Dyspnea. Mechanisms, assessment, and management: a consensus statement. American Thoracic Society.
Am J Respir Crit Care Med. 1999 Jan;159(1):321-40. doi: 10.1164/ajrccm.159.1.ats898.
Abstract/Text
Mark B Parshall, Richard M Schwartzstein, Lewis Adams, Robert B Banzett, Harold L Manning, Jean Bourbeau, Peter M Calverley, Audrey G Gift, Andrew Harver, Suzanne C Lareau, Donald A Mahler, Paula M Meek, Denis E O'Donnell, American Thoracic Society Committee on Dyspnea
An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea.
Am J Respir Crit Care Med. 2012 Feb 15;185(4):435-52. doi: 10.1164/rccm.201111-2042ST.
Abstract/Text
BACKGROUND: Dyspnea is a common, distressing symptom of cardiopulmonary and neuromuscular diseases. Since the ATS published a consensus statement on dyspnea in 1999, there has been enormous growth in knowledge about the neurophysiology of dyspnea and increasing interest in dyspnea as a patient-reported outcome.
PURPOSE: The purpose of this document is to update the 1999 ATS Consensus Statement on dyspnea.
METHODS: An interdisciplinary committee of experts representing ATS assemblies on Nursing, Clinical Problems, Sleep and Respiratory Neurobiology, Pulmonary Rehabilitation, and Behavioral Science determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant expertise. The final content of this statement was agreed upon by all members.
RESULTS: Progress has been made in clarifying mechanisms underlying several qualitatively and mechanistically distinct breathing sensations. Brain imaging studies have consistently shown dyspnea stimuli to be correlated with activation of cortico-limbic areas involved with interoception and nociception. Endogenous and exogenous opioids may modulate perception of dyspnea. Instruments for measuring dyspnea are often poorly characterized; a framework is proposed for more consistent identification of measurement domains.
CONCLUSIONS: Progress in treatment of dyspnea has not matched progress in elucidating underlying mechanisms. There is a critical need for interdisciplinary translational research to connect dyspnea mechanisms with clinical treatment and to validate dyspnea measures as patient-reported outcomes for clinical trials.
Schwartzstein RM. Dyspnea. Chapter 33. In Harrison’s Online. http://accessmedicine.com/content.aspx?aid=9097259.
Marx: Rosen’s Emergency Medicine, 7th edition. Chpater 17: Dyspnea.
B R Celli, W MacNee, ATS/ERS Task Force
Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper.
Eur Respir J. 2004 Jun;23(6):932-46.
Abstract/Text
Jean-Pierre Frat, Arnaud W Thille, Alain Mercat, Christophe Girault, Stéphanie Ragot, Sébastien Perbet, Gwénael Prat, Thierry Boulain, Elise Morawiec, Alice Cottereau, Jérôme Devaquet, Saad Nseir, Keyvan Razazi, Jean-Paul Mira, Laurent Argaud, Jean-Charles Chakarian, Jean-Damien Ricard, Xavier Wittebole, Stéphanie Chevalier, Alexandre Herbland, Muriel Fartoukh, Jean-Michel Constantin, Jean-Marie Tonnelier, Marc Pierrot, Armelle Mathonnet, Gaëtan Béduneau, Céline Delétage-Métreau, Jean-Christophe M Richard, Laurent Brochard, René Robert, FLORALI Study Group, REVA Network
High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure.
N Engl J Med. 2015 Jun 4;372(23):2185-96. doi: 10.1056/NEJMoa1503326. Epub 2015 May 17.
Abstract/Text
BACKGROUND: Whether noninvasive ventilation should be administered in patients with acute hypoxemic respiratory failure is debated. Therapy with high-flow oxygen through a nasal cannula may offer an alternative in patients with hypoxemia.
METHODS: We performed a multicenter, open-label trial in which we randomly assigned patients without hypercapnia who had acute hypoxemic respiratory failure and a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen of 300 mm Hg or less to high-flow oxygen therapy, standard oxygen therapy delivered through a face mask, or noninvasive positive-pressure ventilation. The primary outcome was the proportion of patients intubated at day 28; secondary outcomes included all-cause mortality in the intensive care unit and at 90 days and the number of ventilator-free days at day 28.
RESULTS: A total of 310 patients were included in the analyses. The intubation rate (primary outcome) was 38% (40 of 106 patients) in the high-flow-oxygen group, 47% (44 of 94) in the standard group, and 50% (55 of 110) in the noninvasive-ventilation group (P=0.18 for all comparisons). The number of ventilator-free days at day 28 was significantly higher in the high-flow-oxygen group (24±8 days, vs. 22±10 in the standard-oxygen group and 19±12 in the noninvasive-ventilation group; P=0.02 for all comparisons). The hazard ratio for death at 90 days was 2.01 (95% confidence interval [CI], 1.01 to 3.99) with standard oxygen versus high-flow oxygen (P=0.046) and 2.50 (95% CI, 1.31 to 4.78) with noninvasive ventilation versus high-flow oxygen (P=0.006).
CONCLUSIONS: In patients with nonhypercapnic acute hypoxemic respiratory failure, treatment with high-flow oxygen, standard oxygen, or noninvasive ventilation did not result in significantly different intubation rates. There was a significant difference in favor of high-flow oxygen in 90-day mortality. (Funded by the Programme Hospitalier de Recherche Clinique Interrégional 2010 of the French Ministry of Health; FLORALI ClinicalTrials.gov number, NCT01320384.).
F S F Ram, J Picot, J Lightowler, J A Wedzicha
Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease.
Cochrane Database Syst Rev. 2004;(3):CD004104. doi: 10.1002/14651858.CD004104.pub3.
Abstract/Text
BACKGROUND: Non-invasive positive pressure ventilation (NPPV) is being used increasingly in the management of patients admitted to hospital with acute respiratory failure secondary to an exacerbation of chronic obstructive pulmonary disease (COPD).
OBJECTIVES: To determine the efficacy of NPPV in the management of patients with respiratory failure due to an acute exacerbation of COPD.
SEARCH STRATEGY: An initial search was performed using the Cochrane Airways Group trials register and other relevant electronic databases. An updated search was conducted in September 2003 and another in April 2004.
SELECTION CRITERIA: Randomised controlled trials comparing NPPV plus usual medical care (UMC) versus UMC alone were selected. Trials needed to recruit adult patients admitted to hospital with respiratory failure due to an exacerbation of COPD and with PaCO2 > 6 kPa (45 mmHg).
DATA COLLECTION AND ANALYSIS: Two reviewers independently selected articles for inclusion, evaluated methodological quality of the studies and abstracted the data.
MAIN RESULTS: Fourteen studies were included in the review. NPPV resulted in decreased mortality (Relative Risk 0.52; 95%CI 0.35 to 0.76), decreased need for intubation (RR 0.41; 95%CI 0.33 to 0.53), reduction in treatment failure (RR 0.48; 95%CI 0.37 to 0.63), rapid improvement within the first hour in pH (Weight Mean Difference 0.03; 95%CI 0.02 to 0.04), PaCO2 (WMD -0.40 kPa; 95%CI -0.78 to -0.03) and respiratory rate (WMD -3.08 bpm; 95%CI -4.26 to -1.89). In addition, complications associated with treatment (RR 0.38; 95%CI 0.24 to 0.60) and length of hospital stay (WMD -3.24 days; 95%CI -4.42 to -2.06) was also reduced in the NPPV group.
REVIEWERS' CONCLUSIONS: Data from good quality randomised controlled trials show benefit of NPPV as first line intervention as an adjunct therapy to usual medical care in all suitable patients for the management of respiratory failure secondary to an acute exacerbation of COPD. NPPV should be considered early in the course of respiratory failure and before severe acidosis ensues, as a means of reducing the likelihood of endotracheal intubation, treatment failure and mortality.
Stefano Nava, Giorgio Carbone, Nicola DiBattista, Andrea Bellone, Paola Baiardi, Roberto Cosentini, Mauro Marenco, Fabrizio Giostra, Guido Borasi, Paolo Groff
Noninvasive ventilation in cardiogenic pulmonary edema: a multicenter randomized trial.
Am J Respir Crit Care Med. 2003 Dec 15;168(12):1432-7. doi: 10.1164/rccm.200211-1270OC. Epub 2003 Sep 4.
Abstract/Text
Studies employing noninvasive pressure support ventilation in cardiogenic pulmonary edema have been performed in the intensive care unit when overt respiratory failure is already present and in small groups of patients. In this multicenter study, performed in emergency departments, 130 patients with acute respiratory failure were randomized to receive medical therapy plus O2 (65 patients) or noninvasive pressure support ventilation (65 patients). The primary end point was the need for intubation; secondary end points were in-hospital mortality and changes in some physiological variables. Noninvasive pressure support ventilation improved PaO2/FIO2, respiratory rate, and dyspnea significantly faster. Intubation rate, hospital mortality, and duration of hospital stay were similar in the two groups. In the subgroup of hypercapnic patients noninvasive pressure support ventilation improved PaCO2 significantly faster and reduced the intubation rate compared with medical therapy (2 of 33 versus 9 of 31; p=0.015). Adverse events, including myocardial infarction, were evenly distributed in the two groups. We conclude that during acute respiratory failure due to cardiogenic pulmonary edema the early use of noninvasive pressure support ventilation accelerates the improvement in PaO2/FIO2, PaCO2, dyspnea, and respiratory rate, but does not affect the overall clinical outcome. Noninvasive pressure support ventilation does, however, reduce the intubation rate in the subgroup of hypercapnic patients.
Lorraine B Ware, Michael A Matthay
Clinical practice. Acute pulmonary edema.
N Engl J Med. 2005 Dec 29;353(26):2788-96. doi: 10.1056/NEJMcp052699.
Abstract/Text
S A Sahn, J E Heffner
Spontaneous pneumothorax.
N Engl J Med. 2000 Mar 23;342(12):868-74. doi: 10.1056/NEJM200003233421207.
Abstract/Text
Lionel A Mandell, Richard G Wunderink, Antonio Anzueto, John G Bartlett, G Douglas Campbell, Nathan C Dean, Scott F Dowell, Thomas M File, Daniel M Musher, Michael S Niederman, Antonio Torres, Cynthia G Whitney, Infectious Diseases Society of America, American Thoracic Society
Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults.
Clin Infect Dis. 2007 Mar 1;44 Suppl 2:S27-72. doi: 10.1086/511159.
Abstract/Text
Jay H Ryu, Eric J Olson, David E Midthun, Stephen J Swensen
Diagnostic approach to the patient with diffuse lung disease.
Mayo Clin Proc. 2002 Nov;77(11):1221-7; quiz 1227. doi: 10.4065/77.11.1221.
Abstract/Text
Detecting diffuse lung infiltrates on chest radiography is a common clinical problem. Many diverse pathological processes can cause diffuse lung disease. The presentation of these diseases can vary from acute to chronic and includes a side array of radiological patterns that are optimally evaluated on high-resolution computed tomography of the chest. In diagnosing diffuse lung disease, it is helpful to focus on a few pivotal parameters to narrow the broad differential diagnosis. We describe the diagnostic approach to a patient with diffuse lung disease usingthe following key parameters: tempo of the pathological process, characteristics of the radiological pattern, and clinical context.
G L Colice, A Curtis, J Deslauriers, J Heffner, R Light, B Littenberg, S Sahn, R A Weinstein, R D Yusen
Medical and surgical treatment of parapneumonic effusions : an evidence-based guideline.
Chest. 2000 Oct;118(4):1158-71.
Abstract/Text
OBJECTIVE: A panel was convened by the Health and Science Policy Committee of the American College of Chest Physicians to develop a clinical practice guideline on the medical and surgical treatment of parapneumonic effusions (PPE) using evidence-based methods.
OPTIONS AND OUTCOMES CONSIDERED: Based on consensus of clinical opinion, the expert panel developed an annotated table for evaluating the risk for poor outcome in patients with PPE. Estimates of the risk for poor outcome were based on the clinical judgment that, without adequate drainage of the pleural space, the patient with PPE would be likely to have any or all of the following: prolonged hospitalization, prolonged evidence of systemic toxicity, increased morbidity from any drainage procedure, increased risk for residual ventilatory impairment, increased risk for local spread of the inflammatory reaction, and increased mortality. Three variables, pleural space anatomy, pleural fluid bacteriology, and pleural fluid chemistry, were used in this annotated table to categorize patients into four separate risk levels for poor outcome: categories 1 (very low risk), 2 (low risk), 3 (moderate risk), and 4 (high risk). The panel's consensus opinion supported drainage for patients with moderate (category 3) or high (category 4) risk for a poor outcome, but not for patients with very low (category 1) or low (category 2) risk for a poor outcome. The medical literature was reviewed to evaluate the effectiveness of medical and surgical management approaches for patients with PPE at moderate or high risk for poor outcome. The panel grouped PPE management approaches into six categories: no drainage performed, therapeutic thoracentesis, tube thoracostomy, fibrinolytics, video-assisted thoracoscopic surgery (VATS), and surgery (including thoracotoiny with or without decortication and rib resection). The fibrinolytic approach required tube thoracostomy for administration of drug, and VATS included post-procedure tube thoracostomy. Surgery may have included concomitant lung resection and always included postoperative tube thoracostomy. All management approaches included appropriate treatment of the underlying pneumonia, including systemic antibiotics. Criteria for including articles in the panel review were adequate data provided for >/=20 adult patients with PPE to allow evaluation of at least one relevant outcome (death or need for a second intervention to manage the PPE); reasonable assurance provided that drainage was clinically appropriate (patients receiving drainage were either category 3 or category 4) and drainage procedure was adequately described; and original data were presented. The strength of panel recommendations on management of PPE was based on the following approach: level A, randomized, controlled trials with consistent results or individual randomized, controlled trial with narrow confidence interval (CI); level B, controlled cohort and case control series; level C, historically controlled series and case series; and level D, expert opinion without explicit critical appraisal or based on physiology, bench research, or "first principles."
EVIDENCE: The literature review revealed 24 articles eligible for full review by the panel, 19 of which dealt with the primary management approach to PPE and 5 with a rescue approach after a previous approach had failed. Of the 19 involving the primary management approach to PPE, there were 3 randomized, controlled trials, 2 historically controlled series, and 14 case series. The number of patients included in the randomized controlled trials was small; methodologic weaknesses were found in the 19 articles describing the results of primary management approaches to PPE. The proportion and 95% CI of patients suffering each of the two relevant outcomes (death and need for a second intervention to manage the PPE) were calculated for the pooled data for each management approach from the 19 articles on the primary management approach. (ABST
Stavros V Konstantinides, Guy Meyer, Cecilia Becattini, Héctor Bueno, Geert-Jan Geersing, Veli-Pekka Harjola, Menno V Huisman, Marc Humbert, Catriona Sian Jennings, David Jiménez, Nils Kucher, Irene Marthe Lang, Mareike Lankeit, Roberto Lorusso, Lucia Mazzolai, Nicolas Meneveau, Fionnuala Ní Áinle, Paolo Prandoni, Piotr Pruszczyk, Marc Righini, Adam Torbicki, Eric Van Belle, José Luis Zamorano, ESC Scientific Document Group
2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS).
Eur Heart J. 2020 Jan 21;41(4):543-603. doi: 10.1093/eurheartj/ehz405.
Abstract/Text
Arne van Belle, Harry R Büller, Menno V Huisman, Peter M Huisman, Karin Kaasjager, Pieter W Kamphuisen, Mark H H Kramer, Marieke J H A Kruip, Johanna M Kwakkel-van Erp, Frank W G Leebeek, Mathilde Nijkeuter, Martin H Prins, Maaike Sohne, Lidwine W Tick, Christopher Study Investigators
Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography.
JAMA. 2006 Jan 11;295(2):172-9. doi: 10.1001/jama.295.2.172.
Abstract/Text
CONTEXT: Previous studies have evaluated the safety of relatively complex combinations of clinical decision rules and diagnostic tests in patients with suspected pulmonary embolism.
OBJECTIVE: To assess the clinical effectiveness of a simplified algorithm using a dichotomized clinical decision rule, D-dimer testing, and computed tomography (CT) in patients with suspected pulmonary embolism.
DESIGN, SETTING, AND PATIENTS: Prospective cohort study of consecutive patients with clinically suspected acute pulmonary embolism, conducted in 12 centers in the Netherlands from November 2002 through December 2004. The study population of 3306 patients included 82% outpatients and 57% women.
INTERVENTIONS: Patients were categorized as "pulmonary embolism unlikely" or "pulmonary embolism likely" using a dichotomized version of the Wells clinical decision rule. Patients classified as unlikely had D-dimer testing, and pulmonary embolism was considered excluded if the D-dimer test result was normal. All other patients underwent CT, and pulmonary embolism was considered present or excluded based on the results. Anticoagulants were withheld from patients classified as excluded, and all patients were followed up for 3 months.
MAIN OUTCOME MEASURE: Symptomatic or fatal venous thromboembolism (VTE) during 3-month follow-up.
RESULTS: Pulmonary embolism was classified as unlikely in 2206 patients (66.7%). The combination of pulmonary embolism unlikely and a normal D-dimer test result occurred in 1057 patients (32.0%), of whom 1028 were not treated with anticoagulants; subsequent nonfatal VTE occurred in 5 patients (0.5% [95% confidence interval {CI}, 0.2%-1.1%]). Computed tomography showed pulmonary embolism in 674 patients (20.4%). Computed tomography excluded pulmonary embolism in 1505 patients, of whom 1436 patients were not treated with anticoagulants; in these patients the 3-month incidence of VTE was 1.3% (95% CI, 0.7%-2.0%). Pulmonary embolism was considered a possible cause of death in 7 patients after a negative CT scan (0.5% [95% CI, 0.2%-1.0%]). The algorithm was completed and allowed a management decision in 97.9% of patients.
CONCLUSIONS: A diagnostic management strategy using a simple clinical decision rule, D-dimer testing, and CT is effective in the evaluation and management of patients with clinically suspected pulmonary embolism. Its use is associated with low risk for subsequent fatal and nonfatal VTE.
Hugh A Sampson, Anne Muñoz-Furlong, Ronna L Campbell, N Franklin Adkinson, S Allan Bock, Amy Branum, Simon G A Brown, Carlos A Camargo, Rita Cydulka, Stephen J Galli, Jane Gidudu, Rebecca S Gruchalla, Allen D Harlor, David L Hepner, Lawrence M Lewis, Phillip L Lieberman, Dean D Metcalfe, Robert O'Connor, Antonella Muraro, Amanda Rudman, Cara Schmitt, Debra Scherrer, F Estelle R Simons, Stephen Thomas, Joseph P Wood, Wyatt W Decker
Second symposium on the definition and management of anaphylaxis: summary report--Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium.
J Allergy Clin Immunol. 2006 Feb;117(2):391-7. doi: 10.1016/j.jaci.2005.12.1303.
Abstract/Text
There is no universal agreement on the definition of anaphylaxis or the criteria for diagnosis. In July 2005, the National Institute of Allergy and Infectious Disease and Food Allergy and Anaphylaxis Network convened a second meeting on anaphylaxis, which included representatives from 16 different organizations or government bodies, including representatives from North America, Europe, and Australia, to continue working toward a universally accepted definition of anaphylaxis, establish clinical criteria that would accurately identify cases of anaphylaxis with high precision, further review the evidence on the most appropriate management of anaphylaxis, and outline the research needs in this area.
R Gentry Wilkerson, Michael B Stone
Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs for the identification of pneumothorax after blunt trauma.
Acad Emerg Med. 2010 Jan;17(1):11-7. doi: 10.1111/j.1553-2712.2009.00628.x.
Abstract/Text
OBJECTIVES: Supine anteroposterior (AP) chest radiographs in patients with blunt trauma have poor sensitivity for the identification of pneumothorax. Ultrasound (US) has been proposed as an alternative screening test for pneumothorax in this population. The authors conducted an evidence-based review of the medical literature to compare sensitivity of bedside US and AP chest radiographs in identifying pneumothorax after blunt trauma.
METHODS: MEDLINE and EMBASE databases were searched for trials from 1965 through June 2009 using a search strategy derived from the following PICO formulation of our clinical question: patients included adult (18 + years) emergency department (ED) patients in whom pneumothorax was suspected after blunt trauma. The intervention was thoracic ultrasonography for the detection of pneumothorax. The comparator was the supine AP chest radiograph during the initial evaluation of the patient. The outcome was the diagnostic performance of US in identifying the presence of pneumothorax in the study population. The criterion standard for the presence or absence of pneumothorax was computed tomography (CT) of the chest or a rush of air during thoracostomy tube placement (in unstable patients). Prospective, observational trials of emergency physician (EP)-performed thoracic US were included. Trials in which the exams were performed by radiologists or surgeons, or trials that investigated patients suffering penetrating trauma or with spontaneous or iatrogenic pneumothoraces, were excluded. The methodologic quality of the studies was assessed. Qualitative methods were used to summarize the study results. Data analysis consisted of test performance (sensitivity and specificity, with 95% confidence intervals [CIs]) of thoracic US and supine AP chest radiography.
RESULTS: Four prospective observational studies were identified, with a total of 606 subjects who met the inclusion and exclusion criteria. The sensitivity and specificity of US for the detection of pneumothorax ranged from 86% to 98% and 97% to 100%, respectively. The sensitivity of supine AP chest radiographs for the detection of pneumothorax ranged from 28% to 75%. The specificity of supine AP chest radiographs was 100% in all included studies.
CONCLUSIONS: This evidence-based review suggests that bedside thoracic US is a more sensitive screening test than supine AP chest radiography for the detection of pneumothorax in adult patients with blunt chest trauma.
(c) 2010 by the Society for Academic Emergency Medicine.
Elliott M Antman, Daniel T Anbe, Paul Wayne Armstrong, Eric R Bates, Lee A Green, Mary Hand, Judith S Hochman, Harlan M Krumholz, Frederick G Kushner, Gervasio A Lamas, Charles J Mullany, Joseph P Ornato, David L Pearle, Michael A Sloan, Sidney C Smith, Joseph S Alpert, Jeffrey L Anderson, David P Faxon, Valentin Fuster, Raymond J Gibbons, Gabriel Gregoratos, Jonathan L Halperin, Loren F Hiratzka, Sharon Ann Hunt, Alice K Jacobs, American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction)
ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction).
Circulation. 2004 Aug 3;110(5):588-636. doi: 10.1161/01.CIR.0000134791.68010.FA.
Abstract/Text
Kristian Thygesen, Joseph S Alpert, Harvey D White, Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction
Universal definition of myocardial infarction.
Eur Heart J. 2007 Oct;28(20):2525-38. doi: 10.1093/eurheartj/ehm355.
Abstract/Text
G Permanyer-Miralda
Acute pericardial disease: approach to the aetiologic diagnosis.
Heart. 2004 Mar;90(3):252-4.
Abstract/Text
Richard W Troughton, Craig R Asher, Allan L Klein
Pericarditis.
Lancet. 2004 Feb 28;363(9410):717-27. doi: 10.1016/S0140-6736(04)15648-1.
Abstract/Text
Pericarditis is a common disorder that has multiple causes and presents in various primary-care and secondary-care settings. New diagnostic techniques have improved the sampling and analysis of pericardial fluid and allow comprehensive characterisation of cause. Despite this advance, pericarditis is most commonly idiopathic, and radiation therapy, cardiac surgery, and percutaneous procedures have become important causes. Pericarditis is frequently self-limiting, and non-steroidal anti-inflammatory agents remain the first-line treatment for uncomplicated cases. Integrated use of new imaging methods facilitates accurate detection and management of complications such as pericardial effusion or constriction. Differentiation of constrictive pericarditis from restrictive cardiomyopathy remains a clinical challenge but is facilitated by tissue doppler and colour M-mode echocardiography. Most pericardial effusions can be safely managed with an echo-guided percutaneous approach. Pericardiectomy remains the definitive treatment for constrictive pericarditis and provides symptomatic relief in most cases. In the future, the pericardial space might become a conduit for treatments directed at the pericardium and myocardium.
厚生労働省 新型コロナウイルス感染症 診療の手引き 第6.0版 (https://www.mhlw.go.jp/content/000851077.pdf, accessed on 2022/1/30).
NIH COVID-19 Treatment Guidelines (https://www.covid19treatmentguidelines.nih.gov/, accessed on 2022/1/30).
Charlie S Wang, J Mark FitzGerald, Michael Schulzer, Edwin Mak, Najib T Ayas
Does this dyspneic patient in the emergency department have congestive heart failure?
JAMA. 2005 Oct 19;294(15):1944-56. doi: 10.1001/jama.294.15.1944.
Abstract/Text
CONTEXT: Dyspnea is a common complaint in the emergency department where physicians must accurately make a rapid diagnosis.
OBJECTIVE: To assess the usefulness of history, symptoms, and signs along with routine diagnostic studies (chest radiograph, electrocardiogram, and serum B-type natriuretic peptide [BNP]) that differentiate heart failure from other causes of dyspnea in the emergency department.
DATA SOURCES: We searched MEDLINE (1966-July 2005) and the reference lists from retrieved articles, previous reviews, and physical examination textbooks.
STUDY SELECTION: We retained 22 studies of various findings for diagnosing heart failure in adult patients presenting with dyspnea to the emergency department.
DATA EXTRACTION: Two authors independently abstracted data (sensitivity, specificity, and likelihood ratios [LRs]) and assessed methodological quality.
DATA SYNTHESIS: Many features increased the probability of heart failure, with the best feature for each category being the presence of (1) past history of heart failure (positive LR = 5.8; 95% confidence interval [CI], 4.1-8.0); (2) the symptom of paroxysmal nocturnal dyspnea (positive LR = 2.6; 95% CI, 1.5-4.5); (3) the sign of the third heart sound (S(3)) gallop (positive LR = 11; 95% CI, 4.9-25.0); (4) the chest radiograph showing pulmonary venous congestion (positive LR = 12.0; 95% CI, 6.8-21.0); and (5) electrocardiogram showing atrial fibrillation (positive LR = 3.8; 95% CI, 1.7-8.8). The features that best decreased the probability of heart failure were the absence of (1) past history of heart failure (negative LR = 0.45; 95% CI, 0.38-0.53); (2) the symptom of dyspnea on exertion (negative LR = 0.48; 95% CI, 0.35-0.67); (3) rales (negative LR = 0.51; 95% CI, 0.37-0.70); (4) the chest radiograph showing cardiomegaly (negative LR = 0.33; 95% CI, 0.23-0.48); and (5) any electrocardiogram abnormality (negative LR = 0.64; 95% CI, 0.47-0.88). A low serum BNP proved to be the most useful test (serum B-type natriuretic peptide <100 pg/mL; negative LR = 0.11; 95% CI, 0.07-0.16).
CONCLUSIONS: For dyspneic adult emergency department patients, a directed history, physical examination, chest radiograph, and electrocardiography should be performed. If the suspicion of heart failure remains, obtaining a serum BNP level may be helpful, especially for excluding heart failure.
Sharon Ann Hunt, William T Abraham, Marshall H Chin, Arthur M Feldman, Gary S Francis, Theodore G Ganiats, Mariell Jessup, Marvin A Konstam, Donna M Mancini, Keith Michl, John A Oates, Peter S Rahko, Marc A Silver, Lynne Warner Stevenson, Clyde W Yancy
2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation.
Circulation. 2009 Apr 14;119(14):e391-479. doi: 10.1161/CIRCULATIONAHA.109.192065. Epub 2009 Mar 26.
Abstract/Text
日本循環器学会他：急性・慢性心不全診療ガイドライン （2017年版）．https://www.j-circ.or.jp/cms/wp-content/uploads/2017/06/JCS2017_tsutsui_h.pdf.
Peter A McCullough, Judd E Hollander, Richard M Nowak, Alan B Storrow, Philippe Duc, Torbjørn Omland, James McCord, Howard C Herrmann, Philippe G Steg, Arne Westheim, Cathrine Wold Knudsen, William T Abraham, Sumant Lamba, Alan H B Wu, Alberto Perez, Paul Clopton, Padma Krishnaswamy, Radmila Kazanegra, Alan S Maisel, BNP Multinational Study Investigators
Uncovering heart failure in patients with a history of pulmonary disease: rationale for the early use of B-type natriuretic peptide in the emergency department.
Acad Emerg Med. 2003 Mar;10(3):198-204.
Abstract/Text
UNLABELLED: Plasma B-type natriuretic peptide (BNP) can reliably identify acute congestive heart failure (CHF) in patients presenting to the emergency department (ED) with acute dyspnea. Heart failure, asthma, and chronic obstructive pulmonary disease (COPD) are syndromes where dyspnea and wheezing are overlapping signs, and hence, these syndromes are often difficult to differentiate.
OBJECTIVE: To determine whether BNP can distinguish new-onset heart failure in patients with COPD or asthma presenting with dyspnea to the ED.
METHODS: The BNP Multinational Study was a seven-center prospective study of 1,586 adult patients presenting to the ED with acute dyspnea who had blinded BNP levels measured on arrival with a rapid, point-of-care device. This study evaluated the 417 patients with no previous history of heart failure and a history of asthma or COPD as a subgroup from the 1,586 adult patients in the BNP Multinational Study. The reference standard for CHF was adjudicated by two independent cardiologists, also blinded to BNP results, who reviewed all clinical data and standardized CHF scores.
RESULTS: A total of 417 subjects (mean age 62.2 years, 64.4% male) had a history of asthma or COPD without a history of CHF. Of these, 87/417 (20.9%, 95% CI = 17.1% to 25.1%) were found to have CHF as the final adjudicated diagnosis. The emergency physicians identified a minority, 32/87 (36.8%), of these patients with CHF. The mean BNP values (+/- SD) were 587.0 +/- 426.4 and 108.8 +/- 221.3 pg/mL for those with and without CHF (p < 0.0001). At a cutpoint of 100 pg/mL, BNP had the following decision statistics: sensitivity 93.1%, specificity 77.3%, positive predictive value 51.9%, negative predictive value 97.7%, accuracy 80.6%, positive likelihood ratio 4.10, and negative likelihood ratio 0.09. If BNP would have been added to clinical judgment (high > or = 80% probability of CHF), at a cutpoint of 100 pg/mL, 83/87 (95.4%) of the CHF subjects would have been correctly diagnosed. Multivariate analysis found BNP to be the most important predictor of CHF (OR = 12.1, 95% CI = 5.4 to 27.0, p < 0.0001). In the 87 subjects found to have CHF, 39.0%, 22.2%, and 54.8% were taking angiotensin-converting enzyme inhibitors (ACEIs), beta-blockers (BBs), and diuretics on a chronic basis, respectively.
CONCLUSIONS: The yield of adding routine BNP testing in patients with a history of asthma or COPD in picking up newly diagnosed CHF is approximately 20%. This group of patients presents a substantial therapeutic opportunity for the initiation and chronic administration of ACEI and BB therapy, as well as other CHF management strategies.
Heart Failure Society of America, JoAnn Lindenfeld, Nancy M Albert, John P Boehmer, Sean P Collins, Justin A Ezekowitz, Michael M Givertz, Stuart D Katz, Marc Klapholz, Debra K Moser, Joseph G Rogers, Randall C Starling, William G Stevenson, W H Wilson Tang, John R Teerlink, Mary N Walsh
HFSA 2010 Comprehensive Heart Failure Practice Guideline.
J Card Fail. 2010 Jun;16(6):e1-194. doi: 10.1016/j.cardfail.2010.04.004.
Abstract/Text
Heart failure (HF) is a syndrome characterized by high mortality, frequent hospitalization, reduced quality of life, and a complex therapeutic regimen. Knowledge about HF is accumulating so rapidly that individual clinicians may be unable to readily and adequately synthesize new information into effective strategies of care for patients with this syndrome. Trial data, though valuable, often do not give direction for individual patient management. These characteristics make HF an ideal candidate for practice guidelines. The 2010 Heart Failure Society of America comprehensive practice guideline addresses the full range of evaluation, care, and management of patients with HF.
Copyright 2010. Published by Elsevier Inc.
G Michael Felker, Christopher M O'Connor, Eugene Braunwald, Heart Failure Clinical Research Network Investigators
Loop diuretics in acute decompensated heart failure: necessary? Evil? A necessary evil?
Circ Heart Fail. 2009 Jan;2(1):56-62. doi: 10.1161/CIRCHEARTFAILURE.108.821785.
Abstract/Text
Alan G Kaplan, Meyer S Balter, Alan D Bell, Harold Kim, R Andrew McIvor
Diagnosis of asthma in adults.
CMAJ. 2009 Nov 10;181(10):E210-20. doi: 10.1503/cmaj.080006. Epub 2009 Sep 21.
Abstract/Text
http://www.mdconsult.com/das/article/body/378449065-3/jorg=journal&source=&sp=22686284&sid=0/N/724010/If09606131001.fig#top.
R G Stoodley, S D Aaron, R E Dales
The role of ipratropium bromide in the emergency management of acute asthma exacerbation: a metaanalysis of randomized clinical trials.
Ann Emerg Med. 1999 Jul;34(1):8-18.
Abstract/Text
STUDY OBJECTIVE: This study was conducted to determine whether the addition of inhaled ipratropium to inhaled beta-agonist therapy is effective in the treatment of adults with acute asthma exacerbation.
METHODS: Published reports of randomized, controlled trials assessing the use of ipratropium and beta-agonists in asthma were identified by a search of the MEDLINE, EMBASE, CINAHL, Biological Abstracts on CD, the Cochrane Library, and Current Contents databases. Bibliographies from identified studies and from review articles were manually searched. Published and unpublished reports in English, French, and Italian were identified and assessed for inclusion in the metaanalysis. Randomized, double-blind, placebo-controlled trials were selected in which ipratropium was used as adjunctive therapy to beta-agonists in adult patients with acute asthma exacerbation presenting to a hospital emergency department or similar acute care setting. Data were extracted independently by 2 reviewers. For eligible trials, the mean percent change in peak expiratory flow rate (PEFR), or forced expiratory volume in one second (FEV1), and their SDs were assessed in the ipratropium-treated and control groups. The effect of ipratropium on hospitalization rates and adverse effects were also analyzed.
RESULTS: Data from 10 studies, reporting on a total of 1,377 patients with asthma, were pooled using a weighted average method. Compared with placebo, the use of ipratropium was associated with a pooled 7.3% improvement in FEV1 (95% confidence interval [CI] 3.8% to 10.9%), corresponding to an absolute improvement in FEV1 in the ipratropium/ beta-agonist group, which was 100 mL (95% CI 50 to 149 mL) above that seen for the group that received beta-agonist without ipratropium. Similarly, the pooled estimate of treatment effect in trials that reported data as PEFR was 22.1% (95% CI 11.0% to 33.2%), corresponding to an absolute peak expiratory flow improvement of 32 L/min (95% CI 16 to 47 L/min) in favor of the ipratropium/ beta-agonist combination group. When these data were combined using effect size as a common measure, the use of ipratropium was associated with a summary effect size of.38 (95% CI.27 to.48). Effect sizes were negatively correlated with baseline mean expiratory flows, suggesting that studies enrolling patients with more severe airflow obstruction showed greater absolute benefits of combination bronchodilator therapy. For the 3 trials reporting hospital admission data (n=1,031), patients receiving ipratropium had a relative risk of hospitalization of .73 (95% CI.53 to .99). The use of ipratropium was not associated with any severe adverse effects when used in conjunction with beta2 -agonists.
CONCLUSION: There is a modest statistical improvement in airflow obstruction when ipratropium is used as an adjunctive treatment to beta2 -agonists for the treatment of acute asthma exacerbation. Although the clinical significance of this improvement in airflow obstruction remains unclear, it would seem reasonable to recommend the use of combination ipratropium/ beta-agonist therapy in acute adult asthmatic exacerbations, since the addition of ipratropium seemed to provide physiologic evidence of benefit without risk of adverse effects.
C H Fanta, T H Rossing, E R McFadden
Glucocorticoids in acute asthma. A critical controlled trial.
Am J Med. 1983 May;74(5):845-51.
Abstract/Text
In order to determine objectively the efficacy of corticosteroids in relieving severe acute episodes of asthma, we administered infusions of hydrocortisone or placebo in a random, double-blind manner to 20 asthmatic subjects after they had been documented to be refractory to eight hours of conventional therapy. Eleven subjects received hydrocortisone (2 mg/kg bolus, then 0.5 mg/kg per hour for 24 hours) and nine received saline. All were given identical bronchodilator treatment during the study period, and all had multiple aspects of lung function serially recorded along with plasma cortisol levels. Although subjects in both groups had severe obstruction of similar magnitude at the beginning of treatment (one-second forced expiratory volume [FEV1] in placebo-treated group = 32 +/- 3 [SEM] percent of predicted, and 25 +/- 3 percent of predicted in steroid-treated group, p = NS), at the end of 24 hours, the subjects given corticosteroids had significantly greater resolution of airway obstruction (FEV1 in steroid-treated group increased 118 +/- 25 percent from control value, versus 35 +/- 22 percent with placebo). In five of nine subjects treated with placebo, pulmonary mechanics either were unchanged or deteriorated during the period of observation. There was no effect of the glucocorticoids on arterial blood gases, and no significant correlation could be found between plasma cortisol levels and the improvement in pulmonary mechanics and clinical status. These results provide objective documentation of the time course over which administration of parenteral corticosteroids speeds the recovery of asthmatic patients who are unresponsive to standard therapy.
B H Rowe, J A Bretzlaff, C Bourdon, G W Bota, C A Camargo
Intravenous magnesium sulfate treatment for acute asthma in the emergency department: a systematic review of the literature.
Ann Emerg Med. 2000 Sep;36(3):181-90. doi: 10.1067/mem.2000.105659.
Abstract/Text
STUDY OBJECTIVES: There is some evidence that magnesium, when infused into asthmatic patients, can produce bronchodilation in addition to that obtained from standard treatments. This systematic review examined the effect of intravenous magnesium sulfate used for patients with acute asthma managed in the emergency department.
METHODS: Only randomized controlled trials were eligible for inclusion. Studies were included if patients presented with acute asthma and were treated with intravenous magnesium sulfate versus placebo. Trials were identified from the Cochrane Airways Review Group register, which consists of a combined search of EMBASE, MEDLINE, and CINAHL databases and hand-searching of 20 key respiratory journals. Bibliographies from included studies and known reviews were searched. Primary authors and content experts were contacted. Data were extracted and methodologic quality was assessed independently by 2 reviewers. Missing data were obtained from authors.
RESULTS: Seven trials (5 adult, 2 pediatric) involving a total of 668 patients were included. Overall, admission to hospital was not statistically reduced using magnesium sulfate (odds ratio [OR] 0.31, 95% confidence interval [CI] 0.09 to 1.02). In the severe subgroup, admissions were reduced in those receiving magnesium sulfate (OR 0.10, 95% CI 0.04 to 0.27). Overall, patients receiving magnesium sulfate demonstrated nonsignificant improvements in peak expiratory flow rates (PEFR) when all studies were pooled (weighted mean difference [WMD] 29 L/min, 95% CI -3 to 62). In studies of patients with severe acute asthma, PEFR WMD improved by 52 L/min (95% CI 27 to 78) favoring magnesium sulfate treatment. The absolute FEV(1) also improved by 10% predicted (95% CI 4 to 16) in patients with severe acute asthma. No clinically important changes in vital signs or side effects were reported.
CONCLUSION: Current evidence does not clearly support routine use of intravenous magnesium sulfate in all patients with acute asthma presenting to the ED. However, magnesium sulfate appears to be safe and beneficial for patients who present with severe acute asthma. Practice guidelines need to be changed to reflect these results.
S Rennard, M Decramer, P M A Calverley, N B Pride, J B Soriano, P A Vermeire, J Vestbo
Impact of COPD in North America and Europe in 2000: subjects' perspective of Confronting COPD International Survey.
Eur Respir J. 2002 Oct;20(4):799-805.
Abstract/Text
To date, no international surveys estimating the burden of chronic obstructive pulmonary disease (COPD) in the general population have been published. The Confronting COPD International Survey aimed to quantify morbidity and burden in COPD subjects in 2000. From a total of 201,921 households screened by random-digit dialling in the USA, Canada, France, Italy, Germany, The Netherlands, Spain and the UK, 3,265 subjects with a diagnosis of COPD, chronic bronchitis or emphysema, or with symptoms of chronic bronchitis, were identified. The mean age of the subjects was 63.3 yrs and 44.2% were female. Subjects with COPD in North America and Europe appear to underestimate their morbidity, as shown by the high proportion of subjects with limitations to their basic daily life activities, frequent work loss (45.3% of COPD subjects of <65 yrs reported work loss in the past year) and frequent use of health services (13.8% of subjects required emergency care in the last year), and may be undertreated. There was a significant disparity between subjects' perception of disease severity and the degree of severity indicated by an objective breathlessness scale. Of those with the most severe breathlessness (too breathless to leave the house), 35.8% described their condition as mild or moderate, as did 60.3% of those with the next most severe degree of breathlessness (breathless after walking a few minutes on level ground). This international survey confirmed the great burden to society and high individual morbidity associated with chronic obstructive pulmonary disease in subjects in North America and Europe.
Mark B Stephens, Kenneth S Yew
Diagnosis of chronic obstructive pulmonary disease.
Am Fam Physician. 2008 Jul 1;78(1):87-92.
Abstract/Text
Chronic obstructive pulmonary disease affects more than 26 million adults in the United States. Family physicians provide care for most of these patients. Cigarette smoking is the leading risk factor for chronic obstructive pulmonary disease, although other risk factors, including occupational and environmental exposures, account for up to one in six cases. Patients presenting with chronic cough, increased sputum production, or progressive dyspnea should be evaluated for the disease. Asthma is the disease most often confused with chronic obstructive pulmonary disease. The diagnosis of chronic obstructive pulmonary disease is based on clinical suspicion and spirometry confirmation. A forced expiratory volume in one second/forced vital capacity ratio that is less than 70 percent, and that is incompletely reversible with the administration of an inhaled bronchodilator, suggests chronic obstructive pulmonary disease. Disease severity is classified by symptomatology and spirometry. Joint guidelines from the American Thoracic Society and the European Respiratory Society recommend a single quantitative test for alpha1-antitrypsin deficiency in patients diagnosed with chronic obstructive pulmonary disease who remain symptomatic despite bronchodilator therapy. Other advanced testing is usually not necessary.
James K Stoller
Clinical practice. Acute exacerbations of chronic obstructive pulmonary disease.
N Engl J Med. 2002 Mar 28;346(13):988-94. doi: 10.1056/NEJMcp012477.
Abstract/Text
D E Niewoehner, M L Erbland, R H Deupree, D Collins, N J Gross, R W Light, P Anderson, N A Morgan
Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. Department of Veterans Affairs Cooperative Study Group.
N Engl J Med. 1999 Jun 24;340(25):1941-7. doi: 10.1056/NEJM199906243402502.
Abstract/Text
BACKGROUND AND METHODS: Although their clinical efficacy is unclear and they may cause serious adverse effects, systemic glucocorticoids are a standard treatment for patients hospitalized with exacerbations of chronic obstructive pulmonary disease (COPD). We conducted a double-blind, randomized trial of systemic glucocorticoids (given for two or eight weeks) or placebo in addition to other therapies, for exacerbations of COPD. Most other care was standardized over the six-month period of follow-up. The primary end point was treatment failure, defined as death from any cause or the need for intubation and mechanical ventilation, readmission to the hospital for COPD, or intensification of drug therapy.
RESULTS: Of 1840 potential study participants at 25 Veterans Affairs medical centers, 271 were eligible for participation and were enrolled; 80 received an eight-week course of glucocorticoid therapy, 80 received a two-week course, and 111 received placebo. About half the potential participants were ineligible because they had received systemic glucocorticoids in the previous 30 days. Rates of treatment failure were significantly higher in the placebo group than in the two glucocorticoid groups combined at 30 days (33 percent vs. 23 percent, P=0.04) and at 90 days (48 percent vs. 37 percent, P=0.04). Systemic glucocorticoids (in both groups combined) were associated with a shorter initial hospital stay (8.5 days, vs. 9.7 days for placebo, P=0.03) and with a forced expiratory volume in one second that was about 0.10 liter higher than that in the placebo group by the first day after enrollment. Significant treatment benefits were no longer evident at six months. The eight-week regimen of therapy was not superior to the two-week regimen. The patients who received glucocorticoid therapy were more likely to have hyperglycemia requiring therapy than those who received placebo (15 percent vs. 4 percent, P=0.002).
CONCLUSIONS: Treatment with systemic glucocorticoids results in moderate improvement in clinical outcomes among patients hospitalized for exacerbations of COPD. The maximal benefit is obtained during the first two weeks of therapy. Hyperglycemia of sufficient severity to warrant treatment is the most frequent complication.
Felix Sf Ram, Robert Rodriguez-Roisin, Alicia Granados-Navarrete, Judith Garcia-Aymerich, Neil C Barnes
WITHDRAWN: Antibiotics for exacerbations of chronic obstructive pulmonary disease.
Cochrane Database Syst Rev. 2011 Jan 19;(1):CD004403. doi: 10.1002/14651858.CD004403.pub3. Epub 2011 Jan 19.
Abstract/Text
BACKGROUND: Most patients with an exacerbation of chronic obstructive pulmonary disease (COPD) are treated with antibiotics. However the value of their use remains uncertain. Some controlled trials of antibiotics have shown benefit (Berry 1960; Pines 1972) while others have not (Elmes 1965b; Nicotra 1982).
OBJECTIVES: To conduct a systematic review of the literature estimating the value of antibiotics in the management of acute COPD exacerbations.
SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2005, issue 4) which contains the Acute Respiratory Infections Group's Specialized Register; MEDLINE (1966 to December 2005); EMBASE (1974 to December 2005); Web of Science (December 2005), and other electronically available databases.
SELECTION CRITERIA: Randomised controlled trials (RCTs) in patients with acute COPD exacerbations comparing antibiotic (for a minimum of five days) and placebo.
DATA COLLECTION AND ANALYSIS: Data were analysed using Review Manager software. Continuous data were analysed using weighted mean differences (WMD) and 95% confidence intervals (CI). Relative risks (RR) (and 95% CI) were calculated for all dichotomous data. Where appropriate, number needed to treat to benefit (NNT) and 95% CI were calculated.
MAIN RESULTS: Eleven trials with 917 patients were included. Ten trials used increased cough, sputum volume and purulence diagnostic criteria for COPD exacerbation. Eight-hundred and fifty-seven patients provided data for outcomes including mortality, treatment failure, increased sputum volume, sputum purulence, PaCO(2), PaO(2), peak flow and adverse events. Antibiotic therapy regardless of antibiotic choice significantly reduced mortality (RR 0.23; 95% CI 0.10 to 0.52 with NNT of 8; 95% CI 6 to 17), treatment failure (RR 0.47; 95% CI 0.36 to 0.62 with NNT of 3; 95% CI 3 to 5) and sputum purulence (RR 0.56; 95% CI 0.41 to 0.77 with NNT of 8; 95% CI 6 to 17). There was a small increase in risk of diarrhoea with antibiotics (RR 2.86; 95% CI 1.06 to 7.76). Antibiotics did not improve arterial blood gases and peak flow.
AUTHORS' CONCLUSIONS: This review shows that in COPD exacerbations with increased cough and sputum purulence antibiotics, regardless of choice, reduce the risk of short-term mortality by 77%, decrease the risk of treatment failure by 53% and the risk of sputum purulence by 44%; with a small increase in the risk of diarrhoea. These results should be interpreted with caution due to the differences in patient selection, antibiotic choice, small number of included trials and lack of control for interventions that influence outcome, such as use of systemic corticosteroids and ventilatory support. Nevertheless, this review supports antibiotics for patients with COPD exacerbations with increased cough and sputum purulence who are moderately or severely ill.
Jörg D Leuppi, Philipp Schuetz, Roland Bingisser, Michael Bodmer, Matthias Briel, Tilman Drescher, Ursula Duerring, Christoph Henzen, Yolanda Leibbrandt, Sabrina Maier, David Miedinger, Beat Müller, Andreas Scherr, Christian Schindler, Rolf Stoeckli, Sebastien Viatte, Christophe von Garnier, Michael Tamm, Jonas Rutishauser
Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial.
JAMA. 2013 Jun 5;309(21):2223-31. doi: 10.1001/jama.2013.5023.
Abstract/Text
IMPORTANCE: International guidelines advocate a 7- to 14-day course of systemic glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease (COPD). However, the optimal dose and duration are unknown.
OBJECTIVE: To investigate whether a short-term (5 days) systemic glucocorticoid treatment in patients with COPD exacerbation is noninferior to conventional (14 days) treatment in clinical outcome and whether it decreases the exposure to steroids. DESIGN, SETTING, AND PATIENTS REDUCE: (Reduction in the Use of Corticosteroids in Exacerbated COPD), a randomized, noninferiority multicenter trial in 5 Swiss teaching hospitals, enrolling 314 patients presenting to the emergency department with acute COPD exacerbation, past or present smokers (≥20 pack-years) without a history of asthma, from March 2006 through February 2011.
INTERVENTIONS: Treatment with 40 mg of prednisone daily for either 5 or 14 days in a placebo-controlled, double-blind fashion. The predefined noninferiority criterion was an absolute increase in exacerbations of at most 15%, translating to a critical hazard ratio of 1.515 for a reference event rate of 50%.
MAIN OUTCOME AND MEASURE: Time to next exacerbation within 180 days.
RESULTS: Of 314 randomized patients, 289 (92%) of whom were admitted to the hospital, 311 were included in the intention-to-treat analysis and 296 in the per-protocol analysis. Hazard ratios for the short-term vs conventional treatment group were 0.95 (90% CI, 0.70 to 1.29; P = .006 for noninferiority) in the intention-to-treat analysis and 0.93 (90% CI, 0.68 to 1.26; P = .005 for noninferiority) in the per-protocol analysis, meeting our noninferiority criterion. In the short-term group, 56 patients (35.9%) reached the primary end point; 57 (36.8%) in the conventional group. Estimates of reexacerbation rates within 180 days were 37.2% (95% CI, 29.5% to 44.9%) in the short-term; 38.4% (95% CI, 30.6% to 46.3%) in the conventional, with a difference of -1.2% (95% CI, -12.2% to 9.8%) between the short-term and the conventional. Among patients with a reexacerbation, the median time to event was 43.5 days (interquartile range [IQR], 13 to 118) in the short-term and 29 days (IQR, 16 to 85) in the conventional. There was no difference between groups in time to death, the combined end point of exacerbation, death, or both and recovery of lung function. In the conventional group, mean cumulative prednisone dose was significantly higher (793 mg [95% CI, 710 to 876 mg] vs 379 mg [95% CI, 311 to 446 mg], P < .001), but treatment-associated adverse reactions, including hyperglycemia and hypertension, did not occur more frequently.
CONCLUSIONS AND RELEVANCE: In patients presenting to the emergency department with acute exacerbations of COPD, 5-day treatment with systemic glucocorticoids was noninferior to 14-day treatment with regard to reexacerbation within 6 months of follow-up but significantly reduced glucocorticoid exposure. These findings support the use of a 5-day glucocorticoid treatment in acute exacerbations of COPD.
TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN19646069.
Joshua P Metlay, Michael J Fine
Testing strategies in the initial management of patients with community-acquired pneumonia.
Ann Intern Med. 2003 Jan 21;138(2):109-18.
Abstract/Text
The initial management of patients suspected of having community-acquired pneumonia is challenging because of the broad range of clinical presentations, potential life-threatening nature of the illness, and associated high costs of care. The initial testing strategies should accurately establish a diagnosis and prognosis in order to determine the optimal treatment strategy. The diagnosis is important in determining the need for antibiotic therapy, and the prognosis is important in determining the site of care. This paper reviews the test characteristics of the history, physical examination, and laboratory findings, individually and in combination, in diagnosing community-acquired pneumonia and predicting short-term risk for death from the infection. In addition, we consider the implications of these test characteristics from the perspective of decision thresholds. The history and physical examination cannot provide a high level of certainty in the diagnosis of community-acquired pneumonia, but the absence of vital sign abnormalities substantially reduces the probability of the infection. Chest radiography is considered the gold standard for pneumonia diagnosis; however, we do not know its sensitivity and specificity, and we have limited data on the costs of false-positive and false-negative results. In the absence of empirical evidence, the decision to order a chest radiograph needs to rely on expert opinion in seeking strategies to optimize the balance between harms and benefits. Once community-acquired pneumonia is diagnosed, a combination of history, physical examination, and laboratory items can help estimate the short-term risk for death and, along with the patient's psychosocial characteristics, determine the appropriate site of treatment.
Girish B Nair, Michael S Niederman
Community-acquired pneumonia: an unfinished battle.
Med Clin North Am. 2011 Nov;95(6):1143-61. doi: 10.1016/j.mcna.2011.08.007. Epub 2011 Oct 5.
Abstract/Text
Community-acquired pneumonia remains a common illness with substantial morbidity and mortality. Current management challenges focus on identifying the likely etiologic pathogens based on an assessment of host risk factors, while attempting to make a specific etiologic diagnosis, which is often not possible. Therapy is necessarily empiric and focuses on pneumococcus and atypical pathogens for all patients, with consideration of other pathogens based on specific patient risk factors. It is important to understand the expected response to effective therapy, and to identify and manage clinical failure at the earliest possible time point. Prevention is focused on smoking cessation and vaccination against pneumococcus and influenza.
Copyright © 2011 Elsevier Inc. All rights reserved.
J P Metlay, W N Kapoor, M J Fine
Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination.
JAMA. 1997 Nov 5;278(17):1440-5.
Abstract/Text
Community-acquired pneumonia is an important cause of acute respiratory symptoms (eg, cough) in the ambulatory care setting. Distinguishing pneumonia from other causes of respiratory illnesses, such as acute bronchitis and upper respiratory tract infections, has important therapeutic and prognostic implications. The reference standard for diagnosing pneumonia is chest radiography, but it is likely that many physicians rely on the patient's history and their physical examination to diagnose or exclude this disease. A review of published studies of patients suspected of having pneumonia reveals that there are no individual clinical findings, or combinations of findings, that can rule in the diagnosis of pneumonia for a patient suspected of having this illness. However, some studies have shown that the absence of any vital sign abnormalities or any abnormalities on chest auscultation substantially reduces the likelihood of pneumonia to a point where further diagnostic evaluation may be unnecessary. This article reviews the literature on the appropriate use of the history and physical examination in diagnosing community-acquired pneumonia.
M Henry, T Arnold, J Harvey, Pleural Diseases Group, Standards of Care Committee, British Thoracic Society
BTS guidelines for the management of spontaneous pneumothorax.
Thorax. 2003 May;58 Suppl 2:ii39-52.
Abstract/Text
Jaume Figueras, José A Barrabés, Vicens Serra, Josefa Cortadellas, Rosa-Maria Lidón, Alvaro Carrizo, David Garcia-Dorado
Hospital outcome of moderate to severe pericardial effusion complicating ST-elevation acute myocardial infarction.
Circulation. 2010 Nov 9;122(19):1902-9. doi: 10.1161/CIRCULATIONAHA.109.934968. Epub 2010 Oct 25.
Abstract/Text
BACKGROUND: Hospital prognosis of moderate to severe pericardial effusion (MPE; ≥10 mm) in ST-elevation myocardial infarction is largely unknown.
METHODS AND RESULTS: Data from 446 ST-elevation myocardial infarction patients, 228 with MPE-88 with cardiac tamponade (CT) and electromechanical dissociation (EMD), 44 with CT without EMD (w/oEMD), and 96 without initial CT-and 218 with small PE (5 to 9 mm), were compared. Patients with MPE without initial CT were also compared with 96 patients without PE. CT patients showed larger PE (P<0.001) than those without initial CT; 85% of those with CT+EMD and 86% with CTw/oEMD were treated with pericardiocentesis and 10% and 21% were treated with a surgical repair, respectively. Among MPE patients, 30-day mortality was 43% and was higher in those with CT+EMD (operated, 89%; and nonoperated, 85%) than in those with CTw/oEMD (22% and 11%, respectively; P<0.001) and those without initial CT (17%; P<0.001). It was also higher than in patients with small PE (10%; P<0.001) or those without PE (6%; P=0.001). Death was attributable to cardiac rupture in 83% of patients with CT+EMD, 7% with CTw/oEMD, and 8% with MPE without initial CT and occurred late (≥7 days) in 14%, 67%, and 100%, respectively.
CONCLUSIONS: MPE carries an increased mortality that is highest in patients with CT+EMD. In those with CTw/oEMD, however, mortality is considerably low after pericardiocentesis, and subsequent management may be individualized because a conservative approach is often successful. Importantly, MPE patients without initial CT are not free from late rupture and deserve further investigation.
Dan Gilon, Rajendra H Mehta, Jae K Oh, James L Januzzi, Eduardo Bossone, Jeanna V Cooper, Dean E Smith, Jianming Fang, Christoph A Nienaber, Kim A Eagle, Eric M Isselbacher, International Registry of Acute Aortic Dissection Group
Characteristics and in-hospital outcomes of patients with cardiac tamponade complicating type A acute aortic dissection.
Am J Cardiol. 2009 Apr 1;103(7):1029-31. doi: 10.1016/j.amjcard.2008.12.013.
Abstract/Text
Cardiac tamponade (TMP) is a life-threatening complication of acute type A aortic dissection (AAD). The purpose of this study was to assess the clinical characteristics and in-hospital outcomes of TMP in the setting of AAD on the basis of the findings in the large cohort of the International Registry of Acute Aortic Dissection (IRAD). Six hundred seventy-four patients (mean age 61.8 +/- 14.2 years) with AAD in IRAD were studied. TMP was suspected on clinical grounds and confirmed by diagnostic imaging. Univariate testing was followed by multivariate logistic regression analysis to determine the association of TMP. TMP was detected in 126 patients with AAD (18.7%). Age did not differ between patients with and without TMP. Those with TMP less often had previous cardiac surgery (7.0% vs 17.1%, p = 0.007). Syncope (37.8% vs 13.7%, p <0.0001) and altered mental status (31.2% vs 10.6%, p <0.0001) were more common in patients with AAD with TMP than without TMP. Patients with TMP were more likely to have widened mediastina on chest x-ray (72.6% vs 60.3%, p = 0.02) and to have periaortic hematomas (44.7% vs 21.2%, p <0.0001). In-hospital outcomes were significantly worse in patients with TMP. The mortality of patients with TMP remained significantly higher, even after adjustment for baseline clinical characteristics (p <0.001). On logistic regression, altered mental status, hypotension, and early mortality were identified as independent correlates of TMP. In conclusion, TMP is not uncommon in patients with AAD. Syncope, altered mental status, and a widened mediastinum on chest x-ray on presentation suggest TMP, the presence of which warrants urgent operative therapy to improve outcome.
Christopher L Roy, Melissa A Minor, M Alan Brookhart, Niteesh K Choudhry
Does this patient with a pericardial effusion have cardiac tamponade?
JAMA. 2007 Apr 25;297(16):1810-8. doi: 10.1001/jama.297.16.1810.
Abstract/Text
CONTEXT: Cardiac tamponade is a state of hemodynamic compromise resulting from cardiac compression by fluid trapped in the pericardial space. The clinical examination may assist in the decision to perform pericardiocentesis in patients with cardiac tamponade diagnosed by echocardiography.
OBJECTIVE: To systematically review the accuracy of the history, physical examination, and basic diagnostic tests for the diagnosis of cardiac tamponade.
DATA SOURCES: MEDLINE search of English-language articles published between 1966 and 2006, reference lists of these articles, and reference lists of relevant textbooks.
STUDY SELECTION: We included articles that compared aspects of the clinical examination to a reference standard for the diagnosis of cardiac tamponade. We excluded studies with fewer than 15 patients. Of 787 studies identified by our search strategy, 8 were included in our final analysis.
DATA EXTRACTION: Two authors independently reviewed articles for study results and quality. A third reviewer resolved disagreements.
DATA SYNTHESIS: All studies evaluated patients with known tamponade or those referred for pericardiocentesis with known effusion. Five features occur in the majority of patients with tamponade: dyspnea (sensitivity range, 87%-89%), tachycardia (pooled sensitivity, 77%; 95% confidence interval [CI], 69%-85%), pulsus paradoxus (pooled sensitivity, 82%; 95% CI, 72%-92%), elevated jugular venous pressure (pooled sensitivity, 76%; 95% CI, 62%-90%), and cardiomegaly on chest radiograph (pooled sensitivity, 89%; 95% CI, 73%-100%). Based on 1 study, the presence of pulsus paradoxus greater than 10 mm Hg in a patient with a pericardial effusion increases the likelihood of tamponade (likelihood ratio, 3.3; 95% CI, 1.8-6.3), while a pulsus paradoxus of 10 mm Hg or less greatly lowers the likelihood (likelihood ratio, 0.03; 95% CI, 0.01-0.24).
CONCLUSIONS: Among patients with cardiac tamponade, a minority will not have dyspnea, tachycardia, elevated jugular venous pressure, or cardiomegaly on chest radiograph. A pulsus paradoxus greater than 10 mm Hg among patients with a pericardial effusion helps distinguish those with cardiac tamponade from those without. Diagnostic certainty of the presence of tamponade requires additional testing.
C Bruch, A Schmermund, N Dagres, T Bartel, G Caspari, S Sack, R Erbel
Changes in QRS voltage in cardiac tamponade and pericardial effusion: reversibility after pericardiocentesis and after anti-inflammatory drug treatment.
J Am Coll Cardiol. 2001 Jul;38(1):219-26.
Abstract/Text
OBJECTIVES: The goal of this study was to define the association between low QRS voltage and cardiac tamponade or pericardial effusion and to assess the reversibility of low QRS voltage after therapeutic procedures.
BACKGROUND: It is unclear whether low QRS voltage is a sign of cardiac tamponade or whether it is a sign of pericardial effusion per se.
METHODS: In a prospective study design, we recorded consecutive 12-lead electrocardiograms and echocardiograms in 43 patients who were referred to our institution for evaluation and therapy of a significant pericardial effusion. Cardiac tamponade was present in 23 patients (53%). Low QRS voltage (defined as maximum QRS amplitude <0.5 mV in the limb leads) was found in 14 of these 23 subjects (61%). Nine of these 14 patients were treated by pericardiocentesis (group A). Five patients received anti-inflammatory medication (group B). Group C consisted of nine patients with pericarditis and significant pericardial effusion who had no clinical evidence of tamponade.
RESULTS: In group A, low QRS voltage remained largely unchanged immediately after successful pericardiocentesis (0.36 +/- 0.17 mV before vs. 0.42 +/- 0.21 mV after, p = NS), but QRS amplitude recovered within a week (0.78 +/- 0.33 mV, p < 0.001). In group B, the maximum QRS amplitude increased from 0.40 +/- 0.20 mV to 0.80 +/- 0.36 mV (p < 0.001) within six days. In group C, all patients had a normal QRS amplitude initially (1.09 +/- 0.55 mV) and during a seven-day follow-up (1.10 +/- 0.56 mV, p = NS).
CONCLUSIONS: Low QRS voltage is a feature of cardiac tamponade but not of pericardial effusion per se. Our findings indicate that the presence and severity of cardiac tamponade, in addition to inflammatory mechanisms, may contribute to the development of low QRS voltage in patients with large pericardial effusions.
John W Tole, Phil Lieberman
Biphasic anaphylaxis: review of incidence, clinical predictors, and observation recommendations.
Immunol Allergy Clin North Am. 2007 May;27(2):309-26, viii. doi: 10.1016/j.iac.2007.03.011.
Abstract/Text
Biphasic anaphylactic reactions have been found to develop in as many as 20% of anaphylactic reactions. The biphasic reaction can be less severe, equally severe, or more severe than the initial reaction, ranging in degree from mild symptoms to fatal reactions. In this review, retrospective and prospective studies as well as case studies and case series are discussed in an attempt to gain insight on the incidence of biphasic reactions, the potential clinical characteristics suggestive of a uniphasic reaction developing into a biphasic reaction, and the recommendations for observation periods after an anaphylactic reaction.
Wim Lucassen, Geert-Jan Geersing, Petra M G Erkens, Johannes B Reitsma, Karel G M Moons, Harry Büller, Henk C van Weert
Clinical decision rules for excluding pulmonary embolism: a meta-analysis.
Ann Intern Med. 2011 Oct 4;155(7):448-60. doi: 10.7326/0003-4819-155-7-201110040-00007.
Abstract/Text
BACKGROUND: Clinical probability assessment is combined with d-dimer testing to exclude pulmonary embolism (PE).
PURPOSE: To compare the test characteristics of gestalt (a physician's unstructured estimate) and clinical decision rules for evaluating adults with suspected PE and assess the failure rate of gestalt and rules when used in combination with d-dimer testing.
DATA SOURCES: Articles in MEDLINE and EMBASE in English, French, German, Italian, Spanish, or Dutch that were published between 1966 and June 2011. Study Selection: 3 reviewers, working in pairs, selected prospective studies in consecutive patients suspected of having PE. Studies had to estimate the probability of PE by using gestalt or a decision rule and verify the diagnosis by using an appropriate reference standard.
DATA EXTRACTION: Data on study characteristics, test performance, and prevalence were extracted. Reviewers constructed 2 × 2 tables and assessed the methodological quality of the studies.
DATA SYNTHESIS: 52 studies, comprising 55 268 patients, were selected. Meta-analysis was performed on studies that used gestalt (15 studies; sensitivity, 0.85; specificity, 0.51), the Wells rule with a cutoff value less than 2 (19 studies; sensitivity, 0.84; specificity, 0.58) or 4 or less (11 studies; sensitivity, 0.60; specificity, 0.80), the Geneva rule (5 studies; sensitivity, 0.84; specificity, 0.50), and the revised Geneva rule (4 studies; sensitivity, 0.91; specificity, 0.37). An increased prevalence of PE was associated with higher sensitivity and lower specificity. Combining a decision rule or gestalt with d-dimer testing seemed safe for all strategies, except when the less-sensitive Wells rule (cutoff value ≤4) was combined with less-sensitive qualitative d-dimer testing.
LIMITATIONS: Studies had substantial heterogeneity due to prevalence of PE and differences in threshold. Many studies (63%) had potential bias due to differential disease verification.
CONCLUSION: Clinical decision rules and gestalt can safely exclude PE when combined with sensitive d-dimer testing. The authors recommend standardized rules because gestalt has lower specificity, but the choice of a particular rule and d-dimer test depend on both prevalence and setting.
