shown. The accuracy of prescribers to correctly identify asthma severity, according to guidelines criteria, is quite poor. Although a substantial majority of prescribers believe that biological drugs are safer than low dose long-term treatment with oral steroids, and that they must be used instead of oral steroids, every effort should be made to further increase awareness. Efficacy as disease modifiers, biomarkers for selecting responsive patients, timing for outcomes evaluation, and checks need to be addressed by further research. Practices and beliefs regarding the use of asthma biologics differ between the prescriber's specialty and experience; however, the latter seems more significant in determining beliefs and behavior. Tailored educational measures are needed to ensure research results are better integrated in daily practice.

The factors predicting pneumonia in COVID-19 patients: preliminary results from a university hospital in Turkey

Background/aim: Pneumonia is the most serious clinical presentation of COVID-19. This study aimed to determine the demographic, clinical, and laboratory findings that can properly predict COVID-19 pneumonia. Materials and methods: This study was conducted in the Gazi University hospital. All hospitalized patients with confirmed and suspected SARS-CoV-2 infection between 16 March 2020 and 30 April 2020 were analyzed retrospectively. COVID-19 patients were separated into two groups, pneumonia and nonpneumonia, and then compared to determine predicting factors for COVID-19 pneumonia. Variables that had a P-value of less than 0.20 and were not correlated with each other were included in the logistic regression model. Results: Of the 247 patients included in the study 58% were female, and the median age was 40. COVID-19 was confirmed in 70.9% of these patients. Among the confirmed COVID-19 cases, 21.4% had pneumonia. In the multivariate analysis male sex (P = 0.028), hypertension (P = 0.022), and shortness of breath on hospital admission (P = 0.025) were significant factors predicting COVID-19 pneumonia. Conclusion: Shortness of breath, male sex, and hypertension were significant for predicting COVID-19 pneumonia on admission. Patients with these factors should be evaluated more carefully for diagnostic procedures, such as thorax CT.

How to apply the personalized medicine in obesity-associated asthma?

INTRODUCTION: Obesity-associated asthma (OA) is frequently severe, with an increased rate of hospitalizations, numerous comorbidities and low response to corticosteroids. Despite progress in applying for personalized medicine in asthma, no specific recommendations exist for the management of OA. AREAS COVERED: The aim of this review is to summarize recent data about the relationship obesity-asthma, describe clinical characteristics, potential mechanisms involved and possible therapeutic interventions to improve OA outcomes. Extensive research in the PubMed was performed using the following terms: "asthma and obesity" and "obese asthma" in combination with "phenotypes", "airway inflammation", "biomarkers", "lung function", "weight loss", "lifestyle interventions", "therapies" Currently two phenotypes are described. Early-onset atopic asthma is conventional allergic asthma aggravated by the pro-inflammatory properties of adipose tissue in excess, while late-onset non-atopic asthma is due to airway dysfunction as a consequence of the chronic lung compression caused by the obese chest walls. Previous data showed that different therapeutic strategies used in weight loss have a positive impact on OA outcomes. EXPERT OPINION: The presence of a multidisciplinary team (chest physician, nutritionist, exercise physiologist, physiotherapist, psychologist, bariatric surgeon) and the collaboration between different specialists are mandatory to optimize the management and to apply the personalized medicine in OA.

Adherence to treatment in allergic respiratory diseases.

Introduction: Asthma and allergic rhinitis (AR) are chronic conditions in which management needs adherence to prescribed drugs. Despite the benefits of regular maintenance of asthma and AR therapy, low adherence is a frequent issue in clinical practice. Areas covered: The aim of this review is to provide a targeted analysis of the more recent literature on adherence in asthma and AR, focused on the following areas: adherence extent, barriers and consequences, effects of educational interventions and use of new technologies to improve the level of adherence. Expert commentary: Despite the extent, reasons and effects of this problem being well known, non-adherence in asthma and allergic AR remains worryingly high. Poor adherence leads to unsatisfactory health outcomes, with a negative impact on patients and society. Recent literature suggests that successful programs to improve adherence should include a combination of strategies. The new technologies represent a promising tool to improve adherence.

Phenotypes/endotypes-driven treatment in asthma.

PURPOSE OF REVIEW: Target therapy is the necessary step towards personalized medicine. The definition of asthma phenotypes and underlying mechanisms (endotypes) represent a key point in the development of new asthma treatments. Big data analysis, biomarker research and the availability of monoclonal antibodies, targeting specific cytokines is leading to the rapid evolution of knowledge. In this review, we sought to outline many of the recent advances in the field. RECENT FINDINGS: Several attempts have been made to identify asthma phenotypes, sometimes with contrasting results. More success has been obtained concerning the pathogenetic mechanism of specific asthma patterns with the consequent identification of biomarkers and development of effective ad hoc treatment. SUMMARY: We are in the middle of an extraordinary revolution of our mode of thinking about and approaching asthma. All the effort in the identification of clusters of patients with different disease clinical patterns, prognosis and response to treatment is closely linked to the identification of endotypes (Th2-low and Th2-high). This approach has allowed the development of the specific treatments (anti IgE, Anti IL5 and IL5R) that are now available and is leading to new ones.

Cost Evaluation of Inhaler Therapies Used in Respiratory Diseases: 1998--2015 Period in Turkey.

BACKGROUND: With the rise in life expectancy, the burden of chronic diseases, including obstructive pulmonary diseases, has increased throughout the world. OBJECTIVES: To evaluate the sales trends of inhaler pharmaceuticals. METHODS: The changes in box sales and sales amounts (in Turkish lira) of inhaler pharmaceuticals during the period 1998 to 2015 were examined and sales were projected for the next 3 years. Pharmaceuticals were classified according to form and pharmacological groups. RESULTS: The sales of inhaler pharmaceuticals have increased rapidly since 2008. The fastest increase in consumption has occurred in short-acting ß2 agonist preparations and nebulizer pharmaceuticals. Inhaled corticosteroid and long-acting ß2 agonist combination sales have been the highest since 2002, when these products entered the Turkish market. CONCLUSIONS: The inhaler pharmaceutical market has grown over the years, and this growth will continue in the future. The increased use of short-acting preparations, which should be used as symptom relievers, indicates that treatment management continues to be inadequate.

A cost comparison of warfarin vs enoxaparine or new oral anticoagulants used for the treatment of patients with pulmonary embolism.

INTRODUCTION: Recently, novel oral anticoagulants (rivaroxaban, dabigatran, apixaban) have been approved for pulmonary embolism (PE) treatment. Each anticoagulant used during initial and maintenance therapy has direct and indirect costs for healthcare systems. Demonstrating the costs of treatment with different anticoagulants in a specific patient group will be helpful for clinicians determining treatment strategies. MATERIALS AND METHODS: Retrospective data of 118 patients with PE who were hospitalized and treated with warfarin for at least 3 months were evaluated. Direct medical and nonmedical costs were calculated. True costs with warfarin and modeled costs with rivaroxaban, dabigatran, apixaban and enoxaparine were calculated and compared for maintenance therapy. Estimated costs of initial and maintenance treatment with different anticoagulants were compared for the 49 patients with low complication risk. RESULT: The average total cost of maintenance treatment with warfarin was found to be higher than the novel oral anticoagulants (€286.5 for warfarin, €233.3 for rivaroxaban, €231.7 for dabigatran, and €229.6 for apixaban). In patients with low complication risk, who could be treated without hospitalization, alternative treatment regiments were found to cost less than warfarin treatment (€883.1 for warfarin, €254.3 for rivaroxaban, €238 for apixaban, and €810.6 for enoxaparine). CONCLUSIONS: Maintenance therapy with novel oral anticoagulant costs less than warfarin treatment. In patients with lower complication risks, alternative regimens that do not require hospitalization could cost less.

[Turkish validation study of Morisky 8-item medication adherence questionnaire (MMAS-8) in patients with asthma and chronic obstructive pulmonary disease]. / Astim ve kronik obstrüktif akciger hastalarinda Morisky 8-maddeli ilaca uyum anketinin (MMAS-8) Türkçe geçerliliginin kanitlanmasi çalismasi

INTRODUCTION: Chronic diseases are the major causes of death in the world, and chronic respiratory diseases are important public health problems in our country due to theirhigh mortality and morbidity rates. Adherence to medication is an important issue in the treatment of these diseases. Morisky-8 item medication adherence questionnaire is one of the most widely used instruments for this purpose in the world. This study aimed to validate this scale in Turkish patients. MATERIALS AND METHODS: Turkish translation of Morisky-8 item scale consisted forward translation to Turkish, Turkish linguistic controls, back translation into English, English linguistic controls, and reporting of the process by the physician. Then, Turkish version of the scale was applied to the patients, and evaluated whether the patients understand the questions accurately. Fifty nine patients were included in this study, whomwere consulted in Gazi University Faculty of Medicine Department of Chest Diseases, and met the inclusion criteria. RESULTS: Mean ages of patients with asthma and chronic obstructive pulmonary disease (COPD) were 46.2 ± 15.1 and 64.0 ± 12.1 years, and duration of these diseases were 96.5 ± 102.3 and 66.2 ± 71.5 months, respectively. Patients had similar lengths of drug use. There was no significant differences for responses between groups, but two patients misunderstood two questions, and the remaining questions understood well by the patients. Medication adherence was 74.2% in patients with asthma, and 46.4% in patients with COPD. CONCLUSION: Turkish version of Morisky-8 scale was shown to be a reliable tool for determining the medication adherence in patients with asthma and COPD.

Wells score and Pulmonary Embolism Rule Out Criteria in preventing over investigation of pulmonary embolism in emergency departments.

INTRODUCTION: Unnecessary diagnostic tests are usually ordered to most of the patients with dyspnea or pleuritic chest pain, because of the worse outcomes of missed diagnosis of pulmonary embolism (PE). To identify rates and causes of over investigation for PE and to search whether it was possible to reduce this over investigation by using Wells score and Pulmonary Embolism Rule Out Criteria (PERC). MATERIALS AND METHODS: A retrospective observational cohort study performed in an emergency department of a tertiary care university hospital. All patients who were ordered diagnostic with the suspicion of PE were included in the study. They were grouped into two as PE (+) and PE (-) and compared. RESULTS: Among 108 patients, 53 (49%) were diagnosed as PE (+) and overdiagnosis was present in 55 (51%) patients i.e., PE (-). The sensitivity of high Wells score was 43%, specificity 78%, positive predictive value 66% and negative predictive value 59%. PERC criteria found to be negative (when all of the eight criteria were fulfilled) in only five patients. The sensitivity of the test was 98%, specificity 7%, positive predictive value 50%, negative predictive value 80%. When individual parameters of PERC were evaluated solely for the exclusion of PE; "no leg swelling" and "no previous deep venous thrombosis or PE history" were found significantly negatively correlated with PE diagnosis (p= 0.001, r= -0.325 and p= 0.013, r= -0.214 respectively). CONCLUSION: Over investigation of PE in emergency departments still remains as an important problem. In order to prevent this, the clinical prediction rules must be developed further and their use in combination should be searched in future studies.

[Treatment of severe asthma: expert opinion]. / Agir astim tedavisi: uzman görüsü

Severe asthmatics account 10% of the all asthmatic population. Those asthmatics whose disease is inadequately controlled account for up to half of the cost for asthma, because they have more emergency room visits, more hospital admission and greater absenteeism from work. New therapeutic options were tried in those patients whose asthma was uncontrolled with standart high dose inhaled corticosteroid and long acting beta-2 agonsit combination therapy. In this paper taking into account the conditions of our country, current literature was reviewed and treatment options was discussed and graded recommendations are made for daily clinical practice in patients with severe treatment-refractory asthma.

Delay in diagnosis of pulmonary thromboembolism in emergency department: is it still a problem?

BACKGROUND AND AIM: Pulmonary embolism (PE) is a common and serious disease that can result in death unless emergent diagnosis is made and treatment is initiated. In this study, we aimed to identify whether there is still a delay in the diagnosis of PE and to identify the time to delay in diagnosis and factors leading to this delay. METHODS: This is a prospective observational cohort study performed in an emergency department (ED) of a tertiary care university hospital between September 2008 and September 2010. The rate and cause of delay in diagnosis were analyzed among patients with PE. The "delay" was defined as diagnosing after first 24 hours of symptom onset. RESULTS: Among the 53 patients who were diagnosed with PE, a delay in diagnosis was present in 49 (93%) of them. Total delay time was 6.8 ± 7.7 days. In 33 (62%) patients, there was a delay of 4.6 ± 6.5 days due to patient-related factors. Delay in diagnosis after admission to hospital was 2.2 ± 2.9 days in 40 (75%) patients. In multivariate regression analysis, being female and having chest pain and cough were identified as significant factors causing patient-related delay. Unilateral leg edema, recent operation, and previous venous thromboembolism (VTE) history were the significant factors causing PE diagnosis without a delay. On the other hand, systemic hypertension as comorbidity was the only factor leading to physician-related delay. CONCLUSION: The delay in diagnosis of PE in EDs still remains as an important problem. While being female and having chest pain and cough are significantly and independently associated with patient delay in diagnosis, the unilateral leg edema, recent operation, and previous VTE history cause physicians to diagnose on time. On the other hand, having hypertension as comorbidity may lead to physician delay. In order to prevent the delay in diagnosis, hospital-associated factors must be elucidated totally and more interventions must be made to increase public and professional awareness of the disease.

[The clinical and microbiological comparison of the use of heated humidifiers and heat and moisture exchanger filters with Booster in mechanically ventilated patients]. / Mekanik ventilasyon tedavisi alan hastalarda isiticili nemlendirici ile isi-nem degisimi yapan filtreyle beraber Booster kullaniminin klinik ve bakteriyolojik açidan karsilastirilmasi.

Ventilator associated pneumonia (VAP) is the most frequent nosocomial infection in intensive care units that is associated with prolonged mechanical ventilation, hospitalization and increased health-care costs. Various humidifiers can be used for humidification during mechanical ventilation. Many studies were conducted to identify the effects of two different humidifiers, i.e. heated humidifiers and heat and moisture exchanger filters (HME), on VAP development; and HME filters were found to decrease the VAP frequency. In this study we aimed to compare the efficacy and safety of heated humidifiers and HME-Booster. Heated humidifier with conventional microbiologic filter (CMF-HH) or HME-Booster were used in randomization to 41 mechanically ventilated patients of our intensive care unit, and patients were divided into two groups as group 1 receiving CMF-HH (20 patients) and group 2 (21 patients) receiving HME-Booster. Daily secretion scores, endotracheal tube occlusion due to secretions, VAP development rate for the assessment of microbiological safety of humidifiers and differences in PETCO(2) and PaCO(2) values for the assessment of their effect on arterial blood gas were recorded prospectively. The measurement of PETCO(2) and PaCO(2) values were performed with the presence of humidifiers and after removing them in both groups. In both groups with the removal of CMF-HH and HME-Booster, a decrease in PETCO(2) value was identified, but the decrease in group 2 was statistically significant (p= 0.016). The decrease in PaCO(2) after removal of humidifiers was greater in group 2 than in group 1, but the difference was not significant (p> 0.05).The rate of VAP and endotracheal tube occlusion was not significantly different between the groups. The mean secretion score was lower in group 1 (p= 0.041). In conclusion, although both humidifiers have similar microbiological effects, heated humidifiers could be preferred particularly for the patients with an underlying chronic lung disease due to its positive effects on PETCO(2) values and secretion scores.