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Sleep-disordered breathing (SDB) is a group of sleep-related breathing disorders which includes obstructive sleep apnoea (OSA), central sleep apnoea (CSA), and obesity hypoventilation syndrome (OHS). OHS is characterized by a combination of obesity, daytime hypercapnia and hypoxemia, and sleep-disordered breathing without other known hypoventilation causes, such as severe obstructive or restrictive parenchymal lung disease, kyphoscoliosis, severe hypothyroidism, neuromuscular disease, or congenital central hypoventilation syndrome.490 potentially eligible references were identified ; of these, 462 abstracts or full texts were excluded because they did not fulfil inclusion criteria. We reviewed the full text of the remaining 38 papers which fulfilled the inclusion criteria.The role of gender in SDB and particularly in OHS is not well known; in general, the diseases are under-recognized in women and only a few studies have reported the impact of gender on clinical presentation and treatment outcome. On the other hand, there is often a delay in diagnosing these diseases in women as compared to men; therefore, they are often more advanced when diagnosed in women.Better understanding and clinical awareness of the higher OHS prevalence in postmenopausal women may lead to earlier diagnosis and a more timely and appropriate treatment. Further studies are needed to assess the prevalence of OHS in women, the effect of menopause on OHS, and the increased risk of OHS, which will hopefully lead to optimizing OHS patient care.

High-flow oxygen therapy (HFOT) improves gas exchange and dead space washout and reduces the level of work required for breathing. This study aimed to evaluate pulmonary rehabilitation (PR) combined with HFOT in COPD patients treated with nocturnal non-invasive ventilation (NIV) and long-term oxygen therapy (LTOT). In particular, we sought to discover whether the addition of HFOT during exercise training could improve patients’ performance, mainly with regard to their Six-Minute Walking Test (6MWT) outcomes, and reduce the exacerbation rates, periods of rehospitalization or need to resort to unscheduled visits. Thirty-one COPD subjects (13 female) who used nocturnal NIV were included in a randomized controlled trial and allocated to one of two groups: the experimental group (EG), with 15 subjects, subjected to PR with HFOT; and the control group (CG), with 16 subjects, subjected to PR without HFOT. The primary outcome of the study was the observation of changes in the 6MWT. The secondary outcome of the study was related to the rate of exacerbation and hospitalization. Data were collected at baseline and after one, two and three cycles of cycle-ergometer exercise training performed in 20 supervised sessions of 40 min thrice per week, with a washout period of 3 months between each rehabilitation cycle. Statistical significance was not found for the 6MWT distance (W = 0.974; p = 0.672) at the last follow-up, but statistical significance was found for the Borg scale in regard to dyspnea (W = 2.50; p < 0.001) and fatigue (W = 2.00; p < 0.001). HFOT may offer a positive option for dyspnea-affected COPD patients in the context of LTOT and nocturnal NIV.

BACKGROUND: Early chest physiotherapy is recommended for patients with post-COVID syndrome to improve dyspnea, relieve anxiety, minimize disability, preserve lung function and improve quality of life. However, there is still no consensus on the best treatments to manage respiratory symptoms. We aimed to test a method based on a guided in/expiratory (I/E) modulation to treat the lung inhomogeneity. METHODS: Twenty patients with post-COVID syndrome and mild-to-moderate obstructive syndrome performed 3 15-min sessions/day using the I/E mode of the T-PEP®4 device, for 15 consecutive days. Lung function parameters, dyspnea and quality of life scores, as well as exercise capacity were assessed before and after treatment. RESULTS: All patients concluded the treatment and showed significant improvements in symptoms (chest pain during deep inspiration, chest tightness, inability to yawn, fatigue during activities of daily living [ADL], desaturation ≥4% during ADL) and in health status (BCSS -1.75, p=0.0003; CAT -5.2, p=0.0001). Lung function (FVC +10.9%, p=0.0002; FEV1 +8%, p=0.0001) and respiratory muscle strength (MIP +13.8%, p

Patients with obstructive sleep apnoea (OSA) have a higher risk of developing vascular diseases. In this study, we evaluated the clinical profile of patients with OSA who develop Retinal Vein Occlusion (RVO) compared with a population of OSA patients without RVO.We analysed patients with OSA diagnosed with RVO (21 cases; mean of age 61 (12) yrs. range 44-87 yrs. 67% men), belonging to a large cohort of people with long-term follow-up for RVO (up to 12 years). We compared them with 21 patients with OSA, without RVO, matched by age and gender, selected from the Sleep Unit Registry (control group).There were no differences in the prevalence of arterial hypertension (AHT) or Diabetes mellitus (DM), but the RVO patients presented a higher diastolic blood pressure compared to controls (87.6±12.6 mmHg vs. 77.9±10.1 mm Hg respectively). The polygraphic parameters were similar in both groups. The Apnoea-Hypopnoea Index (IHA) similar in both groups (30.4 ±20.9 RVO vs. 33.7 ± 22.1 controls). In addition, RVO patients had a less favourable lipid profile, with higher total cholesterol (218±52 mg/dL vs. 179±41 mg/dL), higher LDL cholesterol (139±47 mg/dL vs. 107±32 mg/dL) and higher atherogenic indices: LDL/HDL (2.78 ± 0.95 RVO vs. 2.03±0.67 controls) and total cholesterol / HDL (4.37± 1.08 vs. 3.45 ± 0.84). Among the cases, 81% had peripheral RVO (superior temporal branch in 20 out of 21 cases) and 19% had central RVO. 62% of the cases received intravitreal antiangiogenic therapy and dexamethasone implants and 33% received argon laser photocoagulation.Poor control of cardiovascular risk factors, particularly dyslipidaemias, in patients with OSA may lead to the development of this ocular complication.

Background Pneumomediastinum (PNM) can develop as a severe complication of severe COVID 19 and may be correlated with greater morbidity and mortality. PNM is a rarely reported complication in COVID-19 patients and usually associated with endotracheal intubation. Methods Our aim is to describe the characteristics of patients with PNM in twenty-one patients with COVID-19 related pneumonia and acute respiratory failure in a retrospective case series. Results Twenty-one patients were diagnosed, two were treated with high flow nasal cannula, five with non invasive ventilation and four with invasive mechanical ventilation. In four cases PNM was massive PNM was often associated to subcuatneous emphysema; more rarely associated also with pneumothorax. Conservative management was the most used therapeutic strategy. Conclusions PNM should is s serious but not extremely rare complication of severe forms of pulmonary involvement of COVID 19. The clinician should consider this rare complication; moreover, we advise careful attention when clinicians start mechanical ventilation.

Parkinson’s disease (PD) is a chronic neurodegenerative disorder with a typical movement pattern, as well as different, less studied non-motor symptoms such as dysphagia. Disease-related disorders in efficacy or safety in the process of swallowing usually lead to malnutrition, dehydration or pneumonia. Dysphagia and subsequent aspiration pneumonia are common causes of morbidity and mortality in those with PD. The aim of this review is to identify and evaluate the existing literature on swallowing disorders in PD and providing recommendations for clinical practice routine.

Background: In obstructive sleep apnoea (OSA), treatment with mandibular advancement devices (MADs) reduces patients’ Apnoea–Hypopnoea index (AHI) scores and improves their sleepiness and quality of life. MADs are non-invasive alternatives for patients who cannot tolerate traditional continuous positive airway pressure (CPAP) therapy. The variability of responses to these devices makes it necessary to search for predictors of success. The aim of our study was to evaluate the presence of mandibular torus as a predictor of MAD efficacy in OSA and to identify other potential cephalometric factors that could influence the response to treatment. Methods: This was a retrospective cohort study. The study included 103 patients diagnosed of OSA who met the criteria for initiation of treatment with MAD. Structural variables were collected (cephalometric and the presence or absence of mandibular torus). Statistical analysis was performed to evaluate the existence of predictive factors for the efficacy of MADs. Results: A total of 103 patients who were consecutively referred for treatment with MAD were included (89.3% men); the mean age of the participants was 46.3 years, and the mean AHI before MAD was 31.4 (SD 16.2) and post- MAD 11.3 (SD 9.2). Thirty-three percent of patients had mandibular torus. Torus was associated with a better response (odds ratio (OR) = 2.854 (p = 0.035)) after adjustment for sex, age, body mass index (BMI; kg/m2), the angle formed by the occlusal plane to the sella–nasion plane (OCC plane to SN), overinjection, and smoking. No cephalometric predictors of efficacy were found that were predictive of MAD treatment success. Conclusions: The presence of a mandibular torus practically triples the probability of MAD success. This is the simplest examination with the greatest benefits in terms of the efficacy of MAD treatment for OSA.

COVID-19 has high mortality rate mainly stemming from acute respiratory distress leading to respiratory failure (ARF). Aim of the study was to evaluate the management of severe ARF due to COVID-19 pneumonia using noninvasive ventilatory support (NIVS), studying safety and effectiveness of NIVS.This is a retrospective, multicenter study. Primary outcomes were NIVS failure with intubation rate and hospital mortality. Secondary outcomes were hospital stay and factors related to NIVS failure and mortality. These outcomes were compared with patients intubated and admitted to ICU.One hundred sixty-two patients were hospitalized because of severe respiratory failure (PaOinf2/inf/FiOinf2/infratio250). One hundred thirty-eight patients were admitted to Respiratory Intermediate Care Unit (RICU) for a NIVS trial. One hundred patients were treated successfully with NIVS (74.5%); 38 failed NIVS trial (27.5%). In-hospital mortality was 23.18% in RICU group and 30.55% in ICU group. Patients with NIVS failure were older, had a lower number of lymphocytes, a higher IL-6, lower PaOinf2/inf, PaC Oinf2/inf, PaOinf2/inf/FiOinf2/infratio, higher respiratory rate (RR) and heart rate at admission and lower PaO2, and PaOinf2/inf/FiOinf2/infratio and higher RR after 1-6 hours. Multivariate analysis identified higher age, C-reactive protein as well as RR after 1-6 hours and PaOinf2/inf/FiOinf2/infratio after 1-6 hours as an independent predictor mortality.NIVS is a safe and effective strategy in the treatment of severe ARF due to COVID-19 related pneumonia, that reduces mortality and length of hospital stay in the carefully selected patients.

Background Amyotrophic lateral sclerosis (ALS) is an incurable neurodegenerative disease affecting upper and lower motor neurons and resulting in progressive skeletal muscle weakness. Weak cough and difficulty in clearing secretions are often the cause of pulmonary infections and acute respiratory failure. Cough assistance is commonly used to provide support in coughing for patients with ALS. Methods This was a preliminary parallel randomized study comparing two cough-assist devices: one utilizing mechanical insufflation/exsufflation (MI/E) and expiratory flow accelerator (EFA) technology, the other utilizing only MI/E technology. The aim was to compare the effectiveness, safety and acceptability of the two devices. Thirty patients with ALS and similar severity and functional scale were enrolled. The primary outcome was the change in respiratory function, respiratory muscle function, gas exchange, and peak cough expiratory flow as an indicator of cough efficacy. Secondary outcomes were the number of exacerbations at 1, 6 and 12 months of treatment, and the patient-perceived comfort/distress related to the interventions together with the perceived efficacy of cough. Results 30 subjects were recruited and randomized into the two groups (1:1 ratio). Primary outcomes: Respiratory function parameters decreased over time in both groups, but significantly less in the Kalos group, as did the respiratory muscle strength parameters and peak cough flows. Gas exchanges decreased over time in both groups with no clinically relevant differences between groups. Secondary outcomes there were no significant differences between groups regarding the number of exacerbations over time. No adverse events were reported. All participants, in both groups, reported a similar increase in perceived cough efficacy and there was no significant difference in comfort and distress between the two treatments. Conclusions The cough-assist device with EFA technology performed better than a traditional MI/E device in ALS patients regarding respiratory function and cough efficacy, although number of exacerbations and acceptability of the two devices was similar. Following these promising preliminary results, further investigation is required in a larger cohort to confirm the superiority of EFA technology associated with a MI/E device.

Introduction Pneumonia is both the most common type of lower respiratory tract infection and a major cause of morbidity and mortality worldwide. The COVID-19 pandemic caused by the SARS-CoV-2 raised an extremely serious concern, because its most frequent clinical presentation was pneumonia. Features such as sex play an active role in the incidence and outcomes of pneumonia. This study aimed to evaluate differences between sexes concerning COVID-19-related pneumonia. Methods This was a retrospective, multicentre study that enrolled 340 consecutive adult patients admitted to hospital for COVID-19-related pneumonia. Of these patients, 219 were males (64.4%) and 121, females (35.6%). Primary endpoints were differences between both sexes as per clinical features, laboratory and radiologic results, and inhospital and 30-day mortality. Secondary outcomes included differences between both sexes and factors associated with mortality. Results Males admitted to the COVID-19 Unit were older than females (74.5 ± 15.7 vs. 64.5 ± 11.9). Cardiovascular disorders were more frequent in males (19.17% vs 13.25%), whereas obesity was more common in females (54.5% vs 37.45%). In-hospital and 30-day mortality were higher in males than in females (23.3% vs 15.7%; 24.6% vs 19.8%, respectively). No differences were observed in hospital stay; however, males had a longer ICU stay when compared with females (11.04±5.4 vs 7.05±3.4). Variables associated with a higher mortality rate included older age, a lower number of lymphocytes upon admission and higher levels of ferritin and troponin upon admission. Conclusions Males had significantly higher mortality and longer ICU stay than females. More comorbidities in males than in females could explain the difference in mortality rates. The protective role of genetic factors can partially explain the better outcomes observed in female patients with COVID-19.

Thunderstorm asthma is a rare event: in this letter we describe two cases observed during the same month of 2018 at an Italian Emergency department, assessed by the same medical team and according to the same methodology and approach. Given the infrequency of such a phenomenon and the debate around its nature, frequency, and - at times - existence, we strongly believe it is important for all specialists who observe such cases to report them, building an evidence base to expand its knowledge and understanding.

Unlike general anaesthesia, neuraxial anaesthesia (NA) reduces the burden and risk of respiratory adverse events in the post-operative period. However, both patients affected by chronic obstructive pulmonary disease (COPD) and chest wall disorders and/or neuromuscular diseases may experience the development or the worsening of respiratory failure, even during surgery performed under NA; this latter negatively affects the function of accessory respiratory muscles, resulting in a blunted central response to hypercapnia and possibly in an exacerbation of cardiac dysfunction (NA-induced relative hypovolemia). According to European Respiratory Society (ERS) and American Thoracic Society (ATS) guidelines, non-invasive ventilation (NIV) is effective in the post-operative period for the treatment of both impaired pulmonary gas exchange and ventilation, while the intra-operative use of NIV in association with NA is just anecdotally reported in the literature. Whilst NIV does not assure a protected patent airway and requires the patient’s cooperation, it is a handy tool during surgery under NA: NIV is reported to be successful for treatment of acute respiratory failure; it may be delivered through the patient’s home ventilator, may reverse hypoventilation induced by sedatives or inadvertent spread of anaesthetic up to cervical dermatomes, and allow the avoidance of intubation in patients affected by chronic respiratory failure, prolonging the time of non-invasiveness of respiratory support (i.e., neuromuscular patients needing surgery). All these advantages could make NIV preferable to oxygen in carefully selected patients.

Background Chest physiotherapy is an important tool in the treatment of bronchiectasis. High frequency chest wall oscillation (HFCWO) is a technique designed to create a global percussion of the lung which moves secretions and probably clears the peripheral bronchial tree. We propose the comparison between an existing device (SmartVest) and a new device (RespIn 11). Methods Sixty patients were randomized into three groups: a group was treated with SmartVest, a group with RespIn 11, and a group with pharmacological therapy alone. Primary outcome measures included exacerbations at 3, 6 and 12 months after the end of treatment. Secondary outcome measures were pulmonary function testing, arterial blood gas analysis (ABG), and hematological examinations, cough, dyspnea, health and quality of life scores (Bronchiectasis Health Questionnaire [BHQ], Breathlessness, Cough, and Sputum Scale [BCSS], COPD Assessment Test [CAT], Leicester Cough Questionnaire [LCT]). A 5-point Likert scale was used to evaluate patient's preference. Results Both patients in the HFCWO groups showed a significant improvement in the tests of dyspnea, cough and health and quality of life score evaluations (BHQ, BCSS, CAT, LCT) compared to the control group, but not in pulmonary function tests and ABG. Only RespIn 11 significantly reduced exacerbations in comparison with the control group. RespIn 11 also had a higher score regarding patients' preference. Conclusions The two machines have improved health and quality of life scores in patients with bronchiectasis. RespIn 11 also demonstrated a significant lowering of exacerbations and a better patient acceptance.

Objectives Parkinson's disease (PD) causes dysfunction both to swallowing and to the cough mechanism. Oropharyngeal dysphagia is the main cause of pneumonia, due to silent aspiration of food and saliva. Pneumonia is the leading cause of death in PD. Different strategies exist to reduce the risk of inhalation and associated lung infections, but evidence of their efficacy is still unclear. The aim of this preliminary study was to investigate if adding an expiratory flow acceleration (EFA®) technique to standard therapy (ST) for dysphagia can reduce the incidence of bronchopulmonary infections and improve quality of life, respiratory function parameters, cough, and airways encumbrance perception. Materials and Methods Twenty-five patients with PD were randomized to two groups: ST vs. ST + EFA. Patients were re-assessed at 30, 180 and 360 days from start of treatment. The primary outcome was the incidence of respiratory exacerbations together with quality of life score (PDQ-39). Secondary outcomes were changes in respiratory function tests, cough capacity (CPEF), perceived health status (Euro-QOL-VAS), cough, and upper airways encumbrance perception evaluated by visual numeric scale (VNS). Results Twenty patients concluded the study (10 each group). Albeit the difference was not significant, less respiratory infections, symptoms, hospital admissions and medical visits were found in the study group. Furthermore, there was a significant difference in cough effectiveness measured with the peak cough expiratory flow (PCEF) and other spirometry parameters (FEV1, FVC), and also in specific and generic health-related quality of life measures (PDQ-39, Euro-QoL-VAS). Conclusion The results of this preliminary study support the use of EFA® technology in Parkinson's patients with dysphagia to reduce the risk of respiratory complications. Nevertheless, further studies are needed in a larger, more representative sample to definitively confirm the usefulness of this technique in PD patients.

Background Respiratory disorders are a major cause of morbidity and mortality in amyotrophic lateral sclerosis (ALS). Current guidelines suggest the provision of noninvasive ventilation (NIV) for symptomatic hypoventilation in patients with ALS. Inspite of these results the proportion of ALS patients on tracheostomy invasive ventilation (TIV) is relatively high. Methods Thirty-two patients were included in the study: 16 patients were treated with nocturnal NIV associated with diurnal mouthpiece ventilation (MPV) and 16 with TIV .The primary endpoint of the study was to evaluate survival in the two groups. Secondary endpoints were to evaluate differences in the two populations in terms of clinical outcomes and quality of life (HRQoL). Results Cox analysis survival data shows no statically difference in the hazard function of the two groups. The comparison between the two groups showed a significant improvement in the average value of gas indices (paO2, paCO2) in the group treated with TIV in comparison to the group treated with MPV/NIV. Conversely, the evaluation of the questionnaires on HRQoL showed a higher score in patients treated with MPV/NIV compared to those treated with TIV. Conclusions Ventilatory treatment with MPV and TIV did not demonstrate significant differences in survival. Patients treated with MPV reported a better HRQoL, although TIV group showed higher ventilatory parameters improvement than MPV group.

Chest physiotherapy is a set of techniques used to help the draining of the mucus from the lung in pathological situations. The choice of the techniques, and their adjustment to the patients or to the pathologies, remains as of today largely empirical. High Frequency Chest Wall Oscillation (HFCWO) is one of these techniques, performed with a device that applies oscillating pressures on the chest. However, there is no clear understanding of how HFCWO devices interact with the lung biomechanics. Hence, we study idealised HFCWO manipulations applied to a mathematical and numerical model of the biomechanics of the lung. The lung is represented by a fluid--structure interaction model based on an airway tree that is coupled to an homogeneous elastic medium. We show that our model is driven by two dimensionless numbers that drive the effect of the idealised HFCWO manipulation on the model of the lung. Our model allow to analyze the stress applied to an idealised mucus by the air--mucus interaction and by the airway walls deformation. This stress behaves as a buffer and has the effect of reducing the stress needed to overcome the idealised mucus yield stress. Moreover, our model predicts the existence of an optimal range of the working frequencies of HFCWO. This range is in agreement with the frequencies actually used by practitioners during HFCWO maneuvers. Finally, our model suggests that analyzing the mouth airflow during HFCWO maneuvers could allow to estimate the compliance and the hydrodynamic resistance of the lung of a patient.

W ciągu ostatnich dwóch dekad obserwuje się coraz częstsze stosowanie wentylacji nieinwazyjnej (NIV) w leczeniu ostrej niewydolności oddechowej (ARF). Wskaźnik niepowodzeń NIV waha się jednak od 5% do 50%, a warunkiem powodzenia jest dobór pacjentów. Istnieją jednak grupy pacjentów, w których jest większe prawdopodobieństwo skuteczności NIV. Jedna z nich to chorzy na zespół hipowentylacji osób otyłych (OHS). W niniejszym przeglądzie podjęto próbę oceny skuteczności stosowania NIV u chorych z ostrą niewydolnością oddechową i określenia predyktorów niepowodzenia NIV u pacjentów z otyłością patologiczną. Zaledwie w kilku badaniach podjęto problem oceny skuteczności NIV w tej grupie chorych. Metoda ta okazywała się skuteczniejsza przy bardziej restrykcyjnej selekcji pacjentów. Otyli, u których niepowodzenie NIV było zauważalne wcześnie, charakteryzowali się wysokim stopniem ciężkości choroby przy przyjęciu do szpitala. Natomiast u więcej niż połowy pacjentów z hiperkapnią i zdekompensowanym zespołem OHS występowała opóźniona, aczkolwiek pozytywna odpowiedź na NIV. U pacjentów z dekompensacją OHS zaobserwowano korzystniejsze rokowanie i lepszą reakcję na NIV niż u innych chorych z hiperkapnią. Potrzebowali oni wyższych nastawień aparatu, dłuższego czasu do obniżenia PaCO2, częściej występowała u nich opóźniona, ale pozytywna odpowiedź na zastosowane leczenie, co powinno raczej przekonywać do stosowania NIV zamiast wczesnej intubacji. Ponieważ nie odnotowano wyraźnych predyktorów niepowodzenia stosowania NIV, konieczna jest dalsza uważna i długookresowa obserwacja.

Non-invasive ventilation ( NIV ) has been used successfully for the management of acute respiratory failure (ARF) more often in the last two decades than previously. Unfortunately, NIV can have failure rates ranging from 5% to 50% and patient selection is the key to success. There are particular groups of patients that are more likely to benefit from NIV. For patients with hypoventilation syndrome (OHS) this treatment can be beneficial. This review seeks to evaluate the effectiveness of NIV in acute ARF and determine predictors of NIV failure in morbidly obese patients. Only a few studies have investigated NIV success or failure in these patients. NIV was most often effective when patients were carefully selected. Obese patients who exhibited early NIV failure had a high severity score at admission. In contrast, more than half of hypercapnic patients with decompensated OHS exhibited a delayed but successful response to NIV. Patients with decompensation of OHS had better prognosis and response to NIV than other hypercapnic patients. They required more aggressive NIV settings, a longer time to reduce paCO2 levels , and more frequently a delayed but successful response to NIV which should encourage the use of NIV rather than early intubation. Since clear predictors of NIV failure have not been identified, a strict and prolonged monitoring is mandatory.

Parenteral nutrition is indicated in amyotrophic lateral sclerosis (ALS) when dysphagia, loss of appetite, and difficulty protecting the airways cause malnutrition, severe weight loss, dehydration, and increased risk of aspiration pneumonia. The aim of this review is to compare percutaneous endoscopic gastrostomy (PEG), radiologically inserted G-tube (RIG), and percutaneous radiologic gastrostomy (PRG) in patients with ALS, performed with or without noninvasive ventilation (NIV). We searched PubMed, MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), the EBSCO Online Research Database, and Scopus up to December 2015. A priori selection included all randomized controlled trials (RCTs), quasi-randomized trials, and prospective and retrospective studies. The primary outcome was 30-d survival. We found no RCTs or quasi-RCTs. Seven studies about the implementation of the PEG/RIG procedure during the use of NIV and 5 studies without NIV were included. In another study of 59 subjects undergoing open gastrostomy, all with vital capacity < 30% of normal, 18 of whom were dependent on continuous NIV at full ventilatory support settings, there were no respiratory complications. Thus, the use of NIV during the implementation of these procedures, especially when used at full ventilatory support settings of pressure preset 18-25 cm H2O, can support alveolar ventilation before, during, and after the procedures and prevent respiratory complications. The procedures investigated appear equivalent, but the methodological quality of the studies could be improved. Possible benefits with regard to nutrition parameters, quality of life, and psychological features need to be further investigated.

Introduction An ageing population and steady increase in the rates of neoplasms and chronic degenerative diseases poses a challenge for societies and their healthcare systems. Because of the recent and continued advances in therapies, such as the development and widespread use of non-invasive ventilation (NIV), survival rates have increased for these pathologies. For patients with end-stage chronic respiratory diseases, the use of NIV following the onset of acute or severe chronic respiratory failure is a valid option when intubation has been excluded. Evidence acquisition The following electronic databases were searched from their inception to January 2000 to December 2017: MEDLINE, EMBASE, CINHAIL, CENTRAL (Cochrane Central register of Controlled Trials), DARE (Database of Abstracts of Reviews of Effectiveness), the Cochrane Database of Systematic Reviews, ACP Journal Club database. Evidence synthesis The available evidence strongly supports the use of NIV in patients presenting with an exacerbation of chronic obstructive pulmonary disease, as well end-stage neuromuscular disease. Few studies support the use of NIV in end-stage interstitial lung disease and in morbid obesity patients. In patients with cancer has been recommend offering NIV as palliative care to improve dyspnea. Conclusions The decision regarding the treatment should be made by the patient, ideally before reaching the terminal stage and after having a frank dialogue with healthcare professionals and family members.

Patients with chronic obstructive pulmonary disease (COPD) who develop hypercapnic respiratory failure have more severe illness and an increased risk for exacerbations, hospitalization, and mortality [1]. Mechanical ventilation in chronic hypercapnic respiratory failure aims at the unloading of the respiratory muscles, which leads to at least a reduction (ideally the normalization) of PCO2 during the day, improved clinical symptoms, quality of life, life expectancy, and reduction of exacerbations [2].

Background: People with Chronic Obstructive Pulmonary Disease (COPD) suffer from dyspnoea, which may be increased by anxiety. Previous studies suggest that relaxation techniques may have positive effects in pulmonary rehabilitation. The main aim of this study is to explore the clinical impact of a quick, one-session, relaxation training for people with COPD. Methods: In this perspective, 38 participants with COPD were recruited and randomly assigned to listen to a relaxing audio or to watch a neutral stimulus, during their routine exams. Participants were assessed for psychological and physiological variables, analysed through non-parametric tests. Results: Those who joined the relaxation training showed more positive outcomes about respiratory and cardiac assessments, as well as for state anxiety and positive affections, in comparison with the baseline and the control group. Conclusions: Study results suggest that relaxation has a potential to produce improvements in respiratory and cardiac functions, together with a positive emotional effect and a reduction of anxiety.

An ageing population and steady increase in the rates of neoplasms and chronic degenerative diseases poses a challenge for societies and their healthcare systems. Because of the recent and continued advances in therapies, such as the development and widespread use of non-invasive ventilation (NIV), survival rates have increased for these pathologies. For patients with end-stage chronic respiratory diseases, the use of NIV following the onset of acute or severe chronic respiratory failure is a valid option when intubation has been excluded. The available evidence strongly supports the use of NIV in patients presenting with an exacerbation of COPD, as well end-stage neuromuscular disease. Few studies support the use of NIV in end-stage interstitial lung disease. In patients with cancer it has been recommended offering NIV as palliative care to improve dyspnoea. The decision regarding the treatment should be made by the patient, ideally before reaching the terminal stage and after having a frank dialogue with healthcare professionals and family members.

Purpose: Chest physiotherapy is an important tool in the treatment of bronchiectasis. High frequency chest wall oscillation (HFCWO) is techniques designed to create a global percussion of the lung which removes secretions and probably clears the peripheral bronchial tree. We purpose the comparison between a existing machine ( SmartVest ) and a novel machine ( RespIn 11). Methods: Sixty patients were randomized to three groups : a group was treated with SmartVest, a group with RespIn 11 and a group with pharmacological therapy alone. Primary outcome measures included exacerbations 3,6 and 12 months after the end of treatment. Secondary outcome measures were pulmonary function testing, arterial blood gas analysis(ABG), and hematological examinations, cough, dyspnea, health and quality of life scores ( Bronchiectasis Health Questionnaire[BHQ], Breathlessness, Cough, and Sputum Scale[BCSS], COPD Assessment Test[CAT], Leicester Cough Questionnaire[LCT] ).A 5-point Likert scale was used to evaluate patients preference. Results: Both patients in the HFCWO groups showed a significant improvement in the tests of dyspnea, cough and health and quality of life score evaluations (BHQ, BCSS, CAT, LCT) compared to the control group, but not in pulmonary function tests and ABG. Only RespIn 11 reduced exacerbations in comparison with control group. RespIn 11 had a greater score regarding patients preference. Conclusions: The two machines improve health and quality of life scores in patients with bronchiectasis. RespIn 11 demonstrated also a significant lowering of exacerbations and a better acceptance.

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.

Noninvasive ventilatory support (NVS) is sometimes reported as suboptimal in patients with neuromuscular disease (NMD). The reasons for this include inadequate ventilator settings and/or lack of interface tolerance. NVS has been used for many years in patients with NMD disorders as a viable alternative to continuous ventilatory support via a tracheostomy tube. The mouthpiece ventilation (MPV) is a ventilatory mode that is used as daytime ventilatory support in combination with other ventilatory modalities and interfaces for nocturnal NVS. However, there is still a poor understanding of this method’s benefits compared with other modalities. This review aims to highlight the indications and advantages along with the disadvantages of MPV.

BACKGROUND Temporary positive airway pressure (T-PEP) is a tool recently introduced in the treatment of chronic obstructive pulmonary disease (COPD) or bronchiectasis. It demonstrated encouraging results also in severe COPD patients. The aim of this study is verify if adding T-PEP to best bronchodilator therapy both in clinic and home administering could reduce disease exacerbations and improve lung function in patients with severe COPD. METHODS A total of 142 patients with severe COPD (FEV1

Resumen Introduccion La aplicacion de dispositivos de presion espiratoria positiva (PEP) durante el ejercicio se habia propuesto con el objetivo de contrarrestar la hiperinflacion pulmonar, reducir la disnea y mejorar asi la tolerancia al ejercicio de los pacientes con enfermedad pulmonar obstructiva cronica (EPOC) grave. En este ensayo controlado, aleatorizado y cruzado se investigo el efecto de dos niveles de PEP (1 cm de H2O y 10 cm de H2O) sobre la distancia recorrida por pacientes con EPOC grave durante la prueba de marcha de 6 min (PM6 M). Los criterios de valoracion secundarios fueron los efectos de la PEP sobre variables fisiologicas y de la funcion pulmonar. Metodos Se reclutaron setenta y dos pacientes con EPOC grave, hospitalizados o ambulatorios, derivados a nuestros hospitales. El primer dia de este estudio aleatorizado y cruzado se efectuo la PM6 M sin ningun dispositivo, y posteriormente se repitio con una PEP de 1 cm de H2O (PEP1) y de 10 cm de H2O (PEP10). Antes y despues de cada PM6 M se practicaron espirometrias lentas y forzadas, que incluyeron la medicion de la capacidad inspiratoria. Resultados Cincuenta pacientes (edad media 69,92 anos, FEV1 medio 41,42% del previsto) finalizaron el ensayo. La PM6 M mejoro significativamente con los dos niveles de PEP, en comparacion con la situacion inicial (323,8 m al inicio vs. 337,8 con la PEP1 y 341,8 con la PEP10; p Conclusiones En pacientes con EPOC grave, la aplicacion de una PEP de 1 cm de H2O parece mejorar la tolerancia al ejercicio, al igual que lo hace la aplicacion de 10 cm H2O y con un grado similar de disnea. Deben realizarse otros estudios para investigar los efectos de los niveles bajos de PEP en los programas de entrenamiento aerobico.

The application of positive expiratory pressure (PEP) devices during exercise had been proposed in order to counteract the pulmonary hyperinflation, reduce the dyspnea and thus increase the exercise tolerance in patients with severe chronic obstructive pulmonary disease (COPD). This randomized controlled crossover trial investigated the effect of two different levels of PEP (1 cmH2O and 10 cmH2O) on distance covered at 6minute walk test (6MWT) in patients with severe COPD. Secondary outcomes were the evaluation of PEP effects on physiological and pulmonary function variables.Seventy-two severe COPD patients, referred to our hospitals as in and out patients, were recruited. A basal 6MWT without devices was performed on the first day, and then repeated with PEP 1 cmH2O (PEP1) and 10 cmH2O (PEP10), with a randomized crossover design. Slow and forced spirometries, including the inspiratory capacity measure, were repeated before and after each 6MWT.50 patients (average age 69,92 year, mean FEV1 41,42% of predicted) concluded the trial. The 6MWT improved significantly among both PEP levels and baseline (323,8 mt at baseline vs. 337,8 PEP1 and 341,8 PEP10; p.002 and p.018, respectively). The difference between PEP10 and PEP1 did not reach the significance. No improvements were found in pulmonary function, symptoms and physiological variables after the 6MWT.In patients with severe COPD, the application of 1 cmH2O of PEP seems to improve the exercise tolerance as 10 cmH2O, with similar dyspnea. Further studies should investigate the effects of low levels of PEP on aerobic training programs.

Anti-synthetase syndrome (ASS) is defined as a heterogeneous connective tissue disorder characterized by the association of an interstitial lung disease (ILD) with or without inflammatory myositis with the presence of anti-aminoacyl-tRNA-synthetase antibodies. ILD is one of the major extra-muscular manifestations of polymyositis and dermatomyositis. We report a case of a patient with dyspnea, cough, and intermittent fever as well as ILD associated ASS in the absence of muscular involvement. This patient was admitted to the emergency department with severe respiratory failure requiring non-invasive ventilation. Our patient's case demonstrates that the diagnosis of ASS may not be obvious. However, its diagnosis leads to appropriate and potentially life-saving treatment.

The treatment of acute respiratory failure with non-invasive ventilation (NIV) as a first-line therapy is increasingly common in intensive care units. The reduced invasiveness of NIV leads to better outcomes than endotracheal intubation in carefully selected groups of patients. Furthermore, the use of NIV as a palliative treatment for respiratory failure and dyspnea has become increasingly common. NIV also has an impact on the use of "do not intubate" orders. In the present narrative review, we explore the use and outcome of NIV in elderly patients. To accomplish this, we reviewed the most recent available medical literature. Geriatr Gerontol Int 2017; 17: 689-696.

Severe asthma occurs in 5-10% of asthmatic patients, with nasal polyposis as one of the most frequent comorbidity. Benralizumab was recently marketed, thus we could analyse its effects in real-life in severe asthma, and compare the effects of the drug in patients with and without polyposis.Patients with severe asthma, receiving Benralizumab were enrolled in Italian asthma centres. The efficacy criteria for asthma (exacerbation rate, oral corticosteroid intake, hospitalizations, pulmonary function, exhaled nitric oxide) were evaluated at baseline and after 24 weeks of treatment. Patients were then sub-analysed according to the presence/absence of nasal polyposis.Fifty-nine patients with severe uncontrolled asthma (21 males, age range 32-78) and treated with benralizumab for at least 24 weeks has been evaluated, showing significant improvements in asthma-related outcomes, except for pulmonary function and exhaled nitric oxide. This included a reduction in the sino-nasal outcome-22 score versus baseline of 13.7 points (p = .0037) in the 34 patients with nasal polyposis. Anosmia disappeared in 31% patients (p = .0034). When comparing the groups with and without nasal polyposis, a similar reduction of exacerbations was seen, with a greater reduction of the steroid dependence in patients with polyposis (-72% vs -53%; p .0001), whereas lung function was significantly more improved (12% vs 34%, p = .0064) without polyposis patients.Benralizumab, after 6 months of treatment, confirmed its efficacy in severe asthma, and also in nasal polyposis, which is the most frequent comorbidity. The efficacy of Benralizumab in reducing steroid dependence was even higher in patients with polyposis.

INTRODUCTION: Acute respiratory failure (ARF) frequently complicates severe community-acquired pneumonia (CAP) that together with sepsis increases patient mortality. The background of the noninvasive ventilation (NIV) use is to overcome an episode of ARF avoiding invasive mechanical ventilation (IMV) and its associated morbidity. EVIDENCE ACQUISITION: We performed a systematic review of the available English literature published up to December 2018 inclusive and focused on ARF in adult CAP population. Database searches identified 177 articles; of these, only 16 were retained for data extraction. EVIDENCE SYNTHESIS: After analyzing all data, we observed that uncertainties in the current literature do not allow firm and definitive recommendations concerning the early use of NIV in hypoxemic CAP patients. IMV still remains a standard of care for many cases of severe CAP. CONCLUSIONS: Nonetheless, NIV is part of our armamentarium and some optimally selected patients clearly benefit from its use. However, in this setting NIV can be considered a valid and useful strategy in some well-selected patients.

Introduction Non-invasive ventilation (NIV) has been used successfully for the management of acute respiratory failure (ARF) more often in the last two decades compared to prior decades. There are particular groups of patients that are more likely to benefit from NIV. One of these groups is patients with obesity hypoventilation syndrome (OHS). The aim of this review is to evalue the effectiveness of NIV in acute ARF. Evidence acquisition MEDLINE, EMBASE, CINHAIL, Cochrane Central Register of Controlled Trials, DARE, the Cochrane Database of Systematic Reviews, and the ACP Journal Club database were searched from January 2001 to December 2017. Evidence synthesis More than 30% of them have been diagnosed when hospitalized for ARF. NIV rarely failed in reversing ARF. OHS patients who exhibited early NIV failure had a high severity score and a low HCO3 level at admission; more than half of hypercapnic patients with decompensated OHS exhibited a delayed but successful response to NIV. Conclusions Patients with decompensation of OHS have a better prognosis and response to NIV than other hypercapnic patients. They required more aggressive NIV settings, a longer time to reduce paCO2 levels, and showed more frequently a delayed but successful response to NIV.

Worldwide, there is growing concern about the burden of pneumonia. Severe community-acquired pneumonia (CAP) is frequently complicated by pulmonary and extra-pulmonary complications, including sepsis, septic shock, acute respiratory distress syndrome, and acute cardiac events, resulting in significantly increased intensive care admission rates and mortality rates. Streptococcus pneumoniae (Pneumococcus) remains the most common causative pathogen in CAP. However, several bacteria and respiratory viruses are responsible, and approximately 6% of cases are due to the so-called PES (Pseudomonas aeruginosa, extended-spectrum β-lactamase Enterobacteriaceae, and methicillin-resistant Staphylococcus aureus) pathogens. Of these, P. aeruginosa and methicillin-resistant Staphylococcus aureus are the most frequently reported and require different antibiotic therapy to that for typical CAP. It is therefore important to recognize the risk factors for these pathogens to improve the outcomes in patients with CAP.

Community-acquired pneumonia (CAP) remains a major health problem worldwide. The incidence of pneumonia increases with both age and the presence of specific risk factors, which lead to increased health care costs. However, although there is some controversy over the observed trend in CAP mortality over recent decades, it is clear that mortality in CAP patients who require intensive care unit care remains high. The increase in antibiotic resistance is an important global health problem that needs to be addressed, especially for pneumococcus the most frequent pathogen of CAP. The prudent use of current antibiotics will help to limit the spread of antibiotic resistant clones of pneumococcus. Pneumococcal and influenza vaccinations remain the primary strategy for the prevention of CAP, especially in an at-risk population. This article reviews CAP, with a focus on epidemiology, diagnosis, prognostic factors, microbial etiology, therapy, complications, and prevention.

Chronic obstructive pulmonary disease (COPD) is generally considered to be prevalent in males. However, smoking is rising in women in developing and developed countries, while exposure to biomass fuel for domestic purposes is a recognized risk factor among females. Females developing more severe COPD patterns due to tobacco exposure than men may be due to a genetic predisposition, a greater dose-dependent effect of smoke related to smaller airways caliber and an increased oxidative stress with augmented TGF-beta1 signaling. Gender hormones also seem to be involved in tobacco-smoke metabolism and in lung and pulmonary development. while menopause is associated with accelerated alveolar loss and decline of lung function pulmonary function. The time to diagnosis differs between the sexes since a lower rate of spirometry is performed in women. Also, comorbidities vary between genders: osteoporosis, inflammatory bowel diseases, reflux, hypertension, rheumatoid arthritis, and mental diseases are more common in women. Women pay more attention to breathlessness, maybe due to higher emotional response and anxiety. These elements could lead to higher hospitalization rates in women. The aim of this review is to provide the available evidence with the aim of inviting healthcare professionals to evaluate gender differences in patients with COPD, key point for optimizing the care plan.

Objectives Chronic obstructive pulmonary disease (COPD) is associated with a higher risk of pulmonary infections. This risk not only negatively affects patients' quality of life but also increases social and health costs. Hence, there is a need for an effective rehabilitative treatment including airway clearance. The aim of this pilot study was to evaluate the efficacy of a new tool for bronchial clearance based on expiratory flow accelerator (EFA) technology compared with positive expiratory pressure (PEP) treatment. Materials and methods Twenty stable patients with COPD, Global Initiative for Chronic Obstructive Lung Disease 3-4 stage, were enrolled and allocated to treatment with EFA or Bubble-PEP (BP) for 20 days during a pulmonary rehabilitation program. At baseline and the end of treatment, the following parameters were measured: arterial blood gases (ABG); respiratory function, including peak cough expiratory flow (PCEF), maximal inspiratory pressure (MIP), and maximal expiratory pressure exercise capacity using the 6-minute walk test (6MWT), dyspnea using the Medical Research Council scale, and quality of life using the St. George's Respiratory Questionnaire. Results Expiratory flow accelerator showed a significant pre- and post-improvement in ABG and a significantly greater improvement than BP in PCEF, MIP, and 6MWT post-treatment. Conclusion Expiratory flow accelerator is a valid device compared with BP as an adjunctive therapy for the treatment of patients with severe COPD.

Polymicrobial aetiology in community-acquired pneumonia (CAP) is more common than previously recognized. This growing new entity can influence inflammation, host immunity and disease outcomes in CAP patients. However, the true incidence is complicated to determine and probably underestimated due mainly to many cases going undetected, particularly in the outpatient setting, as the diagnostic yield is restricted by the sensitivity of currently available microbiologic tests and the ability to get certain types of clinical specimens. The observed rate of polymicrobial cases may also lead to new antibiotic therapy considerations. In this review, we discuss the pathogenesis, microbial interactions in pneumonia, epidemiology, biomarkers and antibiotic therapy for polymicrobial CAP.

Background People with Chronic Obstructive Pulmonary Disease (COPD) suffer from dyspnoea, which may be increased by anxiety. Previous studies suggest that relaxation techniques may have positive effects in pulmonary rehabilitation. The main aim of this study is to explore the clinical impact of a quick, one-session, relaxation training for people with COPD. Methods In this perspective, 38 participants with COPD were recruited and randomly assigned to listen to a relaxing audio or to watch a neutral stimulus, during their routine exams. Participants were assessed for psychological and physiological variables, analysed through non-parametric tests. Results Those who joined the relaxation training showed more positive outcomes about respiratory and cardiac assessments, as well as for state anxiety and positive affections, in comparison with the baseline and the control group. Conclusions Study results suggest that relaxation has a potential to produce improvements in respiratory and cardiac functions, together with a positive emotional effect and a reduction of anxiety. Trial registration ClinicalTrials.gov ID: NCT02698904. Record Registration: February 2016.

Objective A new type of device has recently been introduced in chest physiotherapy as an aid to tracheo-bronchial airway clearance: expiratory flow accelerator (EFA). It promotes mucus clearance without generating any pressure gradient, allowing patients to breathe at tidal volume against no resistance. Design Pilot randomized controlled study. Setting Tertiary hospital. Participants Fifty adult patients who underwent lung cancer lobectomy were randomized to undergo chest physiotherapy with EFA (n = 26) or PEP (n = 24). Interventions EFA; PEP bottle. Main outcomes Incidence of postoperative pulmonary complications (PPC) and length of stay. Secondary outcomes: trends in inspiratory capacity, respiratory rate, oxygen saturation, and dyspnoea. Patients rated user-friendliness of the two devices on a 5-point Likert scale. Results A slightly different incidence of PPCs was observed between the EFA and PEP group. Nevertheless, the length of stay was similar in the two groups. No substantial differences were seen in trends of inspiratory capacity, respiratory rate, oxygen saturation, dyspnoea between the two groups. Patient-reported user-friendliness of the two devices did not differ significantly, although the use of the EFA device appeared less strenuous. Conclusions Results of this pilot study point to the use of EFA as an alternative treatment option rather than as a replacement for the PEP bottle in chest physiotherapy following lung cancer lobectomy. EFA may be preferable for weaker patients and/or with airway leakages in whom PEP has limited indications. Further investigation in a larger sample is required to statistically confirm the findings. Clinical Trial Registration Number ChiCTR-ONC-17013255.

Patients who are likely to benefit from noninvasive ventilation (NIV) need to be identified early [1, 2]. Failure to do so often results in increased morbidity and mortality as well as inappropriate use of limited resources [2].

The growing interest in the quality of patient care at the levels of the health care managers, insurance companies, and health professionals is evident. Further, the growing population requires good quality health services. In this review, we analyzed the cost-effectiveness of noninvasive ventilation (NIV) in an acute setting for the treatment of respiratory failure. The strength of this review is that it identified and summarized the most relevant studies regarding various aspects of the cost-utility of NIV in an acute setting. This is the first review that focuses on the importance of the skills and training of the team in the reduction of costs associated with NIV. However, the small number of studies, heterogeneity of quality, and different outcomes of the different studies are the greatest limitations of this review. In conclusion, although there is great variation in the data drawn from the literature, NIV seems to be a cost-effective tool, especially in specific patients (those with chronic obstructive pulmonary disease) for whom the addition of NIV improves outcomes and has a positive impact on this expenditure.

Sialorrhea or drooling represents quite a common problem in patients with amyotrophic lateral sclerosis (ALS). In this review, we describe the possible treatments for this issue. Current medical management is not always effective: anticholinergic drugs (atropine, glycopyrrolate, amitriptyline, hyoscyamine, and transdermal scopolamine) are often used, but there is very little evidence of their effectiveness in patients with ALS. More invasive treatments, such as botulinum toxin injections and/or radiation therapy in the salivary glands, can be considered when anticholinergic drugs are not effective. In this review, we also explore the possible surgical options for treatment of sialorrhea. Although no specific studies have been conducted on patients with ALS, surgical therapies might represent a valid option for treatment of sialorrhea since there is no tachyphylaxis or need for repeated therapeutic sessions.