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Individuals with COPD may be staged according to symptoms and exacerbation history (GOLD groups: A-D) and on airflow obstruction (GOLD grades: 1-4). Guidelines recommend pulmonary rehabilitation (PR) for these individuals, including those recovering from an exacerbation (ECOPD) OBJECTIVE: To evaluate whether in individuals with clinically severe COPD, recovering from an ECOPD, the effect size of an in-hospital PR program would be affected by airflow severity grades and assessed outcome measures.Retrospective, multicentre study. Participants were compared according to different GOLD airflow grades. In addition to the MRC dyspnoea scale, six-minute walking distance test and COPD assessment test (CAT), Barthel dyspnoea index (Bid), and Short Physical Performance Battery (SPPB) were assessed, evaluating the proportion of individuals reaching the minimum clinically important difference (MCID) (responders).Data of 479 individuals, completing the program were evaluated. Most of the participants were allocated in GOLD grades 4, (57.6%) and 3 (22.1%). All outcome measures significantly improved after PR (p 0.05), without any significant difference in the proportion of responders in any measure.in individuals with severe COPD, recovering from ECOPD the success rate of PR does not depend on airflow severity, or outcome measure assessed. In addition to the most used outcome measures, also Bid and SPPB are sensitive to PR.

Background: High-flow nasal oxygen (HFNO) improves exercise capacity, oxygen saturation, and symptoms in patients with chronic obstructive pulmonary disease (COPD). Due to the need of electricity supply, HFNO has not been applied during free ambulation. Objective: We evaluated whether HFNO delivered during walking by a battery-supplied portable device was more effective than usual portable oxygen in improving exercise capacity in patients with COPD and severe exercise limitation. The effects on 6-min walking tests (6MWTs) were the primary outcome. Methods: After a baseline 6MWT, 20 stable patients requiring an oxygen inspiratory fraction (FiO2) 2. Walked distance, perceived dyspnea, pulse oximetry, and inspiratory capacity at end of the tests as well as patients’ comfort were compared between the tests. Results: As compared to baseline, walked distance improved significantly more in HFNO than in the control test (by 61.1 ± 37.8 and 39.7 ± 43.8 m, respectively, p = 0.01). There were no significant differences between the tests in dyspnea, peripheral oxygen saturation, or inspiratory capacity, but HFNO test was appreciated as more comfortable. Conclusion: In patients with COPD and severe exercise limitation, HFNO delivered by a battery-supplied portable device was more effective in improving walking distance than usual oxygen supplementation.

STUDY OBJECTIVES: There are few studies evaluating (1) exercise capacity as assessed by the 6-minute walking distance (6MWD) test in large populations with obstructive sleep apnea (OSA); and (2) correlations with patients’ comorbidities. METHODS: This study presents a cluster analysis performed on the data of 1,228 patients. Severity of exercise limitation was defined on the basis of 6MWD. RESULTS: Sixty-one percent showed exercise limitation (29.2% and 31.9% mild and severe exercise limitation, respectively). About 60% and 40% of patients were included in cluster 1 (CL1) and 2 (CL2), respectively. CL1 included younger patients with high prevalence of apneas, desaturations, and hypertension with better exercise tolerance. CL2 included older patients, all with chronic obstructive pulmonary disease (COPD), high prevalence of chronic respiratory failure (CRF), fewer apneas but severe mean desaturation, daytime hypoxemia, more severe exercise limitation, and exercise-induced desaturations. Only CRF and COPD significantly (P < .001) correlated with 6MWD < 85% of predicted value. 6MWD correlated positively with apnea-hypopnea index, oxygen desaturation index, nocturnal pulse oxygen saturation (SpO(2)), resting arterial oxygen tension, mean SpO(2) on exercise, and negatively with age, body mass index, time spent during night with SpO(2) < 90%, mean nocturnal desaturation, arterial carbon dioxide tension, and number of comorbidities. Patients without severe comorbidities had higher exercise capacity than those with severe comorbidities, (P < .001). Exercise limitation was significantly worse in OSA severity class I when compared to other classes (P < .001). CONCLUSIONS: A large number of patients with OSA experience exercise limitation. Older age, comorbidities such as COPD and CRF, OSA severity class I, severe mean nocturnal desaturation, and daytime hypoxemia are associated with worse exercise tolerance. CITATION: Vitacca M, Paneroni M, Braghiroli A, et al. Exercise capacity and comorbidities in patients with obstructive sleep apnea. J Clin Sleep Med. 2020;16(4):531–538.

Background: It is uncertain whether exposure to renin–angiotensin system (RAS) modifiers affects the severity of the new coronavirus disease 2019 (COVID-19) because most of the available studies are retrospective. Methods: We tested the prognostic value of exposure to RAS modifiers (either angiotensin-converting enzyme inhibitors [ACE-Is] or angiotensin receptor blockers [ARBs]) in a prospective study of hypertensive patients with COVID-19. We analyzed data from 566 patients (mean age 75 years, 54% males, 162 ACE-Is users, and 147 ARBs users) hospitalized in five Italian hospitals. The study used systematic prospective data collection according to a pre-specified protocol. All-cause mortality during hospitalization was the primary outcome. Results: Sixty-six patients died during hospitalization. Exposure to RAS modifiers was associated with a significant reduction in the risk of in-hospital mortality when compared to other BP-lowering strategies (odds ratio [OR]: 0.54, 95% confidence interval [CI]: 0.32 to 0.90, p = 0.019). Exposure to ACE-Is was not significantly associated with a reduced risk of in-hospital mortality when compared with patients not treated with RAS modifiers (OR: 0.66, 95% CI: 0.36 to 1.20, p = 0.172). Conversely, ARBs users showed a 59% lower risk of death (OR: 0.41, 95% CI: 0.20 to 0.84, p = 0.016) even after allowance for several prognostic markers, including age, oxygen saturation, occurrence of severe hypotension during hospitalization, and lymphocyte count (adjusted OR: 0.37, 95% CI: 0.17 to 0.80, p = 0.012). The discontinuation of RAS modifiers during hospitalization did not exert a significant effect (p = 0.515). Conclusions: This prospective study indicates that exposure to ARBs reduces mortality in hospitalized patients with COVID-19.

Real-life studies report discordant prescribing of inhaled triple therapy (TT) among individuals with COPD. Guidelines recommend pulmonary rehabilitation (PR) for persistent breathlessness and/or exercise limitation. This real-life study aimed to assess the effects of in-patient PR in individuals under TT as compared to other inhaled therapies (no TT).Multicentric, retrospective analysis of data from individuals admitted to in-hospital PR. Baseline characteristics were recorded and lung function was assessed. Outcome measures were: 6-min walking test (6MWT: primary outcome), Medical Research Council (MRC) scale for dyspnoea, and COPD assessment test (CAT).Data of pre and post program 6MWT of 1139 individuals were available. Pulmonary rehabilitation resulted in significant improvement in 6MWT in both groups, however, the effect size (by 54.3 ± 69.7 vs 42.5 ± 64.2 m, p = 0.004) and proportion of individuals reaching the minimal clinically important difference (MCID) of 6MWT (64.2%, vs 54.3%, p = 0.001) were higher in TT group. Both groups significantly improved also the other outcome measures. The significant independent predictors of reaching the MCID of 6MWT were hospital provenience, TT use, and high eosinophils count.Pulmonary rehabilitation results in significant benefits in individuals with COPD irrespective of the use of TT. However, individuals under TT report larger benefits in exercise tolerance than those under no TT.

Background: Chronic obstructive pulmonary disease (COPD) is a complex, progressive respiratory condition characterized by heterogeneous clinical presentations (phenotypes). The aim of this study was to assess the prevalence of the main COPD phenotypes and match each phenotype to the most fitting clinical and lung function profile.Methods: The CLIMA (Clinical Phenotypes in Actual Clinical Practice) study was an observational, cross-sectional investigation involving twenty-four sites evenly distributed throughout Italy. Patients were tentatively grouped based on their history and claimed prevailing symptoms at recruitment: chronic cough (CB, suggesting chronic bronchitis); dyspnoea (possible emphysema components, E); recurrent wheezing (presuming asthma components, A). Variables collected were: anagraphics; smoking habit; history of asthma; claim of >1 exacerbations in the previous year; blood eosinophil count; total blood IgE and alpha1 anti-trypsin (α1-AT) levels; complete lung function, and the chest X-ray report. mMRC, CAT, BCS, EQ5d-5L were also used. The association between variables and phenotypes were checked by Chi-square test and multinomial logistic regression.Results: The CB phenotype was prevalent (48.3%), followed by the E and the A phenotypes (38.8% and 12.8%, respectively). When dyspnea was the prevailing symptom, the probability of belonging to the COPD-E phenotype was 3.40 times higher. Recurrent wheezing was mostly related to the COPD-A phenotype. Lung function proved more preserved in the COPD-CB phenotype. Smoke; n. exacerbations/year; VR, and BODE index were positively correlated with the COPD-E phenotype, while SpO2, FEV1/FVC, FEV1/VC, and FEV1 reversibility were negatively correlated. Lower DLco values were highly probative for the COPD-E phenotype (p

Aims heart failure (HF) and coronary artery disease (CAD) are independent predictors of death in patients with COVID-19. The adverse prognostic impact of the combination of HF and CAD in these patients is unclear. Methods and results we analysed data from 954 consecutive patients hospitalized for SARS-CoV-2 in five Italian Hospitals from February 23 to May 22, 2020. The study was a systematic prospective data collection according to a pre-specified protocol. All-cause mortality during hospitalization was the outcome measure. Mean duration of hospitalization was 33 days. Mortality was 11% in the total population and 7.4% in the group without evidence of HF or CAD (reference group). Mortality was 11.6% in the group with CAD and without HF (odds ratio [OR]: 1.6, p = 0.120), 15.5% in the group with HF and without CAD (OR: 2.3, p = 0.032), and 35.6% in the group with CAD and HF (OR: 6.9, p, Graphical abstract Image, graphical abstract

As part of the Italian Health Service the respiratory ICS Maugeri network were reconfigured and several in-hospital programs were suspended to be substituted by workforce and facilities reorganization for acute and post-acute COVID-19 care need. The present review shows the time course variation of respiratory ICS network in terms of admissions diagnosis and outcomes. A comparative review of the admissions and outcome measures data (anthropometric, admission diagnosis, provenience, comorbidities, disability, symptoms, effort tolerance, disease impact, length of stay and discharge destinations) over 1 year period (March 2020-March 2021) was undertaken and compared to retrospective data from a corresponding 1 year (March 2019-March 2020) period to determine the impact of the network relocation on the delivery of pulmonary specialist rehabilitation to patients with complex needs during the pandemic episode. One of the changes implemented at the respiratory Maugeri network was the relocation of the Pulmonary Rehabilitation units from its 351 beds base to a repurposed 247 beds and a reduction in total number of admitted patients (n=3912 in pre-COVID time; n=2089 in post COVID time). All respiratory diagnosis, except COVID sequelae, decreased (chronic respiratory failure-CRF, COPD, obstructive sleep apnoea syndrome-OSAS, interstitial lung disease-ILD, tracheostomized patients and other mixed diseases decreased of 734, 705, 157, 87, 79 and 326 units respectively). During the pandemic time, 265 post COVID sequelae with CRF were admitted for rehabilitation (12.62%), % of patients coming from acute hospital increased, LOS and NIV use remained stable while CPAP indication decreased. Disease impact, dyspnea and effort tolerance as their improvements after rehabilitation, were similar in the two periods. Only baseline disability, expressed by Barthel index, seems higher in the 2° observation time as its improvement. Hospital deaths and transfers to acute hospitals were higher during pandemic crisis while home destination decreased. This review demonstrated impact of coronavirus pandemic situation, specifically the relocation of the respiratory inpatient rehabilitation wards in a huge Italian network.

Background Respiratory dysfunction in Late Onset Pompe Disease (LOPD) is attributed primarily to diaphragm weakness; it is not always proportional to skeletal muscle weakness. Beyond diaphragm and rib cage muscles, we know that posterior trunk muscles participate to inspiration, and abdominal wall muscles contribute to forced expiration. We aimed to investigate whether the involvement of axial muscles detected by muscle MRI may correlate with respiratory dysfunction or influence respiratory functional tests. Methods In 19 patients with LOPD in different stages of disease, we analyzed trunk muscle MRI and upright forced vital capacity FVC, postural drop in VC, and maximal inspiratory and expiratory pressures (MIP, MEP). Results While upright FVC did not correlate with trunk muscle involvement, postural drop in VC, reflecting diaphragm weakness, was strongly influenced by the severity of involvement of all posterior and anterior muscles. Conclusion Trunk muscles involvement in LOPD may reveal respiratory dysfunction and contribute to postural drop in VC. It is likely that axial muscle weakness may impair the compensatory mechanisms occurring in clinostatism, and mainly operated by the abdominal muscles. Detection of axial muscle damage by MRI may thus suggest the need of more extensive respiratory assessment, i.e. by polysomnography, even when upright VC is still within normal ranges.

Background: Assessment of intrinsic dynamic positive end-expiratory pressure (PEEPi,dyn) may be clinically important in stable patients with chronic obstructive pulmonary disease (COPD), but epidemiological data are scant. Objectives: The aim of our study was (i) to assess the PEEPi,dyn in a large population of stable patients with COPD and (ii) to evaluate the correlations with some noninvasive measurements routinely assessed. Method: Retrospective analysis of lung mechanics, dynamic volumes, arterial blood gases, dyspnoea by means of the Medical Research Council (MRC) scale, the COPD Assessment Test score, and maximal inspiratory/expiratory pressures in 87 hypercapnic and 62 normocapnic patients. Results: The mean PEEPi,dyn was significantly higher in hypercapnic than normocapnic patients (2.8 ± 2.2 vs. 1.9 ± 1.6 cm H2O, respectively, p = 0.0094). PEEPi,dyn did not differ according to Global Initiative for Chronic Obstructive Lung Disease stage, MRC score, or use or not of long-term oxygen therapy. There were significant although weak correlations between PEEPi,dyn and airway obstruction, hyperinflation, respiratory muscle function, arterial CO2 tension, and number of exacerbations/year. The transdiaphragmatic pressure was the strongest variable associated to PEEPi,dyn (R = 0.5713, p = 0.001). Conclusion: In stable patients with COPD, PEEPi,dyn is higher in hypercapnic patients and weakly correlated to noninvasive measures of lung and respiratory muscle function.

Background: Aspiration community-acquired pneumonia (ACAP) and community-acquired pneumonia (CAP) in patients with aspiration risk factors (AspRFs) are infections associated with anaerobes, but limited evidence suggests their pathogenic role. Research Question: What are the aspiration risk factors, microbiology patterns, and empiric anti-anaerobic use in patients hospitalized with CAP? Study Design and Methods: This is a secondary analysis of GLIMP, an international, multicenter, point-prevalence study of adults hospitalized with CAP. Patients were stratified into three groups: (1) ACAP, (2) CAP/AspRF+ (CAP with AspRF), and (3) CAP/AspRF- (CAP without AspRF). Data on demographics, comorbidities, microbiological results, and anti-anaerobic antibiotics were analyzed in all groups. Patients were further stratified in severe and nonsevere CAP groups. Results: We enrolled 2,606 patients with CAP, of which 193 (7.4%) had ACAP. Risk factors independently associated with ACAP were male, bedridden, underweight, a nursing home resident, and having a history of stroke, dementia, mental illness, and enteral tube feeding. Among non-ACAP patients, 1,709 (70.8%) had CAP/AspRF+ and 704 (29.2%) had CAP/AspRF-. Microbiology patterns including anaerobes were similar between CAP/AspRF-, CAP/AspRF+ and ACAP (0.0% vs 1.03% vs 1.64%). Patients with severe ACAP had higher rates of total gram-negative bacteria (64.3% vs 44.3% vs 33.3%, P =.021) and lower rates of total gram-positive bacteria (7.1% vs 38.1% vs 50.0%, P 50% in all groups) independent of AspRFs or ACAP received specific or broad-spectrum anti-anaerobic coverage antibiotics. Interpretation: Hospitalized patients with ACAP or CAP/AspRF+ had similar anaerobic flora compared with patients without aspiration risk factors. Gram-negative bacteria were more prevalent in patients with severe ACAP. Despite having similar microbiological flora between groups, a large proportion of CAP patients received anti-anaerobic antibiotic coverage.

Background and Aim: The Barthel Dyspnoea Index (BDi) is responsive to change in patients with chronic obstructive pulmonary disease (COPD). However, the minimum clinically important difference (MCID) has not been established. We aimed to identify the MCID for the BDi using anchor-based and distribution-based methods. Methods: In a retrospective analysis we assessed BDi before and after inpatient pulmonary rehabilitation in 2328 patients with COPD (1152 with chronic respiratory failure - CRF). The Medical Research Council (MRC) score was measured concurrently as anchors. We used receiver operating characteristic (ROC) curves, linear regression, and distribution-based methods to estimate the MCID for the BDi; we included only patients with paired BDi scores in the analysis. Results: The mean change for the whole group in BDi score with pulmonary rehabilitation was -10 (IQR -17 : -3; p Conclusions: The most conservative estimate of the MCID for the BDi is -9 points in patients with COPD and -12 in patients without CRF. This estimate could be useful in the clinical interpretation of BDi data, particularly in response to intervention studies.

BACKGROUND: Patients undergoing prolonged mechanical ventilation represent up to 15% of all patients requiring weaning from mechanical ventilation. Although recent guidelines have recommended including physiotherapy early during mechanical ventilation to speed the process of weaning, only indirect evidence supporting the use of physiotherapy is available for patients receiving prolonged mechanical ventilation. The aim of our study was to evaluate the effects of a physiotherapy program in subjects requiring prolonged mechanical ventilation and the correlates of successful weaning. METHODS: A retrospective analysis was performed on 1,313 consecutive patients admitted to a weaning unit over a 15-y period to be liberated from prolonged mechanical ventilation. Subjects underwent a program of intensive physiotherapy organized in 4 incremental steps (1–4) and were analyzed according to the steps achieved (> 2 steps or ≤ 2 steps). The rate of successful weaning was recorded, and possible predictors were considered. The 15-y period of observation was divided into 3 consecutive 5-y intervals. RESULTS: Out of 560 subjects undergoing final analysis, 349 (62.3%) were successfully weaned. The weaning success rate was significantly greater in subjects attaining > 2 steps than in subjects who attained ≤ 2 steps (72.1% vs 55.9%, respectively, odds ratio = 2.04, 95% CI = 1.42–2.96, P 2 physiotherapy steps was the main predictor of successful weaning (odds ratio = 2.17, 95% CI = 1.48–3.23, P

ALS patients should discuss the issue of tracheostomy before the onset of terminal respiratory failure. While the process of shared decision-making is desirable, there are few data on the practical application of this real-life situation.To determine how a decision-making process is actually carried out, we analysed the episodes of acute respiratory failure preceding tracheostomy.We studied the charts of a group of ALS patients after tracheostomy. An interview focusing on the existence of anticipated directives was carried out. Tracheostomies were classified as planned or unplanned according to the presence of a decision plan.A total of 209 ALS patients were cared for during a three-year period. Of these patients, 34 (16%) were tracheotomised. In 38% of cases, tracheostomy was planned, 41% were unplanned, and 21% remained undiagnosed.A minority of ALS patients make a voluntary decision for tracheostomy before the procedure is conducted. The advising process of care still presents limits that have been thus far poorly addressed. In the future, we will need to develop guidelines for the timing and content of the shared-decision making process.

BACKGROUND International Classification Functioning (ICF) Core Sets represent a holistic approach to functioning within rehabilitation field. Information-reporting efficacy of a rehabilitation-based Respiratory ICF set applied on a large scale throughout the ICS Maugeri network was tested. METHODS A prospective multi-center study (May-November 2018) was conducted for all respiratory inpatients consecutively admitted for rehabilitation. Doctors, physiotherapists, psychologists, nurses used an electronic Respiratory ICF set (33 items among the ICF body functions, activity and participations components) at admission and at discharge to assess the disability changes. The ICF report qualifiers, from 0 (no impairment) to 4 (maximum impairment), guided clinical, diagnostic and rehabilitation prescriptions. RESULTS 1886 patients (69.6±10.8 years; M=1045) were admitted (589 chronic obstructive pulmonary disease, 494 chronic respiratory failure [CRF], 21 prolonged mechanical ventilation [PMV], 496 with other respiratory diseases), of whom 15 died, and 117 were transferred to acute care. The mean length of stay was 23.1±11.8 days (range 1-122). The mean time to fill in the ICF set was 23.16±0.70 min. The rate of filled charts improved from 16% in May to 100% in November. The baseline distribution of the more severe qualifiers (>2) progressively increased from the whole sample to the PMV subgroup. After rehabilitation, in the whole sample and in the CRF and PMV subgroups, the severity qualifiers significantly decreased (P

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 and objective: Non invasive ventilation (NIV) is currently employed for weaning from invasive ventilation (IMV) in the acute setting but its use for weaning from prolonged ventilation is still occasional and not standardized. We wanted to evaluate whether a combined protocol of NIV and decannulation in tracheostomized patients needing prolonged mechanical ventilation was feasible and what would be the one-year outcome. Methods: We studied patients still dependent from invasive mechanical ventilation with the following inclusion criteria: a) tolerance of at least 8 h of unsupported breathing, b) progressive hypercapnia/acidosis after invasive ventilation discontinuation, c) good adaptation to NIV, d) favorable criteria for decannulation. These patients were switched from IMV to NIV and decannulated; then they were discharged on home NIV and followed-up for one year in order to evaluate survival and complications rate. Results: Data from patients consecutively admitted to a weaning unit were prospectively collected between 2005 and 2018. Out of 587 patients admitted over that period, 341 were liberated from prolonged mechanical ventilation. Fifty-one out of 147 unweaned patients (35%) were eligible for the protocol but only 46 were enrolled. After a mean length of stay of 35 days they were decannulated and discharged on domiciliary NIV. After one year, 38 patients were still alive (survival rate 82%) and 37 were using NIV with good adherence (only one patient was switched again to invasive ventilation). Conclusions: NIV applied to patients with failed weaning from prolonged IMV is feasible and can facilitate the decannulation process. Patients successfully completing this process show good survival rates and few complications. Keywords: Prolonged weaning, Non invasive ventilation, Tracheostomy decannulation, Survival, Respiratory mechanics, Rehabilitation

We present the clinical case of a 74 years old patient undergoing tracheotomy for persistent hypercapnic respiratory failure after lower right lobectomy surgery, performed as a result of pulmonary cancer recurrence. The patient was transferred to the Department of Respiratory Sub Intensive Care for respiratory weaning, decannulation and cycle of motor and respiratory physiotherapy. The joint evaluation of physicians, nurses and physiotherapists has allowed the identification of ICD-9 and ICF codes of the severe disability shown by the patient in the first days of hospital stay (respiratory failure due to pneumonia that need invasive mechanical ventilation by tracheotomy, prolonged immobility, muscular deconditioning and inability to perform even the simplest activities of daily life; it required also artificial nutrition by naso gastric tube). ICF codes as respiratory functions (respiratory system functions, additional respiratory functions, sensations associated with cardiovascular and respiratory functions, moving with aids, walking, vestibular functions, muscle strength, tolerance to physical exercise, personal care, performing the routine daily sleep functions, energy and drive functions), were particularly compromised at admission. Medical intervention (antibiotic therapy based on microbiological isolations, optimization of inhalatory therapy, management of intestinal complications and cardiological which required cardiological treatment remodulation in order to obtain better heart rate control and better blood pressure control allowed a clear improvement of general and respiratory clinical conditions. The simultaneous physiotherapists'intervention (weaning not only from invasive mechanical ventilation but also from tracheotomic cannula and oxygen therapy, stationary and cycloergometer with arms and exercise training) and nurses'intervention (medication of pressure injuries, surveillance of the sleep-wake rhythm, management of the daily routine) allowed a gradual improvement of both motor and respiratory ability with a consequent indipendence in activities of daily living. Important were also psychological counseling and intervention of speech therapists (removal of naso gastric tube, once excluded dysphagia also by videofluoroscopy). During a long lasting clinical improvement, coincident with patient's discharge to home, has been assessed disability through ICF codes, largely improved under medical, nursing and physiotherapist profile.Presentiamo il caso clinico di un paziente di 74 anni sottoposto a tracheotomia per insufficienza respiratoria ipercapnica persistente dopo intervento di lobectomia inferiore dx, effettuato a seguito di recidiva di ca polmonare. Il paziente è stato trasferito presso il reparto di Sub intensiva respiratoria per weaning respiratorio, decannulazione e ciclo di fisioterapia motoria e respiratoria. La valutazione congiunta di medici, infermieri e fisioterapisti ha permesso di identificare i codici ICD-9 e ICF descrittivi del quadro di severa disabilità mostrata dal paziente nei primi giorni di degenza (polmonite basale dx condizionante insufficienza respiratoria globale e necessità di ventilazione meccanica invasiva tramite tracheotomia). Tale compromissione clinica è coincisa con allettamento prolungato del paziente, decondizionamento muscolare ed inabilità a compiere anche le più semplici attività della vita quotidiana; il paziente ha richiesto inoltre alimentazione artificiale mediante sondino nasograstrico. I codici ICF Funzioni respiratorie (Funzioni dell’apparato respiratorio, ulteriori funzioni respiratorie, Sensazioni associate alle funzioni cardiovascolari e respiratorie, Spostarsi usando apparecchiature/ausili, Camminare, Funzioni vestibolari, Funzioni della forza muscolare, Funzioni di tolleranza all’esercizio fisico, Cura della propria persona, Eseguire la routine quotidiana, Funzioni del sonno, Funzioni dell’energia e delle pulsioni) erano particolarmente compromessi in ingresso. L’intervento medico basato su terapia antibiotica mirata, ottimizzazione della terapia inalatoria in sospetta BPCO, gestione delle complicanze intestinali, accanto a quelle cardiologiche, ha permesso un netto miglioramento delle condizioni cliniche generali e respiratorie. Il simultaneo intervento dei fisioterapisti (svezzamento non solo dalla ventilazione meccanica invasiva ma anche dalla cannula tracheotomica e dall’ossigeno-terapia, cyclette e cicloergometro a braccia e riallenamento all’esercizio fisico) e l’intervento degli infermieri (medicazione delle lesioni da pressione, sorveglianza del ritmo sonno-veglia, riadattamento alla gestione autonoma della routine quotidiana) ha permesso un graduale recupero sia delle abilità motorie e respiratorie sia dell’autonomia nella gestione delle attività di vita quotidiana. Importanti sono stati inoltre l’intervento dei logopedisti (rimozione del sondino nasogastrico con inizio di alimentazione per os una volta esclusa la disfagia) e gli incontri di counseling psicologico (miglioramento dell’assetto emotivo, grazie anche ad un buon supporto famigliare). In fase di stabilità clinica, coincidente con la dimissione a domicilio del paziente, è stato rivalutato il quadro di disabilità attraverso codici ICF, in gran parte migliorati in modo significativo sotto il profilo medico, infermieristico e fisioterapico.

BACKGROUND: Humidification is a standard of care during invasive mechanical ventilation. Two types of devices are used for this purpose: heated humidifiers and heat-and-moisture exchangers (HME). AIM: To compare the short-term physiologic effects of an active HME, with those of heated humidifiers and HMEs in terms of respiratory effort, ventilatory pattern, and arterial blood gases during invasive mechanical ventilation. METHODS: We conducted a randomized crossover study with 3 different devices in 15 stable subjects who had a tracheostomy and were ventilator-dependent. Transdiaphragmatic pressure, ventilatory pattern, arterial blood gases, and dyspnea scale were recorded at baseline and at the end of a 20-min period with each device. RESULTS: Compared with heated humidifiers, the active HME was associated with higher diaphragmatic pressure-time product per minute (117.10 [interquartile range {IQR} 34.58–298.60]) versus 80.86 (IQR, 25.46–110.55) cm H2O×s/min, P = .01), higher PaCO2 (48.50 [IQR, 40.65–53.70] vs 39.60 [IQR, 37.50–49.95]) mm Hg, P = .02) and lower pH (7.41 [IQR, 7.36–7.49] vs 7.45 [IQR, 7.40–7.51], P = .030) without any significant difference in ventilatory pattern. A significantly worse dyspnea scale score (active HME, 3 (2–4) vs heated humidifiers: 4 (3–5); P = .009) was also observed. No significant differences were seen between active HME and HME. CONCLUSIONS: This study indicated that, compared with the heated humidifiers, the use of the active HME or the HME increased inspiratory effort, PaCO2, pH, and dyspnea in stable subjects who were tracheostomized and ventilator-dependent.

High flow nasal cannula (HFNC) was shown to washout the anatomical dead space, permitting a higher fraction of minute ventilation to participate in gas pulmonary exchanges. Moreover, it is able to guarantee the desired inhaled oxygen fraction (FiO2) even at high level of patient's minute ventilation by minimizing the room air entrainment. The effect of HFNC has never been investigated on stable severe COPD patients in term of endurance capacity with standardised laboratory tests.We performed, in a randomized crossover study, two constant load exercise tests at the 75% of maximum workload achieved at a previous incremental exercise test on cycle-ergometer: with (HFNC-test) and without HFNC (Control-test). Both constant load tests were fulfilled at the same inhaled oxygen fraction (isoFiO2).The endurance time significantly increased in the HFNC-test compared to the Control-test (the mean difference between the two groups was 109 ± 104 s, p 0.015). At iso-time, HFNC-test showed a better oxygen saturation (95 ± 3% vs 89 ± 3%, respectively, p 0.005) either in the subgroup of patients who used supplemental oxygen and in the subgroup who did not. Moreover, a significantly lower dyspnea (median of 5.5 vs 10, respectively, p = 0.002) and leg fatigue score (median of 5 vs 9.5, p = 0.002) was recorded at iso-time during HFNC-test.HFNC may improve the exercise performance in severe COPD patients with ventilatory limitation. This effect is associated to an improvement of SaO2 and perceived symptoms at iso-time. In a Pulmonary Rehabilitation program HFNC may allow a given high intensity load to be sustained for a longer time with less symptoms.

Discussion about patients' end-of-life (E-o-L) preferences should be part of the routine practice. Using a semi-structured interview with a scenario-based decision, we performed a prospective multicentre study to elicit the patients' E-o-L preferences in very severe chronic obstructive pulmonary disease (COPD). We also checked their ability to retain this information and the respect of their decisions when they die. Forty-three out of ninety-one of the eligible patients completed the study. The choice of E-o-L practice was equally distributed among the three proposed options: endotracheal intubation (ETI), 'ceiling' non-invasive ventilation (NIV), and palliation of symptoms with oxygen and morphine. NIV and ETI were more frequently chosen by patients who already experienced them. ETI preference was also associated with the use of anti-depressant drugs and a low educational level, while a higher educational level and a previous discussion with a pneumologist significantly correlated with the preference for oxygen and morphine. Less than 50% of the patients retained a full comprehension of the options at 24 hours. About half of the patients who died in the follow-up period were not treated according to their wishes. In conclusion, in end-stage COPD more efforts are needed to improve communication, patients' knowledge of the disease and E-o-L practice.

The aim of our study was to evaluate the prevalence and predictors of obstructive sleep apnea (OSA) in patients with chronic obstructive pulmonary disease (COPD) undergoing inpatient pulmonary rehabilitation programs (PRPs). A retrospective data review of consecutive stable patients with a known diagnosis of COPD, admitted for PRP between January 2007 and December 2013. Full overnight polysomnography (PSG) and Epworth Sleepiness Scale (ESS) were assessed in all patients. Out of 422 evaluated patients, 190 (45%) showed an Apnea Hypopnea Index (AHI) ≥ 15 events/hour and underwent OSA treatment. Patients with OSA were significantly younger and had a less severe airway obstruction as compared to patients without OSA. There were no significant differences in cardiac comorbidities nor in arterial blood gases. As expected, patients with OSA showed significantly more severe diurnal symptoms, as assessed by the ESS and higher body mass index (BMI). However, only 69 out of 190 patients with OSA (36.3%) showed an ESS10, whereas 25% of them had BMI ≤25 and 41% of them had a BMI30. In all, 68% of patients with OSA were discharged with continuous positive airway pressure (CPAP), 15% with Bilevel ventilation, and 17% without any ventilatory treatment. In conclusion, in the population studied, the combination of OSA and COPD was frequent. BMI and ESS values commonly considered cutoff values for the prediction of OSA in the general population may not be accurate in a subgroup of patients with COPD.

Background and Aims: COPD is a heterogeneous disease characterized by different phenotypes with either bronchial airways alterations or emphysema prevailing. We aimed to investigate the levels of blood biomarkers in COPD patients differentiated by phenotype: prevalent chronic airway disease vs. emphysema. Method: In 23 COPD patients with prevalent airway disease (COPD-B), 22 COPD patients with prevalent emphysema (COPD-E), 9 control smokers (CS) and 18 control nonsmokers (CNS), we analyzed the expression levels of IL-1α, IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, TNFα, IFNg, EGF, MCP-1 and VEGF by ELISA in plasma/serum; glutathione peroxidase (GPx1) and superoxide dismutase (SOD1) by immunochemical kits in plasma; and free F2-isoprostanes (F2-IsoPs) by gas chromatography in plasma. Results: F2-IsoPs level was increased in COPD-B and COPD-E compared to CS and CNS; also CS showed higher levels than CNS; SOD1 level was lower in COPD-B and COPD-E than CNS. Interestingly, MCP-1 level was higher only in COPD-E vs. CS and CNS; EGF and IL-8 levels were higher in COPD-B and COPD-E vs. CNS; IL-6 level was increased in all three smoking groups; IFNg and IL-1α levels were higher in CS than CNS; IL-1α level was also higher in CS vs. COPD-B and COPD-E. In all subjects, F2-IsoPs level correlated positively and significantly with MCP-1, IL-2, IL-1β, IFNg and TNFα, and negatively with SOD1. When correlations were restricted to E+B groups, F2-IsoPs maintained the positive associations with IFNg, TNFα and IL-2. Conclusions: The MCP-1 increase in COPD-E, associated to the imbalance of oxidant-anti-oxidant markers, may play a role in inducing emphysema.

Exercise tolerance may be significantly impaired in severe COPD. NIV increases the walking distance; however a 35% of patients do not tolerate it (Walker DJ et al. COPD 2015;1:546-51). Recently, it has been demonstrated that high flow nasal cannula (HFNC) improves the endurance time in severe COPD patients (Cirio S et al. Respir Med. 2016 Sep;118:128-132). However, the lack of an internal battery has limited its use for moving. Our study aimed to investigate if HFNC powered by an external battery increases the walking distance in COPD patients with exercise limitation. Thirteen stable COPD patients with a walking distance lower than 70% of predicted value associated to a modified Borg dyspnea SB ≥5 at 6-minute walk test (6MWT), were included. They performed two consecutive 6MWTs, in a randomised cross-over design: with and without HFNC at the same oxygen inhaled fraction. Twelve patients (one dropped-out) (mean ±SD age 69.5 ±10.3 yrs, forced expiratory volume in 1 second 25±5.6% predicted) were analysed. Walking distance was significantly higher using HFNC (median 306m (IQR 246-342) compare to no-HFNC (267m (IQR 228-294) (p In conclusion, HFNC may be safely used also during walking. In severe COPD with exercise limitation it improves the walking distance without worsening of dynamic hyperinflation.

Antonino Di Stefano,1 Teresa Coccini,2 Elisa Roda,2 Cinzia Signorini,3 Bruno Balbi,1 Giuseppe Brunetti,4 Piero Ceriana4 1Pulmonary Rehabilitation Unit and Laboratory of Cytoimmunopathology of the Heart and Lung, Istituti Clinici Scientifici Maugeri SpA Società Benefit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Veruno, Italy; 2Laboratory of Experimental and Clinical Toxicology, Toxicology Unit, ICS Maugeri SpA Società Benefit, Istituto di Ricovero e Cura a Carattere Scientifico, Pavia, Italy; 3Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy; 4Pulmonary Rehabilitation Unit, Istituti Clinici Scientifici Maugeri SpA Società Benefit, Istituto di Ricovero e Cura a Carattere Scientifico, Pavia, Italy Background and aims: Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease characterized by different phenotypes with either bronchial airways alterations or emphysema prevailing. As blood biomarkers could be clinically useful for COPD stratification, we aimed at investigating the levels of blood biomarkers in COPD patients differentiated by phenotype: prevalent chronic airway disease versus emphysema. Methods: In 23 COPD patients with prevalent airway disease (COPD-B), 22 COPD patients with prevalent emphysema (COPD-E), 9 control smokers (CSs), and 18 control nonsmokers (CNSs), we analyzed the expression levels of interleukin (IL)-1α, IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, tumor necrosis factor (TNF)-α, interferon (IFN)-γ, epidermal growth factor (EGF), monocyte chemotactic protein (MCP)-1, and vascular endothelial growth factor by enzyme-linked immunosorbent assay in plasma/serum; glutathione peroxidase and superoxide dismutase (SOD)-1 by immunochemical kits in plasma; and free F2-isoprostanes (F2-IsoPs) by gas chromatography in plasma. Results: F2-IsoPs level was increased in COPD-B and COPD-E compared with CSs and CNSs; in addition, CS showed higher levels than CNSs; SOD1 level was lower in COPD-B and COPD-E than that in CNSs. Interestingly, MCP-1 level was higher only in COPD-E versus CSs and CNSs; EGF and IL-8 levels were higher in COPD-B and COPD-E versus CNSs; IL-6 level was increased in all three smoking groups (COPD-B, COPD-E, and CSs) versus CNS; IFN-γ and IL-1α levels were higher in CSs than in CNSs; and IL-1α level was also higher in CSs versus COPD-B and COPD-E. In all subjects, F2-IsoPs level correlated positively and significantly with MCP-1, IL-2, IL-1β, IFN-γ, and TNF-α and negatively with SOD1. When correlations were restricted to COPD-E and COPD-B groups, F2-IsoPs maintained the positive associations with IFN-γ, TNF-α, and IL-2. Conclusion: We did not find any specific blood biomarkers that could differentiate COPD patients with prevalent airway disease from those with prevalent emphysema. The MCP-1 increase in COPD-E, associated with the imbalance of oxidant/antioxidant markers, may play a role in inducing emphysema. Keywords: serum, phenotypes, endotypes, biomarkers, asthma, airway inflammation

Background The coexistence of chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA), also referred to as overlap syndrome (OS), is associated with a high rate of morbidity, COPD exacerbations and mortality. Treatment with continuous positive airway pressure (CPAP) has proven to significantly decrease the rate of these complications. However, data concerning the effect of CPAP on pulmonary function are scarce and conflicting. The aim of our study was to evaluate the effect of 1 year of CPAP treatment on arterial blood gases (ABGs) and pulmonary function tests in patients with OS and its potential relationship with the baseline severity of airway obstruction. A secondary aim was to search for predictors of changes in the evaluated parameters. Methods A retrospective study on a cohort of 92 patients (74 males) discharged from the Pulmonary Rehabilitation Unit of the Istituti Clinici Scientifici Maugeri in Pavia (Italy) from January 2013 to January 2016, with a diagnosis of OS and a prescription of CPAP, was conducted. Collected data at discharge were compared with 1-year follow-up data. Results After 1 year of CPAP, we observed the following: (I) a significant improvement in ABGs in all patients [median pO2 65.0 (59.0-70.0) vs. 71 (64.8-77.1) mmHg, pCO2 39.8 (36.2-43.5) vs. 38.3 (32.3-44.2) at baseline and after 1 year respectively, P

Ventilation with continuous positive airway pressure (CPAP) is the gold standard therapy for obstructive sleep apnea (OSA). However, it was recently suggested that a novel mode of ventilation, Bilevel-auto, could be equally effective in treating patients unable to tolerate CPAP. The aim of this study was to investigate the ability of Bilevel-auto to treat OSA patients whose nocturnal ventilatory disturbances are not completely corrected by CPAP.We enrolled 66 consecutive OSA patients, not responsive to (group A) or intolerant of (group B) CPAP treatment, after a full night of manual CPAP titration in a laboratory. Full polysomnography data and daytime sleepiness score were compared for each group in the three different conditions: basal, during CPAP, and during Bilevel-auto.The apnea-hypopnea index decreased significantly during CPAP in both groups; however, in the group A, there was a further significant improvement during Bilevel-auto. The same trend was observed for oxygenation indices, while the distribution and the efficiency of sleep did not differ following the switch from CPAP to Bilevel-auto.This study confirmed the role of Bilevel-auto as an effective therapeutic alternative to CPAP in patients intolerant of this latter mode of ventilation. Moreover, extending the use of Bilevel-auto to those OSA patients not responsive to CPAP, we showed a significantly better correction of nocturnal respiratory disturbances.

Ventilator-associated pneumonia currently in vogue seems to have some pitfalls as far as the nomenclature is concerned and thus it imparts an erroneous impression to the reader. As the driving force is in fact the ventilator, the phraseology should preferably be changed to ventilator-induced pneumonia to convey the in depth meaning of the term thus evading the terminology currently in practice. A new and emerging paradigm dealing with all side effects of mechanical ventilation can be helpful to solve this etymological conflict.

Sepsis is a clinical syndrome affecting about 19 million people all over the world and with a death rate of about 10% among ICU patients. Systemic inflammatory response syndrome (SIRS) is the first step of the clinical cascade, followed by sepsis that is SIRS plus infection, severe sepsis that is sepsis plus acute organ dysfunction, while septic shock is a state of sepsis plus circulatory failure. The lungs and the cardiovascular system are almost always involved, followed by the kidney, the gut, the brain, and the endocrine system. Gram-negative and positive bacteria are responsible for about 75–80% cases of sepsis, while fungi are the etiologic factors in a far lower percentage of cases. Interaction between parts of bacterial cell wall and receptors on host cells of the innate immune system triggers the inflammatory cascade through intracellular transcription factors and signaling pathways, leading to the activation of immune response genes and generation of circulating cytokines. Uncontrolled activation and dysregulation of inflammatory cascade and coagulation system are the main pathogenetic mechanisms of sepsis. Initial management is based on early recognition, respiratory and circulatory resuscitation, and antibiotic treatment. Subsequent patient management is based on revision of initial antimicrobial therapy, vital organ support, tight glycemic control, adequate nutritional support, and prevention of complications and organ failure. It is important to approach the patient with strict diagnostic and therapeutic protocols: the so-called “bundles of care,” a group of evidence-based measures that carried out together and within a limited timeframe are far more effective than the same interventions performed individually and without a tight time constraint.

Symptoms, clinical course, functional and biological data during an exacerbation of chronic obstructive pulmonary disease (EXCOPD) have been investigated, but data on physiological changes of respiratory mechanics during a severe exacerbation with respiratory acidosis requiring noninvasive mechanical ventilation (NIMV) are scant. The aim of this study was to evaluate changes of respiratory mechanics in COPD patients comparing data observed during EXCOPD with those observed during stable state in the recovery phase. In 18 COPD patients having severe EXCOPD requiring NIMV for global respiratory failure, we measured respiratory mechanics during both EXCOPD (T0) and once the patients achieved a stable state (T1). The diaphragm and inspiratory muscles effort was significantly increased under relapse, as well as the pressure-time product of the diaphragm and the inspiratory muscle (PTPdi and PTPes). The resistive loads to breathe (i.e., PEEPi,dyn, compliance and inspiratory resistances) were also markedly increased, while the maximal pressures generated by the diaphragm and the inspiratory muscles, together with forced expired volumes were decreased. All these indices statistically improved but with a great intrasubject variability in stable condition. Moreover, tension-time index (TTdi) significantly improved from the EXCOPD state to the condition of clinical stability (0.156 ± 0.04 at T0 vs. 0.082 ± 0.02 at T1 p < 0.001). During an EXCOPD, the load/capacity of the respiratory pump is impaired, and although the patients exhibit a rapid shallow breathing pattern, this does not necessarily correlate with a TTdi ≥ 0.15. These changes are reverted once they recover from the EXCOPD, despite a large variability between patients.