Long-term effect of weight loss induced by bariatric surgery on asthma control and health related quality of life in asthmatic patients with severe obesity: A pilot study.

BACKGROUND: The weight loss induced by bariatric surgery (BS) improves asthma clinical control evaluated usually after a short time. The long-term effects of weight loss attained by BS on asthma control and health related-quality of life (HRQoL) in patients affected by asthma and obesity are not known. OBJECTIVE: To investigate the five-year effect of weight reduction induced by BS on asthma control, quality of life and pulmonary functional parameters in severely obese intermittent or mild-to-moderate asthmatic patients. METHODS: Twenty-six consecutive severe obese subjects with previous diagnosis of asthma with indication for laparoscopic adjustable gastric banding (LAGB) were enrolled into the study. Fifteen of them agreed to undertake the surgery (treatment group, TG) while the remaining eleven non-operated patients represented the control group (CG). Body mass index (BMI), Asthma Control Test (ACT), Mini Asthma Quality of Life Questionnaire (mini-AQLQ) and spirometric parameters were evaluated at baseline and after one and five years from surgery. RESULTS: Mean BMI of TG significantly decreased at one and five years after the surgery, while it remained unchanged in CG. After surgery, both the overall ACT and the mini-AQLQ score significantly improved in TG after one year, persisting improved after 5-years (p < 0.001), while these outcomes remained unchanged in CG. As compared with the pre-surgery values, the percentage of predicted FEV1 and FVC significantly increased at five-year follow-up from surgery in TG, while it remained unchanged in CG. CONCLUSIONS: In severe obese asthmatic patients, the significant improvement of asthma control test and HRQoL, observed one year after LAGB, persists five years after surgery.

Smoking Habit in Severe Obese after bariatric procedures.

BACKGROUND: Bariatric procedures provide an effective means of short term weight loss and sustained weight control for the morbidly obese. The effect of bariatric procedures on smoking habit in obese subjects is not well known. Therefore, we examined the short term effect of bariatric surgery on smoking habit of severe obese patients up to 12 months from the intervention. PATIENTS AND METHODS: Smoking habit was assessed in a cohort of 78 morbid smoking obese patients followed at our clinic for bariatric procedures. They underwent non surgical intra-gastric balloon (IB) or surgical procedures such as lap-band laparoscopic surgery (LAGB) or sleeve gastrectomy/gastric by-pass (SPG). Subjects were administered a written questionnaire about their smoking habit before and 3, 6 and 12 months after the procedures. RESULTS: No differences were found among the three groups at 6 and 12 months after the procedures (IB 21 %, LAGB 6 %, SPG 5 %; and IB 14 %, LAGB 3 %, SPG 5 %). Only after 3 months, the rate of quitting of the IB group was higher than LAGB and SPG groups (36 %, 6 % and 5 %, respectively; p = 0.02). CONCLUSIONS: Bariatric procedures have no effects on smoking habit of moderate-to-heavy smoker severe obese patients. The use of other traditional smoking cessation methods in patients undergone to bariatric procedures should be implemented.

Extended analysis of exhaled and nasal nitric oxide for the evaluation of chronic cough.

INTRODUCTION: Chronic cough is usually defined as a cough that lasts for eight weeks or longer. Its etiological diagnosis is not always straightforward, and the measurement of exhaled nitric oxide (FeNO) has been proposed in patients' evaluation. No studies have assessed the usefulness of extended exhaled NO measurement for the evaluation of chronic cough. Therefore, we aimed at evaluating the usefulness of an extended exhaled NO measurement and nasal NO for an initial evaluation of chronic cough. METHODS: We studied 52 non-smoker patients with prolonged cough lasting more than eight weeks. Etiologies of cough were identified. Nasal NO and FeNO were assessed using multiple single-breath NO analysis at different constant expiratory flow-rates. From the fractional NO concentration measured at each flow-rate, the total NO flux between tissue and gas phase in the bronchial lumen (J'awNO), and the alveolar NO concentration (Cano) were extrapolated. RESULTS: The patients were classified in four categories: cough variant asthma (CVA), nonasthmatic eosinophilic bronchitis (NAEB), upper airway cough syndrome (UACS) and gastro-esophageal reflux disease (GERD). Compared with UACS and GERD, both exhaled NO and J'awNO were higher in CVA and NAEB, and no differences were found in Cano and nasal NO level among the four groups. CONCLUSIONS: Our study suggests a potentially useful role for FeNO measurement in the etiological diagnosis of chronic cough. We did not find any additive value of performing exhaled NO at multiple flow-rates and nasal NO measurements.

Low alveolar and bronchial nitric oxide in severe uncomplicated obesity.

BACKGROUND: Fractional concentration of exhaled nitric oxide (FeNO) is a recognized biomarker of the lower respiratory tract, where it is produced by the proximal conducting airways and the expansible peripheral bronchoalveolar compartment. We have previously shown that large increase in body mass decreases FeNO. Here we evaluated bronchial and alveolar components of the NO output of the lower respiratory tract in subjects with severe uncomplicated obesity (OB). METHODS: Fifteen OB subjects (BMI 45.3 ± 5.6 kg/m(2)), 15 healthy controls (HC) (BMI 22.4 ± 2.4 kg/m(2)) and 10 obese subjects who experienced weight loss after bariatric surgery (OBS) (BMI 31.2 ± 3.4 kg/m(2)), were examined. Anthropometry and respiratory lung tests were performed. Exhaled NO was assessed using multiple single-breath NO analysis at different constant expiratory flow rates. From the fractional NO concentration measured at each flow-rate, the total NO flux between tissue and gas phase in the bronchial lumen (J'awNO), and the alveolar NO concentration (CANO) were extrapolated. RESULTS: Measured FeNO levels at 50 mL/s were lower in OB compared with HC and OBS (11.6 ± 2.8 ppb, 18.0 ± 4.1 ppb and 17.6 ± 2.9 ppb, respectively, p < 0.05). In OB, both J'awNO and CANO resulted significantly lower than OBS and HC values. CONCLUSIONS: Respiratory NO output is decreased in severe uncomplicated obesity for the reduction of both large/central airway maximal NO flux and alveolar NO concentration. The pathophysiological relevance of airway NO abnormalities in severe obese phenotype remains to be investigated.

Evaluation of a transcutaneous carbon dioxide monitor in severe obesity.

OBJECTIVE: To determine the reliability of estimating arterial CO(2) pressure (PaCO(2)) using a recently introduced transcutaneous CO(2) pressure (PtcCO(2)) monitor in severe obese patients. DESIGN: Observational and interventional study. SETTING: District hospital with respiratory ward and bariatric surgery unit. PATIENTS AND METHODS: PtcCO(2) was measured in 35 obese patients with varied pathology, including chronic obstructive pulmonary disease, obstructive sleep apnea syndrome and hypoventilation syndrome. Ten minutes after the probe had been attached to an earlobe, PtcCO(2) was recorded immediately before arterial blood sampling. The PtcCO(2) and PaCO(2) values obtained with two methods were compared by Bland-Altman analysis. In a subgroup of 18 obese patients with chronic obstructive pulmonary disease and/or obstructive sleep apnea syndrome with moderate to severe hypercapnia both PtcCO(2) and PaCO(2) were re-evaluated during continuous positive airways pressure (CPAP) or bi-level positive airway pressure (Bi-PAP) treatment. RESULTS: The mean difference between PaCO(2) and PtcCO(2) was -1.4 mmHg, and the standard deviation of the difference was 1.3 mmHg. Bland-Altman analysis showed generally good agreement between the two methods with a 95% limit of agreement of -4 to 1.1. The agreement between methods did not significantly change before and during cPAP or Bi-PAP treatment in hypercapnic patients. CONCLUSIONS: The accuracy of estimation of PaCO(2) by transcutaneous monitoring was generally good in comparison with standard arterial blood gases examination. The device appears to be promising for use in obese patients to evaluate abnormalities in their alveolar ventilation.

Weight loss and asthma control in severely obese asthmatic females.

BACKGROUND: Obesity is proposed to represent an important predisposing condition to serious respiratory disturbances including asthma. The effects of consistent weight loss on asthma control are not well known. We investigated the effect of weight reduction induced by bariatric surgery on asthma control in severely obese asthmatic patients. PATIENTS AND METHODS: A consecutive series of 12 asthmatic obese females who had laparoscopic adjustable gastric banding (OB group) and 10 non-operated asthmatic obese females as control group (CG). Body mass index (BMI), Asthma Control Test (ACT), pulmonary function test (PFT), exhaled nitric oxide (NO) were evaluated at baseline and after 1 year. RESULTS: Mean BMI (kg/m(2)) of OB group decreased from 45.2+/-4.7 before surgery to 34.8+/-4.2 post-operatively. After surgery the overall ACT score in OB group significantly improved from 18.7 to 22.2 (p<0.001), while it remained unchanged in CG (from 18.8 to 18.6, p=0.73). In particular, in OB group the parameters of shortness of breath and rescue medication use were significantly improved respectively from 3.2 and 3.9 before surgery to 4.2 and 4.6 after surgery (always p<0.05). Accordingly, none of the CG who did not experience any weight loss was able to obtain a full asthma control. In the OB group after the surgery PFT significantly improved as compared to CG. No significant difference in exhaled NO was found both in OB group after surgery as compared to before surgery. CONCLUSION: Consistent weight loss in severely obese patients with asthma is associated to improvement in respiratory symptoms and lung function. However, the mechanisms underlying the effect of large body mass changes on asthma would require further studies.

Exhaled nitric oxide in severe obesity: effect of weight loss.

Exhaled nitric oxide (NO) is a recognized biomarker in the lower respiratory tract. The effect of large variation in body mass on exhaled NO in the same individuals is not well known. The aim of the study was to evaluate both the effect of severe obesity and the influence of weight reduction on exhaled NO. A consecutive series of 24 uncomplicated obese patients (OB), who had laparoscopic adjustable gastric banding (LAGB) and 15 healthy controls (HC) were studied. Body mass index (BMI), exhaled NO and respiratory function tests were assessed. Exhaled NO was lower in obese in comparison to HC (12.0+/-3.6ppb versus 15.8+/-4.0ppb, p=0.0035). A significant positive correlation was found between exhaled NO and BMI in HC, which was not evident in OB. Among the respiratory indexes, functional residual capacity was significantly associated to exhaled NO. After 1 year, 12 obese patients undergone to LAGB were re-evaluated. Mean BMI (kg/m(2)) decreased from 44.8 before surgery to 32.3 post-operatively. The exhaled NO increased from 11.8+/-3.2ppb before surgery to 14.9+/-3.1ppb 1 year post-operatively (p=0.0023, n=12). In conclusion exhaled NO is consistently reduced in severe obesity and it is restored after weight reduction. The relationship between exhaled NO, large body mass excess and decrease of resting lung volume in severe obesity deserves further studies.

Effect of bariatric surgery on the six-minute walk test in severe uncomplicated obesity.

BACKGROUND: The six-minute walk test (6mWT) is a simple index of functional capacity in healthy people, and it has been used to estimate exercise capacity in obese subjects. The aim of this study was to determine whether weight reduction induced by laparoscopic adjustable gastric banding (LAGB) improves the functional capacity in the severely obese on the 6mWT. METHODS: A prospective 1-year study was carried out at the Hospital Casoria, Naples, involving 15 consecutive severely obese patients who underwent the 6mWT before and 1 year after LAGB. BMI, walking distance, heart rate, dyspnea, and respiratory function tests were also measured. Patients served as their own controls. RESULTS: 15 patients (all females) were evaluated. Mean BMI decreased from 42.1 (range 39-49) before to 31.9 (range 25-38) postoperatively. The distance walked increased from 475.7 meters (range 380-580) before LAGB to 626.3 meters (range 435-880) 1 year postoperatively (P < 0.0001), and the dyspnea score after the 6mWT was significantly reduced postoperatively. All functional variables after the 6mWT showed improvement postoperatively at 1 year study. CONCLUSION: Weight reduction in the obese increases the functional capacity during walking. The improvements are refected in the patients' own assessment.

Association of Adams-Oliver syndrome with pulmonary arterio-venous malformation in the same family: a further support to the vascular hypothesis.

Adams-Oliver syndrome (AOS) is a rare disease characterized by congenital scalp defects, terminal transverse limb defects and cutis marmorata telangiectatica. A significant incidence of cardiac and vascular malformations has been reported, leading to the hypothesis of a vascular defect early involved in the pathogenesis. We report two members of the same family with previously diagnosed AOS based on clinical phenotype and later recognized to have pulmonary arterio-venous malformation (PAVM). None of the subjects fulfilled current diagnostic criteria of hereditary hemorrhagic telangiectasia, which is the most common cause of PAVM. The occurrence of PAVM in AOS lends support to the hypothesis that endothelial specific abnormalities could be a patho-physiological mechanism in its development. Therefore, the role of screening for PAVM in clinical management of subjects with AOS should deserve further studies.