Respiratory treatment in a patient with nemaline myopathy

Respiratory involvement of nemaline myopathy is evident on the diaphragm and intercostal muscles function. The present case study aimed to describe the characteristics of the respiratory physiotherapeutic treatment in a patient with nemaline myopathy. Here, we describe a case of a 43-yearold woman with nemaline myopathy undergoing pulmonary rehabilitation during short hospital admission for an acute exacerbation. At the time of hospitalisation, the patient was already under oxygen therapy (1 L/min) and noninvasive home ventilation using bi-level positive airway pressure with a nasal interface. Supplementary therapeutic exercises were implemented in addition to daily nasal noninvasive ventilation. At discharge, ultrasound examination revealed increased diaphragm trophism if compared with data obtained at hospital admission.

An unusual cause of eosinophilic pleural effusion and migrating biliary stenosis: Strongyloides stercoralis infection in a young immunocompetent man

We present the case of a 33-year-old Italian man who came to our attention for epigastralgia associated with polyserositis (pleural, pericardial, and peritoneal effusion with the involvement of the Douglas excavation), in the absence of a significant medical history. Laboratory analysis revealed exudative eosinophilic pleural effusion; serial imaging techniques showed a transient stenosis of the right hepatic duct and a subsequent stenosis of the left hepatic duct. After several negative serological investigations, a positive anti-strongyloides immunoglobulin G antibodies titer rose suspicions of Strongyloides infection, which was confirmed by positive stool sample for parasite. Ivermectin-therapy was started and the patient has fully recovered.

Different tracheotomy tube diameters influence diaphragmatic effort and indices of weanability in difficult to wean patients

OBJECTIVE

To determine the effects of different tracheotomy tube sizes on diaphragm effort and weanability indices.

METHODS

Ten tracheotomized and difficult to wean subjects were randomized to 2 T-piece trials, with different tracheotomy tube diameters: inner diameters 8 mm and 6.5 mm. Diaphragm pressure-time product per min. (PTP(di/min)), lung compliance and resistance (C(L) and R(L)), breathing pattern, tension-time index of the diaphragm (TT(di)), and the ratio of breathing frequency to tidal volume (f/V(T)) were recorded. In an in vitro model, the flow-pressure relationship was measured using the 2 tracheotomy tubes and 2 endotracheal tubes of the same diameter.

RESULTS

The use of a smaller diameter resulted in an increase of PTP(di) (337.63 ± 194.35 cm H(2)O · s/min vs 263.28 ± 156.23 cm H(2)O · s/min for 6.5 mm and 8 mm, respectively, P = .004) and R(L) (16.74 ± 8.10 cm H(2)O · s/min vs 11.72 ± 7.88 cm H(2)O · s/min, respectively, P = .008). Both weanability indices were also significantly higher using the smaller tube: f/V(T) 93.32 ± 20.91 vs 77.06 ± 19.26 for 6.5 mm and 8 mm, respectively, P < .02; TT(di) 0.09 ± 0.052 vs 0.08 ± 0.04, respectively, P < .02. In vitro measurements confirmed that the resistances were higher with the smaller diameter and similar between the tracheotomy tubes and the endotracheal tubes of the same diameters.

CONCLUSIONS

In tracheotomized difficult to wean subjects the decrease of the tracheotomy tube size was associated with an increased PTP(di), f/V(T), and TT(di), that were otherwise normal, using a higher diameter. The in vitro study showed that the resistances increased similarly for tracheotomy tube and endotracheal tube, decreasing the diameter and increasing the flows.

Effectiveness and predictors of success of noninvasive ventilation during H1N1 pandemics: a multicenter study

BACKGROUND

The use of non-invasive ventilation (NIV) in acute hypoxemic respiratory failure (AHRF) due to H1N1 virus infection is controversial. In this multicenter study we aimed to assess the efficacy of NIV in avoiding endotracheal intubation (ETI) and to identify predictors of success or failure.

METHODS

In this prospective multicenter study, 98 patients with new pulmonary infiltrate(s) sustained by H1N1 virus and a PaO(2)/FiO2<300 were eligible for study; 38/98 required immediate ETI, while the others received NIV as a first line therapy; 13/60 patients failed NIV and were intubated after 5.8+5.5 hours from enrolment. The remaining 47/60 patients were successfully ventilated with NIV.

RESULTS

Hospital mortality was significantly higher in those patients who failed NIV vs. those who succeeded (53.8% vs. 2.1%; OR=0.52, P<0.001). ETI was associated with higher number of infectious complications, mainly sepsis and septic shock. The OR of having one of these events in the NIV failure group vs. NIV success was 16.7, P<0.001. According to logistic regression model, a SAPS II>29 and a PaO(2)/FIO(2)≤127 at admission and PaO2/FIO(2)≤149 after 1 hr of NIV were independently associated with the need for ETI.

CONCLUSION

The early application of NIV, with the aim to avoid invasive ventilation, during the H1N1 pandemics was associated with an overall success rate of 47/98 (48%). Patients presenting at admission with an high SAPS II score and a low PaO(2)/FiO(2) ratio and/or unable to promptly correct gas exchange are at high risk of intubation and mortality.

68Ga-DOTANOC PET/CT allows somatostatin receptor imaging in idiopathic pulmonary fibrosis: preliminary results

Interstitial lung diseases include different clinical entities with variable prognoses. Idiopathic pulmonary fibrosis (IPF), the most common, presents the most severe outcome (death within 3-5 y), whereas nonspecific interstitial pneumonia (NSIP) shows a more indolent progression. Preclinical evidence of somatostatin receptor (SSTR) expression on fibroblasts in vitro and in lung fibrosis murine models, coupled with the longer survival of mice with fibrotic lungs treated with agents blocking SSTR, supports the hypothesis of imaging fibroblast activity in vivo by visualization of SSTR with (68)Ga-DOTANOC PET/CT. The aim of this study was to evaluate (68)Ga-DOTANOC PET/CT in patients with IPF and NSIP.

METHODS

Seven IPF patients and 7 NSIP patients were included in the study. (68)Ga-DOTANOC PET/CT and high-resolution CT (HRCT) were performed in all cases by following a standard procedure. PET/CT results were compared with disease sites and extent on HRCT.

RESULTS

In IPF, (68)Ga-DOTANOC uptake was peripheral, subpleural, and directly correlated with pathologic areas on HRCT (subpleural/reticular fibrosis, honeycombing). NSIP patients showed fainter tracer uptake, whereas corresponding HRCT showed areas of ground-glass opacity and rare fibrotic changes. Only IPF patients showed a linear correlation between maximal SUV and disease extent quantified both automatically (Q) (IPF: P = 0.002, R = 0.93) and using the visual score (Spearman ρ = 0.46, P = 0.0001). Q directly correlated with percentage carbon monoxide diffusing capacity in IPF (P = 0.03, R = 0.79) and NSIP (P = 0.05, R = 0.94), whereas maximal SUV did not present any correlation with percentage carbon monoxide diffusing capacity.

CONCLUSION

Our preliminary data show that (68)Ga-DOTANOC PET/CT demonstrates SSTR overexpression in IPF patients; this may prove interesting for the evaluation of novel treatments with somatostatin analogs.