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  Citation statistics : Table of Contents
   2016| September  | Volume 10 | Issue 3  
    Online since November 9, 2016

 
 
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REVIEW ARTICLE
Rapid on-site evaluation: what a microscope will add to the bronchoscopy unit? a concise review
Maged Hassan
September 2016, 10(3):206-211
DOI:10.4103/1687-8426.193634  
Rapid on-site evaluation (ROSE) of samples obtained by transbronchial needle aspiration during flexible bronchoscopy or endobronchial ultrasound has been practised for more than two decades. Earlier studies evaluating its role have reported a magical impact on improving the diagnostic yield and the adequacy of samples produced by transbronchial needle aspiration. Subsequent studies with more rigorous methodologies failed to find a significant increase in sensitivity with ROSE but consistently demonstrated a trend toward performing shorter procedures with fewer complications when ROSE is utilized. There are new exciting fronts for ROSE, such as using it to direct molecular testing for lung cancer. In the future, we expect more centers to apply ROSE, now that pulmonologists have succeeded in doing so and telecytopathology has become reality.
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AIRWAY DISEASES - ORIGINAL ARTICLES
Role of comorbidities in acquiring pulmonary fungal infection in chronic obstructive pulmonary disease patients
Ashraf Z Mohamed, Ahmad M Moharrm, Maha K Ghanem, Hoda A Makhlouf, Ebtesam M El-Gezawy, Sahar F Youssif
September 2016, 10(3):243-250
DOI:10.4103/1687-8426.193629  
Background Bacteria and viruses have been implicated as a major cause of chronic obstructive pulmonary disease (COPD) exacerbations; however, the potential role of fungal colonization and infection is poorly understood. Objective The aim of this study was to assess the profile of pulmonary fungal infection among COPD patients with and without comorbidities to determine their prevalence, risk factors, and outcome among those patients. Patients and methods In this prospective cross-sectional analytic study, different samples (sputum, bronchoalveolar lavage, blood, and others) from 177 COPD patients at risk for pulmonary fungal infection were examined using mycological analysis (direct microscopy and culture). Bronchoalveolar lavage and blood samples were examined using the human 1,3-β-d-glucan and galactomannan ELISA tests. Results The prevalence of pulmonary fungal infection was significantly higher in COPD patients with comorbidities (77.8%) versus COPD patients without comorbidities (53.1%) (P < 0.001), with a predominance of Candida and Aspergillus spp. in both groups. Mechanical ventilation, corticosteroid therapy, ICU admission, and age were major risk factors for pulmonary fungal infection in COPD patients with comorbidities [P = 0.012, odds ratio (ODR) = 2.23; P = 0.028, ODR = 1.99; P = 0.025, ODR = 1.94; and P = 0.034, ODR = 2.60; respectively]. COPD patients with comorbidities had significantly higher mortality rate (12.3%) compared with COPD patients without comorbidities (3.1%; P < 0.05). Blood galactomannan antigen was positive in 16 (19.7%) COPD patients with comorbidities versus seven (7.3%) in COPD patients without comorbidities (P < 0.05). Conclusion COPD patients with comorbidities had a higher prevalence of pulmonary fungal infection and higher mortality rate compared with COPD patients without comorbidities. Age, mechanical ventilation, corticosteroid therapy, and ICU admission were independent risk factors for pulmonary fungal infection in COPD patients with comorbidities.
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CASE REPORTS
Unusual presentations of lung lesions in children: difficult to diagnose case series
Shaimaa Kandil, Rasha H Hassan, Ashraf Fouda, Magdy Zedan
September 2016, 10(3):212-222
DOI:10.4103/1687-8426.193644  
We present five cases of unusual and rare presentations of different congenital/acquired lung lesions. These cases were encountered during our daily practice. They were misdiagnosed initially and received wrong treatment. There were challenges encountered during the diagnosis and the management of these patients, which required different modalities, ranging from chest radiography, computed tomography to surgical exploration and biopsy, to reach the final diagnosis. These cases range from one absent lung, bilateral intralobar pulmonary sequestrations, bronchogenic cyst, congenital right diaphragmatic hernia to cystic hydatidosis (hydatid cyst). There should be a high index of suspicion when the patient has an abnormal/atypical presentation, a prolonged course of the disease or abnormal imaging. Healthcare providers should also think of rare chest diseases and refer such patients to a paediatric specialist (pulmonologist) to help in the final diagnosis and specific management, which may require invasive procedures or specific imaging.
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Metastatic hepatoblastoma: a rare cause of lung mass in adults
Hinesh N Upadhyay, Abhay P Vakil, Khalid M Sherani, Faraha K Sherani, Mohammed M Babury
September 2016, 10(3):223-224
DOI:10.4103/1687-8426.193642  
Hepatoblastoma is a pediatric malignant tumor of the liver with very few cases reported in adults. There are no case reports on isolated metastatic lung involvement with hepatoblastoma in an adult who had been previously treated for the pediatric form of this disease. We report the case of a 27-year-old asymptomatic man who presented to the hospital after a motor vehicle accident. Imaging studies revealed bilateral lung masses. He had been treated for hepatoblastoma at the age of 10 years. Histopathologic examination of the lung biopsy revealed embryonal subtype of hepatoblastoma. Further imaging studies failed to reveal the presence of any concomitant liver lesions.
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ERRATUM
Erratum: Telomere length in chronic obstructive pulmonary disease

September 2016, 10(3):360-360
DOI:10.4103/1687-8426.193723  
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INTERSTITIAL LUNG DISEASES - ORIGINAL ARTICLE
Correlation between high-resolution computed tomography of the chest and pulmonary functions in idiopathic pulmonary fibrosis
Hoda Ali Abou Youssuf, Yousriah Yahia Sabry, Ahmed M Abd El-Hafeez, Hadeel A Mohamed
September 2016, 10(3):330-336
DOI:10.4103/1687-8426.193633  
Background The idiopathic interstitial pneumonias are a heterogeneous group of non-neoplastic disorders resulting from damage to the lung parenchyma by varying patterns of inflammation and fibrosis. High-resolution computed tomography (HRCT) has become an integral part of the diagnosis and evaluation of the patient with idiopathic interstitial pneumonias. Aim of the study The aim of this work was to correlate between HRCT findings and pulmonary functions in patients with idiopathic pulmonary fibrosis (IPF). Patients and methods Thirty patients with features consistent with IPF as diagnosed by means of HRCT were included. The severity of IPF was scored using ‘Kasr Al Ainy HRCT scoring of IPF’ in which the lung was divided into six zones, three on each side, with a specific score given for each zone according to the extent of fibrosis. Transthorathic echocardiography was performed for all patients with the estimation of pulmonary artery systolic pressure (PASP). Results The mean lower lung zone score according to the HRCT score for severity of IPF was 7.93±2.67, which is consistent with typical basal distribution of IPF. A negative correlation was noted between total HRCT score with forced vital capacity, partial pressure of oxygen, and 6 min walk test. There was a positive correlation between PASP detected using echocardiography and pulmonary artery size measured using HRCT (P=0.022). Conclusion There is a positive correlation between PASP detected using echocardiography and pulmonary artery size measured using HRCT. There is a negative correlation between PASP using echo and partial pressure of oxygen in arterial blood gases and also between total lung zone HRCT score and pulmonary functions.
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INTERVENTIONAL BRONCHOLOGY AND PULMONOLOGY
The role of medical thoracoscopy in the diagnosis of exudative pleural effusion at the Chest Department of Zagazig University Hospitals
Abd El Rehim I Yousef, Amani F Morsi, Mohamed El-Shabrawy, Hadeer A El Shahaat
September 2016, 10(3):225-231
DOI:10.4103/1687-8426.193643  
Background Thoracoscopy is a minimally invasive procedure that allows visualization of the pleural space and intrathoracic structures. It enables taking pleural biopsies under direct vision, therapeutic drainage of effusions, and pleurodesis in one sitting. Persistent and recurrent exudative pleural effusions become common and thoracocentesis and blind pleural biopsy procedures do not give a definitive diagnosis in many patients. Therefore, thoracoscopy today remains the gold standard for these cases. In tuberculous pleuritis, the combined yield of histology and culture for rigid thoracoscopy was nearly 100%. Objective The aim of the present study was to examine the diagnostic yield of medical thoracoscopy in patients with undiagnosed exudative pleural effusion. Patients and methods This study was carried out at the chest department of Zagazig University Hospitals in the period from October 2014 to October 2015. It included 36 patients with undiagnosed pleural effusion. All participants signed a written informed consent. The included patients were subjected to full history taking, clinical examination, plain chest radiograph, ultrasonography, computed tomography of the chest, and tuberculosis assessment. Diagnostic aspiration of pleural fluid was performed by using chemical, cytological, and bacteriological analyses. Closed pleural biopsy was carried out in patients with unhelpful pleural fluid analysis. Lastly, if the etiology remained unknown, thoracoscopy was carried out. Results The present study included 18 men and 18 women patients, with a mean age of 54.4 ± 16.1 years. Dyspnea was the most common presenting symptom among the studied patients. Sixteen (72.2%) patients had moderate right-sided pleural effusion. The diagnostic yield of medical thoracoscopy among the studied patients was 80.6%. The histopathological yield of thoracoscopic pleural biopsies was as follows: 25 (69.4%) malignant cases, two (5.6%) patients with tuberculous pleuritis, one (2.8%) patient diagnosed with empyema, and another one (2.8%) with collagenic disease. There were seven (19.4%) patients who were not diagnosed. The post-thoracoscopic complications in this study occurred only in nine (25%) patients, which were minor complications in the form of surgical emphysema and prolonged air leak, wound infection, dislodged drain, trapped lung, and pain during the procedure. Conclusion Medical thoracoscopy is a good diagnostic procedure for pulmonologists to evaluate undiagnosed pleural effusions.
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LUNG FUNCTION TESTS - ORIGINAL ARTICLE
Assessment of functional lung impairment in patients with thyroid disorders
Eman R Ali
September 2016, 10(3):337-347
DOI:10.4103/1687-8426.193641  
Background and objective Many thyroid diseases can lead to pulmonary problems. Hypothyroidism reduces respiratory drive and can cause obstructive sleep apnea, pleural effusion, skeletal muscle myopathy, and decreased carbon monoxide diffusing capacity, whereas hyperthyroidism increases respiratory drive and can cause dyspnea on exertion. Thus, the aim of this study was to evaluate and compare the frequency of clinical presentations, the extent of lung functional endurance (spirometric and diffusion lung capacity), and arterial blood gases affection between patients with hypothyroidism and hyperthyroidism when compared with normal euthyroid volunteers and find out who could compromise the respiratory system more. Patients and methods This study included 90 participants (30 patients with hyperthyroidism, 30 patients with hypothyroidism, and the remaining 30 were normal healthy volunteers as control) referred from the Endocrinology and Internal Medicine Departments in Ain Shams University Hospitals and Misr University for Science and Technology according to their serum free thyroid hormone 3, free thyroid hormone 4, and thyroid-stimulating hormone values. Spirometric function tests and diffusing capacity of the lung for carbon monoxide evaluation were performed for all participants. Results Respiratory symptoms were more frequent in hypothyroid than in hyperthyroid patients, especially cough, sputum production, and chest wheezes. All spirometric functional parameters and respiratory muscle function were decreased (whether or not significant) among patients with hypothyroidism and hyperthyroidism compared with normal euthyroid controls. More statistically significant respiratory functional impairment was noticed among patients with hypothyroidism than among those with hyperthyroidism. Diffusion was more affected in the hypothyroidism group than in the hyperthyroid group, but it was statistically nonsignificant. A statistically significant increase in partial carbon dioxide pressure was observed among patients with hypothyroidism than in patients in hyperthyroidism (However, there was a statistically significant decrease in partial oxygen pressure and pH in patients with hypothyroidism than in those with hyperthyroidism.). Although oxygen saturation was lower in hypothyroidism, it was statistically nonsignificant. Conclusion Hypothyroidism causes greater respiratory system endurance compared with hyperthyroidism. Early diagnosis and hormonal replacement may be of value.
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MISCELLANEOUS - ORIGINAL ARTICLE
Are we with e-cigarette as a friend or against it as a foe?
Radwa A Elhefny, Mohamed A Ali, Assem F Elessawy, Esam G El-Rab
September 2016, 10(3):348-354
DOI:10.4103/1687-8426.193630  
Background and aim Cigarette smoking is the most important cause of avoidable premature mortality in the world, and quitting is known to reduce the risk of fatal diseases. Electronic cigarettes (e-cigarettes) are becoming increasingly popular, especially among younger adults; they may be effective aids to smoking cessation. Despite the increasing prevalence of e-cigarette use, little is known about their real-world use. The major concerns include the nicotine content and the potential harm due to the high concentrations of propylene glycol, chemicals, and other compounds found in the e-cigarette vapor. To our knowledge, there are no data on the health effects of acute use of nicotine-free e-cigarettes. The aim of this study is to evaluate the immediate effect of e-cigarette vapors on airway mechanics. Participants and methods Forty apparently healthy never-smokers or light smokers were divided into two groups. The first group was instructed to ‘vape’ e-cigarettes with a 12-mg nicotine-filled cartridge, and the second group was asked to ‘vape’ e-cigarettes with an empty cartridge. Pulmonary function tests were assessed before and after ‘vaping’. Results There was a significant increase in peripheral airway resistance of the first group, in which individuals vaped a nicotine-filled cartridge. Conclusion There is potential for more permanent changes in lung function with long-term exposure to e-cigarettes, as with cigarette smoking.
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ORIGINAL ARTICLES
Complications and follow-up of foreign body inhalation
Nehad M Osman, Emad Eldin Korraa, Nevine M Abd Elfattah
September 2016, 10(3):232-237
DOI:10.4103/1687-8426.193631  
Background Foreign body inhalation (FBI) is a dramatic incident with a number of complications. Objective The aim of this study was to follow-up the patients after removal of the foreign body and to record the related complications. Patients and methods This prospective follow-up study included 59 patients who presented to the Bronchology Unit of Chest Department at Ain Shams University Hospital, Cairo, Egypt, for their follow-up after successful removal of FBI. The follow-up consisted of three sections: clinical, radiological, and/or interventional. Results Fifty-nine patients were included in the study, with a median age of 3 ± 7.30 years. A total of 39 (66.1%) patients were followed up for 1 month, whereas 20 (33.9%) were followed up for more than 1 month. As regards the radiological follow-up, 37 (62.71%) patients showed complete radiological resolution of previous abnormalities within the duration of less than or equal to 1 month, and 10 (16.95%) patients needed more than 1 month to reach complete resolution; the difference was highly statistically significant (P < 0.001). Only 16 patients needed rebronchoscopic evaluation; six patients refused to undergo rebronchoscopic evaluation, whereas seven needed it once, one needed it twice, and two needed it thrice. All patients who needed bronchoscope follow-up once performed within less than 1 month recording highly statistically significant different (P < 0.001). The most common complication was bleeding in 37 cases, followed by granulation tissue in 28 and purulent secretion in 24 cases. All patients received systemic steroids at the beginning of the procedure; meanwhile, local injection of steroids through the bronchoscope channel was performed in some selected patients. As regards the use of antibiotics, it was given either locally or systemic empirically until cultures were available. Conclusion Although follow-up of patients with FBI is not an easy job, it is an essential step to complete the management and ensure no residual complications.
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Correlation between pleural fluid cytology and magnitude of pleural invasion in patients with malignant pleural mesothelioma
Amr M Shoukri, Nermine M Riad
September 2016, 10(3):238-242
DOI:10.4103/1687-8426.193645  
Introduction Malignant pleural mesothelioma (MPM) is an aggressive tumor commonly triggered by exposure to asbestos, and commonly presented with unilateral pleural effusion. Pleural fluid cytological assessment is often the first diagnostic step that leads to a confirmed diagnosis in a relatively small percentage of cases. Medical thoracoscopy is considered as the procedure of choice to achieve a definite diagnosis and evaluate the extent of the disease. Aim of the study The aim of this study was to assess the correlation between pleural fluid cytological yield and the invasion of different pleural surfaces detected by means of medical thoracoscopy. Patients and methods In this retrospective study, the medical records of all patients with confirmed MPM who underwent medical thoracoscopy at the Chest Department of Ain Shams University Hospitals from May 2012 to May 2016 were analyzed. Patients were included only if the results of pleural fluid cytology were available, as well as the detailed reports of medical thoracoscopy. Results We included 85 patients with MPM in this study, 71 male and 14 female, with a mean age of 61.56±8.75 years. Types of MPM were epitheliod type (64.7%), biphasic type (23.5%), and sarcomatoid type (11.8%). Positive pleural fluid cytology was found in 24 patients (28.2%). Medical thoracoscopy demonstrated parietal pleural invasion in all patients (100%) and visceral pleural invasion in 26 patients (30.5%). Visceral pleural invasion was found in 83.3% of patients with positive pleural fluid cytology. Our results demonstrated that the presence of visceral pleural invasion could predict a positive pleural fluid cytology with a sensitivity of 79.17%, specificity of 88.52%, positive predictive value of 73.08%, and negative predictive value of 91.83. The pattern of visceral pleural invasion had no impact on the results of pleural fluid cytology (P>0.05). Conclusion The results of our study showed that the overall diagnostic yield of pleural fluid cytology in MPM is 28.2%. Positive pleural fluid cytology results were found to be significantly higher in cases with visceral pleural invasion, and, as visceral pleural invasion indicates a more advanced disease, the positive pleural fluid cytological results may be considered an indicator for advanced MPM.
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Role of mean platelet volume in patients with chronic obstructive pulmonary disease
Eman R Ali
September 2016, 10(3):251-260
DOI:10.4103/1687-8426.193635  
Background and objective Stable chronic obstructive pulmonary disease (COPD) is associated with low-grade systemic inflammation as demonstrated by an increase in blood leukocytes, acute-phase proteins such as C-reactive protein, and inflammatory cytokines. Mean platelet volume (MPV) is one of the platelet (PLT) function indexes. It reflects the PLT production rate and stimulation. The changes in MPV during an exacerbation of COPD versus stable COPD have not been clearly examined. The aim of the present study was to evaluate MPV in participants during their stable phase and during an exacerbation of COPD. Patients and methods This study included a total of 80 COPD patients: group A included 40 patients in the stable state and group B included the remaining 40 who were admitted for exacerbation of COPD, who were followed-up for 6 weeks after recovery, and were matched with 40 healthy, nonsmoking controls. All patients underwent spirometry, laboratory investigations with respect to complete blood count, PLT count and MPV, and echocardiography. Results MPV revealed a highly significant decrease within the exacerbated patient group than stable ones who had lower levels of MPV than the control volunteers. There was a highly significant increase in MPV during the stable follow-up visit than during exacerbation for the same included group of patients. There was a significant positive correlation between MPV and grade of severity of COPD; 60% of the stable COPD patients were found to have pulmonary arterial hypertension by echocardiography. There was a significantly higher MPV among patients with pulmonary hypertension (PH) than those without PH. Although PLT count increased with increased severity of PH, it did not reach significance, and there was a significant increase in MPV with increased severity of PH. Conclusion MPV is a quick and reliable tool for the assessment of inflammatory response. PLT activation is an important prothrombotic manifestation of COPD, which may be a useful therapeutic target.
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Assessment of serum vitamin d levels in different severities of asthmatic patients
Waleed M El-Sorougi, Hisham H Eissa
September 2016, 10(3):261-265
DOI:10.4103/1687-8426.193636  
Background There is conflicting evidence about the association between low vitamin D levels and asthma. Aim The aim of this work was to assess the relation between the serum level of vitamin D and the asthma severity. Patients and method A total of 90 asthmatic patients were diagnosed of bronchial asthma clinically and functionally according to GINA guidelines classification 2012. The serum 25-hydroxy vitamin D level was measured in all the cases. The relation between the serum level of vitamin D and forced expiratory volume at 1 s (FEV1) was analyzed. Then, it was correlated to age, sex, and BMI variables. Results Patients were divided into three groups according to FEV1 prebronchodilators. The mean value of vitamin D was 30.43 in mild cases, whereas it was 20.27 in moderate cases, and 11.97 in severe cases. These data stated that the lower the FEV1, the greater the vitamin D deficiency levels, and this relation was statistically highly significant (P<0.001). When the three groups (of severity of airway obstruction: mild, moderate, and severe) were compared with each other, the P-value was less than 0.001 for all. When the three variables were added as a third cofactor (age, sex, or BMI) separately, we did not find any statistically significant effect on the results. Conclusion In asthmatic patients, the serum level of vitamin D was found to be directly proportional to the severity of asthma with no relation to the age, the sex, or the BMI. Further studies are recommended to assess the effect of the correction of serum vitamin D levels on the severity of asthma and asthma control.
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Role of oxygen and continuous positive airway pressure therapy in chronic obstructive pulmonary disease patients with nocturnal oxygen desaturation
Randa Salah-Eldin Mohammad, Waleed Mohamed El-Sorougi, Abeer Salah El-Din Mohamed, Laila Anwar Mohamed Zaki
September 2016, 10(3):266-273
DOI:10.4103/1687-8426.193637  
Introduction Sleep has a significant effect on respiration, even in healthy individuals. Breathing difficulties in chronic obstructive pulmonary disease (COPD) patients during sleep are one of the most common symptoms in these patients. Nocturnal desaturation may occur in COPD in the absence of severe daytime hypoxemia. Nocturnal desaturation may contribute to the development of pulmonary hypertension, nocturnal cardiac arrhythmias, and death during sleep. However, the optimal treatment for patients with isolated nocturnal hypoxemia remains uncertain. Aim of the work The aim of this study was to assess the role of oxygen and continuous positive airway pressure (CPAP) therapy in COPD patients with nocturnal oxygen desaturation (NOD). Patients and methods This study was conducted on 40 male COPD patients. The included patients were classified into two groups: group 1 included normoxic or mildly hypoxic patients with day time SpO2≥91% defined as NOD by fall of greater than 4% from awake SpO2, and group 2 included moderate and severely hypoxic patients with daytime SpO2≤90% who showed a pulse oximetric plot with at least 5 min with SpO2≤90% and a peak of SpO2≤85% and were considered as nocturnal desaturator. The two groups were subjected to full history taking, clinical examination, the Epworth sleepiness scale, anthropometric measurements, pulmonary function tests (spirometry), radiological examination using chest radiograph, and SpO2 using pulse oximetry. SpO2 evaluation using pulse oximetry was carried out for four nights: the first night while breathing room air, the second night while giving low-flow humidified oxygen (2 l/min) overnight, the third night with patients on noninvasive ventilation using autoset CPAP mask, and the fourth night with patients on noninvasive ventilation using autoset CPAP mask with low-flow humidified oxygen (2 l/min). Results The included patients had moderate, severe, and very severe COPD according to the GOLD spirometric classification. The highest mean value of oxygen saturation was seen in cases that received CPAP with oxygen, followed by cases that received low-flow humidified nasal oxygen, and the lowest mean value was on CPAP. In group 1, there was no significant difference between mean values of oxygen saturation on oxygen and CPAP, but there was a highly significant difference between mean values of oxygen saturation on oxygen and CPAP with oxygen, as well as on CPAP and CPAP with oxygen. In group 2, there was a significant difference between mean values of oxygen saturation on oxygen and CPAP, on nocturnal oxygen and CPAP with oxygen, as well as on CPAP and CPAP with oxygen. Conclusion In group 1, it is better to prescribe nocturnal CPAP with oxygen than nocturnal oxygen alone or nocturnal CPAP alone to COPD patients with NOD in this group, whereas in group 2 it is better to prescribe nocturnal CPAP with oxygen, followed by nocturnal oxygen alone, compared with nocturnal CPAP alone to COPD patients with NOD in this group.
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Role of transthoracic ultrasound in evaluating patients with chronic obstructive pulmonary disease
Hoda Ali Abou Youssuf, Esmat A Abdelnabi, Ahmed M Abd El Hafeez, Waleed F Fathallah, Jumana H Ismail
September 2016, 10(3):274-282
DOI:10.4103/1687-8426.193638  
Background Conventional ultrasound with frequencies ranging from 2 to 10 MHz is increasingly used for the diagnosis of pulmonary diseases including pneumothorax, pleural effusion, alveolar–interstitial syndrome, and lung consolidation. Transthoracic ultrasound (TTUS) can be useful in evaluating diaphragmatic function, air trapping, and A lines for the assessment of patients with chronic obstructive pulmonary disease (COPD) and differentiation from other mimicking conditions. Aim This study was carried out to assess the role of TTUS in evaluating patients with COPD. Patients and methods This was a prospective study carried out on 60 male participants: 40 of them were COPD patients (cases) and 20 were healthy individuals (controls). All cases were examined by TTUS B-mode, low-frequency and high-frequency transducer to detect the regularity of the pleura lines and the prominence of A lines, and all of them were examined by M-mode to assess diaphragmatic excursion. Results There was a statistically significant difference with regard to irregularity of pleura lines and prominence of A lines between COPD and control groups with a P value less than 0.001. Regarding diaphragmatic excursion, there was a statistically significant difference between the two groups (P<0.001). A cut-off value of 2.95 cm for diaphragmatic excursion was assigned with 83.7% sensitivity and 70.6% specificity to differentiate mild and moderate COPD from severe and very severe cases. Conclusion TTUS is a helpful tool for evaluating COPD patients and for assessing disease severity.
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Acute exacerbations of chronic obstructive pulmonary disease: etiological bacterial pathogens and antibiotic resistance in Upper Egypt
Alaa T Hassan, Sherif A.A Mohamed, Mona S.E Mohamed, Mohamed A El-Mokhtar
September 2016, 10(3):283-290
DOI:10.4103/1687-8426.193640  
Context Previous data on etiologic bacteria in acute exacerbations of chronic obstructive pulmonary disease (AECOPD) in Upper Egypt are limited. Aim The aim of this study was to identify the causative bacteria in AECOPD and to determine the antibiotic resistance patterns for AECOPD in Upper Egypt. Settings and design The study design was a prospective one and was conducted in a University Hospital. Materials and methods Patients who were admitted in Assiut University Hospital with AECOPD were prospectively enrolled. Sputum specimens were investigated using culture. Susceptibilities of the isolated bacterial strains to different antibiotics were determined using the disk diffusion method. Results During 18 months, 156 patients who experienced 218 AECOPD were enrolled. A significant bacterial growth was found in 77% of patients during 81% of exacerbations. The most commonly detected bacteria were Haemophilus influenzae (18%), Streptococcus pneumoniae (15%), and Klebsiella pneumoniae (14%). The majority of the isolated strains showed high resistance rates to most groups of antibiotics; 63% of the isolated strains were multidrug resistant, 29% were extensively drug resistant, and 5% were pandrug resistant. High resistance rates were observed against penicillins and cephalosporins, moderate rates against fluoroquinolones, and lowest rates against the carbapenems. All gram-positive bacteria were sensitive to linezolid. Increased severity of chronic obstructive pulmonary disease was related to increased prevalence of antibiotic resistance. Conclusion The predominant bacterial pathogens for AECOPD in Upper Egypt are H. influenzae, S. pneumoniae, and K. pneumoniae. Bacterial resistance rates were the highest against penicillins and cephalosporins, moderate against fluoroquinolones, and least against carbapenems. Increased severity of chronic obstructive pulmonary disease is related to an increased prevalence of antibiotic resistance.
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PLEURAL DISEASES - ORIGINAL ARTICLE
Outcome of patients with spontaneous pneumothorax admitted in Abbasia Chest Hospital
Emad E Korraa, Ashraf M Madkour, Amr M Shoukri, Sameh E Ahmed
September 2016, 10(3):355-359
DOI:10.4103/1687-8426.193646  
Introduction Spontaneous pneumothorax remains a significant global problem. It can present either in a primary form occurring in healthy individuals or in a secondary form essentially associated with an underlying lung disease. The primary goals of therapy are to remove air from the pleural space and to prevent recurrence. The choice of a therapeutic intervention is multifactorial. Aim of the work The aim of this study was to study the clinical course and outcome of patients with spontaneous pneumothorax in Abbasia Chest Hospital. Patients and methods This prospective study was conducted on 100 patients with spontaneous pneumothorax admitted in Abbasia Chest Hospital in Cairo, Egypt. Patients were divided into two main groups: group I, the primary spontaneous pneumothorax (PSP) group, and group II, the secondary spontaneous pneumothorax (SSP) group. Chest tube drainage was performed for patients with large PSP, small PSP increasing in size or associated with symptoms, and all patients with SSP. Patients were subjected to thoracic surgical interventions, whenever indicated. Results We included 100 patients with spontaneous pneumothorax: group I (PSP) consisted of 66 patients, and group II (SSP) consisted of 34 patients. Of them, 92% were male and 8% were female. Comparison between the two groups demonstrated that PSP occurs predominantly in male population, especially younger and taller individuals, whereas there was no significant difference in weight or BMI between the two groups. An overall 77% of all studied patients were smokers. PSP patients had a shorter hospital stay compared with SSP patients. The causes of SSP were chronic obstructive pulmonary disease (64.7%), bronchial asthma (2.9%), interstitial lung diseases (14.7%), tuberculosis (17.6%), and bronchiectasis (2.9%). All patients were subjected to chest tube drainage. Complications were found in 6% of patients in group I and in 26.4% of patients in group II. Different complications were noticed in the form of surgical emphysema, hydropneumothorax, persistent air leak, and pleural infection. In group I, only one patient (1.5%) required further interventions, whereas in group II 11.7% needed surgical interventions. Mortality occurred in three patients (8.8%) in group II. There was no evidence that any mortality was directly related to pneumothorax or its management. Conclusion PSP was more frequent compared with SSP in our study, with a higher incidence in younger and taller male population. Smoking is an important risk factor for spontaneous pneumothorax, and the most common lung disease found in our study to be associated with SSP was chronic obstructive pulmonary disease. We conclude that PSP carries a lesser risk for complications and better outcome compared with SSP. The risk for mortality or major complications from spontaneous pneumothorax in general was negligible in our study.
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PULMONARY CRITICAL CARE AND PULMONARY VASCULAR - ORIGINAL ARTICLES
Study of ventilator-associated tracheobronchitis in respiratory ICU patients and the impact of aerosolized antibiotics on their outcome
Hanaa Ali
September 2016, 10(3):301-309
DOI:10.4103/1687-8426.193628  
Background Lower respiratory tract infections in intubated patients include ventilator-associated tracheobronchitis (VAT) and ventilator-associated pneumonia. Aerosol delivery to intubated patients has improved with advances in techniques and with the development of newer aerosol generators. Aim The aim of the current study was to assess VAT and study the effect of aerosolized antibiotics (AAs) as an adjuvant to systemic antibiotic (SA) on outcome in VAT patients over 18 months, starting from December 2013, who were admitted to the respiratory ICU of Ain Shams University Hospital. Patients and methods Seventy-four patients out of 104 mechanically ventilated patients admitted to the respiratory ICU were subjected to serial mini-BAL sputum sampling from the first day of mechanical ventilation (MV). Thirty-two patients who developed VAT were divided into two groups: group I (13 VAT patients who received AAs in the form of ceftazidime 500 mg/12 h+amikacin 400 mg/12 h added to the SA) and group II (10 VAT patients who received only SA). The current study included only those patients whose relatives agreed to share in the study. All patients were subjected to daily assessment for signs of respiratory tract infection and to twice weekly chest radiography, leukocytic count evaluation, and microbiological assessment using mini-BAL. Results VAT incidence was found to be 22.1%. Eighty percent of patients who received AAs showed clinical improvement in the form of significant decrease in temperature, amount of sputum, and leukocytic count, and significant increase in PaO2/FiO2 ratio, in comparison with 30% in the SA group. Conclusion The incidence of VAT was found to be 22.1%, and was mainly caused by Gram-negative bacteria. AAs adjuvant to SA were effective in rapid resolution of signs of respiratory infection, in causing decreased bacterial load, reduced bacterial resistance, reduced progression of VAT to ventilator-associated pneumonia, reduced days of SA use, decreased MV days and ICU stay days, and probably reduced cost of ICU admission, but did not affect mortality.
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Evaluation of role of computed tomography (CT) in the diagnosis of pulmonary hypertension
Ahmed G Elgazzar, Mohammad Abd-Elmohsen Elmahdy, Islam M Elshazly, Ahmed M Ramzy, Shaimaa M Abo Youssef
September 2016, 10(3):310-318
DOI:10.4103/1687-8426.193632  
Introduction Pulmonary hypertension (PH) has significant morbidity and mortality. Chest computed tomography (CT) scans are increasingly used in the evaluation of patients with dyspnea, including those with suspected PH. Aim The aim was to study the signs of PH shown by CT scans, and to correlate the data obtained with echocardiography in suspected patients with PH in a trial to select patients who are eligible for right-heart catheterization and to confirm the diagnosis of PH in those patients who cannot tolerate right-heart catheterization. Patients and methods This study included 60 patients (50 patients with pulmonary hypertension and 10 patients with no PH) aged 32–70 years. They underwent high-resolution CT (23 cases) and computed tomography pulmonary angiography (37 cases) using 16 multidetector computed tomography scanner for the evaluation of their pulmonary parenchyma and mediastinal structures to detect different diagnostic criteria, causes, associations, and complications of PH. All the 60 patients underwent echocardiography. Results The main pulmonary artery (MPA) was larger than 29 mm in 94% of the echo-positive cases and in 30% of the echocardiography-negative cases. A more than 1 : 1 relationship between the segmental pulmonary artery and the bronchus in at least three pulmonary lobes was seen in 84% of positive cases and in none of the negative cases. A more than 1 : 1 relationship between the MPA and the aorta was seen in 80% of positive cases and in 20% of negative cases. Correlation between MPA diameter in CT and the pulmonary artery systolic pressure measured by echocardiography in all cases showed significant correlation, with a P value of up to 0.001. Conclusion Although right-heart catheterization is the gold standard for the measurement of pulmonary artery pressure, this procedure is not without risk and expense. Multidetector computed tomography (computed tomography pulmonary angiography or high resolution CT (HRCT) can reliably be used, in addition to echocardiography, for the routine evaluation of patients with PH.
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Role of chest ultrasonography in differentiating between acute cardiogenic pulmonary edema and acute respiratory distress syndrome
Taher El-Naggar, Samar H Sharkawy, Hossam Mohamed Abdel-Hamid, Haitham S El-Din Mohamad, Rasha Mustafa A Mohamed
September 2016, 10(3):319-323
DOI:10.4103/1687-8426.193648  
Introduction Sometimes it is difficult to differentiate between acute cardiogenic pulmonary edema (APE) and acute respiratory distress syndrome (ARDS) on clinical basis only. Chest ultrasonography (CUS) may be helpful in providing ultrasonographic pleuropulmonary signs, which aids in such differentiation. Aim The aim of this study was to evaluate the role of CUS in differentiating between ARDS and APE through the characterization of comparative peculiar ultrasonographic pleuropulmonary signs. Patients and methods On admission, CUS was performed in Ain Shams University Hospital and Al-Abbassia Chest Hospital ICUs on 28 consecutive patients who presented with ARDS (15 cases) or APE (13 cases). CUS examination focused on the detection of the following pleuropulmonary signs in both ARDS and APE: alveolar–interstitial syndrome (AIS), pleural line abnormalities, absent or reduced lung sliding, consolidation, and pleural effusion. Results AIS was found in 100% of patients with ARDS and in 100% of patients with APE. Pleural line abnormalities were observed in 100% of patients with ARDS and in 0% of patients with APE (P=0.001). Absent or reduced lung sliding was observed in 100% of patients with ARDS and in 0% of patients with APE (P=0.001). Consolidations were present in 93.3% of patients with ARDS in 7.5% of patients with APE (P=0.001). Pleural effusion was present in 40% of patients with ARDS and in 76.9% of patients with APE (P=0.049). All pleuropulmonary signs, except the presence of AIS, presented a statistically significant difference in presentation between ARDS and APE, resulting peculiar ultrasonographic pleuropulmonary signs of ARDS. Conclusion CUS represents a useful tool for differentiating ARDS from APE in ICU patients. In fact, the presence of absent or reduced lung sliding, pleural line abnormalities, and lung consolidations on a background of AIS seems diagnostic of ARDS.
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PULMONARY INFECTIONS - ORIGINAL ARTICLE
Evaluation of lipoarabinomannan in the diagnosis of tuberculosis
Ayman A Youssef, Mohammed H Kamel, Hisham A Eissa, Tarek S Essawy, Hany H Moussa
September 2016, 10(3):291-300
DOI:10.4103/1687-8426.193639  
Background The detection of lipoarabinomannan (LAM) antigens in body fluids has several potential advantages compared with the diagnostic methods used currently. Aim The aim of this study was to evaluate the possible role of the detection of LAM in the serum and the urine as a diagnostic aid in the diagnosis of different forms of tuberculosis (TB). Patients and methods This study included 62 newly confirmed tuberculosis cases classified into two groups: group A included patients with pulmonary TB (n=36), and was further divided into two groups: group A1 [the smear-positive pulmonary TB group (n=24)] and group A2 [the smear-negative pulmonary TB group (n=12)]; group B included the extrapulmonary TB group (n=26); and 10 apparently healthy individuals served as the control group. The LAM level was measured in the serum and the urine by an enzyme-linked immunosorbant assay. Results The mean level of quantitative serum LAM was higher in group A1 (0.55±0.20?ng/ml) compared with group A2 (0.44±0.30?ng/ml) or group B (0.41±0.27?ng/ml). The mean level of quantitative urine LAM was higher in group A1 (0.81±0.24?ng/ml) compared with group B (0.72±0.35?ng/ml) and group A2 (0.65±0.37?ng/ml; P<0.001). The quantitative urine LAM test correlated positively with the degree of bacillary burden (P<0.05). Quantitative serum LAM had a sensitivity of 88.7%, specificity 90%, accuracy 88.9%, positive predictive value 98.2%, and negative predictive value 56.3%. Quantitative urine LAM had a sensitivity of 85.5%, specificity 90%, accuracy 86.1%, positive predictive value 98.1%, and negative predictive value 50%. A combination of serum and urine LAM tests identified that 98.4% of the cases with a positive TB culture correlated with higher serum LAM levels. Advanced chest radiography involvement and TB culture correlated with higher urine LAM levels (P<0.05). Conclusion The LAM test is a valuable addition in the diagnosis of TB and its different forms. A combination of quantitative serum and urine LAM increased the sensitivity of the test. The quantitative urine LAM test offers additional clinical insight into the degree of TB disease severity and has more applicability.
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SLEEP MEDICINE - ORIGINAL ARTICLE
Effectiveness of nocturnal oximetry in predicting obstructive sleep apnea hypopnea syndrome: value of nocturnal oximetry in prediction of obstructive sleep apnea hypopnea syndrome
Lucy A Suliman, Nesrien M Shalabi, Saad A Elmorsy, MK Moawad Mona
September 2016, 10(3):324-329
DOI:10.4103/1687-8426.193647  
Background Polysomnography (PSG) is the gold standard for diagnosing obstructive sleep apnea (OSA). However, it is time-consuming, expensive and requires technical expertise. Thus, a number of alternatives to PSG have been proposed. The present study was conducted to analyse the sensitivity, specificity and accuracy of night oximetry as a diagnostic tool in patients suspected to have sleep apnea hypopnea syndrome (SAHS), and to reduce the number of saved PSGs. Patients and methods In total, 40 middle-aged patients clinically suspected to have Obstructive Sleep Apnea Hypopnea Syndrome (OSAHS) were included in the study. They were classified into two groups: group I (the SAHS group), comprising 33 patients with apnea hypopnea index greater than or equal to 5; and group II (the non-SAHS group), comprising seven patients with apnea hypopnea index l than 5. All patients were subjected to the following: (a) OSA screening questionnaire; (b) BMI in kg/m2, neck circumference in cm, and cardiac, chest and ENT examinations; (c) investigation in the form of arterial blood gases, chest radiograph, ECG and spirometry; and (d) full PSG and overnight oximetry, which were carried out simultaneously. Results The baseline values of O2 saturation derived from PSG and oximetry were 93.33±2.32 and 91.50±2.79, respectively. The overnight oxygen desaturation index of oximetry was significantly lower in the SAHS group. Minimal SpO2 of PSG was significantly lower in the SAHS group. The best predicted cutoff value of overnight pulse oximetry using oxygen desaturation index for mild to moderate OSA patient diagnosis was 14.78, with 87.88% sensitivity and 88.71% specificity. However, the optimal cutoff value for severe OSA diagnosis was 52.55, with 86.67% sensitivity and 96% specificity. Conclusion Overnight pulse oximetry may be considered a diagnostic tool in patients suspected to have SAHS, with excellent diagnostic sensitivity, specificity and accuracy, which increased with severity.
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