Beyond diagnosis: a narrative review of the evolving therapeutic role of medical thoracoscopy in the management of pleural diseases.

Background and Objective: Medical thoracoscopy (MT) is an endoscopic technique performed by interventional pulmonologists with a favorable safety profile and few contraindications, providing diagnostic and therapeutic intervention in a single sitting. This narrative review was designed to summarize the therapeutic role of MT based on the latest results from the available literature. Methods: Pertinent literature published in English, relative to human studies, between 2010-2022 was searched in Medline/PubMed and Cochrane databases. Publications regarded as relevant were considered for inclusion in this review; additional references were added based on the authors' knowledge and judgment. The review considered population studies, meta-analyses, case series, and case reports. Key Content and Findings: MT has mostly been described and is currently used globally in the diagnostic approach to exudative pleural effusion of undetermined origin. Carefully evaluating the literature, it is clear that there is initial evidence to support the use of MT in the therapeutic approach of malignant pleural effusion, pneumothorax, empyema, and less frequently hemothorax and foreign body retrieval. Conclusions: MT is an effective procedure for treating the clinical entities presented in this document; it must be carried out in selected patients, managed in centers with high procedural expertise. Further evidence is needed to assess the optimal indications and appropriate patients' profiles for therapeutic MT. The endpoints of length of hospital stay, surgical referral, complications and mortality will have to be considered in future studies to validate it as a therapeutic intervention to be applied globally.

Standardized Nursing Approach to Acute Aortic Dissection Patient: A Practice Update.

Background: Acute aortic dissection (AAD) is a rare condition but represents a time-sensitive disease for which a wrong and untimely identification in the triage phase could compromise the subsequent diagnostic, therapeutic path and patient's prognosis. The emergency nurse plays a crucial role in identifying and managing patients with possible AAD. The aim of this paper is to describe the emergency department nursing approach to critical patients with suspected hyperacute/acute AAD. Purpose: It is crucial to examine the emergency departments nursing approach to patients with suspected AAD. It is fundamental to have a rapid and standardized approach related to life-saving procedures, practices, and management of critical patients during the triage phase, with the assessment of the most common presentation of clinical signs and symptoms and patient management during each step in the emergency department. Conclusion: Early identification and diagnosis in ED allow prompt treatment that improves prognosis. The emergency nurse plays a crucial role in correctly identifying and managing patients with acute aortic dissection. High clinical suspicion from the triage stages, early diagnosis, monitoring, and initial clinical stabilization in the emergency department plays a key role while awaiting definitive treatment.

Improving Helmet CPAP Use During COVID-19 Pandemic: A Multidisciplinary Approach in the Emergency Department.

The aim of this article is to describe the importance of a multidisciplinary team dedicated to noninvasive ventilation training of the emergency department's staff. In our experience, the presence of a medical and nursing "noninvasive ventilation group" made it possible to quickly teach expertise on the management of noninvasive ventilation of COVID-19 patients among emergency department doctors and nurses. This allowed improving a standardized approach regarding the identification and ventilatory assistance of patients with SARS-CoV-2 pneumonia needing ventilatory support, the correct use of the devices, and quick identification and reduction of the complications associated with noninvasive ventilation. In this article, we would like to encourage the formation of similar working groups in all situations where this is not yet present.

The Effect of Filters on CPAP Delivery by Helmet.

BACKGROUND: When helmet CPAP is performed using a Venturi system, filters are frequently interposed in the respiratory circuit to reduce noise within the helmet. The effect of the interposition of these filters on delivered fresh gas flow and the resulting FIO2 is currently unknown. METHODS: In a bench study, 2 different Venturi systems (WhisperFlow and Harol) were used to generate 3 different gas flow/FIO2 combinations (80 L/min-FIO2 0.6, 100 L/min-FIO2 0.5, 120 L/min-FIO2 0.4). Different combinations of filters were applied at the flow generator input line and/or at the helmet inlet port. Two types of filters were used for this purpose: a heat and moisture exchanger filter and an electrostatic filter. The setup without filters was used as baseline. Gas flow and FIO2 were measured for each setup. RESULTS: Compared to baseline, the interposition of filters reduced the gas flow between 1-13% (P < .001). The application of a filter at the Venturi system or at the helmet generated a comparable flow reduction (-3 ± 2% vs -4 ± 2%, P = .12), whereas a greater flow reduction (-7 ± 4%) was observed when filters were applied at both sites (P < .001). An increase in FIO2 up to 5% was observed with filters applied. A strong inverse linear relationship (P < .001) was observed between the resulting gas flow and FIO2 . CONCLUSIONS: The use of filters during helmet CPAP reduced the flow delivered to the helmet and, consequently, modified FIO2 . If filters are applied, an adequate gas flow should be administered to guarantee a constant CPAP during the entire respiratory cycle and avoid rebreathing. Moreover, it might be important to measure the effective FIO2 delivered to the patient to guarantee a precise assessment of oxygenation.

Removal of a Tracheal Mesh Stent: How I Do It.

We illustrate how to remove a stent from the tracheal lumen 12 years after its deployment. Maintaining the stent in situ for a long time degrades the stent materials, making it fragile and very difficult to manipulate. A rigid bronchoscopy approach was chosen for the treatment of this case. We describe the preparation of the intervention and its execution step by step.

Ultrasound-guided peripheral intravenous catheters insertion in patient with difficult vascular access: Short axis/out-of-plane versus long axis/in-plane, a randomized controlled trial.

PURPOSE: The aim of this study was to evaluate the rate of successful peripheral cannulation between short-axis and long-axis ultrasound guided techniques. METHODS: A single-center, two-arm randomized controlled, intention-to-treat, open-label study was conducted at the Emergency Department, between August and November 2020. Patients requiring a peripheral intravenous catheter insertion and identified as having a difficult intravascular access, were enrolled and followed for up to 96 h.The primary endpoint was the correct placement of the peripheral intravenous catheter. The secondary endpoints were number of venipunctures, intra-procedural pain, local complications, and positive blood return during the follow up. RESULTS: A total of 283 patients were enrolled: 141 subjects were randomized to the short-axis and 142 to the long-axis group. Success rate was 96.45% (135/141; 95% CI, 91.92%-98.84%) in the short-axis group compared with 92.25% (132/142; 95% CI, 86.56%-96.07%) in the long-axis group (p = 0.126). No significant differences were found in terms of intraprocedural pain and local complications. Higher rate of positive blood return at 72 h [3/17 long-axis, 14/17 short-axis (p = 0.005)] and 96 h [1/10 long-axis, 9/10 short-axis 96 h, (p = 0.022)] was found for the short-axis group. CONCLUSIONS: No differences were found between short-axis and long-axis techniques in terms of success rate, intraprocedural pain, and local complications. Despite this, a slightly higher success rate, a lower number of venipunctures, and a higher rate of positive blood return at 72 and 96 h together with an easier ultrasound technique could suggest a short-axis approach.

Pleural effusion aetiology, presentation, treatment and outcome in haematological diseases: a review.

BACKGROUND AND AIM: Pleural effusions (PE) can complicate the course of hematologic disorders (HD) and may arise in the form of malignant PE or as a consequence of non-neoplastic complications. While a certain amount of data has been published regarding infectious and iatrogenic HD-associated PE (HPE), no comprehensive review regarding the other types of HPE has ever been conducted. To address this issue, we performed a systematic review of the literature regarding HPE, focusing on the clinical and chemical characteristics of PE, therapeutic approaches and ì outcomes at the one-year follow-up. METHODS: We conducted our review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: Overall, 283 manuscripts and 1216 cases were included. In summary, PE frequently signals an underlying HD, especially Hodgkin's lymphoma and IgG4-related disease; it mainly consists of exudate, although chylothorax is diagnosed in some cases. Although cytological examination has a discrete diagnostic yield, it is generally insufficient to render a definitive diagnosis; pleural biopsy remains an important diagnostic means in such cases. Invasive diagnostic procedures are not frequently performed because of an increased risk of haemorrhagic complications. The majority of PE are resolved by means of systemic therapy. When local treatments are attempted, the most frequently adopted procedures are evacuative thoracentesis and indwelling chest tube placement Conclusions: This review highlights the need for well-designed prospective studies comparing diagnostic means and therapeutic interventions for HPE to increase the quality of available data.  (www.actabiomedica.it).

Full medical treatment of COVID-19 associated large pneumothorax - A case report.

A 52-year-old man was re-admitted two weeks after recovering from severe COVD-19 following a 3-days history of cough and worsening shortness of breath. The chest radiograph showed a large right-sided pneumothorax. The first attempt at drainage, performed through a large bored tube, failed. Due to the large dimension of the pneumothorax, and the lung condition (extensive consolidation and diffuse bullous dystrophies), the only thoracic surgical approach prospected was a pneumonectomy. Willing to preserve the lung, the pulmonology team attempted a multi-phase medical-oriented strategy based on medical thoracoscopy. Therefore, the patient underwent 5 chest tube insertions, 2 talc pleurodesis, and an intrapleural blood patch. Air leakage resolution was progressively achieved, and the patient became asymptomatic.