Respiratory Diseases

The association between asthma and pneumococcal disease has been suspected by many clinicians; however, formal investigations confirming an increased risk of pneumococcal disease in patients with asthma are rare. Often, studies examining risk factors for pneumococcal disease have grouped all chronic pulmonary diseases together with no delineation of the specific type of underlying disease.

Q:What is the best and most efficient method ofevaluating pulmonary function in primary careoffice practice?

Abstract: Smoking cessation is still the most important intervention in patients with chronic obstructive pulmonary disease (COPD), regardless of sex. There is some evidence that nicotine replacement therapy may be less effective in women than in men. However, women may derive greater benefits from a sustained quit attempt. For example, one study found that compared with men, women who were sustained quitters had a greater initial rise and a slower age-related decline in forced expiratory volume in 1 second. Men and women do not appear to differ in their response to bupropion or to the various types of bronchodilators. A number of factors contribute to the increased risk of osteoporosis in women with COPD. Both smoking and the degree of airflow obstruction have been identified as important risk factors for osteoporosis. Women may be particularly susceptible to the effects of smoking on bone metabolism. Immobility and decreased physical activity have also been shown to accelerate bone loss. (J Respir Dis. 2006;27(3):115-122)

Abstract: Inhalation of Aspergillus is responsible for a variety of lung infections and diseases; Aspergillus fumigatus is the most common causative agent. Allergic bronchopulmonary aspergillosis (ABPA), caused by sensitivity to A fumigatus, is diagnosed primarily in persons with asthma or cystic fibrosis. Differentiating ABPA from other Aspergillus-related lung infections and diseases is often challenging. A patient's symptoms, underlying risk factors, and any prior pulmonary disease contribute to the diagnosis. Findings include pulmonary infiltrates, total serum IgE levels greater than 1000 IU/mL, IgE and IgA anti-A fumigatus antibodies, peripheral blood and pulmonary eosinophilia, and central bronchiectasis. Untreated ABPA often results in chronic bronchiectasis, pulmonary fibrosis, and dependence on corticosteroids; an accurate diagnosis of ABPA is critical to avoiding irreparable disease. (J Respir Dis. 2006;27(3):123-134)

New recommendations for the treatment of coughs caused by colds and for the vaccination of adults against pertussis are among the changes in the revised guidelines on the mangement of coughs.

Some epidemiologic studies haveindicated that increased consumptionof margarine is a risk factor foratopy in children. Now, Nagel andLinseisen report that a high intakeof margarine is associated with anincreased risk of the developmentof adult-onset asthma.

A number of studies have found an increased prevalence of anxiety and depression in patients with asthma and chronic obstructive pulmonary disease (COPD). Although the relationship is not completely understood, it is clear that psychological disorders can adversely affect the course of both diseases.

Abstract: In the assessment of community-acquired pneumonia, an effort should be made to identify the causal pathogen, since this may permit more focused treatment. However, diagnostic testing should not delay appropriate empiric therapy. The selection of empiric therapy can be guided by a patient stratification system that is based on the severity of illness and underlying risk factors for specific pathogens. For example, outpatients who do not have underlying cardiopulmonary disease or other risk factors can be given azithromycin, clarithromycin, or doxycycline. Higher-risk outpatients should be given a ß-lactam antibiotic plus azithromycin, clarithromycin, or doxycycline, or monotherapy with a fluoroquinolone. If the patient fails to respond to therapy, it may be necessary to do bronchoscopy; CT of the chest; or serologic testing for Legionella species, Mycoplasma pneumoniae, viruses, or other pathogens. (J Respir Dis. 2006;27(2):54-67)

Abstract: The increase in cigarette smoking among women is now being reflected in an increased incidence of chronic obstructive pulmonary disease (COPD). Since 1985, the rate of COPD-related deaths in women has steadily risen, and it nearly tripled from 1980 to 2000. There continues to be debate about whether women are more susceptible than men to COPD. Women on average have airways that are 17% smaller, and further narrowing of the airways by COPD may make women more vulnerable to symptomatic airways obstruction. There also is some evidence of greater bronchial hyperreactivity in women, although conflicting findings have been reported. Gender bias appears to exist in the diagnosis and workup of COPD. For example, there is some evidence that clinicians are more likely to consider the diagnosis of COPD in men than in women. One study showed that women who had symptoms consistent with COPD were significantly less likely than men to undergo spirometric assessment. (J Respir Dis. 2006;27(2):70-74)

Physicians around the country are being bombarded with questions about avian flu. This brief review of the current status of the avian flu outbreak and its treatment and prevention provides the information you will need to answer the most pressing patient questions.

A number of inflammatory diseases have been associated with an increased risk of atherosclerosis. Knoflach and colleagues report findings that support a link between allergic diseases, such as allergic rhinitis and asthma, and atherosclerosis. Their findings came from 2 studies: the Bruneck study, which included 826 men and women aged 40 to 70 years, and the Atherosclerosis Risk Factors in Male Youngsters (ARMY) study, which included 141 male participants aged 17 or 18 years.

My patient has been hospitalized for pneumonia several times by different physicians. He has never received the pneumococcal vaccine. Can this vaccine begiven during the patient’s hospital stay?

Abstract: Although cystic fibrosis (CF) is typically diagnosed during infancy or childhood, it may escape detection until adulthood. Diagnostic accuracy can be sharpened by maintaining a high index of suspicion for CF in an adult who is pancreatic-sufficient but has unexplained recurrent respiratory infections, bronchiectasis, or nutritional deficiencies. The workup begins with the quantitative pilocarpine iontophoresis sweat test. If necessary, additional tests include mutation analysis, full-gene sequencing of CF transmembrane conductance regulator protein, and measurement of nasal transepithelial potential difference. Multidisciplinary care is essential and includes nutritional support, chest physiotherapy, exercise, appropriate antibiotics, and other pulmonary interventions. Dornase alpha, inhaled tobramycin, and azithromycin have been associated with improved outcomes and are considered to be the standard of care for patients with moderate lung involvement. (J Respir Dis. 2006;27(1):32-41)

The influenza vaccine has been used for many years to control outbreaks of influenza, and its role in reducing morbidity and mortality is widely appreciated among health care professionals and patients alike. The panic that occurred in 2004 after announcements of a vaccine shortage bears testimony to the importance placed on this approach to influenza prevention and control.

Abstract: Shortness of breath is a common complaint associated with a number of conditions. Although the results of the history and physical examination, chest radiography, and spirometry frequently identify the diagnosis, dyspnea that remains unexplained after the initial evaluation can be problematic. A stepwise approach that focuses further testing on the most likely diagnoses is most effective in younger patients. Early bronchoprovocation challenge testing is warranted in younger patients because of the high prevalence of asthma in this population. Older patients require more complete evaluation because of their increased risk of multiple cardiopulmonary abnormalities. For patients who have multiple contributing factors or no clear diagnosis, cardiopulmonary exercise testing can help prioritize treatment and focus further evaluation. (J Respir Dis. 2006;27(1):10-24)

A 45-year-old man was referred to our pulmonary clinic for progressive dyspnea and worsening asthma. His shortness of breath had been worsening over the past 2 years. He denied fever, weight loss, and other systemic complaints.

In the October 2004 issue of TheJournal of Respiratory Diseases,Morrison and Gupta1 reviewed theclinical and laboratory approachesto the diagnosis of communityacquiredpneumonia (CAP) causedby Legionella. They discussed theadvantages and limitations of culture,direct fluorescent antibody(DFA) staining, serology, polymerasechain reaction, and Legionellaurinary antigen assays. As the authorsnoted, DFA staining of respiratorysecretions is an underusedtest that has a high specificity in patientswith untreated Legionnairesdisease.

Abstract: The manifestations of indoor mold-related disease (IMRD) include irritant effects, such as conjunctivitis and rhinitis; nonspecific respiratory complaints, such as cough and wheeze; hypersensitivity pneumonitis; allergic fungal sinusitis; and mycotoxicosis. The diagnosis of IMRD depends on eliciting an accurate history and excluding preexisting pathology that would account for the patient's symptoms. Laboratory tests, imaging studies, and spirometry can play an important role in ruling out other diagnoses, such as allergic or nonallergic rhinitis, asthma, and pneumonia. The diagnosis of IMRD also involves integrating the results of immunologic, physiologic, and imaging studies with the results of indoor air-quality studies. (J Respir Dis. 2005;26(12):520-525)

Abstract: Spinal tuberculosis is the most common form of osteoarticular involvement in patients with tuberculosis. Localized pain is a common presenting symptom. In patients who do not present until vertebral wedging and collapse have occurred, a localized knuckle kyphosis is obvious, especially in the dorsal spine. In some patients, a retropharyngeal abscess develops, causing dysphagia, dyspnea, and/or hoarseness. Peripheral joint tuberculosis is characterized by an insidious onset of slowly progressive, painful, and swollen monoarthropathy, most commonly affecting the hip or knee. The radiologic features include juxta-articular osteoporosis, peripheral osseous erosion, and gradual narrowing of the interosseous space. Treatment involves antituberculosis drugs; the indications for surgery are relatively limited. (J Respir Dis. 2005; 26(12):543-546)

Templeton and colleagues report encouraging news about the use of polymerase chain reaction (PCR) in the diagnosis of community- acquired pneumonia (CAP). They found that real-time PCR was more sensitive than conventional techniques for detecting major respiratory viruses and atypical bacteria.

The diagnosis of cystic fibrosis (CF) is typically made in childhood. However, there is increasing evidence that a mild and atypical form of this disease can present in adulthood. The author describes a patient who received the diagnosis of CF when she was 74 years old.

The initial evaluation of a patient with community-acquired pneumonia (CAP) should include a careful search for comorbidities, according to a study by Falguera and associates.

Abstract: In addition to causing pulmonary disease, infection with Mycobacterium tuberculosis can result in a wide range of extrapulmonary manifestations, including abdominal involvement. Patients with acute tuberculous peritonitis typically present with fever, weight loss, night sweats, and abdominal pain and swelling. Intestinal tuberculosis is characterized by weight loss, anorexia, and abdominal pain (usually in the right lower quadrant). A palpable abdominal mass may be present. Patients with primary hepatic tuberculosis may have a hard, nodular liver or recurrent jaundice. The workup may involve tuberculin skin testing, imaging studies, fine-needle aspiration, colonoscopy, and peritoneal biopsy. Percutaneous liver biopsy and laparoscopy are the main methods of diagnosing primary hepatic tuberculosis. Treatment includes antituberculosis drug therapy and, in some cases, surgery. (J Respir Dis. 2005;26(11):485-488)

Although the National Asthma Education and Prevention Program's (NAEPP) guidelines for managing asthma have been widely disseminated, compliance has been less than impressive. Results of a study by Grant and associates in the Chicago area reveal a considerable discrepancy between the NAEPP's therapeutic goals and the asthma control level achieved.

The use of analgesics, specifically acetaminophen, has been proposed as one of the mechanisms for the rise in asthma prevalence in the last 30 to 40 years.1 Acetaminophen, approved by the FDA in 1951, is one of the most commonly used analgesics in adults and children. The association between asthma and acetaminophen has been reported in case reports, in the setting of oral challenge tests, and in larger clinical studies.2

Influenza vaccinationcontinues to be the primarymethod of preventinginfluenza and its lifethreateningcomplications.In preparation forthis year’s influenza season,the Advisory Committeeon ImmunizationPractices (ACIP) has publishedits recommendationsfor the preventionand control of influenza.1

Under what circumstances would asthma or chronic obstructive pulmonary disease (COPD) be a contraindication to scuba diving? What precautions should patients with either asthma or COPD take if they are determined to go diving?

Abstract: Although controller therapies are currently recommended for patients who have persistent asthma, a number of studies indicate that these therapies do not adequately control asthma in a substantial number of these patients. This observation, combined with the potential risk of adverse effects with corticosteroids, supports the conclusion that controller therapies are not appropriate for all patients. However, some patients who do not respond to one type of controller therapy will respond to another, which suggests that we might consider targeting specific medications to select patients. There is increasing evidence that certain biomarkers may be useful in guiding therapy. For example, levels of sputum eosinophils have been shown to predict which patients are at increased risk for deterioration of asthma when inhaled corticosteroids are withdrawn.

Abstract: There is convincing evidence that controller therapies, such as inhaled corticosteroids and leukotriene receptor antagonists, provide many benefits to patients with asthma. These benefits include decreased symptoms, improved lung function, reduced frequency of exacerbations, and improved quality of life. Even patients with mild asthma and normal lung function can benefit from controller therapy. A recent analysis of the burden of asthma suggests that the proportion of patients who have mild intermittent disease is much smaller than previously estimated and that many more patients have persistent asthma. This finding, in combination with the considerable variability of patient responses to therapy and the difficulty in predicting which patients will respond, underscores the importance of considering a trial of controller therapy in patients with asthma.

Abstract: Pulmonary function tests, such as the measurement of forced expiratory volume in 1 second (FEV1) and peak expiratory flow (PEF), provide an objective, standardized, and quantifiable method of patient assessment and can be essential in the evaluation of asthma. However, FEV1 and PEF are relatively insensitive for detecting changes in persons with good baseline pulmonary function, and they do not directly measure worsening airway inflammation. One way to deal with the shortcomings of these tests is to include multiple outcomes assessment. Evaluating patient-oriented variables, such as symptoms, need for rescue medication, nocturnal awakenings, and unscheduled medical care visits, can detect clinically relevant changes that pulmonary function tests do not identify. Composite outcomes provide a more comprehensive approach to patient follow-up. For example, a patient who is considered to be a "nonresponder" to a given therapy on the basis of pulmonary function criteria might, in fact, be responding favorably according to assessment of composite outcomes. Two patient-centric tools for measuring outcome are the asthma control questionnaire and the asthma control test.