Ashtrays and signage as determinants of a smoke-free legislation's success.

INTRODUCTION: Successful smoke-free legislation is dependent on political will, enforcement and societal support. We report the success and pitfalls of a non-enforced nationwide smoke-free legislation in Greece, as well as ways in which compliance and enforcement-related factors, including ashtrays and signage, may impact indoor secondhand smoke (SHS) concentrations. METHODS: A follow-up study of venues (n=150, at baseline, n=75 at 2-year follow-up) in Greece assessed indoor particulate matter with a diameter less than 2.5 micrometers (PM 2.5 ) concentrations attributable to SHS smoke every six months for two years (n=455 venue/measurements). RESULTS: Following the implementation of the 2010 smoke-free legislation, mean PM2.5 concentrations attributable to SHS fell from 175.3 µg/m(3) pre-ban to 84.52 µg/m(3) immediately post-ban, increasing over subsequent waves (103.8 µg/m(3) and 158.2 µg/m(3) respectively). Controlling for potential influential factors such as ventilation, time of day, day of week, city and venue type, all post-ban measurements were still lower than during the pre-ban period (Wave 2 beta: -118.7, Wave 3 beta: -87.6, and Wave 4 beta: -69.9). Outdoor or indoor signage banning smoking was not found to affect SHS concentrations (beta: -10.9, p=0.667 and beta: -18.1, p=0.464 respectively). However, ashtray or ashtray equivalents were strong determinants of the existence of indoor SHS (beta: +67 µg/m(3), p=0.017). CONCLUSIONS: While the public may be supportive of smoke-free legislation, adherence may decline rapidly if enforcement is limited or nonexistent. Moreover, enforcement agencies should also focus on the comprehensive removal of ashtray equivalents that could act as cues for smoking within a venue.

Five-year trends of second-hand smoke exposure in Greece: a comparison between complete, partial, and prelegislation levels.

BACKGROUND: Our aim was to assess second-hand smoke (SHS) exposure in hospitality venues after the smoke-free legislation implemented in September 2010 in Greece and to compare with when a partial ban was in place and in 2006 when no ban was in place. METHODS: Hospitality venues were prospectively assessed for their indoor concentrations of particulate matter (PM(2.5)) during the partial ban phase (n=149) and the complete ban phase (n=120, 80% followed up), while overall and matched by venue comparisons were also performed (no ban vs. partial ban vs. complete ban). Comparisons with previously collected data in 2006 when no ban was in place also was performed. RESULTS: Indoor air levels of PM(2.5) attributable to SHS dropped following the transition from a partial to a complete ban by 34% (137 µg/m(3) vs. 90 µg/m(3), p=0.003). This drop was larger in bars (from 195 µg/m(3) to 121 µg/m(3)), than in cafes (124 µg/m(3) vs. 87 µg/m(3)) or restaurants (42 µg/m(3) vs. 39 µg/m(3)). PM(2.5) concentrations between 2006 (no ban) and the partial ban of 2010 were also found to decrease by 94 µg/m(3); however, among matched venues, the levels of indoor air pollution were not found to change significantly (218 µg/m(3) vs. 178 µg/m(3), p=0.58). Comparing the 2010 complete ban results (n=120) with previously collected data from 2006 when no ban was in place (n=43), overall PM(2.5) concentrations were found to fall from 268 µg/m(3) to 89 µg/m(3), while a matched analysis found a significant reduction in PM(2.5) concentrations (249 µg/m(3) vs. 46 µg/m(3), p=0.011). CONCLUSION: The complete ban of smoking in hospitality venues in Greece led to a reduction in SHS exposure, in comparison to when the partial ban or no ban was in place; however, exposure to SHS was not eliminated indicating the need for stronger enforcement.

Diagnostic accuracy of the rapid shallow breathing index to predict a successful spontaneous breathing trial outcome in mechanically ventilated patients with chronic obstructive pulmonary disease.

OBJECTIVE: To evaluate the diagnostic accuracy of 2 threshold values (105 breaths per minute [bpm]/L and 130 bpm/L) of the rapid shallow breathing index (RSBI) to predict a successful weaning trial outcome in a homogenous group of patients with chronic obstructive pulmonary disease (COPD). METHODS: A consecutive population of patients with COPD who were intubated for hypercapnic respiratory failure during a 2-year period were studied prospectively. RSBI was measured by 2 investigators at minute 5 of the T-piece trial, whereas 2 other physicians evaluated the 30 minute T-piece trial as successful or unsuccessful, according to clinical criteria. RESULTS: Of 64 patients with COPD (53 male, 11 female) who constituted the study population, 42 patients (35 male, 7 female; aged 70 ± 9.2 years) completed the spontaneous breathing trial (SBT) and remained clinically stable (group 1). The remaining 22 patients (18 male, 4 female; aged 71.9 ± 4.7 years) had to return to ventilatory support by the end of the SBT because of clinical deterioration (group 2). The 2 threshold values that were evaluated had low specificity (38.1% for < 105 bpm/L and 66.7% for < 130 bpm/L), low sensitivity (63.6% for < 105 bpm/L and 54.5% for < 130 bpm/L), and low diagnostic accuracy (46.8% for < 105 bpm/L and 65.6% for < 130 bpm/L) in predicting a successful T-piece trial outcome. CONCLUSION: RSBI measured early during an SBT cannot accurately predict the successful outcome of a T-piece trial in a homogenous population of patients with COPD.

Exercise capacity in idiopathic pulmonary fibrosis: the effect of pulmonary hypertension.

BACKGROUND AND OBJECTIVE: Increased pulmonary arterial pressure (PAP) usually coexists with impaired lung function in IPF. Data on the effect of pulmonary hypertension (PH) on cardiopulmonary responses during exercise in IPF patients is very limited. We sought to investigate the impact of PH on exercise capacity and the correlation between systolic PAP (sPAP) and pulmonary function testing, as well as cardiopulmonary exercise parameters, in patients with IPF and PH. METHODS: Eighty-one consecutive patients with IPF, who were evaluated over a 6-year period, were retrospectively studied. Patients underwent pulmonary function testing, Doppler echocardiography and maximal cardiopulmonary exercise testing. PH was defined as sPAP > 35 mm Hg. RESULTS: PH was diagnosed in 57% of the patients. Categorization of patients according to severity of PH indicated a significant reduction in maximum work rate, peak O(2) uptake, anaerobic threshold and peak O(2) pulse in those with sPAP > 50 mm Hg. In IPF patients with PH, estimated sPAP correlated with peak O(2) uptake, anaerobic threshold, peak O(2) pulse and end-tidal CO(2) at anaerobic threshold, while the strongest correlation was between sPAP and ventilatory equivalent for CO(2) at anaerobic threshold (r = 0.611, P < 0.001). There were no differences in pulmonary function or exercise parameters indicative of lung volume reduction, across the patient categories, and none of these parameters correlated with sPAP. CONCLUSIONS: PH has a negative impact on exercise capacity in IPF patients. In IPF patients with PH, resting sPAP correlated with exercise parameters indicative of gas exchange and circulatory impairment, but not with defective lung mechanics.

Sarcoidosis-associated pulmonary hypertension: a role for endothelin receptor antagonists?

Data on the treatment of sarcoidosis-associated pulmonary hypertension are scarce, while the variety of underlying pathophysiologic mechanisms are a major limitation in the implementation of a universal therapy. We report a 47-year-old male patient who presented with stage II sarcoidosis and associated severe pulmonary hypertension. Corticosteroid treatment resolved parenchymal lesions of the lung while vascular involvement did not respond, with the patient remaining in poor functional status. Addition of bosentan, a dual endothelin receptor antagonist, resulted in marked improvement in functional class and exercise capacity of the patient, allowing gradual tapering of steroids.

Successful up-front combination therapy in a patient with idiopathic pulmonary hypertension and patent foramen ovale: an alternative to epoprostenol therapy?

Pulmonary arterial hypertension (PAH) is a life-threatening disease of the pulmonary arterioles, which, in the absence of effective therapy, progresses rapidly to right heart failure and death. Opening of a patent foramen ovale (PFO) is common in patients with severe pulmonary hypertension (PH), resulting in resistive hypoxemia. We report the case of a 40-year-old woman with idiopathic pulmonary hypertension (iPAH) in New York Heart Association (NYHA) class III to IV, who was admitted in the intensive care unit with hemodynamic compromise and severe hypoxemia due to right-to-left shunt throughout a PFO. Combination therapy initially with inhaled iloprost and sildenafil, and then addition of an endothelin A receptor-selective antagonist (sitaxsentan), resulted in impressive improvement in oxygenation with reversal of the right-to-left shunt and marked improvement in functional class of the patient.