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Acute-on-chronic liver failure (ACLF) is a severe clinical condition for which liver transplantation (LT) is the only curative option. Due to the recipients' generally poor pre-operative clinical conditions and extensive surgery, post-LT respiratory disorders are very common and significantly contribute to related morbidity and mortality. We report the case of a 49-year-old patient with ACLF grade 3 who has been taken care of by the Respiratory Physiotherapy Team since hospital admission. After the extubation, the patient was supported with non-invasive ventilation and mechanical in-exsufflation; meanwhile, early resistance and functional training were started. No adverse events occurred during physiotherapy sessions, and the patient returned home without respiratory support. Respiratory and physical therapy in the intensive care unit after LT were safe and feasible interventions for this patient. Given the high incidence of postoperative pulmonary complications and the high rehabilitation needs, we suggest that physiotherapy should be provided for ACLF recipients.

The Lombardy region has been one of the areas most affected by the COVID-19 pandemic since the first months of 2020, providing real-life experiences in the acute phase. It is unclear how the respiratory rehabilitation network responded to this emergency. The aims of this retrospective study were: i) to analyze clinical, functional, and disability data at admission; ii) describe assessment tools and rehabilitative programs; iii) evaluate improvement after rehabilitation. The study was conducted on data collected from ten pulmonary rehabilitation centers in Lombardy, between the period of March 1st 2020 to March 1st 2021, in patients with respiratory failure recovering from COVID-19 both at admission and discharge. The study included demographics, comorbidities, nutritional status, risk of falls, disability status (Barthel index; Short Physical Performance Battery (SPPB); 6 minutes walking test (6MWT), symptoms (dyspnoea with Barthel Dyspnoea and MRC Dyspnoea Scale), length of stay, discharge destination, need for mechanical ventilation, respiratory function, assessment/outcomes indices, and prescribed rehabilitative programs. 413 patients were analyzed. Length of stay in acute and rehabilitative units was less than 30 days. Fifty % of patients used non-invasive ventilation during their stay. Functional status was mildly compromised for forced volumes and oxygenation, while severely compromised for diffusion capacity. Independency was low while physical performance status very low. At discharge, 318 (77%) patients were sent home, 83 (20.1%) were transferred to an acute unit and 12 (2.9%) passed away. Barthel Index and 6MWT were the most used, while MRC score was the least used outcome parameter. The 5 main rehabilitative activities were walking (90.8 %), transfer from bed to armchair (77.5%), limb mobilization in bed (76%), balance (71.2%), and cycle-ergometer or treadmill (43.1%). A huge difference was found in admission, discharge, and delta change among different rehabilitative centers. When available, all outcomes showed a significant improvement. With the limitation of a retrospective study with a clear amount of missing data, COVID-19 subjects admitted to rehabilitative centers presented a reduced physical performance, symptoms of dyspnoea, and severe disability. The 6MWT and Barthel index were the most used measurement.

In February 2020 the first COVID-19 case was reported in Italy and afterwards the virus started spreading rapidly, increasing dramatically the number of infected subjects. To face the pandemic outbreak, hospitals converted wards to assure COVID-19 patients’ care and adopted measures to reduce virus diffusion. The aim of this study was to determine how many physiotherapists, in the Lombardy region, worked during pandemic, whether they continued their usual practice or were employed in COVID-19 wards and in which tasks they were involved. The survey was submitted online by the national professional order. The response rate was 11.79%. During the pandemic, 648 (53.9%) respondents interrupted their services. Less than 20% of the physiotherapists that continued working were assigned to COVID-19 wards with the role of physiotherapist. Only a small proportion of respondents had advanced skills in respiratory physiotherapy. Moreover, this study showed a limited involvement of physiotherapists inside the very acute and intense settings. In conclusion, this work revealed that, during COVID-19 pandemic, in the Lombardy region a small percentage of physiotherapists was employed in COVID-19 wards, mainly in post-acute context. Even though the response rate of this survey was very low, this study highlights the need to define and underline the role of physiotherapy in acute setting during emergency.

Inhaled therapy is widely used for treatment of many respiratory disorders. Drug delivery in lungs is dependent on the correct use of aerosol devices and patients’ training is vital for a correct therapy administration. Therefore, is very important to assess the skills of professionals involved in training patients to the correct use of inhaler devices. The aim of this study was to check the practical skills and the theoretical knowledge of health care personnel in our University Hospital in using aerosol therapy and to determine differences among professional figures in the management of inhaler devices. Three hundred and fifteen (315) volunteers including physicians, residents, nurses and respiratory physiotherapists were enrolled; an independent professional, not working in our University Hospital, assessed their theoretical knowledge related to aerosol throughout a questionnaire. Practical skills were assessed through placebo simulation with the devices that participants declared to use frequently with patients. None of the respondents correctly answered all questions evaluating theoretical knowledge on the proper use of aerosol therapy. Respiratory physiotherapists obtained significantly better results with 17.2 (1.3) average points compared to 10.3 (3.7) obtained by doctors, 9.0 (3.0) by nurses and 9.1 (4.5) by residents. Analysing in detail physicians’ results, pneumologists showed better theoretical knowledge than other specialists. Concerning the practical skills, about 80% of those stating they knew how to use metered dose inhalers, made mistakes in the basic steps for proper inhalation technique and over 50% of respondents were unable to properly simulate placebo administration of dry powder inhalers. Also here, respiratory physiotherapists and pneumologists had significant better performances, when compared to other health professionals. Our data are in line with those published in the literature in other international clinical settings, noting inadequate practical and theoretical knowledge of the available devices for aerosol therapy.

There is a need of consensus about the pulmonary rehabilitation (PR) in patients with COVID-19 after discharge from acute care. To facilitate the knowledge of the evidence and its translation into practice, we developed suggestions based on experts’ opinion. A steering committee identified areas and questions sent to experts. Other international experts participated to a RAND Delphi method in reaching consensus and proposing further suggestions. Strong agreement in suggestions was defined when the mean agreement was >7 (1 = no agreement and 9 = maximal agreement). Panelists response rate was >95%. Twenty-three questions from 4 areas: Personnel protection equipment, phenotypes, assessments, interventions, were identified and experts answered with 121 suggestions, 119 of which received high level of concordance. The evidence-based suggestions provide the clinicians with current evidence and clinical experts opinion. This framework can be used to facilitate clinical decision making within the context of the individual patient. Further studies will evaluate the clinical usefulness of these suggestions.

Respiratory physiotherapy in patients with COVID-19 infection in acute setting: a Position Paper of the Italian Association of Respiratory Physiotherapists (ARIR) On February 2020, Italy, especially the northern regions, was hit by an epidemic of the new SARS-Cov-2 coronavirus that spread from China between December 2019 and January 2020. The entire healthcare system had to respond promptly in a very short time to an exponential growth of the number of subjects affected by COVID-19 (Coronavirus disease 2019) with the need of semi-intensive and intensive care units.

Respiratory physiotherapy and rehabilitation are important therapeutic options in non-cystic fibrosis bronchiectasis (NCFB). The aims of this review of clinical trials were to evaluate the safety and the effects on physiologic and clinical outcomes of airway clearance techniques (ACTs) and rehabilitation in NCFB patients, in comparison to usual care. The search was performed on March 2018 by using PubMed and PeDro databases. 33 studies were selected. The use of ACTs for NCFB were effective in increasing sputum volume although no benefit in quality of life (QoL) or pulmonary exacerbations were observed. There were no differences in effectiveness between the several techniques used. Humidification and saline inhalation were able to aid airway clearance. Hypertonic solution (HS) was more effective than isotonic solutions (IS) in improving expectoration and sputum viscosity. Pulmonary rehabilitation (PR) was found to be associated with short term benefits in exercise capacity, dyspnea and fatigue. Exercise training seems to improve quality of life and lower exacerbation rate, but long-term data are not available. Further studies are necessary to identify the most feasible long-term outcomes such as QoL and exacerbation rate.

Tracheal stenosis represents a possible complication in intubated or tracheotomised patients. Tracheal resection is currently the gold standard for the treatment of complex stenosis while granulomas and simple stenosis (e.g., web-like) are often treated by endoscopic procedures, which do not consistently give satisfactory long-term results, due to frequent relapses. Administering continuous positive airway pressure (CPAP) after endoscopic procedures might represent a new add-on option for the treatment of this complication. In this case series are presented two patients with tracheal stenosis showed after the removal of tracheostomy tube, both treated with CPAP. The results were straightforward: CPAP treatment helped to keep stable the tracheal lumen, without adverse effects. No further endoscopic dilations were necessary thereafter, with a likely positive impact on patients’ quality of life and on health expenditure.

Associazione Riabilitatori dell’Insufficienza Respiratoria (ARIR) is pleased to announce a new editorial project by joining the Monaldi Archives of Chest Disease journal.