The Leicester Cough Monitor (LCM) is an automated cough monitoring system that was validated in this study. The LCM had a 91% sensitivity and 99% specificity for detecting cough sounds compared to manual cough counts. Cough frequency measured by the LCM was repeatable over time. Patients with chronic cough had significantly higher 24-hour and daytime cough frequencies measured by the LCM compared to healthy controls. The LCM provides a valid and reliable measure of 24-hour cough frequency in patients with chronic cough.
This document provides guidelines for managing acute exacerbations of chronic bronchitis in Canada. It defines key terms such as chronic bronchitis, COPD, and acute exacerbations. It discusses the role of bacteria in chronic bronchitis and exacerbations, noting that around 50% of exacerbations are believed to be caused by bacterial or viral infections. Objective lung function measurements are necessary to confirm airway obstruction.
This document summarizes guidelines for diagnosing and managing community-acquired pneumonia (CAP) from the Philippine Clinical Practice Guidelines published in 2010 and updated in 2016. It discusses CAP definitions, pathogenesis, clinical presentation, diagnostic testing including chest x-rays, typical and atypical bacterial causes, treatment recommendations, and prevention. Key points covered include how CAP can often be diagnosed based on history and exam findings alone, the value of chest x-rays in confirming CAP diagnosis and evaluating severity, and emphasis on initial empiric antibiotic therapy targeting the most common bacterial pathogens depending on severity and patient risk factors.
PROSEVA trial - Prone position in severe ARDS.
Why did prone position improve outcome of ARDS while other measures aimed at improving oxygenation such as high PEEP, RM and HFO have failed to do so?
This document provides guidelines for the diagnosis, treatment, and prevention of community-acquired pneumonia (CAP) in immunocompetent adults. It discusses CAP definitions, epidemiology, risk factors, clinical presentation, diagnostic testing including chest x-rays and microbiological studies, site of care decisions, and treatment recommendations. The guidelines outline criteria for hospital admission and recommend empiric antibiotic therapy based on a patient's risk level, with combinations of beta-lactams, macrolides, or fluoroquinolones depending on severity of illness.
Occurrence of COPD in Patients with Respiratory Allergy: A Clinico-Spirometri...DR. SUJOY MUKHERJEE
This study evaluated the occurrence of chronic obstructive pulmonary disease (COPD) in patients with respiratory allergy symptoms. 550 patients aged 18-60 years with chronic respiratory symptoms were divided into two groups - those with symptoms of respiratory allergy like nasal congestion and sneezing (n=260) and those without allergy symptoms (n=290). Both groups underwent spirometric testing and were categorized based on lung function. The study found that 18.97% of the non-allergic group had COPD, compared to only 7.69% of the allergic group, and this difference was statistically significant. Additionally, post-bronchodilator spirometry values were significantly lower in the non-
This document summarizes a study examining the prevalence of pulmonary fungal infection in chronic obstructive pulmonary disease (COPD) patients both with and without comorbidities. The study found that COPD patients with comorbidities had a significantly higher prevalence of pulmonary fungal infection (77.8%) compared to COPD patients without comorbidities (53.1%). Major risk factors for fungal infection in COPD patients with comorbidities included mechanical ventilation, corticosteroid therapy, ICU admission, and older age. COPD patients with comorbidities also had a higher mortality rate (12.3%) than COPD patients without comorbidities (3.1%).
Characteristic and outcomes of patients with ptb requiring icu careEArl Copina
This document summarizes a study of 58 patients with active pulmonary tuberculosis who required admission to an intensive care unit. The mean age was 48 years and 37.9% required mechanical ventilation. The in-hospital mortality rate was 25.9% with a mean survival of 53.6 days for those who died. Factors independently associated with increased mortality included acute renal failure, need for mechanical ventilation, chronic pancreatitis, sepsis, acute respiratory distress syndrome, and hospital-acquired pneumonia. The study identified risk factors for high mortality rates in tuberculosis patients requiring intensive care.
Ventilator Associated Pneumonia (VAP) is a common nosocomial infection that develops in patients on mechanical ventilation. VAP increases mortality, length of stay, and medical costs. Risk factors include prolonged intubation and underlying patient health issues. Symptoms include cough, fever, purulent sputum, and new lung infiltrates. Evidence-based strategies to prevent VAP include oral care, silver coated endotracheal tubes, elevating the head of the bed, and using ventilator bundles.
This document provides guidelines for managing acute exacerbations of chronic bronchitis in Canada. It defines key terms such as chronic bronchitis, COPD, and acute exacerbations. It discusses the role of bacteria in chronic bronchitis and exacerbations, noting that around 50% of exacerbations are believed to be caused by bacterial or viral infections. Objective lung function measurements are necessary to confirm airway obstruction.
This document summarizes guidelines for diagnosing and managing community-acquired pneumonia (CAP) from the Philippine Clinical Practice Guidelines published in 2010 and updated in 2016. It discusses CAP definitions, pathogenesis, clinical presentation, diagnostic testing including chest x-rays, typical and atypical bacterial causes, treatment recommendations, and prevention. Key points covered include how CAP can often be diagnosed based on history and exam findings alone, the value of chest x-rays in confirming CAP diagnosis and evaluating severity, and emphasis on initial empiric antibiotic therapy targeting the most common bacterial pathogens depending on severity and patient risk factors.
PROSEVA trial - Prone position in severe ARDS.
Why did prone position improve outcome of ARDS while other measures aimed at improving oxygenation such as high PEEP, RM and HFO have failed to do so?
This document provides guidelines for the diagnosis, treatment, and prevention of community-acquired pneumonia (CAP) in immunocompetent adults. It discusses CAP definitions, epidemiology, risk factors, clinical presentation, diagnostic testing including chest x-rays and microbiological studies, site of care decisions, and treatment recommendations. The guidelines outline criteria for hospital admission and recommend empiric antibiotic therapy based on a patient's risk level, with combinations of beta-lactams, macrolides, or fluoroquinolones depending on severity of illness.
Occurrence of COPD in Patients with Respiratory Allergy: A Clinico-Spirometri...DR. SUJOY MUKHERJEE
This study evaluated the occurrence of chronic obstructive pulmonary disease (COPD) in patients with respiratory allergy symptoms. 550 patients aged 18-60 years with chronic respiratory symptoms were divided into two groups - those with symptoms of respiratory allergy like nasal congestion and sneezing (n=260) and those without allergy symptoms (n=290). Both groups underwent spirometric testing and were categorized based on lung function. The study found that 18.97% of the non-allergic group had COPD, compared to only 7.69% of the allergic group, and this difference was statistically significant. Additionally, post-bronchodilator spirometry values were significantly lower in the non-
This document summarizes a study examining the prevalence of pulmonary fungal infection in chronic obstructive pulmonary disease (COPD) patients both with and without comorbidities. The study found that COPD patients with comorbidities had a significantly higher prevalence of pulmonary fungal infection (77.8%) compared to COPD patients without comorbidities (53.1%). Major risk factors for fungal infection in COPD patients with comorbidities included mechanical ventilation, corticosteroid therapy, ICU admission, and older age. COPD patients with comorbidities also had a higher mortality rate (12.3%) than COPD patients without comorbidities (3.1%).
Characteristic and outcomes of patients with ptb requiring icu careEArl Copina
This document summarizes a study of 58 patients with active pulmonary tuberculosis who required admission to an intensive care unit. The mean age was 48 years and 37.9% required mechanical ventilation. The in-hospital mortality rate was 25.9% with a mean survival of 53.6 days for those who died. Factors independently associated with increased mortality included acute renal failure, need for mechanical ventilation, chronic pancreatitis, sepsis, acute respiratory distress syndrome, and hospital-acquired pneumonia. The study identified risk factors for high mortality rates in tuberculosis patients requiring intensive care.
Ventilator Associated Pneumonia (VAP) is a common nosocomial infection that develops in patients on mechanical ventilation. VAP increases mortality, length of stay, and medical costs. Risk factors include prolonged intubation and underlying patient health issues. Symptoms include cough, fever, purulent sputum, and new lung infiltrates. Evidence-based strategies to prevent VAP include oral care, silver coated endotracheal tubes, elevating the head of the bed, and using ventilator bundles.
1) The patient presented with severe ARDS due to bilateral pneumonia and septic cardiomyopathy. She required intubation and mechanical ventilation with hypoxemia.
2) She was treated with prone ventilation for 20 hours which improved her oxygenation with PaO2/FiO2 ratio increasing from 96 to 207.
3) Prone positioning has physiological benefits for ARDS including improving ventilation distribution and oxygenation, reducing ventilator-induced lung injury, and facilitates secretion clearance. It has been shown to reduce mortality in patients with severe ARDS.
This document discusses ventilator-associated pneumonia (VAP). It defines VAP as pneumonia occurring 48-72 hours or more after endotracheal intubation. The document reviews statistics on VAP incidence from studies, describes the complex pathophysiology of VAP, and outlines criteria for diagnosing VAP which includes new infiltrates on chest x-ray and signs of infection. It also summarizes treatment guidelines including collecting cultures before antibiotics and using short courses of broad-spectrum antibiotics. Finally, it emphasizes that implementing a high compliance VAP bundle is the most important prevention step and can significantly reduce VAP rates and healthcare costs.
This document discusses the classification and etiology of pneumothorax. It begins with an overview of the historical understanding and definitions of pneumothorax. It then discusses the epidemiology, including incidence and recurrence rates. Pneumothorax is classified based on size (partial, incomplete, complete), pathophysiology (tension vs spontaneous), and etiology (primary spontaneous, secondary spontaneous, traumatic). The exact causes are often unknown but involve an interplay between lung abnormalities and environmental factors in most cases.
SARI CRITICAL CARE TRAINING CLINICAL SYNDROMESSandro Zorzi
- Early identification of patients with severe acute respiratory infection (SARI) and sepsis allows for early implementation of evidence-based therapies that can improve outcomes and reduce mortality. Key signs of severe pneumonia, acute respiratory distress syndrome (ARDS), and sepsis were reviewed to aid in early recognition.
This study evaluated the effects of early prone positioning on outcomes in patients with severe acute respiratory distress syndrome (ARDS). 466 patients with severe ARDS were randomly assigned to undergo at least 16 hours of prone positioning sessions or to remain in the supine position. The primary outcome was 28-day mortality. The results showed significantly lower 28-day mortality in the prone group (16.0%) compared to the supine group (32.8%). Unadjusted 90-day mortality was also significantly lower in the prone group. Complication rates were similar between the groups except cardiac arrests, which were higher in the supine group. The study concluded that in patients with severe ARDS, early application of prolonged prone positioning sessions significantly decreased
Antibiotic Strategy in Lower Respiratory Tract Infections (part 1)Gamal Agmy
This document summarizes guidelines for empiric antibiotic treatment of lower respiratory tract infections such as community-acquired pneumonia. It recommends using a clinical prediction rule like the Pneumonia Severity Index in addition to clinical judgment to determine whether patients should be treated as outpatients or inpatients. For outpatient treatment of CAP, it recommends amoxicillin, doxycycline, or macrolides depending on patient risk factors and local resistance patterns. For inpatient treatment of non-severe CAP without risk of MRSA or Pseudomonas, it recommends beta-lactam plus macrolide or fluoroquinolone monotherapy. It does not recommend routinely adding anaerobic coverage or extended-spectrum antibiotics without
The document discusses H1N1 influenza A virus. It describes the virus's pathogenesis, including that it is an RNA virus belonging to the Orthomyxoviridae family. Major changes in surface proteins HA and NA can lead to antigenic shifts and pandemics, while minor changes cause antigenic drift and localized outbreaks. The 2009 H1N1 strain was a novel quadruple reassortant virus. Clinical presentation is usually similar to seasonal flu but gastrointestinal symptoms may be more common. Treatment involves oseltamivir, zanamivir or peramivir. Vaccination is recommended for at-risk groups.
MERS-CoV infection causes severe respiratory and substantial nonpulmonary organ dysfunctions and has a high mortality rate. Community acquired and health care–associated MERS-CoV infection occurs in patients with chronic comorbid conditions
This document defines different types of pneumonia including community acquired pneumonia (CAP), hospital-acquired pneumonia (HAP), healthcare-associated pneumonia (HCAP), and ventilator-associated pneumonia (VAP). It describes common clinical features, diagnostic testing recommendations including chest radiographs, severity assessment scores, and treatment guidelines based on patient risk factors and pneumonia type. Initial treatment often includes broad-spectrum antibiotics while considering possible multidrug-resistant pathogens, with options to address a lack of improvement such as fungal infections or tuberculosis.
Bundles to prevent ventilator associated pneumoniapravin2k2
This document discusses ventilator-associated pneumonia (VAP), which is a common nosocomial infection in critically ill patients that leads to poor outcomes. It reviews guidelines for preventing VAP, including using orotracheal intubation, limiting circuit changes, and closed suctioning systems. It also describes the Ventilator Bundle, a set of evidence-based practices including elevating the head of the bed, daily sedation vacations, and DVT and stress ulcer prophylaxis that have been shown to reduce VAP rates more than individual measures. While effective, the bundle may not include all strategies recommended in guidelines, so modifying it or creating a specific VAP bundle is suggested.
Antibiotic Strategy in Lower Respiratory Tract Infections (part 2)Gamal Agmy
This document provides guidelines for evaluating and treating patients with hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) based on the latest evidence and expert consensus. It discusses recommendations for using clinical scoring systems to decide whether to initiate antibiotics, recommendations for empiric and pathogen-directed antibiotic therapy, evaluating treatment failure, the role of inhaled antibiotics, duration of treatment, and other important management considerations. The overall aim is to guide clinicians in providing appropriate antibiotic treatment while minimizing unnecessary use of antibiotics.
This document provides guidelines for the diagnosis and treatment of hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) in adults. Some of the key recommendations include:
1) Using noninvasive sampling with semiquantitative cultures rather than invasive sampling with quantitative cultures to diagnose VAP.
2) If invasive quantitative cultures are performed for a patient with suspected VAP and results are below the diagnostic threshold, antibiotics should be withheld rather than continued.
3) For patients with suspected HAP (non-VAP), treatment should be guided by microbiologic studies of respiratory samples rather than being empirically treated.
4) For patients with suspected HAP/V
This document provides guidelines and recommendations from the ATS for the diagnosis and treatment of community-acquired pneumonia (CAP) in adult patients. It addresses questions such as when to obtain cultures, perform testing, and initiate antibiotics and corticosteroids. It recommends obtaining cultures for severe CAP or if treating for specific drug-resistant pathogens. It suggests testing for influenza when circulating and provides guidance on antibiotic selection and duration based on severity and location of treatment. The recommendations are meant to guide clinicians in diagnosing and managing CAP.
This document provides an overview of the radiological presentation of COVID-19 based on CT scans and chest x-rays. It finds that ground glass opacities are the most common CT finding and often appear bilaterally in the lower lobes in a peripheral or subpleural distribution. Later stages may also show consolidation, septal thickening, and traction bronchiectasis. Chest x-rays are less sensitive than CT early on but can still detect signs of disease progression like bilateral opacities and consolidation. Pediatric cases tend to be milder with fewer abnormal CT findings. The document outlines typical features, frequencies of signs, and comparisons between adult and pediatric presentations.
Renin - Angiotensin - Aldosterone System Inhibitors in Patients with Covid-19Valentina Corona
This document summarizes the current understanding of how medications that inhibit the renin-angiotensin-aldosterone system (RAAS), such as ACE inhibitors and angiotensin receptor blockers (ARBs), may impact COVID-19. It notes that while animal studies have found mixed results on how these drugs affect ACE2 levels, human studies provide little evidence they increase ACE2. It also raises the possibility that ACE2 may be beneficial rather than harmful for lung injury in COVID-19. The document concludes more research is needed to understand the complex interactions between SARS-CoV-2 and the RAAS system in humans before making recommendations about RAAS inhibitor use in COVID-19 patients.
The document summarizes pulmonary involvement in people living with HIV. It finds that tuberculosis is the most common pulmonary manifestation, followed by bacterial pneumonia and Pneumocystis jirovecii pneumonia. The risk of specific opportunistic infections depends on CD4 count, with P. jirovecii pneumonia most common when CD4 is below 50 cells/mm3. Chest x-rays show findings characteristic of each disease, such as consolidation in tuberculosis and ground glass opacities in P. jirovecii pneumonia. The study aims to correlate pulmonary diseases with CD4 count in HIV-positive patients in India.
This document discusses the development and implementation of new surveillance definitions for ventilator-associated events (VAEs) by the Centers for Disease Control and Prevention (CDC). It provides an overview of the limitations of previous ventilator-associated pneumonia (VAP) surveillance definitions and the objectives of the CDC to create a more reliable, objective approach. The new VAE definitions focus on ventilator settings and complications rather than clinical diagnosis of VAP. The definitions establish thresholds for worsening oxygenation that could indicate a ventilator-associated condition has occurred.
1) A new device called provides real-time feedback to improve manual ventilation techniques during CPR training which can help save more lives.
2) Proper airway management and ventilation are crucial but difficult parts of performing CPR. Issues like leakage, gastric insufflation, and hyperventilation commonly occur without feedback and training.
3) The device allows trainees to practice airway management skills and receive feedback on ventilation metrics to help ensure adequate volumes while avoiding common issues like hyperventilation that can reduce survival rates.
Ventilator-associated pneumonia (VAP) is a common nosocomial infection that increases ICU stay and mortality. The document discusses risk factors for VAP and strategies to prevent and diagnose it, including implementing a VAP bundle with elements like elevating the head of bed, daily sedation vacations, and oral care. It emphasizes the importance of staff education to properly implement prevention protocols and decrease VAP rates.
This document summarizes information about idiopathic pulmonary fibrosis (IPF):
- IPF is a chronic, progressive lung disease characterized by scarring of the lungs that worsens over time. It typically affects older adults and has an unpredictable decline in lung function.
- Diagnosis involves ruling out other causes, high-resolution CT imaging showing a usual interstitial pneumonia pattern, and sometimes surgical lung biopsy.
- Current treatment options include pirfenidone, nintedanib, oxygen therapy, pulmonary rehabilitation, and sometimes lung transplantation. However, IPF has a generally poor prognosis with median survival of 2-5 years.
Evaluation of lung ultrasound for the diagnosis of pneumonia in the EDMario Robusti
Lung ultrasound was performed on 49 patients suspected of having pneumonia who presented to the emergency department. Pneumonia was confirmed in 32 cases (65.3%). Lung ultrasound detected pneumonia (consolidation with air bronchograms) in 31 of these 32 cases (96.9%), while chest x-ray detected pneumonia in 24 cases (75%). In 8 cases (25%), lung ultrasound detected pneumonia when chest x-ray did not. Computed tomography scans confirmed the lung ultrasound results in these 8 cases. Lung ultrasound took less than 5 minutes to perform and could visualize all areas of the chest, while chest x-rays were only able to image both views in 66% of cases. This study suggests lung ultrasound may be
Management Of Community Acquired PneumoniaAshraf ElAdawy
This document provides information on community-acquired pneumonia (CAP), including its definition, classification, pathogens, pathophysiology, diagnosis, and methods for assessing severity. CAP is defined as an alveolar infection developing outside of a hospital within 48 hours of admission. The most common causative pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and atypical bacteria. Severity must be assessed to determine the appropriate site of care, and several prognostic scoring systems are discussed including the Pneumonia Severity Index (PSI), CURB-65, and CRB-65, which stratify patients into risk groups to guide management decisions.
1) The patient presented with severe ARDS due to bilateral pneumonia and septic cardiomyopathy. She required intubation and mechanical ventilation with hypoxemia.
2) She was treated with prone ventilation for 20 hours which improved her oxygenation with PaO2/FiO2 ratio increasing from 96 to 207.
3) Prone positioning has physiological benefits for ARDS including improving ventilation distribution and oxygenation, reducing ventilator-induced lung injury, and facilitates secretion clearance. It has been shown to reduce mortality in patients with severe ARDS.
This document discusses ventilator-associated pneumonia (VAP). It defines VAP as pneumonia occurring 48-72 hours or more after endotracheal intubation. The document reviews statistics on VAP incidence from studies, describes the complex pathophysiology of VAP, and outlines criteria for diagnosing VAP which includes new infiltrates on chest x-ray and signs of infection. It also summarizes treatment guidelines including collecting cultures before antibiotics and using short courses of broad-spectrum antibiotics. Finally, it emphasizes that implementing a high compliance VAP bundle is the most important prevention step and can significantly reduce VAP rates and healthcare costs.
This document discusses the classification and etiology of pneumothorax. It begins with an overview of the historical understanding and definitions of pneumothorax. It then discusses the epidemiology, including incidence and recurrence rates. Pneumothorax is classified based on size (partial, incomplete, complete), pathophysiology (tension vs spontaneous), and etiology (primary spontaneous, secondary spontaneous, traumatic). The exact causes are often unknown but involve an interplay between lung abnormalities and environmental factors in most cases.
SARI CRITICAL CARE TRAINING CLINICAL SYNDROMESSandro Zorzi
- Early identification of patients with severe acute respiratory infection (SARI) and sepsis allows for early implementation of evidence-based therapies that can improve outcomes and reduce mortality. Key signs of severe pneumonia, acute respiratory distress syndrome (ARDS), and sepsis were reviewed to aid in early recognition.
This study evaluated the effects of early prone positioning on outcomes in patients with severe acute respiratory distress syndrome (ARDS). 466 patients with severe ARDS were randomly assigned to undergo at least 16 hours of prone positioning sessions or to remain in the supine position. The primary outcome was 28-day mortality. The results showed significantly lower 28-day mortality in the prone group (16.0%) compared to the supine group (32.8%). Unadjusted 90-day mortality was also significantly lower in the prone group. Complication rates were similar between the groups except cardiac arrests, which were higher in the supine group. The study concluded that in patients with severe ARDS, early application of prolonged prone positioning sessions significantly decreased
Antibiotic Strategy in Lower Respiratory Tract Infections (part 1)Gamal Agmy
This document summarizes guidelines for empiric antibiotic treatment of lower respiratory tract infections such as community-acquired pneumonia. It recommends using a clinical prediction rule like the Pneumonia Severity Index in addition to clinical judgment to determine whether patients should be treated as outpatients or inpatients. For outpatient treatment of CAP, it recommends amoxicillin, doxycycline, or macrolides depending on patient risk factors and local resistance patterns. For inpatient treatment of non-severe CAP without risk of MRSA or Pseudomonas, it recommends beta-lactam plus macrolide or fluoroquinolone monotherapy. It does not recommend routinely adding anaerobic coverage or extended-spectrum antibiotics without
The document discusses H1N1 influenza A virus. It describes the virus's pathogenesis, including that it is an RNA virus belonging to the Orthomyxoviridae family. Major changes in surface proteins HA and NA can lead to antigenic shifts and pandemics, while minor changes cause antigenic drift and localized outbreaks. The 2009 H1N1 strain was a novel quadruple reassortant virus. Clinical presentation is usually similar to seasonal flu but gastrointestinal symptoms may be more common. Treatment involves oseltamivir, zanamivir or peramivir. Vaccination is recommended for at-risk groups.
MERS-CoV infection causes severe respiratory and substantial nonpulmonary organ dysfunctions and has a high mortality rate. Community acquired and health care–associated MERS-CoV infection occurs in patients with chronic comorbid conditions
This document defines different types of pneumonia including community acquired pneumonia (CAP), hospital-acquired pneumonia (HAP), healthcare-associated pneumonia (HCAP), and ventilator-associated pneumonia (VAP). It describes common clinical features, diagnostic testing recommendations including chest radiographs, severity assessment scores, and treatment guidelines based on patient risk factors and pneumonia type. Initial treatment often includes broad-spectrum antibiotics while considering possible multidrug-resistant pathogens, with options to address a lack of improvement such as fungal infections or tuberculosis.
Bundles to prevent ventilator associated pneumoniapravin2k2
This document discusses ventilator-associated pneumonia (VAP), which is a common nosocomial infection in critically ill patients that leads to poor outcomes. It reviews guidelines for preventing VAP, including using orotracheal intubation, limiting circuit changes, and closed suctioning systems. It also describes the Ventilator Bundle, a set of evidence-based practices including elevating the head of the bed, daily sedation vacations, and DVT and stress ulcer prophylaxis that have been shown to reduce VAP rates more than individual measures. While effective, the bundle may not include all strategies recommended in guidelines, so modifying it or creating a specific VAP bundle is suggested.
Antibiotic Strategy in Lower Respiratory Tract Infections (part 2)Gamal Agmy
This document provides guidelines for evaluating and treating patients with hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) based on the latest evidence and expert consensus. It discusses recommendations for using clinical scoring systems to decide whether to initiate antibiotics, recommendations for empiric and pathogen-directed antibiotic therapy, evaluating treatment failure, the role of inhaled antibiotics, duration of treatment, and other important management considerations. The overall aim is to guide clinicians in providing appropriate antibiotic treatment while minimizing unnecessary use of antibiotics.
This document provides guidelines for the diagnosis and treatment of hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) in adults. Some of the key recommendations include:
1) Using noninvasive sampling with semiquantitative cultures rather than invasive sampling with quantitative cultures to diagnose VAP.
2) If invasive quantitative cultures are performed for a patient with suspected VAP and results are below the diagnostic threshold, antibiotics should be withheld rather than continued.
3) For patients with suspected HAP (non-VAP), treatment should be guided by microbiologic studies of respiratory samples rather than being empirically treated.
4) For patients with suspected HAP/V
This document provides guidelines and recommendations from the ATS for the diagnosis and treatment of community-acquired pneumonia (CAP) in adult patients. It addresses questions such as when to obtain cultures, perform testing, and initiate antibiotics and corticosteroids. It recommends obtaining cultures for severe CAP or if treating for specific drug-resistant pathogens. It suggests testing for influenza when circulating and provides guidance on antibiotic selection and duration based on severity and location of treatment. The recommendations are meant to guide clinicians in diagnosing and managing CAP.
This document provides an overview of the radiological presentation of COVID-19 based on CT scans and chest x-rays. It finds that ground glass opacities are the most common CT finding and often appear bilaterally in the lower lobes in a peripheral or subpleural distribution. Later stages may also show consolidation, septal thickening, and traction bronchiectasis. Chest x-rays are less sensitive than CT early on but can still detect signs of disease progression like bilateral opacities and consolidation. Pediatric cases tend to be milder with fewer abnormal CT findings. The document outlines typical features, frequencies of signs, and comparisons between adult and pediatric presentations.
Renin - Angiotensin - Aldosterone System Inhibitors in Patients with Covid-19Valentina Corona
This document summarizes the current understanding of how medications that inhibit the renin-angiotensin-aldosterone system (RAAS), such as ACE inhibitors and angiotensin receptor blockers (ARBs), may impact COVID-19. It notes that while animal studies have found mixed results on how these drugs affect ACE2 levels, human studies provide little evidence they increase ACE2. It also raises the possibility that ACE2 may be beneficial rather than harmful for lung injury in COVID-19. The document concludes more research is needed to understand the complex interactions between SARS-CoV-2 and the RAAS system in humans before making recommendations about RAAS inhibitor use in COVID-19 patients.
The document summarizes pulmonary involvement in people living with HIV. It finds that tuberculosis is the most common pulmonary manifestation, followed by bacterial pneumonia and Pneumocystis jirovecii pneumonia. The risk of specific opportunistic infections depends on CD4 count, with P. jirovecii pneumonia most common when CD4 is below 50 cells/mm3. Chest x-rays show findings characteristic of each disease, such as consolidation in tuberculosis and ground glass opacities in P. jirovecii pneumonia. The study aims to correlate pulmonary diseases with CD4 count in HIV-positive patients in India.
This document discusses the development and implementation of new surveillance definitions for ventilator-associated events (VAEs) by the Centers for Disease Control and Prevention (CDC). It provides an overview of the limitations of previous ventilator-associated pneumonia (VAP) surveillance definitions and the objectives of the CDC to create a more reliable, objective approach. The new VAE definitions focus on ventilator settings and complications rather than clinical diagnosis of VAP. The definitions establish thresholds for worsening oxygenation that could indicate a ventilator-associated condition has occurred.
1) A new device called provides real-time feedback to improve manual ventilation techniques during CPR training which can help save more lives.
2) Proper airway management and ventilation are crucial but difficult parts of performing CPR. Issues like leakage, gastric insufflation, and hyperventilation commonly occur without feedback and training.
3) The device allows trainees to practice airway management skills and receive feedback on ventilation metrics to help ensure adequate volumes while avoiding common issues like hyperventilation that can reduce survival rates.
Ventilator-associated pneumonia (VAP) is a common nosocomial infection that increases ICU stay and mortality. The document discusses risk factors for VAP and strategies to prevent and diagnose it, including implementing a VAP bundle with elements like elevating the head of bed, daily sedation vacations, and oral care. It emphasizes the importance of staff education to properly implement prevention protocols and decrease VAP rates.
This document summarizes information about idiopathic pulmonary fibrosis (IPF):
- IPF is a chronic, progressive lung disease characterized by scarring of the lungs that worsens over time. It typically affects older adults and has an unpredictable decline in lung function.
- Diagnosis involves ruling out other causes, high-resolution CT imaging showing a usual interstitial pneumonia pattern, and sometimes surgical lung biopsy.
- Current treatment options include pirfenidone, nintedanib, oxygen therapy, pulmonary rehabilitation, and sometimes lung transplantation. However, IPF has a generally poor prognosis with median survival of 2-5 years.
Evaluation of lung ultrasound for the diagnosis of pneumonia in the EDMario Robusti
Lung ultrasound was performed on 49 patients suspected of having pneumonia who presented to the emergency department. Pneumonia was confirmed in 32 cases (65.3%). Lung ultrasound detected pneumonia (consolidation with air bronchograms) in 31 of these 32 cases (96.9%), while chest x-ray detected pneumonia in 24 cases (75%). In 8 cases (25%), lung ultrasound detected pneumonia when chest x-ray did not. Computed tomography scans confirmed the lung ultrasound results in these 8 cases. Lung ultrasound took less than 5 minutes to perform and could visualize all areas of the chest, while chest x-rays were only able to image both views in 66% of cases. This study suggests lung ultrasound may be
Management Of Community Acquired PneumoniaAshraf ElAdawy
This document provides information on community-acquired pneumonia (CAP), including its definition, classification, pathogens, pathophysiology, diagnosis, and methods for assessing severity. CAP is defined as an alveolar infection developing outside of a hospital within 48 hours of admission. The most common causative pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and atypical bacteria. Severity must be assessed to determine the appropriate site of care, and several prognostic scoring systems are discussed including the Pneumonia Severity Index (PSI), CURB-65, and CRB-65, which stratify patients into risk groups to guide management decisions.
Frequency and management of respiratory incidents in invasive home ventilationMissing Man
This study analyzed respiratory incidents in 17 patients receiving invasive home ventilation living in a nursing home attached to a weaning center over a 2-month period. The patients had been ventilated at home for an average of 490 days. During the study period, 8 of the 17 patients (47%) experienced a total of 95 respiratory incidents. The most common incidents were desaturation, dyspnea, and reduced general condition. The most common interventions by nursing staff were use of an Ambu bag and replacement of the tracheal cannula. While most incidents were managed by nursing staff, a doctor was called in 13% of cases. Respiratory incidents were common in long-term invasive home ventilation patients.
This study evaluated the performance of the GeneXpert MTB/RIF assay on pulmonary and extrapulmonary samples. For pulmonary samples (n=12,257), the assay showed 87.1% sensitivity and 99.9% specificity. For extrapulmonary samples (n=2,818), sensitivity ranged from 53.7% for total cavitary fluids to 100% for CSF. Sensitivity was over 80% for urine, pus, gastric aspirates and biopsies but only 53.7% for total cavitary fluids. The study found the GeneXpert MTB/RIF assay to be an accurate test for pulmonary and most extrapulmonary TB diagnosis, except for cavitary fluids which
PATTERN OF HOSPITAL-ACQUIRED PNEUMONIA IN INTENSIVE CARE UNIT OF SUEZ CANAL U...Khaled Mohamed
Hospital-acquired pneumonia occurs more than 48 h after hospital admission and was not present at the time of admission, while ventilator-associated pneumonia occurs
after 48–72 h of endotracheal intubation or within 48 h of extubation. HAP is the second most common nosocomial infection and accounts for approximately 25% of all infections in the Intensive
Care Unit worldwide.
1. This cross-sectional study aims to identify common organisms causing infections in COPD and asthma patients by sputum culture and determine the antimicrobial susceptibility patterns of isolated microorganisms.
2. Sputum samples will be collected from 100 COPD and asthma patients experiencing acute exacerbations at a hospital in Jodhpur, India. Samples will undergo culture and identification of bacteria/fungi followed by antimicrobial susceptibility testing.
3. Preliminary results from previous studies suggest bacteria like H. influenzae, S. pneumoniae, and M. catarrhalis commonly cause COPD exacerbations, while studies of asthma patient microbiota show alterations compared to healthy individuals.
Study of clinical and etiological profile of community acquired pneumonia in ...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Community Acquired Pneumonia can be caused by various pathogens including bacteria, viruses, and fungi. The document discusses classifications of pneumonia based on location and acquisition. It focuses on community acquired pneumonia, describing the most common pathogens such as Streptococcus pneumoniae. Severity assessment is important for determining appropriate treatment setting and prognosis. Several prognostic severity scales are discussed including the Pneumonia Severity Index (PSI), CURB-65, and CRB-65, which stratify patients into risk groups to help decide between outpatient or inpatient care.
Patient ventilator interactions during mechanical ventilationDr.Mahmoud Abbas
Patient Ventilator Interaction during Mechanical Ventilation lecture presented by Dr.Lluis Blanch at Pulmonary Critical Care Egypt Meeting and Exhibition, January 2014. www.pccmegypt.com
This document discusses non-invasive tests for diagnosing and monitoring asthma, focusing on exhaled nitric oxide (eNO) measurement. It describes how eNO levels are elevated in asthmatic patients due to airway inflammation and correlate with tissue eosinophils. The document outlines the procedure for measuring eNO according to guidelines and how it can help diagnose asthma, monitor treatment response, and detect different asthma phenotypes in a safe, repeatable way without invasive procedures.
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1. The Leicester Cough Monitor: preliminary
validation of an automated cough detection
system in chronic cough
S.S. Birring*, T. Fleming*, S. Matos#
, A.A. Raj"
, D.H. Evans#
and I.D. Pavord"
ABSTRACT: Chronic cough is a common condition that presents to both primary and secondary
care. Assessment and management are hampered by the absence of well-validated outcome
measures. The present study comprises the validation of the Leicester Cough Monitor (LCM), an
automated sound-based ambulatory cough monitor.
Cough frequency was measured with the LCM and compared with coughs and other sounds
counted manually over 2 h of a 6-h recording by two observers in nine patients with chronic cough
in order to determine the sensitivity and specificity of the LCM. Automated cough frequency was
also compared with manual counts from one observer in 15 patients with chronic cough and eight
healthy subjects. All subjects underwent 6-h recordings. A subgroup consisting of six control and
five patients with stable chronic cough underwent repeat automated measurements o3 months
apart. A further 50 patients with chronic cough underwent 24-h automated cough monitoring.
The LCM had a sensitivity and specificity of 91 and 99%, respectively, for detecting cough and a
false-positive rate of 2.5 events?h-1
. Mean¡SEM automated cough counts?patient?h-1
was 48¡9 in
patients with chronic cough and 2¡1 in the control group (mean difference 46 counts?patient?h-1
;
95% confidence interval (CI) 20–71). The automated cough counts were repeatable (intra-subject
SD 11.4 coughs?patient?h-1
; intra-class correlation coefficient 0.9). The cough frequency in
patients undergoing 24-h automated monitoring was 19 coughs?patient?h-1
; daytime (08:00–
22:00 h) cough frequency was significantly greater than overnight cough frequency (25 versus
10 coughs?patient?h-1
; mean difference 15 coughs?patient?h-1
, 95% CI 8–22).
The Leicester Cough Monitor is a valid and reliable tool that can be used to assess 24-h cough
frequency in patients with cough. It should be a useful tool to assess patients with cough in
clinical trials and longitudinal studies.
KEYWORDS: Chronic cough, cough counts, cough frequency, cough monitor, Leicester Cough
Monitor
C
hronic cough is a common reason for
referral to respiratory physicians. The
assessment of patients with chronic
cough is often based on the anatomical diagnostic
protocol, which is a systematic evaluation based
on the understanding that most cases are due to
disease of the upper respiratory tract where
cough receptors are most plentiful [1]. The most
common conditions implicated in causing
chronic cough in nonsmokers are asthma, gastro-
oesophageal reflux and rhinitis, or a combination
of these [2].
The identification of an important contribution
by the aforementioned conditions is largely based
on the evaluation of treatment trials [3].
However, there are few well-validated outcome
measures to assess cough severity and treatment
efficacy. Cough visual analogue scores, diary
score cards, quality-of-life questionnaires, cough-
reflex sensitivity measurement and cough moni-
tors have been proposed as potential tools to
assess cough severity [2]. The subjective nature of
symptom scores and quality-of-life question-
naires [4, 5] and the poor specificity of cough-
reflex sensitivity measurement [6] to identify
patients with chronic cough have led to a
renewed interest in the development of auto-
mated ambulatory cough monitors [7–15].
BIRRING et al. [7] have previously shown that
there are marked differences in cough frequency
between patients with chronic cough and healthy
subjects and that these measurements are repea-
table, and have suggested that cough frequency
AFFILIATIONS
*Dept of Respiratory Medicine,
King’s College Hospital, London,
#
Dept of Medical Physics, Leicester
Royal Infirmary, and
"
Institute for Lung Health, Dept of
Respiratory Medicine, Glenfield
Hospital, Leicester, UK.
CORRESPONDENCE
I.D. Pavord
Dept of Respiratory Medicine
Glenfield Hospital Leicester
LE3 9QP
UK
Fax: 44 1162367768
E-mail: ian.pavord@uhl-tr.nhs.uk
Received:
May 10 2007
Accepted after revision:
December 16 2007
STATEMENT OF INTEREST
None declared
European Respiratory Journal
Print ISSN 0903-1936
Online ISSN 1399-3003
EUROPEAN RESPIRATORY JOURNAL VOLUME 31 NUMBER 5 1013
Eur Respir J 2008; 31: 1013–1018
DOI: 10.1183/09031936.00057407
CopyrightßERS Journals Ltd 2008
c
2. measurement is potentially useful in the assessment of patients
with chronic cough. Currently available cough monitors are
limited by difficulty in achieving unrestricted ambulatory
measurement in the patients’ own environment, an inability to
perform 24-h recording and a lack of automated cough
detection systems. The aim of the present study was to
develop an automated cough monitor (the Leicester Cough
Monitor (LCM)) capable of recording cough sounds for 24 h.
The present study shows the validation of the LCM and
preliminary findings of 6- and 24-h recordings in patients with
chronic cough.
METHODS
Subjects
A total of 15 consecutive patients with an isolated chronic
cough (.3 weeks duration) were recruited from a specialised
cough clinic. The clinic receives referrals from primary and
secondary care largely confined to a population of 970,000
within Leicestershire, UK. The causes of cough in patients with
chronic cough were: cough variant asthma (n54); gastro-
oesophageal reflux (n53); eosinophilic bronchitis (n51);
idiopathic (n53); post-viral (n51); bronchiectasis (n51);
chronic obstructive pulmonary disease (n51); and chronic
bronchitis (n51). Nine out of these patients were randomly
selected for the first stage of validation (cough variant asthma
(n54), eosinophilic bronchitis (n51), idiopathic (n52), post-
viral (n51), bronchiectasis (n51)) and all patients were
included in the second validation stage. Investigations were
carried out according to a standardised algorithm [16]. The
protocol for investigation and treatment and the criteria for
accepting diagnosis were as previously described [16]. Eight
controls were recruited from healthy volunteers responding to
local advertising. Control subjects were asymptomatic, non-
smokers and had normal spirometry and a concentration of
methacholine required to cause a 20% decrease in forced
expiratory volume in one second (FEV1) of .16mg?mL-1
. No
patients had received corticosteroids or other specific treat-
ment for the condition causing cough for o6 weeks prior to
the study. A randomly selected subgroup of six control
subjects and five patients with a stable chronic cough and
stable treatment requirements (three with cough variant
asthma, one with gastro-oesophageal reflux-associated cough
and one with idiopathic chronic cough) participated in cough
frequency repeatability studies 3–6 months after the first, at the
same time of day in order to avoid possible bias from diurnal
variations. A total of 50 further consecutive patients with
chronic cough were recruited in order to evaluate 24-h
recordings with the LCM (idiopathic cough (n526), asthma
(n58), eosinophilic bronchitis (n52), rhinitis (n52), sarcoidosis
(n52), gastro-oesophageal reflux (n53), bronchiectasis (n52),
chronic obstructive pulmonary disease (n52), enlarged tonsils
(n52) and obstructive sleep apnoea (n51)). All subjects gave
full informed written consent to participate. The protocol for
the present study was approved by the Leicestershire Research
Ethics Committee.
Cough monitor
The LCM (fig. 1) is a digital ambulatory cough monitor that
records sound continuously from a free-field microphone
necklace (Sennheiser MKE 2-5; Sennheiser electronic GmbH &
Co. KG, Woedemark, Germany) onto a digital sound recorder
(dimensions 26.7687632 mm; iRiver iFP-799; iRiver Europe
GmbH, Eschborn, Germany) at a sampling frequency of
16 kHz and with an encoding bit rate of 64 kbit?s-1
. The cough
monitor was attached at 09:00 h in all subjects and returned 6–
24 h later. Subjects were told that the LCM was a new
investigative tool being developed to assess the nature of the
cough and were encouraged to resume their normal activity in
their usual environment. When the recording was complete,
data stored on the recorder was downloaded onto a computer,
where it was analysed by an automated cough detection
algorithm (the Leicester Cough Algorithm).
A general outline of the Leicester Cough Algorithm has been
described previously [8, 17]. Briefly, the detection algorithm is
based on Hidden Markov Models, a statistical method that can
be used to characterise the spectral properties of a time-
varying pattern. The cough detection algorithm was imple-
mented based on the keyword-spotting approach, as defined in
speech recognition, in which the objective is to detect the
occurrence of a particular set of keywords in a sequence of
continuous speech. Continuous ambulatory recordings in
patients with chronic cough were used to train statistical
models of the characteristics of cough sounds and of the audio
background. During the detection process, the recorded audio
signal was divided into contiguous 10-s segments to be
analysed by the Hidden Markov Models-based algorithm.
Each 10-s audio segment was recognised by the detection
algorithm as a sequence of variable-length audio sections, each
in turn classified either as background audio or as a possible
cough sound, depending on its statistics [8]. A second
algorithm phase then used brief operator input to facilitate
the automated algorithm in order to eliminate sounds that
Microphone
Recorder
FIGURE 1. The Leicester Cough Monitor.
LCM: A NOVEL COUGH MONITOR S.S. BIRRING ET AL.
1014 VOLUME 31 NUMBER 5 EUROPEAN RESPIRATORY JOURNAL
3. might have been wrongly classified as cough events in the first
phase. For this, the operator is asked to classify, as cough or
otherwise, a small fraction of the sounds detected in the first
phase as possible cough sounds (the second phase takes 5 min
to carry out for a 24-h recording and ,50 sounds are
classified). The information is then used to create statistical
models that are adapted to the characteristics of the cough
sounds for that particular recording and the remaining sounds
that were not shown to the operator are classified using these
models.
Cough was defined as a characteristic explosive sound. The
algorithm identifies coughs as single events whether they
occur as isolated events or in a cluster (i.e. attempts were made
to determine how many coughs occurred in paroxysms).
Validation
Stage 1
The first stage of validation compared automated cough counts
against those identified by manual sound analysis of the first
and fourth recorded hours of nine randomly selected patients
with chronic cough. Manual analysis of sound recordings
consisted of three blinded observer counts (observer one twice
and observer two once) and cough or noncough sounds were
positively identified when all three counts were in agreement
based on sound and visual inspection of the acoustic trace.
Each cough sound was identified separately, whether it
occured singularly or in a cluster or epoch of coughs. Intra-
and interobserver variability in cough counts was established
from the two blinded analyses performed by observer one and
by comparing the mean of observer one’s counts for these
periods with counts obtained by observer two. The recordings
were analysed twice using the Leicester Cough Algorithm to
assess intra-recording repeatability. In order to classify non-
cough sounds and determine whether particular sounds were
wrongly classified by the automated system, observer one
listened to all 6 h of the nine patients’ recordings and classified
all recognisable sounds. The results of this analysis were
compared with the automated classification.
Stage 2
The second stage of validation was extended to all recordings
and compared automated cough counts against coughs
identified manually by observer one, who analysed the entire
6-h recording. A further 50 patients with chronic cough
underwent 24-h automated cough frequency measurement.
Automated cough frequency was compared for repeatability
studies.
Analysis
Subject characteristics were described using descriptive statis-
tics and expressed as mean¡SEM for parametric data and
median for non-parametric data. Cough frequency was
expressed as individual coughs?patient?h-1
for the duration of
the recording. The validity of the LCM was presented as
sensitivity, specificity and false-positive rate of the automated
algorithm for detecting coughs as measured by observer
manual analysis. Intra- and interobserver variability of manual
cough counts and repeatability data was assessed as intra-class
correlation coefficients and intra-subject SD.
RESULTS
The subject characteristics are shown in table 1.
Validation stage 1 (First and fourth recorded hour)
Mean cough counts were 39 coughs?patient-1
?h-1
by automated
analysis compared with 43 coughs?patient-1
?h-1
by manual
analysis (mean difference -4 coughs?patient-1
?h-1
, 95% confi-
dence interval (CI) -6–13; p50.4). The intra- and interobserver
intra-class correlation coefficients for manual analysis of sound
recordings (between observers one and two) were 0.99 and
0.98, respectively (both p,0.001). The intra- and interobserver
(i.e. between mean of observer one and observer two) intra-
class correlation coefficients for manual analysis of sound
recordings were 0.99 and 0.98, respectively (both p,0.001). The
intra-class correlation coefficient between automated and
manual observer counts was 0.9 (p,0.001; fig. 2a). The
accuracy of manual and automated cough counts appeared
similar in recordings containing paroxysms and those with
isolated coughs. The Leicester Cough Algorithm had a
sensitivity and a specificity of 91% and 99%, respectively, for
detecting cough sounds and a median false positive rate of
2.5 events?patient-1
?h-1
against the gold standard of coughs
detected manually by observer one twice and observer two
once. There was no evidence that any particular sound was
more likely to be classified as a false positive (fig. 3).
Validation stage 2 (6-h recordings)
Mean¡SEM automated cough counts were 48¡9 coughs?
patient-1
?h-1
in patients with chronic cough and 2¡1 coughs?
patient-1
?h-1
in control subjects (mean difference 46 coughs?
patient-1
?h-1
, 95% CI 20–71 coughs?patient-1
?h-1
; p,0.001;
fig. 4). There were no significant differences in cough
frequency between diagnostic groups. The cough analysis
took 2 h to complete, comprising 5 min for data download,
105 min for computer automated analysis (an operator was not
required to be present during phase 1) and 10 min for operator
input (phase 2) and printing results.
The intra-class correlation coefficient between automated and
observer counts was 0.93 (p,0.001; fig. 2b). The LCM had
sensitivity and specificity of 86 and 99%, respectively, for
detecting cough sounds and a median false-positive rate of
1.0 events?patient-1
?h-1
.
The automated cough counts were repeatable in the 11 subjects
who underwent repeatability testing (intra-subject SD 11.4 coughs?
patient-1
?h-1
, intra-class correlation coefficient 0.9; fig. 5).
TABLE 1 Subject characteristics
Control Chronic cough
Subjects (male) n 8 (0) 15 (5)
Age yrs 48¡3 55¡4
Cough duration yrs 5¡2
FEV1 % pred 91¡5 89¡7
FEV1/FVC % 79¡1 75¡4
Data are expressed as mean¡SEM, unless otherwise stated; FEV1: forced
expiratory volume in one second; pred: predicted; FVC: forced vital capacity.
S.S. BIRRING ET AL. LCM: A NOVEL COUGH MONITOR
c
EUROPEAN RESPIRATORY JOURNAL VOLUME 31 NUMBER 5 1015
4. The cough frequency in patients undergoing 24-h monitoring was
19 coughs?patient-1
?h-1
; daytime (08:00–22:00 h) cough frequency
was significantly greater than overnight cough frequency (25
versus 10 coughs?patient-1
?h-1
; mean difference 15 coughs?pa-
tient-1
?h-1
, 95% CI 8–22 coughs?patient-1
?h-1
; p,0.001; fig. 6).
DISCUSSION
The LCM is a lightweight 24-h automated ambulatory cough
monitor that is easy to use and measures cough in the subjects’
own environment. The present study has shown that it is a
valid and reliable tool for objectively measuring cough
frequency. The high sensitivity and specificity for the detection
of cough sounds is comparable to other routine diagnostic
clinical tools and superior to that reported for other more
cumbersome cough detection systems. Preliminary data is
presented in the current study showing that the cough
frequency measured with the LCM is repeatable over
o3 months, a period relevant to the duration of treatment
trials that form an important part of the assessment of patients
with chronic cough. Repeatability was marginally better than
that of recordings analysed manually [7]. The present data
suggest that the LCM might be a particularly useful outcome
measure in assessing patients with cough and measuring the
response to therapy in the clinic and in clinical trials.
A limitation of the present study is that evaluation of cough
frequency was based on 6-h daytime cough recordings owing
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u
u
u
80
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-40
-80
u u
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u
uuu
uu
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40
0
-40
-80
u
u
uuuuuu
a)
b)
0 50 100 150
Differencebetweenautomatedand
observercoughcounts·patient-1·h-1
Mean of automated and observer coughs·patient-1·h-1
Differencebetweenautomatedand
observercoughcounts·patient-1·h-1
FIGURE 2. Bland-Altman plot of automated versus manual observer cough
counts?patient-1
?h-1
. a) Validation stage 1 at which first and fourth recorded hour
(n59) were analysed. Each hour is depicted individually. b) Validation stage 2 at
which 6-h recordings (n523) were analysed in their entirety. The complete cough
detection algorithm (phases 1 and 2) was tested in each validation stage. –––:
mean difference; ??????: 95% limits of agreement (26 intra-subject SD); e: control
subjects; ¤: chronic cough patients.
31726 sounds:
1834 cough
29892 noncough
Phase 1
2543 accepted sounds:
1573 cough
970 noncough#
Phase 2
1680 accepted sounds:
1528 cough
152 noncough+
29183 rejected sounds:
261 cough
28922 noncough
863 rejected sounds:
45 cough
818 noncough¶
FIGURE 3. False positives characterised manually that were detected by the
automated Leicester Cough Monitor in nine 6-h recordings of patients with chronic
cough. Automated analysis of sound recording is performed during phase 1 and
automated analysis following operator input is performed during phase 2. The
sensitivity for cough detection is slightly lower than that from the gold standard
validation stage 1, since the comparator was a 6-h manual counting by observer
one only. #
: noncough sounds were: speech (n5351), impulsive noise (n5222)
throat clearing (n5119), environmental noise (n5111), laugh (n580), other person
coughing (n531), incomplete coughs (n522), child talking/shouting (n521),
sneeze (n56), telephone ringing (n53), burp (n52) and dog barking (n52).
"
: noncough sounds were: speech (n5293), impulsive noise (n5214), throat
clearing (n596), environmental noise (n587), laugh (n567), other person coughing
(n515), incomplete coughs (n518), child talking/shouting (n517), sneeze (n55),
telephone ringing (n53), burp (n52) and dog barking (n51). +
: noncough sounds
were: speech (n558), impulsive noise (n58), throat clearing (n523), environmental
noise (n524), laugh (n513), other person coughing (n516), incomplete coughs
(n54), child talking/shouting (n54), sneeze (n51) and dog barking (n51).
Chronic cough patients
150
125
100
75
50
25
0
Control subjects
Coughs·patient-1·h-1
uu
uuu
u
u
u
u
u
u
uu
u
u
u u uu uuuu
***
FIGURE 4. Mean¡SEM automated cough counts?patient-1
?h-1
in control
subjects and chronic cough patients (6-h recordings). ***: p,0.001.
LCM: A NOVEL COUGH MONITOR S.S. BIRRING ET AL.
1016 VOLUME 31 NUMBER 5 EUROPEAN RESPIRATORY JOURNAL
5. to limited battery life (6–8 h) at the inception of the study.
Advances in battery technology, since then, have allowed the
extension of recordings to o24 h. The automated system has
allowed these recordings to be analysed relatively quickly and
accurately and should facilitate the investigation of potential
diurnal variations in cough frequency and the effects of
aggravators of potential cough, such as environmental pollu-
tion, cigarette smoking and gastro-oesophageal reflux. In the
present study, a range of sounds including speech, throat
clearing and environmental noises caused false-positive
detected coughs. There was little evidence that any of these
sounds caused particular difficulties with detection, nor did
cough paroxysms appear to present problems for accurate
manual and automated cough counts. However, greater
experience with the monitor may identify sounds or cough
paroxysms that present particular problems for the algorithm
to classify and allow further refinement of the algorithm. The
present study involved small numbers of subjects and it will be
important to study a larger population of control subjects and
patients with well-defined respiratory disease, before and after
treatment, and in different environments, to fully validate the
cough monitor. The present preliminary work suggests that
such a study will be feasible.
Cough frequency was stable through the day and was
significantly reduced overnight compared with daytimes in
accord with previous data, suggesting a diurnal variation in
cough frequency [5, 9, 13]. Further work is required to
determine the validity and the short- and longer-term
repeatability of 24-h cough recordings.
A limitation of the present study is that only 2 h per recording
were used to compare automated cough counts with those
obtained from manual counting for the validation study.
Manual cough counting is very time consuming and laborious
so only the first and fourth hours of each recording were
manually analysed for consistency. Each recording was
manually counted three times in order to obtain a more robust
measure of the true cough frequency. The LCM had a high
sensitivity and specificity for detecting cough against this gold
standard. This was confirmed in the second part of the
validation study where cough counts derived from automated
analysis of 6-h recordings were compared with cough counts
derived from a single manual observer. The sensitivity of the
cough algorithm was slightly lower with 6-h recordings
compared with 2-h recordings. This is most probably because
of the more robust measure of true cough frequency used for
the 2-h recordings, compared with single observer manual
counts used for the 6-h recordings.
A potential criticism of cough counts derived from audio
recordings is that they might not accurately reflect the true
cough rate since it is not possible to visualise the act of
coughing. However, a recent study [18] compared manual
cough counts from audio with video recordings and found
them to be very similar. That study concluded that manual
cough counts from audio recordings should be regarded as the
gold standard to validate cough monitors since audio record-
ings had superior sound quality to that from video recordings.
The LCM quantifies cough frequency as single episodes of
cough rather than epochs or clusters of coughs and cough
seconds (seconds containing cough), as used by others [12].
The present authors believe that single cough episodes are a
more meaningful measure and are easier to interpret by
physicians and patients. Cough frequency, rather than inten-
sity, was measured since cough events are less influenced by
microphone position and muffling of sounds by covering the
mouth during the act of coughing. Furthermore, cough
intensity determined with sound analysis lacks responsiveness
compared with cough frequency in clinical trials of antitussive
drugs [10]. Cough intensity determined by other parameters
such as airflow or chest wall movement is less practical for
routine clinical measurement. The LCM was validated in
subjects with chronic cough due to a wide range of conditions
so it reliably detects coughs with differing characteristics.
One of the challenges of developing cough monitors in the past
has been differentiating cough sounds from throat clearing,
sneezing, speech and other cough-like sounds. The Leicester
Cough Monitor differentiates cough from other sounds reliably
80
60
40
20
0
-20
-40
-60
-80
0 10 20 30 40 50
u
u
u
u
uuu
u
u
u
Differencebetweentests
coughs·patient-1·h-1
Mean of two tests coughs·patient-1·h-1
FIGURE 5. Bland-Altman plot of automated cough counts?patient-1
?h-1
repeated over 3–6 months in chronic cough patients and control subjects. ––––:
mean difference; ???????: 95% limits of agreement (26 intra-subject SD). e: control
subjects; ¤: chronic cough patients.
09:00
07:00
05:00
03:00
01:00
23:00
19:00
17:00
15:00
13:00
11:00
09:00
21:00
35
30
25
20
15
10
5
0
Coughs·patient-1
Time h
FIGURE 6. 24-h ambulatory, automated cough frequency recordings in 50
chronic cough patients. Data are presented as mean+SEM.
S.S. BIRRING ET AL. LCM: A NOVEL COUGH MONITOR
c
EUROPEAN RESPIRATORY JOURNAL VOLUME 31 NUMBER 5 1017
6. as indicated by the high sensitivity and particularly high
specificity for detecting cough. The Leicester Cough Monitor
represents a potential advance over existing cough monitors in
that it is portable outside a controlled environment, it does not
require measurement of abdominal electromyography and it
can be set to record for 24 h. The 24-h sound recording is
discarded after the automated analysis process, thereby
ensuring patient privacy. The Leicester Cough Monitor could
be used to validate the presence of excessive cough, to assess
cough severity and to objectively evaluate response to therapy.
Further studies are required in order to assess the use of the
Leicester Cough Monitor in clinical practice.
ACKNOWLEDGEMENTS
The present authors would like to thank the subjects who
participated in the study, C. Long (Dept of Respiratory
Physiology, Glenfield Hospital, Leicester, UK) for assistance
in data analysis, D.D. Vara (Dept of Respiratory Physiology,
Glenfield Hospital) for assistance in the clinical characterisa-
tion of some of the patients and the lung function unit staff at
King’s College Hospital, London, UK (C. Wood, L. Morgan, D.
Cox and D. Land) and Glenfield Hospital.
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1018 VOLUME 31 NUMBER 5 EUROPEAN RESPIRATORY JOURNAL