Paolo Carlucci

Effect of inhaled bronchodilators on inspiratory capacity and dyspnoea at rest in COPD

It has been shown that patients with chronic obstructive pulmonary disease (COPD) develop dynamic hyperinflation (DH), which contributes to dyspnoea and exercise intolerance. Formoterol, salmeterol and oxitropium have been recommended for maintenance therapy in COPD patients, but their effect on DH has only been assessed for salmeterol. The aim of the present study was to compare the acute effect of four inhaled bronchodilators (salbutamol, formoterol, salmeterol and oxitropium) and placebo on forced expiratory volume in one second, inspiratory capacity, forced vital capacity and dyspnoea in COPD patients. A cross-over, randomised, double-blind, placebo-controlled study was carried out on 20 COPD patients. Patients underwent pulmonary function testing and dyspnoea evaluation, in basal condition and 5, 15, 30, 60 and 120 min after bronchodilator or placebo administration. The results indicate that in chronic obstructive pulmonary disease patients with decreased baseline inspiratory capacity, there was a much greater increase of inspiratory capacity after bronchodilator administration, which correlated closely with the improvement of dyspnoea sensation at rest. For all bronchodilators used, inspiratory capacity reversibility should be tested at 30 min following the bronchodilator. On average, formoterol elicited the greatest increase in inspiratory capacity than the other bronchodilators used, though the difference was significant only with salmeterol and oxitropium. The potential advantage of formoterol needs to be tested in a larger patient population.

Can lung ultrasound replace chest radiography for the diagnosis of pneumonia in hospitalized children

Background: Lung ultrasound is a non-radiating accurate alternative tool to chest X-ray (CXR) in the diagnosis of community-acquired pneumonia (CAP) in adults. Objectives: The aim of our study was to define the accuracy of ultrasound in the diagnosis of CAP in children. Methods: 107 consecutive children with suspected CAP underwent clinical examination, blood sample analysis, CXR and lung ultrasound on admission to the Pediatric Department of the San Paolo Hospital. The diagnosis of pneumonia was made by an independent committee of physicians on the basis of the overall clinical and CXR data. Results: The diagnosis of CAP was confirmed by the committee in 81 patients (76%). Ultrasound and CXR were performed in all patients. Ultrasound had a sensitivity of 94% and specificity of 96%, while CXR showed a sensitivity of 82% and a specificity of 94%. In patients with CAP, ultrasound revealed subpleural consolidations with air bronchogram in 70 cases and focal B-lines in 6. A parapneumonic pleural effusion was detected in 17 patients by ultrasound, while only 11 of them could be detected by CXR. Conclusions: In our series, lung ultrasound was highly accurate for the diagnosis of CAP in hospitalized children. These results provide the rationale for a multicenter study in children.

Rapid On-Site Evaluation Improves Needle Aspiration Sensitivity in the Diagnosis of Central Lung Cancers: A Randomized Trial

Background: Few prospective studies have evaluated the role of endobronchial needle aspiration in diagnosing central airways neoplasms. Rapid on-site evaluation has long been used in transbronchial needle aspiration of adenopathies and peripheral lesions, but its role in sampling central malignancies has not been substantiated yet. Objectives: In this study we evaluated if endobronchial needle aspiration may increase the sensitivity of bronchoscopy for diagnosing central airways neoplasms when added to conventional diagnostic methods (forceps biopsy, brushing and bronchial washing), and if rapid on-site evaluation may be beneficial in patients undergoing endobronchial needle aspiration. Methods: 125 patients (77% males, aged 70 ± 7 years; mean ± SD) with central lung cancers were randomized to undergo bronchoscopy including conventional diagnostic methods and needle aspiration, with or without rapid on-site evaluation, stratifying the patients on the basis of the neoplasm growth pattern (exophytic and submucosal/peribronchial disease). Results: Needle aspiration significantly increased the sensitivity of bronchoscopy when added to conventional methods (from 76 to 91%; p < 0.001), primarily resulting from differences in submucosal/peribronchial diseases (68 vs. 90%; p < 0.001) and independently from the presence of rapid on-site evaluation; needle aspiration guided by rapid on-site evaluation guaranteed a higher improvement in bronchoscopy sensitivity than conventional needle aspiration (98 vs. 84%, respectively; p = 0.004). Needle aspiration guided by rapid on-site evaluation showed a significantly higher sensitivity than the conventional method (97 vs. 76%, respectively; p = 0.001). Conclusions: Needle aspiration increases the sensitivity of bronchoscopy in diagnosing central airways malignancies when added to conventional diagnostic methods, with a further significant improvement when guided by rapid on-site evaluation.

Bronchodilation test in COPD: effect of inspiratory manoeuvre preceding forced expiration

The effects of an inspiratory manoeuvre preceding forced expiration on functional tests performed under routine conditions before and after inhalation of a bronchodilator drug (salbutamol) were assessed on 150 consecutive chronic obstructive pulmonary disease outpatients. The patients performed forced vital capacity manoeuvres either immediately after a rapid inspiration (manoeuvre no. 1) or after a slow inspiration with a 4–6 s pause (manoeuvre no. 2). Under baseline conditions, forced expiratory volume in one second (FEV1) values were 8% (% control) larger with manoeuvre no. 1 than no. 2. FEV1 values increased with salbutamol administration by ∼8% and were, on average, still 7% larger with manoeuvre no. 1 than no. 2. The incidence of reversibility, assessed according to American Thoracic Society criteria, was 76% when manoeuvre no. 2 was selected to represent baseline conditions and manoeuvre no. 1 was chosen to represent the effects of bronchodilator administration, whereas the lowest incidence (2%) was found when manoeuvre no. 1 was selected to represent baseline conditions and manoeuvre no. 2 was chosen to represent the effects of bronchodilator administration. These results indicate that the time dependence of the forced vital capacity manoeuvre has an important impact on the assessment of routine lung function in a clinical setting and supports the notion that the time course of the inspiration preceding the forced vital capacity manoeuvre should be standardised.

Non-pulmonary effects induced by the addition of formoterol to budesonide therapy in patients with mild or moderate persistent asthma

Objective: The present study was designed to assess the non-pulmonary effects of a 2-week treatment with the addition of formoterol to budesonide therapy in 10 patients with mild or moderate asthma. Methods: Each patient was invited to perform a screening visit which included spirometry before and after inhalation of 12 μg formoterol with a metered dose inhaler (MDI), measurement of arterial blood pressure, baseline electrocardiography and 24-hour Holter monitoring, and a test for evaluating upper limb tremor. Patients then began bronchodilating therapy with 12 μg formoterol MDI and 400 μg budesonide Turbuhaler b.i.d. Each patient was also given a peak flowmeter and a diary in which he had to record the morning and evening values measured before taking inhaled drugs. Two weeks later, the patients repeated the same examinations; the diary card was returned 2 months after the beginning of the study. Results: Adding formoterol to budesonide therapy caused a significant improvement in lung function, but neither induced any statistically significant effect on mean heart rate, nor altered the circadian rhythm of autonomic regulation nor elicited significant alterations in cardiac morphology. However, the evaluation of upper limb tremor revealed a statistically significant increase (p = 0.02). Conclusions: This study shows that adding the recommended dose of formoterol to an inhaled corticosteroid therapy does not induce significant cardiac undesirable effects, although tremor, surely due to stimulation of β2 receptors of the skeletal muscles, may sometimes be a limiting effect.

Transbronchial needle aspiration in peripheral pulmonary lesions: a systematic review and meta-analysis.

Fluoroscopy-guided transbronchial needle aspiration (TBNA) has long been used in the diagnosis of peripheral pulmonary lesions (PPLs), although its diagnostic performance varies considerably. We conducted a systematic review and meta-analysis evaluating the accuracy of TBNA in the diagnosis of PPLs, comparing its diagnostic yield with transbronchial biopsy (TBB) and assessing the main predictors of a successful aspirate. In 18 studies, the overall TBNA yield was 0.53 (95% CI 0.44–0.61). TBNA showed a higher accuracy when directly compared to TBB (0.60 (95% CI 0.49–0.71) versus 0.45 (95% CI 0.37–0.54)). The subgroup analyses documented a higher TBNA yield when the computed tomography (CT) bronchus sign was present (0.70 (95% CI 0.63–0.77) versus 0.51 (95% CI 0.38–0.64)), when rapid on-site evaluation (ROSE) was performed (0.62 (95% CI 0.43–0.79) versus 0.51 (95% CI 0.42–0.60)), in the case of malignant lesions (0.55 (95% CI 0.44–0.66) versus 0.17 (95% CI 0.11–0.24)) and for lesions >3 cm (0.81 (95% CI 0.73–0.87) versus 0.55 (95% CI 0.47–0.63)). Conventional TBNA is a useful sampling technique for the diagnosis of PPL, with a higher diagnostic yield than TBB. The presence of CT bronchus sign, an underlying malignant process, lesion size >3 cm and ROSE employment are predictors of a higher yield. Fluoroscopy-guided transbronchial needle aspiration is a useful technique in diagnosing peripheral pulmonary lesions http://ow.ly/4mK0sB

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.

Ultrasound Fissure Observation: Assessment of Lung by Pleural HUB Affiliates (UFO ALPHA)

Background Lung ultrasound examination is becoming an even more important part of pulmonologists’ clinical routine. As indicated in the literature, the coordinates of any findings on lung parenchyma are based on surface landmarks or conventional quadrants. In our experience we have noticed that lung fissures are clearly detectable as interruptions of the pleural line, but this has never been investigated previously. The aim of this study was to evaluate whether lung fissures are detectable under normal conditions in routine clinical practice. Methods Ten operators were enrolled from Pleural‐Hub, a scientific discussion group. After compiling a prestudy survey to investigate whether they had observed fissures previously, they were asked to note if the following fissures were detectable: posterior right (PR) and left (PL), lateral right (LR) and left (LL), anterior right (AR), and anterolateral left (AL). Enrollment was competitive, aiming to reach 100 case subjects. Results We found that general fissure detection was 61.3%, in particular: PR, 59%; LR, 75%; AR, 69%; PL, 45%; LL, 64%; AL, 56%. Single operators yielded different detection rates ranging from 90% to 25%, showing strong operator dependency. Before being made aware of general results operators indicated operator’s skill and rib shadow artifacts as the principal factors affecting fissure detection. Conclusions Lung fissures may be detected with ultrasound once adequate training is provided. This may allow the clinician a more precise anatomical delineation of pathology identified by lung ultrasound.

Observational, multicentre study on the epidemiology of haemoptysis

Haemoptysis, which is a challenging symptom accounting for 10–15% of all pulmonology consultations, may be associated with life-threatening medical conditions such as lung cancer [1–7]. Malignancy is the main haemoptysis aetiology in our Italian cohort http://ow.ly/goUb30gRT5b

Interventional pulmonology techniques in elderly patients with comorbidities

Respiratory diseases are common cause of disability in the elderly and are often concomitant with other non-respiratory medical conditions. Interventional pulmonology includes advanced diagnostic and therapeutic techniques, successfully employed for benign and malignant pulmonary diseases with a good safety profile. A few studies are available on the efficacy and the safety of these procedures (both bronchoscopic and pleural techniques) in the elderly. Paucity of data in these patients may support reluctant clinicians. We carried out a non-systematic review aimed at describing the scientific literature on interventional pulmonology techniques in elderly patients with comorbidities. We summarized indications, performance characteristics, and safety profile of bronchoscopic techniques in the elderly, comparing outcomes between older and younger patients. We explored the role of age on anesthesia and sedation protocols during endoscopic procedures and assessed the influence of comorbidities on bronchoscopic outcomes. This review underlines that older age is not a barrier for implementing interventional pulmonology for diagnostic and therapeutic purposes.