The role of inspiratory effort still has to be determined as a potential predictor of noninvasive mechanical ventilation (NIV) failure in acute hypoxic
respiratory failure.
To explore the hypothesis ...that inspiratory effort might be a major determinant of NIV failure in these patients.
Thirty consecutive patients with acute hypoxic
respiratory failure admitted to a single center and candidates for a 24-hour NIV trial were enrolled. Clinical features, tidal change in esophageal pressure (ΔPes), tidal change in dynamic transpulmonary pressure (ΔPl), expiratory Vt, and respiratory rate were recorded on admission and 2-4 to 12-24 hours after NIV start and were tested for correlation with outcomes.
ΔPes and ΔPes/ΔPl ratio were significantly lower 2 hours after NIV start in patients who successfully completed the NIV trial (
= 18) compared with those who needed endotracheal intubation (
= 12) (median interquartile range, 11 8-15 cm H
O vs. 31.5 30-36 cm H
O;
< 0.0001), whereas other variables differed later. ΔPes was not related to other predictors of NIV failure at baseline. NIV-induced reduction in ΔPes of 10 cm H
O or more after 2 hours of treatment was strongly associated with avoidance of intubation and represented the most accurate predictor of treatment success (odds ratio, 15; 95% confidence interval, 2.8-110;
= 0.001 and area under the curve, 0.97; 95% confidence interval, 0.91-1;
< 0.0001).
The magnitude of inspiratory effort relief as assessed by ΔPes variation within the first 2 hours of NIV was an early and accurate predictor of NIV outcome at 24 hours.Clinical trial registered with www.clinicaltrials.gov (NCT03826797).
As reported by Newsweek magazine on 4 April 2020 1, coronavirus has killed over 100 doctors and nurses around the world, nearly half of whom are reported to be in Italy. This report, however, ...underestimated the size of the problem. To date, 151 doctors and more than 40 nurses have died in Italy from coronavirus disease 2019 (COVID-19).
The report of Italian doctors who died during the COVID-19 outbreak should inform us not to forget
https://bit.ly/3cbSbkU
Pulmonary rehabilitation (PR) has demonstrated physiological, symptom-reducing, psychosocial, and health economic benefits for patients with chronic respiratory diseases, yet it is underutilized ...worldwide. Insufficient funding, resources, and reimbursement; lack of healthcare professional, payer, and patient awareness and knowledge; and additional patient-related barriers all contribute to the gap between the knowledge of the science and benefits of PR and the actual delivery of PR services to suitable patients.
The objectives of this document are to enhance implementation, use, and delivery of pulmonary rehabilitation to suitable individuals worldwide.
Members of the American Thoracic Society (ATS) Pulmonary Rehabilitation Assembly and the European Respiratory Society (ERS) Rehabilitation and Chronic Care Group established a Task Force and writing committee to develop a policy statement on PR. The document was modified based on feedback from expert peer reviewers. After cycles of review and revisions, the statement was reviewed and formally approved by the Board of Directors of the ATS and the Science Council and Executive Committee of the ERS.
This document articulates policy recommendations for advancing healthcare professional, payer, and patient awareness and knowledge of PR, increasing patient access to PR, and ensuring quality of PR programs. It also recommends areas of future research to establish evidence to support the development of an updated funding and reimbursement policy regarding PR.
The ATS and ERS commit to undertake actions that will improve access to and delivery of PR services for suitable patients. They call on their members and other health professional societies, payers, patients, and patient advocacy groups to join in this commitment.
This European Respiratory Society (ERS) statement provides a comprehensive overview on physical activity in patients with chronic obstructive pulmonary disease (COPD). A multidisciplinary Task Force ...of experts representing the ERS Scientific Group 01.02 "Rehabilitation and Chronic Care" determined the overall scope of this statement through consensus. Focused literature reviews were conducted in key topic areas and the final content of this Statement was agreed upon by all members. The current knowledge regarding physical activity in COPD is presented, including the definition of physical activity, the consequences of physical inactivity on lung function decline and COPD incidence, physical activity assessment, prevalence of physical inactivity in COPD, clinical correlates of physical activity, effects of physical inactivity on hospitalisations and mortality, and treatment strategies to improve physical activity in patients with COPD. This Task Force identified multiple major areas of research that need to be addressed further in the coming years. These include, but are not limited to, the disease-modifying potential of increased physical activity, and to further understand how improvements in exercise capacity, dyspnoea and self-efficacy following interventions may translate into increased physical activity. The Task Force recommends that this ERS statement should be reviewed periodically (e.g. every 5-8 years).
Clinical practice should be based on the best scientific evidence, which does not always correspond to evidence-based medicine, involving guidelines, meta-analyses and protocols as a basis for ...clinical approach 1, 2. There is no need of further randomised controlled trials (RCTs) for evidence that pulmonary rehabilitation (PR) improves daily symptoms, exercise performance and health status in patients with chronic obstructive pulmonary disease (COPD), independently of disease stage and complexity 3. Although the direct demonstration of a clear benefit in survival is lacking (as is also true for most therapies used in COPD), PR is well recognised as a fundamental part of the integrated care of these patients and it has been incorporated in most guidelines for their management 4.
The aim was to study the overall content and organisational aspects of pulmonary rehabilitation programmes from a global perspective in order to get an initial appraisal on the degree of ...heterogeneity worldwide. A 12-question survey on content and organisational aspects was completed by representatives of pulmonary rehabilitation programmes that had previously participated in the European Respiratory Society (ERS) COPD Audit. Moreover, all ERS members affiliated with the ERS Rehabilitation and Chronic Care and/or Physiotherapists Scientific Groups, all members of the American Association of Cardiovascular and Pulmonary Rehabilitation, and all American Thoracic Society Pulmonary Rehabilitation Assembly members were asked to complete the survey via multiple e-mailings. The survey has been completed by representatives of 430 centres from 40 countries. The findings demonstrate large differences among pulmonary rehabilitation programmes across continents for all aspects that were surveyed, including the setting, the case mix of individuals with a chronic respiratory disease, composition of the pulmonary rehabilitation team, completion rates, methods of referral and types of reimbursement. The current findings stress the importance of future development of processes and performance metrics to monitor pulmonary rehabilitation programmes, to be able to start international benchmarking, and to provide recommendations for international standards based on evidence and best practice.
ABSTRACT
Background and objective
The prevalence and clinical consequences of diaphragmatic dysfunction (DD) during acute exacerbations of COPD (AECOPD) remain unknown. The aim of this study was (i) ...to evaluate the prevalence of DD as assessed by ultrasonography (US) and (ii) to report the impact of DD on non‐invasive mechanical ventilation (NIV) failure, length of hospital stay and mortality in severe AECOPD admitted to respiratory intensive care unit (RICU).
Methods
Forty‐one consecutive AECOPD patients with respiratory acidosis admitted over a 12‐month period to the RICU of the University Hospital of Modena were studied. Diaphragmatic ultrasound (DU) was performed on admission before starting NIV. A change in diaphragmatic thickness (ΔTdi) less than 20% during spontaneous breathing was considered to confirm the presence of dysfunction (DD+). NIV failure and other clinical outcomes (duration of mechanical ventilation MV, tracheostomy, length of hospital stay and mortality) were recorded.
Results
A total of 10 out of 41 patients (24.3%) presented DD+, which was significantly associated with steroid use (P = 0.002, R‐squared = 0.19). DD+ correlated with NIV failure (P < 0.001, R‐squared = 0.27), longer intensive care unit (ICU) stay (P = 0.02, R‐squared = 0.13), prolonged MV (P = 0.023, R‐squared = 0.15) and need for tracheostomy (P = 0.006, R‐squared = 0.20). Moreover, the Kaplan–Meyer survival estimates showed that NIV failure (log‐rank test P value = 0.001, HR = 8.09 (95% CI: 2.7–24.2)) and mortality in RICU (log‐rank test P value = 0.039, HR = 4.08 (95% CI: 1.0–16.4)) were significantly associated with DD+.
Conclusion
In hospitalized AECOPD patients submitted to NIV, severe DD was seen in almost one‐quarter of patients. DD may cause NIV failure, and impacts on the use of clinical resources and on the patient's short‐term mortality.
In this pilot study, we assessed diaphragmatic dysfunction (DD) by ultrasonography in severe acute exacerbations of COPD (AECOPD) patients admitted in intensive care unit for severe hypercapnic respiratory failure. We found that severe DD is reported in almost one‐quarter of AECOPD patients. This factor may cause non‐invasive mechanical ventilation failure, and impact short‐term mortality.
Dyspnea is the main symptom perceived by patients affected by chronic respiratory diseases. It derives from a complex interaction of signals arising in the central nervous system, which is connected ...through afferent pathway receptors to the peripheral respiratory system (airways, lung, and thorax). Notwithstanding the mechanism that generates the stimulus is always the same, the sensation of dyspnea is often described with different verbal descriptors: these descriptors, or linguistic 'clusters', are clearly influenced by socio-individual factors related to the patient. These factors can play an important role in identifying the etiopathogenesis of the underlying cardiopulmonary disease causing dyspnea. The main goal of rehabilitation is to improve dyspnea; hence, quantifying dyspnea through specific tools (scales) is essential in order to describe the level of chronic disability and to assess eventual changes after intervention. Improvements, even if modest, are likely to determine clinically relevant changes (minimal clinically important difference, MCID) in patients.Currently there exist a large number of scales to classify and characterize dyspnea: the most frequently used in everyday clinical practice are the clinical scales (e.g. MRC or BDI/TDI, in which information is obtained directly from the patients through interview) and psychophysical scales (such as the Borg scale or VAS, which assess symptom intensity in response to a specific stimulus, e.g. exercise).It is also possible to assess the individual's dyspnea in relation to specific situations, e.g. chronic dyspnea (with scales that classify patients according to different levels of respiratory disability); exertional dyspnea (with tools that can measure the level of dyspnea in response to a physical stimulus); and transitional (or 'follow up') dyspnea (with scales that measure the effect in time of a treatment intervention, such as rehabilitation).
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