Rare Cause of Severe Dyspnea After Tracheotomy-Negative Pressure Pulmonary Edema.

Deep neck infections are serious conditions and can present with acute upper airway obstruction. Our priority in the treatment is to ensure airway safety, and tracheotomy may be needed to overcome the upper airway obstruction. Unceasing dyspnea after tracheotomy should suggest serious pulmonary pathologies in patients with upper airway obstruction due to deep neck infection. Acute/chronic obstruction resolved after tracheotomy or upper respiratory tract surgical procedures of obstructive sleep apnea patients can turn into severe dyspnea with pulmonary edema. In this report, we present a 46-year-old male patient with negative pressure pulmonary edema as a complication of tracheotomy. The tracheotomy was performed due to severe upper airway obstruction secondary to a deep neck infection. The importance of early diagnosis and prompt treatment of this rare entity after unceasing dyspnea despite tracheotomy is discussed in the light of the current literature.

The evaluation of disease awareness, caregiver burden, and workday loss in caregivers of COPD patients.

BACKGROUND: Our aim is to determine the caregiver burden of chronic obstructive lung disease (COPD) patient's caregivers, and to determine whether there is a workday loss. METHODS: 252 COPD patients and their caregivers were included. Disease information of the patients were recorded and a questionnaire was applied. Socio-demographic characteristics of the caregivers were recorded and a questionnaire consisting of 24 questions including COPD disease, treatment and loss of working days, and the Zarit Scale were used. RESULTS: 128(50.8%) of the patients according to GOLD were group-D, 97(38.5%) of the patient's relatives were working, 62(24.7%) were not able to go to work for 1-14 days, and 125(57.1%) spent outside the home from 1-14 nights, because those accompanied to patients. In univariate analysis were detected modified medical research council (mMRC) (p < 0.001), CAT (p < 0.001), the number of comorbidities of patients (p = 0.027), forced expiratory volume in 1 FEV1cc (p = 0.009), FEV1% (p < 0.001), the presence of long term oxygen therapy (LTOT), and the number of comorbidities of the patient's relatives (p = 0.06) increased the care load. In multiple linear regression analysis, age (p = 0.03), COPD assessment test (CAT) score (p = 0.001), FEV1% (<0.068) and the number of comorbidities of patients (p = 0.01) and the number of comorbidities of caregivers (p = 0.003) increased the caregiving burden. DISCUSSION: In COPD increases caregiving burden. This burden is greater in symptomatic patients and when comorbidities are present. Psychosocial and legal regulations should be investigated and solutions should be produced for the caregivers of COPD patients.

Is the Perioperative Period No Longer a Problem for Adult Asthmatics under Control?-OPERA Study.

OBJECTIVES: Asthma is a global problem and chronic condition that persists through patient's entire life, during which the possibility of a surgical procedure is common. An accurate clinical and functional evaluation of respiratory functions and asthma control is needed in patients undergoing surgical procedures and requiring general anesthesia. The aim of this study was to disclose any possible relation between postoperative complications and some pre- and postoperative factors. MATERIALS AND METHODS: In this prospective cross-sectional study, randomly selected 111 asthmatic patients who presented to 10 different tertiary centers were included. The patients were evaluated at three different periods; any day between 1-7 days before surgery, and postoperative third and seventh to tenth days. RESULTS: Among the patients included in the study, 86 (77.5%) were women and mean age was 52.2±13.8 years. General anesthesia was the most common anesthesia type (89.2%), and 33.3% of patients had had a thoracoabdominal surgery. There was a statistically significant difference between pre- and postoperative third-day values, including ACT scores (22.2±3.16 and 21.59±3.84, respectively; p<0.001); forced expiratory volume during the first second (84.92±19.12 and 78.26±18.47, respectively; p<0.001); peak flow rate (79.51±21.12 and 70.01±19.72, respectively; p<0.001); and SaO2 (96.95±1.82 and 95.8±3.32, respectively; p<0.001). Bronchospasm and pain were the most common complications during the postoperative period. CONCLUSION: Controlled asthma under treatment steps 1-2-3 does not cause any serious postoperative pulmonary complications (PPCs). Therefore, achieving an optimal control level of asthma during the preoperative period must be considered the "gold standard" to reduce the risk of PPCs in asthmatic patients.

The impact of hypoxemia on serum total and free prostate-specific antigen levels in patients with chronic obstructive pulmonary disease.

Prostate-specific antigen (PSA) is the most important biochemical marker in the diagnosis and follow-up of patients with prostate cancer. In recent years, a relationship between PSA levels and hypoxic conditions has been described. However, no study has investigated the PSA levels in patients with chronic obstructive pulmonary disease (COPD). The aim of the present study was to investigate the impact of hypoxemia on serum total (tPSA) and free PSA (fPSA) levels in patients with COPD. Between January 2010 and January 2014, 95 male patients who hospitalized for acute exacerbations of COPD and 80 control subjects were enrolled in the study. Serum tPSA and fPSA levels and f/tPSA ratios were determined in all patients on the first day of hospitalization (exacerbation) and 7 days after the treatment (stable state). Statistical analysis included paired t test and Mann-Whitney U test. No statistically significant differences were found between COPD and control groups with regard to the baseline characteristics, except for smoking status. The levels of serum tPSA and fPSA during exacerbation of COPD were significantly higher than the levels of the stable period (p < 0.01), whereas f/tPSA ratio did not change (p > 0.05). Hypoxemia during acute exacerbation of COPD can cause a rise in serum tPSA and fPSA levels, but f/tPSA ratio is not affected. Acute exacerbation of COPD may be added to list of the events in which PSA measurements must be interpreted with caution.

[Misdiagnosis of pulmonary embolism and causes]. / Pulmoner embolide yanlis tani ve sebepleri.

INTRODUCTION: Pulmonary thromboembolism (PTE) is not only one of the prevelant diseases with a high mortality risk but also has a high ratio of delayed diagnosis and misdiagnosis. In this study, it was aimed to determine the demographical characteristics, risk factors, clinical and laboratory findings of the patients that were diagnosed as PTE at their first hospital visit and of the PE patients who were misdiagnosed at their first admission. We aimed to investigate the factors which can leads to misdiagnosis of PE, and to determine the ways to avoid misdiagnosis. MATERIALS AND METHODS: One hundred PTE patients who were admitted to University Hospital between the dates January 2007-December 2011 were included in the study. Clinical and laboratory findings of these patients were evaluated. Among these patients, 26 were misdiagnosed at their first admission but diagnosed accurately (as PTE) in our hospital and 74 were diagnosed accurately. Two groups were compared with respect to various data of the patients clinical and demographical characteristics. RESULTS: Between the two groups, there was no difference in terms of physical examination and laboratory findings. The patients with the symptoms onset was over a week ago had a higher misdiagnosis rate (p= 0.002). The patients with no risk of PTE had a higher misdiagnosis rate (p= 0.017). Misdiagnosis rate of the patients with cardiac diseases was lower (p= 0.033) According to Geneva risk score, we observed that the misdiagnosis risk was reduced in the patients with higher clinical probability (p= 0.011). CONCLUSION: In conclusion, misdiagnosis rate was found to be statistically significant in the patients with low score according to the Geneva risk classification, and whose pre-diagnosis period lasted for more than a week and with no risk factors of PTE or cardiac diseases. We are in the opinion that considering these parameters will help to reduce in misdiagnosis of pulmonary embolism cases.

Ventilator-associated pneumonia due to extensive drug-resistant Acinetobacter baumannii: risk factors, clinical features, and outcomes.

Acinetobacter baumannii is characterized by a rapid development of resistance to the commonly used antimicrobial agents. We investigated the risk factors, clinical features, and outcomes in ventilator-associated pneumonia (VAP) caused by extensive drug-resistant Acinetobacter baumannii (XDRAB). Clinical parameters and overall in-hospital mortality rates were compared between the VAP with and without XDRAB infection groups. This study showed that VAP caused by XDRAB was not associated with in-hospital mortality. However, it was related to high Simplified Acute Physiology Score II scores and increasing durations of hospital stays.

[Validity and reliability of Turkish version of St. George's respiratory questionnaire]. / St. George solunum anketinin Türkçe geçerlilik ve güvenilirligi.

INTRODUCTION: The importance of the evaluation of health status in chronic obstructive pulmonary disease (COPD) is recently highlighted in many studies. In this study, we aimed to test the validity and reliability of the Turkish version of St. George Respiratory Questionnaire (SGRQ). MATERIALS AND METHODS: The study was conducted in seven centers in Turkey. Three hundred and twenty one COPD patients (40-75 years) were included to the study. Turkish versions of breathlessness, Cough, and Sputum Scale (BCSS), mMRC (Modified Medical Research Council) dyspnea scale, SGRQ, COPD assessment test (CAT) and Short Form Health Survey (SF-36) were carried out to the patients. The statistical analysis of SGRQ was performed by using the coefficient of internal consistency, discriminative analysis for different stages and the correlation with the other scales. RESULTS: The mean age was 62.4 ± 8.9 years and the mean FEV1 was 51.9 ± 19.2% pred. The coefficient of internal consistency (Cronbach alpha) was 0.8815. The correlation between the total score measured initially and that obtained two weeks later was found to be highly significant (r= 0.90, p< 0.0001). According the results of validation of both total score and the components of SGRQ, the correlation between the total score of SGRQ and CAT was 0.782 (p< 0.0001), SGRQ and SF-36 was between -0.481 ile -0.819 (p< 0.0001). The total and component scores were able to discriminate different disease stages and a significant correlation was found to be with pulmonary function tests. CONCLUSION: SGRQ Turkish version is a reliable and valid assessment tool for COPD patients in clinical practice.

Assessment of long-term omalizumab treatment in patients with severe allergic asthma long-term omalizumab treatment in severe asthma.

OBJECTIVE: Several clinical studies have demonstrated the effectiveness of omalizumab in patients with severe allergic asthma but the treatment period has always been relatively short (4-12 months). In the literature, there are a few data about the long-term omalizumab therapy. We aimed to assess the long-term clinical and functional effectiveness of omalizumab treatment in severe allergic asthmatic patients, METHODS: Medical records describing the patients' status before the start of treatment, and also having been registered at the end of 4th, 12th, and 36th months from the commencement of treatment, and at the last visit where the patient was evaluated were used for omalizumab effectiveness assessments. Twenty-six patients (female/male: 21/5) with severe allergic asthma, uncontrolled despite GINA 2006 Step 4 therapy, were included in the study. Effectiveness outcomes included spirometry measurements, level of asthma control measured by asthma control test (ACT), systemic glucocorticosteroid (sGCS) use, emergency room (ER) visits, and hospitalizations for severe exacerbations. In addition, the quality of life was assessed using the quality of life questionnaire AQLQ(S) before, 4, and 36 months after treatment, RESULTS: The mean age was 47.6 ± 13.9 and duration of allergic asthma was 22.7 ± 10.1 years. Serum total IgE levels were 322.0 ± 178.1 IU/mL. Mean duration of omalizumab treatment was 40.81 ± 8.2 months. FEV1 improved significantly at all control points versus baseline (p < .05). The level of asthma control as evaluated by ACT improved significantly after treatment (p < .05). We determined significantly reduced numbers of exacerbation, emergency visits, hospitalizations, sGCS, and SABA use by the end of 36 months (p < .05). The proportion of patients with improvements larger than 1.5 points in AQLQ(S) total score was 80.7% at the 4th month and 96.1% at the 36th month of treatment, CONCLUSIONS: This study showed that long-term therapy with omalizumab for up to 3 years was well tolerated with significant improvement both in symptoms and lung functions. Accordingly, long-term omalizumab treatment may be recommended for responders.

An integrated index combined by dynamic hyperinflation and exercise capacity in the prediction of morbidity and mortality in COPD.

BACKGROUND: Dynamic hyperinflation (DH) and exercise limitation develop in patients with COPD; however, there is lack of knowledge about their long-term clinical consequences. We aimed to assess the impact of DH and exercise capacity in predicting mortality and also morbidity, as evaluated by emergency visits and hospital admissions in COPD patients during a 4-year period. METHODS: We recruited 73 stable COPD patients. The relationships of different respiratory parameters (FEV(1)%, body mass index, 6 min walk test distance [6MWD], static hyperinflation as measured by the ratio of inspiratory capacity to total lung capacity (IC/TLC) at rest, DH as measured by the change between the post- and pre-exercise values of IC/TLC [ΔIC/TLC], P(aO(2)), and P(aCO(2))) with emergency visits and hospital admissions because of exacerbations and also with respiratory and all-cause mortality were assessed. RESULTS: The median follow-up period was 47 months (IQR 45-48 months, n = 73). During the follow-up there were 8 (11%) deaths. The ΔIC/TLC value was 3.9 ± 4.6%. The Kaplan-Meier survival curve showed that the cumulative survival rate was significantly lower in the patients with ΔIC/TLC > 4 and with 6MWD ≤ 439.56 m, using these values as thresholds. (The rates for sensitivity were 100% and 87.5%, and for specificity were 56.92% and 87.69%, respectively). The Cox proportional hazards model showed that DH (hazard ratio = 1.4, 95% CI = 1.09-1.84, P = .009) and 6MWD (hazard ratio = 0.98, 95% CI = 0.97-0.99, P = .006) were independent predictors of all-cause and respiratory mortality. 6MWD, FEV(1)%, IC/TLC, and ΔIC/TLC were found to be significantly related to emergency visits (r = -0.28, r = -0.41, r = -0.24, and r = 0.38, respectively) and hospital admissions (r = -0.41, r = -0.45, r = -0.36, and r = 0.28, respectively). CONCLUSIONS: DH and exercise capacity are reliable and independent predictors for mortality and morbidity in COPD patients. We propose that DH and exercise capacity be considered in the assessment of long-term clinical consequences of COPD patients.

[Reliability and validity of Turkish version of COPD assessment test]. / KOAH degerlendirme testinin Türkçe geçerlilik ve güvenilirligi.

INTRODUCTION: This study is aimed to evaluate the reliability and validity of the Turkish version of chronic obstructive pulmonary disease (COPD) Assessment Test (CAT) in seven centers. MATERIALS AND METHODS: 321 patients between 4-75 years of age, diagnosed and staged by Global Initiative for Obstructive Lung Disease (GOLD) 2011 criteria were included. The Breathlessness, Cough, Sputum scale (BCSS), mMRC (Modified Medical Research Council ) dyspnea index, St. George Respiratory Questionnaire (SGRQ), CAT and Short Form-36 (SF-36) were used concurrently. In the statistical analyses, internal consistency, item-total score correlation, explorative factor analysis, correlation with other scales were calculated. RESULTS: The mean age was 62.4 ± 8.9 years and 89.7% of the patients were male (n= 288). Mean FEV1% was 51.9 ± 19.2 and most of the patients were in Stage 3. CAT total score was 17.8 ± 9.5. In the internal consistency, Cronbach alpha coefficient was found as 0.9116 and item-total score correlation coefficients were between 0.62-0.79 and all were statistically significant (p< 0.0001). The correlation of the test-retest score calculated after two weeks with the initial score was 0.96 (p< 0.0001). In the structural validity, factor analysis with principle component analysis and varimax rotation was performed. One factor solution was achieved with eigenvalue of 4.956 and it represented 61.9% of the total variance. All the items were contained in the factor and the factor loads were between 0.71-0.85. The correlation coefficients of CAT with other indexes were moderate to good. The discrimination of CAT among disease stages has been shown to be significant (p< 0.0001) and a significant correlation was found with pulmonary function tests (p< 0.0001). CONCLUSION: It is demonstrated The Turkish version of COPD Assessment Tool is reliable and valid.

[How exactly can we predict the prognosis of COPD]. / KOAH hastalarinin progresyonlarini ne ölçüde tahmin edebiliriz?

Predictive models play a pivotal role in the provision of accurate and useful probabilistic assessments of clinical outcomes in chronic diseases. This study was aimed to develop a dedicated prognostic index for quantifying progression risk in chronic obstructive pulmonary disease (COPD). Data were collected prospectively from 75 COPD patients during a three years period. A predictive model of progression risk of COPD was developed using Bayesian logistic regression analysis by Markov chain Monte Carlo method. One-year cycles were used for the disease progression in this model. Primary end points for progression were impairment in basal dyspne index (BDI) score, FEV(1) decline, and exacerbation frequency in last three years. Time-varying covariates age, smoking, body mass index (BMI), severity of disease according to GOLD, PaO2, PaCO(2), IC, RV/TLC, DLCO were used under the study. The mean age was 57.1 + or - 8.1. BDI were strongly correlated with exacerbation frequency (p= 0.001) but not with FEV(1) decline. BMI was found to be a predictor factor for impairment in BDI (p= 0.03). The following independent risk factors were significant to predict exacerbation frequency: GOLD staging (OR for GOLD I vs. II and III = 2.3 and 4.0), hypoxemia (OR for mild vs moderate and severe = 2.1 and 5.1) and hyperinflation (OR= 1.6). PaO2 (p= 0.026), IC (p= 0.02) and RV/TLC (p= 0.03) were found to be predictive factors for FEV(1) decline. The model estimated BDI, lung function and exacerbation frequency at the last time point by testing initial data of three years with 95% reliability (p< 0.001). Accordingly, this model was evaluated as confident of 95% for assessing the future status of COPD patients. Using Bayesian predictive models, it was possible to develop a risk-stratification index that accurately predicted progression of COPD. This model can provide decision-making about future in COPD patients with high reliability looking clinical data of beginning.

[Effect of dynamic hyperinflation on exertional dyspnea, exercise performance and quality of life in COPD]. / KOAH'da dinamik hiperinflasyonun egzersiz dispnesi, egzersiz kapasitesi ve yasam kalitesine etkisi.

There is increasing evidence that dynamic hyperinflation (DH) have negative effects on exercise performance and quality of life in chronic obstructive pulmonary disease (COPD) patients. The aim of this study was to investigate effect of dynamic hyperinflation on exertional dyspnea, exercise performance and quality of life in patients with COPD. 72 clinically stable patients with moderate to severe COPD and 30 healthy age-matched control subjects were included in this study. Pulmonary function tests including lung volumes and maximal respiratory muscle forces, arterial blood gas analyses, evaluation of exertional dyspnea with the Borg scale, and The Saint George Respiratory Questionnaire (SGRQ, Turkish version) were performed at rest and after a 6-min walk test. We measured the change in inspiratory capacity (AlphaIC) after exercise to reflect DH. 80% of patients with COPD significantly decreased IC after exercise (DH). AlphaIC were -0.27 +/- 0.26 L in COPD and 0.8 +/- 0.17 L in controls (p= 0.001). A stepwise multiple regression analysis showed that to be a patient with COPD, Basal Dyspnea Index (BDI) and AlphaIC were the best predictors of 6 MWD (r(2)= 0.53, p< 0.001). FEV1 added an additinal 9% to the variance in 6 MWD. Exertional dyspnea (AlphaBorg) correlated with AlphaIC (r= -0.44, p= 0.0001) and BDI (r= 0.34, p= 0.02). AlphaIC significantly correlated with symptom (r= -0.36, p= 0.008), activity (r= -0.31, p= 0.03) and total scores (r= -0.30, p= 0.04) of SGRQ. Dynamic hyperinflation can often occur during exersice in patients with COPD. Extent of dynamic hyperinflation could able to explain exercise capacity limitation, exercise dyspnea, and poor quality of life in patients with COPD.