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Background Sigh is a cyclic brief recruitment maneuver: previous physiologic studies showed that its use could be an interesting addition to pressure support ventilation to improve lung elastance, decrease regional heterogeneity, and increase release of surfactant. Research Question Is the clinical application of sigh during pressure support ventilation (PSV) feasible? Study Design and Methods We conducted a multicenter noninferiority randomized clinical trial on adult intubated patients with acute hypoxemic respiratory failure or ARDS undergoing PSV. Patients were randomized to the no-sigh group and treated by PSV alone, or to the sigh group, treated by PSV plus sigh (increase in airway pressure to 30 cm H2O for 3 s once per minute) until day 28 or death or successful spontaneous breathing trial. The primary end point of the study was feasibility, assessed as noninferiority (5% tolerance) in the proportion of patients failing assisted ventilation. Secondary outcomes included safety, physiologic parameters in the first week from randomization, 28-day mortality, and ventilator-free days. Results Two-hundred and fifty-eight patients (31% women; median age, 65 [54-75] years) were enrolled. In the sigh group, 23% of patients failed to remain on assisted ventilation vs 30% in the no-sigh group (absolute difference, –7%; 95% CI, –18% to 4%; P = .015 for noninferiority). Adverse events occurred in 12% vs 13% in the sigh vs no-sigh group (P = .852). Oxygenation was improved whereas tidal volume, respiratory rate, and corrected minute ventilation were lower over the first 7 days from randomization in the sigh vs no-sigh group. There was no significant difference in terms of mortality (16% vs 21%; P = .337) and ventilator-free days (22 [7-26] vs 22 [3-25] days; P = .300) for the sigh vs no-sigh group. Interpretation Among hypoxemic intubated ICU patients, application of sigh was feasible and without increased risk. Trial Registry ClinicalTrials.gov ; No.: NCT03201263 ; URL: www.clinicaltrials.gov

An in vitro study was conducted to screen for the inhibitory potential of lactic acid bacteria (LAB), isolated from fermented food matrices, against the honeybee American Foulbrood agent Paenibacil...

Due to the exponential growth of the number of subjects affected by coronavirus disease 2019 (COVID-19), the entire Italian health care system had to respond promptly and in a very short time with the need of semi-intensive and intensive care units. Moreover, trained dedicated COVID-19 teams consisting of physicians were coming from different specialties (intensivists or pneumologists and infectiologists), while respiratory therapists and nurses have been recruited to work on and on without rest. However, due to still limited and evolving knowledge of COVID-19, there are few recommendations concerning the need in respiratory rehabilitation and physiotherapy interventions. The presentation of this paper is the result of a consensus promoted by the Italian societies of respiratory health care professionals who contacted pulmonologists directly involved in the treatment and rehabilitation of COVID-19. The aim was to formulate the more proper and common suggestions to be applied in different hospital settings in offering rehabilitative programs and physiotherapy workforce planning for COVID-19 patients. Two main areas of intervention were identified: organization and treatment, which are described in this paper to face the emergency.

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Background: Early mobilization (EM) in ICU is crucial to improve functional status and reduce mortality. EM within Italian Cardio-Surgical ICUs (CSICU) population seems to be not standardized. This study aimed to gather data from a CSICU to support future research on the benefits of standardized CSICU Early Mobilization. Methods: Prospective transversal study. Adult subjects who underwent elective or emergency heart surgery were enrolled in the Niguarda Hospital’s CSICU, Milan, Italy. Data were collected from October to November 2019. We excluded subjects who underwent major thoracic surgery, pure vascular surgery, and Transcatheter Aortic Valve Implantation surgery. Outcomes assessed: type and duration of mobilization activities, type, and duration of ventilatory supports, length of stay (LOS) at CSICU, days from surgery to EM, pain, delirium, sleep quality, handgrip force, limbs muscle force, heart ejection fraction (HEF). Results: Out of 125 patients, 31 subjects met our inclusion criteria. The mean age was 62 ± 11 years, BMI 26 ± 4,46. Mean LOS was 12 ± 19 days, mean days for the first mobilization were 6 ± 13, and mean patient’s walking distance: 57 ± 33 meters. Table 1 presents the outcomes measured. Conclusion: Considering the feasibility of EM interventions applied in this patient setting, this study reinforces the integration of EM activities within CSICUs.

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

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

Objective The study aimed to evaluate whether high-flow oxygen therapy (HFOT) during training was more effective than oxygen in improving exercise capacity in hypoxemic chronic obstructive pulmonary disease (COPD). Methods A total of 171 patients with COPD and chronic hypoxemia were consecutively recruited in 8 rehabilitation hospitals in a randomized controlled trial. Cycle-ergometer exercise training was used in 20 supervised sessions at iso inspiratory oxygen fraction in both groups. Pre- and post-training endurance time (Tlim), 6-minute walking distance (6MWD), respiratory and limb muscle strength, arterial blood gases, Barthel Index, Barthel Dyspnea Index, COPD Assessment Test, Maugeri Respiratory Failure questionnaire, and patient satisfaction were evaluated. Results Due to 15.4% and 24.1% dropout rates, 71 and 66 patients were analyzed in HFOT and Venturi mask (V-mask) groups, respectively. Exercise capacity significantly improved after training in both groups with similar patient satisfaction. Between-group difference in post-training improvement in 6MWD (mean: 17.14 m; 95% CI = 0.87 to 33.43 m) but not in Tlim (mean: 141.85 seconds; 95% CI = −18.72 to 302.42 seconds) was significantly higher in HFOT. The minimal clinically important difference of Tlim was reached by 47% of patients in the V-mask group and 56% of patients in the HFOT group, whereas the minimal clinically important difference of 6MWD was reached by 51% of patients in the V-mask group and 69% of patients in the HFOT group, respectively. Conclusion In patients with hypoxemic COPD, exercise training is effective in improving exercise capacity. Impact Statement The addition of HFOT during exercise training is not more effective than oxygen through V-mask in improving endurance time, the primary outcome, whereas it is more effective in improving walking distance.

BACKGROUND: Prone position (PP) improves acute respiratory distress syndrome (ARDS) survival by reducing the risk of ventilation-induced lung injury. However, inter-individual variability is a hallmark of ARDS and lung protection by PP might not be optimal in all patients. In the present study, we dynamically assessed physiologic effects of PP by electrical impedance tomography (EIT) and identified predictors of improved lung protection by PP in ARDS patients. METHODS: Prospective physiologic study on 16 intubated, sedated and paralyzed patients with ARDS undergoing PP as per clinical decision. EIT data were recorded during two consecutive steps: 1) baseline supine position before and after a recruitment maneuver (RM); 2) prone position before and after a RM. “Improved lung protection” by PP was defined in the presence of simultaneous improvement of ventilation homogeneity (Hom), alveolar overdistension and collapse (ODCL) and amount of recruitable lung volume by RM in comparison to supine. RESULTS: PP versus supine increased the tidal volume distending the dependent regions (Vtdep), resulting in improved Hom (1.1±0.9 vs. 1.7±0.9, P=0.021). PP also reduced ODCL (19±9% vs. 28±8%, P=0.005) and increased the recruitable lung volume (80 [71-157] vs. 59 [1-110] mL, P=0.025). “Improved lung protection” by PP was predicted by lower Vtdep, higher Vtndep and poorer Hom measured during baseline supine position (P

Background: Despite advances in perioperative care and surgical techniques, patients undergoing pulmonary lobectomy are still at high risk for postoperative complications. Among interventions expected to reduce complications, continuous positive airway pressure (CPAP) is a discussed option. This trial aims to test the hypothesis whether prophylactic application of CPAP following pulmonary lobectomy can reduce postoperative complications. Methods: The study was designed as a prospective, randomized, controlled trial. Patients with clinical stage I non-small cell lung cancer scheduled for pulmonary lobectomy were eligible and were trained for the use of CPAP interface. The control group received standard postoperative pain management and physiotherapy; in addition, the study group received CPAP (PEEP 8–12 cmH 2 O, 2 hours thrice daily for three days). Results: After the appropriate selection, 163 patients were considered for the analysis: 82 patients constituted the control group, 81 the study group. The two groups were substantially comparable for preoperative parameters. The rate of postoperative complications was lower in the study group (24.7% vs . 43.9%; P=0.015) as well as the hospital stay (6 vs . 7 days; P=0.031). The stepwise logistic regression model identified: CPAP [odd ratio (OR): 0.3026, CI: 0.1389–0.6591], smoke habits [OR: 2.5835, confidence interval (CI): 1.0331–6.4610] and length of surgery in minutes (OR: 1.0102, CI: 1.0042–1.0163) as regressors on postoperative complications. Conclusions: The present trial demonstrated that prophylactic application of CPAP during the postoperative period after pulmonary lobectomy for stage I non-small cell lung cancer was effective in prevent postoperative complications.

Physiological and behavioral systems exist to reduce the stress that the intertidal fauna may face during the unsuitable tidal phase. Cerithidea decollata is a common western Indian Ocean mangrove gastropod. It feeds on the ground at low tide, and climbs the trees two-three hours before the water arrival to avoid submersion. Moreover, it regularly settles on the trunk roughly 40 centimeters above the level that the water will reach, in spite of the irregular East African tidal pattern. Migration usually takes place about twice a day unless at Neap Tide, when snails may remain on the dry ground. Biological clock cannot account for water level foreseeing while direct visual cues or chemical information from the water itself or from previous migrations have already been experimentally discarded. Indirect cues could be hypothesize related to the effect of the oceanic wave reaching the coast and the barrier reef (seismic noise), or alternatively related to changes in ground resistivity (self potential) caused by the sea water moving close. To verify these hypotheses a seismic noise and self potential survey was carried out at Mida Creek (Kenya). This paper presents the first results of the seismic noise measurements. A significant correlation between the time evolution (mean value) of the low frequency seismic signal, tides, and snails movements has been identified.

We compared in COPD with CRF undergoing training, HFOT (AIRVO2® FisherP all used the same high-intensity exercise program (1 session/day for ≥ 20 sessions) with different oxygen device. BMI, spirometry and co morbidities have been collected. Baseline and after training exercise tolerance (Constant Work Rate Exercise Test, CWERT + 6-min walk test, 6MWT), respiratory (MIP/MEP) and biceps/quadriceps muscle strength, blood gases, Barthel Index and Barthel Dyspnoea Index, CAT and MRF-26 were measured. Patients’ satisfaction has been evaluated. 71 and 66 patients were analysed for HFOT and V-mask respectively being 15% and 24% the rate of drop-out. All variables improved after training in both groups with similar satisfaction. Comparing the two groups, only meters at 6MWT resulted statistically higher in HFOT group (p=0.029). HFOT group performed 153 seconds more than V-mask at CWERT, without statistical significance (p=0.057). Improvers (gain > 150 sec at CWERT) were 44% and 56% for V-mask and HFOT, respectively. FEV1% prd higher than 30% (OR 2.44, p=0.025) and higher baseline endurance time (OR 1.15, p=0.024) predicted improvers. Low BMI (OR 0.9298, p=0.038) predicted drop-outs. CWERT improvement was positively related to comorbidities (p=0.025) and CAT (p=0.031), while negatively to PaO2/FiO2 (p=0.04). We have confirmed the strong indication to training program in advanced COPD with CRF; HFOT used during training may further increase exercise tolerance.

Background Noninvasive monitoring of maximal inspiratory and expiratory flows (MIF and MEF, respectively) by electrical impedance tomography (EIT) might enable early recognition of changes in the mechanical properties of the respiratory system due to new conditions or in response to treatments. We aimed to validate EIT-based measures of MIF and MEF against spirometry in intubated hypoxemic patients during controlled ventilation and spontaneous breathing. Moreover, regional distribution of maximal airflows might interact with lung pathology and increase the risk of additional ventilation injury. Thus, we also aimed to describe the effects of mechanical ventilation settings on regional MIF and MEF. Methods We performed a new analysis of data from two prospective, randomized, crossover studies. We included intubated patients admitted to the intensive care unit with acute hypoxemic respiratory failure (AHRF) and acute respiratory distress syndrome (ARDS) undergoing pressure support ventilation (PSV, n = 10) and volume-controlled ventilation (VCV, n = 20). We measured MIF and MEF by spirometry and EIT during six different combinations of ventilation settings: higher vs. lower support during PSV and higher vs. lower positive end-expiratory pressure (PEEP) during both PSV and VCV. Regional airflows were assessed by EIT in dependent and non-dependent lung regions, too. Results MIF and MEF measured by EIT were tightly correlated with those measured by spirometry during all conditions (range of R2 0.629–0.776 and R2 0.606–0.772, respectively, p

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

The inhibitory action that a Brevibacillus laterosporus strain isolated from the honeybee body causes against the American Foulbrood (AFB) etiological agent Paenibacillus larvae was studied by in-vitro experiments. A protein fraction isolated from B. laterosporus culture supernatant was involved in the observed inhibition of P. larvae vegetative growth and spore germination. As a result of LC-MS/MS proteomic analyses, the bacteriocin laterosporulin was found to be the major component of this fraction, followed by other antimicrobial proteins and substances including lectins, chaperonins, various enzymes and a number of putative uncharacterized proteins. The results obtained in this study highlight the potential of B. laterosporus as a biological control agent for preserving and improving honeybee health.

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

The safety of the entomopathogenic bacterium Brevibacillus laterosporus for the natural insect predator Chrysoperla agilis was evaluated in this study. For this purpose, laboratory bioassays were conducted exposing different larval instars and adults of the chrysopid to bacterial spore preparations, in order to evaluate the possible effects on survival, longevity, immature development, and adult reproductive performance. The sub-lethal effects were investigated by feeding the bacterium directly to adults and larvae of C. agilis or to mealworm beetles (Tenebrio molitor) used as hosts for chrysopids (tritrophic interaction). Direct feeding of B. laterosporus spores to different lacewing larvae instars and to adults did not cause mean mortality levels significantly different from untreated control, and slight though not significant effects of treatments were generally observed on insect longevity, development, fecundity and egg hatching. In the case of lacewing larvae feeding on treated mealworm beetles, adult emergence percentage was reduced approximately 12%, in comparison with untreated control. Based on these results, the use of B. laterosporus for pest management in the agroecosystem, appears to be compatible with chrysopids.

Background The high-flow nasal cannula (HFNC) delivers up to 60 l/min of humidified air/oxygen blend at a temperature close to that of the human body. In this study, we tested whether higher temperature and flow decrease patient comfort. In more severe patients, instead, we hypothesized that higher flow might be associated with improved comfort. Methods A prospective, randomized, cross-over study was performed on 40 acute hypoxemic respiratory failure (AHRF) patients (PaO2/FiO2 ≤ 300 + pulmonary infiltrates + exclusion of cardiogenic edema) supported by HFNC. The primary outcome was the assessment of patient comfort during HFNC delivery at increasing flow and temperature. Two flows (30 and 60 l/min), each combined with two temperatures (31 and 37 °C), were randomly applied for 20 min (four steps per patient), leaving clinical FiO2 unchanged. Toward the end of each step, the following were recorded: comfort by Visual Numerical Scale ranging between 1 (extreme discomfort) and 5 (very comfortable), together with respiratory parameters. A subgroup of more severe patients was defined by clinical FiO2 ≥ 45%. Results Patient comfort was reported as significantly higher during steps at the lower temperature (31 °C) in comparison to 37 °C, with the HFNC set at both 30 and 60 l/min (p

Introduction: Patients with chronic respiratory conditions suffer from alterations in the mechanics of breathing and mucociliary clearance with symptoms of dyspnoea, cough and reduced exercise capacity. Pulmonary rehabilitation aims to improve these symptoms and subsequently reduce the associated morbidity and improve quality of life.

BACKGROUND: Patients with acquired brain injury (ABI) often require long periods of having a tracheostomy tube for airway protection and prolonged mechanical ventilation. It has been recognized that fast and safe decannulation improves outcomes and facilitates the recovery process. Nevertheless, few studies have provided evidence for decannulation criteria, despite the high prevalence of ABI subjects with tracheostomies. The aim of our study was to assess which clinical parameters are the best predictors for decannulation in subjects with ABI. METHODS: In this cross-sectional study, we recruited 74 consecutive ABI subjects (mean age 51.52 ± 16.76) with tracheostomy tubes. First, the subjects underwent the original decannulation assessment for cannula removal. Second, they underwent our experimental decannulation protocol. The experimental protocol included: voluntary cough (cough peak flow >160 L/min), reflex cough, tracheostomy tube capping (>72 h), swallowing instrumental assessment (penetration aspiration scale 50%), saturation (SpO2 >95%), and level of consciousness evaluation (Glasgow coma scale >8). The reference standard was clinical removal of the tracheostomy tube within 48 h. RESULTS: Parameters showing the highest values of sensitivity and specificity, respectively, were tracheostomy tube capping (80%, 100%), endoscopy assessment of airway patency (100%, 30%), swallowing instrumental assessment (85%, 96%), and the blue dye test (65%, 85%). All these were combined in a clinical cluster parameter, which had higher sensitivity (100%) and specificity (82%). CONCLUSION: These results suggest that the best clinical prediction rule for decannulation in acquired brain injury subjects is a combination of the following assessments: (1) tracheostomy tube capping, (2) endoscopic assessment of patency of airways, (3) swallowing instrumental assessment, and (4) blue dye test.

Objective As precision medicine is becoming a standard of care in selecting tailored rather than average treatments, physiological measurements might represent the first step in applying personalized therapy in the intensive care unit (ICU). A systematic assessment of respiratory mechanics in patients with the acute respiratory distress syndrome (ARDS) could represent a step in this direction, for two main reasons. Approach and Main results: On the one hand, respiratory mechanics are a powerful physiological method to understand the severity of this syndrome in each single patient. Decreased respiratory system compliance, for example, is associated with low end expiratory lung volume and more severe lung injury. On the other hand, respiratory mechanics might guide protective mechanical ventilation settings. Improved gravitationally dependent regional lung compliance could support the selection of positive end-expiratory pressure and maximize alveolar recruitment. Moreover, the association between driving airway pressure and mortality in ARDS patients potentially underlines the importance of sizing tidal volume on respiratory system compliance rather than on predicted body weight. Significance The present review article aims to describe the main alterations of respiratory mechanics in ARDS as a potent bedside tool to understand severity and guide mechanical ventilation settings, thus representing a readily available clinical resource for ICU physicians.

The mangrove gastropod Cerithidea decollata feeds on the ground at low tide and climbs trunks 2–3 h before the arrival of water, settling about 40 cm above the level that the incoming tide will reach at High Water (between 0, at Neap Tide, and 80 cm, at Spring Tide). Biological clocks can explain how snails can foresee the time of the incoming tide, but local environmental signals that are able to inform the snails how high the incoming tide will be are likely to exist. To identify the nature of these possible signals, snails were translocated to three sites within the Mida Creek (Kenya), 0.3–3 km away from the site of snail collection. The study sites had a much wider tidal range than the original site (up to 160 cm), were dominated by Rhizophora mucronata trees and uninhabited by C. decollata . If cueing signals were linked to the upper mangrove belt (site-specific signals), the Avicennia marina area, translocation should affect snail behaviour; conversely, we could conclude that information on the height of the incoming tide should be widely available within the whole creek (widespread signals), independently from cues linked to the home area and home site. Tests were performed by releasing the snails close to vertical plastic pipes (2 m high) following a standardized procedure. Results revealed that snails, even in such unfamiliar surroundings, climbed higher and earlier on pipes where the tide level would be higher, thus allowing rejection of the hypothesis of site specific signals. Where the tide exceeded 80 cm, however, snail effort was not sufficient to avoid submersion and snails had to climb higher. Hypotheses on widespread signals possibly involved in modulating the migratory behaviour of C. decollata are discussed.

The mangrove snail Cerithidea decollata feeds on the ground at low water, and about two hours before high water climbs Avicennia marina trunks settling 20–40 cm above the level that the incoming tide will reach. The moment that C. decollata must start to measure the vertical distance it has to creep up the trunk to avoid submersion corresponds to the point at which creeping switches from a horizontal to vertical movement (the “0” point). Two vertical movements interrupted by a short horizontal movement were added together; however, if the horizontal interruption was wider than 10 cm a new “0” point was set, and snails climbed higher than control snails, according to the level of the horizontal interruption, without adding the two vertical segments. Through forcing snails to both climb and descend, we observed that they do not appear to be capable of subtraction.

SummaryThe steady increase in incidence of chronic respiratory disease (CRD) now constitutes a serious public health problem. CRDs are often underdiagnosed and many patients are not diagnosed until the CRD is too severe to prevent normal daily activities. The prevention of CRDs and reducing their social and individual impacts means modifying environmental and social factors and improving diagnosis and treatment. Prevention of risk factors (tobacco smoke, allergens, occupational agents, indoor/outdoor air pollution) will significantly impact on morbidity and mortality.The Italian Ministry of Health (MoH) has made respiratory disease prevention a top priority and is implementing a comprehensive strategy with policies against tobacco smoking, indoor/outdoor pollution, obesity, and communicable diseases. Presently these actions are not well coordinated. The Global Alliance against Chronic Respiratory Diseases (GARD), set up by the World Health Organization, envisages national bodies; the GARD initiative in Italy, launched 11/6/2009, represents a great opportunity for the MoH.Its main objective is to promote the development of a coordinated CRD program in Italy. Effective prevention implies setting up a health policy with the support of healthcare professionals and citizen associations at national, regional, and district levels. What is required is a true inter-institutional synergy: respiratory diseases prevention cannot and should not be the responsibility of doctors alone, but must involve politicians/policymakers, as well as the media, local institutions, and schools, etc. GARD could be a significant experience and a great opportunity for Italy to share the GARD vision of a world where all people can breathe freely.

Pulmonary rehabilitation requires specific competence and skill, must be a matter for pulmonologists http://ow.ly/xC6tD

The gastropod Cerithidea decollata typically feeds on mud at the mangrove soil surface at low tide and rests on Avicennia marina trunks throughout high tide. Tens of individuals can be observed climbing the trunks and clustering, 2–3 hr before the incoming high tide, approximately 40 cm higher than the level that the tide will reach. As soon as the water disappears, snails descend and disperse on the ground again. Signals able to tell the snails the height of the incoming tide are still unknown but we wanted to investigate whether or not some information may be transferred from resident snails to snails translocated from areas undergoing a different tidal regime. Snails from sites where tides never exceed 5 cm above ground level (translocated) were transported to sites flooded by higher tides (up to 80 cm above the ground), and their behaviour was compared with local snails (residents). At the beginning of the experiment, sea water occasionally made contact with translocated snails as they ascended the tr...

Background: Sigh is a cyclic brief recruitment manoeuvre: previous physiological studies showed that its use could be an interesting addition to pressure support ventilation to improve lung elastance, decrease regional heterogeneity and increase release of surfactant. Research question: Is the clinical application of sigh during pressure support ventilation (PSV) feasible? Study design and methods: We conducted a multi-center non-inferiority randomized clinical trial on adult intubated patients with acute hypoxemic respiratory failure or acute respiratory distress syndrome undergoing PSV. Patients were randomized to the No Sigh group and treated by PSV alone, or to the Sigh group, treated by PSV plus sigh (increase of airway pressure to 30 cmH2Ofor 3 seconds once per minute) until day 28 or death or successful spontaneous breathing trial. The primary endpoint of the study was feasibility, assessed as non-inferiority (5% tolerance) in the proportion of patients failing assisted ventilation. Secondary outcomes included safety, physiological parameters in the first week from randomization, 28-day mortality and ventilator-free days. Results: Two-hundred fifty-eight patients (31% women; median age 65 [54-75] years) were enrolled. In the Sigh group, 23% of patients failed to remain on assisted ventilation vs. 30% in the No Sigh group (absolute difference -7%, 95%CI -18% to 4%; p=0.015 for non-inferiority). Adverse events occurred in 12% vs. 13% in Sigh vs. No Sigh (p=0.852). Oxygenation was improved while tidal volume, respiratory rate and corrected minute ventilation were lower over the first 7 days from randomization in Sigh vs. No Sigh. There was no significant difference in terms of mortality (16% vs. 21%, p=0.342) and ventilator-free days (22 [7-26] vs. 22 [3-25] days, p=0.300) for Sigh vs. No Sigh. Interpretation: Among hypoxemic intubated ICU patients, application of sigh was feasible and without increased risk.