Auscultation of the lung is an important part of the respiratory examination and is helpful in diagnosing various respiratory disorders. Auscultation assesses airflow through the trachea-bronchial tree. It is important to distinguish normal respiratory sounds from abnormal ones for example crackles, wheezes, and pleural rub in order to make correct diagnosis. It is necessary to understand the underlying pathophysiology of various lung sounds generation for better understanding of disease processes. Bedside teaching should be strengthened in order to avoid erosion in this age old procedure in the era of technological explosion.

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Respiratory tract infection during Hajj (pilgrimage to Mecca) is a common illness, and it is responsible for most of the hospital admissions. Influenza virus is the leading cause of upper respiratory tract infection during Hajj, and pneumonia can be serious. Taking into account the close contacts among the pilgrims, as well as the crowding, the potential for transmission of M. tuberculosis is expected to be high. These pilgrims can be a source for spreading infection on their return home. Although vaccination program for influenza is implemented, its efficacy is uncertain in this religious season. Future studies should concentrate on prevention and mitigation of these infections.

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Gastroesophageal reflux disease (GERD) may cause, trigger or exacerbate many pulmonary diseases. The physiological link between GERD and pulmonary disease has been extensively studied in chronic cough and asthma. A primary care physician often encounters patients with extra esophageal manifestations of GERD in the absence of heartburn. Patients may present with symptoms involving the pulmonary system; noncardiac chest pain; and ear, nose and throat disorders. Local irritation in the esophagus can cause symptoms that vary from indigestion, like chest discomfort and abdominal pain, to coughing and wheezing. If the gastric acid reaches the back of the throat, it may cause a bitter taste in the mouth and/or aspiration of the gastric acid into the lungs. The acid can cause throat irritation, postnasal drip and hoarseness, as well as recurrent cough, chest congestion and lung inflammation leading to asthma and/or bronchitis/ pneumonia. This clinical review examines the potential pathophysiological mechanisms of pulmonary manifestations of GERD. It also reviews relevant clinical information concerning GERD-related chronic cough and asthma. Finally, a potential management strategy for GERD in pulmonary patients is discussed.

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Objective: The prevalence of obstructive sleep apnea syndrome (OSAS) and metabolic syndrome is increasing worldwide, in part linked to epidemic of obesity. The purposes of this study were to establish the rate of metabolic syndrome and to compare fibrinogen, homocysteine, high-sensitivity C-reactive protein (hsCRP), leptin levels, and homeostasis model assessment insulin resistance (HOMA-IR) in the obese patients with and without OSAS. Methods: The study population included 36 consecutive obese patients with OSAS (23 males; mean age, 50.0 ±19.7 years), and 34 obese patients without OSAS (17 males; mean age, 49.7±11.1 years) were enrolled as control group. Metabolic syndrome was investigated; fibrinogen, homocysteine, CRP, and leptin levels were measured, and IR was assessed. Results: Metabolic syndrome was found in 17 (47.2%) obese OSAS patients, whereas only 29.4% of obese subjects had metabolic syndrome (P > 0.05). Obese patients with OSAS had significantly higher mean levels of triglyceride (P< 0.001), total-cholesterol ( P = 0.003), low-density lipoprotein-cholesterol ( P = 0.001), fasting glucose ( P = 0.01), HOMA-IR ( P<0.001), thyroid-stimulating hormone ( P = 0.03), fibrinogen ( P < 0.003), hsCRP ( P <0.001), and leptin ( P = 0.03) than control group . Besides, leptin level was positively correlated with waist ( r = 0.512, P = 0.03) and neck circumferences ( r = 0.547, P = 0.03), and fasting glucose (r = 0.471, P = 0.04) in OSAS patients, but not in obese subjects. Conclusion: This study demonstrated that obese OSAS patients may have an increased rate of metabolic syndrome and higher levels of serum lipids, fasting glucose, IR, leptin, fibrinogen, and hsCRP than obese subjects without sleep apnea. Thus, clinicians should be encouraged to systematically evaluate the presence of metabolic abnormalities in OSAS and vice versa.

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Aim: The aim of this study was to investigate the relationship among plasma leptin, ghrelin, adiponectin, resistin levels, and obstructive sleep apnea syndrome (OSAS). Methods: Fifty-five consecutive newly diagnosed OSAS patients and 15 age-matched nonapneic controls were enrolled in this study. After sleep study between 8:00 AM and 9:00 AM on the morning, venous blood was obtained in the fasting state to measure ghrelin and adipokines. Results: Serum ghrelin levels of OSAS group were significantly (P < 0.05) higher than those of the control group. No significant difference was noted in the levels of leptin, adiponectin, and resistin in OSAS group when compared to controls. There was a significant positive correlation between ghrelin and apnea-hypopnea index (AHI) (r = 0.237, P < 0.05) or the Epworth sleepiness scale (ESS) (r = 0.28, P < 0.05). There was also a significant positive correlation between leptin and body mass index (r = 0.592, P < 0.0001). No significant correlation was observed between leptin, adiponectin, resistin, and any polysomnographic parameters. Conclusion : Our findings demonstrated that serum ghrelin levels were higher in OSAS patients than those of control group and correlated with AHI and ESS. Further studies are needed to clarify the complex relation among OSAS, obesity, adipokines, and ghrelin.

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Asthma is a prevalent chronic disease of the respiratory system and acute asthma exacerbations are among the most common causes of presentation to the emergency department (ED) and admission to hospital particularly in children. Bronchial airways inflammation is the most prominent pathological feature of asthma. Inhaled corticosteroids (ICS), through their anti-inflammatory effects have been the mainstay of treatment of asthma for many years. Systemic and ICS are also used in the treatment of acute asthma exacerbations. Several international asthma management guidelines recommend the use of systemic corticosteroids in the management of moderate to severe acute asthma early upon presentation to the ED. On the other hand, ICS use in the management acute asthma has been studied in different contexts with encouraging results in some and negative in others. This review sheds some light on the role of systemic and ICS in the management of acute asthma and discusses the current evidence behind their different ways of application particularly in relation to new developments in the field.

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Background: Middle East Respiratory Syndrome (MERS) is a disease of the lower respiratory tract and is characterized by high mortality. It is caused by a beta coronavirus (CoV) referred to as MERS-CoV. Majority of MERS-CoV cases have been reported from Saudi Arabia. Aim: We investigated the human leukocyte antigen (HLA) Class II alleles in patients with severe MERS who were admitted in our Intensive Care Unit. Methods: A total of 23 Saudi patients with severe MERS-CoV infection were typed for HLA class II, results were compared with those of 161 healthy controls. Results: Two HLA class II alleles were associated with the disease; HLA-DRB1*11:01 and DQB1*02:02, but not with the disease outcome. Conclusions: Our results suggest that the HLA-DRB1*11:01 and DQB1*02:02 may be associated with susceptibility to MERS.

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Background: Tobacco consumption is associated with considerable negative impact on health. Health professionals, including future doctors, should have a leading role in combating smoking in the community. Objectives: The aims of the study were to assess the prevalence of smoking among medical students of newly established medical colleges in Riyadh city, the capital of Saudi Arabia, as well as to assess students' attitude, practice and their knowledge on the risk factors of tobacco consumption. Methods: A cross-sectional, questionnaire-based study of students from two medical colleges in Riyadh, Saudi Arabia was carried out. The questionnaire used was anonymous, self-administered and developed mainly from Global Adult Tobacco Survey (GATS). Results: A total of 215 students participated in this study. Forty students (19%) indicated that they smoke tobacco at the time of the study. All of them were males, which raise the prevalence among male students to 24%. Tobacco smoking was practiced by males more than females (P value <0.0001) and by senior more than junior students (<0.0001). About 94% of the study sample indicated that smoking could cause serious illnesses. About 90% of the students indicated that they would advice their patients to quit smoking in the future and 88% thought that smoking should be banned in public areas. Forty-four students (20%) thought that smoking has some beneficial effects, mainly as a coping strategy for stress alleviation. Conclusion: Despite good knowledge about the hazards of tobacco consumption, about 25% of the medical students in this study continue to smoke. The main reported reasons should be addressed urgently by policy-makers. Special efforts should be taken to educate medical students on the effective strategies in managing stress during their study as they thought that tobacco smoking could be used as a coping strategy to face such a stress.

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Purpose: Asthma control test (ACT) has been devised to assess the degree of asthma control in out-patients setting. The aim of this study is to validate the Arabic version of ACT. Materials and Methods: Patients completed the Arabic version of ACT during regular visit to one of two asthma specialists. Spirometry was obtained. The asthma specialist rated asthma control using a 5-point scale and indicated modification in management as step up, same or step down of asthma treatment. Results: 40 patients completed the study, the mean age was 32.6 + 14.0 years, mean FEV1 was 2.7 + 1.0 L (89.2% + 23.6% of predicted). The mean ACT score was 15.9 + 5.8; mean of specialist asthma control rating was 3.4 + 1.0. The internal consistency reliability of the 5-item ACT survey was alpha = 0.92. The correlation was moderate between ACT and specialists rating ( r = 0.482, P = 0.002) and between ACT and treatment modification ( r = -0.350, P = 0.027). The correlation between FEV1 and ACT was low ( r = 0.185, P = 0.259). ACT distinguished between patients with different specialist rating ( F = 3.37, P = 0.02) and the need to change therapy ( F = 3.62, P = 0.037). The areas under the curve (ROC) for ACT, FEV1, and ACT and FEV1 as independent variables were 0.720, 0.721, and 0.766 respectively. All results were comparable to the initial work for development of ACT. Conclusion: The Arabic version of the ACT is a valid tool to assess asthma control. ACT correlates better with asthma specialist rating of asthma control than with FEV1.

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Sleep-disordered breathing (SDB), which includes obstructive sleep apnea (OSA) as its most extreme variant, is characterized by intermittent episodes of partial or complete obstruction of the upper airway, leading to cessation of breathing while asleep. Cardiac arrhythmias are common problems in OSA patients, although the true prevalence and clinical relevance of cardiac arrhythmias remains to be determined. The presence and complexity of tachyarrhythmias and bradyarrhythmias may influence morbidity, mortality and quality of life for patients with OSA. Although the exact mechanisms underlying the link between OSA and cardiac arrhythmias are not well established, they could be some of the same proposed mechanisms relating OSA to different cardiovascular diseases, such as repetitive pharyngeal collapse during sleep, which leads to markedly reduced or absent airflow, followed by oxyhemoglobin desaturation, persistent inspiratory efforts against an occluded airway and termination by arousal from sleep. These mechanisms elicit a variety of autonomic, hemodynamic, humoral and neuroendocrine responses that evoke acute and chronic changes in cardiovascular function. However, despite substantial research effort, the goals of determining in advance which patients will respond most favorably to certain treatment options (such as continuous positive airway pressure, tracheostomy or cardioversion) and the developing alternative treatments remain largely elusive. Therefore, this literature review aims to summarize a broad array of the pathophysiological mechanisms underlying the relationship between OSA and cardiac arrhythmias and the extent of this association from an epidemiological perspective, thereby attempting to assess the effects of OSA treatment on the presence of cardiac arrhythmias.

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In daily clinical practice, radiologists and pulmonologists are faced with incidental radiographic findings of pulmonary nodules. Deciding how to manage these findings is very important as many of them may be benign and require no further action, but others may represent early disease and importantly early-stage lung cancer and require prompt diagnosis and definitive treatment. As the diagnosis of pulmonary nodules includes invasive procedures which can be relatively minimal, such as bronchoscopy or transthoracic aspiration or biopsy, but also more invasive procedures such as thoracic surgical biopsies, and as these procedures are linked to anxiety and to cost, it is important to have clearly defined algorithms for the description, management, and follow-up of these nodules. Clear algorithms for the imaging protocols and the management of positive findings should also exist in lung cancer screening programs, which are already established in the USA and which will hopefully be established worldwide. This article reviews current knowledge on nodule definition, diagnostic evaluation, and management based on literature data and mainly recent guidelines.

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Context: Asthma is a chronic airway disorder which is associated to the inflammatory cells. Inflammatory and immune cells generate more reactive oxygen species in patients suffering from asthma which leads to tissue injury. Aims: To investigate the role of oxidant-antioxidant imbalance in disease progression of asthmatic patients. Settings and Design: In this study, 130 asthmatic patients and 70 healthy controls were documented. Methods: For this malondialdehyde level, total protein carbonyls, sulfhydryls, activity of superoxide dismutase (SOD), catalase, glutathione peroxidase (GPx), total blood glutathione, and total antioxidant capacity (FRAP) were measured. Statistical Analysis Used: Analysis of the data was done using unpaired student t test and one-way ANOVA analysis. P < 0.05 was considered significant. Results: The present work showed that the systemic levels of MDA (4.19 ± 0.10 nmol/ml, P < 0.001) and protein carbonyls (1.13 ± 0.02 nmol/mg, P < 0.001) were found to be remarkably higher in asthmatic patients while protein sulfhydryls (0.55 ± 0.01 mmol/l, P < 0.05) decreased as compared to controls (2.84 ± 0.12 nmol/ml, 0.79 ± 0.02 nmol/mg and 0.60 ± 0.02 mmol/l, respectively). We also observed decrease in activities of SOD (2047 ± 50.34 U/g Hb, P < 0.05), catalase (4374 ± 67.98 U/g Hb, P < 0.01), and GPx (40.97 ± 1.05 U/g Hb, P < 0.01) in erythrocytes compared to control (2217 ± 60.11 U/g Hb, 4746 ± 89.94 U/g Hb, and 48.37 ± 2.47 U/g Hb, respectively). FRAP level (750.90 ± 21.22 ΅mol/l, P < 0.05) in plasma was decreased, whereas total blood glutathione increased (0.94 ± 0.02 mmol/l, P < 0.05) as seen in control (840.40 ± 28.39 ΅mol/l and 0.84 ± 0.04 mmol/l). Conclusions: This work supports and describes the hypothesis that an imbalance between oxidant-antioxidant is associated to the oxidative stress which plays a significant role in severity of the disease.

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Background: Invasive procedures such as bronchoscopic biopsy, bronchial washing, and bronchial brushing are widely used in diagnosis of lung cancers. The mean diagnostic rate with bronchoscopic forceps biopsy is 74% in central tumors. This study was designed to evaluate the efficacy of cryobiopsies in histopathological diagnosis. Methods : Forty-one patients who had interventional bronchoscopy were included in this study. Three forceps biopsies and one cryobiopsy with cryorecanalization probe were obtained from each subject. Biopsies interpretations were done by one expert pathologist. Results : Hemorrhage was the only complication in both procedures. There was no significant difference between these two procedures in the incidence of hemorrhage (P > 0.05). Mean diameters of samples taken with forceps biopsy and cryoprobe biopsy were 0.2 and 0.8 cm, respectively (P < 0.001). Thirty-two patients (78%) were diagnosed with forceps biopsies, and 38 patients (92.7%) were diagnosed with cryoprobe biopsies (P = 0.031). Conclusions : We concluded that cryoprobe biopsies were more successful than forceps biopsies in diagnosis. Nevertheless, further investigations are warranted to determine an efficacy of cryoprobe biopsy procedures and a rationale to use as a part of routine flexible bronchoscopy.

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Objective : To determine predictive factors, clinical and demographics characteristics of patients with pulmonary embolism (PE) in ICU, and to identify factors associated with poor outcome in the hospital and in the ICU. Methods : During a four-year prospective study, a medical committee of six ICU physicians prospectively examined all available data for each patient in order to classify patients according to the level of clinical suspicion of pulmonary thromboembolism. During the study periods, all patients admitted to our ICU were classified into four groups. The first group includes all patients with confirmed PE; the second group includes some patients without clinical manifestations of PE; the third group includes patients with suspected and not confirmed PE and the fourth group includes all patients with only deep vein thromboses (DVTs) without suspicion of PE. The diagnosis of PE was confirmed either by a high-probability ventilation/perfusion (V/Q) scan or by a spiral computed tomography (CT) scan showing one or more filling defects in the pulmonary artery or in its branches. The diagnosis was also confirmed by echocardiography when a thrombus in the pulmonary artery was observed. Results : During the study periods, 4408 patients were admitted in our ICU. The diagnosis of PE was confirmed in 87 patients (1.9%). The mean delay of development of PE was 7.8 ± 9.5 days. On the day of PE diagnosis, clinical examination showed that 50 patients (57.5%) were hypotensive, 63 (72.4%) have SIRS, 15 (17.2%) have clinical manifestations of DVT and 71 (81.6%) have respiratory distress requiring mechanical ventilation. In our study, intravenous unfractionated heparin was used in 81 cases (93.1%) and low molecular weight heparins were used in 4 cases (4.6%). The mean ICU stay was 20.2 ± 25.3 days and the mean hospital stay was 25.5 ± 25 days. The mortality rate in ICU was 47.1% and the in-hospital mortality rate was 52.9%. Multivariate analysis showed that factors associated with a poor prognosis in ICU are the use of norepinephrine and epinephrine . Furthermore, factors associated with in-hospital poor outcome in multivariate analysis were a number of organ failure associated with PE ≥ 3. Moreover, comparison between patients with and without pe showed that predictive factors of pe are: acute medical illness, the presence of meningeal hemorrhage, the presence of spine fracture, hypoxemia with PaO ₂ /FiO ₂ ratio <300 and the absence of pharmacological prevention of venous thromboembolism. Conclusion : Despite the high frequency of DVT in critically ill patients, symptomatic PE remains not frequently observed, because systematic screening is not performed. Pulmonary embolism is associated with a high ICU and in-hospital mortality rate. Predictive factors of PE are acute medical illness, the presence of meningeal hemorrhage, the presence of spine fracture, hypoxemia with PaO ₂ /FiO ₂ < 300 and the absence of pharmacological prevention of venous thromboembolism.

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The aim of this review is to present a pictorial essay emphasizing the various patterns of calcification in pulmonary nodules (PN) to aid diagnosis and to discuss the differential diagnosis and the pathogenesis where it is known. The imaging evaluation of PN is based on clinical history, size, distribution and the gross appearance of the nodule as well as feasibility of obtaining a tissue diagnosis. Imaging is instrumental in the management of PN and one should strive not only to identify small malignant tumors with high survival rates but to spare patients with benign PN from undergoing unnecessary surgery. The review emphasizes how to achieve these goals. One of the most reliable imaging features of a benign lesion is a benign pattern of calcification and periodic follow-up with computed tomography showing no growth for 2 years. Calcification in PN is generally considered as a pointer toward a possible benign disease. However, as we show here, calcification in PN as a criterion to determine benign nature is fallacious and can be misleading. The differential considerations of a calcified lesion include calcified granuloma, hamartoma, carcinoid, osteosarcoma, chondrosarcoma and lung metastases or a primary bronchogenic carcinoma among others. We describe and illustrate different patterns of calcification as seen in PN on imaging.

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Aims and Objectives: To determine the efficacy of integrated ¹⁸ F-fluorodeoxy glucose positron emission tomography-computed tomography ( ¹⁸ F-FDG PET-CT) in the evaluation and characterization of mediastinal lymph nodes into benign and malignant pathology. Methods: Thirty-five patients with mediastinal lymphadenopathies without primary neoplastic or infective lung pathologies were included in the study. The lymph nodes were detected on contrast-enhanced CT scan of the chest. All patients underwent ¹⁸ F-FDG PET-CT scan for evaluation of mediastinal lymph nodes. Results of PET-CT were compared with histopathology of the lymph nodes and sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated. Statistical Analysis: The data were collected prospectively and analyzed using (SPSS Inc., Chicago, IL) 11.5 software. Results: Histopathology results in 35 patients revealed tuberculosis in 12, sarcoidosis in 8, and lymphoma in 15. Maximum standardized uptake value (SUVmax) of the benign lymph nodes ranged from 2.3 to 11.8 with a mean±standard deviation (SD) of 5.02±3.26. SUVmax of the malignant lymph nodes ranged from 2.4 to 34 with a mean±SD of 10.8±8.12. There was a statistically significant difference between benign and malignant pathology (P<0.0059). ¹⁸ F-FDG PET-CT has sensitivity of 93% and specificity of 40% with SUVmax 2.5 as the cutoff. We found the optimal SUVmax cutoff to be 6.2 as determined by the receiver-operator characteristic curve. With 6.2 as cutoff, the sensitivity, specificity, and accuracy were 87%, 70%, and 77%, respectively. Conclusion : In countries where tuberculosis and other granulomatous diseases are endemic, SUVmax cutoff value of 2.5 has low specificity. Increasing the cutoff value can improve the specificity, while maintaining an acceptable sensitivity.

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Objective: The objective of our study was to identify the incidence and risk factors of anastomotic leaks following transhiatal esophagectomy (THE). Materials and Methods: A prospective study was conducted on 61 patients treated for carcinoma of the esophagus between 2006 and 2007. We examined the following variables: age, gender, preoperative cardiovascular function, intraoperative complications such as hypotension, arrhythmia, mediastinal manipulation period, blood loss volume, blood transfusion, duration of surgery, postoperative complications such as anastomotic leak, anastomotic stricture, requiring reoperation, respiratory complications, and total morbidity and mortality. Variables were compared between the patients with and without anastomotic leak. T-test for quantitative variables and Chi-square test for qualitative variables were used to find out any relationship. P value less than 0.05 was considered significant. Results: Out of 61 patients, anastomotic leaks occurred in 13 (21.3%). Weight loss, forced expiratory volume (FEV1) < 2 lit, preoperative albumin, intaoperative blood loss volume, and respiratory complication were associated with the anastomotic leak in patients undergoing THE. Anastomotic leaks were the leading cause of postoperative morbidity, anastomotic stricture, and reoperation. Conclusion: Anastomotic leakage is a life-threatening postoperative complication. Careful attention to the factors contributing to the development of a leak can reduce the incidence of anastomotic complications postoperatively.

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Background: A key component in the management of chronic obstructive pulmonary disease (COPD) patients is pulmonary rehabilitation (PR), the corner stone of which is exercise training. Aim: This study aims to evaluate the effect of a two-months, home-based PR program with outpatient supervision every two weeks, on exercise tolerance and health-related quality of life (HRQL) using Arabic-translated standardized generic and specific questionnaires in COPD patients recently recovered from acute exacerbation, Design: Randomized clinical trial. Setting and Subjects: A total of 39 COPD patients who recovered from acute exacerbation were randomly allocated either a two-month home-based PR program in addition to standard medical therapy or standard medical therapy alone in the period between July 2008 and March 2009. Methods: Pulmonary function tests (PFTs), six-minute walk distance (6-MWD) test, Arabic-translated chronic respiratory disease questionnaire-self administered standardized format (CRQ-SAS) and quality of life scale Short Form (SF-36) were compared between 25 patients with moderate to severe COPD who underwent a two-month PR program (group 1) and 14 COPD patients who did not (group 2). Results: Group 1 showed significant improvement in the 6-MWD, and HRQL scores at two months compared with the usual care patients in group 2 (P less than 0.05). Improvement in both CRQ-SAS and SF-36 scores were statistically significant and comparable in group 1. Conclusion: The supervised, post discharge, two-month home-based PR program is an effective non pharmacological intervention in the management of stable patients with COPD. The 6-MWD is a simple, inexpensive and safe test to assess physical and functional capabilities among COPD patients. HRQL can be measured in patients with COPD either by disease-specific tools that have been specifically designed for use in patients with respiratory system disorders or by generic HRQL tools that can be used across populations with a variety of medical conditions. The Arabic-translated CRQ-SAS is a new tool for assessment of Arabic-speaking patients with chronic respiratory diseases.

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Background : The aim of this study was to evaluate treatment outcomes in patients with thoracic actinomycosis and identify patient characteristics associated with unfavorable responses to antibiotic therapy. Methods : A retrospective analysis was performed on 40 patients with pathologically confirmed thoracic actinomycosis. Results : Initial surgical treatment was performed on 17 patients to control severe symptoms such as hemoptysis or rule out lung cancer. Sixteen (94%) patients were successfully treated, including three patients who did not receive postoperative antibiotics, and one patient died of a postoperative complication. The median duration of oral antibiotic therapy after surgery was 3 months. After the diagnosis of actinomycosis, 23 patients began antibiotic therapy. The median duration of oral antibiotic therapy was 5 months. Favorable treatment outcomes were achieved in 18 of these 23 patients (78%), while five (22%) showed unfavorable responses to antibiotic therapy. Surgery was successfully performed in these five patients. The patients with unfavorable responses to antibiotic therapy had a longer duration of symptoms prior to treatment (median, 10 months) as compared to patients with favorable responses (median, 2 months; P = 0.012). Conclusions : Medical treatment failure is possible in patients with thoracic actinomycosis, and close monitoring is necessary in those who begin antibiotic therapy. In addition, surgical resection may be a valid option for patients who do not respond to antibiotic therapy, with the consideration of the age and comorbid conditions.

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Bronchiolitis obliterans organizing pneumonia (BOOP) was first described in the early 1980s as a clinicopathologic syndrome characterized symptomatically by subacute or chronic respiratory illness and histopathologically by the presence of granulation tissue in the bronchiolar lumen, alveolar ducts and some alveoli, associated with a variable degree of interstitial and airspace infiltration by mononuclear cells and foamy macrophages. Persons of all ages can be affected. Dry cough and shortness of breath of 2 weeks to 2 months in duration usually characterizes BOOP. Symptoms persist despite antibiotic therapy. On imaging, air space consolidation can be indistinguishable from chronic eosinophilic pneumonia (CEP), interstitial pneumonitis (acute, nonspecific and usual interstitial pneumonitis, neoplasm, inflammation and infection). The definitive diagnosis is achieved by tissue biopsy. Patients with BOOP respond favorably to treatment with steroids.

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The analysis of biomarkers in exhaled breath constituents has recently become of great interest in the diagnosis, treatment and monitoring of many respiratory conditions. Of particular interest is the measurement of fractional exhaled nitric oxide (FENO) in breath. Its measurement is noninvasive, easy and reproducible. The technique has recently been standardized by both American Thoracic Society and European Respiratory Society. The availability of cheap, portable and reliable equipment has made the assay possible in clinics by general physicians and, in the near future, at home by patients. The concentration of exhaled nitric oxide is markedly elevated in bronchial asthma and is positively related to the degree of esinophilic inflammation. Its measurement can be used in the diagnosis of bronchial asthma and titration of dose of steroids as well as to identify steroid responsive patients in chronic obstructive pulmonary disease. In primary ciliary dyskinesia, nasal NO is diagnostically low and of considerable value in diagnosis. Among lung transplant recipients, FENO can be of great value in the early detection of infection, bronchioloitis obliterans syndrome and rejection. This review discusses the biology, factors affecting measurement, and clinical application of FENO in the diagnosis and management of respiratory diseases.

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In the 4 months since it was first recognized, the pandemic strain of a novel influenza A (H1N1) virus has spread to all continents and, after documentation of human-to-human transmission of the virus in at least three countries in two separate World Health Organization (WHO) regions, the pandemic alert was raised to level 6. The agent responsible for this pandemic, a swine-origin influenza A (H1N1) virus (S-OIV), is characterized by a unique combination of gene segments that has not previously been identified among human or swine influenza A viruses. As of 31th July 2009, 168 countries and overseas territories/communities have each reported at least one laboratory-confirmed case of pandemic H1N1 infection. There have been a total of 162,380 reported cases and 1154 associated deaths. Influenza epidemics usually take off in autumn, and it is important to prepare for an earlier start this season. Estimates from Europe indicate that 230 millions Europe inhabitants will have clinical signs and symptoms of S-OIV this autumn, and 7– 35% of the clinical cases will have a fatal outcome, which means that there will be 160,000– 750,000 H1N1-related deaths. A vaccine against H1N1 is expected to be the most effective tool for controlling influenza A (H1N1) infection in terms of reducing morbidity and mortality and limiting diffusion. However, there are several issues with regard to vaccine manufacture and approval, as well as production capacity, that remain unsettled. We searched the literature indexed in PubMed as well as the websites of major international health agencies to obtain the material presented in this update on the current S-OIV pandemic.

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Context: Idiopathic pulmonary fibrosis (IPF) and chronic hypersensitivity pneumonitis (HP) are diffuse parenchymal lung diseases characterized by a mixture of inflammation and fibrosis, leading to lung destruction and finally death. AIMS: The aim of this study was to compare different pathophysiological mechanisms, such as angiogenesis, coagulation, fibrosis, tissue repair, inflammation, epithelial damage, oxidative stress, and matrix remodeling, in both disorders using bronchoalveolar lavage (BAL). Methods: At diagnosis, patients underwent bronchoscopy with BAL and were divided into three groups: Control ( n = 10), HP ( n = 11), and IPF ( n = 11), based on multidisciplinary approach (clinical examination, radiology, and histology): Multiplex searchlight technology was used to analyze 25 proteins representative for different pathophysiological processes: Eotaxin, basic fibroblast growth factor (FGFb), fibronectin, hepatocyte growth factor (HGF), interleukine (IL)-8, IL-12p40, IL-17, IL-23, monocyte chemotactic protein (MCP-1), macrophage-derived chemokine (MDC), myeloperoxidase (MPO), matrix metalloproteinase (MMP)-8, MMP-9, active plasminogen activating inhibitor 1 (PAI-1), pulmonary activation regulated chemokine (PARC), placental growth factor (PlGF), protein-C, receptor for advanced glycation end products (RAGE), regulated on activation normal T cells expressed and secreted (RANTES), surfactant protein-C (SP-C), transforming growth factor-β1 (TGF-β1), tissue inhibitor of metalloproteinase-1 (TIMP-1), tissue factor, thymic stromal lymphopoietin (TSLP), and vascular endothelial growth factor (VEGF). Results: All patients suffered from decreased pulmonary function and abnormal BAL cell differential compared with control. Protein levels were increased in both IPF and HP for MMP-8 ( P = 0.022), MMP-9 ( P = 0.0020), MCP-1 ( P = 0.0006), MDC ( P = 0.0048), IL-8 ( P = 0.013), MPO ( P = 0.019), and protein-C ( P = 0.0087), whereas VEGF was decreased ( P = 0.0003) compared with control. HGF was upregulated in HP ( P = 0.0089) and active PAI-1 was upregulated ( P = 0.019) in IPF compared with control. Differences in expression between IPF and HP were observed for IL-12p40 ( P = 0.0093) and TGF-β1 ( P = 0.0045). Conclusions: Using BAL, we demonstrated not only expected similarities but also important differences in both disorders, many related to the innate immunity. These findings provide new clues for further research in both disorders.

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Background: Ventilator-associated pneumonia (VAP) is an important intensive care unit (ICU) infection in mechanically ventilated patients. VAP occurs approximately in 9-27% of all intubated patients. Due to the increasing incidence of multidrug-resistant organisms in ICUs, early and correct diagnosis of VAP is an urgent challenge for an optimal antibiotic treatment. Aim of the Study: The aim of the study was to assess the incidence of VAP caused by multidrug-resistant organisms in the multidisciplinary intensive care unit (MICU) of our tertiary care 1,400-bedded hospital. Materials and Methods: This prospective study was done in the period from December 2005 to August 2006, enrolling patients undergoing mechanical ventilation (MV) for >48 h. Endotracheal aspirates (ETA) were collected from patients with suspected VAP, and quantitative cultures were performed on all samples. VAP was diagnosed by the growth of pathogenic organism _10 ⁵ cfu/ml. Results: Incidence of VAP was found to be 45.4% among the mechanically ventilated patients, out of which 47.7% had early-onset (<5 days MV) VAP and 52.3% had late-onset (>5 days MV) VAP. Multiresistant bacteria, mainly Acinetobacter spp. (47.9%) and Pseudomonas aeruginosa (27%), were the most commonly isolated pathogens in both types of VAP. Most of the isolates of Escherichia coli (80%) and Klebsiella pneumoniae (100%) produced extended-spectrum beta lactamases (ESBLs). As many as 30.43% isolates of Acinetobacter spp. showed production of AmpC beta lactamases among all types of isolates. Metallo-beta lactamases (MBLs) were produced by 50% of Pseudomonas aeruginosa and 21.74% of Acinetobacter spp. Conclusion : High incidence (45.4%) of VAP and the potential multidrug-resistant organisms are the real threat in our MICU. This study highlighted high incidence of VAP in our setup, emphasizing injudicious use of antimicrobial therapy. Combined approaches of rotational antibiotic therapy and education programs might be beneficial to fight against these MDR pathogens and will also help to decrease the incidence of VAP.

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