Seasons can influence the results of the methacholine challenge test.

OBJECTIVE: This study tried to evaluate whether a methacholine test may be influenced by the seasons. METHODS: We considered 4826 consecutive subjects with normal spirometry (50.53% males; age: 35.1±16.2; forced expiratory volume in one second: 99.5±13.0%) who underwent a methacholine test for suspected asthma symptoms between 2000 and 2010. They were subdivided into four groups, like the seasons, according to the test dates. RESULTS: A total of 1981 (41%) resulted normal (no PD(20) was obtained with 2400 µg of methacholine); the others showed a mean LogPD(20) of 2.52±0.5 µg. The number of subjects with bronchial hyper-responsiveness (BHR) found in autumn (789, 62.3%) was higher than in summer (583, 56.7%; P=0.03). A higher number of females and overweight/obese subjects showed a BHR in autumn compared with the other seasons. The spring mean LogPD(20) value (2.48±0.48 µg) was lower if compared with the one measured in summer (2.59±0.49 µg; P=0.05). LogPD(20) value was lower in females and non-smokers in spring compared with summer (P<0.05). Overweight/obese non-smokers showed a lower LogPD(20) in spring and autumn compared with that in summer (P<0.05). Autumn was a risk factor (OR: 1.378; P=0.001) for BHR (using a PD(20) <2 400 µg as BHR limit), while spring (OR: 1.330; P=0.021) and autumn (OR: 1.331; P=0.020) were risk factors for a more severe BHR (using a PD(20) <400 µg as BHR limit). CONCLUSION: There was a higher probability of finding BHR in outpatients with suspected asthma in autumn and spring compared with summer. Spring is the season where BHR may be more severe. Females and overweight/obese subjects were those mainly involved in this seasonal variability of BHR.

Early fiberoptic bronchoscopy during non-invasive ventilation in patients with decompensated chronic obstructive pulmonary disease due to community-acquired-pneumonia.

INTRODUCTION: Inefficient clearance of copious respiratory secretion is a cause of non-invasive positive pressure ventilation (NPPV) failure, especially in chronic respiratory patients with community-acquired-pneumonia (CAP) and impaired consciousness. We postulated that in such a clinical scenario, when intubation and conventional mechanical ventilation (CMV) are strongly recommended, the suction of secretions with fiberoptic bronchoscopy (FBO) may increase the chance of NPPV success. The objective of this pilot study was, firstly, to verify the safety and effectiveness of early FBO during NPPV and, secondly, to compare the hospital outcomes of this strategy versus a CMV-based strategy in patients with decompensated chronic obstructive pulmonary disease (COPD) due to CAP who are not appropriate candidates for NPPV because of inefficient mucous clearance and hypercapnic encephalopathy (HE). METHODS: This is a 12-month prospective matched case-control study performed in one respiratory semi-intensive care unit (RSICU) with expertise in NPPV and in one intensive care unit (ICU). Fifteen acutely decompensated COPD patients with copious secretion retention and HE due to CAP undergoing NPPV in RSICU, and 15 controls (matched for arterial blood gases, acute physiology and chronic health evaluation score III, Kelly-Matthay scale, pneumonia extension and severity) receiving CMV in the ICU were studied. RESULTS: Two hours of NPPV significantly improved arterial blood gases, Kelly and cough efficiency scores without FBO-related complications. NPPV avoided intubation in 12/15 patients (80%). Improvement in arterial blood gases was similar in the two groups, except for a greater PaO2/fraction of inspired oxygen ratio with CMV. The rates of overall and septic complications, and of tracheostomy were lower in the NPPV group (20%, 20%, and 0%) versus the CMV group (80%, 60%, and 40%; P < 0.05). Hospital mortality, duration of hospitalisation and duration of ventilation were similar in the two groups. CONCLUSIONS: In patients with decompensated COPD due to CAP who are candidates for CMV because of HE and inability to clear copious secretions, NPPV with early therapeutic FBO performed by an experienced team is a feasible, safe and effective alternative strategy.

Ventilators for noninvasive ventilation to treat acute respiratory failure.

The application of noninvasive ventilation (NIV) to treat acute respiratory failure has increased tremendously both inside and outside the intensive care unit. The choice of ventilator is crucial for success of NIV in the acute setting, because poor tolerance and excessive air leaks are significantly correlated with NIV failure. Patient-ventilator asynchrony and discomfort can occur if the physician or respiratory therapist fails to adequately set NIV to respond to the patient's ventilatory demand, so clinicians need to fully understood the ventilator's technical peculiarities (eg, efficiency of trigger and cycle systems, speed of pressurization, air-leak compensation, CO(2) rebreathing, reliability of fraction of inspired oxygen reading, monitoring accuracy). A wide range of ventilators of different complexity have been introduced into clinical practice to noninvasively support patients in acute respiratory failure, but the numerous commercially available ventilators (bi-level, intermediate, and intensive care unit ventilators) have substantial differences that can influence patient comfort, patient-ventilator interaction, and, thus, the chance of NIV clinical success. This report examines the most relevant aspects of the historical evolution, the equipment, and the acute-respiratory-failure clinical application of NIV ventilators.

[Drug-induced diffuse infiltrative pneumopathies]. / Pneumopatie infiltrative diffuse da farmaci.

Drug-induced diffuse infiltrative pneumopathies (DIP) represent an important chapter of respiratory diseases. More than 350 drugs have been described to be potentially pneumo-toxic and the list is constantly increasing. As for other forms of DIP, also for drug-induced lung injury a multidisciplinary approach within pulmonologist, radiologist and pathologist is essential for the better diagnostic accuracy. In this review, clinical-radiological-pathological-therapeutic aspects of the drugs which are more likely to induce DIP in the clinical practice are described.

La ventilación no invasiva con presión positiva en la insuficiencia respiratoria aguda hipercápnica: diez años de experiencia clínica de una unidad de terapia semiintensiva respiratoria / Non-Invasive Positive Pressure Ventilation in Acute Hypercapnic Respiratory Failure: Ten-Year's Clinical Experience of a Respiratory Semi-Intensive Care Unit

Premisa: Si bien numerosos estudios prospectivos, controlados y aleatorizados han demostrado el éxito de la ventilación no invasiva con presión positiva (VNI) en casos seleccionados de insuficiencia respiratoria aguda (IRA) hipercápnica, en contexto con intensidad de cuidado diferente, los datos de práctica clínica relativos al uso de la VNI en escenarios reales son limitados. Objetivo: Reportar los resultados de nuestra experiencia clínica sobre la VNI en la IRA aplicada en la Unidad de Terapia Semiintensiva Respiratoria (UTSIR), de la Unidad Operativa de Neumología de Arezzo, entre 1996-2006, en términos de tolerabilidad, efectos sobre los gases arteriales, tasa de éxito y factores predictivos del fracaso. Métodos: Trescientos cincuenta de los 1.484 pacientes (23,6%) ingresados consecutivamente por IRA en nuestra Unidad Operativa de Neumología, durante el periodo de estudio, recibieronla VNI asociada a la terapia estándar, posterior al cumplimiento de criterios predefinidos, empleados de rutina. Resultados: Ocho pacientes (2,3%) no toleraron la VNI por incomodidad producida por la máscara, mientras los 342 restantes (M: 240; F: 102; edad: mediana [intercuartiles] 74,0 años [68,0-79,3]; enfermedad pulmonar obstructiva crónica (EPOC) [69,3%]) fueron ventilados por más de una hora. Los parámetros de ventilación (y su efecto sobre el pH) y de oxigenación mejoraron significativamente después de dos horas de VNI (media [desviación estándar] pH: 7,33 [0,07] contra 7,28 [7,25-7,31 ], p < 0,0001; PaCO2: 71,4 mmHg [15,3] contra 80,8 mmHg [16,6], p < 0,0001; PaO2/FiO2: 205 [61] contra 183 [150-222 ], p < 0,0001). La VNI evitó la intubación en 285/342 pacientes (83,3%), con una mortalidad hospitalaria del 14,0%. El fracaso de la VNI resultó ser predicho de modo independiente por el puntaje acute physiology and chronic health evaluation III (Apache III), por el índice de masa corporal y por el fracaso tardío de la VNI (mayor a 48 horas de ventilación), después de una respuesta positiva inicial. Conclusiones: Según nuestra experiencia clínica de diez años en una UTSIR, la VNI confirma ser bien tolerada, eficaz en el mejoramiento de los gases arteriales y útil en evitar la intubación en muchos episodios de IRA que no responden a la terapia estándar.

Background Although several prospective controlled randomized trials demonstrated the success of non-invasive positive pressure ventilation (NIPPV) in selected cases of acute hypercapnic respiratory failure (ARF) in setting with different care levels, clinical practice data about the use of VNI in the “real world” are limited. Aim To report the results of our clinical experience in NIPPV applied for ARF in the Respiratory Semi-Intensive Care Unit (UTSIR) allocated within the Respiratory Division of Arezzo between the years 1996- 2006 in terms of: patient tolerance, effects upon arterial blood gases, success rate and predictors of failure. Methods: Three hundred and filthy out of the 1484 patients (23.6%) consecutively admitted for ARF to our Respiratory Division during the study period received NIPPV in addition to standard therapy, according to the predetermined routinely used criteria. Results: Eight patients (2.3%) did not tolerate NIPPV because of mask discomfort, while the remaining 342 (M: 240, F: 102); median (interquartiles) age: 74.0 (68.0-79.3) yrs; COPD: 69.3%) were ventilated for >1 hour. Arterial blood gases significantly improved after two hours of NIPPV (mean (standard deviation) pH: 7.33 (0.07) versus 7.28 (7.25-7.31), p<0.0001; PaCO2: 71.4 (15.3) mmHg versus 80.8 (16.6) mmHg, p<0.0001; PaO2/FiO2: 205 (61) versus 183 (150-222), p<0.0001). NIPPV avoided intubation in 285/342 (83.3%) with a hospital mortality of 14.0%. NIPPV failure was independently predicted by the Apache III (Acute Physiology and Chronic Health Evaluation III) score, the body mass index and by the late failure of NIPPV (> 48 hrs of ventilation) after an initial positive response. Conclusions: As results of ten years of clinical experience at our UTSIR, NIPPV was shown to be well tolerated, effective in improving arterial blood gases and useful in avoiding intubation in most ARF episodes non-responsive to standard therapy.

Noninvasive versus conventional ventilation to treat hypercapnic encephalopathy in chronic obstructive pulmonary disease.

OBJECTIVE: We recently reported a high success rate using noninvasive positive pressure ventilation (NPPV) to treat COPD exacerbations with hypercapnic encephalopathy. This study compared the hospital outcomes of NPPV vs. conventional mechanical ventilation (CMV) in COPD exacerbations with moderate to severe hypercapnic encephalopathy, defined by a Kelly score of 3 or higher. DESIGN AND SETTING: A 3-year prospective matched case-control study in a respiratory semi-intensive care unit (RSICU) and intensive care unit (ICU). PATIENTS AND PARTICIPANTS: From 103 consecutive patients the study included 20 undergoing NPPV and 20 CMV, matched for age, simplified acute physiology score II, and baseline arterial blood gases. MEASUREMENTS AND RESULTS: ABG significantly improved in both groups after 2 h. The rate of complications was lower in the NPPV group than in the CMV group due to fewer cases of nosocomial pneumonia and sepsis. In-hospital mortality, 1-year mortality, and tracheostomy rates were similar in the two groups. Fewer patients remained on ventilation after 30 days in NPPV group. The NPPV group showed a shorter duration of ventilation. CONCLUSIONS: In COPD exacerbations with moderate to severe hypercapnic encephalopathy, the use of NPPV performed by an experienced team compared to CMV leads to similar short and long-term survivals with a reduced nosocomial infection rate and duration of ventilation.

Noninvasive positive pressure ventilation in patients with acute exacerbations of COPD and varying levels of consciousness.

STUDY OBJECTIVES: A severely altered level of consciousness (ALC) has been considered a contraindication to noninvasive positive pressure ventilation (NPPV). We compared the clinical outcome of patients with acute respiratory failure (ARF) due to COPD exacerbations and different degrees of ALC. DESIGN: A 5-year case-control study with a prospective data collection. SETTING: Respiratory Monitoring Unit. PATIENTS: Eighty of 153 consecutive COPD patients requiring NPPV for ARF were divided into four groups, which were carefully matched for the main physiologic variables, according to the level of consciousness assessed with the Kelly-Matthay Score, in which 1 is normal (control subjects) and 6 is severely impaired. MEASUREMENT AND RESULTS: Changes from baseline in arterial blood gas (ABG) levels and Kelly score, the rate and causes of NPPV failure, the rate of nosocomial pneumonia, and the 90-day mortality rate were compared. NPPV significantly improved ABG levels and Kelly score in all groups after 1 to 2 h. NPPV failure (Kelly score 1 = 15%; Kelly score 2 = 25%; Kelly score 3 = 30%; Kelly score > 3 = 45%) and 90-day mortality rate (Kelly score 1 = 20%; Kelly score 2 = 35%; Kelly score 3 = 35%; Kelly score > 3 = 50%) significantly increased with the worsening of the level of consciousness. Using a multivariate analysis, the acute nonrespiratory component of the acute physiology and chronic health evaluation (APACHE) III score, and baseline pH independently predicted baseline Kelly score. After 1 to 2 h of NPPV, changes in the Kelly score were associated with those in pH. No correlation was found with Pa(CO2). CONCLUSIONS: This study confirms that NPPV may be successfully applied to patients experiencing COPD exacerbations with milder ALCs, whereas the rate of failure in patients with severely ALCs (ie, Kelly score > 3) is higher, even though better than expected, so that an initial and cautious attempt with NPPV may be performed even in this latter group. Changes in the level of consciousness induced by NPPV are not correlated with those in Pa(CO2).

Co-morbidity and acute decompensations of COPD requiring non-invasive positive-pressure ventilation.

OBJECTIVE: To assess the prevalence and the impact of chronic and/or acute non-respiratory co-morbidity on short and longer-term outcome of non-invasive positive pressure ventilation (NIPPV) in acute decompensations of chronic obstructive pulmonary disease (COPD) with acute hypercapnic respiratory failure (AHRF). DESIGN AND SETTING: An observational study in a three-bed respiratory monitoring unit in a respiratory ward of a non-university hospital. PATIENTS: We grouped 120 consecutive COPD patients requiring NIPPV for AHRF (pH 7.28+/-0.05, PaO2/FIO2 ratio 192+/-63, PaCO2 78.3+/-12.3 mmHg) according to whether NIPPV succeeded (n=98) or failed (n=22) in avoiding the need for endotracheal intubation and whether alive (n=77) or dead (n=42) at 6 months. MEASUREMENTS AND RESULTS: The prevalence of chronic and acute co-morbidity was, respectively, 20% and 41.7%; most of the cases were cardiovascular. In-hospital NIPPV failure was greater in patients with than in those without chronic (33.3% vs. 14.6%) or acute co-morbidity (32% vs. 8.6%). Six-month mortality was worse in patients with than in those without chronic (54.2% vs. 30.5%) or more than one acute co-morbidity (66.7% vs. 30.8%). Multiple regression analysis predicted in-hospital NIPPV failure by acute co-morbidity and forced expiratory volume in 1 s, while death at 6 months was predicted by having more than one acute co-morbidity, non-cardiovascular chronic co-morbidity and Activities of Daily Living score. CONCLUSIONS: Chronic and acute co-morbidities are common in COPD patients with AHRF needing NIPPV and their presence influences short and longer-term outcome.