Pulmonary/Critical Care News

High prevalence of corrected QT interval prolongation in acutely ill patients is associated with mortality
This article sought to test the potential value of more frequent QT interval measurement in hospitalized patients through a prospective, observational study. In this study a corrected QT interval >500 msecs was considered prolonged. This article found QT prolongation to be common (24%), with Torsade de Pointes representing 6% of in-hospital cardiac arrests. Predictors of QT prolongation in the acutely ill population are similar to those previously identified in ambulatory populations. Acutely ill patients with QT prolongation have longer lengths of hospitalization and nearly three times the odds for mortality then those without QT prolongation.

The Impact of Tiotropium on Mortality 
Tiotropium has been shown to improve lung function, quality of life, and exacerbations and reduce mortality when compared with placebo in COPD. It remains unclear whether benefits are seen when tiotropium is used in conjunction with inhaled corticosteroids (ICSs) plus long-acting β-agonists (LABAs). This study suggests that the addition of tiotropium to ICSs and LABA therapy may confer benefits in reducing all-cause mortality, hospital admissions, and oral corticosteroid bursts in patients with COPD. Triple therapy is widely used in the real-life management of COPD, with only limited scientific support. The study supports the use of triple therapy in COPD and provides a platform for randomized controlled trials specifically addressing this topic.

Influence of Season on Exacerbation Characteristics in Patients With COPD
Patients with COPD experience more frequent exacerbations in the winter. However, little is known about the impact of the seasons on exacerbation characteristics. This study followed 307 patients in the London COPD cohort from 1995-2009 and found that exacerbations are more severe between November and February. This contributes to the increased morbidity during the winter seasons.

Association Between Marijuana Exposure and Pulmonary Function Over 20 Years
Marijuana smoke contains many of the same constituents as tobacco smoke, but whether it has similar adverse effects on pulmonary function is unclear. This article analyzed the associations between marijuana (both current and lifetime exposure) and pulmonary function and found that  occasional and low cumulative marijuana use was not associated with adverse effects on pulmonary function.

Factors Associated With Bronchiectasis in Patients With COPD
Previous studies have shown a high prevalence of bronchiectasis in patients with moderate to severe COPD. However, the factors associated with bronchiectasis remain unknown in these patients. The objective of this study is to identify the factors associated with bronchiectasis in patients with moderate to severe COPD. This article found that the variables independently associated with the presence of bronchiectasis were severe airflow obstruction, isolation of a potentially pathogenic microorganism (PPM), and at least one hospital admission due to COPD exacerbations in the previous year.

Extreme Obesity and Outcomes in Critically Ill Patients
Recent literature suggests that obese critically ill patients do not have worse outcomes than patients who are normal weight. However, outcomes in extreme obesity (BMI ≥ 40 kg/m2) are unclear. We sought to determine the association between extreme obesity and ICU outcomes. This article found that during critical illness, extreme obesity is not associated with a worse survival advantage compared with normal weight. However, among survivors, BMI ≥ 40 kg/m2 is associated with longer time on mechanical ventilation and in the ICU. These results may have prognostic implications for extremely obese critically ill patients.

Small-Airway Obstruction and Emphysema in Chronic Obstructive Pulmonary Disease
The major sites of obstruction in chronic obstructive pulmonary disease (COPD) are small airways (<2 mm in diameter). This article sought to determine whether there was a relationship between small-airway obstruction and emphysematous destruction in COPD. On multidetector CT, in samples from patients with COPD, as compared with control samples, the number of airways measuring 2.0 to 2.5 mm in diameter was reduced in patients with GOLD stage 1 disease (P=0.001), GOLD stage 2 disease (P=0.02), and GOLD stage 3 or 4 disease (P<0.001).  These results show that narrowing and disappearance of small conducting airways before the onset of emphysematous destruction can explain the increased peripheral airway resistance reported in COPD.

Eli Lilly withdraws sepsis treatment Xigris
Drugmaker Eli Lilly and Co. is withdrawing the severe sepsis treatment Xigris from all markets because a recently concluded study showed that it is no longer effective. Severe sepsis is blood poisoning caused by an aggressive bacterial infection that can cause major organ failure. It can develop as a complication from pneumonia or bacterial infections. The Indianapolis company said Tuesday there is no safety issue with the drug, but a study started in 2008 found it failed to reduce mortality in patients with septic shock. Lilly said patients should stop taking Xigris, which U.S. regulators approved in 2001.

Effect of pravastatin on the frequency of ventilator-associated pneumonia
The authors of this article investigated whether the use of pravastatin reduces the frequency of ventilator-associated pneumonia and whether it is related to favorable outcomes in critical care patients. The two arms consisted of treatment plus oral pravastatin sodium (40 mg) (n = 71 patients, pravastatin group) and treatment without pravastatin (n = 81 patients, control group). Treatment was started after randomization and ended 30 days later. Sixteen patients (22.5%) in the pravastatin group and 28 (34.5%) in the control group (p = .11) presented pneumonia during the 30-day treatment period in the intensive care unit. There was an indication for increased probability of being free from ventilator-associated pneumonia during the 30-day treatment period in the pravastatin group compared to the control group (p= .06) and significantly increased probability during the whole intensive care unit period of stay (p = .04) in the pravastatin group compared to the control group. This study provides evidence that pravastatin may favorably affect the outcome of critical care patients.

ECMO and the 2009 Flu Pandemic
Extracorporeal membrane oxygenation (ECMO) can support gas exchange in patients with severe acute respiratory distress syndrome (ARDS), but its role has remained controversial. ECMO was used to treat patients with ARDS during the 2009 influenza A(H1N1) pandemic. This article  compared the hospital mortality of patients with H1N1-related ARDS referred, accepted, and transferred for ECMO with matched patients who were not referred for ECMO. It found that for patients with H1N1-related ARDS, referral and transfer to an ECMO center was associated with lower hospital mortality compared with matched non–ECMO-referred patients.

COPD Stent Fails Clinical Test
Patients with severe emphysema derived no significant benefits from a less invasive alternative to surgical lung-volume reduction, investigators in a randomized trial reported. Airway bypass failed to improve lung function or dyspnea as compared with a sham procedure, despite successful release of trapped air in emphysematous lung tissue.

Obesity Is a Determinant of Asthma Control Independent of Inflammation and Lung Mechanics
It is unclear why obesity is associated with worse asthma control. We hypothesized that (1) obesity affects asthma control independent of spirometry, airway inflammation, and airway hyperresponsiveness (AHR) and (2) residual symptoms after resolution of inflammation are due to obesity-related changes in lung mechanics. Forty-nine subjects with asthma underwent the following tests, before and after 3 months of high-dose inhaled corticosteroid (ICS) treatment: five-item asthma control questionnaire (ACQ-5), spirometry, fraction of exhaled nitric oxide (FENO), methacholine challenge, and the forced oscillation technique, which allows for the calculation of respiratory system resistance (Rrs) and respiratory system reactance (Xrs) as indicators of airway caliber and elastic load, respectively. Overall this article found that BMI is a determinant of asthma control independent of airway inflammation, lung function, and AHR. After ICS treatment, BMI again predicts ACQ-5 results, but independent of obesity-related changes in lung mechanics.

Association between timing of antibiotic administration and mortality from septic shock
This article sought to determine the association between time to initial antibiotics and mortality of patients with septic shock treated with an emergency department-based early resuscitation protocol. In this large, prospective study of emergency department patients with septic shock, we found no increase in mortality with each hour delay to administration of antibiotics after triage. However, delay in antibiotics until after shock recognition was associated with increased mortality.

Syncope Portends a Poorer Prognosis in Adults With Pulmonary Arterial Hypertension
Some patients with PAH have a history of syncope at presentation. The prognostic implications of syncope in PAH have not yet been well characterized. The aim of this study was to determine the prognostic significance of syncope in pulmonary arterial hypertension (PAH). This was a single-center cohort study of 378 patients with PAH seen at a dedicated pulmonary hypertension clinic over an 8-year period. All patients completed a standardized symptom assessment at the time of diagnosis. Syncopal patients presented with higher right atrial pressure and lower cardiac outputswith lower survival rates (1-, 3-, and 5-year rates): 69%, 51%, and 37%, respectively, compared with 82%, 64% and 54%, respectively, in nonsyncopal patients. Syncope was a significant predictor of mortality, after adjusting for age, sex, functional class, 6-min walk distance, diffusing capacity of carbon monoxide, and right atrial pressure. Overall this article showed that syncope in PAH is associated with worsening right heart function and is an independent predictor of a poor prognosis.

Physical Activity Is the Strongest Predictor of All-Cause Mortality in Patients With COPD
Systemic effects of COPD are incompletely reflected by established prognostic assessments. We determined the prognostic value of objectively measured physical activity in comparison with established predictors of mortality and evaluated the prognostic value of noninvasive assessments of cardiovascular status, biomarkers of systemic inflammation, and adipokines. In a prospective cohort study of 170 outpatients with stable COPD (mean FEV1, 56% predicted), we assessed lung function by spirometry and body plethysmography; physical activity level (PAL) by a multisensory armband; exercise capacity by 6-min walk distance test; cardiovascular status by echocardiography, vascular Doppler sonography (ankle-brachial index [ABI]), and N-terminal pro-B-type natriuretic peptide level; nutritional and muscular status by BMI and fat-free mass index; biomarkers by levels of high-sensitivity C-reactive protein, IL-6, fibrinogen, adiponectin, and leptin; and health status, dyspnea, and depressive symptoms by questionnaire. Compared with established predictors, PAL showed the best discriminative properties for 4-year survival (C statistic, 0.81) and was associated with the highest relative risk of death per standardized decrease. 

Atelectasis as a Cause of Postoperative Fever, Where Is the Clinical Evidence?
Atelectasis is considered to be the most common cause of early postoperative fever (EPF) but the existing evidence is contradictory. We sought to determine if atelectasis is associated with EPF by analyzing the relevant published evidence. The authors performed a systematic search in PubMed and Scopus databases to identify studies examining the association between atelectasis and EPF. It was found that the available evidence regarding the association of atelectasis and fever is scarce. We found no clinical evidence supporting the concept that atelectasis is associated with EPF. More so, there is no clear evidence that atelectasis causes fever at all. Large studies are needed to precisely evaluate the contribution of atelectasis in EPF.

Simple test confirms chronic thromboembolic pulmonary hypertension
Researchers have constructed an algorithm that simply and accurately rules out chronic thromboembolic pulmonary hypertension (CTEPH), without the need for invasive testing, in acute pulmonary embolism patients. CTEPH affects up to 3.8% of patients who have suffered acute pulmonary embolism and is associated with poor prognosis unless an early diagnosis is made and pulmonary endarterectomy quickly performed. In this study, Klok and colleagues examined whether CTEPH could be confidently ruled out as a diagnosis based only on the results of conventional 12-lead echocardiography and the measurement of biomarkers. The authors report that electrocardiography detected right ventricular hypertrophy more frequently in patients with confirmed CTEPH (77%) than in those without (11%). Furthermore, levels of multiple biomarkers, including clotting factor FVIII, NT-pro-BNP, GDF-15, CRP, and urate, but not D-dimer levels, were higher in patients with CTEPH than in those without.

Impact of previous antibiotic therapy on outcome of Gram-negative severe sepsis
The authors of this article sought to determine whether exposure to antimicrobial agents in the previous 90 days resulted in decreased bacterial susceptibility and increased hospital mortality in patients with severe sepsis or septic shock attributed to Gram-negative bacteremia through a retrospective cohort study of hospitalized patients.  It was found that hospital mortality was 51.3% in the previous antibiotic exposure group vs. 34.0. Recent antibiotic exposure is associated with increased hospital mortality in Gram-negative bacteremia complicated by severe sepsis or septic shock. Clinicians caring for patients with severe sepsis or septic shock should consider recent antibiotic exposure when formulating empiric antimicrobial regimens for suspected Gram-negative bacterial infection.

Outcomes in severe sepsis and patients with septic shock: Pathogen species and infection sites are not associated with mortality
The authors evaluated the respective influence of the causative pathogen and infection site on hospital mortality from severe sepsis related to community-, hospital-, and intensive care unit-acquired infections using a prospective observational cohort 10-yr database. After analysis the infectious process may not exert as strong a prognostic effect when severity, organ dysfunction and, above all, appropriateness of early antimicrobials are taken into account. Our findings emphasize the importance of developing valid recommendations for early antimicrobial therapy.

Red cell distribution width and all-cause mortality in critically ill patients
Red cell distribution width is a predictor of mortality in the general population. The prevalence of increased red cell distribution width and its significance in the intensive care unit are unknown. The objective of this study was to investigate the association between red cell distribution width at the initiation of critical care and all cause mortality.  The prevalence of increased red cell distribution width and its significance in the intensive care unit are unknown and categorizeda priori in quintiles as ≤13.3%, 13.3% to 14.0%, 14.0% to 14.7%, 14.7% to 15.8%, and >15.8%. Red cell distribution width was a particularly strong predictor of all-cause mortality 30 days after critical care initiation with a significant risk gradient across red cell distribution width quintiles after multivariable adjustment.  The adjusted risk of bloodstream infection was 1.40- and 1.44-fold higher in patients with red cell distribution width values in the 14.7% to 15.8% and >15.8% quintiles, respectively, compared with those with red cell distribution width ≤13.3%. Overall Red cell distribution width is a robust predictor of the risk of all-cause patient mortality and bloodstream infection in the critically ill. Red cell distribution width is commonly measured, inexpensive, and widely available and may reflect overall inflammation, oxidative stress, or arterial underfilling in the critically ill.

Hydrogen Peroxide in Exhaled Breath Condensate in Patients with Asthma,A Promising Biomarker?
The measurement of hydrogen peroxide (H2O2) in exhaled breath condensate (EBC) has been proposed as a noninvasive way of monitoring airway inflammation. However, results from individual studies on EBC H2O2 evaluation of asthma are conflicting. The purpose of this study was to explore whether EBC H2O2 is elevated in people with asthma and whether it reflects disease severity and disease control or responds to corticosteroid treatment. This meta-analysis suggests a relationship between concentrations of hydrogen peroxide in exhaled breath condensate and asthma severity, asthma control status, lung function, and the response to corticosteroid treatment. It also provides evidence to support the measurement of hydrogen peroxide in exhaled breath condensate as a noninvasive biomarker to assess airway inflammation in patients with asthma.

Better Evidence about Screening for Lung Cancer
In October 2010, the National Cancer Institute (NCI) announced that patients who were randomly assigned to screening with low-dose computed tomography (CT) had fewer deaths from lung cancer than did patients randomly assigned to screening with chest radiography. The first report of the NCI-sponsored National Lung Screening Trial (NLST) in a peer-reviewed medical journal appears in this issue of the Journal.

Omega-3 fatty acids no help for the treatment of acute lung injury
Administration of eicosapentaenoic acid and docosahexanoic acid, omega-3 fatty acids in fish oil, has been associated with improved patient outcomes in acute lung injury when studied in a commercial enteral formula. However, fish oil has not been tested independently in acute lung injury. This article therefore sought to determine whether enteral fish oil alone would reduce pulmonary and systemic inflammation in patients with acute lung injury. Fish oil did not reduce biomarkers of pulmonary or systemic inflammation in patients with acute lung injury, and the results do not support the conduct of a larger clinical trial in this population with this agent. This experimental approach is feasible for proof-of-concept studies evaluating new treatments for acute lung injury.

Procalcitonin for reduced antibiotic exposure in the critical care setting: A systematic review and an economic evaluation
Procalcitonin may be associated with reduced antibiotic usage compared to usual care. However, individual randomized controlled trials testing this hypothesis were too small to rule out harm, and the full cost-benefit of this strategy has not been evaluated. The purpose of this analysis was to evaluate the effect of a procalcitonin-guided antibiotic strategy on clinical and economic outcomes. This article found that Procalcitonin-guided antibiotic therapy is associated with a reduction in antibiotic usage that, under certain assumptions, may reduce overall costs of care. However, the overall estimate cannot rule out a 7% increase in hospital mortality.

Right Ventricular Strain for Prediction of Survival in Patients With Pulmonary Arterial Hypertension
Pulmonary arterial hypertension (PAH) is a devastating illness of pulmonary vascular remodeling, right-sided heart failure, and limited survival. Whether strain-based measures of right ventricular (RV) systolic function predict future right-sided heart failure and/or death is untested. RV longitudinal systolic strain and strain rate were evaluated by echocardiography in 80 patients with World Health Organization group 1 pulmonary hypertension (PH) (72% were functional class [FC] III or IV). Survival status was assessed over 4 years. This article showed that noninvasive assessment of RV longitudinal systolic strain and strain rate independently predicts future right-sided heart failure, clinical deterioration, and mortality in patients with PAH.

Mortality associated with tiotropium mist inhaler in patients with chronic obstructive pulmonary disease
Boehringer Ingelheim GmbH and Pfizer Inc. (PFE)’s Spiriva mist inhaler for chronic lung disease may raise the risk of an early death, a review of five studies found. The use of Spiriva administered in mist form was associated with a 52 percent increase in the risk of mortality, compared with patients given only a placebo, according to the review published today in the British Medical Journal. The analysis included five clinical trials involving more than 6,500 patients.

Serum LDH in chronic cough: a potential marker of airway inflammation
Lactate dehydrogenase (LDH) is found in almost all tissues of the body and five different isoenzymes are known (LDH-1 to LDH-5). LDH can be elevated in many pathological conditions. We have observed serum LDH to be increased in patients with chronic cough. We wanted to confirm this finding, study the reproducibility and determine the origin of the LDH. Eighty three patients were included. Forty two percent had LDH values above the reference range and 78% had LDH values in the fourth quartile of the reference range or above. This increase in LDH was predominantly due a rise in isoenzymes 4 and 5. The increase in LDH was found to be reproducible at eight weeks. Ten percent had CK values above the normal range. There was no correlation observed between LDH values and the cough scores, HARQ scores or lung function. Overall Serum LDH levels are elevated in a substantial proportion of patients with chronic cough. This rise is likely to be due to airway inflammation known to be associated with chronic cough.

Prognostic significance of PaO2/PaCO2 ratio in normotensive patients with pulmonary embolism
Risk stratification remains controversial in patients with normotensive PE. The debate has recently focused right ventricular dysfunction detected by echocardiography or spiral computed tomography(CT) and cardiac biomarkers.  The utility of the PaO2/PaCO2 ratio to predict the short-term prognosis of pulmonary embolism(PE) is not currently known and that is the aim of the present study. This study retrospectively enrolled 99(34 males, 65 females, 67 ± 15 years) consecutive patients with acute PE, diagnosed by spiral chest tomography pulmonary angiography(CTPA).On admission cardiac Troponin-T(Tn-T) was measured and on CTPA both right ventricle diameter and left ventricle diameter was calculated(RV/LV ratio).   In-hospital mortality was 12.1 % and all-cause 90-day mortality was 15.2%. Ten of 15 patients who died had a PaO2/PaCO2≤1.8 based on ROC analysis .The cutoff level of PaO2/PaCO2 ≤ 1.8 had a high negative predictive value of 93% for mortality. Multivariable analysis revealed that PaO2/PaCO2≤1.8 HR: 16.8 was the most significant independent predictor, whereas Tn-T, pO2 < 60 mm-Hg and cardiac failure were non-significant factors. In addition, PaO2/PaCO2 ≤ 1.8 showed significant survival differences for overall mortality rates in Kaplan-Meier analysis(p < 0.012). The PaO2/PaCO2 measurement is a highly useful and practical measurement to predict prognosis in patients with acute PE. Moreover, it appears to be a more accurate predictor than RV/LV ratio and Tn-T levels in patients with normotensive PE.

Antimicrobial Susceptibilities and Serotypes ofStreptococcus pneumoniae Isolates from Elderly Patients with Pneumonia and Acute Exacerbation of Chronic Obstructive Pulmonary Disease
In the elderly, Streptococcus pneumoniae is the most common cause of pneumonia and one of the most frequently isolated pathogens in cases of acute exacerbation of chronic obstructive pulmonary disease (AECOPD). This study was conducted to compare the pneumococcal isolates obtained during episodes of AECOPD and pneumonia in patients of 65 years old and to analyze whether in patients with AECOPD and pneumonia within a short interval, the sameisolate caused both episodes. This laboratory-based study was performed between 2005 and 2008. Pneumococcal isolates from episodes of pneumonia (n = 401) and AECOPD (n = 398), matched one-to-one by date of isolation, were characterized. The serotypes and genotypes of other pneumococcal isolates causing pneumonia and AECOPD in the same patient were compared. In patients with pneumonia, COPD as an underlying disease was not associated with more-drug-resistant pneumococci. In contrast, isolates causing AECOPD showed higher rates of resistance than those causing pneumonia. Serotypes 1, 3, and 7F were more frequent in pneumonia. The same pneumococcus was involved in 25.7% (9/35 patients) of patients with two consecutive AECOPD episodes but in only 6.3% (2/32 patients) of COPD patients with pneumonia and exacerbation (Fisher's exact test; P = 0.047). Less invasive serotypes were isolated more often in AECOPD and were more resistant to antimicrobials. The presence of a specific pneumococcal serotype in AECOPD does not predict the etiology of subsequent pneumonia. For More Pulmonology News Visit Our Pulmonology Archives