Influence of Tracheal Obstruction on the Efficacy of Superimposed High-frequency Jet Ventilation and Single-frequency Jet Ventilation.

BACKGROUND: Both superimposed high-frequency jet ventilation (SHFJV) and single-frequency (high-frequency) jet ventilation (HFJV) have been used with success for airway surgery, but SHFJV has been found to provide higher lung volumes and better gas exchange than HFJV in unobstructed airways. The authors systematically compared the ventilation efficacy of SHFJV and HFJV at different ventilation frequencies in a model of tracheal obstruction and describe the frequency and obstruction dependence of SHFJV efficacy. METHODS: Ten anesthetized animals (weight 25 to 31.5 kg) were alternately ventilated with SHFJV and HFJV at a set of different fHF from 50 to 600 min. Obstruction was created by insertion of interchangeable stents with ID 2 to 8 mm into the trachea. Chest wall volume was measured using optoelectronic plethysmography, airway pressures were recorded, and blood gases were analyzed repeatedly. RESULTS: SHFJV provided greater than 1.6 times higher end-expiratory chest wall volume than HFJV, and tidal volume (VT) was always greater than 200 ml with SHFJV. Increase of fHF from 50 to 600 min during HFJV resulted in a more than 30-fold VT decrease from 112 ml (97 to 130 ml) to negligible values and resulted in severe hypoxia and hypercapnia. During SHFJV, stent ID reduction from 8 to 2 mm increased end-expiratory chest wall volume by up to 3 times from approximately 100 to 300 ml and decreased VT by up to 4.2 times from approximately 470 to 110 ml. Oxygenation and ventilation were acceptable for 4 mm ID or more, but hypercapnia occurred with the 2 mm stent. CONCLUSION: In this in vivo porcine model of variable severe tracheal stenosis, SHFJV effectively increased lung volumes and maintained gas exchange and may be advantageous in severe airway obstruction.

Home parasternal electromyography tracks patient-reported and physiological measures of recovery from severe COPD exacerbation.

Physiological phenotyping using daily home-based assessments reveals early improvement in load-capacity-drive imbalance following #AECOPD and feasibility of home parasternal electromyography measurement, which tracks symptoms, health status and spirometry https://bit.ly/3o6I0Ty.

Developing a strategic understanding of telehealth service adoption for COPD care management: A causal loop analysis of healthcare professionals.

BACKGROUND: Telehealth services can improve the quality of health services for chronic obstructive pulmonary disease (COPD) management, but the clinical benefits for patients yet not clear. It is crucial to develop a strategy that supports the engagement of healthcare professionals to promote the sustainable adoption of telehealth services further. The aim of the study was to show how variables related to the perception of telehealth services for COPD by different healthcare professionals interact to influence its adoption and to generate advice for future telehealth service implementation. METHODS: Data was thematically synthesized from published qualitative studies to create causal loop diagrams, further validated by expert interviews. These diagrams visualize dependencies and their polarity between different variables. RESULTS: Adoption of telehealth services from the nurse's perspective is directly affected by change management and autonomous decision making. From the physician's perspective, perceived value is the most important variable. Physical activity management and positive user experience are considered affecting perceived value for physiotherapists. There is no consensus where self-management services should be positioned in the COPD care pathway. CONCLUSION: Our results indicate how complex interactions between multiple variables influence the adoption of telehealth services. Consequently, there is a need for multidimensional interventions to achieve adoption. Moreover, key variables were identified that require attention to ensure success of telehealth services. Furthermore, it is necessary to explore where self-management services are best positioned in the care pathway of COPD patients.

A systematic map and in-depth review of European telehealth interventions efficacy for chronic obstructive pulmonary disease.

BACKGROUND: Evidence to support the implementation of telehealth (TH) interventions in the management of chronic obstructive pulmonary disease (COPD) varies throughout Europe. Despite more than ten years of TH research in COPD management, it is still not possible to define which TH interventions are beneficial to which patient group. Therefore, informing policymakers on TH implementation is complicated. We aimed to examine the provision and efficacy of TH for COPD management to guide future decision-making. METHODS: A mapping study of twelve systematic reviews of TH interventions for COPD management was conducted. This was followed by an in-depth review of fourteen clinical trials performed in Europe extracted from the systematic reviews. Efficacy outcomes for COPD management were synthesized. RESULTS: The mapping study revealed that systematic reviews with a meta-analysis often report positive clinical outcomes. Despite this, we identified a lack of pragmatic trial design affecting the synthesis of reported outcomes. The in-depth review visualized outcomes for three TH categories, which revealed a plethora of heterogeneous outcomes. Suggestions for reporting within these three outcomes are synthesized as targets for future empirical research reporting. CONCLUSION: The present study indicates the need for more standardized and updated systematic reviews. Policymakers should advocate for improved TH trial designs, focusing on the entire intervention's adoption process evaluation. One of the policymakers' priorities should be the harmonization of the outcome sets, which would be considered suitable for deciding about subsequent reimbursement. We propose possible outcome sets in three TH categories which could be used for discussion with stakeholders.

Assessment of diaphragmatic thickness by ultrasonography in Duchenne muscular dystrophy (DMD) patients.

INTRODUCTION: In Duchenne muscular dystrophy (DMD) the assessment of diaphragmatic function is crucial because respiratory muscle weakness can cause respiratory failure. We aimed to noninvasively assess diaphragmatic function in DMD by measuring diaphragmatic thickness by ultrasonography, under the hypothesis that the progressive decrease of lung function is related to alterations of diaphragmatic thickness. METHODS: Forty-four DMD patients and thirteen healthy controls were enrolled and subdivided into three age groups. Diaphragmatic thickness was measured during quiet breathing, inspiratory capacity, maximal inspiratory pressure and expiratory pressure maneuvers. RESULTS: In DMD, absolute values of diaphragmatic thickness were significantly lower than in controls in the majority of the manoeuvers and diaphragmatic thickness significantly decreased with age at end-expiration, remaining constant at end-inspiration and during maximal inspiratory pressure maneuvers. Comparing to controls, absolute values of diaphragmatic thickness and diaphragmatic thickness variations were significantly lower (p<0.001), with the exception of quiet breathing and maximal expiratory pressure maneuvers in the youngest DMD. During maximal inspiratory pressure maneuver, variation of diaphragmatic thickness was not significantly different in the all groups, nevertheless maximal inspiratory pressure decreases with age. CONCLUSIONS: The diaphragm is prone to pseudo-hypertrophy in the youngest DMD, and to progressive atrophy in middle-age and oldest DMD. Diaphragm impairment could be expressed as a dissociation between muscle drive and muscle developed force. Ultrasonography could be used as a noninvasive method to assess progressive diaphragmatic weakness.

Thoraco-abdominal asymmetry and asynchrony in congenital diaphragmatic hernia.

OBJECTIVE: Congenital diaphragmatic hernia (CDH) consists of an incomplete formation of the diaphragm and the subsequent herniation of abdominal bowels. Diaphragmatic defect can be repaired by primary closure or placing a patch. Respiratory follow up usually focuses on spirometric and clinical evaluation. The aim of the study was to assess thoraco-abdominal volumes in CDH patients and to verify whether the action of the diaphragm on the chest wall is altered leading to an asymmetric and asynchronous expansion of the different thoracoabdominal compartments. PATIENTS AND METHODS: Total and compartmental chest wall volumes and asynchronies were measured by Opto-Electronic Plethysmography in 14 CDH patients (7 M/7F, age 5 ± 2 years, 12 left side operated) and in 9 age matched healthy subjects during quiet spontaneous breathing in supine position. Patients were divided in two groups: five patients with suture (group S) and nine patients with diaphragmatic patch (group P). Pulmonary function was assessed by spirometry and spirometric parameters were expressed as Z-score. RESULTS: In group P abdominal contribution to tidal volume was lower than healthy controls and group S. Unlike controls, in both CDH groups the right side of pulmonary rib cage moved inward with a correspondent left side expansion during inspiration. In group S, thoraco-abdominal asynchronies were higher than in group P and controls, especially in the right side. Five patients belonging to group P had a spirometric obstructive pattern. CONCLUSIONS: In overall CDH patients a reduced action of the treated (left) hemi-diaphragm is evident. In patients treated by primary suture, a compensatory action of the right side allows to reach a normal total diaphragmatic displacement and a proper contribution of the whole diaphragm to tidal volume. In patients treated by diaphragmatic patch, instead, thoraco-abdominal asynchronies are prevented.

Alterations of thoraco-abdominal volumes and asynchronies in patients with spinal muscle atrophy type III.

Spinal muscular atrophy (SMA) is characterized by degeneration of motor neurons resulting in muscle weakness. For the mild type III form, a sub-classification into type IIIA and IIIB, based on age of motor impairment, was recently proposed. To investigate if SMA IIIA (more severe) and IIIB differ also in terms of respiratory function, thoracoabdominal kinematics was measured during quiet breathing, inspiration preceding cough and inspiratory capacity on 5 type IIIA and 9 type IIIB patients. Four patients with SMA II (more severe than types III) and 19 healthy controls were also studied. Rib cage motion was similar in SMA IIIB and controls. Conversely, in SMA IIIA and SMA II it was significantly reduced and sometime paradoxical during quiet breathing in supine position. Our results suggest that in SMA IIIA intercostal muscles are weakened and the diaphragm is preserved similarly to SMA II, while in SMA IIIB the action of all inspiratory muscles is maintained. Sub-classification of type III seems feasible also for respiratory function.

The effect of posture on asynchronous chest wall movement in COPD.

Chronic obstructive pulmonary disease (COPD) patients often show asynchronous movement of the lower rib cage during spontaneous quiet breathing and exercise. We speculated that varying body position from seated to supine would influence rib cage asynchrony by changing the configuration of the respiratory muscles. Twenty-three severe COPD patients (forced expiratory volume in 1 s = 32.5 ± 7.0% predicted) and 12 healthy age-matched controls were studied. Measurements of the phase shift between upper and lower rib cage and between upper rib cage and abdomen were performed with opto-electronic plethysmography during quiet breathing in the seated and supine position. Changes in diaphragm zone of apposition were measured by ultrasounds. Control subjects showed no compartmental asynchronous movement, whether seated or supine. In 13 COPD patients, rib cage asynchrony was noticed in the seated posture. This asynchrony disappeared in the supine posture. In COPD, upper rib cage and abdomen were synchronous when seated, but a strong asynchrony was found in supine. The relationships between changes in diaphragm zone of apposition and volume variations of chest wall compartments supported these findings. Rib cage paradox was noticed in approximately one-half of the COPD patients while seated, but was not related to impaired diaphragm motion. In the supine posture, the rib cage paradox disappeared, suggesting that, in this posture, diaphragm mechanics improves. In conclusion, changing body position induces important differences in the chest wall behavior in COPD patients.