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Non-invasive ventilation in treatment of adults with chronic respiratory failure

Nieinwazyjna wentylacja mechaniczna (NIV) jest nowoczesną metodą leczenia przewlekłej niewydolności oddychania (CRF). Wraz z rozwojem medycyny oraz społeczeństwa określanego mianem „zachodniego” wzrasta liczba osób w podeszłym wieku, u których występuje kilka chorób przewlekłych mogących współistnieć, między innymi przewlekła obturacyjna choroba płuc (POChP). W populacji dorosłych pacjentów NIV znajduje zastosowanie w leczeniu chorób nerwowo-mięśniowych, między innymi stwardnienia zanikowego bocznego (ALS) czy rdzeniowego zaniku mięśni. Do pozostałych podstawowych wskazań należą choroby restrykcyjne (wśród nich kifoskolioza), choroby płuc (głównie POChP) oraz zespół bezdechu centralnego i zespół hipowentylacji osób otyłych (OHS). W poszczególnych wskazaniach, u różnych chorych, tryb i intensywność wentylacji mogą się istotnie różnić. Celem niniejszego opracowania jest upowszechnienie wiedzy na temat roli NIV w CRF u osób dorosłych. W pracy podjęto próbę syntezy aktualnej wiedzy na temat NIV. Zwrócono również uwagę na potencjalne patomechanizmy CRF w aspekcie NIV, które powinny stać się tematem przyszłych badań naukowych.Non-invasive mechanical ventilation (NIV) is a modern method of chronic respiratory failure (CRF) treatment. With the development of medicine and society known as “western”, the number of elderly people, in whom there is overlapping of chronic diseases such as COPD, is growing. In adult population NIV is used in the treatment of neuromuscular diseases such as amyotrophic lateral sclerosis (ALS) or spinal muscular atrophy. The other main indications include restrictive diseases such as kyphoscoliosis, pulmonary diseases with COPD which is the primary indication, and various forms of central apnea syndrome with epidemiologically essential role of obesity hypoventilation syndrome (OHS). In each of those indications, and in different patients, the mode and ventilation intensity may significantly differ. The aim of this review is to disseminate knowledge on the potential role of NIV in adults with CRF. This paper attempts to analyze the available knowledge concerning NIV in adults with CRF. Special attention is paid to the potential pathomechanisms which should become the subject of future research

Pulmonary function tests in the preoperative evaluation of lung cancer surgery candidates. A review of guidelines

Streszczenie Przed planowanym operacyjnym leczeniem raka płuca należy dokonać oceny czynności układu oddechowego. Według aktualnych wytycznych w pierwszej kolejności powinno się dokonać pomiaru natężonej objętości wydechowej pierwszosekundowej (FEV 1 ) i zdolności dyfuzyjnej płuc dla tlenku węgla (DLco). Zabieg pneumonektomii można przeprowadzić, gdy wartość zarówno FEV 1 , jak i DLco przekracza 80% wartości należnej. Jeśli jeden z powyższych parametrów jest niższy niż 80% wartości należnej, należy na kolejnym etapie wykonać badanie wysiłkowe z pomiarem VO 2 max. Gdy VO 2 max jest < 35% wartości należnej lub < 10 ml/kg m.c./min, leczenie operacyjne jest obarczone dużym ryzykiem. Jeśli wartość VO 2 max mieści się w przedziale 35-75% wartości należnej lub wynosi 10-20 ml/kg m.c./min, należy wyliczyć należne pooperacyjne wartości FEV 1 , DLco (ppoFEV 1 , ppoDLco). Badanie wysiłkowe z oceną VO 2 max może być zastąpione testem marszowym wahadłowym lub testem wchodzenia po schodach. Pacjent w teście marszowym wahadłowym powinien pokonać dystans > 400 m. Zdolność pokonania 3 kondy gnacji schodów w teście wchodzenia po schodach (12 m) kwa lifikuje do lobektomii. Chory planowany do pneumonektomii powinien pokonać różnicę wysokości równą 5 kondygnacjom (22 m). Słowa kluczowe: rak płuca, ocena przedoperacyjna, testy wysiłkowe. ANAESTHESIOLOGY AND INTENSIVE CARE Abstract Before planned surgical treatment of lung cancer, the patient's respiratory system function should be evaluated. According to the current guidelines, the assessment should start with measurements of FEV 1 (forced expiratory volume in 1 second) and DLco (carbon monoxide lung diffusion capacity). Pneumonectomy is possible when FEV 1 and DLco are > 80% of the predicted value (p.v.). If either of these parameters is < 80%, an exercise test with VO 2 max (oxygen consumption during maximal exercise) measurement should be performed. When VO 2 max is < 35 % p.v. or < 10 ml/kg/min, resection is associated with high risk. If VO 2 max is in the range of 35-75% p.v. or 10-20 ml/kg/min, the postoperative values of FEV 1 and DLco (ppoFEV 1 , ppoDLco) should be determined. The exercise test with VO 2 max measurement may be replaced with other tests such as the shuttle walk test and the stair climbing test. The distance covered during the shuttle walk test should be > 400 m. Patients considered for lobectomy should be able to climb 3 flights of stairs (12 m) and for pneumonectomy 5 flights of stairs (22 m)

Is it possible to predict, whether BAL salvage is going to be diagnostic?

Introduction: Bronchoalveolar lavage (BAL) is used in the diagnosis of interstitial lung diseases. BAL is diagnostic when ≥ 60%of the instilled volume is recovered. There are no reliable markers useful to predict whether BAL volume is going to be diagnostic.Our goal was to search for pulmonary function markers which could anticipate whether the recovered volume of instilled fluidwould be ≥ 60% of administered volume. Material and methods: BAL volumes and quality were analyzed in the context of disease, medical condition and lung functiontest results of the subjects hospitalized at the Pulmonology Ward from January 2015 to October 2016. The patients’ average agewas 61 (29–89). Results: Among 80 procedures, diagnostic BAL (≥ 60%) has been obtained in 58 cases. The analysis of the group of patients withan interstitial lung disease confirmed that there is a correlation between decreasing BAL recovered volume and an increase ofRV[%pred] (r = –0.34) and RV/TLC[%pred] (r = –0.41); p < 0.05. There was no significant correlation with DLCO. RV/TLC[%pred]was the parameter with the highest predictive value for an anticipated correct BAL recovery. The curve analysis of the receiveroperating characteristic (ROC) showed a diagnostic accuracy (AUC 0.73, 95% CI 0.61–0.86). Conclusions: Pulmonary hyperinflation may have a predictive role in anticipating a proper recovery of the BAL fluid volume

Lung-heart clinical crosstalk in the course of COPD exacerbation

 Wstęp: Zaostrzenie POChP jest stanem zagrożenia życia, któremu towarzyszy duszność wtórna do przeciążenia układów oddechowego i/lub krążenia. Jak dotąd w pojedynczym badaniu nie określono istotności klinicznej zmian hiperinflacji, obturacji i wydolności układu krążenia w przebiegu leczenia zaostrzenia POChP. Celem badania była ocena wpływu leczenia zaostrzenia POChP na nasilenie obturacji oskrzeli, rozdęcia płuc, oraz na zmianę stanu hemodynamicznego chorych leczonych z powodu zaostrzenia POChP.Materiał i metody: Do badania włączono 40 pacjentów w wieku 67 ± 8 lat (90% mężczyzn) hospitalizowanych z powodu zaostrzenia POChP. Chorych badano przed i po zakończeniu leczenia z zastosowaniem: badań czynnościowych układu oddechowego, echokardiografii przezklatkowej, sześciominutowego testu marszowego, stężeń Endoteliny-1 i NT-proBNP w surowicy krwi oraz skali mMRC.Wyniki: W trakcie leczenia zaobserwowano istotne zmniejszenie rozdęcia płuc: przed-RV%TLC: 64,3 ± 9,0; po-RV%TLC 60,6 ± 11,1; p = 0,03;, zmniejszenie obturacji FEV1[L] przed FEV1: 1,0 ± 0,4, po-FEV1: 1,2 ± 0,5; p < 0,001; oraz obniżenie średniego ciśnienia w tętnicy płucnej (PAPmean) [mm Hg]: przed-PAPmean: 41,2 ± 11,2; po-PAPmean: 39,1 ± 12,1; p = 0,029. Zaobserwowano trend do zmniejszenia skurczowego ciśnienia w prawej komorze serca (RVSP) [mm Hg]: przed-RVSP: 44,5 ± 12,9; po-RVSP: 36,3 ± 14,3; p = 0,068 oraz stężenia ET-1 [fmol/ml]: przed- ET-1: 1,7 ± 2,8; po-ET-1: 1,3 ± 1,9; p = 0,076, lecz nie NT-proBNP. Zaobserwowano wydłużenie dystansu 6MWT: przed: 294 ± 132; po-leczeniu: 415 ± 102; p < 0.001; oraz zmniejszenie duszności: przed-MRC: 3,3 ± 0,8; po-MRC: 1,8 ± 0,9; [pkt.] p < 0,001. Dystans 6MWT i wynik testu MRC korelowały z RV%TLC (p < 0,05; odpowiednio r = –0,58; r = 0,51), lecz nie z RVSP czy PAPmean.Wnioski: W trakcie leczenia zaostrzenia POChP obserwuje się zmniejszenie rozdęcia płuc i obturacji oskrzeli. Koreluje to ze zmniejszeniem duszności i poprawą wydolności wysiłkowej. Zaobserwowane w trakcie leczenia obniżenie mPAP nie koreluje z wydłużeniem dystansu 6MWT czy nasileniem duszności mierzonym za pomocą skali mMRC. Introduction: COPD exacerbation is a life-threatening condition with acute dyspnoea caused by respiratory or circulatory distress. The significance and co-presence of lung hyperinflation, bronchial obstruction, and changes in haemodynamics in the course of COPD exacerbation treatment have not been well described yet in course of a single study. Our aim was to evaluate the influence of COPD exacerbation treatment on bronchial obstruction, pulmonary hyperinflation, and possible changes of right and left ventricle haemodynamics in relation to the patient’s clinical status.Material and methods: A total of 40 patients (90% males), 67 ± 8 years old, with COPD were assessed pre- and post-exacerbation treatment by the following: respiratory function tests, transthoracic echocardiography, 6MWT, endothelin-1 (ET-1) and NT-proBNP serum concentrations, and MRC scale.Results: A significant decrease in RV%TLC (%) and mean pulmonary artery pressure (PAPmean) [mm Hg] was observed: pre -RV%TLC: 64.3 ± 9.0; post-RV%TLC 60.6 ± 11.1; p = 0.03; pre-PAPmean: 41.2 ± 11.2; post-PAPmean: 39.1 ± 12.1; p = 0.029, coupled with a significant increase of FEV1 [L]-preFEV1: 1.0 ± 0.4, post-FEV1: 1.2 ± 0.5; p < 0.001. A trend for reduced right ventricle systolic pressure (RVSP) [mm Hg]: pre-treatment: 44.5 ± 12.9; post-treatment: 36.3 ± 14.3; p = 0.068 and ET-1 [fmol/ml]: pre-treatment: 1.7 ± 2.8; post-treatment: 1.3 ± 1.9; p = 0.076, but not for NT-proBNP was noticed. Improvement of both, 6MWT [m]: pre-treatment: 294 ± 132; post-treatment: 415 ± 102; p < 0.001 and MRC [pts.]: pre-treatment: 3.3 ± 0.8; post-treatment: 1.8 ± 0.9; p < 0.001, were noticed. 6MWT correlated with RV%TLC (p < 0.05; r = –0.46; r = –0.53; respectively) and FEV1 (p < 0.05; r = 0.55; r = 0.60, respectively) on admission as well as on discharge. There was no such correlation with RVSP or PAPmean.Conclusions: Pulmonary hyperinflation and bronchial obstruction may be reduced by effective COPD exacerbation treatment and are accompanied by clinical improvement. The mPAP reduction observed in the course of treatment was not correlated with the results of 6MWT and MRC score

Functional links between the upper and lower airways in allergic diseases of the respiratory tract

Zapalenie alergiczne układu oddechowego, pomimo tradycyjnego podziału na alergiczny nieżyt nosa i astmę oskrzelową, zazwyczaj nie ogranicza się do błony śluzowej jednego odcinka tego układu, często wykazując charakter uogólniony. Liczne, pochodzące z badań naukowych, dowody na istnienie związków pomiędzy alergicznym nieżytem nosa a astmą oskrzelową doprowadziły do stworzenia "koncepcji jednej choroby". Ujmuje ona górne i dolne drogi oddechowe jako łączną jednostkę, pozostającą pod wpływem procesu zapalnego, który podtrzymują i nasilają wspólne mechanizmy. Celem niniejszej pracy było krytyczne przedstawienie współczesnego stanu wiedzy na temat związków czynnościowych pomiędzy górnymi i dolnymi drogami oddechowymi, z uwzględnieniem wyników badań własnych. W pracy podjęto również próbę oceny znaczenia tych związków dla rozwoju diagnostyki i leczenia chorób alergicznych układu oddechowego.Traditionally, allergic rhinitis and bronchial asthma are described as distinct and separate entities. However, progress made in recent years has brought some great changes in the understanding of pathophysiology of allergic disorders. It has become clear that both of these disorders are characterised by similar triggers, inflammatory cells and mediators involved in their pathogenesis and treatment modalities. The link between these two airway disorders has led to the development of the socalled "integrated airway hypothesis". According to this hypothesis allergic rhinitis and bronchial asthma are regarded as different facets of a generalised inflammatory process involving, although in a different degree, both the upper and lower airways. This review critically discusses the present state of knowledge on the links between the upper and lower airways in asthma and rhinitis on the basis of the recent literature and our own experience. We try to assess the importance of these links for the future diagnosis and treatment of allergic disorders of the respiratory tract

Treatment of acute respiratory failure in the course of COVID-19. Practical hints from the expert panel of the Assembly of Intensive Care and Rehabilitation of the Polish Respiratory Society

In 2019, a pandemic began due to infection with a novel coronavirus, SARS-CoV-2. In many cases, this coronavirus leads to the development of the COVID-19 disease. Lung damage in the course of this disease often leads to acute hypoxic respiratory failure and may eventually lead to acute respiratory distress syndrome (ARDS). Respiratory failure as a result of COVID-19 can develop very quickly and a small percent of those infected will die because of it. There is currently no treatment for COVID-19, therefore the key therapeutic intervention centers around the symptomatic treatment of respiratory failure. The main therapeutic goal is to main-tain gas exchange, mainly oxygenation, at an appropriate level and prevent the intensification of changes in the lung parenchyma. Depending on the severity of hypoxemia different techniques can be used to improve oxygenation. Medical staff dealing with COVID-19 patients should be familiar with both, methods used to treat respiratory failure and the epidemiological risks arising from their use. In some patients, conventional (passive) oxygen therapy alone is sufficient. In patients with worsening respiratory failure high flow nasal oxygen therapy (HFNOT) may be effective. The continuous positive airway pressure (CPAP) and non-invasive ventilation (NIV) methods can be used to a limited extent. With further disease progression, invasive ventilation must be used and in special situations, extracorporeal membrane oxygenation (ECMO) can also be administered.The authors of this article set themselves the goal of presenting the most current knowledge about the epidemiology and patho-physiology of respiratory failure in COVID-19, as well as the methods of its treatment. Given the dynamics of the developing pandemic, this is not an easy task as new scientific data is presented almost every day. However, we believe the knowledge contained in this study will help doctors care for patients with COVID-19. The main target audience of this study is not so much pneumonologists or intensivists who have extensive experience in the application of the techniques discussed here, but rather doctors of other specializations who must master new skills in order to help patients during the time of a pandemic

The second year has been completed

Among many other things, the last European Respiratory Society (ERS) International Congress in Munich brought changes to the ERS Junior Members Committee (JMC). The 3-year term of JMC representatives has seen Indre Butiene, who initiated the Committee 3 years ago, finish her tenure as chair, with Anders Bjerg, respiratory epidemiologist from Gothenburg, Sweden, being elected as her replacement. Indre’s departure has also led to the election of a new representative to the ERS Education Council. We congratulate Agnes Boots from the Netherlands on her election to this important position! Also, here in Breathe, the Doing Science series has been taken over by Georgia Hardavella, UK, whose ideas will take this practical educational series to new levels in 2015. The Hot Topics section is now coordinated by Neil Saad, UK, one of many Juniors outside the JMC who have volunteered for different JMC activities

Non-invasive ventilation in patients with an altered level of consciousness : a clinical review and practical insights

Non-invasive ventilation has gained an increasingly pivotal role in the treatment of acute hypoxemic and/or hypercapnic respiratory failure and offers multiple advantages over invasive mechanical ventilation. Some of these advantages include the preservation of airway defense mechanisms, a reduced need for sedation, and an avoidance of complications related to endotracheal intubation. Despite its advantages, non-invasive ventilation has some contraindications that include, among them, severe encephalopathy. In this review article, the rationale, evidence, and drawbacks of the use of noninvasive ventilation in the context of hypercapnic and non-hypercapnic patients with an altered level of consciousness are analyzed

The influence of chlorine in indoor swimming pools on the composition of breathing phase of professional swimmers

Objectives: Swimming is one of the most popular forms of physical activity. Pool water is cleaned with chlorine, which - in combination with compounds contained in water - could form chloramines and trichloromethane in the swimmer’s lungs. The aim of the present study was to examine the effect of swimming training in an indoor pool on the composition of swimmers’ respiratory phase metabolomics, and develop a system to provide basic information about its impact on the swimmer’s airway mucosa metabolism, which could help to assess the risk of secondary respiratory tract diseases i.e. sport results, condition, and health including lung acute and chronic diseases). Design: A group of competitive swimmers participated in the study and samples of their respiratory phase before training, immediately after training, and 2 h after training were assessed. Methods: Sixteen male national and international-level competitive swimmers participated in this study. Respiratory phase analysis of the indoor swimming pool swimmers was performed. Gas chromatography combined with mass spectrometry (GCMS) was used in the measurements. All collected data were transferred to numerical analysis for trends of tracking and mapping. The breathing phase was collected on special porous material and analyzed using GCMS headspace. Results: The obtained samples of exhaled air were composed of significantly different metabolomics when compared before, during and after exercise training. This suggests that exposition to indoor chlorine causes changes in the airway mucosa Conclusion: This phenomenon may be explained by occurrence of a chlorine-initiated bio-reaction in the swimmers’ lungs. The obtained results indicate that chromatographic exhaled gas analysis is a sensitive method of pulmonary metabolomic changes assessment. Presented analysis of swimmers exhaled air indicates, that indoor swimming may be responsible for airway irritation caused by volatile chlorine compounds and their influence on lung metabolism