Positive Expiratory Pressure Therapy With And Without Oscillation And Hospital Length Of Stay For Acute Exacerbation Of Chronic Obstructive Pulmonary Disease.

Introduction: Pharmacologic management of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is well-established. Our aim in the current study is to determine if therapy with a positive expiratory pressure (PEP) device with or without an oscillatory mechanism (OM) in addition to standard care results in a reduction in hospital length of stay (LOS) among patients hospitalized for AECOPD. Methods: Two studies were performed and are reported here. Study 1: Patients admitted with AECOPD and sputum production were enrolled in a prospective trial comparing PEP therapy versus Oscillatory PEP (OPEP) therapy. Study 2: A retrospective historical cohort, matched in a 2 to 1 manner by age, gender, and season of admission, was compared with the prospectively collected data to determine the effect of PEP ± OM versus standard care on hospital LOS. Results: In the prospective trial (Study 1; 91 subjects), median hospital LOS was 3.2 (95% CI 3.0-4.3) days in the OPEP group and 4.8 (95% CI 3.9-6.1) days in the PEP group (p=0.16). In fully adjusted models comparing the prospective trial data with the retrospective cohort (Study 2; 182 subjects), cases had a median hospital LOS of 4.2 days (95% CI 3.8-5.1) versus 5.2 days (95% CI 4.4-6.0) in controls, consistent with a shorter hospital LOS with adjunctive PEP±OM therapy versus standard care (p=0.04). Conclusion: Adjunctive therapy with a PEP device versus standard care may reduce hospital LOS in patients admitted for AECOPD. Although the addition of an OM component to PEP therapy suggests a further reduction in hospital LOS, comprehensive multicenter randomized controlled trials are needed to confirm these findings. Clinical trial registration number: NCT03094806.

Cystic Lung Diseases: Algorithmic Approach.

Cysts are commonly seen on CT scans of the lungs, and diagnosis can be challenging. Clinical and radiographic features combined with a multidisciplinary approach may help differentiate among various disease entities, allowing correct diagnosis. It is important to distinguish cysts from cavities because they each have distinct etiologies and associated clinical disorders. Conditions such as emphysema, and cystic bronchiectasis may also mimic cystic disease. A simplified classification of cysts is proposed. Cysts can occur in greater profusion in the subpleural areas, when they typically represent paraseptal emphysema, bullae, or honeycombing. Cysts that are present in the lung parenchyma but away from subpleural areas may be present without any other abnormalities on high-resolution CT scans. These are further categorized into solitary or multifocal/diffuse cysts. Solitary cysts may be incidentally discovered and may be an age related phenomenon or may be a remnant of prior trauma or infection. Multifocal/diffuse cysts can occur with lymphoid interstitial pneumonia, Birt-Hogg-Dubé syndrome, tracheobronchial papillomatosis, or primary and metastatic cancers. Multifocal/diffuse cysts may be associated with nodules (lymphoid interstitial pneumonia, light-chain deposition disease, amyloidosis, and Langerhans cell histiocytosis) or with ground-glass opacities (Pneumocystis jirovecii pneumonia and desquamative interstitial pneumonia). Using the results of the high-resolution CT scans as a starting point, and incorporating the patient's clinical history, physical examination, and laboratory findings, is likely to narrow the differential diagnosis of cystic lesions considerably.