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   Table of Contents - Current issue
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May-August 2020
Volume 22 | Issue 2
Page Nos. 73-134

Online since Monday, August 31, 2020

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CONSENSUS REPORT  

Management of bleeding risk before pleural procedures: A consensus statement of Turkish respiratory society – Pleura study group p. 73
Nilgun Yilmaz Demirci, Deniz Koksal, Semra Bilaceroglu, Nalan Ogan, Cansel Atinkaya, Mustafa Ozhan, Ak Guntulu
DOI:10.4103/ejop.ejop_28_20  
Pleural effusion is a common clinical entity. Pleural procedures performed for the diagnosis and management of pleural effusions may increase the risk of bleeding, especially in patients with coagulopathies and comorbidities and those in need for antithrombotic drugs. Current literature provides sparse, low level of evidence, which is insufficient for safe implementation of pleural procedures among these patients. Thoracentesis, pleural biopsy (closed or percutaneous), catheter or chest tube drainage, and thoracoscopy are the main pleural procedures performed in these patients. Considering the bleeding risk associated with a specific pleural procedure, the risk is low for thoracentesis, moderate for insertion or removal of the chest tube or tunneled catheter, and moderate high for pleural biopsies and thoracoscopy. The current statement is prepared mainly for the pulmonologists and intended to provide recommendations to reduce the risk of bleeding following pleural procedures. The management of bleeding complication is out of the scope of this statement.
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ORIGINAL ARTICLES Top

Effects of pulmonary rehabilitation on dyspnea and functional capacity on waiting list for lung transplantation: According to obstructive or restrictive pulmonary disease p. 79
Lutfiye Kilic, Esra Pehlivan, Arif Balcı, Nur Dilek Bakan
DOI:10.4103/ejop.ejop_38_19  
BACKGROUND: Pulmonary rehabilitation (PR) has been shown to be effective on exercise capacity and dyspnea in lung transplantation (LTx) candidates. In this study, we aimed to investigate the efficacy of PR and to compare the outcomes in LTx candidates with obstructive and restrictive lung diseases. METHODS: Between January 2013 and May 2018, medical data of 86 patients who were on the waiting list for LTx were retrospectively analyzed. The patients were divided into two groups based on the diagnosis as obstructive patients (Group 1) and restrictive patients (Group 2). Six-minute walking test (6MWT), the Borg scale, and the modified Medical Research Council dyspnea scores were analyzed. RESULTS: A total of 65 patients completed the 8-week PR protocol (n = 42 in Group 1 and n = 23 in Group 2). Irrespective of the initial diagnosis, there was a significant (P < 0.05) improvement in the 6MWT distance in both groups without any statistically significant difference between the groups (Group 1, 299 m [42–548] vs. 377 m [84–561], mean increase 78 m, P < 0.001; Group 2, 337 m [70–525] vs. 396 m [139–621], mean increase 59 m, P = 0.002; Δ, P = 0.476). The effect of PR on dyspnea was significantly improved in both groups, whereas there were no differences between groups. CONCLUSION: PR has a positive effect on exercise capacity and dyspnea in patients with both obstructive and restrictive lung diseases who are on the waiting list for LTx. Our study results suggest that PR is effective in LTx candidates, irrespective of the initial diagnosis.
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Comparison of different criteria for the diagnosis of position and rapid eye movement-related obstructive sleep apnea syndrome and the value for the determination of prognosis p. 85
Melike Aloglu, Oğuz Köktürk
DOI:10.4103/ejop.ejop_47_19  
INTRODUCTION: Determination of clinical obstructive sleep apnea syndrome (OSAS) types is important for treatment decision. In the literature, there are two different criteria for the diagnosis of position and rapid eye movement (REM) related OSAS. One of them provides the criteria that nonsupine and/or non-REM apnea-hypopnea index (AHI) below 5, the other does not. In this study, these two definitions are named as “strict definition” and “loose definition.” This study is designed to identify which definition is more beneficial to use, and the prognostic value of the definitions by using OSAS severity according to AHI. This is the first study which investigates those issues. MATERIALS AND METHODS: This study is a retrospective cohort study. Obstructive AHI >5 of all adult patients admitted to our sleep disorders center between September 2012 and October 2014 were included to this study. The patients were grouped due to both strict and loose definitions. Patient groups were named as position related, REM related, REM + position related, pure OSAS due to loose definitions, and position dependent, aggravated by position, REM dependent, aggravated by REM, REM + position dependent, aggravated by REM + position, pure OSAS due to strict definitions. All these groups were compared for demographic and polysomnographic parameters. RESULTS: Two hundred and eighty (73.7%) of the patients were male, 100 (26.3%) were female, with a mean age of 49.9 ± 11.6, body mass index of 30.4 ± 5 and neck circumference of 43.2 ± 4.2. The patients had a mean Epworth Sleepiness Scale score: 13.5 ± 7, mean AHI: 32.3 ± 25.4, mean arousal index: 27.1 ± 19.6, mean peripheral capillary oxygen saturation (SpO2): 90.6 ± 4, and mean minimum SpO2: 78.7 ± 9.8. In OSAS aggravated by REM, position, REM + position total AHI, apnea index, hypopnea index, minimum SpO2 and desaturation percentage were all found significantly worse than REM dependent, position-dependent and REM + position-dependent OSAS patients (P < 0.05). CONCLUSION: In light of current findings, when evaluated with their effect on disease severity and complications, it is useful to predict prognosis of the disease when “strict definitions” are used for position- and/or REM-related OSAS cases.
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Effect of visual feedback aerobic exercise training on lung hyperinflation in chronic obstructive pulmonary disease patients – A randomized control trial p. 91
Senthil Kumar Elumalai, Ajeet Kumar Saharan, Neesha Shinde, Khyathi Padia, Ramesh Kumar Jeyaraman, Gauri Godbole
DOI:10.4103/ejop.ejop_53_19  
CONTEXT: Lung hyperinflation is defined as an abnormal increase in the volume of air remaining in the lungs at the end of normal expiration caused by the permanently destructive changes of emphysema and expiratory flow limitation. All the rehabilitation exercise programs have some reinforcement on hyperinflation mechanism directly or indirectly without any associated feedback. AIMS: This study aims to study the effect of visual biofeedback training on lung hyperinflation in chronic obstructive pulmonary disease (COPD) patients. SUBJECTS AND METHODS: 104 mild to moderate (global initiative for chronic obstructive lung disease) COPD patient of age group 40–60 years were recruited and randomly allocated to control and experimental group using random reviewer software 3.3 versions. The baseline and postoutcomes were analyzed by an external observer who is blinded. The visual training group receives biofeedback training on expiratory flow limitation. Both experimental and control group receives aerobic exercise training of 50%–60% of maximum heart rate intensity where all received cycling as a mode for 20–40 min with a warm and cool-down period. All the patients were trained for 4 days a week for 8 weeks. STATISTICAL ANALYSIS USED: Descriptive statistics, independent sample t-test, and repeated measures of analysis of variance. RESULTS: Residual volume and total lung capacity significantly reduced statistics F = 12.23 with P < 0.001 between the group. Breath hold time and maximum expiratory pressure showed increase response with significant statistics of F = 8.53 with P < 0.05 between the group. CONCLUSION: Visual feedback exercise training is one of the effective training methods to relieve the hyperinflation in stable COPD patients thereby improves exercise tolerance and quality of life.
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Health-related quality of life in elderly patients with bronchiectasis p. 98
Elif Yelda Niksarlioglu, Burcu Yigitbas, Güngör Çamsari, Filiz Kosar
DOI:10.4103/ejop.ejop_64_19  
Background: Chronic lung diseases such as bronchiectasis (BR) can adversely affect health-related quality of life (HRQOL), but there are limited studies conducted to investigate HRQOL in elderly BR patients. This study aims to investigate the HRQOL in elderly patients with BR and to assess its relationship with clinical outcomes and radiological findings. Materials and Methods: A total of 74 elderly BR patients involved in the study. BR was diagnosed using high-resolution computed tomography, and all patients were evaluated with the Short Form-36 (SF-36) questionnaire. Symptoms, pulmonary function tests, BR Severity Index (BSI), Reiff's score, and medical treatments were recorded. Results: The mean age of the patients was 70.1 ± 5.0 (range: 65–89) years, and 41 (55.4%) were men. The mean SF-36 Physical Component Summary (PCS) and Mental Health Component Summary (MCS) scores of the 74 elderly patients with BR were 36.6 ± 11.2 (range: 16.3–70) and 44.8 ± 8.9 (range: 23–59.6), respectively. All of the SF-36 subscale results except physical functioning subscale were lower in elderly patients with BR than in the normal Turkish elderly population. There was a major difference in the pain domain between males and females (57.9 ± 27.7 vs. 43.9 ± 27.6, respectively; P = 0.035), but there was no other significant difference between SF-36 domains by gender. The BSI was strongly correlated with all SF-36 subscales. There were statistically significant correlations between Reiff's score, forced expiratory volume in 1 s percent predicted value, forced vital capacity percent predicted value, and number of admissions to the emergency room in the previous year and some SF-36 subscales (P < 0.05). However, there was no correlation between age and PCS, MCS, or SF-36 subscales. Conclusion: Our study demonstrated that elderly patients with BR had poorer HRQOL scores. The BSI, Reiff's score, and pulmonary function tests were correlated with the SF-36 domains.
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Thoracic ultrasonography in the evaluation of lung parenchyma in interstitial lung diseases p. 104
Coskun Dogan, Nesrin Kiral, Elif Torun Parmaksız, Ali Fidan, Benan Çağlayan, Banu Salepçi, Sevda Şener Cömert
DOI:10.4103/ejop.ejop_67_19  
PURPOSE: The changes due to interstitial lung diseases (ILDs) in the lung parenchyma reveal comet tail artifact (CTA) that is defined on ultrasonography (USG), and is a type of reverberation artifact. We planned to investigate the significance of thoracic USG in the evaluation of the effect of ILD on pulmonary tissues in the present study. MATERIALS AND METHODS: The present cross-sectional study included patients diagnosed with ILD, and the control group between January 2016 and December 2017, high resolution computed tomography (HRCT) findings (the severity and extension scores for HRCT), pulmonary function tests, and pulmonary function tests and carbon monoxide diffusion test (PFT-DLCO) findings of all patients were recorded. Then, the number of CTAs detected on thoracic USG was recorded by a different pulmonologist. The data of the two groups were compared with each other. RESULTS: Thirty-six (50.7%) patients and 35 (49.3%) healthy controls were included in the study. The mean number of CTA in the control group was 25 ± 6.4 while the number of CTA in the ILD group was 68.3 ± 16.2 (P < 0.001). Negative correlations were found between the total CTA and DLCO, DLCO%, forced vital capacity (FVC), and FVC% values (P < 0.001). Positive correlation was found between the total number of CTA and the total HRCT score (P: 0.01). The sensitivity of B-lines on USG was 94.4%, and specifitiy was 97.1% with a cutoff value of 39.5 to diagnose intersititial involvement. CONCLUSION: Thoracic USG may be a good diagnostic tool for diseases that commonly involve the lung interstitium such as ILD.
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The impact of physical activity on chronic obstructive pulmonary disease hospitalization: A prospective study in Iran p. 112
Mohammadali Zohal, Sima Rafiei, Neda Esmailzadehha, Sanaz Jamshidi, Nafise Rastgoo
DOI:10.4103/ejop.ejop_68_19  
BACKGROUND: Decreasing hospitalization as a result of chronic obstructive pulmonary disease (COPD) exacerbations is a major objective in an effective process of the disease management. This study aimed to investigate the association between physical activity level in COPD patients, and specific-cause hospitalization in a prospective study of patients referred to a pulmonologist office in Qazvin, Iran. MATERIALS AND METHODS: A prospective study was conducted among 150 patients with COPD from the population of Qazvin, a North West, industrialized city of Iran, from December 2017 to December 2018. Participants were enrolled among patients who referred to an outpatient respiratory care center to undertake respiratory function tests. Patients were followed up for 1 year and their related measures were gathered and recorded at two phases including baseline and 12 months. To assess the effect of several covariates on the response variable, a multivariate regression analysis was applied. Results were reported in the form of odds ratios, incident rate ratio (IRR), and their 95% confidence intervals (CIs). RESULTS: The study findings revealed that individuals with severe pulmonary obstruction (<30%) were 4.21 times more likely to be hospitalized than those with a mild level of disease. Furthermore, the likelihood of hospitalization was ≥3 times higher among current smokers compared with nonsmokers. The history of hospitalization due to COPD 1 year before the enrolment was another significant factor which increased 21% the odds of being hospitalized during follow-up. In a multivariate model with the number of hospitalizations as an outcome variable, patients who reported moderate level of physical activity encountered a lower risk of COPD hospitalization compared to those who had a very low level of physical activity (IRR = 0.66; 95% CI = 0.44–0.92; P = 0.001). CONCLUSIONS: To decrease the risk of hospitalization among COPD patients, it is recommended to include regular physical activity in their integrated care program.
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Coal workers' pneumoconiosis and surveillance: A 5-year experience p. 118
Ayse Coskun Beyan, Hande Bahadir, Arif Çimrin
DOI:10.4103/ejop.ejop_77_19  
BACKGROUND: Coal workers' pneumoconiosis (cwp) is a parenchymal lung disease caused by inhalation of dust from coal and rocks in the mine. It is possible to prevent the disease completely with effective dust control; however, the secondary protection measures (screening and surveillance programs) are recommended in cases where effective dust control cannot be achieved. AIMS AND OBJECTIVES: The aim of this study is to discuss the cwp surveillance program and the duties and powers of the workplace physicians in turkey based on the assessment results of cases referred to our clinic by workplace physicians due to suspicion of cwp. MATERIALS AND METHODS: This is a cross sectional study. The archive data were evaluated by occupational diseases specialists. RESULTS: Of the 127 coal mine workers, all males with a mean age of 40.5 ± 8.9 Years, 63 (49.6%) Were diagnosed as cwp. The duration of exposure to coal dust ranged from 7 to 390 months, and the mean duration of exposure was 129.1 ± 82.2 Months. Of the 127 coal mine workers, 49.6% Were diagnosed as cwp. CONCLUSION: According to the findings obtained in the present study, the assessment made by the workplace physician and radiological evaluation plays a key role in the diagnosis and followup of cwp. In turkey, periodic examinations continue to be the most important component of secondary protection in terms of occupational risk. Pulmonary radiography is used as an indispensable component of early diagnosis in employees at risk of developing pneumoconiosis. Furthermore, screening programs should be evaluated with risk assessment and exposure information. Workplace physicians should reevaluate the periodic examination and ilo assessment services in terms of technical and reader quality.
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CASE REPORTS Top

A rare cause of pleural effusion; yellow nail syndrome p. 123
Hulya Dirol, Ayse Ödemiş, Ömer Özbudak
DOI:10.4103/ejop.ejop_74_19  
Yellow nail syndrome (YNS) is a rare syndrome characterized by yellow-thick nails, lymphedema, and recurrent respiratory symptoms. Respiratory symptoms occur due to asthma, bronchitis, bronchiectasis, pneumonia, sinusitis, pleural, and pericardial effusion. Pleural effusion is usually bilateral, exudative, and lymphocyte-predominant. Although about half of patients have pleural effusion, it is not a component of the triad. Two of the classical triad, yellow-thick nails, lymphedema, and recurrent respiratory symptoms, is enough for the diagnosis. About a hundred cases have been reported in the literature and all what we know is based on these case reports. There is no specific treatment for YNS; the goal is symptom control. Here, we report a successful pleurodesis in a 58-year-old male patient with YNS.
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Legionella pneumonia with rhabdomyolysis in a healthy young patient p. 128
Emel Bayrak, Kayser Çaglar
DOI:10.4103/ejop.ejop_85_19  
Legionella pneumonia is a lung infection caused by Legionella Pneumophila. Immune suppression, smoking, advanced age and chronic lung disease are the risk factors for Legionella Pneumonia. Pneumonia which developed outside hospital in a patient without an immune deficiency is defined as community-acquired pneumonia. Pneumonia with subacute onset, prodromal symptoms and extra pulmonary manifestations, often seen at a young age, is called atypical pneumonia. Although it is more common as a causative agent of pneumonia in patients with immune deficiency, Legionella Pneumophila is also an important cause of community-acquired atypical pneumonia. As a rare complication of legionella pneumonia, rhabdomyolysis causes a significant increase in mortality. We present a case of Legionella Pneumonia accompanied by rhabdomyolysis and acute renal injury.
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Malaria-associated pulmonary edema p. 132
Rene Hage, Macé M Schuurmans
DOI:10.4103/ejop.ejop_99_19  
Malaria-associated (MA) noncardiogenic pulmonary edema, or its more severe forms, i.e. acute lung injury and acute respiratory distress syndrome due to Plasmodium malariae, is a potentially fatal complication of malaria. It can mimic respiratory infections and present with concurrent malarial pulmonary edema and bacteriological respiratory infection. In our patient, malaria was diagnosed by microscopy (peripheral thick and thin Giemsa-stained blood smear) and serology testing. The chest computed tomography showed interstitial edema and a pleural effusion. Bronchoalveolar lavage was performed, which was negative for both bacteria and hemozoin. After initiation of antimalarial treatment, the patient rapidly responded. Recognizing and promptly treating malaria is critical to reduce the mortality of MA pulmonary complications.
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