Giancarlo Garuti

Respiratory failure,nasal cannula,high-flow oxygen,methodology

COVID 19 pneumonia, is a serious event that quickly leads to severe hypoxyemic respiratory failure. Often it occurs bilaterally and has a pattern similar to ARDS. The patient suffering from this pathology, compared to that suffering from ARDS, has a more manageable clinic with non-invasive respiratory supports (CPAP, HFNC, NPSV), so they are often not sedated and not intubated. Pronation is a common practice in the intubated patient but not in the patient with spontaneous or non-invasive breathing; recently studies show conflicting data (1-2). Aim: we would evaluate whether it was possible to carry out pronation in patients in non-invasive ventilatory treatment and its effects. Methods: we retrospectively studied 19 patients, average age 74±10, 16M, 11 pronates (P) in HFNC and 8 no (NP), initial P/F at admission 143.5±58.8) treated in our intermediate respiratory unit. None of the patients were intubated. P patients significantly improved (p=0.01) their P/F (after 2 hours of treatment) from 70.6±9.9 to 150.3±53.1 (113%). Mortality in the P group was 27% (3 out of 11) while in the NP group 50% (4 out of 8). Pronation did not lead to particular side effects, patients tolerated it well, it was quite easy for nurses as patients were not sedated and could help themselves in pronation. Conclusions: this preliminary study shows that pronation: 1) is also feasible in patients undergoing non-invasive treatment, 2) quickly leads to an improvement in P/F, 3) could reduce mortality and the intubation need, 4) it is easy for operators and without side effects. References: 1) Ferrando C. et al. Crit Care (2020)24:597;2) Ng Z et al. Eur Respir J 2020; 56 (1):2001198

Non-invasive ventilation (NIV) is a mainstay of management of chronic respiratory failure in many disorders which are known to cause abnormal airway secretion clearance. Currently, there is no guidance regarding either the secretion handling during NIV use or the role of NIV in secretion management in these patients. The aim of this document was to provide an overview of the various techniques available in the management of respiratory secretions and their use in conjunction with NIV. Literature search was performed using the keywords, “(secretion OR secretions) AND (noninvasive ventilation OR NIV)” on PubMed and EMBASE. The search yielded 1681 and 509 titles from PubMed and EMBASE, respectively. After screening, 19 articles were included in this review. Suggestions of the expert panel were formulated by mutual consensus after reviewing the relevant literature. The draft of the expert panel’s suggestions was circulated among all authors via electronic mail for comments. Any conflicts were resolved by mutual discussion to achieve agreement. The final document was approved by all. This document by the International Network for Airway Secretions Management in NIV describes various airway secretion clearance techniques. It provides the expert panel’s suggestions for the use of these techniques in conjunction with NIV for patients with muco-obstructive and neuromuscular disorders.

We studied 33 patients affected by juvenile and adult myotonic dystrophy type 1 (DM1). The aim of the study was to assess clinical and laboratory parameters that could predict the requirement of noninvasive ventilation (NIV) in DM1. Secondary outcome was to assess the interplay between genetic profile, muscle impairment severity and presence of cardiac comorbidities.Patients with genetic diagnosis of DM1 were recruited. An abnormal trinucleotide repeat (CTG) expansion of dystrophy protein kinase gene (DMPK) on chromosome 19q13.3 was the prerequisite for inclusion. The number of triplet repeats was measured in genomic DNA to classify subjects. A multidisciplinary team evaluated the patients every 6–8 months up to 18 years with serial cardiological and respiratory function assessments. Neurological progression was monitored using a validated DM1-specific rating scale (MIRS). Independent variables considered for the study outcomes were gender, genetic status, age of presentation, MIRS scores, and results of pulmonary function tests (PFTs).Patients were 17 males (51.5%) and 16 females (48.5%). 16 cases were younger than mean age of 31.4 years, the remaining 17 were up to 65. 12 subjects (36.4%) underwent NIV during follow up. Cardiac comorbidities were detected in 63.6% of cases and in 91% of patients in NIV. Among PFTs, forced vital capacity (FVC) was a reliable indicator of respiratory decline. FVC values were significantly associated with clinical muscle severity assessed by MIRS.Severity of muscular impairment, CTG expansion size, age and presence of cardiac comorbidities predict respiratory impairment in DM1

Cerebral palsy (CP) is a condition that can occur at any time during brain development. Although its etiology is multifactorial, CP is usually linked to brain injury or infections during prenatal, perinatal, neonatal or early childhood period. The disability associated with CP varies from mild to severe, and may include involuntary movements, poor coordination, maintaining balance problems and the difficulty of performing voluntary movements. Although this condition (brain impairment) does not directly cause pulmonary complications, neuromuscular dysfunctions do so. In fact, aspiration and ineffective coughing could interfere with normal airway clearance, impair respiratory function, and worsen lung damage, resulting in increased mucus production and reduced secretions elimination. This consequent alteration of the pulmonary defense system increases the susceptibility to serious, progressive lung diseases. Physiotherapy is an essential component in the management of respiratory complications associated with severe CP. For optimal results, however, it is important customized treatment for every patient. This mini non-ystematic review would highlight the possible complications and the possible interventions for reduce them.

Turkthoracj, Turkish Thoracic Journal

Noninvasive ventilation (NIV) is an increasingly used method of respiratory support. The use of NIV is expanding over the time and if properly applied, it can save patients’ lives and improve long-term prognosis. However, both knowledge and skills of its proper use as life support are paramount. This systematic review aimed to assess the importance of NIV education and training. Literature search was conducted (MEDLINE: 1990 to June, 2018) to identify randomized controlled studies and systematic reviews with the results analyzed by a team of experts across the world through e-mail based communications. Clinical trials examining the impact of education and training in NIV as the primary objective was not found. A few studies with indirect evidence, a simulation-based training study, and narrative reviews were identified. Currently organized training in NIV is implemented only in a few developed countries. Due to a lack of high-grade experimental evidence, an international consensus on NIV education and training based on opinions from 64 experts across the twenty-one different countries of the world was formulated. Education and training have the potential to increase knowledge and skills of the clinical staff who deliver medical care using NIV. There is a genuine need to develop structured, organized NIV education and training programs, especially for the developing countries.

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disorder of the motor neuron, which selectively affects it both at central (first motor-neuron) and peripheral level (second motor-neuron). The disease shows up at a mean age of 56 years and the most affected are males. Although ALS may start as a bulbar or spinal disease, with the progression of the disease typically both become evident. Pharmacological approved treatments for ALS are still limited and include riluzole and edaravone which improve survival over time. Despite this, ALS leads to progressive muscle involvement and requires a complex multidisciplinary approach to manage increasing disability which goes beyond motor neurons. Sialorrhea is, amongst others, one of the most disabling symptoms in ALS. The complexity in managing saliva is due to a muscular spasticity and to a scarce palatino-lingual muscles control, rather than to an overproduction of saliva. These features could increase the risk of aspiration pneumonia and limit the use of noninvasive mechanical ventilation. We reviewed the treatment for sialorrhea in ALS patients that are available at this time, emphasizing pros and cons for each approach. Our purpose is to create a practical tool for the diagnosis, in order to facilitate the quantification and management of sialorrhea in everyday practice.