Algorithmic approach in the management of COVID-19 patients with residual pulmonary symptoms.

Coronavirus-19 emerged about 3 years ago and has proven to be a devastating disease, crippling communities worldwide and accounting for more than 6.31 million deaths. The true disease burden of COVID-19 will come to light in the upcoming years as we care for COVID-19 survivors with post-COVID-19 syndrome (PCS) with residual long-term symptoms affecting every organ system. Pulmonary fibrosis is the most severe long-term pulmonary manifestation of PCS, and due to the high incidence of COVID-19 infection rates, PCS-pulmonary fibrosis has the potential of becoming the next large-scale respiratory health crisis. To confront the potentially devastating effects of emerging post-COVID-19 pulmonary fibrosis, dedicated research efforts are needed to focus on surveillance, understanding pathophysiologic mechanisms, and most importantly, an algorithmic approach to managing these patients. We have performed a thorough literature review on post-COVID-19 pulmonary symptoms/imaging/physiology and present an algorithmic approach to these patients based on the best available data and extensive clinical experience.

Does exposure to ammonia concentrations lower than the threshold limit value cause acute pulmonary effects?

One of the major toxic effects of exposure to ammonia is the resulting pulmonary acute and chronic effects. This study investigated the acute pulmonary effects of exposure to ammonia lower than the recommended threshold limit value (TLV). This cross-sectional study was conducted in 2021 in four chemical fertilizer production industries using ammonia as the main raw material. A total of 116 workers who were exposed to ammonia were investigated. The level of exposure to ammonia was measured by NMAM 6016, and the evaluation of pulmonary symptoms and function parameters was done using the American Thoracic Society and European Respiratory Society protocols in four sessions. The paired-sample t-test, repeated measures test, Chi-square, and Fisher's exact test were run to analyze the collected data. The prevalence rates of pulmonary symptoms, including cough, dyspnea, phlegm, and wheezing, were 24.14, 17.24, 14.66, and 16.38%, respectively, after one exposure shift. It was observed that all pulmonary function parameters were reduced after one exposure shift to ammonia. The results revealed that the parameters of vital capacity, forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), the FEV1/FVC ratio, and peak expiratory flow significantly decreased (p < 0.05) across four exposure shifts. The findings indicated that exposure to ammonia at concentrations lower than one-fifth of TLV could bring about acute pulmonary effects and reduce pulmonary function parameters, similar to the pattern observed in obstructive pulmonary diseases.

Physical activity levels respiratory and peripheral muscle strength and pulmonary function in young post-COVID-19 patients : A cross-sectional study.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) causes permanent problems, even mild severity. The long-term consequences of COVID-19 are still unknown. This study aimed to investigate physical activity levels, respiratory and peripheral muscle strength, and pulmonary function in the long term in young adult COVID-19 patients who recovered from mild disease. METHODS: This cross-sectional study was carried out at least 6 months after the COVID-19 diagnosis, 54 patients with COVID-19 (median age: 20 years) and 46 controls (median age: 21 years) were compared. Functional status (post-COVID-19 functional status scale), respiratory (maximum inspiratory and expiratory pressures (MIP, MEP)) and peripheral muscle strength (dynamometer), pulmonary function (Spirometry), dyspnea and fatigue (modified Borg scale), and physical activity levels (International Physical Activity Questionnaire) were evaluated. CLINICALTRIAL NUMBER: NCT05381714. RESULTS: Patients with COVID-19 measured and percent predicted MIP and MEP were statistically decreased compared with the controls (p < 0.05). Shoulder abductors muscle strength (p < 0.001) and the number of individuals with low physical activity levels were significantly higher in patients compared with controls (p = 0.048). Pulmonary function, quadriceps muscle strength, exertional dyspnea, and fatigue scores were similar in groups (p > 0.05). CONCLUSION: Respiratory and peripheral muscle strength and physical activity levels are adversely affected in patients with COVID-19, even though the patients were mildly affected in the long term. Also, symptoms such as dyspnea and fatigue may persist. Therefore, these parameters should be evaluated in the long term, even in young adults who are mildly affected by COVID-19.

Patient-Reported Pulmonary Symptoms, Exacerbations, and Management in a Cohort of Patients With Alpha-1 Antitrypsin Deficiency.

Rationale: Identifying pulmonary exacerbations in patients with alpha-1 antitrypsin deficiency (AATD) is critical as they are associated with disease progression and poor health-related quality of life. Not all changes in usual respiratory symptoms will be identified as exacerbations by patients with AATD. Methods: Data collected via regular monthly telephone calls during the first year of the AlphaNet Step Forward Study were analyzed. AlphaNet subscribers were asked about changes in their usual respiratory symptoms, whether they considered changes in symptoms to be pulmonary exacerbations, and their management. Participants who reported changes in their usual respiratory symptoms throughout the year were included in the study. Per-patient and per-event analyses were performed. Results: Participants (n=316, age 58±10 years, 53% female) reported 797 events of changes in their usual respiratory symptoms in 1 year. Almost half (48%) of these symptom events were identified as pulmonary exacerbations by the study participants. The average number of symptoms was higher in events recognized by participants as exacerbations than those not identified as exacerbations (3.3±1.5 versus 1.8±1.1, respectively). A greater proportion of the exacerbation events were managed by taking antibiotics or corticosteroids or both (81%, 53%, and 41% of the events, respectively). With exacerbations, participants mainly spoke to the pulmonary specialist (39%) or went to the doctor's office (37%). Symptom events not recognized as exacerbations were mostly self-treated (56%). Conclusions: Changes in usual pulmonary symptoms are not universally recognized as exacerbations. Patients' perspectives in recognizing changes in pulmonary symptoms as exacerbation events are critical.

Pulmonary symptoms in adolescent idiopathic scoliosis: a systematic review to identify patient-reported and clinical measurement instruments.

STUDY DESIGN: Systematic review. PURPOSE: Adolescent idiopathic scoliosis (AIS) is a deformity of the trunk and chest and can cause a spectrum of pulmonary symptoms. However, no standardized measurement instrument exists. The aim of this systematic review is to identify and describe patient-reported and clinical measurement instruments used to evaluate pulmonary symptoms in patients with AIS. METHODS: Studies published after 01.01.2000 were included in a systematic search. Patient-reported outcome measures (PROMs) and clinical measurement instruments for pulmonary symptoms were extracted as well as their measurement properties (floor-ceiling effects, validity, reliability, responsivity and interpretability). The Risk of Bias (RoB) was evaluated. RESULTS: Out of 3146 studies, 122 were eligible for inclusion. Seven clinical measurement instruments, measuring 50 measurement parameters, were identified. Five PROMs for pulmonary symptoms were identified. Studies assessing the quality of measurement properties in the AIS population were not identified. As such, the RoB could not be determined. CONCLUSION: No available adequate patent centric instruments were identified that measure pulmonary functioning and symptoms. Although clinical measurement instruments are regularly used, their use in routine practice does not seem feasible. The measurement properties of some identified PROMs seem promising; however, they have not been validated in an AIS population. As pulmonary symptoms in patients with AIS are still poorly understood, the development of such a construct and potentially a subsequent PROM to routinely measure pulmonary functioning and patient experience is recommended.

The effect of chronic exposure to flour dust on pulmonary functions.

Purpose. This study aimed to examine the effect of chronic exposure to flour dust on the pulmonary symptoms and pulmonary indices of mill workers. Methods. The cohort study was conducted on 67 mill workers and 53 controls from 2014 to 2016. Demographic information was collected through interviews and pulmonary indices; flour dust exposure was measured by spirometry, and NIOSH 0500 and NIOSH 0600 methods. Results. The incidences of pulmonary symptoms, including cough, sputum, dyspnea, wheezing and bronchitis, were significantly more in the case group than the control group. At the beginning of the study, there was no significant difference between the case and control groups regarding the pulmonary indices of forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), peak expiratory flow and FEV1/FVC; however, after 2 years of exposure to flour dust, the pulmonary indices significantly decreased in the case group and showed a restrictive pattern. Based on the linear regression model, the most important predictor variables of FVC and FEV1 were age, body mass index, smoking and level of exposure to respirable flour dust. Conclusions: There is a strong correlation between chronic exposure to flour dust and the incidence of pulmonary complications and reduced pulmonary functions.

Comparison of the effects of pulmonary and extra-pulmonary symptoms on health-related quality of life in patients with severe asthma.

OBJECTIVES: To survey the frequency of extra-pulmonary symptoms reported by a sample of patients with severe asthma, their contribution to quality of life and relationship to treatment pathways. METHODS: Consenting patients (N = 100) attending a severe asthma clinic completed questionnaire measures of extra-pulmonary symptoms (the General symptom Questionnaire, GSQ), pulmonary symptoms (Asthma Control Test, ACT), quality of life (the Severe Asthma Questionnaire, SAQ) and health status (EQ-5D-5L). RESULTS: A median of 21 extra-pulmonary symptoms were reported per week. GSQ correlated -0.65 with the ACT and 0.69 with the SAQ. Linear regression showed that both the ACT and GSQ were significant predictors of SAQ mean score, p < 0.001. In patients not receiving biologics, those with high cumulative OCS exposure (≥1120 mg per year) had significantly worse scores (p < 0.05) on all questionnaires except the ACT and GSQ compared to those with low cumulative OCS exposure. DISCUSSION: Extra-pulmonary symptoms were common in this sample of people with severe asthma. Extra-pulmonary and pulmonary symptoms contribute equal variance to the score of HRQoL, showing that they are equally important contributors to patients' experience of severe asthma. Extra-pulmonary symptoms are often overlooked in clinical medicine and in measures of quality of life. Participants receiving biologic treatments had lower extra-pulmonary symptoms possibly indicating that biologics reduce systemic symptoms more effectively than other treatments.

[Three patients with the same diagnosis but very different symptoms]. / Drei Patienten mit der gleichen Diagnose aber sehr unterschiedlichen Symptomen.

We present three cases of patients with a thoracic disc herniation with misinterpretation of the initial symptoms. In a first case, pulmonary symptoms were prominent; in a second case, the patient complained of cardiac symptoms; and in a third case, the patient reported neurological symptoms. Ineffective investigation of thoracic symptoms should raise the suspicion of a thoracic disc herniation.

Gut-lung crosstalk in pulmonary involvement with inflammatory bowel diseases.

Pulmonary abnormalities, dysfunction or hyper-reactivity occurs in association with inflammatory bowel disease (IBD) more frequently than previously recognized. Emerging evidence suggests that subtle inflammation exists in the airways among IBD patients even in the absence of any bronchopulmonary symptoms, and with normal pulmonary functions. The pulmonary impairment is more pronounced in IBD patients with active disease than in those in remission. A growing number of case reports show that the IBD patients develop rapidly progressive respiratory symptoms after colectomy, with failure to isolate bacterial pathogens on repeated sputum culture, and often request oral corticosteroid therapy. All the above evidence indicates that the inflammatory changes in both the intestine and lung during IBD. Clinical or subclinical pulmonary inflammation accompanies the main inflammation of the bowel. Although there are clinical and epidemiological reports of chronic inflammation of the pulmonary and intestinal mucosa in IBD, the detailed mechanisms of pulmonary-intestinal crosstalk remain unknown. The lung has no anatomical connection with the main inflammatory site of the bowel. Why does the inflammatory process shift from the gastrointestinal tract to the airways? The clinical and subclinical pulmonary abnormalities, dysfunction, or hyper-reactivity among IBD patients need further evaluation. Here, we give an overview of the concordance between chronic inflammatory reactions in the airways and the gastrointestinal tract. A better understanding of the possible mechanism of the crosstalk among the distant organs will be beneficial in identifying therapeutic strategies for mucosal inflammatory diseases such as IBD and allergy.

Enfermedad de Kawasaki: reporte de casos / Kawasaki disease: case report

La enfermedad de Kawasaki es una vasculitis multisistémica, aguda, que ataca principalmente losniños lactantes y preescolares, y se ha convertido enla primera causa de enfermedad cardiaca adquiridaen los países industrializados. Puede ser autolimitada,pero suele dañar las arterias de mediano calibre,especialmente las coronarias, ocasionando gravessecuelas e, incluso, la muerte. Además de las alteracionescardiacas, la enfermedad puede tener manifestacionesgastrointestinales, musculoesqueléticas, neurológicas, pulmonares y oculares, entre otras. No se conoce su causa, pero existen evidencias de que puede ser infecciosa y se ha postulado que sería desencadenada por un agente infeccioso ubicuo, probablemente respiratorio, que desencadena una potente reacción inmunológica en ciertos individuos. La enfermedad tiene comportamiento endemo-epidémico. En Colombia, se han descrito casos esporádicos, aunque no existe una vigilancia activa de este problema de salud. En esta revisión se analizan cuatro casos de enfermedad de Kawasaki, captados en unhospital de tercer nivel en un período de un mes ymedio, lo que sugiere un posible brote; se resalta lavariedad de signos y síntomas de la enfermedad y sehace énfasis en el diagnóstico temprano con el fin demejorar el pronóstico.

The Kawasaki disease is a systemic vasculitis thatmainly affects children under five years. It hasbecome the first cause of acquired cardiac illnessesin industrialized countries. Although it can be a self-limited disease, it usually damages medium caliberarteries, especially the coronaries, causing serioussequels and even death. Aside from cardiacalterations, the Kawasaki disease can affect otherorgans and systems: muscles, central nervoussystem, lungs and eyes, among others. Its causeis still unknown, but there is evidence that it mayhave an infectious origin, and it has been postulatedthat it is triggered by an ubiquitous infectious agent,probably a respiratory one, that causes a strongimmunological reaction in certain individuals. TheKawasaki disease has an endemo-epidemic pattern.In Colombia, some isolated cases have beendescribed, although an active surveillance of thisdisease does not exist.In this review, four Kawasaki disease casesare analyzed, attending a third level hospital duringa one and a half month period -which suggests apossible outbreak. The variety of signs andsymptoms of the disease in these cases areemphasized and also is the importance of earlydiagnosis to improve patients' outcome