Different Methods to Improve the Monitoring of Noninvasive Respiratory Support of Patients with Severe Pneumonia / ARDS Due to COVID-19: An Update.

The last guidelines for the hospital care of patients affected by coronavirus disease-2019 (COVID-19)-related acute respiratory failure have moved towards a widely accepted use of noninvasive respiratory support (NIRS) as opposed to early intubation at the pandemic onset. The establishment of severe COVID-19 pneumonia goes through different pathophysiological phases that partially resemble typical acute respiratory distress syndrome (ARDS) and have been categorized into different clinicalradiological phenotypes. These can variably benefit on the application of external positive end-expiratory pressure (PEEP) during noninvasive mechanical ventilation, mainly due to variable levels of lung recruit ability and lung compliance during different phases of the disease. A growing body of evidence suggests that intense respiratory effort producing excessive negative pleural pressure swings (Ppl) plays a critical role in the onset and progression of lung and diaphragm damage in patients treated with noninvasive respiratory support. Routine respiratory monitoring is mandatory to avoid the nasty continuation of NIRS in patients who are at higher risk for respiratory deterioration and could benefit from early initiation of invasive mechanical ventilation instead. Here we propose different monitoring methods both in the clinical and experimental settings adapted for this purpose, despite further research is required to allow their extensive application in clinical practice. We reviewed the needs and available tools for a clinical-physiological monitoring that aims at optimizing the ventilatory management of patients affected by acute respiratory distress syndrome due to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection

Prolonged higher dose methylprednisolone vs. conventional dexamethasone in COVID-19 pneumonia: a randomised controlled trial (MEDEAS)

Dysregulated systemic inflammation is the primary driver of mortality in severe COVID-19 pneumonia. Current guidelines favor a 7-10-day course of any glucocorticoid equivalent to dexamethasone 6 mg·day-1. A comparative RCT with a higher dose and a longer duration of intervention was lacking

Chronic inflammation and frequent exacerbations in patients with COPD: the role of PDE4 inhibitors

Inflammation represents an important hallmark of several diseases. In COPD the inflammatory lung response may be chronic and dysregulated with accumulation of inflammatory cells that causes lung parenchyma damage and airway remodeling. The inflammatory cascade involves different cells, mediators, proteins, oxygen species that leads the local inflammation to become systemic and promotes comorbidities and complications. Different stimuli may worsen the COPD pathology, including the well known COPD exacerbation, a peak of local and systemic inflammation. Also hypoxia may stimulate inflammatory genes worsening local and systemic level of inflammation. Understanding the inflammation can allow us to differentiate COPD phenotype and lead as to personalize the therapy. Several have the specific target of inflammation, particularly PDE4 inhibitors may have a role in certain COPD phenotype

Ground glass alveolar pattern (Short Survey) [Il pattern alveolare ground glass]

Descrizione di un algoritmo per aiutare il clinico ad orientarsi nella diagnosi delle pneumopatie infiltrative diffuse caratterizzate dal pattern a vetro smerigliato (ground glass)

Management of patients with neuromuscular disorders and acute respiratory failure

Acute respiratory failure (ARF) is a common cause of morbidity and mortality in most advanced neuromuscular disorders (NMD). Deterioration of lung function during NMD may have different severity and time course. During slowly progressive neuromuscular disease an acute event can precipitate the respiratory failure, while rapidly progressive NMD may present as ARF at the onset of the disease. During ARF a patient with NMD may be affected by inspiratory muscles weakness responsible for decreased ventilation, expiratory muscles weakness responsible for altered coughing effectiveness, and bulbar involvement responsible for altered swallowing and airway protection. Neuromuscular disorders may also affect central control of breathing, sleep disorder, bones and joints deformities with consequent ventilatory dysfunction. Usually ARF in NMD is prompted by precipitating factors such as upper airways infections, pneumonia, atelectasis etc. It is important to distinguish respiratory failure due to an acute event or to a rapidly progression of underlying conditions to properly allocate the patient in the more appropriate setting of care. Generally, excessive invasiveness of care must be avoided, and a pro-active early rehabilitation program may help early recovery and minimize complications. Mechanical non invasive positive pressure ventilation(NIPPV) combined with mechanically assisted coughing (MAC) has been established as the standard treatment of severe ARF in NMD. Superiority of NIPPV vs invasive mechanical ventilation (MV) was showed in term of lower mortality, treatment failure, duration of ICU in several studies. Home mechanical noninvasive ventilation and MAC may result dramatic reduction in the need for hospitalization and a prolongation of life expectancy of these patients. To avoid the progression of respiratory failure an early identification of respiratory deterioration is needed, as such as prevention of acute episodes. So, especially in the progressive diseases, is very important to monitor respiratory status with periodic lung function tests. Any respiratory tract infection in neuromuscular disease could trigger acute respiratory failure so it is mandatory take any aggressive measures to prevent and treat this complication. Some of principal preventive measures include vaccination against Pneumococcus Pn. and influenza virus, early antibiotic treatment when bacterial infection is suspected, chest physiotherapy for removal airway secretions or mechanical assisted maneuvers to increase cough efficiency. In conclusion, a proactive, preventive approach is the key for optimal management acute respiratory problems in neuromuscular disorders

A bilateral pneumonia following Thai herbal inhaler compulsive use

Traditional herbal therapy is often underestimated as a possible cause of drug-induced lung diseases. We report the case of a 51 years old man who developed acute respiratory failure after abuse and misuse of a traditional Thai herbal inhaler. The composition of the herbal therapy was only partially known. However, we supposed that the menthol balm may have been responsible of the pulmonary lipoid inclusions and trans-anethole may have caused diffuse alveolar lung damage

Monitoring respiratory mechanics by oscillometry in COVID-19 patients receiving non-invasive respiratory support

Background: Non-invasive ventilation (NIV) has been increasingly used in COVID-19 patients. The limited physiological monitoring and the unavailability of respiratory mechanic measures, usually obtainable during invasive ventilation, is a limitation of NIV for ARDS and COVID-19 patients management. Objectives: This pilot study was aimed to evaluate the feasibility of non-invasively monitoring respiratory mechanics by oscillometry in COVID-19 patients with moderate-severe acute respiratory distress syndrome (ARDS) receiving NIV. Method: 15 COVID-19 patients affected by moderate-severe ARDS at the RICU (Respiratory Intensive Care Unit) of the University hospital of Cattinara, Trieste, Italy were recruited. Patients underwent oscillometry tests during short periods of spontaneous breathing between NIV sessions. Results: Oscillometry proved to be feasible, reproducible and well-tolerated by patients. At admission, 8 of the 15 patients showed oscillometry parameters within the normal range which further slightly improved before discharge. At discharge, four patients had still abnormal respiratory mechanics, not exclusively linked to pre-existing respiratory comorbidities. Lung mechanics parameters were not correlated with oxygenation. Conclusions: Our results suggest that lung mechanics provide complementary information for improving patients phenotyping and personalisation of treatments during NIV in COVID 19 patients, especially in the presence of respiratory comorbidities where deterioration of lung mechanics may be less coupled with changes in oxygenation and more difficult to identify. Oscillometry may provide a valuable tool for monitoring lung mechanics in COVID 19 patients receiving NIV

Inspiratory muscle training for diaphragm dysfunction after cardiac surgery

OBJECTIVE: Diaphragm dysfunction is a complication of cardiac surgery with partial or absent spontaneous recovery in most cases. Surgical diaphragm plication represents the only option when symptoms persist. Because training improves functional nerve recovery after a nerve lesion, we hypothesized that early diaphragm muscle training may be beneficial. METHODS: A prospective, randomized at 2:1 ratio, controlled trial of diaphragm training using an adjustable pressure device (Threshold; Philips Respironics Inc, Murrysville, Pa) versus no training (sham device) was performed in patients with diaphragm paralysis after major cardiac surgery. This 1-year study recruited consecutive adult patients with sniff fluoroscopy-defined diaphragm paralysis after coronary bypass, valve replacement, or both. The outcome measures were diaphragm function recovery assessed by sniff fluoroscopy, maximum inspiratory and expiratory pressures, and lung function tests. RESULTS: A total of 69 patients were randomized. At 12 months, 52 patients completed the study assessments, 36 in the treatment group and 16 in the control group. Inspiratory muscle training produced a significant improvement of diaphragm mobility after 12 months (P < .001). Most patients in the training group (77.78%) experienced a partial improvement (41.67%) or achieved a complete improvement (36.11%) versus no improvement (87.5%) or partial recovery (12.5%) among controls. CONCLUSIONS: Inspiratory muscle training may improve inspiratory muscle strength and increases paralyzed diaphragm mobility