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Privitera D, Capsoni N, Bellone A, Langer T. Helmet Continuous Positive Airway Pressure in the Emergency Department: A Practical Guide. J Emerg Nurs 2023; 49:661-665. [PMID: 37256243 DOI: 10.1016/j.jen.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/30/2023] [Accepted: 05/01/2023] [Indexed: 06/01/2023]
Abstract
Helmet continuous positive airway pressure is a simple, noninvasive respiratory support strategy to treat several forms of acute respiratory failure, such as cardiogenic pulmonary edema and pneumonia. Recently, it has been largely used worldwide during the COVID-19 pandemic. Given the increased use of helmet continuous positive airway pressure in the emergency department, we aimed to provide an updated practical guide for nurses and clinicians based on the latest available evidence. We focus our attention on how to set the respiratory circuit. Moreover, we discuss the interactions between flow generators, filters, and positive end-expiratory pressure valves and the consequences regarding the delivered gas flow, fraction of inspired oxygen, positive end-expiratory pressure, and noise level.
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Ghezzi L, Graziano F, Bottani G, Marullo G, Capsoni N, Forni E, Vincenti F, Rebora P, Bellone A. High flow nasal cannula combined with non-invasive ventilation versus high flow nasal cannula alone in patients with acute hypoxemic respiratory failure due to pneumonia: a randomized controlled trial. Emerg Care J 2023. [DOI: 10.4081/ecj.2023.11088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023] Open
Abstract
In this monocentric, open label, randomized controlled trial we aimed to compare the efficacy of combined High Flow Nasal Cannula (HFNC) and Non invasive Ventilation (NIV) versus HFNC alone in acute hypoxemic respiratory failure (hARF) in patients affected by Community Acquired Pneumonia (CAP). We enrolled 49 patients affected by CAP with moderate to severe hypoxemic respiratory failure (P/F < 300). The patients were randomized into two groups: one has been treated with HFNC alone (group A) while the other received NIV alternated to HFNC every 3 hours (group B). The primary outcome was P/F change from baseline to 21 hours. Secondary outcomes included variation of pH and pCO2, need to continue HFNC or NIV/HFNC after 45 hours, orotracheal intubation, mortality rate, and the devices comfort. Not statistical significant differences between the two arms were shown in the P/F change at 21 hours since baseline, in pCO2 and pH variation, mortality at hospital and at follow-up. We emphasize the importance of combined HFNC with NIV as a first step for severe pneumonia treatment whereas HFNC might represent as the first step treatment in less severe patients and during the NIV intervals.
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Privitera D, Capsoni N, Zadek F, Mazzone A, Bellone A, Fumagalli R, Langer T. Flow generators for helmet CPAP: Which to prefer? A bench study. Intensive Crit Care Nurs 2023; 74:103344. [PMID: 36357234 DOI: 10.1016/j.iccn.2022.103344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 10/23/2022] [Accepted: 10/28/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess the different effect of filters' application during helmet-CPAP delivered with three different flow generators on the delivered fresh gas flow, FiO2, and the noise level inside and outside the helmet. METHODS In a bench study, three flow generators (air-oxygen blender, turbine ventilator and Venturi system) were used to generate two different gas flows (60 L/min and 80 L/min), with a fixed FiO2 at 0.6, to perform a helmet-CPAP on a manikin. Three different fixed PEEP valves (7.5, 10, and 12.5 cmH2O) were applied at the expiratory port. Gas flow, FiO2 and noise were recorded for each Flow-generator/Flow/PEEP combination, first without filter interposition and then after positioning a heat and moister exchanger filter (HMEF) at the helmet inlet port. RESULTS The application of the HMEF lead to a significant difference in the flow variation among the three flow generators (p < 0.001). Compared to baseline, the highest flow reduction was observed with the VENTURI (-13.4 ± 1.2 %, p < 0.001), a slight increase with the BLENDER (1.2 ± 0.5 %, p < 0.001), whereas no difference was recorded with the TURBINE (0.1 ± 0.6 %, p = 0.12). After HMEF was interposed, a significant FiO2 variation was observed only with VENTURI (11.3 ± 1.8 %, p < 0.001). As for the noise, the TURBINE was the least noisy system, both with and without the filter interposition. CONCLUSIONS Flow generators used to deliver helmet-CPAP have different characteristics and responses to HMEF interposition. Users should be aware of the effects on FiO2 and flow of the different devices in order to make a precise setup of the circuit.
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Affiliation(s)
- Daniele Privitera
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
| | - Nicolò Capsoni
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesco Zadek
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy; Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy
| | - Annamaria Mazzone
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Andrea Bellone
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Roberto Fumagalli
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy; Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy
| | - Thomas Langer
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy; Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy
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Casagranda I, Gola M, Bellone A, Coen D, Brambilla A, Guiddo G, Paolillo C, Lerza R, Capolongo S, Boeri S. Challenges of the next generation hospitals: Rethinking the Emergency Department. Emer Care J 2022. [DOI: 10.4081/ecj.2022.10840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The COVID 19 outbreak dramatically highlighted the inadequacy of the Emergency Department (ED) settings in dealing with events that can acutely affect a wide range of population. The immediate urgency to create strictly distinct pathways became also a strategic aspect for reducing possible sources of contagion inside the hospital.1 This need has often clashed with inadequate structural conditions of the hospital: in fact, the rigidity of many EDs is due to the hospital typology and its localization (affected by functional program);2,3 and it prevents them from being quickly adapted to new needs in the case of maxi-emergencies.4 In several recent international projects, the presence of a multifunctional space and/or a buffer area guarantees different scenarios in relation to the healthcare/emergency needs.5 [...]
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Privitera D, Capsoni N, Zadek F, Vailati P, Airoldi C, Cozzi M, Pierotti F, Fumagalli R, Bellone A, Langer T. The Effect of Filters on CPAP Delivery by Helmet. Respir Care 2022; 67:995-1001. [PMID: 35232821 PMCID: PMC9994150 DOI: 10.4187/respcare.09822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND When helmet CPAP is performed using a Venturi system, filters are frequently interposed in the respiratory circuit to reduce noise within the helmet. The effect of the interposition of these filters on delivered fresh gas flow and the resulting FIO2 is currently unknown. METHODS In a bench study, 2 different Venturi systems (WhisperFlow and Harol) were used to generate 3 different gas flow/FIO2 combinations (80 L/min-FIO2 0.6, 100 L/min-FIO2 0.5, 120 L/min-FIO2 0.4). Different combinations of filters were applied at the flow generator input line and/or at the helmet inlet port. Two types of filters were used for this purpose: a heat and moisture exchanger filter and an electrostatic filter. The setup without filters was used as baseline. Gas flow and FIO2 were measured for each setup. RESULTS Compared to baseline, the interposition of filters reduced the gas flow between 1-13% (P < .001). The application of a filter at the Venturi system or at the helmet generated a comparable flow reduction (-3 ± 2% vs -4 ± 2%, P = .12), whereas a greater flow reduction (-7 ± 4%) was observed when filters were applied at both sites (P < .001). An increase in FIO2 up to 5% was observed with filters applied. A strong inverse linear relationship (P < .001) was observed between the resulting gas flow and FIO2 . CONCLUSIONS The use of filters during helmet CPAP reduced the flow delivered to the helmet and, consequently, modified FIO2 . If filters are applied, an adequate gas flow should be administered to guarantee a constant CPAP during the entire respiratory cycle and avoid rebreathing. Moreover, it might be important to measure the effective FIO2 delivered to the patient to guarantee a precise assessment of oxygenation.
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Affiliation(s)
- Daniele Privitera
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
| | - Nicolò Capsoni
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesco Zadek
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy; and Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy
| | - Paolo Vailati
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Chiara Airoldi
- Department of Translation Medicine, University of Piemonte Orientale, Novara, Italy
| | - Mattia Cozzi
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Federico Pierotti
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Roberto Fumagalli
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy; and Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy
| | - Andrea Bellone
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Thomas Langer
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy; and Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy
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Tombini V, Di Capua M, Capsoni N, Lazzati A, Bergamaschi M, Gheda S, Ghezzi L, Cassano G, Albertini V, Porta L, Zacchino M, Campanella C, Guarnieri L, Cazzola KB, Velati M, Di Domenico SL, Tonani M, Spina MT, Paglia S, Bellone A. Risk Stratification in COVID-19 Pneumonia - Determining the Role of Lung Ultrasound. Ultraschall Med 2022; 43:168-176. [PMID: 33601427 DOI: 10.1055/a-1344-4715] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
UNLABELLED LUS patterns of COVID-19 pneumonia have been described and shown to be characteristic. The aim of the study was to predict the prognosis of patients with COVID-19 pneumonia, using a score based on LUS findings. MATERIALS AND METHODS An observational, retrospective study was conducted on patients admitted to Niguarda hospital with a diagnosis of COVID-19 pneumonia during the period of a month, from March 2nd to April 3rd 2020. Demographics, clinical, laboratory, and radiological findings were collected. LUS was performed in all patients. The chest was divided into 12 areas. The LUS report was drafted using a score from 0 to 3 with 0 corresponding to A pattern, 1 corresponding to well separated vertical artifacts (B lines), 2 corresponding to white lung and small consolidations, 3 corresponding to wide consolidations. The total score results from the sum of the scores for each area. The primary outcome was endotracheal intubation, no active further management, or death. The secondary outcome was discharge from the emergency room (ER). RESULTS 255 patients were enrolled. 93.7 % had a positive LUS. ETI was performed in 43 patients, and 24 received a DNI order. The general mortality rate was 15.7 %. Male sex (OR 3.04, p = 0.014), cardiovascular disease and hypertension (OR 2.75, p = 0.006), P/F (OR 0.99, p < 0.001) and an LUS score > 20 (OR 2.52, p = 0.046) were independent risk factors associated with the primary outcome. Receiver operating characteristic (ROC) curve analysis for an LUS score > 20 was performed with an AUC of 0.837. Independent risk factors associated with the secondary outcome were age (OR 0.96, p = 0.073), BMI (OR 0.87, p = 0,13), P/F (OR 1.03, p < 0.001), and LUS score < 10 (OR 20.9, p = 0.006). ROC curve analysis was performed using an LUS score < 10 with an AUC 0.967. CONCLUSION The extent of lung abnormalities evaluated by LUS score is a predictor of a worse outcome, ETI, or death. Moreover, the LUS score could be an additional tool for the safe discharge of patient from the ER.
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Affiliation(s)
| | | | - Nicolò Capsoni
- Emergency Medicine Residency, University of Milan-Bicocca, Milano, Italy
| | - Andrea Lazzati
- General and Digestive Surgery, Centre Hospitalier Intercommunal de Creteil, France
| | - Marta Bergamaschi
- Emergency Medicine Residency, University of Milan-Bicocca, Milano, Italy
| | - Silvia Gheda
- Emergency Medicine Residency, University of Milan-Bicocca, Milano, Italy
| | | | - Giulio Cassano
- Emergency Medicine Residency, University of Milan-Bicocca, Milano, Italy
| | | | - Lorenzo Porta
- Emergency Medicine Residency, University of Milan-Bicocca, Milano, Italy
| | - Massimo Zacchino
- Emergency Medicine Residency, University of Milan-Bicocca, Milano, Italy
| | - Carlo Campanella
- Emergency Medicine Residency, University of Milan-Bicocca, Milano, Italy
| | | | | | - Marta Velati
- Emergency Department, Niguarda Hospital, Milano, Italy
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Privitera D, Capsoni N, Bellone A. Author’s response to “Continuous positive airway pressure helmet in patients with ARDS due to COVID-19 pneumonia. Insights about a therapy monitoring protocol”. Aust Crit Care 2022; 35:335. [PMID: 35490107 PMCID: PMC8947945 DOI: 10.1016/j.aucc.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 03/19/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
- Daniele Privitera
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
| | - Nicolò Capsoni
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Andrea Bellone
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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Ughi N, Bernasconi DP, Del Gaudio F, Dicuonzo A, Maloberti A, Giannattasio C, Tarsia P, Puoti M, Scaglione F, Beltrami L, Colombo F, Bertuzzi M, Bellone A, Adinolfi A, Valsecchi MG, Epis OM, Rossetti C. Trends in all-cause mortality of hospitalized patients due to SARS-CoV-2 infection from a monocentric cohort in Milan (Lombardy, Italy). J Public Health (Oxf) 2022; 30:1985-1993. [PMID: 35004128 PMCID: PMC8723908 DOI: 10.1007/s10389-021-01675-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 11/07/2021] [Indexed: 12/19/2022] Open
Abstract
Background Robust data on case fatality rate (CFR) among inpatients with COVID-19 are still lacking, and the role of patient characteristics in in-hospital deaths remains under-investigated. This study quantified the overall CFR and described its trend in a cohort of hospitalized patients with SARS-CoV-2 in Italy. Admission to ICU, death, or discharge were the secondary outcomes. Methods This retrospective study is based on administrative health data and electronic case records of inpatients consecutively admitted to Niguarda Hospital between 21 February and 8 November 2020. Results An overall CFR of 18% was observed. CFR was significantly reduced during the second wave of contagion (1 June to 30 September, 16%) compared with the first wave (21 February to 31 May, 21% p = 0.015). Such reduction was mainly observed among male inpatients between 40 and 80 years with limited comorbidities. Admission to ICU was associated with a high risk of mortality in both waves. The incidence of severe disease and the need for ICU admission were lower in the second wave. Conclusion CFR in SARS-CoV-2 inpatients was demonstrated to decrease over time. This reduction may partly reflect the changes in hospital strategy and clinical practice. The reasons for this improvement should be further investigated to plan an exit strategy in case of future outbreaks. Key messages What is already known on this topic Before the advent of anti-COVID-19 vaccines, a multi-wave pattern of contagion was observed, and this trend conditioned the inpatient case fatality rate (CFR), which varied over time accordingly to the waves of contagion. Only preliminary results on the in-hospital mortality trend are available, along with a partial analysis of its determinants. Consequently, robust data on CFR among inpatients with SARS-CoV-2 infection are still lacking, and the role of patient characteristics in in-hospital deaths remains under-investigated. What this study adds This study shows that the in-hospital mortality in patients with SARS-CoV-2 infection decreases over time. Such reduction was mainly observed among male inpatients between 40 and 80 years with limited comorbidities. Admission to ICU was invariably associated with a high risk of mortality during the whole study period (21 February to 8 November 2020), but the incidence of severe disease and the need for ICU admission were lower in the second wave of contagions (1 October to 8 November 2020). This reduction may partly reflect the impact of changes in hospital strategy and clinical practice. The reasons for this improvement should be further investigated to inform the response to future outbreaks and to plan exit strategy by prioritizing high-risk populations. Supplementary Information The online version contains supplementary material available at 10.1007/s10389-021-01675-y.
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Affiliation(s)
- Nicola Ughi
- Division of Rheumatology, Multispecialist Medical Department, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy
| | - Davide Paolo Bernasconi
- Bicocca Bioinformatics Biostatistics and Bioimaging Centre - B4, School of Medicine and Surgery, University of Milano--Bicocca, Milan, Italy
| | - Francesca Del Gaudio
- Functional Department for Higher Education, Research, and Development, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Armanda Dicuonzo
- Functional Department for Higher Education, Research, and Development, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Alessandro Maloberti
- Division of Cardiology 4, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.,School of Medicine and Surgery, Milano-Bicocca University, Milan, Italy
| | - Cristina Giannattasio
- Division of Cardiology 4, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.,School of Medicine and Surgery, Milano-Bicocca University, Milan, Italy
| | - Paolo Tarsia
- Division of Pneumology, Multispecialist Medical Department, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Massimo Puoti
- School of Medicine and Surgery, Milano-Bicocca University, Milan, Italy.,Division of Infectious Disease, Multi-specialist Medical Department, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesco Scaglione
- Department of Oncology and Hemato-Oncology, Division of chemical-Clinical and Microbiological Analyses, Department of Laboratory Medicine, ASST Grande Ospedale Metropolitano Niguarda, Università degli Studi di Milano, Milan, Italy
| | - Laura Beltrami
- Division of Internal Medicine 1, Multispecialist Medical Department, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Fabrizio Colombo
- Division of Internal Medicine 1, Multispecialist Medical Department, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Michaela Bertuzzi
- Division of Quality and Clinical Risk, Continuous Quality Improvement, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Andrea Bellone
- Division of Emergency Medicine and Emergency Room, Department of Emergencies and Admissions (DEA), ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Antonella Adinolfi
- Division of Rheumatology, Multispecialist Medical Department, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy
| | - Maria Grazia Valsecchi
- Bicocca Bioinformatics Biostatistics and Bioimaging Centre - B4, School of Medicine and Surgery, University of Milano--Bicocca, Milan, Italy
| | - Oscar Massimiliano Epis
- Division of Rheumatology, Multispecialist Medical Department, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy
| | - Claudio Rossetti
- Functional Department for Higher Education, Research, and Development, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.,Functional Department for Higher Education, Research, and Development, Interhospital Functional Department of Nuclear Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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Pani A, Inglese E, Puoti M, Cento V, Alteri C, Romandini A, Di Ruscio F, Senatore M, Moreno M, Tarsia P, Colombo F, Epis OM, Panetta V, Vismara C, Bellone A, Scaglione F. Sex differences in electrolyte imbalances caused by SARS-CoV-2: A cross-sectional study. Int J Clin Pract 2021; 75:e14882. [PMID: 34529866 PMCID: PMC8646642 DOI: 10.1111/ijcp.14882] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 09/07/2021] [Accepted: 09/14/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Since SARS-CoV-2 spread, evidence regarding sex differences in progression and prognosis of COVID-19 have emerged. Besides this, studies on patients' clinical characteristics have described electrolyte imbalances as one of the recurrent features of COVID-19. METHODS We performed a cross-sectional study on all patients admitted to the emergency department (ED) from 1 March to 31 May 2020 who had undergone a blood gas analysis and a nasopharyngeal swab test for SARS-CoV-2 by rtPCR. We defined positive patients as cases (n = 710) and negatives as controls (n = 619), for a total number of patients of 1.329. The study was approved by the local ethics committee Area 3 Milan. Data were automatically extracted from the hospital laboratory SQL-based repository in anonymised form. We considered as outcomes potassium (K+ ), sodium (Na+ ), chlorine (Cl- ) and calcium (Ca++ ) as continuous and as categorical variables, in their relation with age, sex and SARS-CoV-2 infection status. RESULTS We observed a higher prevalence of hypokalaemia among patients positive for SARS-CoV-2 (13.7% vs 6% of negative subjects). Positive patients had a higher probability to be admitted to the ED with hypokalaemia (OR 2.75, 95% CI 1.8-4.1, P < .0001) and women were twice as likely to be affected than men (OR 2.43, 95% CI 1.67-3.54, P < .001). Odds ratios for positive patients to manifest with an alteration in serum Na+ was (OR 1.6, 95% CI 1.17-2.35, P < .001) and serum chlorine (OR 1.6, 95% CI 1.03-2.69, P < .001). Notably, OR for positive patients to be hypocalcaemic was 7.2 (95% CI 4.8-10.6, P < .0001) with a low probability for women to be hypocalcaemic (OR 0.63, 95% CI 0.4-0.8, P = .005). CONCLUSIONS SARS-CoV-2 infection is associated with a higher prevalence of hypokalaemia, hypocalcaemia, hypochloraemia and sodium alterations. Hypokalaemia is more frequent among women and hypocalcaemia among men.
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Affiliation(s)
- Arianna Pani
- Department of Oncology and Hemato‐OncologyUniversity of MilanMilanItaly
| | - Elvira Inglese
- SC Clinical Chemistry and MicrobiologyASST Grande Ospedale Metropolitano NiguardaMilanItaly
- Department of Brain and Behavioral SciencesUniversity of PaviaPaviaItaly
| | - Massimo Puoti
- Infectious Diseases UnitASST Grande Ospedale Metropolitano NiguardaMilanItaly
| | - Valeria Cento
- Department of Oncology and Hemato‐OncologyUniversity of MilanMilanItaly
| | - Claudia Alteri
- Department of Oncology and Hemato‐OncologyUniversity of MilanMilanItaly
| | | | - Federica Di Ruscio
- SC Clinical Chemistry and MicrobiologyASST Grande Ospedale Metropolitano NiguardaMilanItaly
| | - Michele Senatore
- Department of Oncology and Hemato‐OncologyUniversity of MilanMilanItaly
| | - Mauro Moreno
- Healthcare Management DepartmentASST Grande Ospedale Metropolitano NiguardaMilanItaly
| | - Paolo Tarsia
- Pneumology UnitASST Grande Ospedale Metropolitano NiguardaMilanItaly
| | - Fabrizio Colombo
- Internal Medicine DepartmentASST Grande Ospedale Metropolitano NiguardaMilanItaly
| | | | - Valentina Panetta
- Biostatistics OfficeL'altrastatistica srl‐Consultancy & TrainingRomeItaly
| | - Chiara Vismara
- SC Clinical Chemistry and MicrobiologyASST Grande Ospedale Metropolitano NiguardaMilanItaly
| | - Andrea Bellone
- Emergency DepartmentASST Grande Ospedale Metropolitano NiguardaMilanItaly
| | - Francesco Scaglione
- Department of Oncology and Hemato‐OncologyUniversity of MilanMilanItaly
- SC Clinical Chemistry and MicrobiologyASST Grande Ospedale Metropolitano NiguardaMilanItaly
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Privitera D, Capsoni N, Mazzone A, Airoldi C, Angaroni L, Pierotti F, Rocca E, Dal Molin A, Bellone A. Nursing evaluation during treatment with helmet continuous positive airway pressure in patients with respiratory failure due to COVID-19 pneumonia: A case series. Aust Crit Care 2021; 35:46-51. [PMID: 34802843 PMCID: PMC8536817 DOI: 10.1016/j.aucc.2021.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 10/04/2021] [Accepted: 10/10/2021] [Indexed: 12/27/2022] Open
Abstract
Background During COVID-19 outbreak, with the increasing number of patients presenting with acute respiratory failure, a large use of non invasive positive pressure ventilation was done in the emergency departments and medical wards despite the lack of recommendations. Objectives This study describes the clinical characteristics of patients presenting to the hospital with acute respiratory failure due to COVID-19 related pneumonia undergoing treatment with helmet continuous positive airway pressure (CPAP) with a strict nursing evaluation and monitoring. Methods A case series study enrolling adult patients admitted to an emergency department of an Italian hospital with acute respiratory failure due to COVID-19 pneumonia from March 18th to April 18th, 2020, was conducted. Only patients who strictly followed a local CPAP protocol were enrolled. Results A total of 52 patients were included in this study. Thirty-eight patients (73%) were judged eligible for endotracheal intubation (ETI). Eighteen (34.6%) were intubated. Sixteen (30.8%) patients died: seven (38.9%) and nine (26.5%) in the eligible-for-ETI and non eligible-for-ETI group, respectively. The median hospital length of stay was different in the ETI and non-ETI group: 26 days (interquartile range [IQR]: 16–37) vs 15 days [IQR 9–17] (p = 0.005). The median invasive mechanical ventilation time was 11 days [IQR 7–21] with an ICU length of stay of 14.5 days [IQR 10–28]. During the CPAP trial, among patients eligible for ETI variations over time for positive end-expiratory pressure (p = 0.003) and respiratory rate (p = 0.059) were found between intubated and non-intubated patients. Conclusions A short closed monitored CPAP trial could be considered for acute respiratory failure due to COVID-19 pneumonia before considering ETI. A progressive positive end-expiratory pressure titration should target reduction in a patient’s respiratory rate. More studies are needed to evaluate the efficacy and predictors of failure of CPAP and non-invasive positive pressure ventilation in patients with acute respiratory failure due to COVID-19 pneumonia.
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Affiliation(s)
- Daniele Privitera
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
| | - Nicolò Capsoni
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Annamaria Mazzone
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Chiara Airoldi
- Department of Translation Medicine, University of Piemonte Orientale, Novara, Italy
| | - Laura Angaroni
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Federico Pierotti
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Eugenia Rocca
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Alberto Dal Molin
- Department of Translation Medicine, University of Piemonte Orientale, Novara, Italy; Health Professions' Direction, Maggiore Della Carità Hospital, Novara, Italy
| | - Andrea Bellone
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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Porta L, Ghezzi R, Cadonici AC, Dalino Ciaramella P, Martes C, Basile A, Bellone A. An unusual case of neck hematoma and hypercalcemia. Emer Care J 2021. [DOI: 10.4081/ecj.2021.9548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
One of the most frequent cause of hypercalcemia is primary hyperparathyroidism, which can lead to systemic involvement and life-threatening conditions. We described a rare case of a parathyroid adenoma rupture with consequent bleeding and respiratory airway compression. An 84-year-old man presented to the emergency department complaining neck swelling and related dysphagia. A computer tomography of the neck revealed an extensive left lateral hematoma, and a neck ultrasonography evidenced a hemorrhagic parathyroid adenoma, later confirmed by a 99 mTc-MIBI scintigraphy. To date only 40 cases of ruptured parathyroid adenomas have been described in literature, however due to the possibility of massive bleeding and compression of the airways this diagnosis should always be ruled out. The rupture of a parathyroid adenoma is a rare, but possibly life-threatening event due to airways compression and hemodynamic instability. Testing for hypercalcemia and hyperparathyroidism is mandatory to obtain a correct diagnosis.
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12
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Lanza A, Sommariva M, Mariani S, Ferreyra G, Stagni GE, Tombini V, Oppizzi A, Pontiggia C, Bellone A. Prolonged non-invasive respiratory support in a COVID-19 patient with severe acute hypoxemic respiratory failure. Monaldi Arch Chest Dis 2021; 92. [PMID: 34461700 DOI: 10.4081/monaldi.2021.1783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 07/07/2021] [Indexed: 11/23/2022] Open
Abstract
A pandemic caused by the Severe Acute Respiratory Syndrome Coronavirus 2 was declared in 2020. Severe cases were characterized by the development of acute hypoxemic respiratory failure (AHRF) requiring advanced respiratory support. However, intensive care units (ICU) were saturated, and many patients had to be treated out of ICU. This case describes a 75-year-old man affected by AHRF due to Coronavirus Disease 2019 (COVID-19), hospitalized in a high-dependency unit, with PaO2/FiO2 <100 for 28 consecutive days. An experienced team with respiratory physiotherapists was in charge of the noninvasive ventilatory support (NIVS). The patient required permanent NIVS with continuous positive airway pressure, non-invasive ventilation, high flow nasal oxygen and body positioning. He was weaned from NIVS after 37 days and started exercise training afterwards. The patient was discharged at home with low-flow oxygen therapy. This case represents an example of a successful treatment of AHRF with the still controversial noninvasive respiratory support in one patient with COVID-19.
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Affiliation(s)
- Andrea Lanza
- Respiratory Physiotherapists Equipe, ASST Grande Ospedale Metropolitano Niguarda, Milan.
| | - Maurizio Sommariva
- Respiratory Physiotherapists Equipe, ASST Grande Ospedale Metropolitano Niguarda, Milan.
| | - Sara Mariani
- Respiratory Physiotherapists Equipe, ASST Grande Ospedale Metropolitano Niguarda, Milan.
| | - Gabriela Ferreyra
- Department of Surgical Science, Anesthesia and Critical Care, University of Turin.
| | - Giuliana Enrica Stagni
- Respiratory Physiotherapists Equipe, ASST Grande Ospedale Metropolitano Niguarda, Milan.
| | - Valeria Tombini
- Emergency Department, ASST Grande Ospedale Metropolitano Niguarda, Milan.
| | - Angela Oppizzi
- Emergency Department, ASST Grande Ospedale Metropolitano Niguarda, Milan.
| | - Catia Pontiggia
- Emergency Department, ASST Grande Ospedale Metropolitano Niguarda, Milan.
| | - Andrea Bellone
- Emergency Department, ASST Grande Ospedale Metropolitano Niguarda, Milan.
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Giostra F, Mirarchi MG, Farina G, Paolillo C, Sepe C, Benedusi F, Bellone A, Ghiadoni L, Barbieri G, Santini M, Guiddo G, Riccardi A, Lerza R, Coen D. Impact of COVID-19 pandemic and lockdown on emergency room access in Northern and Central Italy. Emerg Care J 2021. [DOI: 10.4081/ecj.2021.9705] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
In Northern Italy the coronavirus infection has spread since February 2020: the increase in admissions of COVID-19 patients corresponded to a drastic decrease in admissions of regular patients to the Emergency Room (ER). This retrospective study was conducted by Academy of Emergency Medicine and Care (AcEMC). During the lockdown period the accesses were reduced by more than 50%, and in the following months of May and June 2020, there was a recovery clearly below (70%) previous year’s numbers. We have observed a drastic reduction in white and green codes, a fair reduction in yellow codes, while red codes remained stable. The decrease in access to the ER mainly concerned patients with low priority color codes, but also the reduction in the number of accesses of yellow and red codes, insignificant at a superficial glance, is notable. If we consider that yellow and red codes during the months of the lockdown included many patients with COVIDrelated respiratory insufficiency, it is evident that there was a clear reduction in the number of serious illnesses not COVID-related. This is certainly another serious consequence of the COVID-19 pandemic.
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14
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Costantino G, Solbiati M, Elli S, Paganuzzi M, Massabò D, Montano N, Mancarella M, Cortellaro F, Cataudella E, Bellone A, Capsoni N, Bertolini G, Nattino G, Casazza G. Utility of hospitalization for elderly individuals affected by COVID-19. PLoS One 2021; 16:e0250730. [PMID: 33901228 PMCID: PMC8075227 DOI: 10.1371/journal.pone.0250730] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 03/31/2021] [Indexed: 12/29/2022] Open
Abstract
Background During the COVID-19 pandemic, the number of individuals needing hospital admission has sometimes exceeded the availability of hospital beds. Since hospitalization can have detrimental effects on older individuals, preference has been given to younger patients. The aim of this study was to assess the utility of hospitalization for elderly affected by COVID-19. We hypothesized that their mortality decreases when there is greater access to hospitals. Methods This study examined 1902 COVID-19 patients consecutively admitted to three large hospitals in Milan, Italy. Overall mortality data for Milan from the same period was retrieved. Based on emergency department (ED) data, both peak and off-peak phases were identified. The percentage of elderly patients admitted to EDs during these two phases were compared by calculating the standardized mortality ratio (SMR) of the individuals younger than, versus older than, 80 years. Results The median age of the patients hospitalized during the peak phase was lower than the median age during the off-peak phase (64 vs. 75 years, respectively; p <0.001). However, while the SMR for the younger patients was lower during the off-peak phase (1.98, 95% CI: 1.72–2.29 versus 1.40, 95% CI: 1.25–1.58, respectively), the SMR was similar between both phases for the elderly patients (2.28, 95% CI: 2.07–2.52 versus 2.48, 95% CI: 2.32–2.65, respectively). Conclusions Greater access to hospitals during an off-peak phase did not affect the mortality rate of COVID-19-positive elderly patients in Milan. This finding, if confirmed in other settings, should influence future decisions regarding resource management of health care organizations.
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Affiliation(s)
- Giorgio Costantino
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy
| | - Monica Solbiati
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy
- * E-mail:
| | - Silvia Elli
- Università degli Studi di Milano, Milan, Italy
| | | | | | - Nicola Montano
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy
| | - Marta Mancarella
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Cortellaro
- ASST Santi Paolo e Carlo, Pronto Soccorso e Degenza Breve San Carlo, Milan, Italy
| | - Emanuela Cataudella
- ASST Santi Paolo e Carlo, Pronto Soccorso e Degenza Breve San Carlo, Milan, Italy
| | - Andrea Bellone
- ASST Grande Ospedale Metropolitano Niguarda, Medicina d’Urgenza e Pronto Soccorso, Milan, Italy
| | - Nicolò Capsoni
- ASST Grande Ospedale Metropolitano Niguarda, Medicina d’Urgenza e Pronto Soccorso, Milan, Italy
| | - Guido Bertolini
- Laboratorio di Epidemiologia Clinica, Dipartimento di Salute Pubblica, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Giovanni Nattino
- Laboratorio di Epidemiologia Clinica, Dipartimento di Salute Pubblica, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Giovanni Casazza
- Dipartimento di Scienze Biomediche e Cliniche “L. Sacco”, Università degli Studi di Milano, Milan, Italy
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15
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Bellone A. Covid-pandemia: Learning from mistakes during the pandemic? Emerg Care J 2020. [DOI: 10.4081/ecj.2020.9242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Hospitals managing the pandemic more successfully were the ones which started working on it ahead of times: so, let’s look back at it. Those who acted early, differentiating routes within the Emergency Department (EDpt), creating different areas with varying intensity of care (...)
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16
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Privitera D, Angaroni L, Capsoni N, Forni E, Pierotti F, Vincenti F, Bellone A. Flowchart for non-invasive ventilation support in COVID-19 patients from a northern Italy Emergency Department. Intern Emerg Med 2020; 15:767-771. [PMID: 32435934 PMCID: PMC7238716 DOI: 10.1007/s11739-020-02370-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/06/2020] [Indexed: 11/19/2022]
Abstract
With the rapid pandemic spread of the novel coronavirus (SARS-CoV2), Emergency Departments of affected countries are facing an increasing number of patients presenting with hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19). Providing mechanical support and endotracheal intubation can be challenging due to a number of patients larger than usual, often exceeding available resources. Considering the lack of recommendations available, we developed a flowchart to standardize the first approach to patients presenting to the Emergency Department with hypoxemic respiratory failure due to COVID-19.
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Affiliation(s)
- Daniele Privitera
- Dipartimento Emergenza Urgenza - Pronto Soccorso, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell’Ospedale Maggiore 3, 20162 Milan, Italy
| | - Laura Angaroni
- Dipartimento Emergenza Urgenza - Pronto Soccorso, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell’Ospedale Maggiore 3, 20162 Milan, Italy
| | - Nicolò Capsoni
- Dipartimento Emergenza Urgenza - Pronto Soccorso, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell’Ospedale Maggiore 3, 20162 Milan, Italy
| | - Elisa Forni
- Dipartimento Emergenza Urgenza - Pronto Soccorso, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell’Ospedale Maggiore 3, 20162 Milan, Italy
| | - Federico Pierotti
- Dipartimento Emergenza Urgenza - Pronto Soccorso, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell’Ospedale Maggiore 3, 20162 Milan, Italy
| | - Fabrizio Vincenti
- Dipartimento Emergenza Urgenza - Pronto Soccorso, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell’Ospedale Maggiore 3, 20162 Milan, Italy
| | - Andrea Bellone
- Dipartimento Emergenza Urgenza - Pronto Soccorso, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell’Ospedale Maggiore 3, 20162 Milan, Italy
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17
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Rossotti R, Travi G, Ughi N, Corradin M, Baiguera C, Fumagalli R, Bottiroli M, Mondino M, Merli M, Bellone A, Basile A, Ruggeri R, Colombo F, Moreno M, Pastori S, Perno CF, Tarsia P, Epis OM, Puoti M. Safety and efficacy of anti-il6-receptor tocilizumab use in severe and critical patients affected by coronavirus disease 2019: A comparative analysis. J Infect 2020; 81:e11-e17. [PMID: 32652164 PMCID: PMC7345400 DOI: 10.1016/j.jinf.2020.07.008] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/27/2020] [Accepted: 07/06/2020] [Indexed: 01/08/2023]
Abstract
Cytokine release syndrome seems to play a pivotal role in COVID-19 pathogenesis. Tocilizumab is one of the most promising drugs for COVID-19. Tocilizumab halved the mortality in critical patients compared to standard of care. A transient respiratory function worsening is observed soon after administration. Severe infective complications are more common than in rheumatologic setting.
Background As the novel SARS-CoV-2 pandemic occurred, no specific treatment was yet available. Inflammatory response secondary to viral infection might be the driver of severe diseases. We report the safety and efficacy (in terms of overall survival and hospital discharge) of the anti-IL6 tocilizumab (TCZ) in subjects with COVID-19. Methods This retrospective, single-center analysis included all the patients consecutively admitted to our Hospital with severe or critical COVID-19 who started TCZ treatment from March 13th to April 03rd, 2020. A 1:2 matching to patients not treated with TCZ was performed according to age, sex, severity of disease, P/F, Charlson Comorbidity Index and length of time between symptoms onset and hospital admittance. Descriptive statistics and non-parametric tests to compare the groups were applied. Kaplan Meier probability curves and Cox regression models for survival, hospital discharge and orotracheal intubation were used. Results Seventy-four patients treated with TCZ were matched with 148 matched controls. They were mainly males (81.5%), Caucasian (82.0%) and with a median age of 59 years. The majority (69.8%) showed critical stage COVID-19 disease. TCZ use was associated with a better overall survival (HR 0.499 [95% CI 0.262–0.952], p = 0.035) compared to controls but with a longer hospital stay (HR 1.658 [95% CI 1.088–2.524], p = 0.019) mainly due to biochemical, respiratory and infectious adverse events. Discussion TCZ use resulted potentially effective on COVID-19 in terms of overall survival. Caution is warranted given the potential occurrence of adverse events. Financial support Some of the tocilizumab doses used in the subjects included in this analysis were provided by the “Multicenter study on the efficacy and tolerability of tocilizumab in the treatment of patients with COVID-19 pneumonia” (EudraCT Number: 2020-001110-38) supported by the Italian National Agency for Drugs (AIFA). No specific funding support was planned for study design, data collection and analysis and manuscript writing of this paper.
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Affiliation(s)
- Roberto Rossotti
- Infectious Diseases Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy.
| | - Giovanna Travi
- Infectious Diseases Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy
| | - Nicola Ughi
- Rheumatology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Matteo Corradin
- Healthcare Management Department, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Chiara Baiguera
- Infectious Diseases Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy
| | - Roberto Fumagalli
- Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Maurizio Bottiroli
- Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Michele Mondino
- Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marco Merli
- Infectious Diseases Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy
| | - Andrea Bellone
- Emergency Department, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Andriano Basile
- Emergency Department, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Ruggero Ruggeri
- Internal Medicine Department, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Fabrizio Colombo
- Internal Medicine Department, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Mauro Moreno
- Healthcare Management Department, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Stefano Pastori
- Chemical-Clinical and Microbiological Analysis, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Carlo Federico Perno
- Chemical-Clinical and Microbiological Analysis, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Oncology and Oncohematology, University of Milan, Milan, Italy
| | - Paolo Tarsia
- Pneumology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Massimo Puoti
- Infectious Diseases Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy
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Coen D, Paolillo C, Cavazza M, Cervellin G, Bellone A, Perlini S, Casagranda I. Changing Emergency Department and hospital organization in response to a changing epidemic. Emerg Care J 2020. [DOI: 10.4081/ecj.2020.8969] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The world is facing a new pandemic that sets the national health systems, their structures and professionals in a crisis never experienced before. (...)
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Tombini V, Cazzola KB, Guarnieri L, Velati M, Bellone A. Lung Ultrasound Diagnosis and Follow-up in a Case of Reexpansion Pulmonary Edema. Chest 2019; 155:e33-e36. [DOI: 10.1016/j.chest.2018.08.1091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 08/24/2018] [Accepted: 08/27/2018] [Indexed: 10/27/2022] Open
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Cervellin G, Comelli I, Bellone A, Giostra F, Acierno N, Mitaritonno M, Paolillo C, Mastroianni F, Pistorello M, Rastelli G, Ricci G, Tenci A, Caironi G. Multicenter survey on emergency nurses’ perception of Numerical Rating Scale reliability at triage time in adult Emergency Department patients. Emerg Care J 2018. [DOI: 10.4081/ecj.2018.7787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Since pain perception is highly subjective and culturally mediated, its objective evaluation remains difficult. Nevertheless, pain measurement should ideally be a part of the assessment of patients in order to plan adequate pain relief. Several scales have been proposed for pain measurement, being the numerical rating scale (NRS) the most widely used, often at triage time. NRS have demonstrated acceptable reliability and validity, in post-operative medicine and in oncologic pain, but data in the Emergency Departments (EDs) are poor. The aim of this study is to evaluate the Emergency Nurses’ (ENs) perception about the reliability of NRS in the triage process. A questionnaire based on 11 items was designed and subsequently administered to a large number of ENs in several EDs in Northern and Central Italy. 301 questionnaires were filled out and returned. The majority declares using NRS scale to measure pain (item 2, mode = 4, mean = 3.8), and attributing priority code based on NRS value (item 3, mode = 4, mean = 3.4). In general, triage nurses believe that NRS is only indicative and that their judgement matters (item 4, mode = 4, mean = 3.2). The vast majority of triage nurses do believe that the patients will indicate a fake higher NRS value with the aim to get a more urgent code (item 5, mode = 5, mean = 4), while only a small minority expects that patients would underestimate their NRS for fear of penalizing more urgent patients. Very few believe that such scale underestimates the patients’ condition, while the majority is ambivalent about whether such scale overestimates it. In conclusion, NRS confirms to be a potentially valuable tool for pain evaluation at triage time, but many nurses express some doubts on its reliability, and will attribute the triage code mainly basing on their own judgement.
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Abstract
Tetanus with cephalic involvement is not a typical presentation of the disease; characteristic signs and symptoms are strictly localized in cranial district, although it could frequently progress to the classical generalized form. Tetanus is still spread worldwide, especially in particular subgroups as elderly and newborn babies and in countries with an inadequate vaccine coverage.We report a case of an adult man with generalized tetanus with cephalic presentation in Emergency Department. We aim to outline how difficult it was to diagnose in an adult patient without apparent exposition of previous minimal trauma or injury because of a lot of confusing factors and slow progressing clinical signs. Prompt recognition of signs and symptoms, opportune target therapy and supportive care, in association with correct vaccination schedule, are paramount to determine the prognosis for affected patients.
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Di Domenico S, Aseni P, Bonacchini L, Bottiroli M, Guerrieri R, Basile A, Bellone A. Respiratory distress due to platypnea-orthodeoxia syndrome: A diagnostic challenge in emergency setting. Emerg Care J 2018. [DOI: 10.4081/ecj.2018.7265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Platypnea-orthodeoxia syndrome (POS) is an unusual cause of hypoxia characterized by enormous variation in oxygen saturation during postural changes. We describe here the clinical presentation, the diagnostic challenge of POS and discuss the main pathophysiological etiologies of the disease in a 75-year-old woman who was admitted because shortness of breath. After ruling out the most important causes of dyspnea we observed that the symptoms improved when the patient was lying flat. The diagnostic workup with computed tomography scan and air bubble saline echocardiography lead us to a correct diagnosis.
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Abstract
This paper reports the authors’ preliminary experience with three patients affected by severe acute hypoxemic respiratory failure due to bilateral pneumonia placed in a prone position in Emergency Medicine Ward during application of high flow oxygen nasal cannula.
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Bottani G, Centurioni F, Veronese G, Vincenti F, Forni E, Bellone A. Current application of high flow oxygen nasal cannula in acute hypoxemic respiratory failure in the emergency department. Emerg Care J 2018. [DOI: 10.4081/ecj.2017.7036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
High flow oxygen with nasal cannula (HFONC) is a relatively new mode of oxygen delivery. Advantages of HFONC versus conventional oxygen therapy (COT) encompass carbon dioxide washout, generation of a slight positive end-expiratory pressure and maintenance of humidified gas flow through airways. These features are mostly shared with non-invasive mechanical ventilation (NIMV), although with lack of a clearly comparable efficacy. In the last few years, HFONC has gained interest as a third alternative to COT and NIMV in the management of acute hypoxemic respiratory failure in the critically ill patient, both in intensive care units and emergency departments. The aim of this article is to review indications, effects and existing evidence on HFONC, COT and NIMV in the setting of acute hypoxemic respiratory failure.
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Bozzano V, Aseni P, Di Domenico S, Colombo R, Corciulo M, Bellone A. A rare cause of acute abdominal pain. Emerg Care J 2017. [DOI: 10.4081/ecj.2017.6966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Acute abdominal pain represents a challenge for the physician because it can hide a serious intra-abdominal pathology necessitating emergency intervention. A 65-year-old man presented to Emergency Department with sudden-onset abdominal pain. He underwent liver transplantation four years before. He complained tenderness on abdominal palpation. Blood chemistry and abdominal x-ray were normal. Contrast-enhanced computed tomography showed acute renal artery thrombosis. The patient underwent renal arterial thrombectomy and stent placement in less than two hours. Organ transplantation is a condition that makes patients at greater risk of life-threatening conditions. Renal artery thrombosis is a rare, severe and misdiagnosed condition which can benefit from a prompt cooperation among emergency physician, surgeon, and interventional radiologist. Transplant patients with acute abdominal pain should be considered at high risk of medical emergency. Acute renal artery thrombosis is a time dependent medical emergency in those patients with chronic drug-induced nephrotoxicity.
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Lippi G, Montagnana M, Balboni F, Bellone A, Casagranda I, Cavazza M, Da Rin G, Coen D, Giavarina D, Giostra F, Guzzetti S, Pauri P, Sbrojavacca R, Trenti T, Ciaccio M, Cervellin G. Academy of Emergency Medicine and Care-Society of Clinical Biochemistry and Clinical Molecular Biology consensus recommendations for clinical use of sepsis biomarkers in the emergency department. Emerg Care J 2017. [DOI: 10.4081/ecj.2017.6877] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Increasing evidence is emerging that the measurement of circulating biomarkers may be clinically useful for diagnosing and monitoring sepsis. Eight members of AcEMC (Academy of Emergency Medicine and Care) and eight members of SIBioC (Italian Society of Clinical Biochemistry and Laboratory Medicine) were identified by the two scientific societies for producing a consensus document aimed to define practical recommendations about the use of biomarkers for diagnosing of sepsis and managing antibiotic therapy in the emergency department (ED). The cumulative opinions allowed defining three grade A recommendations (i.e., highly recommended indications), entailing ordering modality (biomarkers always available on prescription), practical use (results should be interpreted according to clinical information) and test ordering defined according to biomarker kinetics. Additional grade B recommendations (i.e., potentially valuable indications) entailed general agreement that biomarkers assessment may be of clinical value in the diagnostic approach of ED patients with suspected sepsis, suggestion for combined assessment of procalcitonin (PCT) and Creactive protein (CRP), free availability of the selected biomarker(s) on prescription, adoption of diagnostic threshold prioritizing high negative predictive value, preference for more analytically sensitive techniques, along with potential clinical usefulness of measuring PCT for monitoring antibiotic treatment, with serial testing defined according to biomarker kinetics. PCT and CRP were the two biomarkers that received the largest consensus as sepsis biomarkers (grade B recommendation), and a grade B recommendation was also reached for routine assessment of blood lactate. The assessment of biomarkers other than PCT and CRP was discouraged, with exception of presepsin for which substantial uncertainty in favor or against remained.
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Aliberti S, Ramirez J, Giuliani F, Wiemken T, Sotgiu G, Tedeschi S, Carugati M, Valenti V, Marchioni M, Camera M, Piro R, Del Forno M, Milani G, Faverio P, Richeldi L, Deotto M, Villani M, Voza A, Tobaldini E, Bernardi M, Bellone A, Bassetti M, Blasi F. Individualizing duration of antibiotic therapy in community-acquired pneumonia. Pulm Pharmacol Ther 2017; 45:191-201. [PMID: 28666965 DOI: 10.1016/j.pupt.2017.06.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 06/24/2017] [Accepted: 06/26/2017] [Indexed: 11/19/2022]
Abstract
International experts suggest tailoring antibiotic duration in community-acquired pneumonia (CAP) according to patients' characteristics. We aimed to assess the effectiveness of an individualized approach to antibiotic duration based on time in which CAP patients reach clinical stability during hospitalization. In a multicenter, non-inferiority, randomized, controlled trial hospitalized adult patients with CAP reaching clinical stability within 5 days after hospitalization were randomized to a standard vs. individualized antibiotic duration. In the Individualized group, antibiotics were discontinued 48 h after the patient reached clinical stability, with at least five days of total antibiotic treatment. Early failure within 30 days was the primary composite outcome. 135 patients were randomized to the Standard group and 125 to the Individualized group. The trial was interrupted by the safety committee because of an apparent inferiority of the Individualized group over the Standard treatment: 14 (11.2%) patients in the Individualized group experienced early failure vs. 10 (7.4%) patients in the Standard group, p = 0.200, at the intention-to-treat analysis. 30-day mortality rate was four-time higher in the Individualized group than the Standard group. Shortening antibiotic duration according to patients' characteristics still remains an open question.
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Affiliation(s)
- Stefano Aliberti
- Department of Pathophysiology and Transplantation, University of Milan, Internal Medicine Department, Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Julio Ramirez
- University of Louisville, School of Medicine, Department of Medicine, Division of Infectious Diseases, Louisville, KY, United States
| | - Fabio Giuliani
- Department of Pathophysiology and Transplantation, University of Milan, Internal Medicine Department, Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Timothy Wiemken
- University of Louisville, School of Medicine, Department of Medicine, Division of Infectious Diseases, Louisville, KY, United States
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Biomedical Sciences, University of Sassari - Research, Medical Education and Professional Development Unit, AOU Sassari, Sassari, Italy
| | - Sara Tedeschi
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola Malpighi Hospital, Alma Mater Studiorum University of Bologna, Italy
| | - Manuela Carugati
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, Milan, Italy
| | - Vincenzo Valenti
- Department of Health Bioscience, University of Milan - Respiratory Unit, Policlinico di San Donato, IRCCS - San Donato Milanese, Milan, Italy
| | | | - Marco Camera
- Clinica Malattie Infettive, DIPMI, DISSAL, IRCCS AOU San Martino-IST, Università di Genova, Genova, Italy
| | - Roberto Piro
- Pulmonology Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Manuela Del Forno
- Respiratory and Critical Care, Sant'Orsola Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), Bologna, Italy
| | - Giuseppe Milani
- UO Pneumologia, ASST Lariana Ospedale S.Anna, S. Fermo della Battaglia, Como, Italy
| | - Paola Faverio
- School of Medicine and Surgery, University of Milan Bicocca, San Gerardo Hospital, Monza, Italy
| | - Luca Richeldi
- National Institute for Health Research Respiratory Biomedical Research Unit, Mailpoint 813, LE75 E Level, South Academic Block, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Martina Deotto
- Division of Internal Medicine, Azienda Ospedaliero-Universitaria S. Maria della Misericordia, Udine, Italy
| | - Massimiliano Villani
- Dipartimento Cardio-Respiratorio, Unità Operativa di Pneumologia, San Carlo Borromeo Hospital, Via Pio II, 3, 20153 Milan, Italy
| | - Antonio Voza
- U.O. di Pronto Soccorso e Medicina d'Urgenza, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Eleonora Tobaldini
- Fondazione IRCSS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Mauro Bernardi
- Semeiotica Medica, Policlinico Sant'Orsola Malpighi, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Andrea Bellone
- Department of Emergency Medicine, San Anna Hospital, San Fermo della Battaglia, Como, Italy
| | - Matteo Bassetti
- Santa Maria Misericordia University Hospital, Infectious Diseases Division, Udine, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, Internal Medicine Department, Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Cervellin G, Casagranda I, Ricci G, Mezzocolli I, Paolillo C, Rossi R, Bellone A, Guzzetti S, Giostra F, Rastelli G, Cavazza M. Unavoidable deaths in the Italian Emergency Departments. Results of a ten years survey. A mirror of substantial social changes, or a warning for a hospital-system pathology? Emerg Care J 2017. [DOI: 10.4081/ecj.2017.6718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Emergency departments (EDs) are increasingly used for patients at the end of life stage of their diseases worldwide, even if they do not have acute and potentially treatable conditions. Moreover, an increasingly shortage of hospital beds, in spite of the wellrecognized ageing of the population, has led to a progressive prolongation of the average length of stay (LOS) time in the vast majority of Italians EDs. Therefore, the aim of this study was to describe the trend of ED non-traumatic deaths in 11 Italians EDs, and to correlate these deaths with the medium length of stay in the same EDs. All cases classified as “died during ambulance transfer or while in the ED” have been retrieved from the hospital database of the 11 participating EDs, from January 1st 2007 to December 31st 2016, with the exclusion of traumatic events. The average LOS in minutes of the seven hospitals that could provide this information was then calculated. A continuously increasing number of ED deaths was observed in the vast majority of participating EDs, showing a nearly 30% increases in the last four years. The average LOS of the vast majority of participating hospitals displayed a significant increase during the observational period. We also found a linear correlation between average LOS and total number of ED deaths in the same seven hospitals. We believe that there is a compelling need to reconsider the end of life trajectories, not only under an economical perspective, but mainly according to a more ethical view.
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Abstract
Not available.
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Etteri M, Bellone A, Vella M, Capiaghi E, Motta L, Malfasi I. Survivor by asphyxiation due to helium inhalation. Emerg Care J 2016. [DOI: 10.4081/ecj.2016.5597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
In this rare case report we describe a 27-year-old white man survived suicide by asphyxiation using so-called <em>suicide bag</em> (or <em>exit bag</em>) filled with helium supplied through a plastic tube. He had no previous psychiatric or organic illness. At the time of presentation to our emergency department, he was awake and reported severe dyspnea with a clinical pattern of acute respiratory failure. Imaging studies showed pulmonary edema and the patient was treated with non-invasive ventilation in intensive care unit. After 15 days patient was discharged from hospital in optimal conditions. These rare cases of survivor might suggest the possible causes of death from inhaling helium.
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Rusconi AM, Bossi I, Lampard JG, Szava-Kovats M, Bellone A, Lang E. Early goal-directed therapy vs usual care in the treatment of severe sepsis and septic shock: a systematic review and meta-analysis. Intern Emerg Med 2015; 10:731-43. [PMID: 25982917 DOI: 10.1007/s11739-015-1248-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 04/18/2015] [Indexed: 01/18/2023]
Abstract
Sepsis is a common and high-burden healthcare problem with a mortality exceeding 20 % in severe sepsis and nearly 50 % when septic shock is present. Early goal-directed therapy (EGDT) is recommended by sepsis guidelines as the standard of care following a landmark study by Rivers et al. alongside other observational studies. Three recent randomized controlled trials have questioned the Rivers' results. The objective of our systematic review was to assess the effectiveness of EGDT in reducing the mortality of severe sepsis or septic shock. Relevant primary studies were identified by searching the MEDLINE and EMBASE databases and the Cochrane Central Register of Controlled Clinical Trials to identify randomized controlled trials assessing the effectiveness of EGDT for sepsis. Data from all trials were combined and analyzed using a random effects model. Five studies, enrolling a total of 4033 patients, were included in the meta-analysis. In-hospital mortality did not differ between the two treatment groups (RR 0.93, 95 % CI 0.77-1.11, P = 0.42), although moderate heterogeneity between studies was noted (I (2) = 48 %). A non-significant trend toward reduction in 60-day mortality in the EGDT group was noted (RR 0.93, 95 % CI 0.82-1.05, P = 0.22, I (2) = 24 %). Heterogeneity between trials precludes a definitive conclusion on the utility of EGDT in severe sepsis. Until further evidence is available, it is reasonable to consider EGDT in the care of patients with severe sepsis and septic shock.
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Affiliation(s)
- Anna Maria Rusconi
- Department of Emergency Medicine, San Anna Hospital, San Fermo della Battaglia, Como, Italy,
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Pisani L, Mega C, Vaschetto R, Bellone A, Scala R, Cosentini R, Musti M, Del Forno M, Grassi M, Fasano L, Navalesi P, Nava S. Oronasal mask versus helmet in acute hypercapnic respiratory failure. Eur Respir J 2014; 45:691-9. [PMID: 25504992 DOI: 10.1183/09031936.00053814] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The choice of the interface for noninvasive ventilation (NIV) is a key factor in NIV success. We hypothesised that a new helmet specifically design to improve performance in hypercapnic patients would be clinically equivalent to a standard oronasal mask. In a multicentre, short-term, physiological, randomised trial in chronic obstructive pulmonary disease patients facing an acute hypercapnic respiratory failure episode, we compared the changes in arterial blood gases (ABGs) and tolerance score obtained using the helmet or mask, and, as secondary end-points, dyspnoea, vital signs, early NIV discontinuation and rate of intubation. 80 patients were randomly assigned to receive NIV either with the helmet (n=39) or mask (n=41), using an intensive care unit ventilator. Compared with baseline, in the first 6 h, NIV improved ABGs, dyspnoea and respiratory rate (p<0.05) in both groups. Changes in ABGs and discomfort were similar with the two groups, while dyspnoea decreased more (p<0.005) using the mask. The rate of intubation and the need for interface change during the whole period of NIV were very low and not different between groups. The new helmet may be a valid alternative to a mask in improving ABGs and achieving a good tolerance during an episode of acute hypercapnic respiratory failure.
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Affiliation(s)
- Lara Pisani
- Alma Mater University, Dept of Clinical, Integrated and Experimental Medicine (DIMES), Respiratory and Critical Care Unit, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Chiara Mega
- Alma Mater University, Dept of Clinical, Integrated and Experimental Medicine (DIMES), Respiratory and Critical Care Unit, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Rosanna Vaschetto
- "Maggiore Della Carità" Hospital, Dept of Anesthesia and Intensive Care, Novara, Italy
| | | | - Raffaele Scala
- U.O. Pneumologia, Ospedale S. Donato, ASL 8, Arezzo, Italy
| | - Roberto Cosentini
- IRCCS Fondazione Ca' Granda, Ospedale Maggiore Policlinico, Emergency Medicine Dept, Milan, Italy
| | - Muriel Musti
- Public Health-Care, Dept of Epidemiology, Bologna, Italy
| | - Manuela Del Forno
- Alma Mater University, Dept of Clinical, Integrated and Experimental Medicine (DIMES), Respiratory and Critical Care Unit, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Mario Grassi
- Dept of Brain and Behavioural Sciences, Medical and Genomic Statistics Unit, Università degli Studi di Pavia, Pavia, Italy
| | - Luca Fasano
- S. Orsola-Malpighi Hospital, Respiratory and Critical Care Unit, Bologna, Italy
| | - Paolo Navalesi
- Dept of Translational Medicine, Eastern Piedmont University "A. Avogadro", Novara, Italy CRRF Mons. L. Novarese, Moncrivello, Italy
| | - Stefano Nava
- Alma Mater University, Dept of Clinical, Integrated and Experimental Medicine (DIMES), Respiratory and Critical Care Unit, S. Orsola-Malpighi Hospital, Bologna, Italy
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Bellone A, Motta L, Etteri M, Bianchi AM, Cappelletti A, Bossi I, Guanziroli M, Pina P, Colombo L. Ventimask in exacerbation of chronic obstructive pulmonary disease and mild acidosis before starting with bilevel positive airway pressure. Emerg Care J 2014. [DOI: 10.4081/ecj.2014.3754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Esquinas AM, Bellone A. CPAP and Short-Term Mortality in Acute Cardiac Pulmonary Edema: Now, What Can We Be Expecting? J Card Fail 2013; 19:722. [DOI: 10.1016/j.cardfail.2013.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Indexed: 11/26/2022]
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Bellone A, Etteri M, Motta L, Cappelletti A, Morichetti C, Pina P, Pusinelli R, Guanziroli M. Noninvasive ventilation in patients with acute cardiogenic pulmonary edema. Emerg Care J 2013. [DOI: 10.4081/ecj.2013.e6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Bellone A, Etteri M, Maino C, Bonetti C, Natalizi A. The role of bedside ultrasound in the diagnosis and outcome of patients with acute respiratory failure. Emerg Care J 2013. [DOI: 10.4081/ecj.2013.e2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Deps P, Lucas S, Porro AM, Maeda SM, Tomimori J, Guidella C, Reuter T, Oliveira NS, Madureira BPR, Souza VA, Loureiro RM, Alves BL, Bellone A, Lockwood DNJ. Clinical and histological features of leprosy and human immunodeficiency virus co-infection in Brazil. Clin Exp Dermatol 2013; 38:470-7. [PMID: 23678890 DOI: 10.1111/ced.12028] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2011] [Indexed: 10/26/2022]
Abstract
BACKGROUND Both leprosy and human immunodeficiency virus (HIV) are infectious diseases, and are an important global health problem. Patients with leprosy who are co-infected with HIV seem to be at higher risk of developing leprosy reactions. AIM To examine the histological features of leprosy in patients with HIV and leprosy co-infection, particularly to determine whether the typical leprosy histopathology is present in skin biopsies, and to assess the histological features of leprosy reactions in co-infected patients. METHODS This was a matched cohort study with 11 co-infected patients and 31 HIV-negative patients with leprosy. A structured protocol for skin-biopsy evaluation was followed, focusing on inflammation of the skin and dermal nerves. RESULTS Of the 11 HIV-positive patients, 7 (63%) had borderline tuberculoid (BT) leprosy and 5 (70%) of these 7 patients had developed a type 1 reaction. The lesions in these patients were immunologically active, with 100% of biopsies having evidence of compact granulomas, 90% evidence of oedema and 30% evidence of necrosis. CONCLUSIONS In this study, patients co-infected with HIV and M. leprae had the typical histological lesions of leprosy. There was evidence of immune activation in patients who received combination antiretroviral therapy, and these patients had BT leprosy and leprosy-upgrading reactions.
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Affiliation(s)
- P Deps
- Department of Social Medicine, Federal University of Espírito Santo, Vitória, ES, Brazil.
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Fasano L, Mega C, Pisani L, Navalesi P, Bellone A, Scala R, Repetto V, Zenesini C, Nava S. Efficacy of Helmet as Interface for Noninvasive Ventilation (NIV) in Acute Hypercapnic Respiratory Failure (AHRF). Chest 2012. [DOI: 10.1378/chest.1390032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Di Marco F, Centanni S, Bellone A, Messinesi G, Pesci A, Scala R, Perren A, Nava S. Optimization of ventilator setting by flow and pressure waveforms analysis during noninvasive ventilation for acute exacerbations of COPD: a multicentric randomized controlled trial. Crit Care 2011; 15:R283. [PMID: 22115190 PMCID: PMC3388700 DOI: 10.1186/cc10567] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Revised: 10/21/2011] [Accepted: 11/24/2011] [Indexed: 12/22/2022]
Abstract
Introduction The analysis of flow and pressure waveforms generated by ventilators can be useful in the optimization of patient-ventilator interactions, notably in chronic obstructive pulmonary disease (COPD) patients. To date, however, a real clinical benefit of this approach has not been proven. Methods The aim of the present randomized, multi-centric, controlled study was to compare optimized ventilation, driven by the analysis of flow and pressure waveforms, to standard ventilation (same physician, same initial ventilator setting, same time spent at the bedside while the ventilator screen was obscured with numerical data always available). The primary aim was the rate of pH normalization at two hours, while secondary aims were changes in PaCO2, respiratory rate and the patient's tolerance to ventilation (all parameters evaluated at baseline, 30, 120, 360 minutes and 24 hours after the beginning of ventilation). Seventy patients (35 for each group) with acute exacerbation of COPD were enrolled. Results Optimized ventilation led to a more rapid normalization of pH at two hours (51 vs. 26% of patients), to a significant improvement of the patient's tolerance to ventilation at two hours, and to a higher decrease of PaCO2 at two and six hours. Optimized ventilation induced physicians to use higher levels of external positive end-expiratory pressure, more sensitive inspiratory triggers and a faster speed of pressurization. Conclusions The analysis of the waveforms generated by ventilators has a significant positive effect on physiological and patient-centered outcomes during acute exacerbation of COPD. The acquisition of specific skills in this field should be encouraged. Trial registration ClinicalTrials.gov NCT01291303.
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Affiliation(s)
- Fabiano Di Marco
- Pneumologia Ospedale San Paolo, Università degli Studi di Milano, via A, di Rudinì 8, Milano, 20142, Italy.
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Bellone A, Etteri M, Vettorello M, Bonetti C, Clerici D, Gini G, Maino C, Mariani M, Natalizi A, Nessi I, Rampoldi A, Colombo L. Cardioversion of acute atrial fibrillation in the emergency department: a prospective randomised trial. Emerg Med J 2011; 29:188-91. [DOI: 10.1136/emj.2010.109702] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Bellone A, Etteri M, Vettorello M, Berruti V, Maino C, Mariani M, Clerici D, Nessi I, Gini G, Natalizi A, Brunati P. The effects of continuous positive airway pressure on plasma brain natriuretic peptide concentrations in patients presenting with acute cardiogenic pulmonary edema with preserved left ventricular systolic function. Am J Emerg Med 2010; 28:230-4. [PMID: 20159397 DOI: 10.1016/j.ajem.2008.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2008] [Revised: 10/29/2008] [Accepted: 11/01/2008] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND It has been established that plasma brain natriuretic peptide (BNP) concentrations in patients with acute cardiogenic pulmonary edema (ACPE) increase in proportion to heart failure. OBJECTIVES The aim of this study is to assess the effects of continuous positive airway pressure (CPAP) treatment on plasma BNP concentrations in patients presenting with ACPE with preserved left ventricular (LV) systolic function. METHODS This was a prospective, observational single-center study in the emergency unit of Valduce Hospital. Twelve patients (group A) presenting with ACPE and preserved LV ejection fraction and 14 patients (group B) with systolic heart dysfunction (LV ejection fraction <45%) underwent CPAP (10 cm H(2)O) through a face mask and standard medical therapy. Plasma BNP concentrations were collected immediately before CPAP and 3, 6, and 24 hours after treatment. All patients underwent a morphological echocardiographic investigation shortly before CPAP. RESULTS Three hours after admission, BNP significantly decreased in patients with ACPE and preserved LVEF (from 998 + or - 467 pg/mL to 858 + or - 420 pg/mL; P < .05), whereas in those with systolic dysfunction, BNP was higher than during baseline (from 1352 + or - 473 pg/mL to 1570 + or - 595 pg/mL; P < .05). CONCLUSIONS The preliminary results of the present study show that CPAP, after 3 hours, lowers BNP levels in patients with ACPE and preserved LV systolic function compared with patients affected by systolic ACPE dysfunction where BNP levels do not change significantly.
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Bellone A, Vettorello M, Etteri M, Bonetti C, Gini G, Mariani M, Berruti V, Clerici D, Minelli C, Nessi I, Maino C. The role of continuous positive airway pressure in acute cardiogenic edema with preserved left ventricular systolic function. Am J Emerg Med 2009; 27:986-91. [PMID: 19857420 DOI: 10.1016/j.ajem.2008.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2008] [Revised: 06/04/2008] [Accepted: 07/03/2008] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE The objective of the study was to compare the effect of continuous positive airway pressure (CPAP) in patients with acute cardiogenic pulmonary edema (ACPE) with preserved or impaired left ventricular systolic function with regard to resolution time. METHODS In a prospective, preliminary observational cohort study, 18 patients with preserved left ventricular systolic function (group A) and 18 patients with systolic heart dysfunction (group B) with ACPE underwent CPAP (10 cmH(2)0) through a face mask with standard medical therapy after a morphologic echocardiographic investigation shortly before CPAP. RESULTS Resolution time did not differ significantly between the 2 groups of patients (64 +/- 25 minutes in diastolic group vs 80 +/- 33 minutes in systolic group). One patient in preserved left ventricular systolic function group required endotracheal intubation (not statistically significant). No patient died during hospital stay. Arterial blood gases improved after a trial of CPAP in both groups of patients. CONCLUSIONS The results of this preliminary study show that resolution time is not significantly different in patients with ACPE with preserved or impaired systolic function submitted to CPAP.
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Affiliation(s)
- Andrea Bellone
- Emergency Unit, Ospedale Valduce, Via Dante 11, Como 22100, Italy.
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Abstract
Noninvasive ventilation (NIV) is a safe and effective technique that can prevent side effects and complications related to endotracheal intubation. Acute cardiogenic pulmonary edema is currently the second most common indication for NIV, mainly in emergency departments. In this article we examine recent literature related to the applications of NIV in the acute setting with regard to patients with acute cardiogenic pulmonary edema. In addition, we examine the epidemiology and the pathophysiology of acute heart failure.
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Affiliation(s)
- Andrea Bellone
- Emergency Department, Valduce Hospital (Como),Via Moncalvo 4/4, Milano 20146, Italy.
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Bellone A, Vettorello M. The role of continuous positive airway pressure in diastolic heart dysfunction. Intensive Care Med 2005. [DOI: 10.1007/s00134-005-2753-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Bellone A, Vettorello M, Monari A, Cortellaro F, Coen D. Noninvasive pressure support ventilation vs. continuous positive airway pressure in acute hypercapnic pulmonary edema. Intensive Care Med 2005; 31:807-11. [PMID: 15871011 DOI: 10.1007/s00134-005-2649-6] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2004] [Accepted: 04/08/2005] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This study compared noninvasive pressure support ventilation (NIPSV) and continuous positive airway pressure (CPAP) in patients with acute hypercapnic pulmonary edema with regard to resolution time. DESIGN AND SETTING Randomized prospective study in an emergency department. PATIENTS AND PARTICIPANTS We randomly assigned 36 patients with respiratory failure due to acute pulmonary edema and arterial hypercapnia (PaCO(2) >45 mmHg) to NIPSV (n=18) or CPAP through a face mask (n=18). MEASUREMENTS AND RESULTS Electrocardiographic and physiological measurements were made over 36 h. There was no difference in resolution time defined as clinical improvement with a respiratory rate of fewer than 30 breaths/min and SpO(2)of 96% or more between CPAP and NIPSV groups. Arterial carbon dioxide tension was significantly decreased after 1 h of ventilation (CPAP, 60.5+/-13.6 to 42.8+/-4.9 mmHg; NIPSV, 65.7+/-13.6 to 44.0+/-5.5 mmHg); respective improvements were seen in pH (CPAP, 7.22+/-0.11 to 7.37+/-0.04; NIPSV, 7.19+/-0.11 to 7.38+/-0.04), SpO(2) (CPAP, 86.9+/-3.7% to 95.1+/-2.6%; NIPSV, 83.7+/-6.6% to 96.0+/-2.9%), and respiratory rate (CPAP, 37.9+/-4.5 to 21.3+/-5.1 breaths/min; NIPSV, 39.8+/-4.4 to 21.2+/-4.6 breaths/min). No significant differences were seen with regards to endotracheal intubation and in-hospital mortality. CONCLUSIONS NIPSV proved as effective as CPAP in the treatment of patients with acute pulmonary edema and hypercapnia but did not improve resolution time.
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Scarduelli C, Ambrosino N, Confalonieri M, Gorini M, Sturani C, Mollica C, Bellone A, Magni G, Corrado A. Prevalence and prognostic role of cardiovascular complications in patients with exacerbation of chronic obstructive pulmonary disease admitted to Italian respiratory intensive care units. Ital Heart J 2004; 5:932-8. [PMID: 15706999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
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.
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Affiliation(s)
- Cleante Scarduelli
- Pulmonary Division and Respiratory Intensive Care Unit, C. Poma Hospital, Mantova, Italy.
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Barbieri A, Grimaldi T, Bursi F, Ratti C, Bellone A, Modena MG. Acute idiopathic pericarditis with transient constriction. Int J Cardiol 2004; 97:313-5. [PMID: 15458703 DOI: 10.1016/j.ijcard.2003.06.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2003] [Accepted: 06/09/2003] [Indexed: 11/30/2022]
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Bellone A, Monari A, Cortellaro F, Vettorello M, Arlati S, Coen D. Myocardial infarction rate in acute pulmonary edema: noninvasive pressure support ventilation versus continuous positive airway pressure. Crit Care Med 2004; 32:1860-5. [PMID: 15343013 DOI: 10.1097/01.ccm.0000139694.47326.b6] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Noninvasive pressure support ventilation (NIPSV) delivered by face mask has proved an effective treatment for patients with acute pulmonary edema. However, an increase in acute myocardial infarction rate has been reported with this ventilation modality. We investigated whether the use of NIPSV increases the incidence of acute myocardial infarction compared with continuous positive airway pressure (CPAP) in patients with acute pulmonary edema. DESIGN Randomized, prospective, controlled study. SETTING Emergency Department, Niguarda Hospital of Milano (Italy). PATIENTS Forty-six patients affected by acute pulmonary edema. INTERVENTIONS The patients received either NIPSV (24 patients) or CPAP (22 patients) through a face mask. MEASUREMENTS AND MAIN RESULTS Cardiac enzymes (myoglobin, creatine kinase isoenzyme MB, and troponin I) were determined and electrocardiographic and physiologic measurements made over the subsequent 36 hrs. No significant differences were observed in the incidence of acute myocardial infarction in the CPAP group (13.6%) compared with the NIPSV group (8.3%). Both modalities of noninvasive ventilation improved ventilation and vital signs in patients with acute pulmonary edema. Two patients of the NIPSV group (8.3%) and one of the CPAP group (4.5%) required endotracheal intubation because vital signs and arterial blood gases worsened 1 hr after the start of noninvasive ventilation. No significant differences were found in in-hospital mortality rate. CONCLUSIONS NIPSV proved to be equally effective in improving vital signs and ventilation without increasing acute myocardial infarction rate in patients with nonischemic acute pulmonary edema in comparison to CPAP alone. However, because the study lacked statistical power and excluded patients with acute coronary syndromes, caution is still advised when applying NIPSV to the latter subgroup of patients.
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Affiliation(s)
- Andrea Bellone
- Emergency Department, Niguarda Ca' Granda Hospital, P.za Ospedale, Milano, Italy
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Nava S, Carbone G, DiBattista N, Bellone A, Baiardi P, Cosentini R, Marenco M, Giostra F, Borasi G, Groff P. Noninvasive ventilation in cardiogenic pulmonary edema: a multicenter randomized trial. Am J Respir Crit Care Med 2003; 168:1432-7. [PMID: 12958051 DOI: 10.1164/rccm.200211-1270oc] [Citation(s) in RCA: 165] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Studies employing noninvasive pressure support ventilation in cardiogenic pulmonary edema have been performed in the intensive care unit when overt respiratory failure is already present and in small groups of patients. In this multicenter study, performed in emergency departments, 130 patients with acute respiratory failure were randomized to receive medical therapy plus O2 (65 patients) or noninvasive pressure support ventilation (65 patients). The primary end point was the need for intubation; secondary end points were in-hospital mortality and changes in some physiological variables. Noninvasive pressure support ventilation improved PaO2/FIO2, respiratory rate, and dyspnea significantly faster. Intubation rate, hospital mortality, and duration of hospital stay were similar in the two groups. In the subgroup of hypercapnic patients noninvasive pressure support ventilation improved PaCO2 significantly faster and reduced the intubation rate compared with medical therapy (2 of 33 versus 9 of 31; p=0.015). Adverse events, including myocardial infarction, were evenly distributed in the two groups. We conclude that during acute respiratory failure due to cardiogenic pulmonary edema the early use of noninvasive pressure support ventilation accelerates the improvement in PaO2/FIO2, PaCO2, dyspnea, and respiratory rate, but does not affect the overall clinical outcome. Noninvasive pressure support ventilation does, however, reduce the intubation rate in the subgroup of hypercapnic patients.
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Affiliation(s)
- Stefano Nava
- Respiratory Intensive Care Unit, Istituto Scientifico di Pavia, Fondazione S Maugeri, 27100 Pavia, Italy.
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