PNEUMON

PNEUMON • VOL. 31 • No 1 • JANUARY - MARCH 2018

QUARTERLY MEDICAL JOURNAL

HELLENIC
THORACIC
SOCIETY ΠΝΕΥΜΩΝ
ΤΡΙΜΗΝΗ ΙΑΤΡΙΚΗ ΕΚΔΟΣΗ
ΕΛΛΗΝΙΚΗ
ΠΝΕΥΜΟΝΟΛΟΓΙΚΗ
ΕΤΑΙΡΕΙΑ

ISSN 1105-848X

e-ISSN 1791-4914

PNEUMON • VOL. 31 • No 1 • JANUARY - MARCH 2018

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 PNEUMON QUARTERLY MEDICAL JOURNAL

HELLENIC
THORACIC
SOCIETY ΠΝΕΥΜΩΝ
ΤΡΙΜΗΝΗ ΙΑΤΡΙΚΗ ΕΚΔΟΣΗ
ΕΛΛΗΝΙΚΗ
ΠΝΕΥΜΟNOΛΟΓΙΚΗ
ΕΤΑΙΡΕΙΑ

OFFICIAL JOURNAL OF THE

HELLENIC THORACIC SOCIETY
(HTS)

ISSN 1105-848X EDITORIAL BOARD

e-ISSN 1791-4914
Editor-in-Chief: Demosthenes Bouros, MD, PhD, FCCP, FERS, FAPSR (Greece)
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 Contents
PNEUMON QUARTERLY MEDICAL JOURNAL

Editorials
HELLENIC
THORACIC
SOCIETY ΠΝΕΥΜΩΝ
ΤΡΙΜΗΝΗ ΙΑΤΡΙΚΗ ΕΚΔΟΣΗ
ΕΛΛΗΝΙΚΗ
ΠΝΕΥΜΟNOΛΟΓΙΚΗ
ΕΤΑΙΡΕΙΑ

Non Tuberculous Mycobacterial Infection

From Oscar Wilde to Gene Sequencing
A. Tzouvelekis, D. Bouros.........................................................................................................11
Lung function in the elderly: Nascentes morimur
P. Panagou, E. Bouros, A. Tzouvelekis, V. Tzilas, D. Bouros............................................14

Original Paper
Introduction of new technologies in Pneumonology training
Μedical students can show us the way
E. Pilitsi, P. Steiropoulos............................................................................................................17

Reviews
Biomedical Applications of Biopolymers in Airway Disease
G.T. Noutsios, A.A. Pantazaki..................................................................................................24
Physiotherapy in cystic fibrosis. Α comprehensive clinical overview
A. Spinou ...................................................................................................................................... 35

Case Report
Reversed halo sign in community acquired pneumonia.
A case report
R. Pechlivanidou, A. Mitka, E. Giovanis, V. Drampa,
D. Mpompotas, A. Antoniadis............................................................................................... 44

Images in Pneumonology
The Rivulet Sign
U. Desai, J.M. Joshi..................................................................................................................... 49
Pulmonary Langerhans Cell Histiocytosis
Evolution of radiologic findings after smoking cessation
V. Tzilas, D. Bouros...................................................................................................................... 50
Septic thromboembolism in intravenous drug users
L. Kolilekas, M. Eliopoulou, G. Konstantopoulou, K. Loverdos, M. Gaga.................51

PNEUMON
Vol. 31, No 1
January - March 2018

Non Tuberculous Mycobacterial Infection
From Oscar Wilde to Gene Sequencing
Argyrios Tzouvelekis,
Demosthenes Bouros
1
First Academic Department of
Pneumonology, Interstitial Lung Diseases
Unit, Hospital for Diseases
of the Chest, “Sotiria”, Medical School,
National and Kapodistrian University
of Athens, Athens, Greece
Key words:
- Non Tuberculous Mycobacterial Infection
- NTBM
- Diagnosis
Correspondence to:
Argyrios Tzouvelekis
First Academic Department of Pneumonology
Hospital for Diseases of the Chest, “Sotiria”
152 Messogion Avenue, 11527, Athens, Greece
E-mail: argyrios.tzouvelekis@fleming.gr
Editorial
A 70-year old female, lifetime non-smoker was admitted to our outpa-
tient clinic complaining of mild productive cough, dyspnea on exertion
and general fatigue. During the last ten years she reported multiple lower
respiratory tract infections and was diagnosed with bronchiectasis based on
compatible HRCT findings 5 years ago. Four years ago, Pseudomonas Aerugi-
nosa was isolated from her sputum and was treated with oral ciprofloxacin
for 21 days. During the last three years she reported no hospitalizations
and was self-prescribing antibiotics during worsening of her symptoms.
On admission she was afebrile, thin and pthysic and had mild kyphosco-
liosis. Her clinical examination revealed: SaO2: 95%, (FiO2: 21%), heart rate:
90 bpm, respiratory rate: 12/min, and inspiratory squeaks on auscultation,
mainly localized on lower lobes. She had no clubbing or ankle edema.
She reported no Raynaud’s phenomenon or other symptoms of arthritis
(arthralgias, morning stiffness) or myositis. Her high resolution computed
tomography revealed multiple cystic bronchiectases and nodular tree-in-
bud opacities (Figure 1). A complete etiologic investigation of non-cystic
Figure 1. High-resolution chest computed tomography shows extensive bronchi-
ectatic lesions and tree-in-bud opacities with linear branching pattern and nearly
uniform distribution in the right middle and lower lobe, as well as the lingula and
the left lower lobe, indicating architectural distortion and terminal airway mucous
impaction with adjacent peribronchiolar inflammation. Insets are showing bron-
chiectatic lesions and tree-in-bud opacities (left panels and right upper panel) as
well as signet-ring shaped bronchiectasis (right lower panel).
12
fibrosis bronchiectasis was performed.
The patient was immunocompetent based on quan-
titative serum immunoglobulin and general blood tests,
revealed no history compatible with pertussis infection
at infancy or childhood and her serum immunologic
profile was negative. She was HIV and hepatitis B and
C negative. Her tuberculin skin test was 8 mm and the
interferon-gamma release assay (IGRA-QuantiferonTB-
gold) was negative. Her sputum smears (n=3), PCR assays
and solid-medium (Lowenstein Jensen) culture were
negative for mycobacterium tuberculosis (MTB). Solid
medium cultures of sputum specimens revealed colonies
of non-tuberculous mycobacterium avium complex (MAC).
She was commenced treatment with a thrice-weekly
regimen consisted of: rifampicin – 600 mg (qid), clar-
ithromycin - 1000 mg (bid) and ethambutol-1000 mgr
(qid). Two months later the patient reported significant
improvement of her dyspnea, fatigue and cough as well
as sputum purulence and volume.
The isolation of non-tuberculous mycobacterial
(NTM) remains a clinical dilemma. Because NTM naturally
exist in the environment, isolation of NTM from a non-
sterile respiratory specimen does not necessary mean
infection. NTM pulmonary infection develops commonly
in structural lung disease such as chronic obstructive
pulmonary disease (COPD), bronchiectasis, cystic fibro-
sis, pneumonoconiosis, prior tuberculosis, pulmonary
alveolar proteinosis and esophageal motility disorders1.
In addition, clinicians should be highly aware and raise
suspicion for NTM infection in cases of recurrent respira-
tory infections in immunocompetent individuals with
radiological features of bronchiectasis.
More than 20 years ago, NTM pulmonary infection
has been described in the context of Lady Windermere’s
syndrome which typically consists of the phenotype of
a thin, well-mannered elderly woman with voluntarily
cough suppression, mainly middle-lobe bronchiectasis
and pulmonary mycobacterium avium complex infection2,3.
The fastidious nature and reticence to expectorate are
believed to be the main predisposing factors for lung
infection by allowing secretions to collect into airways,
particularly in the right middle lobe which has the longest
and narrowest structure among lobar bronchi. The name
originates from the lead character in Oscar Wilde’s play
Lady Windermere’s Fan, which satirizes the strict morals and
polite manners typical of the Victorian era in Great Britain.
The diagnosis of NTM pulmonary infection can be
challenging and to this end clinicians should integrate
PNEUMON Number 4, Vol. 30, October - December 2017
atypical respiratory symptoms (cough, sputum, dyspnea)
and radiological features (cylindrical bronchiectasis, mul-
tifocal tree-in bud opacities or cavitary lesions) to highly
specific microbiological findings (positive culture for NTM
in more than 2 expectorated sputum specimens or one
specimen from bronchial lavage or washing) (Table 1)4.
It is important to note that AFB stains (Kinyoun method
seems to be superior to Ziehl-Neelsen) cannot distinguish
between NTM and MTB. Nucleic acid amplification (NAA)
tests are needed. Culture remains the gold standard for
confirmation of NTM diagnosis. Culture media are similar
to MTB. Both solid (Lowenstein Jensen) and liquid culture
(Middlebrook 7H9) platforms are required. Nevertheless,
since treatment and outcomes are different among NTM
species, precise NTM identification is critical. Sequencing
of the 16sRNA gene is the reference method of choice
for NTM discrimination up to the subspecies level. Gene
sequencing can also be used to identify Inducible mac-
rolide resistance, especially in mycobacteria with rapidly
growing taxonomy, such as M. abscessus complex4.
Macrolides represent the cornerstone of NTM-MAC
treatment (Table 1). Management can be difficult and
lengthy (at least 12 months) and should be individually
tailored based on the NTM species, disease symptoms,
radiological extent and patients’ preferences1. On the
other hand, current guidelines suggest similar to MTB
therapeutic regimens (except for pyrazinamide) for the
treatment of M. Kansasii, which is a relatively treatable
pathogen. The therapy for M. Abscessus still remains a
bottleneck for physicians and researchers. Guidelines sug-
gest an oral macrolide and two parenteral agents such as
amikacin, imipenem, tygecycline, cefoxitin and linezolid
for several months. Bedaquiline, tigecycline, linezolid and
clofazimine (an anti-leprosy drug) represent therapeutic
agents used for MDR-TB infections5-9.
In NTM refractory cases, debulking surgery of the
most affected area of the lung may be helpful in selected
number of patients10. In general, except from M. Kansasii,
NTM infection is difficult to eradicate with anti-microbial
therapy alone and is characterized by frequent relapses.
Clinical trials enrolling patients with refractory NTM infec-
tion are sorely needed. Multiple combination therapies
involving both surgical and anti-microbial interventions
with novel therapeutic agents may hold promise for the
future. Early referral to a reference center of excellence
and multidisciplinary approaches are mandatory for
optimal therapeutic decisions.
PNEUMON Number 4, Vol. 30, October - December 2017 13

Table 1. Diagnostic Criteria and Therapeutic Approach for Non Tuberculous Mycobacterial (NTM)- MAC (Mycobacterium Avium
complex) lung Disease
Category Criteria
Clinical Pulmonary symptoms
1. Cough
2. Expectoration
3. Exclusion of alternative diagnoses
Radiological 1. CXR – Nodular or cavitary opacities
2. HRCT – Multifocal bronchiectatic lesions with multiple small nodules
Microbiologic 1. Positive culture in at least 2 sputum samples and AFB negative
2. Positive culture in at least 1 bronchial wash or lavage
3. TBB or other lung biopsy with granulomatous inflammation and positive culture for NTM and one positive
culture in bronchial wash or lavage
Additional 1. Clinical and radiological criteria are both required for diagnosis
considerations 2. Expert referral and consultation for diagnosis and treatment
3. Diagnosis does not necessitate treatment. Treatment should be individually tailored
Treatment A. Daily regimen:
1. Macrolides (azithromycin 250 mgr or Clarithromycin 1000 mg/day)
2. Rifamycin (rifampin or rifabutin) – 600 mg/day
3. Ethambutol 15 mg/kg/day
B. Thrice weekly regimen:
1. Macrolides (azithromycin 500 mg or Clarithromycin 1000 mg)
2. Rifampin 600 mg
3. Ethambutol 25 mg/kg
Duration 1. 18-24 months
2. At least 12 months after culture negativity

References 6. Peloquin C. The Role of Therapeutic Drug Monitoring in Myco-

1. Griffith DE, Aksamit T, Brown-Elliott BA, et al. An official ATS/
IDSA statement: diagnosis, treatment, and prevention of
nontuberculous mycobacterial diseases. Am J Respir Crit Care
Med 2007; 175:367-416.
2. Ballard DH, Previgliano CH. Lady Windermere Syndrome. Am
J Med Sci 2016; 351:e7.
3. Donatelli C, Mehta AC. Lady Windermere syndrome: Myco-
bacterium of sophistication. Cleve Clin J Med 2015; 82:641-3.
4. Ryu YJ, Koh WJ, Daley CL. Diagnosis and Treatment of Nontu-
berculous Mycobacterial Lung Disease: Clinicians’ Perspectives.
Tuberc Respir Dis (Seoul) 2016; 79:74-84.
5. Philley JV, Wallace RJ, Jr., Benwill JL, et al. Preliminary Results
of Bedaquiline as Salvage Therapy for Patients With Nontuber-
culous Mycobacterial Lung Disease. Chest 2015; 148:499-506.
bacterial Infections. Microbiol Spectr 2017; 5(1): doi: 10.1128/
microbiolspec. TNMI7-0029-2016.
7. Egelund EF, Fennelly KP, Peloquin CA. Medications and moni-
toring in nontuberculous mycobacteria infections. Clin Chest
Med 2015; 36:55-66.
8. Cowman S, Burns K, Benson S, Wilson R, Loebinger MR. The
antimicrobial susceptibility of non-tuberculous mycobacteria.
J Infect 2016; 72:324-31.
9. Wallace RJ, Jr., Brown-Elliott BA, Crist CJ, Mann L, Wilson RW.
Comparison of the in vitro activity of the glycylcycline tige-
cycline (formerly GAR-936) with those of tetracycline, mino-
cycline, and doxycycline against isolates of nontuberculous
mycobacteria. Antimicrob Agents Chemother 2002; 46:3164-7.
10. Mitchell JD. Surgical approach to pulmonary nontuberculous
mycobacterial infections. Clin Chest Med 2015; 36:117-22.
 Editorial

Lung function in the elderly:

Nascentes morimur
Panagiotis Panagou, Pulmonary structure and function change significantly between young
Evangelos Bouros, adulthood and old age. Aging generates four important changes in the
Argyrios Tzouvelekis, structure and function of the respiratory system.1 There is a reduction
Vassilios Tzilas, in the elastic recoil of the lung causing “senile emphysema”, a condition
characterized by reduction in the alveolar surface area (elastic elements of
Demosthenes Bouros
the lung degenerate, parenchymal tissue is lost) without alveolar destruc-
tion, which is associated with hyperinflation, increased lung compliance
and reduction in alveolar-capillary diffusing capacity. There is a decrease
First Academic Department of Pneumonology, in the compliance of the chest wall, due to calcification of its articulations,
Interstitial Lung Diseases Unit, Hospital for dorsal kyphosis and “barrel chest”. There is a decrease in the strength of
Diseases of the Chest, “Sotiria”, Medical School,
National and Kapodistrian University of
respiratory muscles (intercostal muscle mass and force are reduced) which
Athens, Athens, Greece correlates with cardiac Index, nutritional status and hyperinflation and there
is a reduction in the ventilatory response to hypoxia and hypercapnia as
well as in the perception of increased airway resistance.2,3
Furthermore aging depresses cough reflexes and disturbances of in-
Key words:
nate immunity predispose the elderly to pulmonary inflammation. These
- Lung function
- Pulmonary function changes affect pulmonary function tests and gas exchange, but adaptive
- Elderly changes in breathing frequency and tidal volume serve to maintain adequate
- Spirometry ventilation and ventilatory responsiveness to hypoxia and hypercapnia.4
Spirometry is underused and difficult to perform in older people and
there is no spirometric gold standard specific in this population for the
diagnosis of obstructive disease, with the most common error being the
lack of a plateau at the end of exhalation, so a FET ≤6 s can be used. Imag-
ing can to some extent integrate or also substitute for respiratory function
data in highly problematic cases, providing important clinical information.5
The Global Initiative for Chronic Obstructive Lung Disease (GOLD)
Workshop Summary has defined stage 1 chronic obstructive pulmonary
disease (COPD) as airflow limitation where forced expiratory volume in one
Correspondence to: second/forced vital capacity (FEV1/FVC)% is ≤70% and FEV1% predicted
Prof. Demosthenes Bouros MD, PhD, FERS, FAPSR, FCCP; is ≥80%. Stage 2 COPD has been defined as a FEV1/FVC% of ≤70% and an
First Academic Department of Pneumonology, FEV1% pred of ≤80%. These criteria are set regardless of age in an attempt
Interstitial Lung Diseases Unit,
Hospital for Diseases of the Chest, “Sotiria”,
to simplify the diagnosis.6
Medical School, National and Kapodistrian University The trade-off with simplicity, however, comes at the expense of misclas-
of Athens, Athens, Greece; sification. Since the FEV1/FVC ratio falls with age,7 the use of a fixed cut-off
152 Messogion Ave., Athens 11527, Greece
E-mail: debouros@med.uoa.gr point for defining COPD becomes more inaccurate with increasing age.
debouros@gmail.com These criteria were proven to lead to a significant degree of over-diagnosis of
PNEUMON Number 1, Vol. 31, January - March 2018
chronic airflow obstruction in those aged ≥70 yrs normal
subjects and in those ≥80 years to even stage 2 COPD.8
Additionally one fifth of older adults with observed
FEV1/FVC% above the NHANES-III fifth percentile had
FEV1/FVC% ratios <70% (normals misidentified as ab-
normal).9
The lower limit of normal was estimated as: Predict-
ed-1.65 x residual SD (i.e. the estimated 5th percentile).
Furthermore in normal elderly blacks it was found that
they had an FVC about 6% lower than elderly whites, even
after correcting for standing height, sitting height (trunk
length), and age, so the popular use of spirometry refer-
ence values from studies of middle-aged white subjects
by applying a 12% race correction factor for black patients
appears to overestimate predicted values.10
Also in another study cognitive impairment, shorter
6-min walk distance, and lower educational level were
found to be independent risk factors for a poorer accept-
ability rate for spirometry (logistic regression analysis).
Male sex and age were risk factors for a poorer repro-
ducibility of FEV1 and reproducibility tended to improve
with time.11
The use of Forced Oscillation technique (FOT) by
impulse oscillometry (IOS) and in particular respiratory
impedance (Z5), resonant frequency (Fres), and respiratory
resistance (R5, R20, R5–R20) and respiratory reactance
(X5) were shown to have good relevance compared with
spirometry for geriatric patients, so IOS may serve as an
alternative method for spirometry in elderly subjects for
the evaluation of the state of lung function.12
Expiratory flow limitation (EFL) as assessed by the
negative expiratory pressure method during tidal breath-
ing may be also be of value in cases when spirometry is
inadequate in the elderly.13
The calculation of spirometric Z-scores (predicted-
measured/RSD) by Lambda-Mu-Sigma (LMS) rigorously ac-
counts for age-related changes in lung function. Recently,
the Global Lung Function Initiative (GLI)14 expanded
the availability of LMS spirometric Z-scores to multiple
ethnicities. Hence, in aging populations, the GLI provides
an opportunity to rigorously evaluate ethnic differences
in respiratory impairment. The LMS describes the mean
(Mu) — representing how spirometric measures change
based on predictor variables (age and height); the coeffi-
cient-of-variation (Sigma) — representing the spread of
reference values; and skewness (Lambda, incorporating a
spline function) — representing departure from normal-
ity. A Z-score of -1.64 defines the lower limit of normal
as the 5th percentile of the distribution. Notably, using
15
data from large reference populations of asymptomatic
lifelong non-smokers, the GLI has recently published
equations that expand the availability of LMS-calculated
spirometric Z-scores, allowing respiratory impairment to
be established across multiple ethnicities.
So by using these reference equations ethnic differ-
ences in an aging population was found in respiratory
impairment, including prevalence and associations with
health outcomes. In particular, African-Americans pres-
ent a unique public health challenge, with high rates of
respiratory impairment being associated with mortality
but not respiratory symptoms.15
It was recently observed that a small proportion (7%)
of subjects with CT-defined emphysema were identified
by the 0.70 threshold for FEV1/FVC but not by the LLN.
However, there is no evidence that CT-emphysema cor-
responds to a clinical entity that can benefit by inhaled
therapy.16
In a cohort of very old adults, low FEV1 expressed as
FEV1/Ht3 was found to be a short-term predictor of all-
cause mortality, hospitalization and decline in physical
and mental functioning independently of age, smoking
status, chronic lung disease and other co-morbidities. So
FEV1/Ht3 may be a potential risk marker for frailty and
adverse health outcomes in the elderly.17
The incidence of airflow limitation per 1000 person-
years was 28.2 using a fixed ratio and 11.7 with LLN, cor-
responding to a 1.41-fold higher incidence rate using a
fixed ratio. The incidence increased dramatically with age
when using a fixed ratio, but less so when using LLN. In
addition, a sex effect was observed with the LLN criterion.
LLN airflow limitation was associated with increased
5-year mortality. Presence of fixed-ratio airflow limitation
in individuals classified by LLN as non-obstructive was
not associated with increased mortality.18
In the Perspective of classic spirometry with MEFV
curve was argued many years ago that it is an overall ex-
pression of the lung’s mechanical behaviour but reflects a
very complex system and a series of mechanical events that
is very poorly understood.19 So we come to the question:
Do we need to measure airway resistance? Within the lung,
at breathing frequencies, 50% of the resistance originates
within the large airways, 40% within the lung tissue (due
to dissipative frictional losses among the various structural
elements), and only 10% within the small airways, again
reflecting their enormous cross-sectional area. Because
such a small amount of resistance emanates from the
small airways, it is very difficult to detect changes in this
area using conventional spirometry, and so this region has
16
been dubbed the “Silent” or “Quiet” zone of the lung.
Because of this RAW is more sensitive than spirometry to
detect changes in the aging lung.
Since Raw is highly dependent on lung volume, it is
better expressed as specific airway conductance, sGaw,
where sGaw = (1/Raw)/ thoracic gas volume (TGV). sGaw
is a measure of intrinsic airway resistance, which is volume
independent.
Raw can also be measured by the interrupter technique
(Rint),20 and the forced oscillation technique (RFOT), both
of which are performed during quiet breathing and require
no special maneuvers like the FEV1. As such, both Rint
and R-FOT are also more sensitive indicators of intrinsic
Raw than FEV1.
In addition, the FOT offers additional insight into the
elastic properties of the respiratory system and airway
distensibility21-23 as well as into the homogeneity of ven-
tilation. Because these methods are non-invasive and can
be performed during quiet breathing, they have special
appeal for patients who cannot perform spirometry or
may have difficulty with proper technique, including
children, the elderly, patients during sleep, or those with
neuromuscular disease. Each of the methods has its own
advantages and disadvantages.
In conclusion: 1) GLI reference equations for spirom-
etry should be used by all lung function laboratories for all
ages and ethnic groups. 2) The GLI LLN 5th percentile may
be used along with GOLD guidelines to detect changes in
lung function in the elderly in order to avoid overdiagnosis
of airway obstruction. 3) In cases of clinical doubt more
sensitive RAW measurements may have a role.
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 Original Paper

Introduction of new technologies

in Pneumonology training
Μedical students can show us the way
Eleni Pilitsi1, SUMMARY
Paschalis Steiropoulos2 BACKGROUND: Over the last years new technologies are used
to enhance the quality of medical education and to improve the
educational experience. Social media are becoming popular tools
1
MD, Research Fellow, Medical School, for augmenting the effectiveness of education in various academic
Democritus University of Thrace, aspects and, especially, YouTube has been used as an adjunctive tool
Alexandroupolis, Greece
2
Assistant Professor in Pneumonology,
in medical students’ training. Aim of the study was to examine the
Medical School and University Hospital, use of YouTube videos as learning tools for Pneumonology clerk-
Democritus University of Thrace, ship by the students and their impact in the acquisition of clinical
Alexandroupolis, Greece skills and theoretical knowledge. METHODS: An anonymous, online
survey completed by medical students attending their fourth year
of studies at the Medical School, Democritus University of Thrace
Key words: (six year curriculum) was conducted. The questionnaire contained
- Internet demographic questions and questions about the potential benefit
- Medical Education of YouTube channel videos in the pulmonary training of medical
- Multimedia
- Pneumonology students. RESULTS: Response rate was 87%. Respondents’ perception
- Social media was that YouTube channels are useful as educational tools. Specifi-
- YouTube channels cally, 41.1% of them reported getting “very much” or “much” benefit
from online videos and the percentage increased to 65%, when
specific videos were used as examples (p<0.001). CONCLUSIONS:
Usage of YouTube videos as adjunct educational tools has an appar-
ent positive impact on students’ comprehension of Pneumonology.
Therefore, their value as a potential official training method should
be further tested and could be strongly considered in the future.
Pneumon 2018, 31(1):17-23.

Correspondence:
Paschalis Steiropoulos MD, PhD, FCCP,
Medical School and University Hospital, Democritus
Introduction
University of Thrace, 68100 Alexandroupolis, Greece,
Tel./Fax: +30 2551030377 Over the last years, various new technologies have emerged and have
E-mail: pstirop@med.duth.gr become available to most Medical Schools in developed countries, for the
18
purpose of facilitating and enhancing education process1-3.
E-learning4-7, simulation based techniques8, virtual real-
ity, interactive 3D software, educational video games9,
podcast/vodcast and social media including Facebook10,
Twitter11, WhatsΑpp and YouTube12, are all used in order
to increase the quality of medical education offered
and to improve the educational experience of medical
students13. These technologies have introduced a whole
new era into medical education, addressing to the rapidly
expanding knowledge14.
However, not all universities have the financial ca-
pability to experiment with the previously mentioned
technologies, nor they can afford the burden of incorpo-
rating those in their curriculum15-17. Greece is one of the
less privileged countries, due to the ongoing financial
crisis that started in 2010. As expected, Greek Medical
Schools were not able to make significant changes in the
traditional ways of training young doctors. It is obvious
that the necessity of curriculum modernization appears
imperative18; however it is conflicting with the lack of
funding to the Greek Universities. Thus, less expensive
methods to improve the quality of Greek medical educa-
tion need to be used, one of which might be educational
YouTube channels.
Social media are becoming very popular tools for
enhancing the effectiveness of education in diverse aca-
demic areas19-21. YouTube, a web-platform that enables
users to watch, post, share, like/dislike and discuss
videos, is the third most frequently used social media
worldwide with more than 1 billion users, according to
statistics available at YouTube’s site. There is already some
literature regarding the use of YouTube channels as adjunc-
tive tools in training medical students and residents22 in
specific fields23,24. YouTube channels contain videos aiming
at improving technical skills as well as at acquiring and
retaining theoretical knowledge25. There are studies that
have already evaluated the use and effectiveness of social
media, such as Twitter, in various clerkships/courses and
show emerging positive results26-28.
Anatomy, for instance, is one of the courses that can
significantly benefit from YouTube videos due to the
complexity of understanding 3D structures and organ
relationships from printed or digital atlases. Jaffar con-
cluded that YouTube can be considered as an effective
educational tool and that faculties should produce their
own videos to encourage student participation29.
As per November 2017, there is no published data
describing or assessing the methods used by Greek medi-
cal students in understanding Pneumonology. Thus, we
PNEUMON Number 1, Vol. 31, January - March 2018
aimed to record how often students in our Institution are
using YouTube videos as a learning tool for their Clerkship
in Pneumonology; which YouTube channels they mostly
prefer, and which is the perceived effect of these videos in
both clinical skills and theoretical knowledge acquisition.
METHODS
We conducted an anonymous, online survey among
medical students attending their fourth year of studies
at Medical School of the Democritus University of Thrace
taking a Pneumonology course. The questionnaire ad-
dressed 16 questions: certain ones were of demographic
type, some involved the general medical education ex-
perience so far and others were concerned with the
potential benefit of viewing YouTube channel videos in
the Pulmonary training of medical students.
More specifically, the general questions were referring
to gender and age information. In addition, students were
asked to report the number of courses not yet taken from
previous semesters along with frequency of attending
lectures. Furthermore, we specifically asked the students
about subject matter in the Pneumonology posing con-
ceptual difficulty and about certain weak parts in their
physical examination skills that lead them to search online
for explanatory YouTube videos. They were also asked to
report the frequency of searching online videos, the im-
pact of these videos and the effectiveness that a specific
YouTube channel, may have on their understanding of the
material. In order to capture the frequency/intensity of
responding to the above questions, we used a quantita-
tive scale from 1 to 5, with 1 representing “never/not at
all” and 5 “always/very much”.
RESULTS
The survey was anonymously answered by 114 (from a
total number of 130, response rate 87%) medical students
attending the Pneumonology class during the second
semester of the academic year 2016-1017. About half of
the participants (50.9%) were female, aged between 21
and 26 years, with the vast majority being younger than
24 years old. Age distribution was as follows: 21 years
(19.3%), 22 years (33.3%), 23 years (35.1%), 24 years (3.5%),
25 years (5.3%), and 26 years (3.5%).
The number of previous semester courses that stu-
dents needed to take again ranged between 0 and 17.
The median was 2 courses.
Frequency of lecture attendance by the students
PNEUMON Number 1, Vol. 31, January - March 2018
was as follows: 21.1% (n=24) of them reported “always
attending”, 40.4% (n=46) “frequently attending”, 26.3%
(n=30) declared “sometimes attending”, 10.5% (n=12)
“rarely attending” and 1.8% (n=2) “never attending”, as
demonstrated in Figure 1.
An attempt was made to investigate possible associa-
tion between the reported lecture attendance frequency
and the number of courses that need to be retaken.
More specifically, the objective was to discover whether
students attending lectures at a low frequency (response
ranging between never and sometimes), need to retake
more courses compared to students attending classes at
a high frequency (response ranging between frequently
and always); however, no such association was revealed.
Nevertheless, students attending lectures at the highest
frequency appeared to have retaken very few courses.
According to students’ replies, the most difficult parts
of the Pulmonary course are considered to be respiratory
physiology and pathophysiology, acid base disorders,
interstitial lung diseases and lung cancer. Additionally,
students reported difficulties in reading chest CT scans.
However, the latter particular skill should mostly be de-
veloped during the Radiology course.
Our students were also asked to rate the level of
comprehension of Pneumonology-related material via
the existing educational methods. The responses are
shown in Figure 2.
We used a scale from 1 (very poor) to 5 (excellent).
Data suggest that our students do not gain the maximum
out of their Clerkship, since there is undoubtedly room
for improvement.
The majority of students (87.7%) search online for
FIGURE 1. Self reported frequency of attending lectures.
19
videos related to the Pneumonology course in order to
better comprehend the material and prepare for the final
exam at the end of the semester. Four students (3.5%)
reported doing this every time they study, 24 students
(21.1%) almost always, 40 students (35.1%) frequently,
32 students (28.1%) rarely and 14 students (12.3%) never.
In order to qualitatively assess whether watching
medical videos on YouTube has already helped our stu-
dents comprehend difficult chapters and concepts in
Pneumonology we used the scale from 1 (not at all) to 5
(very much). More specifically, 18 students (16%) stated
that they were benefiting very much, 28 students (25%)
much, 46 students (41%) fairly, 12 students (11%) slightly
and 8 students (7%) not at all.
In order to assess whether lecture attendance fre-
quency correlates to students’ response to the questions
about effectiveness of YouTube videos in studying during
Pneumonology rotation and preparing for the exam, we
divided the students into two groups. The first group
consisted of students who attended lectures at a high
frequency (answers given: very frequently or always)
and the second group consisted of students attending
lectures at a low frequency (answers given: never, rarely
or sometimes).
Out of the 70 students with increased lecture atten-
dance frequency, 36 answered with high scores (4 or 5)
in the video effectiveness question as well. From the 44
students who reported low lecture attendance, only 10
ranked high (with 4 or 5) the potential effectiveness of
YouTube videos. In other words, 51% of students attend-
ing lectures with high frequency believe that YouTube
videos can help them comprehend Pneumonology bet-
FIGURE 2. Level of Pneumonology comprehension (X axis:1-
very poor, 5-excellent).
20
ter, whereas only 23% of students not attending lectures
have similar point of view.
An attempt to explore a possible association between
the number of courses needed to be repeated and the
perceived effectiveness of YouTube videos revealed the
lack of any association. Specifically, the number of courses
students needed to reiterate was independent of their
perception of YouTube effectiveness. No significant differ-
ence was determined in perceived YouTube effectiveness
between males and females participating in our study.
Additionally, we collected more information regard-
ing the most popular YouTube channels among students
from our Institution. Only 80 of the students replied to
this specific question. Fifty two students did not men-
tion using any specific YouTube channel. Among the rest
of the responders (28), Osmosis was the most popular
channel, followed by Dr. Najeeb lectures and Armando
Hasudungan channel.
To further investigate the value of YouTube videos as
adjunct learning tools we proposed a series of Pneumonol-
ogy related videos by Osmosis YouTube channel, which
is becoming more and more popular among medical
students worldwide, including Greek medical students,
(367,524 subscribers and 22,442,849 views, as per Novem-
ber 28, 2017, according to numbers presented at Osmosis
YouTube channel). Students were asked to watch these
videos and comment on their effectiveness in order to
understand Pneumonology related topics more efficiently.
Our findings are illustrated in Figure 3, which contains the
rating of YouTube videos effectiveness up until students
were exposed to Osmosis videos compared to the rating
after watching these videos.
There was an increase in the number of respondents
ranking the effectiveness of Osmosis videos with either
4 or 5 compared to the general question about the ef-
TABLE 1. Students’ search on YouTube channels for videos
helping in improving performance of the following clinical skills.
Number of Percentage
Clinical skills students (%)
History taking 10 8.8
Lung palpation 20 17.5
Lung percussion 28 24.6
Lung auscultation 84 73.7
Venous blood sampling 30 26.3
Arterial blood gas sampling 44 38.6
Placement of thoracic drainage 30 26.3
PNEUMON Number 1, Vol. 31, January - March 2018
fectiveness of online videos in the learning process. More
specifically, 36 of the students having ranked the potential
effect of YouTube videos with an 1 or 2 or 3, changed their
mind when they watched the Osmosis videos by choos-
ing 4 or 5 (8 students of those that picked 2, changed to
4, 22 students of those that picked 3, changed to 4 and
6 of those that picked 3, changed to 5).
Moreover, the average rating of the perceived effec-
tiveness of YouTube channels before watching Osmosis
videos was 3.32, whereas after watching Osmosis videos
the average increased to 3.77. Paired sample t-test ex-
amination revealed that this increase in average rating
before and after watching Osmosis videos was statistically
significant (p<0.001).
An additional finding was that medical students in
our Institution refer to YouTube videos for enhancing
their clinical skills required in Pneumonology and their
knowledge about routinely used interventions in clini-
cal practice. We specifically asked the students about
certain parts of physical examination and some of the
most frequently used interventions in clinical medicine.
Our findings are summarized in Table 1.
Lastly, we inquired about any perceived improvement
in the level of technology incorporation into the medical
curriculum and medical education, since the beginning
of the medical studies of our study group, four years ago.
Our students’ perspective is presented in Figure 4.
DISCUSSION
The results of our study contain valuable messages
that should be carefully interpreted. One of the most
FIGURE 3. Perceived effectiveness of YouTube channels before
and after watching the Osmosis videos in comprehending dif-
ficult concepts (1 for not at all, 5 for very much).
PNEUMON Number 1, Vol. 31, January - March 2018
important findings is the feeling of our students that
they have accomplished only an intermediate level (3 in
a scale from 1 to 5) of comprehension of Pneumonology
course with the existing teaching methods. The above
finding may have various etiologies, but it is obvious that
there is room for improvement regarding the educational
experience offered.
One of the many ways to upgrade medical education
that has been proven effective even since the 80s41, is to
assimilate new media and technologies into traditional
teaching.
YouTube hosts a great variety of educational chan-
nels with numerous medical topics accessible by medi-
cal students and graduates all over the world, provided
that there is an internet connection. Most channels offer
at least part of their video collection at no cost, so they
constitute a good solution for all those having a limited
budget. There are many different kinds of videos offered,
some contain graphics and text, others animation, others
recorded lectures or drawings. Thus, medical information
can be taught in a more creative and understandable way
compared to traditional teaching methods30. Additionally,
incorporation of social media, and, particularly YouTube
videos, in medical education can trigger students’ interest
about the topic31, motivate them to engage more actively
in the learning process32,33 and keep them concentrated
for longer periods. However, we should not ignore the
fact that the quality of these videos varies, depending,
among other factors, on the source34. Thus, not all chan-
FIGURE 4. Perspective of students about improvement in
technology incorporation during the past 4 years. (1 for not at
all, 5 for very much).
21
nels should be blindly trusted. More specifically, there are
three types of videos hosted on YouTube:
• Videos uploaded by individuals that are not part of
an official educational process
• Videos uploaded by channels created to provide
education such as official Medical School channels,
Medical Organizations, Health care related companies
• Videos uploaded by channels related to educational
sites. An example under this particular category is
FOAMed (Free Open Access Medical education), a
network of free, online educational services and re-
sources, such as blogs, podcasts, tweets, Google hang-
outs, online videos, text documents, photographs,
Facebook groups and many more. The main goal is
to provide means to enhance traditional education.
It is self-sponsored or supported by advertisements
and does not require a registration fee from the user.
Osmosis videos belong to the same category, since
they are linked to a website that offers educational
material, mnemonics, quizzes, question banks and
reference articles. The videos are part of the open ac-
cess content, but there is also the option to purchase
a plan after a free trial.
Furthermore, information shared on the Internet is
not strictly regulated, which is a major drawback when
considering the possibility of using social media in medical
education and learning. Apart from this, policies about
the professional use of social media need to be clearly
set and taught by the Institution, given the continuous
alterations in the social media environment35-38.
It is common practice that medical students utilize
social media such as YouTube videos to obtain medical
knowledge and cultivate their current skills39, but there
is limited amount of literature reporting this attitude
and evaluating the impact on medical students’ perfor-
mance. According to the results of the present survey,
we concluded that the utilization of YouTube videos may
help medical students obtain a better understanding of
concepts taught in the Pneumonology course, especially
if the videos are oriented toward course objectives. How-
ever, it is obvious that quality and content of the videos
of each YouTube channel influence their impact on the
learning experience.
According to our findings, there is a clear difference
in perception regarding effectiveness of YouTube videos
in studying during Pneumonology rotation and in exam
preparing among students that regularly attend lectures
compared to those that do not. This fact may have various
possible explanations and needs further investigation.
22 PNEUMON Number 1, Vol. 31, January - March 2018

Furthermore, the aforementioned finding should be
assessed taking into account a study from the literature
suggesting that students’ opinions about the efficiency
of social media as learning tools vary between preclini-
cal and clinical years. Particularly, students’ perspective
may be dependent upon the academic year attending40.
To conclude, utilization of social media, like YouTube, in
medical education is very promising in terms of enhanc-
ing the learning and educational experience, but certain
aspects of this new trend need further investigation. In
our study, which comprised a relatively small sample of
medical students, Osmosis channel appears to be more
helpful and effective in self-learning than other channels.
All these findings should be taken into account by Admin-
istrators of Medical Schools in Greece, which have been
in the process of reforming the curricula in an attempt to
approach a more technologically up to date level, while
facing continual financial problems that considerably
influence the available solutions.

ΠΕΡΙΛΗΨΗ
Εισαγωγή νέων τεχνολογιών στην εκπαίδευση στην Πνευμονολογία -
Οι φοιτητές της Ιατρικής μας δείχνουν το δρόμο
Ελένη Πηλίτση1, Πασχάλης Στειρόπουλος2
1
Τμήμα Ιατρικής, Δημοκρίτειο Πανεπιστήμιο Θράκης, Αλεξανδρούπολη, 2Επίκουρος Καθηγητής
Πνευμονολογίας, Τμήμα Ιατρικής, Δημοκρίτειο Πανεπιστήμιο Θράκης, Αλεξανδρούπολη

Εισαγωγή: Νέες τεχνολογίες γίνονται διαθέσιμες τα τελευταία χρόνια και χρησιμοποιούνται για την ανα-
βάθμιση της ποιότητας της παρεχόμενης ιατρικής εκπαίδευσης και τη βελτίωση της εκπαιδευτικής εμπειρί-
ας των φοιτητών. Τα μέσα κοινωνικής δικτύωσης χρησιμοποιούνται ολοένα και περισσότερο για το σκοπό
αυτό και πιο συγκεκριμένα, κανάλια του YouTube έχουν ήδη αξιοποιηθεί ως συμπληρωματικά εργαλεία
στην εκπαίδευση των φοιτητών. Στόχος μας ήταν να καταγράψουμε τη συχνότητα χρήσης βίντεο του
YouTube από τους φοιτητές στο μάθημα της Πνευμονολογίας και να αξιολογήσουμε την επίδρασή τους
στην απόκτηση κλινικών δεξιοτήτων και θεωρητικών γνώσεων. Μέθοδοι: Οι τεταρτοετείς φοιτητές του
Τμήματος Ιατρικής του Δημοκρίτειου Πανεπιστημίου Θράκης συμπλήρωσαν ένα ανώνυμο, διαδικτυακό
ερωτηματολόγιο. Το ερωτηματολόγιο περιείχε γενικές ερωτήσεις δημογραφικού περιεχομένου και εξειδι-
κευμένες ερωτήσεις σχετικά με την επίδραση της χρήσης των βίντεο του YouTube στην εκπαίδευση των
φοιτητών στην Πνευμονολογία. Αποτελέσματα: Απάντησε το 87% των ερωτώμενων φοιτητών. Οι φοιτη-
τές αναφέρουν ότι τα κανάλια του YouTube είναι χρήσιμα ως εκπαιδευτικά εργαλεία στην Πνευμονολο-
γία. Αναλυτικότερα, το 41,1% αναφέρει ότι επωφελείται «πάρα πολύ» ή «πολύ» από την παρακολούθηση
διαδικτυακών βίντεο και το ποσοστό φτάνει το 65% όταν χρησιμοποιούνται συγκεκριμένα βίντεο ως πα-
ράδειγμα (p<0.001). Συμπεράσματα: Η χρήση βίντεο στο YouTube ως συμπληρωματικών εκπαιδευτικών
εργαλείων έχει θετική επίδραση στην κατανόηση του μαθήματος της Πνευμονολογίας από τους φοιτητές.
Η αξία τους ως συμπληρωματικών μέσων εκπαίδευσης θα πρέπει να μελετηθεί περαιτέρω.
Πνεύμων 2018, 31(1):17-23.
Λέξεις - Kλειδιά: Διαδίκτυο, Ιατρική Εκπαίδευση, Πολυμέσα, Πνευμονολογία, Μέσα κοινωνικής δικτύωσης,
Κανάλια YouTube

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 Review

Biomedical Applications of Biopolymers

in Airway Disease
George T. Noutsios1, SUMMARY
Anastasia A. Pantazaki2* Airway disease is a group of devastating conditions the prevalence
of which has increased substantially in past decades despite the
advanced therapeutic interventions. The term describes several
1
School of Mathematical and Natural Sciences, events that lead to lung tissue scarring, poor lung circulation, and
Arizona State University, Glendale AZ, USA, airway obstruction that prevent the lungs from working properly.
2
Department of Chemistry, Laboratory
of Biochemistry, Aristotle University,
Biodegradable polymers have emerged as significant advancements
Thessaloniki, Greece of modern medicine. In this review, we sought to discuss the clinical
potential of biopolymers in airway disease. First, we describe suc-
cinctly the biosynthesis of biomaterials, their use in lung tissue scaf-
folding, and their use as substrates for in vitro culture of respiratory
Key words:
- Polyhydroxyalkanoates (PHAs) epithelial cells. We then discuss their utilization as bio-absorbable
- Lung disease nanostructured drug delivery systems that combat lung cancer and
- Lung tissue engineering prevent metastasis by targeting lung cancer stem-like cells. Addition-
- Drug delivery systems ally, we review the use of biopolymers as substitutes of pulmonary
- Nanovaccinology
surfactant in acute respiratory distress syndrome. We bring forward
the use of biopolymers as surgical implants in lung blood vessels.
Also, the encapsulation of plasmids or antibiotics in polymer-based
nanoparticles is discussed for pulmonary gene therapy in the con-
text of modulating the function of alveolar macrophages, dendritic
cells and adaptive immune responses. The use of nanoparticles for
nasal, bronchial and lung vaccine administration is also reviewed
as a novel method to induce favorable immune responses at the
respiratory mucosa with the potential to induce systemic immunity.
This review summarizes the most recent advances in the field over
the past decade, specifically highlighting new and interesting ap-
plications in airway disease.
Pneumon 2018, 31(1):24-34.

Correspondence:
Anastasia A. Pantazaki, Ph.D.
Associate Professor, Department of Chemistry, Introduction
Laboratory of Biochemistry, Aristotle University,
GR-54124 Thessaloniki, Greece The term biopolymer includes high molecular weight polymeric struc-
Tel.: +30-2310997838 tured produced by living organisms with biological methods as opposed
E-mail: natasa@chem.auth.gr
to synthetic polymers that are produced by chemical methods. Biodegrad-
PNEUMON Number 1, Vol. 31, January - March 2018
able biopolymers have gained a great deal of scientific
and industrial interest because they can be produced by
a wide range of sources and be used in a growing range
of biomedical applications. The organic bioplastics, i.e.
biopolymers, are derived from renewable biomass sources
such as vegetable oils, starch, proteins, etc., as opposed
to petroleum-derived fossil fuels. Biopolymers provide
the dual benefits of conserving mineral resources and
reducing CO2 emissions, which make them an important
innovation for sustainable development1.
Biosynthesis of polymers
Polyesters
Biodegradable polyesters providing a sustainable
alternative to petroleum-originated plastics consist of
ester, amide and other functional groups that can be
categorized into four classes, based on their synthesis
process: i) natural polymers of plants and animals origin
e.g. cellulose, chitosan, starch, and proteins, ii) microbial
biopolymers like polyhydroxyalkanoates (PHAs), iii) poly-
mers synthesized from natural monomers like polylactic
acid (PLA), and iv) conventional polymers chemically
synthesized from monomers produced from petrochemi-
cal products e.g. polycaprolactone1,2. Additionally, the
properties of these biodegradable polymers are usually
altered and improved through blending3. The potential
sources for their biosynthesis varies from different sorts
Figure 1. Biosynthesis of polymers that are used to treat airway diseases.
25
of biomass, including proteins, lipids and polysaccha-
rides (such as cellulose- and starch- based biopolymers,
chitosan) (Figure 1).
Proteins
In this category of biopolymers, the proteins that of-
ten are used are albumin, casein, collagen, feather meal
(by product of poultry processing), gelatin, gluten, meal
soy, peanuts, whey, and zein (a class of prolamine protein
found in corn). Collagen is a naturally occurring struc-
tural extra-cellular matrix polymer and the predominant
component of the mammalian body connective tissue,
which is highly conserved across species. Biopolymers
synthesized by collagen are often the best candidates for
synthetic replacement of connective tissues due to their
excellent structural and mechanical properties. Collagen
biomedical applications in regenerative medicine are
described in detail elsewhere4.
A gelatinous protein mixture used for many applica-
tions and known with the commercial name matrigel is
secreted by Engelbreth-Holm-Swarm mouse sarcoma cells,
produced and commercialized by Corning Life Sciences
and BD Biosciences. Matrigel is utilized by cell biologists
as a matrix for cell culturing due to its resemblance to the
complex extracellular environment that lies in various
tissues. Gel foam is another gelatin-derived biomate-
rial that is used as an efficient hemostatic agent during
surgical procedures.
26
Polysaccharides
Chitosan is a natural polysaccharide, with cationic and
biocompatible properties constituted of co-monomeric
units, 2-deoxy-2-acetamido-D-glucose and 2-deoxy-
2-amino-D-glucose. The major advantage of chitosan
is its mild antimicrobial activity that is attributed to its
cationic residue, making it an important biomaterial
since it suppresses bacterial growth by adhering to the
bacterial cell wall. Furthermore, chitosan is biocompatible
with human tissues and biodegrades in vivo. Its functional
groups (hydroxyl, amine and amide) can be chemically
modified to synthesize polyhydroxyalkanoates/chitosan
mixtures that are applicable in wide range of biomedical
applications.
Microbial polymers
Polyhydroxyalkanoates (PHAs) belong to a family of
microbial polyesters and constitute the only bioplastics,
synthesized by several Gram-negative and Gram-positive
bacteria. PHAs serve as both source of energy for bacte-
rial cultures and carbon storage. We have shown that
PHAs can be synthesized in Thermus thermophilus under
nutrient starvation conditions5-7. PHAs can be combined
with more than 150 different monomers and give rise
to a wide range of biomaterials with various properties
making them ideal candidates for a number of biomedical
applications8-11. Depending on their chemical structure,
PHAs display flexible mechanical, structural, and thermal
properties, biodegradability, biocompatibility and they are
environmentally friendly. PHAs are often used in medicine
as biodegradable and biocompatible implants and drug
delivery capsules3,12.
Poly-α-hydroxy acids
The most well-known poly-α-hydroxy acid is polygly-
colideor poly(glycolic acid) (PGA). It constitutes the sim-
plest linear, aliphatic polyester that is ranked among the
biodegradable, thermoplastic polymers. Its biosynthesis
takes place through polycondensation or ring-opening
polymerization of the smallest α-hydroxy acid (AHA), or
by solid-state polycondensation of halogenoacetates.
Initially PGA had very limited use due to its tough fiber-
forming structure and its rapid hydrolysis rate compared
to other polymers13. However, when PGA is coated with
L-lysine and N-laurin, it makes an ideal soft bio-absorbable
material for sub- and intra- cutaneous sutures and clo-
sures, respectively, in abdominal and thoracic surgeries.
In the past decades PGA has been co-polymerized with a
PNEUMON Number 1, Vol. 31, January - March 2018
number of other different monomers such as lactic acid,
trimethylene carbonate, e-caprolactone to bioengineer
implantable medical devices including anastomosis rings,
pins, rods, plates and screws14.
Table 1 summarizes the biosynthesis and current ap-
plications of biopolymers used in airway diseases.
Applications in Airway Disease
Lung Tissue Engineering
Engineering of lung tissue is part of the regenerative
medicine that aims to reconstruct tissue parts and repair
physiological functions of the lung rendered dysfunctional
after lung injury or lung disease. Although there has been
some progress in the de novo lung tissue engineering and
transplantation of live human cells into patients to confront
several respiratory diseases, it is not yet a clinical reality.
Considerable effort has been placed to design matrices
that can support 3-D structure, lung cell differentiation, and
tissue development15. Biopolymers such as collagen16,17, gel
foam18 and matrigel19 have been employed in lung tissue
engineering and have been shown to allow lung tissue
growth, albeit the development of a whole functioning
organ has not been substantiated so far.
The biomaterials used for these purposes are expected
to be biocompatible and their adsorption kinetics must
be such so that the biopolymers will remain long enough
to allow cell colonization and differentiation, without im-
peding the mechanical properties of the bioengineered
tissue. It is now realized that the complexity of the human
lung cannot be mimicked by a single biomaterial and
development of a hybrid of biopolymers is required to
generate lung tissue and different pulmonary cell types
that can replicate the specific functions of the lung20.
For example, Club cells (Clara cells) that are found in the
lung bronchioles, the function of which is to protect the
bronchial epithelium, have been shown to differentiate
from mouse embryonic stem cells on several biopolymers
such as gelatine, collagen types I, IV, and VI either in sub-
merged or air-liquid interface cultures21. Another example
is the alveolar type II pneumocytes; these produce the
pulmonary surfactant that has critical role in reducing the
surface tension formed at the air-liquid interface of the
alveoli. We have shown that type II cells can maintain their
phenotype in vitro in 3-D cultures system when grown on
mixture of matrigel and collagen22. We have also shown
that upper airway nasal epithelial cells maintain their
ciliated phenotype when grown in vitro in collagen IV
coated air-liquid surfaces23.
PNEUMON Number 1, Vol. 31, January - March 2018 27

Table 1. Biopolymers used in airway disease, their origin and their biosynthesis.
Biopolymers Application Origin Biosynthesis
References
Chitosan Synthetic surfactants, Mucorrouxii 62
nanovaccinology

Collagen types i, iv, and vi Cartilage graft, 3-D cultures Porcine 63

system

DODAC:DOPE (dioleoyl-dimethyl-ammonium Nanobeads Liposomes 64

chloride: dioleoyl-phosphatidyl-ethanolamine)

Gel foam Lung tissue engineering, Porcine skin gelatin 65

hemostatic agent

Gelatine Lung tissue engineering Acetobacterxylinum 66

HYAFF-11 Nasal Cartilage Graft Streptococcus zooepidemicus 67

Μatrigel In vitro airway cell culture Mouse 68

Polyethylene glycol (PEG)-substituted polylysine/ Nanostructured drug Chemical agent 32

PEBP-b-PBYP-g-PEG delivery systems

Poly-amino acids Nanoparticles Plants 69

Polyethylene imine (PEI) Nanovaccinology Chemical agent 70

Poly-hydroxy alkanoic acids (PHAs) Nanoparticles Plants, Thermus thermophilus 5, 6, 7

Poly-lactic-co-glycolic acid (PLGA) Cartilage graft engineering, Chemical agent 71

Nanovaccinology

Polylysine/glycocylated polylysine and Nanoparticles Streptomyces albulus 72

polyethylenimine

Polysaccharides Nanovaccinology Leuconostocmesenteroides, 73

starch

Poly-α-hydroxy acids Nanoparticles Chemical agent 74

Bio-absorbable Nanostructured Drug Delivery Systems often this lack of selectivity results in damage of healthy
cells and adverse side effects. Furthermore, the half-life of
Lung cancer is by far the commonest form of cancer
these anti-lung cancer drugs is very transient in the blood
worldwide, with 1.7 million new cases just in 2012, a 13%
stream, with low efficacies, and therefore higher doses of
annual incidence, and a leading cause of cancer death
chemicals are needed with concomitant dire side effects.
among both sexes. It is estimated that more people die
In this sense, customized bio-absorbable nanostructured
of lung cancer than breast, prostate and colon cancers
drug delivery systems (DDS) can offer great breakthroughs
combined24. Surgery and radiotherapy are the most com-
in the fight against lung cancer.
mon methods to remove and treat local, non-metastatic
DDS have a wide range of advantages compared to
malignancies, while chemotherapy is employed to treat
regular chemotherapy. Not only they can deliver anti-
the metastatic cases of lung cancer. One of the major
cancer agents in a controlled time and release rate but
drawbacks of chemotherapy is that although the anti-
they can be customized to target lung specific cells and
cancer drugs are designed to target the fast dividing
tissues and maintain efficient therapeutic drug levels25.
cells, they are not highly specific for just cancer cells, and
Polymeric DDS can be bioengineered in different forms
28
(liposomes, micelles, micro- and nano- particles) infused
with the appropriate anti-lung cancer agent and admin-
istered in different routes such as oral (inhaled DDS),
injectable gels (blood stream DDS) and surgical implants
(DDS scaffolds, foams, films/sheets)26. An additional feature
of the bio-absorbable DDS is that after they deliver the
desired anti-cancer agents, the biopolymers themselves
can be metabolized by the patient’s body.
An example of increased efficacy of biopolymers is
the PLGA nanoparticles loaded with the anti-lung cancer
agent suberoylanilidehydroxamic acid (SAHA). It was
shown in vitro that these particles were able to release an
initial burst of SAHA followed by sustained release for up
to 50 h, showing higher antineoplastic activity compared
to direct SAHA administration in human adenocarcinomic
alveolar basal epithelial A549 cells27. Another example of
utilization of biopolymers to increase specificity in lung
cancer cells is the bioengineering of PLGA nanoparticles
coated with vascular endothelial growth factor receptor
(VEGFR) on their outside surface and their infusion with
paclitalex, a tubulin-binding agent, which is widely used
for the treatment of non-small cell lung cancer28. The
concept is that since vascular endothelial growth factor
is over expressed in lung cancer cells, the coating of the
nanoparticles with the receptor (VEGFR) facilitates the
specific conjugation of the nanoparticles to the cancer
cells and subsequent increased inhibitory activity of tumor
growth compared to native paclitalex or paclitalex-loaded
PLGA nanoparticles in the A549 cell line. Additionally, in
vivo mouse studies showed that biopolymeric DDS can be
used to prevent lung cancer metastasis to other organs.
Yang et al identified a peptide that specifically binds to pul-
monary adenocarcinoma tissue, and conjugated it to PLA
particles encapsulated with anti-cancer agent docetaxel.
These nanoparticles were shown to specifically target the
lung cancer stem-like cells, eliminate them and prevent
metastasis to the liver29. Long et al. used the same concept
and showed in mouse studies that inhalation of thiolated
gelatin nanoparticles carrying a specific epidermal growth
factor receptor (EGFR) binding peptide and encapsulated
with doxorubicin, not only were specifically internalized
by lung cancer cells but they also released high doses of
the anti-cancer agents for more than 24h post inhalation
resulting in 90% increased efficacy30.
Another interesting use of biopolymers is that of
micelles, which serve as vehicles for delivering insoluble
hydrophobic anti-cancer chemicals. Micelles are bioengi-
neering as organized auto-assembly amphiphilic copo-
lymers formed in a liquid, composed of solvophilic and
PNEUMON Number 1, Vol. 31, January - March 2018
solvophobic blocks. The core of micelles is hydrophobic,
and the place where water insoluble drugs are loaded,
while the outside of micelle is comprised of a hydrophilic
polymer that renders the whole micelle stable and bio-
compatible with tissues and blood. Albumin nanocarriers
were used to deliver niclosamide, a very potent anti-lung
cancer agent that is normally hydrophobic, and therefore
cannot be delivered systemically to the patient. In vitro
trials showed that the albumin coated nanoparticles
were hydrophilic and were are able to deliver efficiently
the agent, resulting in significant tumor inhibition and
apoptosis of cancer cells31. To augment the pharmacoki-
netics of paclitalex, Zhang et al generated a micelle cross-
linked with amphiphilic terpolymer PEBP-b-PBYP-g-PEG
formulating a shell, which was shown to increase paclitalex
intra-tracheal delivery by 2400-fold, thus preventing lung
metastasis of osteosarcoma in a mouse model32.
Nanopolymers in Respiratory Gene Therapy
Gene therapy is currently used to treat several re-
spiratory disorders such as cystic fibrosis (CF) and acute
respiratory distress syndrome (ARDS). The overall concept
is to replace a mutated gene that causes the disease
with a healthy copy of the gene, inhibit or knock-out a
mutated gene that is malfunctioning, or introduce a new
gene that helps fight the disease, providing permanent
therapeutic solutions rather than treating just the symp-
toms. The application of biodegradable nanoparticles as
gene transferring agents is being currently evaluated for
a wide range of airway diseases.
CF is a lethal autosomal disease, in which the cystic
fibrosis transmembrane conductance regulator gene
(CFTR) is malfunctioning. The CFTR channel is present on
the apical surface of epithelial cells and is critical in the
chloride (Cl-) and bicarbonate (HCO3-) transport. These
channels are important for the optimal levels of water
and ion components of the mucosa. CFTR gene mutations
result in epithelial cell dysfunction, mucus thickening,
propagation of recalcitrant bacterial populations affect-
ing not just the lung, but also the sinuses33, intestines,
pancreas and other organs34. In this direction glycocylated
polylysine and polyethylenimine nanobeads carrying a
functional CFTR gene were internalized in airway epithelial
cell cultures. This was based on the fact that lectins, such
as pulmonary surfactant protein A (SP-A) and D (SP-D),
which are expressed in airway epithelial cells selectively
bind and internalize the above glycoconjugates35. In vivo
studies also showed that polylysine nanobeads loaded
PNEUMON Number 1, Vol. 31, January - March 2018
with serpin-enzyme complex receptor (that binds to
airway epithelia) and CFTR plasmid, restored the chloride
ion transport in a CFTR knock-out mouse model36. In the
same way, nanoparticles conjugated with shortpeptides
resembling integrin-binding domains successfully deliv-
ered the CFTR gene via bronchoscopic administration
in a porcine CF model37. Furthermore, clinical trials in CF
patients have been conducted using polyethyleneglycol
(PEG)-substituted polylysine nanoparticles delivering intra-
nasally the correct CFTR gene. Correction of CFTR transfer
channel has been confirmed by detecting plasmid-specific
DNA and mRNA while the ion transfer was corrected in
seven out of twelve of the patients38.
The major advantage of the biodegradable nanobeads
is their small size (18-25 nm), which allows them to enter
the nuclear envelope by passive diffusion and deliver
the CFTR plasmid for transcription. Another advantage
of their small size is the possibility to be systemically
delivered via intravenous (i.v.) injection which can lead
to specific lung transfection. It has been shown that
DODAC:DOPE (dioleoyl-dimethyl-ammonium chloride:
dioleoyl-phosphatidyl-ethanolamine) nanoparticles in-
fused with human cytokeratin 18 gene (KRT18) gene
when administered i.v. can reach the left side of the heart
and travel to the bronchial circulation which supplies the
alveolar capillaries of the pulmonary circulation. There, the
nanoparticles deliver the KRT18 plasmid to the alveolar
epithelial cells, which mitigates the CF phenotype39. In
addition, novel nebulization therapeutic modalities have
been investigated to delivery polymeric gene vectors for
several lung diseases. Alton et al showed that inhaled
gene therapy has presented safety and effectiveness
in phase 2b clinical trials. Liposome nanoparticles were
biosynthesized containing the CFTR cDNA, nebulized and
derived to the patients via inhalation resulting in signifi-
cant stabilization in the lung function of CF patients40.
The use of biopolymers in pulmonary gene therapy is
currently being evaluated and it is expected, soon, to
lead to efficient therapeutic interventions that address
the mechanism of airway disease, therefore providing
permanent solutions.
Biopolymers in Respiratory Distress Syndrome
Pulmonary surfactant (PS) is a mixture consisting
of 90% lipids and 10% proteins that is produced by the
alveolar type II cells. It’s major bio-physiological func-
tion is to lower the surface tension that is formed at the
air-liquid interface during the respiration process and
prevent the alveolar collapse. Absence or deficiency of PS
29
leads to respiratory distress syndrome (RDS)41. In preterm
neonates, the lungs are not fully developed and the lack
of PS production leads to neonatal RDS (NRDS). Natural
and synthetic surfactants have been used successfully
to alleviate RDS. In the case of synthetic surfactants, it
has been found that supplementation with biopolymers
enhances the surface activity of the synthetic lipids and
prevents the inhibition of the natural PS in the lungs.
For example, although dipalmitoyl-phosphatidylcholine
(DPPC) and phosphatidyl-glycerol (PG) are natural compo-
nents of PS, when administered exogenously in neonatal
rabbit lungs, they proved ineffective. Supplementation of
DPPC and PG with tyloxapol (a nonionic liquid polymer
of the alkylaryl polyether alcohol) facilitated dispersion
of the synthetic surfactant and prevention of NRDS. This
synthetic surfactant supplement is FDA-approved and
used in clinic (Exosurf )42. The biopolymers that have
been tested so far with the intent to improve the surface
activity of synthetic surfactants include nonionic, such as
polyethylene glycol (PEG)43 and dextran44, anionic, such
as hyaluronan45, and cationic polymers (e.g. chitosan)46.
Another advantage of these polymers is that their ad-
dition reduces surfactant inhibition and improves lung
function after pulmonary injury47. PS inhibition takes place
when surfactant encounters plasma proteins, meconium
(fetal feces aspiration during gestation), and cholesterol,
conditions that are associated with acute lung injury
(ALI), acute respiratory distress syndrome (ARDS), NRDS,
and pulmonary edema. The use of low cost, hydrophilic
biopolymers as surfactant substitutes and additives has
proven to be an effective approach to treat RDS.
Nanovaccinology
Traditional vaccines usually contain attenuated patho-
gens, and although they have been proven effective in
preventing contagious diseases, they are not safe for im-
munocompromised individuals. To address these issues,
components of pathogens such as bacterial lipopolysac-
charides, viral proteins, or even naked DNA encoding a
protective antigen, have been utilized to manufacture less
reactogenic vaccines. These were proven to be less im-
munogenic. Although their addition resulted in enhanced
immunogenicity, they also increased the topical reactions.
In this direction, nanotechnology has come to introduce
a new era in vaccinology. Nanovaccines are defined as the
bioengineered nanoparticles that are formulated to either
encapsulate within or absorb on their surface specific
antigens to elicit a desired adaptive immune response.
They induce cellular memory, which is central to protection
30
against pathogens, and generate long-term protective
immunity. Nanotechnology and biomedical engineer-
ing are now facilitating cross-disciplinary research that
has come to increase the biocompatibility, permeability,
solubility and stability of vaccines48.
Nanoparticles can be prepared by a range of biode-
gradable polymers such as poly-α-hydroxyacids, poly-
hydroxyalkanoates, poly-amino acids, or polysaccharides
to generate a vesicle that either contains or displays on
its surface the antigen of interest. The most commonly
used biomaterials are poly-lactic-co-glycolic acid (PLGA)
and poly-lactic acid (PLA)49. Also, chitosan nanoparticles
apart from being biodegradable and non-toxic, they are
particularly useful for vaccinology since their small size
allows them to pass through the tight junctions of epi-
thelial cells and deliver the antigen50. In vivo studies have
shown that the delivery and uptake of nanoparticles by
the antigen presenting cells such as dendritic cells (DCs)
increased by 30- fold compared to the soluble antigen
alone51. Another example is the chicken ovalbumin (OVA)
challenge model for studying antigen-specific immune
responses in mice. When mice were injected with poly-
aminoacid nanoparticles encapsulated with OVA they
produced significantly higher levels of IgG, IgG1, and
IgG2a compared to the injections of soluble OVA. Mohr
et al showed that the nanoparticles induced cellular and
humoral immune responses by CD8+ and CD4+ T cell
activation that produced interferon gamma (INF-γ) and
polarization towards IgG2a52. Likewise, hepatitis B antigen
encapsulated into a PLGA nanoparticle was shown to in-
duce a significantly more pronounced immune response
compared to the soluble virus antigen53.
Moreover, shape and surface charge of nanopar-
ticles are important for efficient delivery of antigens.
Spherical nanoparticles compared to rod-like vehicles
are more readily phagocytosed by macrophages and
DCs. Also, positively charged biomaterials are taken up
more easily by the anionic epithelial cell membranes54,55.
In this concept nanoparticles composed of PLGA and
polyethylene imine (PEI) were encapsulated with naked
DNA encoding the Mycobacterium tuberculosis Rv1733c
latency antigen. The bioengineered nanoparticles were
small and positively charged and when endotracheally
intubated in a mouse model, they adhered to the nega-
tively charged lung mucosal membranes with subsequent
epithelial cellular uptake. M. tuberculosis antigen was then
expressed resulting in antigen presentation to DCs, T-cell
proliferation, INF-γ production, secretion of interleukin 12
PNEUMON Number 1, Vol. 31, January - March 2018
(IL-12), and tumor necrosis factor alpha (TNF-α) at levels
comparable to lipopolysaccharides stimulation56. Taken
together, the above demonstrate that biodegradable
polymers are becoming the novel platforms for lung
DNA vaccinations. However, given their short history in
vaccinology applications, they have not established yet
their safety for human use, thus further research needs
to be carried out to assess their toxicity before they are
incorporated in clinical trials.
Implants for Lung Circulation Diseases
Without doubt, one of the most common uses of
biopolymers has been the development of pulmonary
cardiovascular products. In the 1990s poly (3HB) patches
were developed to close pericardium during open heart
surgery57 and the same material was used for augmenta-
tion of pulmonary artery58. These biodegradable patches
had sufficient strength to close the arteries and drove
the formation of regenerative tissue that resembled the
native atrial wall. Perhaps one of the most outstanding
application of biopolymers is that of the development
of tissue engineered cell-seeded pulmonary valves that
was successfully applied in animal models59. Research-
ers have used bio-absorbable poly-4-hydroxybutyric
acid patches with autologous vascular cell seeding as a
feasible biomaterial to augment pulmonary circulation60.
Mettler et al used a mixture of polyglycolic acid and poly-
4-hydroxybutyrate biopolymer and seeded the biomate-
rial with ovine endothelial progenitor and mesenchymal
stem cells for 5 days. The patches when implanted into the
ovine pulmonary artery showed the successful creation
of artificial bioengineered blood vessel61.
Discussion
Biopolymers are the natural metabolite products
formed during the life cycle of animals, bacteria, fungi
and plants. Because of their high biocompatibility, and
their non-toxic degradation products they have come to
be ideal biomaterials that found applications in a number
of airway diseases, as they are summarized on Figure 2.
We are expecting that in the near future a number of
biomaterials will be utilized to bioengineer fully func-
tional lung tissues from the very own stem cell lines of
the recipient. It is without doubt that in the approximate
future biopolymers will continue to find more biomedical
applications in airway disease.
PNEUMON Number 1, Vol. 31, January - March 2018
Figure 2. Schematic representation of biomedical applications of biopolymers in airway disease.
Competing interests
The authors declare that they have no competing
interests.
Funding
This work was supported by School of Mathematical
and Natural Sciences, Arizona State University and by the
Department of Chemistry of Aristotle University.
Acknowledgements
We would like to thank the Arizona State University
and Aristotle University of Thessaloniki for granting us ac-
cess to the scientific literature listed in the present review.
31
Declarations
Ethics approval
This review article was evaluated and approved by the
Arizona State University and Aristotle University.
Consent for publication
Not applicable.
Authors’ contributions
GTN reviewed the relevant literature, designed the
structure of the review article, integrated and synthe-
sized published data, contributed to manuscript writing,
prepared figures. AAP, contributed to manuscript writing,
prepared figures, contributed to manuscript writing, and
provided oversight to the entire review progress.
32 PNEUMON Number 1, Vol. 31, January - March 2018

ΠΕΡΙΛΗΨΗ
Βιοϊατρικές εφαρμογές των βιοπολυμερών στη νόσο των αεραγωγών
Γεώργιος Θ. Νούτσιος, PhD, MS1, Αναστασία A. Πανταζάκη2
1
Assistant Research Professor, Arizona State University School of Mathematical and Natural Sciences,
Phoenix, USA, 2Τμήμα Χημείας, Εργαστήριο Βιοχημείας, Αριστοτέλειο Πανεπιστήμιο, Θεσσαλονίκη

Ο όρος “νόσος των αεραγωγών” περιγράφει διάφορα γεγονότα που οδηγούν σε καταστροφή του πνευμο-
νικού ιστού, κακή αιματική κυκλοφορία, και απόφραξη των αεραγωγών που εμποδίζουν τη λειτουργία των
πνευμόνων. Πολυμερικά βιοϋλικά που είναι βιοαποικοδομήσιμα έχουν αναδυθεί ως σημαντικά επιτεύγμα-
τα της σύγχρονης ιατρικής. Σε αυτήν την ανασκόπηση, επιδιώξαμε να διερευνήσουμε το κλινικό δυναμικό
των βιοπολυμερών στην ασθένεια των αεραγωγών. Αρχικά συζητούμε συνοπτικά τη βιοσύνθεση των βι-
οϋλικών και τη χρήση τους σε ικριώματα των ιστών των πνευμόνων, στη μηχανική των μοσχευμάτων χόν-
δρων και τη χρήση τους ως υποστρώματα για in vitro καλλιέργεια αναπνευστικών επιθηλιακών κυττάρων.
Στη συνέχεια συζητάμε τη χρήση τους ως βιοαπορροφήσιμα νανοδομημένα συστήματα χορήγησης φαρ-
μάκων που καταπολεμούν τον καρκίνο του πνεύμονα καθώς και την πρόληψη της μετάστασης με στόχο
την παρεμπόδιση του πολλαπλασιασμού των καρκινικών πνευμονικών κύτταρων. Επιπλέον, αναφερόμα-
στε στη χρήση των βιοπολυμερών μαζί με λιπίδια ως υποκατάστατα του πνευμονικού επιφανειοδραστικού
παράγοντα στο σύνδρομο οξείας αναπνευστικής δυσχέρειας. Προτείνουμε τη χρήση βιοπολυμερών ως
χειρουργικά εμφυτεύματα σε αιμοφόρα αγγεία του πνεύμονα. Επίσης, η ενθυλάκωση πλασμιδίων ή αντιβι-
οτικών σε βιοπολυμερή νανοσωματίδια συζητείται για την γονιδιακή θεραπεία στο πλαίσιο της ρύθμισης
της λειτουργίας των κυψελιδικών μακροφάγων, των δενδριτικών κυττάρων και των προσαρμοστικών ανο-
σοποιητικών αποκρίσεων στην κυστική ίνωση. Η χρήση νανοσωματιδίων για χορήγηση ρινικού, βρογχικού
και πνευμονικού εμβολίου (νανοεμβολιολογία) επίσης καταγράφεται ως μια νέα μέθοδος για την πρόκληση
ευνοϊκών ανοσοαποκρίσεων στον βλεννογόνο του αναπνευστικού συστήματος με πιθανότητα να επάγει
συστημική ανοσία. Η παρούσα ανασκόπηση συνοψίζει τις πιο πρόσφατες εξελίξεις στον τομέα κατά την
παρελθούσα δεκαετία, επισημαίνοντας συγκεκριμένα νέες και ενδιαφέρουσες εφαρμογές στις παθήσεις
των αεραγωγών.
Πνεύμων 2018, 31(1):24-34.
Λέξεις - Κλειδιά: πολυυδροξυαλκανοϊκά, νόσος των αεραγωγών, καταστροφή πνευμονικού ιστού, συστή-
ματα απελευθέρωσης φαρμάκων, νανοεμβολιολογία

polyhydroxyalkanoates from whey by Thermus thermophilus

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4.

Physiotherapy in cystic fibrosis
Α comprehensive clinical overview
Arietta Spinou MSc, PhD
Health, Sports and Bioscience,
University of East London, UK
Key words:
- Physiotherapy
- Cystic Fibrosis
- Airway Clearance
- Chest Physiotherapy
- Exercise
Correspondence:
Arietta Spinou,
Lecturer in Physiotherapy,
Health, Sports and Bioscience,
University of East London, Water Lane,
Stratford, E15 4LZ, London, UK
E-mail: a.spinou@uel.ac.uk
Review
SUMMARY
Physiotherapy remains the cornerstone of cystic fibrosis (CF) man-
agement alongside medical treatment. Traditionally, physiotherapy
intervention focussed on airway clearance during the clinically stable
stage and chest infections. Research evidence consistently supports
greater mucus clearance with chest physiotherapy compared to
cough alone or no treatment. Various methods and techniques of
airway clearance have been developed and investigated, and data
suggest that most of them are of similar effectiveness. Nowadays
physiotherapy management also extends to other areas, supported
by studies and clinical practice. The physiotherapists plan, supervise
and follow-up systematic exercise or personalised rehabilitation
programs, which, similarly to airway clearance, are recommended
in all patients with CF. Furthermore, based on a comprehensive as-
sessment, physiotherapists incorporate the management of accom-
panying musculoskeletal problems such as back pain and postural
disorders, as well as urine incontinence issues. In the era that aims
to improve quality of life, it is essential that physiotherapists are
aware of specific conditions that might affect the management of CF.
Their role is to work alongside and within the CF multi-disciplinary
team throughout patient’s treatment and consistently support the
patient and carers, in particular whilst on clinical pathways of the
lung transplantation and palliative care.
Pneumon 2018, 31(1):35-43.
Introduction
Cystic fibrosis (CF) is a recessive genetic disease that affects the patient
on multiple systems, with profound manifestations in the respiratory and
digestive systems1. It is characterised by the mutation and therefore dys-
function of the gene for the cystic fibrosis transmembrane conductance
regulator (CFTR). This protein mainly functions as an ion channel, regulating
fluid volume on epithelial surfaces via chlorine secretion and inhibition
of sodium resorption. In the airways of the patients with CF, dysfunction
36
of the CFTR results in periciliary liquid layer depletion2.
Clinically, patients with CF present abnormal consistency
and high volumes of sputum, cough, dyspnoea, bronchi-
ectasis and weight loss. As the survival of these patients
is increasing, it is crucial that health care professionals
address symptoms and support individuals in evolving
issues developed throughout their life span.
Physiotherapy is an integral part of the therapeutic
management of CF patients, both at the clinically stable
stage of the disease and during respiratory infections.
In the past, physiotherapy was focused on airway clear-
ance, also known as chest physiotherapy, by teaching or
applying methods such as the postural drainage with or
without the additional application of manual techniques3.
Postural drainage of the tracheobronchial tree uses spe-
cific gravitational positions to assist mucus mobilisation
downwards (towards the mouth) within the airways.
Manual techniques (percussions, vibrations and/or shakes)
use mechanical forces to assist the detachment of mucus
from the airway epithelium and its mobilisation. Nowa-
days, the choice of airway clearance techniques has been
expanded to methods such as the autogenic drainage,
the active cycle of breathing techniques (ACBT), the use
of positive expiratory pressure (PEP) devices with or with-
out oscillation, and others. Still, modern physiotherapy
in CF also includes the assessment of the cardiovascular
system and improvement of the patient’s fitness level,
muscle strength and endurance through exercise, as well
as specialised interventions to improve musculoskeletal
symptoms of pain, posture and incontinence4.
PHYSIOTHERAPY
Airway clearance
Patient education, application and monitoring of the
airway clearance techniques remain the main physio-
therapy treatment for patients with CF4. Physiotherapists
facilitate the establishment of an individualised airway
clearance routine by supporting patients and their families
to establish regular regimes during a clinically stable stage
and have an escalation plan for disease exacerbations5.
Airway clearance is usually performed on a daily basis
and as required. The selected method applied, duration and
frequency of each session are tailored to the patient, their
general health condition and the severity of the disease. For
instance, airway clearance becomes more regular during
exacerbations or hospitalisations6. Hospitalisations also
provide an opportunity for physiotherapists to re-assess
PNEUMON Number 1, Vol. 31, January - March 2018
the effectiveness of daily airway clearance and provide
appropriate feedback and guidance for improving the
patient’s usual technique prior to discharge.
Table 1 presents the main categories of airway clear-
ance techniques and methods in CF. These can be used
in isolation or in combination regimes. Assessment of
effectiveness is based on measuring sputum volume or
weight, lung function by spirometry, frequency of hospitali-
sations and quality of life. Airway clearance is extensively
supported in the literature when compared to no airway
clearance or cough alone4,7-9. A recent systematic review
supported a significant increase in the amount of sputum
(wet or dry) in the patient groups that applied airway
clearance using postural drainage with or without the
addition of manual techniques or using PEP, compared
to spontaneous cough or not using any technique7. The
weight of the sputum was higher after the application
of the active cycle of breathing techniques compared to
the use of the flutter (an oscillating PEP device) or high
frequency chest wall oscillation (vest)10. The weight of
the sputum expectorated was greater after using the
PEP mask compared to autogenic drainage, postural
drainage positions and their combination, although this
difference was short-term (up to one week)11. On the
other hand, there was no difference in the amount of the
expectorated mucus after autogenic drainage compared
to the flutter, or between the high frequency chest wall
oscillation compared to the autogenic drainage or the
PEP mask for longer time-intervals10,12.
Systematic reviews did not show significant differ-
ences in the lung function (FEV1) of adult patients fol-
Table 1. Common airway clearance techniques and methods.
Airway clearance techniques
• Postural drainage
• Manual techniques
• Active circle of breathing techniques (ACBT)
• Autogenous drainage (AD)
• Positive expiratory pressure (PEP) devices (PEP mask, Pari-
PEP, etc)
• Positive expiratory pressure (PEP) devices with oscillation
(flutter, acapella, cornet, etc.)
• Intermittent Positive Pressure Breathing (IPPB)
• High frequency chest wall oscillation (HFCWO) or vest
• Non-invasive mechanical ventilation (NIV)
• Aerobic exercise
PNEUMON Number 1, Vol. 31, January - March 2018
lowing the use of PEP, when assessed patients prior and
immediately after a physiotherapy session or up to 3
months later7,10,11,13. Additionally, the lung function did
not change after applying the active cycle of breathing
techniques in combination with the PEP mask, postural
drainage with or without manual techniques, or the high
frequency chest wall oscillation12. However, treatment
in children and adolescents that was applied up to one
year showed 6% increase in FEV1 with the use of PEP13.
Regarding the hospitalisation frequency, no differences
were found for those who practiced the active cycle of
breathing techniques compared to the postural drain-
age with or without manual techniques12. The number
of hospitalisations, however, was lower for those who
used PEP than the patients who used the flutter (5 vs 18
hospitalisations, respectively)10. Similarly, fewer patients
used intravenous antibiotics from the group that used PEP
devices, compared to the group of the high frequency
chest wall oscillation13.
For the quality of life, there is no difference amongst
techniques and devices, such as the postural drainage with
or without manual techniques, active cycle of breathing
techniques, autogenic drainage, PEP mask, flutter, and
cornet10,12,13. However, patients preferred the PEP mask for
long-term use (>1 month), and also preferred seating in-
stead of using postural drainage positions10,11,13. Autogenic
drainage was preferred among children between 12-18
years old, compared to postural drainage in combination
with manual techniques14.
Important factors for the success of the selected
airway clearance plan are the compliance to treatment
and patient satisfaction. Factors that increase the rate of
compliance are good patient knowledge of the technique
and confidence in its application, independence and pref-
erence15,16. Evidence indicate that patients who receive
help, those who produce more sputum, and children with
CF whose parents believe in the necessity of treatment
are those with higher compliance in airway clearance17,18.
Airway clearance adaptations
Mucolitics and other agents
Patients with CF often receive medications that aim
to increase the effectiveness of airway clearance, such
as nebulised hypertonic saline (3% to 7% NaCl), dornase
alpha (DNase), and mannitol. The use of inhaled hypertonic
saline (osmotic pressure >0.9% NaCl) in patients with CF
is considered to improve the rheological characteristics of
sputum and increase the hydration of the airway epithe-
37
lium; thus, increase the sputum motility and facilitate the
mucus clearance19. There is good evidence that the use
of hypertonic saline reduces the incidence of respiratory
infections, increases FEV1, and improves the quality of
life, although the changes are not maintained in the long
term (48 weeks)20,21. During the hospitalisation of patients
with CF, hypertonic saline improves the chances of quick
return of the lung function (FEV1) to pre-infectious levels22.
With regards to timing the hypertonic saline administra-
tion, a recent systematic review supports its use before
or during the performance of airway clearance, rather
than its administration afterwards23. If the prescribed
doses are two, it is recommended to administer one in
the morning and one in the evening, and if the patient
receives a single dose this is given at a convenient time
chosen by the patient23.
Dornase alpha (DNase) is a recombinant human de-
oxyribonuclease that reduces sputum viscosity by selec-
tively hydrolysing the large extracellular DNA molecules
contained in the mucus into smaller structures, thereby
increasing the potential for its elimination24. This drug
is administered via a jet-nebuliser device and has been
shown to reduce the incidence of respiratory infections,
increase respiratory function, and improve quality of
life24. With regards to timing its administration, it appears
that using DNase before or after airway clearance does
not have any difference in improving lung function (FEV1
and FVC) or patient’s quality of life25,26. In clinical practice,
physiotherapy often follows the proposed guidelines of
the pharmaceutical company to perform airway clearance
30 minutes after the DNase administration27.
Inhaled mannitol is a naturally occurring sugar alcohol
which enhances osmosis, causing mucus hydration28. In-
haled mannitol is administered as dry powder (capsules)
using an inhaler. As demonstrated by two 26-week multi-
centre studies with a total number of 600 participants with
CF, inhaled mannitol improves the respiratory function
of patients but does not improve their quality of life29,30.
Although its use usually precedes airway clearance in
clinical practice, there is no research data to compare
different timings of administration.
Haemoptysis
Haemoptysis is a major change in the patient’s clini-
cal presentation and may be life-threatening. The phys-
iotherapy assessment should include questions about
sputum description and reference to current or past
haemoptysis episodes. Active frank haemoptysis (>100-
1000 ml haemoptysis in 24 hours or 48 hours) is treated
38
exclusively medically, e.g. with bronchial embolisation of
the arteries or thoracic surgery, while the airway clearance
treatment is temporarily discontinued31,32. In moderate or
low haemoptysis, physiotherapists, in collaboration with
the medical team, decide whether or not it is appropriate
to continue airway clearance using clinically reasoning. If
the treatment is appropriate and safe to continue, then
the active cycle of breathing techniques or autogenic
drainage is often selected over other techniques.
Pneumothorax
Spontaneous pneumothorax is a common complica-
tion in patients with CF. It is associated with a reduction
in pulmonary function and 50-90% chance of recur-
rence32,33. If the pneumothorax occurs for the first time
and it is small, then it can be treated conservatively with
oxygen supply34. In patients continuing airway clearance,
it is suggested to liaise with the medical team for add-
ing humidification to the oxygen supply and ensuring
adequate analgesia for the duration of the treatment
sessions35. In the case of large pneumothorax (>2 cm
between parietal pleura and visceral pleura) or recur-
rent pneumothorax, chest drainage is performed using
thoracic catheters, while patients might get pleurodesis
in resistant cases34. Positive pressure devices such as PEP,
flutter and acapella are contraindicated in the presence
of pneumothorax34. Regarding physical activity, patients
need to be engaged with moderate activities but should
avoid bearing weights over 2 kg or strenuous aerobic ex-
ercise for a period of two to six weeks after the complete
drainage of the pneumothorax34.
Exercise
Exercise is an integral part of the comprehensive
physiotherapy intervention for patients with CF36. Ameri-
can College of Sports Medicine guidelines advocate 3-5
sessions of moderate exercise per week, with the aim to
adopt exercise as a way of living37. Benefits of specific
exercise modalities in cystic fibrosis are yet to be identified
in methodologically strong studies38. Despite research
interest, evidence has not established the effectiveness
of inspiratory muscle training on this group of patients,
therefore this is currently not routinely incorporated in
the CF treatment. In the clinical setting, the assessment of
patients with CF uses simple and cost-effective exercise
field tests, such as the 6-minute walk test (6MWT) and
the incremental shuttle walk test (ISWT), whilst the level
of dyspnoea is assessed using the Borg dyspnoea scale39.
PNEUMON Number 1, Vol. 31, January - March 2018
Exercise can theoretically assist airway clearance
through the kinetic forces and vibrations generated
within the airways, but it cannot substitute for the formal
airway clearance40. When compared to airway clearance
techniques, moderate aerobic exercise leads to less mucus
expectoration41. Also, exercise as a single agent does not
increase cough immediately after its completion, although
it improves the subjective ease of sputum clearance42.
Clinically, exercise is mainly used additionally to airway
clearance, as a means to improve the exercise capacity
of the patient and is usually performed before the imple-
mentation of airway clearance.
Exercise considerations
Musculoskeletal and postural issues
Back and thoracic pain are frequently reported in
patients with CF, although they do not have an effect on
lung function43,44. Higher thoracic kyphosis is associated
with lower lung function, but nowadays it is more uncom-
mon compared to a few years ago45. Low bone density
and osteopenia is also a common issue in patients with
CF46,47. Counselling and appropriate exercise programs
from physiotherapists can potentially address and improve
these postural and structural issues36.
Urinary incontinence
Surveys show that urinary incontinence in patients
with CF is reported in 30% to 68% of women or girls and
5% to 16% of men or boys48-51. The dynamic pressure cre-
ated during coughing is potentially a key mechanism of
CF urinary incontinence, although it may not be the only
one52. Coughing, sneezing, laughing and spirometry are
among the activities that trigger urinary incontinence
incidents53. Incontinence worsens during respiratory infec-
tions and has been associated with poorer quality of life
and higher anxiety and depression scores51,54,55. Assessing
incontinence using screening tools and clarifying ques-
tions should be an integral part of the CF physiotherapy
assessment, regardless of gender56. Physiotherapy treat-
ment of urinary incontinence includes counselling and
specialised training involving pelvic floor exercises, such
as Kegel exercises55,57,58.
Diabetes mellitus
Diabetes mellitus is associated with CF and is the
most common comorbidity of the disease, occurring in
up to 20-50% of adult patients59-61. This comorbidity re-
quires the co-operation of the physiotherapists with the
PNEUMON Number 1, Vol. 31, January - March 2018
endocrine team, especially for the patients who require
insulin therapy62. Additionally, the presence of diabetes
mellitus needs to be considered in the physiotherapy
plan, mainly in the exercise prescription and performance.
In this case, the proper scheduling of the meal times or
insulin intake is essential.
Quality of life
Over time and as the CF severity and symptoms prog-
ress, the quality of life of patients is deteriorating. Females
with CF often report poorer quality of life compared to
their male age-matched peers63. Although the correla-
tion between lung function and quality of life is weak
to moderate, patients with better lung function report
higher quality of life54. Also, the presence of Pseudomonas
aeruginosa and frequent respiratory infections appear to
have a negative impact on the quality of life of patients54.
Researchers and clinicians can use a number of vali-
dated questionnaires for the assessment of quality of life
in people with CF. Those include: generic questionnaires
or questionnaires for a specific disease symptom, such as
the Short Form-36 (SF-36) and the Leicester Cough Ques-
tionnaire, respectively64,65; disease-specific questionnaires,
such as the Manchester Questionnaire, the Cystic Fibrosis
Questionnaire-Revised and the Cystic Fibrosis-Quality of
Life64,66-69; and questionnaires for babies and children of
young age, such as the Modified Parent Cystic Fibrosis
Questionnaire-Revised70.
Special considerations
Long term oxygen therapy and non-invasive ventilation
A recent systematic review in patient with CF did not
show long-term benefits from the long-term oxygen
therapy, in survival, respiratory function or cardiovascu-
lar health, although it showed improved school or work
attendance rates71. When oxygen is administered during
exercise only, it helps to improve oxygenation, reduces
the feeling of dyspnoea and increases the duration of
the exercise71,72. However, supplemental oxygen during
exercise in patients with initially low arterial oxygen
values appears to cause hypercapnia in the short term
(PCO2 up to 16 mmHg)71. Also, oxygen therapy during
sleep improves oxygenation, but is accompanied by small
hypercapnia71. The use of supplemental oxygen should
follow the established clinical guidelines that are based
on hypoxia (PaO2 ≤55 mmHg or 60 mmHg) and the pres-
ence of clinical symptoms73.
Non-invasive ventilation (NIV) is used in patients with
39
CF on respiratory failure, hypoventilation during sleep,
as well as a bridge to lung transplantation3. For patients
with severe clinical presentation where airway clearance
causes fatigue and high levels of dyspnoea, NIV can be
used to assist airway clearance74. The use of NIV during the
physiotherapy session facilitates mucus expectoration and
reduces the sensation of dyspnoea during the treatment
compared to other techniques particularly for patients
with low lung function75. However, the long-term effects
of NIV on airway clearance need further investigation76.
Paediatric population
Choosing a treatment plan for children with CF is based
on age, clinical presentation and certain social criteria77.
There is no agreement on the most appropriate starting
age for airway clearance. A proposal for early disease
management (pre-symptomatic) is to carefully monitor
the clinical presentation of children and adopt an active
treatment plan following the onset of symptoms78. At
young ages, where the child can not follow instructions
and cooperate, assisted autogenic drainage or PEP de-
vices with a child mask can be used. Physiotherapists
are also responsible for educating the child’s parents or
carers for appropriate evaluation of the child’s symptoms
and treatment implementation as required79. Postural
drainage with tilt (head-down positions) is no longer
advised for babies, as it has been shown to increase the
gastroesophageal reflux80.
As children grow older, they can more actively partici-
pate in their treatment. Children over 3 years old can also
use an airway clearance game, the bubble PEP. This is a
positive-pressure home-made device, where children are
encouraged to generate soap bubbles by breathing out
through a small plastic tube and into a bottle of soapy
water81. According to the UK Cystic Fibrosis Foundation, at
the age of 6 years or more, the use of nebulised hypertonic
saline can be initiated in combination with airway clear-
ance82. Also, at all ages, activity games and engagement
with exercise are encouraged and used, for instance racing,
trampolines and exercises using a gym ball83.
Palliative care
CF is a disease that limits life expectancy and requires
discipline and consistency to many hours of daily treat-
ment. As a result, its psychological impact should not
be ignored84. If patients are in respiratory failure and in
lung transplantation list, pulmonary rehabilitation is the
treatment priority, alongside the aim to relieve symptoms.
Working in line with the patient’s wishes is very impor-
40 PNEUMON Number 1, Vol. 31, January - March 2018

tant, particularly during the palliative care stage. Airway
clearance of less active patient participation (eg. postural
drainage), massage and some dyspnoea relieving posi-
tions could be applied during this stage, if they provide
comfort to the patient85.
CONCLUSIONS
CF management is highly demanding, mainly aiming
to the reduction and treatment of chest infections, im-
provement of quality of life and increase of life expectancy.
Physiotherapy is an integral part of the patient’s daily
treatment routine, and additionally to airway clearance
other important issues should be addressed. Interna-
tional clinical guidelines suggest access to specialised
physiotherapy care both during a clinically stable stage
of the disease and during respiratory infections. At the
clinically stable stage, patients should be evaluated by
physiotherapists every 3-6 months to re-evaluate and op-
timize their treatment plan. During respiratory infections,
physiotherapy interventions are intensified according to
the clinical presentation. Although in CF airway clearance
is the cornerstone of physiotherapy treatment, physio-
therapists work beyond the respiratory system and play an
important role in the management of other issues, mainly
using individualised exercise programmes. The exercise
programmes need to be tailored to patient-related needs
and issues, such as pain, diabetes and incontinence. This
way, the patient-centred and individualised treatment
follows the international standards and clinical guidelines.
Conflict of interest declaration
No conflict of interest.
Funding
None.

ΠΕΡΙΛΗΨΗ
Φυσικοθεραπεία στην κυστική ίνωση: Mια περιεκτική κλινική ανασκόπηση
Αριέττα Σπίνου MSc, PhD
Λέκτορας Φυσικοθεραπείας, Health, Sports and Bioscience, University of East London, UK

Η φυσικοθεραπεία παραμένει μια από τις κύριες μεθόδους διαχείρισης την κυστικής ίνωσης, σε συνδυα-
σμό με την ιατρική θεραπεία. Παραδοσιακά, η φυσικοθεραπεία επικεντρώνονταν στον τραχειοβρογχικό
καθαρισμό κατά τη διάρκεια της κλινικά σταθερής φάσης και των αναπνευστικών λοιμώξεων, με τα ερευ-
νητικά δεδομένα να υποστηρίζουν την αποτελεσματικότητά της συγκριτικά με τον βήχα ή τη μη θεραπεία.
Διάφορες μέθοδοι και τεχνικές τραχειοβρογχικού καθαρισμού έχουν αναπτυχθεί και διερευνηθεί, και τα
δεδομένα προτείνουν ότι οι περισσότερες από αυτές είναι παρόμοιας αποτελεσματικότητας. Επιπλέον, σή-
μερα, οι έρευνες και η κλινική πρακτική επεκτείνουν τη φυσικοθεραπευτική διαχείριση πέραν του αμιγώς
αναπνευστικού συστήματος. Οι φυσικοθεραπευτές σχεδιάζουν, επιβλέπουν και επανελέγχουν τη συστη-
ματική άσκηση ή εξατομικευμένο πρόγραμμα αποκατάστασης, που ομοίως με τον τραχειοβρογχικό κα-
θαρισμό συστήνεται σε όλους τους ασθενείς με κυστική ίνωση. Ακόμα, όταν χρειάζεται και με βάση μια
ολοκληρωμένη αξιολόγηση, η φυσικοθεραπεία πραγματεύεται τη διαχείριση συνοδών μυοσκελετικών
προβλημάτων όπως οσφυαλγίας, εργονομικών προβλημάτων στάσης και ακράτειας. Σε μια εποχή που
στοχεύει στη βελτίωση της ποιότητας ζωής, οι φυσικοθεραπευτές είναι απαραίτητο να γνωρίζουν τις ει-
δικές περιπτώσεις που επηρεάζουν τη διαχείριση της κυστικής ίνωσης. Ο ρόλος τους είναι να εργάζονται
σε συνεργασία με την πολύ-επιστημονική ομάδα για την υποστήριξη των ασθενών και του περιβάλλοντός
τους, ιδιαίτερα όταν οι ασθενείς είναι σε αναμονή για μεταμόσχευση ή κατά την παρηγορητική φροντίδα.
Πνεύμων 2018, 31(1):35-43.
Λέξεις - Κλειδιά: φυσικοθεραπεία, κυστική ίνωση, τραχειοβρογχικός καθαρισμός, αναπνευστική φυσικο-
θεραπεία, άσκηση
PNEUMON Number 1, Vol. 31, January - March 2018
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quality of life in clinical trials in cystic fibrosis. J Cyst Fibros
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opment and validation of The Cystic Fibrosis Questionnaire
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πό
ά-
ως
άλλα
σαρ-
Case Report
ει-
πηση
μω-
σεις
ολόνη,
τι ο
σκό- Reversed halo sign in community
ίμη-
κή acquired pneumonia
A case report
νωμο-

Rouzana Pechlivanidou, SUMMARY

Aikaterina Mitka, Reversed halo sign (RHS) is defined as central annular ground-glass
Efstratios Giovanis, opacity surrounded by a ring of denser consolidation at least 2mm
Vasiliki Drampa, thickness. It was first described by Voludaki et al. in a case report of
nser Dimitrios Mpompotas, two COP cases and later concluded that it was specific to cryptogenic
OP Antonios Antoniadis organizing pneumonia. Since then, the RHS was associated with a
S was wide range of pulmonary diseases: pulmonary fungal infections,
unity tuberculosis, community – acquired pneumonia, sarcoidosis, pul-
ction
Pneumonology Department of General monary neoplasms, Wegener granulomatosis, pulmonary infraction
and
Hospital of Serres, Greece and other diseases. We report a patient case of community-acquired
o
ealed pneumonia with of RHS on HRCT, and we review the literature on
this radiological sign. We present a 70 years-old male, who was
one. Key words: admitted to emergency department with lower tract respiratory
p- - Reversed halo sign infection symptoms, HRCT was performed and revealed multiple
t CT - Atoll sign round ground-glass opacities fringed with peripheral consolidation
- HRCT
ons, in both lungs. The patient was diagnosed with community-acquired
- Ommunity acquired pneumonia
pneumonia and treated successfully with respiratory quinolone.
Unfortunately, the infectious agent was not determined, as well as
bronchoscopy with BAL was not helpful for diagnosis. At follow up,
in 21 days and 4 months, the patient remained asymptomatic, and
chest CT revealed a clear improvement. Finally, reversed halo sign
has been reported in a wide range of conditions, and investigation
of its aetiological factors is required.
Pneumon 2018, 31(1):44-48.

Introduction

Correspondence:
Dr Andonis Antoniadis, Director of Pneumonology
Clinic, General Hospital of Serres, Greece,
Tel.: +30 23210-94607, Fax: +30 23210-94624,
e-mail: andonisant100@gmail.com
Reversed halo sign, also known as atoll sign, is defined as central ground-
glass opacity surrounded by denser consolidation of crescentinc or ring
shape of at least 2mm thickness. It was first described on high-resolution
CT (HRCT) as being specific for cryptogenic organizing pneumonia (COP).
PNEUMON Number 1, Vol. 31, January - March 2018 45

Since then, the reversed halo sign was associated with not provide any significant information.
a wide range of pulmonary diseases : pulmonary fungal The patient’s white blood count was 5,760 cells/mm3
infections, pneumonocystis pneumonia, tuberculosis, (lymphocytes = 20%, neutrophils = 69%, and atypical =
community – acquired pneumonia, lymphomatoid granu- 8%). CRP level was 8,4 mg/L.
lomatosis, Wegener granulomatosis, lipoid pneumonia, At presentation the chest X-ray showed a consolida-
sarcoidosis, pulmonary neoplasms, pulmonary infraction tive pattern in the right middle and lower lung fields.
and following radiation and radiofrequency therapy of Chest computed tomography (CT) revealed multiple
pulmonary malignancies. round ground-glass opacities fringed with consolidation
in both lungs, namely the “reversed halo sign” (Figure 1).
Afterwards bronchoscopy with BAL was done and
Case Presentation didn’t reveal any remarkable endoscopic findings (bron-
We are reporting a 70 years-old male patient who was choalveolar lavage fluid (BALF) cell analysis: alveolar
admitted to our hospital with a one-week history of fever macrophages 84%, CD4+ 5%, CD8+ 3%, CD4+/CD8+ =1,6,
and non-productive cough. The patient also complained neutrophils 5%, squamous epithelial cells 3% ). Tests for
for anorexia and weight loss. He was treated with antibiot- antinuclear antibody (ANA) and anti neutrophil cytoplas-
ics (Amoxicillin/Clavulanic Acid Tb 875/125mg 1x2 + Clar- mic antibody (ANCA) were negative. The Legionella and
ithromycin Tb 500mg 1x2) five days before his admission Pneumonococcal antigen urine testing were negative.
by his general practitioner. Due to the persistence of fever Blood cultures were negative. Sputum cultures were
he was referred to our clinic. His past medical history was
unremarkable for any chronic medical illness. He was a
smoker of 50 pack/years and denied ethanol, drug abuse
and recent travel. No drug allergies were noted.
At presentation the patient’s body temperature was
37.8°C, blood pressure was 120/75 mm Hg and percuta-
neous oxygen saturation was 97% in room air. His heart
rate was 100 to 110 beats per minute with a sinus rhythm
revealed on ECG. Respiratory rate was 18 to 20 breaths per
minute. His heart sounds were normal with no murmurs
or extra sounds. Auscultation revealed coarse crackles
over the posterior right lung. There was no clubbing,
cervical or axillary lymphadenopathy, skin lesions or joint
swelling. Physical examinations of the rest systems did
Figure 2. After 21 days.

Figure 1. Multiple round ground-glass opacities fringed with

consolidation in both lungs. Figure 3. After 4 month.
46
not performed, since the patient had no expectoration.
The patient was diagnosed with community – acquired
pneumonia and treated successfully with Moxifloxacin
i.v. (400mg/d), without receiving corticosteroids. The
symptoms were improved dramatically and he became
afebrile within the fourth day. At follow up the patient
remained afebrile. Computed tomography of the chest
(after 21 days and 4 months) revealed a clear improve-
ment (Figure 2, Figure 3).
Review
The reversed halo sign was first described and associ-
ated with COP1, but it is not specific to this disease. A wide
spectrum of conditions can manifest with the reversed
halo sign on chest HRCT2.
The reversed halo sign (RHS) is characterized by a
focal area of ground-glass opacity surrounded by a more
or less complete ring of consolidation on high-resolution
CT (HRCT)3.
Sometimes RHS can have specific morphological
findings helpful in differential diagnosis as RHS with
thickened rim and reticulation or “bird nest sign” and
RHS with micronodules. The reticular RHS is linked with
invasive fungal disease. RHS with micronodules is related
to active granulomatous disease, mainly tuberculosis4,
but also paracoccidioidomycosis (PCM) or cryptococ-
cosis and non-infectious granulomatous diseases such
as sarcoidosis5.
The presence of RHS on HRCT can be useful to narrow
the differential diagnosis. Analyzing the patient’s clinical
history and additional CT findings is helpful for the final
decision and treatment.
There is a spectrum of infectious, neoplastic, non-
infectious/non-neoplastic diseases that may appear as
RHS on HRCT. Various clinical situations that can guide
the clinicians were described.
Clinical signs and symptoms of pulmonary infection
In immunosuppressed patients opportunistic fungal
diseases should be included in the differential diagnosis5.
Opportunistic invasive fungal pneumonias (IFPs) have
high morbidity and mortality. The most common IFP is an
invasive pulmonary aspergilosis (IPA). Other angioinvasive
moulds, such as Zygomycetes species are encountered in
immunosuppressed patients7,8. In cases of IFP, the RHS is
an early sign that results from pulmonary infarct. Other
findings include nodules and pleural effusion9.
PNEUMON Number 1, Vol. 31, January - March 2018
The RHS has been described in up to 10% of patients
with PCM10. PCM is frequent mycosis in Latin America. The
HRCT findings of patients with pulmoparacoccidioido-
mycosis include ground-glass areas, small centrolobular
nodules, cavitated nodules, and areas of emphysema10.
In patients from areas with high rates of Mycobacte-
rium tuberculosis infection (TB), pulmonary tuberculosis
should always be included in the differential diagnosis. Ad-
ditional CT findings can help the radiologist: centrilobular
nodules and tree-in-bud opacities, as well as subcarinal
and hilar lymphadenopathy, areas of consolidation with
cavitation11,12. It is remarkable that areas of consolidation
have usually upper lobe distribution in these cases.
Pneumocystic Jiroveci Pneumonia (PJP) is the most
common opportunistic infection in HIV-positive patients.
The RHS has been described in AIDS patients with pneu-
mocystis pneumonia13,6.
The RHS has been reported in cases of bacterial, pneu-
mococcal14, psittacosis or legionella pneumonias. Since
infection can cause organizing pneumonia, it is possible
that in some of the reported cases of bacterial pneumonia
the RHS was a part of secondary organizing pneumonia,
provoked by the inflammatory damage.
Known primary neoplasm
The RHS has been described as an early secondary
finding of radiofrequency ablation (RFA) of pulmonary
nodules. The central GGO area is corresponded to an area
of coagulative necrosis of the nodule, whereas peripheral
consolidation is corresponded to fibrotic tissue15.
Radiation-induced lung disease (RILD) is common
following radiation therapy of the thorax. The RHS may
be seen during the acute phase of RILD, in the first 4-12
weeks after treatment. It is probably related to inflamma-
tory process or pulmonary necrosis related to radiation, or
secondary organizing pneumonia triggered by radiation
injury of the lung2.
In patients under chemotherapy, multiple RHS lesions
may correlate with non-specific interstitial pneumonia
(NSIP) or organizing pneumonia linked with drug-induced
toxicity7.
In patients with a known primary malignancy RHS
lesions may appear as atypical presentation of metastatic
disease. The presence of new RHS lesions in these patients
should be examined for lung metastatic progression7.
Patients with vascular or thromboembolic disease
Patients with pulmonary embolism (PE) may pres-
PNEUMON Number 1, Vol. 31, January - March 2018 47

ent RHS on CT in case of pulmonary infarction. The RHS
in patients with pulmonary infarction translates central
coagulative necrosis with peripheral rim of collagen tissue
produced by fibroblasts16,17.
The RHS has been described in patient with Wegener’s
granulomatosis, in association with lung nodules, ground-
glass opacities and cavitary lesions. RHS in this condition
represent an intermediate stage that preceded cavitation18.
Asymptomatic patient or with subacute clinical
symptoms
RHS has been described as an atypical manifestation
in sarcoidosis. Sarcoidosis is a granulomatous disease.
In 90% of cases lungs and intrathoracic lymph nodes are
affected. RHS in sarcoidosis can represent either non-
caseating granulomatous inflammation or secondary
organizing pneumonia7.
Cryptogenic organizing pneumonia (COP) is the most
common lung disease described in immunocompetent
patients with the RHS1. This sign can also be seen in cases
of secondary organizing pneumonia. Histopathologically,
the central ground-glass opacity of the RHS corresponds
to alveolar septal inflammation; the peripheral consolida-
tion represents organizing pneumonia within the alveolar
ducts6.
Non-specific interstitial pneumonia (NSIP) is an in-
terstitial lung disease that may be idiopathic, but is more
commonly associated with collagen vascular disease,
hypersensitivity pneumonitis or drug toxicity7. The RHS
correlates with interstitial inflammation that predominates
in the middle and lower lung. HRCT in patient with NSIP
reveal also reticular pattern, areas of consolidation and
traction bronchiectasis.
The RHS has been described by Kanaji et al. in case
of exogenous lipoid pneumonia after inhaling spray
paint. In this case RHS represented organizing pneumonia
resulting from lipoid pneumonia19.
Pulmonary adenocarcinoma may present as an area
of consolidation, a single node or as multiple nodules.
The RHS is an uncommon presentation of lung adeno-
carcinoma7.
Lymphomatoid granulomatosis (LG) is associated
with Epstein-Barr virus (EBV) which mainly affects the
lungs. In this case, the RHS corresponds to area of aer-
ated parenchyma with a peripheral ring of lymphomatoid
vascular invasion2.
Conclusion
A wide variety of diseases, infectious and noninfec-
tious, may present with the reversed halo sign on chest
CT. The two most commonly associated diseases are the
organizing pneumonia and invasive fungal pneumonia.
The patient’s history and clinical data in combination
with the additional radiological findings should help to
narrow the differential diagnosis. Although a biopsy is
needed in many diseases with RHS on HRCT, it can be
avoided in certain scenarios.
In the clinical case reported above, the RHS on chest
CT was related with inflammatory process, provoked by
infection. The diagnosis of CAP was based on clinical
presentation, laboratory tests (acute phase protein), and
clinical improvement after treatment with antibiotics only.
Unfortunately, the infectious agent was not determined,
as well as bronchoscopy with BAL was not helpful, since it
was performed in the convalescent phase. Nevertheless,
we assume that the causative agent provoked organizing
pneumonia and persistent inflammation in lung paren-
chyma, causing prolonged symptoms.

ΠΕΡΙΛΗΨΗ
Ανάστροφο σημείο της άλω στα πλαίσια πνευμονίας της κοινότητας
Ρουζάνα Πεχλιβανίδου, Αικατερίνη Μήτκα, Ευστράτιος Γιοβάνης, Βασιλική Δράμπα,
Δημήτριος Μπομπότας, Αντώνιος Αντωνιάδης
Πνευμονολογικό Τμήμα, Γενικό Νοσοκομείο Σερρών

Ανάστροφο σημείο της άλω ορίζεται ως δακτυλιοειδής σκίαση τύπου θολής υάλου περιβαλλόμενη από
πυκνωτική περιφερική ζώνη πάχους τουλάχιστον 2 χλστ. Πρώτη φορά περιγράφτηκε από την Βολουδάκη
και συνεργάτες σε 2 περιστατικά κρυπτογενούς οργανούμενης πνευμονίας και αρχικά θεωρήθηκε ως πα-
θογνωμονικό σημείο της νόσου. Αργότερα ανάστροφο σημείο της άλω περιγράφτηκε σε διάφορα άλλα
48 PNEUMON Number 1, Vol. 31, January - March 2018

πνευμονικά νοσήματα: μυκητιασικές πνευμονικές λοιμώξεις, φυματίωση, πνευμονία της κοινότητας, σαρ-
κοείδωση, κοκκιωμάτωση Vegener, πνευμονικά έμφρακτα, νεοπλάσματα πνεύμονα κ.α. Στο παρόν άρθρο
παρουσιάζεται περίπτωση ασθενούς με πνευμονία της κοινότητας με ακτινολογική εικόνα ανάστροφου
σημείου της άλω στην αξονική τομογραφία υψηλής ευκρίνειας και γίνεται ανασκόπηση της βιβλιογραφί-
ας. Πρόκειται για ασθενή ηλικίας 70 ετών που προσήλθε στο ΤΕΠ με συμπτώματα λοίμωξης κατώτερου
αναπνευστικού, υπεβλήθη σε HRCT, η οποία ανέδειξε πολλαπλές δακτυλιοειδείς σκιάσεις τύπου θολής υά-
λου με πυκνωτική περιφερική ζώνη. Aντιμετωπίστηκε επιτυχώς με αναπνευστική κινολόνη, ως περιστατικό
πνευμονίας της κοινότητας με μη ταυτοποιημένο αιτιολογικό παθογόνο, δεδομένου ότι ο εργαστηριακός
έλεγχος δεν απομόνωσε υπεύθυνο μικροοργανισμό, όπως επίσης αργότερα η βρογχοσκόπηση με βρογ-
χοκυψελιδικό έκπλυμα δεν ανέδειξε ιδιαιτέρα παθολογικά ευρήματα. Κατά την επανεκτίμηση σε 21 ημέρες
και 4 μήνες ο ασθενής παρέμεινε ασυμπτωματικός με σαφώς βελτιωμένη ακτινολογική εικόνα. Συμπερα-
σματικά, ακτινολογική εικόνα ανάστροφου σημείου της άλω στην HRCT δεν αποτελεί παθογνωμονικό ση-
μείο μίας νόσου και συνιστάται να διερευνηθούν όλα τα αίτια εμφάνισης της RHS.
Πνεύμων 2018, 31(1):44-48.
Λέξεις - Κλειδιά: Ανάστροφο σημείο της άλω, υψηλής ανάλυσης αξονική τομογραφία, πνευμονίας της κοι-
νότητας

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EG, Gourtfoyiannis NC. Crescentic and ring-shaped opacities.
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2. Del Rio B, Esteba Bech de Careda L, Ferrer M, et al. Interpret-
ing the reversed halo sign: Differential characteristics and key
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3. Hansell DM, Bankier AA, MacMahon H, McLoud TC, Muller
NL, Remy J. Fleischner society: Glossary of terms for thoracic
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istics of the reversed halo sign narrow the differential diagnosis
of pulmonary infections? American Journal of Roentgenology
2014; 203:557-8.
5. Marchiori E, Zanetti G, Escuissato DL, et al. The reversed halo
sign: High-resolution CT scan findings in 79 patients. Chest
2012; 5:1260-66.
6. Marchiori E, Zanetti G, Meirelles GS, Escuissato DL, Souza AS,
Hochhegger B. The reversed halo sign on high-resolution CT
in infectious and noninfectious pulmonary diseases. American
Journal of Roentgenology 2011; 197:69-75.
7. Goboy MC, Viswanathan C, Marchiori E, et al. The reversed halo
sign: Update and differential diagnosis. The British Journal of
Radiology 2012; 85:1226-35.
8. Chamilos G, Marom EM, Lewis RE, Lionakis MS, Kontoyannis
DP. Predictors of pulmonary zygomycosis versus invasive pul-
monary aspergolosis in patients with cancer. Clinical Infectious
Diseases 2005; 42:60-66.
9. Marom EM, Kontoyiannis DP. Imaging studies for diagnosing
Current Opinion in Infectious Diseases 2011; 24:309-14.
10. Gasparetto EL, Escuissato DL, Davaus T, et al. Reversed halo
sign in pulmonary paracoccidioidomycosis. American Journal
of Roentgenology 2005; 184:1932-4.
11. Ahuja A, Gothi D, Joshi JM. A 15-year-old boy with “Reversed
Halo”. The Indian Journal of Chest Diseases and Allied Sciences
2007; 49:99-101.
12. Marchiori E, Grando RD, Simoes Dos Santos CE, et al. Pulmo-
nary tuberculosis associated with the reversed halo sign on
high-resolution CT. British Journal of Radiology 2010; 83:58-60.
13. Otera H, Tada K, Sakurai T, Hashimoto K, Ikeda A. Reversed Halo
sign in pneumocystis pneumonia: a case report. BMC Medical
Imaging 2010; 14: 481-6.
14. Tzilas V, Provata A, Koti A, Tzouda V, Tsoukalas G. The “Reversed
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radiofrequency ablation of a lung nodule. Journal of Thoracic
Imaging 2011; 26:150-52.
16. Casullo J, Semionov A. Reversed halo sign in acute pulmonary
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17. Tzilas V, Bouros D. Reversed halo sign in pulmonary infarction.
Pneumon 2015, 27:188.
18. Agarwal R, Gupta D. Another couse of reversed halo sign:
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80:849-50.
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 Images in Pneumonology

The Rivulet Sign

Unnati Desai MD,
Jyotsna M. Joshi MD
Department of Pulmonary Medicine,
T.N. Medical College, B.Y.L. Nair Hospital,
Mumbai, India
Correspondence:
Dr J.M. Joshi, Professor and Head, Department of
Pulmonary Medicine, T.N. Medical College and B.Y.L.
Nair Hospital, Mumbai-400008; India
Tel.: 91 022 23027642/43;
E-mail: drjoshijm@gmail.com.
A twenty-four-year-old man was referred to us in view of high grade fever, breathless-
ness, right-sided pleuritic chest pain, dry cough since 2 months and abdominal pain since
6 months. He was a chronic-alcohol-consumer. Examination revealed fever, tachycardia,
tachypnea, signs of right massive pleural effusion, abdominal distension and tenderness.
The blood investigations including serum amylase were normal. The pleural fluid analysis
confirmed pancreatitis-associated-empyema with high pleural fluid amylase (13705U/L).
Contrast-Enhanced-Computed-Tomography (CT) of thorax & abdomen was reported as
acute-on-chronic pancreatitis with intra and peripancreatic, posterior mediastinal collec-
tions, minimal pericardial, right pleural effusion with a pancreatico-pleural fistula (PPF)
extending through the diaphragmatic hiatus connecting the mediastinal pleura and the
intrapancreatic collections. The CT-sagittal-reconstruction image demonstrated the PPF
which appears like a small stream of water (figure, red arrow). Hence we it named “The
Rivulet Sign”. He was managed with
intercostal drainage, broad spectrum
antibiotics and octreotide with reso-
lution empyema and closure of the
fistulous tract.
PPF is a complication of acute/
chronic pancreatitis. It develops due
to leak from an incompletely formed
or ruptured pseudocyst or direct
pancreatic duct leak. The duct dis-
rupts posteriorly, pancreatic secre-
tion flows through diaphragmatic hi-
atus into mediastinum/pleura form-
ing a PPF.1 High clinical suspicion
and pleural fluid amylase clinches
the diagnosis. CT demonstrates the
fistula in 50% and endoscopic-ret-
rograde cholangiopancreatography
(ERCP) or magnetic-resonance-chol-
angiopancreatography (MRCP) in
80%.2 Treatment modalities include
(1) octreotide and thoracentesis,
(2) ERCP with stent placement,
(3) surgery.1 Our case highlights the FIGURE 1. HRCT was performed showing severe
rare complication of PPF with a novel bilateral cystic bronchiectasis lesions affecting all
radiologic sign “The Rivulet sign”. lobes, more excessive in middle lobe, lingula and
Conflicts of interest. None. lower lobes bilaterally.
References
1. Machado NO. Pancreaticopleural Fistula: Revisited.Diagnostic and Therapeutic Endoscopy
2012; Article ID 815476, 5 pages, 2012. doi:10.1155/2012/815476 accessed from http://
www.hindawi.com/journals/dte/2012/815476/cta/ on 16th July 2016.
2. Ali T, Srinivasan N, Le V, Chimpiri AR, Tierney WM. Pancreaticopleural fistula. Pancreas
2009; 38:e26-31.
 Images in Pneumonology

Pulmonary Langerhans Cell Histiocytosis

Evolution of radiologic findings after smoking cessation
Vasilios Tzilas,
Demosthenes Bouros
First Academic Department of Pneumonology,
Hospital for Thoracic Diseases, “Sotiria”,
Medical School, National and Kapodistrian
University of Athens, Athens, Greece
We present the case of a 30 year old male with non productive cough for the last 2
months. No other symptoms were reported. He had been a farmer since the age of 15 and
was a current smoker (1 pack of cigarettes for 25 years). His personal medical history was
negative and he was on no medication. Physical examination revealed no abnormal findings.
High Resolution Computed Tomography (HRCT) revealed the presence of bilateral and
symmetrically distributed innumerable centrilobular nodules and cysts with clearly percep-
tible walls allowing them to be differentiated from emphysema. The abnormal findings had
striking upper lobe predominance, with characteristic sparing of the costophrenic angles.
The patient was subjected to bronchoscopy and bronchoalveolar lavage (BAL). The results of
BAL were: Macrophages: 78%, Lymphocytes: 18%, Eosinophils: 1%, Neutrophils: 3%, CD1α:
6%. The combination of radiologic and BAL findings secured the diagnosis of Pulmonary
Langerhans Cell Histiocytosis (PLCH) obviating the need for tissue confirmation1. Smoking
cessation was strongly advised. A new HRCT performed 9 months later showed an almost
complete resolution of radiographic findings.
It is worth noting that the early “cavitation” of nodules seen in PLCH is due to the bron-
chocentric localization of inflammation and not to a necrotic process, hence the quotation
marks. As the granulomatous inflammation progresses in the peribronchial area, it causes
destruction of the bronchiolar wall and dilation of the lumen2. The resulting increased contrast
in attenuation between the bronchial wall/peribronchial area and the airway lumen gives the
impression of early “cavitation”. This also explains the radiologic progression of PLCH from
nodules to thick wall cysts to thin wall cysts and finally to bizarre shaped cysts.
With this case, we would like to highlight the characteristic HRCT findings of PLCH, the
potential diagnostic value of BAL and also the fact that in term of management smoking
cessation is of utmost importance3.

Figure 1. Level of Right Upper
Lobe bronchus. Bilateral and sym-
metric distribution of innumerable
centrilobular nodules and thick
walled cysts (arrows)
Figure 2. Characteristic sparing
of the lung bases.
Figure 3. Coronal reformation
showing centrilobular nodules
and thick walled cysts (arrows). The
upper/middle zone predominance
of the disease with sparing of the
lung bases is clearly demonstrated.
Figure 4. HRCT after 9 months
in the same axial level as Figure
1. There is an almost complete
resolution of abnormal findings.

Correspondence:
Prof. Demosthenes Bouros MD, PhD, FERS, FAPSR, FCCP
First Academic Department of Pneumonology,
Hospital for Diseases of the Chest, “Sotiria”, Medical
School, National and Kapodistrian University of Athens,
Athens, Greece,
152 Messogion Av., Athens 11527, Greece
e-mail: debouros@med.uoa.gr, debouros@gmail.com
References
1. Lorillon G, Tazi A. How I manage pulmonary Langerhans cell histiocytosis. Eur Respir Rev 2017;
26:170070.
2. Kambouchner M, Basset F, Marchal J, et al. Three-dimensional characterization of pathologic lesions
in pulmonary langerhans cell histiocytosis. Am J Respir Crit Care Med 2002;166:1483-90.
3. Vassallo R, Harari S, Tazi A. Current understanding and management of pulmonary Langerhans cell
histiocytosis. Thorax 2017;72:937-45.
 Images in Pneumonology

Septic thromboembolism
in intravenous drug users
Likurgos Kolilekas, A 35-year-old male, intravenous drug user (IVDU), was admitted because
Marianthi Eliopoulou, of fever and cough with blood-tinged sputum. Chest X-ray revealed multiple
Georgia Konstantopoulou, pulmonary lesions (not shown). Contrast enhanced chest and abdominopelvic
Konstantinos Loverdos, computed tomography (CT) demonstrated multiple pulmonary nodules with
cavitation (arrowheads, Panel A) with the presence of feeding vessel sign
Mina Gaga
highly suggestive but not pathognomonic of the septic nature of them (ar-
rows, Panel A) and the relevance of extensive thrombosis with the presence
of air within the thrombus, in the inferior vena cava (arrowhead, Panel B).
7th Pulmonary Department and Asthma Transthoracic ecocardiography shown vegetation at the aortic valve. Treat-
Center, Athens Chest Hospital "Sotiria", ment was started with vancomycin plus gentamycin, and low-molecular-
Athens, Greece
weight-heparin. As blood cultures subsequently grew Staphylococcus Aureus
methicillin-sensitive, antimicrobial treatment continued with oxacillin for 4
weeks, and the patient had a full recovery. Drug injection into proximal veins
Key words: may lead to septic deep vein thrombosis. Often septic pulmonary emboli
- Intravenous drug users are the first indication of a serious underlying focus of infection, either right-
- Septic pulmonary emboli
sided endocarditis or venous sepsis. Frequently the clinical picture is one
- Feeding vessel sign
of severe pneumonia with
staphylococcal septicaemia1.
CT is usefull in demonstrating
the full extent of thrombotic
occlusion of proximal veins,
recognize septic pulmonary
emboli and pathologies of
adiacent structures1,2.
Figure 1

COMPETING INTERESTS
All the authors declare that they do not have a financial relationship with
a commercial entity that has an interest in the subject of this manuscript.
No conflict of interest to declare.

Correspondence:
Likurgos Kolilekas MD, PhD, Consultant,
7th Pulmonary Department, Athens Chest Hospital
"Sotiria", 152 Mesogion Ave, 11527, Athens, Greece
Tel.: +30 210 7763306, Fax: +30 210 77681911,
E-mail: lykol@yahoo.gr.
References
1. Fäh F, Zimmerli W, Jordi M, et al. Septic deep venous thrombosis in intravenous drug
users. Swiss Med Wkly 2002; 132:386–92.
2. Mori H, Fukada T, Isomoto I, et al. CT diagnosis of catheter-induced septic thrombus
of vena cava. J Comput Assist Tomogr 1990;14:236–8.
52
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54 PNEUMON Number 4, Vol. 30, October - December 2017

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PNEUMON Number 4, Vol. 30, October - December 2017 55

References
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●● Standard journal article: Bouros D, Antoniou KM, Light RW.
Intrapleuralstreptokinase for pleural infection. BMJ2006;
332:133-4.
●● Books and other monographs: Siafakas NM, Anthonisen N,
Georgopoulos D.Acute exacerbations of COPD. Marcel Dekker,
NewYork, 2004.
●● Chapter in a book: Kyriakou D, Alexandrakis M, Bouros D. Pleural
effusionsin blood diseases. In: Bouros D. (editor). Pleural Disease.
Marcel Dekker, NewYork, 2004, pp. 621-638.
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