Dijagnostička vrijednost ultrazvučnoga pregleda prsnoga koša u razlikovanju pleuralnih izljeva maligne i nemaligne etiologije [Diagnostic validity of thoracic ultrasound in distinguishing malignant and nonmalignant pleural effusions]

Thoracic ultrasound is a diagnostic procedure that may help in the prediction of the pleural effusion etiology. Analyzing the ultrasound characteristics of pleural effusion, visceral and parietal pleura, the best predicting parameters for malignant pleural effusion (MPI) were pleural nodularity (sensitivity of 76,19 %, specificity of 71,43 %, accuracy of 73,81 %). Using various combinations of ultrasound and macroscopic characteristics of typical MPI (nodular pleura together with hemorrhagic/sanguinolent effusion; nodular pleura together with the fibrin absence in pleural effusion; pleural thickness over 10 mm together with hemorrhagic/sanguinolent effusion) finding accuracy in prediction of MPI increased up to 82,50 %. Using integrated statistical analyses of ultrasound, macroscopic and biochemical parameters (logistic regression), the three parameters were obtained (pleural nodularity, fibrin absence, serum proteins) which were the best predictors for MPI (sensitivity of 81,58 %, specificity of 76,09 %, accuracy of 89,64 %). The best single predicting parameter for non-malignant pleural effusion (NMPI) was the fibrinous remodeling (sensitivity of 45,24 %, specificity of 90,48 %, accuracy of 67,86 %). Using various combinations of ultrasound and macroscopic characteristics of typical NMPI (clear/serous pleural effusion together with fibrinous remodeling; pleural effusion fibrinous remodeling together with absent pleural nodularity; pleural effusion fibrinous remodeling together with pleural thickness less than 10 mm), finding accuracy in prediction of NMPI increased up to 88,24 %. Based on these findings, together with results of previous studies, a simple diagnostic algorithm for lymphocytic pleural effusions was proposed

Acute Asthma Management in Emergency Room

Egzacerbaciju astme karakterizira pogoršanje osnovnih simptoma bolesti – zaduhe, kašlja, piskanja i/ili pritiska u prsima, koji se javljaju kao posljedica progresivne bronhoopstrukcije i otežanog ekspirija. Dok se blage egzacerbacije uglavnom uspješno liječe ambulantno u okviru primarne zdravstvene zaštite, one umjerene i teške zahtijevaju liječenje u bolničkoj hitnoj službi, a nerijetko i hospitalizaciju. Pristup bolesniku s astmom u hitnoj službi uključuje brzu procjenu težine egzacerbacije na temelju fizikalnog nalaza, parametara plućne funkcije (saturacija krvi kisikom, plinska analiza arterijske krvi) i težine opstruktivnih smetnja disanja (inicijalno i kontrolno mjerenje PEF ili FEV1). Liječenje akutnog napadaja astme temelji se na ponavljanoj primjeni inhalacijskih bronhodilatatora brzog djelovanja, ranom uvođenju sustavnih glukokortikoida i adekvatnoj oksigenoterapiji. Cilj zbrinjavanja u hitnoj službi jest razriješiti ili barem ublažiti bronhoopstrukciju i korigirati hipoksemiju što je prije moguće, kao i na vrijeme prepoznati refraktorne slučajeve koji zahtijevaju hospitalizaciju ili čak prijam u jedinicu intenzivnog liječenja.Asthma exacerbation is characterised by worsening of asthma symptoms, i.e. dyspnoea, cough, wheezing and/or chest tightness, which result from a progressive airway obstruction and expiratory airflow limitation. While mild exacerbations are usually successfully treated in outpatient settings, moderate and severe exacerbations require management in the emergency department, sometimes with subsequent hospital admission. The approach to the asthma patient in the emergency room includes rapid assessment of exacerbation severity based on physical findings, pulmonary function parameters (oxygen saturation, arterial blood gases analysis) and severity of airflow limitation (initial and repeated measurement of PEF or FEV1). The treatment of acute asthma includes the repeated administration of rapid-acting inhaled bronchodilators, the early administration of systemic glucocorticoids, and oxygen supplementation. The aim of the emergency management is to resolve or at least alleviate airflow obstruction and hypoxemia as quickly as possible, and to recognise without delay refractory cases requiring hospital admission or even intensive care unit treatment

Mistakes in Asthma Diagnosis – A Differential Diagnostic Trap or an Inadequate Diagnostic Procedure?

Dijagnoza astme temelji se na detaljnoj anamnezi, fizikalnom pregledu prsnog koša te rezultatima testova plućne funkcije i procjene alergijskog statusa. Najčešće diferencijalnodijagnostičke nedoumice uzrokuju bolesti prezentirane sličnim kliničkim obilježjima: kronična opstruktivna plućna bolest, bolesti gornjih dišnih putova, gastroezofagealna refluksna bolest, disfunkcija glasnica, lokalizirana opstrukcija velikih dišnih putova te brojni drugi rijetki poremećaji. Treba istaknuti da se u većini slučajeva diferencijalnodijagnostičke dvojbe mogu razriješiti pridržavanjem standardnih dijagnostičkih postupaka preporučenih u smjernicama za zbrinjavanje astme. Nepridržavanje naputaka smjernica, tj. dijagnosticiranje astme isključivo na temelju kliničkog dojma može rezultirati pogrešnom dijagnozom i nepotrebnim prolongiranim propisivanjem diferentne terapije.Asthma diagnosis is based on a detailed medical history, physical examination of the chest, lung function tests and allergic status assessment. The diseases with similar clinical features, i.e. chronic obstructive pulmonary disease, upper airways diseases, gastroesophageal reflux disease, vocal cord dysfunction, localized obstruction of airways and other numerous rare disorders are the most common differential diagnostic traps. One should note that these ambiguities may be solved in the majority of cases by complying with diagnostic standards given in asthma management guidelines. The noncompliance with these guidelines, i.e. asthma diagnosis made exclusively on the basis of a clinical impression, may lead to a wrong diagnosis and unnecessarily long administration of a differential therapy

Churg-Straussov sindrom sa zahvaćenim mioperikardom

Churg-Strauss syndrome (CSS) is a small-vessel necrotizing vasculitis typically characterized by asthma, lung infiltrates, extravascular necrotizing granulomas and hypereosinophilia. Cardiac disease is a major contributor to disease-related death in CSS. We describe a 38-year- old man with late-onset asthma, allergic rhinosinusitis, and high extravascular and peripheral blood eosinophilia, who presented with migratory pulmonary infiltrates and acute myopericarditis. Antineutrophilic cytoplasmic antibodies (ANCA) were negative. Early therapy with medium-dose methylprednisolone led to resolution of the pericardial effusion and significant clinical improvement. In the present case report, the importance of early recognition of CSS in patients with asthma and peripheral eosinophilia is discussed. Cardiac magnetic resonance imaging, besides electro- and echocardiography, may be helpful in early detection of cardiac involvement in CSS, enabling appropriate treatment aimed to prevent further disease progression and potentially fatal consequences.Churg-Straussov sindrom (CSS) je nekrotizirajući vaskulitis malih krvnih žila koji je znakovito obilježen astmom, plućnim infiltracijama, ekstravaskularnim nekrotizirajućim granulomima i hipereozinofilijom. Srčana bolest je najvažniji uzrok smrti kod CSS. Opisuje se 38-godišnji muškarac s astmom kasnog nastupa, alergijskim rinosinusitisom i visokom ekstravaskularnom i perifernom eozinofilijom, koji se prezentira s migrirajućim plućnim infiltratima i akutnim mioperikarditisom. Antineutrofilna citoplazmatska antitijela (ANCA) bila su negativna. Rana terapija srednjom dozom metilprednizolona riješila je perikardijalni izljev i dovela do značajnog kliničkog poboljšanja. U ovom prikazu slučaja raspravlja se o važnosti ranog prepoznavanja CSS kod bolesnika s astmom i perifernom eozinofilijom. Uz elektro- i ehokardiografiju, magnetska rezonancija srca može pomoći u ranom otkrivanju zahvaćenosti srca kod CSS, te tako omogućiti primjereno liječenje kako bi se spriječilo napredovanje bolesti i moguće pogubne posljedice

SPONTANI PNEUMOMEDIJASTINUM NAKON SPIROMETRIJE U BOLESNIKA DVA MJESECA NAKON PREBOLJENJA PNEUMONIJE COVID-19

We present a case report of a middle-aged man who developed spontaneous pneumomediastinum and pneumothorax after performing spirometry. The patient was evaluated in post-COVID-19 outpatient hospital 70 days after his initial hospitalization for severe COVID-19 pneumonia. After performing forced expiratory maneuver on spirometry, high-resolution computed tomography (HRCT) showed a small right-sided pneumothorax and pneumomediastinum along the bronchi, large blood vessels, and cardiac contour with ‘ground-glass’ opacifications in all lung lobes. The patient was cardiopulmonary compensated and conservative treatment was recommended. The long-term consequences of COVID-19 pneumonia are still not suffi ciently known. Spontaneous pneumomediastinum can very rarely occur as a complication during regular investigation of lung function caused by forced expiratory maneuver on spirometry. Due to lung parenchymal damage, pneumomediastinum with or without pneumothorax in post-COVID-19 patients occurring after spirometry can be expected as a rare but possible complication.Spontani pneumomedijastinum (SPM) je rijetka komplikacija plućnih bolesti. U ovom prikazu bolesnika opisan je bolesnik koji je 70 dana nakon hospitalizacije zbog teške pneumonije COVID-19 nakon izvođenja spirometrije dobio spontani pneumomedijastinum i pneumotoraks. Na HRCT-u (CT toraksa visoke rezolucije) prsnog koša nakon spirometrije bio je vidljiv manji desnostrani pneumotoraks te pneumomedijastinum uz uzorak takozvanog \u27mliječnog stakla\u27 u svim plućnim režnjevima. Budući da je bolesnik bio kardiopulmonalno kompenziran, preporučen je konzervativni pristup i daljnje praćenje. Budući da su dugoročne posljedice pneumonije COVID-19 još uvijek nedovoljno poznate, učinci infekcije na respiracijski te druge organske sustave pratit će se u idućim godinama. SPM može nastati kao vrlo rijetka komplikacija redovnog ispitivanja plućne funkcije spirometrijom tijekom koje se provodi forsirani ekspirij. S obzirom na oštećenje plućnog parenhima uzrokovano pneumonijom COVID-19, Pneumomedijastinum se može očekivati kao moguća, iako rijetka komplikacija nakon provođenja spirometrije u razdoblju bolesti \u27post-COVID-19\u27

Is the Use of Long Acting Beta Agonists Justified in Asthma Patients?

Sigurnost primjene simpatomimetika dugog djelovanja (LABA) u bolesnika s astmom zasigurno je jedan od najčešće raspravljanih predmeta u farmakoterapiji ove bolesti tijekom posljednjih dvadesetak godina. Prisutni su stavovi u rasponu od mišljenja o njihovoj potpunoj sigurnosti do prijedloga da budu zabranjeni. Kao moguće posljedice primjene LABE zagovornici njihove štetnosti ističu toleranciju i smanjenu učinkovitost simpatomimetika kratkog djelovanja (SABA). To bi moglo rezultirati gubitkom kontrole astme, povećanom stopom egzacerbacija, a u konačnici i povećanim mortalitetom. Višestruke pažljive, nezavisne i nepristrane analize baza podataka dosadašnjih ispitivanja nisu potvrdile rizičnost propisivanja LABE kada se, sukladno preporukama smjernica, propisuje uz inhalacijske kortikosteroide (ICS). Konačan odgovor trebalo bi dati planirano prospektivno ispitivanje s ciljem usporedbe primjene kombinacije LABE i ICS-a u odnosu prema samom ICS-u. Neki autoriteti ističu da je ovakvo istraživanje neracionalno te da će s obzirom na potrebnu veličinu uzorka biti vrlo skupo, a da precizan odgovor možda neće bit moguć ni nakon njegova završetka. Bilo kako bilo, do objave rezultata tog ispitivanja vrijede višestruko provjereni naputci aktualnih smjernica. Oni dopuštaju propisivanje LABE u liječenju astme samo u kombinaciji s ICS- -om, i to u bolesnika u kojih kontrola astme nije postignuta niskim ili srednje visokim dozama ICS-a. Preporučuje se uporaba fiksnih kombinacija u istom raspršivaču što onemogućuju potencijalno rizično uzimanje same LABE.The safety of long acting beta agonists (LABAs) in asthma patients has been certainly one of the most discussed issues in the pharmacotherapy of this disease over the last twenty years. The opinions range from those favouring their full safety to those suggesting their ban. Those opposing their use claim that LABAs may reduce tolerance and efficiency of SABA. This could lead to the loss of asthma control, increased exacerbation rate, and finally, to increased mortality. Multiple, thorough, independent and unbiased analyses of data obtained by trials so far have not confirmed LABA related risks if used concomitantly with inhaled corticosteroids (ICS) in line with the relevant guidelines. A planned prospective trial, whose aim is to compare the co-administration of LABA and ICS with ICS administered as monotherapy, should give the final answer. Some authorities in this field claim that such a research would be irrational and very expensive due to the requisite sample size. Additionally, they claim that it may not be possible to give a precise answer even after its completion. In any case, the current guidelines, which have been verified on multiple occasions, are valid until the results of this trial become available. The current guidelines allow the administration of LABA in asthma patients in combination with ICS, however, only in those patients whose asthma cannot be controlled by low or moderately high doses of ICS. The use of fixed combinations in the same spray, which would prevent potential risks of LABA used in monotherapy, is therefore recommended

The Role of Anticholinergics in Asthma Treatment

Iako su antikolinergici prihvaćeni kao prva linija bronhodilatacijskog liječenja KOPB-a, mnogi ih liječnici tradicionalno propisuju i u astmatičara. Učinkovitost ipratropija u akutnoj i stabilnoj astmi etablirana je još prije dvadesetak godina, a nekoliko recentnih ispitivanja ističe terapijski potencijal tiotropija u liječenju ove bolesti. Antikolinergici su tradicionalno klasificirani kao brohodilatatori. Na temelju istraživanja “neživčanoga” kolinergičkog sustava dišnih putova očito je da barem neki od njih (tiotropij) uz poznati mehanički, bronhorelaksacijski učinak manifestiraju i nemehaničke, protuupalne i protuproliferativne, učinke. Ovi rezultati promiču tiotropij od pukog bronhodilatatora u preparat s potencijalnim protuupalnim djelovanjem koji bi mogao modificirati tijek astme i/ili KOPB-a. Za potvrdu ovog koncepta potrebni su dodatni klinički pokusi planirani na način da se izravno dokažu navedene postavke.Although anticholinergics have been accepted as first-line bronchodilators in COPD, many physicians also prescribe them to asthmatics. The efficacy of ipratropium in acute and stable asthma was established about twenty years ago, and some recent studies emphasize the therapeutic potential of tiotropium in asthma treatment. Traditionally, anticholinergics have been classified as bronchodilators. On the basis of the research of non-neuronal cholinergic respiratory system, it is obvious that at least some of them (tiotropium) exhibit non-mechanical, anti-inflammatory, and antiproliferative effects in addition to their known mechanical and bronchorelaxing effects. These results promote tiotropium from its position of a mere bronchodilator to that of a potential anti-inflammatory agent that could modify asthma and/or COPD course. Additional clinical trials should be conducted to confirm these hypotheses

Ultrasound of the Diaphragm and Its Application in the Clinical Practice

Ultrazvuk dijafragme dijagnostička je metoda kojom se može utvrditi dijafragmalna disfunkcija ili paraliza. Dijafragmalna disfunkcija može uzrokovati otežano disanje i intoleranciju napora. Rijetko se utvrđuje u kliničkoj praksi te prava incidencija nije poznata. Javlja se u nekih neuromišićnih bolesti poput multiple skleroze, amiotrofične lateralne skleroze, poliomijelitisa, lezije N. phrenicusa te u nekih bolesti vezivnog tkiva, plućnim bolestima ili idiopatski. Za razliku od ranije upotrebljavanih metoda procjene dijafragmalne funkcije poput elektromiografije, mjerenja transdijafragmalnog tlaka i fluoroskopije, ultrazvuk je neinvazivna i jednostavna pretraga koja ne izlaže bolesnike ionizirajućem zračenju. Cilj je ovog rada opisati pregled dijafragme ultrazvučnom metodom te primjenu ultrazvuka u kliničkoj praksi uz pregled literature.Ultrasound of the diaphragm is a diagnostic method that can determine diaphragmatic dysfunction or paralysis. Diaphragmatic dysfunction can cause dyspnea and exercise intolerance. It is rarely diagnosed in clinical practice and its true incidence is unknown. It can occur in some neuromuscular diseases such as multiple sclerosis, amyotrophic lateral sclerosis, poliomyelitis, phrenic nerve lesions, and in some connective tissue diseases, lung diseases or it can be idiopathic. Unlike previously used diagnostic methods for assessing diaphragmatic function such as electromyography, transdiaphragmatic pressure measurement and fluoroscopy, ultrasound is a fast, non-invasive and simple examination, which does not expose patients to ionizing radiation. The aim of this review is to describe the examination of the diaphragm using the ultrasound method and its application in clinical practice along with a literature review

INITIAL RESULTS OF DIAGNOSTIC APPLICATION OF ENDOBRONCHIAL ULTRASOUND IN CLINICAL HOSPITAL DUBRAVA

Endobronhalni ultrazvuk (engl. Endobronchial ultrasound – EBUS) omogućuje vizualizaciju medijastinalnih i hilusnih limfnih čvorova, a prema potrebi i njihovu punkciju (engl. Transbronchial Needle Aspiration – TBNA). Metodom doplera moguće je istodobno pregledati i krvne žile. Najčešće indikacije za ovu pretragu jesu povećanje medijastinalnih i/ili hilusnih limfnih čvorova nejasna uzroka te procjena proširenosti plućnoga nemikrocelularnog karcinoma (engl. Non-Small Cell Lung Cancer – NSCLC). U radu su prikazani prvi rezultati primjene ove dijagnostičke metode u Zavodu za pulmologiju Interne klinike Kliničke bolnice Dubrava. S obzirom na visoku osjetljivost i specifičnost te dobru podnošljivost, EBUS-TBNA pokazala se temeljnom pretragom u dijagnostici medijastinalne limfadenopatije.Endobronchial ultrasound (EBUS) enables visualization of mediastinal and hilar lymph nodes as well as, in case of clinical indication, its transbronchial needle aspiration (TBNA). Simultaneous application of color doppler gives the ­additional prospects to investigate the blood vessels. The primary indication for EBUS is radiographic finding of mediastinal and/or hilar lymph nodes enlargement as well as the staging of non-small cell lung cancer (NSCLC). In this article we present the initial results of application of this valuable diagnostic procedure performed at the Department for pulmonary diseases in Clinical hospital Dubrava in Zagreb. According to its high sensitivity and specificity, and being safe and well tolerated, EBUS-TBNA was positioned as basic diagnostic procedure in patients with mediastinal lymphadenopathy

Prvi rezultati dijagnostičke primjene endobronhalnog ultrazvuka u Kliničkoj bolnici Dubrava [Initial results of diagnostic application of endobronchial ultrasound in Clinical hospital Dubrava]

Endobronchial ultrasound (EBUS) enables visualization of mediastinal and hilar lymph nodes as well as, in case of clinical indication, its transbronchial needle aspiration (TBNA). Simultaneous application of color doppler gives the additional prospects to investigate the blood vessels. The primary indication for EBUS is radiographic finding of mediastinal and/or hilar lymph nodes enlargement as well as the staging of non-small cell lung cancer (NSCLC). In this article we present the initial results of application of this valuable diagnostic procedure performed at the Department for pulmonary diseases in Clinical hospital Dubrava in Zagreb. According to its high sensitivity and specificity, and being safe and well tolerated, EBUS-TBNA was positioned as basic diagnostic procedure in patients with mediastinal lymphadenopathy