Effectiveness of treatment with high-frequency chest wall oscillation in patients with bronchiectasis.

BACKGROUND: High-frequency airway clearance (HFCWC) assist devices generate either positive or negative trans-respiratory pressure excursions to produce high-frequency, small-volume oscillations in the airways.HFCWC can lead to changes in volume of 15-57 ml and in flow up to 1.6 L/s, which generate minimal coughing to mobilize secretions. The typical treatment lasts 20-30 minutes, and consists of short periods of compression at different frequencies, separated by coughing.The aim of this study was to find the more efficacious treatment in patients with bronchiectasis: traditional techniques of chest physiotherapy (CPT) versus high frequency oscillation of the chest wall in patients with bronchiectasis. METHODS: 37 patients were enrolled. Seven of them were excluded. Computer randomization divided the patients into three groups: - 10 patients treated with HFCWO by using the Vest® Airway Clearance System; - 10 patients treated with traditional techniques of air way clearance (PEP bottle, PEP mask, ELTGOL, vibratory positive expiratory pressure); - 10 patients received medical therapy only (control group). To be eligible for enrollment, participants had to be between 18 and 85 years old and have a diagnosis of bronchiectasis, confirmed on high resolution computed tomography. EXCLUSION CRITERIA: lack of informed consent, signs of exacerbation, cystic fibrosis. Before the treatment, each patient had blood tests, sputum volume and cell count, pulmonary function tests and on the quality of life inventories (MMRC, CAT, BCSS). The results were processed through the covariance analysis, performed with the R-Project statistical program. It has been considered a positive result p <005. RESULTS: Both treatments (traditional CPT and HFCWO) showed a significant improvement in some biochemical and functional respiratory tests as well as in the quality of life compared to the control group. The use of HFCWO compared to CPT also produced a significant improvement in blood inflammation parameter C-RP (p ≤0.019), parameters of lung functionality associated with bronchial obstruction (FVC, FEV1) (p ≤0.006 and p ≤0.001), and in the dyspnea. Improvement in quality of life scales was noted. (BCSS, CAT) (both p ≤0.001). No significant changes of total cell counts in sputum samples were observed in the two groups. In the HFCWO group a significant reduction of neutrophils percentage (p≤0.002) and a significant increase of macrophages percentage (p ≤0.012). CONCLUSIONS: The HFCWO technique provides an improvement both in pulmonary function and quality of life related parameters in patients with chronic hypersecretive disease. Since those patients need daily airway clearance, this treatment should be included among the principal options in chest physiotherapy. The study was registered as ChiCTR-TRC-12002134 at http://www.chictr.org.

Safety and effectiveness of the high-frequency chest wall oscillation vs intrapulmonary percussive ventilation in patients with severe COPD.

Purpose: Chest physiotherapy is an important tool in the treatment of COPD. Intrapulmonary percussive ventilation (IPV) and high-frequency chest wall oscillation (HFCWO) are techniques designed to create a global percussion of the lung which removes secretions and probably clears the peripheral bronchial tree. We tested the hypothesis that adding IPV or HFCWO to the best pharmacological therapy (PT) may provide additional clinical benefit over chest physiotherapy in patients with severe COPD. Methods: Sixty patients were randomized into three groups (20 patients in each group): IPV group (treated with PT and IPV), PT group with (treated with PT and HFCWO), and control group (treated with PT alone). Primary outcome measures included results on the dyspnea scale (modified Medical Research Council) and Breathlessness, Cough, and Sputum scale (BCSS), as well as an evaluation of daily life activity (COPD Assessment Test [CAT]). Secondary outcome measures were pulmonary function testing, arterial blood gas analysis, and hematological examinations. Moreover, sputum cell counts were performed at the beginning and at the end of the study. Results: Patients in both the IPV group and the HFCWO group showed a significant improvement in the tests of dyspnea and daily life activity evaluations (modified Medical Research Council scale, BCSS, and CAT) compared to the control group, as well as in pulmonary function tests (forced vital capacity, forced expiratory volume in 1 second, forced expiratory volume in 1 second/forced vital capacity%, total lung capacity, residual volume, diffusing lung capacity monoxide, maximal inspiratory pressure, maximal expiratory pressure) and arterial blood gas values. However, in the group comparison analysis for the same variables between IPV group and HFCWO group, we observed a significant improvement in the IPV group maximal inspiratory pressure, maximal expiratory pressure, BCSS, and CAT. Similar results were observed in changes of sputum cytology with reduction of inflammatory cells (neutrophils and macrophages). Conclusion: The two techniques improved daily life activities and lung function in patients with severe COPD. IPV demonstrated a significantly greater effectiveness in improving some pulmonary function tests linked to the small bronchial airways obstruction and respiratory muscle strength and scores on health status assessment scales (BCSS and CAT) as well as a reduction of sputum inflammatory cells compared with HFCWO.

Comparison of effectiveness of temporary positive expiratory pressure versus oscillatory positive expiratory pressure in severe COPD patients.

INTRODUCTION: In chronic obstructive pulmonary disease (COPD) patients few modalities of airway clearance have demonstrated effectiveness in reducing hypersecretion and bronchial obstruction. Positive expiratory pressure (PEP) is one of these. OBJECTIVE: Our goal was to compare the effectiveness of 2 devices Temporary PEP (T-PEP) and Oscillatory PEP (O-PEP) which use PEP applied at a low expiratory pressure of 1 cm H2 O which creates oscillations that decrease bronchial obstruction in reducing COPD exacerbations and improving respiratory and health status assessment parameters. Each has different mechanism of action. METHODS: A 26 week randomized controlled study evaluated their efficacy in reducing exacerbations and improving health status assessment tests as well as respiratory function parameters in severe to very severe COPD patients. One hundred-twenty patients were enrolled: 40 patients received T-PEP therapy; 40 underwent treatment with O-PEP; 40 constituted the control group. The primary outcome was the reduction of exacerbations after 1, 3 and 6 months; secondary outcomes were improvement of lung function and health status assessment tests [Modified Medical Research Council (MMRC) scale, Breathlessness, Cough, and Sputum Scale (BCSS) scale, and COPD Assessment Test (CAT) score]. RESULTS: Only T-PEP statistically reduced the exacerbations after 1 and 3 months compared to the control group. Both the 2 devices improved dyspnea scale (MMRC), lung function parameters, and health status assessment (CAT) tests compared to the control group. Both interventions were well-tolerated by our patients. CONCLUSIONS: O-PEP and T-PEP are useful for COPD treatment but only T-PEP reduces exacerbations. Adding tools for airway clearance to medical therapy can help the management of COPD.

Assessment of Malnutrition in Community-dwelling Elderly People: Cooperation among General Practitioners and Public Health.

BACKGROUND: Malnutrition, a very common condition in the elderly, is known to increase their vulnerability to adverse health events. This study aimed to estimate the prevalence of malnutrition in the over 75-yr-old community-dwelling population in the "Chiavarese" Local Health Unit district (North West Italy). METHODS: The short version of the Mini Nutritional Assessment (MNA-SF) was used by General Practitioners (GP) as a screening tool to investigate the nutritional status of elderly people (1039 subjects). The study was conducted in 2012-2013 in the Local Health Unit of Chiavari (Liguria Region), Italy. The malnutrition was subsequently confirmed by means of biochemical parameters. Subjects at risk of malnutrition or malnourished (n=22) received personalized dietary counseling by the GP. RESULTS: The MNA-SF recognized 21% of the elderly people being at risk of malnutrition and biochemical tests confirmed a malnutrition prevalence of 3.5%. The dietary counseling improved the MNA-SF score and biochemical parameters, but the difference was statistically significant only for the MNA-SF score (P=0.00613). CONCLUSION: Malnutrition can be evaluated with a simple tool such as the MNA-SF, recognized at the earliest stage and successfully treated by the GP.

Early non-invasive ventilation treatment for respiratory failure due to severe community-acquired pneumonia.

BACKGROUND AND AIMS: Severe community-acquired pneumonia (sCAP) have been as defined pneumonia requiring admission to the intensive care unit or carrying a high risk of death. Currently, the treatment of sCAP consists of antibiotic therapy and ventilator support. The use of invasive ventilation causes several complications as does admission to ICU. For this reason, non-invasive ventilation (NIV) has been used for acute respiratory failure to avoid endotracheal intubation. However, few studies have currently assessed the usefulness of NIV in sCAP. METHODS: We prospectively assessed 127 patients with sCAP and severe acute respiratory failure [oxygen arterial pressure/oxygen inspiratory fraction ratio (PaO2/FiO2) <250]. We defined successful NIV as avoidance of intubation and the achievement of PaO2/FiO2 >250 with spontaneous breathing. We assessed predictors of NIV failure and hospital mortality using univariate and multivariate analyses. RESULTS: NIV failed in 32 patients (25.1%). Higher chest X-ray score at admission, chest X-ray worsening, and a lower PaO2/FiO2 and higher alveolar-arteriolar gradient (A-aDO2) after 1 h of NIV all independently predicted NIV failure. Higher lactate dehydrogenase and confusion, elevated blood urea, respiratory rate, blood pressure plus age ≥65 years at admission, higher A-aDO2, respiratory rate and lower PaO2/FiO2 after 1 h of NIV and intubation rate were directly related to hospital mortality. CONCLUSIONS: Successful treatment is strongly related to less severe illness as well as to a good initial and sustained response to medical therapy and NIV treatment. Constant monitoring of these patients is mandatory.

Can ultrasound guidance reduce the risk of pneumothorax following thoracentesis? .

OBJECTIVE: Thoracentesis is one of the bedside procedures most commonly associated with iatrogenic complications, particularly pneumothorax. Various risk factors for complications associated with thoracentesis have recently been identified, including an inexperienced operator; an inadequate or inexperienced support team; the lack of a standardized protocol; and the lack of ultrasound guidance. We sought to determine whether ultrasound-guided thoracentesis can reduce the risk of pneumothorax and improve outcomes (fewer procedures without fluid removal and greater volumes of fluid removed during the procedures). In our comparison of thoracentesis with and without ultrasound guidance, all procedures were performed by a team of expert pulmonologists, using the same standardized protocol in both conditions. METHODS: A total of 160 participants were randomly allocated to undergo thoracentesis with or without ultrasound guidance (n = 80 per group). The primary outcome was pneumothorax following thoracentesis. Secondary outcomes included the number of procedures without fluid removal and the volume of fluid drained during the procedure. RESULTS: Pneumothorax occurred in 1 of the 80 patients who underwent ultrasound-guided thoracentesis and in 10 of the 80 patients who underwent thoracentesis without ultrasound guidance, the difference being statistically significant (p = 0.009). Fluid was removed in 79 of the 80 procedures performed with ultrasound guidance and in 72 of the 80 procedures performed without it. The mean volume of fluid drained was larger during the former than during the latter (960 ± 500 mL vs. 770 ± 480 mL), the difference being statistically significant (p = 0.03). CONCLUSIONS: Ultrasound guidance increases the yield of thoracentesis and reduces the risk of post-procedure pneumothorax. (Chinese Clinical Trial Registry identifier: ChiCTR-TRC-12002174 [http://www.chictr.org/en/]).

Open-mouthpiece ventilation versus nasal mask ventilation in subjects with COPD exacerbation and mild to moderate acidosis: a randomized trial.

BACKGROUND: Open mouthpiece ventilation is efficacious in patients with neuromuscular disease. We used this ventilation technique in patients with exacerbations of COPD with mild to moderate acidosis. METHODS: The study was performed in 2 respiratory monitoring care units. Fifty subjects with exacerbations of COPD, breathing frequency > 25, PaCO2 > 45, and pH between 7.25 and 7.30, as well as Kelly scale ≤ 2 were enrolled. Subjects were randomly assigned to receive noninvasive ventilation (NIV) via nasal mask or mouthpiece ventilation. The primary outcome was improvement in arterial blood gases. Arterial blood gases and breathing frequency were recorded 2 h after the start of the enrollment and then after 12, 24, and 48 h. The duration of NIV, hospital stay, and acceptability of the interface (mouthpiece or nasal mask) using a Likert scale were assessed. RESULTS: No subjects had deterioration of gas exchange. The 2 groups had similar trends in arterial blood gases and breathing frequency. No differences in duration of NIV or hospital stay were noted. However, a significant difference in acceptability was found: subjects preferred mouthpiece ventilation (P < .01). CONCLUSIONS: Open mouthpiece ventilation is a useful technique and may prevent further deterioration of gas exchange in COPD patients with mild to moderate acidosis (similar to traditional NIV delivered by a nasal mask). www.chictr.org registration ChiCTR-TRC-12002672.

Noninvasive ventilation for hypercapnic exacerbation of chronic obstructive pulmonary disease: factors related to noninvasive ventilation failure.

INTRODUCTION: Noninvasive ventilation (NIV) has changed the prognosis of patients with chronic obstructive pulmonary disease (COPD) suffering from hypercapnic exacerbations. OBJECTIVES: The aim of the study was to evaluate the mortality rate and need for intubation of patients with during hypercapnic COPD exacerbation treated with NIV and to estimate factors related to either success or failure of NIV in a real-life setting. PATIENTS AND METHODS: In a multicenter prospective study conducted over a period of 10 years (2002-2012), we assessed 1809 patients with COPD with hypercapnic exacerbation on admission who were treated with NIV. The primary outcomes were the intubation rate and hospital mortality. RESULTS: In all patients, NIV was conducted by experienced specialists. The intubation rate was 6.6% and the mortality rate was 5.3%. The severity of exacerbations, defined by pH and the Simplified Acute Physiology Score (SAPS II) on admission, worsened during the study period. The presence of comorbidities, SAPS II, pH, the ratio of oxygen arterial pressure to oxygen inspiratory fraction on admission, and, above all, no increase in pH after 1 hour of NIV were closely related to hospital mortality. CONCLUSIONS: Team expertise in NIV and identification of the risk factors for NIV failure may allow to treat patients with more severe hypercapnic exacerbations of COPD during and improve treatment success rates.

Symptom onset-to-balloon time and mortality in the first seven years after STEMI treated with primary percutaneous coronary intervention.

OBJECTIVE: To evaluate the consequence of treatment delay of primary percutaneous coronary intervention (PPCI) on long-term survival. BACKGROUND: Network organisation based on early recognition, shortening prehospital time delays and procedural delays is the cornerstone of optimal clinical results in the acute phase of ST-segment elevation myocardial infarction (STEMI). Nevertheless, the evidence of a relationship between symptom onset-to-balloon time and mortality is weak, and few long-term data are available. SETTING AND MEASURES: In this single-centre observational follow-up study, we evaluated the long-term survival of 790 consecutive STEMI patients (mean age 68 ± 13 years; 73% males) undergoing PPCI ≤ 12 h from symptom onset, or 12-36 h in the case of persistence of symptoms or hemodynamic instability. RESULTS: The median (IQR) treatment delay, defined as the time from symptom onset to reperfusion, was 180 min (120;310), fairly balanced between patient delay (80 min (40;140)) and system delay (80 min (60-114)). Patients with a treatment delay <180 min displayed lower mortality at 1, 3, 5 and 7 years (12%, 17%, 22% and 26%, respectively) than those with a treatment delay >180 min (15%, 24%, 28% and 37%, respectively). The HR was 0.7 (95% CI 0.5 to 0.9). On univariate and stepwise multiple regression analysis, field triage and transportation (p=0.0001), shorter distance from hospital (p=0.02) and male gender (p=0.02), but not clinical variables, were independent predictors of shorter treatment delay. CONCLUSIONS: Shorter symptom onset-to-balloon time predicts long-term lower mortality in STEMI patients treated with PPCI. Our findings emphasise the need to minimise any component of treatment delay.

Can ultrasound guidance reduce the risk of pneumothorax following thoracentesis? / A ultrassonografia pode reduzir o risco de pneumotórax após toracocentese?

OBJECTIVE: Thoracentesis is one of the bedside procedures most commonly associated with iatrogenic complications, particularly pneumothorax. Various risk factors for complications associated with thoracentesis have recently been identified, including an inexperienced operator; an inadequate or inexperienced support team; the lack of a standardized protocol; and the lack of ultrasound guidance. We sought to determine whether ultrasound-guided thoracentesis can reduce the risk of pneumothorax and improve outcomes (fewer procedures without fluid removal and greater volumes of fluid removed during the procedures). In our comparison of thoracentesis with and without ultrasound guidance, all procedures were performed by a team of expert pulmonologists, using the same standardized protocol in both conditions. METHODS: A total of 160 participants were randomly allocated to undergo thoracentesis with or without ultrasound guidance (n = 80 per group). The primary outcome was pneumothorax following thoracentesis. Secondary outcomes included the number of procedures without fluid removal and the volume of fluid drained during the procedure. RESULTS: Pneumothorax occurred in 1 of the 80 patients who underwent ultrasound-guided thoracentesis and in 10 of the 80 patients who underwent thoracentesis without ultrasound guidance, the difference being statistically significant (p = 0.009). Fluid was removed in 79 of the 80 procedures performed with ultrasound guidance and in 72 of the 80 procedures performed without it. The mean volume of fluid drained was larger during the former than during the latter (960 ± 500 mL vs. 770 ± 480 mL), the difference being statistically significant (p = 0.03). CONCLUSIONS: Ultrasound guidance increases the yield of thoracentesis and reduces the risk of post-procedure pneumothorax. (Chinese Clinical Trial Registry identifier: ChiCTR-TRC-12002174 [http://www.chictr.org/en/]) .

OBJETIVO: Dentre os procedimentos realizados à beira do leito, a toracocentese é um dos mais comumente associados a complicações iatrogênicas, particularmente pneumotórax. Foram recentemente identificados vários fatores de risco de complicações associadas à toracocentese: a inexperiência do operador, a inadequação ou inexperiência da equipe de apoio, a ausência de um protocolo padronizado e a ausência de ultrassonografia para guiar o procedimento. Nosso objetivo foi determinar se a toracocentese guiada por ultrassonografia pode reduzir o risco de pneumotórax e melhorar os desfechos (menos procedimentos sem remoção de líquido e maior volume de líquido removido durante os procedimentos). Para compararmos a toracocentese guiada por ultrassonografia à toracocentese sem ultrassonografia, todos os procedimentos foram realizados pela mesma equipe de pneumologistas especialistas, os quais usaram o mesmo protocolo padronizado em ambas as condições. MÉTODOS: Cento e sessenta pacientes foram aleatoriamente divididos em dois grupos: toracocentese guiada por ultrassonografia e toracocentese sem ultrassonografia (n = 80 por grupo). O desfecho primário foi pneumotórax após a toracocentese. Os desfechos secundários foram o número de procedimentos sem remoção de líquido e o volume de líquido drenado durante o procedimento. RESULTADOS: Houve pneumotórax em 1 dos 80 pacientes submetidos a toracocentese guiada por ultrassonografia e em 10 dos 80 submetidos a toracocentese sem ultrassonografia; a diferença foi estatisticamente significante (p = 0,009). Líquido foi removido em 79 dos 80 procedimentos guiados por ultrassonografia e em 72 dos 80 que não o foram. A média do volume de líquido drenado foi maior nos procedimentos guiados por ultrassonografia ...