The Conundrum of Volume Status Assessment: Revisiting Current and Future Tools Available for Physicians at the Bedside.

Assessment of patients' volume status at the bedside is a very important clinical skill that physicians need in many clinical scenarios. Hypovolemia with hypotension and tissue under-perfusion are usually more alarming to physicians, but hypervolemia is also associated with poor outcomes, making euvolemia a crucial goal in clinical practice. Nevertheless, the assessment of volume status can be challenging, especially in the absence of a gold standard test that is reliable and easily accessible to assist with clinical decision-making. Physicians need to have a broad knowledge of the individual non-invasive clinical tools available for them at the bedside to evaluate volume status. In this review, we will discuss the strengths and limitations of the traditional tools, which include careful history taking, physical examination, and basic laboratory tests, and also include the relatively new tool of point-of-care ultrasound.

Does a history of exercise in COPD patients affect functional status? A study using a lifetime physical activity questionnaire investigates a correlation between exercise and functional status as evidenced by six-minute walk distance.

Recent studies have shown strong associations between chronic exercise and improved spirometric values. Building on these findings, we investigated whether habitual lifetime exercise influences six-minute walk test performance (6MWT) in subjects with at least 10 pack-years smoking history. The 6MWT was chosen for its correlation with performance on activities of daily living and predictive value for inactivity, morbidity and mortality in individuals with chronic obstructive pulmonary disease (COPD) versus spirometric values, which are less adept at predicting functional status. Because COPD is a global cause of disability, therapeutic measures that delay symptom-induced immobility are more cost-effective versus late-stage interventional therapies. Among 49 subjects, we compared lifetime exercise assessed with a validated physical activity questionnaire with six-minute walk distances (6MWD). The American College of Sports Medicine's (ACSM) recommended exercise levels (30 minutes/day, 1000 kcal/week) were used as a benchmark. Among subjects with spirometry-determined lung obstruction (n = 21), those who have not met at least half of ACSM guidelines (500 kcal/week) were classified as "Inactive," while others were "Active." A significant difference in 6MWD was found between Inactive and Active subjects: (1123.86ft vs. 1468.25ft, STDev = 210.07 vs. 240.25, p = 0.0045). This difference was not found in subjects without lung obstruction. Pack-years was a significant covariate: subjects who smoked less walked farther distances. No relation was found between exercise and predicted FEV(1)%. In summary, our case-control study suggests that meeting even half of ACSM exercise guidelines could improve functional status in smokers if habitual exercise is adopted early in life.

2007 San Diego wildfires and asthmatics.

CONTEXT: This case series reports the changes in the respiratory health of eight asthmatic subjects and the relationship with air quality associated with the October 2007 firestorm in San Diego County of California. CASE PRESENTATION: Participants were eight subjects with asthma enrolled in Asthma Clinical Research Network (ACRN) (NIH# U10-HL074218) studies at the University of California San Diego (UCSD), School of Medicine, who had study data collected immediately prior, during and 1 month after the 5-day firestorm in San Diego County. Air quality deteriorated to an extreme average of 71.5 mg/m(3) small particulate matter less than 2.5 µm (PM(2.5)) during the firestorm. Respiratory health data included morning and evening peak expiratory flow rates (PEFR), morning and evening Forced Expiratory Volume in one second (FEV(1)), rescue medication usage, and sputum eosinophils. Morning and evening PEFR and FEV(1) rates remained stable. The two subjects tested during the fires had elevated eosinophil counts and rescue medication usage was increased in five of the eight subjects. DISCUSSION: Pulmonary function test values were stable during the wildfires for all eight subjects but there was a statistically significant increase in rescue medication usage during the wildfires that correlated with PM(2.5) values. The two subjects tested during the fires showed increases in sputum eosinophil counts consistent with increased airways inflammation. RELEVANCE: These findings suggest that poor air quality associated with wildfires resulted in an increase in airways inflammation in these asthmatic subjects, but pulmonary function tests remained stable, possibly due to increased rescue medication usage. This is especially pertinent as there is an increase in incidence of wildfires this decade.