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The authors review the principles of the organization of the management of pulmonologic patients at the ambulatory stage. Describe the structure of the pulmonologic room, its functions and personnel. Based on the experience gained in the work of the pulmonologic rooms within the system of the All-Union Institute of Pulmonology, USSR Ministry of Health, give an account of the efficient organization of the work of the physician, the scope of diagnostic and treatment measures performed at the room. Describe the principles of the follow-up of patients afflicted with respiratory diseases. Give a critical review of the current standardized documents on pulmonology. Provide a schedule for the patients' diagnosis and treatment.
Consideration is given to the place occupied by diseases of respiratory organs in the general structure of morbidity. In many ways, growth in their number has been determined by amplification of anthropogenic factors. This is manifested in emergence of new eco-dependent diseases and syndromes including more difficult course of pulmonary pathology. One of the prioritized disciplines of the modern pulmonology is ecological pulmonology which lies in the domain of medical ecology and is central to the concept of eco-dependent human diseases. A factorial structure of ecological pulmonology built on the etiological principle is proposed to facilitate inquiry into the origin and course of various forms of eco-dependent pathology of the lung.
The direction of research work in phthisiology and pulmonology is determined by the epidemiologic situation for tuberculosis and CNPD in the republic. The results of a complex research work in phthisiology and pulmonology carried out in the rural areas of Uzbekistan, and in the cotton--growing regions in particular, are given. Practical significance of this work is stressed, which comprises direct inspection of the tuberculosis infection foci and subjects in contact and subsequent accomplishment of preventive and health--improvement measures, comprehensive screening of the rural population for tuberculosis and CNPD detection, conduction of chemotherapy and pathogenetic and surgical treatment of tuberculosis patients. The results of research into phthisiology and pulmonology will make the basis of the national program with respect to tuberculosis in Uzbekistan.
In 1996, the Future of Pediatric Education (FOPE) Project of the American Academy of Pediatrics (AAP) developed surveys to describe the nature of pediatric practices, recent trends in clinical practice, and anticipated workforce needs for both pediatric generalists and pediatric sub-specialists. A survey was specifically developed to describe the features of pediatric pulmonology as self-reported by pediatric pulmonologists. The survey was distributed to members of the AAP Pulmonology Section, the Pediatric Assembly of the American Thoracic Society, and certified pediatric pulmonologists recognized by the American Board of Pediatrics. Of the 535 respondents (67% of those invited to respond), the responses of 388 certified and 94 trained but not board-certified pulmonologists were included in the results. The characteristics of certified and non-certified respondents were the same for most survey questions. Clinical activities occupy 73 +/- 29% of professional time. Most pulmonologists work in urban, inner city, or suburban settings and 85% are affiliated with a medical school. One third are in private practice. As a group, research activities occupy less than 15% of their time. Most pediatric pulmonologists maintain a referral practice and use physician extenders to provide care. Patients with asthma and cystic fibrosis comprise 60-70% of patient volume. Both the volume and complexity of patients are increasing, as is competition for pediatric sub-specialty services. Pediatric pulmonary practices vary in size and in volume of patients that they manage in various settings. Forty percent of respondents identify allergists and other pediatric pulmonologists as sources of competition. Sixty-nine percent of respondents do not believe that there is a current need for additional pediatric pulmonologists in their respective communities. Only 15% of respondents plan to retire in the next decade.
The objective of this study was to characterize current practice patterns for clinical exercise stress testing (EST) in children in the United States. We conducted a survey of 109 pediatric cardiology programs and 91 pediatric pulmonology programs at children's hospitals or university hospitals in the United States. A total of 115 programs from 88 hospitals responded (response rate, 58%). A higher percentage of cardiology programs (98.7%) have exercise laboratories compared with pulmonology programs (77.5%). Sixty-three percent of respondents have both a treadmill and a cycle ergometer. A larger proportion of respondents (76%) rely primarily or exclusively on treadmill, whereas a smaller number use cycle ergometer (24%). Sixty-seven percent of respondents reported that they include metabolic measurements in EST protocols. Respondents have varying minimum age criteria for EST, with 9% reporting < or = 4 years, 25% reporting 5 years, 31% reporting 6 years, 16% reporting 7 years, and 20% reporting > or =8 years. Programs using cycle ergometers tend to test children at a younger age and to measure metabolic parameters. Seventy-nine percent of respondents use Bruce and modified Bruce protocols. Institutional protocols are used by 14%. Ninety percent of respondents use technicians to perform EST and 8% use nurses, but 76% require physician presence during testing. The majority of respondents (57%) perform < 100 pediatric tests per year. There are wide variations in the current practice of EST among pediatric subspecialty programs in the United States. Treadmills are used more frequently than cycle ergometers, and Bruce and modified Bruce protocols are commonly used. Most survey respondents measure metabolic parameters during EST.
OBJECTIVES: To analyze the rate of inappropriate admissions to a pulmonology department over the period of a year and to establish the reasons for such admission and predictors. PATIENTS AND METHODS: All 2004 admissions to the pulmonology department of the Hospital de Valme were analyzed using a version of the Appropriateness Evaluation Protocol (AEP) developed for concurrent review. Two physicians who were not directly involved in admitting the patients performed the review. A logistic regression analysis was performed in order to identify the independent predictors of inappropriate hospital admission. RESULTS: Of the 633 admissions analyzed, 92.1% (n = 583) were appropriate and 7.9% (n = 50) were inappropriate. The main reason for considering an admission to be inappropriate was that the patients in question could have been managed as outpatients (70%), whereas appropriate admissions were most frequently justified by the need for parenteral treatment (76.3%) or respiratory therapy (62%). In the logistic regression analysis, the variables that were independently associated with inappropriate admission were nonurgent admission (odds ratio, 2.82; 95% confidence interval, 1.28-6.21; P = .01), and a neoplasia diagnosis as the reason for admission (odds ratio, 8.57; 95% confidence interval, 2.69-27.24; P < .0005). CONCLUSIONS: The rate of inappropriate hospital admissions was lower than that reported in other studies. Most inappropriate admissions were of patients who could have been managed as outpatients. An admission diagnosis of neoplasm and nonurgent admission were independent predictors of inappropriateness.
PURPOSE OF REVIEW: This paper reviews the recent literature on the management of malignant large airway obstruction using interventional pulmonology techniques. RECENT FINDINGS: A number of interventional techniques have been developed during the last 25 years. Recent papers expand on this work, reaffirming the utility of laser bronchoscopy; introducing newer, less expensive technologies with similar outcomes; and attesting to the benefit of airway stenting. Electrocautery is likely to replace laser as the preferred tool for coagulation of intrinsic airway tumors because it is readily available in most hospitals and is much less expensive to set up. Several large series have attested to the excellent results achieved with airway stents placed to relieve extrinsic large airway obstruction. Investigators are using new technologies in an attempt to predict the proper location of stent placement to achieve maximum palliation of symptoms. Published guidelines are available describing the application of interventional techniques. SUMMARY: A number of interventional pulmonology techniques are available to treat large airway obstruction from malignant tumor. Clinical studies and personal experience attest to their utility. More evidenced-based studies are needed to help determine the best technique for a particular type of obstruction.
The organization of medicine in Europe, the UK and the Commonwealth countries was always much less formal than in the USA for many years and pediatricians interested in pediatric lung disease and asthma often started off as adult internists or specialists in adult pulmonary medicine. The early leaders in developing a special interest in the breathing of children during the 1940s and 1950s were predominantly physiologists and clinicians who began to apply physiological techniques to the study lung function in healthy and sick infants and children. A major contribution to our understanding of the epidemiology of wheezing in children was the early establishment of a cohort study in Australia which is still yielding important information. It was during the early 1970s that pediatric pulmonary "politics" began to emerge in the UK when pediatricians interested in lung diseases began to arrange an informal society and meet regularly under the auspices of the British Paediatric Association. In fairly characteristic fashion, pulmonology in Europe was represented for a while by several different societies but due to the efforts of some dedicated enthusiasts there finally emerged the Paediatric Assembly of the European Respiratory Society (ERS) and its first Head, Max Zach, went to become President of the ERS itself. Despite some early doubts abut the future for pediatric pulmonology as a specialty in Europe and Australasia it is clearly flourishing as shown by the rising membership of the professional societies and the constant stream of high quality basic science and clinical publications.
At present, pulmonological units admit patients with pulmonary tuberculosis forms that are epidemiologically hazardous, such as disseminated caseous and fibrocavernous pneumonia. The forms are characterized by abundant bacterial isolation and multiple bilateral lung tissue destruction. The causes of death in new cases of tuberculosis were their late referral for medical aid in the period of drastic deterioration of their health due to progression. Nineteen (63.3%) patients were found to have a gradual onset detected while thoroughly obtaining history data. Salivary MT tests were performed only in 50% of the patients admitted to pulmonological units, which makes an error diagnosis of acute pneumonia and unjustifiable treatment with broad-spectrum antibiotics.
An account is given of the work done by scientists and practical workers in establishing and putting into operation an interregional research and practical complex of phthisio-pulmonology on the basis of three regional antituberculosis services of North-Western region of the Russian Federation (Novgorod, Pskov and Leningrad regions) and Leningrad Research Institute of Phthisio-pulmonology on the basis of economic mechanism of their interrelationships.
This review describe the current state of knowledge and the clinical application of immunomodulating drugs in pediatric pulmonology. Some of those drugs are able to stimulate the macrophages, even in an aspecific way, via the gut associated lymphatic tissue (GALT), that is in connection with the bronchial associated lymphatic tissue (BALT). The most important field of application of the immunomodulating drugs in pediatric pulmonology is the child with recurrent upper respiratory tract.
Analysis of clinical forms of tuberculosis in patients of a pulmonological showed that 65.5% of them had infiltrative tuberculosis, 13.8% fibrocavernous tuberculosis, 10.4% disseminated tuberculosis, 6.9% focal tuberculosis, and 1.7% tuberculoma. It was ascertained that in these patients destructive tuberculous changes were common and occurred in 67.2% and tuberculosis was concurrent with other lung diseases in 70.7%. This follows that special attention should be given to the patients of pulmonological hospitals and sputum tests for mycobacteria are to be performed 3 times.
In 2003 and 2004 the Swiss Paediatric Pulmonology Group (SAPP) revised the recommendations for the management of obstructive airways disease in infancy and childhood (Paediatrica 2004;15:13-28) and published recommendations for the management of acute bronchiolitis in infancy (Paediatrica 2003;14:18-21). The concept underlying these new guidelines is the fact that childhood wheezing illness encompasses a range of disorders or phenotypes with a similar clinical manifestation (wheeze, cough and breathlessness) but varying pathology, aetiology, prognosis and response to treatment. Based on the available scientific evidence, phenotype-specific and age-dependent management of wheezing illness is advocated in the revised guidelines. Major changes compared to earlier recommendations include a stepwise approach to management depending on age, phenotype and severity of disease and use of beta 2-agonists purely on an on-demand basis. Comparison of these recommendations with epidemiological data on current treatment practice of obstructive airways disease in Swiss children suggests that many children with bronchiolitis and mild viral wheeze might be overtreated while management of children with severe persistent symptoms could be improved.
We retrospectively analysed adverse drug reactions (ADRs) associated with antibiotic therapy and reported over a 6-year period, from January 1995 to December 2000, in clinical notes of two Pulmonology Units of "Mater Domini" University Hospital and "Pugliese-Ciaccio" Hospital, both located in Catanzaro, Italy. Antibiotics were responsible for 92 (44.9%) out of 205 episodes of ADRs. In particular, 22 episodes (23.9%) were observed after penicillin G administration, 19 episodes (20.7%) following ceftazidime and cefotaxime administration, 16 episodes (17.4%) after therapy with ampicillin, and 35 reactions (38%) were further reported during treatments with other antibiotics. We determined that the drug-ADR relationship was certain in 63% of the reports; withdrawal of the suspected drug led to recovery in 95% of cases. In conclusion, this retrospective evaluation demonstrated that antibiotics are a common cause of ADRs in hospitalised patients and, therefore, drug surveillance can successfully identify targeted adverse events.
OBJECTIVE: The usefulness of the recently published guidelines of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) on the diagnosis and treatment of chronic cough has not yet been demonstrated. The objectives of the present study were a) to evaluate the usefulness of the SEPAR guidelines for identifying the possible causes of chronic cough, and b) to determine the most frequent causes of chronic cough treated by primary care physicians. METHODS: We carried out a prospective descriptive study that included 57 consecutive patients (mean age, 62 years) seeking medical attention for chronic cough in a primary health care area. The patients were evaluated using the algorithm proposed in the SEPAR guidelines, whereby the diagnostic procedure is divided into 3 phases in function of complexity. Phase I was carried out at the primary care level, and phases II and III at a hospital pneumology department. RESULTS: For 56 patients (98%), the potential cause of cough was identified: for 52 (91%) in phase I; for 3 (5%), in phase II; and for 1 (2%), in phase III. In 30 patients (53%), a single cause was identified; in 20 (36%), 2 causes; and in 6 (11%), more than 2 causes. Considered individually, the most common causes were postnasal drip in 26 cases (46%), the use of cough-inducing drugs (10 of them attributable to angiotensin-converting enzyme inhibitors) in 16 (28%), asthma in 15 (27%), infection in 13 (23%), gastroesophageal reflux in 12 (21%), and others in 9 (16%). CONCLUSIONS: The application of the SEPAR guidelines on chronic cough is useful for the identification of its causes. The use of angiotensin-converting enzyme inhibitors is a frequent cause of coughs diagnosed at the level of primary outpatient health care.
OBJECTIVE: Although the presence of hyperventilation syndrome can affect the symptoms of patients with asthma, there is very little information available regarding its frequency in Spain. The aim of this study was to investigate the prevalence of hyperventilation syndrome in the asthmatic population treated as outpatients and establish its relationship with anxiety disorders. PATIENTS AND METHOD: We studied 157 consecutive asthmatic patients (61 men and 96 women; mean [SD] age, 45 [17] years; forced expiratory volume in the first second, 84% [21%] of the predicted value) treated in our outpatients clinic. The patients had stable disease with varying degrees of severity. After collecting demographic data and medical histories, we asked the patients to complete the Spanish versions of the Anxiety Sensitivity Index, the Asthma Symptom Checklist, and the Nijmegen questionnaire; in the latter test, a score of 23 or over was considered diagnostic for hyperventilation syndrome. Finally, patients were evaluated to determine whether they had suffered from panic disorder in the last 6 months (according to the criteria of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders). RESULTS: Hyperventilation syndrome was present in 57 asthmatic patients (36%) and panic disorder in 4 patients (2%). The majority of patients with hyperventilation syndrome were women (78% vs 51%; P=.001) and were older (49 vs 42; P=.01); they displayed more basal dyspnea (1.26 vs 0.89 on the Medical Research Council scale; P=.01), greater sensitivity to anxiety (P=.001), and went to the emergency room more often for exacerbations (P=.002). Patients with hyperventilation syndrome scored significantly higher on all subscales of the Asthma Symptoms Checklist. Finally, the variables introduced in the regression analysis (stepwise) to explain the score on the Nijmegen questionnaire (r(2)=0.57) were basal dyspnea and sensitivity to anxiety. CONCLUSIONS: Approximately one third of the asthmatic patients treated in a pulmonology clinic also present hyperventilation syndrome. This cannot be explained by comorbidity of asthma with panic disorder, and is only partly linked to the symptoms associated with hyperventilation that appear during an asthma attack.