Francesco Mojoli

Epidural Local Anesthetic Plus Corticosteroid for the Treatment of Cervical Brachial Radicular Pain: Single Injection Versus Continuous Infusion

BackgroundEfficacy of epidural local anesthetics plus steroids for the treatment of cervicobrachial pain is uncertain. MethodsA prospective study randomized 160 patients with cervicobrachial pain resistant to conventional therapy. Patients were divided into 4 groups on the basis of the time between pain onset and treatment initiation: group A, 40 patients with pain onset 15 to 30 days; group B, 40 patients with pain from 31 to 60 days; group C, 40 patients, 61 to 180 days; and group D, 40 patients with pain >180 days. Patients of each group were randomized to receive an epidural block with bupivacaine and methylprednisolone at intervals of 4 to 5 days (Single injection) or continuous epidural bupivacaine every 6, 12, or 24 hours plus methylprednisolone every 4 to 5 days (Continuos epidural). The maximum duration of treatment (9 blocks in Single injection, and 30 days in Continuos epidural) was dependent on achieving Pain Control (PC) ≥80% [PC is defined by this formulae: (100) (VASinitial−VASfinal)/VASinitial]. Follow-up at 1 month and 6 months compared PC and the number of pain-free hours of sleep. ResultsOne hundred forty-one patients completed the study. The 4 groups had similar characteristics. At the 1-month and 6-month follow-up analysis based on the time between pain onset and treatment initiation showed that patients of group D, who received the Continuous epidural treatment, had significantly greater PC and significantly more pain-free hours of sleep compared with similar patients in Single injection. ConclusionsTherapy with continuous epidural local anesthetic and methylprednisolone provides better control of chronic cervicobrachial pain compared with Single injection. These results are discussed with respect to the possible mechanism of action of the drugs and may relate to the physiopathologic mechanisms associated with neuronal plasticity that result in chronic pain.

Esophageal and transpulmonary pressure in the clinical setting: meaning, usefulness and perspectives

PurposeEsophageal pressure (Pes) is a minimally invasive advanced respiratory monitoring method with the potential to guide management of ventilation support and enhance specific diagnoses in acute respiratory failure patients. To date, the use of Pes in the clinical setting is limited, and it is often seen as a research tool only.MethodsThis is a review of the relevant technical, physiological and clinical details that support the clinical utility of Pes.ResultsAfter appropriately positioning of the esophageal balloon, Pes monitoring allows titration of controlled and assisted mechanical ventilation to achieve personalized protective settings and the desired level of patient effort from the acute phase through to weaning. Moreover, Pes monitoring permits accurate measurement of transmural vascular pressure and intrinsic positive end-expiratory pressure and facilitates detection of patient–ventilator asynchrony, thereby supporting specific diagnoses and interventions. Finally, some Pes-derived measures may also be obtained by monitoring electrical activity of the diaphragm.ConclusionsPes monitoring provides unique bedside measures for a better understanding of the pathophysiology of acute respiratory failure patients. Including Pes monitoring in the intensivist’s clinical armamentarium may enhance treatment to improve clinical outcomes.

Whole lung lavage: a unique model for ultrasound assessment of lung aeration changes

PurposeWhole lung lavage (WLL) pathophysiologically represents a human model of controlled lung de-aeration, resembling various pathological conditions encountered in the critically ill. Through one-lung ventilation and progressive alveolar flooding, it mimics, respectively, re-absorption atelectasis formation and lung consolidation. With re-ventilation of the treated lung, PEEP application and diuretics administration, it then creates a model of pulmonary edema and its progressive resolution. No studies have so far described lung aeration changes during WLL with ultrasound: objectives of the study were to describe ultrasound findings during WLL with validated semiotics in the critically ill and to investigate their relation with the lung’s state of relative aeration.MethodsIn seven patients, 12 lung areas/patient were prospectively studied with ultrasound during six procedural steps of WLL. A three-tiered pattern classification was assigned (1, normal/nearly normal; 2, alveolar-interstitial syndrome; 3, alveolar consolidation) consistently with their previously described meaning in terms of relative air content. The distribution was compared throughout different WLL maneuvers as it was for arterial oxygen measurement distribution.ResultsDuring one-lung ventilation and saline flooding, ultrasound findings shifted from artifact patterns (normal/nearly normal and alveolar-interstitial syndrome) to alveolar consolidation. Saline removal, re-ventilation and negative water balance were associated with a gradual return to alveolar-interstitial syndrome, then to a normal/nearly normal pattern. Arterial oxygen tension variations were not always consistent with these changes.ConclusionsIn a controlled human model of lung air content variation, the different states of aeration determined by WLL procedure were reliably described with lung ultrasound.

Imaging in acute respiratory distress syndrome

PurposeImaging has become increasingly important across medical specialties for diagnostic, monitoring, and investigative purposes in acute respiratory distress syndrome (ARDS).MethodsThis review addresses the use of imaging techniques for the diagnosis and management of ARDS as well as gaining knowledge about its pathogenesis and pathophysiology. The techniques described in this article are computed tomography, positron emission tomography, and two easily accessible imaging techniques available at the bedside—ultrasound and electrical impedance tomography (EIT).ResultsThe use of computed tomography has provided new insights into ARDS pathophysiology, demonstrating that ARDS does not homogeneously affect the lung parenchyma and that lung injury severity is widely distributed in the ARDS population. Positron emission tomography is a functional imaging technique whose value resides in adding incremental insights to morphological imaging. It can quantify regional perfusion, ventilation, aeration, lung vascular permeability, edema, and inflammation. Lung ultrasound and EIT are radiation-free, noninvasive tools available at the bedside. Lung ultrasound can provide useful information on ARDS diagnosis when x-rays or CT scan are not available. EIT is a useful tool to monitor lung ventilation and to assess the regional distribution of perfusion.ConclusionsThe future of imaging in critical care will probably develop in two main directions: easily accessible imaging techniques that can be used at the bedside and sophisticated imaging methods that will be used to aid in difficult diagnostic cases or to advance our understanding of the pathogenesis and pathophysiology of an array of critical illnesses.

Pulmonary alveolar proteinosis: diagnostic and therapeutic challenges

Pulmonary Alveolar Proteinosis (PAP) is a rare syndrome characterized by pulmonary surfactant accumulation within the alveolar spaces. It occurs with a reported prevalence of 0.1 per 100,000 individuals and in distinct clinical forms: autoimmune (previously referred to as the idiopathic form, represents the vast majority of PAP cases, and is associated with Granulocyte-Macrophage Colony Stimulating Factor (GM-CSF) auto-antibodies; GMAbs), secondary (is a consequence of underlying disorders), congenital (caused by mutations in the genes encoding for the GM-CSF receptor), and PAP-like syndromes (disorders associated with surfactant gene mutations). The clinical course of PAP is variable, ranging from spontaneous remission to respiratory failure. Whole lung lavage (WLL) is the current standard treatment for PAP patients and although it is effective in the majority of cases, disease persistence is not an unusual outcome, even if disease is well controlled by WLL.In this paper we review the therapeutic strategies which have been proposed for the treatment of PAP patients and the progress which has been made in the understanding of the disease pathogenesis.

Lung Ultrasound for Early Diagnosis of Ventilator-Associated Pneumonia

BACKGROUND Lung ultrasound (LUS) has been successfully applied for monitoring aeration in ventilator-associated pneumonia (VAP) and to diagnose and monitor community-acquired pneumonia. However, no scientific evidence is yet available on whether LUS reliably improves the diagnosis of VAP. METHODS In a multicenter prospective study of 99 patients with suspected VAP, we investigated the diagnostic performance of LUS findings of infection, subpleural consolidation, lobar consolidation, and dynamic arborescent/linear air bronchogram. We also evaluated the combination of LUS with direct microbiologic examination of endotracheal aspirates (EA). Scores for LUS findings and EA were analyzed in two ways. First, the clinical-LUS score (ventilator-associated pneumonia lung ultrasound score [VPLUS]) was calculated as follows: ≥ 2 areas with subpleural consolidations, 1 point; ≥ 1 area with dynamic arborescent/linear air bronchogram, 2 points; and purulent EA, 1 point. Second, the VPLUS-direct gram stain examination (EAgram) was scored as follows: ≥ 2 areas with subpleural consolidations, 1 point; ≥ 1 area with dynamic arborescent/linear air bronchogram, 2 points; purulent EA, 1 point; and positive direct gram stain EA examination, 2 points. RESULTS For the diagnosis of VAP, subpleural consolidation and dynamic arborescent/linear air bronchogram had a positive predictive value of 86% with a positive likelihood ratio of 2.8. Two dynamic linear/arborescent air bronchograms produced a positive predictive value of 94% with a positive likelihood ratio of 7.1. The area under the curve for VPLUS-EAgram and VPLUS were 0.832 and 0.743, respectively. VPLUS-EAgram ≥ 3 had 77% (58-90) specificity and 78% (65-88) sensitivity; VPLUS ≥ 2 had 69% (50-84) specificity and 71% (58-81) sensitivity. CONCLUSIONS By detecting ultrasound features of infection, LUS was a reliable tool for early VAP diagnosis at the bedside. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT02244723; URL: www.clinicaltrials.gov.

In vivo calibration of esophageal pressure in the mechanically ventilated patient makes measurements reliable.

BackgroundEsophageal pressure (Pes) can provide information to guide mechanical ventilation in acute respiratory failure. However, both relative changes and absolute values of Pes can be affected by inappropriate filling of the esophageal balloon and by the elastance of the esophagus wall. We evaluated the feasibility and effectiveness of a calibration procedure consisting in optimization of balloon filling and subtraction of the pressure generated by the esophagus wall (Pew).MethodsAn esophageal balloon was progressively filled in 36 patients under controlled mechanical ventilation. VBEST was the filling volume associated with the largest tidal increase of Pes. Esophageal wall elastance was quantified and Pew was computed at each filling volume. Different filling strategies were compared by performing a validation occlusion test.ResultsFifty series of measurements were performed. VBEST was 3.5 ± 1.9 ml (range 0.5–6.0). Esophagus elastance was 1.1 ± 0.5 cmH2O/ml (0.3–3.1). Both Pew and the result of the occlusion test differed among filling strategies. At filling volumes of 0.5, VBEST and 4.0 ml respectively, Pew was 0.0 ± 0.1, 2.0 ± 1.9, and 3.0 ± 1.7 cmH2O (p < 0.0001), whereas the occlusion test was satisfactory in 22 %, 98 %, and 88 % of cases (p < 0.0001).ConclusionsUnder mechanical ventilation, an increase of balloon filling above the conventionally recommended low volumes warrants complete transmission of Pes swings, but is associated with significant elevation of baseline. A simple calibration procedure allows finding the filling volume associated with the best transmission of tidal Pes change and subtracting the associated baseline artifact, thus making measurement of absolute values of Pes reliable.

Usefulness of combined bedside lung ultrasound and echocardiography to assess weaning failure from mechanical ventilation: A suggestive case

Objective:Recognition of the cardiac origin of weaning failure is a crucial issue for successful discontinuation of mechanical ventilation. Bedside lung ultrasound and echocardiography have shown a potential in predicting weaning failure. Objective of this report was to describe the case of a patient repeatedly failing to wean from mechanical ventilation, where the combined use of lung ultrasound and echocardiography during a spontaneous breathing trial uncovered an unexpected cause of the failure. Design:Case report. Setting:General ICU of a university teaching hospital. Patients:Single case, abdominal surgery postoperative patient, not predicted to experience a difficult weaning. Interventions:Cardiovascular therapy adjustments consistent with lung ultrasound and echocardiography findings acquired during spontaneous breathing trials. Measurements and Main Results:All patient’s standard hemodynamic and respiratory parameters, datasets from comprehensive lung ultrasound and echocardiographic examinations, and pertinent data from biochemistry exams, were collected during two spontaneous breathing trials. Data from beginning and end of each of the two ultrasound monitored weaning trials, and from the end of the successful weaning trial following therapy and the previously failed one, were analyzed and qualitatively compared. Lung ultrasound performed at the end of the failed spontaneous breathing trial showed a pattern consistent with increased extravascular lung water (diffuse, bilateral, symmetrical, homogeneous sonographic interstitial syndrome). Concurrent echocardiography diagnosed left ventricular diastolic failure. Ultrasound findings at the end of the successful weaning trial showed normalization of the lung pattern and improvement of the echocardiographic one. The atient eventually returned to spontaneous respiration and was discharged from the ICU. Conclusions:The use of bedside lung ultrasound and echocardiography disclosed left ventricular diastolic dysfunction as unexpected cardiogenic cause of weaning failure and lead to subsequent correct patient management.

The importance of protecting the mechanical ventilator during colistin methanesulfonate nebulization

Dear Editor, We read with interest the paper by Athanassa and colleagues [1] on the pharmacokinetics of inhaled colistin methanesulfonate (CMS) in mechanically ventilated patients, demonstrating that aerosol administration allows one to achieve high drug concentrations in the epithelial lining fluid of the deep lung. The authors underline the importance of nebulization technology to optimize drug delivery to the lungs. Actually, the effective amount of drug reaching the airways can be increased from about 4 % up to 30 % of the emitted dose by selecting an optimal combination of respiratory circuit, nebulizer type, and position [2]. This also means that, whatever the method of nebulization, a substantial amount (70–96 %) of drug dose is lost within the ventilator circuit, possibly interfering with the function of sensors and/or valves. We report a case of sudden expiratory valve malfunction associated with CMS nebulization in a patient with multidrug-resistant Acinetobacter baumannii pneumonia. Pressuresupport ventilation was delivered by a Hamilton-G5 ventilator (Hamilton Medical, Bonaduz, Switzerland) through a heated circuit with active humidifier (RT340 Evaqua and MR850, Fisher&Paykel Healthcare, Auckland, New Zealand). CMS (UCB-Pharma, Turin, Italy; 1 M units in 5 ml) was administered 4 times/ day by a jet nebulizer (MallinckrodtDAR, Mirandola, Italy) placed between the inspiratory limb and Y-piece of the ventilator circuit. About 30 min after a nebulization session, an ‘‘exhalation obstructed’’ alarm message appeared, while a severe malfunction of the expiratory valve could be detected on the ventilator screen: at fulfillment of the criteria for cycling, the expiratory valve opened only after a hold lasting about 1 s (Fig. 1). By backward analysis we found that the problem had started as a slight opening delay just 5 min before critically worsening. The malfunction was resolved by the immediate replacement of the membrane and cover of the expiratory valve, thereafter protected with a DAR mechanical filter large (Covidien, Mansfield, USA). Expiratory filtering increased the expiratory resistance by 2 cmH2O/l/s, without further increase during the following 72 h of continuous use of the same filter. Our current policy in ventilated patients needing nebulization is to protect the expiratory valve with a mechanical filter that must be changed every 24 h or whenever signs of increased expiratory resistance appear. It should be emphasized that this solution seems effective and safe in our setting, with a specific combination of mechanical ventilator, circuit, humidifier, nebulizer type, and expiratory filter; different combinations might adversely affect the effectiveness or safety. Note that severe obstructions of the expiratory filters by aerosol particles (in one case complicated by cardiac arrest) have been reported during ceftazidime/ amikacin nebulization, despite filter removal after each aerosol administration as dictated by the study protocol [3]. In conclusion, clinicians must be aware that aerosol administration of CMS, or also other drugs, can lead to sudden and potentially dangerous malfunction of mechanical ventilators. Expiratory filtering may prevent this problem, but must be managed carefully because, in turn, it may be a source of dangerous obstruction. Automatic monitoring and alarming of expiratory resistance are important safety features of ventilators, but personnel should also be trained in detecting and correcting ventilator -1500 -1000 -500 0 50

Swine influenza A (H1N1) virus (SIV) infection requiring extracorporeal life support in an immunocompetent adult patient with indirect exposure to pigs, Italy, October 2016

We describe a case of severe swine influenza A(H1N1) virus infection in an immunocompetent middle-aged man in October 2016 in Italy who had only indirect exposure to pigs. The patient developed a severe acute distress respiratory syndrome which was successfully supported by extracorporeal membrane oxygenation and treated with antiviral therapy. The sole risk factor for influenza was a body mass index > 30 kg/m2. After a month of hospitalisation, the patient was discharged in good health.