Multidisciplinary Respiratory Medicine最新文献

The novel coronavirus called "Severe Acute Respiratory Syndrome Coronavirus 2" (SARS-CoV-2) caused an outbreak in December 2019, starting from the Chinese city of Wuhan, in the Hubei province, and rapidly spreading to the rest of the world. Consequently, the World Health Organization (WHO) declared that the coronavirus disease of 2019 (COVID-19) can be characterized as a pandemic. During COVID-19 several immunological alterations have been observed: in plasma of severe patients, inflammatory cytokines are at a much higher concentration ("cytokine storm"). These aspects are associated with pulmonary inflammation and parenchymal infiltrates with an extensive lung tissue damage in COVID-19 patients. To date, clinical evidence and guidelines based on reliable data and randomized clinical trials (RCTs) for the treatment of COVID-19 are lacking. In the absence of definitive management protocols, many treatments are currently being evaluated worldwide. Some of these options were soon abandoned due to ineffectiveness, while others showed promising results. As for ventilatory strategies, at the moment there are still no consistent data published about the different approaches and how they may influence disease progression. What will probably represent the real solution to this pandemic is the identification of a safe and effective vaccine, for which enormous efforts and investments are being put in place. This review will summarize the state-of-the-art of COVID-19 current treatment options and those potentially available in the future, as well as high flow oxygen therapy and non-invasive mechanical ventilation approaches.

The recent Coronavirus disease 19 (COVID-19) pandemic, first in China and then also in Italy, brought to the attention the problem of the saturation of Intensive Care Units (ICUs). Almost all previous reports showed that in ICU less than half of patients were treated with invasive mechanical ventilation (IMV) and the rest of them with non-invasive respiratory support. This highlighted the role of respiratory intensive care units (RICUs), where patients with moderate to severe respiratory failure can be treated with non-invasive respiratory support, avoiding ICU admission. In this report, we describe baseline characteristics and clinical outcomes of 97 patients with moderate to severe respiratory failure due to COVID-19 admitted to the RICU of the Policlinico of Bari from March 11^th to May 31^st 2020. In our population, most of the subjects were male (72%), non-smokers (76%), with a mean age of 69.65±14 years. Ninety-one percent of patients presented at least one comorbidity and 60% had more than two comorbidities. At admission, 40% of patients showed PaO²/FiO₂ ratio between 100 and 200 and 17% showed Pa0₂/FiO₂ ratio <100. Mean Pa0₂/FiO₂ ratio at admission was 186.4±80. These patients were treated with non-invasive respiratory support 40% with CPAP, 38% with BPAP, 3% with HFNC, 11% with standard oxygen therapy or with IMV through tracheostomy (patients in step down from ICU, 8%). Patients discharged to general ward (GW) were 51%, 30% were transferred to ICU and 19% died. To the best of our knowledge, this is one of the few described experiences of patients with respiratory failure due to COVID-19 treated outside the ICU, in a RICU. Outcomes of our patients, characterized by several risk factors for disease progression, were satisfactory compared with other experiences regarding patients treated with non-invasive respiratory support in ICU. The strategical allocation of our RICU, between ED and ICU, might have positively influenced clinical outcomes of our patients.

Background: In patients with obstructive lung disease, maintaining adequate ventilation during exercise may require greater contraction of the respiratory muscles, which may lead to a compression of muscle capillaries. Furthermore, dynamic hyperinflation (DH) is frequent during exercise in these patients, as it allows to reach higher expiratory flows and to satisfy respiratory demand. However, in such situation, intercostal muscles are likely to be stretched, which could affect the diameter of their capillaries. Thus, in a context of high level of expiratory resistance, intercostal muscle oxygenation may be disturbed during exercise, especially if DH occurs.

Methods: Twelve participants (22±2 years) performed two sessions of moderate exercise (20 min) by breathing freely with and without a 20-cmH₂O expiratory threshold load (ETL). Tissue saturation index (TSI) and concentration changes from rest (Δ) in oxygenated ([O₂Hb]) and total haemoglobin ([tHb]) were measured in the seventh intercostal space using near-infrared spectroscopy. Respiratory, metabolic and cardiac variables were likewise recorded.

Results: Throughout exercise, dyspnea was higher and TSI was lower in ETL condition than in control (p<0.01). After a few minutes of exercise, Δ [O₂Hb] was also lower in ETL condition, as well as Δ [tHb], when inspiratory capacity started to be reduced (p<0.05). Changes in [O₂Hb] and dyspnea were correlated with changes in expiratory flow rate (Vt/Te) (r = -0.66 and 0.66, respectively; p<0.05).

Conclusion: During exercise with ETL, impaired muscle oxygenation could be due to a limited increase in blood volume resulting from strong muscle contraction and/or occurrence of DH.

Background: To date, the effects of COVID-19 pneumonia on health-related quality of life (HRQoL) and dyspnoea are unknown.

Methods: In a real-life observational study, 20 patients with COVID-19-related pneumonia received usual care plus erdosteine (300 mg twice daily) for 15 days after hospital discharge following local standard operating procedures. At discharge (T0) and on Day 15 (T1), participants completed the St George's Respiratory Questionnaire (SGRQ), the modified Medical Research Council (mMRC) scale of dyspnoea during daily activity, the BORG scale for dyspnoea during exertion, and Visual Analogue Scale (VAS) for dyspnoea at rest. Paired t-tests compared scores at T0 and T1.

Results: The mean (SD) SGRQ total score decreased from 25.5 (15.5) at T0 to 16.9 (13.2) at T1 (p<0.01); 65% of patients achieved a clinically important change of ≥4 points. SGRQ domain scores (symptoms, activity, and impact) were also significantly reduced (all p<0.01). The mean (SD) VAS score decreased from 1.6 (1.7) to 1.4 (2.5); p<0.01. The mean mMRC score decreased significantly (p=0.031) and 30% of patients achieved a clinically important change of ≥1 point. The mean (SD) Borg score increased from 12.8 (4.2) to 14.3 (2.4); p<0.01.

Conclusion: The present proof of concept study is the first to report HRQoL in patients with COVID-19. During 15 days after hospital discharge, patients reported significant improvements in HRQoL and dyspnoea at rest and during daily activities.

Introduction: Bronchiolitis is a leading cause of hospital admissions and death in young children. Clinical practice guidelines (CPG) to diagnose and manage bronchiolitis have helped healthcare providers to avoid unnecessary investigations and interventions and to provide evidence-based treatment. Aim of this study is to determine the effect of implementing CPG for the diagnosis and management of bronchiolitis in a tertiary hospital in Jordan.

Methods: The study compared children (age <24 months) diagnosed with bronchiolitis and who required admission to King Abdullah University Hospital in Irbid during the winter of 2017 (after CPG implementation) and age-matched children admitted in the winter of 2016. The proportion of patients receiving diagnostic tests and treatments in the two groups were compared.

Results: Eighty-eight and 91 patients were diagnosed with bronchiolitis before and after CPG implementation, respectively. Respiratory syncytial virus rapid antigen detection testing decreased after CPG implementation [n=64 (72.7%) vs n=46 (50.5%), p=0.002]. However, there was no significant change in terms of other diagnostic tests. The use of nebulized salbutamol [n=44 (50%) vs n=29 (31.9%), p=0.01], hypertonic saline [n=39 (44.3%) vs n=8 (8.8%), p<0.001], and inappropriate antibiotics [n=31 (35.2%) vs n=15 (16.5%), p=0.004] decreased after CPG implementation. There was no difference in mean LOS (standard deviation; SD) between the pre- and post-CPG groups [3.5(2) vs 4 (3.4) days, p=0.19]. The mean cost of stay (SD) was 449.4 (329.1) US dollars for pre-CPG compared to 507.3 (286.1) US dollars for the post-CPG group (p=0.24).

Conclusion: We observed that the implementation of CPG for bronchiolitis diagnosis and management helped change physicians' behavior toward evidence-based practices. However, adherence to guidelines must be emphasized to improve practices in developing countries, focusing on the rational use of diagnostic testing, and avoiding use of unnecessary medications when managing children with a diagnosis of bronchiolitis.

Introduction: Acute respiratory infections are still a major public health problem resulting in morbidity and mortality among under-five children. This study aims to assess the extent of respiratory symptoms and associated risk factors among under-five children in Gondar city, Northwest Ethiopia.

Methods: A community-based cross-sectional study was carried out from February to June 2019. From 792 study participants, data were collected via face to face interviews by using a semi-structured pre-tested questionnaire. Data were entered in Epi Info version 7, then exported to Stata 14.00 for analysis. Binary (Bivariable and Multivariable) logistic regression analysis was used to test the association of explanatory and outcome variables. Variables with p<0.05 were considered as significantly associated with the outcome variable.

Results: The prevalence of respiratory symptoms among under-five children was 37.5% at [95% (CI: 34.3-41)]. Uterine irritability during pregnancy [AOR = 1.89 at 95% CI: (1.11-3.23)], physical exercise during pregnancy [AOR = 0.60 at 95% CI: (0.41-0.89)], using wood and coal for heating [AOR = 2.42 at 95% CI: (1.65-3.53)], cockroaches infestation [AOR = 1.95 at 95% CI: (1.36 - 2.90)], presence of new carpets [AOR = 2.38 at 95% CI: (1.33-4.29)], damp stain [AOR = 2.45 at 95% CI: (1.02-2.69)], opening windows during cooking [AOR = 0.58 at 95% CI: (0.36-0 .93)], living less than 100 m heavy traffic [AOR = 1.94 at 95% CI: (1.16-3.27)], and living less than 100 m (unpaved roads/streets) [AOR= 2.89 at 95% CI: (1.89-4.55)] were significantly associated with respiratory symptoms.

Conclusion: The prevalence of respiratory symptoms among under-five children was relatively high in the study area. Personal and environmental characteristics influencing symptom occurrence were identified. Respiratory symptoms will be minimized by reducing exposure to indoor and outdoor air pollution and enhancing housing quality.

Background: Influenza A (H1N1) virus often compromises the respiratory tract, leading to pneumonia, which is the principal cause of death in these patients. The purpose of this study was to review the acute and late phase pulmonary findings in influenza A(H1N1) associated pneumonia using high resolution computed tomography (HRCT), and to determine the importance of performing end expiration series.

Methods: Between July and August 2009, 140 patients presented with influenza A (H1N1) confirmed by real-timepolymerase chain reaction. Out of these, 27 patients underwent HRCT in the acute and late phases of pneumonia, allowing for a comparative study. Late phase exams were performed due to clinical worsening and up to 120 days later in patients with persistent complaints of dyspnea.

Results: Ground glass opacities, consolidations, and the combination of both were associated with the acute phase, whereas persistence or worsening of the lesions, lesion improvement, and air trapping in the end expiration series (as seen using HRCT, n=6) were observed in the late phase.

Conclusions: In the HRCT end expiration series, air trapping was found in the late phase of H1N1 associated pneumonia. Generally, these exams are not evaluated in research articles, and air trapping has not previously been studied using the end expiration series. Our study brings more scientific knowledge about aspects of pulmonary involvement by influenza A (H1N1), through evaluation with end expiration series, which makes the CT exam dynamic, translating the respiratory movement, and showing bronchial alteration.

The COVID-19 pandemic is straining health systems worldwide. The World Health Organization has provided guidelines on a set of targeted and immediate actions that countries can use on a national, regional, and local level. Recommendations go from public hand hygiene stations, making face masks use obligatory, testing, and index finding which together with national closure of borders have been used to limit the disease so the countries' health care system can cope with the challenges. This is especially important as there seems to be an increased mortality rate even in countries normally regarded as well-functioning and having strong health system. In more susceptible countries this maybe even more important. The effect of these measures should be easier seen in small communities or countries. Societies have acted differently on when to apply the lockdown but most European countries have initiated lockdown after the first SARS-CoV-2 was diagnosed in their countries. With the COVID-19 pandemic and its economic consequences, it became especially important to re-evaluate the effect of response in light of a possible second wave. Yet, little is known about the effect of lockdown with respect to disease development and its handling. Hereby, we compare responses from relatively small 17 European countries including islands in three groups based on their population and report the response from North Cyprus in comparison to other small European countries. Our results indicate the importance of population per meter square, degree of isolation from others as well as social distancing, hygiene rules, timing of lockdowns in response to COVID-19 pandemic in small countries/ societies that are more susceptible for overwhelming their health system.

Introduction: High-flow nasal cannula oxygen therapy (HFNC) has been shown to be a useful therapy in the treatment of patients with Acute Respiratory Distress Syndrome (ARDS), but its efficacy is still unknown in patients with COVID-19. Our objective is to describe its utility as therapy for the treatment of ARDS caused by SARS-CoV-2.

Methods: A retrospective, observational study was performed at a single centre, evaluating patients with ARDS secondary to COVID-19 treated with HFNC. The main outcome was the intubation rate at day 30, which defined failure of therapy. We also analysed the role of the ROX index to predict the need for intubation.

Results: In the study period, 196 patients with bilateral pneumonia were admitted to our pulmonology unit, 40 of whom were treated with HFNC due to the presence of ARDS. The intubation rate at day 30 was 52.5%, and overall mortality was 22.5%. After initiating HFNC, the SpO²/FiO² ratio was significantly better in the group that did not require intubation (113.4±6.6 vs 93.7±6.7, p=0.020), as was the ROX index (5.0±1.6 vs 4.0±1.0, p=0.018). A ROX index less than 4.94 measured 2 to 6 h after the start of therapy was associated with increased risk of intubation (HR 4.03 [95% CI 1.18 - 13.7]; p=0.026).

Conclusion: High-flow therapy is a useful treatment in ARDS in order to avoid intubation or as a bridge therapy, and no increased mortality was observed secondary to the delay in intubation. After initiating HFNC, a ROX index below 4.94 predicts the need for intubation.

Thunderstorm asthma is a rare event: in this letter we describe two cases observed during the same month of 2018 at an Italian Emergency department, assessed by the same medical team and according to the same methodology and approach. Given the infrequency of such a phenomenon and the debate around its nature, frequency, and - at times - existence, we strongly believe it is important for all specialists who observe such cases to report them, building an evidence base to expand its knowledge and understanding.