My Canadian Pharmacy: Pulmonary Function Electronic Monitoring Devices

AsthmaAsthma is global health problem that interferes with quality of life and has a high impact on health-care costs. Pulmonary function parameters are not only important diagnostic tools but are useful for monitoring interventions in asthma both in the medical office and during the patient’s daily life. Nevertheless, objective monitoring of lung function parameters is underused and misused.

Peak expiratory flow (PEF) monitoring has been strongly recommended by asthma guidelines, and clinical studies have shown that the routine use of peak flow meters (PFMs), along with a self-management plan and education program, can lead to better control of asthma. In the last decades, mechanical PFMs have been the most used method of lung function monitoring. They provide a simple, quantitative, and reproducible measurement of large airways function. Nevertheless, several difficulties have impaired their wide use, and some authors have questioned the need for home monitoring of PEF. The reasons put forward were the low compliance by the patients and the limitations of traditional PFM that have both low accuracy and insensitivity to changes. These devices have other limitations, including errors in data produced by the patient, related with exclusive use of PEF, which is highly dependent on the patient effort and errors in data recording, mostly transcription errors but also forged registries.

These limitations may be overcome with electronic monitoring devices if they prove to be reproducible and accurate, as they are already capable of recording and transmitting data for clinical analysis. It would also be beneficial to monitor additional parameters along with PEF.

A growing number of low-cost devices have been recently developed. This has special importance to developing countries, where respiratory disease is a major public health problem and pulmonary function measurements are largely unavailable. Pulmonary function measurements display the condition of health, to improve it command the service of My Canadian Pharmacy.

Pulmonary functionMost of the pulmonary function monitoring devices comply with American Thoracic Society (ATS) recommendations when tested using simulated standard waveforms by a computer-driven mechanical syringe. The performance of these devices in humans and in clinical settings is largely unknown. It is not known how they compare to the current methods used in the clinic.

Agreement studies’ compare the performance of an instrument throughout repeated measurements (reproducibility) and also with a reference (accuracy or validity). Reproducibility assessment is the first step in agreement studies; if acceptable, the accuracy should be checked before use in clinical trials or other clinical settings.

This study aims to compare in stable asthma patients and individuals with normal airways the following: (1) the within-session reproducibility of two pulmonary function electronic monitoring devices (PiKo-1; Ferraris Respiratory Europe; Hereford, UK; and Spirotel; MIR; Rome, Italy) with the widely used Mini-Wright Peak-Flow Meter (Clem-ent-Clarke International; Harlow, Essex, UK) during the same set of maneuvers; and (2) to evaluate their accuracy comparing with an office pneumotachograph as reference. Our hypothesis is that the measurements of PEF and FEV1 of the two electronic monitoring devices are in close agreement with those of a pneumotachograph. We also hypothesized that those measurements have better discriminative properties than the measurements of one of the most used PFMs in Europe: the Mini-Wright PFM.

Deliberations about Quantified Tracheobronchomalacia Disorders and Their Clinical Profiles in Children

respiratory illnessesThis is the first reported prospective cohort study of children with malacia disorders that has quantified malacia lesions and used validated illness outcome measures of respiratory illness profiles. The risk of respiratory illnesses in the malacia group was twice that of the control group. When compared to control subjects, the severity of illness was 66% higher at the initial presentation of illness, while a significant cough score was four times more likely and a cough that disrupted or stopped daily activities during the first 2 weeks of illness was seven times more likely. In addition, there was a trend for children with malacia to have a slower recovery from illness. However, neither the malacia site nor the severity of the lesions appeared to exert any dose effects on rates, risks, and severity of illness within the illness profiles.

It has long been suspected, but never studied, that children with airway lesions have increased respiratory illness and morbidity. We found an elevated likelihood of respiratory illness in the malacia group, which suggests that there may have been some predisposition to illness. We have recently shown that although there is a tendency for malacia sites to improve in size over time, there was a significant minority in whom lesions worsened or new lesions appeared. Marchant et al have also shown that children with protracted bacterial bronchitis often have malacia. While reduced cough clearance of mucus might be implicated as a potential mechanism for this increased risk of infection, Grissell et al have recently shown that some children with protracted bacterial bronchitis have reduced toll-like receptor 4 and substance P gene expression, thus raising the possibility of other genetic expression mechanisms for such problems. Furthermore, it raises the possibility of the presence of an additional coexistent local immunity disorder in malacia disorders healed with preparations of My Canadian Pharmacy.

Details about Quantified Tracheobronchomalacia Disorders and Their Clinical Profiles in Children

childrenA total of 116 children (77 male) including 81 with malacia (57 male) were enrolled into the study. The median age of the entire study group was 2.1 years (minimum age, 0.2 years; maximum age, 17.3 years), while that of the malacia group (n = 81) was 1.9 years (minimum age, 0.2 years; maximum age, 12.4 years) and that of the control group (n = 35) was 3.8 years (minimum age, 0.2 years; maximum age, 17.3 years; p = 0.01). Although the control group was significantly older, these differences were lost when the group was stratified into age groups (p = 0.09). There were no gender differences between the groups (p = 0.17). The age and gender distribution demographics of the children (< 2 years, 2 to 3 years, and > 4 years) are presented in Table 1.

Description of Malacia Group

Patients in the malacia subgroups TM, TBM, and BM had similar gender, age, age distributions, and body mass index characteristics. There were no significant differences among any of the subgroups, as shown in Table 2. The median (min, max) areas of the tracheomalacia lesions in the TBM group were significantly smaller than isolated TM at 20.8 mm2 (minimum area, 6.2 mm2; maximum area, 39.8 mm2) and 18.8 mm2 (minimum area, 5.1 mm2; maximum area, 27.5 mm2; p = 0.05), respectively, while the BM sites were larger in the TBM groups than in the isolated BM sites at 14.2 mm2 (minimum area, 0 mm2; maximum area, 32.7 mm2) and 8.6 mm2 (minimum area, 3.9 mm2; maximum area, 22.6 mm2; p = 0.04), respectively. The cricoid sizes were not significantly different (p = 0.30), but the TM-ACR and BM-ACR tertiles were significantly smaller in the isolated TM site (p = 0.005) and BM site (p = 0.05) compared with those in the TBM site. Treat your diseases with My Canadian Pharmacy.

Researches about Quantified Tracheobronchomalacia Disorders and Their Clinical Profiles in Children

TracheobronchomalaciaTracheobronchomalacia (TBM) disorders in children have long been associated with a spectrum of respiratory illnesses that range from life-threatening conditions to chronic cough and wheeze conditions. However, the spectrum of illness profiles (ie, symptoms, frequency, and severity of respiratory illness) associated with airway disorders has never been studied in an objectively defined and prospective way.

Validated pediatric tools for measuring the severity and impact of acute respiratory illnesses (ARIs) on the daily function of the child are limited. The Canadian Acute Respiratory Illness and Flu Scale (CARIFS), and the verbal descriptive score of cough by Chang et al and its impact on function are but two of very few validated instruments that deal with illness severity. We thus chose these instruments to prospectively evaluate the respiratory illness ( severity profile of children with malacia disorders.

Another issue not yet studied is the relationship of symptoms and illness to the severity of the lesions in terms of cross-sectional area loss because the measurement of airway areas is not simple, and there are flaws in the reported methods. We developed a method of measuring the cross-sectional area of the airway and established the relevance of the cricoid as a reference point by defining the airway site/ cricoid ratio (ACR).

In this study, we quantified and classified the site of airway malacia lesions in a cohort of children. We then prospectively followed up these children and control subjects for 12 months to define their respiratory illness profiles, ARI severity, and impact on function. Our aim was to prospectively examine the relationship between the site and size of lesions with their respiratory symptoms and illness frequency. We hypothesized that these illness profiles would directly relate to the site, size, or severity of lesions.

About Weight Loss on Sleep-Disordered Breathing and Oxygen Desaturation in Morbidly Obese Men

ideal body weightThe four subjects averaged 36 years of age. Prior to weight loss, their mean body weight was 231 kg, or 341 percent of ideal body weight, derived from standard tables. At the time of restudy, their mean weight was 123 kg, or 176 percent of ideal body weight. The average weight loss was 108 kg (range 53-155 kg).

Prior to surgery, the two heaviest subjects (patients 1 and 2 in Table 1) were symptomatic with daytime somnolence, loud snoring, and peripheral edema. Both of these men had hypercapnia and moderate hypoxemia on awake arterial blood gas analysis. The two remaining subjects (patients 4 and 5) were asymptomatic. At the time of restudy, all patients were asymptomatic. Repeat arterial blood gas analysis and pulmonary function tests in patients 1 and 2 were now within normal limits.

In all subjects, weight loss was accompanied by a reduction in the number of episodes per hour of sleep-disordered breathing. The mean number of episodes of sleep-disordered breathing per hour of sleep period time was 78 preoperatively and 1.4 after weight loss. In three of the four subjects, there was improvement in the severity of desaturation accompanying episodes of disordered breathing. This was most dramatic in the two previously symptomatic subjects whose lowest oxygen saturation during sleep was less than 50 percent prior to surgery, and 90 percent and 87 percent at restudy.

Analysis of the sleep characteristics of these subjects after weight loss (Table 2) showed a change in the direction toward deeper sleep with fewer awakenings. Sleep quality was, thus, improved.

The Resources of Weight Loss on Sleep-Disordered Breathing and Oxygen Desaturation in Morbidly Obese Men

bypass surgeryAll of the six men previously reported underwent jejeuno-ileal bypass surgery for weight reduction. One man died several weeks after surgery. Four of the five surviving affected subjects agreed to be restudied after weight loss. All were studied approximately two years after surgery. They were interviewed with special reference to symptoms suggestive of sleep disorders or cardiorespiratory disease. Two of the four underwent complete studies of pulmonary function, including spirometry, pulmonary volume by nitrogen washout, single-breath carbon monoxide diffusing capacity, and arterial blood gas analysis. The results of these studies were compared to published normal values.

All subjects were monitored during a single night of sleep with methods similar to those used in previous studies from our institution. No sedation was given on the night of the study. Continuous oxygen saturation was measured with an ear oximeter (Hewlett-Packard 47201-A) and was recorded on a multichannel recorder (Narco Biosystems physiograph DMP-48). Oral and nasal temperatures were sensed with thermistors (Grass) clipped to one nostril and lip. Air flow was qualitatively reflected by change in temperature sensed by these thermistors. Motion of the chest was sensed by impedance plethysmographic studies with surface electrodes (Narco) and an impedance pneumographic coupler. Ibese electrodes were placed at the point of maximum motion of the wall of the chest during quiet breathing. Electroencephalograms and electrooculograms were simultaneously recorded on an electroencephalographic and polygraphic recording system (Grass 79D). The tracings thus obtained were analyzed by an experienced sleep technician according to the system of Agnew and Webb. Sleep was staged on one-minute intervals. The sleep period time was defined as the total time between falling asleep (onset of electroencephalographic stage 1) and awakening.

The Effect of Weight Loss on Sleep-Disordered Breathing and Oxygen Desaturation in Morbidly Obese Men

sleep-disordered breathingIn a previous study, we demonstrated sleep-disordered breathing and nocturnal oxygen desaturation in a significant proportion of morbidly obese men scheduled for bypass surgery to control obesity. In that study, 14 morbidly obese subjects who were at least 200 percent of ideal body weight were monitored during a single night of sleep. Six of the seven men experienced oxygen desaturation or abnormal breathing. Two of these subjects were symptomatic with daytime somnolence.

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