The prevalence of pulmonary embolism among patients suffering from acute exacerbations of chronic obstructive pulmonary disease.

The clinical diagnosis of acute pulmonary embolism (PE) in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) is often difficult due to the similarity in the presenting symptoms of the two conditions. The purpose of this study was to determine the prevalence of PE in patients with acute exacerbation of COPD. Forty-nine consecutive patients admitted to our medical center for acute exacerbation of COPD were investigated for PE (whether or not clinically suspected), following a standardized algorithm based on D-dimer testing and computed tomography pulmonary angiography (CTPA). PE was ruled out by a D-dimer value <500 µg/L in 20 (41 %) patients and by negative CTPA in 40 (82 %). PE was confirmed in 9 patients. The prevalence of PE was 18 %. One patient with normal D-dimer had PE. Presenting symptoms and signs were similar between patients who did and did not have PE. PE was detected in 18 % of COPD patients who were hospitalized for an acute exacerbation. This finding supports the systematic evaluation of PE in hospitalized COPD exacerbated patients.

[Anxiety dyspnea].

BACKGROUND: Patients complaining about chronic dyspnea, in whom the dyspnea remains unexplained following a thorough diagnostic evaluation, will be defined as having unexplained psychogenic or anxiety dyspnea. AIM: To evaluate the clinical picture of patients with anxiety dyspnea, to evaluate their state of anxiety and whether their dyspnea is related to higher than normal perception of dyspnea. PATIENTS AND METHODS: Forty-six patients with continuous complaints of dyspnea, with no obvious cause of dyspnea, were recruited for the study. The perception of dyspnea (POD) and their anxiety state (using the HADS questionnaire) were evaluated. RESULTS: Dyspnea that is not related to effort (100% of the patients), difficulties in filling the lung (93%), the need for occasional sigh breathing (93%), and the need for occasional yawns in order to fill the lung (83%) were the most characteristic symptoms. Thirty-two patients (70%) were positive for anxiety states and surprisingly had lower than normal POD. CONCLUSIONS: Our study suggests that patients with anxiety dyspnea have characteristic clinical presentation: dyspnea that is not related to effort, difficulties in filling the lung, and need for occasional sighs and/or yawns in order to be able to fill the lung. If baseline evaluation is negative for an organic cause of dyspnea, the diagnosis of anxiety dyspnea can be established with no further costly diagnostic procedures.

[Chronic obstructive pulmonary disorder (COPD) patients with the syndrome of combined pulmonary fibrosis and emphysema, compared to patients with emphysema alone].

BACKGROUND: In recent years the syndrome of combined puLmonary fibrosis and emphysema (CPFE) was recognized as a unique disorder. The diagnosis of CPFE is based on the pulmonary findings of High ResoLution Computed Tomography (HRCT) of the Lung. Patients with this entity have reLativeLy preserved lung volumes and spirometry but marked reductions in diffusing capacity on pulmonary function testing. OBJECTIVES: Since dyspnea is the main symptom that limits daily activities in patients with COPD, we wanted to compare the clinical features, exercise tolerance, quality of life and dyspnea of patient with CPFE to patients with emphysema alone. METHODS: A total of 14 patients with CPFE were compared to 16 patients with COPD and emphysema alone. All patients had HRCT, spirometery, body ptethysmography, CO diffusion capacity, 6 minute walk test, inspiratory muscle strength, measurements of the perception of dyspnea at rest and following effort, and they completed a questionnaire on quality of Life aspects. RESULTS: Patients with CPFE were a littLe younger, had a similar smoking history, had milder airway obstruction, smaller RV and FRC, and more severe reductions in diffusing capacity. They had more dyspnea at rest and following effort, and their exercise tolerance and quality of life were significantly reduced compared to patients with emphysema alone. CONCLUSIONS: The group of patients with combined pulmonary fibrosis and emphysema (CPFE), based on the HRCT, is characterized by relatively preserved lung volumes and spirometry but marked reductions in diffusing capacity, exercise tolerance, quality of life and higher perception of dyspnea, compared to patients with emphysema alone.

Inspiratory muscle training in pulmonary rehabilitation program in COPD patients.

Most pulmonary rehabilitation (PR) programs do not currently incorporate IMT in their PR programs for COPD patients. The aim of the present study was to assess the influence of adding IMT to the patients already involved in a rehabilitation program. Thirty-four patients with significant COPD were recruited for the study. All patients participated in a general exercise reconditioning (GER) program for 12 weeks. The patients were then randomized to receive IMT or sham IMT, in addition to GER for the next 6 months. Following three months of GER training there was a significant increase in the 6-min walk test (6MWT) (from mean+/-SEM 254+/-38 to 322+/-42 m, p<0.01), and small but non-significant decreases in the perception of dyspnea (POD), and in the St. George Respiratory Questionnaire score (SGRQ). Following the addition of IMT to the GER program there was a significant increase in the PI(max) in the GER+IMT group (from 66+/-4.7 to 78+/-4.5 cm H(2)O, p<0.01). This was accompanied by a significant improvement in the POD and a further significant improvement in the SGRQ score. IMT provides additional benefits to patients undergoing PR program and is worthwhile even in patients who have already undergone a GER program.

The effects of 1 year of specific inspiratory muscle training in patients with COPD.

AIM: We assessed the long-term benefits of inspiratory muscle training (IMT) on inspiratory muscle strength, exercise capacity, the perception of dyspnea, quality of life, primary care use, and hospitalizations in patients with significant COPD. PATIENTS: Forty-two consecutive COPD patients with FEV(1) < 50% of predicted were randomized into a group that received IMT for 1 year, and a control group that received training with a very low load. RESULTS: There was a statistically significant increase in inspiratory muscle strength (at the end of the third month of training) as assessed by maximal inspiratory pressure (from 71 +/- 4.9 to 90 +/- 5.1 cm H(2)O [+/- SEM], p < 0.005) and 6-min walk distance (at the end of the third month of training; from 256 +/- 41 to 312 +/- 54 m; p < 0.005), a decrease in the mean Borg score during breathing against resistance (at the end of the ninth month of training), improvement in the health-related quality-of-life scores (at the end of the sixth month of training) in the training group but not in the control group. At the end of the training year, these changes were maintained; in addition, a decrease in primary health-care use and hospitalization days was observed. CONCLUSIONS: Our study shows that during IMT in patients with significant COPD, there is an increase in exercise capacity, improvement in quality of life, and decrease in dyspnea. Our study also provides evidence that long-term IMT can decrease the use of health services and hospitalization days.

Comparison of specific expiratory, inspiratory, and combined muscle training programs in COPD.

BACKGROUND: Respiratory muscle weakness may contribute to dyspnea and exercise limitation in patients with significant COPD. In an attempt to reduce the severity of breathlessness and to improve exercise tolerance, inspiratory muscle training has been applied in many COPD patients. On the other hand, there is a paucity of data related to expiratory muscle performance and training in COPD. METHODS: Thirty-two patients with significant COPD (ie, mean FEV(1), 37% of predicted) were recruited for the study. The patients were randomized into four groups: eight patients were assigned to receive specific expiratory muscle training (SEMT); eight patients received specific inspiratory muscle training (SIMT); eight patients received SEMT and SIMT (ie, the SEMT + SIMT group); and eight patients who were assigned to a control group received training with very low load. All patients trained daily, six times a week, with each session consisting of one half hour of training, for 3 months. Spirometry, respiratory muscle strength and endurance, 6-min walk test distance, the perception of dyspnea, and the Mahler baseline dyspnea index (BDI) were measured before and following training. RESULTS: Training caused a statistically significant specific increase in the expiratory muscle strength and endurance (in the SEMT and SEMT + SIMT groups) and in the inspiratory muscle strength and endurance (in the SIMT and SEMT + SIMT groups). There was significant increase in the distance walked in 6 min in the SEMT, SIMT, and SEMT + SIMT groups. However, the increase in the SIMT and SEMT + SIMT groups was significantly greater than that in the SEMT group. There was a statistically significant increase in the BDI, and a decrease in the mean Borg score during breathing against resistance in the SIMT and SEMT + SIMT groups, with no changes in the SEMT and control groups. CONCLUSIONS: The inspiratory and expiratory muscles can be specifically trained with improvement of both muscle strength and endurance. The improvement in the inspiratory muscle performance is associated with an increase in the 6-min walk test distance and the sensation of dyspnea. There is no additional benefit gained by combining SIMT with SEMT, compared to using SIMT alone.

The perception of dyspnea after bronchoconstriction and bronchodilation in patients with asthma.

BACKGROUND: It is well documented that the perception of dyspnea (POD), subjectively reported by patients, is an important index used to guide treatment. The severity of dyspnea following methacholine-induced bronchoconstriction and added mechanical loads is increasing in popular. No formal attention has been addressed to the reduction in dyspnea following bronchodilators. STUDY OBJECTIVE: To investigate if the magnitude of dyspnea perceived by a subject is independent on the direction (e.g., bronchoconstriction or bronchodilation) of the change in airway resistance. METHODS: The POD was measured in 26 mild moderate asthmatic patients following bronchodilation, using beta2-agonists, and following bronchoconstriction, induced by methacholine challenge, to almost the same magnitude. RESULTS: The increase in forced expiratory volume in 1 s (FEV1), 30 min after the inhalation of beta2-agonist (mean +/- SEM 22.3 +/- 0.8%), was associated with a statistically significant decrease (P < 0.005) in the POD. The mean decrease in FEV1 following methacoline challenge, was 23 +/- 0.7% and was followed by a statistically significant increase (P < 0.005) in the POD. The magnitude of the decrease in the POD following albuterol was almost identical to the magnitude of the increase in the POD following methacholine. CONCLUSIONS: In stable mild-moderate asthmatic patients, the changes in the magnitude of dyspnea, perceived by a subject, is independent on the direction of the change in the FEV1.

Specific expiratory muscle training in COPD.

BACKGROUND: There are several reports showing that expiratory muscle strength and endurance can be impaired in patients with COPD. This muscle weakness may have clinically relevant implications. Expiratory muscle training tended to improve cough and to reduce the sensation of respiratory effort during exercise in patients other than those with COPD. METHODS: Twenty-six patients with COPD (FEV(1) 38% predicted) were recruited for the study. The patients were randomized into two groups: group 1, 13 patients were assigned to receive specific expiratory muscle training (SEMT) daily, six times a week, each session consisting of 1/2 h of training, for 3 months; and group 2, 13 patients were assigned to be a control group and received training with very low load. Spirometry, respiratory muscle strength and endurance, 6-min walk test, Mahler baseline dyspnea index (before), and the transitional dyspnea index (after) were measured before and after training. RESULTS: The training-induced changes were significantly greater in the SEMT group than in the control group for the following variables: expiratory muscle strength (from 86 +/- 4.1 to 104 +/- 4.9 cm H(2)O, p < 0.005; mean difference from the control group, 24%; 95% confidence interval, 18 to 32%), expiratory muscle endurance (from 57 +/- 2.9% to 76 +/- 4.0%, p < 0.001; mean difference from the control group, 29%; 95% confidence interval, 21 to 39%), and in the distance walked in 6 min (from 262 +/- 38 to 312 +/- 47 m, p < 0.05; mean difference from the control group, 14%; 95% confidence interval, 9 to 20%). There was also a small but not significant increase (from 5.1 +/- 0.9 to 5.6 +/- 0.7, p = 0.14) in the dyspnea index. CONCLUSIONS: The expiratory muscles can be specifically trained with improvement of both strength and endurance in patients with COPD. This improvement is associated with increase in exercise performance and no significant change in the sensation of dyspnea in daily activities.

[The effect of time on the perception of dyspnea following inhaled long-acting bronchodilator].

STUDY OBJECTIVES: To assess the effect of time on the change in the perception of dyspnea (POD) following inhalation of long-acting bronchodilator. PATIENTS AND METHODS: Spirometry and the POD were measured in 32 asthmatic patients, with moderate asthma, before and following inhalation of placebo, and salmeterol. The POD was measured while breathing against progressive loads, using a visual analogue scale (VAS). RESULTS: The highest FEV1 levels and the lowest POD were measured one hour after salmeterol inhalation. Although the mean FEV1 remained close to its peak value for at least six hours following the inhalation of salmeterol, there was a gradual statistically significant increase in the POD. CONCLUSIONS: Following inhalation of long-acting bronchodilator (LABD) there is relationship between the increase in the FEV1 and the decrease in POD. With time there is a gradual increase in the perception of dyspnea regardless of the FEV1.

[The relation between the perception of dyspnea and beta 2-agonists consumption in patients with mild-moderate asthma].

It is well documented that, in patients with asthma, there is a considerable variation in the severity of breathlessness for any particular degree of airflow obstruction. The factors underlying this variability are still to be explored. The consumption of beta 2-agonists and the perception of dyspnea were assessed in eighty asthmatic patients, with mild-moderate asthma, attending the asthma clinic. The perception of dyspnea was compared to sixty normal subjects. All patients received treatment with inhaled corticosteroid and beta 2-agonists as needed. Nine patients were excluded from the study, hence the data reported relates to 71 patients. In 55% of the patients the mean score of the perception of dyspnea during breathing against resistance was normal, it was low in 20 (28%) and high in the remaining 12 (17%). There was no correlation between the FEV1 and the perception of dyspnea. The mean +/- SEM beta 2-agonists consumption was 2.9 +/- 0.4 puffs/day (range 0-7.2). There was a statistically significant difference in beta 2-agonists consumption between the mid asthmatic and the moderate asthmatic groups (p < 0.01). In both groups the mean beta 2-agonists consumption was significantly higher in the high preception of dyspnea group than in the normal (p < 0.05) and the low (p < 0.01) perception of dyspnea groups. We conclude that about half of mild-moderate asthmatic patients have normal perception of dyspnea while the other half have either high or low perception of dyspnea. More obstructed patients have higher beta 2-agonists consumption. However, in every degree of severity there is a close relation between the perception of dyspnea and the beta 2-agonists consumption.

The relationship among inspiratory muscle strength, the perception of dyspnea and inhaled beta2-agonist use in patients with asthma.

BACKGROUND: It is well documented that the perception of dyspnea (POD), subjectively reported by patients, is related to the activity and strength of the inspiratory muscles, and influences the use of 'as needed' beta2-agonists. STUDY OBJECTIVE: To investigate the relationship among the increase in inspiratory muscle strength after specific inspiratory muscle training, beta2-agonist consumption and the POD in patients with persistent, mild to moderate asthma. METHODS: Inspiratory muscle strength, daily beta2-agonist consumption and the POD were measured in 30 patients with mild to moderate asthma. Patients were then randomly assigned to two groups: one group received specific inspiratory muscle training until an increase of more than 20 cm H2O was reached, and one group was a control group and received sham training. Inspiratory muscle strength, the POD and daily beta2-agonist consumption were assessed during and after the training period. RESULTS: There was no good correlation between the baseline maximal inspiratory pressure and the POD, or between the baseline maximal inspiratory pressure and the mean daily beta2-agonist consumption. However, there was a significant correlation between the POD and the mean daily beta2-agonist consumption. The increase in inspiratory muscle strength after the inspiratory muscle training was closely correlated with the decrease in the POD (P<0.001) and the decrease in beta2-agonist consumption (P<0.001). CONCLUSIONS: The present study shows that, in patients with mild to moderate, persistent asthma, there is a correlation between the POD and the mean daily beta2-agonist consumption. When the inspiratory muscles are strengthened, there is a significant decrease in the POD and in beta2-agonist consumption.

C-reactive protein as a marker for active coronary artery disease in patients with chest pain in the emergency room.

BACKGROUND: Markers of inflammation, such as C-reactive protein (CRP), were found to be related to risk for cardiovascular disease (CVD) events in patients with angina pectoris. In addition, recent studies have shown that, in the case of atherosclerosis, increased CRP concentration reflects the inflammatory condition of the vascular wall. HYPOTHESIS: The study was undertaken to determine whether CRP levels in individuals with chest pain attending the emergency room (ER) may be used as a marker of active CVD. METHODS: Serum CRP level was measured in 226 of 326 consecutive patients (128 men, 98 women; mean age 61.3 +/- 5.9 years; range 19-87 years) referred to the ER with chest pain. The decision whether to admit orrelease the subjects was determined without taking the CRP level into account. Follow-up was then performed for 1 year. RESULTS: Eighty-four patients were admitted to the hospital. Of these, 9 with acute coronary syndrome (ACS) had very high levels of CRP (25-40 mg/l), 35 had had an acute coronary event within the preceding 3 months, with levels of CRP 14-20 mg/l. Only eight patients with nonsignificant CVD had elevated CRP levels. Twenty-eight subjects who were released from the ER had elevated CRP levels (7-14 mg/l); 8 of these, in addition to 4 subjects with normal CRP levels, had a late coronary event. CONCLUSION: This study indicates that in patients referred to the ER with chest pain and no other indication for hospitalization, a normal level of CRP suggests safe release. Most hospitalized patients with normal CRP will not have acute coronary syndrome. Patients who will develop early coronary events have very high CRP levels. High serum CRP level, after excluding other inflammatory sources, was proven to be a sensitive diagnostic and prognostic marker for significant coronary disease.

[Fatal attack in patients with bronchial asthma].

What is most notable about asthma deaths is that they continue to occur despite increased understanding of the pathophysiology of asthma, more effective treatment and improvements in asthma education. Studies of fatal and near fatal asthma revealed two distinct groups of patients. The first is a "slow onset-late arrival" group (type I) in whom the final common pathway is a period of poor asthma control, increased use of bronchodilators, late arrival for care of the final attack and underutilization of glucocorticosteroids. This group of patients is characterized by the presence of eosinophilia in the airways. The second group (type II), includes only the minority of death cases. These patients have a sudden, unexpected and rapidly progressive attack. This group of patients is characterized by the presence of neutrophilia in the airways. Two cases of death due to asthma attach, one presenting type I patients and the second type II patients, are described.

Influence of gender and inspiratory muscle training on the perception of dyspnea in patients with asthma.

BACKGROUND: Men and women respond differently to asthma. PATIENTS AND METHODS: Maximal inspiratory mouth pressure (P(Imax)), beta(2)-agonist consumption, and perception of dyspnea (POD) were measured in 22 women and 22 men with mild persistent-to-moderate asthma. Next, the women were randomized into two groups: those who received inspiratory muscle training and those who received sham training. The training ended when the P(Imax) of the training group was equal to that of the male subjects. POD was then measured once again. RESULTS: Baseline P(Imax) was significantly lower (p < 0.01) while POD and mean daily beta(2)-agonist consumption were significantly higher in the female subjects. P(Imax) reached the level of the male subjects at the end of the 20th week of training. The increase in the P(Imax) was associated with a statistically significant decrease in mean daily beta(2)-agonist use and in POD to a similar level as in male subjects. CONCLUSIONS: POD and mean daily beta(2)-agonist consumption in asthmatic women are significantly higher, and the P(Imax) significantly lower, than that of their male counterparts. When the P(Imax) of female subjects following training is equal to that in male subjects, the differences in POD and mean daily beta(2)-agonist consumption disappear.