Tanaffos Respiration Journal
Volume:22 Issue: 2, Spring 2023

Chronic obstructive pulmonary disease (COPD) is one of the most common pulmonary diseases. The current therapeutic outcomes are not satisfactory and may cause adverse events such as cardiovascular complications. In this study, we aimed to discuss some effective medicinal herbs for the management of COPD.

In this review, we looked for effective medicinal herbs for productive cough with thick and sticky mucus in Persian medicine sources such as Qanoon fi al-Teb, Exir Azam, and Zakhire Kharazmshahi. Then, to find relevant evidence about them, the data sources (PubMed and Google Scholar) were searched in the English language without time restriction from inception up to March 2022.

We found that Zataria multiflora, Thymus vulgaris L, Glycyrrhiza glabra L., Crocus sativus L., Nepeta bracteata Benth., and Hyssopus officinalis have beneficial effects on COPD due to their properties including anti-inflammatory and antioxidant activity. In addition, considering asthma COPD overlap (ACO), medicinal herbs including Cordia myxa, Adiantum capillus-veneris, Cinnamomum verum, Viola odorata, Borago officinalis, Linum usitatissimum and Vitis viniferia L. were found to have useful effects on asthma.

Considering the mentioned beneficial mechanisms of action of these medicinal herbs, they could be used as a complementary therapy in COPD and asthma. However, more experimental and clinical research should be done to confirm their clinical effects.

Positivity of cardiac troponins is common in hospitalized COVID-19 patients and may serve as an additional risk stratification tool in everyday clinical settings. Since patients with elevated troponins have a higher risk of in-hospital mortality, troponins have prognostic importance. As well as in-hospital mortality, high-sensitive troponin T may reflect 4-month mortality. We analyzed the relationship between cardiac troponin T levels and 4-month mortality of COVID-19.
It was conducted as a retrospective cross-sectional study in Health Sciences University Dr. Suat Seren Chest Diseases and Chest Surgery Training and Research Hospital Izmir, Turkey, with COVID-19 pneumonia patients during the first wave of the pandemic. We analyzed their comorbidities, C-reactive protein, ferritin, aspartate transaminase, alanine transaminase, cardiac troponin T, N-terminal-prohormone B-type-natriuretic peptide, international normalized ratio; duration of hospital stay, and survival status.
Factors associated with mortality were cardiac troponin T > 0.53 pg/dl (p = 0.009) and aspartate transaminase > 26.5 U/l (p = 0.012). The threshold for cardiac troponin T to predict 4-month mortality was 5.83pg/ml. Its sensitivity was 82.8% and its specificity was 66.4%.
Cardiac troponin T and AST are indicators that can be used to predict 4-month mortality in addition to showing in-hospital mortality. The threshold for cardiac troponin T to predict 4-month all-cause mortality is 5.83pg/ml. The mortality difference persists at the beginning, middle, and end of the 4 months. Reference thresholds likely underestimate the true prognostic extent of cardiac injury and lower cutoff values may show mortality.

Bronchoscopy is one of the most accurate procedures to diagnose airway stenosis which is an invasive procedure. However, a quick and non-invasive estimation of the percent area of obstruction (%AO) of the lumen is helpful in decision-making before performing a bronchoscopy procedure. We hypothesized that there is a relationship between %AO and tracheal resistance against fluid flow.
By measuring airway resistance, %AO could be estimated before the procedure. Using computational fluid dynamics (CFD), this study simulates the fluid flow through trachea models with web-liked stenosis using CFD. A cylindrical segment was inserted into the trachea to represent cross-sectional areas corresponding to 20%, 40%, 60%, and 80% AO. The fluid flow and pressure distribution in these models were studied. Our CFD simulations revealed that the tracheal resistance is exponentially increased by %AO.
The results showed a 130% and 55% increase in lung airway resistance and resistive work of breathing for an 80% AO, respectively. Moreover, a curve-fitted relationship was obtained to estimate %AO based on the measured airway resistance by body plethysmography or forced oscillation technique.
This pre-estimation is very useful in diagnostic evaluation and treatment planning in patients with tracheal stenosis.

Chronic Obstructive Pulmonary Disease (COPD) is an inflammatory pulmonary disorder with systemic inflammatory manifestations. This study aims to identify the profile of systemic inflammatory markers in the different phenotypes of COPD to help predict the disease and identify suitable treatment options.
A prospective observational study was conducted on 92 patients with COPD admitted to Victoria Hospital, Bangalore between August 2021 to December 2021. Levels of C-reactive protein (CRP), Serum Creatinine, Erythrocyte Sedimentation Rate (ESR), Absolute Lymphocyte Count (ALC), Absolute Eosinophil Count (AEC), and Lactate Dehydrogenase (LDH) were measured within 48 hours of presentation.
Significantly higher levels of CRP were found in frequent exacerbator emphysema and chronic bronchitis phenotypes (p=0.001). The frequent exacerbator emphysema phenotype had significantly higher levels of LDH (p=0.001) and serum creatinine (p=0.001). Not surprisingly, absolute eosinophil counts were significantly raised in the overlap COPD-Asthma phenotype (p=0.001).
Raised serum CRP levels in the frequent exacerbator phenotypes of emphysema and chronic bronchitis suggest a possible inflammatory response to an infective etiology. Raised LDH levels in frequent exacerbator emphysema phenotype could signify underlying lung parenchymal destruction. Systemic inflammation and oxidative stress can lead to skeletal muscle injury and atrophy in COPD patients. This may explain the raised serum creatinine levels in frequent exacerbator emphysema phenotype. Eosinophilia seen in Overlap COPD-Asthma phenotype is suggestive of type 2 inflammation of the airways with better response to steroids.

Bronchiectasis is a condition characterized by abnormal and permanent bronchial constriction that leads to sputum production and bronchial infection. The current study was done to evaluate the effects of symbiotic probiotics on the clinical manifestations and exacerbation of bronchiectasis.
26 patients in the placebo group (A) and 24 patients in the probiotic group (B) were allocated. In group A, patients took the placebo capsules two times daily for six months. In group B, patients took the LactoCare two times daily for six months.
The mean age of patients was 55.73±13.62 (group A) and 54.5±12.59 years (group B). Most of the patients had consumed azithromycin in both groups. The current study demonstrated there was no statistically significant difference between the decreased rate of pulmonary exacerbations in both groups. However, a decreasing trend was shown in the rate of pulmonary exacerbations without hospitalization (P=0.610). Also, there was a decreasing trend in the rate of pulmonary exacerbations leading to hospitalization (P=0.956). The most frequent etiologic pathogen was Pseudomonas sp. FEV1 and FVC/FEV1 ratios were higher in group B than in group A. However, there was no statistically significant difference between groups A and B (P=0.908 vs 0.403).
The symbiotic probiotics were not effective in the clinical improvement of bronchiectasis, consumption of antibiotics, the rate of pulmonary exacerbations with or without hospitalization, FEV1 and FEV1/FVC, and microbiological pattern.

The role of caffeine as a brain stimulant in improving the respiratory characteristics of patients under mechanical ventilation is unclear. This study aimed at determining the effect of oral caffeine in helping to release (Liberation) from the ventilator in intubated patients under mechanical ventilation admitted to the intensive care unit.
General ICU patients with more than 48 hours of dependency on a ventilator were randomly divided into two groups. The intervention group received 200mg caffeine tablets twice a day through a gastric tube, while the control group received a placebo of the same amount. Every day, patients were assessed for the likelihood of being disconnected from the device. If their clinical condition was deemed suitable, the device mode was switched to spontaneous, and their Rapid Shallow Breathing Index (RSBI) was calculated. Based on this information, a decision was made regarding whether to proceed with weaning.
Caffeine use in ICU patients significantly reduced the airway resistance index of patients (P <0.05). However, although this drug reduced the length of hospital stay in the ICU and the duration of intubation of patients, these changes were not statistically significant (P> 0.05).
Caffeine may improve respiratory status and reduce the duration of intubation and hospitalization in the ICU.

The COVID-19 pandemic is considered a major health problem all over the world which has caused extensive and worldwide mortality and morbidities along with vast economic and political impact. Limitations of our knowledge and controversies in treatment modalities make the control and management of this disease more difficult. The status of electrolytes especially Mg and Zn in plasma and its correlation with the clinical situation and criteria for recovery has been investigated in various studies. Limited data in Iran mandate the design of a trial for evaluating our critically ill patients. We designed this study to investigate the correlation between plasma levels of Mg and Zn and the outcome including patients' need for assisted/ controlled ventilation, time required for weaning, length of ICU stay, and probable cause of death.
413 patients with severe respiratory signs of COVID-19 disease who were admitted to the ICUs of 3 medical centers of Shahid Beheshti University of Medical Sciences were evaluated for plasma levels of Mg and Zn. Supplemental therapy was introduced when needed and was followed until discharge from ICU or death. All recorded data were analyzed by statistical methods and results were compared with similar studies.
20.6% and 35.1% of all participants had low serum levels of Mg and Zn, respectively. 11 patients (2.7%) died through the treatment period. 56.9% and 61.0% of participants received Mg and Zn supplements, respectively.
According to our results, serum Mg and Zn levels did not show a significant correlation with the risk of death due to severe COVID-19 disease, prolonged assisted ventilation, or duration of ICU stay. There was no significant association between Mg and Zn supplementation with the risk of death due to severe COVID-19; however, it showed an inverse relationship with the time required for assisted ventilation and the duration of ICU stay. It seems that Mg and Zn supplementation can be useful in preventing or managing some of the morbidities among COVID-19 patients.

Since last decade, a device called PAKDAM (means clean inspiration) was invented in Iran which has been used in some cafe to prepare N2O and O2 as a new instrument instead of using water pipe. This study aimed to evaluate the respiratory and health effects of Pakdam and investigate its short and midterm side effects in users.
In a case-control pilot study between September 2021 and March 2022, 152 individuals were divided into two groups: 76 consumers (case) and 76 non- consumers (control). Both groups were divided into two groups of 36 smokers and 36 non-smokers. Participants signed the participation form and filled out the demographic data questionnaire, and then their vital signs, O2 saturation, expiratory CO, and spirometry tests were recorded.
The subjects who used the device had a mean blood pressure of 123.71±16.11 mmHg, oxygen saturation of 97.2±1.9, exhaled carbon monoxide of 9.8±5.5, and an FVC / FEV1 ratio of 88.5±7.9. These figures in control group were (137.79±18.15) - (94.1±4.2) - (14.3 ± 9.3) and (83.9 ± 10.4), respectively. In addition to the effects on the respiratory system, consumers had lower heart rates and lower systolic and diastolic blood pressures.
The blood oxygen level and FEV1/FVC ratio were higher in subjects using Pakdam and the amount of exhaled carbon monoxide and blood pressure were lower. This condition was more common in smokers and less in non-smokers. It is possible to see the favorable effects of using Pakdam device on people especially in smokers.

The current study aimed to assess some parameters of the cardiopulmonary exercise test (CPET) among end-stage renal disease patients who underwent dialysis. The ultimate goal is to improve disease management to achieve optimal quality of life and exercise capacity in this group of patients.

Through a cross-sectional design, the current study enrolled 46 dialysis patients by simple sampling between Jan 2019 and Jan 2020. Some CPET parameters such as AT, VO2, VO2/kg, SPO2, minute ventilation CO2 production/O2 consumption ratios (VE/VCO2 and VE/VO2, respectively), O2 pulse, heart rate reserve (HRR), breathing reserve (BR) and end-tidal carbon dioxide pressure (PETCO2) were focused.

Although a limited sample size, the current study showed that VO2/Kg, VE/VCO2, PETCO2, and SPO2 are the main parameters affected by dialysis as expected.

The current study suggests using cardiopulmonary rehabilitation for all chronic medical conditions such as chronic kidney disease and end-stage renal disease that increase the rate of metabolic acidosis.

Achieving procedural skills is one of the pillars of health higher education which is in line with the social responsibility of medical education. Since it is not possible to encounter important cases in bronchoscopy during the training course, the common cases that the students encounter in their future work environment were prepared as an educational video. Therefore, the purpose of this study was to find out the impact of using bronchoscopy educational video intervention on medical assistants’ knowledge, skill, and medical error comparing it with the traditional method at Dr. Masih Daneshvari Hospital.
In this experimental study, two groups were randomly assigned: the experimental and the control. Each one consists of 15 participants.  The first group used mannequins (traditional method) and the second used multimedia as the experimental group. Both groups were evaluated by pre and post-tests. Multiple choices (MCQs) were given to evaluate the knowledge and a checklist for skills. A comparison of the impact of intervention before and after education in both groups was statistically analyzed using the independent t-test.
There were statistically significant differences between the experimental group and the control group at a significance level of 0.042 for the skill. An average increase of 3 points was observed in the experiment group, while the control group increased by 1.4 points. No significant difference was seen for knowledge. The number of patients with pneumothorax was also decreased.
Results showed that the multimedia training method effectively promotes the assistants’ skills and reduces medical errors following bronchoscopy Administration. It is recommended to use educational videos (multimedia) to improve assistants' skills. It is suggested to apply the new model of education rather than sticking to the traditional one.

The coronavirus disease 2019 (COVID-19) has caused a global pandemic with a significant negative impact on health worldwide. Although it primarily involves the respiratory tract system, cardiovascular complications, particularly thrombotic events are increasingly reported and are associated with adverse outcomes.

Case Summary: 

We describe a 30-year-old male who presented with exaggerated dyspnea and hypoxia with mild constitutional symptoms along with a positive PCR test for SARS-CoV-2. He was a known case of bronchiectasis and large bullae in the left lung. Transthoracic echocardiography showed a large right ventricle (RV) mass entrapped within RV papillary muscles and apex. Cardiac MRI was suggestive of RV thrombosis. Regarding diffuse underlying lung disease and improving respiratory symptoms with COVID-19 negative PCR test, we decided to prescribe anticoagulation with heparin infusion and then oral anticoagulant with Rivaroxaban 20 mg daily and follow up after 30 days. Unfortunately, the patient died after 2 weeks in his hometown.

Thrombotic complications are frequently encountered in COVID-19 patients. We report a fatal case of large intracardiac thrombus associated with SARS-CoV-2 infection managed with anticoagulant therapy with a catastrophic outcome.

Nonspecific clinical features and imaging findings of COVID-19 may lead to misdiagnosis with other diseases that have specific risks and treatments. Here a patient is reported with Pneumocystis Pneumonia with an undiagnosed HIV disease who was treated for COVID-19 with no response after one week. COVID-19 was diagnosed by CT findings but PCR was negative. Further evaluation for ground glass opacities confirmed AIDS and clinical response to Pneumocystis Pneumonia treatment.