Is it possible to predict the success of non-invasive positive pressure ventilation in acute respiratory failure due to COPD?

AbstractThere is now sufficient evidence that non-invasive positive pressure ventilation (NIPPV) in selected patients with severe hypercapnic acute respiratory failure due to chronic obstructive pulmonary disease (COPD) is more effective than pharmacological therapy alone. The aim of this study was to identify prognostic factors to predict the success of this technique. Fifty-nine consecutive patients with COPD admitted to a respiratory ward for 75 episodes of acute respiratory failure treated with NIPPV were analysed: success (77%) or failure (23%) were evaluated by survival and the need for endotracheal intubation. There were no significant differences in age, sex, cause of relapse and lung function tests between the two groups. Patients in whom NIPPV was unsuccessful were significantly underweight, had an higher Acute Physiology and Chronic Health Evaluation (APACHE) II score, and a lower serum level of albumin in comparison with those in whom NIPPV was successful. They demonstrated significantly greater abnormalities in pH and P a CO2at baseline and after 2 h of NIPPV. The logistic regression analysis demonstrated that, when all the variables were tested together, a high APACHE II score and a low albumin level continued to have a significant predictive effect. This analysis could predict the outcome in 82% of patients. In conclusion, our study suggests that low albumin serum levels and a high APACHE II score may be important indices in predicting the success of NIPPV

Forced expiratory volume in one second: A novel predictor of work disability in subjects with suspected obstructive sleep apnea

Whether the association of work disability with obstructive sleep apnea (OSA) is mainly due to the disease, i.e. the number and frequency of apneas-hypoapneas, or to coexisting factors independent from the disease, is not well-established. In this study, we aim to evaluate work ability in a group of subjects undergoing OSA workup and to identify the major contributors of impaired work ability. In a cross-sectional study, we enrolled 146 consecutive subjects who have been working for the last five years and referred to the sleep disorders outpatients’ clinic of the University-Hospital of Ferrara, Italy, with suspected OSA. After completing an interview in which the Work Ability Index (WAI) and the Epworth Sleepiness Scale (ESS) questionnaires were administered to assess work ability and excessive daytime sleepiness, respectively, subjects underwent overnight polysomnography for OSA diagnosing and spirometry. Of the 146 subjects, 140 (96%) completed the tests and questionnaires and, of these, 66 exhibited work disability (WAI < 37). OSA was diagnosed (apnea-hypopnea index 5) in 45 (68%) of the 66 subjects. After controlling for confounders, a lower level of forced expiratory volume at 1 second (FEV1), [odds ratio 0.97 (95% CI 0.95–1.00)], older age [1.09 (95% CI 1.03–1.15)], excessive daytime sleepiness [3.16 (95% CI 1.20–8.34)] and a worse quality of life [0.96 (95% CI 0.94–1.00)], but not OSA [1.04 (95% CI 0.41–2.62)], were associated with work disability. Patients with a higher number of diseases, in which OSA was not included, and a lower quality of life had an increased probability of absenteeism in the previous 12 months. In subjects with suspected OSA, FEV1 can be an important predictor of work disability

Survey on health care resources for diagnostic and therapeutic OSA management from Italian region Emilia-Romagna [Censimento delle strutture e delle risorse impegnate in Emilia-Romagna nella diagnosi e terapia dell'OSA]

Background. It is estimated that in Italy more than 2 million people are affected by a moderate to severe form of obstructive sleep apnea syndrome (OSA). In the Italian region Emilia-Romagna, OSA patients are expected to be over 110,000. Aim and methods. To evaluate the amount of OSA patients diagnosed and treated every year by the regional health service and the standards of clinical and instrumental management, a questionnaire was submitted to the centers operating in Emilia-Romagna on sleep disordered breathing. The questionnaire was endorsed by AIPO (Italian Association of Hospital Pulmunologists), AIMS (Italian Association of Sleep Medicine), AOOI (Italian Association of Hospital ENT). A total of 19 clinical units answered the questionnaire. Results. Patients/year with a diagnosis of OSA were 3,000, 4,000 examinations/year were carried out by 39 doctors who dedicated to OSA an average of 31% of their working time. Sleep centers followed the most important indications of guidelines for the diagnosis and management of OSA. 83% of sleep centers guaranteed a first-visit within 6 months, 24% were able to provide it within 30 days. Diagnostic investigation occurred within 3 months after the first visit in 41% of the centers, in 29% the interval could last 1 year. In more than 50% of the centers, CPAP titrations were accomplished within 30 days following the diagnostic exam. However, the waiting list was longer than 6 months in 24% of the centers. An active follow-up was provided by 59% of the centers, and 41% regularly monitored the CPAP memory card. Conclusions. Besides the split between potential (110,000) and diagnosed (3,000/year) OSA patients, the survey also indicates that the health professionals, though fulfilling guidelines, cannot carry out the entire procedures from diagnosis to follow-up. Additional energies and a stronger coordination in the framework of a regional health network are deemed necessary to allow the existing sleep centers to operate effectively

Combined inhaled salbutamol and mannitol therapy for mucus hyper-secretion in pulmonary diseases

This study focuses on the co-engineering of salbutamol sulphate (SS), a common bronchodilator and mannitol (MA), a mucolytic, as a potential combination therapy for mucus hypersecretion. This combination was chosen to have a synergic effect on the airways: the SS will act on the β2-receptor for relaxation of smooth muscle and enhancement of ciliary beat frequency, while mannitol will improve the fluidity of mucusdecrease mucus viscosity, consequently enhancing its clearance from the lung. A series of co-spray dried samples, containing therapeutically relevant doses of SS and MA were prepared. The physico-chemical characteristics of the formulations were evaluated in terms of size distribution, morphology, thermal and moisture response and aerosol performance. Additionally the formulations were evaluated for their effects on cell viability and transport across an air interface Calu-3 bronchial epithelial cells, contractibility effects on bronchial smooth muscle cells and cilia beat activity using ciliated nasal epithelial cells in vitro. The formulations demonstrated size distribution and aerosol performance suitable for inhalation therapy. Transport studies revealed that the MA component of the formulation enhanced penetration of SS across the complex mucus layer and the lung epithelia cells. Furthermore, the formulation in the ratios of SS 10-6 and MA 10-3 M gave a significant increase in cilia beat frequency, while simultaneously preventing smooth muscle contraction associated with mannitol administration. These studies have established that co-spray dried combination formulations of MA and SS can be successfully prepared with limited toxicity, good aerosol performance and ability to increase the ciliary beat frequency for improving the mucociliary clearance in patients suffering form hyper secretory diseases, whilst simultaneously acting on the underlying smooth muscle

Cellularità dell'escreato in soggetti esposti a rischio professionale per broncopneumopatia cronica ostruttiva

Occupational exposure to irritants is an important risk factor for chronic obstructive pulmonary disease (COPD). COPD is characterized by pulmonary emphysema and increased inflammatory sputum cells. We studied 2 groups, only one of which was exposed to respiratory irritants, in order to quantify emphysema and cell counts in the induced sputum. The amount of emphysema did not differ in the 2 groups, whereas cell counts and neutrophils were greater in the induced sputum of subjects with occupational exposure. We conclude that the exposure to respiratory irritants in our subjects did not cause emphysema but it increased inflammatory sputum cells, in particular neutrophils

Residual volume in a general population; Effects of body size, age, cigarette smoking, and respiratory symptoms

Residual volume (RV) was obtained by subtracting vital capacity from total lung capacity determined by the single breath helium dilution (TLCsb) to measure CO diffusing capacity in 2,680 subjects (8 to 64 years old) of a general population sample. There were 712 normal subjects (243 male and 469 female subjects) selected to evaluate the pattern of RV by age and to derive reference values for internal comparisons. From 8 to 20 years old, RV showed an increase because of the cross-sectional body size effect; after 20 to 30 years, RV was still increasing, however, at a lower level. Age and height coefficients were significantly related to RV in younger and older ages, both in male and female subjects. The RV percent predicted and RV/TLC percent were higher in smokers when compared to nonsmokers and exsmokers (the difference was significant in male subjects). A dose-response effect was observed between RV percent predicted, RV/TLC percent, and pack-years. The RV percent predicted and RV/TLC percent were significantly higher in smokers and nonsmokers with FEV1 percent predicted below the normal limit (the difference was significant in male subjects). Moreover, higher values of RV percent predicted and RV/TLC percent were observed in subjects with wheezy symptoms in male smokers and nonsmokers. A negative significant correlation was observed between RV/TLC percent and the diffusing capacity adjusted for lung volume (DL/VA) in smokers, exsmokers and nonsmokers of both sexes, confirming the hypothesis that the decrease in DL/VA may be ascribed to the enlargement of terminal air spaces. In conclusion, determination of RV by the single breath helium dilution method is suitable in epidemiology, and it allows additional important information for understanding the physiopathologic mechanisms related to the pathogenesis of chronic obstructive lung disease

Poor adherence to guidelines for long-term oxygen therapy (LTOT) in two Italian university hospitals

Long-term oxygen therapy (LTOT) improves survival in patients with chronic obstructive pulmonary disease (COPD) and severe hypoxemia. Adherence to LTOT guidelines is problematic, both because efficacy has been demonstrated only in specific groups of COPD patients, and because it implies high costs. Introduces treatment high costs. The aim of our study was to examine retrospectively the adherence to LTOT guidelines in a sample of medical records of patients prescribed LTOT between January 2005 and December 2006 in two Italian university hospitals (Ferrara and Modena). Out of a total of 191 medical records of patients prescribed LTOT, only 157 had adequate clinical data considering the three main criteria for appropriateness (arterial blood gas and/or pulse oximetry measurement, oxygen administration, smoking status). Out of these 157 patients, only 73 (46.5 %) fulfilled all three criteria recommended by the guidelines. Adherence was higher for LTOT prescribed by pulmonologists compared to internists. This survey showed that the adherence to LTOT guidelines in a sample of medical records of patients prescribed LTOT is poor. Considering the high costs and the impact on the patients' quality of life of LTOT, these results suggest that the adherence should be carefully monitored

Poor adherence to guidelines for long-term oxygen therapy (LTOT) in two Italian university hospitals

Long-term oxygen therapy (LTOT) improves survival in patients with chronic obstructive pulmonary disease (COPD) and severe hypoxemia. Adherence to LTOT guidelines is problematic, both because efficacy has been demonstrated only in specific groups of COPD patients, and because it implies high costs. Introduces treatment high costs. The aim of our study was to examine retrospectively the adherence to LTOT guidelines in a sample of medical records of patients prescribed LTOT between January 2005 and December 2006 in two Italian university hospitals (Ferrara and Modena). Out of a total of 191 medical records of patients prescribed LTOT, only 157 had adequate clinical data considering the three main criteria for appropriateness (arterial blood gas and/or pulse oximetry measurement, oxygen administration, smoking status). Out of these 157 patients, only 73 (46.5 %) fulfilled all three criteria recommended by the guidelines. Adherence was higher for LTOT prescribed by pulmonologists compared to internists. This survey showed that the adherence to LTOT guidelines in a sample of medical records of patients prescribed LTOT is poor. Considering the high costs and the impact on the patients' quality of life of LTOT, these results suggest that the adherence should be carefully monitored