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RATIONALE: Endoscopic lung volume reduction improves lung function, quality of life and exercise capacity in severe emphysema patients. However, its effect on the diaphragm function is not well understood. We hypothesised that endoscopic lung volume reduction increases its strength by modifying its shape. OBJECTIVES: To investigate changes in both diaphragm shape and strength induced by the insertion of endobronchial valves. METHODS: In 19 patients, both the diaphragm shape and strength were investigated respectively by 3D Slicer software applied on CT scans acquired at functional residual capacity and by transdiaphragmatic pressure measurements by bilateral magnetic stimulation of the phrenic nerves before and 3 months after unilateral valves insertion. MEASUREMENTS AND MAIN RESULTS: After lung volume reduction (median (IQR), 434 mL (-597 to -156], p<0.0001), diaphragm strength increased (transdiaphragmatic pressure: 3 cmH2O (2.3 to 4.2), p<0.0001). On the treated side, this increase was associated with an increase in the coronal (16 mm (13 to 24), p<0.0001) and sagittal (26 mm (21 to 30), p<0.0001) lengths as well as in the area of the zone of apposition (62 cm2 (3 to 100), p<0.0001) with a decrease in the coronal (8 mm (-12 to -4), p<0.0001) and sagittal (9 mm (-18 to -2), p=0.0029) radii of curvature. CONCLUSIONS: Endoscopic lung volume reduction modifies the diaphragm shape by increasing its length and its zone of apposition and by decreasing its radius of curvature on the treated side, resulting in an increase in its strength. TRIAL REGISTRATION NUMBER: NCT05799352.
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Diafragma , Pneumonectomia , Enfisema Pulmonar , Tomografia Computadorizada por Raios X , Humanos , Diafragma/diagnóstico por imagem , Masculino , Pneumonectomia/métodos , Feminino , Pessoa de Meia-Idade , Idoso , Enfisema Pulmonar/cirurgia , Enfisema Pulmonar/fisiopatologia , Enfisema Pulmonar/diagnóstico por imagem , Broncoscopia/métodos , Força Muscular/fisiologia , Capacidade Residual Funcional/fisiologiaRESUMO
BACKGROUND: Home mechanical ventilation (HMV) is the treatment for chronic hypercapnic alveolar hypoventilation. The proportion and evolution of paediatric invasive (IMV) and non-invasive (NIV) HMV across the world is unknown, as well as the disorders and age of children using HMV. METHODS: Search of Medline/PubMed for publications of paediatric surveys on HMV from 2000 to 2023. RESULTS: Data from 32 international reports, representing 8815 children (59% boys) using HMV, were analysed. A substantial number of children had neuromuscular disorders (NMD; 37%), followed by cardiorespiratory (Cardio-Resp; 16%), central nervous system (CNS; 16%), upper airway (UA; 13%), other disorders (Others; 10%), central hypoventilation (4%), thoracic (3%) and genetic/congenital disorders (Gen/Cong; 1%). Mean age±SD (range) at HMV initiation was 6.7±3.7 (0.5-14.7) years. Age distribution was bimodal, with two peaks around 1-2 and 14-15 years. The number and proportion of children using NIV was significantly greater than that of children using IMV (n=6362 vs 2453, p=0.03; 72% vs 28%, p=0.048), with wide variations among countries, studies and disorders. NIV was used preferentially in the preponderance of children affected by UA, Gen/Cong, Thoracic, NMD and Cardio-Resp disorders. Children with NMD still receiving primary invasive HMV were mainly type I spinal muscular atrophy (SMA). Mean age±SD at initiation of IMV and NIV was 3.3±3.3 and 8.2±4.4 years (p<0.01), respectively. The rate of children receiving additional daytime HMV was higher with IMV as compared with NIV (69% vs 10%, p<0.001). The evolution of paediatric HMV over the last two decades consists of a growing number of children using HMV, in parallel to an increasing use of NIV in recent years (2020-2023). There is no clear trend in the profile of children over time (age at HMV). However, an increasing number of patients requiring HMV were observed in the Gen/Cong, CNS and Others groups. Finally, the estimated prevalence of paediatric HMV was calculated at 7.4/100 000 children. CONCLUSIONS: Patients with NMD represent the largest group of children using HMV. NIV is increasingly favoured in recent years, but IMV is still a prevalent intervention in young children, particularly in countries indicating less experience with NIV.
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Serviços de Assistência Domiciliar , Ventilação não Invasiva , Respiração Artificial , Humanos , Criança , Respiração Artificial/métodos , Respiração Artificial/estatística & dados numéricos , Adolescente , Lactente , Pré-EscolarRESUMO
BACKGROUND: With the increasing use of low dose CT scans, numerous pulmonary nodules are detected. As majority of them are benign, development of efficient non-surgical diagnostic intervention is mandatory. Electromagnetic navigation bronchoscopy (ENB) has been developed to reach difficult to access lesions. The aim of the present study was to compare the diagnostic yield of ENB procedures performed in a classical endoscopy suite or in a hybrid room equipped by a cone beam CT (CBCT). METHODS: A monocentric randomized study was performed in the Erasme Hospital between January 2020 and December 2021. Lung nodules of maximum 30 mm of diameter were eligible. In both arms (endoscopy or CBCT suites), ENB, fluoroscopic guidance and a radial endobronchial ultrasound were used to reach the lesion. Then six trans-bronchial biopsies (TBB) and one trans-bronchial lung cryobiopsy (TBLC) were performed. Primary outcomes were the diagnostic yield and diagnostic accuracy of the procedure. RESULTS: Forty-nine patients were randomized (24 in the endoscopy and 25 in the CBCT arms). The lesion size was 15,9 ± 4,6 mm and 16,6 ± 6,0 mm respectively (mean ± SD, p = NS). The diagnostic yield of ENB performed under CBCT guidance was 80% compared to 42% when performed in the endoscopy suite under standard fluoroscopic guidance (p < 0,05). Similarly, the diagnostic accuracy in the CBCT group was 87% compared to 54% for the endoscopy group (p < 0,05). Duration of the procedure in the CBCT and endoscopy arms was 80 ± 23 and 61 ± 13 min respectively (mean ± SD, p < 0,01). Performing TBLC in addition to TBB increased the diagnostic yield by 14% (17 and 12,5% in CBCT and endoscopy suites respectively, p = NS). CONCLUSION: This study highlighted the additional value to perform ENB procedure under CBCT guidance for small size (less than 2 cm of diameter) pulmonary nodules. TRIAL REGISTRATION: Clinical trial registration number: NCT05257382.
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Neoplasias Pulmonares , Nódulos Pulmonares Múltiplos , Humanos , Broncoscopia/métodos , Neoplasias Pulmonares/patologia , Bélgica , Fenômenos Eletromagnéticos , Nódulos Pulmonares Múltiplos/patologia , Tomografia Computadorizada de Feixe CônicoRESUMO
BACKGROUND: Platypnea-orthodeoxia syndrome (POS) is a rare condition characterized by dyspnoea (platypnea) and arterial desaturation in the upright position resolved in the supine position (orthodeoxia). Intracardiac shunt, pulmonary ventilation-perfusion mismatch and others intrapulmonary abnormalities are involved. CASE PRESENTATION: We report a case of POS associated with two pathophysiological issues: one, cardiac POS caused by a patent foramen ovale (PFO) and second, pulmonary POS due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) interstitial pneumonia. POS has resolved after recovery of coronavirus disease 2019 (COVID-19) pneumonia. CONCLUSIONS: Right-to-left interatrial shunt and intrapulmonary shunt caused by SARS-CoV-2 pneumonia contributed to refractory hypoxemia and POS. Therefore, in case of COVID-19 patient with unexplained POS, the existence of PFO must be investigated.
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COVID-19 , Dispneia , Forame Oval Patente , Hipóxia , Pulmão/diagnóstico por imagem , Pneumonia Viral , COVID-19/diagnóstico , COVID-19/fisiopatologia , Dispneia/diagnóstico , Dispneia/etiologia , Dispneia/fisiopatologia , Ecocardiografia/métodos , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico , Forame Oval Patente/fisiopatologia , Hemodinâmica , Humanos , Hipóxia/diagnóstico , Hipóxia/etiologia , Hipóxia/fisiopatologia , Doenças Pulmonares Intersticiais/complicações , Doenças Pulmonares Intersticiais/fisiopatologia , Doenças Pulmonares Intersticiais/virologia , Masculino , Pessoa de Meia-Idade , Oxigênio/análise , Pneumonia Viral/complicações , Pneumonia Viral/diagnóstico , Pneumonia Viral/fisiopatologia , Postura/fisiologia , SARS-CoV-2/isolamento & purificação , Síndrome , Resultado do TratamentoRESUMO
BACKGROUND: The surgical lung biopsy (SLB) is the recommended sampling technique when the pathological analysis of the lung is required in the work-up of an interstitial lung disease (ILD) but trans-bronchial lung cryobiopsy (TBLC) is increasingly recognized as an alternative approach. As TBLCs have lower mortality and morbidity risks than SLB, this study aimed to investigate the safety of TBLCs in patients at higher risk of complications and for whom SLB was not considered as an alternative. METHOD: This prospective study was conducted in two hospitals in which TBLCs were performed in patients with body mass index (BMI) > 35, and/or older than 75 years, and/or with severely impaired lung function (FVC < 50% or DLCO < 30%), and/or systolic pulmonary artery pressure > 45 mmHg, and/or a clinically significant cardiac disease. Patients with any of these risk factors constituted the high-risk group. Clinical outcomes were compared with those obtained in patients without these risk factors (low-risk group). RESULTS: Ninety-six patients were included between April 2015 and April 2020, respectively 38 and 58 in the high-risk or the low-risk group. No statistically significant difference was observed between both groups in terms of severity and rate of bleeding, pneumothorax, or duration of hospital stay (p value ranging from 0.419 to 0.914). CONCLUSION: This preliminary study on a limited number of patients suggests that TBLC appears safe in those in whom lung biopsy is at high-risk of complications according to their age, BMI, lung impairment, and cardiac comorbidities.
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Doenças Pulmonares Intersticiais/patologia , Pulmão/patologia , Idoso , Biópsia/efeitos adversos , Biópsia/métodos , Brônquios , Criocirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Prospectivos , Fatores de RiscoRESUMO
BACKGROUND: Although increasing data supports the use of transbronchial lung cryobiopsies (TBLCs) for the diagnosis of diffuse parenchymal lung diseases (DPLDs), its role as an alternative to surgical lung biopsy (SLB) is still under debate. The aim of this study was to assess the benefit of additional SLBs performed in selected patients after TBLCs. METHOD: We conducted a multicentric Belgian prospective trial in which SLBs were performed after TBLCs when the pathological diagnosis was uncertain or if a nonspecific interstitial pneumonia (NSIP) pattern was observed hypothesizing that SLB could provide additional information and that a co-existent UIP pattern could be missed. RESULTS: Eighty-one patients with TBLCs performed for a DPLD were included in the study between April 2015 and December 2019. A specific histological diagnosis was obtained in 52 patients (64%) whereas no pathological diagnosis following TBLCs was obtained in 13 patients (16%) and a pattern suggestive of a NSIP was observed in 16 patients (20%). Fourteen out of these 29 patients had SLBs after TBLCs. SLBs showed a UIP pattern in 11 (79%), a pattern suggestive of a hypersensitivity pneumonitis in two (14%) and a NSIP pattern in one patient (7%). Among the 16 patients with pathological NSIP following TBLCs, six underwent a SLBs showing a UIP in five and confirming a NSIP in one patient only. A retrospective pathological analysis of patients having both procedures showed a lower diagnostic confidence and agreement among pathologists for TBLCs compared to SLBs. Major factors underlying the added value of SLBs were the bigger size of the sample as well as the subpleural localization of the biopsies. CONCLUSIONS: TBLCs are useful in the setting of DPLDs with a good diagnostic yield. However, our study suggests that SLB provides critical additional information in case TBLCs are inconclusive or show a pattern suggestive of a NSIP, questioning the accuracy of TBLC to adequately identify this histological pattern.
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Broncoscopia/métodos , Criocirurgia/métodos , Pneumonias Intersticiais Idiopáticas/patologia , Pulmão/patologia , Pulmão/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Bélgica/epidemiologia , Biópsia/métodos , Feminino , Humanos , Pneumonias Intersticiais Idiopáticas/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos RetrospectivosRESUMO
Transbronchial cryobiopsies (TBCB) have recently been introduced as a promising and safer alternative to surgical lung biopsy in the diagnostic approach to diffuse parenchymal lung diseases (DPLD). Despite a substantial and expanding body of literature, the technique has not yet been standardized and its place in the diagnostic algorithm of DPLD remains to be defined. In part, this reflects concerns over the diagnostic yield and safety of the procedure, together with the rapid spread of the technique without competency and safety standards; furthermore, there is a substantial procedural variability among centers and interventional pulmonologists. We report this expert statement proposed during the third international conference on "Transbronchial Cryobiopsy in Diffuse Parenchymal Lung Disease" (Ravenna, October 27-28, 2016), which formulates evidence- and expert-based suggestions on the indications, contraindications, patient selection, and procedural aspects of the procedure. The following 5 domains were reviewed: (1) what is the role of TBCB in the diagnostic evaluation of DPLD: patient selection; (2) pathological considerations; (3) contraindications and safety considerations; (4) how should TBCB be performed and in what procedural environment; and (5) who should perform TBCB. Finally, the existence of white paper recommendations may also reassure local hospital credentialing committees tasked with endorsing an adoption of the technique.
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Broncoscopia/métodos , Criocirurgia/métodos , Doenças Pulmonares Intersticiais/diagnóstico , Biópsia/normas , Broncoscopia/normas , Criocirurgia/normas , Humanos , Pulmão/patologia , Doenças Pulmonares Intersticiais/patologiaRESUMO
The diaphragm is the main inspiratory muscle and separates the thorax and the abdomen. In COPD, the evaluation of the diaphragm shape is clinically important, especially in the case of hyperinflation. However, delineating the diaphragm remains a challenge as it cannot be seen entirely on CT scans. Therefore, the lungs, ribs, sternum, and lumbar vertebrae are used as surrogate landmarks to delineate the diaphragm. We herein describe a CT-based method for evaluating the shape of the diaphragm using 3D Slicer-a free software that allows delineation of the diaphragm landmarks-in ten COPD patients. Using the segmentation performed with 3D Slicer, the diaphragm shape was reconstructed with open-source Free Pascal Compiler. From this graduated model, the length of the muscle fibers, the radius of curvature, and the area of the diaphragm-the main determinants of its function-can be measured. Inter- and intra-user variabilities were evaluated with Bland and Altman plots and linear mixed models. Except for the coronal length (p = 0.049), there were not statistically significant inter- or intra-user differences (p values ranging from 0.326 to 0.910) suggesting that this method is reproducible and repeatable. In conclusion, 3D Slicer can be applied to CT scans for determining the shape of the diaphragm in COPD patients.
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Diafragma , Imageamento Tridimensional , Doença Pulmonar Obstrutiva Crônica , Tomografia Computadorizada por Raios X , Humanos , Diafragma/diagnóstico por imagem , Diafragma/anatomia & histologia , Tomografia Computadorizada por Raios X/métodos , Imageamento Tridimensional/métodos , Doença Pulmonar Obstrutiva Crônica/diagnóstico por imagem , Masculino , Idoso , Feminino , Pessoa de Meia-Idade , Software , Reprodutibilidade dos TestesRESUMO
INTRODUCTION: Over the last 5 years, the analysis of respiratory patterns presents a growing usage in clinical and research purposes, but there is still currently a lack of easy-to-use and affordable devices to perform such kind of evaluation. OBJECTIVES: The aim of this study is to validate a new specifically developed method, based on Kinect sensor, to assess respiratory patterns against spirometry under various conditions. METHODS: One hundred and one participants took parts in one of the three validations studies. Twenty-five chronic respiratory disease patients (14 with chronic obstructive pulmonary disease (COPD) [65 ± 10 years old, FEV1 = 37 (15% predicted value), VC = 62 (20% predicted value)], and 11 with lung fibrosis (LF) [64 ± 14 years old, FEV1 = 55 (19% predicted value), VC = 62 (20% predicted value)]) and 76 healthy controls (HC) were recruited. The correlations between the signal of the Kinect (depth and respiratory rate) and the spirometer (tidal volume and respiratory rate) were computed in part 1. We then included 66 HC to test the ability of the system to detect modifications of respiratory patterns induced by various conditions known to modify respiratory pattern (cognitive load, inspiratory load and combination) in parts 2 and 3. RESULTS: There is a strong correlation between the depth recorded by the Kinect and the tidal volume recorded by the spirometer: r = 0.973 for COPD patients, r = 0.989 for LF patients and r = 0.984 for HC. The Kinect is able to detect changes in breathing patterns induced by different respiratory disturbance conditions, gender and oral task. CONCLUSIONS: Measurements performed with the Kinect sensors are highly correlated with the spirometer in HC and patients with COPD and LF. Kinect is also able to assess respiratory patterns under various loads and disturbances. This method is affordable, easy to use, fully automated and could be used in the current clinical context. Respiratory patterns are important to assess in daily clinics. However, there is currently no affordable and easy-to-use tool to evaluate these parameters in clinics. We validated a new system to assess respiratory patterns using the Kinect sensor in patients with chronic respiratory diseases.
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Doença Pulmonar Obstrutiva Crônica , Fibrose Pulmonar , Transtornos Respiratórios , Doenças Respiratórias , Humanos , Pessoa de Meia-Idade , Idoso , Taxa Respiratória , Doença Pulmonar Obstrutiva Crônica/diagnósticoRESUMO
Endoscopic lung volume reduction using unidirectional endobronchial valves is a new technique in the treatment of patients with severe emphysema. However, the movements of the thoracic structures after endobronchial valves insertion are still unpredictable We report the unusual outcome of six patients after valves insertion in the left upper lobe. They all developed a complete atelectasis of the target lobe, a pneumothorax and sequential genuine bullae in the treated left lung of unknown etiology. The chest CT scan prior to the valves insertion was unremarkable. Three patients developed an air-liquid level in the bullae the day before a bacterial infection of their left lower lobe. The three other patients had an uneventful spontaneous resolution of their bullae at long-term follow-up. Therefore, a conservative attitude should be followed in this particular setting.
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Enfisema , Pneumotórax , Doença Pulmonar Obstrutiva Crônica , Enfisema Pulmonar , Vesícula/diagnóstico por imagem , Vesícula/etiologia , Vesícula/cirurgia , Broncoscopia/efeitos adversos , Enfisema/complicações , Seguimentos , Humanos , Pneumonectomia/efeitos adversos , Pneumonectomia/métodos , Pneumotórax/diagnóstico por imagem , Pneumotórax/etiologia , Pneumotórax/cirurgia , Doença Pulmonar Obstrutiva Crônica/complicações , Enfisema Pulmonar/diagnóstico por imagem , Enfisema Pulmonar/etiologia , Enfisema Pulmonar/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: Our aims were to explore the feasibility, safety, and efficacy of peroperative transbronchial lung cryobiopsy (TBLC) guided by electromagnetic navigation bronchoscopy (ENB) and ENB-guided methylene blue marking of presumably non-palpable pulmonary nodules, and to assess its impact on video-assisted thoracoscopic surgery (VATS) and postoperative lung function. METHODS: This approach was applied to 16 consecutive patients (Group A, mean age 64 years) who were compared retrospectively to a historical group of 49 patients (Group B, mean age 62 years) with similar nodules resected without guidance. The usefulness of dye marking was graded. The success rates of both ENB-guided TBLC and nodule localization through dye marking were computed. The type of resection, volume of resected parenchyma, duration of procedures, and postoperative lung function were compared between groups. Unpaired t-test, chi-square test, unpaired Wilcoxon test, and exact Fisher test were used when appropriate. RESULTS: Malignancy was pathologically proven in all patients. TBLC revealed malignancy in 9 patients in Group A. The success rate of ENB-guided dye marking was 94%. Lobectomy was less frequently performed in Group A than in Group B (p = 0.022). Forced expiratory volume in 1 s and total lung capacity were significantly less reduced in Group A than in Group B (p = 0.006 and p = 0.019, respectively). Combined procedure was longer than surgery alone (p<0.001), but its surgical part was shorter than VATS without guidance (p < 0.001). CONCLUSION: Peroperative ENB-guided TBLC with methylene blue marking of non-palpable lung nodules is feasible. A sparing lung parenchyma procedure could be achieved thanks to the ENB-guided dye marking before VATS.
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Neoplasias Pulmonares , Lesões Pré-Cancerosas , Broncoscopia/métodos , Fenômenos Eletromagnéticos , Humanos , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/patologia , Neoplasias Pulmonares/cirurgia , Azul de Metileno , Pessoa de Meia-Idade , Estudos Retrospectivos , Cirurgia Torácica Vídeoassistida/efeitos adversos , Cirurgia Torácica Vídeoassistida/métodosRESUMO
The different waves of the COVID-19 pandemic caused dramatic issues regarding the organization of care. In this context innovative solutions have to be developed in a timely manner to adapt to the organization of the care. The establishment of middle care (MC) units is a bright example of such an adaptation. A multidisciplinary MC team, including expert and non-expert respiratory health care personnel, was developed and trained to work in a COVID-19 MC unit. Important educational resources were set up to ensure rapid and effective training of the MC team, limiting the admission or delaying transfers to ICU and ensuring optimal management of palliative care. We conducted a retrospective analysis of patient data in the MC unit during the second COVID-19 wave in Belgium. The aim of this study was to demonstrate the feasibility of quickly developing an effective respiratory MC unit mixing respiratory expert and non-expert members from outside ICUs. The establishment of an MC unit during a pandemic is feasible and needed. MC units possibly relieve the pressure exerted on ICUs. A highly trained multidisciplinary team is key to ensuring the success of an MC unit during such kind of a pandemic.
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COVID-19 , COVID-19/epidemiologia , Humanos , Unidades de Terapia Intensiva , Pandemias , Estudos Retrospectivos , SARS-CoV-2RESUMO
INTRODUCTION: Patients with chronic obstructive pulmonary disease (COPD) may demonstrate cognitive function and balance deterioration. These two phenomena are often realized simultaneously during daily living activities, where the risk of falling may be increased due to possible postural disturbance when focusing on a cognitive task during motion. Despite the high rate of falls in COPD, there is currently a lack of affordable clinical instruments to quantify the interaction between cognitive tasks and static balance in these patients. Therefore, this study aims to assess the balance perturbation induced by cognitive tasks using a new cost-effective protocol which can easily be implemented in clinical settings. METHOD: A total of 21 COPD patients (Age: 64 ± 8 yrs, Forced Expiratory Volume in one second = 41 ± 17%, Women: 7) and 21 matched healthy controls participated in the study. They performed two cognitive tasks (counting backward by 3s and naming animals) with eyes open and with eyes closed. Each trial lasted 60 s, with balance-related parameters recorded and quantified using a Wii Balance Board. A three-way ANOVA (cognitive task, eyes action, and health status) for balance-related parameters derived from the center of pressure displacement was performed. RESULTS: COPD, vision, and cognitive tasks altered the balance; no interaction between conditions was observed. There was no correlation between cognitive ability, respiratory function, and the balance-related parameters. CONCLUSION: Compared to healthy controls, the COPD patients had impaired balance. Cognitive tasks altered postural control in both COPD and controls, where this alteration was more pronounced with eyes closed.
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Equilíbrio Postural , Doença Pulmonar Obstrutiva Crônica , Atividades Cotidianas , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Cognição , Feminino , Volume Expiratório Forçado , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
The current gold-standard treatment for COVID-19-related hypoxemic respiratory failure is invasive mechanical ventilation. However, do not intubate orders (DNI), prevent the use of this treatment in some cases. The aim of this study was to evaluate if non-invasive ventilatory supports can provide a good therapeutic alternative to invasive ventilation in patients with severe COVID-19 infection and a DNI. Data were collected from four centres in three European countries. Patients with severe COVID-19 infection were included. We emulated a hypothetical target trial in which outcomes were compared in patients with a DNI order treated exclusively by non-invasive respiratory support with patients who could be intubated if necessary. We set up a propensity score and an inverse probability of treatment weighting to remove confounding by indication. Four-hundred patients were included: 270 were eligible for intubation and 130 had a DNI order. The adjusted risk ratio for death among patients eligible for intubation was 0.81 (95% CI 0.46 to 1.42). The median length of stay in acute care for survivors was similar between groups (18 (10-31) vs. (19 (13-23.5); p = 0.76). The use of non-invasive respiratory support is a good compromise for patients with severe COVID-19 and a do not intubate order.
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The relationship between cognitive function and breath-holding time is in need of further investigation. We aim to determine whether cognitive mobile games (CMG) are sensitive enough to assess the link between cognition and breath-holding time in non-trained subjects. Thirty-one healthy subjects participated in this study. A set of 3 short CMG: Must Sort (response control), Rush Back (attention, working memory) and True Color (mental flexibility, inhibition) was used. Apneic time was recorded in three different conditions: Total Lung Capacity (TLC): 88 ± 35 s, Functional Residual Capacity (FRC): 49 ± 17 s, and Residual Volume (RV): 32 ± 14 s. In males, breath-holding time at RV was correlated with True Color (r = 0.48) and Rush Back (r = 0.65) and at TLC with True Color (r = 0.45). In women, breath-holding time at TLC and FRC was inversely correlated with Must Sort (r = -0.59 and r = -0.49 respectively). Males and females appeared to differ in their use of cognitive resources during different breath-holding conditions.
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Apneia/fisiopatologia , Atenção/fisiologia , Suspensão da Respiração , Função Executiva/fisiologia , Inibição Psicológica , Memória de Curto Prazo/fisiologia , Testes Neuropsicológicos , Desempenho Psicomotor/fisiologia , Adulto , Diagnóstico por Computador , Feminino , Jogos Experimentais , Humanos , Masculino , Aplicativos Móveis , Fatores de Tempo , Adulto JovemRESUMO
BACKGROUND: Bronchoalveolar lavage (BAL) is currently not recommended in noncritically ill patients for the diagnosis of SARS-CoV-2 infection. Indeed, the diagnosis is based on the RT-PCR test on a nasopharyngeal swab (NPS) and abnormal findings on the chest CT scan. However, the sensitivity of the NPS and the specificity of the chest CT scan are low. Results of BAL in case of negative NPS testing are underreported, especially in the subgroup of immunocompromised patients. OBJECTIVES: The added value of BAL in the management of unstable, but noncritically ill patients, suspected of having SARS-CoV-2 infection despite one previous negative NPS and the side effects of the procedure for the patients and the health-care providers, were assessed during the epidemic peak of the COVID-19 outbreak in Belgium. METHODS: This multicentric study included all consecutive noncritically ill patients hospitalized with a clinical and radiological suspicion of SARS-CoV-2 infection but with a negative NPS. BAL was performed according to a predefined decisional algorithm based on their state of immunocompetence, the chest CT scan features, and their respiratory status. RESULTS: Among the 55 patients included in the study, 14 patients were diagnosed with a SARS-CoV-2 infection. Interestingly, there was a relationship between the cycle threshold of the RT-PCR and the interval of time between the symptom onset and the BAL procedure (Pearson's correlation coefficient = 0.8, p = 0.0004). Therapeutic management was changed in 33 patients because another infectious agent was identified in 23 patients or because an alternative diagnosis was made in 10 patients. In immunocompromised patients, the impact of BAL was even more marked (change in therapy for 13/17 patients). No significant adverse event was noted for patients or health-care staff. All health-care workers remained negative for SARS-CoV-2 NPS and serology at the end of the study. CONCLUSIONS: In this real-life study, BAL can be performed safely in selected noncritically ill patients suspected of SARS-CoV-2 infection, providing significant clinical benefits that outweigh the risks.
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Lavagem Broncoalveolar , Teste para COVID-19 , COVID-19/diagnóstico , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Bélgica , Feminino , Pessoal de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Sensibilidade e Especificidade , Tomografia Computadorizada por Raios XRESUMO
The detrimental effect of ascites on the lung-expanding action of the diaphragm is partly compensated for by an increase in the inspiratory elevation of the ribs, but the mechanism of this increase is uncertain. To identify this mechanism, the effect of ascites on the response of rib 4 to isolated phrenic nerve stimulation was first assessed in four dogs with bilateral pneumothoraces. Stimulation did not produce any axial displacement of the rib (X(r)) in the control condition and caused a cranial rib displacement in the presence of ascites. This displacement, however, was small. In a second experiment, the effects of ascites on the pleural pressure swing (DeltaP(pl)), intercostal activity, and X(r) during spontaneous inspiration were measured in eight animals. As the volume of ascites increased from 0 to 200 ml/kg body wt, X(r) increased from 3.5 +/- 0.5 to 7.5 +/- 0.9 mm (P < 0.001), DeltaP(pl) decreased from -6.4 +/- 0.4 to -3.6 +/- 0.3 cmH(2)0 (P < 0.001), and parasternal intercostal activity increased 61 +/- 19% (P < 0.001). The role of the decrease in DeltaP(pl) in causing the increase in X(r) was then separated from that of the increase in intercostal muscle force using the relation between X(r) and DeltaP(pl) during passive lung inflation. The loss in DeltaP(pl) accounted for two-thirds of the increase in X(r). These observations indicate that 1) the increased inspiratory elevation of the ribs in ascites is not the result of the increase in the rib cage-expanding action of the diaphragm and 2) it is due mostly to the decrease in DeltaP(pl) and partly to the increase in the force exerted by the parasternal intercostals on the ribs. These observations also suggest, however, that the rib cage expansion caused by ascites makes the parasternal intercostals less effective in pulling the ribs cranially.
Assuntos
Ascite/fisiopatologia , Mecânica Respiratória/fisiologia , Músculos Respiratórios/fisiopatologia , Costelas/fisiopatologia , Animais , Fenômenos Biomecânicos , Diafragma/fisiologia , Cães , Estimulação Elétrica , Eletromiografia , Músculos Intercostais/fisiologia , Pulmão/fisiologia , Contração Muscular/fisiologia , Nervo Frênico/fisiologia , Parede Torácica/fisiologiaRESUMO
The present study was designed to test the hypothesis that the expansion of a particular lung during breathing is partly related to the action of the hemidiaphragm on the opposite side. Two endotracheal tubes were inserted in the right and left main stem bronchi of anesthetized dogs, and the changes in pleural pressure (DeltaPpl) over the two lungs were assessed separately, first before and then after section of one phrenic nerve, by measuring the changes in airway opening pressure (DeltaPao) in the two tubes during occluded breaths. After phrenic nerve section, DeltaPao in the ipsilateral lung decreased 28+/-2%, and DeltaPao in the contralateral lung decreased 16+/-2% (P<0.01 for both). Parasternal intercostal activity, however, increased 15% on either side of the chest (P<0.05), thus indicating that the neural inspiratory drive was greater. Analysis of the results also suggested that after phrenic section, the contralateral (intact) hemidiaphragm still contributed nearly a third of the DeltaPpl over the ipsilateral lung. These observations indicate, in agreement with the hypothesis, that hemidiaphragmatic paralysis in the dog has a direct detrimental effect on the expansion of both lungs. They may account for the fact that in patients with hemidiaphragmatic paralysis, ventilation is reduced in both lung bases.