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The aim of our study was to investigate the presence of dysphagia in patients with Obstructive Sleep Apnoea (OSA) and to correlate swallowing impairment with hypnologic and anatomic parameters.The study population includes 36 patients suffering from OSA. Patients were divided into two groups using the presence of dysphagia as a distinctive parameter. Group 1 included 27 OSA patients without signs of dysphagia and Group 2 included 9 OSA patients with signs of dysphagia.The age of patients in Group 2 was higher compared with the age of patients in Group 1. Analysis of Continuous Positive Airway Pressure (CPAP), obtained in the titration phase, showed that OSA patients with signs of dysphagia required a higher level of CPAP pressure than those who were not affected by swallowing abnormalities (12.6 ± 1In clinical practice, all OSA patients should undergo a complete ENT exam, including assessment of swallowing, before CPAP therapy is started. This may predict the need for higher CPAP pressure settings to resolve apnoea episodes in the presence of dysphagia as well as guide the choice of CPAP interfaces (orofacial vs. nasal) in these patients.Disfagia e OSA.Il nostro studio ha avuto come obiettivo la ricerca nei pazienti OSA di evidenze di disfagia e l’associazione della presenza di disfagia alla anatomia delle prime vie aero-digestive e ai parametri ipnologici ed emogasanalitici di questi pazienti.Tutti i pazienti sono stati sottoposti a emogasanalisi, spirometria, rinomanometria, videofibrorinolaringoscopia, valutazione fibroendoscopica della deglutizione (FEES), polisonnografia notturna, studio di titolazione della pressione di lavoro di CPAP, somministrazione del questionario “SWAL-QOL”.Il 25% della popolazione studiata ha presentato segni subclinici di disfagia. Il gruppo dei pazienti non disfagici era formato da soggetti più giovani rispetto al gruppo dei pazienti disfagici. Il distretto orofaringeo è risultato essere il sito di ostruzione più frequente per entrambi i gruppi. Nello studio di titolazione della pressione di lavoro di CPAP, i pazienti disfagici necessitano di valori di pressione più alti.Un paziente OSA su 4 ha presentato segni di disfagia. La disfagia è associata a valori più elevati di pressione allo studio di titolazione della CPAP. I pazienti OSA hanno un rischio più elevato di presentare disturbi di deglutizione con l’avanzare dell’età rispetto alla popolazione generale.

Objectives: There are no comparative studies between patients belonging to the first and second waves of the SARS-CoV-2 pandemic, the virus triggering coronavirus disease 2019 (COVID-19). In this retrospective observational study, we analyzed the clinical characteristics and the short-term outcomes of two groups of laboratory-confirmed COVID-19 patients with moderate-to-severe acute respiratory distress syndrome (ARDS) belonging to two different waves of the pandemic. Methods: We analyzed 97 consecutive patients from 11 March 2020 to 31 May 2020 and 52 consecutive patients from 28 August 2020 to 15 October 2020. Results: Patients belonging to the second wave were younger, had a lower number of concomitant chronic conditions (multimorbidity), and had a milder clinical phenotype. Medical treatments and respiratory support use have changed during the COVID-19 pandemic, based on different laboratory results and disease clinical features. Patients in the second wave had better short-term clinical outcomes, with lower death rates and more step-down transfers to a general ward. Conclusion: The present findings show a clear phenotypic difference in patients hospitalized at different stages of the COVID-19 pandemic in Italy. These results can help to stratify clinical risk and to better tailor medical treatments and respiratory support for patients with ARDS and COVID-19 pneumonia.

Background The most impacting direct costs associated to COPD for the National Health Systems (NHS) are those related to accesses to the emergency room and hospital admissions, due to the onset of one or more COPD exacerbations. At the same time, severe COPD treatment, that often require a combination of medicaments, represents a substantial economic burden for the National Health Systems (NHS). This study aimed to evaluate the potential saving deriving from the implementation in the prescription of the two currently available single-inhaler triple therapies (SITTs) versus the currently used multiple-inhaler triple therapies (MITTs) in an eligible COPD population residing in the Apulia Region. Methods A budget impact model was developed hypothesizing the progressive replacement of the different MITTs on the reference market (Scenario A) with the pre-established SITTs, assuming a degree of penetration of 30%, 50% and 100% (Scenario B). Drug costs were based on prices published on the Official Gazette and therapy durations were based on prescribing information over the year 2019 (IQVIA™ prescription dataset). Results Our analysis showed that the extemporaneous MITT with the highest prevalence on the reference market was the inhaled corticosteroids/long-acting β2-agonists (ICS/LABA) combination plus a long-acting muscarinic antagonists (LAMA). This association of medicaments was paradoxically also the one associated to the highest expense value. The expanded use of a pre-established ICS/LAMA/LABA SITT was associated to a significant economic saving, ranging from a minimum of -€ 1,108,814 (SITT use: 30%) to a maximum of -€ 3,658,950 (SITT use: 100%). The cheapest pre-established SITT contained the fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) combination. Conclusion A pre-fixed ICS/LAMA/LABA SITT is cost-saving, compared to the different currently used extemporaneous MITTs. Clinicians should consider the potential benefits of finding less expensive regimens while maintaining adequate efficacy in the prescriptive decision making process of COPD patients.

Objectives: In the present single-centered, retrospective, observational study, we reported findings from 78 consecutive laboratory-confirmed COVID-19 patients with moderate-to-severe acute respiratory distress syndrome (ARDS) hospitalized in an intermediate Respiratory Intensive Care Unit, subdividing the patients into two groups according to their clinical outcome, dead patients and discharged patients. Methods: We further subdivided patients depending on the noninvasive respiratory support used during hospitalization. Results: In those patients who died, we found significant older age and higher multimorbidity and higher values of serum lactate dehydrogenase, C-reactive protein, and D-dimer. Among patients who were submitted to bilevel positive airway pressure (BPAP), those who died had a significant shorter number of days in overall length of stay and lower values of arterial oxygen partial pressure to fractional inspired oxygen ratio (PaO2/FiO2 ratio) compared to those who survived. No difference in all-cause mortality was observed between the two different noninvasive respiratory support groups [48% for continuous positive airway pressure (CPAP) and 52% for BPAP]. Conclusion: In COVID-19 patients with moderate-to-severe ARDS using BPAP in an intermediate level of hospital care had more factors associated to all-cause mortality (shorter length of stay and lower baseline PaO2/FiO2 ratio) compared to those who underwent CPAP.

Background: Dupilumab is a humanized monoclonal antibody targeting the IL4/IL13 signaling pathway, already used for atopic dermatitis and chronic rhinitis with nasal polyps, recently approved for severe type-2 asthma. It demonstrated its efficacy in randomized control trials. The aim of our study is to evaluate possible early clinical improvement and type 2 biomarkers modifications in severe asthmatic patients treated with dupilumab in a real-life setting.Methods: We included 12 patients with severe, uncontrolled asthma and dupilumab was chosen if there was at least one evidence of blood eosinophils >150 cells/ml and/or FeNO >25 ppb during last year. Recent blood eosinophil count report, assessment through ACT, FeNO test and spirometry were performed at baseline and after 3 months of treatment. We calculated also the number of patients achieving a minimal, yet clinically relevant difference in FEV1 and ACT.Results: After three months of treatment with dupilumab, ACT had a significant improvement (mean ACT pre 13.25±4.65 vs mean ACT post 19.17±4.45; p

Introduction Several studies have previously demonstrated that long-term exposure to outdoor pollution present airway inflammation in term of an increase of sputum neutrophils. Aim and methods The aim of our study was to evaluate the level of airway inflammation by induced sputum in a group of 15 non-professionally exposed population of well-characterized COPD patients, residing in urban areas with high rate of outdoor pollution, compared to a control group of 13 individuals with COPD, living in rural areas with a low pollution rate. All participants underwent spirometry and sputum induction. Results A statistically significant increase in the percentage of neutrophil cell count was found among the residents in urban areas compared to those living in rural regions (89.1 vs 79.0, p Conclusions In conclusion, we showed that non-professionally exposed patients with COPD residing in highly-polluted urban areas had greater airway inflammation in terms of sputum neutrophils compared to a population with very similar characteristics, living in rural areas with lower outdoor pollution. The results of this pilot study may be relevant for the long term effect of environmental outdoor pollution in vulnerable patients like those with COPD.

The impact of obstructive sleep apnea syndrome (OSAS) in terms of mortality, morbidity, and quality of life has been well established. Phenotyping OSAS is essential in order to make the best therapeutic choice. A particular subset of patients with OSAS shows nocturnal respiratory failure, defined by a nighttime oxygen saturation90% in more than 30% of the total sleep time (TST90). The aim of this study was to identify possible predictive factors for nighttime respiratory failure (NRF) in patients with OSAS.In this retrospective study, patients with suspected OSAS who underwent a sleep study were enrolled. Of 116 patients with moderate/severe OSAS who met the inclusion criteria, 67 also had nocturnal respiratory failure. We compared clinical, anthropometric, and laboratory data in patients with OSAS vs. OSAS and nocturnal respiratory failure.Patients with OSAS and nocturnal respiratory failure were more frequently female, had a higher BMI, lower daytime oxygen partial pressure (PaO2) in arterial blood, higher Apnea Hypopnea Index (AHI), and a lower number of sleep hours per night. Chronic obstructive pulmonary disease (COPD) was more diagnosed in the group of patients with nocturnal respiratory failure. A lower number of total sleep hours, lower daytime PaO2, lower AHI, increased oxygen desaturation index (ODI), and the presence of a diagnosed COPD were all found to increase the risk of having nocturnal respiratory failure.COPD, AHI, ODI, daytime PaO2, and total sleep hours are the main predictors for NRF in patients with moderate and severe OSAS.

BACKGROUND Obstructive sleep apnea (OSA) is a worldwide increasing syndrome, which, by promoting endothelial dysfunction, contributes to extend the cardiovascular risk. We evaluated the cardiovascular risk in a group of OSA patients. METHODS A total of 185 OSA subjects (19 normal weight, 57 overweight, 109 obese), who entered the Ambulatory of Sleep Disorders of the Institute of Respiratory Diseases of the University of Bari, during 1 year, were enrolled in the study. We assessed anthropometric features, polysomnographic findings, cardiovascular risk factors, smoking habit, Pulmonary Function Test, Arterial Blood Gas Analysis, Epworth Questionnaire, and Charlson Co-morbidities Index (CCI). Subjects were divided into three groups, according to their BMI: individuals with BMI ≥30 kg/m2 (Group 1 n = 109, mean age 61 ± 1; 74.3% men), individuals with BMI ranging from 25.0 to 29.9 kg/m2 defined as overweight subjects (Group 2 n = 57, mean age 58.8 ± 1.4; 77% men), and subjects with a BMI ranging from 18.5 to 24.9 kg/m2 defined as normal weight subjects (Group 3 n = 19, mean age 54.2 ± 2.3; 64,2% men). RESULTS In the whole population, the percentage cardiovascular risk was weakly related with BMI (r = 0.33; P

The prevalence of asthma in Italy is estimated to be around 4%; it affects approximately 2,000,000 citizens, and up to 80-90% of patients have mild-to-moderate asthma. Despite the clinical relevance of mild-to-moderate asthma, longitudinal observational data are very limited, including data on disease progression (worsening vs. improvement), the response to treatment, and prognosis. Studies are needed to develop long-term, observational, real-life research in large cohorts. The primary outcomes of this study will be based on prospective observation and the epidemiological evolution of mild and moderate asthma. Secondary outcomes will include patient-reported outcomes, treatments over time, disease-related functional and inflammatory patterns, and environmental and life-style influences.This study, called the Mild/Moderate Asthma Network of Italy (MANI), is a research initiative launched by the Italian Respiratory Society and the Italian Society of Allergology, Asthma and Clinical Immunology. MANI is a cluster-based, real world, cross-sectional, prospective, observational cohort study that includes 20,000 patients with mild-to-moderate asthma. (ClinicalTrials.gov Identifier: NCT04796844).Despite advances in asthma care, several research gaps remain to be addressed through clinical research. This study will add important new knowledge about long-term disease history, the transferability of clinical research results to daily practice, the efficacy of currently recommended strategies, and their impact on the burden and evolution of the disease.MANI:Mild/Moderate Asthma Network of ItalySANI:Severe Asthma Network ItalyGINA:Global Initiative for AsthmaSABA:short acting β2-agonistsICS:inhaled corticosteroidsCRF:Case Report Form.

Background: The COVID-19 pandemic has led to new approaches to manage patients outside the ICU, including prone positioning in non-intubated patients.Objectives: To report the use of prolonged active prone positioning in spontaneously breathing patients with COVID-19-associated acute respiratory failure. Spontaneously breathing vs non-invasive respiratory support for COVID19 associated acute respiratory failure.Methods: Patients with PaO2/FiO2 > 150, with lung posterior consolidations as assessed by means of lung ultrasound, and chest x-ray were studied. Under continuous pulse oximetry (SpO2) monitoring, patients maintained active prone position. A PaO2/FiO2 < 150 was considered as treatment failure and patients had to be switched to non-invasive respiratory support. Retrospectively, data of 16 patients undergoing who refused proning and underwent non-invasive respiratory support were used as controls. The primary outcome was the proportion of patients maintaining prolonged prone position and discharged home. Secondary outcomes included improvement in oxygenation, hospital length of stay, and 6-month survival.Results: Three out of 16 (18.7%) patients did not tolerate the procedure. Three more patients showed a worsening in PaO2/FiO2 to 2/FiO2: from 194.6 (42.1) to 304.7 (79.3.2) (p < 0.001)] and were discharged home. In the control group, three out of 16 failed, required invasive ventilatory support, and died within 1 month in ICU. Thirteen were successful and discharged home.Conclusion: In non-intubated spontaneously breathing COVID-19 patients with PaO2/FiO2 >150, active prolonged prone positioning was feasible and tolerated with significant improvement in oxygenation.

Background An association between systemic corticosteroids and tuberculosis (TB) is reported in the literature. Here within, we conducted a systematic review and meta-analysis to evaluate the effects of inhaled corticosteroids (ICS) on the risk of TB in patients with obstructive lung diseases. Methods The review was registered on PROSPERO (CRD42018095874). PubMed, CENTRAL, Scopus and Web of Science were searched from inception to September 2018. Papers reporting cases of incident TB in patients with obstructive lung diseases were included; studies without data on ICS use were excluded. Simultaneous use of oral corticosteroids (OCS) and population attributable fraction (PAF) for TB from ICS exposure were also assessed. Data were analyzed using a generic inverse variance method with a random-effects model. ORs with 95% CI were estimated. Results Out of 4044 retrieved papers, 9 articles evaluating adult patients only were included in the review. 36,351 patients were prescribed ICS, while 147,171 were not. Any ICS use was associated with an increased risk of TB versus no ICS use (OR=1.46; 95% CI 1.06 to 2.01; p=0.02; I2=96%). A similar result was also found for current ICS use versus prior/no ICS use, as well as for high, moderate and low ICS dose versus no ICS. When simultaneous OCS use was evaluated, the independent contribution of ICS was confirmed only in patients not on OCS (OR=1.63; 95% CI 1.05 to 2.52; p=0.03; I2=94%). Only 0.49% of all TB cases could be attributable to ICS exposure. Conclusions Despite the association between ICS and TB, the contribution of this risk factor to the epidemiology of TB seems to be limited. As a consequence, no population-based interventions are warranted. Rather, this risk should be taken into account on an individual basis, particularly in those patients with a high risk of progression from LTBI to TB.

The importance of nocturnal hypoventilation (nHyp) in the development of cardiovascular comorbidity (CVM) in patients with obesity hypoventilation syndrome (OHS) is controversial. We recently hypothesized that nHyp may have a protective effect on CVM in OHS. The aim of this study was to evaluate the link between nHyp and CVM in patients with OHS. We performed a retrospective analysis of the clinical records of 60 patients with OHS. The initial population was divided into two groups: (1) 31 subjects with OHS and nHyp (nhOHS); (2) 29 individuals with OHS without nHyp (wnhOHS). All patients had also obstructive sleep apnea. Anthropometric data, medical history, electrocardiogram, pulmonary function testing, arterial blood gas test, and sleep recordings were collected. Patients with nhOHS, compared with those wnhOHS, showed higher values of PaCO

Background Obstructive Sleep Apnea (OSA) is a worldwide increasing syndrome, which, by promoting endothelial dysfunction, contributes to extend the cardiovascular risk. We evaluated the cardiovascular risk in a group of OSA patients. Methods A total of 185 OSA subjects (19 normal weight, 57 overweight, 109 obeses), seen at the Ambulatory of Sleep Disorders, during one year, entered the study. We assessed anthropometric features, polysomnographic findings, cardiovascular risk factors, smoking habit, Pulmonary Function Test, Arterial Blood Gas Analysis, Epworth Questionnaire, and Charlson Co-morbidities Index (CCI). Subjects were divided into three groups, according to their BMI: individuals with BMI ≥30 Kg/m2 (Group 1 n=109, mean age 61 ± 1; 74.3 % males), individuals with BMI ranging from 25.0 to 29.9 Kg/m2 defined as overweight subjects (Group 2 n=57, mean age 58.8 ± 1.4; 77% males) and subjects with a BMI ranging from 18.5 to 24.9 Kg/m2 defined normal weight subjects (Group 3 n=19, mean age 54.2 ± 2.3; 64,2% males). Results In the whole population, the percentage cardiovascular risk was weakly related with BMI (r=0.33; P

Background Patients hospitalized for COVID-19-related pneumonia often need several degrees of ventilatory support, which are performed between Respiratory Intermediate Care Units (RICUs) and Intensive Care Units (ICUs), and which depend on the severity of acute respiratory distress syndrome. There is no firm consensus on transfer predictors from the RICU to the ICU. Methods In this retrospective observational single center study, we evaluated 96 COVID-19 patients referred to the RICU for acute respiratory failure (ARF) according to their transferal to the ICU or their stay at the RICU. We compared demographic data, baseline laboratory profile, and final clinical outcomes to identify early risk factors for transfer. Results The best predictors for transfer to the ICU were elevated C-reactive protein and lymphopenia. The mortality rate was lower in the RICU than in the ICU, where transferred patients who died were mostly younger men and with less comorbidities than those in the RICU. Conclusions Few inflammatory markers can predict the need for transfer from the RICU to the ICU. Due to the ongoing COVID-19 pandemic, we urge better clinical stratification by early and meaningful profiles in patients admitted to the RICU who are at risk of transferal to the ICU.

Galectin-3, considered as a new inflammatory marker; it is increased in cardiovascular disease. We investigated Galectin-3 in relation to heart damage in patients with OSA and its role in inflammation, based on the Neutrophil-to-Lymphocyte Ratio (NLR).Sixty-three consecutive patients (45 males, 18 females, 58.60 ± 12.28 years old) were studied. According to the Apnoea-Hypopnoea Index (AHI) patients were divided into Group 1 - non-severe (AHI30) (17 males and 10 females, 59.89 ± 10.62 years old) and Group 2 - severe (AHI ≥30) (29 males and 6 females, aged 57.53 ± 13.30 years old) OSA. All patients underwent morning blood gas analysis, laboratory tests, nocturnal polygraphy, and echocardiography.Galectin-3 was significantly increased in Group 2 (p = 0.027) patients. Moreover, it was directly related to left ventricle (LV) mass, left ventricle hypertrophy and LV posterior wall diameter. Tissue Doppler septal velocity (e'), that measures wall motion, was inversely correlated to Galectin-3. Furthermore, a direct association to diastolic dysfunction, evaluated as E/e' ratio, was observed. In line with these data, a direct correlation between Galectin-3 and left atrium volume was also found. Galectin-3 and percentage of total registration time with nocturnal oxygen saturation90% (TST90) were directly correlated (p = 0.0003), while Galectin-3 and mean nocturnal SpOGalectin-3 showed a direct association to nocturnal respiratory indices and to cardiac remodelling in patients with OSA. OSA-induced inflammation may play an important role in the pathogenesis of heart damage.

The recent Coronavirus disease 19 (COVID-19) pandemic, first in China and then also in Italy, brought to the attention the problem of the saturation of Intensive Care Units (ICUs). Almost all previous reports showed that in ICU less than half of patients were treated with invasive mechanical ventilation (IMV) and the rest of them with non-invasive respiratory support. This highlighted the role of respiratory intensive care units (RICUs), where patients with moderate to severe respiratory failure can be treated with non-invasive respiratory support, avoiding ICU admission. In this report, we describe baseline characteristics and clinical outcomes of 97 patients with moderate to severe respiratory failure due to COVID-19 admitted to the RICU of the Policlinico of Bari from March 11th to May 31st 2020. In our population, most of the subjects were male (72%), non-smokers (76%), with a mean age of 69.65±14 years. Ninety-one percent of patients presented at least one comorbidity and 60% had more than two comorbidities. At admission, 40% of patients showed PaO2/FiO2 ratio between 100 and 200 and 17% showed Pa02/FiO2 ratio

Background: The COVID-19 pandemic has led to new approaches to manage patients outside the ICU, including prone positioning in non-intubated patients. Objectives: To report the use of prolonged active prone positioning in spontaneously breathing patients with COVID-19-associated acute respiratory failure. Spontaneously breathing vs non-invasive respiratory support for COVID19 associated acute respiratory failure. Methods: Patients with PaO2/FiO2 > 150, with lung posterior consolidations as assessed by means of lung ultrasound, and chest x-ray were studied. Under continuous pulse oximetry (SpO2) monitoring, patients maintained active prone position. A PaO2/FiO2 < 150 was considered as treatment failure and patients had to be switched to non-invasive respiratory support. Retrospectively, data of 16 patients undergoing who refused proning and underwent non-invasive respiratory support were used as controls. The primary outcome was the proportion of patients maintaining prolonged prone position and discharged home. Secondary outcomes included improvement in oxygenation, hospital length of stay, and 6-month survival. Results: Three out of 16 (18.7%) patients did not tolerate the procedure. Three more patients showed a worsening in PaO2/FiO2 to 150, active prolonged prone positioning was feasible and tolerated with significant improvement in oxygenation.

Background: Severe asthma is burdened by frequent exacerbations and use of oral corticosteroids, which worsen patients’ health and increase healthcare spending. The aim of this study was to assess the clinical and economic impact of switching from omalizumab to mepolizumab in patients eligible for both biologics, but not optimally controlled by omalizumab.Methods: We retrospectively enrolled uncontrolled severe asthmatic patients, referred to seven asthma clinics in Italy, who switched from omalizumab to mepolizumab during the last two years. Clinical, functional, and laboratory information included blood eosinophil count, asthma control test, spirometry, serum IgE, fractional exhaled nitric oxide, oral corticosteroids intake, use of controller and rescue drugs, exacerbations/hospitalizations, visits and diagnostic exams. Within the perspective of Italian National Health System, a pre- and post-mepolizumab 12-month standardized total cost per patient was calculated.Results: 33 patients were enrolled: 5 males and 28 females, mean age 57 years, mean disease onset 24 years. At omalizumab discontinuation, 88% were oral corticosteroids-dependent with annual mean rate of 4.0 clinically significant exacerbations, 0.30 exacerbations needing emergency room visits or hospitalization; absenteeism due to disease was 10.4 days per patient. Switch to mepolizumab improved all clinical outcomes, reducing total exacerbation rate (RR = 0.06, 95% CI 0.03 to 0.14), oral corticosteroids -dependent patients (OR = 0.02, 95% CI 0.005 to 0.08), and the number of lost working days because of uncontrolled disease (Δ = -7.9, 95% CI -11.2 to -4.6). Pulmonary function improved, as well as serum IgE, fractional exhaled nitric oxide and eosinophils decreased. Mean annual costs were € 12,239 for omalizumab and € 12,639 for mepolizumab (Δ = € 400, 95% CI -1,588 to 2,389); the increment due to drug therapy (+ € 1,581) was almost offset by savings regarding all other cost items (- € 1,181). Conclusions: Patients with severe eosinophilic asthma, not controlled by omalizumab, experienced comprehensive benefits in asthma control by switching to mepolizumab. These relevant improvements were burdened by only very slight increases in economic costs.

Introdution. In order to prevent or slow down the transmission of COVID-19, various public health measures have been introduced, including social distancing, environmental disinfection and the use of personal protective equipment (PPE). In this perspective, the clinical practice of healthcare professionals has changed dramatically. As a matter of fact, the use of surgical masks and N95 has significantly worsened the job performance of workers who deal directly with COVID-19 disease. Methods. The study included 116 health workers employed in the pulmonology, intensive care and infectious diseases departments of Bari and Foggia Hospital, directly involved in the healthcare of patients affected by COVID-19. Between May 1, 2020 and May 31, 2020, each participant completed an online questionnaire aimed to investigate the impact of the COVID-19 pandemic on workers’ lifestyle changes and job performances. We compared the results based on the type of mask used by each participant (surgical mask vs N95). Results. Although disturbances related to the use of the mask arose earlier in subjects who wore the N95 (p = 0.0094), healthcare workers that wore surgical masks reported a statistically higher average score for a greater number of disorders. Conclusions. This is the first study that compares the effects of the two most used PPE on the quality of life of health workers and which highlights the greater discomfort caused by surgical masks. This result brings to light a serious social problem, being surgical masks widely used in everyday life by ordinary people and non-healthcare workers. (www.actabiomedica.it)

Background: Severe asthma is burdened by frequent exacerbations and use of oral corticosteroids (OCS) which worsen patients’ quality of life and increased healthcare spending. Objectives: To assess the clinical and economic impact of switching from omalizumab (OMA) to mepolizumab (MEP) in patients eligible for both biologics but not optimally controlled with OMA. Methods: Uncontrolled patients referred to 6 asthma clinics in south of Italy switched from OMA to MEP, were enrolled and followed-up to Jan 2020. Clinical information included blood eosinophil count, asthma control test (ACT), pulmonary function, IgE, exhaled nitric oxide (FeNO), OCS intake, drugs, exacerbations/hospitalizations, visits and exams. A 12-months standardized total cost per patient pre and post MEP was calculated in the perspective of Italian National Health System. Results: 33 patients were enrolled: 5 male, median age 59 years, disease onset 24 years. At OMA discontinuation, 89% were OCS-dependent with annual mean rate of 3.1 exacerbations. The switch to MEP reduced both exacerbation (-2.8) and OCS-dependent patients (-76%). Pulmonary function improved and both IgE, FENO and eosinophils serum decreased. Annual cost was €11,277 with OMA and €12,498 with MEP (p=0.2041), the increment due to biologic (+€1,673) was partially offset by the saving due to all other cost items (-€452). Conclusions: Patients with severe eosinophilic asthma not controlled by OMA experienced a clinically benefit in asthma control switching to MEP with a slight economic impact.

Background: Little is known about the current use of long term home NIV (LTHNIV) in restrictive diseases (RD) including Chest wall and Neuromuscular disorders (CWD, NMD). Aims: This survey aimed to assess LTHNIV use in RD within the ERS Respiratory Intensive care Assembly and to compare its findings with Eurovent Methods: A survey was performed over a 3-month-period. Information on prescribers, diseases involved, NIV-modes, circuits, interfaces, humidification and follow-up were collected. Results: Response rate: 165 responders (20,5%) from 41 countries; 80% were physicians, and they were working in 63% in respiratory ward/intensive care unit (RICU). Ratio of CWD vs NMD on LTHNIV was 1:5. Amyotrophic lateral sclerosis (ALS) was the n°1 indication for LTHNIV (76% of RD), n°2 Muscular dystrophy (11%). Diurnal hypercapnia was the first reason to start LTHNIV (71%). Quality of life/sleep was the best achieved benefit. Among NIV-modes PSV S/T,PSV+VT, PCV were the 3 most used. Daytime-NIV was mainly provided via 1.mouthpiece; 2.nasal pillows; 3.nasal mask. Night-time NIV interfaces were: 1.oro-nasal; 2.full-face; 3.nasal. Heated humidification was n°1 prescribed humidification (72%). Tubings/valves used were: single with intentional leaks (79%), true expiration valve (13%), double (8%). Follow up was most often provided in an outpatient setting on average every three-month period. Conclusions: This survey highlighted specifics of LTHNIV in RD, showing that patients with NMD affected by ALS are the biggest group. In comparison to Eurovent, LTHNIV has increased in NMD while it has decreased in CWD. Bi-level PSV-ST,PSV+VT, PCV are the most used modes and oro-nasal mask is the preferred interface.

Background: Impulse Oscillometry (IOS) is a non-invasive test that evaluates the respiratory system resistance, reactance of large and small airways. No available data are available in patients with Amyotrophic Lateral Sclerosis (Als). Aims: The study aimed to assess the reliability of IOS test, and to compare its values with anthropometric parameters and respiratory test (spirometry and sniff inspiratory nasal pressure, SNIP). Methods: Thirty-eight consecutive ALS patients (M/F=18/20) underwent routine respiratory function test, including spirometry, SNIP, and IOS. Snip values were divided into 2 groups above and below 60cmH20. Lung reactance of small airways was defined by X5 values. T student analysis for unpaired samples and ANOVA analysis were performed. Interclass correlations (ICCs) were calculated to evaluate the reliability of IOS compared to spirometry. Results: Individual and average ICC for X5 (0.89; 0.97) showed good reliability compared with individual and average ICC for FVC (0.91; 0.97). Als patients with lower X5 values had lower BMI mean values (p 60cmH20 (p Conclusions: In Als patients, lower X5 values are related to lower BMI, and SNIP values

Background: considering high prevalence and burden of obstructive sleep apnoea (OSA), effective diagnostic and treatment strategies are needed to minimize the negative health impacts and to maximize cost–effectiveness (Lugo VM et al. PLoS ONE 14(10):e0224069). Aims: to compare the costs, in terms of health expenditure, of home Continuous Positive Airway Pressure (CPAP) titration with a telemedicine system with respect to a hospital procedure. Methods: we conducted a prospective study on 31 patients (pts) affected by moderate or severe OSA (AHI>15), matched for anthropometric and clinical parameters. They were divided into 2 groups: pts who underwent home CPAP titration using a telemedicine system (group A), and pts referred to an inpatient sleep lab titration (group B). For each group we evaluated costs related to the titration procedure. Variables were compared with Student’s T-Test. Results: 15 pts were included in group A and 16 pts in group B. For home CPAP titration we considered costs related to equipment (APAP device with a remote monitoring system and material replacements), procedures (polysomnography) and working hours dedicated to the pts by the medical staff involved, for a total of 294.12€ per patient. For hospital titration, the total cost per patient was calculated based on the Diagnosis-Related Group (DRG) number 73 (annex 1, decree of the Ministry of Health, 18 October 2012, Italian National Health Service) and it amounts to about 1186€. Comparison between the groups showed a net saving of 75% in the home CPAP titration group. Conclusions: telemedicine is a useful tool for OSA management, facilitating access to healthcare and reducing expenditures.

IntroductionThere are no clear guidelines as yet for the selection of patients affected by COVID-19 who can be treated in intermediate RICU, neither shared criteria for their intubation and transfer in ICU.In the present study we described the clinical course and risk factors for transfer to ICU and mortality of SARS-Cov-2 positive patients affected by acute respiratory failure, hospitalized in a Respiratory Intermediate Care Unit in the south of Italy.MethodsIn this retrospective, observational single centre study we evaluated 96 laboratory confirmed COVID-19 patients affected by acute respiratory failure (ARF). We compared demographic data, laboratory data and clinical outcomes between deceased and survived patients, aiming to identify risk factors for transfer to ICU and mortality, and possible gender-related differences.ResultsOf 96 patients, 51 (53.1%) survived and 45 (46.9 %) died. Among those who died, 23 (51.1%) deceased in RICU. Twenty-nine (30.2%) were transferred to ICU, of whom 22 (75.9%) died in ICU. Patients affected by COPD have a higher mortality compared to patients without this comorbidity (p = 0.002). Lower baseline P/F ratio (p = 0,014) and neurologic comorbidities (p = 0,008) emerged as risk factors for death.Male were younger than female patients (66 vs 80 y.o.; p = 0.042). In female patients, lower peripheral blood lymphocyte count (p = 0.007) is a risk factor for death, characteristic gender-related in our sample.Female sex was a protective parameter against transfer to ICU (p = 0,036) and P/F ratio wasn’t a significant predictor of transfer to ICU (p = 0,227).Only higher baseline CRP (p = 0,034) has shown a predictive role for transfer to ICU in our sample. Patients deceased after a transfer to ICU had younger age (p = 0,000), lower median comorbidity number (p = 0,000), lower D-dimer (p = 0,029) and lower prevalence of female sex (p = 0,029).DiscussionMortality in our study was similar to that found in other studies involving patients in non-invasive ventilation. In our study older age and comorbidities play as predictors of death in COVID-19 patients. COPD, despite presenting low prevalence, is a risk factor for death, both in men and women. In female patients chronic ischemic heart disease and congestive heart failure are death predictors. High CRP and lymphopenia, linked to inflammatory status, are predictors of transfer to ICU. Patients transferred to ICU higher mortality than the others, and patients who die in ICU are mostly men, younger and have less comorbidities. Baseline P/F ratio is not a good predictor of transfer to ICU, while in our sample is a sensible predictor of death. More studies need to be performed on COVID-19 patients, in the urgency of COVID-19 pandemic persistence.

In recent years, high flow nasal cannula is being increasingly used. Most studies showed positive results when used in hypoxaemic respiratory failure. Its use in a patient with a large endobronchial mass has not yet being described. We report a patient who presented with hemoptysis and hypoxaemic respiratory failure second to a large mass obstructing the right main bronchus. High flow oxygen via nasal cannula was initiated with a quick improvement of the hemoptysis and the oxygen saturation. Thus, allowing the patient to be rapidly stabilized.

Purpose Hypovitaminosis D is a highly spread condition correlated with increased risk of respiratory tract infections. Nowadays, the world is in the grip of the Coronavirus disease 19 (COVID 19) pandemic. In these patients, cytokine storm is associated with disease severity. In consideration of the role of vitamin D in the immune system, aim of this study was to analyse vitamin D levels in patients with acute respiratory failure due to COVID-19 and to assess any correlations with disease severity and prognosis. Methods In this retrospective, observational study, we analysed demographic, clinical and laboratory data of 42 patients with acute respiratory failure due to COVID-19, treated in Respiratory Intermediate Care Unit (RICU) of the Policlinic of Bari from March, 11 to April 30, 2020. Results Eighty one percent of patients had hypovitaminosis D. Based on vitamin D levels, the population was stratified into four groups: no hypovitaminosis D, insufficiency, moderate deficiency, and severe deficiency. No differences regarding demographic and clinical characteristics were found. A survival analysis highlighted that, after 10 days of hospitalization, severe vitamin D deficiency patients had a 50% mortality probability, while those with vitamin D ≥ 10 ng/mL had a 5% mortality risk (p = 0.019). Conclusions High prevalence of hypovitaminosis D was found in COVID-19 patients with acute respiratory failure, treated in a RICU. Patients with severe vitamin D deficiency had a significantly higher mortality risk. Severe vitamin D deficiency may be a marker of poor prognosis in these patients, suggesting that adjunctive treatment might improve disease outcomes.

Objective: Sniff nasal inspiratory pressure (SNIP), a useful tool for the assessment of diaphragm function in patients with Amyotrophic Lateral Sclerosis (ALS), is usually performed together with l...

To date, there is still a lack of unanimity regarding the definition of exacerbation of asthma and COPD and about objective measurements in the currently used criteria. The aim of our study was to conduct a survey among general practitioners (GPs) and pulmonologists regarding the clinical criteria arbitrarily considered as important to start a course of systemic corticoids and/or antibiotics in asthma and COPD. We conducted a survey enrolling 50 general practitioners (GPs) and 50 pulmonologists, that evaluated the clinical criteria arbitrated as essential to start a course of systemic corticosteroids or antibiotics during asthma and/or COPD exacerbations. Our results demonstrated incongruities between GPs and pulmonologist and within the same professional category concerning systemic corticosteroids. Conversely, we showed higher consensus between and within the groups about criteria to prescribe antibiotics. (www.actabiomedica.it)

Background: The analysis of volatile organic compounds (VOCs) by an electronic nose is an innovative technique that has shown its potential in the non-invasive diagnosis of several respiratory diseases, including asthma. We postulated that an electronic nose could discriminate between subjects affected by allergic rhinitis with and without concomitant extrinsic asthma, as well as from healthy controls, in terms of exhaled VOCS profile. This pilot study sought to explore the above mentioned hypothesis. Methods: 14 patients with Extrinsic Asthma and Allergic Rhinitis (AAR), 14 patients with Allergic Rhinitis without asthma (AR) and 14 healthy controls (HC) participated in a cross-sectional study. Exhaled breath was collected by a widely-used method and sampled by an electronic nose (Cyranose 320). Raw data were reduced by Principal component analysis and analysed by canonical discriminant analysis. Cross-validation accuracy (CVA) and ROC-curves were calculated. External validation in newly recruited patients (7 AAR, 7 AR and 7 HC) was tested using the previous training set. Results: Breathprints of patients with AR clustered from those with AAR (CVA = 85.7%), as well as HC (CVA = 82.1%). Breathprints from AAR were also separated from those of HC (CVA = 75.0%). External validation confirmed the above findings. Conclusions: An electronic nose can discriminate exhaled breath from well-characterized subjects with allergic rhinitis with and without extrinsic asthma, which represent two different diseases with partly overlapping features. Our results support the view of using exhaled molecular profiling to help diagnosing asthma also in patients with allergic rhinitis.

Alberto Capozzolo, Giorgio Castellana, Silvano Dragonieri, Pierluigi Carratù, Vito Liotino, Maria Rosaria Vulpi, Lorenzo Marra, Emanuela Resta, Pierluigi Intiglietta, Onofrio Resta Department of Cardiac, Thoracic, and Vascular Science, Institute of Respiratory Disease, School of Medicine, University of Bari, Bari, Italy Background: Underdiagnosis of COPD is a relevant issue, and most frequently involves patients at early stages of the disease. Physicians do not routinely recommend smokers to undergo spirometry, unless they are symptomatic.Aims: To investigate the effectiveness of voluntary lung function screening in bringing to light patients with previously unknown COPD and to evaluate the relationships among symptoms, smoking status, and airway obstruction.Methods: A voluntary screening study for COPD was conducted during two editions of the annual Fiera del Levante (2014 and 2015), an international trade fair in Bari. Subjects were eligible for the study if they fulfilled the following inclusion criteria: age ≥35 years, smoker/ex-smoker ≥5 pack-years (PYs), or at least one chronic respiratory symptom (cough, sputum production, shortness of breath, and wheezing). A free post-β2-agonist spirometry test was performed by trained physicians for each participant using portable spirometers. Post-β2-agonist forced expiratory volume in 1 second (FEV1):forced vital capacity ratio

BACKGROUND: COPD is currently recognized as a syndrome associated with a high prevalence of comorbidities and various phenotypes. Exacerbations are very important events in the clinical history of COPD because they drive the decline in lung function. In the present study, we aim to identify whether there are any clinical and functional specific features of frequent exacerbators in a population of patients with severe COPD. METHODS: We conducted a cross-sectional, case control study. All subjects had Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage 3 or 4 COPD (FEV 1 n = 183) reported ≥2 exacerbations or ≥1 determining hospitalization during the previous 12 months, and infrequent exacerbators ( n = 162) reported RESULTS: Frequent exacerbators had a significantly lower inspiratory capacity percentage predicted. The Motley index (residual volume/total lung capacity percentage) was significantly increased in frequent exacerbators. Infrequent exacerbators had lower Modified Medical Research Council dyspnea scale and BODE index than frequent exacerbators. In the multivariate model, a reduced inspiratory capacity percentage predicted and an increase of residual volume/total lung capacity percentage, BODE index and Modified Medical Research Council dyspnea scale were associated with the frequent exacerbation phenotype. CONCLUSIONS: Static hyperinflation and respiratory disability, measured by Motley index and Modified Medical Research Council dyspnea scale, respectively, in the same way as the multidimensional BODE index staging system, were independently associated with frequent exacerbation status in subjects with severe COPD.

Background: The current diagnostic work-up and monitoring of idiopathic pulmonary fibrosis (IPF) is often invasive, time consuming and expensive. Breath analysis by electronic nose technology has shown potential in the diagnosis of numerous respiratory diseases. In this pilot study, we investigated whether exhaled breath analysis by an electronic nose could discriminate between patients with and without IPF. Methods: We enrolled 10 patients with well-characterized IPF (UIP and NSIP patterns), 10 individuals with COPD and 10 healthy controls. An electronic nose (Cyranose 320) was used to analyze exhaled breath samples. Raw data were processed by Principal component reduction and Canonical discriminant analysis. Results: The electronic nose could adequately discriminate among breath profiles of IPF, COPD and healthy controls, with a Cross Validated Accuracy of 96.7% (p Conclusions: The exhaled breath Volatile Organic Compounds- profile of patients with IPF can be detected by an electronic nose. This suggests that breath analysis has potential for diagnosis and/or monitoring of IPF.

Background: Obstructive sleep apnea (OSA) is a widespread respiratory disorder and it is associated with cardiogical comorbidities. Galectin-3 is a seric protein used as biomarker of cardiac macrophages activation and it is upregulated in failing and remodelling hearts. Aims: To evaluate correlations between seric level of galectin-3 and nocturnal cardiorespiratory indices, such as Apnea-Hypopnea Index (AHI), Oxygen Desaturation Index (ODI), Total Sleep Time with oxyhemoglobin saturation Methods: We enrolled patients affected by OSA defined at our sleep center according to International Classification of Sleep Disorder Breathing III edition (Sateia MJ, Chest 2014;146(5):1387-1394). Patients affected by Overlap Syndrome (OSA-Chronic Obstructive Pulmonary Disease) and Obesity Hypoventilation Syndrome (OHS) were excluded. We evaluated linear correlation between hypnological parameters (AHI, ODI, TST90 and mean nocturnal SpO2) and seric level of Galectin-3. Statistical significance: p Results: 75 patients were eligible for the study. There was no correlation between AHI, ODI and seric level of galectin-3. A significant direct correlation was found between TST90 and Galectin-3 (p:0.00, r:0,360). Moreover, a significant negative correlation was found between mean nocturnal SpO2 and Galectin-3 (p:0.00, r:-0,356). Conclusions: In OSA patients, severity of nocturnal hypoxemia (TST90/mean nocturnal SpO2), rather than number of obstructive events for hour (AHI), could contribute to cardiac remodelling and therefore to the onset of cardiological comorbidities.

Introduction: Pulmonary embolism (PE) is described in 25% of Chronic Obstructive Pulmonary Disease (COPD) hospitalized patients and may simulate or worsen an episode of acute exacerbation. It should be taken into account in COPD patients with clinical worsening. Aim: To assess whether COPD may be an independent risk factor for PE. Methods: We investigated 91 patients (M:F=1:2, mean age of 69 years) hospitalized for PE at our department from January 2014 to February 2016 and divided them in two groups according to the presence of COPD defined according to GOLD guideline: Group1, PE with COPD (54 patients); Group2, PE without COPD (37 patients). We searched the presence of deep vein thrombosis (DVT), with compression ultrasound sonography plus eco-color doppler, and PE risk factors in all patients. Statistical significance: p ≤0.05. Results: Group1 had less prevalence of DVT (49% vs 66%), next the significance (p=0,09), and of male sex (p=0,009), higher prevalence of smokers (p=0,000), proximal PE (0,04), mean age (p=0,03), paO2 and paCO2 (0,0003) and diabetes than Group2 (p=0,000). No difference was documented in risk factor of PE, i.e. obesity, cancer, atrial fibrillation, liver disease, bed rest and contraceptives. Limiting the analysis to proximal PE, the difference of prevalence of DVT increases (33% Group1 vs. 70% Group2) and becomes significant (p = 0,04). COPD patients without DVT (37) had higher age, lower PaCO2, minor increase in Ddimers, the lower FE, lower prevalence of renal failure (p Conclusion: COPD may be an indipendent risk factor for PE, in particular with proximal location. Absence of DVT is more frequent than in patient without COPD.

Background The human respiratory tract represents the major portal of entry for numerous microorganisms, primarily those occurring as airborne particles such as viral and bacterial entities, or fungal spores. Microorganism characteristics coupled with the local host immune response will determine whether they will be cleared or adhere and colonize the airways leading to acute or chronic pulmonary disease. Like bacteria, fungi can cause severe lung diseases, but their infection rates are much lower. The lung microbiota is commonly sampled using relatively invasive bronchoscopic procedures. Exhaled breath condensate (EBC) collection offers a potentially less invasive alternative for lung microbiota sampling. This study tries to determine the composition of fungal communities in a cohort of healthy adult volunteer subjects from Puglia (Apulia), Italy. Methods Fungi diversity in 27 EBC samples collected from Italian adult volunteers was investigated using conventional microbiological culturing and DNA sequencing approach. Results Ten tested subjects (37,03%) turned out to present fungi in the EBC. We observed complex fungal communities, in which more than 10% of the isolated species are represented by Aspergillus sydowii (14,8%) and Cladosporium spp (11,11%). Three subjects that showed fungal presence in EBC have been diagnosed with a respiratory disease. Conclusions We present a survey of an important scientific field in its early stages that is fungal contamination of airways of healthy subjects in a small geographic area. Furthermore, we interpreted our results to highlight the potential role of fungi in the context of respiratory diseases.

The nasal valve area has the minimal cross-sectional area of the upper airways. Obstructive sleep apnea (OSA) is a common disorder. It has been reported that nasal obstruction may be associated with OSA. The aim of this study was to investigate whether the use an internal nasal dilator may be able to affect respiratory pattern in a group of patients with OSA. The use of internal nasal dilator was able to significantly reduce two relevant respiratory outcomes, such as the apnea-hypopnea index and the oxygen desaturation index, notably there was also a positive trend for the reduction of total sleep time with HbO2

The nasal valve area has the minimal cross-sectional area of the upper airways. Obstructive sleep apnea syndrome (OSAS) is a common disorder. It has been reported that nasal obstruction may be associated with OSAS. The aim of this study was to investigate whether the use an internal nasal dilator may be able to affect respiratory pattern in a group of patients with OSAS and treated with continuous positive airway pressure (CPAP). The use of internal nasal dilator significantly reduced the pressure of CPAP (from 11.4±1.5 to 10.8±1.5; p=0.012) able to resolve apnea episodes. In conclusion, this study showed that Nas-air® is a new internal nasal dilator potentially capable to significantly improve adherence and compliance to CPAP. (www.actabiomedica.it)

Background/Objective: Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease characterized by the progressive loss of central and peripheral motor neurons. Some studies have found discordant data in the presence of sleep apnea in ALS patients. An obstructive component also occurs with upper airways hypotonia and muscle weakness that may result in an excessive reduction of airway lumen, leading to obstructive sleep apnea (OSA). The aim of this study was to assess the role of obstructive apneic events at disease onset in the ALS prognosis. Methods: A longitudinal retrospective study was conducted on 42 clinically diagnosed ALS patients. The study population was divided into 2 groups according to their obstructive apnea/hypopnea index (AHIo): group 1 consisted of 20 patients with an AHIo ≥5 and group 2 consisted of 22 patients with an AHIo Results: The mean survival in ALS patients with an AHIo ≥5 was significantly shorter than in ALS without OSA (p = 0.0237). The sniff nasal inspiratory pressure test was significantly correlated with AHIo, time of oxyhemoglobin saturation below 90% and the oxyhemoglobin desaturation index (p < 0.0001). Conclusions: Our study highlights the importance of an early diagnosis of OSA in ALS patients, allowing the identification of ALS patients with an OSA phenotype (AHIo ≥5), who are characterized by a worse prognosis.

The current diagnostic work-up and monitoring of idiopathic pulmonary fibrosis (IPF) is often invasive and time consuming. Breath analysis by e-nose technology has shown potential in the diagnosis of numerous respiratory diseases. In this pilot study, we investigated whether exhaled breath analysis by an e-nose could discriminate among patients with IPF, healthy controls and COPD. Second, we verified whether these classification could be repeated in a set of newly recruited patients as external validation. Third, we evaluated any significant relationships between exhaled VOCs and Bronchoalveolar lavage fluid (BALF) in IPF patients. We enrolled 32 patients with well-characterized IPF, 33 individuals with COPD and 36 healthy controls. An electronic nose (Cyranose 320) was used to analyze exhaled breath samples. Raw data were processed by Principal component reduction and linear discriminant analysis. External validation in newly recruited patients (10 IPF, 10 COPD and 10 controls) was tested using the previous training set. Exhaled VOC-profiles of patients with IPF were distinct from those of healthy controls (CVA = 98.5%) as well as those with COPD (CVA = 80.0%). External validation confirmed the above findings (IPF vs COPD vs healthy controls, CVA 96.7%). Moreover, a significant inversely proportional correlation was shown between BALF total cell count and both Principal Components 1 and 2 (r = 0.543, r2 = 0.295, p < 0.01; r = 0.501, r2 = 0.251; p < 0.01, respectively). The exhaled breath Volatile Organic Compounds- profile of patients with IPF can be detected by an electronic nose. This suggests that breath analysis has potential for diagnosis and/or monitoring of IPF.