Impulse oscillometry (IOS) is the most commonly used type of forced oscillation technique in clinical practice, although relatively little is known about its application in COPD. Resistance at 20 Hz (R20) is unrelated to COPD severity and does not improve with bronchodilatation or bronchoconstriction, inferring a lack of large airway involvement in COPD. Peripheral airway resistance expressed as frequency dependent heterogeneity between 5 Hz and 20 Hz (R5-R20), and peripheral airway compliance as area under the reactance curve (AX), are both closely related to COPD severity and exacerbations. Both R5-R20 and AX markedly improve in response to long acting bronchodilators, while AX appears to be more sensitive than R5-R20 in response to bronchoconstriction. Future studies may be directed to assess if IOS in combination with spirometry is more sensitive at predicting future exacerbations. Perhaps AX might also be useful as a screening tool in early stage disease or to monitor long term decline in COPD.

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Background The forced oscillation technique (FOT) measures respiratory impedance during normal tidal breathing and requires minimal patient cooperation. Objective To compare IOS and AOS devices in patients with asthma and COPD. Methods We compared two different FOT devices, namely impulse oscillometry using a loudspeaker (IOS: Jaeger Masterscreen) and airwave oscillometry using a vibrating mesh (AOS: Thorasys Tremoflo) for pre- and post-bronchodilator measurements in 84 patients with asthma and COPD. Results The overall pattern of measurement bias was for higher resistance with IOS and higher reactance with AOS, this being the case in asthma and COPD separately. There were small but significantly higher values using IOS for resistance at 5 Hz (R5) and 20(19) Hz (R20(19)). In converse, values for reactance at 5 Hz (X5), reactance area (AX) and resonant frequency (Fres) were significantly higher using AOS but to a much larger extent. The difference in AX between devices was more pronounced in COPD than in asthma. Salbutamol reversibility as % change was greater in asthma than COPD patients with AX but not FEV1. Conclusion Our study showed evidence of better agreement for resistance than reactance when comparing IOS and AOS, perhaps inferring that AOS may be more sensitive at measuring reactance in patients with airflow obstruction. Electronic supplementary material The online version of this article (10.1007/s00408-019-00247-y) contains supplementary material, which is available to authorised users.

Long-term loss of response in proton pump inhibitor-responsive esophageal eosinophilia is uncommon and influenced by CYP2C19 genotype and rhinoconjunctivitis.

A single inhaler containing inhaled corticosteroid (ICS)/long-acting beta-agonist (LABA)/long-acting muscarinic antagonist (LAMA) is a more convenient way of delivering triple therapy in patients with COPD. Single triple therapy has been shown to be superior at reducing exacerbations and improving quality of life compared to LABA/LAMA, especially in patients with a prior history of frequent exacerbations and blood eosinophilia, who have ICS responsive disease. The corollary is that patients with infrequent exacerbations who are noneosinophilic may be safely de-escalated from triple therapy to LABA/LAMA without loss of control. Pointedly, there is a substantially increased risk of pneumonia associated with the triple therapy containing fluticasone furoate but not beclometasone dipropionate or budesonide. Since triple therapy is also better than ICS/LABA at reducing exacerbations and improving lung function, symptoms, and quality of life, this brings into question the rationale for using ICS/LABA. Hence, we propose a simplified pragmatic decision process based on symptoms, prior to exacerbation history, and blood eosinophils to select which patients should be given a single triple inhaler or LABA/LAMA. Differences in patient preference of inhaler device, formulations and drugs will also determine which triple inhaler prescribers elect to use.

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SummaryPermanent paraplegia following coeliac plexus block has been reported on several occasions. We report a case of reversible paraplegia following coeliac plexus block. Key wordsAnaesthetic techniques, regional; coeliac plexus block. Complications; paraplegia. Case historyA 53-year-old man presented with a 6 month history of loss of weight, anorexia, nausea, vomiting and severe abdominal pain. A computerised axial tomograph (CAT) scan of his abdomen showed a number of masses in the region of the head of the pancreas, and a diagnostic laparotomy revealed an 8 cm x 8 cm hard mass in the posterior aspect of the right lobe of the liver adjacent to the inferior vena cava. In addition, there were two small nodules in the left lobe of liver, a small 'chain of pearls' of tumour at the porta hepatis and a 3 cm x 4 cm tumour anterior to the right kidney but separated from the head of the pancreas. The pancreas appeared clear of tumour on palpation. The omentum had four large nodules which were excised. Histology showed the excised nodes to be a poorly differentiated adenocarcinoma of uncertain origin. As this tumour was unlikely to be responsive to chemotherapy or radiotherapy, a coeliac plexus block was offered to the patient to relieve the severe upper abdominal pain, which was worse in the right loin and radiated into the chest.A neurolytic coeliac plexus block was carried out under X ray control in the prone position using 2 x 2 0 m l of alcohol 50% in bupivacaine 0.25%. A radiological dye was not used. Propofol 200mg was given intravenously and oxygen and nitrous oxide was administered by face mask. Electrocardiogram, oxygen saturation, and blood pressure were monitored.Following the procedure the patient was free of the upper abdominal pain although a little sleepy from the anaesthetic. However, he was complaining of pain at the injection site and was given papaveretum 15 mg intramuscularly. Approximately 1 h later he complained that his right leg felt peculiar and he had paraesthesia. This became worse over a short period and spread to the left leg. Paraesthesia intensified overnight and by the following morning he had, on the right side, complete loss of flexion and extension of the hip, gross weakness of flexion and extension of the knee, gross weakness of foot dorsiflexion and weak plantar flexion. The left leg, although a little weak, was much better than the right leg. He continued to complain of paraesthesia, mainly in the right leg, and of numbness of the buttocks. On examination, sensation to light touch was normal, although with dysaesthesia. Reflexes were brisker on the right than the left and both plantar responses were flexor. Neurosurgical opinion suggested a L,-3 paraparesis. Myelography did not reveal any spinal cord compression and the cause of this complication was attributed to a vascular incident.Physiotherapy was started immediately and a slow improvement occurred with the patient able to walk with a stick within a week of the event and discharged from hospital 10 days after the coeliac plex...

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