Jurnal Respirasi

Front Matter Vol 10 No 3, 2024

Front Matter — 2024-09-30

Right Lung Agenesis Associated with Dextrocardia in Adulthood

Made Yogi Krisnanda — 2024-09-30

Introduction: Pulmonary agenesis is a rare lung disease, occurring in approximately 1 out of every 100,000 births. Most cases of pulmonary agenesis result in death during the neonatal period. Although survival in cases of pulmonary agenesis is rare, it is possible to encounter lung agenesis in adults.

Case: A 26-year-old female patient presented with progressive dyspnea. On physical examination, retraction of the breathing muscles, reduced chest excursions, and decreased breath sounds on the right side were observed. A chest X-ray raised suspicion of pulmonary agenesis. A computed tomography (CT) scan showed hypoplasia of the right lung, accompanied by mediastinal shift, hyperinflation of the left lung, and retraction of the diaphragm and liver to the right. Spirometry showed moderate obstruction.

Conclusion: Pulmonary agenesis in adult patients is extremely rare. Chest X-rays and CT scans are the main diagnostic modalities for pulmonary agenesis. There is no specific treatment for asymptomatic cases. Management focuses on conservative and symptomatic care.

A Rare Case of Pulmonary Tuberculosis Masquerading as Laryngeal Tuberculosis or Malignant Manifestation

Jamaluddin Madolangan — 2024-09-30

Introduction: Laryngeal tuberculosis (LTB) is usually accompanied by pulmonary tuberculosis (TB) involvement. Misdiagnosis often occurs because the symptoms are non-specific and resemble laryngeal malignancy. We reported a rare condition of pulmonary TB masquerading as larynx abnormalities such as malignant manifestations.

Case: A 59-year-old man presented with a main complaint of prolonged hoarseness without clinical respiratory complaints. The patient additionally reported coughing as a symptom while receiving medical treatment in the hospital. A computed tomography (CT) scan of the neck without contrast revealed a glottic tumor invading the vocal cord – T3N2cMx. Laryngoscopy examination revealed T1-T1 tonsils. The pharyngeal mucosa was slightly hyperemic. The arytenoids and epiglottis were less hyperemic. There was no edema, the left vocal fold was paralyzed, could not be adducted, and there was a lump. The glottis rima gap was narrow, size 3–4 mm, and the mass could not be evaluated. Chest X-ray examination was normal, but rapid molecular tests of TB detected very low Mycobacterium tuberculosis (MTB) levels. The patient was treated with anti-TB treatment (ATT) according to body weight. An evaluation was performed after 2 weeks, and the patient's clinical and physical condition improved.

Conclusion: Pulmonary TB patients in endemic countries can have clinical manifestations such as LTB or laryngeal malignancy in 1% of cases. The prognosis for LTB with pulmonary T involvement is quite good with ATT administration.

Chronic Pulmonary Aspergillosis with Tracheobronchial Involvement

Yosua Kevin Hermawan — 2024-09-30

Introduction: Aspergillosis is a fungal infection commonly found in human lungs and takes several forms. Chronic pulmonary aspergillosis (CPA) commonly affects individuals with underlying disease, most usually lung tuberculosis (TB). Aspergillosis can cause the formation of a fungus ball in the lung cavity and can also manifest in the tracheobronchial area, although this is rarely seen in immunocompetent patients.

Case: A 23-year-old woman came with persistent cough, hemoptysis, and shortness of breath for 4 months. The patient also had a significant weight loss and a history of lung TB 3 years ago. She had completed her lung TB medication. Physical examination showed increased respiratory rate and rhonchi on the left lung. GeneXpert showed no Mycobacterium tuberculosis (MTB) detected. The chest X-ray showed a cavity on the left superior lobe of the lung. Bronchoscopy showed multiple plaques along the trachea, carina, and left main bronchus. A chest computed tomography (CT) scan with contrast enhancement was performed, and a fungus ball was found inside the cavity in the left upper lobe of the lung. The patient was given intravenous fluconazole as therapy and continued with oral fluconazole when discharged. A second bronchoscopy was performed, and improvement was shown.

Conclusion: Early detection and treatment should be applied to CPA patients since some studies showed poor prognosis and low five-year survival rates.

Factors Associated with the Outcomes of Patients with Hospital-Acquired Pneumonia (HAP) at Dr. Moewardi General Hospital, Surakarta

Natasha Nawanindha — 2024-09-30

Introduction: Hospital-acquired pneumonia (HAP) is a common infection with a poor prognosis. Previous studies on factors influencing HAP outcomes have yielded inconsistent findings. Therefore, further research is needed to determine risk factors that affect HAP outcomes. This study evaluated the factors associated with HAP outcomes to enable timely interventions to reduce mortality, costs, and length of stay (LOS).

Methods: This cross-sectional study was conducted at Dr. Moewardi General Hospital, Surakarta, using medical record data from January to December 2022. The data included age, gender, malnutrition, anemia, level of consciousness, comorbidities, bacterial culture, and multidrug-resistant organisms (MDROs). The analyses were performed using the Chi-squared and Mann-Whitney U tests, followed by multiple logistic and linear regression tests to determine the correlation between risk factors and outcomes (recovery, death, and LOS).

Results: This study included 102 patients with HAP, the majority being males (64.7%) aged 60 years old and above. Additionally, most patients did not exhibit malnutrition (87.3%) or anemia (96.1%), had normal levels of consciousness (67.6%) and mild comorbidities (60.8%), were not infected with MDROs (66.7%), and were predominantly infected by Klebsiella pneumoniae (21.6%). The multiple logistic regression test revealed that decreased consciousness was significantly associated with increased mortality (p < 0.001). Meanwhile, age 60 years old and above was significantly associated with a shorter LOS (p = 0.05).

Conclusion: The majority of HAP cases occurred in men aged 60 years and above. Furthermore, there was a significant relationship between decreased consciousness and increased mortality, as well as between the age of 60 years and above and a shorter LOS.

Diabetes Mellitus Associated with Sputum Conversion Time in Drug-Resistant Pulmonary TB Patients at Dr. Soebandi Regional General Hospital, Jember

Nahla Ahmad Rahami — 2024-09-30

Introduction: Diabetes mellitus (DM) comorbidity in drug-resistant (DR) pulmonary tuberculosis (TB) patients can be associated with the treatment outcome. In DR-TB patients with DM, the immune system is impaired, which will decrease the success of treatment. Sputum conversion time is an indicator used to predict the treatment outcome. However, there is still no further study related to the association between DM comorbidity and the sputum conversion time in DR-TB patients, especially in Jember. This study aimed to determine the association between DM and sputum conversion time in DR-TB patients at Dr. Soebandi Regional General Hospital, Jember.

Methods: This was an analytic observational study with a cross-sectional design. A total of 122 samples of DR-TB patients were taken using the purposive sampling method in 2018-2023 at Dr. Soebandi Regional General Hospital, Jember. The data were analyzed using the Chi-square and logistic regression statistical test.

Results: Chi-square analysis showed that DM (p = 0.015; OR = 2.604; 95% CI 1.195-5.674) and age (p = 0.021; OR = 0.377; 95% CI 0.162-0.878) were associated with sputum conversion time. Logistic regression showed that DM was the most associated variable with the sputum conversion time (p = 0.016; OR = 2.604; 95% CI 1.195-5.674) compared to gender, age, TB resistance type, and anti-TB regimen.

Conclusion: DM is associated with prolonged sputum conversion time in DR-TB patients at Dr. Soebandi Regional General Hospital, Jember. DM was also the most associated variable with the sputum conversion time compared to gender, age, TB resistance type, and anti-TB regimen.

Effect of Different Levofloxacin Doses on QTc Interval Prolongation in Multidrug-Resistant Tuberculosis Patients Treated with the 9-Month All-Oral Regimen

Soedarsono Soedarsono — 2024-09-30

Introduction: The World Health Organization (WHO) has recommended the 9-month all-oral regimen for multidrug-resistant tuberculosis (MDR-TB) treatment. This regimen is expected to increase the treatment success rate. Bedaquiline, levofloxacin, and clofazimine are QT-prolonging drugs included in the 9-month all-oral regimen. Bedaquiline and clofazimine are given at the same dose for all patients, while levofloxacine dose is given in 750 mg and 1,000 mg based on the body weight. This study analyzed the correlation between different levofloxacin doses and certain factors on QTc interval prolongation.

Methods: This observational retrospective study used the medical records of MDR-TB patients who underwent the 9-month all-oral regimen. Electrocardiography (ECG) for QTc interval measurement was recorded at the baseline before and 2 weeks after treatment. The measured variables included patient demographic data, body mass index (BMI), electrolyte levels, and comorbidities.

Results: Thirty MDR-TB patients were included in this study. Gender, diabetes mellitus (DM), and levofloxacin dose did not correlate with QTc interval prolongation at 2 weeks after drug administration (p-values of 0.558, 0.197, and 0.134, respectively). Age, potassium level, magnesium level, calcium level, and baseline QTc interval also did not correlate with QTc interval prolongation at 2 weeks after drug administration (p-values of 0.433, 0.479, 0.705, 0.746, and 0.333, respectively). Multivariate analysis showed that the risk factor associated with QTc interval prolongation at 2 weeks after drug administration was a BMI of 0.013.

Conclusion: Different levofloxacin doses did not correlate with QTc interval prolongation in MDR-TB patients treated with the 9-month all-oral regimen. The incidence of QTc interval prolongation was significantly associated with the lower BMI level.

Neutrophil-Lymphocyte Ratio (NLR) as a Prognostic Marker in Advanced Lung Cancer Patients Undergoing First-Line Treatment

Dinda Ary Miranda Dewi — 2024-09-30

Introduction: Neutrophil-lymphocyte ratio (NLR) is one of the systemic inflammatory markers that play a role in detecting the degree of sepsis in the cancer microenvironment. A high NLR, with a dominant predominance of neutrophil cells, can release cytokines and chemokines that induce cancer cell proliferation and metastasis. Conversely, a low NLR, predominately of lymphocyte cells, can activate the immune system to handle chronic inflammation. From its mechanism of action, NLR is often used to predict the future prognosis and survival rate of cancer patients. This study aimed to analyze the effect of first-line therapy in lung cancer patients with an alternative prognostic indicator in the form of changes in NLR values confirmed by the response evaluation criteria in solid tumors (RECIST).

Methods: This study used an analytical observational method with a cross-sectional approach and was conducted using secondary data samples from the medical records of lung cancer patients treated at Dr. Saiful Anwar General Hospital, Malang.

Results: Spearman’s correlation analysis between NLR and RECIST revealed a relationship (p = 0.001). Determining the NLR cut-off point using the receiver operating characteristic (ROC) curve yielded a value of 3.55, with NLR sensitivity and specificity at 69.44% and 69.76%, respectively. The therapy administration to lung cancer patients significantly decreased NLR (p = 0.032).

Conclusion: NLR is a valuable tool for routinely monitoring therapy outcomes in lung cancer patients and can be considered an alternative prognostic marker due to its promising results.

Vitamin C Intake and Anti-Tuberculosis Drugs-Induced Hepatitis in Pulmonary Tuberculosis Patients

Hadiati Rabbani — 2024-09-30

Introduction: Drug-induced hepatitis (DIH) is one of the serious side effects of anti-tuberculosis drugs (ATD) that can reduce patient compliance with tuberculosis (TB) treatment, increase the risk of treatment failure, or develop drug resistance. Vitamin C is a potential antioxidant known to have a protective effect against DIH. This study examined the relationship between vitamin C intake and the incidence of ATD-induced hepatitis (ATDIH) in pulmonary TB patients at Persahabatan National Respiratory Referral Hospital, Jakarta.

Methods: This was a cross-sectional study of 108 patients with drug-sensitive pulmonary TB. Data was collected using a sociodemographic questionnaire, anthropometric measurements, semi-quantitative food frequency questionnaire (SQ FFQ), and data on the subject's liver function laboratory results in the last 1 month. Fisher exact test was utilized to analyze the association between adequacy of vitamin C intake and DIH.

Results: The proportion of DIH in pulmonary TB patients in this study was 6.5%. Most subjects were males (54.6%) with a median age of 41. The median vitamin C intake was 66.65 mg/day, with 63.0% of patients having an intake below the recommendation. Fisher's exact test showed that vitamin C intake was not statistically significantly associated with the incidence of ATDIH (OR 3.77 95% CI 0.44-32.55, p-value 0.256). No factors also influenced the incidence of ATDIH in this study.

Conclusion: No association was found between vitamin C intake and other factors related to the incidence of ATDIH. This is the first study in Indonesia to link vitamin C and E intake with the incidence of DIH in drug-sensitive pulmonary TB patients, providing information for future studies.

Volatile Organic Compounds (VOC) and Serum Leukotriene B4 between COPD Patients and COPD with Lung Cancer Patients

Susanthy Djajalaksana — 2024-09-30

Introduction: Chronic obstructive pulmonary disease (COPD) is estimated to become the third leading cause of death worldwide in 2030. COPD can affect the lungs and cause chronic systemic inflammation. Leukotriene B4 (LTB4) is involved in COPD and lung cancer pathogenesis. There has been the development of non-invasive methods for detecting lung disease in the last few decades, such as the examination of volatile organic compounds (VOC). This study aimed to analyze the serum LTB4 and the difference of VOCs in exhaled breath of stable COPD patients and COPD with lung cancer patients.

Methods: This case-control study recruited 20 stable COPD patients and 20 patients with COPD and lung cancer. An exhaled breath sample was collected in Tedlar bags and analyzed using an arrayed sensor breath analyzer to check the concentration of VOCs. Meanwhile, a venous blood sample was collected to examine the level of LTB4 using an ELISA kit. Independent t-test and Mann-Whitney test were used to analyze the data.

Results: The carbon dioxide (CO₂), nitrogen dioxide (NO₂), carbon monoxide (CO), benzene (C₆H₆), and propane (C₃H₈) levels were significantly different (p <0.05) in COPD-only patients compared to COPD with lung cancer patients. Serum LTB4 increased in both groups.

Conclusion: CO₂, CO, and C₃H₈ levels increased, but the NO₂ level decreased in COPD patients with lung cancer compared to COPD-only patients. Serum LTB4 increased in COPD with lung cancer patients.

Assessment of Quality of Life in Advanced-Stage Lung Cancer Patients Using EORTC QLQ-C30 Questionnaire

Ariantika Ariantika — 2024-09-30

Introduction: Quality of life (QoL) is a multidomain concept that assesses a person through health status, functional status, and symptoms. The patient's QoL is greatly reduced due to the course of disease, severity of symptoms, and side effects of chemotherapy treatment. This study aimed to assess the QoL in advanced lung cancer patients using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30).

Methods: This descriptive and observational study was conducted at the Pulmonary Polyclinic, Prof. Dr. Chairuddin Panusunan Lubis Universitas Sumatera Utara (USU) Hospital from February to July 2024, with a cross-sectional design using patient medical records and EORTC QLQ-C30 questionnaire. The EORTC QLQ-C30 questionnaire was analyzed with a score formula and categorized as good, moderate, and bad. The sample was 100 lung cancer patients using a purposive sampling technique according to the criteria.

Results: The results showed that almost all QoL was in the moderate category (80%). The general health status was mostly in the moderate category (61.66%), the functional status was mostly in the good category (75.35%), and the symptoms were in the moderate category (35.65%). In the functional scale, the role domain had the lowest mean, 69.99 ± 29.43. In the symptoms scale, the pain domain had the highest mean, 52.66 ± 29.43.

Conclusion: The overall QoL of lung cancer patients was in the moderate category, lower than the healthy population. It needs to be improved, especially in the role domain, by providing supportive-expressive group therapy.

Back Matter Vol 10 No 1, 2024

Back Matter — 2024-09-30

The Role of Gut Microbiota as a Trigger for Exacerbations in Pulmonary Obstruction Disorder in General

Dewi Wijaya — 2024-09-30

Pulmonary diseases can be associated with the gastrointestinal (GI) system, particularly if an infection causes them. This relationship between organs is known as the gut-lung axis (GLA). Skin and mucosal surfaces are associated with microbiota (bacteria, fungi, viruses, macrophages, archaea, protists, helminths), which can trigger an immune response in GLA and serve a role in respiratory diseases. For instance, asthma can be inhibited by a specific antigen that is triggered by probiotics, the microorganisms found in the GI tract. Asthma incidence can be reduced by consuming fiber due to its ability to protect airways from infection. Pattern recognition receptors (PRRs) are the first immune component to identify microbial compounds in GI and lung epithelial cells. The PRRs then induce regulatory T-cell (T-reg) and Th-17 differentiation. Diet, antibiotics, and stress can all influence the structure and function of bacteria. This is known as dysbiosis. Lung microbiota can influence immune cell maturation and homeostasis. If the diversity of lung microbiota decreases, it will affect intestinal microbiota and may result in chronic respiratory disorders such as chronic obstructive pulmonary disease (COPD), asthma, and cystic fibrosis. This literature review explained how the interactions between the intestines and lungs can affect humans’ health and well-being.

The Cancer Mycobiome: A Highlight to Lung Cancer

Edho Yuwono — 2024-09-30

Microbiota is a collection of microorganisms such as bacteria, fungi, viruses, and archaea, with bacteria being the most numerous in the human body. Meanwhile, the mycobiome consists of commensal fungi, which are a small part of the microbiota. Examples found in the human body, from the skin to the internal organs, play a role in the immune response, homeostasis, metabolism, and disease. The composition of mycobiome varies over time, and the human intestine is the most studied organ due to the diversity of microbiota. Furthermore, lung cancer is the leading cause of death in oncology patients worldwide. Various studies suggest that mycobiomes play a role in cancer associated with dysbiosis. Chronic inflammation, biofilm formation, and carcinogen products are parts of cancer pathogenesis. Metagenome analysis has provided information about the diversity of microbiota, specifically mycobiome in the human body. The common method for gene sequencing in the metagenome is next-generation sequencing (NGS). Analysis through metagenomes in chronic diseases such as cancer shows that mycobiomes play a role in the process of cancer formation. However, the causal relationship between mycobiomes and cancer remains unknown.

Late-Onset Asthma: A Review

Yandi Noer Moelamsyah — 2024-09-30

Asthma is a chronic respiratory condition with a growing global prevalence, affecting millions of individuals annually. While asthma can develop at any age, late-onset asthma is a specific phenotype that begins in adulthood, as recognized by the Global Initiative for Asthma (GINA) in its 2024 guidelines. This form of asthma is often associated with several predisposing factors, including gender, obesity, occupational exposure, rhinitis, respiratory infections, smoking, stress, and diminished lung function. Unlike early-onset asthma, which frequently involves a history of allergies, late-onset asthma tends to lack allergic triggers, making it a distinct and challenging form of the disease. Managing late-onset asthma is often more complex, as it typically requires higher doses of corticosteroids and demonstrates a reduced responsiveness to standard steroid treatments. The exact mechanisms and pathophysiological processes contributing to the increased severity and poorer clinical outcomes in late-onset asthma remain largely unclear. This uncertainty often leads to underdiagnosis and inadequate management, further complicating patient care. Phenotypic analysis is recommended to improve treatment outcomes. This includes assessing clinical features and utilizing biomarkers, such as inflammatory markers and immunoglobulin E (IgE) levels, to guide targeted therapy when conventional steroid treatments are insufficient. However, there is a significant need for further research to elucidate the underlying mechanisms of late-onset asthma. This literature review is essential to develop more effective, personalized treatment strategies that can address the unique challenges posed by this asthma phenotype, ultimately leading to better management and improved patient outcomes.