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Zhang K, Shi Y, Han Y, Cai TY, Gu FM, Gu ZX, Zhang T, Huang MX. J-Shaped Association Between Respiratory Rate and In-Hospital Mortality in Acute Myocardial Infarction Patients Complicated by Congestive Heart Failure in Intensive Care Unit. Dose Response 2024; 22:15593258241303040. [PMID: 39629219 PMCID: PMC11613282 DOI: 10.1177/15593258241303040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Revised: 10/18/2024] [Accepted: 11/04/2024] [Indexed: 12/07/2024] Open
Abstract
Background: While respiratory rate has proven to be a sensitive prognostic indicator in ICU settings, its relevance in the context of Acute Myocardial Infarction (AMI) patients complicated by Congestive Heart Failure (CHF) remains underexplored. Therefore, this study aims to investigate the relationship between respiratory rate and in-hospital mortality in this specific patient cohort. Methods: This retrospective cohort study utilized the Medical Information Mart for Intensive Care-IV database to analyze all AMI patients with concomitant CHF. The primary outcome, in-hospital mortality, was assessed through multivariate analysis. Logistic regression models, restricted cubic spline regression models, and subgroup analyses were employed to explore the association between respiratory rate and in-hospital mortality. Results: The study encompassed 5056 participants diagnosed with both CHF and AMI. After adjusting for confounding variables, each incremental unit rise in respiratory rate was associated with an 8% increase in the risk of patient mortality (OR = 1.08, 95% CI: 1.05∼1.11, P < 0.001). When comparing individuals with respiratory rates in the first tertile (≤17 breaths per minute) and the third tertile (>17-20 breaths per minute) to those in the second tertile (17-20 breaths per minute), the adjusted ORs for in-hospital mortality were 1.09 (95% CI: 0.82∼1.46, P = 0.546) and 1.62 (95% CI: 1.27∼2.06, P < 0.001), respectively. A dose-response relationship depicted a J-shaped curve between respiratory rate and the risk of in-hospital mortality, with an inflection point at approximately 19 breaths per minute. Stratified analyses confirmed the robustness of this correlation. Conclusions: This study reveals a J-shaped association between respiratory rate and in-hospital mortality in ICU patients suffering from both AMI and CHF.
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Affiliation(s)
- Kai Zhang
- The Second Hospital of Jilin University, Changchun, China
| | - Yu Shi
- The Second Hospital of Jilin University, Changchun, China
| | - Yu Han
- Department of Ophthalmology, First Hospital of Jilin University, Changchun, China
- Department of Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Tian Yi Cai
- Jilin University Second Clinical School of Medicine, Changchun, China
| | - Fang Ming Gu
- Jilin University Second Clinical School of Medicine, Changchun, China
| | - Zhao Xuan Gu
- Jilin University Second Clinical School of Medicine, Changchun, China
| | - Tianqi Zhang
- Jilin University Second Clinical School of Medicine, Changchun, China
| | - Mao Xun Huang
- The Second Hospital of Jilin University, Changchun, China
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Plachi F, Balzan FM, Gass R, Käfer KD, Santos AZ, Gazzana MB, Neder JA, Berton DC. Mechanisms and consequences of excess exercise ventilation in fibrosing interstitial lung disease. Respir Physiol Neurobiol 2024; 325:104255. [PMID: 38555042 DOI: 10.1016/j.resp.2024.104255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/18/2024] [Accepted: 03/26/2024] [Indexed: 04/02/2024]
Abstract
The causes and consequences of excess exercise ventilation (EEV) in patients with fibrosing interstitial lung disease (f-ILD) were explored. Twenty-eight adults with f-ILD and 13 controls performed an incremental cardiopulmonary exercise test. EEV was defined as ventilation-carbon dioxide output (⩒E-⩒CO2) slope ≥36 L/L. Patients showed lower pulmonary function and exercise capacity compared to controls. Lower DLCO was related to higher ⩒E-⩒CO2 slope in patients (P<0.05). 13/28 patients (46.4%) showed EEV, reporting higher dyspnea scores (P=0.033). Patients with EEV showed a higher dead space (VD)/tidal volume (VT) ratio while O2 saturation dropped to a greater extent during exercise compared to those without EEV. Higher breathing frequency and VT/inspiratory capacity ratio were observed during exercise in the former group (P<0.05). An exaggerated ventilatory response to exercise in patients with f-ILD is associated with a blunted decrease in the wasted ventilation in the physiological dead space and greater hypoxemia, prompting higher inspiratory constraints and breathlessness.
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Affiliation(s)
- Franciele Plachi
- Programa de Pós-Graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul & Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Fernanda M Balzan
- Serviço de Emergência, Departamento de Fisioterapia, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Ricardo Gass
- Programa de Pós-Graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul & Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Kimberli D Käfer
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Artur Z Santos
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Marcelo B Gazzana
- Programa de Pós-Graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul & Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - J A Neder
- Pulmonary Function Laboratory and Respiratory Investigation Unit, Division of Respirology, Kingston Health Science Center & Queen's University, Kingston, ON, Canada
| | - Danilo C Berton
- Programa de Pós-Graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul & Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil.
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Palleschi A, Mattioni G, LoMauro A, Privitera E, Musso V, Morlacchi L, Vergari M, Velardo D, Grasselli G. Diaphragm and Lung Transplantation. Transpl Int 2024; 37:12897. [PMID: 38979122 PMCID: PMC11228173 DOI: 10.3389/ti.2024.12897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 06/05/2024] [Indexed: 07/10/2024]
Abstract
Mutual interactions between the diaphragm and lung transplantation (LTx) are known to exist. Before LTx, many factors can exert notable impact on the diaphragmatic function, such as the underlying respiratory disease, the comorbidities, and the chronic treatments of the patient. In the post-LTx setting, even the surgical procedure itself can cause a stressful trauma to the diaphragm, potentially leading to morphological and functional alterations. Conversely, the diaphragm can significantly influence various aspects of the LTx process, ranging from graft-to-chest cavity size matching to the long-term postoperative respiratory performance of the recipient. Despite this, there are still no standard criteria for evaluating, defining, and managing diaphragmatic dysfunction in the context of LTx to date. This deficiency hampers the accurate assessment of those factors which affect the diaphragm and its reciprocal influence on LTx outcomes. The objective of this narrative review is to delve into the complex role the diaphragm plays in the different stages of LTx and into the modifications of this muscle following surgery.
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Affiliation(s)
- Alessandro Palleschi
- Thoracic Surgery and Lung Transplantation Unit, IRCCS Foundation Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giovanni Mattioni
- Thoracic Surgery and Lung Transplantation Unit, IRCCS Foundation Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- School of Thoracic Surgery, University of Milan, Milan, Italy
| | - Antonella LoMauro
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Emilia Privitera
- Department of Healthcare Professions, IRCCS Foundation Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Valeria Musso
- Thoracic Surgery and Lung Transplantation Unit, IRCCS Foundation Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Letizia Morlacchi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Pneumology Unit, IRCCS Foundation Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maurizio Vergari
- Neuropathophysiology Unit, IRCCS Foundation Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniele Velardo
- Neuromuscular and Rare Diseases Unit, IRCCS Foundation Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Grasselli
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Intensive Care and Emergencies, IRCCS Foundation Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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Pagliaro R, Aronne L, Fomez R, Ferri V, Montella A, Sanduzzi Zamparelli S, Bianco A, Perrotta F. High-Flow Nasal Cannula System in Respiratory Failure Associated with Interstitial Lung Diseases: A Systematic Review and Narrative Synthesis. J Clin Med 2024; 13:2956. [PMID: 38792497 PMCID: PMC11122032 DOI: 10.3390/jcm13102956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 05/09/2024] [Accepted: 05/15/2024] [Indexed: 05/26/2024] Open
Abstract
Background: High-flow nasal cannula (HFNC) therapy has emerged as a promising treatment modality for interstitial lung disease (ILD)-related respiratory failure. This systematic review aims to evaluate the efficacy and safety of HFNC therapy in patients with ILDs. Methods: A comprehensive literature search was conducted using major electronic databases to identify relevant studies investigating the use of HFNC therapy in ILD patients with respiratory failure. Outcome measures of interest included improvements in oxygenation, dyspnea relief, respiratory rate control, hospital length of stay, and mortality. Results: Twelve studies were analyzed with an overall population of 715 patients included. Idiopathic Pulmonary Fibrosis (IPF) was the most prevalent type of ILD. Evaluated clinical settings were acute (7 studies), chronic (2 studies), and end-stage (3 studies) ILDs. The HFNC as a support for acute respiratory failure seems not inferior to non-invasive ventilation while offering better comfort and patient's perception. Poor data are available about use in chronic/long-term or rehabilitative settings. In end of life/palliative care, an HFNC might improve quality of life. Despite the promising results, further research is warranted to establish optimal HFNC protocols, identify patient subgroups most likely to benefit, and explore long-term outcomes. Conclusions: Overall, the HFNC appears to be a valuable therapeutic option for managing respiratory failure in ILD patients, offering potential improvements in oxygenation and symptom relief.
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Affiliation(s)
- Raffaella Pagliaro
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (R.P.); (R.F.); (V.F.); (A.M.); (A.B.)
- U.O.C. Clinica Pneumologica L. Vanvitelli, A. O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | - Luigi Aronne
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (R.P.); (R.F.); (V.F.); (A.M.); (A.B.)
- U.O.C. Clinica Pneumologica L. Vanvitelli, A. O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | - Ramona Fomez
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (R.P.); (R.F.); (V.F.); (A.M.); (A.B.)
- U.O.C. Clinica Pneumologica L. Vanvitelli, A. O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | - Vincenzo Ferri
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (R.P.); (R.F.); (V.F.); (A.M.); (A.B.)
- U.O.C. Clinica Pneumologica L. Vanvitelli, A. O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | - Antonia Montella
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (R.P.); (R.F.); (V.F.); (A.M.); (A.B.)
- U.O.C. Clinica Pneumologica L. Vanvitelli, A. O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | | | - Andrea Bianco
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (R.P.); (R.F.); (V.F.); (A.M.); (A.B.)
- U.O.C. Clinica Pneumologica L. Vanvitelli, A. O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | - Fabio Perrotta
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (R.P.); (R.F.); (V.F.); (A.M.); (A.B.)
- U.O.C. Clinica Pneumologica L. Vanvitelli, A. O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
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Donaldson MA, Donohoe K, Assayag D, Durand C, Fisher JH, Johannson K, Kolb M, Lok SD, Manganas H, Marcoux V, Min B, Morisset J, Marinescu DC, Ryerson CJ. Characteristics of pulse oximetry and arterial blood gas in patients with fibrotic interstitial lung disease. BMJ Open Respir Res 2024; 11:e002250. [PMID: 38479819 PMCID: PMC10941153 DOI: 10.1136/bmjresp-2023-002250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/28/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND Fibrotic interstitial lung disease (ILD) is frequently associated with abnormal oxygenation; however, little is known about the accuracy of oxygen saturation by pulse oximetry (SpO2) compared with arterial blood gas (ABG) saturation (SaO2), the factors that influence the partial pressure of carbon dioxide (PaCO2) and the impact of PaCO2 on outcomes in patients with fibrotic ILD. STUDY DESIGN AND METHODS Patients with fibrotic ILD enrolled in a large prospective registry with a room air ABG were included. Prespecified analyses included testing the correlation between SaO2 and SpO2, the difference between SaO2 and SpO2, the association of baseline characteristics with both the difference between SaO2 and SpO2 and the PaCO2, the association of baseline characteristics with acid-base category, and the association of PaCO2 and acid-base category with time to death or transplant. RESULTS A total of 532 patients with fibrotic ILD were included. Mean resting SaO2 was 92±4% and SpO2 was 95±3%. Mean PaCO2 was 38±6 mmHg, with 135 patients having PaCO2 <35 mmHg and 62 having PaCO2 >45 mmHg. Correlation between SaO2 and SpO2 was mild to moderate (r=0.39), with SpO2 on average 3.0% higher than SaO2. No baseline characteristics were associated with the difference in SaO2 and SpO2. Variables associated with either elevated or abnormal (elevated or low) PaCO2 included higher smoking pack-years and lower baseline forced vital capacity (FVC). Lower baseline lung function was associated with an increased risk of chronic respiratory acidosis. PaCO2 and acid-base status were not associated with time to death or transplant. INTERPRETATION SaO2 and SpO2 are weakly-to-moderately correlated in fibrotic ILD, with limited ability to accurately predict this difference. Abnormal PaCO2 was associated with baseline FVC but was not associated with outcomes.
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Affiliation(s)
- Mira A Donaldson
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Kathryn Donohoe
- College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Deborah Assayag
- Department of Medicine, McGill University, Montreal, Québec, Canada
| | - Celine Durand
- Département de Médecine, Centre de Recherche du Centre Hospitalier de l'Universite de Montreal, Montreal, Québec, Canada
| | - Jolene H Fisher
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kerri Johannson
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Martin Kolb
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Stacey D Lok
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Hélène Manganas
- Département de Médecine, Centre de Recherche du Centre Hospitalier de l'Universite de Montreal, Montreal, Québec, Canada
| | - Veronica Marcoux
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Bohyung Min
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Julie Morisset
- Département de Médecine, Centre de Recherche du Centre Hospitalier de l'Universite de Montreal, Montreal, Québec, Canada
| | - Daniel-Costin Marinescu
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher J Ryerson
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, British Columbia, Canada
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Pelaia C, Armentaro G, Lupia C, Maiorano A, Montenegro N, Miceli S, Condoleo V, Cassano V, Bruni A, Garofalo E, Crimi C, Vatrella A, Pelaia G, Longhini F, Sciacqua A. Effects of High-Flow Nasal Cannula on Right Heart Dysfunction in Patients with Acute-on-Chronic Respiratory Failure and Pulmonary Hypertension. J Clin Med 2023; 12:5472. [PMID: 37685538 PMCID: PMC10488050 DOI: 10.3390/jcm12175472] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 08/20/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
High-flow nasal cannula (HFNC) has several benefits in patients affected by different forms of acute respiratory failure, based on its own mechanisms. We postulated that HFNC may have some advantages over conventional oxygen therapy (COT) on the heart function in patients with acute-on-chronic respiratory failure with concomitant pulmonary hypertension (PH). We therefore designed this retrospective observational study to assess if HFNC improves the right and left ventricle functions and morphologies, arterial blood gases (ABGs), and patients' dyspnea, compared to COT. We enrolled 17 hospitalized patients receiving HFNC, matched with 17 patients receiving COT. Echocardiographic evaluation was performed at the time of admission (baseline) and 10 days after (T10). HFNC showed significant improvements in right ventricular morphology and function, and a reduction in sPAP. However, there were no significant changes in the left heart measurements with HFNC application. Conversely, COT did not lead to any modifications in echocardiographic measurements. In both groups, oxygenation significantly improved from baseline to T10 (in the HFNC group, from 155 ± 47 to 204 ± 61 mmHg while in the COT group, from 157 ± 27 to 207 ± 27 mmHg; p < 0.0001 for both comparisons). In conclusion, these data suggest an improvement of oxygenation with both treatments; however, only HFNC was able to improve the right ventricular morphology and function after 10 days from the beginning of treatment in a small cohort of patients with acute-on-chronic respiratory failure with PH.
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Affiliation(s)
- Corrado Pelaia
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (C.P.); (C.L.); (A.M.); (N.M.); (G.P.)
| | - Giuseppe Armentaro
- Department of Medical and Surgical Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (G.A.); (S.M.); (V.C.); (V.C.); (A.B.); (E.G.); (A.S.)
| | - Chiara Lupia
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (C.P.); (C.L.); (A.M.); (N.M.); (G.P.)
| | - Antonio Maiorano
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (C.P.); (C.L.); (A.M.); (N.M.); (G.P.)
| | - Nicola Montenegro
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (C.P.); (C.L.); (A.M.); (N.M.); (G.P.)
| | - Sofia Miceli
- Department of Medical and Surgical Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (G.A.); (S.M.); (V.C.); (V.C.); (A.B.); (E.G.); (A.S.)
| | - Valentino Condoleo
- Department of Medical and Surgical Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (G.A.); (S.M.); (V.C.); (V.C.); (A.B.); (E.G.); (A.S.)
| | - Velia Cassano
- Department of Medical and Surgical Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (G.A.); (S.M.); (V.C.); (V.C.); (A.B.); (E.G.); (A.S.)
| | - Andrea Bruni
- Department of Medical and Surgical Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (G.A.); (S.M.); (V.C.); (V.C.); (A.B.); (E.G.); (A.S.)
| | - Eugenio Garofalo
- Department of Medical and Surgical Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (G.A.); (S.M.); (V.C.); (V.C.); (A.B.); (E.G.); (A.S.)
| | - Claudia Crimi
- Department of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy;
| | - Alessandro Vatrella
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Salerno, Italy;
| | - Girolamo Pelaia
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (C.P.); (C.L.); (A.M.); (N.M.); (G.P.)
| | - Federico Longhini
- Department of Medical and Surgical Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (G.A.); (S.M.); (V.C.); (V.C.); (A.B.); (E.G.); (A.S.)
| | - Angela Sciacqua
- Department of Medical and Surgical Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (G.A.); (S.M.); (V.C.); (V.C.); (A.B.); (E.G.); (A.S.)
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Santus P, Radovanovic D, Saad M, Zilianti C, Coppola S, Chiumello DA, Pecchiari M. Acute dyspnea in the emergency department: a clinical review. Intern Emerg Med 2023; 18:1491-1507. [PMID: 37266791 PMCID: PMC10235852 DOI: 10.1007/s11739-023-03322-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/22/2023] [Indexed: 06/03/2023]
Abstract
Acute dyspnea represents one of the most frequent symptoms leading to emergency room evaluation. Its significant prognostic value warrants a careful evaluation. The differential diagnosis of dyspnea is complex due to the lack of specificity and the loose association between its intensity and the severity of the underlying pathological condition. The initial assessment of dyspnea calls for prompt diagnostic evaluation and identification of optimal monitoring strategy and provides information useful to allocate the patient to the most appropriate setting of care. In recent years, accumulating evidence indicated that lung ultrasound, along with echocardiography, represents the first rapid and non-invasive line of assessment that accurately differentiates heart, lung or extra-pulmonary involvement in patients with dyspnea. Moreover, non-invasive respiratory support modalities such as high-flow nasal oxygen and continuous positive airway pressure have aroused major clinical interest, in light of their efficacy and practicality to treat patients with dyspnea requiring ventilatory support, without using invasive mechanical ventilation. This clinical review is focused on the pathophysiology of acute dyspnea, on its clinical presentation and evaluation, including ultrasound-based diagnostic workup, and on available non-invasive modalities of respiratory support that may be required in patients with acute dyspnea secondary or associated with respiratory failure.
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Affiliation(s)
- Pierachille Santus
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74, 20157, Milan, Italy.
- Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi Di Milano, Milan, Italy.
| | - Dejan Radovanovic
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74, 20157, Milan, Italy
- Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi Di Milano, Milan, Italy
| | - Marina Saad
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74, 20157, Milan, Italy
| | - Camilla Zilianti
- Department of Pathophysiology and Transplantation, Università Degli Studi Di Milano, Milan, Italy
| | - Silvia Coppola
- Department of Anesthesia and Intensive Care, ASST Santi Paolo E Carlo, Ospedale Universitario San Paolo, Milan, Italy
| | - Davide Alberto Chiumello
- Department of Anesthesia and Intensive Care, ASST Santi Paolo E Carlo, Ospedale Universitario San Paolo, Milan, Italy
- Department of Health Sciences, Università Degli Studi Di Milano, Milan, Italy
- Coordinated Research Center On Respiratory Failure, Università Degli Studi Di Milano, Milan, Italy
| | - Matteo Pecchiari
- Department of Pathophysiology and Transplantation, Università Degli Studi Di Milano, Milan, Italy
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8
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Yegen CH, Marchant D, Bernaudin JF, Planes C, Boncoeur E, Voituron N. Chronic pulmonary fibrosis alters the functioning of the respiratory neural network. Front Physiol 2023; 14:1205924. [PMID: 37383147 PMCID: PMC10293840 DOI: 10.3389/fphys.2023.1205924] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 06/02/2023] [Indexed: 06/30/2023] Open
Abstract
Some patients with idiopathic pulmonary fibrosis present impaired ventilatory variables characterised by low forced vital capacity values associated with an increase in respiratory rate and a decrease in tidal volume which could be related to the increased pulmonary stiffness. The lung stiffness observed in pulmonary fibrosis may also have an effect on the functioning of the brainstem respiratory neural network, which could ultimately reinforce or accentuate ventilatory alterations. To this end, we sought to uncover the consequences of pulmonary fibrosis on ventilatory variables and how the modification of pulmonary rigidity could influence the functioning of the respiratory neuronal network. In a mouse model of pulmonary fibrosis obtained by 6 repeated intratracheal instillations of bleomycin (BLM), we first observed an increase in minute ventilation characterised by an increase in respiratory rate and tidal volume, a desaturation and a decrease in lung compliance. The changes in these ventilatory variables were correlated with the severity of the lung injury. The impact of lung fibrosis was also evaluated on the functioning of the medullary areas involved in the elaboration of the central respiratory drive. Thus, BLM-induced pulmonary fibrosis led to a change in the long-term activity of the medullary neuronal respiratory network, especially at the level of the nucleus of the solitary tract, the first central relay of the peripheral afferents, and the Pre-Bötzinger complex, the inspiratory rhythm generator. Our results showed that pulmonary fibrosis induced modifications not only of pulmonary architecture but also of central control of the respiratory neural network.
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Affiliation(s)
- Céline-Hivda Yegen
- Laboratoire Hypoxie & Poumon, UMR INSERM U1272, Université Sorbonne Paris Nord, Bobigny, France
| | - Dominique Marchant
- Laboratoire Hypoxie & Poumon, UMR INSERM U1272, Université Sorbonne Paris Nord, Bobigny, France
| | - Jean-François Bernaudin
- Laboratoire Hypoxie & Poumon, UMR INSERM U1272, Université Sorbonne Paris Nord, Bobigny, France
- Faculté de Médecine, Sorbonne Université, Paris, France
| | - Carole Planes
- Laboratoire Hypoxie & Poumon, UMR INSERM U1272, Université Sorbonne Paris Nord, Bobigny, France
- Service de Physiologie et d’Explorations Fonctionnelles, Hôpital Avicenne, APHP, Bobigny, France
| | - Emilie Boncoeur
- Laboratoire Hypoxie & Poumon, UMR INSERM U1272, Université Sorbonne Paris Nord, Bobigny, France
| | - Nicolas Voituron
- Laboratoire Hypoxie & Poumon, UMR INSERM U1272, Université Sorbonne Paris Nord, Bobigny, France
- Département STAPS, Université Sorbonne Paris Nord, Bobigny, France
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9
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Kinoshita Y, Utsunomiya T, Koide Y, Wada K, Ueda Y, Yoshida Y, Kushima H, Ishii H. Partial pressure of carbon dioxide levels reflect disease severity in idiopathic pleuroparenchymal fibroelastosis. Respir Investig 2023; 61:379-386. [PMID: 37079943 DOI: 10.1016/j.resinv.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/17/2023] [Accepted: 03/12/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Hypercapnia can cause a disturbance of consciousness and adversely affect a patient's general condition. Patients with interstitial lung disease seldom experience hypercapnia. Hypercapnia is a typical phenomenon in patients with pleuroparenchymal fibroelastosis (PPFE), especially in advanced stages. However, the clinical significance of hypercapnia in patients with idiopathic PPFE (iPPFE) has not been studied in detail. METHODS We retrospectively selected patients with iPPFE who had undergone blood gas analysis. The first blood gas data obtained after iPPFE diagnosis were examined. The partial pressure of carbon dioxide (PCO2) levels and their association with characteristic iPPFE parameters, including the flat chest index (the ratio of the anteroposterior diameter of the thoracic cage to the transverse diameter of the thoracic cage), were investigated. RESULTS A total of 47 patients with iPPFE were included in this study. The PCO2 level was moderately and inversely correlated with the forced vital capacity. (r = -0.431, P = 0.014), flat chest index (r = -0.497, P < 0.001), and body mass index (r = -0.313, P = 0.038) and was positively correlated with residual volume/total lung capacity. (r = 0.514, P < 0.01). A higher PCO2 level was also significantly associated with poorer prognosis in patients with iPPFE. CONCLUSIONS PCO2 levels could be used as an indicator of disease severity in patients with iPPFE.
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Affiliation(s)
- Yoshiaki Kinoshita
- Department of Respiratory Medicine, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Takuhide Utsunomiya
- Department of Respiratory Medicine, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Yohei Koide
- Department of Respiratory Medicine, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Kenji Wada
- Department of Respiratory Medicine, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Yusuke Ueda
- Department of Respiratory Medicine, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Yuji Yoshida
- Department of Respiratory Medicine, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Hisako Kushima
- Department of Respiratory Medicine, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Hiroshi Ishii
- Department of Respiratory Medicine, Fukuoka University Chikushi Hospital, Chikushino, Japan.
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10
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Ionescu MD, Popescu NA, Stănescu D, Enculescu A, Bălgrădean M, Căpitănescu GM, Bumbăcea D. The Challenging Diagnosis of Interstitial Lung Disease in Children-One Case Report and Literature Review. J Clin Med 2022; 11:jcm11226736. [PMID: 36431212 PMCID: PMC9698870 DOI: 10.3390/jcm11226736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 11/08/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
Childhood interstitial lung disease (chILD) includes a heterogeneous spectrum of rare respiratory disorders in children associated with substantial morbi-mortality. Interstitial tissue, and other pulmonary structures, epithelium, blood vessels, or pleura are involved, resulting in a restrictive lung disfunction. Respiratory symptoms set in progressively and are often subtle, making thorough clinical history and physical examination fundamental. The etiology often is obscure. The clinical presentation mimics pneumonia or asthma, leading to a diagnostic delay. Challenging diagnosis may require genetic tests, bronchoalveolar lavage, or lung biopsy. Alongside general supportive therapeutic measures, anti-inflammatory, immunosuppressive or antifibrotic agents may be used, based on data derived from adult studies. However, if accurate diagnosis and treatment are delayed, irreversible chronic respiratory failure may ensue, impacting prognosis. The most frequent chILD is hypersensitivity pneumonitis (HP), although it is rare in children. HP is associated with exposure to an environmental antigen, resulting in inflammation of the airways. Detailed antigen exposure history and identification of the inciting trigger are the cornerstones of diagnostic. This article provides the current state of chILD, revealing specific features of HP, based on a clinical case report of a patient admitted in our clinic, requiring extensive investigations for diagnosis, with a favorable long-term outcome.
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Affiliation(s)
- Marcela Daniela Ionescu
- Department of Pediatrics, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- “Marie S. Curie” Emergency Children’s Clinical Hospital, 041451 Bucharest, Romania
| | | | - Diana Stănescu
- “Marie S. Curie” Emergency Children’s Clinical Hospital, 041451 Bucharest, Romania
| | - Augustina Enculescu
- “Marie S. Curie” Emergency Children’s Clinical Hospital, 041451 Bucharest, Romania
| | - Mihaela Bălgrădean
- Department of Pediatrics, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- “Marie S. Curie” Emergency Children’s Clinical Hospital, 041451 Bucharest, Romania
| | | | - Dragos Bumbăcea
- Department of Cardio-Thoracic Medicine, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Pneumology and Acute Respiratory Care, Elias Emergency University Hospital, 041451 Bucharest, Romania
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11
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Resting respiration rate predicts all-cause mortality in older outpatients. Aging Clin Exp Res 2022; 34:1697-1705. [PMID: 35471696 DOI: 10.1007/s40520-022-02104-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 02/24/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Although respiratory rate has been a sensitive predictor for prognosis in acute settings, resting respiratory rate (RRR) is undervalued in chronic care. The clinical significance of RRR among older people is not well documented. AIM We investigated the association between RRR and all-cause mortality among older outpatients. METHODS A retrospective cohort study exhaustively included patients who had undergone medical checkups in a facility between April 2017 and March 2018 and followed up for at least 2 years. We excluded patients who were less than 60 years of age or had not undergone regular outpatient appointments. Sex, age, smoking habits, history of hospitalization, polypharmacy, long-term care insurance certification status, Mazzaglia index, pulse rate, systolic blood pressure, and Charlson Comorbidity Index were measured at the baseline medical checkup. Survival was confirmed by chart review and by contacting physicians in charge. The risk ratios were estimated by converting the odds ratios derived from the multivariable logistic regression models. RESULTS Of the 853 patients who underwent baseline checkups, 749 were enrolled in the analyses; death occurred in 53 patients (7.1%), with no loss to follow-up. The RRR was independently associated with all-cause mortality after adjusting for covariates [adjusted risk ratio of RRR per 1 bpm = 1.14, 95% confidence interval (CI): 1.06 - 1.22]. DISCUSSION Given the independent association of RRR for existing predictors, this simple index seems worthy of consideration in further studies aimed at defining its predictive role in older people and in different settings. CONCLUSION RRR was independently associated with all-cause mortality.
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12
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Lux S, Ramos D, Pinto A, Schilling S, Salinas M. Diaphragm Ultrasound in the Evaluation of Diaphragmatic Dysfunction in Lung Disease. Open Respir Med J 2021. [DOI: 10.2174/1874306402115010082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The diaphragm is the most important respiratory muscle, and its function may be limited by acute and chronic diseases. A diaphragmatic ultrasound, which quantifies dysfunction through different approaches, is useful in evaluating work of breathing and diaphragm atrophy, predicting successful weaning, and diagnosing critically ill patients. This technique has been used to determine reduced diaphragmatic function in patients with chronic obstructive pulmonary disease and interstitial diseases, while in those with COVID-19, diaphragmatic ultrasound has been used to predict weaning failure from mechanical ventilation.
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13
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Santana PV, Cardenas LZ, Ferreira JG, de Carvalho CRR, de Albuquerque ALP, Caruso P. Thoracoabdominal asynchrony associates with exercise intolerance in fibrotic interstitial lung diseases. Respirology 2021; 26:673-682. [PMID: 33860975 DOI: 10.1111/resp.14064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 02/07/2021] [Accepted: 03/31/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND OBJECTIVE The precise coordination of respiratory muscles during exercise minimizes work of breathing and avoids exercise intolerance. Fibrotic interstitial lung disease (f-ILD) patients are exercise-intolerant. We assessed whether respiratory muscle incoordination and thoracoabdominal asynchrony (TAA) occur in f-ILD during exercise, and their relationship with pulmonary function and exercise performance. METHODS We compared breathing pattern, respiratory mechanics, TAA and respiratory muscle recruitment in 31 f-ILD patients and 31 healthy subjects at rest and during incremental cycle exercise. TAA was defined as phase angle (PhAng) >20°. RESULTS During exercise, when compared with controls, f-ILD patients presented increased and early recruitment of inspiratory rib cage muscle (p < 0.05), and an increase in PhAng, indicating TAA. TAA was more frequent in f-ILD patients than in controls, both at 50% of the maximum workload (42.3% vs. 10.7%, p = 0.01) and at the peak (53.8% vs. 23%, p = 0.02). Compared with f-ILD patients without TAA, f-ILD patients with TAA had lower lung volumes (forced vital capacity, p < 0.01), greater dyspnoea (Medical Research Council > 2 in 64.3%, p = 0.02), worse exercise performance (lower maximal work rate % predicted, p = 0.03; lower tidal volume, p = 0.03; greater desaturation and dyspnoea, p < 0.01) and presented higher oesophageal inspiratory pressures with lower gastric inspiratory pressures and higher recruitment of scalene (p < 0.05). CONCLUSION Exercise induces TAA and higher recruitment of inspiratory accessory muscle in ILD patients. TAA during exercise occurred in more severely restricted ILD patients and was associated with exertional dyspnoea, desaturation and limited exercise performance.
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Affiliation(s)
- Pauliane Vieira Santana
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Intensive Care Unit, AC Camargo Cancer Center, São Paulo, Brazil
| | - Leticia Zumpano Cardenas
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Intensive Care Unit, AC Camargo Cancer Center, São Paulo, Brazil
| | - Jeferson George Ferreira
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Intensive Care Unit, AC Camargo Cancer Center, São Paulo, Brazil
| | - Carlos Roberto Ribeiro de Carvalho
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - André Luis Pereira de Albuquerque
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Sírio-Libanês Teaching and Research Institute, Hospital Sírio Libanês, São Paulo, SP, Brazil
| | - Pedro Caruso
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Intensive Care Unit, AC Camargo Cancer Center, São Paulo, Brazil
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14
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Bandyopadhyaya I, Islam MA, Bhattacharyya P, Saha G. Automatic lung sound cycle extraction from single and multichannel acoustic recordings. Biomed Signal Process Control 2021. [DOI: 10.1016/j.bspc.2020.102332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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15
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Molgat-Seon Y, Schaeffer MR, Ryerson CJ, Guenette JA. Exercise Pathophysiology in Interstitial Lung Disease. Clin Chest Med 2020; 40:405-420. [PMID: 31078218 DOI: 10.1016/j.ccm.2019.02.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Interstitial lung disease (ILD) is a heterogeneous group of disorders that primarily affect the lung parenchyma. Patients with ILD have reduced lung volumes, impaired pulmonary gas exchange, and decreased cardiovascular function. These pathologic features of ILD become exacerbated during physical exertion, leading to exercise intolerance and abnormally high levels of exertional dyspnea. In this review, the authors summarize the primary pathophysiologic features of patients with ILD and their effect on the integrative response to exercise.
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Affiliation(s)
- Yannick Molgat-Seon
- Centre for Heart Lung Innovation, St. Paul's Hospital, 166-1081 Burrard Street, Vancouver, British Columbia V6T 1Y6, Canada; Department of Physical Therapy, Faculty of Medicine, University of British Columbia, 212 Friedman Building, 2177 Wesbrook Mall, Vancouver, British Columbia V6T 1Z3, Canada
| | - Michele R Schaeffer
- Centre for Heart Lung Innovation, St. Paul's Hospital, 166-1081 Burrard Street, Vancouver, British Columbia V6T 1Y6, Canada; Department of Physical Therapy, Faculty of Medicine, University of British Columbia, 212 Friedman Building, 2177 Wesbrook Mall, Vancouver, British Columbia V6T 1Z3, Canada
| | - Christopher J Ryerson
- Centre for Heart Lung Innovation, St. Paul's Hospital, 166-1081 Burrard Street, Vancouver, British Columbia V6T 1Y6, Canada; Division of Respiratory Medicine, Faculty of Medicine, University of British Columbia, Gordon and Leslie Diamond Health Care Centre, 7th Floor, 2775 Laurel Street, Vancouver, British Columbia V5Z 1M9, Canada
| | - Jordan A Guenette
- Centre for Heart Lung Innovation, St. Paul's Hospital, 166-1081 Burrard Street, Vancouver, British Columbia V6T 1Y6, Canada; Department of Physical Therapy, Faculty of Medicine, University of British Columbia, 212 Friedman Building, 2177 Wesbrook Mall, Vancouver, British Columbia V6T 1Z3, Canada; Division of Respiratory Medicine, Faculty of Medicine, University of British Columbia, Gordon and Leslie Diamond Health Care Centre, 7th Floor, 2775 Laurel Street, Vancouver, British Columbia V5Z 1M9, Canada.
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16
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Development of an ex vivo preclinical respiratory model of idiopathic pulmonary fibrosis for aerosol regional studies. Sci Rep 2019; 9:17949. [PMID: 31784683 PMCID: PMC6884587 DOI: 10.1038/s41598-019-54479-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 11/12/2019] [Indexed: 01/27/2023] Open
Abstract
Idiopathic pulmonary fibrosis is a progressive disease with unsatisfactory systemic treatments. Aerosol drug delivery to the lungs is expected to be an interesting route of administration. However, due to the alterations of lung compliance caused by fibrosis, local delivery remains challenging. This work aimed to develop a practical, relevant and ethically less restricted ex vivo respiratory model of fibrotic lung for regional aerosol deposition studies. This model is composed of an Ear-Nose-Throat replica connected to a sealed enclosure containing an ex vivo porcine respiratory tract, which was modified to mimic the mechanical properties of fibrotic lung parenchyma - i.e. reduced compliance. Passive respiratory mechanics were measured. 81mKr scintigraphies were used to assess the homogeneity of gas-ventilation, while regional aerosol deposition was assessed with 99mTc-DTPA scintigraphies. We validated the procedure to induce modifications of lung parenchyma to obtain aimed variation of compliance. Compared to the healthy model, lung respiratory mechanics were modified to the same extent as IPF-suffering patients. 81mKr gas-ventilation and 99mTc-DTPA regional aerosol deposition showed results comparable to clinical studies, qualitatively. This ex vivo respiratory model could simulate lung fibrosis for aerosol regional deposition studies giving an interesting alternative to animal experiments, accelerating and facilitating preclinical studies before clinical trials.
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17
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Abstract
PURPOSE OF REVIEW There is an increasing recognition of the impact of sleep and sleep disorders on respiratory disease. Recent years have seen a new focus on the relationship between sleep and outcomes in patients interstitial lung disease (ILD). RECENT FINDINGS Recent studies suggest a high prevalence of sleep issues in ILD cohorts, which seem to have a meaningful negative impact on quality of life, disease progression, and survival. SUMMARY Sleep disordered breathing is common in ILD patients: obstructive sleep apnoea (OSA) is found in 44-72% of ILD patients, and nocturnal hypoxemia is relatively common even in the absence of OSA. Sleep disorders are associated with worse quality of life in ILD, and may also predict more rapid disease progression and increased mortality. It remains unknown if nocturnal hypoxemia may itself cause progression of ILD. Uncontrolled and retrospective studies have suggested that treating OSA may improve ILD-related outcomes, but prospective studies are lacking in this field.
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18
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O’Donnell DE, Milne KM, Vincent SG, Neder JA. Unraveling the Causes of Unexplained Dyspnea. Clin Chest Med 2019; 40:471-499. [DOI: 10.1016/j.ccm.2019.02.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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19
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Effects of Pursed Lip Breathing on Exercise Capacity and Dyspnea in Patients With Interstitial Lung Disease. J Cardiopulm Rehabil Prev 2019; 39:112-117. [DOI: 10.1097/hcr.0000000000000387] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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20
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Faverio P, De Giacomi F, Bonaiti G, Stainer A, Sardella L, Pellegrino G, Sferrazza Papa GF, Bini F, Bodini BD, Carone M, Annoni S, Messinesi G, Pesci A. Management of Chronic Respiratory Failure in Interstitial Lung Diseases: Overview and Clinical Insights. Int J Med Sci 2019; 16:967-980. [PMID: 31341410 PMCID: PMC6643124 DOI: 10.7150/ijms.32752] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 05/05/2019] [Indexed: 01/11/2023] Open
Abstract
Interstitial lung diseases (ILDs) may be complicated by chronic respiratory failure (CRF), especially in the advanced stages. Aim of this narrative review is to evaluate the current evidence in management of CRF in ILDs. Many physiological mechanisms underlie CRF in ILDs, including lung restriction, ventilation/perfusion mismatch, impaired diffusion capacity and pulmonary vascular damage. Intermittent exertional hypoxemia is often the initial sign of CRF, evolving, as ILD progresses, into continuous hypoxemia. In the majority of the cases, the development of CRF is secondary to the worsening of the underlying disease; however, associated comorbidities may also play a role. When managing CRF in ILDs, the need for pulmonary rehabilitation, the referral to lung transplant centers and palliative care should be assessed and, if necessary, promptly offered. Long-term oxygen therapy is commonly prescribed in case of resting or exertional hypoxemia with the purpose to decrease dyspnea and improve exercise tolerance. High-Flow Nasal Cannula oxygen therapy may be used as an alternative to conventional oxygen therapy for ILD patients with severe hypoxemia requiring both high flows and high oxygen concentrations. Non-Invasive Ventilation may be used in the chronic setting for palliation of end-stage ILD patients, although the evidence to support this application is very limited.
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Affiliation(s)
- Paola Faverio
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
| | - Federica De Giacomi
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
| | - Giulia Bonaiti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
| | - Anna Stainer
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
| | - Luca Sardella
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
| | - Giulia Pellegrino
- Casa di Cura del Policlinico, Dipartimento di Scienze Neuroriabilitative, Milan, Italy
| | | | - Francesco Bini
- UOC Pulmonology, Department of Internal Medicine, Ospedale ASST-Rhodense, Garbagnate Milanese, Italy
| | - Bruno Dino Bodini
- Pulmonology Unit, Ospedale Maggiore della Carità, University of Piemonte Orientale, Novara, Italy
| | - Mauro Carone
- UOC Pulmonology and Pulmonary Rehabilitation, Istituti Clinici Scientifici Maugeri, IRCCS di Cassano Murge (BA), Italy
| | - Sara Annoni
- Physical therapy and Rehabilitation Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
| | - Grazia Messinesi
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
| | - Alberto Pesci
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
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21
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Delineation of a Cardiac Planning Organ-At-Risk Volume Using Real-Time Magnetic Resonance Imaging for Cardiac Protection in Thoracic and Breast Radiation Therapy. Pract Radiat Oncol 2018; 9:e298-e306. [PMID: 30576844 DOI: 10.1016/j.prro.2018.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 11/15/2018] [Accepted: 12/08/2018] [Indexed: 12/25/2022]
Abstract
PURPOSE Cardiac radiation is associated with cardiotoxicity in patients with thoracic and breast malignancies. We conducted a prospective study using cine magnetic resonance imaging (MRI) scans to evaluate heart motion. We hypothesized that cine MRI could be used to define population-based cardiac planning organ-at-risk volumes (PRV). METHODS AND MATERIALS A total of 16 real-time acquisitions were obtained per subject on a 1.5 Tesla MRI (Philips Ingenia). Planar cine MRI was performed in 4 sequential sagittal and coronal planes at free-breathing (FB) and deep-inspiratory breath hold (DIBH). In-plane cardiac motion was assessed using a scale-invariant feature transformation-based algorithm. Subject-specific pixel motion ranges were defined in anteroposterior (AP), left-right (LR), and superoinferior (SI) planes. Averages of the 98% and 67% of the maximum ranges of pixel displacement were defined by subject, then averaged across the cohort to calculate PRV expansions at FB and DIBH. RESULTS Data from 20 subjects with a total of 3120 image frames collected per subject in coronal and sagittal planes at DIBH and FB, and 62,400 total frames were analyzed. Cohort averages of 98% of the maximum cardiac motion ranges comprised margin expansions of 12.5 ± 1.1 mm SI, 5.8 ± 1.2 mm AP, and 6.6 ± 1.0 mm LR at FB and 6.7 ± 1.5 mm SI, 4.7 ± 1.3 mm AP, and 5.3 ± 1.3 mm LR at DIBH. Margins for 67% of the maximum range comprised 7.7 ± 0.7 mm SI, 3.2 ± 0.6 mm AP, and 3.7 ± 0.6 mm LR at FB and 4.1 ± 0.9 mm SI, 2.7 ± 0.8 mm AP, and 3.2 ± 0.8 mm LR at DIBH. Subsequently, these margins were simplified to form PRVs for treatment planning. CONCLUSIONS We implemented scale-invariant feature transformation-based motion tracking for analysis of the cardiac cine MRI scans to quantify motion and create cohort-based cardiac PRVs to improve cardioprotection in breast and thoracic radiation.
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22
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Schertel A, Funke-Chambour M, Geiser T, Brill AK. Novel insights in cough and breathing patterns of patients with idiopathic pulmonary fibrosis performing repeated 24-hour-respiratory polygraphies. Respir Res 2017; 18:190. [PMID: 29132424 PMCID: PMC5683431 DOI: 10.1186/s12931-017-0674-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 11/06/2017] [Indexed: 01/05/2023] Open
Abstract
Background The main symptoms of patients with idiopathic pulmonary fibrosis (IPF) are cough and dyspnea. IPF leads to a restrictive lung disorder impacting daytime and nocturnal breathing patterns. In this pilot study we assessed the course of day- and nighttime respiration, oxygenation, and cough over a period of 8 months as well as differences between wakefulness and sleep in IPF patients. Methods Repetitive 24-h respiratory polygraphies (RP) and pulmonary function tests were performed at baseline and after 3, 4, 7 and 8 months. Cough-index, oxygenation parameters (SpO2, time with SpO2 < 90%, desaturation index), respiratory rate and heart rate were assessed for differences between wakefulness and sleep. The first and the last RP were compared to identify changes of these parameters over time. Statistical analyses were performed with Wilcoxon signed rank tests. Results Nine IPF patients (8 male, median age 67 years (IQR 60, 77) with 37 valid 24-h RPs were included. Eight patients (88.9%) received antifibrotic treatment. Cough was more prevalent during wakefulness with a median cough-index of 14.8/h (IQR 10.9, 16.8) and 1.6/h (IQR 1.3–2.8) during sleep, p = 0.0039. Oxygenation parameters showed no difference, while respiratory- and heart rate were significantly higher during wakefulness. Despite stable pulmonary function tests over 8 months, the initially elevated respiratory rate increased further during wakefulness (baseline RR median 25.7/min (IQR 19.8, 26.6) vs. RR median 32.2/min (IQR 26.5, 40.9) at follow-up, p = 0.0273). The other respiratory parameters remained stable over time. Conclusion Cough in IPF patients is more prevalent during wakefulness than during sleep. Further studies with a larger sample size and longer a follow-up period are needed to evaluate the role of the respiratory rate during wakefulness as a potential clinical follow up parameter in IPF. Electronic supplementary material The online version of this article (10.1186/s12931-017-0674-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anke Schertel
- Department of Pulmonary Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland.
| | - Manuela Funke-Chambour
- Department of Pulmonary Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Thomas Geiser
- Department of Pulmonary Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Anne-Kathrin Brill
- Department of Pulmonary Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
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O'Donnell DE, Elbehairy AF, Berton DC, Domnik NJ, Neder JA. Advances in the Evaluation of Respiratory Pathophysiology during Exercise in Chronic Lung Diseases. Front Physiol 2017; 8:82. [PMID: 28275353 PMCID: PMC5319975 DOI: 10.3389/fphys.2017.00082] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 01/30/2017] [Indexed: 11/13/2022] Open
Abstract
Dyspnea and exercise limitation are among the most common symptoms experienced by patients with various chronic lung diseases and are linked to poor quality of life. Our understanding of the source and nature of perceived respiratory discomfort and exercise intolerance in chronic lung diseases has increased substantially in recent years. These new mechanistic insights are the primary focus of the current review. Cardiopulmonary exercise testing (CPET) provides a unique opportunity to objectively evaluate the ability of the respiratory system to respond to imposed incremental physiological stress. In addition to measuring aerobic capacity and quantifying an individual's cardiac and ventilatory reserves, we have expanded the role of CPET to include evaluation of symptom intensity, together with a simple "non-invasive" assessment of relevant ventilatory control parameters and dynamic respiratory mechanics during standardized incremental tests to tolerance. This review explores the application of the new advances in the clinical evaluation of the pathophysiology of exercise intolerance in chronic obstructive pulmonary disease (COPD), chronic asthma, interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH). We hope to demonstrate how this novel approach to CPET interpretation, which includes a quantification of activity-related dyspnea and evaluation of its underlying mechanisms, enhances our ability to meaningfully intervene to improve quality of life in these pathologically-distinct conditions.
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Affiliation(s)
- Denis E. O'Donnell
- Division of Respiratory Medicine, Department of Medicine, Queen's University and Kingston General HospitalKingston, ON, Canada
| | - Amany F. Elbehairy
- Division of Respiratory Medicine, Department of Medicine, Queen's University and Kingston General HospitalKingston, ON, Canada
- Department of Chest Diseases, Faculty of Medicine, Alexandria UniversityAlexandria, Egypt
| | - Danilo C. Berton
- Division of Respiratory Medicine, Department of Medicine, Queen's University and Kingston General HospitalKingston, ON, Canada
| | - Nicolle J. Domnik
- Division of Respiratory Medicine, Department of Medicine, Queen's University and Kingston General HospitalKingston, ON, Canada
| | - J. Alberto Neder
- Division of Respiratory Medicine, Department of Medicine, Queen's University and Kingston General HospitalKingston, ON, Canada
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Bonini M, Fiorenzano G. Exertional dyspnoea in interstitial lung diseases: the clinical utility of cardiopulmonary exercise testing. Eur Respir Rev 2017; 26:26/143/160099. [DOI: 10.1183/16000617.0099-2016] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 12/01/2016] [Indexed: 01/08/2023] Open
Abstract
Interstitial lung diseases (ILDs) represent a heterogeneous group of pathologies characterised by alveolar and interstitial damage, pulmonary inflammation (usually associated with fibrosis), decreased lung function and impaired gas exchange, which can be attributed to either a known or an unknown aetiology. Dyspnoea is one of the most common and disabling symptoms in patients with ILD, significantly impacting quality of life. The mechanisms causing dyspnoea are complex and not yet fully understood. However, it is recognised that dyspnoea occurs when there is an imbalance between the central respiratory efferent drive and the response of the respiratory musculature. The respiratory derangement observed in ILD patients at rest is even more evident during exercise. Pathophysiological mechanisms responsible for exertional dyspnoea and reduced exercise tolerance include altered respiratory mechanics, impaired gas exchange, cardiovascular abnormalities and peripheral muscle dysfunction.This review describes the respiratory physiology of ILD, both at rest and during exercise, and aims to provide comprehensive and updated evidence on the clinical utility of the cardiopulmonary exercise test in the assessment and management of these pathological entities. In addition, the role of exercise training and pulmonary rehabilitation programmes in the ILD population is addressed.
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25
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Lutfi MF. The physiological basis and clinical significance of lung volume measurements. Multidiscip Respir Med 2017; 12:3. [PMID: 28194273 PMCID: PMC5299792 DOI: 10.1186/s40248-017-0084-5] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 01/02/2017] [Indexed: 11/10/2022] Open
Abstract
From a physiological standpoint, the lung volumes are either dynamic or static. Both subclasses are measured at different degrees of inspiration or expiration; however, dynamic lung volumes are characteristically dependent on the rate of air flow. The static lung volumes/capacities are further subdivided into four standard volumes (tidal, inspiratory reserve, expiratory reserve, and residual volumes) and four standard capacities (inspiratory, functional residual, vital and total lung capacities). The dynamic lung volumes are mostly derived from vital capacity. While dynamic lung volumes are essential for diagnosis and follow up of obstructive lung diseases, static lung volumes are equally important for evaluation of obstructive as well as restrictive ventilatory defects. This review intends to update the reader with the physiological basis, clinical significance and interpretative approaches of the standard static lung volumes and capacities.
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Affiliation(s)
- Mohamed Faisal Lutfi
- Department of Physiology, Faculty of Medicine and Health Sciences, Al-Neelain University, Khartoum, Sudan
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26
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Abstract
Oxygen is an essential element for life and without oxygen humans can survive for few minutes only. There should be a balance between oxygen demand and delivery in order to maintain homeostasis within the body. The two main organ systems responsible for oxygen delivery in the body and maintaining homeostasis are respiratory and cardiovascular system. Abnormal function of any of these two would lead to the development of hypoxemia and its detrimental consequences. There are various mechanisms of hypoxemia but ventilation/perfusion mismatch is the most common underlying mechanism of hypoxemia. The present review will focus on definition, various causes, mechanisms, and approach of hypoxemia in human.
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Affiliation(s)
- Malay Sarkar
- Department of Pulmonary Medicine, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
| | - N Niranjan
- Navodaya Medical College Hospital and Research Center, Raichur, Karnataka, India
| | - P K Banyal
- Community Health Center, Kupvi, Nerwa, Shimla, Himachal Pradesh, India
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27
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The impact of severe lung disease on evidential breath analysis collection. Sci Justice 2016; 56:256-9. [DOI: 10.1016/j.scijus.2016.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 04/11/2016] [Accepted: 04/19/2016] [Indexed: 11/18/2022]
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Berg RMG, Plovsing RR. The hardships of being a Sith Lord: implications of the biopsychosocial model in a space opera. ADVANCES IN PHYSIOLOGY EDUCATION 2016; 40:234-236. [PMID: 27105743 DOI: 10.1152/advan.00026.2016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 03/11/2016] [Indexed: 06/05/2023]
Affiliation(s)
- Ronan M G Berg
- Department of Clinical Physiology and Nuclear Medicine, Frederiksberg and Bispebjerg Hospitals, Frederiksberg, Denmark; and
| | - Ronni R Plovsing
- Department of Intensive Care 4131, University Hospital Rigshospitalet, Copenhagen, Denmark
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29
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Troy LK, Young IH, Lau EM, Corte TJ. Exercise pathophysiology and the role of oxygen therapy in idiopathic interstitial pneumonia. Respirology 2015; 21:1005-14. [DOI: 10.1111/resp.12650] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Revised: 01/29/2015] [Accepted: 08/03/2015] [Indexed: 12/22/2022]
Affiliation(s)
- Lauren K. Troy
- Department of Respiratory Medicine; Royal Prince Alfred Hospital; Sydney Australia
- Sydney Medical School; University of Sydney; Sydney Australia
| | - Iven H. Young
- Department of Respiratory Medicine; Royal Prince Alfred Hospital; Sydney Australia
- Sydney Medical School; University of Sydney; Sydney Australia
| | - Edmund M.T. Lau
- Department of Respiratory Medicine; Royal Prince Alfred Hospital; Sydney Australia
- Sydney Medical School; University of Sydney; Sydney Australia
| | - Tamera J. Corte
- Department of Respiratory Medicine; Royal Prince Alfred Hospital; Sydney Australia
- Sydney Medical School; University of Sydney; Sydney Australia
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30
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Berend N. Respiratory disease and respiratory physiology: putting lung function into perspective interstitial lung disease. Respirology 2014; 19:952-9. [PMID: 25039623 DOI: 10.1111/resp.12348] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 05/26/2014] [Indexed: 01/18/2023]
Abstract
The interstitial lung diseases pathologically involve the pulmonary interstitium but may also involve the airways, pleura and pulmonary circulation. They may be idiopathic, be part of other conditions, or be related to drug or environmental exposures. This review will focus on diagnostic and prognostic information provided by lung function tests in the idiopathic interstitial pneumonias, particularly idiopathic pulmonary fibrosis and non-specific interstitial pneumonia. These disorders are characterized by small stiff lungs with impaired gas exchange. Lung function tests, particularly lung volumes and gas transfer, used initially on patient presentation and then repeatedly on follow up, together with high-resolution computed tomography scans, can generate predictive formulae which are superior to single tests and can be used to provide useful information to assess the natural history of the disease or guide therapy. The concomitant presence of emphysema may mask the degree of restriction and may have adverse prognostic implications when accompanied by pulmonary hypertension.
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Affiliation(s)
- Norbert Berend
- The George Institute for Global Health, Woolcock Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
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Respiratory Determinants of Diurnal Hypercapnia in Obesity Hypoventilation Syndrome. What Does Weight Have to Do with It? Ann Am Thorac Soc 2014; 11:945-50. [DOI: 10.1513/annalsats.201403-099oc] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Seccombe LM, Peters MJ. Physiology in Medicine: Acute altitude exposure in patients with pulmonary and cardiovascular disease. J Appl Physiol (1985) 2014; 116:478-85. [DOI: 10.1152/japplphysiol.01013.2013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Travel is more affordable and improved high-altitude airports, railways, and roads allow rapid access to altitude destinations without acclimatization. The physiology of exposure to altitude has been extensively described in healthy individuals; however, there is a paucity of data pertaining to those who have reduced reserve. This Physiology in Medicine article discusses the physiological considerations relevant to the safe travel to altitude and by commercial aircraft in patients with pulmonary and/or cardiac disease.
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Affiliation(s)
- Leigh M. Seccombe
- Australian School of Advanced Medicine, Macquarie University, Sydney, New South Wales, Australia; and
- Thoracic Medicine, Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Matthew J. Peters
- Australian School of Advanced Medicine, Macquarie University, Sydney, New South Wales, Australia; and
- Thoracic Medicine, Concord Repatriation General Hospital, Concord, New South Wales, Australia
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Young IH, Bye PTP. Gas exchange in disease: asthma, chronic obstructive pulmonary disease, cystic fibrosis, and interstitial lung disease. Compr Physiol 2013; 1:663-97. [PMID: 23737199 DOI: 10.1002/cphy.c090012] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Ventilation-perfusion (VA/Q) inequality is the underlying abnormality determining hypoxemia and hypercapnia in lung diseases. Hypoxemia in asthma is characterized by the presence of low VA/Q units, which persist despite improvement in airway function after an attack. This hypoxemia is generally attenuated by compensatory redistribution of blood flow mediated by hypoxic vasoconstriction and changes in cardiac output, however, mediator release and bronchodilator therapy may cause deterioration. Patients with chronic obstructive pulmonary disease have more complex patterns of VA/Q inequality, which appear more fixed, and changes in blood flow and ventilation have less benefit in improving gas exchange efficiency. The inability of ventilation to match increasing cardiac output limits exercise capacity as the disease progresses. Deteriorating hypoxemia during exacerbations reflects the falling mixed venous oxygen tension from increased respiratory muscle activity, which is not compensated by any redistribution of VA/Q ratios. Shunt is not a feature of any of these diseases. Patients with cystic fibrosis (CF) have no substantial shunt when managed according to modern treatment regimens. Interstitial lung diseases demonstrate impaired oxygen diffusion across the alveolar-capillary barrier, particularly during exercise, although VA/Q inequality still accounts for most of the gas exchange abnormality. Hypoxemia may limit exercise capacity in these diseases and in CF. Persistent hypercapnic respiratory failure is a feature of advancing chronic obstructive pulmonary disease and CF, closely associated with sleep disordered breathing, which is not a prominent feature of the other diseases. Better understanding of the mechanisms of hypercapnic respiratory failure, and of the detailed mechanisms controlling the distribution of ventilation and blood flow in the lung, are high priorities for future research.
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Affiliation(s)
- Iven H Young
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, and The University of Sydney, Australia.
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Enomoto Y, Takemura T, Hagiwara E, Iwasawa T, Fukuda Y, Yanagawa N, Sakai F, Baba T, Nagaoka S, Ogura T. Prognostic factors in interstitial lung disease associated with primary Sjögren's syndrome: a retrospective analysis of 33 pathologically-proven cases. PLoS One 2013; 8:e73774. [PMID: 24040065 PMCID: PMC3767611 DOI: 10.1371/journal.pone.0073774] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Accepted: 07/21/2013] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Interstitial lung disease associated with primary Sjögren's syndrome (pSS-ILD) shows several patterns such as nonspecific interstitial pneumonia (NSIP) and usual interstitial pneumonia (UIP). Although UIP is a well-recognized prognostic determinant in idiopathic interstitial pneumonias, whether this is also the case in pSS-ILD is unclear. The objectives of this study were to evaluate the prognostic effect of UIP, and to identify the prognostic factors in pSS-ILD. METHODS A retrospective review of medical records identified 33 consecutive patients with pathologically-proven pSS-ILD. Each patient was classified into each ILD pattern by multidisciplinary analysis. Baseline clinical-radiologic-pathologic characteristics and survival rates were compared between the ILD patterns. Finally, the prognostic factors in pSS-ILD were assessed by univariate and subsequent multivariate analyses using Cox's proportional hazards regression model. RESULTS pSS-ILD patients were diagnosed with NSIP (n = 22) or UIP (n = 11). The median follow-up period was 110 months, and five-year survival rate was 87.3% in the total patient population. The prognosis of the UIP patients was not significantly different from that of the NSIP patients (NSIP to UIP, hazard ratio [HR]: 0.77, 95% confidence interval [CI]: 0.18-3.36, P = 0.73). Multivariate analysis identified PaCO2 (HR: 1.68 per 1 Torr increase, 95% CI: 1.24-2.28, P < 0.01), extent of reticular abnormality on high-resolution CT (HR: 4.17 per 1-grade increment, 95% CI: 1.18-14.73, P = 0.03), and severity of fibroblastic foci (HR: 9.26 per 1-grade increment, 95% CI: 1.74-49.35, P < 0.01) as prognostic factors in pSS-ILD. CONCLUSIONS UIP in pSS-ILD was not related to poorer prognosis than NSIP. Assessment of detailed clinical-radiologic-pathologic findings is more important than distinguishing UIP to evaluate prognosis in this disease.
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Affiliation(s)
- Yasunori Enomoto
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Tamiko Takemura
- Department of Pathology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Eri Hagiwara
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Tae Iwasawa
- Department of Radiology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Yuh Fukuda
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Noriyo Yanagawa
- Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Fumikazu Sakai
- Department of Diagnostic Radiology, Saitama International Medical Center, Saitama Medical University, Saitama, Japan
| | - Tomohisa Baba
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Shouhei Nagaoka
- Department of Rheumatology, Yokohama Minami Kyosai Hospital, Yokohama, Japan
| | - Takashi Ogura
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
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Abstract
A wide variety of mechanisms can lead to the hypoventilation associated with various medical disorders, including derangements in central ventilatory control, mechanical impediments to breathing, and abnormalities in gas exchange leading to increased dead space ventilation. The pathogenesis of hypercapnia in obesity hypoventilation syndrome remains somewhat obscure, although in many patients comorbid obstructive sleep apnea appears to play an important role. Hypoventilation in neurologic or neuromuscular disorders is primarily explained by weakness of respiratory muscles, although some central nervous system diseases may affect control of breathing. In other chest wall disorders, obstructive airways disease, and cystic fibrosis, much of the pathogenesis is explained by mechanical impediments to breathing, but an element of increased dead space ventilation also often occurs. Central alveolar hypoventilation syndrome involves a genetically determined defect in central respiratory control. Treatment in all of these disorders involves coordinated management of the primary disorder (when possible) and, increasingly, the use of noninvasive positive pressure ventilation.
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Affiliation(s)
- Lee K Brown
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, 1101 Medical Arts Avenue NE, Building #2, Albuquerque, NM 87102, USA.
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Clement A, Nathan N, Epaud R, Fauroux B, Corvol H. Interstitial lung diseases in children. Orphanet J Rare Dis 2010; 5:22. [PMID: 20727133 PMCID: PMC2939531 DOI: 10.1186/1750-1172-5-22] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Accepted: 08/20/2010] [Indexed: 12/30/2022] Open
Abstract
Interstitial lung disease (ILD) in infants and children comprises a large spectrum of rare respiratory disorders that are mostly chronic and associated with high morbidity and mortality. These disorders are characterized by inflammatory and fibrotic changes that affect alveolar walls. Typical features of ILD include dyspnea, diffuse infiltrates on chest radiographs, and abnormal pulmonary function tests with restrictive ventilatory defect and/or impaired gas exchange. Many pathological situations can impair gas exchange and, therefore, may contribute to progressive lung damage and ILD. Consequently, diagnosis approach needs to be structured with a clinical evaluation requiring a careful history paying attention to exposures and systemic diseases. Several classifications for ILD have been proposed but none is entirely satisfactory especially in children. The present article reviews current concepts of pathophysiological mechanisms, etiology and diagnostic approaches, as well as therapeutic strategies. The following diagnostic grouping is used to discuss the various causes of pediatric ILD: 1) exposure-related ILD; 2) systemic disease-associated ILD; 3) alveolar structure disorder-associated ILD; and 4) ILD specific to infancy. Therapeutic options include mainly anti-inflammatory, immunosuppressive, and/or anti-fibrotic drugs. The outcome is highly variable with a mortality rate around 15%. An overall favorable response to corticosteroid therapy is observed in around 50% of cases, often associated with sequelae such as limited exercise tolerance or the need for long-term oxygen therapy.
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Affiliation(s)
- Annick Clement
- Pediatric Pulmonary Department, Reference Center for Rare Lung Diseases, AP-HP, Hôpital Trousseau, Inserm UMR S-938, Université Pierre et Marie Curie-Paris 6, Paris, F-75012 France.
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Holland AE. Exercise limitation in interstitial lung disease - mechanisms, significance and therapeutic options. Chron Respir Dis 2010; 7:101-11. [PMID: 20056733 DOI: 10.1177/1479972309354689] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Exercise limitation is a cardinal feature of the interstitial lung diseases and is frequently associated with marked dyspnoea on exertion. People with interstitial lung disease exhibit a rapid, shallow breathing pattern during exercise that worsens as disease progresses. Despite this, ventilatory mechanics are not the major limitation to exercise in most patients, with impaired gas exchange and circulatory limitation playing a more important role. Peripheral and respiratory muscle dysfunction may also contribute to impaired exercise tolerance, either due to systemic manifestations of the underlying disease, treatment side-effects or deconditioning. Measures of exercise capacity or desaturation obtained from maximal and submaximal exercise tests are good predictors of survival in patients with idiopathic pulmonary fibrosis. However, to date few pharmaceutical treatments have affected exercise outcomes despite improvements in other important clinical markers. Supplemental oxygen acutely improves exercise capacity in interstitial lung disease and is recommended for hypoxic patients, although quality of life or survival benefits have not yet been demonstrated. Exercise training improves walking capacity and dyspnoea in short-term trials and is useful to maximize functional capacity. The role of exercise testing in the routine management of patients with interstitial lung disease is not clearly defined. However, given the poor prognosis in patients with idiopathic pulmonary fibrosis and the marked variation in clinical course, assessment of exercise capacity may provide useful information for both clinicians and patients when evaluating the risks and benefits of new treatments. The extent of resting or exercise-induced hypoxia in patients with interstitial lung disease may influence the selection of an appropriate exercise test, and oxygen administration should be standardized on repeat testing.
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39
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Effects of proportional assisted ventilation on exercise performance in idiopathic pulmonary fibrosis patients. Respir Med 2010; 104:134-41. [DOI: 10.1016/j.rmed.2009.08.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2009] [Revised: 07/24/2009] [Accepted: 08/02/2009] [Indexed: 11/22/2022]
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Abstract
Interstitial lung diseases (ILDs) are a heterogeneous group of parenchymal pulmonary disorders with varying histologic appearances. Pulmonary function tests have gained a prominent role in the diagnosis and management of patients with these disorders. Although their role in the differential diagnosis of the various ILDs is limited, physiologic measurements are pivotal studies providing clues regarding disease severity, prognosis,and response to therapy.
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Affiliation(s)
- Vibha N Lama
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, 1500 East Medical Center Drive, 3916 Taubman Center, Ann Arbor, MI 48109-0360, USA
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Okutan O, Kartaloglu Z, Ilvan A, Kutlu A, Bozkanat E, Silit E. Evaluation of high-resolution computed tomography and pulmonary function tests in patients with chronic hepatitis C virus infection. World J Gastroenterol 2004; 10:381-4. [PMID: 14760762 PMCID: PMC4724917 DOI: 10.3748/wjg.v10.i3.381] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIM: To investigate pulmonary involvement via pulmonary function tests (PFT) and high-resolution computed tomography (HRCT) in patients with chronic hepatitis C virus (HCV) infection.
METHODS: Thirty-four patients with chronic HCV infection without diagnosis of any pulmonary diseases and 10 healthy cases were enrolled in the study. PFT and HRCT were performed in all cases.
RESULTS: A decrease lower than 80% of the predicted value was detected in vital capacity in 9/34 patients, in forced expiratory volume in one second in 8/34 patients, and in forced expiratory flow 25 - 75 in 15/34 patients, respectively. Carbon monoxide diffusing capacity (DLCO) was decreased in 26/34 patients. Findings of interstitial pulmonary involvement were detected in the HRCT of 16/34 patients. Significant difference was found between controls and patients with HCV infection in findings of HRCT (χ2 = 4.7, P = 0.003). Knodell histological activity index (KHAI) of 28/34 patients in whom liver biopsy was applied was 9.0 ± 4.7. HRCT findings, PFT values and DLCO were not affected by KHAI in patients with HCV infection. In these patients, all the parameters were related with age.
CONCLUSION: We suggest that chronic hepatitis C virus infection may cause pulmonary interstitial involvement without evident respiratory symptoms.
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Affiliation(s)
- Oguzhan Okutan
- GATA Haydarpasa Training Hospital, Department of Pulmonary Diseases, Istanbul, Turkey.
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Kinnula VL, Sovijärvi AR. Hyperventilation during exercise: independence on exercise-induced bronchoconstriction in mild asthma. Respir Med 1996; 90:145-51. [PMID: 8736206 DOI: 10.1016/s0954-6111(96)90156-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Ventilatory gas exchange during exercise was compared in patients with mild asthma (11 females and 11 males), hyperventilation syndrome (HVS, 11 females), and healthy subjects (11 females and 11 males) in order to assess hyperventilation during exercise and its association with exercise-induced bronchoconstriction. The asthmatics showed decreased working capacity and decreased maximal oxygen consumption, with no evidence of limitation due to impairment of ventilatory capacity. Ventilatory equivalents for CO2 and O2 (VE/VCO2 and VE/VO2) at rest did not differ between the controls and asthmatics, but they were significantly elevated in HVS. In female asthmatics, ventilatory equivalents during exercise were significantly (P < 0.05) elevated compared with those of healthy subjects; in female controls, VE/VCO2 was 30.1 +/- 3.3 at low exercise and 27.4 +/- 6.5 at maximal exercise. In female asthmatics, the corresponding figures were 34.9 +/- 6.1 and 36.7 +/- 5.3. Furthermore, VE/VCO2 individually related to percent of maximal oxygen consumption (VO2max) was significantly increased in female asthmatics both at low and high VO2. The highest ventilatory equivalents were obtained in HVS, 41.7 +/- 6.7 and 43.9 +/- 0.9, respectively. Significant exercise-induced bronchoconstriction (decrease of FEV1 > 15%) was found in 50% of the asthmatics. The ventilatory equivalents did not correlate with exercise-induced changes in FEV1 (r2 < 0.3). Mild exercise-induced hyperventilation which was observed in mild female asthmatics, did not appear to be related to exercise-induced bronchoconstriction.
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Affiliation(s)
- V L Kinnula
- Department of Medicine, Helsinki University Central Hospital, Finland
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43
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Affiliation(s)
- W N Gardner
- Department of Thoracic Medicine, Kings College School of Medicine and Dentistry, London, United Kingdom
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44
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Webb AK, Dodd ME, Moorcroft J. Exercise and cystic fibrosis. J R Soc Med 1995; 88 Suppl 25:30-6. [PMID: 7776326 PMCID: PMC1295056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Affiliation(s)
- A K Webb
- Cystic Fibrosis Unit, Wythenshawe Hospital, Manchester
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