Giulia Michela Pellegrino

Ventilation heterogeneity in obesity

Obesity is associated with important decrements in lung volumes. Despite this, ventilation remains normally or near normally distributed at least for moderate decrements in functional residual capacity (FRC). We tested the hypothesis that this is because maximum flow increases presumably as a result of an increased lung elastic recoil. Forced expiratory flows corrected for thoracic gas compression volume, lung volumes, and forced oscillation technique at 5-11-19 Hz were measured in 133 healthy subjects with a body mass index (BMI) ranging from 18 to 50 kg/m(2). Short-term temporal variability of ventilation heterogeneity was estimated from the interquartile range of the frequency distribution of the difference in inspiratory resistance between 5 and 19 Hz (R5-19_IQR). FRC % predicted negatively correlated with BMI (r = -0.72, P < 0.001) and with an increase in slope of either maximal (r = -0.34, P < 0.01) or partial flow-volume curves (r = -0.30, P < 0.01). Together with a slight decrease in residual volume, this suggests an increased lung elastic recoil. Regression analysis of R5-19_IQR against FRC % predicted and expiratory reserve volume (ERV) yielded significantly higher correlation coefficients by nonlinear than linear fitting models (r(2) = 0.40 vs. 0.30 for FRC % predicted and r(2) = 0.28 vs. 0.19 for ERV). In conclusion, temporal variability of ventilation heterogeneities increases in obesity only when FRC falls approximately below 65% of predicted or ERV below 0.6 liters. Above these thresholds distribution is quite well preserved presumably as a result of an increase in lung recoil.

Physical Activity Impairment in Depressed COPD Subjects

BACKGROUND: Limited exercise tolerance is a cardinal clinical feature in COPD. Depression and COPD share some clinical features, such as reduced physical activity and impaired nutritional status. The aim of the present study was to evaluate maximum and daily physical activities and the nutritional status of COPD patients affected or not by depression. METHODS: In 70 COPD out-patients, daily and maximum physical activities were assessed by multisensor accelerometer armband, 6-min walk test, and cardiopulmonary exercise test. Mental status, metabolic/muscular status, and systemic inflammation were evaluated using the Hospital Anxiety and Depression Scale, by bioelectrical impedance analysis, and with regard to fibrinogen/C-reactive protein, respectively. RESULTS: Depressed subjects (27% of the sample) showed a similar level of respiratory functional impairment but a higher level of shortness of breath and a worse quality of life compared to non-depressed subjects (P < .05). Specifically, they displayed a physical activity impairment consisting of a reduced number of steps per day, a lower peak of oxygen consumption, an early anaerobic threshold, and a reduced distance in the 6-min walk test (P < .05) but the same nutritional status compared to non-depressed subjects. In the multivariate analysis, a reduced breathing reserve, obesity, and a higher level of shortness of breath, but not depression, were found to be independent factors associated with a reduced daily number of steps. CONCLUSIONS: Our study found that depressed COPD patients have a reduced daily and maximum exercise capacity compared to non-depressed patients. This further suggests the potential utility of screening for depression in COPD.

Asthma and respiratory physiology: Putting lung function into perspective

Bronchial asthma is a chronic disease characterized by airway hyperresponsiveness, airway inflammation and remodelling. The hypothesis that the illness is inflammatory in nature has recently been challenged by studies showing that airway smooth muscle (ASM) plays a more important role than previously thought. For example, it is now known that in asthma patients, ASM proliferates more and faster than in healthy subjects, carries intrinsic defects and exhibits impaired relaxation, increased velocity of shortening, plastic adaptation to short length and perturbed equilibrium of actin‐to‐myosin during cycling. Similar conclusions can be drawn from studies on airway mechanics. For instance, in asthma, abnormal ASM contributes to limiting the response to deep lung stretching and accelerates the return of bronchial tone to baseline conditions, and contributes to increased airway stiffness. Upon stimulation, ASM causes airway narrowing that is heterogeneous across the lung and variable over time. This heterogeneity leads to patchy ventilation. Experimental studies have shown that patchy ventilation may precipitate an asthma attack, and inability to maintain bronchial tone control over time can predict the occurrence of bronchospastic attacks over a matter of a few days. To improve our knowledge on the pathogenesis of asthma, we believe that it is necessary to explore the disease within the framework of the topographical, volume and time domains of the lung that play an important role in setting the severity and progression of the disease. Application of the forced oscillation technique and multiple breath nitrogen washout may, alone or in combination, help address questions unsolvable until now.

Doctor–patient relationship: A resource to improve respiratory diseases management ☆

BACKGROUND Many respiratory diseases are chronic conditions that are strongly linked with the patient-physician relationship, disease perception and therapy adherence. The aim of the present study was to evaluate patients viewpoint about the different aspects involved in their respiratory diseases. METHODS This is a prospective observational survey. 46 Italian medical centres were involved and equally distributed. The interviews were carried out and were performed by means of a questionnaire which consisted of 32 questions regarding lung disease, modality of access to medical facilities, therapy and level of medical assistance. RESULTS 1116 patients were enrolled and the most important respiratory symptoms referred were: dyspnoea (69%), chronic phlegm (28%), cough (13%). During programmed visits 98.3% and 98.8% of interviewed patients knew were aware of asthma and COPD respectively, percentage that dropped, during emergency accesses, to 1.7% and 1.1% knew to have asthma and COPD respectively. Primarily were prescribed 1.67 spirometry/patient/year while only the 2% of patients referred to have performed a blood gas analysis. The 18% of patients spontaneously discontinued the therapy, considering it too complex. The average time that patients identified as being used by the doctor to perform the visit was of 22 minutes, with an high mean medical assistance satisfaction score. DISCUSSION There has been little research examining what factors may influence patient acceptance and participation of chronic respiratory diseases. Our national survey demonstrated that a good patient-physician relationship represents one of the first points in the successful management of respiratory diseases.

CPAP as a novel treatment for bronchial asthma

airway hyperresponsiveness in bronchial asthma is deemed to be sustained by airway wall inflammation, which ultimately triggers the airway smooth muscle (ASM) to contract. Yet the magnitude of the resulting airway narrowing in vivo depends on several factors, including the ASM mass, its

A Review of the Ultrasound Assessment of Diaphragmatic Function in Clinical Practice

Ultrasonography is the only non-invasive, non-ionizing imaging technique widely available to directly assess diaphragmatic function. Two different sonographic approaches permit the assessment of muscle thickening in the zone of apposition and excursion of the dome of the diaphragm. Thanks to the new hand-held ultrasound instruments, the morphology and function of the diaphragm can be assessed in different settings, such as outpatient clinic, pulmonary function test laboratory, hospital department and intensive care unit, and under different conditions. Despite the existence of different acoustic views and several codified approaches, a comprehensive sonographic examination has never been standardized for clinical use. In this review, we summarize the clinical indications, methods and perspectives of the technique in adults.

Point-of-Care Lung Sonography: An Audit of 1150 Examinations

Point‐of‐care lung sonography has theoretical usefulness in numerous diseases; however clinical indications and the impact of this technique have not been fully investigated. We aimed to describe the current use of point‐of‐care lung sonography.

Management of acute respiratory failure in interstitial lung diseases: overview and clinical insights

BackgroundInterstitial lung diseases (ILDs) are a heterogeneous group of diseases characterized by widespread fibrotic and inflammatory abnormalities of the lung. Respiratory failure is a common complication in advanced stages or following acute worsening of the underlying disease. Aim of this review is to evaluate the current evidence in determining the best management of acute respiratory failure (ARF) in ILDs.MethodsA literature search was performed in the Medline/PubMed and EMBASE databases to identify studies that investigated the management of ARF in ILDs (the last search was conducted on November 2017).ResultsIn managing ARF, it is important to establish an adequate diagnostic and therapeutic management depending on whether the patient has an underlying known chronic ILD or ARF is presenting in an unknown or de novo ILD. In the first case both primary causes, such as acute exacerbations of the disease, and secondary causes, including concomitant pulmonary infections, fluid overload and pulmonary embolism need to be investigated. In the second case, a diagnostic work-up that includes investigations in regards to ILD etiology, such as autoimmune screening and bronchoalveolar lavage, should be performed, and possible concomitant causes of ARF have to be ruled out.Oxygen supplementation and ventilatory support need to be titrated according to the severity of ARF and patients’ therapeutic options. High-Flow Nasal oxygen might potentially be an alternative to conventional oxygen therapy in patients requiring both high flows and high oxygen concentrations to correct hypoxemia and control dyspnea, however the evidence is still scarce. Neither Non-Invasive Ventilation (NIV) nor Invasive Mechanical Ventilation (IMV) seem to change the poor outcomes associated to advanced stages of ILDs. However, in selected patients, such as those with less severe ARF, a NIV trial might help in the early recognition of NIV-responder patients, who may present a better short-term prognosis. More invasive techniques, including IMV and Extracorporeal Membrane Oxygenation, should be limited to patients listed for lung transplant or with reversible causes of ARF.ConclusionsDespite the overall poor prognosis of ARF in ILDs, a personalized approach may positively influence patients’ management, possibly leading to improved outcomes. However, further studies are warranted.

Predicting Survival in Amyotrophic Lateral Sclerosis: Should We Move Forward from Vital Capacity?

are needed for further differentiation (3). Even the presence of air bronchogram inside the consolidation on lung ultrasound has been reported in patients with pulmonary neoplasm, not pneumonia (4). In summary, the presence of air bronchogram inside the consolidation is not specific for pneumonia, and further sonographic signs such as dynamic air bronchogram are needed to support the diagnosis. In this case, resorptive atelectasis rather than pneumonia is more likely to be the cause of the rapid relief of pulmonary consolidation on lung ultrasound. n

Lung Ultrasound B Lines: Etiologies and Evolution with Age

nologist-performed lung ultrasounds in an Italian university hospital [2] . We included all lung ultrasound examinations showing a B-line pattern (multiple close B lines visible in 1 single scan) in at least 1 lung field. Ultrasound findings were standardized according to guidelines [4] , and final diagnoses were adjudicated by the attending physician at patient discharge [2] . Overall, a B-line pattern was reported in 397 cases (34.5%) of the 1,150 examinations performed. Of these, 54 were obtained in children (18 females, [mean ± standard deviation] 4 ± 3 years old), 69 in adults between 19 and 64 years of age (29 females, 46 ± 13 years old), 178 in patients aged >64 years (68 females, 75 ± 5 years old), and 96 in patients >80 years (50 females, 86 ± 5 years old). Figure 1 shows that community-acquired pneumonia represents the main cause of B-line patterns in children (89%) and middle-aged adults (51%), whereas acute heart failure prevails in the elderly (37% between 64 and 80 years old, 50% if older than 80 years). However, etiologies are heterogeneous since interstitial lung diseases, lung cancer, empyema, atelectasis, pulmonary infarction, and even the normal lung may show lung areas with a B-line pattern in about half of the adult population. In conclusion, when a large population and multiple conditions are considered, we should expect that one-third of the lung ultrasound studies show a B-line pattern in at least 1 thoracic area, with etiology varying throughout different age groups. Since this pattern could be attributed to a wide range of conditions, its interpretation cannot withstand analysis of the distribution, extension, and severity of the B-line pattern together with an accurate clinical correlation. Lung ultrasound is a field of growing importance in respiratory medicine [1, 2] . B lines, previously termed ‘‘comet tails,” are vertical hyperechoic reverberations moving synchronously with the lung and represent key artifacts in interpreting pulmonary ultrasound findings [3, 4] . The physiologic basis of B lines relates to decreased lung aeration [5] , a finding that is nonspecific. Here, we aimed to explore the specific clinical diagnoses associated with the B-line pattern and their evolution with age. We therefore undertook a secondary analysis of a 2-year audit of consecutive pulmoPublished online: July 22, 2017