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BACKGROUND: Laparoscopic surgery and Trendelenburg position may affect the respiratory function and alter the gas exchange. Further the reduction of the lung volumes may contribute to the development of expiratory flow limitation (EFL). The latter is associated with an increased risk of postoperative pulmonary complications. Our aim was to investigate the incidence of EFL and to evaluate its effect on pulmonary function and intraoperative V/Q mismatch.METHODS: This is a prospective study on patients undergoing elective laparoscopic gynecological surgery. We evaluated respiratory mechanics, V/Q mismatch and presence of EFL after anesthesia induction, during pneumoperitoneum and Trendelenburg position and at the end of surgery. Intraoperative gas exchange and hemodynamic were also recorded. Clinical data were collected until 7 days after surgery to evaluate the onset of pulmonary postoperative complications (PPCs).RESULTS: Among the 66 patients enrolled, 25/66 (38%) exhibited EFL during surgery, of whom 10/66 (15%) after anesthesia induction, and the remaining 15 patients after pneumoperitoneum and Trendelenburg position. Median PEEP able to reverse flow limitation was 7 [7-10] cmH2O after anesthesia induction and 9 [8-15] cmH2O after pneumoperitoneum and Trendelenburg position. Patients with EFL had significantly higher shunt (17 [2-25] vs. 9 [1-19]; P=0.05), low V̇/Q̇ (27 [20-70] vs. 15 [10-22]; P=0.05) and high V̇/Q̇ (10 [7-14] vs. 6 [4-7]; P=0.024). At the end of surgery, only high V/Q was significantly higher in EFL patients. Further, they exhibited higher incidence of postoperative pulmonary complication (48% (12/25) vs. 15% (6/41), P=0.005), hypoxemia and hypercapnia (80% [20/25] vs. 32% [13/41]; PCONCLUSIONS: Expiratory flow limitation is a common phenomenon during gynecological laparoscopic surgery associated with worsen gas exchange, increased V/Q mismatch and altered lung mechanics. Our study showed that patients experiencing EFL during surgery showed a higher risk for PPCs.

Background: The COVID-19 pandemic had a relevant impact on the organization of intensive care units (ICU) and may have reduced the overall compliance with healthcare-associated infections (HAIs) prevention programs. Invasively ventilated patients are at high risk of ICU-associated infection, but there is little evidence regarding the impact of the pandemic on their occurrence in non-COVID-19 patients. Moreover, little is known of antibiotic prescription trends in the ICU during the first wave of the pandemic. The purpose of this investigation is to assess the incidence, characteristics, and risk factors for ICU-associated HAIs in a population of invasively ventilated patients affected by non-COVID-19 acute respiratory failure (ARF) admitted to the ICU in the first wave of the COVID-19 pandemic, and to evaluate the ICU antimicrobial prescription strategies. Moreover, we compared HAIs and antibiotic use to a cohort of ARF patients admitted to the ICU the year before the pandemic during the same period. Methods: this is a retrospective, single-centered cohort study conducted at S. Anna University Hospital (Ferrara, Italy). We enrolled patients admitted to the ICU for acute respiratory failure requiring invasive mechanical ventilation (MV) between February and April 2020 (intra-pandemic group, IP) and February and April 2019 (before the pandemic group, PP). We excluded patients admitted to the ICU for COVID-19 pneumonia. We recorded patients’ baseline characteristics, ICU-associated procedures and devices. Moreover, we evaluated antimicrobial therapy and classified it as prophylactic, empirical or target therapy, according to the evidence of infection at the time of prescription and to the presence of a positive culture sample. We compared the results of the two groups (PP and IP) to assess differences between the two years. Results: One hundred and twenty-eight patients were screened for inclusion and 83 patients were analyzed, 45 and 38 in the PP and I group, respectively. We found a comparable incidence of HAIs (62.2% vs. 65.8%, p = 0.74) and multidrug-resistant (MDR) isolations (44.4% vs. 36.8% p= 0.48) in the two groups. The year of ICU admission was not independently associated with an increased risk of developing HAIs (OR = 0.35, 95% CI 0.16–1.92, p = 0.55). The approach to antimicrobial therapy was characterized by a significant reduction in total antimicrobial use (21.4 ± 18.7 vs. 11.6 ± 9.4 days, p = 0.003), especially of target therapy, in the IP group. Conclusions: ICU admission for non-COVID-19 ARF during the first wave of the SARS-CoV-2 pandemic was not associated with an increased risk of ICU-associated HAIs. Nevertheless, ICU prescription of antimicrobial therapy changed and significantly decreased during the pandemic.

BACKGROUND: High intraoperative PEEP with recruitment manoeuvres may improve perioperative outcomes. We re-examined this question by conducting a patient-level meta-analysis of three clinical trials in adult patients at increased risk for postoperative pulmonary complications who underwent non-cardiothoracic and non-neurological surgery. METHODS: The three trials enrolled patients at 128 hospitals in 24 countries from February 2011 to February 2018. All patients received volume-controlled ventilation with low tidal volume. Analyses were performed using one-stage, two-level, mixed modelling (site as a random effect; trial as a fixed effect). The primary outcome was a composite of postoperative pulmonary complications within the first week, analysed using mixed-effect logistic regression. Pre-specified subgroup analyses of nine patient characteristics and seven procedure and care-delivery characteristics were also performed. RESULTS: Complete datasets were available for 1913 participants ventilated with high PEEP and recruitment manoeuvres, compared with 1924 participants who received low PEEP. The primary outcome occurred in 562/1913 (29.4%) participants randomised to high PEEP, compared with 620/1924 (32.2%) participants randomised to low PEEP (unadjusted odds ratio [OR]=0.87; 95% confidence interval [95% CI], 0.75-1.01; P=0.06). Higher PEEP resulted in 87/1913 (4.5%) participants requiring interventions for desaturation, compared with 216/1924 (11.2%) participants randomised to low PEEP (OR=0.34; 95% CI, 0.26-0.45). Intraoperative hypotension was associated more frequently (784/1913 [41.0%]) with high PEEP, compared with low PEEP (579/1924 [30.1%]; OR=1.87; 95% CI, 1.60-2.17). CONCLUSIONS: High PEEP combined with recruitment manoeuvres during low tidal volume ventilation in patients undergoing major surgery did not reduce postoperative pulmonary complications. CLINICAL TRIAL REGISTRATION: NCT03937375 (Clinicaltrials.gov).

Objectives Different techniques exist to select personalized positive end-expiratory pressure in patients affected by the acute respiratory distress syndrome. The positive end-expiratory transpulmonary pressure strategy aims to counteract dorsal lung collapse, whereas electrical impedance tomography could guide positive end-expiratory pressure selection based on optimal homogeneity of ventilation distribution. We compared the physiologic effects of positive end-expiratory pressure guided by electrical impedance tomography versus transpulmonary pressure in patients affected by acute respiratory distress syndrome. Design Cross-over prospective physiologic study. Setting Two academic ICUs. Patients Twenty ICU patients affected by acute respiratory distress syndrome undergoing mechanical ventilation. Intervention Patients monitored by an esophageal catheter and a 32-electrode electrical impedance tomography monitor underwent two positive end-expiratory pressure titration trials by randomized cross-over design to find the level of positive end-expiratory pressure associated with: 1) positive end-expiratory transpulmonary pressure (PEEPPL) and 2) proportion of poorly or nonventilated lung units (Silent Spaces) less than or equal to 15% (PEEPEIT). Each positive end-expiratory pressure level was maintained for 20 minutes, and afterward, lung mechanics, gas exchange, and electrical impedance tomography data were collected. Measurements and main results PEEPEIT and PEEPPL differed in all patients, and there was no correlation between the levels identified by the two methods (Rs = 0.25; p = 0.29). PEEPEIT determined a more homogeneous distribution of ventilation with a lower percentage of dependent Silent Spaces (p = 0.02), whereas PEEPPL was characterized by lower airway-but not transpulmonary-driving pressure (p = 0.04). PEEPEIT was significantly higher than PEEPPL in subjects with extrapulmonary acute respiratory distress syndrome (p = 0.006), whereas the opposite was true for pulmonary acute respiratory distress syndrome (p = 0.03). Conclusions Personalized positive end-expiratory pressure levels selected by electrical impedance tomography- and transpulmonary pressure-based methods are not correlated at the individual patient level. PEEPPL is associated with lower dynamic stress, whereas PEEPEIT may help to optimize lung recruitment and homogeneity of ventilation. The underlying etiology of acute respiratory distress syndrome could deeply influence results from each method.

BACKGROUND: One key element of lung-protective ventilation is the use of a low tidal volume (V(T)). A sex difference in use of low tidal volume ventilation (LTVV) has been described in critically ill ICU patients. OBJECTIVES: The aim of this study was to determine whether a sex difference in use of LTVV also exists in operating room patients, and if present what factors drive this difference. DESIGN, PATIENTS AND SETTING: This is a posthoc analysis of LAS VEGAS, a 1-week worldwide observational study in adults requiring intra-operative ventilation during general anaesthesia for surgery in 146 hospitals in 29 countries. MAIN OUTCOME MEASURES: Women and men were compared with respect to use of LTVV, defined as V(T) of 8 ml kg(−1) or less predicted bodyweight (PBW). A V(T) was deemed ‘default’ if the set V(T) was a round number. A mediation analysis assessed which factors may explain the sex difference in use of LTVV during intra-operative ventilation. RESULTS: This analysis includes 9864 patients, of whom 5425 (55%) were women. A default V(T) was often set, both in women and men; mode V(T) was 500 ml. Median [IQR] V(T) was higher in women than in men (8.6 [7.7 to 9.6] vs. 7.6 [6.8 to 8.4] ml kg(−1) PBW, P*** < 0.001). Compared with men, women were twice as likely not to receive LTVV [68.8 vs. 36.0%; relative risk ratio 2.1 (95% CI 1.9 to 2.1), P*** < 0.001]. In the mediation analysis, patients’ height and actual body weight (ABW) explained 81 and 18% of the sex difference in use of LTVV, respectively; it was not explained by the use of a default V(T). CONCLUSION: In this worldwide cohort of patients receiving intra-operative ventilation during general anaesthesia for surgery, women received a higher V(T) than men during intra-operative ventilation. The risk for a female not to receive LTVV during surgery was double that of males. Height and ABW were the two mediators of the sex difference in use of LTVV. TRIAL REGISTRATION: The study was registered at Clinicaltrials.gov, NCT01601223

Background Expiratory flow limitation (EFL) is characterised by a markedly reduced expiratory flow insensitive to the expiratory driving pressure. The presence of EFL can influence the respiratory and cardiovascular function and damage the small airways; its occurrence has been demonstrated in different diseases, such as COPD, asthma, obesity, cardiac failure, ARDS, and cystic fibrosis. Our aim was to evaluate the prevalence of EFL in patients requiring mechanical ventilation for acute respiratory failure and to determine the main clinical characteristics, the risk factors and clinical outcome associated with the presence of EFL. Methods Patients admitted to the intensive care unit (ICU) with an expected length of mechanical ventilation of 72 h were enrolled in this prospective, observational study. Patients were evaluated, within 24 h from ICU admission and for at least 72 h, in terms of respiratory mechanics, presence of EFL through the PEEP test, daily fluid balance and followed for outcome measurements. Results Among the 121 patients enrolled, 37 (31%) exhibited EFL upon admission. Flow-limited patients had higher BMI, history of pulmonary or heart disease, worse respiratory dyspnoea score, higher intrinsic positive end-expiratory pressure, flow and additional resistance. Over the course of the initial 72 h of mechanical ventilation, additional 21 patients (17%) developed EFL. New onset EFL was associated with a more positive cumulative fluid balance at day 3 (103.3 ml/kg) compared to that of patients without EFL (65.8 ml/kg). Flow-limited patients had longer duration of mechanical ventilation, longer ICU length of stay and higher in-ICU mortality. Conclusions EFL is common among ICU patients and correlates with adverse outcomes. The major determinant for developing EFL in patients during the first 3 days of their ICU stay is a positive fluid balance. Further studies are needed to assess if a restrictive fluid therapy might be associated with a lower incidence of EFL.

Coagulation disorders and thrombocytopenia are common in patients with septic shock, but only few studies have focused on platelet variables beyond platelet count. The aim of this study was to evaluate whether platelets reactivity predicts sepsis-induced thrombocytopenia in patients with septic shock. We therefore enrolled consecutive patients with septic shock and platelets count >150*103/μL on the day of the diagnosis. Platelets reactivity tests were performed daily from the diagnosis of septic shock until day five; platelet volume distribution and mean platelet volume were also recorded daily. Sepsis-induced thrombocytopenia was defined as a platelet count

Mechanical ventilation (MV) is still necessary in many surgical procedures; nonetheless, intraoperative MV is not free from harmful effects. Protective ventilation strategies, which include the combination of low tidal volume and adequate positive end expiratory pressure (PEEP) levels, are usually adopted to minimize the ventilation-induced lung injury and to avoid post-operative pulmonary complications (PPCs). Even so, volutrauma and atelectrauma may co-exist at different levels of tidal volume and PEEP, and therefore, the physiological response to the MV settings should be monitored in each patient. A personalized perioperative approach is gaining relevance in the field of intraoperative MV; in particular, many efforts have been made to individualize PEEP, giving more emphasis on physiological and functional status to the whole body. In this review, we summarized the latest findings about the optimization of PEEP and intraoperative MV in different surgical settings. Starting from a physiological point of view, we described how to approach the individualized MV and monitor the effects of MV on lung function.

Co-infections in critically ill patients hospitalized for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have an important impact on the outcome of coronavirus disease 2019 (COVID-19). We compared the microbial isolations found in COVID-19 patients hospitalized in an intensive care unit (ICU) with those in a non-COVID-19 ICU from 22 February to 30 April 2020 and in the same period of 2019. We considered blood, urine or respiratory specimens obtained with bronchoalveolar lavage (BAL) or bronchial aspirate (BASP), collected from all patients admitted in ICUs with or without COVID-19 infection. We found a higher frequency of infections due to methicillin-resistant (MR) staphylococci, vancomycin-resistant Enterococcus faecium, carbapenem-resistant Acinetobacter baumannii and Candida parapsilosis in COVID-19-positive patients admitted in ICUs compared to those who were COVID-19 negative. Carbapenem-resistant Pseudomonas aeruginosa was more frequently isolated from patients admitted in non-COVID-19 ICUs. Several conditions favor the increased frequency of these infections by antibiotic-resistant microorganisms. Among all, the severity of the respiratory tracts was definitely decisive, which required assisted ventilation with invasive procedures. The turnover in the ICU of a large number of patients in a very short time requiring urgent invasive interventions has favored the not always suitable execution of assistance procedures. No less important is the increased exposure to infectious risk from bacteria and fungi in patients with severe impairment due to ventilation. The highest costs for antifungal drugs were shown in the ICU-COVID group.

In this proof-of-concept study the impact of central venous pressure (CVP) on internal jugular veins cross-sectional area (CSA) and blood flow time-average velocity (TAV) was evaluated in eight subjects, with the aim of understanding the drivers of the jugular venous pulse. CVP was measured using a central venous catheter while CSA variation and TAV along a cardiac cycle were acquired using ultrasound. Analysis of CVP, CSA and TAV time-series signals revealed TAV and CSA to lag behind CVP by on average 0.129 s and 0.138 s, with an inverse correlation between CSA and TAV (r= –0.316). The respective autocorrelation signals were strongly correlated (mean r=0.729-0.764), with mean CSA periodicity being 1.062 Hz. Fourier analysis revealed the frequency spectrums of CVP, TAV and CSA signals to be dominated by frequencies at approximately 1 and 2 Hz, with those >1 Hz greatly attenuated in the CSA signal. Because the autocorrelograms and periodograms of the respective signals were aligned and dominated by the same underlying frequencies, this suggested that they are more easily interpreted in the frequency domain rather than the time domain.

During one-lung ventilation (OLV), titrating the positive end-expiratory pressure (PEEP) to target a low driving pressure (∆P) could reduce postoperative pulmonary complications. However, it is unclear how to conduct PEEP titration: by stepwise increase starting from zero PEEP (PEEP INCREMENTAL) or by stepwise decrease after a lung recruiting manoeuvre (PEEP DECREMENTAL). In this randomized trial, we compared the physiological effects of these two PEEP titration strategies on respiratory mechanics, ventilation/perfusion mismatch and gas exchange. Patients undergoing video-assisted thoracoscopic surgery in OLV were randomly assigned to a PEEP INCREMENTAL or PEEP DECREMENTAL strategy to match the lowest ∆P. In the PEEP INCREMENTAL group, PEEP was stepwise titrated from ZEEP up to 16 cm H 2O, whereas in the PEEP DECREMENTAL group PEEP was decrementally titrated, starting from 16 cm H 2O, immediately after a lung recruiting manoeuvre. Respiratory mechanics, ventilation/perfusion mismatch and blood gas analyses were recorded at baseline, after PEEP titration and at the end of surgery. Sixty patients were included in the study. After PEEP titration, shunt decreased similarly in both groups, from 50 [39–55]% to 35 [28–42]% in the PEEP INCREMENTAL and from 45 [37–58]% to 33 [25–45]% in the PEEP DECREMENTAL group (both p < 0.001 vs baseline). The resulting ∆P, however, was lower in the PEEP DECREMENTAL than in the PEEP INCREMENTAL group (8 [7–11] vs 10 [9–11] cm H 2O; p = 0.03). In the PEEP DECREMENTAL group the PaO 2/ FIO 2 ratio increased significantly after intervention (from 140 [99–176] to 186 [152–243], p < 0.001). Both the PEEP INCREMENTAL and the PEEP DECREMENTAL strategies were able to decrease intraoperative shunt, but only PEEP DECREMENTAL improved oxygenation and lowered intraoperative ΔP. Clinical trial number NCT03635281; August 2018; “retrospectively registered”.

ObjectivesAcquiring central venous pressure (CVP), an important clinical parameter, requires an invasive procedure, which poses risk to patients. The aim of the study was to develop a non-invasive methodology for determining mean-CVP from ultrasound assessment of the jugular venous pulse.MethodsIn thirty-four adult patients (age = 60 ± 12 years; 10 males), CVP was measured using a central venous catheter, with internal jugular vein (IJV) cross-sectional area (CSA) variation along the cardiac beat acquired using ultrasound. The resultant CVP and IJV-CSA signals were synchronized with electrocardiogram (ECG) signals acquired from the patients. Autocorrelation signals were derived from the IJV-CSA signals using algorithms in R (open-source statistical software). The correlation r-values for successive lag intervals were extracted and used to build a linear regression model in which mean-CVP was the response variable and the lagging autocorrelation r-values and mean IJV-CSA, were the predictor variables. The optimum model was identified using the minimum AIC value and validated using 10-fold cross-validation.ResultsWhile the CVP and IJV-CSA signals were poorly correlated (mean r = -0.018, SD = 0.357) due to the IJV-CSA signal lagging behind the CVP signal, their autocorrelation counterparts were highly positively correlated (mean r = 0.725, SD = 0.215). Using the lagging autocorrelation r-values as predictors, mean-CVP was predicted with reasonable accuracy (r2 = 0.612), with a mean-absolute-error of 1.455 cmH2O, which rose to 2.436 cmH2O when cross-validation was performed.ConclusionsMean-CVP can be estimated non-invasively by using the lagged autocorrelation r-values of the IJV-CSA signal. This new methodology may have considerable potential as a clinical monitoring and diagnostic tool.

BACKGROUND Red blood cell distribution width (RDW) is a measure of anisocytosis, generally used in the differential diagnosis of anemia. Recently, RDW was associated with increased mortality in critically ill patients. Red blood cell (RBC) transfusions are potential confounders on RDW values interpretation. The aim of this study was to analyze the changes in RDW after RBC transfusion in intensive care unit (ICU) patients. STUDY DESIGN AND METHODS This was a prospective, observational study including patients admitted to ICU requiring 1 RBC unit. We analyzed RDW values of the patients at four study points: before RBC transfusion (T1), immediately after transfusion (T2), 24 hours after transfusion (T3), and 48 hours after transfusion (T4). We also collected laboratory data from donors and RBC units. Changes of RDW (ΔRDW) were computed as the difference between baseline RDW value and RDW at each time point after transfusion. RESULTS We enrolled 36 patients. RDW values increased after transfusion (p

Background Arterial oxygenation is often impaired during one-lung ventilation, due to both pulmonary shunt and atelectasis. The use of low tidal volume (VT) (5 ml/kg predicted body weight) in the context of a lung-protective approach exacerbates atelectasis. This study sought to determine the combined physiologic effects of positive end-expiratory pressure and low VT during one-lung ventilation. Methods Data from 41 patients studied during general anesthesia for thoracic surgery were collected and analyzed. Shunt fraction, high V/Q and respiratory mechanics were measured at positive end-expiratory pressure 0 cm H2O during bilateral lung ventilation and one-lung ventilation and, subsequently, during one-lung ventilation at 5 or 10 cm H2O of positive end-expiratory pressure. Shunt fraction and high V/Q were measured using variation of inspired oxygen fraction and measurement of respiratory gas concentration and arterial blood gas. The level of positive end-expiratory pressure was applied in random order and maintained for 15 min before measurements. Results During one-lung ventilation, increasing positive end-expiratory pressure from 0 cm H2O to 5 cm H2O and 10 cm H2O resulted in a shunt fraction decrease of 5% (0 to 11) and 11% (5 to 16), respectively (P < 0.001). The Pao2/Fio2 ratio increased significantly only at a positive end-expiratory pressure of 10 cm H2O (P < 0.001). Driving pressure decreased from 16 ± 3 cm H2O at a positive end-expiratory pressure of 0 cm H2O to 12 ± 3 cm H2O at a positive end-expiratory pressure of 10 cm H2O (P < 0.001). The high V/Q ratio did not change. Conclusions During low VT one-lung ventilation, high positive end-expiratory pressure levels improve pulmonary function without increasing high V/Q and reduce driving pressure.

BACKGROUND Prolonged storage of red blood cells (RBCs) is a potential risk factor for postoperative infections. The objective of this study was to examine the effect of age of RBCs transfused on development of postoperative infection. STUDY DESIGN AND METHODS In this prospective, double-blind randomized trial, 199 patients undergoing elective noncardiac surgery and requiring RBC transfusion were assigned to receive nonleukoreduced RBCs stored for not more than 14 days (“fresh blood” group, n = 101) or for more than 14 days (“old blood” group, n = 98). The primary outcome was occurrence of infection within 28 days after surgery; secondary outcomes were postoperative acute kidney injury (AKI), in-hospital and 90-day mortality, admission to intensive care unit, and hospital length of stay (LOS). As older blood was not always available, an “as-treated” (AT) analysis was also performed according to actual age of the RBCs transfused. RESULTS The median [interquartile range] storage time of RBCs was 6 [5-10] and 15 [11-20] days in fresh blood and in old blood groups, respectively. The occurrence of postoperative infection did not differ between groups (fresh blood 22% vs. old blood 25%; relative risk [RR], 1.17; confidence interval [CI], 0.71-1.93), although wound infections occurred more frequently in old blood (15% vs. 5%; RR, 3.09; CI, 1.17- 8.18). Patients receiving older units had a higher rate of AKI (24% vs. 6%; p

Background Guidelines recommend a restrictive red blood cell transfusion strategy based on hemoglobin (Hb) concentrations in critically ill patients. We hypothesized that the arterial-venous oxygen difference (A-V O2diff), a surrogate for the oxygen delivery to consumption ratio, could provide a more personalized approach to identify patients who may benefit from transfusion. Methods A prospective observational study including 177 non-bleeding adult patients with a Hb concentration of 7.0–10.0 g/dL within 72 h after ICU admission. The A-V O2diff, central venous oxygen saturation (ScvO2), and oxygen extraction ratio (O2ER) were noted when a patient’s Hb was first within this range. Transfusion decisions were made by the treating physician according to institutional policy. We used the median A-V O2diff value in the study cohort (3.7 mL) to classify the transfusion strategy in each patient as “appropriate” (patient transfused when the A-V O2diff > 3.7 mL or not transfused when the A-V O2diff ≤ 3.7 mL) or “inappropriate” (patient transfused when the A-V O2diff ≤ 3.7 mL or not transfused when the A-V O2diff > 3.7 mL). The primary outcome was 90-day mortality. Results Patients managed with an “appropriate” strategy had lower mortality rates (23/96 [24%] vs. 36/81 [44%]; p = 0.004), and an “appropriate” strategy was independently associated with reduced mortality (hazard ratio [HR] 0.51 [95% CI 0.30–0.89], p = 0.01). There was a trend to less acute kidney injury with the “appropriate” than with the “inappropriate” strategy (13% vs. 26%, p = 0.06), and the Sequential Organ Failure Assessment (SOFA) score decreased more rapidly (p = 0.01). The A-V O2diff, but not the ScvO2, predicted 90-day mortality in transfused (AUROC = 0.656) and non-transfused (AUROC = 0.630) patients with moderate accuracy. Using the ROC curve analysis, the best A-V O2diff cutoffs for predicting mortality were 3.6 mL in transfused and 3.5 mL in non-transfused patients. Conclusions In anemic, non-bleeding critically ill patients, transfusion may be associated with lower 90-day mortality and morbidity in patients with higher A-V O2diff. Trial registration ClinicalTrials.gov, NCT03767127. Retrospectively registered on 6 December 2018.

Background Red blood cell distribution width (RDW) value is gaining popularity as a prognostic factor in critically ill patients. However, its role in transfused patients is unclear. The aim of this study was to evaluate the predictive value of Red blood cell distribution width (RDW) on Intensive Care Unit (ICU) admission for 90-day mortality among either transfused or non-transfused critically ill patients. Methods This observational cohort study includes 286 patients with at least 48 hours of ICU length of stay. Patients were analyzed separately in two groups, depending on whether or not they were transfused in the last 72 hours before ICU admission. Results One hundred seventeen (117) patients (41%) were transfused. Patients with high RDW on admission (N.=181, 63%) had higher 90-day mortality both in non-transfused (26/87, 30% vs. 12/82, 14% P=0.03) or transfused (39/94, 41% vs. 2/23, 8% P=0.003) patients. The area under the curve of admission RDW values to predict 90-day mortality was 0.660 and 0.610 for non-transfused and transfused patients, respectively. The Youden Index analysis showed that an RDW value of 14.3% was the best cut-off to predict mortality in the non-transfused group, while 15.3% was the best cut-off in the transfused group. Conclusions High RDW values on ICU admission are independently associated with 90-day mortality in critically ill patients regardless of previous red blood cells transfusion. However, we identified two different cut-offs of "high RDW" to be used in ICU in transfused and non-transfused patients.

Acute lung injury (ALI) affects over 10% of patients hospitalised in critical care, with acute respiratory distress syndrome (ARDS) being the most severe form of ALI and having a mortality rate in the region of 40%. There has been slow but incremental progress in identification of biomarkers that contribute to the pathophysiology of ARDS, have utility in diagnosis and monitoring, and that are potential therapeutic targets (Calfee CS, Delucchi K, Parsons PE, Thompson BT, Ware LB, Matthay MA, Thompson T, Ware LB, Matthay MA, Lancet Respir Med 2014, 2:611–-620). However, a major issue is that ARDS is such a heterogeneous, multi-factorial, end-stage condition that the strategies for “lumping and splitting” are critical (Prescott HC, Calfee CS, Thompson BT, Angus DC, Liu VX, Am J Respir Crit Care Med 2016, 194:147–-155). Nevertheless, sequencing of the human genome, the availability of improved methods for analysis of transcription to mRNA (gene expression), and development of sensitive immunoassays has allowed the application of network biology to ARDS, with these biomarkers offering potential for personalised or precision medicine (Sweeney TE, Khatri P, Toward precision medicine Crit Care Med; 2017 45:934-939). Biomarker panels have potential applications in molecular phenotyping for identifying patients at risk of developing ARDS, diagnosis of ARDS, risk stratification and monitoring. Two subphenotypes of ARDS have been identified on the basis of blood biomarkers: hypo-inflammatory and hyper-inflammatory. The hyper-inflammatory subphenotype is associated with shock, metabolic acidosis and worst clinical outcomes. Biomarkers of particular interest have included interleukins (IL-6 and IL-8), interferon gamma (IFN-γ), surfactant proteins (SPD and SPB), von Willebrand factor antigen, angiopoietin 1/2 and plasminogen activator inhibitor-1 (PAI-1). In terms of gene expression (mRNA) in blood there have been found to be increases in neutrophil-related genes in sepsis-induced and influenza-induced ARDS, but whole blood expression does not give a robust diagnostic test for ARDS. Despite improvements in management of ARDS on the critical care unit, this complex disease continues to be a major life-threatening event. Clinical trials of β2-agonists, statins, surfactants and keratinocyte growth factor (KGF) have been disappointing. In addition, monoclonal antibodies (anti-TNF) and TNFR fusion protein have also been unconvincing. However, there have been major advances in methods of mechanical ventilation, a neuromuscular blocker (cisatracurium besilate) has shown some benefit, and stem cell therapy is being developed. In the future, by understanding the role of biomarkers in the pathophysiology of ARDS and lung injury, it is hoped that this will provide rational therapeutic targets and ultimately improve clinical care (Seymour CW, Gomez H, Chang CH, Clermont G, Kellum JA, Kennedy J, Yende S, Angus DC, Crit Care 2017, 21:257).

Background The pressure-volume (P-V) curve has been suggested as a bedside tool to set mechanical ventilation; however, it reflects a global behavior of the lung without giving information on the regional mechanical properties. Regional P-V (PVr) curves derived from electrical impedance tomography (EIT) could provide valuable clinical information at bedside, being able to explore the regional mechanics of the lung. In the present study, we hypothesized that regional P-V curves would provide different information from those obtained from global P-V curves, both in terms of upper and lower inflection points. Therefore, we constructed pressure-volume curves for each pixel row from non-dependent to dependent lung regions of patients affected by acute hypoxemic respiratory failure (AHRF) and acute respiratory distress syndrome (ARDS). Methods We analyzed slow-inflation P-V maneuvers data from 12 mechanically ventilated patients. During the inflation, the pneumotachograph was used to record flow and airway pressure while the EIT signals were recorded digitally. From each maneuver, global respiratory system P-V curve (PVg) and PVr curves were obtained, each one corresponding to a pixel row within the EIT image. PVg and PVr curves were fitted using a sigmoidal equation, and the upper (UIP) and lower (LIP) inflection points for each curve were mathematically identified; LIP and UIP from PVg were respectively called LIPg and UIPg. From each measurement, the highest regional LIP (LIPrMAX) and the lowest regional UIP (UIPrMIN) were identified and the pressure difference between those two points was defined as linear driving pressure (ΔPLIN). Results A significant difference (p

BACKGROUND: General anaesthesia decreases pulmonary compliance and increases pulmonary shunt due to the development of atelectasis. The presence of capnoperitoneum during laparoscopic surgery may further decrease functional residual capacity, promoting an increased amount of atelectasis compared with laparotomy. The aim of this study was to evaluate the effects of different levels of positive end-expiratory pressure (PEEP) in both types of surgery and to investigate whether higher levels of PEEP should be used during laparoscopic surgery.METHODS: This prospective observational study included 52 patients undergoing either laparotomy or laparoscopic surgery. Three levels of PEEP were applied in random order: (1) zero (ZEEP), (2) 5 cmH2O and (3) 10 cmH2O. Pulmonary shunt and ventilation/perfusion mismatch were assessed by the automatic lung parameter estimator system.RESULTS: Pulmonary shunt was similar in both groups. However, in laparotomy, a PEEP of 5 cmH2O significantly decreased shunt when compared with ZEEP (12 vs 6%; P=0.001), with additional PEEP having no further effect. In laparoscopic surgery, a significant reduction in shunt (13 vs 6%; P=0.001) was obtained only at a PEEP of 10 cmH2O. Although laparoscopic surgery was associated with a lower pulmonary compliance, increasing levels of PEEP were able to ameliorate it in both groups.CONCLUSION: Both surgeries have similar negative effects on pulmonary shunt, while the presence of capnoperitoneum reduced only the pulmonary compliance. It appears that a more aggressive PEEP level is required to reduce shunt and to maximize compliance in case of laparoscopic surgery.

Video-assisted thoracoscopic surgery (VATS) is a minimally invasive technique that allows a faster recovery after thoracic surgery. Although enhanced recovery after surgery (ERAS) principles seem reasonably applicable to thoracic surgery, there is little literature on the application of such a strategy in this context. In regard to pain management, ERAS pathways promote the adoption of a multimodal strategy, tailored to the patients. This approach is based on combining systemic and loco-regional analgesia to favour opioid-sparing strategies. Thoracic paravertebral block is considered the first-line loco-regional technique for VATS. Other techniques include intercostal nerve block and serratus anterior plane block. Nonsteroidal anti-inflammatory drugs and paracetamol are essential part of the multimodal treatment of pain. Also, adjuvant drugs can be useful as opioid-sparing agents. Nevertheless, the treatment of postoperative pain must take into account opioid agents too, if necessary. All above is useful for careful planning and execution of a multimodal analgesic treatment to enhance the recovery of patients. This article summarizes the most recent evidences from literature and authors' experiences on perioperative multimodal analgesia principles for implementing an ERAS program after VATS lobectomy.

Effective postoperative pain control after thoracic surgery is a significant clinical issue because it reduces pulmonary complications and accelerates the pace of recovery. Persistent postoperative pain syndrome is a recognized and frequent complication after thoracoscopic surgery. The capsaicin 8% patch contains a high concentration of synthetic capsaicin approved for treatment of peripheral neuropathic pain in adults. Little clinical data exist on the use of capsaicin patch in thoracic persistent postoperative pain syndrome. This report included two patients who were evaluated after receiving capsaicin for thoracic surgery. Satisfactory pain relief was achieved in both cases without side effects.

OBJECTIVES: To evaluate the physiologic effects of applying advice on mechanical ventilation by an open-loop, physiologic model-based clinical decision support system.DESIGN: Prospective, observational study.SETTING: University and Regional Hospitals' ICUs.PATIENTS: Varied adult ICU population.INTERVENTIONS: Advice were applied if accepted by physicians for a period of up to 4-8 hours.MEASUREMENTS AND MAIN RESULTS: Seventy-two patients were included for data analysis. Acceptance of advice was high with 95.7% of advice applied. In 41 patients in pressure support ventilation, following system advice led to significant decrease in PS, with PS reduced below 8 cm H2O in 15 patients (37%), a level not prohibiting extubation. Fraction of end-tidal CO2 values did not change, and increase in respiratory rate/VT was within clinical limits, indicating that in general, the system maintained appropriate patient breathing effort. In 31 patients in control mode ventilation, pressure control and tidal volume settings were decreased significantly, with tidal volume reduced below 8 mL/kg predicted body weight in nine patients (29%). Minute ventilation was maintained by a significant increase in respiratory rate. Significant reductions in FIO2 were seen on elevated baseline median values of 50% in both support and control mode-ventilated patients, causing clinically acceptable reductions in oxygen saturation.CONCLUSIONS: The results indicate that during a short period, the clinical decision support system provided appropriate suggestions of mechanical ventilation in a varied ICU population, significantly reducing ventilation to levels which might be considered safe and beneficial.

Red blood cell distribution width (RDW) is a measure of anisocytosis, generally used in the differential diagnosis of anemia. Recently, RDW was associated with increased mortality in critically ill patients. Red blood cell (RBC) transfusions are potential confounders on RDW values interpretation. The aim of this study was to analyze the changes in RDW after RBC transfusion in intensive care unit (ICU) patients.This was a prospective, observational study including patients admitted to ICU requiring 1 RBC unit. We analyzed RDW values of the patients at four study points: before RBC transfusion (T1), immediately after transfusion (T2), 24 hours after transfusion (T3), and 48 hours after transfusion (T4). We also collected laboratory data from donors and RBC units. Changes of RDW (ΔRDW) were computed as the difference between baseline RDW value and RDW at each time point after transfusion.We enrolled 36 patients. RDW values increased after transfusion (p 0.001 at all points vs. baseline), with the highest level at T3. At T3, 34 of 36 patients (94%) had an abnormal RDW value (vs. 26/36, 72%) at baseline (p = 0.023). The maximum ΔRDW for each patient was moderately correlated with the difference between mean corpuscular volume (MCV)RBC transfusion significantly increased RDW values. This intervention should be accurately reported in the studies evaluating the prognostic role of RDW.

Enhanced recovery after surgery (ERAS) programs are developed to prevent factors that delay postoperative recovery as well as issues that cause complications. The development of video-assist thoracoscopic surgery (VATS) techniques favors the fast recovery after thoracic procedures. ERAS strategies are based on multidisciplinary approach in which the anesthetist plays an important role from the preoperative to the postoperative phase with several goals. After preoperative evaluation and medical optimization, the anesthetist must ensure a tailored anesthetic plan aiming to a fast recovery and adequate pain relief to reduce the response to the surgical stress. The present narrative review presents the major parts of the ERAS anesthetic approach to VATS lobectomy like short-acting drugs, protective one-lung ventilation (OLV), fluid administration and opioid-sparing multimodal analgesia.

Background Assessing alveolar recruitment at different positive end-expiratory pressure (PEEP) levels is a major clinical and research interest because protective ventilation implies opening the lung without inducing overdistention. The pressure-volume (P-V) curve is a validated method of assessing recruitment but reflects global characteristics, and changes at the regional level may remain undetected. The aim of the present study was to compare, in intubated patients with acute hypoxemic respiratory failure (AHRF) and acute respiratory distress syndrome (ARDS), lung recruitment measured by P-V curve analysis, with dynamic changes in poorly ventilated units of the dorsal lung (dependent silent spaces [DSSs]) assessed by electrical impedance tomography (EIT). We hypothesized that DSSs might represent a dynamic bedside measure of recruitment. Methods We carried out a prospective interventional study of 14 patients with AHRF and ARDS admitted to the intensive care unit undergoing mechanical ventilation. Each patient underwent an incremental/decremental PEEP trial that included five consecutive phases: PEEP 5 and 10 cmH2O, recruitment maneuver + PEEP 15 cmH2O, then PEEP 10 and 5 cmH2O again. We measured, at the end of each phase, recruitment from previous PEEP using the P-V curve method, and changes in DSS were continuously monitored by EIT. Results PEEP changes induced alveolar recruitment as assessed by the P-V curve method and changes in the amount of DSS (p

INTRODUCTION: Advances in knowledge regarding mechanical ventilation (MV), in particular lung-protective ventilation strategies, have been shown to reduce mortality. However, the translation of these advances in knowledge into better therapeutic performance in real-life clinical settings continues to lag. High-fidelity simulation with a mannequin allows students to interact in lifelike situations; this may be a valuable addition to traditional didactic teaching. The purpose of this study is to compare computer-based and mannequin-based approaches for training residents on MV.METHODS: This prospective randomized single-blind trial involved 50 residents. All participants attended the same didactic lecture on respiratory pathophysiology and were subsequently randomized into two groups: the mannequin group (n = 25) and the computer screenbased simulator group (n = 25). One week later, each underwent a training assessment using five different scenarios of acute respiratory failure of different etiologies. Later, both groups underwent further testing of patient management, using in situ high-fidelity simulation of a patient with acute respiratory distress syndrome.RESULTS: Baseline knowledge was not significantly different between the two groups (P = 0.72). Regarding the training assessment, no significant differences were detected between the groups. In the final assessment, the scores of only the mannequin group significantly improved between the training and final session in terms of either global rating score [3.0 (2.54.0) vs. 2.0 (2.03.0), P = 0.005] or percentage of key score (82% vs. 71%, P = 0.001).CONCLUSIONS: Mannequin-based simulation has the potential to improve skills in managing MV.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Prolonged storage of red blood cells (RBCs) is a potential risk factor for postoperative infections. The objective of this study was to examine the effect of age of RBCs transfused on development of postoperative infection.In this prospective, double-blind randomized trial, 199 patients undergoing elective noncardiac surgery and requiring RBC transfusion were assigned to receive nonleukoreduced RBCs stored for not more than 14 days ("fresh blood" group, n = 101) or for more than 14 days ("old blood" group, n = 98). The primary outcome was occurrence of infection within 28 days after surgery; secondary outcomes were postoperative acute kidney injury (AKI), in-hospital and 90-day mortality, admission to intensive care unit, and hospital length of stay (LOS). As older blood was not always available, an "as-treated" (AT) analysis was also performed according to actual age of the RBCs transfused.The median [interquartile range] storage time of RBCs was 6 [5-10] and 15 [11-20] days in fresh blood and in old blood groups, respectively. The occurrence of postoperative infection did not differ between groups (fresh blood 22% vs. old blood 25%; relative risk [RR], 1.17; confidence interval [CI], 0.71-1.93), although wound infections occurred more frequently in old blood (15% vs. 5%; RR, 3.09; CI, 1.17- 8.18). Patients receiving older units had a higher rate of AKI (24% vs. 6%; p 0.001) and, according to AT analysis, longer LOS (mean difference, 3.6 days; CI, 0.6-7.5).Prolonged RBC storage time did not increase the risk of postoperative infection. However, old blood transfusion increased wound infections rate and incidence of AKI.

BACKGROUND Regional epidural analgesia is considered the gold standard for pain treatment in labor. However, epidural catheter placement may be a challenging procedure because of the difficulty in the palpation of anatomical landmarks, particularly in pregnant women. Pre-procedural neuroaxial ultrasound may facilitate the procedure. METHODS A prospective randomized controlled study was conducted in a labor ward. Two groups of women undergoing epidural analgesia were randomized: Group A (N.=28), which was subjected to the loss of resistance technique, and Group B (N.=30) which was subjected to an ultrasound (US)-assisted procedure. The real depth of epidural space was calculated in both groups by measuring the needle skin-to-tip distance, while the US depth was measured only in Group B. RESULTS The mean number of attempts in group A (3.43±3.8) was significantly higher than in Group B (1.70±0.87, P=0.019). Analysis of data from Group B revealed a strong positive correlation between the epidural real depth and US depth (r=0.88, P

Postoperative pulmonary complications are major causes of postoperative morbidity and mortality. Although several risk factors have been associated with postoperative pulmonary complications, they are not consistent between studies and, even in those studies in which these factors were identified, the predictive power is low. We hypothesized that postoperative pulmonary complications would correlate with the presence of intraoperative expiratory flow limitation.Candidates for this prospective observational study were patients undergoing general anesthesia for major abdominal surgery. Preoperative data collection included age, body mass index, American Society of Anesthesiologists class, smoking and dyspnea history, and room air PO2. Expiratory flow limitation was assessed intraoperatively using the positive end-expiratory pressure test. Postoperative data collection included the incidence of postoperative pulmonary complications.Of the 330 patients we enrolled, 31% exhibited expiratory flow limitation. On univariate analysis, patients with expiratory flow limitation were more likely to have postoperative pneumonia (5% vs 0%, P.001) and acute respiratory failure (11% vs 1%, P.001) and a longer length of hospital stay (7 vs 9 days, P.01). Multivariate analysis identified that expiratory flow limitation increased the risk of developing postoperative pulmonary complications by50% (risk ratio, 2.7; 95% confidence interval, 1.7-4.2). Age and Medical Research Council dyspnea score were also significant multivariate risk factors for pulmonary complications.Our results show that intraoperative expiratory flow limitation correlates with that of postoperative pulmonary complication after major abdominal surgery. Further work is needed to better understand the relevance of expiratory flow limitation on postoperative pulmonary outcomes.

Introduction Our knowledge of acute respiratory distress syndrome (ARDS) pathogenesis is incomplete. The goal of this pilot study is to investigate the feasibility of measuring lower airways inflammation in patients with ARDS using repeated endotracheal aspirates (ETAs). Methods ETAs were obtained within 24 hours by intensive care unit admission from 25 mechanically ventilated patients with ARDS and 10 of them underwent a second ETA within 96 hours after the first sampling. In each sample, cell viability was assessed using trypan blue exclusion method and the total and differential cell counts were measured using Neubauer-improved cell counting chamber and cytospins stained with Diff-Quik. Results The median cell viability was 89 (IQR 80–93)%, with a median total cell count of 305 (IQR 130–1270)×103/mL and a median macrophage, neutrophil, lymphocyte and eosinophil count, respectively, of 19.8 (IQR 5.4–71.6)×103/mL; 279 (IQR 109–1213)×103/mL; 0 (IQR 0–0.188)×103/mL; 0 (IQR 0–1.050)×103/mL. Eosinophil count in the ETA correlated with the number of blood eosinophils (r=0.4840, p=0.0142). Cell viability and total and differential cell counts were neither significantly different in the second ETA compared with the first ETA nor were unaffected by the presence or absence of bacteria in the blood and/or ETA, or by the ARDS aetiology, apart from the macrophage count which was significantly increased in patients with ARDS associated with acute pancreatitis compared with those associated with pneumonia (p=0.0143). Conclusions ETA can be used to investigate the cellularity of the lower airways in patients with ARDS and it is an easy-to-perform and non-invasive procedure. Eosinophil counts in ETA and blood are significantly correlated. The number of macrophages in ETA may be affected by the aetiology of the ARDS.

Pre-hospital trauma treatment is an important situation in which pain should be appropriately assessed and treated, but there is a great lack of studies about it. Literature has widely pointed out that the underanalgesia problem is spread to all groups of patients. The objective of the study is to verify the efficacy of a sedation-analgesia protocol based on the use of NSAIDs, Fentanyl and Midazolam, for prehospital treatment of trauma patients. The protocol was tested in three Emergency Medical Services for a four month period, in which 30 patients were included in the study. Results evidenced a good management of both pain and anxiety in the majority of patients treated, with the achievement of analgesia target in 80% of the patients and sedation target in 100% of the patients.

Background The rapid shallow breathing index (RSBI), which is the ratio between respiratory rate (RR) and tidal volume (VT), is one of the most widely used indices to predict weaning outcome. Whereas the diaphragm plays a fundamental role in generating VT, in the case of diaphragmatic dysfunction the inspiratory accessory muscles may contribute. If this occurs during a weaning trial, delayed weaning failure is likely since the accessory muscles are more fatigable than the diaphragm. Hence, we hypothesised that the traditional RSBI could be implemented by substituting VT with the ultrasonographic evaluation of diaphragmatic displacement (DD). We named the new index the diaphragmatic-RSBI (D-RSBI). The aim of this study was to compare the ability of the traditional RSBI and D-RSBI to predict weaning failure in ready-to-wean patients. Methods We performed a prospective observational study. During a T-tube spontaneous breathing trial (SBT) we simultaneously evaluated right hemidiaphragm displacement (i.e., DD) by using M-mode ultrasonography as well as the RSBI. Outcome of the weaning attempt, length of mechanical ventilation, length of intensive care unit and hospital stay, and hospital mortality were recorded. Receiver operator characteristic (ROC) curves were used to evaluate the diagnostic accuracy of D-RSBI and RSBI. Results We enrolled 51 patients requiring mechanical ventilation for more than 48 h who were ready to perform a SBT. Most of the patients, 34 (66 %), were successfully weaned from mechanical ventilation. When considering the 17 patients that failed the weaning attempt, 11 (64 %) had to be reconnected to the ventilator during the SBT, three (18 %) had to be re-intubated within 48 h of extubation, and three (18 %) required non-invasive ventilation support within 48 h of extubation. The areas under the ROC curves for D-RSBI and RSBI were 0.89 and 0.72, respectively (P = 0.006). Conclusions D-RSBI (RR/DD) was more accurate than traditional RSBI (RR/VT) in predicting the weaning outcome. Trial registration Our clinical trial was retrospectively registered with ClinicalTrials.gov (identifier: NCT02696018). ClinicalTrials.gov processed our record on 25 February 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1479-y) contains supplementary material, which is available to authorized users.

It is already recognised that laparoscopic surgery produces less postoperative inflammation than open surgery, reducing surgical stress. There is less postoperative pain and respiratory compromise.

Fatigue has not been investigated in long-term Intensive Care Unit (ICU) survivors. This study aimed to assess fatigue through a specific instrument, namely the Functional Assessment of Chronic Illness Therapy Fatigue (FACIT-F) scale, in ICU survivors one year after hospital discharge. A secondary aim was to compare the findings of FACIT-F with those of the Vitality domain (VT) of the 36-item Short-Form Health Survey (SF-36). This prospective cohort study was performed on 56 adult patients with a Length Of Stay (LOS) in ICU longer than 72 h. At one year after hospital discharge, FACIT-F and SF-36 questionnaires were administered to consenting patients by direct interview. FACIT-F was measured as raw (range 0–52), and FACIT-F-trans value (range 0–100). Past medical history, and demographic and clinical ICU-related variables were collected. The patients’ median age was 67.5, Simplified Acute Physiology Score II 31, and LOS in ICU 5 days. The median raw FACIT-F of the patients was 41, and Cronbach’s α was 0.937. The correlation coefficient between FACIT-F-trans and VT of SF-36 was 0.660 (p

Acute respiratory failure (ARF) is characterised by a discrepancy between load imposed on respiratory muscles and their capacity. The evaluation of inspiratory muscles performance is based mainly on Maximum Inspiratory Pressure (MIP) calculation. However, MIP is determined by the contraction of all the inspiratory muscles and doesn't give information about diaphragmatic function. Recently the Diaphragmatic Displacement (DD) measured by ultrasonography has been introduced in the clinical practice to evaluate diaphragmatic function.