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2.
Respirology ; 21(1): 128-36, 2016 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-26603971

RESUMEN

BACKGROUND AND OBJECTIVE: Patients with chronic obstructive pulmonary disease (COPD) experiencing acute exacerbation (AE-COPD) with decompensated respiratory acidosis are known to have poor outcomes in terms of recurrent respiratory failure and death. However, the outcomes of AE-COPD patients with compensated respiratory acidosis are not known. METHODS: We performed a 1-year prospective, single-centre, cohort study in patients surviving the index admission for AE-COPD to compare baseline factors between groups with normocapnia, compensated respiratory acidosis and decompensated respiratory acidosis. Survival analysis was done to examine time to readmissions, life-threatening events and death. RESULTS: A total of 250 patients fulfilling the inclusion and exclusion criteria were recruited and 245 patients were analysed. Compared with normocapnia, both compensated and decompensated respiratory acidosis are associated with lower FEV1 % (P < 0.001), higher GOLD stage (P = 0.003, <0.001) and higher BODE index (P = 0.038, 0.001) and a shorter time to life-threatening events (P < 0.001). Comparing compensated and decompensated respiratory acidosis, there was no difference in FEV1 (% predicted) (P = 0.15), GOLD stage (P = 0.091), BODE index (P = 0.158) or time to life-threatening events (P = 0.301). High PaCO2 level (P = 0.002) and previous use of non-invasive ventilation (NIV) in acute setting (P < 0.001) are predictive factors of future life-threatening events by multivariate analysis. CONCLUSIONS: Compared with normocapnia, both compensated and decompensated respiratory acidosis are associated with poorer lung function and higher risk of future life-threatening events. High PaCO2 level and past history of NIV use in acute settings were predictive factors for future life-threatening events. Compensated respiratory acidosis warrants special attention and optimization of medical therapy as it poses risk of life-threatening events.


Asunto(s)
Acidosis Respiratoria , Hospitalización/estadística & datos numéricos , Enfermedad Pulmonar Obstructiva Crónica , Insuficiencia Respiratoria , Acidosis Respiratoria/sangre , Acidosis Respiratoria/diagnóstico , Acidosis Respiratoria/fisiopatología , Anciano , Anciano de 80 o más Años , Análisis de los Gases de la Sangre/métodos , Estudios de Cohortes , Femenino , Hong Kong/epidemiología , Humanos , Masculino , Ventilación no Invasiva/métodos , Ventilación no Invasiva/estadística & datos numéricos , Proyectos Piloto , Pronóstico , Estudios Prospectivos , Enfermedad Pulmonar Obstructiva Crónica/sangre , Enfermedad Pulmonar Obstructiva Crónica/epidemiología , Enfermedad Pulmonar Obstructiva Crónica/fisiopatología , Pruebas de Función Respiratoria/métodos , Insuficiencia Respiratoria/sangre , Insuficiencia Respiratoria/diagnóstico , Insuficiencia Respiratoria/fisiopatología , Medición de Riesgo , Análisis de Supervivencia , Brote de los Síntomas
3.
Respirology ; 18(5): 814-9, 2013 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-23490403

RESUMEN

BACKGROUND AND OBJECTIVE: Patients with chronic obstructive pulmonary disease (COPD) presenting with acute hypercapnic respiratory failure (AHcRF) benefit from non-invasive ventilation (NIV). The best way to withdraw NIV is not known, and we conducted a pilot study comparing stepwise versus immediate withdrawal of NIV in these patients. METHODS: This was a prospective, single-centre, open-labelled randomized study comparing stepwise versus immediate withdrawal of NIV in patients with COPD exacerbation recovering from AHcRF. The primary end-point was the success rate of NIV withdrawal, defined as no restarting of NIV from randomization to 48 h after complete withdrawal of NIV. RESULTS: Sixty patients were randomized, 35 patients to stepwise withdrawal and 25 patients to immediate withdrawal. The two study arms were clinically comparable. There was no statistically significant difference in the success rate, with NIV successfully stopped in 74.3% and 56% in the stepwise and immediate withdrawal groups, respectively (P = 0.139). CONCLUSIONS: We could not show any benefits for either strategy to withdraw NIV. The study may have been underpowered to detect differences, and larger prospective studies are required.


Asunto(s)
Ventilación no Invasiva/métodos , Enfermedad Pulmonar Obstructiva Crónica/complicaciones , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/terapia , Privación de Tratamiento , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Determinación de Punto Final , Femenino , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Proyectos Piloto , Estudios Prospectivos , Recurrencia , Factores de Tiempo
4.
Respirology ; 17(4): 735-6, 2012 May.
Artículo en Inglés | MEDLINE | ID: mdl-22420583

RESUMEN

Home non-invasive ventilation (NIV) is being increasingly employed to treat chronic hypercapnic respiratory failure. However, there is little data on compliance with home NIV. Sixty-five patients, aged 72.6 ± 9.4 years, who were using home NIV were administered a questionnaire on symptomatology and adverse effects associated with home NIV. Mean daily use of home NIV was 7.3 ± 2.9 h/day, and the median percentage of days on which home NIV was used for ≥4 h/day was 96.7%.


Asunto(s)
Cooperación del Paciente/estadística & datos numéricos , Respiración con Presión Positiva/estadística & datos numéricos , Enfermedad Pulmonar Obstructiva Crónica/terapia , Apnea Obstructiva del Sueño/terapia , Anciano , Anciano de 80 o más Años , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad
5.
Hong Kong Med J ; 13(3): 178-86, 2007 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-17548905

RESUMEN

OBJECTIVES: To describe the microbiological characteristics of a cohort of patients with complicated parapneumonic effusion and empyema thoracis, and to identify the potential risk factors for adverse outcomes, with particular reference to the choice of empirical antibiotics, intrapleural fibrinolytics, adherence to management guidelines, and input from pulmonologists. DESIGN: Retrospective review. SETTING: Regional hospital, Hong Kong. PATIENTS: All patients with a diagnosis of complicated parapneumonic effusion/empyema thoracis admitted between January 2003 and June 2005. MAIN OUTCOME MEASURES: Microbiological characteristics, mortality, and surgery-free survival. RESULTS. There were 63 patients, with a mean age of 64 (standard deviation, 16) years and a male-to-female ratio of 45:18. The pleural fluid culture positivity rate was 68%; Streptococcus milleri (19%), Bacteroides (14%), Klebsiella pneumoniae (12%), and Peptostreptococcus (7%) were the most common organisms. Thirteen (21%) patients died during their index admission. Use of intrapleural fibrinolytics according to the guideline was associated with survival (P=0.001) while discordant initial antibiotic use was associated with mortality (P=0.002). Discordant initial antibiotic use was also independently associated with reduced surgery-free survival (P<0.001). Subgroup analysis showed that early intrapleural fibrinolytic use (within 4 days of diagnosis) was associated with decreased mortality (P<0.001), increased surgery-free survival (P=0.005), and shorter hospital stay (P=0.039). CONCLUSION: Organisms identified from complicated parapneumonic effusion and empyema thoracis differ from those giving rise to community-acquired pneumonia. In these patients, adherence to guidelines, early concordant antibiotic treatment, intrapleural fibrinolytics, and input from a pulmonologist were associated with improved outcomes.


Asunto(s)
Empiema Pleural/tratamiento farmacológico , Empiema Pleural/microbiología , Derrame Pleural/tratamiento farmacológico , Derrame Pleural/microbiología , Neumonía Bacteriana/tratamiento farmacológico , Adulto , Anciano , Antibacterianos/farmacología , Antibacterianos/uso terapéutico , Bacteroides/efectos de los fármacos , Bacteroides/aislamiento & purificación , Revisión de la Utilización de Medicamentos , Empiema Pleural/complicaciones , Empiema Pleural/mortalidad , Femenino , Fibrinolíticos/farmacología , Fibrinolíticos/uso terapéutico , Adhesión a Directriz , Hong Kong , Mortalidad Hospitalaria , Humanos , Klebsiella pneumoniae/efectos de los fármacos , Klebsiella pneumoniae/aislamiento & purificación , Masculino , Persona de Mediana Edad , Peptostreptococcus/efectos de los fármacos , Peptostreptococcus/aislamiento & purificación , Derrame Pleural/complicaciones , Derrame Pleural/mortalidad , Neumonía Bacteriana/complicaciones , Neumonía Bacteriana/mortalidad , Estudios Retrospectivos , Factores de Riesgo , Streptococcus milleri (Grupo)/efectos de los fármacos , Streptococcus milleri (Grupo)/aislamiento & purificación , Análisis de Supervivencia , Resultado del Tratamiento
7.
CMAJ ; 171(11): 1349-52, 2004 Nov 23.
Artículo en Inglés | MEDLINE | ID: mdl-15557587

RESUMEN

BACKGROUND: Severe acute respiratory syndrome (SARS) is caused by a novel coronavirus. It may progress to respiratory failure, and a significant proportion of patients die. Preliminary data suggest that a high viral load of the SARS coronavirus is associated with adverse outcomes in the intensive care unit, but the relation of viral load to survival is unclear. METHODS: We prospectively studied an inception cohort of 133 patients with virologically confirmed SARS who were admitted to 2 general acute care hospitals in Hong Kong from Mar. 24 to May 4, 2003. The patients were followed until death or for a minimum of 90 days. We used Cox proportional hazard modelling to analyze potential predictors of survival recorded at the time of presentation, including viral load from nasopharyngeal specimens (measured by quantitative reverse transcriptase polymerase chain reaction [PCR] of the SARS-associated coronavirus). RESULTS: Thirty-two patients (24.1%) met the criteria for acute respiratory distress syndrome, and 24 patients (18.0%) died. The following baseline factors were independently associated with worse survival: older age (61-80 years) (adjusted hazard ratio [HR] 5.24, 95% confidence interval [CI] 2.03-13.53), presence of an active comorbid condition (adjusted HR 3.36, 95% CI 1.44-7.82) and higher initial viral load of SARS coronavirus, according to quantitative PCR of nasopharyngeal specimens (adjusted HR 1.21 per log10 increase in number of RNA copies per millilitre, 95% CI 1.06-1.39). INTERPRETATION: We found preliminary evidence that higher initial viral load is independently associated with worse prognosis in SARS. Mortality data for patients with SARS should be interpreted in light of age, comorbidity and viral load. These considerations will be important in future studies of SARS.


Asunto(s)
Síndrome Respiratorio Agudo Grave/mortalidad , Síndrome Respiratorio Agudo Grave/virología , Coronavirus Relacionado al Síndrome Respiratorio Agudo Severo/aislamiento & purificación , Carga Viral , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Comorbilidad , Femenino , Hong Kong/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Nasofaringe/virología , Modelos de Riesgos Proporcionales , Estudios Prospectivos , ARN Viral/análisis , Síndrome Respiratorio Agudo Grave/sangre , Análisis de Supervivencia
8.
Crit Care Med ; 32(2): 372-7, 2004 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-14758150

RESUMEN

OBJECTIVE: To determine the long-term outcome of noninvasive ventilation in chronic obstructive pulmonary disease patients who refused intubation for acute hypercapnic respiratory failure. DESIGN: Prospective, observational study. SETTING: Noninvasive ventilation unit in an acute regional hospital in Hong Kong. METHODS: The study recruited 37 chronic obstructive pulmonary disease patients who had the do-not-intubate code and developed acute hypercapnic respiratory failure. They were offered noninvasive ventilation, and their long-term outcomes were followed. Survival and event-free survival (an event is death or recurrent acute hypercapnic respiratory failure) were analyzed by survival analysis. Their disease profile and outcome were compared with another 43 chronic obstructive pulmonary disease patients without the do-not-intubate codes, who had acute hypercapnic respiratory failure and received noninvasive ventilation during the study period (usual care group). RESULTS: Patients in the do-not-intubate group were significantly older (p =.029), had worse dyspnea score (p <.001), worse Katz Activities of Daily Living score (p <.001), worse comorbidity score (p =.024), worse Acute Physiology and Chronic Health Evaluation II score (p =.032), lower hemoglobin (p =.001), and longer stay in the hospital during the past year (p =.001) than patients who received usual care. In the do-not-intubate group, the median survival was 179 days, and 1-yr actuarial survival was 29.7%; in the usual care group, the median survival was not reached during follow-up, and 1-yr actuarial survival was 65.1% (p <.0001). In the do-not-intubate group, the median event-free survival was 102 days, and 1-yr event-free survival was 16.2%; in the usual care group, median event-free survival was 292 days, and 1-yr event-free survival was 46.5% (p =.0004). CONCLUSIONS: A 1-yr survival of about 30% was recorded in chronic obstructive pulmonary disease patients with the do-not-intubate code who developed acute hypercapnic respiratory failure requiring noninvasive ventilation. The majority of survivors developed another life-threatening event in the following year. Information generated from this study is important to physicians and chronic obstructive pulmonary disease patients when they are considering using noninvasive ventilation as a last resort.


Asunto(s)
Hipercapnia/complicaciones , Hipercapnia/terapia , Enfermedad Pulmonar Obstructiva Crónica/complicaciones , Respiración Artificial , Negativa del Paciente al Tratamiento , Enfermedad Aguda , Anciano , Femenino , Humanos , Hipercapnia/mortalidad , Masculino , Estudios Prospectivos , Enfermedad Pulmonar Obstructiva Crónica/mortalidad , Recurrencia , Factores de Tiempo
9.
J Clin Microbiol ; 42(2): 665-9, 2004 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-14766834

RESUMEN

Old tuberculosis and bronchiectasis are the two most important causes of chronic structural changes of lungs in our locality. In the absence of radiologically visible mycetoma, the cause of hemoptysis in these two groups of patients is largely unknown. A 17-month prospective study was carried out to compare the prevalence of Aspergillus fumigatus and Aspergillus flavus antibodies in hemoptysis patients with old tuberculosis or bronchiectasis but no radiologically visible mycetoma (cases, n = 38), hemoptysis patients with other diagnosis (control group 1, n = 29), and patients with old tuberculosis or bronchiectasis but no hemoptysis (control group 2, n = 47) by a recently developed sensitive and specific A. fumigatus and A. flavus antibody assay. There were a significantly larger number of patients with antibody against A. fumigatus or A. flavus among the cases than among the patients in control groups 1 and 2 (P < 0.05 in both comparisons). Molds were not recovered from any of the patients. Among the 10 cases with Aspergillus antibody, eight and two had antibody against A. flavus and A. fumigatus, respectively. We conclude that there was an association between the presence of Aspergillus antibodies and hemoptysis in patients with old tuberculosis or bronchiectasis, suggesting that these patients probably had occult infections caused by the corresponding fungi. Development of serological tests against other Aspergillus species as well as other causes of mycetoma will probably increase the detection of occult mold infections in patients with existing parenchymal lung diseases, and treatment of fungal microinvasion may help to alleviate hemoptysis in these patients with bronchiectasis or old tuberculosis who have Aspergillus antibodies.


Asunto(s)
Anticuerpos Antibacterianos/sangre , Aspergilosis/diagnóstico , Aspergillus/inmunología , Hemoptisis/etiología , Anciano , Aspergilosis/complicaciones , Aspergillus/aislamiento & purificación , Aspergillus flavus/aislamiento & purificación , Aspergillus fumigatus/aislamiento & purificación , Bronquiectasia/complicaciones , Carcinoma Broncogénico/diagnóstico , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Tuberculosis/complicaciones
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