Prospective Study of Nocturnal Desaturation in Patients Receiving Home Oxygen Therapy.

Objective Nocturnal desaturation is common in patients with chronic respiratory disease and often worsens the prognosis. Therefore, it should be diagnosed accurately and appropriately treated. The aim of this study was to clarify the diversity of nocturnal desaturation. Methods We prospectively enrolled 58 outpatients diagnosed with chronic respiratory disease receiving home oxygen therapy and measured nocturnal SpO2 using a portable oximeter. We classified nocturnal desaturation (3% decrease in SpO2 from baseline) into three patterns: periodic pattern (desaturation duration of <655 seconds), sustained pattern (desaturation duration of ≥655 seconds), and intermittent pattern (desaturation and recovery of SpO2 repeated with a cycle of several minutes). Results Nocturnal hypoxemia (SpO2≤88% for more than 5 minutes) was found in 23.8% of patients. The percentage of patients with chronic obstructive pulmonary disease (COPD) was significantly higher in the nocturnal hypoxemia group than in the non-hypoxemia group (80% vs. 40.6%, p=0.03). Desaturation with a periodic pattern was found in 81% of patients, desaturation with a sustained pattern was found in 40.5% of patients, and desaturation with an intermittent pattern was found in 59.5% of patients. In patients with COPD, desaturation with a periodic pattern was found in 85.7%, desaturation with a sustained pattern was found in 47.6%, and desaturation with an intermittent pattern was found in 57.1%. Conclusion The SpO2 waveform of nocturnal hypoxemia was able to be classified into three patterns. Suitable treatment for each pattern might improve the prognosis of these patients.

Occupational respiratory allergy to lettuce in lettuce farmers.

BACKGROUND: Lettuce-associated respiratory allergy has never been reported before. The aim of this study was to clarify the clinical condition of lettuce-associated respiratory allergy and to identify the lettuce antigen which induces allergic symptoms. METHODS: We distributed questionnaires to 1168 lettuce farmers and performed medical examinations in those who exhibited respiratory symptoms related to occupational exposure to lettuce. We analysed specific IgE-binding proteins in the sera of patients through immunoblotting analysis and determined molecular characterization of the IgE-binding bands using liquid chromatography-mass spectrometry. RESULTS: A total of 932 farmers (80%) responded to the questionnaire. Of those, 7% exhibited lettuce-associated respiratory symptoms, during harvesting and packaging. Thirteen patients were diagnosed with allergy to lettuce and agreed to undergo further examinations. The percentage of activated basophils in these patients was significantly higher compared with that reported in negative controls (P < .05). Lettuce-specific IgE (ImmunoCAP® ) and skin prick testing was positive in 46% and 62% of patients, respectively. Notably, occupational lettuce-allergic asthma was detected in one patient through specific bronchial provocation testing. The IgE-binding bands recognized in the sera of >50% of patients were identified as epidermis-specific secreted glycoprotein EP1-like (51 kDa). CONCLUSION: The present analysis identified a novel lettuce allergen. This allergen may have clinically useful applications, such as specific IgE testing and allergen-specific immunotherapy.

Questionnaire Survey for Bronchial Asthma in Elderly Care Facilities.

In developed countries such as North America, the decline in mortality from bronchial asthma has ceased since 2006. The decline in mortality rate is also decreasing in Japan, where about 1,500 asthma deaths have been reported. Among these, elderly people aged 65 years or over account for about 90% of cases. Therefore, the treatment of elderly patients with asthma is an important subject. However, few studies have been conducted on asthma in elderly patients. In this survey, we distributed a questionnaire to 253 elderly care facilities in Kobe, Japan. Ninety facilities responded, and 223 patients in 70 out of 90 facilities were diagnosed with asthma. Dry powder inhaler was the most commonly used dosage form of inhaled corticosteroids. Many facilities have patients who need some assistance during inhalation: only 60% of facilities reported that inhalation is performed accurately. While 31 facilities had patients with a history of hospitalization for asthma attacks, only 14 of these facilities were able to provide appropriate initial treatment. Many facilities have difficulty providing assistance with inhalation to elderly patients whose cognitive function has deteriorated. This survey highlights challenges experienced by care facilities in treating asthma in the elderly.

Bronchoscopy Using Virtual Navigation and Endobronchial Ultrasonography with a Guide Sheath (EBUS-GS) with or without Fluoroscopy for Peripheral Pulmonary Lesions.

OBJECTIVE: Endobronchial ultrasonography and guide sheath (EBUS-GS) technique has high diagnostic yield in lung nodules. Virtual bronchoscopic navigation (VBN) can lead bronchoscope to the target bronchi. The aim of this prospective study was to compare the diagnostic yield of two bronchoscopic procedures: bronchoscopy under EBUS-GS and VBN with or without x-ray fluoroscopy in small peripheral pulmonary lesions (PPLs, ≤30mm) with apparent CT-bronchus sign. METHODS: 31 patients with PPLs which had apparent CT-bronchus sign were randomly assigned to the X-ray or the non-X-ray groups (18 with and 13 without fluoroscopy) between September 1, 2012, and September 30, 2015. A bronchoscope was introduced into the target bronchus using the VBN system. Sites of specimen sampling were verified using EBUS-GS with or without fluoroscopy. RESULTS: The overall diagnostic yield was 83.3% in the X-ray and 69.2% in the non-X-ray group. The diagnostic yield of malignancy was 88.2% and 81.8%, respectively. The duration of the examination and time elapsed until the first EBUS visualization were similar in the X-ray and the non-X-ray group (9.0 (5.8-20.) min vs 11.0 (5.3-17.3) min, and 2.5 (1.3-14.2) min vs 4.1 (1.4-8.1) min, respectively). The fluoroscopy exposure time was 3.7 (2.9-10.56) min. The only adverse event was mild pneumothorax in a patient from the non-X-ray group, who had consequent TBB under fluoroscopy. CONCLUSIONS: There was a possibility that VBN-guided EBUS-transbronchial diagnosis without fluoroscopy might be equivalent to that under fluoroscopy. Further multi-center randomized study may be desired. (UMIN000008592).

Utility of cell blocks obtained by catheter aspiration via a guide sheath during endobronchial ultrasonography.

BACKGROUND: The demand for adequate tissue samples for both morphological assessment and molecular studies on lung cancer treatment has increased. The aim of this study was to evaluate whether cell blocks (CBs) prepared from endobronchial ultrasonography with guide sheath (EBUS-GS) rinsing following catheter aspiration provide additional information. METHODS: We produced CBs from rinse fluid obtained from washing the inside of the sheath with saline after conventional EBUS-GS between May 2012 and April 2013. During the first 7 months, the sheath was aspirated with 20mL of negative pressure while moving the catheter back and forth [aspiration group (Asp)]. During the next 5 months, the sheath was not aspirated, but only rinsed out [conventional group (Con)]. Patients diagnosed with lung cancer by EBUS-GS and/or CBs were identified and evaluated. The diagnostic rate of each sampling method was compared between the two groups. The number of tumor cells was also compared between the CB and EBUS-guided transbronchial lung biopsy (EBUS-TBB) groups. RESULTS: EBUS-GS was performed on 113 patients. Fifty-five patients were included in this study (Asp=30, Con=25). The diagnostic yield of CBs in Asp was higher than that in Con (56.7% vs 32.0%; p=0.06). Asp showed no significant difference in the number of tumor cells between CB and EBUS-TBB. One patient who showed negative EBUS-TBB pathological results but positive CB results was diagnosed only by immunohistological staining of CB. CONCLUSION: CB prepared from EBUS-GS rinsing following catheter aspiration may provide additional information.

Diagnostic utility of additional conventional techniques after endobronchial ultrasonography guidance during transbronchial biopsy.

BACKGROUND AND OBJECTIVE: Endobronchial ultrasonography with a guide sheath transbronchial biopsy (EBUS-GS TBB) has been used to diagnose peripheral pulmonary lesions (PPLs). In this study, we evaluated the diagnostic utility of conventional TBB after EBUS-GS TBB. METHODS: A retrospective analysis of patients who underwent conventional TBB after EBUS-GS TBB for PPL between August 1, 2012 and December 31, 2014. We performed multivariate analysis to examine the association of various clinical factors, including EBUS probe distance and sample size area, with diagnostic yield. RESULTS: Of 88 eligible patients, 57 (65%) were successfully diagnosed by EBUS-GS TBB. In 31 patients not diagnosed by EBUS-GS TBB, 15 (48%) were successfully diagnosed by additional conventional TBB. Ground glass opacity (GGO) was a significant factor associated with the diagnostic yield of additional conventional TBB following EBUS-GS TBB. Multivariate analysis and receiver operator curves revealed that distance between the PPL and the EBUS probe of less than 2.55 mm favored the utility of conventional TBB. CONCLUSION: Additional conventional TBB after EBUS-GS TBB could be a useful procedure for the diagnosis of ground glass opacity PPLs and in cases of a distance of less than 2.55 mm between the EBUS probe and the lesion.

[Survey findings about elucidating the actual condition of asthma treatment in emergency settings. ∼Activity report of "zero asthma death committee in Hyogo"∼].

OBJECTIVE: To elucidate the actual condition of asthma treatment in emergency settings. METHODS: A questionnaire survey on the situation of emergency care was conducted on 175 medical institutions providing either secondary or tertiary emergency care in Hyogo Prefecture during a 1-year period starting in April 2010. Data were investigated for each secondary medical region. RESULTS: Responses were obtained from 143 medical institutions (response rate, 81.7%). Steroid injection, aminophylline injection, and short-acting beta-agonists (SABA) were selected as drugs in emergency room treatment in many districts (in order, means of 86.7%, 79.5%, 72.3%). Concerning drugs prescribed on leaving hospital, transdermal ß2 stimulator and SABA were selected in >50% of districts. Prescriptions for long-term management varied among districts, as follows: inhaled corticosteroids (ICS), mean of 37.3% (0-66.7%); ICS/long-acting ß-agonists (LABA), 27.9% (16.7-66.7%); and leukotriene receptor antagonist (LTRA), 20.5% (0-50.0%) CONCLUSION: These findings suggest that asthma treatment in emergency settings varies by facility and region.

Semipermeable membrane dressings can be used with the nicotine transdermal system and do not interfere with nicotine absorption.

OBJECTIVE: Adverse skin reactions as a local side effect of nicotine patches sometimes interfere with smoking cessation therapy. We studied the effects of semipermeable membrane dressings (SMD) used under nicotine patches (NP) on nicotine absorption, as assessed according to the urinary cotinine levels, and skin symptoms. METHODS: First, the urinary cotinine levels were compared in eight nonsmokers that applied NP over SMD and NP without SMD (Study 1). The urinary cotinine levels were measured using a highly sensitive competitive enzyme immunoassay. Second, 28 subjects undergoing NP therapy for diagnosed nicotine dependence were randomly assigned into two groups in a crossover design to receive NP over SMD and NP without SMD. The urinary cotinine levels and skin symptoms were compared between the two treatment groups. During the follow-up period of 48 weeks, the smoking cessation rate was evaluated (Study 2). RESULTS: No statistical differences were observed in the urinary cotinine levels between the NP over SMD and NP without SMD groups. In Study 2, the skin symptoms improved with the use of SMD in 42.8% (6/14) of the patients and worsened in 28.5% (4/14) of the patients. No serious skin disorders were reported. The subjects followed in Study 2 exhibited smoking cessation rates of 92.8%, 78.5% and 64.2% at 12, 24 and 48 weeks, respectively. CONCLUSION: The use of NP over SMD is a safe and effective alternative application to NP treatment for preventing the skin symptoms caused by NP without interfering with nicotine absorption.

Visualized changes in respiratory resistance and reactance along a time axis in smokers: a cross-sectional study.

BACKGROUND: Early detection of changes in respiratory function in smokers is important for the prevention of chronic obstructive pulmonary disease (COPD). The objective of this study was to investigate any changes in the respiratory impedance of smokers with normal FEV1/FVC. METHODS: We assessed and compared the impedance components, respiratory resistance, and reactance in both the inspiratory and expiratory phases of nonsmokers, smokers, and COPD patients. RESULTS: Approximately 60% of smokers showed elevated resistance and a negative shift in reactance, mainly in the expiratory phase, as observed in COPD patients. Smokers showed an increased gap between the maximum and minimum R5 and X5 values (R5sub, X5sub) in comparison with nonsmokers. Furthermore, R5-R20 was significantly higher in smokers than in nonsmokers. The expiratory-inspiratory gaps in resistance and reactance were also significantly higher in smokers than in nonsmokers. In smokers and COPD patients, the magnitude of expiratory X5 was more negative than that in nonsmokers. In smokers with V·50/V·25≥3, R5-R20 was significantly higher than those in smokers with V·50/V·25<3. CONCLUSIONS: Approximately 60% of smokers were shown to exhibit apparent impedance changes despite having normal FEV1/FVC values. Smoking-induced early remodeling of the small airways may be responsible for the observed changes in airway function of smokers. Further studies are necessary to determine if the change in respiratory impedance observed in smokers is an early indicator of COPD.

[Pulmonary tumor thrombotic microangiopathy associated with cancer of unknown origin].

A nonsmoking, 52-year-old woman presented with a 4-month history of persistent dry cough. Chest X-ray film on admission showed small granular shadow in bilateral lung fields. Bronchoscopic biopsy did not yield a diagnosis. Two months later, she complained of dyspnea. Physical examination showed signs of pulmonary hypertension. Five days after the onset of dyspnea, she died of respiratory failure. An autopsy showed pulmonary embolism and swollen abdominal lymph nodes consisting of metastatic signet-ring cell carcinoma and poorly differentiated adenocarcinoma. There was also marked fibrocellular intimal proliferation and thrombus formation causing luminal stenosis in small pulmonary arterioles. Thrombi were organized by recanalization and included atypical cells. We diagnosed pulmonary tumor thrombotic microangiopathy (PTTM). In spite of various immunohistological staining procedure, we could not find out the primary lesion of this cancer. This case suggests that we should aggressively biopsy a large specimen of the lung to make a differential diagnosis of PTTM, because bronchoscopic biopsy is not enough to diagnose PTTM.