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1.
Panminerva Med ; 2021 Oct 04.
Artigo em Inglês | MEDLINE | ID: mdl-34606187

RESUMO

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has changed bronchoscopy practices worldwide. Bronchoscopy is a high-risk aerosol-generating procedure with a potential for direct SARS-CoV-2 exposure and hospital-acquired infection. Current guidelines about personal protective equipment and environment considerations represent key competencies to minimize droplets dispersion and reduce the risk of transmission. Different measures should be put in field based on setting, patient's clinical characteristics, urgency and indications of bronchoscopy. The use of this technique in SARS-CoV-2 patients is reported primarily for removal of airway plugs and for obtaining microbiological culture samples. In mechanically ventilated patients with SARS-CoV-2, bronchoscopy is commonly used to manage complications such as hemoptysis, atelectasis or lung collapse when prone positioning, physiotherapy or recruitment maneuvers have failed. Further indications are represented by assistance during percutaneous tracheostomy. Continuous positive airway pressure, non-invasive ventilation support and high flow nasal cannula oxygen are frequently used in patient affected by Coronavirus Disease-2019 (COVID-19): management of patients' airways and ventilation strategies differs from bronchoscopy indications, patient's clinical status and in course or required ventilatory support. Sedation is usually administered by the pulmonologist (performing the bronchoscopy) or by the anesthetist depending on the complexity of the procedure and the level of sedation required. Finally, elective bronchoscopy for diagnostic indications during COVID-19 pandemic should be carried on respecting rigid standards which allow to minimize potential viral transmission, independently from patient's COVID-19 status. This narrative review aims to evaluate the indications, procedural measures and ventilatory strategies of bronchoscopy performed in different settings during COVID-19 pandemic.

2.
Artigo em Inglês | MEDLINE | ID: mdl-34348536

RESUMO

Objective: To investigate the role of arterial blood gas (ABG) analysis parameters (blood carbon dioxide, pCO2; oxygen, pO2; carbonate, HCO3-; standard base excess, SBE) in monitoring respiratory function and ventilation compliance after noninvasive mechanical ventilation (NIV) adaptation, predicting survival in ALS patients. Methods: We selected the first ABG performed after NIV start in ALS patients followed from 2000 to 2015 in Turin ALS Center. Correlations between ABG parameters and survival were calculated. Risk for death/tracheostomy was computed at modifying ABG parameters by using Cox regression models, adjusted for the main prognostic factors. Kaplan-Meier curves were then performed and compared. Results: A total of 186 post-NIV ABGs were included. HCO3- and SBE showed a significant correlation with survival after NIV (respectively, R = -0.183, p = 0.018 and R = -0.200, p = 0.010). Risk for death/tracheostomy after NIV was significantly higher at increasing HCO3- and SBE blood levels, especially when HCO3- was >29 mmol/L and SBE >4 mmol/L (respectively, HR 1.466, 95% CI 1.068-2.011, p = 0.018 and HR = 1.411, 95% CI 1.030-1.32, p = 0.032). Survival in NIV was higher in patients with HCO3- < 29.0 mmol/L and SBE < 4.0 mmol/L. Conclusions: HCO3- and SBE blood levels are markers of ventilation compliance, tolerance and efficacy, being able to predict survival after NIV start in ALS.


Assuntos
Esclerose Amiotrófica Lateral , Ventilação não Invasiva , Insuficiência Respiratória , Esclerose Amiotrófica Lateral/terapia , Gasometria , Carbonatos , Humanos , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/terapia
3.
Artigo em Inglês | MEDLINE | ID: mdl-34355622

RESUMO

Objective: To evaluate how Amyotrophic Lateral Sclerosis (ALS) patients' mortality rates change, based on different levels of forced vital capacity (FVC) and disease duration, providing a scheme of mortality rates of a real population of ALS patients to improve the design of future RCTs. Methods: One random spirometry for each ALS patient was selected during four time intervals from disease onset: (1) ≤12 months; (2) ≤18 months; (3) ≤24 months; (4) ≤36 months. Date of spirometry corresponded to date of trial entry, while time interval onset-spirometry to disease duration at enrollment. Mortality rates from inclusion were computed at different time intervals. Based on progression rates, patients were stratified in slow, intermediate and fast progressors. Survival from recruitment was calculated depending on FVC, disease duration and progression rate. Results: We included 659 patients in group 1, 888 in group 2, 1019 in group 3 and 1102 in group 4. Mortality rates were higher in each group at reducing the FVC cutoff used for recruitment (p < 0.001). Median survival decreased when lowering FVC and disease duration cutoffs (p < 0.001); a higher median disease progression rate of included patients led to lower median survival from recruitment. The proportion of recruited fast progressors raised when shortening disease duration and lowering FVC cutoff. Conclusions: This is a simple model for setting eligibility criteria, based on mortality rates of patients depending on FVC and disease duration, to select the best population for RCTs, tailored to trials' primary endpoints and duration.

5.
J Neurol ; 267(6): 1615-1621, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32052165

RESUMO

OBJECTIVES: To compare the prognostic role of FVC and SVC at diagnosis in amyotrophic lateral sclerosis (ALS) patients. METHODS: We included all patients from the Piemonte and Valle D'Aosta ALS register (PARALS) who had been diagnosed with ALS between 1995 and 2015 and underwent spirometry at diagnosis. Survival was considered as time to death/tracheostomy; to assess the prognostic value in typical trial timeframes, survival at 12 and 18 months was calculated too. Cox proportional hazard regression models adjusted by sex, age at diagnosis, diagnostic delay, onset site, and ALSFRS-R total score at the moment of diagnosis were used to assess the prognostic role of FVC and SVC. RESULTS: A total of 795 ALS patients underwent spirometry at diagnosis during the study period. Four hundred and sixteen (52.3%) performed both FVC and SVC, whereas the others performed FVC only. FVC and SVC values were highly correlated (r = 0.92, p < 0.001) in the overall population and slightly less correlated in patients with bulbar onset (r = 0.86, p < 0.001). Both FVC and SVC proved to have a prognostic role with comparable hazard ratios (HRs) (HR 1.83, 95% CI 1.48-2.27 and 1.88, 95% CI 1.51-2.33, respectively). When considering typical trial timeframes, HRs remained similar and were inversely proportional to FVC and SVC values. DISCUSSION: FVC and SVC at diagnosis can be used interchangeably as independent predictors of survival in both clinical and research settings.


Assuntos
Esclerose Amiotrófica Lateral/diagnóstico , Esclerose Amiotrófica Lateral/mortalidade , Esclerose Amiotrófica Lateral/fisiopatologia , Sistema de Registros , Capacidade Vital/fisiologia , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Espirometria
6.
Hypertension ; 74(6): 1532-1540, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31679423

RESUMO

The association between primary aldosteronism (PA) and obstructive sleep apnea (OSA) has been a matter of debate. 2016 Endocrine Society guideline recommends screening for PA all hypertensive patients with OSA. We designed a multicenter, multiethnic, cross-sectional study to evaluate the prevalence of PA in patients with OSA and the prevalence of OSA in unselected patients with PA. Two hundred and three patients with OSA (102 whites and 101 Chinese) were screened for PA, and 207 patients with PA (104 whites, 100 Chinese, and 3 of African descent) were screened for OSA by cardiorespiratory polygraphy. Eighteen patients with OSA (8.9%) had PA (11.8% of white and 5.9% of Chinese ethnicity). In patients without other indications for PA screening, the prevalence of PA dropped to 1.5%. The prevalence of OSA in patients with PA was 67.6%, consistent in both white and Chinese patients. A correlation between aldosterone levels and apnea/hypopnea index was observed in white patients with PA (R2=0.225, P=0.016) but not in Chinese patients. Multinomial logistic regression confirmed a significant and independent association between plasma aldosterone levels and moderate to severe OSA diagnosis in white patients (odds ratio, 1.002; P=0.002). In conclusion, aldosterone levels may contribute to the severity of OSA in white patients with hyperaldosteronism, but patients with OSA are not at high risk of PA. Results of the present study challenge the current recommendation of the Endocrine Society guideline that all patients with OSA should be screened for PA, irrespective of the grade of hypertension.


Assuntos
Hiperaldosteronismo/diagnóstico , Hiperaldosteronismo/etnologia , Hipertensão/diagnóstico , Apneia Obstrutiva do Sono/diagnóstico , Apneia Obstrutiva do Sono/etnologia , Adulto , Fatores Etários , Determinação da Pressão Arterial , Comorbidade , Estudos Transversais , Grupos Étnicos , Feminino , Seguimentos , Alemanha , Humanos , Hipertensão/etnologia , Internacionalidade , Masculino , Pessoa de Meia-Idade , Polissonografia/métodos , Prevalência , Medição de Risco , Índice de Gravidade de Doença , Fatores Sexuais , Estatísticas não Paramétricas
7.
Nutrients ; 9(11)2017 Nov 11.
Artigo em Inglês | MEDLINE | ID: mdl-29137124

RESUMO

BACKGROUND: Intervention studies with vitamin D in asthma are inconclusive for several reasons, such as inadequate dosing or duration of supplementation or uncontrolled baseline vitamin D status. Our aim was to evaluate the benefit of long term vitamin D add-on in asthmatic patients with actual vitamin D deficiency, that is a serum 25-hydroxy vitamin D (25-OHD ) below 20 ng/mL. METHODS: Serum 25-OHD, asthma exacerbations, spirometry and inhaled corticosteroids (CS) dose were evaluated in a cohort of 119 asthmatic patients. Patients with deficiency were evaluated again after one year vitamin supplementation. RESULTS: 25-OHD was low in 111 patients and was negatively related to exacerbations (p < 0.001), inhaled CS dose (p = 0.008) and asthma severity (p = 0.001). Deficiency was found in 90 patients, 55 of whom took the supplement regularly for one year, while 24 discontinued the study and 11 were not adherent. Patients with vitamin D deficiency after 12 months supplementation showed significant decrease of exacerbations (from 2.6 ± 1.2 to 1.6 ± 1.1, p < 0.001), circulating eosinophils (from 395 ± 330 to 272 ± 212 106/L, p < 0.001), and need of oral CS courses (from 35 to 20, p = 0.007) and improvement of airway obstruction. CONCLUSIONS: Asthma exacerbations are favored by vitamin D deficiency and decrease after long-term vitamin D replacement. Patients who are vitamin D deficient benefit from vitamin D supplementation.


Assuntos
Corticosteroides/administração & dosagem , Asma/tratamento farmacológico , Colecalciferol/administração & dosagem , Suplementos Nutricionais , Pulmão/efeitos dos fármacos , Deficiência de Vitamina D/tratamento farmacológico , Vitamina D/análogos & derivados , Administração por Inalação , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Asma/complicações , Asma/diagnóstico , Asma/fisiopatologia , Biomarcadores/sangue , Estudos Transversais , Progressão da Doença , Feminino , Humanos , Estudos Longitudinais , Pulmão/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Vitamina D/sangue , Deficiência de Vitamina D/sangue , Deficiência de Vitamina D/complicações , Deficiência de Vitamina D/diagnóstico , Adulto Jovem
8.
Respir Care ; 61(4): 462-7, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26670472

RESUMO

BACKGROUND: A recent study found that activation of disconnection and low-pressure alarms is common during mouthpiece ventilation and may represent a major limitation to its use. The aim of this bench study was: (1) to investigate the technical aspects that can influence the setting of the ventilator during mouthpiece ventilation and (2) to provide a practical setting strategy to avoid the alarm activation. METHODS: Eight life-support ventilators able to deliver volume controlled ventilation were tested in a bench study using a single-limb non-vented circuit configuration connected to a standard mouthpiece. Disconnection and apnea alarm were turned off or set at the least sensitive setting. The backup frequency was set at the lowest available level. Different tidal volumes (VT) (from 500 to 1,200 mL) were tested with the rectangular and descending flow shape. For each VT, we reported the maximum set inspiratory time (TI) that allowed preventing activation of the low-pressure alarm. The presence of auto-triggering was also surveyed. RESULTS: We found that a correct combination of VT and TI avoided the activation of disconnection and low-pressure alarms in all but 3 ventilators. One ventilator did not allow mouthpiece ventilation independently from the settings used. The inability to turn off the apnea alarm in two other ventilators led to the alarm going off in any tested conditions after 120 s without triggered breaths. Auto-triggering was seldom found and easily worked out, except for in one ventilator. CONCLUSIONS: An appropriate alarm setting and combination of VT and TI would allow the majority of the tested ventilators to be used for mouthpiece ventilation without alarm activation.


Assuntos
Alarmes Clínicos , Análise de Falha de Equipamento , Ventilação não Invasiva/instrumentação , Ventiladores Mecânicos , Desenho de Equipamento , Humanos , Volume de Ventilação Pulmonar
9.
Respir Res ; 15: 131, 2014 Dec 13.
Artigo em Inglês | MEDLINE | ID: mdl-25496239

RESUMO

BACKGROUND: Acute exacerbations of COPD (AECOPD) are common and strongly influence disease severity and relative healthcare costs. Vitamin D deficiency is frequent among COPD patients and its contributory role in disease exacerbations is widely debated. Our aim was to assess the relationship of serum vitamin D levels with COPD severity and AECOPD. METHODS: Serum vitamin D (25-hydroxyvitamin D) levels were measured in 97 COPD patients and related to lung function, comorbidities, FEV1 decline, AECOPD and hospital admission during the previous year. RESULTS: Most patients (96%) had vitamin D deficiency, which was severe in 35 (36%). No significant relationship was found between vitamin D and FEV1 or annual FEV1 decline. No difference between patients with and without severe vitamin D deficiency was found in age, gender, BMI, smoking history, lung function, and comorbidities, apart from osteoporosis (60.9% in severe deficiency vs 22.7%, p = 0.001). In multiple logistic regression models, severe deficiency was independently associated with AECOPD [adjusted odds ratios (aOR) of 30.5 (95% CI 5.55, 168), p < 0.001] and hospitalization [aOR 3.83 (95% CI 1.29, 11.4), p = 0.02]. The odds ratio of being a frequent exacerbator if having severe vitamin D deficiency was 18.1 (95% CI 4.98, 65.8) (p < 0.001), while that of hospitalization was 4.57 (95% CI 1.83, 11.4) (p = 0.001). CONCLUSIONS: In COPD patients severe vitamin D deficiency was related to more frequent disease exacerbations and hospitalization during the year previous to the measurement of vitamin D. This association was independent of patients' characteristics and comorbidities.


Assuntos
Hospitalização , Pulmão/fisiopatologia , Doença Pulmonar Obstrutiva Crônica/complicações , Deficiência de Vitamina D/complicações , Idoso , Biomarcadores/sangue , Progressão da Doença , Feminino , Volume Expiratório Forçado , Humanos , Modelos Lineares , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Vitamina D/análogos & derivados , Vitamina D/sangue , Deficiência de Vitamina D/sangue , Deficiência de Vitamina D/diagnóstico
10.
Multidiscip Respir Med ; 9(1): 60, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25485108

RESUMO

Adherence to medical therapies is a growing issue, so much so that the World Health Organization defined it as "a new pharmacological problem". The main factors affecting compliance are: frequency of administration, rapid onset of action, role of device. The most severe consequence of non-adherence is the increased risk of poor clinical outcome, associated with worsening of the quality of life and increase in health-care expenditure. It appears crucial to identify those COPD patients who are "poorly or not at all compliant with their treatment". In order to evaluate adherence to the medical therapy, several methods were proposed, the most effective of which turned out to be self-reports, i.e. simple, brief questionnaires (e.g. Morisky test). To increase the likelihood of quickly identifying non-compliant patients, it may be useful to administer a simple questionnaire to naïve subjects (for example, in the waiting room before an examination) including six specific items allowing to identify the patient's key characteristics. Depending on the answers, patients who do not comply with their pharmacological treatment may be classified as belonging to 6 phenotypes. For patients who are already under treatment it might be useful to administer another short questionnaire during follow up examination. Once the risk of non-compliance is identified, four possible types of measures can be taken: prescription-related, educational, behavioral and complex combined measures (combination of two or more actions). Therefore, while it is clear that adherence in COPD is a critical issue, it is also obvious that raising awareness on the disease and improving cooperation among specialists, general practitioners, health-care professionals, and patients is the starting point at which this evolution should immediately begin. Each medication is able to foster good compliance with the therapy, and consequently to maximize the efficacy, by virtue of its specific inhaler and its own active ingredient.

11.
Intensive Care Med ; 39(1): 59-65, 2013 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-23052951

RESUMO

PURPOSE: To assess the behaviour of a pressure-preset volume-guaranteed (V(TG)) mode of ventilation in the presence of non-intentional leaks in single-limb circuit (SLC) home ventilators. METHODS: All SLC home ventilators commercially available in Italy can be used in a V(TG) mode with an intentional leak ("vented") or a true expiratory valve ("non-vented") configuration were selected. Using an experimental model consisting of a mannequin connected to an active lung simulator, for each level of leak (15, 25 and 37 l/min) three different conditions of respiratory mechanics (normal, restrictive and obstructive) were simulated using the ventilators in either a "vented" or "non-vented" configuration. RESULTS: Three home ventilators were tested: Vivo50 (Breas), PB560 (Covidien) and Ventilogic LS (Weimann). In a "vented" circuit configuration all three ventilators kept constant or increased inspiratory pressure in all leak conditions to guarantee the V(TG). Conversely, in a "non-vented" circuit configuration, all tested ventilators showed a drop in inspiratory pressure in all leak conditions, resulting in a concomitant reduction in delivered tidal volume. The same behaviour was found in all conditions of respiratory mechanics. In the absence of leaks, all the ventilators, independently of circuit configuration, were able to maintain the set V(TG) in the presence of modifications of the respiratory mechanics. CONCLUSIONS: The ability of the V(TG) mode to compensate for non-intentional leaks depends strictly on whether a "vented" or "non-vented" circuit configuration is used. This difference must be taken into account as a possible risk when a V(TG) mode is used in the presence of non-intentional leaks.


Assuntos
Ventiladores Mecânicos , Desenho de Equipamento , Serviços de Assistência Domiciliar , Humanos , Volume de Ventilação Pulmonar
12.
J Neurol Neurosurg Psychiatry ; 83(4): 377-81, 2012 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-22013242

RESUMO

OBJECTIVE: To evaluate the clinical characteristics and outcome of non-invasive ventilation (NIV) in an epidemiological based series of amyotrophic lateral sclerosis (ALS) patients. METHODS: The study was performed using data from the Piemonte and Valle d'Aosta Register for ALS, a prospective epidemiological register enrolling all ALS incident cases in two Italian regions. RESULTS: Among the 1260 patients incident in the period 1995-2004, 259 (20.6%) underwent NIV. Young male patients and subjects attending the tertiary ALS centres were more likely to undergo NIV. There was a progressive significant increase in the use of NIV during the study but was limited to patients attending the ALS tertiary centres. Median survival after NIV was 289 days (95% CI 255 to 333). CONCLUSIONS: In an epidemiological setting, NIV represents an increasingly utilised option for the treatment of respiratory disturbances in ALS and has favourable effects on survival, in particular among patients followed by tertiary ALS centres. Sociocultural factors, such as age, gender and marital status, strongly influence the probability of undergoing NIV. Efforts should be made to remove these obstacles in order to spread the use of NIV in all ALS patients with respiratory failure.


Assuntos
Esclerose Amiotrófica Lateral/terapia , Neurologia/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Respiração Artificial/estatística & dados numéricos , Adulto , Idade de Início , Idoso , Idoso de 80 Anos ou mais , Esclerose Amiotrófica Lateral/mortalidade , Comorbidade , Intervalo Livre de Doença , Feminino , Humanos , Itália , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Vigilância da População , Insuficiência Respiratória/mortalidade , Insuficiência Respiratória/prevenção & controle , Distribuição por Sexo , Fatores Sexuais , Fatores Socioeconômicos , Inquéritos e Questionários , Taxa de Sobrevida , Prevenção Terciária
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