Evaluation of superiority of FEV1/VC Over FEV1/FVC for classification of pulmonary disorders

Introduction: Forced expiratory value in one score [FEV1]/ Forced vital capacity [FVC] was used in classical literature for primary classifications of pulmonary disorders. American Thoracic Society/ European Respiratory Society guidelines recommended using FEV1/VC instead of FEV1/FVC. The aim of study was determination of the extent of superiority of FEV1/VC over the FEV1/FVC

Materials and Methods: Two hundred seven subjects whom suffered from different pulmonary disorders were evaluated by standard spirometry, lung volume and Carbon mono-oxide lung diffusion capacity [DLCO]. Accuracy of FEV1/VC and FEV1/FVC for diagnosing lung disease was compared by area under the ROC curve, sensitivity and specificity analysis including Kraemer efficiency and likelihood ration methods. Gold standards were diagnosis confirmed by over-all clinical and para-clinical judgment

Results: Primary classification of FEV1/FVC and FEV1/VC according to gold standards showed that FEV1/FVC detected obstructive and restrictive lung disease better than FEV1/VC. FEV1/FVC was able to detect the obstructive and restrictive lung disease correctly in 61% and 34% and FEV1/VC in 56% and 33% respectively. FEV1/FVC showed 100% agreement with forced expiratory flow [FEF]=25-75%, and Maximum expiratory flow [MEF]=50% but this agreement for FEV1/VC was 95-96%. Accuracy assessments revealed the superiority of FEV/FVC in the likelihood ratio method. Also, based on the ROC curve and Kraemer's coefficient, more accurate results were obtained by FEV1/FVC, compared to FEV1/VC

Conclusion: FEV1/FVC showed marginally higher accuracy for detecting lung disease than FEV1/VC

Computed tomography imaging findings in chemical warfare victims with pulmonary complications

Data on imaging findings in pulmonary complications of chemical agents is scarce. The current study aimed to evaluate radiological findings of late onset pulmonary complications in chemical warfare victims [CWV] and to guide pulmonologists in diagnosis of these subjects. Ninety- three male CWV were enrolled in this prospective study, 20-25 years [mean=23] after exposure. Demographic and clinical data were recorded. High resolution computed Tomography [HRCT] of the lung was performed during inspiration and expiration and was double reported blindly by two radiologists. Final diagnosis was made according to HRCT findings. The HRCT findings, final diagnosis, and distribution of the abnormalities were compared between subjects whom had been exposed to more complex chemical agents used during the second half of the war and simpler agents during the first half. The most frequent HRCT findings were air trapping [56.7%] and mosaic attenuation [35.1%]. The distribution of abnormalities was mostly local [79.4%] and bilateral [73%] especially in lower regions [61.3%]. The diagnosed respiratory diseases included bronchiolitis obliterans [43%], chronic obstructive pulmonary disease [COPD] [27.9%], asthma [23.6%], bronchiectasis [13.9%] and interstitial lung disease [ILD] [9.6%]. Frequency of subjects involved in the second half of the period of war was more than the first period [P-value < 0.05] but the HRCT findings were similar. Bronchiolitis obliterans with picture of focal bilateral air trapping was the most common finding in CWV but asthma appeared to have become a new problem in these subjects

Atypical radiological findings in patients with Hydatid cysts of the lung, study of 1024 cases

Introduction: The objective of this study was to give a description of the most prominent atypical radiological presentations of lung hydatidosis

Materials and Methods: All patients diagnosed with pulmonary hydatidosis by surgical exploration were included in this study. Standard chest roentgenogram and computed tomography CT] were evaluated before surgery for lung cysts or unknown lesions. Radiological findings were divided into two categories: 1- Typical hydatid cysts that were previously presented by imaging as a hydatid cyst in the form of an intact cyst, water lily sign and crescent sign. 2- Atypical hydatid cysts that were not similar to typical previously mentioned hydatid cysts

Results: During a 26-year period, 1024 subjects with pulmonary hydatidosis were diagnosed and operated on. Chest X-rays [interpreted in 832 cases] showed perforated cysts in 190 [23%] and atypical findings such as mass, alveolar type infiltration, abscess and collapse in 113 [13%] patients. Seventy-nine patients had a thoracic CT scan in which atypical cysts were detected in 32 subjects [40.5%] such as: thick wall cavity in 9 patients [28%], solid masses in 7 [21%], abscesses in 6 [18%], consolidation in 3 [9%], fungus balls in 3 [9%], collapse [atelectasis] in 2 [6%] and round pneumonia in 2 [6%]. Cavity was significantly more frequent in the right lung [90%] and mass-like opacity was significantly more frequent in the lower lung field [100%]

Conclusion: Hydatid cysts should be considered for most of localized radiological pictures of the lung without respect to localization, size and count of lesions

Pattern of pulmonary function test abnormalities in anthracofibrosis of the lungs

The objective of this study was to discuss the spirometric characteristics of anthracofibrosis which is a from of bronchial anthracosis associated with deformity. Forty anthracofibrosis subjects who were diagnosed with bronchoscopy were enrolled in this prospective study. Static and dynamic spirometry plus lung volumes and diffusion capacity were measured in this group and compared to a healthy control group. Dyspnea [95%], cough [86%] and wheezing [68%] were the most frequent clinical findings. Spirometry showed significant decrease in all parameters including VC [FVC], FEV1, FEV1/FVC, FEF25-75 and FEF25-75 /FVC. The low value of FEV1/FVC and FEF25-75 and the increment of RV were in favor of obstructive patterns in 95% of subjects. Improving the obstruction with bronchodilator was not significant and diffusion capacity was mostly normal. Anthracofibrosis should be added to the list of chronic obstructive pulmonary diseases

Level of eosinophil cationic protein in sputum of chemical warfare victims

Considering fair response to inhaled corticosteroids and reports of severe air way hyper responsiveness in chemical warfare victims [CWV], a role for eosinophilic inflammation [i.e. asthma] was postulated. The objective of this study was to determine the presence of eosinophilic inflammation in CWV by evaluation of Sputum cellularity and eosinophil cationic protein [ECP]. Forty CWV and 15 control subjects entered this cross sectional study. Demographic data, dyspnea severity scale, spirometry results and 6 min walk test were determined. Sputum was collected with inducing by nebulizing hypertonic saline and analyzed for total inflammatory cell count, the cellular differential count and ECP level. Control group was normal volunteers with PC[20] more than 8 mg/ml. Mean +/- SD of eosinophil percentage [11.7 +/- 11.1%] and ECP level in sputum of CWV [46.1 +/- 19.5 ng/ml] were significantly more than control group. Regression analysis showed significant correlation between ECP level and percentage of eosinophils in sputum [r= +0.43, P< 0.01]. ECP level of CWV subjects with obstructive pattern did not show any significant difference from CWV with normal spirometry. ECP level in CWV subjects who revealed more than 12% improvement in forced expiratory volume in one second [FEV1] was significantly higher than CWV who had improvement less than 12% [P= 0.01]. BO and asthma as final clinical diagnosis of CWV did not show any significant difference of sputum ECP. Bronchial inflammation in different types of pulmonary complication of CWV is eosinophil dependent. ECP level of sputum in CWV could guide physician to select CWV who would respond to corticosteroids

Prevalence of asthma in children of chemical warfare victims

Exposure of DNA to sulfur mustard gas may increase the inheritance of asthma in chemical warfare victims' [CWV] offspring. The objective of this study was to determine the prevalence of asthma in children of CWV and compare it to asthmatic children in the general population. Four hundred and nine children from 130 CWV fathers and 440 children from 145 asthmatic parents from two cities in Iran participated in this study. The prevalence of asthma was determined by standard questionnaire released for epidemiological survey of asthma in children and compared between two groups. The prevalence of asthma in the CWV group was 15%; this was not significantly different from the control group [12.5%]. The children of the CWV group reported a significantly greater incidence of wheezing [1.2 +/- 3.1 attacks] per year, but the control group reported more severe attacks leading to speech difficulties [3%] and coughing [7%]. Regression analysis showed that with increasing family size in the control group, the number of subjects suffering from asthmatic symptoms decreases significantly [r=0.86, P=0.001]

Acute effect of water pipe smoke on sensitized animals

This study aimed to compare the inflammatory effects of water pipe smoke with cigarette smoke on inducing exacerbation in asthmatic murine model, under similar conditions of exposure. Thirty-six BALB-C mice in six different groups [one control group, one asthmatic group and four groups of asthmatic exposed to smoke] were entered the study. Animals were exposed to cigarette and water pipe smokes and samples were obtained after 6 and 24 hours. Bronchoalveolar lavage fluid [BALF] was collected and analyzed for neutrophils, eosinophils, nitric oxide, Interferon-gamma [IFN-delta] and lnterleukin-4 [IL-4]. Serum Interferon-gamma and IL-4 were also evaluated. Both lungs were sent for histopathological examination. In all sensitized animals, BALF cytology showed a significant decrease in neutrophils and lymphocyte percentage and significant increase of eosinophils. The level of nitric oxide in all smoke exposed animals was significantly higher than sensitized controls. Water pipe smoke did not affect the IL-4 level, but cigarette smoke decreased IL-4 after 6 hours. The level of IFN-gamma in BALF decreased after 6 hours of exposure in both exposed groups and returned to baseline after 24 hours. Exacerbation of asthma by water pipe smoke is comparable to that of cigarette smoke. The mechanism of action may be through the suppression of the type 1 T helper cells

Loose body in the main bronchus due to broncholithiasis

Anthracosis of the lung is black discoloration of bronchial mucosa that may distort and occlude the bronchial lumen and cause significant clinical findings named "Anthracofibrosis". In this article a rare presentation of this disease and related complications were reported. A 73 year-old woman with a 10-year history of chronic cough, dyspnea, weight loss and wheezing was referred to us for exacerbation of her symptoms in winter. She was a known case of anthracosis. Her previous bronchoscopy and sampling were inconclusive. Her recent computed tomography [CT] scan showed bilateral parenchymal infiltration, multiple lymph node calcifications and an intra-luminal calcified material in the left main bronchus. Bronchoscopy showed a floating foreign body in the left main bronchus and infiltration of the right and left main bronchi. Bronchial lavage showed plenty of acid fast bacilli and biopsy showed granulomatous reaction in favor of tuberculosis. In conclusion, we believe that broncholithiasis should be considered as a chronic complication of anthracosis

Accuracy of mid expiratory flow and dysanapsis parameters for evaluation of methacholine provocation test

The most sensitive parameter for evaluation of airway hyper-responsiveness is PC35 [35% decrease in specific airway conductance]. But assessment of this parameter requires expensive equipments. This study aimed to evaluate mid expiratory flow and dysanapsis parameters in standard spirometry for possible substitution of PC35.Thirty-seven subjects with clinical findings suggestive of asthma who had normal standard spirogram were entered in this case-control prospective study. Thirty- seven healthy volunteers were also included in this study as controls. Airway responsiveness was examined by methacholine challenge test and measurement of PC20 and PC35. In addition, concentration of methacholine needed for 20% reduction in FEF25-75%, MEF50%, and FEF25-75%/FVC was determined and compared with PC35 as the gold standard. FEF25-75%/FVC ratio was used for evaluation of dysanapsis. PC35 was more sensitive than PC20 and was obtained in 93% [68/73] of patients in both groups. Although PC35 and new parameters could be positive in both groups, the concentrations in two groups were significantly different. Regression model showed that in asthmatic patients all the conventional and new parameters had good and comparable correlations with PC35. But in the control group alone and in both asthmatic and control groups, PC 20 of FEF25-75%/FVC showed a significant correlation with PC35. PC20 of FEF25-75/FVC was also significantly correlated with PC20 of FEV1 in asthmatic and control groups. PC20 of FEF25-75/FVC and MEF50% revealed the best accuracy. An equation was determined for calculation of PC35 according to PC20 of FEF25-75/FVC and MEF50% when PC35 was unavailable. PC20 of FEF25-75/FVC ratio and MEF50% are sensitive parameters for diagnosis of airway responsiveness. PC20 of FEF25-75/FVC is the best substitution for PC35

Best drugs for avoiding paradoxical bronchospasm during spirometry

Asthma could be diagnosed by its characteristic presentation. Spirometry can help the diagnosis by revealing post-bronchodilator response. Classically, salbutamol [albuterol] is used for evaluating post-bronchodilator response. This drug causes paradoxical bronchospasm in less than 10% of asthmatic patients. This study aimed to evaluate the frequency of paradoxical bronchospasm with salbutamol during spirometry and compare it with other drugs that did not reveal paradoxical bronchospasm such as levalbuterol and ipratropium. One hundred-Ninety two asthmatic subjects were entered in this clinical trial. All patients showed clinical manifestations of asthma and revealed obstructive pattern during spirometry. They were randomly assigned into three groups of drugs included: salbutamol, levalbuterol and ipratropium. Two puffs of these drugs were administered via a spacer and patients waited for fifteen minutes for the maximal effect to take place. Then spirometry was obtained again and postbronchodilator FEV1 and its alterations were compared among the three groups. The mean +/- SD age of patients was 49.40 +/- 17.4 years; the mean age, demographic data, clinical findings and spirometry results showed no significant difference among groups. FEV1 percent of predicted was 58.6 +/- 19.5 which proved that most subjects were suffering from severe asthma. Improvement of FEV1 by salbutamol [22.2 +/- 3%] and levalbuterol [16 +/- 18%] was significantly more compared with ipratropium [9.4 +/- 11%] [t=2.5, P=0.01 and t=2.2, P=0.01, respectively]. Paradoxical bronchospasm [more than 12% decrease in FEV1] was seen in two [3%], one [1.5%] and four [6%] subjects of salbutamol, ipratropium and levalbuterol groups, respectively. Regarding clinical improvement, levalbuterol resulted in the higher frequency of clinical improvement compared to salbutamol and ipratropium. With the dosage recommended for reversibility testing during spirometry, salbutamol showed comparable bronchodilator response and paradoxical bronchospasm frequency compared to levalbuterol and ipratropium

Inhaled corticosteroids and bone density in chemical warfare patients with pulmonary complications

The most effective treatment in chemical warfare victims [CWV] suffering from severe long-term obstructive pulmonary disease is inhaled corticosteroids [ICS] and long acting beta-2 agonists. Study results on adverse effects of ICS on bone were conflicting. In the present study, we evaluated the effect of ICS on bone mineral density [BMD] of CWV and possible effects of chemical warfare agents on BMD. Thirty-five CWVs entered this study. Demographic and spirometric data [including staging of severity of lung disease] and BMD results as shown by z-score and t- score measured in lumbar and femoral regions were evaluated in this group of patients. In comparison, 75 normal subjects as controls were included in this study and their BMD results were compared with those of the case group. The mean age in CWVs was 41.40 +/- 7.74 years, which showed no significant difference with that of the control group. According to spirometric data, CWVs had obstructive lung disease. BMD in lumbar and femoral regions in the case group was 1.14 +/- 0.14 and 0.93 +/- 0.13 g/cm[2] respectively, which showed no significant difference with that of the control group. Regression analysis showed that BMD in the femoral region was correlated with forced expiratory volume in 1 second [FEV1] and forced vital capacity [FVC] and t-score in lumbar region was correlated with FEV1. BMD in the femoral region decreased as the severity of bronchial obstruction increased [0.99 +/- 1.07 g/cm[2] in mild form to 0.75 +/- 0.27 in severe form; F=3.91, P=0.03] but in the lumbar region BMD had no significant correlation with severity of bronchial obstruction. BMD did not decrease during long-term therapy with ICS in CWVs. Severity of bronchial obstruction can be an important risk factor

Surgical resection: the mainstay of management of type II pulmonary arteriovenous malformations

Twenty percent of pulmonary arteriovenous malformations [PAVM] are type II PAVMs. This type of PAVM is characterized by less than 5 AVMs in the body and no other vascular anomalies such as AV fistulas or aneurisms. We studied seven cases of type II PAVMs in which surgical resection was the mainstay of treatment. All were free of symptoms and without relapse after the surgery. During a 26-year period, 7 subjects proven to have PAVM by imaging studies were entered in this cross-sectional study. Demographic, clinical and imaging findings along with results of catheterization and angiography were collected. All cases were operated on and followed to assess the results of surgery, complications and recurrence. Seven cases were entered in this study [five males and two females]. Seventy-one percent of our patients were in the first decade of life. Dyspnea and cough were present in 6[85%] and 5 cases [71%], respectively. Physical exam showed polycythemia in 5 [71%], clubbing in 4[57%] and arterial bruit over the chest in 2 [28%] cases. Two paradoxical emboli were seen, [one to the brain and one to the coronary artery]. Family history was negative. Chest x-rays revealed large PAVMs in 5 cases [71%]. Diagnosis was made by CT-scan, catheterization, angiography, and histopathology. Location of lesions was in the lower lobes in all cases. Surgical approach was lobectomy in 5 cases and segmentectomy in two cases. Operations were without any compilcation and the patients were symptom-free thereafter. Surgical resection of large PAVMs was completely curative without any early or late complications