Factors related to quality of life in patients receiving home mechanical ventilation

OBJECTIVES

The objective of this study was to evaluate factors associated with health-related quality of life (HRQOL) among patients receiving home mechanical ventilation (HMV).

METHODS

Observational, cross-sectional study. Patients receiving HMV were recruited from hospital outpatients facilities at five participating centers; a single follow-up visit was scheduled. The Spanish version of the Severe Respiratory Insufficiency (SRI) Questionnaire was used and the following variables were collected: socio-demographic status, previous medical history (Charlson-Age Comorbidity Index), current symptoms, administration of questionnaires, pulmonary function tests (PFT), current ventilatory support, and oxygen therapy.

RESULTS

One hundred and fifteen patients (57 males and 58 females, mean age 62+/-13 years) were investigated. The reasons for HMV were as follows: thoracic cage abnormalities (33 patients), obesity hypoventilation syndrome (37 patients), neuromuscular disorders (18 patients), sequelae of tuberculosis (12 patients), and chronic obstructive pulmonary disease (15 patients). In a bivariate approach, dyspnea, the number of hospitalizations, and the number of emergency room admissions in last year were the main predictors of each HRQOL dimension. Multivariate analysis showed that dyspnea, FEV(1)/FVC, and the number of hospitalizations in the previous year were independently associated with HRQOL.

CONCLUSIONS

HRQOL of patients receiving HMV is influenced by many factors, especially by dyspnea and the number of admissions. An obstructive pattern in the PFT also influences HRQOL. These findings may have therapeutic implications.

Failure of talc pleurodesis is associated with increased pleural fibrinolysis

Diffuse pleural inflammation and fibrin deposition following the instillation of the sclerosing agent is considered necessary for a successful pleural symphysis. We hypothesized that an impairment in fibrin formation or an increased endopleural fibrinolysis would lead to failure of pleurodesis. To investigate changes in the pleural coagulation/fibrinolysis balance, we studied 75 consecutive patients who underwent thoracoscopy. Fifty-four of these patients with malignant pleural effusions and four with a benign recurrent effusion underwent thoracoscopic talc pleurodesis. Another four patients with malignancy and 13 with benign effusions had no talc poudrage performed and were included as a control group. Serial determinations of thrombin-antithrombin III complex (TAT), plasminogen activator inhibitor (PAI), and D-dimer were made in pleural fluid samples taken at the beginning of thoracoscopy (baseline), immediately after thoracoscopic biopsies had been done (postbiopsy), 3 h after thoracoscopy--either with talc poudrage or without--and 24 and 48 h after the procedure, as well as in cases of recurrence of effusions (farline). Successful pleurodesis was obtained in 42 of 52 patients who could be evaluated (81%), and failure was seen in 10. Strong activation of coagulation and production of PAI was observed in all groups, including the control (no talc) group. Fibrinolytic activity (as expressed by D-dimer levels) showed a clear decline 24 h after talc poudrage in patients with a good outcome of pleurodesis, as oppossed to those with bad results and to the control group, and returned to the baseline by 15 d. We conclude that increased pleural fibrinolytic activity is associated with failure of pleurodesis, despite significant inhibitory activity of PAI in all groups.

[Pulmonary aspiration puncture in the etiological diagnosis of pneumonias]

In pneumonias, the short diagnostic results of non-invasive procedures lead frequently to use invasive techniques, among which we find pulmonary puncture aspiration (PPA). In this study, the profitability of PPA in the diagnosis of pneumonias is evaluated. One hundred and thirteen PPA were performed on 107 patients diagnosed of pneumonia. The PPA was performed with a 22-25 G needle without radioscopic control. Hemocultures were gathered in 104 cases, serological tests for productive agents of atypical pneumonia were applied in 50 cases, sputum test in 95 cases, and bronchofibroscopy with occluded telescopic brush in 25. The PPA had a specificity of 98 percent and a sensibility of 54% which rose to 73% in patients without antibiotic treatment prior to the puncture. Only 10 patients had complications with pneumothorax (9 percent) and four (3 percent) presented hemoptysic sputum. In the 53 patients with a positive PPA, knowledge of an etiological agent allowed the antibiotic treatment to be switched in 32 cases (60 percent). In addition, a decrease in the number of days of hospitalization was confirmed in the group of patients who received an etiological diagnosis while alive (p < 0.03). In conclusion, the PPA is a technique with excellent specificity, acceptable sensitivity, and a short rate of complications which allowed the treatment to be changed in 60 percent of the cases and reduced the number of days of hospitalization for patients who received a diagnosis. Thus, it constitutes a very useful technique in the etiological diagnosis of severe pulmonary infections.