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   2016| May-August  | Volume 10 | Issue 2  
    Online since June 23, 2016

 
 
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CRITICAL CARE
Effect of gastroesophageal reflux disease on spirometry, lung diffusion, and impulse oscillometry
Eman R Ali, Hossam M Abdelhamid, Hassan Shalaby
May-August 2016, 10(2):189-196
DOI:10.4103/1687-8426.184368  
Background: Gastroesophageal reflux disease (GERD) is known to be associated with many forms of respiratory diseases, including asthma, pulmonary fibrosis, cystic fibrosis, and obstructive sleep apnea syndrome. It is frequently coexistent, and may be causative or may exacerbate pre-existing lung disease. The main purpose of this study was to assess the effects of GERD on spirometry, lung diffusion, and impulse oscillometry. Patients and methods: This study included 48 consecutive newly endoscopically diagnosed GERD patients with no pulmonary symptoms or previous smoking history who attended the Gastrointestinal Clinic at Ain Shams Hospital and Misr University for Science and Technology with complaints of reflux symptoms. Spirometry, lung diffusion, and oscillometry were performed in all included patients. Results: There were statistically significant differences between cases with different grades of reflux as regards age. Most of the patients were included within grade B GERD with the highest mean age being 46.33±11.51. However, there was no significant difference as regards sex. There were statistically significant differences between cases with different grades of reflux as regards forced expiratory volume at the first second/forced vital capacity, maximum expiratory flow 25–75, and diffusing capacity of the lung for carbon monoxide (DLCO), but there was a highly statistically significant difference regarding residual volume/total lung capacity and residual volume. The grade of reflux was the only independent factor affecting DLCO, and grade B patients showed lower DLCO compared with grade A patients. There was a statistically significant positive correlation between grades of reflux and forced expiratory volume at the first second/forced vital capacity, maximum expiratory flow 25–75, and maximum mid-expiratory flow/peak expiratory flow, and a statistically significant negative correlation between grades of reflux and R20. There was a negative correlation between grades of reflux and DLCO, but it was not significant. Conclusion: GERD severity is associated with impairment of gas exchange (DLCO) and central airway affection (R20) on impulse oscillometry. This may be due to microaspiration of gastric acid or fluid into the airways.
  4,142 285 1
PULMONARY INFECTIONS
Diagnostic utility of serum adenosine deaminase level in the diagnosis of pulmonary tuberculosis
Abdelsadek H Alaarag, Osama I Mohammad, Naglaa M Farag
May-August 2016, 10(2):133-139
DOI:10.4103/1687-8426.184369  
Aim of the work: This study was conducted to evaluate the role of serum adenosine deaminase (ADA) level in the diagnosis of pulmonary tuberculosis (TB) and its relationship with clinical, radiological, and laboratory parameters. Patients and methods: This study was performed on 70 individuals: 60 patients with tuberculous and nontuberculous pulmonary diseases and 10 apparently healthy individuals as a control group. The participants were divided into four groups: group I included 30 patients with active pulmonary TB who were subdivided into group IA, which included 20 patients with sputum smear-positive pulmonary TB, and group IB, which included 10 patients with sputum smear-negative pulmonary TB (culture positive); group II included 10 patients with tuberculous pleural effusion; group III included 20 patients with nontuberculous lung diseases (five cases with pneumonia, five cases with pyogenic lung abscess, five cases with bronchiectasis, three cases with lung cancer, and two cases with mesothelioma); and group IV included 10 apparently healthy individuals as a control group. Patients were subjected to history taking, clinical examination, plain chest radiography posterior–anterior view, three consecutive sputum smears for acid-fast bacilli (AFB), sputum culture for AFB using BACTEC TB-460 system in group IB, laboratory investigations, tuberculin skin test, serum ADA level evaluation in all participants, and pleural ADA level evaluation in cases of tuberculous pleural effusion. Results: Serum ADA showed high percentage positivity (90%) in the diagnosis of pulmonary TB, followed by tuberculin skin test (83.3%), chest radiography (73.3%), erythrocyte sedimentation rate (70%), sputum for AFB (66.6%), toxic symptoms (53.3%), and hemoptysis (36.3%). Serum ADA sensitivity and specificity at cut-off point 30.15 µ/l were 95 and 86.7%, respectively, with a positive predictive value of 90.5%, negative predictive value of 92.2%, and accuracy of 91.4%. Conclusion: Serum ADA level shows higher percentage positivity compared with clinical, radiological, and laboratory parameters in the diagnosis of pulmonary TB.
  2,658 246 -
CRITICAL CARE
Diaphragmatic ultrasound as a predictor of successful extubation from mechanical ventilation: thickness, displacement, or both?
Ayman I Baess, Tamer H Abdallah, Doaa M Emara, Maged Hassan
May-August 2016, 10(2):162-166
DOI:10.4103/1687-8426.184370  
Background: Best predictor of successful extubation after mechanical ventilation is a matter of debate. Objective: The aim of this study was to assess whether the degree of diaphragm thickening and/or diaphragm displacement (DD) as measured by means of ultrasound during a weaning trial can predict extubation outcomes. Methods: Thirty patients who were planned for weaning after being intubated and mechanically ventilated were prospectively enrolled in the study between January and June 2015. The rapid-shallow breathing index (RSBI) was subsequently calculated, and diaphragmatic ultrasound was then carried out to assess DD and diaphragm thickening during tidal inspiration. The primary outcome was extubation success or failure. Results: Of the 30 patients included in the study, 15 were male. The mean age of patients was 59.17+13.17 years. The median duration of intubation before weaning was 4 days. There was a significant difference between mean inspiratory and expiratory diaphragmatic thickness (TDI) (t=9.66, P<0.001). An receiver operating characteristic curve was constructed for the end inspiratory TDI, end expiratory TDI, delta TDI, DD, and RSBI. The RSBI performed better than all other parameters, with an area under the curve of 0.968. A cut-off value of 73.5 had 87% sensitivity and 100% specificity for predicting extubation success. All other parameters had an area under the curve less than 0.7. (0.559, 0.624, 0.655, and 0.512 for end inspiratory TDI, end expiratory TDI, delta TDI, and diaphragmatic displacement, respectively). Conclusion: Sonographically measured TDI performed better than displacement in predicting value for weaning outcome. In a respiratory ICU, however, the RSBI seems to be a more reliable and accurate tool for the purpose and should be considered in every weaning protocol. Whether TDI can be evaluated using low-frequency ultrasound probes needs to be validated by further studies.
  1,795 428 5
INTERVENTIONAL BRONCHOLOGY AND PULMONOLOGY
Assessment of transthoracic sonography in patients with interstitial lung diseases
Suzan S Sayed, Gamal M Agmy, Azza F Said, Ahmed H Kasem
May-August 2016, 10(2):105-112
DOI:10.4103/1687-8426.184375  
Aim: This study was designed to recognize the sonographic features of interstitial lung diseases (ILD). Furthermore, the possible correlations of these features with the functional and radiological parameters of the disease were assessed. Patients and methods: Forty-two patients with ILD were included; each patient underwent spirometry, Multi Detector CT chest (MDCT) and transthoracic sonography (TS). Fifteen healthy volunteers were also studied as controls. Results: The sonographic features among ILD patients were B lines in 73.8% , abolished lung sliding in 23.8%, irregular and thickened pleura in 47.6%and 35.7% respectively and subpleural lesions in 38.1%.Increasing distance between the B lines was negatively correlated with both of Forced Vital Capacity % predicted , ground glass opacities and positively correlated with reticular opacities patterns on MDCT chest. Conclusion: TS can be used as an additional imaging method for assessment of ILD and as a marker to estimate the severity of disease.
  1,711 252 -
CRITICAL CARE
Role of ultrasound in assessment of diaphragmatic function in chronic obstructive pulmonary disease patients during weaning from mechanical ventilation
Adel M Saeed, Gehan I El Assal, Tamer M Ali, Mahmoud M Hendawy
May-August 2016, 10(2):167-172
DOI:10.4103/1687-8426.184363  
Objectives: The aim of the study was to investigate the role of ultrasound in the evaluation of movement of the diaphragm and its value in predicting successful extubation in mechanically ventilated chronic obstructive pulmonary disease (COPD) patients in relation to other weaning parameters. Introduction: Chest ultrasound is a beneficial tool for evaluation of the diaphragm during weaning from mechanical ventilation in COPD patients. Chest ultrasound offers some advantages over fluoroscopy, including the lack of ionizing radiation and the possibility of use at the bedside of the patient, as well as facilitating direct quantification of the movement of the diaphragm. Patients and methods: The present study was conducted on 50 patients in the respiratory ICU and the Chest Department of Ain Shams University Hospitals. Patients were divided into two groups: group A and group B. Group A consisted of 30 mechanically ventilated COPD patients admitted to the respiratory ICU and group B consisted of 20 COPD patients not mechanically ventilated during attendance at the Chest Department. Results: Diaphragmatic movement was assessed in the two groups. The mean value of diaphragmatic displacement was higher in group B. In group A this value was higher among those with successful weaning using a cutoff value of 1.1 cm with sensitivity of 86.4%, specificity of 87.5%, and accuracy of 89.5%. There was a significant correlation between diaphragmatic displacement and other weaning parameters, which was better in the group with successful weaning. Conclusion: Diaphragmatic displacement measured by ultrasound is one of the most sensitive, specific, and accurate parameters for weaning of COPD patients from mechanical ventilation, especially in relationship with other weaning parameters.
  1,549 284 6
PULMONARY INFECTIONS
Mortality predictors in patients with severe community-acquired pneumonia requiring ICU admission
Ali O Abdel Aziz, Mohammad T Abdel Fattah, Ahmed H Mohamed, Mohammad O Abdel Aziz, Mohammed S Mohammed
May-August 2016, 10(2):155-161
DOI:10.4103/1687-8426.184373  
Background: Community-acquired pneumonia (CAP) is a major cause of mortality. This prospective study was conducted to describe patient’s characteristics, mortality rate, and etiological pathogens in patients with severe CAP who required ICU admission and to determine the predictors of mortality. Patients and methods: This was a multicenter prospective observational study of 57 consecutive patients who were admitted to the ICU with diagnosis of severe CAP from October 2012 to August 2015. Results: Overall 57 patients were included in the study and the overall ICU mortality rate was 49.1%. Heart disease and chronic obstructive pulmonary disease were the most common comorbidities associated with severe CAP. Comparison between survivors and nonsurvivors revealed that mortality was associated with old age (P=0.01), low diastolic blood pressure (P=0.04), low PaO2/FiO2 (P=0.04), high acute physiology and chronic health evaluation II (APACHE II) score (P=0.001), (CURB-65) score (P=0.005), low hemoglobin (P=0.008), and high urea (P=0.04). The univariate analysis demonstrated that the following were the predictors of mortality: age older than 65 years (P=0.03); APACHE II score greater than 20 (P=0.007); CURB-65 of 3 or greater (0.03); total leukocyte count less than 4 or greater than 11×109/(P=0.04); PaO2/FiO2 less than 250 (P=0.03); serum urea greater than 30 mg/dl (P=0.04); presence of septic shock (P=0.003); mechanical ventilation requirement (P=0.02); and bilateral or multilobar infiltrate on chest radiograph (P=0.03). Multiple regression analysis identified high APACHE II score (>20) and septic shock as significant independent predictors of mortality in severe CAP. Microbiological identification was obtained in 52.6% of cases, with positive blood culture in 17.5%. The most frequently isolated pathogens were Streptococcus pneumonia (S. pneumonia) (19.3%) and Staphylococcus aureus (S. aureus) (15.8%). Conclusion: Mortality rate in patients with severe CAP was high as reported by most of the other studies. The presence of septic shock and high APACHE II were independent predictors of mortality. Heart disease and chronic obstructive pulmonary disease were the most common comorbidities. Microbiological identification was obtained in 52.6% of cases, and S. pneumonia and S. aureus were the most frequently isolated pathogens.
  1,330 188 -
Delayed-onset chest infections in liver transplant recipients: a prospective study
Mohammad Khairy El-Badrawy, Raed El-Metwaly Ali, Amr Mohamad Yassen, Mohammad Ahmad Abou Elela, Rehab Ahmad Elmorsey
May-August 2016, 10(2):147-154
DOI:10.4103/1687-8426.184362  
Objectives: Liver transplant recipients are liable to many infectious and noninfectious chest complications, especially post-transplant pneumonia, which is the major cause of morbidity and mortality. Many studies have evaluated post-liver-transplant early-onset pneumonia. The aim of this study was to evaluate delayed-onset chest infections following liver transplantation. Materials and methods: This prospective study was carried out on 50 adult living donor liver transplant recipients (mean age: 49.68±6.4 years; 44 men and six women). Delayed-onset chest infections that developed after the first month after transplant until the end of the first year were evaluated to determine their frequency, causative microorganisms, associated risk factors, and effect on mortality. Results: Delayed-onset chest infections were detected in six patients (12%) and were complicated, with a 50% mortality rate. The causative organisms were carbapenemase-producing Enterobacteriaceae spp., multidrug-resistant Pseudomonas aeruginosa, and methicillin-resistant Staphylococcus aureus and Streptococcus pneumoniae. Only one case was diagnosed as pleural tuberculosis in the late period of 6–12 months post liver transplantation. The mortality rate was significantly higher in patients who developed chest infections than among those who developed graft- related complications (P=0.009). Persistent moderate-to-large post-transplant transudative pleural effusion and the use of tacrolimus were associated with increased frequency of post-transplant delayed-onset chest infections (P=0.029 and 0.021, respectively). Conclusion: Despite the relatively low incidence of post-transplant delayed-onset pulmonary infections, they are a major cause of morbidity and mortality in liver transplant recipients. Tuberculosis should be considered as a cause of post-transplant delayed-onset chest infections.
  1,359 118 1
INTERVENTIONAL BRONCHOLOGY AND PULMONOLOGY
Outcomes and complications of medical thoracoscopy in undiagnosed exudative pleural effusion
Mona M Ahmed, Hesham Atef Abdel Halim, Ehab Thabet Aziz, Rania Mohammed El-Shorbagy
May-August 2016, 10(2):93-99
DOI:10.4103/1687-8426.184367  
Background: Thoracoscopy has long been established as the procedure of choice for various chest diseases, among which is undiagnosed pleural effusions. Thoracoscopy does not only visualizes the extent of the disease but allows adequate tissue biopsy sampling. Objective: The aim of the present study was to detect outcomes and complications of medical thoracoscopy in undiagnosed pleural effusion. Patients and methods: This study was conducted on 50 patients with unexplained exudative pleural effusion referred for medical thoracoscopy at Abbassia Chest Hospital. Results: Medical thoracoscopy is a safe and valuable tool for the diagnosis of pleural effusion, particularly for patients with suspected malignancy. Overall cost-effectiveness of thoracoscopy is better due to its better yield and lesser duration of hospital stay. Medical thoracoscopy gave a definitive diagnosis with a diagnostic yield of 96%. Histopathological results of thoracoscopic pleural biopsy revealed that the most common diagnosis was malignancy (92%), followed by tuberculous pleurisy (2%), and fibrotic pleurisy (2%); only 4% of the patients remained undiagnosed. The most common malignant pathological type was malignant pleural mesothelioma (60%), followed by metastatic adenocarcinoma (12%). According to the residence of studied patients, we found that environmental exposure to asbestos has a relationship with mesothelioma in patients living in Shoubra El-Kheima and Helwan. Medical thoracoscopy is a safe tool for diagnosing pleural effusion; although no major complications were found in the present study, minor complications occurred only in 10% of the patients. Conclusion: Medical thoracoscopy is a valuable tool in the diagnosis of undiagnosed pleural effusion. It is a simple and safe method with a high diagnostic yield and low complication rates.
  1,269 151 -
AIRWAY DISEASES
Evaluation of serum vitamin D and IgE in patients with bronchial asthma
Ahmed G El Gazzar, Tarek S Essawy, Ahmed H Awaad, Amira I Mansour
May-August 2016, 10(2):113-116
DOI:10.4103/1687-8426.184365  
Background: Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. Aim: This study was carried out to evaluate the level of vitamin D and immunoglobulin E (IgE) in asthmatic patients during exacerbation and after remission. Patients and methods: This study was carried out on 30 patients with bronchial asthma diagnosed and classified according to Global Initiative for Asthma 2015 and 20 healthy individuals. Serum vitamin D and IgE were measured using enzyme-linked immunosorbent assay for all participants. Results: Vitamin D level was highly significantly lower in the asthmatic group during exacerbation compared with the asthmatic group after remission and the control group, and the total IgE level was highly significantly higher in the asthmatic groups compared with the control group. Conclusion: Asthmatic patients might have an increased risk of having vitamin D deficiency during exacerbation and after remission, whereas the levels of serum total IgE level was high in asthmatic patients compared with normal individuals.
  1,170 144 -
PULMONARY INFECTIONS
Serum neopterin level in cases of pulmonary tuberculosis and pneumonia
Wafaa S El-Shimy, Adel S Bediwy, Azza M Hassan, Lamiaa R Ismail
May-August 2016, 10(2):140-146
DOI:10.4103/1687-8426.184360  
Background: Pulmonary tuberculosis (TB) sometimes has diagnostic difficulties and a lot of differential diagnosis such as pneumonia. The aim of this work was to assess the role of serum neopterin in differentiating between pulmonary TB and pneumonia and to estimate the effect of antituberculous drugs for 2 months on serum levels of neopterin in patients with pulmonary TB. Patients and methods: We measured serum neopterin in patients with TB, pneumonia patients, and controls. Serum neopterin was measured again after 2 months of antituberculous therapy in patients with pulmonary TB. Results: Serum neopterin was significantly higher in tuberculous patients than in pneumonia patients, with a sensitivity of 90% and a specificity of 80% at an optimal cut-off value of 20.5 nmol/l. It decreased significantly after 2 months of antituberculous therapy in tuberculous patients. Conclusion: Serum neopterin levels significantly increase in pulmonary TB and correlate with the radiological extent of the disease. Combined anti-TB treatment decreases the levels of serum neopterin. Measurement of the serum neopterin levels may be useful in following up the drug response in pulmonary TB. Serum neopterin levels may also be helpful in discriminating pulmonary TB from pneumonia.
  954 137 1
AIRWAY DISEASES
Effect of procalcitonin-guided therapy on antibiotic usage in the management of patients with chronic obstructive pulmonary disease with acute exacerbation
Randa S Mohammad, Waleed M El-Sorougi, Hisham H Eissa, Abeer S Mohamed, Khaled E Hassan
May-August 2016, 10(2):117-125
DOI:10.4103/1687-8426.184376  
Background: Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease. In patients with COPD, the clinical manifestations of acute exacerbations due to infectious and noninfectious causes are similar. The differential diagnosis of these two conditions is very important for administering the correct treatment regimen and for avoiding unnecessary antibiotic use, thus reducing the morbidity, mortality, and care-related costs. The aim of this study was to evaluate the diagnostic role of procalcitonin (PCT) and its sensitivity as a marker of bacterial infection in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients. Patients and methods: A total of 53 patients with AECOPD and 30 apparently healthy individuals (control group) were studied. Serum PCT concentrations were measured, and Gram staining of the sputum and sputum culture were performed for the patients with AECOPD. The patients were classified into two subgroups: the bacterial group and the nonbacterial group. The bacterial group included patients with bacterial COPDAE (n=32) and the nonbacterial group included patients with nonbacterial AECOPD (n=21). Results: The mean level of PCT in patients of the bacterial group (151.65±38.13) was significantly higher than that of the nonbacterial group (60.16±23.98) and control group (36.03±16.52) (P<0.01). Other parameters such as inflammatory markers were also measured in the studied groups (total leukocyte count, erythrocyte sedimentation rate in the first and second hours, and C-reactive protein). There was no significant correlation between serum PCT level and the studied parameters in the bacterial group (P>0.05), and there was no significant correlation between serum PCT level and the studied parameters in the nonbacterial group (P>0.05). Pulmonary function testing was done for the studied groups and included forced expiratory volume in 1 s (FEV1)/forced vital capacity (%) and FEV1. The association between serum PCT and FEV1% in the two studied group was not significant (P>0.05). Conclusion: PCT can be used as a marker for differentiation between bacterial and nonbacterial COPDAE and could be used to guide antibiotic therapy and reduce antibiotic abuse in hospitalized patients with AECOPD.
  964 105 -
CRITICAL CARE
Role of nebulized heparin inhalation on mechanically ventilated critically ill patients
Randa S Mohammad, Sameh K El-Maraghi, Waleed M El-Sorougi, Sherif M Sabri, Mohammad F Mohammad
May-August 2016, 10(2):179-188
DOI:10.4103/1687-8426.184374  
Introduction: Mechanical ventilation is one of the most important tools in the treatment of respiratory failure in critically ill patients, but it may cause lung injury and inflammatory response in the whole body. Aim of work: The aim of our study was to justify the effect of nebulized heparin on morbidity, oxygenation parameters, lung mechanics, and mortality in mechanically ventilated critically ill patients who are assumed to require mechanical ventilation for more than 48 h for different indications. Patients and methods: This study was conducted on 50 ICU patients who were in need of mechanical ventilation for more than 48 h. They were grouped randomly into two groups. One of the two groups was given nebulized heparin sodium until weaning or for a maximum of 14 days. Patients with coagulopathy or scheduled for any invasive intervention that may lead to bleeding were excluded. In addition, patients who were weaned or who died before day 4 of admission were also excluded. Both groups were followed up for a maximum of 28 days. The study medication was reduced or withheld if any significant bleeding occurred. The endpoint results were primary oxygenation parameters [mainly arterial oxygen partial pressure (PaO2)/inspired oxygen fraction (FIO2)] and ventilator-free days. All other data were recorded and analyzed to find out the adverse positive effect of heparin nebulization. Results: Data analysis revealed that the following data showed no statistically significant difference within groups over time or between the two groups: PaCO2, pH, PaO2, HCO3, SO2, PaO2/FIO2, FIO2×mean airway pressure/PaO2, peak inspiratory pressure, mean airway pressure, tumor necrosis factor α, systolic blood pressure, diastolic blood pressure, hemoglobin, hematocrit value, white blood cells count, platelet count, prothrombin concentration, international normalized ratio, presence of bloody sputum, ICU-free days at day 28, ventilator-free days at day 28, acute renal failure-free days at day 28, vasopressor-free days at day 28, and mortality and sputum culture results at day 4. However, the following data showed a statistically significant difference in the heparin-treated group: plateau pressure showed a statistically significant decrease between days 1 and 4 in the heparin-treated group (P=0.003) and a statistically significant difference when we compared the percentage change between the two groups (P=0.015). Compliance rate showed a statistically significant increase between days 1 and 4 in the heparin-treated group (P=0.019) but when we compared the percentage change between the two groups the difference was not statistically significant (P=0.256). Activated partial thromboplastin time showed a statistically significant increase between days 1 and 4 in the heparin-treated group (P=0.001), but when we compared the percentage change between the two groups the difference was not statistically significant (P=0.153). No cases of heparin-induced thrombocytopenia was noted in the heparin-treated group, nor was there major bleeding or need for blood transfusion related to the tested medication in this group. Conclusion: We recommend nebulized heparin as a safe drug that has a favorable effect in patients receiving mechanical ventilation especially with reduced compliance as in cases of acute respiratory distress syndrome.
  892 122 -
INTERVENTIONAL BRONCHOLOGY AND PULMONOLOGY
Comparative study between different methods of aliquots suction during bronchoalveolar lavage
Mohammad S Soliman Atta, Ayman I Baess, Reham F Moftah, Ebtesam H Abomandour
May-August 2016, 10(2):85-92
DOI:10.4103/1687-8426.184366  
Background: Bronchoalveolar lavage (BAL) is a widely performed diagnostic and research procedure. Objectives: The aim of the present study was to standardize the method of retrieving BAL in our institution through comparing three methods of BAL retrieval regarding efficacy and safety. Methods: A total of 60 adult patients were randomly divided according to the method for retrieving BAL infusate into three groups, of 20 patients each. These are by using gentle hand suction into sterile syringe (Group I), using gentle syringe suction into a fluid trap (Group II), or using gentle suction by aspirator, collecting the lavage specimen into a collection trap (Group III). Results: No statistical difference was noted between groups regarding age, sex, presenting symptoms, anesthesia, patient position, introduction site, postprocedural complications, and total cell count in the retrieved fluid. The volume of the recovered fluid using the method in group III was significantly higher than that of the method used in group II (P=0.001). Although the volume of the recovered fluid by the method in group III was apparently higher than that of the method in group I, and that for the method in group I was apparently higher than that in group II, both lacked significance (P=0.188 and 0.066, respectively). Conclusion: All studied methods of retrieving BAL infusate are safe. Using an aspirator into a fluid trap is superior to using syringe suction into a fluid trap in retrieving more voluminous BAL infusate.
  869 118 -
Thoracoscopic tetracycline poudrage for pleurodesis in malignant pleural effusion
Magdy Khalil, Amr M Shoukri
May-August 2016, 10(2):100-104
DOI:10.4103/1687-8426.184358  
Introduction: Malignant pleural effusion (MPE) is a common problem and a real challenge to pulmonologists and oncologists. The optimum management of MPE depends on several factors, including patient’s symptoms and primary tumor status. Complete drainage and pleurodesis to prevent recurrence is usually needed. Tetracycline, talc, and bleomycin are considered the primary sclerosing agents. Aim of the study: The aim of the study was to investigate the feasibility, effectiveness, and safety of thoracoscopically insufflated tetracycline powder to achieve pleurodesis in patients with MPE. Patients and methods: Twenty patients with recurrent pleural effusion that proved to be malignant, or showing a picture highly suggestive of pleural malignancy at thoracoscopy, were included in the study. They were subjected to tetracycline poudrage (35 mg/kg) through medical thoracoscopy. Following discharge, patients were followed up at 3 and 6 months; the primary outcome was the measure of pleurodesis failure, defined as the reaccumulation of pleural fluid requiring further pleural intervention. Results: Of the 20 patients included in this study, five were excluded from evaluation (two because of failure of lung re-expansion and three because of death within 2 months of the procedure). The overall success rate of thoracoscopic tetracycline poudrage pleurodesis in the 15 patients with MPE who completed the study was 86.6%. There was no recorded mortality or significant complications. Conclusion: From this pilot study, we can conclude that thoracoscopy with tetracycline poudrage is an easy, safe, and effective method for performing pleurodesis in MPE.
  878 103 -
AIRWAY DISEASES
Endoscopic prevalence of different grades of gastroesophageal reflux in adult asthmatics with or without reflux symptoms
Ahmed M Abd-El-Hafeez, Shawky A Fouad
May-August 2016, 10(2):126-132
DOI:10.4103/1687-8426.184357  
Background: Gastroesophageal reflux and asthma often coexist in the same patient. Persons with asthma are particularly prone to asymptomatic gastroesophageal reflux disease (GERD). Esophageal pH-probe studies have documented that 32–84% of the asthmatics have abnormal acid reflux. The endoscopic assessment of esophageal mucosal changes in patients with reflux symptoms is important to diagnose patients with various degrees of severity. Aim of the study: The aim of the study was to detect the prevalence of different grades of GERD in adult asthmatics with or without GERD symptoms by using upper gastrointestinal endoscopy. Patients and methods: This study included 50 adult patients with different levels of asthma control according to the Asthma Control Test scoring system. Patients were classified into two groups (symptomatic and less symptomatic) according to the GERD questionnaire. All patients were blindly subjected to upper gastrointestinal endoscopy. Endoscopic grading was carried out using the Los Angeles grading system for GERD. Results: GERD was endoscopically detected in 36 patients out of 50 (72%); most of them presented with grade B gastroesophageal reflux (28%). No significant difference was observed in GERD prevalence related to the level of asthma control (P=0.98). No significant difference was observed in endoscopic GERD prevalence between symptomatic and less symptomatic groups (P=0.53). Conclusion: GERD with variable grades is prevalent endoscopically among adult asthmatics at all levels of asthma control with no difference between symptomatic and less symptomatic groups.
  815 88 -
CASE REPORTS
A solitary anthracotic lower lobe lung mass mimicking lung malignancy: an unusual presentation
Amit K Jain, Parvati Nandy
May-August 2016, 10(2):82-84
DOI:10.4103/1687-8426.184359  
Pneumoconiosis in coal workers is seen as small nodular aggregations of anthracotic macrophages in the collagen network, which are known as coal macules, with larger aggregations known as coal nodules/mass with or without fibrosis. These are usually seen around the initial site of coal dust accumulation that is the upper regions around respiratory bronchioles; however, in our case the anthracotic mass is present in the anterior basal segment of the lower lobe of the left lung. Although coal workers’ pneumoconiosis is a form of pneumoconiosis that is a common affliction of coal workers and/or chronic smokers. In our patient, prior exposure to biomass fuel exhaust seems to be the only risk factor. We present the case of an 80-year-old man presenting with fever and cough of 4 months’ duration. On evaluation, he was found to have a well-defined mass lesion in the anterior basal segment of the lower lobe of the left lung, which on core biopsy revealed features consistent with an anthracotic mass.
  768 88 -
Pleural thymoma: our first case
Reham M Elkolaly
May-August 2016, 10(2):79-81
DOI:10.4103/1687-8426.184361  
Thymoma is not a very rare disease; many cases have been diagnosed all over the world. However, it was the first time to diagnose pleural thymoma in our department, and was diagnosed by means of medical thoracoscope. It is not usual for a pulmonologist to expect pleural thymoma; thus, it was the main challenge for us and for the pathologist to diagnose it.
  753 93 -
CRITICAL CARE
Bone mineral density and its contributing factors in Egyptian children with cystic fibrosis
Maggie L Naguib, Hala M Koura, Mona M Mahmoud, Atef S Mohamed, Samiha S Wissa
May-August 2016, 10(2):197-205
DOI:10.4103/1687-8426.184372  
Background: Cystic fibrosis (CF) is an autosomal recessive disorder that, despite advances in medical care, continues to be a life-limiting disease. With increase in life expectancy of the CF population, bone disease has emerged as a common complication. Aim: The aim of the study was to determine bone mineral density (BMD) and total body composition (TBC) in a sample of Egyptian children with CF and assess the contributing factors that might be related to BMD deficits. Materials and methods: This was a cross-sectional case–control study that included 15 children with CF who were of a mean age of 6.3±3.68 years (2.5–15 years) and were diagnosed by sweat chloride testing. All CF children were subjected to detailed history taking, thorough clinical examination, laboratory investigations, and pulmonary function tests. They also underwent growth, puberty, and nutrition evaluation. BMD and TBC were evaluated using dual-energy X-ray absorptiometry. Results: CF children had significantly decreased mean BMD and TBC compared with the control group. An overall 26.66% of these patients had osteopenia and one patient was 3 years old. They also showed delayed growth when compared with Egyptian standards, and most of them (>80%) presented with recurrent chest infections, malabsorption, undernutrition, and treatment with inhaled steroids for more than 6 months. Conclusion: We demonstrated the presence of osteopenia in our CF patients that presented early in life. Improving nutritional status, correcting malabsorption, and limiting chest infections are necessary for prevention. Annual assessment of BMD and body composition should be initiated early in life to target those who need preventive treatment against osteoporosis and reduce the risk for fractures later in life.
  660 81 -
Role of noninvasive ventilation in decreasing the length of postextubation ICU stay
Hoda A Abou Youssefa, Amany A Abou Zeida, Raef H Emama, Hebatallah H Assal, Yasser M Elsarem
May-August 2016, 10(2):173-178
DOI:10.4103/1687-8426.184364  
Background: Respiratory failure after a planned extubation is reported to be a common event, leading to reintubation. These reintubated patients have higher morbidity, mortality, hospitalization charges, and an increased length of hospital stay. Aim of the study: The aim of this study was to assess the role of noninvasive ventilation (NIV) in decreasing the length of postextubation ICU stay. Results: Fifty-six patients with respiratory failure type II were included in our study after exclusion of four patients who had self-extubation. Twenty-six patients were allocated to the NIV group and 26 to the control group. Physiological variables of the patients 1 h after the trial were mainly significantly better in the NIV group than in the standard medical treatment (SMT) group. Trial duration was significantly shorter in the NIV group than in the SMT group. Conclusion: This supports the use of NIV early after extubation in all patients regardless of risk for respiratory failure.
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