Tracheostomy decannulation in severe acquired brain injury patients: The role of flexible bronchoscopy.

INTRODUCTION AND OBJECTIVES: Subjects with severe acquired brain injury (sABI) require long-term mechanical ventilation and, as a consequence, the tracheostomy tube stays in place for a long time. In this observational study, we investigated to what extent the identification of late tracheostomy complications by flexible bronchoscopy (FBS) might guide clinicians in the treatment of tracheal lesions throughout the weaning process and lead to successful decannulation. SUBJECTS AND METHODS: One hundred and ninety-four subjects with sABI admitted to our rehabilitation unit were enrolled in the study. All subjects received FBS and tracheal lesions were treated either by choosing a more suitable tracheostomy tube, or by laser therapy, or by steroid therapy, or by a combination of the above treatments. RESULTS: Overall, 122 subjects (63%) were decannulated successfully. Our subjects received 495 FBSs (2.55 per subject) and as many as 270 late tracheostomy complications were identified. At least one complication was found in 160 subjects (82%). In only 11 subjects, late tracheostomy complications did not respond to the treatment and were the cause of decannulation failure. CONCLUSIONS: In conclusion, in sABI patients FBS is able to guide successful tracheostomy weaning in the presence of late tracheostomy complications that could get in the way decannulation.

Inhaler technique: facts and fantasies. A view from the Aerosol Drug Management Improvement Team (ADMIT).

Health professionals tasked with advising patients with asthma and chronic obstructive pulmonary disease (COPD) how to use inhaler devices properly and what to do about unwanted effects will be aware of a variety of commonly held precepts. The evidence for many of these is, however, lacking or old and therefore in need of re-examination. Few would disagree that facilitating and encouraging regular and proper use of inhaler devices for the treatment of asthma and COPD is critical for successful outcomes. It seems logical that the abandonment of unnecessary or ill-founded practices forms an integral part of this process: the use of inhalers is bewildering enough, particularly with regular introduction of new drugs, devices and ancillary equipment, without unnecessary and pointless adages. We review the evidence, or lack thereof, underlying ten items of inhaler 'lore' commonly passed on by health professionals to each other and thence to patients. The exercise is intended as a pragmatic, evidence-informed review by a group of clinicians with appropriate experience. It is not intended to be an exhaustive review of the literature; rather, we aim to stimulate debate, and to encourage researchers to challenge some of these ideas and to provide new, updated evidence on which to base relevant, meaningful advice in the future. The discussion on each item is followed by a formal, expert opinion by members of the ADMIT Working Group.

Erratum: Inhaler technique: facts and fantasies. A view from the Aerosol Drug Management Improvement Team (ADMIT).

[This corrects the article DOI: 10.1038/npjpcrm.2016.17.].

Rhinitis and asthma in athletes: an ARIA document in collaboration with GA2LEN.

This consensus document is aimed at reviewing evidence that the rhinitis-asthma links have peculiar features in athletes. Beside a review of epidemological data on the high prevalence of rhinitis and asthma in athletes, the effects on intense physical exercise on the immune system and repiratory functions are discussed, with special reference to the role of allergens and pollutants. In extending the Allergic Rhinitis and its Impact on Asthma (ARIA) recommendations to athletes, the issue is addressed of adapting diagnosis and management to criteria set by the International Olympic Committee (IOC) and regulations adopted by the World Anti-Doping Agency (WADA).

The need to improve inhalation technique in Europe: a report from the Aerosol Drug Management Improvement Team.

Although the principles of asthma management are well established in Europe, the available data indicate that asthma in patients is not well controlled. Many patients derive incomplete benefit from their inhaled medication because they do not use inhaler devices correctly and this may compromise asthma control. The Aerosol Drug Management Improvement Team (ADMIT), incorporating clinicians from the UK, Germany, France, Italy, Spain and The Netherlands, reviewed published evidence to examine ways to improve the treatment of reversible airways disease in Europe. Data indicate that there is a clear need for specific training of patients in correct inhalation technique for the various devices currently available, and this should be repeated frequently to maintain correct inhalation technique. Devices which provide reassurance to patients and their physicians that inhalation is performed correctly should help to improve patient compliance and asthma control. Educational efforts should also focus on primary prescribers of inhaler devices. ADMIT recommends dissemination of information on the correct inhalation technique for each model of device by the use of an accessible dedicated literature base or website which would enable to match the appropriate inhaler to the individual patient. There is also a need for standardisation of prescribing practices throughout Europe. Regular checking of inhalation technique by prescribers is crucial as correct inhalation is one of the keystones of successful asthma management.

Macrolides in the treatment of asthma and cystic fibrosis.

Asthma and cystic fibrosis are two respiratory diseases characterized by chronic inflammation, leading to remodelling of the airways. Macrolides are widely used antibiotics, with a peculiar anti-inflammatory effect. On the basis of the methodologies used by the Cochrane collaboration, this review discusses the evidence for their long-term use as anti-inflammatory agents in these two diseases. Three randomized-controlled trials (RCTs) were identified for both asthma and cystic fibrosis. A positive effect of macrolides on reducing eosinophil numbers and markers of eosinophilic inflammation was demonstrated in patients with asthma. Data on cystic fibrosis demonstrated an effect on lung function with an increase of 5.4% in forced vital capacity (FVC) in patients treated with macrolide vs. placebo, but without a significant effect on FEV1. Side-effects were rare, mild and reversible on withdrawal of treatment. Although preliminary data from small studies are promising, the role of macrolides in the treatment of these chronic disorders needs to be more firmly established with larger, well-designed trials, targeted to investigate major clinical outcomes.

Triggering receptor expressed on myeloid cells: role in the diagnosis of lung infections.

The triggering receptor expressed on myeloid cells (TREM)-1 is a recently described molecule, which plays an important role in myeloid cell-activated inflammatory responses. TREM-1 is expressed on blood neutrophils and monocytes, and also on alveolar macrophages, thus suggesting a potential role in lung inflammatory responses against infections. To investigate the differential expression of TREM-1 in lung infections, its levels were assessed in bronchoalveolar lavage specimens from patients with community-acquired pneumonia or tuberculosis. TREM-1 was also investigated in patients with interstitial lung diseases, as a model of noninfectious inflammatory disease of the lung. TREM-1 expression was significantly increased in lung neutrophils and in lung macrophages of patients with pneumonia (n=7; 387.9+/-61.4 and 660.5+/-18.3, respectively) compared with patients with pulmonary tuberculosis (n=7; 59.2+/-13.1 and 80.6+/-291.2) and patients with interstitial lung diseases (n=10; 91.8+/-23.3 and 123.9+/-22.8). In contrast, TREM-1 expression on peripheral blood neutrophils was no different among the three groups. In conclusion, these data suggest that triggering receptor expressed on myeloid cells-1 is selectively expressed in the lungs of patients with pneumonia caused by extracellular bacteria and not in patients with tuberculosis, providing a potential marker for differential diagnosis.

COPD increases the risk of squamous histological subtype in smokers who develop non-small cell lung carcinoma.

BACKGROUND: Squamous cell carcinoma has a stronger association with tobacco smoking than other non-small cell lung cancers (NSCLC). A study was undertaken to determine whether chronic obstructive pulmonary disease (COPD) is a risk factor for the squamous cell carcinoma histological subtype in smokers with surgically resectable NSCLC. METHODS: Using a case-control design, subjects with a surgically confirmed diagnosis of squamous cell carcinoma were enrolled from smokers undergoing lung resection for NSCLC in the District Hospital of Ferrara, Italy. Control subjects were smokers who underwent lung resection for NSCLC in the same hospital and had a surgically confirmed diagnosis of NSCLC of any histological type other than squamous cell. RESULTS: Eighty six cases and 54 controls (mainly adenocarcinoma, n = 50) were enrolled. The presence of COPD was found to increase the risk for the squamous cell histological subtype by more than four times. Conversely, the presence of chronic bronchitis was found to decrease the risk for this histological subtype by more than four times. Among patients with chronic bronchitis (n = 77), those with COPD had a 3.5 times higher risk of having the squamous cell histological subtype. CONCLUSIONS: These data suggest that, among smokers with surgically resectable NSCLC, COPD is a risk factor for the squamous cell histological subtype and chronic bronchitis, particularly when not associated with COPD, is a risk factor for the adenocarcinoma histological subtype.

[The therapy of bronchial asthma]. / Terapia dell'asma bronchiale.

Asthma (Greek word that means "breathlessness" or "open-mouth breath") is a chronic inflammatory disorder of the airways, with extensive infiltration of the airway lumen and wall with eosinophils, mast cells, activated T-lymphocytes. Airway inflammation is associated with airway hyperresponsiveness, recurrent episodes of reversible airflow limitation and respiratory symptoms such as wheezing, chest tightness, breathlessness and cough with mucus production. Curiously, asthma worsens particularly at night and in the early hours of the morning. The current consensus on asthma therapy suggests that pharmacological control of asthma can be achieved with antiinflammatory "controller" medications such as inhaled glucocorticoids and cromones. Short-acting bronchodilators act as "reliever" medications and rapidly reverse acute manifestations of asthma. Asthmatic exacerbations require the repetitive administration of inhaled short-acting beta-2-agonist and the early introduction of oral glucocorticoids. Rarely the severity of exacerbation requires the administration of oxygen (that, if available, is not contraindicated), intravenous bronchodilators, glucocorticoids and epinephryne and mechanical ventilation.

Patient satisfaction with conscious sedation for bronchoscopy.

STUDY OBJECTIVE: Bronchoscopic technique is not standardized. Controversies exist with regard to premedication with sedatives before the test. To evaluate safety and efficacy of conscious sedation, we studied 100 randomized patients undergoing diagnostic bronchoscopy; patients received premedication with lidocaine spray and atropine sulfate i.m. (nonsedation group; 50 patients) or lidocaine spray, atropine i.m. and diazepam i.v. (sedation group; 50 patients). METHODS AND RESULTS: Monitoring during flexible fiberoptic bronchoscopy included continuous ECG and pulse oximetry. The procedure could not be completed in six patients. None received premedication with diazepam; among the patients who ended the examination, tolerance to the examination (visual analogue scale, 0 to 100; 0 = excellent; 100 = unbearable) was better in the sedation group. Low anxiety, male sex, but not age were also associated with improved patient tolerance to the test. Oxygen desaturation occurred in 17% of patients, and it was not more frequent after diazepam treatment. CONCLUSIONS: In our study, sedation had a beneficial effect on patient tolerance and rarely induced significant alterations in cardiorespiratory monitoring parameters.

What can we learn from late-onset and occupational asthma?

Late-onset asthma and occupational asthma may provide interesting models of human asthma to compare with the most frequent type of atopic early-onset asthma. The discovery of similarities and discrepancies in the aetiology and pathogenesis of these different diseases might provide new insights on different mechanisms producing the same phenotype and, thus, by recognizing the different underlying mechanisms of the different forms of asthma, may allow better targeting of prevention and treatment. Occupational asthma, in addition to being a late-onset asthma, provides the unique opportunity to study the development of asthma under measurable exposure conditions, and consequently to examine the effect of cessation of exposure which, at variance with allergen avoidance, is possible in most of the cases.

Efficacy of noninvasive positive pressure ventilation by facial and nasal mask in hypercapnic acute respiratory failure: experience in a respiratory ward under usual care.

Noninvasive intermittent positive pressure ventilation (NIPPV) via a nasal or facial mask is an effective treatment of hypercapnic acute respiratory failure (ARF) caused by various diseases preventing endotracheal intubation (ETI) in 60-90% of patients. The technique can even be effective for routine care, using simplified ventilators, after adequate personnel training. In this study, the effectiveness, in a general respiratory ward under usual care, of NIPPV delivered by simplified ventilators via facial or nasal mask was evaluated in 40 patients with hypercapnic ARF (NIPPV group) and compared to 30 matched historical patients under conventional treatment (Conv group). Compared to conventional treatment, NIPPV was associated with a reduction in negative events such as ETI and mortality together (17% versus 60%, p = 0.0002), but not mortality alone (5% versus 13.5%, NS) or in the mean (+/- SD) length of the hospital stay (27.31 +/- 16.2 versus 27.5 +/- 20.5 days, NS). Patients treated with NIPPV, but not those treated conventionally, showed significant and rapid changes in arterial carbon dioxide tension (Pa,CO2) and pH between baseline and subsequent evaluation after 6 h, 1, 3 and 7 days and upon the discharge from hospital; in fact, in the NIPPV group after 6 h the arterial pH had risen from 7.30 +/- 0.062 to 7.35 +/- 0.066 and Pa,CO2 had decreased from 9.4 +/- 1.5 to 8.5 +/- 1.1 kPa. In the Conv group pH was stable at 7.29 and Pa,CO2 had risen from 9.39 +/- 1.8 to 9.43 +/- 1.6 kPa. In the NIPPV group no differences were found in the admission characteristics between patients successfully and unsuccessfully ventilated, although a significant improvement was observed after 1 h, for pH from 7.31 +/- 0.058 to 7.36 +/- 0.57 and Pa,CO2 from 9.2 +/- 1.3 to 8.3 +/- 1.3 kPa in successfully ventilated patients. In patients who failed to be ventilated with NIPPV pH worsened, from 7.26 +/- 0.069 to 7.24 +/- 0.078 and Pa,CO2 from 10.0 +/- 2.1 to 11.3 +/- 2.5 kPa. In conclusion, addition of noninvasive positive pressure ventilation delivered by nasal or face mask to conventional therapy, reducing the need for endotracheal intubation, may improve the management of patients with hypercapnic acute respiratory failure as compared to conventional therapy alone, even when instituted in a respiratory ward under usual care with simplified ventilators.

Asthma after consumption of snails in house-dust-mite-allergic patients: a case of IgE cross-reactivity.

A group of 28 patients from Italy was studied who had asthma after consumption of snail. All patients also had asthma and/or rhinitis caused by house-dust mite. RAST analyses confirmed the combined sensitization to snail and mite. In a few sera, IgE antibodies reactive with other foods of invertebrate origin (mussel and shrimp) were detected. RAST inhibition showed that most IgE antibodies against snail were cross-reactive with house-dust mite. In contrast, the mite RAST was not significantly inhibited by snail. This indicates that house-dust mite was the sensitizing agent. Immunoblot analyses revealed multiple bands in snail extract recognized by IgE. In contrast to what has been described for cross-reactivity between shrimp and mite, tropomyosin played only a minor role as a cross-reactive allergen in these patients. The observations in this study indicate that snail consumption can cause severe asthmatic symptoms in house-dust-mite-allergic patients. It might, therefore, be advisable to screen mite-allergic asthma patients for allergy to snail and other invertebrate animal foods.

Improvement of fog and exercise-induced bronchoconstriction after local and subcutaneous immunotherapy in mite asthma.

We compared the changes of non-specific bronchial hyperreactivity to methacholine, UNDW and exercise in 2 groups of patients with mite asthma treated with local immunotherapy (LIT group: 12 patients) and subcutaneous immunotherapy (SIT group: 8 patients) for 1 year. Bronchial challenges were done 1 week before the beginning and 1 week after the end of 1 year of treatment. The results showed a reduction of bronchial hyperreactivity to methacholine in the LIT group (PD 20FEV1 before: 223 +/- 193, after: 434 +/- 548) but not in the SIT group (PD 20FEV1: before: 143 +/- 188, after: 125 +/- 121) but the difference was not statistically significant. Exercise-induced bronchoconstriction completely disappeared in all the patients of LIT group (8/8) although only in 2 out of 4 patients of SIT group. Water-induced bronchoconstriction improved in 66% of LIT group (4/6) compared with none of SIT group (0/4). We conclude that, with the protocol of the present study, LIT is able to improve, more than SIT, non-specific bronchial hyperreactivity evaluated with osmotic stimuli as exercise and UNDW but not with pharmacologic stimuli as methacholine.

A young meningitically deaf child with a cochlear implant: a case study.

This study describes the development of the auditory, cognitive, linguistic, and social domains of a child deafened by meningitis at 20 months of age. He received a 3M/House cochlear implant at 27 months and is believed to be the youngest child to receive a cochlear implant. He was seen for intervention emphasizing audiometric conditioning and testing and language (speech and sign) stimulation for a period of 2:9 years (6 months pre-implant to 2:3 years post-implant). Videotapes of intervention; interviews with parents, teachers, and clinicians; test results; and medical and clinical reports were documented from pre-implant to two years post-implantation. The child regressed in all areas evaluated following his illness and subsequent deafness and cochlear implantation. At about one year after implantation, his social and cognitive skills began to improve. By two years after implantation (chronological age (CA) = 4:6), his abilities in all areas except auditory reception and speech had progressed to about the 4:0 age level. He communicates primarily through signs and seems to derive environmental sound and speech duration cues from the implant. Although it is difficult to separate the effects of the implant from maturational factors, he now willingly uses the implant simultaneously with his hearing aid on the non-implanted ear every day and seems to be functioning well with them. He responds inconsistently to his name when called, and consistently provides appropriate signed responses to questions. His imitative skills are improving; he can discriminate one- vs two-syllable words; and produces limited spontaneous speech. His cognitive and social abilities are at least age-appropriate and he signs 3- and 4-word combinations.