A study of plasma copeptin level as a predictor of severity during acute exacerbation of bronchial asthma Ahmed G El Gazzar, Khaled M Belal, Tarek S Essawy, Neveen M Abd-Elfattah Egyptian Journal of Bronchology 2019 13(4):443-451 Background An exacerbation of asthma is an episode, characterized by a progressive increase in one or more typical asthma symptoms (shortness of breath, wheezing, cough, and chest tightness). Copeptin is a 39-amino acid glycopeptide that is derived from the c-terminal part of the pre–pro-hormone of arginine vasopressin. Aim The aim of our study was to evaluate the role of copeptin in asthmatic patients and its relationship to disease severity. Patients and methods This was a prospective observational study carried out on 45 patients during acute exacerbation of bronchial asthma (15 mild, 15 moderate, and 15 severe cases) and 15 healthy participants. Results Our study showed no significant difference in age, sex, and BMI between case and control groups. There was a statistical highly significant differences in pulmonary function tests, partial pressure of oxygen in arterial blood, partial pressure of carbon dioxide in arterial blood, and oxygen saturation among mild, moderate, and severe cases, and significant increase in total leukocytic count and hospital stay in severe cases than mild and moderate cases. There was a highly significant increase of plasma copeptin in moderate and severe cases than mild cases and control groups. There were nonsignificant correlations between copeptin and pulmonary function tests in mild cases; a significant negative correlation between copeptin and forced expiratory volume in 1 s (FEV1) actual in moderate cases; significant negative correlations between copeptin, FEV1 actual, FEV1% predicted, forced vital capacity% predicted, and peak expiratory flow% predicted in severe cases; and highly significant negative correlations between copeptin and partial pressure of oxygen in arterial blood and oxygen saturation in all cases (P<0.001). Partial pressure of carbon dioxide in arterial blood exhibited a nonsignificant positive correlation with copeptin (P<0.05). Conclusion Copeptin is proven to be a novel biomarker and is increased in patients with asthma as compared with healthy controls.

Impulse oscillometry usefulness in small-airway dysfunction in asthmatics and its utility in asthma control Ragia S Sharshar Egyptian Journal of Bronchology 2019 13(4):452-458 Background Small-airway affection and its relation to clinical status in asthmatic patients became an increasing interest during the last decade. Spirometry is a basic diagnostic tool for measuring pulmonary function in asthmatics but not fully illustrative especially in assessing small airways. Impulse oscillometry (IOS) can be considered a complementary and sometimes alternative technique to spirometry because it is used during quiet breathing and so gives more data about small-airways affection in asthmatic patients. Aim To evaluate IOS usefulness in the detection of small-airways disease in asthma and its correlation to the level of disease control. Patients and methods The study was conducted on 44 asthmatic patients who were classified into two groups: controlled asthma and uncontrolled asthma by asthma control test questionnaire (ACT score). Spirometry and IOS were performed on all patients. Results Small-airway IOS values (R5–20, X5, and AX) were found to be statistically significant between two groups. Moreover, they strongly correlated significantly with clinical symptoms, assessed by ACT. There was high sensitivity and specificity of (R5–20) 80 and 82%, (X5) 80 and 86%, and (AX) 86 and 89%, while for spirometric data only forced expiratory flow (FEF25–75%) showed a statistically significant difference between the two groups, and not FEV1% and there was poor correlation between ACT and FEF25–75%. Conclusion IOS provides an easy and rapid tool to diagnose and assess small-airways disease in adult, asthmatic patients

Correlation between ventricular function as assessed by echocardiography and six-minute walk test as a surrogate of functional capacity in patients with chronic obstructive pulmonary disease Magdy M Khalil, Hala M Salem, Hossam-Eldin M Abdil-Hamid, Muhammad Y Zakaria Egyptian Journal of Bronchology 2019 13(4):459-468 Background Exercise intolerance is common in patients with chronic obstructive pulmonary disease (COPD), which has multiple mechanisms underlying its progression. Ventricular dysfunction may play a role in the development of exercise incapacity in patients with COPD. Aim To investigate the possible contribution of left ventricular (LV) and right ventricular (RV) dysfunction (either systolic or diastolic) in development of exercise intolerance in patients with COPD. Patients and methods A total of 60 patients with diagnosis of COPD were categorized according to GOLD spirometric stage into two groups (group 1: mild to moderate COPD, and group 2: severe to very severe COPD). Both groups were evaluated by spirometry, ECG, chest radiography, routine laboratory investigation, 6-min walk test, and echocardiography including tissue Doppler imaging. Results The average age in the whole study group was 56.63±10.33 years. Male patients in the study were 46 (76.7%) and female patients were 14 (23.3%). Mean maximum walk distance among the whole group was 342.75±54.85 m. There was a significant correlation between 6-min walk distance and transtricuspid E velocity, tricuspid E/A, and transtricuspid deceleration time (P=0.011, 0.015, and 0.021, respectively). There was no significant correlation between 6-min walk distance and parameters of LV diastolic dysfunction. Prevalence of ventricular dysfunction was as follow: LV systolic dysfunction 3.3%, LV diastolic dysfunction 30%, RV systolic dysfunction 21%, and RV diastolic dysfunction 46%. Conclusion RV diastolic dysfunction may be a contributing factor in the progression of exercise intolerance in COPD. Although LV diastolic dysfunction may not be associated with exercise intolerance, it is still prevalent in COPD and must be assessed and managed through the course of the disease and especially during exacerbation.

Diagnostic yield of ultrasound-guided transthoracic biopsy in peripheral lung lesions Fayed H Kawshty, Ahmed A Abd Elradi, Ahmed M Ahmed Egyptian Journal of Bronchology 2019 13(4):469-476 Background Ultrasonography (US) guidance of transthoracic needle biopsy of peripheral lung lesions is a useful diagnostic technique. It is a relatively easy and safe procedure under real-time US guidance and may give enough tissue sampling of lesions for histopathological examination. The aim of this study was to determine the diagnostic accuracy and safety of this technique in the diagnosis of peripheral lung lesions. Patients and methods A total of 60 patients underwent US-guided percutaneous needle biopsy of peripheral lung lesions from November 2017 to October 2018 in the Chest Department. The age of patients ranged from 27 to 79 years, with mean age of 58.4 years. Overall, 48 (80%) patients of the studied group were males, whereas 12 (20%) patients were females. Results According to the final diagnoses, 48 (80%) cases were malignant and 12 (20%) cases were benign. Diagnostic accuracy was 90%, sensitivity was 96%, both specificity and positive predictive value were 100%, and the negative predictive value was 60%. Pneumothorax and hemoptysis occurred in two (3.33%) patients each. Conclusion Chest US-guided biopsy in the diagnosis of peripheral lung lesions is a safe and fast procedure with high diagnostic yield and fewer complications.

Sonographic measurement of lung aeration versus rapid shallow breathing index as a predictor of successful weaning from mechanical ventilation Nabila I Laz, Mohammad F Mohammad, Sahar M Abdelsalam, Radwa M Abdelwahab Egyptian Journal of Bronchology 2019 13(4):477-483 Background Lung ultrasonography is a beneficial tool for evaluation of the extent of lung aeration through measurement of the amount of extravascular lung water. Lung ultrasonography offers some advantages over other methods of assessment of lung aeration including the lack of ionizing radiation and the possibility of use at patient’s bedside. It facilitates dynamic assessment of the lung during mechanical ventilation and during weaning. Aim To assess lung aeration by lung ultrasonography in patients ready for weaning and to validate the significance of its use as a predictor of weaning outcome in comparison with rapid shallow breathing index. Patients and methods A prospective observational study was conducted on 30 critically ill mechanically ventilated patients for 48 h or more, and ready to undergo spontaneous breathing trial (SBT), according to the readiness criteria. It was conducted in Beni-Suef University Hospital from October 2017 to May 2018. Rapid shallow breathing index was measured before initiation of SBT, and lung ultrasound was done, before, during, and after SBT [lung ultrasound score (LUS) 1, 2, and 3] and were used as predictors for SBT outcome. Patients were divided, according to outcome, into successful weaning group (group A) and failed weaning group (group B). Results In the failed weaning group, LUS1, LUS2, and LUS3 were significantly higher than those of the successful weaning group. At cutoff value of 8.5, LUS3 could be used for prediction of weaning failure with sensitivity 85% and specificity 100%. Moreover, there was a statistically significant relation between LUS and the other variables including hospital stay, mechanical ventilation duration, and mortality. Conclusion Lung ultrasound is useful as a bedside tool that can help physicians in their weaning decisions.

Clinical outcome of weaning in mechanically ventilated patients with chronic obstructive pulmonary disease Suzan Salama Sayed, Khalid Hussein Ahmed, Sayed Abdelsabour Kinawy, Islam Galal Sayed Egyptian Journal of Bronchology 2019 13(4):484-488 Background Chronic obstructive pulmonary disease (COPD) represents a significant reason for mortality and morbidity worldwide that induces a high socioeconomic burden, with exacerbations necessitating mechanical ventilation representing a major aspect of illness management. Many patients with COPD frequently presented with troubles in the liberation from mechanical ventilation. The aim of the current study was to verify the validity of the weaning categorization that is classified according to the difficulty and length of the weaning procedure in mechanically ventilated patients with COPD and its effect on the different clinical and mortality outcome variables. Patients and methods A total of 102 patients with COPD who achieved the weaning criteria were classified according to the length and difficulty of weaning procedure into simple weaning group (n=60, 58.8%) and nonsimple weaning group (which include difficult and prolonged weaning categories) (n=42, 42.2%). The outcome measures are the length of mechanical ventilation, the duration of ICU stay, and lastly the mortality rate. Results Regarding baseline data recorded at admission, no significant difference between both weaning groups was found apart from Acute Physiology and Chronic Health Evaluation score II. The nonsimple weaning group had considerably higher duration of invasive mechanical ventilation, length of ICU stays, and lastly the mortality rate, in comparison with the simple weaning group. Conclusion Weaning categorization according to the length and the difficulty of the weaning procedure may be used as a suitable predictor of outcome in severe COPD exacerbation with the requirement for invasive mechanical ventilation.

Diaphragm and weaning from mechanical ventilation: anticipation and outcome Rasha M Abdelhafeez, Ahmed M Abumossalam, Eman O Arram, Mohsen M Elshafey, Mohammed E Abushehata Egyptian Journal of Bronchology 2019 13(4):489-497 Background Determining the optimal moment to extubate a critically ill patient remains a challenge. The parameters of diaphragm sonography offer precious data in the evaluation and follow-up of critically ill patients on mechanical ventilation. Aim To evaluate the diaphragm role in the weaning outcome through the following objectives: detect the association between ultrasonographic parameters of diaphragm [thickness, excursion, and velocity of contraction (slope)] and weaning outcome, success, or failure, in addition to evaluation of the weaning process by measuring the total duration of ventilation, weaning duration, ICU stay, and reventilation. Patients and methods A longitudinal, observational, prospective study. The primary endpoint was weaning outcome (failed or successful), while the secondary endpoints included length of ICU stay, weaning duration, ventilation duration, presence or absence of complications, and mortality. It was conducted on 240 (138 men and 102 women) invasively mechanically ventilated patients aged between 20 and 78 years were chosen from our Respiratory ICU of Chest Department, Mansoura University Hospital. Results There were statistically significant higher values of all sonographic measurements in the survived compared with the died group (P<0.001). There was statistically significantly higher sonographic diaphragmatic measurements in the successful group compared with the failed group (P<0.001). Conclusion The measurement of percent change of diaphragmatic thickness as well as excursion and slope could be applied in correlation more with weaning outcome with a sensitivity of 100% and specificity of 97.4%.

Usefulness of different prognostic scores for AECOPD: APACHE II, BAP65, 2008, and CAPS scores Rania A Sweed, Mostafa Abd El Mageed Shaheen, Esraa A El Gendy Egyptian Journal of Bronchology 2019 13(4):498-504 Purpose The purpose of this study was to compare four different scores [Acute Physiology and Chronic Health Evaluation (APACHE II); elevated blood urea nitrogen, altered mental status, pulse >109/min, age >65 years (BAP65); chronic obstructive pulmonary disease (COPD) and Asthma Physiology Score (CAPS); and 2008 score) to test their predictive properties for the need of mechanical ventilation (MV) and short-term mortality in patients with acute exacerbation COPD (AECOPD). Patients and methods This study enrolled 100 consecutive patients with acute exacerbation COPD, over a 6-month duration, admitted to the Emergency Department in Alexandria Main University Hospitals. The four scores were calculated for each patient, and clinical data and outcome (need for MV and mortality during hospitalization or within a week after discharge) were recorded. Results Their mean age was 61.1±10.7 years, and 88% were males. Duration of hospital stay was less than or equal to 20 days in 67%. Mortality rate was 4%. Overall, 40% required MV. Blood urea nitrogen, pulse, CO2, pH, altered consciousness, and white blood cell were significant predictors of mortality in univariate but not multivariate analysis. Previous MV, cyanosis, and paradoxical abdominal movement were significant predictors of need for MV. The highest area under the receiver operating characteristic curve was that of APACHE II score regarding either mortality prediction [area under the curve (AUC), 0.982; P=0.001] or need for MV (AUC, 0.959; P<0.001), followed by BAP65 score for mortality prediction (AUC, 0.967; P=0.002) and 2008 score for predicting the need for MV (AUC, 0.851; P<0.001). Conclusion All studied scores correlated significantly with mortality, but only APACHE II and 2008 score correlated significantly with the need for MV. The highest area under the receiver operating characteristic curve was that of APACHE II score regarding either mortality or need for MV prediction. Previous need for MV was the most important predictor for the need for MV. The routine use of these practical scores in triage of patients may direct early interventions to reduce mortality rate.

Post ICU syndrome among survivors from respiratory critical illness. A prospective study Ahmad Abbas, Niveen E Zayed, Samah M Lutfy Egyptian Journal of Bronchology 2019 13(4):505-509 Context Post-ICU syndrome (PICS) is a common impairment that develops after critical illness and persists after discharge. It is considered when a new or worsening impairment in physical, cognitive, or mental status develops among survivors from critical illness. Aim To assess the prevalence of PICS and to define the profile of patients at risk of each domain. Patients and methods A total of 420 critically ill patients were assessed at the time of ICU discharge for presence of one or more domains of PICS: cognitive dysfunction, psychiatric impairment, and physical disability. Results A total of 220 (52.4%) patients without preexisting impairment developed one or more PICS forms. Half of the participants developed cognitive impairment, 14.29% developed depression, 26.19 developed anxiety, and 35.71% experienced both muscle weakness and impaired balance. PICS presented in three different patterns: pattern A, with one domain, in which 2.38% presented with either cognitive or psychiatric affection; pattern B, with two (19.05%) domains, where 80 patients had cognitive dysfunction, combined with physical affection in 30 patients and psychiatric impairment in 50 patients; and pattern C, with all PICS domains (28.57%). Multivariate analysis was used to detect independent predictors associated with each domain of PICS. Conclusion Survivors from critical illness should be screened for different domains of PICS. Cognitive impairment was evident in those with prolonged duration of mechanical ventilation (MV), delirium, stroke, and hypotension. Psychiatric impairment was evident in females with prolonged sedation and duration of MV, delirium, and hypoglycemia. Physical impairments were evident in those with sepsis, undernutrition, and prolonged duration of MV.

Effect of different classes of obesity on the pulmonary functions among adult Egyptians: a cross-sectional study Ashraf M Hatem, Mohamed S Ismail, Yasmine H El-Hinnawy Egyptian Journal of Bronchology 2019 13(4):510-515 Introduction Obesity is a common chronic disease, representing a major health hazard. Obesity has several delirious effects on the respiratory functions. Aim of the study To study the effect of obesity on pulmonary functions among our local population of obese adults and to assess the correlation between the severity of lung function impairment and the degree of obesity. Patients and methods Healthy nonsmoker adult patients were recruited in our cross-sectional study. After full medical evaluation, measurement of height and weight, and calculation of BMI, patients underwent spirometry tests with measurement of forced expiratory volume in first second (FEV1), forced vital capacity (FVC), forced mid-expiratory flow, and peak expiratory flow rate. Then, they were classified according to their BMI into five groups. Results The study included 293 patients divided into five groups according to their BMI. Significant statistical differences were noticed between nonobese patients and patients with classes II and III obesity regarding FVC, FEV1, and forced mid-expiratory flow, but no differences regarding peak expiratory flow rate and FEV1/FVC ratio. Overall, 28.9% of the total obese patients presented with restrictive pattern of spirometry, 2.8% with obstructive, and 2.4% with mixed patterns. Conclusion Obesity of especially marked degrees with BMI of more than 35 kg/m2 negatively affects the spirometric parameters. Restrictive pattern was the commonest abnormality observed in the spirometry of obese patients.