Pulmonology

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Chronic obstructive pulmonary disease in South Africa : under-recognised and undertreated
(Health & Medical Publishing Group, 2015) Allwood, Brian W.; Van Zyl-Smit, Richard N.
Chronic obstructive pulmonary disease (COPD) is a common, preventable but incurable condition currently ranked third in global mortality estimates. Worldwide, 65 million people are estimated to have moderate to severe COPD, and the disease accounts for 3 million deaths annually, of which 90% are said to occur in low- and middle-income countries. Yet, despite these staggering numbers, COPD remains both under-recognised and undertreated in most populations, also in South Africa (SA). There are many reasons for this, not least of which is the attitude of clinicians, which can often be fatalistic with regard to COPD. This edition of CME highlights key aspects of the diagnosis and treatment – pharmacological and non-pharmacological – and new developments in the management of severe disease. Furthermore, we have included articles focusing on non-smokingrelated COPD and tips for good spirometry.
Complete resolution of apparently definite radiological and histological usual interstitial pneumonia
(Health & Medical Publishing Group, 2018-08-30) Simon, D.; Irusen, E. M.; Allwood, Brian W.; Rigby, J.; Koegelenberg, C. F. N.
ENGLISH ABSTRACT: Idiopathic pulmonary fibrosis is considered to be the most common form of pulmonary fibrosis. It is a progressive and irreversible disease with a reported median survival of ~3 years. The pathological correlate is usual interstitial pneumonia (UIP), and although antifibrotic agents can slow down lung function decline, they do not completely reverse the disease process. To date, there have been no case reports describing reversal of UIP. We present a case where both the imaging and histology were compatible with definite UIP, yet it reversed with immunosuppressive therapy without the use of antifibrotic agents.
COVID-19 in Africa : care and protection for frontline healthcare workers
(BioMed Central, 2020) Chersich, Matthew F.; Gray, Glenda; Fairlie, Lee; Eichbaum, Quentin; Mayhew, Susannah; Allwood, Brian W.; English, Rene; Scorgie, Fiona; Luchters, Stanley; Simpson, Greg; Mosalman Haghighi, Marjan; Duc Pham, Minh; Rees, Helen
Medical staff caring for COVID-19 patients face mental stress, physical exhaustion, separation from families, stigma, and the pain of losing patients and colleagues. Many of them have acquired SARS-CoV-2 and some have died. In Africa, where the pandemic is escalating, there are major gaps in response capacity, especially in human resources and protective equipment. We examine these challenges and propose interventions to protect healthcare workers on the continent, drawing on articles identified on Medline (Pubmed) in a search on 24 March 2020. Global jostling means that supplies of personal protective equipment are limited in Africa. Even low-cost interventions such as facemasks for patients with a cough and water supplies for handwashing may be challenging, as is ‘physical distancing’ in overcrowded primary health care clinics. Without adequate protection, COVID-19 mortality may be high among healthcare workers and their family in Africa given limited critical care beds and difficulties in transporting ill healthcare workers from rural to urban care centres. Much can be done to protect healthcare workers, however. The continent has learnt invaluable lessons from Ebola and HIV control. HIV counselors and community healthcare workers are key resources, and could promote social distancing and related interventions, dispel myths, support healthcare workers, perform symptom screening and trace contacts. Staff motivation and retention may be enhanced through carefully managed risk ‘allowances’ or compensation. International support with personnel and protective equipment, especially from China, could turn the pandemic’s trajectory in Africa around. Telemedicine holds promise as it rationalises human resources and reduces patient contact and thus infection risks. Importantly, healthcare workers, using their authoritative voice, can promote effective COVID-19 policies and prioritization of their safety. Prioritizing healthcare workers for SARS-CoV-2 testing, hospital beds and targeted research, as well as ensuring that public figures and the population acknowledge the commitment of healthcare workers may help to maintain morale. Clearly there are multiple ways that international support and national commitment could help safeguard healthcare workers in Africa, essential for limiting the pandemic’s potentially devastating heath, socio-economic and security impacts on the continent.
The current aetiology of malignant pleural effusion in the Western Cape Province, South Africa
(Health & Medical Publishing Group, 2018-04) Koegelenberg, C. F. N.; Bennji, S. M.; Boer, E.; Schubert, P. T.; Shaw, J. A.; Allwood, Brian W.; Irusen, E. M.
Background: Malignant pleural effusion (MPE) represents a very common cause of pleural exudates, and is one of the most challenging pleural disorders to manage. This could be attributed to the paucity of high-quality experimental evidence, and inconsistent practice worldwide. South Africa (SA) currently has no data regarding the aetiology of MPE. Objectives: To identify the most common malignancies causing MPE in a population served by a large tertiary hospital in SA, and specifically the relative contribution of mesothelioma. A secondary objective was to evaluate the efficacy of chemical pleurodesis in a subset of patients. Methods: We retrospectively included all known cases of MPE evaluated at our institution over a 3-year period with a tissue diagnosis of MPE. Results: The most common causes of MPE in a total of 274 patients were lung cancer (n=174, 63.5%), breast cancer (n=32, 11.7%), unknown primary (n=22, 11.7%) and mesothelioma (n=27, 9.9%). Talc pleurodesis was performed in 81 of 194 patients (41.8%) referred to our division, and was radiologically successful in 22 of 25 (88.0%) followed up to 3 months. Conclusions: The main cause of MPE in our setting was lung cancer, followed by breast cancer, unknown primary and mesothelioma. Chemical pleurodesis was a viable palliative measure for MPE in this population.
Endoscopic lung volume reduction in severe emphysema
(Health & Medical Publishing Group, 2015) Koegelenberg, Coenraad Frederik N.; Theron, Johan; Bruwer, J. W.; Allwood, Brian W.; Vorster, Morne J.; Von Groote-Bidlingmaier, Florian; Dheda, Keertan
ENGLISH ABSTRACT: Therapeutic options in severe emphysema are limited. Endoscopic lung volume reduction (ELVR) refers to bronchoscopically inducing volume loss to improve pulmonary mechanics and compliance, thereby reducing the work of breathing. Globally, this technique is increasingly used as treatment for advanced emphysema with the aim of obtaining similar functional advantages to surgical lung volume reduction, while reducing risks and costs. There is a growing body of evidence that certain well-defined subgroups of patients with advanced emphysema benefit from ELVR, provided that a systematic approach is followed and selection criteria are met. In addition to endobronchial valves, ELVR using endobronchial coils is now available in South Africa. The high cost of these interventions underscores the need for careful patient selection to best identify those likely to benefit from such procedures.
Fatal tumour pulmonary embolism
(Wiley Open Access, 2017) Masoud, Salim Rashid; Koegelenberg, Coenraad Frederik Nicolaas; Van Wyk, Abraham Christoffel; Allwood, Brian W.
A 30-year-old female with no significant past medical history was referred to our facility with sudden onset of shortness of breath. She had a low clinical probability for pulmonary thromboembolism and a computed tomography angiogram showed enlarged pulmonary arteries but no in situ thrombi. She developed recurrent episodes of hypotension and hypoxia, and was transferred to the intensive care unit where she died despite active resuscitation. An autopsy revealed extensive lymphatic and pulmonary vascular tumour emboli as the immediate cause of death. Pulmonary tumour embolism is a very rare cause of death, but can occur in patients who have an occult neoplasm.
Five-year follow-up of participants diagnosed with chronic airflow obstruction in a South African Burden of Obstructive Lung Disease (BOLD) survey
(Health & Medical Publishing Group, 2018-02-01) Allwood, Brian W.; Gillespie, R.; Bateman, M.; Olckers, H.; Taborda-Barata, Luis; Calligaro, G.; Van Zyl-Smit, R.; Cooper, C. B.; Beyers, Nulda; Bateman, E. D.
Background. A community-based prevalence survey performed in two suburbs in Cape Town, South Africa (SA), in 2005, using the international Burden of Obstructive Lung Disease (BOLD) method, confirmed a prevalence of chronic airflow obstruction (CAO) in 23.1% of adults aged >40 years. Objectives. To study the clinical course and prognosis over 5 years of patients with CAO identified in the 2005 survey. Methods. Patients with CAO in 2005 were invited to participate. Standard BOLD and modified questionnaires were completed. Spirometry was performed using spirometers of the same make as in 2005. Results. Of 196 eligible participants from BOLD 2005, 45 (23.0%) had died, 8 from respiratory causes, 10 from cardiovascular causes and 6 from other known causes, while in 21 cases the cause of death was not known. On multivariate analysis, only age and Global initiative for Obstructive Lung Disease (GOLD) stage 4 disease at baseline were significantly associated with death. Of the 151 survivors, 11 (5.6% of the original cohort) were unavailable and 33 (16.8%) declined or had medical exclusions. One hundred and seven survivors were enrolled in the follow-up study (54.6%, median age 63.1 years, 45.8% males). Post-bronchodilator spirometry performed in 106 participants failed to confirm CAO, defined as a forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ratio of <0.7, in 16 participants (15.1%), but CAO was present in 90. The median decline in FEV1 was 28.9 mL/year (interquartile range –54.8 - 0.0) and was similar between GOLD stages. The median total decline in FVC was 75 mL, and was significantly greater in GOLD stage 1 (–350 mL) than in stages 2 or 3 (–80 mL and +140 mL, respectively; p<0.01). Fifty-eight participants with CAO in 2005 (64.4%) remained in the same GOLD stage, while 21 (23.3%) deteriorated and 11 (12.2%) improved by ≥1 stage. Only one-third were receiving any treatment for chronic obstructive pulmonary disease (COPD). Conclusions. The prevalence, morbidity and mortality of CAO and COPD in SA are high and the level of appropriate treatment is very low, pointing to underdiagnosis and inadequate provision of and access to effective treatments and preventive strategies for this priority chronic non-communicable disease.
Pathogenesis of chronic obstructive pulmonary disease : an African perspective
(Health & Medical Publishing Group, 2015) Allwood, Brian W.; Calligaro, G .
The importance of chronic obstructive pulmonary disease (COPD) as a global health problem cannot be overstated. According to the latest World Health Organization statistics (2005), 210 million people suffer from COPD worldwide, and 5% of all deaths globally are estimated to be caused by this disease. This corresponds to >3 million deaths annually, of which 90% are thought to occur in low- and middle-income countries. While cigarette smoking remains the major risk factor, and much of the increase in COPD is associated with projected increases in tobacco use, epidemiological studies have demonstrated that in the majority of patients in developing countries the aetiology of COPD is multifactorial. This article summarises the epidemiology of and risk factors for COPD in Africa, including influences other than cigarette smoking that are important contributors to chronic irreversible airflow limitation in our setting.
Post-pulmonary tuberculosis complications in South Africa and a potential link with pulmonary hypertension : premise for clinical and scientific investigations
(Health & Medical Publishing Group, 2018) Allwood, Brian W.; Maarman, G. J.; Kyriakakis, C. G.; Doubell, A. F.
The magnitude of the pulmonary tuberculosis (TB) epidemic in South Africa (SA) and globally[1] has received increased attention. Efforts have been made to explore new and improved diagnostic[2] and treatment strategies,[3] but the story does not end with treatment, and TB frequently results in long-term lung damage.
Transition from restrictive to obstructive lung function impairment during treatment and follow-up of active tuberculosis
(Dove Medical Press, 2020) Allwood, Brian W.; Maasdorp, Elizna; Kim, Grace J.; Cooper, Christopher B.; Goldin, Jonathan; Van Zyl-Smit, Richard N.; Bateman, Eric D.; Dawson, Rodney
Background: Pulmonary tuberculosis (PTB) is associated with many forms of chronic lung disease including the development of chronic airflow obstruction (AFO). However, the nature, evolution and mechanisms responsible for the AFO after PTB are poorly understood. The aim of this study was to examine the progression of changes in lung physiology in patients treated for PTB. Methods: Immunocompetent, previously healthy, adult patients receiving ambulatory treatment for a first episode of tuberculosis were prospectively followed up with serial lung physiology and quantitative computed tomography (CT) lung scans performed at diagnosis of tuberculosis, 2, 6, 12 and 18 months during and after the completion of treatment. Results: Forty-nine patients (median age 26 years; 37.2% males) were included, and 43 were studied. During treatment, lung volumes improved and CT fibrosis scores decreased, but features of AFO and gas trapping emerged, while reduced diffusing capacity (DLco) seen in a majority of patients persisted. Significant increases in total lung capacity (TLC) by plethysmography were seen in the year following treatment completion (median change 5.9% pred., P< 0.01) and were driven by large increases in residual volume (RV) (median change +19%pred., P< 0.01) but not inspiratory capacity (IC; P=0.41). The change in RV/TLC correlated with significant progression of radiological gas trapping after treatment (P=0.04) but not with emphysema scores. One year after completing treatment, 18.6% of patients had residual restriction (total lung capacity, TLC < 80%pred), 16.3% had AFO, 32.6% had gas trapping (RV/TLC> 45%), and 78.6% had reduced DLco. Conclusion: Simple spirometry alone does not fully reveal the residual respiratory impairments resulting after a first episode of PTB. Changes in physiology evolve after treatment completion, and these findings when taken together, suggest emergence of gas trapping after treatment likely caused by progression of small airway pathology during the healing process.
Transition from restrictive to obstructive lung function impairment during treatment and follow-up of active tuberculosis
(Dove Press, 2020-05) Allwood, Brian W.; Maasdorp, Elizna; Kim, Grace J.; Cooper, Christopher B.; Goldin, Jonathan; van Zyl-Smit, Richard N.; Bateman, Eric D.; Dawson, Rodney
Background: Pulmonary tuberculosis (PTB) is associated with many forms of chronic lung disease including the development of chronic airflow obstruction (AFO). However, the nature, evolution and mechanisms responsible for the AFO after PTB are poorly understood. The aim of this study was to examine the progression of changes in lung physiology in patients treated for PTB. Methods: Immunocompetent, previously healthy, adult patients receiving ambulatory treatment for a first episode of tuberculosis were prospectively followed up with serial lung physiology and quantitative computed tomography (CT) lung scans performed at diagnosis of tuberculosis, 2, 6, 12 and 18 months during and after the completion of treatment. Results: Forty-nine patients (median age 26 years; 37.2% males) were included, and 43 were studied. During treatment, lung volumes improved and CT fibrosis scores decreased, but features of AFO and gas trapping emerged, while reduced diffusing capacity (DLco) seen in a majority of patients persisted. Significant increases in total lung capacity (TLC) by plethysmography were seen in the year following treatment completion (median change 5.9% pred., P<0.01) and were driven by large increases in residual volume (RV) (median change +19%pred., P<0.01) but not inspiratory capacity (IC; P=0.41). The change in RV/TLC correlated with significant progression of radiological gas trapping after treatment (P=0.04) but not with emphysema scores. One year after completing treatment, 18.6% of patients had residual restriction (total lung capacity, TLC <80%pred), 16.3% had AFO, 32.6% had gas trapping (RV/TLC>45%), and 78.6% had reduced DLco. Conclusion: Simple spirometry alone does not fully reveal the residual respiratory impairments resulting after a first episode of PTB. Changes in physiology evolve after treatment completion, and these findings when taken together, suggest emergence of gas trapping after treatment likely caused by progression of small airway pathology during the healing process. Keywords: airflow obstruction; chronic obstructive pulmonary disease; computed tomography; lung function; post-tuberculosis; tuberculosis.
The utility of high-flow nasal cannula oxygen therapy in the management of respiratory failure secondary to COVID-19 pneumonia
(Health & Medical Publishing Group, 2020-05-07) Lalla, Usha; Allwood, Brian W.; Louw, Elizabeth H.; Nortje, Andre; Parker, Arifa; Taljaard, Jantjie J.; Moodley, Desiree; Koegelenberg, Coenraad F. N.
COVID-19 is a potentially fatal infection caused by SARS-CoV-2.[1] As of 4 May 2020, more than 6 000 cases had been confirmed in South Africa (SA) with numbers rising steadily, a situation that will place a major strain on the country’s health resources, including its ability to provide intensive care and ventilatory support to patients with severe disease.

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