Feasibility of high-frequency percussions in people with severe acquired brain injury and tracheostomy: an observational study.

People with severe acquired brain injury (pwSABI) frequently experience pulmonary complications. Among these, atelectasis can occur as a result of pneumonia, thus increasing the chance of developing acute respiratory failure. Respiratory physiotherapy contribution to the management of atelectasis in pwSABI is yet poorly understood. We conducted a retrospective analysis on 15 non-cooperative pwSABI with tracheostomy and spontaneously breathing, hospitalized and treated with high-frequency percussion physiotherapy between September 2018 and February 2021 at the Neurological Rehabilitation Unit of the IRCCS "S.Maria Nascente - Fondazione Don Gnocchi", Milan. Our primary aim was to investigate the feasibility of such a physiotherapy intervention method. Then, we assessed changes in respiratory measures (arterial blood gas analysis and peripheral night-time oxygen saturation) and high-resolution computed tomography lung images, evaluated before and after the physiotherapy treatment. The radiological measures were a modified radiological atelectasis score (mRAS) assigned by two radiologists, and an opacity score automatically provided by the software CT Pneumonia Analysis® that identifies the regions of abnormal lung patterns. Treatment diaries showed that all treatments were completed, and no adverse events during treatment were registered. Among the 15 pwSABI analyzed, 8 were treated with IPV® and 7 with MetaNeb®. After a median of 14 (I-III quartile=12.5-14.5) days of treatment, we observed a statistical improvement in various arterial blood gas measures and peripheral night-time oxygen saturation measures. We also found radiological improvement or stability in more than 80% of pwSABI. In conclusion, our physiotherapy approach was feasible, and we observed respiratory parameters and radiological improvements. Using technology to assess abnormal tomographic patterns could be of interest to disentangle the short-term effects of respiratory physiotherapy on non-collaborating people.

Exploring perceptions and expectations of COPD patients: A grounded theory approach for personalized therapeutic interventions.

Objectives: This study aimed to investigate the dynamic patterns of perception and expectations among COPD patients. Methods: Conducted at the Heart-Respiratory Rehabilitation Unit, IRCCS Fondazione Don Carlo Gnocchi, in Milan, Italy, the research involved 28 participants (16 males; mean age 72.8 ± 9.9) in face-to-face interviews. Utilizing a Grounded Theory approach, complemented by clinical data, recorded, and transcribed interviews underwent enhancement through the integration of two pictorial tools. Results: The central theme that emerged was a profound sense of responsibility toward their condition, perceived as a significant threat to life. Key symptoms, such as shortness of breath, coupled with negative expectations about their condition, contributed to depressive mood and avoidance behaviors. A notable proportion (N = 17; 60.71%) of participants struggled to envision a positive future, expressing a pervasive sense of hopelessness, which significantly influenced their health behaviors and adherence to medical recommendations. Conversely, individuals who felt supported and optimistic about treatment efficacy exhibited more positive expectations and adopted proactive coping strategies. Discussion: Recognizing the dynamic nature of patients' perceptions and negative illness expectations is essential to create personalized therapeutic interventions and meet the specific needs of COPD patients, ultimately improving the overall effectiveness of their care journey.

Promoting Acceptance and Adherence to Noninvasive Ventilation in Chronic Obstructive Pulmonary Disease: A Randomized Controlled Trial.

OBJECTIVE: People with chronic obstructive pulmonary disease (COPD) may suffer from anxiety, depression, low quality of life, and cognitive deficits that could play a role in their clinical conditions. These situations could be worsened during the adaptation process to a new treatment such as noninvasive ventilation (NIV), which is often rejected or inappropriately used. The study aimed to analyze the impact of a brief psychological support intervention on adherence to NIV among patients with COPD. METHODS: A two-branch randomized controlled trial was conducted on 90 patients with COPD who had an indication for NIV. The experimental group received cognitive behavioral therapy support, including counseling, relaxation, and mindfulness-based exercises. Controls received standard care and watched educational videos. The course had been structured for four to eight meetings at the hospital, at home, and/or via telemedicine. RESULTS: The psychological intervention was related to improvements in both adherence to NIV (F(304) = 19.054, p < .001) and quality of life (F(156) = 10.264, p = .002) after eight meetings from baseline compared with the control group. Results indicated a significant change in the quality of life also over time (F(71.480) = 8.114, p = .006). CONCLUSIONS: The findings suggest that the psychological intervention is an appropriate treatment for acceptance of and adherence to NIV in COPD in clinical practice and highlight the importance of determining the underlying reasons for NIV use.Trial Registration:ClinicalTrials.gov identifier NCT02499653.

Psychoeducational groups for people with Amyotrophic Lateral Sclerosis and their caregiver: a qualitative study.

OBJECTIVE: The current study aimed to describe the implementation of a structured psychoeducational intervention in Amyotrophic Lateral Sclerosis (ALS), identifying the needs of both patients and their caregivers. METHODS: Five patients and thirteen caregivers attended eight psychoeducational group meetings at the Respiratory Rehabilitation Unit of IRCCS Santa Maria Nascente of Fondazione Don Carlo Gnocchi, Milan (Italy) and eight participants underwent semi-structured interviews once the group sessions ended. Group sessions and semi-structured interviews were audio-recorded and transcribed verbatim. Then, data obtained by group meetings' transcripts have been analysed using the grounded theory (GT) paradigm, while those obtained by interviews have been analysed using the interpretative phenomenological analysis (IPA). RESULTS: The analysis of the meetings allowed us to identify seven main themes: "practical advice", "explanation of the pathology", "recognition of emotions", "adaptation", "family and relationships", "being caregiver of oneself", and "sharing". Twenty-one sub-themes also emerged from the transcripts' analysis. The analysis of the interviews allowed us to deduce the main reasons to participate (i.e., to have information and to be able to share experiences), the positive and negative aspects of the experiences. These results suggested the usefulness of psychoeducational groups in the regular clinical practise to allow patients and caregivers to share advice, emotions, and experiences with others in the same situation. CONCLUSIONS: This study displays the utility of psychoeducational group intervention in supporting people with ALS and their caregivers because of two main reasons: first for the psychoeducation provided by professionals; second for the possibility of sharing experiences and emotions with people in the same situation.

The Role of Depression on Treatment Adherence in Patients with Heart Failure-a Systematic Review of the Literature.

INTRODUCTION: Although poor medication adherence is considered an impacting risk factor for worsening heart failure (HF) outcomes, adherence rates in HF patients continue to be considerably low. To improve this condition, several studies investigated the impact of many determinants on medication adherence; however, few authors explored the role of depression on it. PURPOSE OF REVIEW: The purpose of this systematic review was to explore the association between depressive symptoms and medication adherence in HF patients. In particular, the research question was is depression a barrier to medication adherence in HF patients? METHODS: A systematic review of quantitative analysis studies was undertaken. Six electronic databases were searched between the end of October and March 2022. Thirty-one trials were included, all of them assessed depression, adherence to medication, and their possible relationship. RESULTS: As was intended, findings showed that the impact of a mild to moderate level of depression was significant on adherence to treatment in HF patients. However, many other risk factors emerged, like family support and health practices (es. low sodium diet). CONCLUSION: The detection of depression in the setting of HF should be crucial to HF patients' physical health and quality of life. Future research should take depression into account, exploring this area through self-report and qualitative interview as well.

Effects of Air Stacking on Dyspnea and Lung Function in Neuromuscular Diseases.

OBJECTIVE: To investigate whether the decrease in dyspnea in neuromuscular diseases after air stacking (AS) occurs mostly in patients with decreased inspiratory muscle force and ensuing chest wall restriction or heterogeneous ventilation across the lungs. DESIGN: Interventional, before-after study. SETTING: A neurorehabilitation inpatient and outpatient center. PARTICIPANTS: Fifteen consecutive adult patients affected by neuromuscular diseases (N=15). INTERVENTIONS: AS treatment. MAIN OUTCOME MEASURES: Patients had vital capacity (VC) and sniff nasal inspiratory pressure (SNIP) measured. We measured Borg score, oxygen saturation, and ventilation heterogeneity across the lung as estimated from the difference between respiratory resistance at 5 and 19 Hz (R5-19) with the forced oscillation technique before and 5, 30, 60, and 120 minutes after applying AS. RESULTS: Before AS, Borg score was significantly related to R5-19 (r2 0.46, P<.05) but not to VC % predicted, SNIP % predicted, and time since symptom onset. After AS, average Borg score gradually decreased (P=.005), whereas inspiratory flow resistance at 5 Hz, R5-19, and inspiratory reactance at 5 Hz tended to improve, despite not reaching statistical significance. The decrease in dyspnea at 60 and 120 minutes after AS significantly correlated with baseline R5-19 (r2 0.49, P<.01 and r2 0.29, P<.05, respectively), but not with VC % predicted, SNIP % predicted, time since symptom onset, and clinical severity score for patients affected by amyotrophic lateral sclerosis. CONCLUSIONS: These findings suggest that dyspnea in neuromuscular diseases is related to heterogeneous ventilation rather than inspiratory muscle force and/or lung volumes decrease. Restoring ventilation distribution across the lungs with AS appears to improve dyspnea.

Intermittent abdominal pressure ventilation: feasibility and efficacy in neuromuscular disease. A case report.

The standard treatment for patients with neuromuscular respiratory failure is non-invasive ventilation (NIV) as non-invasive ventilation support-setting (NVS). NVS is administered through a nasal or face mask and/or mouthpiece with the potential to cause nasal ulcers, discomfort, and/or aesthetic issues, resulting in poor compliance. We reported the observation of a 45-year-old woman with limb-girdle muscular dystrophy (LGMD), secondary to Dysferlin deficiency, who was on NVS since 2017 for nocturnal hypoventilation. In 2018, despite nocturnal ventilation, due to weight gain and daytime hypoventilation, a nasal mask was introduced. We initiated daytime intermittent abdominal pressure ventilation (IAPV) to mitigate cosmetic problems, improving in pO2 and decreasing in pCO2 versus baseline (52>84 mmHg, 46>33 mmHg respectively) at 6 (85 mmHg, 42 mmHg) and 18 months (93 mmHg, 38 mmHg), respectively. IAPV was effective, safe, and well-tolerated in our patients who did not tolerate standard daytime NVS with the known interface.

The unleashing of the immune system in COVID-19 and sepsis: the calm before the storm?

The novel coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is sorely testing health care systems and economies around the world and is rightly considered as the major health emergency in a century. Despite the course of the disease appearing to be mild in many cases, a significant proportion of symptomatic patients develop pneumonia requiring hospitalisation or progress to manifest respiratory complications leading to intensive care treatment. Potential interventions for SARS-CoV2-associated pneumonia are being tested, some of which holding promise, but as of today none of these has yet demonstrated outstanding efficacy in treating COVID-19. In this article, we discuss fresh perspectives and insights into the potential role of immune dysregulation in COVID-19 as well as similarities with systemic inflammatory response in sepsis and the rationale for exploring novel treatment options affecting host immune response.

Joint Statement on the Role of Respiratory Rehabilitation in the COVID-19 Crisis: The Italian Position Paper.

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

How people with chronic obstructive pulmonary disease perceive their illness: a qualitative study between mind and body.

BACKGROUND: Although many studies on people with Chronic Obstructive Pulmonary Disease (COPD) have examined the mutual impact of physical status and emotional experience, there is limited knowledge about the way COPD people first-hand perceive their condition. This study was designed to investigate the illness perceptions of the patients and, secondarily, to explore their beliefs about the mind-body relationship. METHODS: This qualitative study has exploited an ad-hoc semi-structured interview to collect personal perspectives of participants on their illness. Twenty-seven patients (15 males and 12 females), with a mild to severe COPD, were recruited within the Respiratory Rehabilitation Unit of Don Carlo Gnocchi Foundation, in Milan. The thematic analysis of the interviews' content was facilitated by NVivo (12th version, QSR International®). RESULTS: The thematic analysis of the corpus resulted in four master themes. Illness experience has been considered the primary one. Indeed, dealing with COPD every day allows these people to portray a specific representation of the mind-body relationship, to gain a certain degree of expertise and to develop a perspective on the future. CONCLUSIONS: Individual perceptions of the illness vary among people with COPD, but some common experiences characterize them. Many patients share a profound belief that their mental state and their physical symptoms are highly interrelated.

Italian suggestions for pulmonary rehabilitation in COVID-19 patients recovering from acute respiratory failure: results of a Delphi process.

There is a need of consensus about the pulmonary rehabilitation (PR) in patients with COVID-19 after discharge from acute care. To facilitate the knowledge of the evidence and its translation into practice, we developed suggestions based on experts' opinion. A steering committee identified areas and questions sent to experts. Other international experts participated to a RAND Delphi method in reaching consensus and proposing further suggestions. Strong agreement in suggestions was defined when the mean agreement was >7 (1 = no agreement and 9 = maximal agreement). Panelists response rate was >95%. Twenty-three questions from 4 areas: Personnel protection equipment, phenotypes, assessments, interventions, were identified and experts answered with 121 suggestions, 119 of which received high level of concordance. The evidence-based suggestions provide the clinicians with current evidence and clinical experts opinion. This framework can be used to facilitate clinical decision making within the context of the individual patient. Further studies will evaluate the clinical usefulness of these suggestions.

Mouthpiece ventilation and complementary techniques in patients with neuromuscular disease: A brief clinical review and update.

Noninvasive ventilatory support (NVS) is sometimes reported as suboptimal in patients with neuromuscular disease (NMD). The reasons for this include inadequate ventilator settings and/or lack of interface tolerance. NVS has been used for many years in patients with NMD disorders as a viable alternative to continuous ventilatory support via a tracheostomy tube. The mouthpiece ventilation (MPV) is a ventilatory mode that is used as daytime ventilatory support in combination with other ventilatory modalities and interfaces for nocturnal NVS. However, there is still a poor understanding of this method's benefits compared with other modalities. This review aims to highlight the indications and advantages along with the disadvantages of MPV.

Living beyond loss: a qualitative investigation of caregivers' experiences after the death of their relatives with amyotrophic lateral sclerosis.

BACKGROUND: Caregivers of Amyotrophic Lateral Sclerosis (ALS) patients experience varying psychological responses following the patient's death, including sadness, loneliness, guilt, and a loss of purpose. OBJECTIVES: This research aims to investigate the caregiver journey experienced from the time of diagnosis to the loss of a care recipient, with a specific focus on understanding the factors that contribute to improved coping with bereavement. METHODS: The present study used the Interpretative Phenomenological Approach (IPA) to qualitatively explore the accounts of 41 Italian bereaved caregivers of people affected by ALS (Mean Age = 59.78; Female: 60.98%; Male: 39.02%). RESULTS: Results revealed 5 overarching themes representing 5 macro areas that emerged from the analysis of the interviews ("Caregiver's perception of his/her life", "Caregiver's feelings", "Caregiver's life after patient's death", "Caregiver's disease description", "Caregiver's help resources"), these were further defined based on 12 main themes, which were, in turn, articulated into 30 subthemes. The transition from life before ALS ("a peaceful landscape") to caregiver life (compared to the color "black") was a "shock", during which caregivers had to change their needs. However, life after the person living with ALS' death was both characterized by a sense of "re-birth" and "emptiness", and a general need for "psychological assistance" and "social support". CONCLUSIONS: Results emphasize the need to improve the psychological support offered to caregivers of person living with ALS after the patient's death, tailoring it to the specificity of the condition, to meet their emotional needs, reduce isolation and help them cope with practical challenges and plans.

The pathogenesis of OSA-related hypertension: what are the determining factors?

Sleep-disordered breathing has a relatively high prevalence, which varies from 3-7% in males and from 2-5% in females in the adult population. Studies published in the literature have shown that sleep apnea is closely related to an increased risk of developing various pathologies, among which arterial hypertension stands out. The prevalence of hypertension in patients suffering from obstructive sleep apnea (OSA) ranges from 35-80% and appears to be related to OSA severity. Approximately 40-50% of patients affected by hypertension are also affected by OSA and this association seems to be stronger in young and middle-aged adults (<50 years of age). The primary objective of this narrative review is to provide an update on what are the main contributing comorbidities to the development of a hypertensive state in patients suffering from OSA, an independent risk factor for diurnal hypertension, implicated as a risk factor for the first stroke, recurrent stroke, and post-stroke mortality. There are a lot of factors that contribute to developing a hypertensive state in OSA patients, some more decisive, others less. More evidence from longitudinal studies is needed on the impact of OSA on cardiovascular risk in females, on the causal link between OSA and arterial hypertension or metabolic diseases, like diabetes and glucose intolerance, and the effect of different kinds of OSA treatment.

Pulmonary hypertension in patients affected by sleep-related breathing disorders: up to date from the literature.

Sleep-related breathing disorders (SBD) are conditions of abnormal and difficult respiration during sleep, including chronic snoring, obstructive sleep apnea (OSA), central sleep apnea (CSA), sleep-related hypoventilation disorders and sleep-related hypoxemia. Some of them have a limited impact on health, but others (e.g., OSA) can have serious consequences, because of their dangerous effects on sleep and the hematic balance of oxygen and carbon dioxide. According to several population-based studies, prevalence of OSA is relatively high, approximately 3-7% for adult males and 2-5% for adult females in the general population. However, methodological differences and difficulties in characterizing this syndrome yielded to variability in estimates. Moreover, it is estimated that only about 40% of patients with OSA are diagnosed, which can lead to underestimation of disease prevalence. OSA is directly correlated with age and male sex and to risk factors such as obesity. Several studies found that OSA is associated with an increased risk of diabetes, some cancer types, cardiovascular and cerebrovascular diseases, such as hypertension, coronary artery disease and stroke. Pulmonary hypertension (PH), a noted cardiovascular disease, is significantly associated with sleep-related breathing disorders and lot of scientific studies published in the literature demonstrated a strong link between these conditions and the development of pulmonary hypertension PH. PH is relatively less common than sleep-related breathing disorders. The purpose of this systematic review is to analyze both the current knowledge around the consequences that SBD may have on pulmonary hemodynamics and the effects resulting from pharmacological and non-pharmacological treatments of SDB on PH.

Management of respiratory issues in patients with Rett syndrome: Italian experts' consensus using a Delphi approach.

BACKGROUND: Despite the publication of the 2020 guidelines on how to manage Rett Syndrome (RS), some fundamental topics are still open, in particular respiratory problems. OBJECTIVE: Identification and reinforcement of current recommendations concerning the management of respiratory issues in RS patients. MATERIALS AND METHODS: Using a Delphi approach, the leading group reviewed the literature and formulated 14 statements. A multidisciplinary panel of 29 experts were invited to score, for each statement, their agreement on a 1-5 scale. The cut-off level for consensus was 75%, obtained through multiple rounds. RESULTS: The panel agreed that in all RS types, respiratory issues should be faced at an early stage, regardless of epilepsy onset. It is recommended to perform periodically sleep studies in all Congenital Rett Syndrome, and in selected cases with other RS types. Noninvasive ventilation should be considered in all RS subjects with sleep respiratory disorders and in those with hypotonia associated with hypercapnia. Chest physiotherapy should be performed in all RS patients with difficult management of the accumulation of respiratory secretions, using airway clearance techniques and devices (PEP-mask, AMBU bag, or cough machine), more appropriate and tolerated by the patients. The panel recommended individualized programs for the management of scoliosis, and to consider performing gastrostomy in patients at increased risk of ab ingestis pneumonia. CONCLUSIONS: This consensus could support everyday clinical practice on respiratory issues in RS patients, complementary to existing recommendations by regulatory agencies and guidelines.

Enhancing respiratory function in neuromuscular disease: the role of non-invasive ventilation. A narrative review.

Neuromuscular diseases (NMDs) comprise a heterogeneous group of conditions characterized by extreme progressive muscle weakness leading to respiratory failure. Noninvasive mechanical ventilation (NIV) has emerged as a cornerstone in the management of respiratory complications associated with NMDs. This review aims to elucidate the role of NMV in respiratory function, improving quality of life, and prolonging survival in individuals with NMD. The physiological basis of respiratory impairment in NMDs, principles of NMV application, evidence supporting its efficacy, patient selection criteria, and potential challenges in its application are discussed.

Effectiveness of a new "focused pulse" high-frequency chest wall oscillation in patients with moderate to severe COPD.

BACKGROUND: Chest physiotherapy plays a crucial role in the treatment of COPD, although the optimal techniques for airway clearance have not been definitively established. Among the different techniques, high-frequency chest wall oscillation (HFCWO) has gained attention for its potential to create a widespread lung percussion, facilitating the removal of secretions and potentially clearing the peripheral bronchial tree. This study aims to assess the effectiveness of a novel "focused pulse" HFCWO in patients with moderate to severe COPD. METHODS: Sixty patients were randomized to three groups: a group treated with the PEP technique, a group with "focused pulse "HFCWO" and a group with pharmacological therapy alone (control group). The primary outcomes were changes in respiratory function parameters, changes in dyspnea and quality of life scores as well as daily life activity and health status assessment. The secondary outcomes were the number of exacerbations and the number of practitioner or emergency department (ED) visits after 1, 3, and 6 months. RESULTS: Sixty patients concluded the study with 20 patients allocated to each group. The two devices improved respiratory function tests, quality of life and health scores and dyspnea compared to the control group. Maximal expiratory pressure and diffusing lung carbon oxide were significantly improved in the focused pulse HFCWO group compared to the PEP group. Only pulse-focused HFCWO showed a statistically significant lower number of exacerbations and visits to ED or practitioner compared to the control group. CONCLUSIONS: The focused pulse HFCWO technique improves daily life activities and lung function in patients with stable COPD. The device demonstrated significantly greater effectiveness in lowering COPD exacerbations as well as visits to ED or practitioner.