American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation.
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Anxiety↗
Biomedical subjects
Nicolino Ambrosino
Publications and source records attributed to Nicolino Ambrosino.
Treatments for COPD.
The multicomponent nature of chronic obstructive pulmonary disease (COPD) has provided a challenging environment in which to develop successful treatments. A combination of pharmacological and non-pharmacological approaches is used to combat this problem, and an overview of these approaches and their possible future direction is given. Bronchodilators are the mainstay of COPD treatment and can be combined with inhaled corticosteroids for greater efficacy and fewer side effects. A new generation of pharmacotherapeutic agents, most notably phosphodiesterase-4 inhibitors, which are already in the advanced stages of clinical development, and leukotriene B4 inhibitors (in early clinical development), may shape future treatment as further insight is gained into the pathological mechanisms underlying COPD. Non-pharmacologic treatments for COPD include long-term oxygen therapy (LTOT), nasal positive pressure ventilation (nPPV), pulmonary rehabilitation and lung-volume-reduction surgery (LVRS). Apart from smoking cessation, LTOT is the only treatment to date which has been shown to modify survival rates in severe cases; thus its role in COPD is well defined. The roles of nPPV and LVRS are less clear, though recent progress is reported here. In the future, it will be important to establish the precise value of the different treatments available for COPD--evaluating both clinical and physiological endpoints and using the data to more accurately define candidate patients accordingly. The challenge will be to develop this base of knowledge in order to shape future research and allow clinicians to deliver tailored COPD management programmes for the growing number of patients afflicted with this disease.
Bronchodilator Agents↗
Early physiotherapy in the respiratory intensive care unit.
Physiotherapy is an integral part of the management of patients in respiratory intensive care units (RICUs). The most important aim in this area is to enhance the overall patient's functional capacity and to restore his/her respiratory and physical independence, thus decreasing the risks of bed rest associated complications. This article is a review of evidence-based effectiveness of weaning practices and physiotherapy treatment for patients with respiratory insufficiency in a RICU. Literature searches were performed using general and specialty databases with appropriate keywords. The evidence for applying a weaning process and physiotherapy techniques in these patients has been described according to their individual rationale and efficacy. The growing number of patients treated in RICUs all over the world makes this non pharmacological approach both welcome and interesting. However, to date, there are only strong recommendations concerning the evidence-based strategies to speed weaning. Early physiotherapy may be effective in ICU: however, most techniques (postures, limb exercise and percussion/vibration in particular) need to be further studied in a large population. Evidence supporting physiotherapy intervention is limited as there are no studies examining the specific effects of interventions on long-term outcome.
Breathing Exercises↗
Weaning and respiratory muscle dysfunction: the egg-chicken dilemma.
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Humans↗
Effects of acute on chronic respiratory failure on hypercapnia and 3-month survival.
BACKGROUND: There is a lack of information on respiratory function and mechanics after COPD exacerbations. STUDY OBJECTIVES: To find their role in short-term survival and occurrence of chronic hypercapnia after these events. PATIENTS AND INTERVENTIONS: Seventy-three COPD patients recovering from a recent severe exacerbation underwent evaluation of breathing pattern, breathing mechanics, lung function, and arterial blood gas levels at the time of discharge from a respiratory ICU (RICU). RESULTS: The 3-month mortality rate after RICU discharge was 11%. The percent of ideal body weight (%IBW) [R = 6.04; p = 0.01] and occlusion pressure (R = 5.41; p = 0.02) provided significant distinction between deceased patients and survivors; the final discriminant equation showed that %IBW was able to predict patient death or survival with an accuracy of 90%. With decreasing order of power, the ratio of inspiratory time to total breathing cycle time (Ti/Ttot) [R = 8.87; p = 0.003], pressure-time product of the inspiratory muscles (R = 7.12; p = 0.009), maximal esophageal pressure (R = 6.00; p = 0.01), esophageal pressure (R = 5.50; p = 0.02), Pa(O2)/fraction of inspired oxygen (R = 4.72; p = 0.03), and pressure time index (PTI) [R = 4.57; p = 0.03] provided a significant distinction between hypercapnia and normocapnia at discharge. The discriminant equation, including Ti/Ttot and PTI, could correctly separate hypercapnic or normocapnic patients with an accuracy of 76%. CONCLUSIONS: In COPD patients who are recovering from a severe exacerbation, hypercapnia is strongly related to inspiratory muscle work, strength, and breathing pattern; and only body weight predicts short-term survival.
Aged↗
Supported arm training in patients recently weaned from mechanical ventilation.
STUDY OBJECTIVES: To evaluate the effects of early exercise training in patients recovering from acute respiratory failure needing mechanical ventilation (MV). DESIGN: Prospective, randomized, and controlled study. SETTING: Three respiratory intermediate ICUs (RIICUs). PATIENTS: Of 228 patients admitted to an RIICU, 66 patients weaned from MV from > 48 to < 96 h were considered eligible and enrolled in the study. INTERVENTION: Sixty-six patients were randomized to either supported arm exercise training plus general physiotherapy (gPT) [group 1, 32 patients] or to gPT alone (group 2, 34 patients). MEASUREMENTS AND RESULTS: Twenty-five patients in each group completed the protocol. Group 1 showed a greater improvement in exercise capacity, as assessed by an arm incremental test (IT) [p = 0.003] and an endurance test (ET) [p = 0.021], compared to group 2. Posttraining maximal inspiratory pressure (MIP) significantly improved in both groups (p < 0.001 and p = 0.003 in groups 1 and 2 respectively; not significant). IT isoworkload dyspnea improved significantly in both groups (p = 0.005 and p = 0.009 in groups 1 and 2, respectively; not significant between groups), whereas IT isoworkload peripheral muscle fatigue (p < 0.001), ET isotime dyspnea (p < 0.01), and ET isotime muscular fatigue (p < 0.005) improved significantly in group 1 but not in group 2. IT improvers (chi2 = 0.004) and ET improvers (chi2 = 0.047) were more frequently observed in group 1 than in group 2. Baseline MIP could discriminate for IT (p = 0.013; odds ratio [OR], 1.116) and ET improvers (p = 0.022; OR, 1.067). CONCLUSION: Early upper-limb exercise training is feasible in RIICU patients recently weaned from MV and can enhance the effects of gPT. Baseline inspiratory muscle function is related to exercise capacity improvement.
Aged↗
Pattern of variables describing desaturator COPD patients, as revealed by cluster analysis.
STUDY OBJECTIVES: The aims of this study were to define, by cluster analysis, a pattern of clinical variables that differentiate desaturator (D) from nondesaturator (ND) patients affected by COPD, and to identify daytime variables that are predictive of nocturnal desaturation. PATIENTS: Fifty-one random, consecutive COPD outpatients (20 women; mean [+/- SD] age, 69.6 +/- 4.0 years) with mild daytime hypoxemia (Pao(2), 60 to 70 mm Hg) were enrolled into the study. Obstructive sleep apnea syndrome patients were excluded. MEASUREMENTS AND RESULTS: Lung volumes, arterial blood gas levels, and mean pulmonary artery pressure (MPAP) were measured, and nocturnal desaturation was evaluated with nighttime polygraphy. With least squares simple linear regression, the percentage of total recording time was highly correlated with a total nocturnal recording time of arterial oxygen saturation of < 90 mm Hg (T90) and MPAP (R = 0.84; R2= 71.20%); T90 was also highly correlated with daytime Paco2 (R = 0.70; R2= 48.96%). Multiple regression showed that T90 was highly correlated with both MPAP and Paco2 (R2= 97.75%). Hierarchical cluster analysis conducted with these three variables showed that D and ND patients differed in both nocturnal and daytime variables. The mean T90 was 30 +/- 3.5% in 19.2% and 8%, respectively, of the D and ND groups. Moreover, two D subgroups differing in MPAP and two ND subgroups differing in Paco2 were identified. CONCLUSIONS: D patients may be identified by a pattern of T90, MPAP, and Paco2 values, rather than by T90 alone, with the latter two variables being predictors of nocturnal desaturation severity.
Age Distribution↗
Physiological effects of meals in difficult-to-wean tracheostomised patients with chronic obstructive pulmonary disease.
OBJECTIVES: To evaluate effects of meals in difficult-to-wean tracheostomised patients with chronic obstructive pulmonary diseases during spontaneous breathing or Inspiratory Pressure Support. DESIGN: Prospective, crossover, randomised, and physiological study. SETTING: Weaning centre. PATIENTS: Sixteen COPD undergoing either decreasing levels of pressure support or increasing periods of spontaneous breathing. MEASUREMENTS: Each patient underwent monitoring during a 30-min procedure, during and after meals either under pressure support or spontaneous breathing on two consecutive days. Inductance plethysmography was used to monitor respiratory rate and tidal volume. Tidal volume by a flow transducer, arterial oxygen saturation, pulse rate, end-tidal CO2(,) and dyspnoea by a visual analogue scale were also assessed. RESULTS: ANOVA analysis showed a significant increase under spontaneous breathing for respiratory rate (P<0.001) and for end tidal CO(2) (P<0.03) induced by the meals. Inspiratory pressure support was associated to significantly greater tidal volume (P<0.001), lower respiratory rate (P<0.032), lower respiratory rate/tidal volume (P<0.001), and lower pulse rate (P<0.047) than spontaneous breathing. Under spontaneous breathing but not under pressure support a statistically worsening in meal-induced dispnoea (P<0.001) was found. CONCLUSIONS: In tracheostomised difficult-to-wean COPD patients: 1) under unassisted breathing, meals may induce an increase in respiratory rate, end-tidal CO(2), and dyspnoea; 2) inspiratory pressure support ventilation prevents dyspnoea from worsening during meals.
Aged↗
Walking modality affects respiratory muscle action and contribution to respiratory effort.
We hypothesized that walking at increased speed or increasing gradient might have different effects on chest wall kinematics and respiratory muscle power components, and contribute differently to respiratory effort sensation. We measured the volumes of chest wall compartments by optoelectronic plethysmography, esophageal, gastric and transdiaphragmatic ( P(di)) pressures, and the sensation of the respiratory effort by a Borg scale in five normal subjects walking both at ascending gradient with constant speed (AG) and at ascending speed with constant gradient (AS). Chest wall kinematics, evaluated by displacement of chest wall compartments, did not show any significant difference between AS and AG. Muscle power, calculated as the product of mean flow and mean pressure, increased similarly, but its partitioning into pressure and velocity of shortening differed in the two modes. A greater increase in the pressure developed by the abdominal muscles ( P(abm)) (4.06-fold), and in the velocity of shortening of both rib cage inspiratory muscles ( v(rcm,i)) (2.01-fold) and the diaphragm ( v(di)) (1.90-fold) was associated with a lower increase in the pressure developed by the rib cage inspiratory muscles ( P(rcm,i)) (1.24-fold) and P(di) (0.99-fold) with AG. Instead, with AS, a lower increase in P(abm) (2.12-fold), v(rcm,i) (1.66-fold) and v(di) (1.54-fold) was associated with a greater increase in P(rcm,i) (1.56-fold) and P(di) (1.97-fold). A combination of P(abm) and v(di) during AG (Wald chi(2)=23.19, P<0.0000), with the addition of P(rcm,i) during AS (Wald chi(2)=29.46, P<0.0000), was the best predictor of Borg score. In conclusion, the general strategy adopted by respiratory centers during different walking modes does not differ in terms of ventilation, chest wall kinematics, and respiratory muscle power production, whereas it does in terms of partitioning of power into pressure and velocity of shortening, and respiratory muscle contribution to respiratory effort sensation. Combinations of different patterns of flow and pressure generation made the respiratory effort sensation similar during AS and AG modes.
Adult↗
Long-term mechanical ventilation and nutrition.
Mechanical ventilation (MV) in chronic situations is commonly used, either delivered invasively or by means of non-invasive interfaces, to control hypoventilation in patients with chest wall, neuromuscular or obstructive lung diseases (either in adulthood or childhood). The global prevalence of ventilator-assisted individuals (VAI) in Europe ranges from 2 to 30 per 100000 population according to different countries. Nutrition is a common problem to face with in patients with chronic respiratory diseases: nonetheless, it is a key component in the long-term management of underweight COPD patients whose muscular disfunction may rapidly turn to peripheral muscle waste. Since long-term mechanical ventilation (LTMV) is usually prescribed in end-stage respiratory diseases with poor nutritional status, nutrition and dietary intake related problems need to be carefully assessed and corrected in these patients. This paper aims to review the most recent innovations in the field of nutritional status and food intake-related problems of VAI (both in adulthood and in childhood).
Adult↗
Tolerance and physiologic effects of nocturnal mask pressure support vs proportional assist ventilation in chronic ventilatory failure.
STUDY OBJECTIVES: To compare the tolerance and physiologic effects of a 5-night treatment with either nasal proportional assist ventilation (PAV) or pressure support ventilation (PSV) in patients with chronic ventilatory failure. DESIGN: Cross-over, randomized, controlled study. SETTING: Rehabilitation units of pneumology department. PATIENTS OR PARTICIPANTS: Four patients with COPD and 10 patients with restrictive thoracic diseases with chronic hypercapnia (median baseline Paco(2), 55.1 mm Hg) were studied. INTERVENTIONS: In a cross-over study, nasal PAV and PSV set at the patient's comfort were randomly applied during 5 consecutive nights (with a 2-night washout period). MEASUREMENTS AND RESULTS: Continuous nocturnal pulse oximetric saturation (Spo(2)) and arterial blood gas results at wake-up were evaluated at baseline during spontaneous breathing and on the fifth day of ventilatory support. Dyspnea, sleep quality, adaptation, and comfort at inspiration and expiration by visual analog scale (VAS) were evaluated every day as well as a side effects score. On the fifth day, there were no significant differences in daytime Paco(2) (median PAV, 53.3 mm Hg; median PSV, 50.2; p = 0.168). Mean nocturnal Spo(2) improved significantly with both PAV and PSV without any significant differences between modes (baseline median, 92%; PAV median, 94.5%; PSV median, 95%). The percentage of the study night spent < 90% Spo(2) (T90) was slightly but significantly higher with PAV than with PSV (median PAV T90, 4%; median PSV T90, 2%; p = 0.049). The VAS symptom score was similar at day 5 between modes; however, nasal and oral dryness were lower (p = 0.05) and alarm noise was higher (p = 0.037) with PAV. CONCLUSIONS: After 5 days of treatment, both modes had similar tolerance, and were equally effective in reducing daytime hypercapnia and improving nocturnal saturation and symptoms. However, PAV induced less nasal and oral dryness but was associated with higher alarm noise.
Adult↗
Prevalence and prognostic role of cardiovascular complications in patients with exacerbation of chronic obstructive pulmonary disease admitted to Italian respiratory intensive care units.
BACKGROUND: Cardiovascular complications are frequently observed in patients with chronic obstructive pulmonary disease (COPD) admitted to respiratory intensive care units and may affect the prognosis. The aims of this study were to evaluate a) the prevalence of cardiovascular complications in patients with COPD exacerbation admitted to respiratory intensive care units, b) which parameters detected at admission were predictive of cardiovascular complications, and c) the prognostic role of cardiovascular complications. METHODS: A series of 278 consecutive patients with COPD admitted to 11 Italian respiratory intensive care units between November 1997 and January 1998 has been retrospectively analyzed. All cardiovascular complications were recorded. RESULTS: One hundred and ten patients (39.6%) developed cardiovascular complications: congestive heart failure 49 (17.6%), arrhythmias 40 (14.4%), shock 13 (4.7%), and hypotension 11 (4%). Multivariate analysis showed that the APACHE II score, ECG abnormalities (supraventricular ectopic beats, right and/or left ventricular hypertrophy) and digoxin therapy were independent predictors of cardiovascular complications. The overall mortality was 9% being 4.7% in patients without and 15.5% in patients with cardiovascular complications (p = 0.0044). Multivariate analysis showed that the APACHE II score, respiratory rate, pneumonia and end-stage respiratory diseases were independent predictors of mortality. CONCLUSIONS: Cardiovascular complications occurred in many patients with COPD exacerbation admitted to respiratory intensive care units, and identify a subset of patients with higher mortality.
APACHE↗
Where to perform long-term ventilation.
Given that most VAI prefer to be cared for at home and that their return home is the desire of families, health care professionals, and others concerned with LTMV, the effort to transform prolonged mechanical ventilation from a hospital-centered to a home-centered treatment needs to be continued and further developed. Nevertheless, the future of high-technology home care will undoubtedly be influenced by improvements in quality and containment of costs, as in its current status treatment of VAI at home too often leads to family disruption and presents a dramatically increasing cost burden. Careful selection of patients, closer attention to education and training, and collection of outcome data are all factors that presumably will facilitate the development of better-quality and cost-saving home care.
Chronic Disease↗
Mask proportional assist vs pressure support ventilation in patients in clinically stable condition with chronic ventilatory failure.
OBJECTIVE: To compare the short-term physiologic effects of mask pressure support ventilation (PSV) and proportional assist ventilation (PAV) in patients in clinically stable condition with chronic ventilatory failure (CVF). DESIGN: Randomized, controlled physiologic study. SETTING: Lung function units of two pulmonary rehabilitation centers. PATIENTS: Eighteen patients with CVF caused by COPD (11 patients) and restrictive chest wall diseases (RCWDs) [7 patients]. METHODS: Assessment of breathing pattern and minute ventilation (E), respiratory muscles and lung mechanics, and patient/ventilator interaction during both unassisted and assisted ventilation. After baseline assessment during spontaneous breathing (SB), mask PSV and PAV were randomly applied at the patient's comfort, with the addition of the same level of continuous positive airway pressure (2 cm H2O or 4 cm H2O in all patients), for 30 min each, with a 20-min interval of SB between periods of assisted ventilation. RESULTS: A longer time was spent to set PAV than PSV (663 +/- 179 s and 246 +/- 58 s, respectively; p < 0.001). Mean airway opening pressure (Pao) computed over a period of 1 min, but not peak Pao, was significantly lower with PAV than with PSV (151 +/- 45 cm H2O/s/min and 207 +/- 73 cm H2O/s/min, respectively; p < 0.002). Tidal volume (VT) exhibited a greater variability with PAV than with PSV (variation coefficient, 16.3% +/- 10.5% vs 11.6% +/- 7.7%, respectively; p < 0.05). Compared with SB, both modalities resulted in a significant increase in VT (by 40% and 36% with PAV and PSV, respectively, on average) and E (by 37% and 35%) with unchanged breathing frequency and duty cycle. Both modalities significantly reduced esophageal (by 39% and 51%) and diaphragmatic (by 42% and 63%) pressure-time products, respectively. Ineffective efforts were observed with neither modes of assistance in any patient. CONCLUSIONS: In resting, awake patients in clinically stable condition with CVF caused by either COPD or RCWD, noninvasive application of PAV, set at the patient's comfort, was not superior to PSV either in increasing VT and E or in unloading the inspiratory muscles. We failed to find any difference in patient/ventilator interaction between ventilatory modes.
Aged↗
Comparison of five bilevel pressure ventilators in patients with chronic ventilatory failure: a physiologic study.
OBJECTIVE: To compare patient-ventilator interaction and comfort in patients with chronic ventilatory failure (CVF) who are undergoing noninvasive positive-pressure ventilation with five different commercial bilevel pressure home ventilators. Also, we wanted to evaluate the short-term effects of the five ventilators on physiologic variables, namely, breathing patterns and inspiratory muscles. DESIGN: Randomized, controlled physiologic study. SETTING: Pulmonary division of a rehabilitation institution. PATIENTS: Twenty-eight patients with CVF due to COPD (17 patients) and restrictive chest wall diseases (11 patients). MEASUREMENTS: Sensation of comfort, breathing patterns and minute ventilation (E), respiratory muscles and mechanics, and patient-ventilator interaction during both unassisted and assisted ventilation with the five ventilators applied randomly. RESULTS: The five ventilators showed different flow and pressure waveforms. The level of comfort was somehow different among the studied ventilators. When compared to unassisted ventilation, all ventilators induced a significant increase in E (p < 0.01) without any significant difference among ventilators. Use of the five ventilators resulted in significant differences in peak airway opening pressure (Pao,peak) but not in mean airway opening pressure computed over a period of 1 min (PTPao,min), and in a duty cycle. Ineffective efforts (IEs) were similar among the studied ventilators. In comparison with unassisted ventilation, all ventilators induced significant reductions in inspiratory muscle effort (p < 0.001). No significant relationship was found between level of comfort and PTPao,min, Pao,peak, or the number of IEs. CONCLUSIONS: In stable, awake patients with CVF, all of the studied ventilators were well-tolerated, although with a great intersubject variability in comfort, and performed well in terms of improvement in E and inspiratory muscle unloading, thus fulfilling the aims of mechanical ventilation. This effect was obtained with similar levels of PTPao,min, despite the fact that Pao,peak was different among some ventilators. The number of IEs was similar among the studied ventilators.
Aged↗
Nitric oxide and pulmonary circulation.
The aim of this review is to outline the characteristics of pulmonary circulation in health and disease and to define the value of exhaled NO (eNO) as a means to assess the involvement of pulmonary circulation in pathology. The discovery of the endocrine role of the endothelium has generated great interest in its potential role in regulating the vascular tone of the pulmonary vascular bed. Nitric oxide (NO)-mediated, endothelium-dependent relaxation has been demonstrated in the pulmonary arteries of animals and humans. Changes in the NO pathway in pulmonary hypertension are not completely understood. It is clear that NO has an important role in modulating the response to acute hypoxia, increased flow, and shear stress. The amount of exhaled NO (eNO) in different species may be easily measured, reflecting the overall NO metabolism from the lung (thus including epithelial, endothelial and other cell activity). The development of pulmonary hypertension secondary to systemic (systemic sclerosis, chronic heart failure) or pulmonary (COPD) diseases appears to be associated with a decrease in eNO production both at rest and during exercise. Chronic inhalation of NO appears to protect against pulmonary hypertension in animal models. Exhaled NO is attracting interest for its in vivo ability to represent the features of pulmonary circulation in pathology.
Animals↗
Cognitive and perceived health status in patient with chronic obstructive pulmonary disease surviving acute on chronic respiratory failure: a controlled study.
OBJECTIVE: To evaluate the perceived health and cognitive status in survivors of chronic obstructive pulmonary disease (COPD) exacerbations requiring mechanical ventilation. DESIGN AND SETTING: Prospective controlled cohort study in a respiratory intermediate intensive care unit. PATIENTS: Sixty-three COPD patients at their first episode of acute on chronic respiratory failure requiring mechanical ventilation, controls were 34 consecutive stable COPD patients on long-term oxygen therapy with no previous ICU admission. MEASUREMENTS AND RESULTS: Perceived health and cognitive status by means of the Nottingham Health Profile (NHP) and the Mini Mental State (MMS), respectively, at discharge and 3 and 6 months thereafter. At discharge patients showed significantly worse mean values than controls in MMS and in all NHP dimensions except pain. The MMS score was below 24, the threshold level of cognitive impairment, in 43% patients of the study group but only 3% of controls ( p=0.006). Six months after discharge patients showed NHP and MMS values similar to those of controls and the proportion of patients with a MMS score below 24 had significantly decreased to 17%, a value not significantly different from that in controls (5%). CONCLUSIONS: COPD patients surviving their first episode of acute on chronic respiratory failure requiring mechanical ventilation, suffer worsen perceived health status and cognitive function, which 6 months after discharge may improve to levels similar to those in stable COPD patients on long-term oxygen therapy with no previous ICU admission.
Blood Gas Analysis↗