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   Table of Contents - Current issue
Coverpage
January-April 2019
Volume 21 | Issue 1
Page Nos. 1-79

Online since Tuesday, April 30, 2019

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INVITED REVIEW ARTICLE  

How to optimize aerosol drug delivery during noninvasive ventilation: What to use, how to use it, and why? Highly accessed article p. 1
Arzu Ari
DOI:10.4103/ejop.ejop_10_19  
Much evidence supports the use of non-invasive ventilation (NIV) in patients who have acute and chronic respiratory failure and aerosolized medications are increasingly used in this patient population. Successful application of aerosol therapy during NIV depends on the effectiveness of the drug deposition in the lungs. Previous evidence showed that many factors impact aerosol delivery to patients receiving NIV. Those factors include mode of ventilation, ventilator parameters, type of ventilator circuit, the position of the aerosol device, the location of leak port, type of exhalation valve, humidity, enhanced condensational growth, type of aerosol device, and interface as well as delivery technique. The purpose of this paper is to review the available evidence related to aerosol therapy during NIV and provide recommendations to optimize aerosol drug delivery to patients receiving NIV.
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REVIEW ARTICLE Top

Silent enemy: Environmental tobacco smoke p. 9
Evrim Eylem Akpinar
DOI:10.4103/ejop.ejop_15_19  
Second-hand smoke, also known as environmental tobacco smoke (ETS), is one of the most harmful indoor pollutants. Exposure to ETS is a worldwide silent cause of mortality and morbidity. Although ETS had been decreased for 20 years, a lot of people who do not smoke still exposed to ETS at home, work, public places, and in vehicles. ETS is a risk factor for many important diseases such as lung cancer, chronic obstructive lung disease, asthma, cardiovascular diseases, upper and lower respiratory tract infections, and sudden infant death. In this article, the harmful effects of ETS and the effects of smoke-free environment regulation on ETS exposure were reviewed.
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ORIGINAL ARTICLES Top

Effect of low-intensity pulmonary rehabilitation program on quality of life and pulmonary functions in patients with stable chronic obstructive pulmonary disease p. 14
Sule Cilekar, Baykal Tülek, Fikret Kanat, Mecit Süerdem, Funda Levendoglu, Ibrahim Tugrul Taşpınar
DOI:10.4103/ejop.ejop_16_19  
OBJECTİVES: The effectiveness of low-intensity pulmonary rehabilitation program applied patients with chronic obstructive pulmonary disease (COPD) in terms of exercise capacity, dyspnea scale, life quality and respiratory muscle strength. METHODS: The study included 30 patients with COPD. The program was 3 days in a week, for a 6 weeks period between December 1st 2012 and August 31st 2013. Arterial blood gas (ABG), 6 minute walking test (SMWT), respiratory function tests and respiratory muscle strength were evaluated before and after treatment. St George's breathing questionnaire (SGRQ) was used to assess quality of life. The dyspnea scores were assessed by the Modified Medical Research Council (mMRC) and the COPD Assessment Test (CAT). Patient approvals were obtained for the study. For analysis of results kolmogorov smirnov test, shapiro – wilk test, wilcoxon test and sample ttest were used. RESULTS: Of 30 patients participated in our study, 26 completed the treatment program. There were increases in SMWT distance (P = 0.049), forced expiratory volume in one second, and forced expiratory flow (FEF 25-75) value (P < 0.05); and decreases in mMRC dyspnea scale score (P = 0.001), CAT score (p=0.003) and SGRQ score (P <= 0.001). Maximum inspiratory pressure and maximum expiratory pressure values and ABG parameters did not show significant change. CONCLUSION: Low intensity pulmonary rehabilitation therapy has positive effects on exercise capacity, dyspnea scale, walking distance, and quality of life. Patient compliance was high in this treatment modality so according to our study results, low intensity pulmonary rehabilitation treatment can be prefer to high intensity pulmonary rehabilitation treatment in COPD.
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The relationship of bronchiectasis to airway obstruction and inflammation in patients with chronic obstructive pulmonary disease p. 21
Baris Seker, Burcu Arpinar Yigitbas, Celal Satici, Sibel Yurt, A Filiz Kosar
DOI:10.4103/ejop.ejop_17_19  
Background: Chronic obstructive pulmonary disease (COPD) and bronchiectasis are diseases of respiratory tract with significant mortality and morbidity. These two diseases can be seen together occasionally and are thought to change each other's course by adversely affecting the prognosis. The aim of our study was to identify the signs of bronchiectasis in COPD patients, to investigate its possible effects on disease prognosis, and to evaluate these signs for diagnostic convenience. Materials and Methods: This prospective study included a total of s[table 60] moderate/severe COPD patients who were admitted to Yedikule Chest Diseases and Chest Surgery Training and Research Hospital between January 2015 and February 2016. The patients were divided into two groups according to the presence of bronchiectasis as confirmed radiologically: 35 patients in the bronchiectasis group and 25 patients in the control group. Demographic data of the patients were questioned and systemic inflammation parameters, spirometric measurements, blood gas analysis, and clinical evaluation findings were recorded. Results: Bronchiectasis was detected in 58.3% of COPD patients. Patients in two groups are similar in sociodemographical, spirometrical and clinical parameters (P > 0.05). Laboratory tests showed similar result in between two groups but carbon dioxide(CO2) values in the blood gas analysis were found to be higher in the bronchiectasis group (P < 0.05). The increase in the number of bronchiectasis segments was shown to reduce the FEV1/FVC (P < 0.05). In the overall evaluation, FEV1%, mMRC, FVC% and CRP levels were found to be associated with exacerbations in COPD (P < 0.05). The use of antibiotics increased as FEV1% and FEV1/FVC levels of patients decreased (P < 0.05). In addition, sputum polymorphonuclear leukocyte (PMNL) values were correlated with spirometric values and as sputum PMNL values increased, spirometric values were found to decrease (P < 0.05 for FEV1% and FVC%). Conclusion: Bronchiectasis is common in COPD patients. In two divided groups, blood gas carbon dioxide values, which affect mortality, were shown to be higher in the bronchiectasis group. This is a new addition to literature that bronchiectatic COPD patients are experiencing different respiratory failure patterns affecting mortality. Diffuse type bronchiectasis has more effect in spirometric results of COPD patients. Also, airway obstruction in COPD is well correlated with elevated sputum PMNL values which represent airway inflammation and if this is combined with high clinical suspicion it guides to a cost effective way for guiding radiological investigations for bronchiectasis.
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The value of preoperative pulmonary assessment in predicting postoperative pulmonary complications p. 29
Ozlem Ercen Diken, Nevin Fazlıoǧlu, Nurhan Sarıoǧlu, Nalan Ogan, Nafiye Yılmaz, Hakan Tanrıverdi, Aysun Şengül, Emre Demir, Akif Turna, Arzu Mirici
DOI:10.4103/ejop.ejop_18_19  
OBJECTIVE: We aimed to determine the preoperative parameters that may predict postoperative pulmonary complications (POPCs) and the value of some current practical indexes in predicting POPCs. MATERIALS and METHODS: Our study is a retrospective cohort study carried out in 9 different centers. Patients admitted to the chest diseases outpatient clinic for preoperative evaluation were followed up during the 6-month study period. Patients with or without postoperative complications were evaluated retrospectively, and the effect of some parameters and indexes recorded during the preoperative evaluation of chest diseases on POPC development was investigated statistically. RESULTS: A total of 307 patients were included in the study. POPCs were observed in 100 patients (32.6%). About 13% of these complications were respiratory tract infections, 59% were respiratory failure, 45% were pleural effusion, and 42% were atelectasis, which were the most common pulmonary complications. The probability of experiencing POPCs by patients with chronic obstructive pulmonary disease (COPD) is 2.5 (1.18–5.67) times more than those without COPD. We determined that patients with the history of upper respiratory tract infection during the preoperative period are 5.3 times more likely to have POPCs; similarly, the number was 4.7 for patients undergoing cardiac operation and 3.3 for patients with interstitial infiltration. CONCLUSION: The risk of pulmonary complications was higher for those with the history of upper respiratory tract infection during the preoperative period, those undergoing cardiac surgery, those with the shortness of breath, those with the history of COPD, and those with the reticular/interstitial infiltrations in the chest X-ray. These parameters should be examined carefully in the preoperative period and should be careful in terms of pulmonary complications that may develop during the postoperative period.
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Tuberculin skin test evaluation in healthcare workers and distribution by occupation p. 38
Sami Deniz, Jülide Çeldir Emre
DOI:10.4103/ejop.ejop_20_19  
OBJECTIVE: Tuberculosis (TB) is a potential occupational threat for healthcare workers (HCWs) worldwide. We aimed to evaluate the tuberculin skin test (TST) and investigated if there was any difference between occupations. METHODS: This was designed as a prospective study. The analysis was performed on 331 participants. Purified protein derivative was administered to all cases. In addition, cases' age, gender, and smoking status were questioned and their comorbidities were recorded. Both shoulder areas were checked, and the Bacille Calmette-Guérin (BCG) scar counts were recorded. RESULTS: Out of a total of 331 participants, 207 were female and 124 were male; mean age was 39 ± 8 (min; 18, max; 61) and TST was 12 ± 6 mm. The cases were categorized by considering participants' exposure to TB (Group-1 - Doctor; Group-2 - Midwife-Nurse-Health Technician-Laboratorian; Group-3 - Technician-Administrative Staff; Group-4 - Secretary-Auxilliary Staff; and Group-5 - Security, Cleaning, Cafeteria Staff). When compared in terms of TST, there was a statistically significant difference (P < 0.001). The cases had at least 1 and maximum 3 BCG scars. Based on this, three groups were formed. Two hundred and twenty-three cases had 2 scars, 58 had 1, and 41 had 3. Significant difference was found among three groups, and similarly, there was a statistically significant difference in paired comparisons (P < 0.001; for all comparisons). While the difference was detected in the group with two BCG scars, there was no difference in other groups (P = 0.7, 0.001, and 0.5, respectively). There was a significant difference in terms of TST between genders (P < 0.001). CONCLUSION: Exposure to TB may vary according to professions, but the socioeconomic situation cannot be determined by professions.
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The evaluation of psychological status in newly diagnosed chronic obstructive pulmonary disease patients p. 44
Onur Turan, Pakize Ayse Turan, Arzu Mirici
DOI:10.4103/ejop.ejop_22_19  
BACKGROUND: As chronic obstructive pulmonary disease (COPD) and its symptoms may change psychological attributes, psychiatric disorders may be seen in COPD. AIMS: We aimed to assess the effect of taking diagnosis of COPD and using bronchodilator therapy on the psychological status of COPD patients. MATERIALS AND METHODS: It is a cross-sectional study including newly diagnosed COPD outpatients. Spirometry, Hospital Anxiety and Depression Scale (HADS), Beck Depression Inventory (BDI), and St. George's Respiratory Questionnaire (SGRQ) were performed at the first visit (date of new diagnosis) and 6 months later as the second visit. RESULTS: Ninety new diagnosed COPD patients (71 men and 19 women) with a mean age of 61.7 ± 9.8 were included. There were high scores of anxiety in 23.5% and depression in 38.2% (HADS)–52.9% (BDI) patients at the first visit. The symptoms about anxiety reduced to 19%, depression to 33.3% (HADS)/47.6% (BDI) six months later. All the participants who were active smokers had lower spirometric levels (42.9%) at the second visit compared with the first visit levels. There was an improvement in psychological status and quality of life (QOL) (P < 0.001). There was a negative correlation between SGRQ score and forced expiratory volume in 1 s levels (P = 0.045) and positive correlation of SGRQ score with HAD and BDI scores (P = 0.041 and 0.011). Participants who quitted smoking in 6-month period had statistically lower anxiety and depression scores (P = 0.003 and 0.026). CONCLUSION: Depression and anxiety states are frequent among COPD patients. Pulmonary symptoms may regress with the bronchodilator therapy at newly diagnosed COPD patients, which can cause an improvement in pulmonary functions, psychological status, and QOL. Psychological aspects need to be carefully assessed in patients with new diagnosis of COPD.
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The relationship between treatment cost and prognosis of malignant pleural mesothelioma in Turkey p. 50
AK Guntulu, Selma Metintas, Tunc Kose, Filiz Bogar, Nuray Girginer, Hasan Fevzi Batırel, Nurullah Uckun, Muzaffer Metintas
DOI:10.4103/ejop.ejop_41_18  
BACKGROUND: Malignant pleural mesothelioma (MPM) is endemic in the population exposed to asbestos and has high health-care cost with a limited life expectancy. The aim of this study is to evaluate the relationship between cost according to treatment type and prognosis in MPM. MATERIALS AND METHODS: A total of 309 patients with MPM were evaluated. Direct medical costs were estimated as the sum of hospital bills attributed to MPM for all patients followed up from hospital application to death. Three treatment strategies were compared to each other in terms of survival and median incremental costs per month gained cost. RESULTS: The mean age of the patients was 63.2 ± 11.2 years. The total median costs per patient and median survivals were $1838 and 5 months, $10,540 and 11 months, and $17,022 and 22 months for the best supportive care, the chemotherapy, and the multimodality groups, respectively. Factors affecting the cost of MPM were histology, treatment type, received second- and third-line chemotherapy, and number of hospitalization. CONCLUSION: MPM has a limited survival time despite treatment, and treatment cost is relatively high by prolongation of lifetime. Chemotherapy and multimodality approaches seem to be cost-effective until to be find more effective targeted therapies.
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Correlation between the probability of malignancy and maximum standard uptake values of mediastinal lymph nodes on 18F-FDG positron emission tomography scan sampled by endobronchial ultrasound-guided-transbronchial needle aspiration:A retrospective analysis p. 57
Ali Kadri Cirak, Sami Deniz, Yelda Varol, Görkem Vayisoglu, Serpil Tekgül, Dursun Alizoroglu, Enver Yalniz
DOI:10.4103/ejop.ejop_64_18  
INTRODUCTION: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is frequently used as an important initial investigation for diagnosing and staging for both suspected malignant and benign mediastinal lesions for the last 10 years. AIM: We aimed to analyze the correlation between probability of malignity by EBUS-TBNA and maximum standard uptake value (SUVmax) obtained by 18F-labeled fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET CT). METHODS: This is a retrospective study using hospitals' database records. Demographic features of the patients, characteristics of the biopsied lymph nodes (LNs), PET-CT results, and SUVmax are obtained from hospital database system. RESULTS: A total of 322 patients underwent EBUS-TBNA for a final diagnosis. The mean age was 59.4 years. The most common final diagnosis was nonsmall cell lung cancer. When we compared the average SUVmax, as the SUVmax increased, the probability of malignity increased significantly (P < 0.001). We studied a Youden index for SUVmax and the cutoff point for SUVmax was 9 for 54.39% sensitivity and 79.1% specificity. CONCLUSION: Our study in a real-life setting showed that EBUS-TBNA is effective in diagnosing patients who had mediastinal LNs suspected of malignancy. We also showed that as the SUVmax increased, the probability of malignancy increased. We believe that more data are needed from a larger number of patients from different centers.
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The Course of Renal Functions in COPD. Two Statition: Exacerbation and Stable Period p. 63
Ayse Baha, Nalan Ogan, Evrim Eylem Akpinar, Can Ateş, Meral Gülhan
DOI:10.4103/ejop.ejop_28_19  
OBJECTIVE: Comorbidities in chronic obstructive pulmonary disease (COPD) are important factors that determine the prognosis of the disease. However, there are few studies about renal dysfunction. We aimed to compare the renal functions in COPD patients with stable and exacerbation periods and to determine the frequency of acute renal failure (ARF) during exacerbation. MATERIALS AND METHODS: The files of 320 patients with COPD (forced expiratory volume in 1 s/forced vital capacity <70% in pulmonary function test) who were admitted to our hospital between 2015 and 2016 were evaluated retrospectively. After exclusion criteria, 113 patients were included in the study. Data were analyzed by appropriate statistical method. RESULTS: Ninety (80.4%) of the patients were male and 23 (19.6%) were female. In the exacerbation period, blood urea nitrogen (P < 0.001), creatinine (P < 0.001), white blood cell (P < 0.001), C-reactive protein (P < 0.001), and sedimentation (P < 0.001) were higher than that in the stable period. Furthermore, hemoglobin (P = 0.021) and estimated glomerular filtration rate (eGFR) (P < 0.001) were significantly lower. The number of emergency department admission in patients with eGFR <60 ml/min during the exacerbation more than the patients with eGFR ≥60 ml/min. Twenty (17.7%) patients have developed ARF during exacerbation (eGFR <60 ml/min). CONCLUSION: In COPD exacerbation period, kidney function is affected negatively in most patients (even if it does not reach the ABY border) and tends to improve in the stable period. In patients with COPD, it is thought that the causes of respiratory failure negatively affect renal function.
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CASE REPORTS Top

Diagnosis and treatment of coincident Hodgkin's lymphoma and hamartoma by endobronchial methods: A Case report p. 69
Ayperi Ozturk, Zafer Aktaş, Sezgi Şahin Duyar, Aydın Yılmaz, Funda Demiraǧ
DOI:10.4103/ejop.ejop_23_19  
Endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) is recommended for the diagnosis of malign and benign mediastinal lymphadenopathies and lesions adjacent to the central airways. However the diagnostic yield of EBUS-TBNA in diagnosis of lymphoma is weak. Additionally, the challenge of cathcing Reed-Sternberg cells in such a small sample size lowers the sensitivitiy of EBUS-TBNA for diagnosis of Hodgkin lymphoma. EBUS-TBNA can be performed with rigid bronchoscopy. A 64 years old male patient with multiple abdominal and mediastinal lymphadenopathies with coinciding hamartoma and Hodgkin lymphoma is reported for presenting diagnostic and therapeutic interventional methods performed for this unique coincidance.
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Traffic accident like suicide p. 72
Huseyin Fatih Sezer, Hakan Dayanir, Mehmet Yavuz Zıraman
DOI:10.4103/ejop.ejop_40_18  
Tracheal injury is a rare pathology, but 30% of all cases can be fatal and 50% of those patients will deteriorate in a couple of hours and may lead to death. The course of treatment must be scheduled by clinical status and severity of pathology; conservative approaches can be followed for minor injuries, but major surgeries must be performed for advanced cases. A 28-year-old male, who suffered from caught with a lasso around the neck in a traffic accident, was brought to our emergency service from a distant medical facility. It has been observed that tracheal integrity was lost, subcutaneous and mediastinal emphysema were evident, and bilateral pneumothorax was significant, especially at right with thorax computed tomography. His clinical condition was bad. Tube thoracostomy placement was successfully achieved from the right side, and neck exploration was performed for tracheostomy in operating theater; a total tracheal rupture was observed between the level of 2 amd 3 cricoid cartilage, and the procedure was terminated after placing a tracheostomy cannula to the distal segment of trachea to wait for considering reconstruction following clinical progression and hemodynamic stabilization of the patient. Following the 7th day after the first operation, the patient was operated. The trachea was repaired by suturing using 3-0 polypropylene sutures. The patient was discharged after 12 h of intensive care and 5 days of follow-up in surgery service. Blunt tracheal injuries may not present any symptoms or signs but may also manifest dramatically. Mortality and morbidity rates may be drastically higher. For this reason, physical examination, radiological findings, and bronchoscopy should be performed early in diagnosis and the most appropriate treatment option that can prevent mortality should be decided quickly.
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LETTERS TO EDITOR Top

Community-acquired Pseudomonas aeruginosa pneumonia in a previously healthy young woman p. 76
Abdullah Simsek, Mesiha Babalık, Gülay Çekiç Mor
DOI:10.4103/ejop.ejop_24_19  
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Sputum bacteriology of patients with acute exacerbations of bronchiectasis p. 78
Beuy Joob, Viroj Wiwanitkit
DOI:10.4103/ejop.ejop_61_18  
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Effect of sputum bacteriology on the prognosis of patients with acute exacerbations of bronchiectasis in the intensive care unit p. 79
Fatma Ciftci, Deniz Dogan Mülazimoglu, Serhat Erol, Aydin Ciledag, Akin Kaya
DOI:10.4103/ejop.ejop_73_18  
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