Therapeutic Advances in Respiratory Disease current issue

Characterisation of exacerbations of chronic bronchitis and COPD in Europe: the GIANT study

Miravitlles, M., Anzueto, A., Ewig, S., Legnani, D., Stauch, K. — Tue, 24 Nov 2009 08:59:09 PST

Objective: The GIANT study collected information on patients with acute exacerbations of chronic bronchitis (AECB) and chronic obstructive pulmonary disease (COPD) and the effect of treatment with moxifloxacin.

Methods: AECB history, concomitant diseases, moxifloxacin treatment, concomitant medication, clinical symptoms and adverse events were recorded. A questionnaire at the end of treatment recorded the impact on patients’ daily lives.

Results: Among 9225 patients from eight European countries, marked variation was seen in characteristics including age, smoking history and type of exacerbation. Spirometry use was more common among chest physicians (66.7%) than GPs (15.5%). Patients with Anthonisen type 1 and 2 exacerbations had more frequent exacerbations and these patients experienced a greater impact on daily activities compared with patients with type 3 episodes. Patient symptoms improved with moxifloxacin treatment after a mean (SD) of 3.4 (1.8) days, allowing return to normal daily activities after 5.4 (4.4) days and with full recovery taking 6.5 (3.1) days.

Conclusions: Characteristics of patients with AECB and acute exacerbations of COPD differ among European countries. Spirometry is under-used, particularly in primary care and antibiotic treatment does not always follow current guidelines. Results confirm the efficacy of moxifloxacin in the treatment of AECB in real-life conditions.

Effectiveness of pharmacotherapy and behavioral interventions for smoking cessation in actual clinical practice

Tue, 24 Nov 2009 08:59:09 PST

Objectives: This study evaluated the effectiveness of behavioral interventions (brief counseling, nonspecific psychological support in groups — NSGS and cognitive behavioral group therapy — CBGT) in combination with bupropion SR for smoking cessation in the field, through a smoking cessation clinic.

Methods: Two-hundred-and-five smokers were enrolled in a 19-week course during 2007/ 2008, and were randomly assigned to: bupropion SR combined with brief counseling (group A), bupropion SR combined with NSGS (group B), bupropion SR combined with CBGT (group C), or CBGT as the only approach (group D).

Results: Continuous abstinence rates at the end of therapy were 53.2% for group A, 62.9% for group B, 50.0% for group C, and 22.2% (p < 0.05) for group D. Sustained abstinence rates in 12 months were 29.6%, 28.1%, 34.3% and 19.4% (p > 0.05), respectively.

Conclusions: Bupropion SR is an effective aid for smoking cessation in clinical practice. NSGT increased the chances for success at the end of therapy when combined with bupropion SR, while CBGT as monotherapy was less effective compared with the approaches including pharmacotherapy. It is suggested that smoking cessation interventions in real-life healthcare settings should be implemented through comprehensive programs using pharmacotherapy where applicable, combined with NSGT, and integrated by specialized healthcare professionals.

Reduction of amiodarone pulmonary toxicity in patients treated with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers

Tue, 24 Nov 2009 08:59:09 PST

Background: Amiodarone (AM) is a widely used anti-arrhythmic medication. Its utility is, however, limited by adverse side effects. The mechanism of amiodarone-induced toxicity (APT) in the lungs is attributed primarily to stimulation of the angiotensin enzyme system leading to lung cell apoptosis and cell death. This mechanism has been demonstrated by in vitro and in vivo experimental animal studies. To date, however, no in vivo human studies have confirmed this mechanism for APT.

Purpose: This study was undertaken to determine whether angiotensin converting enzyme inhibitors (ACE-I) or angiotensin receptor blockers (ARB) offer a protective effect against APT in humans. Demonstration of a protective effect of an ACE-I or ARB would suggest that stimulation of the angiotensin enzyme system may be a key process in APT.

Design: An 8-year retrospective analysis of all patients on AM therapy at the James H. Quillen Veterans Affairs Medical Center was undertaken.

Results: A total of 1000 patients on AM were identified. One-hundred-and-seventeen were excluded from the study. Five-hundred-and-twenty-four patients were simultaneously on an ACE-I or ARB. The remaining 359 patients were not. Pulmonary toxicity attributed to AM was identified in five and 14 patients with and without concomitant ACE-I or ARB therapy, respectively. The APT rate for the entire patient sample was 2.2%. APT occurred in 1% of patients on an ACE-I or ARB and in 3.9% of patients not taking an ACE-I or ARB. This observed difference in percentage of APT was statistically significant.

Conclusion: The concomitant use of ACE-I or ARB in patients taking AM appears to offer a protective effect against APT. This observation suggests that the stimulation of the angiotensin enzyme system may play an important role in APT in humans.

Intrapleural hemorrhage after administration of tPA: a case report and review of the literature

Goralski, J. L., Bromberg, P. A., Haithcock, B. — Tue, 24 Nov 2009 08:59:09 PST

Objective: Intrapleural fibrinolytic enzymes have been used for over 60 years in the treatment of complicated pleural effusions to lyse loculations and promote resolution. Despite this extensive history of use, however, little is known about complications that may arise with the use of this therapy. Here we discuss a patient with chronic renal failure on hemodialysis who developed an intrapleural hemorrhage after the administration of intrapleural tPA to treat a complicated parapneumonic effusion. A review of the literature examines the efficacy and safety of this therapy, focusing on bleeding complications. Specific attention is paid to patients who have underlying coagulopathies or who are receiving anticoagulation.

Data sources: A review of the literature, as indexed in PubMed, was undertaken using the following search terms in combination: tPA, pleural effusion, complications of thrombolytics, and intrapleural hemorrhage. The search was inclusive of patients under the age of 18, but was limited by English language and human subjects.

Study selection/data extraction: All relevant articles identified during the search were reviewed. Those studies that reported on bleeding complications, or lack thereof, were included in this review. Limitations of each article are noted in the text.

Conclusions: Multiple studies, including a 2000 ACP consensus statement and a 2008 Cochrane review, indicate the need for further investigations to evaluate the safety and efficacy of intrapleural thrombolytics for the treatment of complicated pleural effusions and empyemas. Limited studies specifically address bleeding complications, especially in subpopulations of patients receiving concurrent anticoagulant therapy.

Spontaneous pneumomediastinum: an algorithm for diagnosis and management

Tue, 24 Nov 2009 08:59:09 PST

Spontaneous pneumomediastinum (SPM) is a rare disorder most often affecting young males which is generally self-limiting. Despite the benign prognosis with few complications and little morbidity, it frequently confuses clinicians in primary settings, who may have difficulty differentiating SPM from other serious organ ruptures, especially oesophageal rupture (the so-called Boerhaave syndrome), which may lead to mediastinitis and may be fatal, even with appropriate interventions. An overview of adult SPM is provided, reviewing 17 studies (414 patients), including our clinical experience, and finally an algorithm for diagnosis and management of SPM is proposed, based on the characteristics of SPM.

Sleep disorders and their management in patients with COPD

Sharafkhaneh, A., Jayaraman, G., Kaleekal, T., Sharafkhaneh, H., Hirshkowitz, M. — Tue, 24 Nov 2009 08:59:09 PST

Chronic obstructive pulmonary disease (COPD) is a prevalent progressive condition that adversely affects quality of life and sleep. Patients with COPD suffer from variety of sleep disorders including insomnia, sleep disordered breathing and restless leg syndrome. The sleep disorders in COPD patients may stem from poor control of primary disease or due to side effects of pharmacotherapy. Thus, optimization of COPD therapy is the main step in treating insomnia in these patients. Further, pharmacotherapy of sleep disorders may result in respiratory depression and related complications. Therefore, clear understanding of respiratory physiology during transition from wakefulness to sleep and during various stages of sleep plays an important role in therapies that are recommended in patients with significant airway obstruction. In this publication, we review respiratory physiology as it relates to sleep and discuss sleep disorders and their management in patients with COPD.

The traditional diagnosis and treatment of respiratory diseases: a description from Avicenna's Canon of Medicine

Hashemi, S. M., Raza, M. — Tue, 24 Nov 2009 08:59:09 PST

This article presents selected text on respiratory medicine from the famous book of medicine, Al-Qanun fi al-Tibb (the Canon of Medicine) by Avicenna (981—1037 AD), which was taught for 600 years as a standard text of medicine across medieval Europe. The authentic manuscript of the Canon of Medicine is located in the Central Library of the Tehran University of Medical Sciences, and the section on respiratory diseases was studied for the most relevant information — information that would be informative and interesting for present day physicians and pulmonologists. The results of the analysis are presented in the article. Respiratory diseases are discussed in depth in volume 3 of the Canon of Medicine. Avicenna discusses in detail the functional anatomy and physiopathology of the pulmonary diseases that were known in his time. He also describes the signs and symptoms of various respiratory diseases and conditions in the five chapters of volume 3 (breathing, voice, cough and hemoptysis, internal wounds and inflammations and principles of treatments) that are remarkably similar to those of modern pulmonary medicine. In addition, the herbal and nonherbal treatment of respiratory diseases and their signs and symptoms, mentioned in volume 2 of the Canon of Medicine, is also presented. In the time of Avicenna, the presentation of respiratory diseases, their treatment and their prognosis was much different than in modern times. There was more reliance on history, physical examination (which was mostly based on visual observation), individual variation, environmental factors, diet, and so on, for diagnosis and treatment. Nevertheless, going through a popular historic text such as the Canon of Medicine adds to our knowledge of the developments in the area of respiratory medicine at the time of Avicenna.

Acknowledgements

Tue, 24 Nov 2009 08:59:09 PST