UNLABELLED The analysis of the Management Unit of the National TB Programme (NTP) database, together with the reports of the TB county managers, allowed to the authors to identify some weaknesses of TB control in Romania in the recent years and to propose the appropriate measures. PROBLEMS The marked decrease in the reduction of TB cases reported annually from 2,761 in 2005-2006, to 145 in 2007-2008 and the stagnation of mortality rate: 7.5 per ten thousand in 2007 and 7.6 per ten thousand in 2008. Deficiencies in data recording and reporting through informatic system of the NTP. Lack of financial resources for system maintenance and upgrade. Deficiencies in monitoring and control of mycobacterium resistance to antituberculous drugs phenomenon at national level. Sensitivity testing only for a small percentage of culture confirmed new TB cases (21%). Higher percentage of MDR in new TB cases compared to the results of national survey of mycobacterium drug resistance 2003-2004. Lack of personnel: 16 TB dispensaries without any pulmonologist, vacancies for 259 doctors, 436 nurses and 433 auxiliary personnel. Important deficiencies in the NTP network's infrastructure and logistics countrywide. Discontinuities in the supply with first and second line antituberculous drugs resulting in interruption of treatments. Lack of an officially endorsed protocol for the diagnosis, treatment and monitoring of cases with TB/HIV co-infection. Solutions: Revitalization of monitoring-supervision activities of the NTP running countrywide, provision with necessary financial resources to perform the scheduled visits in counties. Providing maintenance and upgrade of the informatic system for data collection. Implementation of the necessary measures in order to attract and maintain the personnel in the NTP network. Conduct the national survey of mycobacterium susceptibility to first and second line antituberculous drugs and drug susceptibility testing of the most culture confirmed TB cases. Restore the centralized procurement of TB drugs. Finalization and official endorsement of the protocol for TB/HIV co-infection initiated in 2004.
UNLABELLED Community respiratory tract infections are common in clinical practice. Antimicrobial treatment should be promptly administered and guided by a probabilistic approach according to the clinical presentation and local patterns of bacterial resistance. Bacterial resistance is widespread, with large geographical variations related to behaviors in antibiotics prescription. S. pneumoniae and H. influenzae are the most frequent pathogens responsible for respiratory tract infections etiology. METHODS We assessed the antibiotics susceptibility of S. pneumoniae and H. influenzae strains isolated from patients with community respiratory tract infections, prospectively enrolled over a period of 3 consecutive years, by determining the MIC. Analysis was performed using both cutoffs provided by European Committee on Antimicrobial Susceptibility testing (EUCAST) and CLSI. Consequently we evaluated the influence of different factors associated with the development of bacterial resistance. RESULTS We analyzed 293 S. pneumoniae strains and 265 H. influenzae strains isolated during 1999-2001, mainly from sputum (68.3% and 74.9% respectively of total isolates). We observed a high proportion of S. pneumoniae resistant to penicillin (6.1% resistant and 48.5% with intermediate susceptibility) and to erythromycin (39% resistant strains). H. influenzae strains were resistant to amoxicillin in 26% of cases and the presence of betalactamase was certified in 13% of tested isolates; 18.3% of H. influenzae strains were resistant to amoxicillin through specific mechanisms other than by producing betalactamase. Other antibiotic resistances were assessed. CONCLUSIONS In Romania clinician must consider the high prevalence of antibiotic resistance, particulary of S. pneumoniae to macrolides and beta-lactams (thus requiring the use of high doses of betalactams) and the high proportion of beta-lactamase producing H. influenzae.
Background: Patients with COPD have severe breathlessness induced by the increased mechanical work of respiratory muscles in relation to dynamic hyperinflation. Pulmonary rehabilitation programs have been shown to relieve dyspneea, but the mechanism by which they succeed remains controversial. Aim: To evaluate the effect of pulmonary rehabilitation on thoracic mechanics. Method: The association between thoracic hyperinflation measured by plethysmography (functional residual capacity FRC, residual volume RV), respiratory muscle strength (maximal inspiratory pressure MIP, maximal expiratory pressure MEP) and dyspnoea scores (MRC scale) were analyzed in patients with stable COPD before and after pulmonary rehabilitation (outpatient program, 2 months, 3 sessions/week, including daily respiratory muscle training). Results: Twenty patients with COPD stage II-IV GOLD were included. Thoracic hyperinflation was present in all cases: mean FRC 164.9% of the predicted value and RV 209.2% before the rehabilitation program. Mean MIP was 69.6% and mean MEP 105.3%. The severity of dyspnoea before the pulmonary rehabilitation was negatively associated with inspiratory muscle strength (r -0.68) and hyperinflation (r -0.45). Hyperinflation decreased at the end of the rehabilitation program (mean RV decreased with 15.1% and mean FRC with 9.2%), mean MIP increased with 14.3% and the mean dyspnoea score decreased from 3.5 to 2.2. Conclusion: Pulmonary rehabilitation optimized thoracic mechanics in our patients by reducing thoracic hyperinflation and increasing the effectiveness of inspiratory muscles work.
Noninvasive ventilation (NIV) reduces the rate of endotracheal intubation (ETI) and overall mortality in severe acute exacerbation of COPD (AECOPD) with acute respiratory failure and is increasingly applied in respiratory intermediate care units. However, inadequate patient selection and incorrect management of NIV increase mortality. We aimed to identify factors that predict the outcome of NIV in AECOPD. Also, we looked for factors that influence ventilator settings and duration. A prospective cohort study was undertaken in a respiratory intermediate care unit in an academic medical center between 2016 and 2017. Age, BMI, lung function, arterial pH and pCO2 at admission (t0), at 1–2 h (t1) and 4–6 h (t2) after admission, creatinine clearance, echocardiographic data (that defined left heart dysfunction), mean inspiratory pressure during the first 72 h (mIPAP-72 h) and hours of NIV during the first 72 h (dNIV-72 h) were recorded. Main outcome was NIV failure (i.e., ETI or in-hospital death). Secondary outcomes were in-hospital mortality, length of stay (LOS), duration of NIV (days), mIPAP-72 h, and dNIV-72 h. We included 89 patients (45 male, mean age 67.6 years) with AECOPD that required NIV. NIV failure was 12.4%, and in-hospital mortality was 11.2%. NIV failure was correlated with days of NIV, LOS, in-hospital mortality (p < 0.01), and kidney dysfunction (p < 0.05). In-hospital mortality was strongly associated with days of NIV (OR 1.27, 95%CI: 1.07–1.5, p < 0.01) and with FEV1 (p < 0.05). All other investigated parameters (including left heart dysfunction, dNIV-72 h, mIPAP-72 h, pH, etc.) did not influence NIV failure or mortality. dNIV-72 h and days of NIV were independent predictors of LOS (p < 0.01). Regarding the secondary outcomes, left heart dysfunction and pH at 1-2 h independently predicted NIV duration (dNIV-72 h, p < 0.01), while BMI and baseline pCO2 predicted NIV settings (mIPAP-72 h, p < 0.01). In-hospital mortality and NIV failure were not influenced by BMI, left heart dysfunction, age, nor by arterial blood gas values in the first 6 h of NIV. Patients with severe acidosis and left heart dysfunction required prolonged use of NIV. BMI and pCO2 levels influence the NIV settings in AECOPD regardless of lung function.
Background: Granulomatosis with polyangiitis (GPA), eosinophilic granulomatosis with polyangiitis (EGPA) and microscopic polyangiitis(MPA) are antineutrophil cytoplasmic antibodies (ANCA) – associated vasculitides with significant morbidity and mortality.
Objective: We evaluated the evolution of 68 patients diagnosed with vasculitis between 1997 and 2013, treated with conventional treatment (prednisolone and pulse cyclophosphamide initially, and after remission with prednisolone and azathioprine).
Results: We evaluated 68 patients (36 females), median age of 54 years (range 17-84), with a median duration of follow up of 39.5 months (range 1-144 months), 26 with GPA, 40 with MPA and 2 with EGPA. Seven patients out of 13 performed had alveolar haemorrhage at broncho-alveolar lavage. Seventeen patients had relapses (25%), 1 developed subglottic stenosis, 1 retro-orbital pseudo tumor and 2 patients developed opportunistic infectious of the lung cavities and needed lung resection. Due to immunosuppressive therapy 2 patients developed lung tuberculosis (one multi-drug-resistant) and 1 pulmonary nocardiosis. Patients with GPA had renal failure at diagnosis in a procent of 46,2% and MPA 90%. Twenty seven patients needed definitive hemodialysis for renal failure. Fifteen patients died: 10 with alveolar haemorrhage, 3 with sepsis, 1 with stroke and one cancer. MPA diagnosis, older age and renal failure were predictors of death.
Conclusions: Significant differences exist between GPA and MPA at the initial presentation that can predict the evolution of the disease. The management of patients with ANCA-associated vasculitides is difficult and marked by the adverse effects of the therapy.
Background: Respiratory muscle impairment could contribute to severe breathlessness and exercise intolerance in COPD patients. Aim: To evaluate the respiratory muscle function and exercise tolerance in COPD patients before and after pulmonary rehabilitation. Subjects and methods: Respiratory muscle strength (maximal inspiratory pressure MIP, maximal expiratory pressure MEP), exercise tolerance (6 minutes walking test 6MWT) and dyspnoea score (BORG scale) were analyzed in patients with stable COPD before and after pulmonary rehabilitation (outpatient program, 2 months, 3 sessions/week, including daily respiratory muscle training). Results: Twenty-two patients with COPD stage II-IV GOLD were included. Mean MIP value was 68.6% of the predicted value (less than 70% in 16 cases) and mean MEP value 104.4%. The mean 6MWT distance (6MWD) was 410 meters. 6MWD was better associated with MIP (r 0.62) than with MEP (r 0.38). Severity of dyspnoea was negatively associated with MIP values (r -0.49) and with 6MWD (r -0.49). Mean 6MWD increased with 70 meters at the end of the rehabilitation program, mean dyspnoea score diminished at rest (from 3.3 to 2.1) and after exercise (from 5.3 to 2.6), and mean MIP values increased to 81.6%. Conclusions: An improvement in exercise tolerance was seen after pulmonary rehabilitation. Increased walking distance accompanied by lower dyspnoea scores could be related to the increased respiratory muscle performance measured by MIP.
Introduction: Improving patient-ventilator interaction during mechanical ventilation with acute hypercapnic respiratory failure (AHRF) reduces mortality. The esophageal pressure (Pes) measurement is an established way of detecting asynchronies in mechanically ventilated patients. This study aimed to evaluate the potential of Pes measurement in detecting patient-ventilator asynchronies in patients with AHRF due to severe COPD exacerbation requiring NIV. Methods: A prospective cohort study was undertaken in a respiratory intermediate care unit in an academic medical center between 2018 and 2019. Pes and ventilator pressure (Paw) curves and other data were recorded. The signal analysis comprised of artifact elimination and measurement of the phase difference between Pes and Paw curves. The objective was to assess the potential of using the phase difference value as an indicator of asynchrony. Results: 15 patients (8 males, mean age 65 years) with severe COPD exacerbation with AHRF requiring NIV were included. All patients were successfully managed with NIV. Patient-ventilator asynchrony was clinically detected in 3 patients at admission. The signal analysis identified all episodes of asynchrony with phase difference values of 10-15° during asynchrony and value of 170-180° during synchrony period for the same patient. Conclusion: Pes measurement can be used to detect patient-ventilator asynchronies in severe COPD exacerbation with AHRF that requires NIV.
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