[Show abstract][Hide abstract] ABSTRACT: Chronic Obstructive Pulmonary Disease (COPD) ranks third as cause of mortality and disability-adjusted life years (DALY) worldwide and also in Italy it imposes a huge health, social and economic load. Early symptoms of COPD are often disregarded by patients and physicians, spirometry is underutilized, and the diagnosis is delayed till the disease has reached a distinct severity level. Despite the availability of various guidelines, the behavior of health workers involved in the management of COPD is still rather unlike. These considerations are the reason why in October 2013 AIMAR (Interdisciplinary Scientific Association for Research in Lung Disease) devised and organized a "Third Consensus Conference", aimed at pointing out the standards of suitability for COPD management. In this context three important topics of discussion were identified: early and more widespread diagnosis, management of acute and subacute phases, long-term assistance to chronic patients.
The procedure recommended by the Italian Health Superior Institute (ISS) for Consensus Conferences organization was applied. The Conference was structured in three sessions, each dealing with one of the above mentioned topics and including a short update of the subject-matter and presentation, discussion and voting of some statements with a choice ranging from total agreement to total disagreement or no knowledge. The results of voting were eventually recorded in the document, reviewed by an independent jury, that forms the substance of this paper.
The essential role of spirometry, the need for distinguish between different COPD phenotypes, and the obligatoriness to base on the blood gas analysis findings the long-term oxygen therapy, were largely agreed, as well as the need for interventions aimed at decreasing the rate of acute exacerbations. More specific topics like the use of noninvasive ventilation, recognizing the factors affecting outcome and mortality, the choice of pharmacological and non pharmacological treatments in COPD patients led to lively discussing, but they did not always reach the total agreement, probably because of insufficient familiarity with these problems and of diversities in organization and instruments availability. The chronic respiratory assistance was treated with particular regard to smoking cessation, whose implementation is still insufficient. Many doubts rose due to uncertainty, lack of ability and standardization of procedures, insufficient institutional support, and difficulties to realize a network for assistance to chronic patients.
The results of this Third Consensus Conference revealed some certainties and many doubts and diversities of view also on topics whose importance is well demonstrated in scientific literature. Thus, there is still a long distance to cover before reaching a suitable standardization of COPD management and such situation urges the need for improving not only the health professional's operativeness but also the organizational support by competent institutions. In this context some initiatives organized by AIMAR in cooperation with other respiratory scientific societies and patients' associations are going on.
Full-text · Article · Dec 2014 · Multidisciplinary respiratory medicine
[Show abstract][Hide abstract] ABSTRACT: Background
While the effects of postural change on arterial oxygenation have been well documented in normal subjects, and attributed to the relationship of closing volume (CV) to the tidal volume, in liver cirrhosis such postural changes have been evaluated mainly in a rare, peculiar clinical end-stage condition which is characterized by increased dyspnea shifting from supine to upright position ("platypnea"). The latter is associated with worsening of PaO2 ("orthodeoxia"). Our study was undertaken to evaluate the effects of postural change on arterial oxygenation in patients affected by mild/moderate liver cirrhosis.
We studied pulmonary function tests and arterial blood gases in sitting and supine position in 22 consecutive, biopsy-proved, mild/moderate liver cirrhosis, non-smokers patients, and 22 matched non-smokers control subjects.
Recumbency elicited a decrease of PaO2 (Δ(sup-sit)PaO2) in 19 out of 22 controls and in all but one cirrhotics. The magnitude of this postural change was significantly (p= 0.04) greater in cirrhotics (9.6±5.3%) compared to controls (6.7±3.7%). In the subset of cirrhotics older than 60 yrs and with PaO2 greater than 80 mmHg in sitting position, the Δ(sup-sit)PaO2 in recumbency further increased to 12±5.8 mmHg, significantly (p= 0.014) greater than in same subgroup of controls (7.1±3.8 mmHg).
In mild/moderate liver cirrhosis the postural variations in PaO2 follow the normal trends, but are of greater magnitude probably as a consequence of hypoventilated units of lung for postural and disease-linked tidal airway closure, resulting in more pronounced recumbent hypoxemia ("clinodeoxia").
No preview · Article · Jul 2014 · Respiratory medicine
[Show abstract][Hide abstract] ABSTRACT: Coughing is an important defensive reflex that occurs through the stimulation of a complex reflex arc. It accounts for a significant number of consultations both at the level of general practitioner and of respiratory specialists. In this review we first analyze the cough reflex under normal conditions; then we analyze the anatomy and the neuro-pathophysiology of the cough reflex arc. The aim of this review is to provide the anatomic and pathophysiologic elements of evaluation of the complex and multiple etiologies of cough.
[Show abstract][Hide abstract] ABSTRACT: Sexual activity is an important component of quality of life in patients suffering from chronic illnesses. To our knowledge, the effects of sexual activity on gas exchange in patients with respiratory failure have not been yet studied. To such an extent, we evaluated the oxygen saturation (SaO2), by a pulse oxymeter, during three different sexual performances in a 63-yr-old patient affected by chronic obstructive pulmonary disease (COPD) on long-term oxygen therapy (LTOT). The sexual performances were divided in four periods: basal, sex, 10 min after sex and relax. In each performance during sex, we observed a significant increase of either heart rate (HR) or SaO2, with the highest value of the latter achieved within the 10 min of the post-sex period. SaO2 returned to basal value (pre-sex) by the end of the relax period. We conclude that the observed improvement of SaO2 during sexual activity might be due to a better ventilation/perfusion ratio (V/Q) obtained for either an increase of ventilation (hyperventilation) and perfusion (tachycardia), without significant muscle expenditure.
Full-text · Article · Jul 2008 · Respiratory Medicine
[Show abstract][Hide abstract] ABSTRACT: It has been documented that tiotropium is less likely to induce oxygen desaturation in stable COPD patients compared to long-acting beta2-agonists (LABAs) and combined administration of a LABA and an inhaled corticosteroid (ICS) reduces the potential for acute effects of LABA on blood-gas tensions. In this study, we have compared the acute effects of tiotropium 18 microg and salmeterol/fluticasone combination (SFC) 50/250 microg on arterial blood gases in 20 patients with stable COPD. Each subject was studied on 2 days, separated from one another by at least 4 days. Blood specimens were taken just before the inhalation and at 15, 30, 60, 180 and 360 min after inhalation of each treatment, and spirometry was performed at the same time points. As expected, both treatments significantly improved FEV1 (greatest changes were 0.20 L, 95% CI: 0.13-0.27 at 360 min after tiotropium; and 0.13 L, 95% CI: 0.06-0.19 at 180 min after SFC). The greatest mean changes from baseline in PaO2 were -1.7 (95% CI: -4.0 to 0.6)mmHg, p=0.134, after tiotropium; -0.8 (95% CI: -2.2 to 0.6)mmHg, after SFC. Both changes were observed after 15 min. Both drugs caused a small decrease in PaCO2 (greater changes: -1.9 (95% CI -3.2 to -0.6)mmHg, p=0.005 at 60 min after tiotropium; and -2.4 (95% CI: -3.5 to -1.3) mmHg, p=0.0002 at 180 min after SFC). These results indicate that both tiotropium and SFC are able to induce a significant long-last bronchodilation without affecting arterial blood gases. Moreover, they confirm that the impact of tiotropium on PaO2 is small and without clinical significance and the addition of a LABA to an ICS can reduce the potentially dangerous acute effect of the LABA on blood gases.
Full-text · Article · Jul 2008 · Respiratory Medicine
[Show abstract][Hide abstract] ABSTRACT: The aim of this pilot study was to explore the relative efficacy in terms of improvement in symptoms and lung function of combining fluticasone propionate/salmeterol combination (FSC) and tiotropium in patients with severe-to-very severe stable COPD. Ninety patients were randomized to receive 3 months of treatment in one of three treatment groups: (1) FSC 500/50 microg Diskus, 1 inhalation twice daily+placebo Handihaler 1 inhalation once-daily daily; (2) tiotropium 18 microg Handihaler, 1 inhalation once daily+placebo Diskus, 1 inhalation twice daily; (3) FSC 500/50 microg Diskus, 1 inhalation twice daily+tiotropium 18 microg Handihaler, 1 inhalation once-daily daily. Patients attended the clinic before and after 1 month, 2 months, and 3 months of treatment for evaluations of pulmonary function, and dyspnea, which was assessed using a visual analog scale (VAS). Also the supplemental salbutamol use was measured. Eighty-one patients completed the 3-month treatment period: 26 patients receiving FSC, 26 patients receiving tiotropium, and 29 patients receiving FSC+tiotropium. Patients were withdrawn for COPD exacerbation. Improvements in trough FEV(1) with all treatments medications were observed by the first month when trough FEV(1) had improved significantly above baseline by 74 mL (p<0.05) in the tiotropium group, by 117 mL (p<0.05) in the FSC group and by 115 mL (p<0.05) in FSC+tiotropium group. At the end of the study, trough FEV(1) had improved significantly above baseline by 141 mL (p<0.05) in the tiotropium group, by 140 mL (p<0.05) in the FSC group and by 186 mL (p<0.05) in FSC+tiotropium group. The difference between FSC and tiotropium appeared to decrease, that between FSC and FSC+tiotropium appeared to increase and that between tiotropium and FSC+tiotropium remained almost similar with study duration. Our results suggest that adding FSC and tiotropium may provide benefits in symptomatic patients with severe-to-very severe stable COPD.
[Show abstract][Hide abstract] ABSTRACT: The aim of the present study was to evaluate the pulmonary sequelae and diaphragmatic motility in infant, adolescent and adult patients (pts) who had undergone the repair of a congenital diaphragmatic hernia. Thirty-one (81.5%) out of 38 survivors after left side CDH repair, without using a patch, were followed-up. They were subdivided in two groups. Group A (mid-term follow-up): 12 pts (39%) (5 males, 7 females) with a mean age of 4.5 years; Group B (long-term follow-up): 19 pts (61%) (9 males, 10 females) with a mean age of 21.0 years. All pts underwent physical examination, chest X-ray, diaphragmatic ultrasonographic (US) examination, pulmonary perfusion scintigraphy. Patients of the group B were also submitted to spirometry. All pts had a normal life-style and no one complained of respiratory symptoms. The chest X-ray revealed pathologic findings in 12 pts (39%). 8 pts (26%) showed chest wall alterations. The profile of the left diaphragmatic dome appeared irregular in 9 pts (29%). In all pts M-mode sonography disclosed a reduced diaphragmatic motility on the treated side. The mean pulmonary perfusion scintigraphy value on the affected side was 39.2+/-0.7%. The spirometric study showed normal values. We noted that the lung perfusion significantly and rapidly improved after CDH repair even the apparently hypoplastic and small lungs, the diaphragm maintained a good contractility during forced respiration.
Full-text · Article · Mar 2006 · Pediatric Surgery International
[Show abstract][Hide abstract] ABSTRACT: The follow-up of sarcoidosis is usually performed by invasive tools such as thoracic biopsy, supported by Broncho-Alveolar Lavage (BAL), Gallium-scintigraphy and Gadolinium Magnetic Resonance Imaging (Gd-MRI) to evaluate the degree of disease. Its pathogenesis can be ascribed to an accumulation of cells due to the disregulation of the immune system which involves Th1/Th2 cells as well as the soluble factors they generate. We evaluated serum cytokine and membrane marker levels (cytokine network) in sarcoid patients in order to study the correlation with the disease activity, in particular with the occurrence of sarcoidosis relapses.
Seven sarcoid patients clinically stable without therapy, at different stages, were enrolled in our study. Cytokine and membrane marker serum values were measured monthly for 24 months, after a six-month period of run-in, by ELISA assay and MoAb indirect immunofluorescence, respectively.
In some patients at the first and second stages of the disease we observed MCP-1 and inflammatory cytokine peaks and, moreover, MCP-1 values were increased before other cytokine values. After three subsequent increases of these parameters were observed, according to our personal experience, Gadolinium-MRI confirmed the presence of an increase of the lesion and therefore our hypothesis of sarcoidosis relapse. Only one patient at stage III showed constantly elevated values of fibro-angiogenic cytokines and membrane receptors of the TNF receptor family.
Cytokine network monitoring could be a non-invasive means of following up the clinical course of sarcoidosis.
No preview · Article · Apr 2003 · Sarcoidosis, vasculitis, and diffuse lung diseases: official journal of WASOG / World Association of Sarcoidosis and Other Granulomatous Disorders
[Show abstract][Hide abstract] ABSTRACT: Bacterial infections of the respiratory tract account for a large proportion of total medical consultations in general practice. In recent years, antibiotic resistance has increased alarmingly in a number of bacterial species that are common causes of these infections. The aim of this observational study was to determine the antibiotic resistance of microbial agents isolated from patients with acute or acutely exacerbated respiratory infections. Subjects recruited as potential sources of bacteria were either outpatients seen in a number of specialized clinics and hospital practices, or hospitalized patients. Overall, 648 consecutive patients (67% male, mean age 48.1+/-27.0 years) with infection of the upper or lower respiratory tract were observed during a 13-month period. A total of 551 pathogenic microbial strains were isolated and tested for their in vitro susceptibility to piperacillin, piperacillin/tazobactam, ceftazidime, and ceftriaxone. Among all isolates, the four most frequent pathogens were Pseudomonas aeruginosa (132 isolates, 24%), Streptococcus pyogenes (99 isolates, 18%), Staphylococcus aureus (93 isolates, 17%), and Klebsiella pneumoniae (46 isolates, 8%). The susceptibility of gram-positive isolates ranged from 97.5% to 95.1%, and no remarkable difference was found in the antibacterial activity of tested b-lactam antibiotics. The susceptibility of gram-negative isolates to piperacillin and piperacillin/tazobactam was also similar: 96.5% and 97.1%, respectively. In contrast, differences were found between piperacillin (or piperacillin/tazobactam) and either ceftazidime (p=0.003) or ceftriaxone (p<0.0003) in gram-negative isolates. We conclude that, despite the extensive use of beta-lactam antibiotics (piperacillin, ceftazidime, and ceftriaxone) in medical practice during the past three decades, the susceptibility of the most common pathogens involved in the etiology of upper and lower respiratory tract infections to these antibiotics is still high. In particular, bacterial resistance developed by gram-positive organisms against piperacillin is negligible and not alarming.
Full-text · Article · Aug 2001 · Journal of chemotherapy (Florence, Italy)
[Show abstract][Hide abstract] ABSTRACT: To determine the value of gadolinium-enhanced MRI in the assessment of disease activity in chronic infiltrative lung diseases (CILDs).
University hospital. Materials and Methods: Twenty-five consecutive patients with CILD were studied. The following diseases were diagnosed: sarcoidosis (n = 10), bronchiolitis obliterans organizing pneumonia (n = 3), usual interstitial pneumonia (n = 4), radiation pneumonia (n = 2), desquamative interstitial pneumonia (n = 1), rheumatoid lung (n = 1), vasculitis (n = 1), alveolar proteinosis (n = 1), bronchioloalveolar carcinoma (n = 1), and chronic eosinophilic pneumonia (n = 1). In each patient, the disease activity was assessed by one or more of the following studies: BAL (n = 18), gallium-radioisotope lung scanning (n = 6), serum angiotensin-converting enzyme assay (n = 10), and open lung biopsy (n = 4). T1-weighted breath-hold MRI studies were obtained before and after IV injection of gadolinium. The MRI examinations were analyzed to assess the presence or absence of lesional enhancement.
The presence of enhanced pulmonary lesions was seen in 14 patients. All of these patients had active disease. Of the 17 patients with active disease, 14 had enhanced lesions, and 3 had unenhanced lesions. Pulmonary lesions were not enhanced in any patients with inactive disease. The difference was statistically significant (Fisher Exact Test, p < 0.05).
Gadolinium-enhanced MRI may prove to be a useful tool in assessing disease activity in CILDs.
[Show abstract][Hide abstract] ABSTRACT: The usefulness of a metered-dose inhaler equipped with a new spacer device (Jet spacer) was evaluated and compared with that of a standard actuator in the administration of high-dose inhaled beclomethasone dipropionate (0.5 mg four times daily) to adults with moderate asthma. After a 2-week run-in period, 36 patients were enrolled in a 4-week study according to a randomized, parallel-group design. Efficacy was assessed by measurements of pulmonary function and daily beta 2-agonist consumption. Morning serum and 24-hour urinary cortisol levels were measured at baseline and after treatment; adrenocorticotropic hormone (ACTH) stress testing was also done. Spirometric parameters significantly improved in both groups; peak expiratory flow rate measured at the final visit was significantly higher (P < .01) in the group using the Jet spacer than in patients using the standard actuator. Beta 2-agonist consumption decreased in both groups. The number of patients with a normal response to ACTH was significantly higher (P < .01) in the Jet group than in the standard actuator group; concomitant urinary cortisol excretion decreased significantly (P < .05) in the standard actuator group. Local irritation was reported by 1 patient in the Jet group and by 2 patients in the standard actuator group. Use of the new Jet spacer was found to reduce the potential for adrenal suppression and increase the efficacy of high-dose inhaled beclomethasone dipropionate given to adults with asthma.
No preview · Article · Jan 1996 · Advances in Therapy
[Show abstract][Hide abstract] ABSTRACT: Bronchial provocation tests (TBP) allow to detect airways hyperreactivity in asthmatics. Twenty asthmatic children and sixteen rhinitics underwent a standard methacholine challenge and a free running exercise test on two separate days. Metacholine challenge pointed out bronchial hyperreactivity in 90% of the asthmatics. An exercise induced bronchospasm occurred in 70% of them. TPB resulted positive also in 18% of the rhinitics. Our study confirms diagnostic usefulness of the TBP and a good correlation between both tests.
No preview · Article · Mar 1989 · La Pediatria medica e chirurgica: Medical and surgical pediatrics
[Show abstract][Hide abstract] ABSTRACT: Twenty patients (10 males and 10 females), ranging in age from 53 to 81 years, were treated with ceftazidime, 2-3 g/day i.m., for 12 to 15 days. All patients were suffering from moderate to severe infections of the lower respiratory tract (6 cases of pneumonia and 14 cases of acute exacerbation of chronic bronchitis). In addition, almost all patients presented severe local and general predisposing factors (three patients with lung cancer, two with bronchiectasis and 14 with respiratory insufficiency). The aetiological agents responsible for the infections were mainly Gram-negative bacteria (6 Klebsiella pneumoniae, 4 Haemophilus influenzae, 4 Pseudomonas aeruginosa and 3 Proteus strains). The clinical and microbiological results of the treatment were good. With the exception of one case of maculopapular rash, none of the patients complained of adverse reactions and no toxic effects were observed.
No preview · Article · Feb 1985 · Drugs under experimental and clinical research