Validation of the Greek version of the Severe Respiratory Insufficiency questionnaire.

BACKGROUND: The Severe Respiratory Insufficiency (SRI) questionnaire is a multidimensional, well-validated tool for the assessment of health-related quality of life (HRQL) in patients with severe chronic respiratory failure (CRF), due to a variety of underlying disorders. The aim of this study was to validate the SRI questionnaire in the Greek language (Gr-SRI). METHODS: Reliability and validity analyses were performed for the Gr-SRI using data of 136 consecutive patients with CRF, due to chronic obstructive pulmonary disease (COPD) or non-COPD respiratory diseases (kyphoscoliosis, obesity-hypoventilation, and post-tuberculosis sequelae). Sixty-three patients (46.3 %) were under long-term oxygen therapy (LTOT), while 73 (53.7 %) under long-term non-invasive mechanical ventilation at home (HMV), either with or without LTOT. RESULTS: Cronbach's alpha was high for the Summary Score of the SRI (0.86) showing high internal consistency, comparable to that of the original German version. The results of the principal component analysis on the SRI Summary Score produced a one-factor construct with a variance of 54 %, which confirmed a single Summary Score for the Greek SRI also. The highest and the lowest scores were detected in Respiratory Complaints and Physical Functioning subscales, respectively. The SRI was capable of discriminating COPD patients and non-COPD patients, with COPD patients having lower mean SRI scores, but no difference was observed between COPD patients under HMV or LTOT. CONCLUSIONS: Greek SRI has high psychometric properties qualifying its use for HRQL assessment in patients with CRF. HIPPOKRATIA 2017, 21(4): 186-190.

Influence of torso and arm positions on chest examinations by electrical impedance tomography.

Electrical impedance tomography (EIT) is increasingly used in patients suffering from respiratory disorders during pulmonary function testing (PFT). The EIT chest examinations often take place simultaneously to conventional PFT during which the patients involuntarily move in order to facilitate their breathing. Since the influence of torso and arm movements on EIT chest examinations is unknown, we studied this effect in 13 healthy subjects (37 ± 4 years, mean age ± SD) and 15 patients with obstructive lung diseases (72 ± 8 years) during stable tidal breathing. We carried out the examinations in an upright sitting position with both arms adducted, in a leaning forward position and in an upright sitting position with consecutive right and left arm elevations. We analysed the differences in EIT-derived regional end-expiratory impedance values, tidal impedance variations and their spatial distributions during all successive study phases. Both the torso and the arm movements had a highly significant influence on the end-expiratory impedance values in the healthy subjects (p = 0.0054 and p < 0.0001, respectively) and the patients (p < 0.0001 in both cases). The global tidal impedance variation was affected by the torso, but not the arm movements in both study groups (p = 0.0447 and p = 0.0418, respectively). The spatial heterogeneity of the tidal ventilation distribution was slightly influenced by the alteration of the torso position only in the patients (p = 0.0391). The arm movements did not impact the ventilation distribution in either study group. In summary, the forward torso movement and the arms' abduction exert significant effects on the EIT waveforms during tidal breathing. We recommend strict adherence to the upright sitting position during PFT when EIT is used.

Evaluation of lung ventilation distribution in chronic obstructive pulmonary disease patients using the global inhomogeneity index.

The global inhomogeneity (GI) index is a electrical impedance tomography (EIT) parameter that quantifies the tidal volume distribution within the lung. In this work the global inhomogeneity index was computed for twenty subjects in order to evaluate his potential use in the detection and follow up of chronic obstructive pulmonary disease (COPD) patients. EIT data of 17 subjects were acquired: 14 patients with the main diagnoses of COPD and 3 healthy subjects which served as a control group. Two or three datasets of around 30 seconds were acquired at 33 scans/s and analysed for each subject. After reconstruction, a tidal EIT image was computed for each breathing cycle and a GI index calculated from it. Results have shown significant differences in GI values between the two groups (0.745 ± 0.007 for COPD and 0.668 ± 0.006 for lung-healthy subject, p <; 0.005). The GI values obtained for each subject have shown small variance between them, which is a good indication of stability. The results suggested that the GI may be useful for the identification and follow up of ventilation problems in patients with COPD.

Characteristics and outcome of patients with difficult weaning from mechanical ventilation: an 18 years' experience of a respiratory intermediate unit attached to a pulmonary department.

BACKGROUND: Respiratory dysfunction often persists in post intensive care unit (ICU) patients and intermediate care facilities have been established to ensure the continuous of appropriate care. METHODS: The data of patients with difficult weaning from mechanical ventilation admitted to a respiratory intermediate unit (RIU) attached to a pulmonary department of a General Hospital, were retrospectively analyzed. Clinical characteristics, weaning from mechanical ventilation and tracheostomy, ICU readmission and RIU mortality were examined over a period of 18 years (1993- 2010) that was randomly divided into three six-year-periods. RESULTS: A total of 548 patients (age 56.7±17.9 years) [mean ± standard deviation (SD)], of whom 80% with tracheostomy in place and 37.6% with pressure ulcers, were examined. The ICU stay was 30.1±24.7 days (mean ± SD) and increased over time (p<0.05). Patients' baseline disorders were: chronic respiratory disease (41.3%), chronic cardiovascular diseases (10.6%), neuromuscular disease (22.8%) and miscellaneous (25.3%). The length of RIU stay (22.8±19.5 days) was constant over the examined periods but an increase in age and maintenance of tracheostomy were observed; 80% of patients were liberated from mechanical ventilation and 58.5% from tracheostomy, whereas the RIU mortality was 15%. CONCLUSION: In their vast majority patients with chronic respiratory failure, who were admitted to RIU,were weaned from mechanical ventilation, although in a substantial percentage the maintenance of tracheostomy was mandatory after discharge. Hippokratia 2015, 19 (1): 37-40.

Detection of wheezes using their signature in the spectrogram space and musical features.

In this work thirty features were tested in order to identify the best feature set for the robust detection of wheezes. The features include the detection of the wheezes signature in the spectrogram space (WS-SS) and twenty-nine musical features usually used in the context of Music Information Retrieval. The method proposed to detect the signature of wheezes imposes a temporal Gaussian regularization and a reduction of the false positives based on the (geodesic) morphological opening by reconstruction operator. Our dataset contains wheezes, crackles and normal breath sounds. Four selection algorithms were used to rank the features. The performance of the features was asserted having into account the Matthews correlation coefficient (MCC). All the selection algorithms ranked the WS-SS feature as the most important. A significant boost in performance was obtained by using around ten features. This improvement was independent of the selection algorithm. The use of more than ten features only allows for a small increase of the MCC value.

Respiratory function in amyotrophic lateral sclerosis patients. The role of sleep studies.

BACKGROUND AND AIM: Respiratory function decline in association with sleep breathing abnormalities in Amyotrophic Lateral Sclerosis (ALS) patients are fully recognized as crucial manifestations in the natural course of the disease, severely affecting the prognosis. The aim of this study was to evaluate the respiratory function at daytime and during sleep in a population of ALS patients and investigate the necessity of sleep study performance for the appropriate management of the disease. PATIENTS AND METHODS: Twenty eight (10 male, 18 female) unselected patients with ALS, were evaluated in terms with their functional status by means of the ALS Functional Scale (ALSFSC). Baseline anthropometric measurements, pulmonary function tests and arterial blood gases analysis were performed, as well as evaluation of patients' perception of dyspnoea. A polysomnography was performed using a multichannel ambulatory recording. RESULTS: Nineteen patients had sleep disordered breathing with an RDI (Respiratory Disorder Index)>5/h (from 5.6/h to 83/h) and 10 patients had an RDI>15/h. All patients had impaired functional capacity by the ALSFSC and 11 patients (39.3%) reported mild to moderate dyspnoea. FVC was below 80% predictive value in 22 patients and in 8 patients hypoxaemia (PaO2<80 mmHg) and in 12 patients hypercapnia (PaCO2>40 mmHg) was present. There was no correlation found between spirometric values, maximum inspiratory and expiratory pressures and sleep study parameters. There was a significant correlation between PaCO2 and RDI (r=0.498, p<0.01), and PaO2 with nocturnal hypoxaemia (average SpO2, r=0.436,p<0.05). CONCLUSIONS: Sleep-breathing abnormality is common in ALS patients even in the absence of documented respiratory failure. Clinical evaluation and respiratory function tests alone may not be sufficient to predict sleep disordered breathing (SDB) and nocturnal breathing assessment should be included in the evaluation of respiratory function.

Problems in diagnosis and treatment of tuberculosis infection.

Tuberculosis is still a major health problem in industrialized countries due to specific socioeconomic factors and there is the growing need of new rapid and accurate diagnostic methods, in order to achieve higher sensitivity and specificity compared to traditional methods of microscopic sputum examination and culture. Such methods, recently introduced, are nucleic acid amplification (NAA) tests, used directly on clinical specimens and blood tests (QuantiFERON-TB, T-SPOT.TB test), measuring the IFN-gamma released by stimulated T cells. Furthermore, new drugs for the disease need to be developed, aiming to better treatment results and to prevention of Multiple Drug Resistance (MDR) cases. Critical aspects in the management of drug resistance cases should be the careful choices of drugs combination, the close follow up of the patients alongside with the patients adherence to therapy. The role of national and international tuberculosis programs is invaluable in TB control and therapy, as well as the collaboration of all the health system departments. However, most of the clinical problems that may arise are addressed by the International Standards for Tuberculosis Care-ISTC and these guidelines should be taken into consideration, at least until future research provides more promising diagnostic and therapeutic modalities for control of the disease.

Percutaneous bronchial artery embolization in the management of massive hemoptysis in chronic lung diseases. Immediate and long-term outcomes.

AIM: Bronchial artery embolization (BAE) is a well-established, non-surgical procedure in the emergency treatment of massive hemoptysis. This study aims to evaluate the immediate and long-term prognosis of BAE for the management of massive hemoptysis in our center. METHODS: Twenty consecutive patients (mean age: 59+/-14 years) with massive hemoptysis, underwent BAE with microspheres (Embospheres BioSphere Medical SA, Paris, France), polyvinyl alcohol particles (PVA, Ivalon, Cathmed Science; Paris, France) or/and steel coils (Cook, Denmark) after thoracic aortography and diagnostic selective and superselective catheterization of bronchial arteries and systemic collateral vessels in the bleeding lung area. Hemoptysis was due to bronchiectasis (55%), non-operable aspergillomas (15%), active tuberculosis (15%), malignancy (10%) and cystic fibrosis (5%). Mean duration of follow-up was 29+/-18 months. The recurrent-free time was calculated with Kaplan-Meier analysis. RESULTS: Immediate control of bleeding was achieved in all patients. Recurrent cases of hemoptysis were observed in 6/20 patients (30%) within 3 years and 4 of them (66.6%) occurred early in the first 3 months. Recurrent-free time was 9 months (standard error: 4) (95% confidence interval: 0-17). Repeated interventions were required in all early recurrences, due to either recanalization of the occluded arteries or non-bronchial systemic artery supply. Combined use of PVA and coils was proved effective in these cases. No serious complications were observed. CONCLUSION: BAE is an effective and safe intervention in cases of massive hemoptysis. However, recurrences are common and long-term follow-up is considered important with a view to perform repeated interventions with combination of embolic materials.

Burden and coping strategies in families of patients under noninvasive home mechanical ventilation.

BACKGROUND: It is well documented that caregivers of patients with chronic respiratory failure under noninvasive mechanical ventilation (NIMV) are at high risk to develop depression, burden, overload and declining health over time. OBJECTIVES: The purpose of the study was to investigate the subjective and objective burden imposed on families of patients under NIMV at home and explore the coping strategies they adopt. METHODS: The study population consisted of 50 informal caregivers of patients with chronic respiratory failure under NIMV at home for at least 6 months. The burden of the families, as well as the adaptation strategies, were estimated by a modified version of the Family Burden Questionnaire validated in Greek. RESULTS: Profound objective burden was reported in the field of social relations in 49%, in household management in 43.2%, in financial issues in 31.3% and in employment issues in 29.4% of the families. The subjective burden which the families experienced was usually lower and it was reported in household management in 33.4%, in employment issues in 29.4%, in social relations in 21.6% and in financial issues in 21.5% of the families. The strategies adopted by the families in order to cope with the imposed burden included reorientation of goals in 92.2%, resignation in 88.2%, passivity in 62.7%, hopefulness in 45.3%, ambivalence in 19.6% and guilt in 13.7% of the families. CONCLUSIONS: The families of patients under NIMV seem to face major problems (severe burden) in household management and their social relations. Families do not seem to subjectively experience the burden that is objectively recorded and, in the vast majority, they adopt healthy coping strategies.

Sensorineural hearing loss and word deafness caused by a mesencephalic lesion: clinicoelectrophysiologic correlations.

OBJECTIVE: To assess the role of inferior colliculi as a generator of Wave V of brainstem auditory evoked potentials and in modulating the olivocochlear efferent auditory system. STUDY DESIGN: Case review. SETTING: University and tertiary referral centers. PATIENTS: Case report of a patient with word deafness caused by mesencephalic hemorrhage according to audiologic and electrophysiologic findings. RESULTS: The patient is a 48-year-old woman who suffered word deafness caused by hemorrhage localized at the quadrigeminal plate (including the inferior colliculi). At a follow-up visit, her pure-tone audiogram revealed symmetric severe sensorineural hearing loss that had partially resolved, whereas speech audiometry showed persistent word deafness. Acoustic reflexes were elicited, with normal thresholds bilaterally. Transient evoked otoacoustic emissions were recorded from both ears, with normal response and signal-to-noise ratio, but there was a failure for their amplitude to be suppressed with contralateral sound stimulation. Brainstem auditory evoked potentials were of normal amplitude and latencies bilaterally. CONCLUSION: The finding of normal brainstem auditory evoked potentials supports the view that the neural generator of Wave V lies caudally to the inferior colliculi. Moreover, the abnormal suppression of transient evoked otoacoustic emissions indicates that descending collicular input is capable of modulating levels of excitability within the olivary nucleus and the cochlea.

Respiratory short-term poststimulus potentiation (after-discharge) in patients with obstructive sleep apnea.

In conscious normal humans after a brief hypoxic ventilatory stimulus, ventilation slowly decays to baseline and does not undershoot though the subjects are hyperoxic and hypocapnic. This phenomenon is attributed to short-term poststimulus potentiation (STP), which may be an important factor promoting ventilatory stability by preventing periodic breathing. It has been proposed that obstructive sleep apnea (OSA) is a variant of periodic breathing, with obstruction occurring when ventilatory drive is low. If this were the case, patients with OSA might have reduced STP. To test this, seven normal adults and 12 patients with OSA (mean apnea index, 52.4 +/- 6.9 SE events/h) were studied. Ventilation (VI) was measured in awake seated subjects during 30 to 45 s of exposure to hypoxia (end-tidal O2: 50 mm Hg) followed by hyperoxia. A total of 57 hypoxic-hyperoxic runs were analyzed (36 in the patients and 21 in the normal subjects). During hypoxia VI increased and end-tidal CO2 decreased by similar amounts in both groups. In normal subjects after hypoxia there was a gradual decay in VI to prehypoxic levels without an undershoot. In patients, there was on average a ventilatory undershoot at 35 s of hyperoxia, with a mean VI of 83% of baseline. The undershoot was due mainly to a decrease in tidal volume, which was significantly lower than that of the normal subjects for several seconds. These changes were particularly prominent in seven patients who were not different from the others in terms of baseline characteristics, hypoxic responses, and OSA severity.(ABSTRACT TRUNCATED AT 250 WORDS)

Nocturnal hypoxia in unilateral diaphragmatic paralysis.

Pulmonary function has been studied extensively in patients with unilateral diaphragmatic paralysis (UDP), but there is scarce information regarding the respiratory function during sleep in this condition. We therefore studied pulmonary function in 12 patients with UDP when awake and when asleep. Diaphragmatic dysfunction was confirmed by the demonstration of low maximal transdiaphragmatic pressures in most of our patients; paradoxical gastric pressure swing was observed in 6 patients. There was a restrictive pattern in pulmonary function tests and resting arterial blood gases were rather well preserved (range SaO2 90-95%). Overnight sleep monitoring showed that the time spent in REM sleep and stage 3 and 4 sleep was reduced. The mean maximum decrease in SaO2 was 15.2 +/- 6.2% and the time with an SaO2 drop of more than 5% of the awake SaO2 was 25.4 +/- 22.8 min. None of our patients was in respiratory failure or had clinical evidence of cor pulmonale. We conclude that UDP leads to significant nocturnal hypoxemia but, in the absence of systemic lung disease, does not lead to chronic respiratory failure and cor pulmonale.

Comparison of almitrine bismesylate and medroxyprogesterone acetate on oxygenation during wakefulness and sleep in patients with chronic obstructive lung disease.

The effects of almitrine bismesylate and medroxyprogesterone acetate on oxygenation during wakefulness and sleep were compared in six patients with chronic obstructive lung disease and carbon dioxide retention. Patients received 1.5 mg/kg almitrine (a peripheral chemoreceptor stimulant), 100 mg of medroxyprogesterone (a central respiratory stimulant), or matched placebo daily for 15 days in random order in a crossover trial. When subjects were awake almitrine increased the ventilatory response to hypoxia and increased arterial oxygen tension (PaO2) to a greater extent than medroxyprogesterone, whereas medroxyprogesterone augmented the ventilatory response to hypercapnia and decreased arterial carbon dioxide tension (PaCO2) to a greater extent than almitrine. Neither drug influenced sleep architecture significantly, except that medroxyprogesterone increased the number of arousals. Almitrine had a more favourable effect than placebo on oxygenation as estimated from arterial oxygen saturation (SaO2) during the different stages of sleep, the number of episodes of hypoxaemia, and the amount of time that SaO2 was below 80%. The only change with medroxyprogesterone by comparison with placebo was a decrease in the number of hypoxaemic episodes. It is concluded that both active drugs improved blood gases during wakefulness, but that 1.5 mg/kg of almitrine is superior to 100 mg of medroxyprogesterone in improving SaO2 during sleep.

Breathing pattern and eye movement density during REM sleep in humans.

Changes in the density of eye movement during rapid eye movement (REM) sleep are associated with changes in ventilation and ventilatory response in animals. Recent data in patients with chronic obstructive pulmonary disease suggest that periods of frequent eye movements may be associated with hypoxemia during REM sleep. We have therefore investigated the association between eye movements and ventilation and ventilatory pattern in 10 normal men. Expired ventilation was measured using a pneumotachograph attached to a valved face mask with a dead space of 50 ml and incorporating a peripheral CO2 leak detector. Ventilation was reduced (p less than 0.02) in all stages of sleep compared with that during wakefulness, with no difference between the level of ventilation in each sleep stage (awake, 7.18 +/- 0.43 SEM; Stage 2, 6.47 +/- 0.43; Stage 3/4, 6.45 +/- 0.52; REM sleep, 6.55 +/- 0.47 L/min). During REM sleep, eye movements (EMs) were associated with rapid shallow breathing. Dividing REM into 20-s epochs with or without EMs, EMs were associated with a raised breathing frequency (no EMs, 14.4 +/- 0.4 breaths/min; EMs, 15.8 +/- 0.5 breaths/min; p = 0.01), reduced tidal volume (0.49 +/- 0.03 L; 0.41 +/- 0.03 L; p less than 0.01), and reduced minute ventilation (6.87 +/- 0.45 L; 6.27 +/- 0.51 L; p = 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Intermittent and continuous salbutamol rotacaps inhalation in asthmatic patients.

We studied 18 asthmatic patients over an 8-week period. Each patient received for 4 weeks continuous and for 4 weeks intermittent salbutamol rotacaps (400 micrograms) using a double-crossover technique. No significant differences were found between the two treatment regimens as judged by daily card scores and daily PEFR (both a.m and p.m.). Lung Function tests performed monthly in the hospital showed no significant differences between two treatments or the development of bronchial beta-adrenoreceptor resistance.

Almitrine effect on nocturnal hypoxaemia in patients with chronic obstructive pulmonary disease (COPD).

Almitrine bismesylate (A) is a peripheral chemoreceptor agonist that increases ventilation, improves V/Q matching, increases PaO2 and decreases PaCO2 in patients with COPD. We have used a placebo-controlled double-blind cross-over study to compare the effect of 1.5 mg.kg-1 A and placebo (P) (given orally twice a day for 14 days with a 2 wk wash-out period between) on sleep quality, blood oxygenation during sleep and the ventilatory response to hypoxia and hypercapnia when awake. We have measured ear oxygen saturation (SaO2) and EEG sleep stages during nocturnal sleep in 13 patients with COPD (FEV1 0.94 +/- 0.31 1). When awake and during P period PaO2 was 51.4 +/- 10.7 mmHg (SD), PaCO2 53.1 +/- 7.1 mmHg and SaO2: 83.1 +/- 8.0%: during A treatment PaO2 increased to 55.8 +/- 7.8 mmHg (p less than 0.01 paired Wilcoxon test), PaCO2 decreased to 48.5 +/- 6.4 mmHg (p less than 0.05) and SaO2 increased to 86.9 +/- 2.6 (p less than 0.01). A reduced nocturnal hypoxaemia: 1) during P treatment mean stage I SaO2 was 73.2 +/- 13.2%, stage II 70.5 +/- 15.7%, stage III 66.5 +/- 18.5%, stage IV 73.3 +/- 12.7% and rapid eye movement (REM) sleep 59.2 +/- 14.8%; the corresponding SaO2 values during A treatment were higher: stage I SaO2 80.6 +/- 5.2% (p less than 0.05), II 78.6 +/- 6.2% (p less than 0.01), III 77.3 +/- 7.4% (p less than 0.01), IV 80.4 +/- 3.8% (p less than 0.05), REM 69.9 +/- 7.9% (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)