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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)

The use of continuous positive airway pressure (CPAP) in asthma has been a point of debate over the past several years. Various studies, including those on animals and humans have attempted to understand the role and pathophysiology of CPAP in patients with either well controlled or poorly controlled asthma. The aim of this manuscript is to review the currently available literature on the physiologic and clinical effects of CPAP in animal models of asthma and on humans with stable asthma.

Background: Current availability of several biologic treatments for severe asthma makes it possible to choose the most appropriate for each patient. Sometimes a good percentage of patients with severe asthma may be eligible for biologics that target either the allergic phenotype or the eosinophilic one, but not all respond to that selected as first choice. The aim of our real-life study was to assess whether, for patients with severe eosinophilic allergic asthma, not previously controlled by the anti-IgE omalizumab, the shift to another biologic targeting interleukin-5, such as mepolizumab, may represent a good therapeutic choice. Methods: A total of 41 consecutive patients with severe, persistent allergic, eosinophilic asthma, uncontrolled despite treatment with omalizumab, were enrolled in seven certified Clinical Respiratory Units of Southern Italy (Catania, Catanzaro, Foggia, Bari, Palermo, and two University Respiratory Units of Naples) and shifted to mepolizumab without a wash-out period. Data at baseline, after at least 12 months of therapy with omalizumab, and after at least 12 months of treatment with mepolizumab were collected. Results: After at least 12 months of therapy with mepolizumab, patients experienced a significant decrease in the number of exacerbations/year (5.8 ± 1.8 versus 0.7 ± 0.9, p Conclusion: Results of our real-life multicentric experience confirms that the shift to mepolizumab could be a good therapeutic strategy in severe eosinophilic allergic asthma not previously controlled by omalizumab. The reviews of this paper are available via the supplemental material section.

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.

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.

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

Noninvasive ventilation (NIV) is an increasingly used method of respiratory support. The use of NIV is expanding over the time and if properly applied, it can save patients' lives and improve long-term prognosis. However, both knowledge and skills of its proper use as life support are paramount. This systematic review aimed to assess the importance of NIV education and training. Literature search was conducted (MEDLINE: 1990 to June, 2018) to identify randomized controlled studies and systematic reviews with the results analyzed by a team of experts across the world through e-mail based communications. Clinical trials examining the impact of education and training in NIV as the primary objective was not found. A few studies with indirect evidence, a simulation-based training study, and narrative reviews were identified. Currently organized training in NIV is implemented only in a few developed countries. Due to a lack of high-grade experimental evidence, an international consensus on NIV education and training based on opinions from 64 experts across the twenty-one different countries of the world was formulated. Education and training have the potential to increase knowledge and skills of the clinical staff who deliver medical care using NIV. There is a genuine need to develop structured, organized NIV education and training programs, especially for the developing countries. info:eu-repo/semantics/publishedVersion

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.

Background: Falling asleep behind the wheel is one of the most relevant consequences of obstructive sleep apnea (OSA). We created a new screening questionnaire, named the Driver Sleepiness Score (DSS), aiming to assess sleepiness in drivers with suspected OSA. The primary aim of our study was to evaluate sleepiness in drivers with a suspicion of OSA by the DSS in order to assess its correlation with the apnea-hypopnea index (AHI), oxygen desaturation index (ODI), and total sleep time with oxyhemoglobin saturation below 90% (TST90). We also aimed to assess the diagnostic accuracy of DSS for three different cutoffs of AHI (AHI = 5, AHI = 15, AHI = 30), which allow stratification of the severity of OSA. Materials and Methods: Seventy-three driving patients at risk for OSA participated in the study. DSS and the Epworth Sleepiness Scale (ESS) were both administered in operator-dependent modality and in randomized sequence. Results: The DSS showed higher accuracy in screening patients with mild OSA [area under curve (AUC): 0.88 vs 0.74] and moderate OSA (AUC: 0.88 vs 0.79), whereas ESS showed higher accuracy in screening patients with severe OSA (AUC: 0.91 vs 0.78). A DSS score ≥ 7 is the optimal cutoff for distinguishing true positives from false positives for the presence of OSA and for its different severity levels. The administration of both questionnaires increases the accuracy for the detection of all OSA severity levels. Conclusions: If validated, DSS may qualify as a new screening tool specifically for drivers with the suspicion of having OSA, in combination with the ESS.

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.

Background Inflammation in small airways is particularly clinically active in severe asthma but they still continue to be ignored as considered silent. Recently, the Atlantis study reports small airways involvement in 91% of the asthma population. Therefore in the era of phenotype driven therapy, the aim of this study was to verify if high-strength extrafine ICS/LABA in fixed dose increases clinical efficacy in moderate asthmatic patients with small airways dysfunction and it could be proposed as phenotype driven therapy. Methods In this prospective, non-interventional, real-life pilot study we enrolled 37 consecutive patients with moderate asthma who were uncontrolled despite GINA step 3 treatment. All subjects at enrollment were divided in two groups according to the presence of small airways dysfunction:1) small airways phenotype (SAP) group: smokers (≥10 packs/die), ex-smokers (>20 packs/year) with air trapping (FVC 100% - FEF 25–75% Results Treatment with extrafine BDP/FF(200/6 μg) in SAP group showed a more significant improvement of FEF25-75%, FVC, RV, and a reduction of alveolar inflammatory markers such as FENO350 and alveolar exhaled pH compared with NSAP patients. Conclusions Our preliminary results support the use of high-strength extrafine pMDI BDP/FF (200/6 μg) as phenotype driven treatment directed to small airways dysfunction demonstrating an increase of clinical efficacy in moderate asthmatics with SAP.

Background: Obstructive Sleep Apnoea (OSA) is a common nocturnal respiratory disorder and its role as a risk factor for the development of Pulmonary Hypertension (PH) is well known. It was already demonstrated that systolic pulmonary artery pressure (PAPs) in obese patients with OSA is higher than in obese patients without OSA (Carratu P. et al, Sleep Breath 2016; 20: 613-619). Aims: to evaluate correlations between nocturnal cardiorespiratory indices, as Apnoea-Hypopnea Index (AHI), Oxygen Desaturation Index (ODI) and Total Sleep Time with oxyhemoglobin saturation below 90% (TST90), and PAPs in obese patients affected by OSA. Methods: We studied 48 consecutive patients affected by OSA, defined according to AASM guideline (Berry RB et al, J Clin Sleep Med 2012; 8 (5): 597-619). Nocturnal Respiratory failure is defined as TST90 ≥ 30%. Eight patients were excluded due to the presence of Overlap Syndrome OSA-Chronic Obstructive Pulmonary Disease (COPD). We evaluated linear correlation between hypnological parameters (AHI, ODI and TST90) and PAPs. Statistical significance: P Results: We demonstrated that there is no correlation between severity of OSA and PAPs. Comparing AHI and ODI with PAPs, statistical significance was not obtained (respectively P: 0.20; P: 0.33). A significant direct correlation was found only between PAPs and TST90 (P: 0.03). Conclusions: Nocturnal respiratory failure could be the real determining factor for pulmonary hypertension in patients with OSA, but these preliminary results need further studies on a bigger sample to be confirmed.

Introduction: Obstructive Sleep Apnea (OSA) represents an increasing worldwide syndrome, promoting over time endothelial dysfunction and contributing to left and right heart diseases, as well as to metabolic disorders. Methods and Aim: We evaluated retrospectively a newly diagnosed population of OSA, who were admitted to our Sleep Ambulatory in the year 2016. All consecutive patients who provided anthropometric features, polysomnographic findings, cardiovascular risk, smoking habit, Pulmonary Function Test, Arterial Blood Gas analysis, Epworth Questionnaire, and Charlson Index Score, were enrolled into the study. Aim of the study was to calculate the cardiovascular risk of our OSA patients, according to their BMI. Results: We found, in 199 consecutive patients (144 M), a positive correlation existing between level of BMI and number of cardiovascular risks (p=0.0035), as well as between degree of OSA, calculated as Apnea/Hypopnea Index (AHI), and number of comorbidities (p Conclusions: OSA patients with higher levels of BMI experience the presence of elevated number of cardiovascular risks. Similarly, in OSA patients with a higher AHI, an increased number of comorbidities was shown. No correlation has been disclosed between smoking habit and degree of OSA.

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.

Introduction: Overlap Syndrome (OS) is a chronic respiratory disease defined by coexistence of Obstructive Sleep Apnea (OSA) and Chronic Obstructive Pulmonary Disease (COPD). An increasing number of studies have established the presence of a link between chronic respiratory diseases and metabolic ones. No studies have been conducted to define the prevalence of diabetes mellitus 2 (DM2) in patients (pts) with OS. Aims: First, to define prevalence of DM2 in pts with OS. Second, to identify predictive parameters of DM2 in OS. Methods: We performed a retrospective analysis of the clinical records of 93 pts with diagnosis of OS. DM2 was identified by anamnesis and by screening with glycosylated haemoglobin or fasting blood sugar measurement according to ADA guidelines. For the second objective, we analyzed anamnestic, anthropometric, haemogasanalytic, spirometric, nocturnal cardio-respiratory and haematochemical variables. Patients with incomplete records were excluded. Statistical significance: p Results: 83 pts were included in the analysis. Prevalence of DM2: Prevalence was 42% (35 cases), with 10 new diagnosis made by screening. Among the latter, 4 pts had ischemic heart disease and 2 pts had atrial fibrillation. Predictive Parameters: Difference was found only for FVC, creatinine and belonging to group D, as showed in Table 1. Conclusion: The prevalence of DM2 is high in OS. Screening allows the recognition of new cases of DM2, whose therapy is decisive for cardiovascular prevention. Patients with DM2 have worse lung fuction and belong mainly to group D.

Background: sleep disordered breathing (SDB) may be an important modifiable risk factor for cognitive impairment in elderly people. Obstructive sleep apnoea (OSA) is a common SDB in older people. Its prevalence ranges between 13 and 32% in people over 65 yrs old, but despite this OSA is frequently undiagnosed in older population. Aim: to extimate the prevalence of OSA in a population aged 65 and over resident in southern Italy. Methods: we conducted a screening study for OSA from 1 Sept 2016 to 30 Aug 2017 during the Great Age study, a population-based study on neurodegeneration aging, frailty in Castellana Grotte (BA). Only patients aged 65 and over were included; gender and age were recorded for each patient. Screening was conducted using the STOP BANG questionnaire, that is more accurate for detecting mild, moderate, and severe OSA compared with the Berline Questionaire and Epworth Sleepiness Scale. Results: we investigated 259 patients(F=212, M=47). Mean age was 73(±6). Our analysis showed low, intermediate and high risk in 47%, 35% and 18% of patients, respectively. Distribution of risk according to gender or age is reported in Table 1 and 2. Conclusions: 53% of the subjects examined have an intermediate-high risk of OSA. The percentage of low-risk subjects decreases with increasing age. We expect the data to be further strengthened with the balance of the F:M ratio. Correlations between the risk of OSA and other parameters are in progress, starting from neurological ones.

Obstructive sleep apnea (OSA) is a well-known risk factor for cardiovascular diseases. Several studies have shown that OSA is associated with vessel remodeling, but few studies have examined aorta. Aim: to analyse aortic remodelling in OSA. Methods: Thirty consecutive OSA patients (22 males and 8 females, aged 58.5 ± 13.2 years) were studied. All patients underwent a morning blood gas analysis, a full cardiorespiratory evaluation, including nocturnal polygraphy and echocardiography, that assessed aortic root diameter (ARD) and aortic stiffness index (ASI). Patients were grouped as follows: Group 1, non-severe OSA (Apnea-Hypopnea Index; AHI

Introduction. We aimed to investigate whether the sex hormone profile during the ovarian cycle in healthy women could affect the volatile organic compound (VOC) profile analyzed by an electronic nose (e-nose). Methods. We enrolled 21 healthy, never-smoking, regularly menstruating women who were not taking any medications. A series of exhaled breath measurements were performed on all subjects at predefined intervals (days 1–6, 7–12, 13–19, 20–25 and 26–31; day 1 was the first day of menstruation) during their ovarian cycle and analyzed by an e-nose (Cyranose 320). Results. By principal component analysis, significant modifications of the exhaled VOC profile were observed over the cycle for principal component 1 (PC1; p = 0.001). In particular, the PC1 value was significantly higher during the premenstrual period and during menstruation compared with the first third of estrogen phase, mid-cycle and the first third of progestational phase (for all parameters p < 0.05 and p < 0.01, respectively). Subsequent linear discriminant analysis confirmed the above findings. Conclusions. The ovarian cycle may alter the exhaled VOC pattern and this should be taken into account during serial measurements of these markers in the female population.

Obstructive sleep apnea (OSA) and obesity are increasingly prevalent worldwide. Both promote endothelial dysfunction contributing to systemic and pulmonary hypertension over time. Endothelin-1 (ET-1) plays a pivotal role in the development of pulmonary hypertension (PH). The aim of the present study was to assess the association between plasma ET-1 and echocardiographic findings in obese individuals with and without OSA, as well as in non-obese patients with OSA. Ninety-seven subjects (56 males) were enrolled in the study. All subjects underwent the following tests: venous endothelin-1 levels, pulmonary function testing, and arterial blood gas analysis. All patients except controls underwent transthoracic echocardiography and portable testing for sleep-disordered breathing. Plasma ET-1 levels were significantly higher in obese patients, both with and without OSA (respectively, n = 30 (mean value, 268.06 ± 49.56 pg/ml) and n = 32 (mean value, 263.12 ± 65.26 pg/ml)), compared with non-obese patients with OSA or to healthy controls (respectively, n = 20 (mean value, 149.8 ± 23.09 pg/ml) and n = 15 (mean value, 152.3 ± 27.64 pg/ml); p