L¿ECOGRAFIA IN MEDICINA RESPIRATORIA: REALTÀ ITALIANA, UTILIZZO CLINICO E NUOVE INDICAZIONI

ULTRASOUND IN RESPIRATORY MEDICINE: AN ITALIAN EXPERIENCE AND CURRENT AND NOVEL CLINICAL APPLICATIONS Over the last couple of decades, thoracic ultrasound witnessed a growing attention especially in the emergency medicine/intensive care units and respiratory medicine. This is presumably due to its point-of-care ability to detect and monitor a wide spectrum of lung and pleural diseases at relatively low costs and with no ionizing radiation. On this ground, dr. Giuseppe Francesco Sferrazza Papa\u2019s PhD program was conceived to expand current knowledge on clinical applications of ultrasound in respiratory medicine that are reported in details in the present thesis. As a first step of the project, a two-year longitudinal study in a hospital setting and a cross-sectional survey have been conducted with the aim to examine the practical interest and application of ultrasound within the pulmonary medical Italian community. Both studies showed a widespread interest and use in Italy, a fact that provides a strong rationale to further explore the potentials of ultrasound in this field. Subsequently, four clinical studies were performed with the aim to best examine the accuracy of ultrasound to diagnose community-acquired pneumonia in children, to clarify the clinical meaning of the ultrasound interstitial pattern, to evaluate the effects of adding ultrasound to the Wells score for suspected pulmonary embolism, and finally to check the accuracy of the technique in detecting the pathogenesis of pleuritic thoracic pain. All these studies achieved the expected targets, thus providing solid evidence that ultrasound is important in clinical practice and has a large potential that respiratory medicine has yet to exploit

Avoiding misdiagnosis in patients with dyspnea and wheezing : a case report illustrating the clinical implications of fixation error

BACKGROUND: Bronchial asthma is a heterogeneous respiratory condition which can be mimicked by a wide range of pathologies including upper airways stenosis. The accurate diagnosis of asthma, as with other conditions, may be influenced by fixation errors, which are common in medicine and occur when a physician concentrates on only one element of a clinical case without considering other relevant aspects. Here we report a challenging case characterized by the contemporaneous presence of a common disease, asthma, together with a rare respiratory disease, idiopathic tracheal stenosis. CASE PRESENTATION: The 56-year-old female patient, a former smoker, was referred to our outpatient clinic for exertional dyspnea and persistent wheezing. There were no other respiratory or systemic symptoms over the past three months, and a psychological component was suspected. Spirometry with flow-volume evaluation and bronchoscopy were the key elements to establish the diagnoses and provide treatments. Once the diagnosis of asthma was confirmed, the combination of the anti-inflammatory corticosteroid fluticasone and the rapid-acting bronchodilator formoterol in a single inhaler effectively controlled the patient's symptoms, confirming the favorable efficacy and safety profile which are reflected in the recommendations of the international guidelines. CONCLUSIONS: In this paper we describe the clinical investigations and interventions that eventually confirmed a diagnosis of asthma complicated by an idiopathic tracheal stenosis and led to effective treatment of the patient. Awareness of fixation error may avoid misdiagnosis in patients with respiratory disease and a complicated history at presentation

Diagnostic performance of Wells score combined with point-of-care lung and venous ultrasound in suspected pulmonary embolism

Objective: Lung and venous ultrasound are bedside diagnostic tools increasingly used in the early diagnostic approach of suspected pulmonary embolism (PE). However, the possibility of improving the conventional prediction rule for PE by integrating ultrasound has never been investigated. Methods: We performed lung and venous ultrasound in consecutive patients suspected of PE in four emergency departments. Conventional Wells score (Ws) was adjudicated by the attending physician, and ultrasound was performed by one of 20 investigators. Signs of deep venous thrombosis (DVT) at venous ultrasound and signs of pulmonary infarcts or alternative diagnoses at lung ultrasound were considered to recalculate two items of the Ws: signs and symptoms of DVT and alternative diagnosis less likely than PE. The diagnostic performances of the ultrasound-enhanced Ws (USWs) and Ws were then compared after confirmation of the final diagnosis. Results: A total of 446 patients were studied. PE was confirmed in 125 patients (28%). USWs performed significantly better than Ws, with a sensitivity of 69.6% versus 57.6% and a specificity of 88.2% versus 68.2%. In combination with D-dimer, USWs showed an optimal failure rate (0.8%) and a significantly superior efficiency than Ws (32.3% vs. 27.2%). A strategy based on lung and venous ultrasound combined with D-dimer would allow to avoid CT pulmonary angiography in 50.5% of patients with suspected PE, compared to 27.2% when the rule without ultrasound is applied. Conclusions: A pretest risk stratification enhanced by ultrasound of lung and venous performs better than Ws in the early diagnostic process of PE

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

Omalizumab : When and to whom

Immunoglobulin E plays a central role in the pathogenesis of asthma. Omalizumab is a recombinant humanised monoclonal antibody directed against Immunoglobulin E to inhibit the immune system's response to allergen exposure. Omalizumab binds to free Immunoglobulin E decreasing cell-bound Immunoglobulin E and reduces high-affinity receptors on mast cells and basophils blocking the allergic cascade at its primary step. Approximately 20% of asthma patients have severe asthma, 20% are uncontrolled and 50% have allergic asthma, and about 2% of asthmatic patients would be eligible for anti-Immunoglobulin E treatment. Uncontrolled asthma remains a major issue. In fact, despite inhaled corticosteroid (ICS) or ICS plus long-acting \u3b22-agonist therapy, 72% of patients are uncontrolled or not well controlled according to the Asthma Control Questionnaire. Omalizumab as add-on therapy reduces exacerbations, need of emergency visits and systemic steroid administration, and hospitalizations, Finally, omalizumab is generally well tolerated

Role and challenges of severe asthma services: insights from the UK registry

Severe bronchial asthma affects at least 5% of the asthmatic population and remains a clinical challenge. Data from the UK National Registry for Severe Asthma suggest that dedicated centers may improve asthma control, quality of life, reduce healthcare use and oral steroid burden. A multidisciplinary approach through complete lung function evaluation, optimization of adherence to treatment and immunological characterization are key issues to improve patients' care. In this paper, we provide an overview of the challenges of managing patients with severe asthma and the role of dedicated services

Recent advances in interfaces for non-invasive ventilation : from bench studies to practical issues

The interface is the defining element of non-invasive ventilation (NIV). Nowadays different types of interfaces, which differ in terms of shape, mechanical properties and comfort, are available, and their choice and fitting is a key element of NIV success. In the last decade, larger masks covering the entire face and specifically designed helmets have been developed for delivering NIV, theoretically improving comfort and patient tolerance. Recent studies have shown that, despite marked heterogeneity in mask internal volume and compliance, the dynamic dead space and, above all, the clinical efficacy of different masks is on average very similar. Thus, with the exception of the nasal mask and the mouthpiece, a variety of interfaces for NIV can be used in the acute care setting. However, prevention and monitoring of interfaces related side-effects and evaluation of patient tolerance are crucial to avoid NIV failure. To optimize effectiveness and costs, an interface strategy for NIV in acute respiratory failure could be convenient in clinical practice

Is neural drive the missing piece in the puzzle of COPD exacerbation?

The decision to discharge in patients affected by acute exacerbation of COPD remains a common problem due to the complexity of the assessment of clinical recovery, with early readmission perceived as a marker of incompleteness of the received treatment. The neural respiratory drive, assessed by parasternal muscle electromyography, represents an estimate of the load imposed to the respiratory muscles and it may identify early clinical deterioration. The test is noninvasive, may be executed bedside, but requires experienced operators. Yet, feasibility and clinical interpretation outside reference centers seem to be the main unsolved issues in the implementation of the technique in clinical practice