Effect of tripod position on objective parameters of respiratory function in stable chronic obstructive pulmonary disease.

Objective. To examine changes in respiratory dynamics in patients with chronic obstructive pulmonary disease (COPD) sitting leaning forward with hands supported on the knees (tripod position), a posture frequently assumed by patients in respiratory distress. Methods. Spirometry, maximal inspiratory and expiratory pressures (MIP and MEP) generated at the mouth, and diaphragmatic excursion during tidal and vital capacity maneuver breathing measured by B-mode ultrasonography were studied in 13 patients with stable COPD in sitting, supine and tripod positions. Results. Mean±SD age of patients was 52.2±6.8 years. Median disease duration was three years. There was no statistically significant difference in spirometry for sitting, supine and tripod positions (FEV1: 1.11±0.4L, 1.14±0.5L and 1.11±0.4L; p=0.99), respectively, (FEV1/FVC: 49.2±11.0, 53.7±8.5 and 48.5±11.3, p=0.37), mouth pressures (MIP: 102.9±28.9, 90.6±29.1 and 99.2±32.9 cm H2O, p=0.61 and MEP: 100.8±29.9, 100.4±34.4 and 90.6±32.6 cmH2O, p=0.74) and diaphragmatic movements during tidal (16.1±5.9, 20.1±6.8 and 16.6±6.2 mm, p=0.22) and forced breathing (33.9±11.0, 43.1±19.6 and 37.4±17.1 mm, p=0.35). Conclusion. Commonly measured indices of respiratory function were not different in the tripod compared to sitting and supine positions.

Derivation of a prognostic equation to predict in-hospital mortality and requirement of invasive mechanical ventilation in patients with acute exacerbation of chronic obstructive pulmonary disease.

OBJECTIVE: Predicting in-hospital mortality and formulating a scoring system derived from predictors of mortality may aid prognostication. METHODS: One hundred and fifty-one consecutive patients admitted with a diagnosis of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) were followed to discharge or death in hospital stay. Secondary variables studied were duration of hospital stay, and need for and duration of mechanical ventilation (MV). RESULTS: Mean (SD) age of patients was 60.5 (11.4) years; 65.6% were mechanically ventilated, and 25.2% died in hospital. Independent predictors of mortality at admission were serum creatinine (odds ratio [OR] 2.1, 95% Confidence intervals [CI] 1.03 to 4.30; p = 0.04), and serum sodium (OR 0.94, 95% CI 0.90 to 0.99; p = 0.03). An equation derived [Score = 8+ (0.74 x creatinine) = (0.015 x sodium)] to predict mortality, had an area under receiver operating characteristic (ROC) curve of 73%, with a cut-off of 6.74 having sensitivity, specificity, positive and negative predictive values for predicting death of 71%, 64%, 40% and 87%, respectively. Glasgow coma scale (GCS), partial pressure of oxygen in arterial blood (PaO2) and partial pressure of carbon dioxide in arterial blood (PaCO2) at admission independently predicted need for invasive ventilation. An equation derived [Score = 2.36+(0.02 x PaO2)+(0.05 x PaCO2)-(0.47 x GCS)] to predict need for MV, had an area under ROC curve of 85%, with a cut-off of 0.54 having sensitivity, specificity, positive and negative predictive values for predicting need for MV of 82%, 81%, 89% and 70%, respectively. CONCLUSIONS: Serum creatinine and sodium at admission are independent predictors of mortality for patients admitted with AECOPD. The equation derived from these two variables is a simple and useful method for predicting outcome.

Non-pharmacological management of hypertension.

Hypertension is a silent killer. Indians are racially predisposed to cardiovascular disease and the increasing burden of hypertension has only added to the problem. Economic constraints and the allure of additional benefits without adverse effects have made lifestyle modifications an attractive proposition in developing and developed countries alike. Blood pressure is a continuum and any increase above optimal confers additional independent risk of vascular disease, even in ranges previously considered normal. While antihypertensive agents have been used for those patients with blood pressure above the traditional cutoff, there has been increasing emphasis on the prevention and treatment of hypertension by non-pharmacological means, termed 'lifestyle modifications.' A MEDLINE search was done for relevant references with emphasis on original studies, randomized controlled trials and meta-analyses. Lifestyle modifications that effectively lower blood pressure are increased physical activity, weight loss, limited alcohol consumption, reduced sodium intake and the Dietary Approaches to Stop Hypertension diet. Lifestyle modification is recommended as initial therapy in stage 1 hypertension before initiation of drug therapy and as an adjunct to medication in persons already on drug therapy. In pre-hypertensives, it can reduce the incidence of hypertension and lower end-organ damage. It is emphasized that simple advice from physicians can have a positive influence on patients' motivation to make lifestyle changes.