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Percutaneous endoscopic gastrostomy (PEG) is the standard procedure for feeding severely dysphagic patients with amyotrophic lateral sclerosis (ALS). It is associated with prolonged survival and improvement in quality of life. Nasal inspiratory pressure during a sniff (SNIP) is a respiratory test used extensively in ALS for the assessment of inspiratory muscle strength. In this study, we aimed to investigate the role of SNIP at baseline to predict PEG placement in ALS. Data from a clinical incident cohort of 179 ALS cases attending the multidisciplinary ALS unit of the University of Bari between April 2006 and December 2012 were retrospectively analysed. At baseline, patients underwent detailed neurological, nutritional and respiratory assessments, including measurements of SNIP and forced vital capacity (FVC). Patients were therefore followed up approximately every three to six months until they were able to attend the centre. The censoring date for the survival analysis was 15 April 2014, with PEG placement as the main outcome. Cox proportional hazard regression models were used to examine the association between SNIP and PEG placement, adjusted for possible confounders. During the follow-up period, 75 participants (42%) received PEG implant. PEG placement was more frequent (57% vs. 31%, p = 0.001) and earlier (after 11.6 ± 14.0 months from the first visit, vs. 23.3 ± 15.5 months, p &lt, 0.0001) in the group of patients with baseline SNIP ≤ 40 cm H2O. Baseline SNIP was a predictor of PEG placement even after correction for multiple potential confounders (HR 0.98, 95% CI: 0.96–0.99, p = 0.02). To conclude, the present study showed that SNIP at baseline is an early indicator of disease progression and therefore of the need for enteral nutrition in ALS.

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...

A 22-year-old white male presented complaining of a 3-week history of fatigue, cough and haemoptysis, accompanied by fever (38°C max), dyspnoea and mucopurulent sputum in the last few days. He denied nausea, vomiting, diarrhoea, dysuria and weight loss., Can you diagnose the cause of this man’s bilateral pulmonary nodules and acute respiratory failure? http://ow.ly/NfED30dDBzm

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.

Introduction: Sniff nasal inspiratory pressure (SNIP) is reliable for the diaphragm strength assessment in Amyotrophic lateral sclerosis (ALS) patients (pts). Recent studies in pts with neuromuscolar diseases demonstrated SNIP improvement after training. Aim: To determine if SNIP can improve after training in ALS pts, and to compare SNIP value before and after respiratory function tests (RFTs). Methods: We recruited 103 consecutive ALS pts at Bari Regional referring Centre, (62/41=M/F);80/103 had spinal onset. They performed 5-10 sniffs, and best value was recorded(S1). Spirometry, peak cough flow(PCF) and peak expiratory flow(PEF) were then performed. Moreover, further 5-10 sniffs were repeated, and the highest value recorded(S2). All RFTs were carried out as per international guidelines. T- student, chi-quadro tests, and linear regression were performed. Results: In group1 (78/103) S2 was ≥than S1. In Group2 (25/103) S2 was at least 20% Conclusions: Conversely to prior studies in other neuromuscular diseases, this study highlighted that SNIP values in ALS pts do not improve when training with repeated maneuvers was performed. Furthermore 25% of pts had a 20%drop instead. Thus, it might show a group more sensitive to diaphragm fatigue in need of closer follow-up.

Giuseppe Antonio Palmiotti,1 Donato Lacedonia,1 Vito Liotino,2 Pietro Schino,3 Francesco Satriano,4 Pier Luigi Di Napoli,3 Eugenio Sabato,5 Vincenzo Mastrosimone,6 Alfredo Scoditti,7 Mauro Carone,8 Elio Costantino,9 Emanuela Resta,2 Ettore Attolini,10 Maria Pia Foschino Barbaro1 1Department of Medical and Surgical Sciences, Institute of Respiratory Diseases, University of Foggia, Foggia, Italy; 2Department of Cardiac, Thoracic, and Vascular Science, Institute of Respiratory Diseases, School of Medicine, University of Bari, Bari, Italy; 3Physiopathology Respiratory Unit, F Miulli General Hospital, Acquaviva delle Fonti, Bari, Italy; 4Pneumology Clinic, Vito Fazzi Hospital, Lecce, Italy; 5UOC of Pneumology, “N Melli” Hospital, San Pietro Vernotico, Italy; 6Division of Pulmonary Disease, Medical Center of Rehabilitation, Foundation Salvatore Maugeri, IRCCS, Marina di Ginosa, Italy; 7Department of Respiratory Diseases, San Camillo Clinic, Taranto, Italy; 8Division of Pulmonary Disease, Medical Center of Rehabilitation, Foundation Salvatore Maugeri, IRCCS, Cassano delle Murge, Italy; 9UOC of Pneumology, Hospital “Madonna delle Grazie”, Matera, Italy; 10Regional Health Agency (ARES), Bari, Italy Background: COPD is a disease associated with significant economic burden. It was reported that Global initiative for chronic Obstructive Lung Disease (GOLD) guideline-oriented pharmacotherapy improves airflow limitation and reduces health care costs. However, several studies showed a significant dissociation between international recommendations and clinicians’ practices. The consequent reduced diagnostic and therapeutic inappropriateness has proved to be associated with an increase in costs and a waste of economic resources in the health sector. The aim of the study was to evaluate COPD management in the Puglia region. The study was performed in collaboration with the pulmonology centers and the Regional Health Agency (AReS Puglia). Methods: An IT platform allowed the pulmonologists to enter data via the Internet. All COPD patients who visited a pneumological outpatient clinic for the first time or for regular follow-ups or were admitted to a pneumological department for an exacerbation were considered eligible for the study. COPD’s diagnosis was confirmed by a pulmonologist at the moment of the visit. The project lasted 18months and involved 17 centers located in the Puglia region. Results: Six hundred ninety-three patients were enrolled, evenly distributed throughout the region. The mean age was 71±9years, and 85% of them were males. Approximately 23% were current smokers, 63% former smokers and 13.5% never smokers. The mean post-bronchodilator forced expiratory volume in 1second was 59%±20% predicted. The platform allowed the classification of patients according to the GOLD guidelines (Group A: 20.6%, Group B: 32.3%, Group C: 5.9% and Group D: 39.2%), assessed the presence and severity of exacerbations (20% of the patients had an exacerbation defined as mild [13%], moderate [37%] and severe [49%]) and evaluated the appropriateness of inhalation therapy at the time of the visit. Forty-nine percent of Group A patients were following inappropriate therapy; in Group B, 45.8% were following a therapy in contrast with the guidelines. Among Group C patients, 41.46% resulted in triple combination therapy, while ~14% of Group D patients did not have a therapy or were following an inappropriate therapy. In conclusion, 30% of all patients evaluated had been following an inadequate therapy. Subsequently, an online survey was developed to inquire about the reasons for the results obtained. In particular, we investigated the reasons why 30% of our population did not follow the therapy suggested by the GOLD guidelines: 1) why was there an excessive use of inhaled corticosteroids, 2) why a significantly high percentage was inappropriately treated with triple therapy and 3) why a consistent percentage (11%) of Group D patients were not treated at all. Conclusion: The data provides an overview on the management of COPD in the region of Puglia (Italy) and represents a resource in order to improve appropriateness and reduce the waste of health resources. Keywords: COPD, appropriateness, web platform, health care spending, online survey

Introduction: the COPD exacerbations are associated with a high mortality rate, a faster decline in lung function, poor quality of life and increased health resource utilization. Aims and objectives: to evaluate COPD management in Apulia region. In this context, an “Exacerbation in COPD " study was performed in collaboration between pulmonology centers and the Regional Health Agency (AReS Puglia). Methods: an IT platform developed by the Interuniversity Consortium CINECA allowed pulmonologists the insertion of data via internet. The project lasted 18 months and involved 11 centers. Results: 764 patients were enrolled (16% female and 84% male), evenly distributed throughout the region. The platform allowed the classification of patients according to GOLD guidelines (Group A 22%, B 33.6%, C 5.9% D 38.4%), assess the presence and severity of exacerbations (19.9% had an exacerbation at the moment of the visit, respectively slight 13%, 37% mild and 49% severe) and evaluate the appropriateness of inhalation therapy at the time of the visit. We found that 49% of group A patients were following inappropriate therapy, with 14% already in ICS/LABA+LAMA; in group B, 34% of patients were following a triple combination therapy and 31% used ICS, in contrast with guidelines. Among group C patients, 41% resulted in triple combination therapy, while 22% of group D patients did not have a therapy or used a single drug. In conclusion, 47% of all patients evaluated had been following an inadequate therapy. Conclusion: the data provide an overview on the management of COPD in the Apulia region and represent a resource in order to improve appropriateness and reduce the waste of health resources.

Background: acute exacerbations are very important events in the clinical history of COPD because are responsible for the decline in lung function. Aims and objectives: we aim to identify whether there are any clinical and functional features of frequent exacerbators in severe COPD patients. Methods: we assessed an observational, cross sectional, case control cohort study. All subjects had GOLD stage 3 or 4. “Frequent exacerbators” (n = 183) reported a number of >2 exacerbations in the last 12 months or > 1 with hospitalization and “infrequent exacerbators” (n = 162) had Results: no significant differences were found in age, sex, body mass index, presence of chronic cough, six minute walking test and Charlson Comorbidity Index between the two groups. Frequent exacerbators had significantly lower inspiratory capacity (IC) % of predicted and higher residual volume/total lung capacity (RV/TLC) ratio. Infrequent exacerbators had lower mMRC score and BODE index than frequent exacerbators. In the multivariate model an increase of RV/TLC ratio and mMRC score were independently associated with frequent exacerbations. Conclusions: static hyperinflation and respiratory disability, misured by mMRC score, were independently associated w ith frequent exacerbations in severe COPD patients.

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Background A close relationship between Metabolic Syndrome (MetS) and Chronic Obstructive Pulmonary Disease (COPD) has been described, but the exact nature of this link remains unclear. Current epidemiological data refer exclusively to the MetS prevalence among patients with COPD and data about the prevalence of COPD in MetS patients are still unavailable. Aim of the study To analyse and compare risk factors, clinical and metabolic characteristics, as well as the main respiratory function parameters, among patients affected by MetS, COPD or both diseases. Patients We recruited 59 outpatients with MetS and 76 outpatients with COPD. After medical history collection, physical examination, blood sampling for routine analysis, spirometric evaluation, they were subdivided into MetS (n = 46), MetS+COPD (n = 60), COPD (n = 29). Results A MetS diagnosis was assigned to 62% of COPD patients recruited in the COPD Outpatients Clinic of the Pneumology Department, while the COPD prevalence in MetS patients enrolled in the Internal Medicine Metabolic Disorders Outpatients Clinic was 22%. More than 60% of subjects enrolled in each Department were unaware that they suffered from an additional disease. MetS+COPD patients exhibited significantly higher C-peptide levels. We also found a positive relation between C-peptide and pack-years in all subjects and a negative correlation between C-peptide and vitamin D only in current smokers. Finally, a negative association emerged between smoking and vitamin D. Conclusions We have estimated, for the first time, the COPD prevalence in MetS and suggest a potential role of smoking in inducing insulin resistance. Moreover, a direct effect of smoking on vitamin D levels is proposed as a novel mechanism, which may account for both insulin resistance and COPD development.