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Pagina personale di Enrico CLINI

Dipartimento di Scienze Mediche e Chirurgiche Materno-Infantili e dell'Adulto

MA Spruit, F Pitta, C Garvey, RL ZuWallack, CM Roberts, EG Collins, R Goldstein , R McNamara, P Surpas, K Atsuyoshi, J López-Campos, I Vogiatzis, JA Williams, S Lareau, D Brooks, T Troosters , SJ Singh, S Hartl , E Clini, EFM Wouters. On behalf of ERS Scientific Groups 01.02 and 09.02, AACVPR, ATS Pulmonary Rehabilitation Assembly, and ERS COPD Audit team. ( in corso di stampa ) - Differences in content and organizational aspects of pulmonary rehabilitation programs. - EUROPEAN RESPIRATORY JOURNAL - n. volume 43 - pp. da 1326 a 1337 ISSN: 0903-1936 [Articolo su rivista - Articolo su rivista]
Abstract

Objective: To study the overall content and organizational aspects of pulmonary rehabilitation programs from a global perspective to get an initial appraisal on the degree of heterogeneity worldwide. Methods: A twelve-question survey on content and organizational aspects was completed by representatives of pulmonary rehabilitation programs that previously participated in the European Respiratory Society (ERS) COPD Audit. Moreover, all ERS members affiliated with the ERS Scientific Groups 01.02 (Rehabilitation and Chronic Care) and/or 09.02 (Physiotherapy), all members of the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), and all ATS Pulmonary Rehabilitation Assembly members were asked to complete the survey via multiple e-mailings. Results: The survey has been completed by representatives of 430 centres from 40 countries. The findings demonstrate large differences among pulmonary rehabilitation programs across continents for all aspects that were surveyed, including the setting, the case-mix of individuals with a chronic respiratory disease, composition of the pulmonary rehabilitation team, completion rates, methods of referral, and types of reimbursement. Conclusions: The current findings stress the importance of future development of process and performance metrics to monitor pulmonary rehabilitation programs, to be able to start international benchmarking, and to provide recommendations for international standards based on evidence and best practice.

Pitta F, Mitchell F, Chatwin M, Clini E, Emtner M, Gosselink R, Grant K, Inal-Ince K, Lewko A, Oberwaldner B, Williams J, Troosters T. ( 2014 ) - A core syllabus for postgraduate training in respiratory physiotherapy. - BREATHE - n. volume 10(3) - pp. da 221 a 228 ISSN: 1810-6838 [Articolo su rivista - Articolo su rivista]
Abstract

Physiotherapy contributes significantly to improving quality of life for patients with respiratory disease. Physiotherapists specialised in dealing with respiratory pathology and its associated problems are not only central in the delivery of pulmonary rehabilitation but also provide strategies and techniques for exercise testing, airway clearance, breathlessness management, mobility and function improvement and pain management. Published evidence-based recommendations have paved the way for standardised practice while also unravelling the extended scope of responsibilities of the respiratory physiotherapist. The breakdown of traditional roles and allocation of new responsibilities is not confined to the respiratory physiotherapist within healthcare systems. Team-based healthcare and interprofessional treatment of patients is prevalent in the provision of care across the globe. New methods of healthcare delivery indicate that tasks are entrusted to those deemed competent to perform them. It has therefore been necessary to train allied health professionals to take over parts of clinical care.

MA.Spruit, M.Marvisi, J.Coolen, V.Poletti, S.Gasparini, B.Ställberg, FJF.Herth, E.Clini ( 2014 ) - Clinical highlights from the ERS congress in Barcelona. - EUROPEAN RESPIRATORY JOURNAL - n. volume 44 - pp. da 198 a 206 ISSN: 0903-1936 [Articolo su rivista - Articolo su rivista]
Abstract

This article reviews a selection of scientific presentations in the area of clinical problems at the 2013 European Respiratory Society Annual Congress in Barcelona, Spain. The article discusses the most relevant topics of interest in the field of clinicalrespiratory medicine, including breakthrough reports, and studies of particular interest to the healthcare professionals. Topics are presented and discussed in the context of the most up-to-date literature, including basic science and translational research. In particular, the reviewed topics especially deal with the areas of the complex chronic obstructive pulmonary disease and asthma even in the primary care setting, idiopathic pulmonary fibrosis (pathogenesis and therapy), advances in functional chest imaging, interventional pulmonology, pulmonary rehabilitation and chronic care. The 2013 European Respiratory Society (ERS) Annual Congress was held in Barcelona, Spain, with the largest worldwide attendance in the field of respiratory medicine (around 20.900 participants). A total of 4.401 abstracts were presented (77% acceptance rate), of which half dealt with clinical problems. Furthermore, outstanding lectures based on the most recent clinical updates were presented by international experts (1-6). The present article summarizes the most relevant topics of interest in the field of clinical respiratory medicine.

E.Clini, P.Boschetto, M.Lainsscak, W.Janssens. ( 2014 ) - Comorbidities in Chronic Obstructive Pulmonary Disease from Assessment to Treatment. - BIOMED RESEARCH INTERNATIONAL - n. volume Article ID 354276 [Articolo su rivista - Articolo su rivista]
Abstract

Not available

E.Crisafulli, E.Venturelli, G.Biscione, G.Vagheggini, A.Iattoni, S.Lucic, N.Ambrosino, F.Pasqua, A.Cesario, E.Clini ( 2014 ) - Exercise performance after standard rehabilitation in COPD patients with lung hyperinflation. An observational multicentre cohort study. - INTERNAL AND EMERGENCY MEDICINE - n. volume 9 (1) - pp. da 23 a 31 ISSN: 1828-0447 [Articolo su rivista - Articolo su rivista]
Abstract

Background: The role of pulmonary rehabilitation (PR) in COPD patients with lung hyperinflation has not yet been fully investigated. Aim: In three Italian rehabilitation centres we retrospectively evaluated the effect of a standard PR course on exercise tolerance and symptoms according to the presence or absence of associated lung hyperinflation, as defined by lung function parameters. Methods: In a cohort of 823 COPD patients (age 71±8 yrs, FEV1 56±18 % pred.) we have systematically recorded: changes (D) in six minute walking test (6MWD) as the primary outcome; dyspnoea (D); muscle fatigue (F); SO2nadir during effort; perceived breathlessness score (MRC); and specific health related Quality-of-Life (SGRQ). Outcomes were compared between patients with lung hyperinflation (n=283, LH) or without (n=540 No-LH).Results: Groups were comparable for age, body mass index, baseline exercise tolerance, and breathlessness. D-6MWD (+72±47 vs +62±42 m, p<0.05); D-D (- 2.3±1.7 vs -1.9±1.3 point, p<0.05) and D-SO2nadir (+1.4±3.0 and +0.5±3.3 point, p<0.05) were greater in LH than in No-LH. Using a multivariate linear regression model, D-6MWD in the LH group significantly correlated with lower functional residual capacity (p=0.021) and baseline 6MWD (p=0.004).Conclusion: Tolerance, gas exchange and perceived symptoms during effort are the parameters that proved to gain a significant benefit from standard rehabilitation in COPD patients with a lung hyperinflation condition.

E.Teopompi, P.Tzani, M.Aiello, S.Ramponi, F.Andrani, E.Marangio, E.Clini, A.Chetta ( 2014 ) - Fat Free Mass Depletion is Associated to Poor Exercise Capacity Irrespective of Dynamic Hyperinflation in COPD Patients. - RESPIRATORY CARE - n. volume 59(5) - pp. da 718 a 725 ISSN: 0020-1324 [Articolo su rivista - Articolo su rivista]
Abstract

BACKGROUND: In patients with COPD, we investigated the effect of the fat-free mass (FFM) on maximal exercise capacity and the relationship with changes in operational lung volumes during exercise. METHODS: In a cross-sectional study fifty-seven patients (16 females; age 65 ± 8 yrs) were consecutively assessed by resting lung function, symptom-limited cardiopulmonary exercise test, and body composition by means of bioelectrical impedance analysis to measure the FFM index (FFMI, kg/m2). RESULTS: Patients were categorized as depleted (n = 14) or non depleted (n = 43) according to FFMI. No significant difference in gender, age and in resting lung function was found between depleted and non depleted patients. When compared with non depleted, the depleted COPD patients had a significantly lower O2 uptake at peak of exercise and at anaerobic threshold as well as peak O2 pulse, O2 uptake efficiency slope (OUES) and heart rate recovery (HRR) (p < 0.05 for all comparisons), but similar inspiratory capacity/total lung capacity ratio at peak of exercise. Moreover, they also reported significantly higher leg fatigue (p < 0.05), but not dyspnea on exertion. In all patients, significant correlations (p < 0.01) were found between FFMI and peak O2Pulse, OUES, HRR and leg fatigue. CONCLUSIONS: This study shows that FFM depletion per se plays a part in the reduction of exercise capacity of COPD patients, regardless of dynamic hyperinflation, and is strictly associated to poor cardiovascular response to exercise and to leg fatigue, but not to dyspnoea.

Clini E, Ambrosino N. ( 2014 ) - Impaired arm activity in COPD: a questionable goal for rehabilitation. - EUROPEAN RESPIRATORY JOURNAL - n. volume 43 - pp. da 1551 a 1553 ISSN: 0903-1936 [Articolo su rivista - Articolo su rivista]
Abstract

Not available

M.Vitacca, S.Scalvini, M.Volterrani, E.Clini, M.Paneroni, A.Giordano, N.Ambrosino. ( 2014 ) - In COPD patients on prolonged mechanical ventilation Heart Rate Variability during the T-piece trial is better after Pressure Support Ventilation plus PEEP. A pilot physiological study. - HEART & LUNG - n. volume 43 - pp. da 420 a 426 ISSN: 0147-9563 [Articolo su rivista - Articolo su rivista]
Abstract

Objectives- To evaluate heart rate variability (HRV), hemodynamics, mechanics, dyspnea and blood gases following different mechanical ventilation (MV) settings. Background- No study has evaluated physiological changes during T-piece trials following different MV settings. Methods- In 8 COPD patients on prolonged MV we applied in random order two MV settings: i) pressure support (PS) 20cmH2O + positive end-expiratory pressure (PEEP) 0cmH2O (setting-1) and ii) PS 15cmH2O + PEEP 5cmH2O (setting-2), each followed by a 30-min T-piece trial. Results- Setting-1 induced greater minute ventilation, tidal volume/inspiratory time and lower pulmonary artery occlusion pressure; setting-2 reduced intrinsic PEEP. Mechanics and hemodynamics data did not differ, but all HRV time domain indices were reduced only after setting-1, suggesting a decreased parasympathetic and increased sympathetic cardiac modulation. Conclusions- The T-piece trial following setting-2 seems less stressful on neural control of HRV. Future studies on T-piece trials should consider the residual effect of the MV setting.

P-R. Burgel, E.Clini ( 2014 ) - Multimorbidity in elderly patients with chronic obstructive pulmonary disease: stop smoking! Go exercise? - AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE - n. volume 189 (1) - pp. da 7 a 8 ISSN: 1535-4970 [Articolo su rivista - Articolo su rivista]
Abstract

Not available

A.Verduri, L.Ballerin, M.Simoni, M.Cellini, E.Vagnoni, P.Roversi, A.Papi, E.Clini, LM.Fabbri, A.Potena. ( 2014 ) - Poor adherence to guidelines for long-term oxygen therapy (LTOT) in two Italian university hospitals. - INTERNAL AND EMERGENCY MEDICINE - n. volume 9 (3) - pp. da 319 a 324 ISSN: 1970-9366 [Articolo su rivista - Articolo su rivista]
Abstract

Long-term oxygen therapy (LTOT) improves survival in patients with chronic obstructive pulmonary disease (COPD) and severe hypoxemia. Adherence to LTOT guidelines is problematic, both because efficacy has been demonstrated only in specific groups of COPD patients, and because it implies high costs. Introduces treatment high costs. The aim of our study was to examine retrospectively the adherence to LTOT guidelines in a sample of medical records of patients prescribed LTOT between January 2005 and December 2006 in two Italian university hospitals (Ferrara and Modena). Out of a total of 191 medical records of patients prescribed LTOT, only 157 had adequate clinical data considering the three main criteria for appropriateness (arterial blood gas and/or pulse oximetry measurement, oxygen administration, smoking status). Out of these 157 patients, only 73 (46.5 %) fulfilled all three criteria recommended by the guidelines. Adherence was higher for LTOT prescribed by pulmonologists compared to internists. This survey showed that the adherence to LTOT guidelines in a sample of medical records of patients prescribed LTOT is poor. Considering the high costs and the impact on the patients' quality of life of LTOT, these results suggest that the adherence should be carefully monitored.

Crisafulli E, Morandi A, Olivini A, Malerba M, Clini E. ( 2014 ) - Rehabilitation and supportive therapy in elderly patients with COPD. - EUROPEAN JOURNAL OF INTERNAL MEDICINE - n. volume 25 - pp. da 329 a 335 ISSN: 0953-6205 [Articolo su rivista - Articolo su rivista]
Abstract

Chronic Obstructive Pulmonary Disease (COPD) very often coexists with cardiovascular, musculoskeletal and metabolic comorbidities. This condition significantly impact on the general health, function, frailty and disability of such patients, and consequently on their prognosis. Indeed, complex and recurrent symptoms of general dysfunction are commonly present and burden on the health status. Symptomatic COPD patients, even with chronic and complex comorbidities or with different degree of severity, may benefit from rehabilitation including exercise and maintenance of physical activity, in order to reducing symptoms and restoring the highest possible level of independent function. This review will focus on the associated and relevant clinical problems of these patients at the onset of disability, methods of assessment and useful non-pharmacological treatments for caring and supporting them.

MA.Spruit, SJ.Singh, C.Garvey,R.ZuWallack, L.Nici, C.Rochester, K.Hill, AE.Holland, SC.Lareau, WDC.Man, F.Pitta, L.Sewell, J.Raskin, J.Bourbeau, R:Crouch, FME.Franssen, R.Casaburi, JH.Vercoulen, I.Vogiatzis, R.Gosselink, E.Clini, TW.Effing, F.Maltais, J.Van der Palen, T.Troosters, DJA.Janssen, E.Collins, J.Garcia-Aymerich, D.Brooks, BF.Fahy, MA.Puhan, M.Hoogendoorn, R.Garrod, A.Schols, B.Carlin, R.Benzo, P.Meek, M.Morgan, MP.Rutten-van Mölken, AL.Ries, B.Make, RS.Goldstein, CA.Dowson, JL.Brozek, CF.Donner, EFM.Wouters. ( 2013 ) - An Official American Thoracic Society / European Respiratory Society Statement: Key concepts and advances in pulmonary rehabilitation - An Executive Summary. - AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE - n. volume 188(8) - pp. da 1011 a 1027 ISSN: 1535-4970 [Articolo su rivista - Articolo su rivista]
Abstract

Background: Pulmonary rehabilitation is recognized as a core-component of the management of individuals with chronic respiratory disease. Since the 2006 American Thoracic Society (ATS)/European Respiratory Society (ERS) Statement on Pulmonary Rehabilitation, there has been considerable growth in our knowledge of its efficacy and scope. Purpose: The purpose of this Statement is to update the 2006 document, including a new definition of pulmonary rehabilitation and highlighting key concepts and major advances in the field. Methods: A multidisciplinary committee of experts representing the ATS Pulmonary Rehabilitation Assembly and the ERS Scientific Group 01.02 ‘Rehabilitation & Chronic Care’ determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant clinical and scientific expertise. The final content of this Statement was agreed upon by all members. Results: An updated definition of pulmonary rehabilitation is proposed. New data are presented on the science and application of pulmonary rehabilitation, including its effectiveness in acutely ill individuals with chronic obstructive pulmonary disease (COPD), and in individuals with other chronic respiratory diseases. The important role of pulmonary rehabilitation in chronic disease management is highlighted. In addition, the role of health behavior change in optimizing and maintaining benefits is discussed. Conclusion: The considerable growth in the science and application of pulmonary rehabilitation since 2006 adds further support for its efficacy in a wide range of individuals with chronic respiratory disease.

E.Clini, B.Beghè, L.Fabbri ( 2013 ) - Chronic Obstructive Pulmonary Disease is just one component of the complex multimorbidities in patients with COPD. - AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE - n. volume 187(7) - pp. da 668 a 671 ISSN: 1535-4970 [Articolo su rivista - Articolo su rivista]
Abstract

Not available

E. Clini, E. Crisafulli, A. Radaeli, M.Malerba ( 2013 ) - COPD and metabolic syndrome: an intriguing association - INTERNAL AND EMERGENCY MEDICINE - n. volume 8(4) - pp. da 283 a 289 ISSN: 1970-9366 [Articolo su rivista - Articolo su rivista]
Abstract

Chronic Obstructive Pulmonary Disease (COPD) has been recently recognized a condition involving not only the lungs. The presence of common factors in COPD and in other chronic extrapulmonary diseases, as well as the co-existence of these conditions in the same adult individual, support the hypothesis of a shared pathogenetic pathway.We will here review the interplay role between coexisting COPD and Metabolic Syndrome (MS), based on the most updated knowledge we will discuss this clinical condition from the definition, to the pathophysiology, and to the clinical implications.Basically, MS is more likely to be present in a COPD patients, and increased levels of circulatory pro-inflammatory proteins from both the lung and the adipose tissue coincide in these patients.Actually, the relative impact of the coexisting COPD and MS may depend on several factors: mainly the presence of physical inactivity and of systemic inflammation related to smoking habit,sedentary lifestyle, airways inflammation and obstruction, adipose tissue and inflammatory markers activation. More studies will be required to elucidate the association between COPD and MS andto formulate individualized management approaches for this specific disease phenotype.

E. Clini, E. Crisafulli, M. Roca, M. Malerba. ( 2013 ) - Diagnosis of Chronic Obstructive Pulmonary Disease, simpler is better. Complexity and simplicity. - EUROPEAN JOURNAL OF INTERNAL MEDICINE - n. volume 24 (3) - pp. da 195 a 198 ISSN: 0953-6205 [Articolo su rivista - Articolo su rivista]
Abstract

So far, spirometry has always been the basis for diagnosis of COPD using FEV1/FVC fixed ratio or LLN, but no one of these two parameters is actually able to fully characterize the complex diagnostic features of this disease. Indeed, COPD presents additional and remarkable extra pulmonary and systemic manifestations which need to be captured and addressed. For this reason, the GOLD initiative have recently introduced the concept of a COPD staging and classification including factors which stand over the spirometric definition of the disease. Moreover, in the last decade, multidimensional indices such as BODE, ADO, DOSE, and COTE came up from research field in the appropriate attempt to "simplify the complex diagnosis" of a COPD patient. In particular,assessment of different phenotypes according to either clinical and biological features appears to be a still unmet expectation in helping the most accurate identification of each patients, thus providing a therapy targeted on his/her specified needs. In the era of the system biology, this olistic approach appears to be a real step forward a more accurate diagnosis, prognosis and cure rather than the assessment and identification of lung function and bronchodilating properties only in the COPD population.

I. Nasis,EA. Kortianou, E. Clini, NG. Koulouris, I.Vogiatzis. ( 2013 ) - Effect of rehabilitative exercise training on peripheral muscle remodelling in patients with COPD: targeting beyond the lungs - CURRENT DRUG TARGETS - n. volume 14 - pp. da 262 a 273 ISSN: 1873-5592 [Articolo su rivista - Articolo su rivista]
Abstract

Locomotor muscle dysfunction and weakness are frequently observed in patients with Chronic Obstructive Pulmonary Disease (COPD). In addition to intolerable sensations of dyspnoea which importantly contribute to exercise limitation, intrinsic muscle abnormalities have also been implicated in inducing leg muscle fatigue/discomfort during exercise in these patients. It is, however, uncertain whether these intrinsic muscle abnormalities are linked to a specific 'myopathy' or they constitute a consequence of the disease. Besides muscle disuse, other factors which may contribute to peripheral muscle dysfunction include systemic inflammation, oxidative and nitrosative stress, chronic hypoxia, corticosteroid use and malnutrition. There is clear evidence that rehabilitative exercise training induces significant skeletal muscle fibre remodelling and improvements in functionality in the absence of changes in lung function. The ultimate purpose of this review is to identify and summarize the results of studies implementing diverse types of exercise training on peripheral muscle fibre phenotypic and genotypic modifications in patients with COPD.

E. Venturelli, E. Crisafulli, A. De Biase, D. Righi, P. Cavicchioli, G. Vagheggini, F. Dabrosca, B. Balbi, M.Paneroni, L. Bianchi, M. Vitacca, V. Galimberti, M. Zaurino, G. Schiavoni, A. Iattoni, N. Ambrosino, E. Clini ( 2013 ) - Efficacy of Temporary Positive Expiratory Pressure (TPEP) in patients with lung diseases and chronic mucus hypersecretion. The UNIKO project: a multicentre randomised controlled trial. - CLINICAL REHABILITATION - n. volume 27 - pp. da 336 a 346 ISSN: 0269-2155 [Articolo su rivista - Articolo su rivista]
Abstract

Objective: To evaluate whether Temporary Positive Expiratory Pressure provides benefit in patients with lung diseases and chronic hypersecretion.Design: Single blind multicentre randomised trial.Setting: 5 Italian rehabilitation centres.Participants: 98 patients with Chronic Obstructive Pulmonary Disease and/or Chronic Bronchitis (n=78), or Bronchiectasis (n=20), with a Peak Cough Expiratory Flow >150 l/min and sputum production >30 mL/day, randomly included in two treatment groups. Interventions: For 10 consecutive days, Active group performed twice a day 20-min cycles of Manually Assisted Breathing Techniques in sequence with the addition of 15-min of Temporary Positive Expiratory Pressure, while Control group was treated by Manually Assisted Breathing Techniques alone.Measures: Within and between group changes of arterial oxygenation index, lung volumes and respiratory muscles strength were recorded at enrolment, after 3, and 10 treatment sessions. Pre-to-post treatment change of sputum volume and bronchial encumbrance (Δ-VAS), sputum density and purulence, were compared daily within the study period. Results: No significant changes were recorded for the oxygenation index, while dynamic lung volumes and respiratory muscle strength significantly (p <0.05) improved in Active group. The group comparison analysis of the pre-to-post change showed that Inspiratory Capacity was significantly higher in Active than in Control group (+19.5% and +2.2%, p=0.044) at day 10. A greater improvement in Δ-VAS was recorded in Active group at day 3 and 8. Conclusions: These preliminary data suggest that Temporary Positive Expiratory Pressure improves lung volumes and speeds up the improvement of bronchial encumbrance in patients with lung diseases and hypersecretion.

M.Paneroni, E.Clini, E.Crisafulli, E.Guffanti, A.Fumagalli, A.Bernasconi, A.Cabiaglia, A.Nicolini, S.Brogi, N.Ambrosino, R.Peroni, L.Bianchi, M.Vitacca. ( 2013 ) - Feasibility and effectiveness of an educational program in italian COPD patients undergoing rehabilitation. - RESPIRATORY CARE - n. volume 58 (2) - pp. da 327 a 333 ISSN: 0020-1324 [Articolo su rivista - Articolo su rivista]
Abstract

Background. Self-management education is associated with improvement in quality of life and reduction of hospital admissions. Despite this, data are insufficient to formulate clearrecommendations regarding the type and content of education programs for COPD patients and few data are available on knowledge of the disease itself. Aim. To test: i) the level of patients’ knowledge of their disease and therapy at baseline and after an educational program (COPD-EP), ii) the feasibility of structured educational sessions, iii)influence of clinical status (degree of severity of disease, presence of comorbidities, oxygen use), demographics status (age, sex), previous knowledge level, previous lessons attendance and adherence of COPD-EP to the variation ofknowledge after program.Methods. Selected COPD inpatients and outpatients referred to Rehabilitative hospital departments were enrolled. The study was divided in two parts: i) Pre Study Phase (educational materials andhealth team preparation) and ii) Study Phase: all COPD patients received one educational brochure and were invited to attend seven 30-min group lessons to complete the educational program.Learning effect was evaluated by a 20-questions multiple choice Learning Questionnaire (LQ).Results. 158 patients were enrolled. 69.7 % of patients had previous formal education lessons on COPD management and 44.9 % had previous rehabilitative hospitalizations. At baseline, LQ total score was 15.2±3.5 points which increased to 16.9±3.0 point post COPD-EP (p<0.001). Pre-to-post change of LQ scores significantly correlated with adherence (R=0.24, p=0.002) and Severity Index of Cumulative Illness Rating Scale score (R= -0.22, p=0.001). Patients with low baseline knowledge were more likely to have improved LQ scores than patients with greater levels of knowledge. Patients without prior educational COPD lessons improved more than patients which attended previous education.Conclusions. A formal COPD-EP is feasible and effective in improving patient knowledge and self-management. Specific learning instruments to follow in this population should be validated.

E.Clini, E.Venturelli, E.Crisafulli ( 2013 ) - La Riabilitazione Respiratoria. In: Malattie dell'Apparato Respiratorio (eds. L.M.Fabbri, S.A.Marsico)) - EdiSES s.r.l. Napoli ITA) - pp. da 604 a 610 ISBN: 9788879597494 [Monografia o trattato scientifico - Monografia/Trattato scient. con ISBN]
Abstract

Non disponibile

M.Roca, A.Verduri, L.Corbetta, E.Clini, L.M.Fabbri, B.Beghé ( 2013 ) - Mechanisms of acute exacerbation of respiratory symptoms in COPD. - EUROPEAN JOURNAL OF CLINICAL INVESTIGATION - n. volume 43 (5) - pp. da 510 a 521 ISSN: 0014-2972 [Articolo su rivista - Articolo su rivista]
Abstract

ECOPD are complex events in the natural history of COPD, dramatically affecting lung function decline, patients’ quality of life and long-term mortality. ECOPD are heterogeneous events with respect to associated inflammatory response and aetiology. Biological and clinical phenotypes in ECOPD are determined by intricate interactions between different etiologic pathogen factors and by the host–pathogen interaction. The pathogenic relationship between ECOPD and comorbidities is extremely complex and poorly understood. The direction of this relationship is sometimes uncertain, and the interactions between diseases appear to be reciprocal. However, it has clearly been proved that comorbidities affect ECOPD frequency and severity and alter the long-term prognosis. The clinical presentation of ECOPD can be determined not only by acute “bronchitis” or “alveolitis” induced by infections or pollutants, i.e., the properly named exacerbations of COPD, but also by acute de-compensation of respiratory or no respiratory concomitant disorders, i.e., the more properly, exacerbations of respiratory symptoms in patients with COPD [88]. This distinction generates diagnostic and therapeutic issues, and more comprehensive approaches are needed. Not only the baseline lung disease but also the comorbidities must be considered. More sensitive and specific biomarkers are necessary to identify and establish the real weight of every concomitant pathogenic entity in the clinical presentation of ECOPD.

A.Esquinas, G.Siscaro, E.Clini ( 2013 ) - Noninvasive mechanical ventilation with high pressure strategy remains a “double edged sword” ? - INTERNATIONAL JOURNAL OF COPD - n. volume 8 - pp. da 255 a 258 ISSN: 1178-2005 [Articolo su rivista - Articolo su rivista]
Abstract

Not available

M.Malerba, E.Clini, M.Malagola, GC.Avanzi. ( 2013 ) - Platelet activation as a novel mechanism of atherothrombotic risk in chronic obstructive pulmonary disease. - EXPERT REVIEW OF HEMATOLOGY - n. volume 6 (4) - pp. da 475 a 483 ISSN: 1747-4086 [Articolo su rivista - Articolo su rivista]
Abstract

Chronic pulmonary Obstructive Disease (COPD) is characterised by pulmonary and systemic inflammation. In particular, the clinical course of this disease typically leads to periodic exacerbation involving inflammatory response and both respiratory and cardiovascular symptoms. Even though the exact mechanisms underlying the pathogenesis of COPD and its chronic and acute inflammation have not yet been fully understood, many studies have been highlighting the role of the endothelium, platelets (PTLs), and other circulating blood cells. PLTs themselves are crucial for haemostasis and, once activated by a number of different factors, will mediate endothelium adhesion and the rolling and activation of other circulating cells, such as neutrophils, which itself becomes a cause of cause tissue damage during the inflammatory process. The aim of this review is to highlight the onset of activation, thrombus formation, and inflammatory amplification with particular regard to the COPD patients and the course of their acute exacerbations.

E.Crisafulli, A.Iattoni, E.Venturelli, G.Siscaro, C.Beneventi, A.Cesario, E.Clini ( 2013 ) - Predicting walking-induced oxygen desaturations in COPD patients: a statistical model. - RESPIRATORY CARE - n. volume 58 (9) - pp. da 1495 a 1503 ISSN: 0020-1324 [Articolo su rivista - Articolo su rivista]
Abstract

Background- Oxygen desaturation during walking can have important consequence on prognosis of COPD patients. However, a standard 6-minute walking test (6MWT) useful to detect walking desaturators (WD+), can be difficult to execute in some settings of COPD management, as in the community health care service. Aim of our study was to validate and evaluate the accuracy of a newly composed score of risk of oxygen desaturation during walking in COPD patients: the Walking Desaturation Score-WDS. Methods- Data on symptomatic COPD inpatients admitted for rehabilitation (derivation cohort) and outpatients referred to the local community health service (validation cohort) were recorded. By pulse-oximetry oxygen saturation (SpO2) was monitored during 6MWT to obtain minimal values (SpO2 nadir); patients were thus divided into WD+ or non-desaturators (WD-). By a regression analysis model we have assigned a weighted score proportional to the measured percentage of explained variance for each variable. Risk estimate was computed by odds ratio (OR). A Receiver Operating Curve (ROC) analysis and a Hosmer-Lemeshow (HL) goodness of fit test were then performed to measure discrimination and calibration of WDS. Results- Baseline characteristics in derivation (n=435, WD+ 74%) and validation (n=238, WD+ 37%) cohorts were different. Resting arterial oxygen saturation-SO2, arterial partial pressure of oxygen-PaO2 and forced expiratory volume in the 1st second-FEV1 % pred. were the variables predicting walking desaturation. The proportion of WD+ patients (and OR estimate) gradually increased according to WDS (range 0 to 6) and associated categories of desaturation risk (low 0-1 in total score of WDS, high 2-3, and very high 4-6) (X2<0.001). A considerable predictive discrimination (area under curve-AUC 0.90, 95% CI 0.86 to 0.93, P< 0.001) and calibration (HL X2 1.31, P=0.859) values have been shown. Conclusions- WDS accurately predicts and classifies the risk of walking desaturation in COPD patients.

S.Ramponi, P.Tzani, M.Aiello, E.Marangio, E.Clini, A.Chetta. ( 2013 ) - Pulmonary Rehabilitation Improves Cardiovascular Response to Exercise in COPD. - RESPIRATION - n. volume 86 - pp. da 17 a 24 ISSN: 0025-7931 [Articolo su rivista - Articolo su rivista]
Abstract

Background: Pulmonary rehabilitation (PR) has emerged as a recommended standard of care in symptomatic COPD. Objectives: We now studied whether PR may affect cardiovascular response to exercise in these patients. Methods: Twenty-seven patients (9F; age: 69 yrs ± 8) with moderate to severe airflow obstruction admitted to a 9-week PR course performed a pre-to-post evaluation of lung function test and symptom-limited cardiopulmonary exercise test (CPET). Oxygen uptake (VO2), tidal volume (VT), dyspnoea and leg fatigue scores were measured during CPET. Cardiovascular response was assessed by means of oxygen pulse (O2Pulse), the oxygen uptake efficiency slope (OUES) and heart rate recovery at the 1st min (HRR). Results: A significant increase in peak VO2 and in all cardiovascular parameters (p<0.05) was found following PR, as compared to baseline. Leg fatigue (p<0.05), but not dyspnoea was significantly reduced after RP. When assessed at metabolic and ventilatory iso levels (%VCO2max and %VEmax), O2Pulse and VT were significantly higher (p<0.05) at submaximal exercise (75% and 50% of VCO2max and VEmax) after RP, when compared to baseline. VT percent changes at 75% VCO2max and 75% VEmax after RP significantly correlated with corresponding changes in O2Pulse (p<0.01). Conclusions: In COPD patients, a PR training program improved the cardiovascular response during exercise at submaximal exercise independent on the external workload. This change was associated with an enhanced ventilatory function during exercise.

E.Crisafulli, E.Venturelli, G.Siscaro, F.Florini, A.Papetti, D.Lugli, M.Cerulli, E.Clini ( 2013 ) - Respiratory muscle training in patients recovering recent open cardio-thoracic surgery: a randomized-controlled trial. - BIOMED RESEARCH INTERNATIONAL - n. volume 2013 [Articolo su rivista - Articolo su rivista]
Abstract

Objectives- To evaluate the clinical efficacy and feasibility of an expiratory muscle training (EMT) device (Respilift™) applied to patients recovering from recent open cardio-thoracic surgery (CTS). Design- Prospective, double-blind, 14-day randomised-controlled trial. Participants and setting- 60 inpatients recovering from recent CTS and early admitted to a pulmonary rehabilitation program. Interventions- Chest physiotherapy plus EMT with a resistive load of 30 cm H2O for active group and chest physiotherapy plus EMT with a sham load for control group. Measures- Changes in maximal expiratory pressure (MEP) was considered as primary outcome, while maximal inspiratory pressures (MIP), dynamic and static lung volumes, oxygenation, perceived symptoms of dyspnoea, thoracic pain and well being (evaluated by visual analogic scale-VAS) and general health status were considered secondary outcomes. Results- All outcomes recorded showed significant improvements in both groups; however, the change of MEP (+34.2 mmHg, p<0.001 and +26.1%, p<0.001 for absolute and % of predicted, respectively) was significantly higher in Active group. Also VAS-dyspnoea improved faster and more significantly (p<0.05) at day 12 and 14 in Active group when compared with Control. The drop out rate was 6%, without differences between groups. Conclusions- In patients recovering from recent CTS specific EMT by Respilift™ is feasible and effective.

M.Marvisi, F.J.F.Herth, S.Ley, V.Poletti, N.H.Chavannes, M.A.Spruit, E.Clini, V.Cottin ( 2013 ) - Selected clinical highlights from the 2012 ERS Congress in Vienna. - EUROPEAN RESPIRATORY JOURNAL - n. volume 41 - pp. da 1219 a 1227 ISSN: 0903-1936 [Articolo su rivista - Articolo su rivista]
Abstract

This article reviews a selection of scientific presentations at the 2012 annual meeting of the European Respiratory Society held in Vienna, Austria. The best abstracts from the groups of the Clinical Assembly (Clinical Problems, Rehabilitation and Chronic Care, Imaging, Interventional Pulmonology, Diffuse Parenchymal Lung Disease, and General Practice and Primary Care) are here presented and discussed in the context of the most updated literature. The reviewed topics especially deal with the area of chronic obstructive pulmonary disease (acute exacerbations, comorbidities, prognosis, rehabilitation), the diagnosis and management of idiopathic pulmonary fibrosis, sarcoidosis, endobronchial techniques in emphysema, functional imaging, and issues in respiratory medicine relevant for the primary care setting, including aspects related to the end-of-life and palliation.

E.Crisafulli, R.Menendez, A.Huerta, R.Martinez, B.Montull, E.Clini, A.Torres ( 2013 ) - Systemic inflammatory pattern of community-acquired pneumonia (CAP) patients with and without chronic obstructive pulmonary disease (COPD) - CHEST - n. volume 143 (4) - pp. da 1009 a 1017 ISSN: 1931-3543 [Articolo su rivista - Articolo su rivista]
Abstract

BackgroundSeveral clinical studies have evaluated the role of chronic obstructive pulmonary disease (COPD) in community-acquired pneumonia (CAP) patients. We investigated the systemic inflammatory response of CAP patients with (CAP+COPD) and patients without associated COPD (CAP only).MethodsClinical, microbiological and immunological data were collected from367 prospective patients on admission towere collected at hospital admission during a 3-year period. Comparative analyses were performed between CAP+COPD (n=117) and CAP only patients (n=250) and between patients with and without domiciliary use of inhaled (ICS) and oral corticosteroids.ResultsDetailed characteristics of clinical severity and prognosis (mortality on hospitalization, at 30 days and at 90 days) were similar between CAP+COPD and CAP only patients. The re-admission rate and the frequency of a previous pneumonia were higher in the group of CAP+COPD patients. On day -1 (admission to hospital) CAP+COPD patients had significantly lower serum levels of tumour necrosis factor (TNF) α, interleukin (IL) 1 and IL-6 compared with CAP only patients; the remaining inflammatory biomarkers (C-reactive protein, procalcitonin, IL-8 and IL-10) were similar at days 1 and 3. The exclusion of patients with domiciliary use of ICS and oral corticosteroids confirms lower levels of TNF-α on day 1 in CAP+COPD patients. Finally, lower levels of IL-6 was were found only among those COPD patients who were currently using habitually used ICS.ConclusionOur prospective study demonstrates a different, disease-specific early inflammatory pattern between CAP patients with and without associated COPD; these finding are not completely corticosteroid-mediated.

M.Spruit, E.Clini ( 2013 ) - Towards health benefits in chronic respiratory diseases: Pulmonary Rehabilitation - EUROPEAN RESPIRATORY REVIEW - n. volume 22 - pp. da 202 a 204 ISSN: 1600-0617 [Articolo su rivista - Articolo su rivista]
Abstract

To date, pulmonary rehabilitation is defined by the ATS and ERS as a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies which include, but are not limited to, exercise training, education and behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviors. Daily symptoms, lower-limb muscle function, exercise capacity and health status will improve following pulmonary rehabilitation in individuals with chronic respiratory disease. Moreover, healthcare costs are likely to decrease following a pulmonary rehabilitation course. So, it seems fair to conclude that pulmonary rehabilitation is a cardinal part of COPD management, and a useful intervention in other chronic respiratory diseases. Taking all these facts into account, the Editorial Board of the European Respiratory Review decided to invite a group of international experts to write a review series on pulmonary rehabilitation

E.Crisafulli, S.Costi, E.Clini ( 2012 ) - Anthropometry as Measure of Risk in COPD Patients (chapter 145) (V.R. Preedy - Handbook of Anthropometry: Physical Measuresof Human Form in Health and Disease - Springer Science+Business Media Berlino DEU) - pp. da 2357 a 2371 ISBN: 9781441917874 [Contributo in volume (Capitolo o Saggio) - Capitolo/Saggio con ISBN]
Abstract

In the last decade, Chronic Obstructive Pulmonary Disease (COPD) has been redefined and newly approached not only as an airway-disease condition, but as a multi-component disease including extra-pulmonary manifestations, such as peripheral muscle weakness and malnutrition.The evaluation of body composition (as a part of nutritional assessment) fairly integrates the simple body mass index (BMI) measure by measuring the individual’s active metabolism (fat free mass, FFM). Indeed, BMI and FFM are both parameters correlated with many COPD-strong out- comes. In several epidemiological studies of COPD population admitted to both in- or outpatient rehabilitation programmes, the estimated prevalence of weight loss ranges from 17% to 53%. Nonetheless, weight reduction, together with FFM depletion, is a common feature in emphysema as well as in chronic bronchitis.A nutritionally depleted patient is usually defined by a BMI of £ 20 kg/m2. Several studies aimed at evaluating the prognostic value of BMI in COPD patients have documented that BMI £ 25 kg/m2 and weight reduction of >3 kg/m2 are strong predictors of mortality. Moreover, other studies confirmed that FFM and measurement of the cross-sectional area of muscle mass (mid-thigh and mid-arm) also correlate to survival rates.In future research, studies looking at other anthropometric, metabolic and functional factors able to predict the long-term survival should be welcomed in patients with other diseases, such as pul- monary fibrosis, similarly leading to chronic respiratory failure.

E.Crisafulli, S.Costi, E.Clini. ( 2012 ) - Anthropometry as measure of risk in COPD patients (chapter 146). In: Preedy VR. (ed) Handbook on Anthropometry: Physical Measures of Human Form in Health and Disease. - Springer Science LLC Berlin DEU) - pp. da 2357 a 2371 ISBN: 9781441917874 [Monografia o trattato scientifico - Monografia/Trattato scient. con ISBN]
Abstract

In the last decade, Chronic Obstructive Pulmonary Disease (COPD) has been redefined and newly approached not only as a airway-disease condition, but as a multi-component disease including extra-pulmonary manifestations, such as peripheral muscle weakness and malnutrition.The evaluation of body composition (as a part of nutritional assessment) by measuring the individual’s active metabolism (fat free mass, FFM), fairly integrates the simple body mass index (BMI) measure. Indeed, BMI and FFM are both parameters correlated with many COPD strong outcomes. In several epidemiological studies regarding COPD population admitted to both in- or outpatients rehabilitation programmes, the estimated prevalence of weight loss ranges from 17 to 53%. Nonetheless, weight reduction, together with FFM depletion, are common features in emphysema as well as in chronic bronchitis. A nutritionally depleted patient is usually defined by a BMI of ≤ 20 kg/m2. Several studies aimed at evaluating the prognostic value of BMI in COPD patients, have documented that BMI ≤ 25 kg/m2 and weight reduction of >3 kg/m2 are strong predictors of mortality. Moreover, other studies confirmed that FFM and measurement of the cross-sectional area of muscle mass (mid-thigh and mid-arm) also correlate to survival rates.In future research, studies looking at other anthropometric, metabolic and functional factors able to predict the long-term survival should be welcomed in patients other than COPD, such as pulmonary fibrosis, similarly leading to chronic respiratory failure.

M.A.Spruit, N.H.Chavannes, F.J.F.Herth, V. Poletti, S.Ley, O.C.Burghuber, E.Clini, V.Cottin. ( 2012 ) - Clinical highlights from the 2011 ERS Congress in Amsterdam - EUROPEAN RESPIRATORY JOURNAL - n. volume 39 - pp. da 1501 a 1510 ISSN: 0903-1936 [Articolo su rivista - Articolo su rivista]
Abstract

This review article reports selected news pertinent to most important clinical problems in the field of respiratory medicine. Expert authors from the Clinical Assembly have selected updated reports related to the presentations at the 2011 annual meeting of the European Respiratory Society held in Amsterdam (TheNetherlands), where more than 20,000 attendants met. The hot topics and selected abstracts from the study groups of the Clinical Assembly are discussed here in the context of recent literature.

F.Pasqua, D'Angelillo, F.Mattei, S.Bonassi, GL.Biscione, K.Geraneo, V.Cardaci, L.Ferri, S.Ramella, P.Granone, S.Sterzi, E.Crisafulli, E.Clini, F.Lococo, L.Trodella, A.Cesario. ( 2012 ) - Pulmonary rehabilitation following radical chemo-radiation in locally-advanced non surgical NSCLC: preliminary evidences. - LUNG CANCER - n. volume 76(2) - pp. da 258 a 259 ISSN: 0169-5002 [Articolo su rivista - Articolo su rivista]
Abstract

Non disponibile (letter)

N.Ambrosino, E.Venturelli, G.Vagheggini, E.Clini ( 2012 ) - Rehabilitation, Weaning and Physical Therapy Strategies in the Critically Ill patients - EUROPEAN RESPIRATORY JOURNAL - n. volume 39 (2) - pp. da 487 a 492 ISSN: 0903-1936 [Articolo su rivista - Articolo su rivista]
Abstract

In critically ill patients prolonged hospital stay as a consequence of the initial acute insult, combined with adverse side effects of drug therapy, often on the background of chronic disease, causes severe late complications like muscle weakness, prolonged symptoms, mood alterations and poor health-related quality of life. The clinical aims of physical rehabilitation for patients in both medical and surgical intensive care units (ICUs) are focussed on the patient as a whole to improve short- and even long-term care of patients admitted to these units.Purpose of this review article is to sum up the currently available evidence of comprehensive rehabilitation programs in critically ill patients, with a description of the key components and techniques used particularly in those individuals specifically admitted to specialised ICUs.Despite literature suggesting that several techniques have led to beneficial effects, and that muscle training is associated with weaning success, the scientific evidence is limited. Although there are limitations associated with undertaking comparative studies in the intensive care environment, further studies with solid clinical short- and long-term outcome measures are now welcomed.

M.Vitacca, L.Bianchi, A.Bazza, E.Clini. ( 2011 ) - Advanced COPD patients under home mechanical ventilation and/or long term oxygen therapy: italian health care costs. - MONALDI ARCHIVES FOR CHEST DISEASE - n. volume 75 (4) - pp. da 207 a 214 ISSN: 1122-0643 [Articolo su rivista - Articolo su rivista]
Abstract

Introduction. Little information is available on health care costs for patients with very severe chronic obstructive pulmonary disease The aim of the current work was to evaluate Italian health care costs in these patients. Patients and Methods. Prospective 1-year analysis were assessed in three subgroups of patients; non-invasively ventilated (n=30); invasively-ventilated (n=12) and on long-term oxygen therapy (n= 41). Acute costs for care were a sum of fees for doctor’s consultations, admissions to hospital (ward and intensive care unit) and emergency drugs. Chronic costs were the sum of costs for pharmacotherapy and home ventilation and/or oxygen care. Results. Mean cost/day/patient was 96±112 € (range 9-526 €), with acute costs accounting for 72% and chronic costs for 28% of the total cost burden, with no significant differences in costs associated with the three subgroups. Acute costs had a non-normally distribution (range 0 to 510 €) with cost for hospitalization being the highest cost burden with greater than 30 % of acute care costs were attributed to only a small segment of patients. Chronic care costs were also unevenly distributed among the various groups (ANOVA p=0.006), with home oxygen supply being the highest cost burden. Conclusions. The current Health Care System is in urgent need for a reassessment of the high cost burden associated with hospitalizations and home oxygen supply.

E. Crisafulli, E. Venturelli, A. Iattoni, E. Clini ( 2011 ) - Co-morbidities in chronic respiratory patients: limitations or opportunities for caring ? - JOURNAL OF MEDICINE AND THE PERSON - n. volume 9 (3) - pp. da 99 a 103 ISSN: 2035-9411 [Articolo su rivista - Articolo su rivista]
Abstract

In the population of chronic respiratory patients a new subset with clinical complexity and with multiple coexisting organ failure and diseases is rapidly growing. Mainly due to the aging process, the associated frailty - not strictly related to the patient’s age - consists in a progressive and physiologic decline in multiple body systems leading to a substantial loss of functions and physiologic reserve. It is commonly acquainted that frailty, co-morbidities (several medical conditions associated) and disability (decline in physical functions) overlap each other: both frailty and co-morbidities can predict physical disability, whereas disability per se may exacerbate frailty and co-morbidities. Specific interventions (as rehabilitation) targeting at the physical activity the old population have been shown to improve physical function and have a benefit along the full spectrum of health status. However, there is a substantial need for a multidimensional and personalized care approach: patient’s complexity, in fact, may play a role in determining the patient’s response to treatment. In particular, each disease as a single entity might reduce the response to treatment, depending on its effect on body functions and target therapies. Notwithstanding, the clinical complexity of these patients and the presence of several co-morbidities, does not preclude per se the application and the effectiveness of a comprehensive rehabilitation program targeted to the individual’s needs.

F.Sgambato, E.Clini ( 2011 ) - Complessità del paziente con insufficienza respiratoria cronica associata a BPCO - THE ITALIAN JOURNAL OF MEDICINE - n. volume 5 (1) supplemento 1 - pp. da 159 a 170 ISSN: 0393-8166 [Articolo su rivista - Articolo su rivista]
Abstract

Article Outline-Introduzione-Epidemiologia-Complessità e fisiopatologia-Patogenesi-Ventilazione alveolare-Capacità funzionale residua, rapporto ventilazione/perfusione, pressione dell’arteria polmonare-Quantità di acqua intrapolmonare e/o intratoracica-Terapia-Interventi non farmacologici-Conclusioni

P.Tzani, M.Aiello, D.Elia, L.Boracchia, E.Marangio, D.Olivieri, E.Clini, A.Chetta ( 2011 ) - Dynamic Hyperinflation is Associated with a Poor Cardiovascular Response to Exercise in COPD Patients. - RESPIRATORY RESEARCH - n. volume 12 - pp. da 150 a 150 ISSN: 1465-9921 [Articolo su rivista - Articolo su rivista]
Abstract

Background: Pulmonary hyperinflation has the potential for significant adverse effects on cardiovascular function in COPD. The aim of this study was to investigate the relationship between dynamic hyperinflation and cardiovascular response to maximal exercise in COPD patients. Methods: We studied 48 patients (16F; age 68 yrs ± 8; BMI 26 ± 4) with COPD. All patients performed spirometry, plethysmography, lung diffusion capacity for carbon monoxide (TLco) measurement, and symptom-limited cardiopulmonary exercise test (CPET). The end-expiratory lung volume (EELV) was evaluated during the CPET. Cardiovascular response was assessed by change during exercise in oxygen pulse (ΔO2Pulse) and double product, i.e. the product of systolic blood pressure and heart rate (DP reserve), and by the oxygen uptake efficiency slope (OUES), i.e. the relation between oxygen uptake and ventilation. Results: Patients with a peak exercise EELV (%TLC) ≥ 75% had a significantly lower resting FEV1/VC, FEF50/FIF50 ratio and IC/TLC ratio, when compared to patients with a peak exercise EELV (%TLC) < 75%. Dynamic hyperinflation was strictly associated to a poor cardiovascular response to exercise: EELV (%TLC) showed a negative correlation with ΔO2Pulse (r = - 0.476, p = 0.001), OUES (r = - 0.452, p = 0.001) and DP reserve (r = - 0.425, p = 0.004). Furthermore, according to the ROC curve method, ΔO2Pulse and DP reserve cut-off points which maximized sensitivity and specificity, with respect to a EELV (% TLC) value ≥ 75 % as a threshold value, were ≤ 5.5 mL/bpm (0.640 sensitivity and 0.696 specificity) and ≤ 10,000 Hg ∙ bpm (0.720 sensitivity and 0.783 specificity), respectively. Conclusion: The present study shows that COPD patients with dynamic hyperinflation have a poor cardiovascular response to exercise. This finding supports the view that in COPD patients, dynamic hyperinflation may affect exercise performance not only by affecting ventilation, but also cardiac function.

P.Tzani, E.Crisafulli, G.Nicolini, M.Aiello, A.Chetta, E.Clini, D.Olivieri ( 2011 ) - Effects of beclomethasone/formoterol fixed combination on lung hyperinflation and dyspnoea in COPD patients. A pilot study. - INTERNATIONAL JOURNAL OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE - n. volume 6 - pp. da 503 a 509 ISSN: 1176-9106 [Articolo su rivista - Articolo su rivista]
Abstract

Background: Chronic obstructive pulmonary disease (COPD) is a common disease characterized by airflow obstruction and lung hyperinflation leading to dyspnoea and exercise capacity limitation.Objectives: the present study was designed to evaluate whether an extra-fine combination of beclomethasone and formoterol (BDP/F) was effective in reducing air trapping in COPD patients with hyperinflation. Fluticasone salmeterol (FP/S) combination treatment was the active control.Methods: COPD patients with FEV1 <65% and plethysmographic functional residual capacity 120% of predicted were randomized to a double-blind, double-dummy, 12 week, parallel group, treatment with either BDP/F 400/24 µg/day or FP/S 500/100µg/day. Lung volumes were measured with full body plethysmography and dyspnoea was measured with transition dyspnoea index.Results: 18 patients were evaluable for intention to treat. A significant reduction in air trapping and clinically meaningful improvement in transition dyspnoea index total score was detected in the BDP/F group but not in the FP/S group. Functional residual capacity, residual volume (RV) and total lung capacity significantly improved from baseline in the BDP/F group only. With regard to group comparison, a significantly greater reduction in RV was observed with BDP/F vs. FP/S. Conclusion: BDP/F extra-fine combination is effective in reducing air trapping and dyspnoea in COPD patients with lung hyperinflation.

E. Crisafulli, C. Beneventi, V. Bortolotti, N. Kidonias, L.M. Fabbri, A. Chetta, E. Clini ( 2011 ) - Energy expenditure at rest and during walking in patients with chronic respiratory failure: a prospective two-phase case-control study - PLOS ONE - n. volume 6(8) [Articolo su rivista - Articolo su rivista]
Abstract

Measurement of Energy Expenditure (EE) at rest (REE) and during physical activities are increasing in interest in chronic patients. In this study we aimed at evaluating the validity/reliability of the SenseWear®Armband (SWA) device in terms of REE and EE during assisted walking in Chronic Respiratory Failure (CRF) patients receiving long-term oxygen therapy (LTOT).In a two-phase prospective protocol we studied 40 severe patients and 35 age-matched healthy controls. In phase-1 we determined the validity and repeatability of REE measured by SWA (REEa) in comparison with standard calorimetry (REEc). In phase-2 we then assessed EE and Metabolic Equivalents-METs by SWA during the 6-minute walking test while breathing oxygen in both assisted (Aid) or unassisted (No-Aid) modalities. When compared with REEc, REEa was slightly lower in patients (1351±169 vs 1413±194 kcal/day respectively, p<0.05), and less repeatable ithan in healthy controls (0.14 and 0.43 coefficient respectively). COPD patients with CRF patients reported a significant gain with Aid as compared with No-Aid modality in terms of meters walked, perceived symptoms and EE.SWA provides a feasible and valid method to assess the energy expenditure in CRF patients on LTOT, and it shows that aided walking results in a substantial energy saving in this population.

Clini E, Crisafulli E, Degli Antoni F, Beneventi C, Costi S, Fabbri L, Nava S. ( 2011 ) - Functional recovery following physical training in tracheotomised and chronically ventilated patients. An observational prospective cohort study. - RESPIRATORY CARE - n. volume 56(3) - pp. da 306 a 313 ISSN: 0020-1324 [Articolo su rivista - Articolo su rivista]
Abstract

Background: Rehabilitation is a non-pharmacological therapy able to restore health status and reversing the patient’s disability. Since the efficacy of this treatment in critically ill patients is not enough documented, the present study aimed to assess whether the degree of change in individual’s functional status after comprehensive rehabilitation may influences the in-hospital clinical outcomes in a population of long-term ventilated patients.Methods: In a prospective cohort study we observed 77 tracheotomized patients (aged 75±7 yrs) admitted for difficult weaning in a regional weaning centre (RICU). Care plan including peripheral muscle training was delivered on a daily basis. Demographic, anthropometric and functional characteristics were measured at admission in all patients. Pre-to-post change in basic activity of daily living score (Δ-BADL), survival and weaning success rate were recorded as clinical outcomes. Pearson’s correlation analysis and a linear regression model with Δ-BADL as the dependent variable were performed to test the predictive power of any measurement taken at baseline.Results: Sixty-seven patients (87%) survived whereas 55 of them (74%) succeded weaning during stay in RICU. Δ-BADL was +2.53 point (SD 2.03, median 2). Performance of the broadest muscle of back (BMB) at baseline predicted Δ-BADL (β 0.388, 95% CI 0.111-1,664, p=0.026). Probability to remain ventilator-free (p=0.043) and to survive (p=0.001) differed across the categories of Δ-BADL (0=no change, 1-2=least improvement, and >2=improvement above median change). Conclusions: Mortality rate and weaning success vary according to the degree of change in basic activities following active training in tracheotomised, ventilated and difficult-to-wean patients. Broadest muscle of back performance was the only significant predictor of change in these activities.

Nava S, Grassi M, Fanfulla F, Domenighetti G, Carlucci C, Perren A, Dell’Orso D, Vitacca M, Ceriana P, Clini E. ( 2011 ) - Non-invasive ventilation in elderly patients with acute hypercapnic respiratory failure: a randomized controlled trial. - AGE AND AGEING - n. volume 40 (4) - pp. da 444 a 450 ISSN: 0002-0729 [Articolo su rivista - Articolo su rivista]
Abstract

Background Older patients usually receive less invasive and costly hospital care, especially if they meet the criteria for Intensive Care Unit (ICU) admission or have a ‘do not intubate’(DNI) order. Objective: The aim of this randomized, control trial was to assess the effectiveness of non-invasive mechanical ventilation (NIV) vs standard medical therapy (SMT) in reducing the need of intubation, improving survival and reducing respiratory distress in very old patients with acute hypercapnic respiratory failure.Methods: Eighty-two patients aged >75 years (mean age 81.3±3.5 years) with acute hypercapnic respiratory failure were randomized to receive NIV or SMT Results: primary outcome was the need of meeting the intubation criteria (ETIc);secondary outcomes were: 12-months mortality “history”; respiratory rate, dyspnea score, and arterial blood gases.Meeting the ETIc was lower in the NIV in comparison with SMT group (7.3 vs. 63.4% of patients, respectively; p<0.001), as well as the mortality risk (OR=0.40; 95%CI: 0.19-0.83; p=0.014). 22/41 SMT patients with DNI received NIV as a “rescue” therapy. The risk of death in this latter group was comparable with the NIV group and significantly lower than in those patients receiving ETI(OR=0.60, 95%CI: 0.18-1.92 vs. 4.03, 95%CI: 2.35-6.94, respectively; p=0.009). Arterial blood gases, respiratory rate and dyspnoea improved significantly faster with NIV than with SMT.Conclusions Compared to SMT, NIV decreased the meeting of ETIc, and the mortality “history” of very old patients with AHRF. NIV should be offered as an alternative to patients considered poor candidates for intubation and those with a DNI order.NCT00600639 at: www.ClinicalTrials.gov

E.Clini, E.Venturelli, E.Crisafulli ( 2011 ) - Rehabilitation in COPD patients admitted for exacerbation - PNEUMONOLOGIA I ALERGOLOGIA POLSKA - n. volume 79(2) - pp. da 116 a 120 ISSN: 0867-7077 [Articolo su rivista - Articolo su rivista]
Abstract

Recovery of lung function is delayed up to 2 months following acute exacerbation (AE) of COPD patients. After AE, even with optimal medical therapy, it takes considerable time for COPD patients to recover to baseline ability to perform usual physical activity.Despite pulmonary rehabilitation (PR) has been so far considered a useful non-pharmacological therapy in stable COPD individuals, still few studies have examined the effect of rehabilitation during and/or early after AE.The present review updates the application of early PR and main physical therapies both during hospital acute care and following discharge of COPD patients undergoing exacerbation.Only recently, literature has shown feasibility and effectiveness of early PR in COPD patients undergoing AE. Notwithstanding, it clearly appears a treatment indicated just after or even during an acute episode in hospital.Future studies should be able to clarify the practical role and effects of a timely application of rehabilitation to acute COPD, as well as the preferred modalities, duration and techniques to apply in this condition.

E.Clini, N.Ambrosino ( 2011 ) - Rehabilitation in COPD patients: evergreen in Pneumology and beyond. - EUROPEAN RESPIRATORY JOURNAL - n. volume 38 - pp. da 514 a 515 ISSN: 0903-1936 [Articolo su rivista - Articolo su rivista]
Abstract

Several studies have shown so far that pulmonary rehabilitation (PR) has a beneficial effect on symptoms and on Health Related Quality of Life (HRQoL) in stable COPD patients.Nowadays major effort should be addressed to implement optimal rehabilitation regimens focused on individual needs, clarifying the effects of different PR components, exercise modalities and feasible settings. In this issue of the journal the first review article of a new series “Novelties in Pulmonary Rehabilitation” dealing with all these innovative aspects associated to the rehabilitation of COPD patients is invited (see also table 1). As the guest editors of these review articles we have chosen 5 main topics of interest to assure readers of some of the hot topics and/or unanswered questions on the clinical ground.

E.Venturelli, E.Crisafulli, F.Degli Antoni, L.Trianni, E.Clini ( 2011 ) - Rehabilitation in Critically Ill Patients - THE ANNALS OF RESPIRATORY MEDICINE - n. volume 1 (3) - pp. da 00 a 00 ISSN: 2042-4701 [Articolo su rivista - Articolo su rivista]
Abstract

Prolonged stay in the hospital and difficult response to pharmacotherapy can often lead to severe complications in critically ill patients for muscle weakness, physical deconditioning, recurrent symptoms, mood alterations, and poor quality of life. Rehabilitation is a treatment able to expand short- and long-term management of chronic patients admitted to intensive care. Recovery of individual’s physical and respiratory functions are both aims of a rehabilitation course in this area.The purpose of this review article is to resume a ‘‘state of art’’ of the currently available evidence for a rehabilitation strategy in critically illpatients, with a description of the main activities and techniques adopted.Despite the use of several activities and techniques that have led to short-term beneficial effects on both pulmonary and physical functions,muscle retraining represents the most important evidence-based aspect of Intensive Care Unit-rehabilitation: indeed, it is associated with weaning success and helps patients to recover at their maximum at discharge.

Paneroni M, Clini E, Simonelli C, Bianchi L, Degli Antoni F, Vitacca M. ( 2011 ) - Safety and efficacy of short-term intrapulmonary percussive ventilation in patients with bronchiectasis - RESPIRATORY CARE - n. volume 56 (7) - pp. da 984 a 988 ISSN: 0020-1324 [Articolo su rivista - Articolo su rivista]
Abstract

Background. Treatment of bronchiectasis includes drugs, oxygen therapy and bronchial clearance maneuvers. The aim of the current study was to assess safety and efficacy of IntrapulmonaryPercussive Ventilation when compared with usual Chest Physical Therapy in patients with bronchiectasis Methods. In two consecutive days, 22 patients underwent both Intrapulmonary Percussive Ventilation and Chest Physical Therapy following a randomized cross-over design. At inclusion (T0), at the end of 30-min session (T1), and after 30 min (T2) and 4 hrs (T3), side effects, heart rate, oxygen saturation rate, respiratory rate, sensation of phlegm encumbrance and dyspneameasured by visual analogue scales, were recorded. At T1, discomfort measured by visual analogue scales was also recorded. At T3, we evaluated efficacy in terms of volume (ml), and wet and dry weight (g) of sputum. Results. Side effects were not so severe as to determine study discontinuation and were similar (27%) between the two treatments. Heart rate (p<.001) and respiratory rate (p=0.047) decreased over time while sensation of phlegm encumbrance improved (p=0.026) withboth treatments. Only Intrapulmonary Percussive Ventilation improved (p=0.004) sensation of dyspnea and resulted more comfortable than Chest Physical Therapy (p=0.032). The two treatments caused important phlegm production without differences in total volume, and both wet and dry weight. Conclusions. In patients with bronchiectasis and productive cough, short-term application of Intrapulmonary Percussive Ventilation is similarly safe and effective than traditional chestPhysical Therapy with less discomfort. Further studies on cost-effectiveness of using IPV is recommended.

C.Robalo Cordeiro, S.Singh, F.Herth, S.Ley, NH.Chavannes, E.Clini, V.Cottin ( 2011 ) - Selected clinical highlights from the ERS congress. - EUROPEAN RESPIRATORY JOURNAL - n. volume 38 - pp. da 209 a 217 ISSN: 0903-1936 [Articolo su rivista - Articolo su rivista]
Abstract

This article reviews a selection of presentations at the 2010 annual meeting of the European Respiratory Society held in Barcelona, Spain, which was the largest congress ever in the field of respiratory medicine. The best abstracts from the groups of the clinical assembly (clinical problems, rehabilitation and chronic care, imaging of the lung, interventional pulmonology, diffuse parenchymal lung disease, and general practice and primary care) are presented in the context of the current literature. The 2010 European Respiratory Society (ERS) meeting congress was held in Barcelona, Spain, September 18-22, 2010. The largest congress ever in the field of respiratory medicine included a large programme, with both presentation of original scientific presentations with published abstracts, and many symposia devoted to synthetic presentation of medical literature and experience. Here is reported an overview of the abstracts of the Clinical Assembly based on scientific merit, novelty, and relevance. Due to space constraints, only a non-exhaustive selection in the field of the six scientific groups of this Assembly can be presented. They cover the spectrum of clinical problems, rehabilitation and chronic care, imaging of the lung, interventional pulmonology, diffuse parenchymal lung disease, and general practice and primary care.The 2010 European Respiratory Society (ERS) meeting congress was held in Barcelona, Spain, September 18-22, 2010. The largest congress ever in the field of respiratory medicine included a large programme, with both presentation of original scientific presentations with published abstracts, and many symposia devoted to synthetic presentation of medical literature and experience. Here is reported an overview of the abstracts of the Clinical Assembly based on scientific merit, novelty, and relevance. Due to space constraints, only a non-exhaustive selection in the field of the six scientific groups of this Assembly can be presented. They cover the spectrum of clinical problems, rehabilitation and chronic care, imaging of the lung, interventional pulmonology, diffuse parenchymal lung disease, and general practice and primary care.

M. Malerba, B. Ragnoli, M. Salameh, G. Sennino, M.L. Sorlini, A. Radaeli, E. Clini ( 2011 ) - Sub-clinical left ventricular diastolic dysfunction in early stage of chronic obstructive pulmonary disease - JOURNAL OF BIOLOGICAL REGULATORS & HOMEOSTATIC AGENTS - n. volume 25(3) - pp. da 443 a 451 ISSN: 0393-974X [Articolo su rivista - Articolo su rivista]
Abstract

Sub-clinical cardiac dysfunction may be significantly associated with chronic obstructive pulmonary disease (COPD) with different degree of severity. In a cross-sectional design we aimed at evaluating the frequency of left ventricular diastolic dysfunction (LVdd) and its correlation with lung function, pulmonary arterial pressure and systemic inflammation in a selected population of COPD at an early stage of their disease. Fifty-five COPD patients with no clinical signs of cardiovascular dysfunction were recruited and compared to 40 matched healthy controls. All the subjects underwent pulmonary function testing, doppler echocardiography, and interleukin 6 blood sampling. Presence of LVdd was defined and according to the significant change in both the ratio between early and late diastolic transmitral flow velocity (E/A ratio), isovolumetric relaxation time (IVRT), and deceleration time (DT) . The frequency of LVdd was higher in COPD group (70,9%) compared to controls (27,5%). In these patients decreased E/A ratio, and prolonged IVRT and DT clearly pointed to left ventricular filling impairment, a condition we found to be especially severe in those patients suffering from lung static hyperinflation as expressed by inspiratory-to-total lung capacity ratio (IC/TLC) <0.25. Circulating levels of interleukin 6 as well were higher among COPD patients compared to controls. The results of the present study suggest that sub-clinical left ventricular filling impairment is frequently found in COPD patients at the earlier stage of the disease even in the absence of any other cardiovascular dysfunction. Doppler echocardiography may help the early identification of LVdd in COPD patients .

E.Clini, P.Roversi, E.Crisafulli ( 2010 ) - Early rehabilitation: much better than nothing - AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE - n. volume 181 - pp. da 1016 a 1017 ISSN: 1535-4970 [Articolo su rivista - Articolo su rivista]
Abstract

Not available

Crisafulli E, Gorgone P, Vagaggini B, Pagani M, Rossi G, Costa F, Guarriello V, Paggiaro P, Chetta A, de Blasio F, Olivieri D, Fabbri L, Clini E. ( 2010 ) - Efficacy of standard Rehabilitation in COPD Outpatients with Co-morbidities. - EUROPEAN RESPIRATORY JOURNAL - n. volume 36 - pp. da 1042 a 1048 ISSN: 0903-1936 [Articolo su rivista - Articolo su rivista]
Abstract

A prospective study was performed to 1) confirm the prevalence pattern of the most frequent co-morbidities and 2) evaluate whether characteristics of patients, specific co-morbidities, and increasing number of co-morbidities are independently associated with poorer outcomes in a population of complex COPD submitted to rehabilitation (PR). Three-hundred and sixteen outpatients (age 68±7 yrs) were studied. Co-morbidities and proportion of patients with a pre-defined minimally significant change in exercise tolerance (6MWD, +54 mt), breathlessness (MRC score, -1 point) and quality-of-life (SGRQ, -4 points) as outcomes were recorded. Sixty-two % of patients reported co-morbidities; systemic hypertension (35%), dyslipidemia (13%), diabetes (12%), and coronary disease (11%) were the most frequent. Above 45% of them improved over MCID in all the outcomes. In a logistic regression model, baseline 6MWD (OR 0.99 95%CI 0.98-0.99, p=0.001), MRC (OR 12.88 95%CI 6.89-24.00, p=0.001), and PaCO2 (OR 1.08 95%CI 1.00-1.15, p=0.034) related with the proportion of patients who improved 6MWD and MRC, respectively. Presence of osteoporosis reduced the success rate in 6MWD (OR 0.28 95%CI 0.11-0.70, p=0.006). A substantial prevalence of co-morbidities in COPD outpatients referred to rehabilitation was confirmed. The individual’s disability and the presence of osteoporosis only were independently associated with poorer rehabilitation outcomes. (registered at ClinicalTrials.gov: NCT00992498.)

Corrado A, Crisafulli E, Moretti M, Nava S, Clini E. ( 2010 ) - Insufficienza Respiratoria acuta e cronica (cap.20). In: Rugarli C. (ed) Trattato di Medicina Interna. - Masson Milano ITA) - pp. da 481 a 499 ISBN: 9780070002012 [Monografia o trattato scientifico - Monografia/Trattato scient. con ISBN]
Abstract

Trattazione della fisiopatologia eclinica della insufficienza respiratoria acuta ecronica; guida alle terapie correnti (razionale, obiettivi, indicazioni, efficacia)

Beghe' B, Fabbri L, Clini E. ( 2010 ) - La broncopneumopatia cronica ostruttiva nell'anziano. In: M.Mongardi (ed) L'Assistenza all'Anziano. - Mc-Graw Hill (Milano) Milano ITA) - pp. da 456 a 486 ISBN: 9788838636813 [Monografia o trattato scientifico - Monografia/Trattato scient. con ISBN]
Abstract

Nel capitolo vengono delineati gli aspetti epidemiologici, diagnostici, clinici e terapeutici della BPCO, patologia di assoluto rilievo nell'età avanzata. Completano il capitolo aspetti di integrazione dell'assistenza professionale nella patologia in oggetto.

M.Vitacca, M.Grassi, N.Hill, L.Barbano, V.Galavotti, C.Sturani, A.Vianello, E.Zanotti, L.Ballerin, A.Potena, R.Scala, A.Peratoner, P.Ceriana, L.Di Buono, E.Clini, N.Ambrosino, S.Nava. ( 2010 ) - Last 3 months of life in home ventilated patients: the family perception - EUROPEAN RESPIRATORY JOURNAL - n. volume 35 - pp. da 1064 a 1071 ISSN: 0903-1936 [Articolo su rivista - Articolo su rivista]
Abstract

Background: Information on quality of care in end-stage home ventilated patients is lackingMethods: To describe the family’s perception of quality of care delivered to these patients during the last 3 months of life, 11 Respiratory Units proposed a questionnaire to close relatives of 168 deceased patients. Results: Response rate was 98.8%. Answers to the binary 35-item questionnaire were distributed into just 4 groups (COPD or non-COPD and tracheostomized or NIV users) for each of 6 identified domains (Control of symptoms, awareness of disease, family burden, process of dying, medical troubles, technical problems). More than 80% of patients were thought to be conscious of their illness, and only 59% had satisfactory control of symptoms, while who did not, mainly COPD patients (50%), required increased use of drugs. 46% of patients died at home, but a large portion (83%) of COPD patients required hospital admission (mainly in ICU) during the last 3 months of life. NIV patients required more technical interventions and settings adjustments than tracheotomized patients (20% and 12 % p=0.038, respectively), irrespective of the diagnosis. Conclusions: Close relatives of home ventilated patients in their last 3 months of life, perceive that most of their beloved have high awareness of prognosis. Symptoms control was not always achieved and COPD patients and those with NIV needed more frequent health care assistance, notwithstanding, half of patients died at home. This report suggests a stronger way forward improvement in the quality of care in terminally-ill ventilated patients.

Crisafulli E, Loschi S, Beneventi C, De Biase A, Tazzioli B, Papetti A, Lorenzi C, Clini E. ( 2010 ) - Learning impact of education during pulmonary rehabilitation program. An observational short-term cohort study - MONALDI ARCHIVES FOR CHEST DISEASE - n. volume 73 (2) - pp. da 64 a 71 ISSN: 1122-0643 [Articolo su rivista - Articolo su rivista]
Abstract

Background: Among the several components integrating a pulmonary rehabilitation (PR) course, education may contribute to the individual’s recognition of symptoms and worsening of the disease. However, the specific gain of education is far to be clearly documented to the health care providers. Aim of our preliminary study was to assess the learning impact of educational sessions (ES) in Chronic Obstructive Pulmonary Disease (COPD) patients referred to standard PR.Methods: Six ES on 3 areas (Symptoms-Therapies, Aids, Mood) were applied during PR at our clinic. The learning effect was prospectively evaluated by a specific questionnaire (ESQ) in 285 COPD patients (age 69±8 years, FEV1 53±14 % pred), then grouped into those who have completed ES (Completers group, n=226) or who did not (mean 2±1 ES) (Control group, n=59). Total and partial ESQ scores, and PR outcomes (6-minute walking test-6MWD, effort-dyspnoea at Medical Research Council scale-MRC, and health-related quality of life scale-SGRQ) were assessed in a pre (T0) to post (Tend) design.Results: Similar improvement in PR outcomes was recorded in both groups at Tend, whereas ESQ total and partial scores significantly increased in Completers only (p<0.001). ESQ-Aids score improved to a greater extent in Completers than in Control (+0.60±1.03 vs +0.27±1.27 point respectively, p=0.036). A higher proportion of Completers improved above the median change of both ESQ total and aids scores (p<0.05).Conclusion: Attending educational sessions produces a specific short-term learning effect during rehabilitation of COPD patients.

E.Crisafulli, E.Clini ( 2010 ) - Measures of dyspnea in pulmonary rehabilitation. - MULTIDISCIPLINARY RESPIRATORY MEDICINE - n. volume 5 (3) - pp. da 202 a 210 ISSN: 1828-695X [Articolo su rivista - Articolo su rivista]
Abstract

Dyspnea is the main symptom perceived by patients affectedby chronic respiratory diseases. It derives from a complex interaction of signals arising in the central nervous system, which is connected through afferent pathway receptors to the peripheral respiratory system (airways, lung, and thorax). Notwithstanding the mechanism that generates the stimulus is always the same, the sensation of dyspnea is often described with different verbal descriptors: these descriptors, or linguistic ‘clusters’, are clearly influenced by socio-individual factors related to the patient. These factors can play an important role in identifying the etiopathogenesis of the underlying cardiopulmonary disease causing dyspnea. The main goal of rehabilitation is to improve dyspnea; hence, quantifying dyspnea through specific tools (scales) is essential in order to describe the level of chronic disability and to assess eventual changes after intervention. Improvements, even if modest, are likely to determine clinically relevant changes (minimal clinically important difference, MCID) in patients.Currently there exist a large number of scales to classify andcharacterize dyspnea: the most frequently used in everydayclinical practice are the clinical scales (e.g. MRC or BDI/TDI, inwhich information is obtained directly from the patients through interview) and psychophysical scales (such as the Borg scale or VAS, which assess symptom intensity in response to a specific stimulus, e.g. exercise).It is also possible to assess the individual’s dyspnea in relationto specific situations, e.g. chronic dyspnea (with scales that classify patients according to different levels of respiratorydisability); exertional dyspnea (with tools that can measure the level of dyspnea in response to a physical stimulus); and transitional (or ‘follow up’) dyspnea (with scales that measure the effect in time of a treatment intervention, such as rehabilitation).

Clini E, Crisafulli E, Ambrosino N. ( 2010 ) - Non-invasive ventilation in chronic obstructive pulmonary disaese (chapter 23). In: Elliott M, Nava S, Schonhofer B. (eds) Non-inavsive Ventilation and Weaning: principles and practice. - Arnold-Hodder, London (UK). London GBR) - pp. da 228 a 235 ISBN: 00100 [Monografia o trattato scientifico - Monografia/Trattato scient. con ISBN]
Abstract

Advanced chronic obstructive pulmonary disease (COPD) is associated with peripheral and respiratory muscular weakness with nocturnal and daytime arterial blood gases abnormalities (including hypercapnia) leading to chronic respiratory failure (CRF). At present, long-term oxygen-therapy (LTOT) is the only recognized long-term treatment that has been shown to significantly improve survival in these patients. An alternative therapeutic approach proposed, especially in patients with worsening hypercapnia, is nocturnal non-invasive ventilation (NIV). The three main theories that explain the efficacy of NIV, as applied by positive pressure (NIPPV), in these patients are:opportunity for resting of fatigued respiratory muscles, improvement in thoracic-pulmonary mechanics, and the ‘resetting’ of the central respiratory drive. In contrast with the strong evidence favouring the use of NIV in acute exacerbation of COPD, many studies performed in severe but stable patients have shown inconsistent and conflicting results. In the short term, NIV has been shown to reduce the rate of hospitalization, as well as to improve both the patient’s quality of life and their functional status. However, long-term assessments did not find any effect on survival and the strongest outcomes were not affected by the use of NIPPV even when added to LTOT.Recommendations of an international consensus conference published in 1999 provided the basis for NIV prescription in stableadvanced COPD patients – nocturnal hypoventilation, sleep fragmentation and daytime arterial hypercapnia; which are stillconsidered the optimal indications for domiciliary NIV, in particular in the presence of severe-progressive deterioration of the clinical condition and instability of respiratory function.

Donini LM, Cuzzolaro M, Spera G, Badiali M, Basso N, Bollea MR, Bosello O, Brunani A, Busetto L, Cairella G, Cannella C, Capodaglio P, Carbonelli MG, Castellaneta E, Castra R, Clini E, Contaldo F, Dalla Ragione L, Dalle Grave R, D'Andrea F, Del Balzo V, De Cristofaro P, Di Flaviano E, Fassino S, Ferro AM, Forestieri P, Franzoni E, Gentile MG, Giustini A, Jacoangeli F, Lubrano C, Lucchin L, Manara F, Marangi G, Marcelli M, Marchesini G, Marri G, Marrocco W, Melchionda N, Mezzani B, Migliaccio P, Muratori F, Nizzoli U, Ostuzzi R, Panzolato G, Pasanisi F, Persichetti P, Petroni ML, Pontieri V, Prosperi E, Renna C, Rovera G, Santini F, Saraceni V, Savina C, Scuderi N, Silecchia G, Strollo F, Todisco P, Tubili C, Ugolini G, Zamboni M. ( 2010 ) - Obesity and eating disorders. Indications for the different levels of care. An italian Expert Consensus Document - EATING AND WEIGHT DISORDERS - n. volume 15 (suppl.1-2) - pp. da 1 a 31 ISSN: 1124-4909 [Articolo su rivista - Articolo su rivista]
Abstract

This paper is an Italian Expert Consensus Document on multidimensional treatment of obesity and eating disorders. The Document is based on a wide survey of expert opinion. It presents, in particular, considerations regarding how clinicians go about choosing the most appropriate site of treatment for a given patient suffering from obesity and/or eating disorders: outpatient, partial hospitalization, residential rehabilitation centre, inpatient hospitalization. In a majority of instances obesity and eating disorders are long-term diseases and require a multiprofessional team-approach. In determining an initial level of care or a change to a different level of care, it is essential to consider together the overall physical condition, medical complications, disabilities, psychiatric comorbidity, psychology, behaviour, family, social resources, environment, and available services. We first created a review manuscript, a skeleton algorithm and two rating scales, based on the published guidelines and the existing research literature. As the second point we highlighted a number of clinical questions that had to be addressed in the specific context of our National Health Service and available specialized care units. Then we submitted eleven progressive revisions of the Document to the experts up to the final synthesis that was approved by the group. Of course, from point to point, some of the individual experts would differ with the consensus view. The document can be viewed as an expert consultation and the clinical judgement must always be tailored to the particular needs of each clinical situation. We will continue to revise the Document periodically based on new research information and on reassessment of expert opinion to keep it up-to-date. The Document was not financially sponsored.

M.Confalonieri, C.Torregiani, E.Clini ( 2010 ) - Sindrome da distress respiratorio acuto (cap. 21). In: Rugarli C. (ed) Trattato di Medicina Interna. - Masson Milano ITA) - pp. da 551 a 555 ISBN: 9780070002012 [Monografia o trattato scientifico - Monografia/Trattato scient. con ISBN]
Abstract

Trattazione della fisiopatologia, clinica e intervento terapeutico razionale nelle sindromi ipossiemiche dell'adulto.

E.Venturelli, E.Crisafulli, A.De Biase, C.Lorenzi, E.Clini. ( 2010 ) - The role of pre- and post rehabilitation in lung resection surgery - MINERVA PNEUMOLOGICA - n. volume 49 - pp. da 65 a 72 ISSN: 0026-4954 [Articolo su rivista - Articolo su rivista]
Abstract

Pulmonary Rehabilitation (PR) is a non-pharmacologic hospital-based multidisciplinary and comprehensive intervention aimed at reducing disability of candidates. The surgical patient may per se represent a “serious” patient to be evaluated with the scope to be included in rehabilitation. Indeed, it is clear from the clinical experience that a considerable proportion of patients undergoing thoracic surgery may have a increased risk for severe postoperative pulmonary complications and/or death. Notwithstanding, relevance of PR in special conditions such as pre-post abdominal and or thoracic surgery is not widely valuable. In this review we would like to emphasize both the rationale and the activities of a pre- or post rehabilitation program dedicated to candidates to lung resection. We deal with selection of candidates, role of rehabilitation and the most popular applied techniques in this clinical area.At present PR, which is known to hasten respiratory patients’ physical performance, may be of benefit in patients who have to undergo lung resection surgery and also may improve respiratory functions in their postoperative period. However, further research is urgent in order to consider priorities of PR application in this field.

E.M. Clini, E. Crisafulli, S. Costi, G. Rossi, C. Lorenzi, L.M. Fabbri, N. Ambrosino ( 2009 ) - Effects of early inpatient rehabilitation after acute exacerbation of COPD - RESPIRATORY MEDICINE - n. volume 103 - pp. da 1526 a 1531 ISSN: 0954-6111 [Articolo su rivista - Articolo su rivista]
Abstract

We have undertaken an observational retrospective cohort study to assess feasibility and clinical effectiveness of early rehabilitation in patients recovering from acute exacerbation of COPD (AECOPD). A cohort of 1826 inpatients (73% male, age 70+/-8 yrs, FEV(1) 50+/-16% pred.) admitted to a pulmonary rehabilitation (PR) program and completing at least 15 sessions were divided into categories according to their dyspnoea grade (Medical Research Council--MRC scores 2-5) as assessed before AECOPD. The pre-post changes in 6-minute walking distance (6MWD) test, perceived end-effort dyspnoea (Borg scale), and self-reported quality of life (St. George's respiratory Questionnaire: SGRQ) were measured throughout. Absolute change in 6MWD (52 [95%CI 45-59], 65 [95%CI 60-70], 63 [95%CI 59-66], and 70 [95%CI 67-74] meters in MRC 2-5 respectively) and the percentage of patients achieving the minimal clinically important difference (MCID) of +54 m (40, 55, 57, and 61%, respectively, p=0.001) differed across MRC grades. Proportion of patients able to reach > or = 350 m at the 6MWD after PR was higher in MRC 4 and 5 (18 and 22%) as compared to MRC 2 and 3 (6 and 15%). Early PR in a cohort of AECOPD patients is feasible and it is associated to clinically meaningful improvement in exercise tolerance independent on the severity of dyspnoea. The proportion of patients reaching the limit of > or = 350 m after this intervention is higher in the most severe patients.

Enrico M.Clini, Ernesto Crisafulli, Stefania Costi, Giuseppina Rossi, Cristina Lorenzi, Leonardo M.Fabbri, Nicolino Ambrosino. ( 2009 ) - Effects of early inpatient rehabilitation after acute exacerbation of COPD - RESPIRATORY MEDICINE - n. volume 103 - pp. da 1526 a 1531 ISSN: 1745-0454 [Articolo su rivista - Articolo su rivista]
Abstract

We have undertaken an observational retrospective cohort study to assess feasibility and clinical effectiveness of early rehabilitation in patients recovering from acute exacerbation of COPD (AECOPD).A cohort of 1826 inpatients (73% male, age 70±8 yrs, FEV1 50±16% pred.) admitted to a pulmonary rehabilitation (PR) program and completing at least 15 sessions were divided into categories according to their dyspnoea grade (Medical Research Council -MRC scores 2 to 5) as assessed before AECOPD. The pre-post changes in 6 minute walking distance test (6MWD), perceived end-effort dyspnoea (Borg scale), and self-reported quality of life (St George respiratory Questionnaire: SGRQ) were measured throughout. Absolute change in 6MWD (52 [95%CI 45 to 59], 65 [95%CI 60 to 70], 63 [95%CI 59 to 66], and 70 [95%CI 67 to 74] meters in MRC-2 to 5 respectively) and the percentage of patients achieving the minimal clinically important difference (MCID) of +54 m (40, 55, 57, and 61%, respectively, p=0.001) differed across MRC grades. Proportion of patients able to reach ≥350 m at the 6MWD after PR was higher in MRC 4 and 5 (18 and 22%) as compared to MRC 2 and 3 (6 and 15%). Early PR in a cohort of AECOPD patients is feasible and it is associated to clinically meaningful improvement in exercise tolerance independent on the severity of dyspnoea. The proportion of patients reaching the limit of ≥350 m after this intervention is higher in the most severe patients.

Stefania Costi, Ernesto Crisafulli, Francesca Degli Antoni, Claudio Beneventi, Leonardo M.Fabbri, Enrico M.Clini ( 2009 ) - Effects of unsupported upper extremity training in patients with chronic airway obstruction: a randomized clinical trial. - CHEST - n. volume 136 - pp. da 387 a 395 ISSN: 0012-3692 [Articolo su rivista - Articolo su rivista]
Abstract

Introduction: Recent guidelines on pulmonary rehabilitation (PR) recommend upper extremity exercise training (UEET) in patients with chronic obstructive pulmonary disease (COPD). However, literature still questions the effectiveness of systematic UEET in this population.Objective: We aimed to verify the effects of unsupported UEET on functional exercise capacity, ability to perform activities of daily living (ADL) and symptoms perceived during activities involving upper extremity in COPD patients.Methods: We conducted a randomized trial comparing the effects of unsupported UEET plus PR (Intervention) to those of PR alone (Control). Change in 6-minute ring test (6MRT) was the primary outcome; ADL field test (4 shuttle stations), dyspnea score as assessed by Medical Research Council (MRC) scale, London Chest Activity of Daily Living scale (LCADL), and 6-minute walked distance (6MWT) served as secondary outcomes of the study . Results: Fifty COPD patients were consecutively randomized into the two groups and completed the study. At the end of rehabilitation period, 6MRT specifically improved in Intervention (p<0.001) but not in Control group; number of rings moved at 6MRT, shuttles completed at the ADL field test, 6MWT and MRC significantly and greatly changed (p<0.01) in Intervention as compared with Control group. At 6-month follow-up, rings moved at 6MRT (p=0.039) and LCADL (p=0.001) were still significantly better in Intervention as compared with Control group.Conclusion: Our trial corroborates the effectiveness of unsupported UEET in specifically improving functional exercise capacity of COPD patients. Moreover, it also provides evidence that this training modality may ameliorate and maintain the patients’ autonomy over and above standard PR.

Brunelli A,Charloux A, Bolliger CT, Rocco G, Sculier JP, Varela G, Licker MJ, Ferguson MK, Faivre-Finn C, Huber RM, Clini EM, Win T, De Ruysscher D, Goldman L, on behalf of the European Respiratory Society and European Society of Thoracic Surgeons joint task force on fitness for radical therapy. ( 2009 ) - ERS-ESTS guidelines on fitness for surgery and radiochemotherapy in lung cancer patients. - EUROPEAN RESPIRATORY JOURNAL - n. volume 34 - pp. da 17 a 41 ISSN: 0903-1936 [Articolo su rivista - Articolo su rivista]
Abstract

The European Respiratory Society (ERS), in collaboration with the European Society of Thoracic Surgery (ESTS), has proposed to bring together multidisciplinary experts on functional evaluation of lung cancer patients to draw up recommendations in order to provide clinicians with clear, up-to-date guidelines on fitness for surgery and chemo-radiotherapy.The subject was divided in different topics, which were in turn assigned to at least two experts. The authors searched the literature according to their own strategies, no central literature review being performed. The draft reports written by the experts on each topic were reviewed, discussed and voted by the entire expert panel. The evidence supporting each recommendation was summarized, and graded as described by the Scottish intercollegiate Guidelines Network Grading Review Group. Clinical practice guidelines were generated and finalized in a functional algorithm for risk-stratification of the lung resection candidatesemphasizing cardiologic evaluation, systematic carbon monoxide lung diffusion capacity and exercise testing. Contrary to lung resection, for which the scientific evidences are more robust, we were unable to recommend any specific test, cut-off value, or algorithm before radio-chemotherapy due to the lack of data. We recommend that lung cancer patients should be managed in specialized settings by multidisciplinary teams.

Clini EM, Crisafulli E ( 2009 ) - Exercise Capacity as a Pulmonary Rehabilitation Outcome - RESPIRATION - n. volume 77 - pp. da 121 a 128 ISSN: 0025-7931 [Articolo su rivista - Articolo su rivista]
Abstract

Disabled patients with chronic respiratory disease and peripheral skeletal muscle disorders have limitations in their exercise capacity, which may be improved after specific training in a pulmonary rehabilitation (PR) program. Individual assessment of exercise capacity by clinically available exercise tests represents an important patient-centered outcome that should be embedded in the rehabilitation process. These measurements include laboratory (treadmill and/or cycle ergometer) and field (walking) tests. The cardiopulmonary exercise test, both performed with incremental (incremental-load test) or predetermined (constant-load or endurance test) loading, is an excellent means to describe the profile of an individual's maximal exercise capacity and to record its change after PR. Among the variety of field-based tests, 6-min walking and shuttle walking are 2 simple tests widely used during PR. These tests are inexpensive and provide information on an individual's functional abilities: the 6-min walking test has been shown to provide level of disability and functional status, whereas the shuttle walking test has been shown to be more suitable to detect change of physical performance following PR. Overall, several available physiologically targeted tests are useful to measure the patient's tolerance to exercise, and many are even sensitive to change once intervention has taken place. In particular, endurance modality tests seem to provide better measurement of changes after PR than incremental exercise tests.

Clini E, Lugli D, Prato F, Crisafulli E. ( 2009 ) - Long-Term Weight Loss and Maintenance in Morbidly Obese Individuals with Obstructive Sleep Apnea. (letter) - AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE - n. volume 180 - pp. da 190 a 191 ISSN: 1073-449X [Articolo su rivista - Articolo su rivista]
Abstract

Non disponibile

A.Charloux, A.Brunelli, CT.Bolliger, G.Rocco, JP.Sculier, G.Varela M.Licker, MK.Ferguson, C.Faivre-Finn, R.Huber, E.Clini, T.Win, D.De Ruysscher, L.Goldman, on behalf of the European Respiratory Society and European Society of Thoracic Surgeons Joint Task Force on Fitness for Radical Therapy ( 2009 ) - Lung function evaluation before surgery in lung cancer patients: how are recent advances put into practice ? - INTERACTIVE CARDIOVASCULAR AND THORACIC SURGERY - n. volume 9 (6) - pp. da 925 a 931 ISSN: 1569-9293 [Articolo su rivista - Articolo su rivista]
Abstract

Objective: This survey in preparation of the task force work investigated how the recent advances in pre-operative assessment of lung cancer patients have been put into practice among the European Society of Thoracic Surgeons (ESTS) and of the Thoracic Oncology Section of the European Respiratory Society (ERS). Methods: A web-based questionnaire was designed by the ERS/ESTS Task Force on Fitness for Radical Therapy in Lung Cancer Patients and sent to all members of the ESTS and of the ERS thoracic oncology section. Results: Two hundred sixty five physicians responded and 179 completely answered the questionnaire. Most of them (72%) were surgeons and worked in academic hospitals. Forty-two percent answered that the pre-op work-up is planned by a multidisciplinary team and 33% followed published recommendations. Only 30% of respondents use recommended cardiac indexes to stratify cardiac risk before lung resection. One third of participants assess DLCO in all patients although 75% think DLCO is a strong predictor of outcomes. About 80% of respondents think exercise tests have an important role in the decision to operate or not, but an integrated cardio-pulmonary exercise test is performed in only 0-30% of cases by about 80% of respondents. Exercise tests are prescribed by most physicians in patients with low predicted post-operative FEV1 or DLCO. Low-technology tests are of wide interest (only 7% never perform them) but various tests are used with various indications. Regarding patients’care management, 80% of physicians use physiotherapy before or after lung surgery and most of them assign many advantages to pulmonary rehabilitation. Eighty percent of respondents think that patients should be admitted to intensive care units after pneumonectomy. Almost 90% of participants emphasize that the ability to predict impairment of quality of life is an appropriate goal for future studies. Finally, about 70% of respondents stated that lung cancer patients should be treated only in specialized centres. Conclusions: This survey provides a snapshot of the opinion of more than 200 specialists from 38 countries regarding the management of patients with potentially resectable lung cancer. The results identify a lack of consensus in some areas as well as the difficulties of putting some recommendations into practice.

E.Polverino, S.Nava, M.Ferrer, P.Ceriana, E.Clini, E.Spada, E.Zanotti, L.Trianni, L.Barbano, C.Fracchia, B.Balbi, M.Vitacca. ( 2009 ) - Patients’ characterization, hospital course and clinical outcomes in five Italian Respiratory Intensive Care Units - INTENSIVE CARE MEDICINE - n. volume 36 - pp. da 137 a 142 ISSN: 0342-4642 [Articolo su rivista - Articolo su rivista]
Abstract

Background: Respiratory intensive care units (RICU) dedicated to weaning could be suitable facilities for clinical management of “post-ICU” patients Methods: We retrospectively analyzed the time course of patients' characteristics, clinical outcomes and sanitary staff utilization in 5 Italian RICU by comparing 3 periods of 5 consecutive years (from 1991 to 2005). Results: 3,106 patients (age, 76±4 yrs; 72% males) were analyzed. The number of co-morbidities per patient (from 1.8 to 3.0, p=0.05) and the previous intensive care unit stay (from 25 to 32 days, p=0.002) increased over time. The doctor-to-patients ratio significantly decreased over time (from 1:3 to 1:5, p<0.01) while the physiotherapist-to-patients ratio mildly increased (from 1:6 to 1:4.5, p<0.05). The overall weaning success rate decreased (from 87% to 66%, p<0.001) and the discharge destination changed (p<0.001) over time; less patients were discharged to home (from 22% to 10%), and more patients to nursing home (from 3% to 6%), acute hospitals (from 6% to 10%) and rehabilitative units (from 70% to 75%). The mortality rate increased over time (from 9% to 15%). Significant correlations between the doctor-to-patients ratio and the rates of weaning success (r=0.679, p=0.005), home discharge (r=0.722, p=0.002), and the RICU length of stay (LOS) (r=-0.683, p=0.005) were observed.Conclusions: The clinical outcomes of our units worsened over 15 years, likely as consequence of admitting more severely-ill patients. The potential negative influence of reduced medical staff availability on weaning success, home discharge and LOS warrants further prospective investigations.

S.Costi, M.Di Bari, P.Pillastrini, R.D’Amico, E.Crisafulli, C.Arletti, L.M.Fabbri, E.M.Clini ( 2009 ) - Short-Term Efficacy of Upper-Extremity Exercise Training in Patients With Chronic Airway Obstruction: A Systematic Review. - PHYSICAL THERAPY - n. volume 89 - pp. da 443 a 455 ISSN: 0031-9023 [Articolo su rivista - Articolo su rivista]
Abstract

Background, Objectives, and Measurements Patients with chronic airway obstruction (CAO) frequently experience dyspnea and fatigue during activities performed by accessory muscles of ventilation, which competitively participate in arm elevation. This systematic review of randomized controlled trials (RCTs) concerning patients with CAO addresses the effects of upper-extremity exercise training (UEET), added to lower-extremity training or comprehensive pulmonary rehabilitation, on the following patient-centered outcomes: exercise capacity, symptoms, ability to perform daily activities, and health-related quality of life. METHODS:/b> Studies were retrieved using comprehensive database and hand-search strategies. Two independent reviewers determined study eligibility based on inclusion criteria. A detailed description of treatments was mandatory. Reviewers rated study quality and extracted information on study methods, design, intervention, and results. RESULTS: /b> Forty publications were evaluated. Four RCTs met the inclusion criteria but had serious methodological limitations, which introduce possible biases that reduce their internal validity. The outcomes measured were heterogeneous, and the results were inconsistent regarding maximal exercise capacity, dyspnea, and health-related quality of life. No effect of UEET was demonstrated for measures of arm fatigue. Limitations and CONCLUSIONS:/b> The limited methodological quality of the studies retrieved prevented us from performing a meta-analysis, the results of which could be misleading. This systematic review shows that there is limited evidence examining UEET and that the evidence available is of poor quality. Therefore, a recommendation for the inclusion or exclusion of UEET in pulmonary rehabilitation programs for individuals with CAO is not possible. Further research is needed to definitively ascertain the effects of this training modality on patient-centered outcomes.

S. Costi, M. Di Bari, P. Pillastrini, R. D'Amico, E. Crisafulli, C. Arletti, L.M. Fabbri, E.M. Clini ( 2009 ) - Short-term efficacy of upper-extremity exercise training in patients with chronic airway obstruction: a systematic review - PHYSICAL THERAPY - n. volume 89 - pp. da 443 a 455 ISSN: 0031-9023 [Articolo su rivista - Articolo su rivista]
Abstract

Background, Objectives, and Measurements: Patients with chronic airway obstruction (CAO) frequently experience dyspnea and fatigue during activities performed by accessory muscles of ventilation, which competitively participate in arm elevation. This systematic review of randomized controlled trials (RCTs) concerning patients with CAO addresses the effects of upper-extremity exercise training (UEET), added to lower-extremity training or comprehensive pulmonary rehabilitation, on the following patient-centered outcomes: exercise capacity, symptoms, ability to perform daily activities, and health-related quality of life.Methods: Studies were retrieved using comprehensive database and hand-search strategies. Two independent reviewers determined study eligibility based on inclusion criteria. A detailed description of treatments was mandatory. Reviewers rated study quality and extracted information on study methods, design, intervention, and results.Results: Forty publications were evaluated. Four RCTs met the inclusion criteria but had serious methodological limitations, which introduce possible biases that reduce their internal validity. The outcomes measured were heterogeneous, and the results were inconsistent regarding maximal exercise capacity, dyspnea, and health-related quality of life. No effect of UEET was demonstrated for measures of arm fatigue.Limitations and Conclusions: The limited methodological quality of the studies retrieved prevented us from performing a meta-analysis, the results of which could be misleading. This systematic review shows that there is limited evidence examining UEET and that the evidence available is of poor quality. Therefore, a recommendation for the inclusion or exclusion of UEET in pulmonary rehabilitation programs for individuals with CAO is not possible. Further research is needed to definitively ascertain the effects of this training modality on patient-centered outcomes.

Crisafulli E, Manni G, Kidonias M, Trianni L, Clini E. ( 2009 ) - Subjective sleep quality during average volume assured pressure support (AVAPS) ventilation in patients with hypercapnic COPD. A Physiological Pilot Study. - LUNG - n. volume 187 - pp. da 299 a 305 ISSN: 0341-2040 [Articolo su rivista - Articolo su rivista]
Abstract

Non-invasive Positive Pressure Ventilation (NPPV) is an advanced treatment (1) aimed to improve both physiological (2-4) and clinical outcomes (5-7), including sleep (8-10), during the long-term management of patients with Chronic Respiratory Failure (CRF) due to severe hypercapnic Chronic Obstructive Pulmonary Disease (COPD). Several studies evaluating the nocturnal application of mask ventilation in stable COPD patients (11-13) have shown a limited effectiveness of pressure based modes of NPPV in this patient group. However, further studies have shown that compliance to ventilation may influence the long-term efficacy of this treatment as patients who are compliant with NPPV are able to maintain arterial blood gase (ABG) improvements over 6-months when compared with those who discontinued this therapy (14).A new NPPV modality, called Average Volume Assured Pressure Support (AVAPS), combines both the pressure and volume characteristics of ventilation and, accordingly, delivers a range of inspiratory pressures to guarantee a pre-fixed inspiratory tidal volume. This hybrid mode of ventilation has been studied in intubated patients with acute respiratory failure (15) and in patients with chronic hypoventilation linked to obesity (16,17) and other conditions (16). Under these circumstances AVAPS is able to induce high pulmonary volumes and reduce muscle workload, thus providing physiological benefits and comfort similar to those achieved by pressure support (PS) modes. However, positive effects on sleep quality have not yet been confirmed.This pilot evaluated short-term compliance, night-time efficacy and physiological responses to Average Volume Assured Pressure Support (AVAPS) ventilation in patients with stable hypercapnic COPD.

Brunelli A,Charloux A, Bolliger CT, Rocco G, Sculier JP, Varela G, Licker MJ, Ferguson MK, Faivre-Finn C, Huber RM, Clini E, Win T, De Ruysscher D, Goldman L. ( 2009 ) - The European Respiratory Society and European Society of Thoracic Surgeon guidelines for evaluating fitness for radical treatment (surgery and chemoradiotherapy) in patients with lung cancer. - EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY - n. volume 36 - pp. da 181 a 184 ISSN: 1010-7940 [Articolo su rivista - Articolo su rivista]
Abstract

The European Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS) established a joint task force with the purpose to develop clinical evidence-based guidelines on evaluation of fitness for radical therapy in patients with lung cancer. The following topics were discussed, and are summarized in the final report along with graded recommendations: Cardiologic evaluation before lung resection; lung function tests and exercise tests (limitations of ppoFEV1; DLCO: systematic or selective?; split function studies; exercise tests: systematic; low-tech exercise tests; cardiopulmonary (high tech) exercise tests); future trends in preoperative work-up; physiotherapy/rehabilitation and smoking cessation; scoring systems; advanced care management (ICU/HDU); quality of life in patients submitted to radical treatment; combined cancer surgery and lung volume reduction surgery; compromised parenchymal sparing resections and minimally invasive techniques: the balance between oncological radicality and functional reserve; neoadjuvant chemotherapy and complications; definitive chemo and radiotherapy: functional selection criteria and definition of risk; should surgical criteria be re-calibrated for radiotherapy?; the patient at prohibitive surgicalrisk: alternatives to surgery; who should treat thoracic patients and where these patients should be treated?

E. M. Clini, P. Siddu, L. Trianni, R. Graziosi, E. Crisafulli, M. T. Nobile ( 2008 ) - Activity and analysis of costs in a dedicated weaning centre. - MONALDI ARCHIVES FOR CHEST DISEASE - n. volume 69 - pp. da 55 a 58 ISSN: 1122-0643 [Articolo su rivista - Articolo su rivista]
Abstract

AIM: To analyse the diagnosis-related characteristics and the costs of treating patients with difficult/prolonged weaning from mechanical ventilation we have undertaken a retrospective observational study. METHODS: The study has considered all the patients admitted to our weaning unit of a regional Rehabilitation department during 3 consecutive periods since the opening date. Characteristics of the admitted patients and the DRG-related cares delivered have been recorded. A cost analysis has been obtained over time. RESULTS: The number of beds allocated to this unit (from 4 in the 1st period to 6 in the 2nd and 3rd periods) and the number of patients cared for (from 32 to 43 and to 65, respectively) increased over time. In particular, the COPD to non-COPD patient ratio (from 2.2 to 1.3 and to 1.0) and the DRG/patient weight (from 3.0 +/- 0.3 to 3.1 +/- 0.2 and to 3.3 +/- 0.2 point) changed significantly (p < 0.05). The daily reimbursement per patient from the public health care system only slightly increased, whereas the operating margin (reimbursement less costs) per patient significantly improved (from -304, to +17 and +55 Euro/pt/day, respectively, p < 0.05) due to a gradual restriction in the variable costs. Length of stay, mortality rate and weaning rate did not change over time. CONCLUSION: The weaning centre is a hospital area where economic burdens should be carefully evaluated. Given the actual reimbursement received on a national level for these patients, variable costs might be better spread, thus optimising the burdens without losing out on clinical outcomes.

E.Clini, F.Degli Antoni, S.Costi, L.Trianni ( 2008 ) - Commencing rehabilitation in the ICU. - MULTIDISCIPLINARY RESPIRATORY MEDICINE - n. volume 3 (3) - pp. da 207 a 210 ISSN: 1828-695X [Articolo su rivista - Articolo su rivista]
Abstract

Rehabilitation is an integral part of the management of patients inIntensive Care Units (ICUs).The most important aim in this area isto enhance the patient's overall functional capacity and to restorehis/her respiratory and physical independence, thus decreasing the risks of bed-rest and associated complications.The evidence for applying a weaning protocol and physiotherapytechniques (postures, percussion/vibration, limb exercise, and active mobilization) in these patients has proved to be effective according to the application rationale of each process. However, todate, there are only strong recommendations concerning the evidence-based strategies to speed weaning from mechanical ventilation.Early physiotherapy may be effective in the ICU: nonetheless,most techniques need to be further studied in a wider population.In particular, evidence supporting physiotherapy interventionsis limited as there are no studies examining the specific effectsof interventions on long-term outcomes.

Clini E, Crisafulli E, Moretti M, Fabbri L. ( 2008 ) - Cost-effectiveness of NIV applied to chronic respiratory failure.(Chapter 26). - ERJ Publishing Sheffield GBR) - pp. da 377 a 391 ISBN: 005 [Monografia o trattato scientifico - Monografia/Trattato scient. con ISBN]
Abstract

The expansion of HMV in the last 15 yrs was stimulated by the introduction of non-invasive mask ventilation and the recognition that more patient groups could benefit.In the management of health-care resources the costs-analysis currently represents a method to evaluate the expenditure due to the effects on health of a new (or specific) intervention and to assess it in the economic perspective. Disability-adjusted life years (DALYs), healthy year equivalents (HYEs), or quality-adjusted life years (QALYs) are all time-based measures of health that include the impact of interventions on years of life lost due to premature mortality and years of life lived with a non-fatal health outcome, weighted by the severity of that outcome.Despite effectiveness of non-invasive HMV has been addressed so far, the impact of this treatment on the overall costs is not clearly reported nor still demonstrated and very few data based on a true economic analysis in patients under non-invasive HMV are published. Direct and (partially) indirect cost calculation have been observed and reported especially in COPD patients under non-invasive HMV. The most recent data underlie the large impact of non-invasive HMV on both patients’ outcome (reduction of recurrent admissions and increase in quality of life) and families’ burden (unemployment, financial and social issues), thus prompting new studies with appropriate cost-effectiveness and/or cost-utility analysis.

Enrico M Clini, Giovanna Magni, Ernesto Crisafulli, Stefano Viaggi, Nicolino Ambrosino ( 2008 ) - Home non-invasive mechanical ventilation and long-term oxygen therapy in stable hypercapnic chronic obstructive pulmonary disease patients: comparison of costs. - RESPIRATION - n. volume 77 - pp. da 44 a 50 ISSN: 0025-7931 [Articolo su rivista - Articolo su rivista]
Abstract

BACKGROUND: A cost analysis of nocturnal non-invasive ventilation (NNV) in stable chronic obstructive pulmonary disease (COPD) patients would be helpful in decision making, when the balance between the increased demand and the availability of resources should be checked. OBJECTIVES: Based on data from the Italian trial in stable hypercapnic COPD patients, this study compares the cost of care associated with the use of NNV when added to the usual long-term oxygen therapy (LTOT) with the cost of care of LTOT regimen alone. METHODS: Cost was calculated in 77 of 90 patients included into that trial. Analysis included drug therapy, hospitalisations due to acute exacerbation, oxygen and ventilator equipment. An estimation of charges was made according to the national sources of cost for drugs and hospital admissions and the actualised reimbursement for the home care provided to both oxygen and ventilator users. The cost/day comparison was made between the individual patients in the 2 groups (NNV + LTOT, n = 35; LTOT, n = 42). RESULTS: The mean cost of drugs and oxygen was similar in both groups, whereas the cost of hospitalisation tended to be lower in NNV + LTOT compared to LTOT alone (8.25 +/-10.29 vs. 12.50 +/- 20.28 EUR/patient/day, p < 0.05). Inclusion of the ventilator equipment increased the total cost to 23.73 EUR/day in the NNV + LTOT compared to 21.42 EUR/day in the LTOT group (not significant). CONCLUSIONS: The present report suggests that long-term management with addition of non-invasive ventilation does not increase costs compared with the usual LTOT regimen: the hospital-related costs were reduced when using the ventilator in these hypercapnic COPD patients.

Riccardo Tumiati, Gianni Mazzoni, Ernesto Crisafulli, Barbara Serri, Claudio Beneventi, Cristina M Lorenzi, Giovanni Grazzi, Francesco Prato, Francesco Conconi, Leonardo M Fabbri, Enrico M Clini ( 2008 ) - Home-centred physical fitness programme in morbidly obese individuals: a randomized controlled trial - CLINICAL REHABILITATION - n. volume 22 - pp. da 940 a 950 ISSN: 0269-2155 [Articolo su rivista - Articolo su rivista]
Abstract

OBJECTIVE: To assess the effectiveness of domiciliary physical fitness programmes in obese individuals. DESIGN: Nine-month randomized controlled trial. SETTING: Home-based intervention with outpatient visits. SUBJECTS: Morbidly obese subjects (body mass index (BMI) > or = 30) aged 25-65 years suitable for physical activities at home. INTERVENTION: At the end of a preliminary one-month in-hospital rehabilitation programme (baseline), 52 patients were randomly assigned either to a structured educational programme (intervention group) of daily incremental physical activity at home (walking and skeletal muscle resistance training, with booklets and written instructions) or to a programme of general advice (control group) regarding exercise and long-term fitness. MAIN MEASURES: Both groups were evaluated at baseline and every three months for: (1) time, metabolic equivalents (METs), and heart rate reserve (HRR) during a standardized 2-km walking test (2kmWT); (2) anthropometric measures (body weight, BMI, abdominal and neck circumference); (3) the Polar Fitness Test index (PFTI), and (4) time to exhaustion while sustaining consecutive isoload extensions in the dominant leg (isoload LE). Time during 2kmWT was the study primary outcome. RESULTS: Body weight, BMI and abdominal circumference improved significantly (P < 0.05) over time in the intervention group. The cardiopulmonary fitness variables changed significantly (P < 0.05) over time in both study groups. However, all variables improved in the intervention patients, while some worsened or remained stable in the controls. Thus, the mean group difference in changes was significant (P < 0.05) for 2kmWT time (-77.4 seconds), HRR (11.7\%), and PFTI (5.4 points). CONCLUSION: This structured domiciliary fitness programme is feasible and provides sustained anthropometric and physiological benefits in some morbidly obese individuals.

E. Clini, N.Ambrosino ( 2008 ) - Indications and physiological basis of rehabilitation in ICU. (Chapter 9) (Ambrosino N, Goldstein RS. Eds - Ventilatory support for Chronic Respiratory Failure. - INFORMA HEALTHCARE NEW YORK USA) - pp. da 125 a 133 ISBN: 9780849384981 [Contributo in volume (Capitolo o Saggio) - Capitolo/Saggio con ISBN]
Abstract

Not available

Clini E, Ambrosino N. ( 2008 ) - Indications and physiological basis of rehabilitation in ICU. In: Ambrosino N, Goldstein RS. (eds) Ventilatory support for Chronic Respiratory Failure. - Informa Healthcare New York USA) - pp. da 125 a 133 ISBN: 004 [Monografia o trattato scientifico - Monografia/Trattato scient. con ISBN]
Abstract

Description of new approach to early physiotherapy in severy ill patients admitted to intensive care areas.

E. M. Clini, N. Ambrosino ( 2008 ) - Nonpharmacological treatment and relief of symptoms in COPD. - EUROPEAN RESPIRATORY JOURNAL - n. volume 32 - pp. da 218 a 228 ISSN: 0903-1936 [Articolo su rivista - Articolo su rivista]
Abstract

Evidence-based guidelines for chronic obstructive pulmonary disease (COPD) have recently been developed. Nonpharmacological treatments have evolved rapidly as an essential part of COPD therapy. They are especially important as complementary interventions in severe or very severe disease, when there is loss in function, a reduction in quality of life and when psychological impairments further complicate the disease. The present article discusses the most used nonpharmacological treatments for severe COPD patients (rehabilitation, long-term oxygen therapy, surgery, noninvasive positive pressure ventilation and supportive nutrition) and their evidence-based usefulness in promoting strategies that relieve symptoms. All of these interventions are used during end-stage disease, to promote self-efficacy, relieve symptoms and prevent further deterioration. These therapeutic options support physicians and allied professionals in improving symptom management for their patients.

E. Clini, L. Trianni, N. Ambrosino ( 2008 ) - Nutrition in the ICU. (Ambrosino N, Goldstein RS. Eds - Ventilatory support for Chronic Respiratory Failure. - INFORMA HEALTHCARE NEW YORK USA) - pp. da 399 a 413 ISBN: 9780849384981 [Contributo in volume (Capitolo o Saggio) - Capitolo/Saggio con ISBN]
Abstract

Not available

Clini E, Trianni L, Ambrosino N ( 2008 ) - Nutrition in the ICU. In: Ambrosino N, Goldstein RS. (eds) Ventilatory support for Chronic Respiratory Failure. - Informa Healthcare New York USA) - pp. da 399 a 413 ISBN: 004 [Monografia o trattato scientifico - Monografia/Trattato scient. con ISBN]
Abstract

Description of nutritional support techniques in critically ill individuals. Long-term strategies to implement nutrition at home in chronically ventilated individuals

Piera Ranieri, Angelo Bianchetti, Alessandro Margiotta, Adriana Virgillo, Enrico M Clini, Marco Trabucchi ( 2008 ) - Predictors of 6-month mortality in elderly patients with mild chronic obstructive pulmonary disease discharged from a medical ward after acute nonacidotic exacerbation. - JOURNAL OF THE AMERICAN GERIATRICS SOCIETY - n. volume 56 - pp. da 909 a 913 ISSN: 0002-8614 [Articolo su rivista - Articolo su rivista]
Abstract

OBJECTIVES: To identify clinical outcomes and variables associated with 6-month mortality in very elderly patients admitted for nonacidotic acute exacerbation of chronic obstructive pulmonary disease (AECOPD). DESIGN: Prospective cohort study. SETTING: General medicine acute care ward. PARTICIPANTS: Two hundred forty-four elderly patients with COPD (mean age+/-standard deviation 82+/-7, 55.7\% female) admitted to the hospital because of non-acidotic AECOPD. MEASUREMENTS: Cognitive and mood status and physiological variables were measured. Self-reported comorbidities were assessed using the Charlson Comorbidity Index. In-hospital and long-term mortality and clinical outcomes were recorded. RESULTS: At admission, this elderly population with AECOPD had low cognitive performance (mean Mini-Mental State Examination score 21+/-5), no presence of significant depressive symptoms (Geriatric Depression Scale score 4+/-3), good nutritional status (body mass index (BMI) 25.1+/-5.5), moderate comorbidity (Charlson Comorbidity Index 4.0+/-1.9), high functional disability (Barthel Index (BI) 52+/-34), and moderate severity of acute exacerbation (Acute Physiology and Chronic Health Evaluation (APACHE) II score 9.7+/-4.2). Two hundred twenty-five inpatients with AECOPD were successfully discharged, whereas 15 were transferred to the intensive care unit, and four died in the hospital. The 6-month cumulative mortality rate in discharged patients with AECOPD was 20\%. Multivariate Cox analysis shows that lower BMI (beta=-0.16; 95\% confidence interval (CI)=0.73-0.99), higher APACHE II score (beta=0,17; 95\% CI=1.03-1.36), and lower BI at discharge (beta=-0.02; 95\% CI=0.96-0.99) were independently associated with 6-month mortality. CONCLUSION: Malnutrition, severity of exacerbation and disability status could be identified as risk factors associated with 6-month mortality of elderly patients admitted for nonacidotic AECOPD.

E. Crisafulli, S. Costi, F. Luppi, G. Cirelli, C. Cilione, O. Coletti, L. M. Fabbri, E. M. Clini ( 2008 ) - Role of comorbidities in a cohort of patients with COPD undergoing pulmonary rehabilitation - THORAX - n. volume 63 - pp. da 487 a 492 ISSN: 0040-6376 [Articolo su rivista - Articolo su rivista]
Abstract

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is often associated with other chronic diseases. These patients are often admitted to hospital based rehabilitation programmes. OBJECTIVES: To determine the prevalence of chronic comorbidities in patients with COPD undergoing pulmonary rehabilitation and to assess their influence on outcome. DESIGN: Observational retrospective cohort study. SETTING: A single rehabilitation centre. PATIENTS: 2962 inpatients and outpatients with COPD (73\% male, aged 71 (SD 8) years, forced expiratory volume in 1 s (FEV(1)) 49.3 (SD 14.8)\% of predicted), graded 0, 1 or >/=2 according to the comorbidity categories and included in a pulmonary rehabilitation programme. Measurements: The authors analysed the number of self-reported comorbidities and recorded the Charlson Index. They then calculated the percentage of patients with a predefined positive response to pulmonary rehabilitation (minimum clinically important difference (MCID)), as measured by improvement in exercise tolerance (6 min walking distance test (6MWD)), dyspnoea (Medical Research Council scale) and/or health related quality of life (St George's Respiratory Questionnaire (SGRQ)). RESULTS: 51\% of the patients reported at least one chronic comorbidity added to COPD. Metabolic (systemic hypertension, diabetes and/or dyslipidaemia) and heart diseases (chronic heart failure and/or coronary heart disease) were the most frequently reported comorbid combinations (61\% and 24\%, respectively) among the overall diseases associated with COPD. The prevalence of patients with MCID was different across the comorbidity categories and outcomes. In a multiple categorical logistic regression model, the Charlson Index (OR 0.72 (96\% CI 0.54 to 0.98) and 0.51 (96\% CI 0.38 to 0.68) vs 6MWD and SGRQ, respectively), metabolic diseases (OR 0.57 (96\% CI 0.49 to 0.67) vs 6MWD) and heart diseases (OR 0.67 (96\% CI 0.55 to 0.83) vs SGRQ) reduced the probability to improve outcomes of rehabilitation. CONCLUSIONS: Most patients with COPD undergoing pulmonary rehabilitation have one or more comorbidities. Despite the fact that the presence of comorbidities does not preclude access to rehabilitation, the improvement in exercise tolerance and quality of life after rehabilitation may be reduced depending on the comorbidity.

I. Romagnoli, P. Laveneziana, E. M. Clini, P. Palange, G. Valli, F. de Blasio, F. Gigliotti, G. Scano ( 2008 ) - Role of hyperinflation vs. deflation on dyspnoea in severely to extremely obese subjects. - ACTA PHYSIOLOGICA - n. volume 193 - pp. da 393 a 402 ISSN: 1748-1708 [Articolo su rivista - Articolo su rivista]
Abstract

AIM: To test the hypothesis that obese individuals may either hyperinflate or deflate the lung when exercising. In both cases breathlessness is an inescapable consequence. METHODS: Ventilatory variables, end-expiratory lung volume and end-inspiratory lung volume, and dyspnoea score (Borg scale) were studied in 20 class II-III obese subjects and 14 healthy controls during incremental symptom-limited cycle exercise. RESULTS: Ventilation increased with increasing work rate, in obese and in control subjects; most obese subjects had to increase end-expiratory lung volume to escape from flow limitation; in contrast, like controls, a few subjects deflated the lung on heavy-to-peak exercise. Dyspnoea was equal in degree at anaerobic threshold and peak exercise in obese as in control subjects, and in obese who hyperinflated as in those who deflated the lung. In particular, end-expiratory lung volume at baseline (r = -0.84, P = 0.04) was negatively correlated with changes in Borg score in obese who did not hyperinflate: the lower the former the higher the latter. On the other hand, tidal volume (r = 0.54, P = 0.045) and decrease in inspiratory reserve volume (r = 0.59, P = 0.028) were positively correlated with the Borg score in obese subjects who hyperinflated. No other independent variable correlated with the Borg score. CONCLUSIONS: We conclude that not all obese subjects had to increase end-expiratory lung volume on heavy-to-peak exercise. Changes in dyspnoea for unit changes in ventilation were similar in obese who did hyperinflate as well as in those who did not, suggesting that the increase in respiratory neural drive, associated with an increase in ventilation, is an important source of dyspnoea in obese as well as in control subjects.

E.Clini (Modena), P.Montuschi (Roma), G.Folco (Milano), M.Aiello (Parma) ( 2008 ) - Ruolo dell’Ossido Nitrico esalato nella flogosi polmonare dei pazienti con BPCO [Altro - Partecipazione a progetti di ricerca]
Abstract

Il principale obiettivo di questa unità di ricerca sarà quello di studiare il ruolo del monossido di azoto e della sua modulazione farmacologica nella BPCO mediante misurazione delle concentrazioni di monossido di azoto nell'aria espirata (eNO) in pazienti con BPCO.Il progetto di ricerca sarà articolato in uno studio osservazionale ed in uno studio interventistico.Compiti specifici di questa unità di ricerca saranno:1) reclutamento dei pazienti con BPCO ed esecuzione dello studio osservazionale ed interventistico;2) raccolta di campioni di condensato del respiro, plasma ed urine dai pazienti arruolati negli studi clinici;3) misurazione dell'eNO;4) esecuzione delle prove di funzionalità respiratoria.

Franco Pasqua, Gian Luca Biscione, Girolmina Crigna, Romana Gargano, Vittorio Cardaci, Luigi Ferri, Alfredo Cesario, Enrico Clini ( 2008 ) - Use of functional independence measure in rehabilitation of inpatients with respiratory failure. - RESPIRATORY MEDICINE - n. volume 103(3) - pp. da 471 a 476 ISSN: 1745-0454 [Articolo su rivista - Articolo su rivista]
Abstract

Most outcomes do not deeply express the degree of disability in patients with respiratory failure (RF) following inpatient pulmonary rehabilitation (IPR). The aim of our study was to evaluate the efficacy of an IPR in patients with confirmed COPD and RF using functional independence measure (FIM) that determines the degree of disability experienced by patients and the progress they make during rehabilitation. This scale includes several items: self care, mobility, locomotion, communication and social recognition. Twenty-two patients (age 70+/-2 years, PO(2) 58.18+/-7.63mmHg, PCO(2) 46.82+/-9.11mmHg) were prospectively observed and studied. IPR included respiratory and peripheral muscle training, mucus evacuation techniques, and energy conservation techniques. FIM, Medical Research Council dyspnoea scale (MRC), St. George's Respiratory Questionnaire (SGRQ), and 6-min walking distance (6-MWD) were assessed on admission (pre) and discharge (post) from IPR. After IPR there was a statistically significant improvement (p<0.01) in all the FIM items (total score in self care, mobility, locomotion, social recognition) except for communication. Changes of MRC (pre 4.32+/-0.84; post 3.00+/-1.15, p<0.001), SGRQ (\%) (pre 69.86+/-4.62; post 46.50+/-11.94, p<0.001), and 6-MWD (pre 164.54+/-98.63; post 214.32+/-97.64, p<0.001) paralleled those improvements. An inverse correlation between MRC and FIM (r=-0.5042, p=0.016) was observed. Our preliminary study has shown that the benefits of IPR in COPD with RF do not only translate in dyspnoea, exercise capacity and quality of life but also within neuromotor disabilities as assessed by FIM. Our results warrant future studies in pulmonary rehabilitation using FIM as an outcome measure.

Ernesto Crisafulli, Orietta Coletti, Stefania Costi, Emanuela Zanasi, Cristina Lorenzi, Sasa Lucic, Leonardo M Fabbri, Marco Bertini, Enrico M Clini ( 2007 ) - A 15-Day, Prospective, Parallel, Open-label, Pilot Study on the Effectiveness of Erdosteine In Elderly Patients With Bronchiectasis and Hypersecretion. - CLINICAL THERAPEUTICS - n. volume 29 - pp. da 2001 a 2009 ISSN: 0149-2918 [Articolo su rivista - Articolo su rivista]
Abstract

BACKGROUND: Mucus plugging and hypersecretion have been associated with an increased relative risk of death in patients with bronchiectasis who may or may not have chronic obstructive pulmonary disease (COPD), which is of prognostic relevance in the elderly. However, chest physiotherapy and/or the use of mucoactive agents is considered to be an effective therapeutic model in treating patients with COPD and bronchiectasis. OBJECTIVE: The objective of this study was to test the effectiveness of oral erdosteine in treating elderly patients with bronchiectasis and chronic mucus hypersecretion who have been referred to a pulmonary rehabilitation program. METHODS: In this 15-day, prospective, parallel, open label, pilot study, elderly patients with bronchiectasis, hypersecretion, a noncurrent smoking status, who had been consecutively enrolled at Ospedale Villa Pineta's Pulmonary Rehabilitation Center, Pavullo-Modena, Italy, were randomized into 2 treatment groups. Group 1 consisted of those patients receiving PO erdosteine 225 mg BID and chest physiotherapy; group 2 comprised those patients receiving chest physiotherapy alone. Forced lung volumes, arterial blood gases, respiratory muscle strength, walking capacity (as measured by 6-minute walking test [6MWT]), and visual analog scale (VAS) symptoms (cough and dyspnea) were recorded at enrollment and at the conclusion of the study. Mucus density (MD), mucus purulence (MP), and mucus volume produced (MVP) were assessed using a 3-point scale (0 = best or low; 1 = moderate; and 2 = worst or high) at baseline and at 5-day time points during the study period. All measurements were assessed by personnel blinded and not directly associated with the study administration. RESULTS: Thirty patients (21 [70\%] male and 9 [30\%] female; mean [SD] age, 71 [11] years; and mean [SD] weight, 66 [3] kg) were enrolled. Characteristics were similar in the 2 groups at baseline. At day 15, significant improvements were observed in 6MWT, VAS cough, and VAS dyspnea (P < 0.01) in both groups. However, a significant improvement in forced expiratory volume in 1 second and forced vital capacity (in milliliters) was observed only in group i (0.2 [0.3]; P < 0.05). At day 15, improvement was observed in mean (SD) in MD, MP, and MVP scores for both groups. Significant changes, however, were observed in all 3 measurements in group 1 (-0.80 [0.22], -0.71 [0.51], and 1.01 [0.39], respectively), whereas a significant improvement was observed only in MD (-0.55 [0.44]) and MVP (0.45 [0.62]) in group 2. The improvement in MVP observed in group 1 was significantly better than that observed in group 2 (P < 0.05). CONCLUSION: This pilot study found that a regimen of PO erdosteine 225 mg BID in addition to routine chest physiotherapy provided some physiologic and clinical benefits in the treatment of these elderly patients with bronchiectasis and chronic mucus hyper-secretion.

E. CRISAFULLI, S. COSTI, F. DE BLASIO, G. BISCIONE, F. AMERICI, S. PENZA, E. EUTROPIO, F. PASQUA, L. FABBRI, E.M. CLINI ( 2007 ) - Effects of a walking aid in COPD patients receiving oxygen therapy - CHEST - n. volume 131 - pp. da 1068 a 1074 ISSN: 0012-3692 [Articolo su rivista - Articolo su rivista]
Abstract

STUDY OBJECTIVES: To elucidate whether a simple walking aid may improve physical performance in COPD patients with chronic respiratory insufficiency who usually carry their own heavy oxygen canister. DESIGN: Randomized crossover trial. SETTING: Physiopathology laboratory of three rehabilitation centers. PATIENTS AND INTERVENTIONS: We studied 60 stable COPD patients (mean age, 70.6 +/- 7.9 years; FEV(1), 44.8 +/- 14.3% of predicted [+/- SD]) with chronic respiratory insufficiency who randomly performed, on 2 consecutive days, a standardized 6-min walking test using two different modalities: a full-weight oxygen canister transported using a small wheeled cart and pulled by the patient (Aid modality) or full-weight oxygen canister carried on the patient's shoulder (No-Aid modality). MEASUREMENTS AND RESULTS: The distance walked, peak effort dyspnea, and leg fatigue scores as primary outcomes, and other cardiorespiratory parameters as secondary outcomes were recorded during both tests. A significant difference (p < 0.05) between the two tests occurred for all the measured outcomes in favor of the Aid modality. Most importantly, significant changes for distance (+ 43 m, p < 0.001), peak effort dyspnea (- 2.0 points, p < 0.001), leg fatigue (- 1.4 points, p < 0.001), as well as for mean and nadir oxygen saturation and heart rate with the Aid modality (but not with the No-Aid modality) were recorded in the subgroup of patients walking < 300 m at baseline. CONCLUSIONS: This study suggests that a simple walking aid may be helpful in COPD patients receiving long-term oxygen therapy, particularly in those with lower residual exercise capacity.

Clini E, D’Armini M, Sampablo IIn: Donner CF, Carone M. (eds) Clinical Challanges in COPD. ( 2007 ) - Higher than expected rest hypoxemia in a 74-year old COPD patient with only mild airway obstruction. - Clinical Publishing Oxford GBR) - pp. da 169 a 177 ISBN: 003 [Monografia o trattato scientifico - Monografia/Trattato scient. con ISBN]
Abstract

Descrizione di un caso clinico di paziente con leve compromissione della funzione polmonare e alterazione grave degli scambi respiratori imputabile a trombosi delle arterie polmonari

E. Clini, A.D'Armini, I. Sampablo ( 2007 ) - Higher than expected rest hypoxemia in a 74-year old COPD patient with only mild airway obstruction. (Donner CF, Carone M. Eds - Clinical Challanges in COPD. - CLINICAL PUBLISHING OXFORD GBR) - n. volume 6.COPD - pp. da 169 a 177 ISBN: 1904392911 [Contributo in volume (Capitolo o Saggio) - Capitolo/Saggio con ISBN]
Abstract

Not available

CLINI E., AMBROSINO N ( 2007 ) - La Riabilitazione Respiratoria. - EDI-AIPO Pisa ITA) [Monografia o trattato scientifico - Monografia/Trattato scient. con ISBN]
Abstract

Trattato aggiornato sul razionale e la applicazione delle metodologie cliniche riabilitative nell'ambito delel patologie respiratorie a evoluzione disabilitante.

Alfredo Cesario, Luigi Ferri, Domenico Galetta, Franco Pasqua, Stefano Bonassi, Enrico Clini, Gianluca Biscione, Vittorio Cardaci, Stefania di Toro, Alessia Zarzana, Stefano Margaritora, Alessio Piraino, Patrizia Russo, Silvia Sterzi, Pierluigi Granone ( 2007 ) - Post-operative respiratory rehabilitation after lung resection for non-small cell lung cancer. - LUNG CANCER - n. volume 57 - pp. da 175 a 180 ISSN: 0169-5002 [Articolo su rivista - Articolo su rivista]
Abstract

BACKGROUND: To investigate the efficacy of an inpatient Pulmonary Rehabilitation program (i-PR) after lung resection (LR) for Non-Small Cell Lung Cancer (NSCLC). PATIENTS AND METHODS: From January 2001 to December 2004, 211 out of 618 patients who underwent LR were considered eligible for i-PR. Twenty-five patients accepted the i-PR and were included in the case group. The remaining 186 who refused i-PR were taken as controls. RESULTS: The two study groups were comparable for demographic and surgical characteristics, as well as for the peri-operative morbidity (4\% in the controls and 3\% among patients undergoing i-PR). Most functional parameters among treated patients were improved when baseline versus 1-month figures were compared, despite the strong correction for multiple comparison limited statistical significance to Borg scale dyspnoea on exertion - median - (2 versus 0; p<0.01); pH (7.45 versus 7.42; p<0.05); timed walk-6MWD (297.8m versus 393.4m; p<0.01) and Hb saturation during 6MWD (95.4\% versus 93.9\%; p<0.05). On the contrary, global function in the group of controls was homogeneously decreased (FEV(1) and PEF p<0.01) after operation. The comparison of treated and untreated patients 1 month after the operation did not show any significant difference in terms of FEV(1), FVC, PEF, distance, Hb saturation, and KCO that instead were homogeneously and significantly worse at baseline (before the surgical operation) in the case group. CONCLUSIONS: Respiratory Function and exercise capacity significantly improve following a post-operative 4-week i-PR in lung resected patients. i-PR could be regarded as a component of the management of patients who have undergone LR for cancer.

Ernesto Crisafulli, Stefania Costi, Leonardo M Fabbri, Enrico M Clini ( 2007 ) - Respiratory muscles training in COPD patients - INTERNATIONAL JOURNAL OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE - n. volume 2 - pp. da 19 a 25 ISSN: 1176-9106 [Articolo su rivista - Articolo su rivista]
Abstract

It is known that respiratory muscles undergo adaptation in response to overload stimuli during exercise training in stable COPD patients, thus resulting in significant increase of respiratory muscle function as well as the individual's improvements. The present article reviews the most updated evidence with regard to the use of respiratory muscle training (RMT) methods in COPD patients. Basically, three types of RMT (resistive training, pressure threshold loading, and normocapnic hyperpnea) have been reported. Frequency, duration, and intensity of exercise must be carefully considered for a training effect. In contrast with the plentitude of existing data inherent to inspiratory muscle training (IMT), literature is still lacking in showing clinical and physiological studies related to expiratory muscle training (EMT). In particular, while it seems that IMT is slightly superior to EMT in providing additional benefits other than respiratory muscle function such as a reduction in dyspnea, both the effects and the safety of EMT is still to be definitively elucidated in patients with COPD.

LAZZERI M, CLINI E., REPOSSINI E, CORRADO A ( 2006 ) - Esame clinico in Riabilitazione Respiratoria. - MASSON Milano ITA) [Monografia o trattato scientifico - Monografia/Trattato scient. con ISBN]
Abstract

Trattato aggiornato sulle le valutazioni e le misure di outcome all'interno dei programmi di riabilitazione dedicati ai pazienti con patologie respiratorie a evoluzione disabilitante.

E. CLINI; COSTI S. EDITORIAL ( 2006 ) - Inspiratory muscle training: a way to breathe more easily. - RESPIRATION - n. volume 73 - pp. da 143 a 144 ISSN: 0025-7931 [Articolo su rivista - Articolo su rivista]
Abstract

nd

E. Clini, F. Prato, M. Nobile, M. Bondi, B. Serri, C. Cilione, D. Lugli ( 2006 ) - Interdisciplinary rehabilitation in morbidly obese subjects: an observational pilot study. - MONALDI ARCHIVES FOR CHEST DISEASE - n. volume 65 - pp. da 89 a 95 ISSN: 1122-0643 [Articolo su rivista - Articolo su rivista]
Abstract

BACKGROUND AND AIM: To assess the clinical effectiveness of a interdisciplinary rehabilitation programme (CR), in a population of morbidly obese subjects we have undertaken a observational study. METHODS: The study included fifty-nine adult subjects (18 M, 60+/-10 years, BMI 47+/-8) with sleep-disturbance related symptoms and disabilities. Assessment and correction of sleep disordered breathing (SDB) abnormalities, improvement of exercise tolerance, body weight and associated psychological features were the aims of this CR, which has been carried out over a 1 month period.Lung functions, apnea/hypopnea index (AHI), 6-minute walking distance (6MWD), body weight (BW), quality of life by means of Sat-P questionnaire and serum metabolic data has been recorded at baseline (TO), at the end (Ti) and 6 months after (T2) the CR. RESULTS: The percentage of patients with AHI > 10 declined from 65\% (at TO) to 20\% (at both T1 and T2). 6MWD and BW significantly improved (p < 0.005) at T1 and still maintained at T2; a significant relationship (r = 0.379, p < 0.01) has been found between changes of BW and 6MWD recorded in between TO and T2. Sat-P item scores dealing with sleep efficiency, problem solving, and social interactions improved (p < 0.01) at T1 and still maintained at T2. CONCLUSIONS: This hospital-based CR provides indication for effectiveness in advanced morbidly obese subjects and warrants further controlled trials to confirm the results.

E.Clini, F.Degli Antoni, M.Vitacca, E.Crisafulli, M.Paneroni, S.Chezzi-Silva, M.Moretti, L.Trianni, L.M.Fabbri ( 2006 ) - Intrapulmonary percussive ventilation in tracheostomized patients: a randomized controlled trial. - INTENSIVE CARE MEDICINE - n. volume 32 - pp. da 1994 a 2001 ISSN: 0342-4642 [Articolo su rivista - Articolo su rivista]
Abstract

OBJECTIVE: To investigate whether the addition of intrapulmonary percussive ventilation to the usual chest physiotherapy improves gas exchange and lung mechanics in tracheostomized patients. DESIGN AND SETTING: Randomized multicenter trial in two weaning centers in northern Italy. PATIENTS AND PARTICIPANTS: 46 tracheostomized patients (age 70 +/- 7 years, 28 men, arterial blood pH 7.436 +/- 0.06, PaO(2)/FIO(2) 238 +/- 46) weaned from mechanical ventilation. INTERVENTIONS: Patients were assigned to two treatment groups performing chest physiotherapy (control), or percussive ventilation (IMP2 Breas, Sweden) 10 min twice/day in addition to chest physiotherapy (intervention). MEASUREMENTS AND RESULTS: Arterial blood gases, PaO(2)/FIO(2) ratio, and maximal expiratory pressure were assessed every 5th day for 15 day. Treatment complications that showed up in 1 month of follow-up were recorded. At 15 days the intervention group had a significantly better PaO(2)/FIO(2) ratio and higher maximal expiratory pressure; after follow-up this group also had a lower incidence of pneumonia. CONCLUSIONS: The addition of percussive ventilation to the usual chest physiotherapy regimen in tracheostomized patients improves gas exchange and expiratory muscle performance and reduces the incidence of pneumonia.

M. Vitacca, M. Paneroni, L. Bianchi, E. Clini, A. Vianello, P. Ceriana, L. Barbano, B. Balbi, S. Nava ( 2006 ) - Maximal inspiratory and expiratory pressure measurement in tracheotomised patients. - EUROPEAN RESPIRATORY JOURNAL - n. volume 27 - pp. da 343 a 349 ISSN: 0903-1936 [Articolo su rivista - Articolo su rivista]
Abstract

The present study compared four different sites and conditions for the measurement of maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) in 38 spontaneous breathing tracheotomised patients. Of the patients, 28 had chronic obstructive pulmonary disease (COPD). The four different conditions were: 1) through a cuff inflated cannula (condition A); 2) through the mouth with a deflated cannula (condition B); 3) through the mouth with a phonetic uncuffed cannula (condition C); and 4) through the mouth after stoma closure (condition D). Five trials in each condition were performed using a standardised method. The measurement of both MIP and MEP differed significantly depending on the condition of measurement. MIP taken in condition A was significantly higher when compared with conditions B, C and D. MEP in condition A was significantly higher when compared with condition B and D. In condition A the highest frequency of the best measurement of MIP and MEP was observed at the fourth and fifth effort, respectively. The same results were obtained after the selection of only COPD patients. In conclusion, respiratory muscle assessment differs significantly depending on measurement condition. Measurement through inflated cannula tracheotomy yields higher values of both maximal inspiratory and maximal expiratory pressure.

Micaela Romagnoli, Daniela Dell'Orso, Cristina Lorenzi, Ernesto Crisafulli, Stefania Costi, Daniela Lugli, Enrico M Clini ( 2006 ) - Repeated pulmonary rehabilitation in severe and disabled COPD patients. - RESPIRATION - n. volume 73 - pp. da 769 a 776 ISSN: 0025-7931 [Articolo su rivista - Articolo su rivista]
Abstract

BACKGROUND: The optimal frequency of delivering a pulmonary rehabilitation program (PR) is not yet a well established issue. It is still unclear whether repeated PR at established intervals will result in effective maintenance or further improvement in the patient's health status. OBJECTIVES: To investigate whether more frequently repeated PR in patients with COPD (1) leads to similar short and long-term physiological gains, and (2) decreases the burden due to hospitalization. METHODS: Thirty-five disabled COPD patients (FEV(1) below 50\% predicted, MRC score 3) in a stable state were studied in a randomized controlled trial. After completing an initial inpatient PR program, they were randomly assigned to either group 1 (performing a second and a third PR after 6 and 12 months) or group 2 (performing only a second PR after 12 months). RESULTS: Lung functions, exercise capacity (by means of a timed walk test - 6MWT), peak-effort dyspnea (D) and leg fatigue (F), and health-related quality of life by means of SGRQ were assessed prior to (T1, T3, T5) and after (T2, T4, T6) each PR program: the same measures were taken on an outpatient basis at T3 in group 2. The number of hospital admissions (HA) and days spent in the hospital (DH) were also recorded over the year. The two groups did not differ in any parameter at baseline. 6MWD, D, F and SGRQ improved to the same level (p = 0.05) after each PR in both groups. However, the baseline level of D, F and SGRQ symptoms and impact scores progressively improved over time in group 1 but not in group 2. After 12 months, a larger amount of patients in Group 1, as compared to Group 2, reported H10 DH/year (p < 0.0001). CONCLUSIONS: In severe and disabled COPD, a more frequently repeated inpatient PR may lead to some additional physiological and clinical benefits over 1 year.

COSTI S, CRISAFULLI E, FABBRI L.M, CLINI E. ( 2006 ) - Update in pulmonary rehabilitation. - MINERVA PNEUMOLOGICA - n. volume 45 - pp. da 197 a 205 ISSN: 0026-4954 [Articolo su rivista - Articolo su rivista]
Abstract

nd

E. Clini (Modena), N.Ambrosino (Pisa) ( 2005 ) - Costo-Efficacia del trattamento con ventilazione noninvasiva in pazienti BPCO ipercapnici [Altro - Partecipazione a progetti di ricerca]
Abstract

Valutazione dei costi del trattamento domiciliare a lungo termine in pazienti BPCO trattati con ventilazione non invasiva (VMD) e confronto con analoghi pazienti sottoposti a ossigenoterapia (OLT).

Enrico Clini, Nicolino Ambrosino ( 2005 ) - Early physiotherapy in the respiratory intensive care unit. - RESPIRATORY MEDICINE - n. volume 99 - pp. da 1096 a 1104 ISSN: 1745-0454 [Articolo su rivista - Articolo su rivista]
Abstract

Physiotherapy is an integral part of the management of patients in respiratory intensive care units (RICUs). The most important aim in this area is to enhance the overall patient's functional capacity and to restore his/her respiratory and physical independence, thus decreasing the risks of bed rest associated complications. This article is a review of evidence-based effectiveness of weaning practices and physiotherapy treatment for patients with respiratory insufficiency in a RICU. Literature searches were performed using general and specialty databases with appropriate keywords. The evidence for applying a weaning process and physiotherapy techniques in these patients has been described according to their individual rationale and efficacy. The growing number of patients treated in RICUs all over the world makes this non pharmacological approach both welcome and interesting. However, to date, there are only strong recommendations concerning the evidence-based strategies to speed weaning. Early physiotherapy may be effective in ICU: however, most techniques (postures, limb exercise and percussion/vibration in particular) need to be further studied in a large population. Evidence supporting physiotherapy intervention is limited as there are no studies examining the specific effects of interventions on long-term outcome.

E. M. Clini, M. Romagnoli ( 2005 ) - Inpatient pulmonary rehabilitation: does it make sense? - CHRONIC RESPIRATORY DISEASE - n. volume 2 - pp. da 43 a 46 ISSN: 1479-9723 [Articolo su rivista - Articolo su rivista]
Abstract

Among the nonpharmacological therapies, pulmonary rehabilitation (PR) is particularly appropriate for patients with chronic respiratory impairment who, despite any optimal drug management, are still symptomatic and experience restriction in every day activities. Pulmonary rehabilitation performed in inpatient, outpatient, or home settings demonstrates short- and long-term clinical efficacy. Although disease severity does not inherently dictate candidacy for exercise training, the degree of physiological and functional impairment may influence setting in which the training should occur. Therefore, inpatient rehabilitation is generally best-suited for the most sick and most disabled patients. The overall results from the literature confirm that the inpatient setting for a PR program is a feasible option and does not necessarily result in higher direct costs when balanced against duration and effectiveness in terms of improved outcomes.

Rossi G; Florini F; Romagnoli M; Bellantone T; Lucic S; Lugli D; Clini E ( 2005 ) - Length and clinical effectiveness of pulmonary rehabilitation in outpatients with chronic airway obstruction - CHEST - n. volume 127 - pp. da 105 a 109 ISSN: 0012-3692 [Articolo su rivista - Articolo su rivista]
Abstract

Study objective: To assess the clinical effectiveness of pulmonary rehabilitation (PR) after 10 or 20 consecutive sessions in outpatients with chronic airway obstruction (CAO). Design: Observational prospective cohort trial. Setting: Outpatient clinic of a rehabilitation center. Patients and interventions: Twenty-five outpatients (mean age, 65 +/- 9 years [+/- SD]; FEV1, 64 +/- 12% predicted) admitted to a comprehensive PR program, including exercise training. Measurements and results: The load reached on a cycloergometer (maximal achieved load [W-max]), the maximal and isoload dyspnea and leg fatigue on a Borg scale, 6-min walk distance (6MWD), and the health-related quality of life as assessed using the St. George's Respiratory Questionnaire (SGRQ) [total and components score] have been recorded as outcome measures at baseline, after 10 sessions (T10), and after 20 sessions (T20). The predefined criteria of the clinically significant improvement were as follows: + 15% W-max, + 54 m at 6MWD, - 1 point at isoload dyspnea and leg fatigue, and - 4% at SGRQ scores. There was a mean significant difference between changes at T20 and T10 for 6MWD (- 42.96 m; 95% confidence interval [0], - 57.79 to - 28.12 m; p = 0.001), total SGRQ (4.80; 95% CI, 2.29 to 7.31; p = 0.001), activity SGRQ (3.60; 95% CI, 0.48 to 6.71; p = 0.025), and symptoms SGRQ (5.96; 95% CI, 2.72 to 9.2; p = 0.001). The percentage of patients who improved was different at T20 as compared with T 10 for W-max (68% and 48%, respectively; p = 0.025), 6MWD (76% and 20%, p = 0.001), and total SGRQ (64% and 36%, p = 0.008). Conclusions: A 10-session course of PR provides only limited clinically significant changes of outcome measures when compared with a 20-session course in outpatients with CAO of mild-to-moderate severity.

Roberto Porta, Michele Vitacca, Lucia Sonia Gilè, Enrico Clini, Luca Bianchi, Ercole Zanotti, Nicolino Ambrosino ( 2005 ) - Supported arm training in patients recently weaned from mechanical ventilation. - CHEST - n. volume 128 - pp. da 2511 a 2520 ISSN: 0012-3692 [Articolo su rivista - Articolo su rivista]
Abstract

STUDY OBJECTIVES: To evaluate the effects of early exercise training in patients recovering from acute respiratory failure needing mechanical ventilation (MV). DESIGN: Prospective, randomized, and controlled study. SETTING: Three respiratory intermediate ICUs (RIICUs). PATIENTS: Of 228 patients admitted to an RIICU, 66 patients weaned from MV from > 48 to < 96 h were considered eligible and enrolled in the study. INTERVENTION: Sixty-six patients were randomized to either supported arm exercise training plus general physiotherapy (gPT) [group 1, 32 patients] or to gPT alone (group 2, 34 patients). MEASUREMENTS AND RESULTS: Twenty-five patients in each group completed the protocol. Group 1 showed a greater improvement in exercise capacity, as assessed by an arm incremental test (IT) [p = 0.003] and an endurance test (ET) [p = 0.021], compared to group 2. Posttraining maximal inspiratory pressure (MIP) significantly improved in both groups (p < 0.001 and p = 0.003 in groups 1 and 2 respectively; not significant). IT isoworkload dyspnea improved significantly in both groups (p = 0.005 and p = 0.009 in groups 1 and 2, respectively; not significant between groups), whereas IT isoworkload peripheral muscle fatigue (p < 0.001), ET isotime dyspnea (p < 0.01), and ET isotime muscular fatigue (p < 0.005) improved significantly in group 1 but not in group 2. IT improvers (chi2 = 0.004) and ET improvers (chi2 = 0.047) were more frequently observed in group 1 than in group 2. Baseline MIP could discriminate for IT (p = 0.013; odds ratio [OR], 1.116) and ET improvers (p = 0.022; OR, 1.067). CONCLUSION: Early upper-limb exercise training is feasible in RIICU patients recently weaned from MV and can enhance the effects of gPT. Baseline inspiratory muscle function is related to exercise capacity improvement.

Michele Vitacca, Luca Bianchi, Ercole Zanotti, Andrea Vianello, Luca Barbano, Roberto Porta, Enrico Clini ( 2004 ) - Assessment of physiologic variables and subjective comfort under different levels of pressure support ventilation. - CHEST - n. volume 126 - pp. da 851 a 859 ISSN: 0012-3692 [Articolo su rivista - Articolo su rivista]
Abstract

STUDY OBJECTIVES: To evaluate the effects of 12 ventilator settings (pressure support ventilation [PSV] plus positive end-expiratory pressure [PEEP], 30 + 0 cm H(2)O; 25 + 5 cm H(2)O; 25 + 0 cm H(2)O; 20 + 5 cm H(2)O; 20 + 0 cm H(2)O; 15 + 5 cm H(2)O; 15 + 0 cm H(2)O; 10 + 5 cm H(2)O; 10 + 0 cm H(2)O; 5 + 5 cm H(2)O; 5 + 0 cm H(2)O; and 0 + 5 cm H(2)O) on physiologic variables; the percentage of ineffective efforts; patient comfort; and whether the diagnosis of COPD may influence results. DESIGN: Prospective, randomized, physiologic study. SETTING: Three weaning centers. PATIENTS: Thirty-six consecutive patients (20 patients with COPD). INTERVENTION: Patients were randomly submitted to the 12 settings. MEASUREMENTS AND RESULTS: Breathing pattern, respiratory drive (p0.1), arterial oxygen saturation (Sato(2)), heart rate, percentage of ineffective efforts per minute, patient comfort measured by means of a visual analogue scale (VAS), and BORG scale were recorded under each setting. Under different levels of assistance, breathing pattern, Sato(2), and p0.1 significantly and linearly changed (p < 0.0001) while VAS and BORG scale presented a significant (p = 0.027) U-shaped trend; high or low assistance caused the most discomfort. Under high levels of assistance, a higher (analysis of variance, p = 0.023) frequency of ineffective effort percentage was observed in the subgroup of 26 patients who presented this phenomenon. Breathing pattern significantly (p = 0.013) changed when compared to PSV alone (PSV plus zero end-expiratory pressure [ZEEP]) at the same total inspiratory pressure assistance (PSV plus PEEP). A huge variability among patients in breathing pattern and comfort was found under the setting rated as the most comfortable by patients. The diagnosis of COPD did not influence the overall results. CONCLUSIONS: The following conclusions are made: (1) physiologic variables followed a linear trend, while comfort followed a U-shaped trend under different levels of PSV (irrespective of COPD diagnosis); (2) high assistance caused an increase in ineffective efforts; (3) only the breathing pattern significantly changed when total assistance was given as PSV plus PEEP when compared to PSV alone (PSV plus ZEEP); and (4) the extreme levels of PSV are not associated with the best comfort.

TRAMACERE A; RIZZARDI R; CILIONE C; SERRI B; FLORINI F; LORENZI C; E. CLINI ( 2004 ) - Effects of respiratory-therapist directed protocol on prescription and outcome of pulmonary rehabilitation in COPD inpatients. - RESPIRATION - n. volume 71 - pp. da 60 a 65 ISSN: 0025-7931 [Articolo su rivista - Articolo su rivista]
Abstract

BACKGROUND: The use of respiratory therapist-directed (RD) protocols in non-ICU hospitalized patients decreases respiratory care charges as compared with physician-directed (PD) protocols. OBJECTIVES: To determine whether RD or PD protocol assessments in COPD patients may impact: (1) prescription of respiratory treatments, and (2) outcomes of pulmonary rehabilitation program (PRP). METHODS: In a retrospective observational case-control study, 73 cases (RD) were compared with controls (PD) matched for age, sex, FEV1 and diagnosis of either chronic airflow obstruction (CAO), pulmonary emphysema (PE) or chronic respiratory insufficiency (CRI). PRP programs were specifically tailored and assessed for inpatients with moderate to severe COPD. Type of PRP protocol (P), number of respiratory treatments (RT), number of exercise training prescription (EXP) and failure (EXF), time to start PRP (T) and length of hospital stay (LOS) were recorded. Perceived breathlessness (B) as assessed by MRC scale, 6-min walk meters (6MWD), and BORG-dyspnea at rest (D-rest) and end of effort (D-effort) were also assessed as outcome measures before (T0) and after (T1) the PRP. RESULTS: Frequency distribution of P, EXP and EXF was similar in the two groups. However, prescription of additional RT (1.9 +/- 0.8 and 2.5 +/- 1.1 days, p<0.01), T (1.2 +/- 0.4 and 1.8 +/- 1.2 days, p<0.001) and LOS (17.2 +/- 2.0 and 18.2 +/- 1.8 days, p<0.05) were lower in cases than in controls. Both cases and controls similarly improved (p<0.0001) B, 6MWD, D-rest and D-effort at T1. CONCLUSIONS: RT-directed assessment results in less respiratory treatments prescription than PD-directed protocol and it does not affect the outcomes of in-hospital pulmonary rehabilitation of COPD patients.

ROMAGNOLI M, CLINI E., FABBRI LM ( 2004 ) - Fixed airflow limitation caused by COPD or Asthma: from definition to management - MEDICAL HYPOTHESES AND RESEARCH - n. volume 1 - pp. da 101 a 110 ISSN: 1545-6129 [Articolo su rivista - Articolo su rivista]
Abstract

Patients with fixed airflow limitation are often classified as chronic obstructive pulmonary disease (COPD), and some international guidelines recommend classifying asthma with fixed airflow limitation as COPD. Indeed, both COPD (induced by smoking or other noxious agents) and asthma may be associated with a decline of lung function that should cause fixed airflow limitation. In the presence of fixed airflow limitation, patients are often diagnosed COPD, even if the differential diagnosis between asthma and COPD in these patients may be important as the natural history as well as the response to treatment are different, depending on whether fixed airflow limitation is due to asthma or COPD. The assessment of patients presenting with fixed airflow limitation has recently hightlighted that airway inflammation is markedly different in asthma and COPD although characterized by the same degree of airflow limitation. Thus, asthma with fixed airflow limitation maintain the same pathological characteristics as asthma with completely reversible airflow limitation. In conclusion, subjects with asthma have distinct characteristics compared with subjects with COPD. Despite the presence of fixed airflow limitation both patients should be properly identified and treated.

M. Vitacca, B. Lanini, S. Nava, L. Barbano, R. Porta, E. Clini, N. Ambrosino ( 2004 ) - Inspiratory muscle workload due to dynamic intrinsic PEEP in stable COPD patients: effects of two different settings of non-invasive pressure-support ventilation. - MONALDI ARCHIVES FOR CHEST DISEASE - n. volume 61 - pp. da 81 a 85 ISSN: 1122-0643 [Articolo su rivista - Articolo su rivista]
Abstract

BACKGROUND: In severe stable hypercapnic COPD patients the amount of pressure time product (PTP) spent to counterbalance their dynamic intrinsic positive end expiratory pressure (PEEPi,dyn) is high: no data are available on the best setting of non invasive pressure support ventilation (NPSV) to reduce the inspiratory muscle workload due to PEEPi,dyn. METHODS: The objectives of this randomised controlled physiological study were: 1. To measure the inspiratory muscle workload due to PEEPi,dyn 2. To measure the effects on this parameter of two settings of NPSV in stable COPD patients with chronic hypercapnia admitted in a Pulmonary Division of two Rehabilitation Centers. Twenty-three stable COPD patients with chronic hypercapnia on domiciliary nocturnal NPSV for 30 +/- 20 months were submitted to an evaluation of breathing pattern, PEEPi,dyn, inspiratory muscle workload and its partitioning during both assisted and unassisted ventilation. Two settings of NPSV were randomly applied for 30 minutes each: i- "at patient's comfort" (C): Inspiratory pressure support (IPS) was the maximal tolerated pressure able to reduce awake PaCO2 with the addition of a pre-set level of external PEEP (PEEPe); ii- "physiological setting" (PH): the level of IPS able to achieve a > 40\% and < 90\% decrease in transdiaphragmatic pressure in comparison to spontaneous breathing (SB). A PEEPe level able to reduce PEEPi,dyn by at least 50\% was added. RESULTS: During SB the tidal diaphragmatic pressure-time product (PTPdi/b) was 17.62 +/- 7.22 cmH2O*sec, the component due to PEEPi,dyn (PTPdiPEEPi,dyn) being 38 +/- 17\% (range: 16-65\%). Compared to SB,PTPdiPEEPi,dyn was reduced significantly with both settings, the reduction being greater with PH compared to C. CONCLUSIONS: In conclusion in severe COPD patients with chronic hypercapnia the inspiratory muscle workload due to PEEPidyn is high and is reduced by NPSV at a greater extent when ventilator setting is tailored to patient's mechanics.

AMBROSINO N; E. CLINI ( 2004 ) - Long-term mechanical ventilation and nutrition. - RESPIRATORY MEDICINE - n. volume 98 - pp. da 413 a 420 ISSN: 0954-6111 [Articolo su rivista - Articolo su rivista]
Abstract

Mechanical ventilation (MV) in chronic situations is commonly used, either delivered invasively or by means of non-invasive interfaces, to control hypoventilation in patients with chest wall, neuromuscular or obstructive lung diseases (either in adulthood or childhood). The global prevalence of ventilator-assisted individuals (VAI) in Europe ranges from 2 to 30 per 100000 population according to different countries. Nutrition is a common problem to face with in patients with chronic respiratory diseases: nonetheless, it is a key component in the long-term management of underweight COPD patients whose muscular disfunction may rapidly turn to peripheral muscle waste. Since long-term mechanical ventilation (LTMV) is usually prescribed in end-stage respiratory diseases with poor nutritional status, nutrition and dietary intake related problems need to be carefully assessed and corrected in these patients. This paper aims to review the most recent innovations in the field of nutritional status and food intake-related problems of VAI (both in adulthood and in childhood).

Cristina M Lorenzi, Carmela Cilione, Roberta Rizzardi, Vittoria Furino, Tommasina Bellantone, Daniela Lugli, Enrico Clini ( 2004 ) - Occupational therapy and pulmonary rehabilitation of disabled COPD patients. - RESPIRATION - n. volume 71 - pp. da 246 a 251 ISSN: 0025-7931 [Articolo su rivista - Articolo su rivista]
Abstract

BACKGROUND: Occupational therapy (OT) has been defined as a task of rehabilitation for disabled patients, giving them maximal function and independence to sustain specific activities of daily living. OBJECTIVES: To evaluate the effectiveness of OT as an adjunctive measuring during pulmonary rehabilitation (PR) of hospitalized COPD patients. METHODS: A prospective clinical trial with parallel groups was undertaken in severely disabled COPD patients (n = 71, age 73 +/- 5 years). They were assigned to either OT+PR (n = 47, FEV1 46 +/- 21\%pred.) or PR (n = 24, FEV1 44 +/- 12\%pred.). PR consisted of eighteen 3-hour daily sessions, whilst OT (domestic activities) was added 3 times a week up to nine 1-hour sessions. Six-min walk (6MWD) with evaluation of BORG dyspnea (D) and leg fatigue (F) scores at end of effort, breathlessness sensation (B) by means of the MRC scale as well as the number of functions lost in the Basic Activity of Daily Living (BADL) categories were assessed as outcomes before (T0) and after (T1) rehabilitation. RESULTS: 6MWD (from 165 +/- 63 to 233 +/- 66 and from 187 +/- 52 to 234 +/- 65 m in the OT+PR and PR groups, respectively), D (from 4.9 +/- 2.1 to 3.2 +/- 1.6 and from 5.3 +/- 2.1 to 3.4 +/- 2.1), F (from 6.1 +/- 0.5 to 4.5 +/- 1.7 and from 5.9 +/- 0.8 to 4.3 +/- 0.8) and B (from 4.3 +/- 0.9 to 3.0 +/- 0.9 and from 4.2 +/- 1.0 to 3.2 +/- 0.8) had similarly improved (p < 0.01) in both groups at T1. The percentage distribution of patients across the BADL categories significantly changed (p = 0.004) in OT+PR (from 17 to 61\%, from 70 to 34\% and from 23 to 5\% in categories A, B and C, respectively) but not in the PR group. CONCLUSIONS: The addition of OT to comprehensive PR is able to specifically improve the outcome of severely disabled COPD inpatients.

E. CLINI; AMBROSINO N ( 2004 ) - Physiotherapy in the critical care area. - MINERVA PNEUMOLOGICA - n. volume 3 - pp. da 165 a 175 ISSN: 0026-4954 [Articolo su rivista - Articolo su rivista]
Abstract

nd

E. Clini, S. Costi, M. Romagnoli, F. Florini ( 2004 ) - Rehabilitation of COPD patients: which training modality? - MONALDI ARCHIVES FOR CHEST DISEASE - n. volume 61 - pp. da 167 a 173 ISSN: 1122-0643 [Articolo su rivista - Articolo su rivista]
Abstract

Non pharmacological therapy has been gaining more interest and has been evolving rapidly over the last decade as an essential part of therapy for COPD patients. Pulmonary Rehabilitation (PR), the most important non pharmacological treatment in patients with COPD, has a primary goal: to achieve the highest possible level of individual exercise tolerance, thus reducing the primary and/or secondary health care utilisation. The aim of the present review is to focus the role of exercise training in these patients as well as to address the question on which training methods are the most beneficial. We have therefore undertaken a MEDLINE-based search including the terms: pulmonary rehabilitation, exercise, lung disease/obstructive. Several strategies based on endurance or strength training are nowadays implemented during PR programmes in order to maximise the benefits for each patient. The impaired function of ambulation muscles causing breathlessness as one of the more frequent symptoms in many COPD, suggests that training the lower extremities is the most important goal to achieve during pulmonary rehabilitation of these patients. On the other hand, as muscle strength appears to be an independent contributor to survival and utilisation of health care resources, it seems largely justified also to include this further modality in the PR program of these patients. In conclusion, both modalities are effective and useful for COPD patients. However, whether resistance training should be administered to all COPD and which is the optimal length of strength training still needs to be elucidated.

MORETTI M; E. CLINI; FABBRI LM ( 2004 ) - Water / electrolyte imbalances in AECOPD. (SIAFAKAS N; ANTHONISEN NR; GEORGOPOULOS D. EDS - Acute exacerbations of Chronic Obstrutive Pulmonary Disease. - MARCEL-DEKKER NEW YORK USA) - n. volume Volume 183 - pp. da 264 a 279 ISBN: 0824741285 [Contributo in volume (Capitolo o Saggio) - Capitolo/Saggio con ISBN]
Abstract

Not available

Moretti M, Clini E, Fabbri L. ( 2004 ) - Water / electrolyte imbalances in AECOPD. In: Siafakas N, Anthonisen NR, Georgopoulos D. (eds) Acute exacerbations of Chronic Obstrutive Pulmonary Disease. - Marcel Dekker New York USA) - pp. da 264 a 279 ISBN: 006 [Monografia o trattato scientifico - Monografia/Trattato scient. con ISBN]
Abstract

Water and electrolyte imbalance occuring in AECOPD suggests a complex interactions between pulmonary haemodynamics, acid-base balance, hormonal and renal mechanisms. Further studies are required 1) to investigate the contribution of different mechanisms in oedema formation , 2) to select COPD patients at risk of developing chronic right ventricular failure, and 3) to define more effective therapeutical approaches in preventing oedema formation.

D. Fiorenza, M. Vitacca, E. Clini ( 2003 ) - Hospital monitoring, setting and training for home non invasive ventilation. - MONALDI ARCHIVES FOR CHEST DISEASE - n. volume 59 - pp. da 119 a 122 ISSN: 1122-0643 [Articolo su rivista - Articolo su rivista]
Abstract

Although in recent years guidelines have been published in order to define indications, applications and delivery of long-term home non invasive mechanical ventilation (HNMV), there is lack of information with regards to in-hospital assessment, planning and training to initiate and prescribe it. Discontinuation and lack of compliance versus HNMV may affect the follow-up of these patients adding a costly burden for care. The present review proposes an operative flow chart for optimisation of HNMV prescription from initial patient's selection to post discharge follow up including; 1. assessment of the correct choice of ventilator, interfaces, ventilation setting. 2. Timing for different physiological monitoring (arterial gases, mechanics, sleep) 3. Timing for clinical evaluation, machine adaptation, carer training and long term follow-up.

G. Garuti, C. Cilione, D. Dell'Orso, P. Gorini, M. C. Lorenzi, L. Totaro, G. Cirelli, E. Clini ( 2003 ) - Impact of comprehensive pulmonary rehabilitation on anxiety and depression in hospitalized COPD patients. - MONALDI ARCHIVES FOR CHEST DISEASE - n. volume 59 - pp. da 56 a 61 ISSN: 1122-0643 [Articolo su rivista - Articolo su rivista]
Abstract

To prospectively evaluate the effect of inpatient pulmonary rehabilitation (iPR) on anxiety and depression as outcome measures in patients with COPD, we studied 149 consecutive adults COPD referred to our iPR after an exacerbation. Patients were divided according to the GOLD staging into: Group 1 (stage 2a, n = 48, FEV1 63 +/- 9\% pred.), Group 2 (stage 2b, n = 53, FEV1 42 +/- 6\% pred.) and Group 3 (stage 3, n = 48, FEV1 25 +/- 7\% pred.). The iPR consisted of twelve 3-hours daily sessions. Hospital Anxiety Depression (HAD) Scale as well as 6-minute walk (6MWD) with evaluation of dyspnea (D) and leg fatigue (F) at rest and end of effort, and health related quality of life by means of St. George Respiratory Questionnaire (SGRQ) were assessed before (T0) and after (T1) the iPR. 6MWD, D and F at end of effort and SGRQ total score similarly improved (p < 0.001) in all groups after iPR. The mean level of HAD-anxiety (from 9.1 +/- 4.0 to 7.7 +/- 3.5, from 9.0 +/- 4.6 to 7.2 +/- 4.6 and from 8.1 +/- 4.1 to 6.7 +/- 4.3 in group 1,2 and 3 respectively) and HAD-depression (from 9.4 +/- 3.5 to 8.2 +/- 3.5, from 9.1 +/- 4.2 to 8.2 +/- 4.5 and from 9.0 +/- 4.0 to 7.4 +/- 4.5 respectively) similarly changed (p < 0.0001) over time in all groups. The total percentage of patients with abnormal score (> 10) of HAD-anxiety (from 31\% to 21\%) and HAD-depression (from 30\% to 22\%) significantly decreased (p < 0.05) after the iPR. Inpatient pulmonary rehabilitation may improve levels of anxiety and depression as well as symptoms, exercise capacity and health related quality of life in moderate to severe COPD patients after an acute exacerbation.

KOHNLEIN T; WELTE T; E. CLINI; AMBROSINO N ( 2003 ) - Noninvasive ventilation in stable chronic obstructive pulmonary.(letter) - EUROPEAN RESPIRATORY JOURNAL - n. volume 21 - pp. da 558 a 559 ISSN: 0903-1936 [Articolo su rivista - Articolo su rivista]
Abstract

Non disponibile

Enrico Clini, Stefania Costi, Silvano Lodi, Giuseppina Rossi ( 2003 ) - Non-pharmacological treatment for chronic obstructive pulmonary disease. - MEDICAL SCIENCE MONITOR - n. volume 9 [Articolo su rivista - Articolo su rivista]
Abstract

Evidence-based guidelines on treatment of patients with Chronic Obstructive Pulmonary Disease (COPD) have recently been developed. Non-pharmacological therapy of COPD has been receiving more interest and has been evolving rapidly in the last decade as an essential part of COPD treatment. In fact, non-pharmacological treatment is a complementary approach mainly in the advanced stages of COPD. Most of these care options appear to benefit patients in terms of quality of life and cost-effectiveness. The aim of the present review is to survey the most important non-pharmacological treatments for COPD (smoking cessation, rehabilitation, long-term oxygen therapy, noninvasive positive pressure ventilation, and surgery) and their usefulness based on the currently available evidence. This review is based on an evaluation of the literature using a multimethod approach. A computerized MEDLINE search from 1966 through June 2003 was undertaken using the search terms pulmonary rehabilitation, surgery, smoking cessation, respiratory insufficiency/failure, and lung disease/obstructive. Non pharmacological treatment of COPD is a real option to successfully treat these patients and prevent further deterioration. All the included therapies are based on actual scientific evidence for patient benefits. To date, smoking cessation, comprehensive rehabilitation and long-term oxygen therapy are widely accepted as therapies which may positively impact the long-term management of COPD patients.

E. Clini, L. Bianchi, K. Foglio, M. Vitacca, N. Ambrosino ( 2002 ) - Exhaled nitric oxide and exercise tolerance in severe COPD patients. - RESPIRATORY MEDICINE - n. volume 96 - pp. da 312 a 316 ISSN: 0954-6111 [Articolo su rivista - Articolo su rivista]
Abstract

Study objective: To evaluate exhaled nitric oxide (eNO) during exercise in stable COPD patients.Setting: Outpatients' evaluation in a rehabilitation center.Patients: Eleven consecutive stable male COPD patients (age 65±6 years, FEV1 56±10% pred). Eight healthy (6 male; age: 51±16 years) non-smoking, non-atopic volunteers served as controls.Methods: In each subject a symptom-limited cycloergometry was carried out by monitoring eNO with the tidal-breath method to assess eNO concentration (FENO) and output ( NO ) at rest, peak exercise and recovery time.Results: Resting FENO (9.8±5.1 and 14.1±6.3 ppb respectively) and NO (4.2±2.0 and 5.9±3.4 nM*min-1 respectively) were lower though non significantly in COPD than in controls. In both groups FENO significantly decreased whereas NO significantly increased during exercise. Both parameters returned to baseline during the recovery time. Peak exercise NO but not FENO was significantly lower in COPD than in controls (7.9±5.4 and 12.7±6.0 nM*min-1 respectively, p<0.05). The rise in VNO was weakly correlated to O2 both in controls (R=0.31, p=0.002) and in COPD patients (R=0.22, p=0.03). FENO showed an inverse correlation to O2 in both groups (R= -0.53, p=0.000; R= -0.31, p=0.003 in controls and COPD respectively). Conclusions: In mild and moderate COPD patients eNO during exercise parallels that observed in normal controls. Exhaled NO output but not concentration is significantly reduced at peak exercise in COPD as compared to controls. The long-term effects of exercise training on eNo has to be evaluated by further studies.

E. CLINI; AMBROSINO N ON BEHALF OF INOC ( 2002 ) - Exhaled nitric oxide in chronic obstructive pulmonary disease. - MINERVA PNEUMOLOGICA - n. volume 41 - pp. da 49 a 56 ISSN: 0026-4954 [Articolo su rivista - Articolo su rivista]
Abstract

Non disponibile

BARALDI E; E. CLINI; CREMONA G; VIGNOLA M EDS. IL PENSIERO SCIENTIFICO ( 2002 ) - Focus on nitric oxide. - Il Pensiero Scientifico Roma ITA) [Monografia o trattato scientifico - Monografia/Trattato scient. con ISBN]
Abstract

Trattato aggiornato sulla metodica della misura dell'ossido nitrico (NO) nell'aria esalata. Definizione dei profili caratteristici in corso di varie patologie dell'apparato respiratorio.

Enrico Clini, Nicolino Ambrosino, on behalf of I. N. O.C. ( 2002 ) - Nitric oxide and pulmonary circulation. - MEDICAL SCIENCE MONITOR - n. volume 8 [Articolo su rivista - Articolo su rivista]
Abstract

The aim of this review is to outline the characteristics of the pulmonary circulation in healthy and disease status and the power of exhaled NO (eNO) as a means to assess the involvement of pulmonary circulation in pathological conditions.The discovery of the endocrine role of the endothelium has generated a great interest in its potential regulatory role on the vascular tone of the pulmonary vascular bed. Nitric oxide (NO) mediated-endothelium-dependent relaxation has been demonstrated in pulmonary arteries of animals and humans. The changes in the NO pathway with pulmonary hypertension are not clear. As a matter of fact NO is important in modulating the response to acute hypoxia and the responses to increased flow and to shear stress. The amount of exhaled NO (eNO) of different species may be easily measured reflecting overall NO metabolism from the lung (thus including epithelial, endothelial and other cells activities). The development of pulmonary hypertension secondary to systemic (systemic sclerosis, chronic heart failure) or pulmonary (COPD) diseases appears to be associated with a decrease in eNO production both at rest or during exercise. Chronic inhalation of NO appears to protect against pulmonary hypertension in animal settings.Exhaled NO is growing in interest for its in vivo ability to represent the feature of pulmonary circulation in the pathological condition.

Carmela Cilione, Cristina Lorenzi, Daniela Dell Orso, Giancarlo Garuti, Giuseppina Rossi, Lina Totaro, Enrico Clini ( 2002 ) - Predictors of change in exercise capacity after comprehensive COPD inpatient rehabilitation. - MEDICAL SCIENCE MONITOR - n. volume 8 [Articolo su rivista - Articolo su rivista]
Abstract

BACKGROUND: In order to evaluate the factors associated with change in exercise capacity after comprehensive inpatient Pulmonary Rehabilitation (IPR) we studied 132 consecutive adults with Chronic Obstructive Pulmonary Disease (COPD) recovering from an acute exacerbation. MATERIAL/METHODS: Lung function, arterial blood gases, and respiratory muscle strength were measured at baseline. Perceived breathlessness (B), 6-minute walk distance (6MWD), dyspnea at rest and post-exertion (D), hospital anxiety and depression (HAD), and health-related quality of life were assessed before (T0) and after (T1) IPR. The patients were divided into two groups depending on the change in 6MWD: Improvers (IM at least +54 meters after IPR, n=81) or Non-Improvers (NIM, less than 54 meters or no change, n=51). RESULTS: At T1 61\% of the patients showed improvement as here defined. The IM group showed lower 6MWD and higher B and resting-D at T0 than NIM (p<0.05). A stepwise multiple regression analysis was performed using 6MWD change as the dependent variable. and anthropometric and physiological measures at T0 as the independent variables. This regression model explained 26\% of the 6MWD-change; 6MWD and PaO2 significantly contributed to this model. CONCLUSIONS: In COPD patients recovering from an acute exacerbation, the predicted change in exercise capacity using anthropometric, demographic, clinical, and physiological variables after 2 weeks of comprehensive IPR is likely to be low. The baseline level of exercise performance and arterial oxygenation show the most consistent correlation with change in walking ability in these patients.

E. Clini, C. Sturani, A. Rossi, S. Viaggi, A. Corrado, C. F. Donner, N. Ambrosino, Rehabilitation, Italian Association of Hospital Pneumology (AIPO) ( 2002 ) - The Italian multicentre study on noninvasive ventilation in chronic obstructive pulmonary disease patients - EUROPEAN RESPIRATORY JOURNAL - n. volume 20 - pp. da 529 a 538 ISSN: 0903-1936 [Articolo su rivista - Articolo su rivista]
Abstract

Chronic obstructive pulmonary disease (COPD) patients with chronic ventilatory failure (CVF) are more likely to develop exacerbations, which are an important determinant of health-related quality of life (HRQL). Long-term noninvasive positive-pressure ventilation (NPPV) has been proposed in addition to long-term oxygen therapy (LTOT) to treat CVF but little information is available on its effects on HRQL and resource consumption. Therefore, the current authors undertook a 2-yr multicentric, prospective, randomised, controlled trial to assess the effect of NPPV+ LTOT on: 1) severity of hypercapnia; 2) use of healthcare resources, and 3) HRQL, in comparison with LTOT alone. One hundred and twenty-two stable hypercapnic COPD patients on LTOT for > or = 6 months were consecutively enrolled. After inclusion and 1-month run-in, 90 patients were randomly assigned to NPPV+LTOT (n=43) or to LTOT alone (n=47). Arterial blood gases, hospital and intensive care unit (ICU) admissions, total hospital and ICU length of stay and HRQL were primary outcome measures; survival and drop-out rates, symptoms (dyspnoea and sleep quality) and exercise tolerance were secondary outcome measures. Follow-up was performed at 3-month intervals up to 2 yrs. Lung function, inspiratory muscle function, exercise tolerance and sleep quality score did not change over time in either group. By contrast the carbon dioxide tension in arterial blood on usual oxygen, resting dyspnoea and HRQL, as assessed by the Maugeri Foundation Respiratory Failure Questionnaire, changed differently over time in the two groups in favour of NPPV+LTOT. Hospital admissions were not different between groups during the follow-up. Nevertheless, overall hospital admissions showed a different trend to change in the NPPV+LTOT (decreasing by 45\%) as compared with the LTOT group (increasing by 27\%) when comparing the follow-up with the follow-back periods. ICU stay decreased over time by 75\% and 20\% in the NPPV+LTOT and LTOT groups, respectively. Survival was similar. Compared with long-term oxygen therapy alone, the addition of noninvasive positive-pressure ventilation to long-term oxygen therapy in stable chronic obstructive pulmonary disease patients with chronic ventilatory failure: 1) slightly decreased the trend to carbon dioxide retention in patients receiving oxygen at home and 2) improved dyspnoea and health-related quality of life. The results of this study show some significant benefits with the use of nocturnal, home noninvasive positive-pressure ventilation in patients with chronic ventilatory failure due to advanced chronic obstructive pulmonary disease patients. Further work is required to evaluate the effect of noninvasive positive-pressure ventilation on reducing the frequency and severity of chronic obstructive pulmonary disease exacerbation.

E. Clini, N. Ambrosino ( 2001 ) - A molecule across centuries. - MONALDI ARCHIVES FOR CHEST DISEASE - n. volume 56 - pp. da 3 a 4 ISSN: 1122-0643 [Articolo su rivista - Articolo su rivista]
Abstract

Non disponibile

M. Vitacca, A. Vianello, D. Colombo, E. Clini, R. Porta, L. Bianchi, G. Arcaro, G. Vitale, E. Guffanti, A. Lo Coco, N. Ambrosino ( 2001 ) - Comparison of two methods for weaning patients with chronic obstructive pulmonary disease requiring mechanical ventilation for more than 15 days. - AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE - n. volume 164 - pp. da 225 a 230 ISSN: 1073-449X [Articolo su rivista - Articolo su rivista]
Abstract

We designed a prospective multicenter randomized controlled study in three long-term weaning units (LWU) to evaluate which protocol, inspiratory pressure support ventilation (PSV) or spontaneous breathing trials (SB), is more effective in weaning patients with chronic obstructive pulmonary disease (COPD) requiring mechanical ventilation for more than 15 d. Fifty-two of 75 patients, failing an initial T-piece trial at admission, were randomly assigned to PSV or SB (26 in both groups). No significant difference was found in weaning success rate (73\% versus 77\% in the PSV and SB group, respectively), mortality rate (11.5\% versus 7.6\%), duration of ventilatory assistance (181 +/- 161 versus 130 +/- 106 h), LWU (33 +/- 12 versus 35 +/- 19 d), or total hospital stay. The results of these defined protocols were retrospectively compared with an "uncontrolled clinical practice" in weaning historical control patients. The overall 30-d weaning success rate was significantly greater (87\% versus 70\%) and the time spent under mechanical ventilation by survived and weaned patients was shorter in the patients in the study than in historical control patients (103 +/- 144 versus 170 +/- 127 h). The LWU and hospital stays were also significantly shorter (27 +/- 12 versus 38 +/- 18 and 38 +/- 17 versus 47 +/- 18 d). Spontaneous breathing trials and decreasing levels of PSV are equally effective in difficult-to-wean patients with COPD. The application of a well-defined protocol, independent of the mode used, may result in better outcomes than uncontrolled clinical practice.

E. Clini, L. Bianchi, K. Foglio, R. Porta, M. Vitacca, N. Ambrosino ( 2001 ) - Effect of pulmonary rehabilitation on exhaled nitric oxide in patients with chronic obstructive pulmonary disease. - THORAX - n. volume 56 - pp. da 519 a 523 ISSN: 0040-6376 [Articolo su rivista - Articolo su rivista]
Abstract

BACKGROUND: In patients with mild to moderate chronic obstructive pulmonary disease (COPD) the exercise induced increase in exhaled nitric oxide (eNO) parallels that observed in normal untrained subjects. There is no information on the effects of the level of exercise tolerance on eNO in these patients. The aim of this study was to evaluate the effect of a pulmonary rehabilitation programme including exercise training on eNO in patients with COPD. METHODS: In 14 consecutive male patients with stable COPD of mean (SD) age 64 (9) years and forced expiratory volume in one second (FEV1) 55 (14)\% predicted, fractional eNO concentration (FeNO), peak work rate (Wpeak) and oxygen uptake (VO2peak) were assessed at baseline (T-1), at the end of a 1 month run in period (T0), and after an 8 week outpatient multidisciplinary pulmonary rehabilitation programme (T1) including cycloergometer training. RESULTS: FeNO did not significantly differ at T-1 and T0 (mean (SE) 4.3 (0.6) and 4.4 (0.6) ppb, respectively), whereas it rose significantly at T1 to 6.4 (0.7) ppb (p<0.02). Compared with T0, both Wpeak and VO2 were significantly (p<0.05) increased at T1 (mean (SE) Wpeak from 89 (5.6) W to 109 (6.9) W); VO2peak from 1.27 (0.1) l/min to 1.48 (0.1) l/min). A significant correlation was found between baseline FEV1 and the change in FeNO following the rehabilitation programme (r=-0.71; p<0.05) and between changes in FeNO and Wpeak from T0 to T1(r=0.60; p<0.05). CONCLUSIONS: Pulmonary rehabilitation in patients with mild to moderate COPD is associated with an increase in exhaled nitric oxide.

E. Clini, L. Bianchi, N. Ambrosino ( 2001 ) - Exhaled nitric oxide in COPD patients. - MONALDI ARCHIVES FOR CHEST DISEASE - n. volume 56 - pp. da 169 a 170 ISSN: 1122-0643 [Articolo su rivista - Articolo su rivista]
Abstract

nd

M. Malerba, E. Clini, A. Radaeli, L. Corda, L. Pini, L. Ceriani, V. Grassi ( 2001 ) - Exhaled nitric oxide in patients with alpha 1 antitrypsin (AAT) deficiency. - MONALDI ARCHIVES FOR CHEST DISEASE - n. volume 56 - pp. da 175 a 176 ISSN: 1122-0643 [Articolo su rivista - Articolo su rivista]
Abstract

nd

M. Malerba, E. Clini, G. Cremona, A. Radaeli, L. Bianchi, L. Corda, L. Pini, F. Ricciardolo, V. Grassi, N. Ambrosino, F. Ricclardolo ( 2001 ) - Exhaled nitric oxide in patients with PiZZ phenotype-related alpha1-anti-trypsin deficiency. - RESPIRATORY MEDICINE - n. volume 95 - pp. da 520 a 525 ISSN: 0954-6111 [Articolo su rivista - Articolo su rivista]
Abstract

There is no report of exhaled NO (eNO) in subjects with different phenotypes of alpha1-anti-trypsin (AAT) deficiency. Exhaled nitric oxide was evaluated by means of single-breath chemiluminescence analysis (fractional exhaled concentration at the plateau level [plFE(NO)]) in 40 patients with AAT deficiency. Patients were divided according to the protease inhibitor (Pi) phenotype: PiMZ/MS, n = 25; PiSZ n = 6; PiZZ, n = 9. Nineteen healthy subjects served as controls. Levels of eNO in PiZZ patients were also compared with those of subjects, without AAT deficiency (PiMM), matched for diagnosis, sex, age, smoking habit and forced expiratory volume in 1 sec (FEV1). In AAT deficiency subjects airway hyper-responsiveness to methacholine (PD20 FEV1) was also assessed. plFE(NO) was significantly lower in the PiZZ group (4.5+/-1.4 ppb) than in matched PiMM subjects (8.2+/-3.8 ppb), in healthy controls (9.3+/-2.8 ppb) and in patients of other phenotypes. Dynamic lung volumes and DL(CO) were significantly lower in PiZZ than in other AAT-deficient patients. Bronchial hyper-responsiveness was not different among AAT phenotypes. These results suggest that eNO may be significantly reduced in PiZZ as compared to healthy control subjects and to AAT subjects with other phenotypes, independent of the level of airway obstruction. Whether, at least potentially, eNO may be considered as an early marker of lung involvement in AAT deficiency must be confirmed with studies on larger number of subjects.

E. Clini, K. Foglio, L. Bianchi, R. Porta, M. Vitacca, N. Ambrosino ( 2001 ) - In-hospital short-term training program for patients with chronic airway obstruction. - CHEST - n. volume 120 - pp. da 1500 a 1505 ISSN: 0012-3692 [Articolo su rivista - Articolo su rivista]
Abstract

OBJECTIVE: To compare the functional benefits and relative costs of administering an intense short-term inpatient vs a longer outpatient pulmonary rehabilitation program (PRP) for patients with chronic airway obstruction (CAO). DESIGN: Retrospective case-control study. SETTING: Pulmonary ward and outpatient clinic of a rehabilitation center. PATIENTS: Forty-three patients (case subjects) selected on the basis of selection criteria were compared with control subjects matched to them for age, sex, FEV(1), and diagnosis of either COPD or asthma. Case subjects performed 10 to 12 daily sessions (5 sessions a week) of inpatient PRP; control subjects performed 20 to 24 sessions (3 sessions a week) of outpatient PRP. MEASUREMENTS: At baseline and after the PRP, an incremental exercise test was performed, including evaluation of dyspnea and leg fatigue by Borg scale (D and F, respectively) at each workload step. The cost of PRP was also evaluated. RESULTS: Both PRPs resulted in similar significant improvements in cycloergometry peak workload (from 68 +/- 18 to 82 +/- 22 and from 75 +/- 17 to 87 +/- 27 W in case subjects and control subjects, respectively), isoload D (from 6.4 +/- 1.6 to 4.2 +/- 1.8 for case subjects and from 8.5 +/- 1.9 to 6.3 +/- 2.4 for control subjects) and isoload F (from 6.6 +/- 1.8 to 4.2 +/- 1.8 for case subjects and from 8.9 +/- 1.9 to 7.0 +/- 1.8 for control subjects). Although the single daily session was less expensive, the outpatient PRP total costs were greater because of the higher number of sessions and the cost of daily transportation. CONCLUSIONS: In patients with CAO, a shorter inpatient PRP may result in improvement in exercise tolerance similar to a longer outpatient PRP but with lower costs. Whether a shorter outpatient PRP may get physiologic and clinical benefits, while further reducing costs, must be evaluated by future controlled, randomized, prospective studies.

P. Ranieri, R. Rozzini, S. Franzoni, M. Trabucchi, E. Clini ( 2001 ) - One-year mortality in elderly stable patients with COPD. - MONALDI ARCHIVES FOR CHEST DISEASE - n. volume 56 - pp. da 481 a 485 ISSN: 1122-0643 [Articolo su rivista - Articolo su rivista]
Abstract

A retrospective study was performed to evaluate the risks of one-year mortality in very old hospitalized patients including those suffering from chronic obstructive pulmonary disease (COPD). Six hundred and fifty-eight disabled patients (M = 194, mean age 79.2 +/- 7.4 years) consecutively admitted to and discharged from a Geriatric Evaluation and Rehabilitation Unit (GERU) after a comprehensive rehabilitation program were studied and divided into two groups: COPD (n = 337, 51\%) and non-COPD (n = 321, 49\%). Multidimensional evaluation including information on demographics, cognitive status [Mini Mental State Examination (MMSE)], physical health [number of diseases, Greenfield's Individual Disease Severity (IDS), and number of drugs used], functional disability [Basic Activity of Daily Living (BADL), Tinetti scale, and Physical Performance Test (PPT)], and nutritional status [Prognostic Nutritional Index (PNI)] were assessed at admission. Survival rate was assessed over a 1-year period following discharge. COPD patients mainly differed from non-COPD in terms of older age, smoking habit, number of associated diseases and drugs used. Aggregating the IDS 2-3-4 COPD classes (symptoms + functional impairment), the risk of one-year mortality was double that of the IDS 1 COPD class (symptoms only) and of non-COPD subjects (IDS 0 class) after adjusting for age, sex, disability, malnutrition, and comorbility. Moreover, IDS 2-3-4 COPD patients suffering from cor pulmonale (CP) had a fourfold 1-year risk of mortality in comparison with the IDS 1 COPD group after adjusting for the same covariates. Hospitalized stable very old COPD patients presenting functional impairment have a higher 1-year risk of mortality than only symptomatic COPD or non-COPD subjects. The presence of cor pulmonale with COPD further increases this risk.

M. Vitacca, N. Ambrosino, E. Clini, R. Porta, C. Rampulla, B. Lanini, S. Nava ( 2001 ) - Physiological response to pressure support ventilation delivered before and after extubation in patients not capable of totally spontaneous autonomous breathing. - AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE - n. volume 164 - pp. da 638 a 641 ISSN: 1073-449X [Articolo su rivista - Articolo su rivista]
Abstract

We designed a prospective, physiological study in 12 patients affected by chronic respiratory disorders. The study was aimed at assessing the diaphragm energy expenditure (PTPdi), lung resistance (RL) and elastance (EL), arterial blood gases (ABG), breathing pattern, and dyspnea measured by a visual analog scale during invasive pressure support ventilation (i-PSV) and noninvasive PSV (n-PSV). The ventilator settings were kept the same. Both i-PSV and n-PSV significantly reduced the PTPdi per minute, compared with that during a T-piece trial (204.4 +/- 93.8 cm H(2)O x s/min [i-PSV]; 197.5 +/- 119.8 [n-PSV]; 393.8 +/- 129.0 [T-piece]). Expired tidal volume (VTe) was significantly higher (p < 0.05) during n-PSV (615 +/- 166 ml) than during i-PSV (519 +/- 140 ml). The respiratory pump (PTPdi/VTe) was more effective (p < 0.05) with noninvasive ventilation (22.3 +/- 2.3 cm H(2)O x s/L for i-PSV versus 17.2 +/- 3.3 for n-PSV). RL and EL were similar with the two modes of ventilation. Overall dyspnea was significantly (p < 0.05) better during n-PSV than i-PSV, whereas ABG were similar. We have shown, in patients affected by stable chronic respiratory disorders not ready to sustain totally spontaneous breathing, that i-PSV and n-PSV are equally effective in reducing the PTPdi and in improving ABG, but that n-PSV seems to be better tolerated.

E. Clini, M. Volterrani, M. Pagani, L. Bianchi, R. Porta, L. S. Gile', A. Giordano, N. Ambrosino ( 2000 ) - Endogenous nitric oxide in patients with chronic heart failure (CHF): relation to functional impairment and nitrate-containing therapies. - INTERNATIONAL JOURNAL OF CARDIOLOGY - n. volume 73 - pp. da 123 a 130 ISSN: 0167-5273 [Articolo su rivista - Articolo su rivista]
Abstract

We assessed the levels of exhaled nitric oxide (eNO) in patients with chronic heart failure (CHF) according to the functional impairment and the use of nitrate-containing agents. Forty patients (age 55+/-9 years) were classified according to the NYHA classes I-II (n=18, group 1) and classes III-IV (n=22, group 2), and to the use of nitrate-containing drugs (Nitrate+, Nitrate-). Twenty-two healthy age-related subjects served as controls (group 3). Respiratory function, symptom-limited incremental cycloergometry and resting eNO concentration at peak (FENOp) or plateau (FENOpl) of the single-breath exhalation curve were assessed in all subjects. FENOpl was significantly lower in patients than in controls (7.8+/-2.7 and 10.6+/-2.8 ppb, respectively, P<0.005) and lower in most severe CHF patients (7.1+/-2.6 and 8.8+/-2.7 ppb in group 2 and group 1, respectively, P<0.05). A significant correlation between peak V'O(2), Watts and FENOpl (r=0.42, P<0.013 and r=0.46, P=0.008, respectively) was found. Independent of NYHA class, Nitrate+ showed higher FENOp levels than Nitrate- patients (36.9+/-15.7 vs. 28. 1+/-15.1 ppb, P<0.05). Resting eNO was lower in the most compromised CHF patients and was significantly related to exercise capacity. Nitrate-containing agents might influence the levels of eNO in these patients.

E. Clini, L. Bianchi, M. Vitacca, R. Porta, K. Foglio, N. Ambrosino ( 2000 ) - Exhaled nitric oxide and exercise in stable COPD patients. - CHEST - n. volume 117 - pp. da 702 a 707 ISSN: 0012-3692 [Articolo su rivista - Articolo su rivista]
Abstract

STUDY OBJECTIVE: To evaluate exhaled nitric oxide (eNO) during exercise in patients with stable COPD. SETTING: Outpatient evaluation in a rehabilitation center. PATIENTS: Eleven consecutive male patients with stable COPD (age, 65 +/- 6 years; FEV(1), 56 +/- 10\% predicted). Eight healthy (six men; age, 51 +/- 16 years) nonsmoking, nonatopic volunteers served as control subjects. METHODS: In each subject, a symptom-limited cycle ergometry test was performed by monitoring eNO with the tidal-breath method to assess eNO concentration (FENO) and output (VNO) at rest, peak exercise, and recovery time. RESULTS: Resting FENO (9.8 +/- 5.1 and 14.1 +/- 6.3 parts per billion, respectively) and VNO (4.2 +/- 2.0 and 5.9 +/- 3.4 nmol/min, respectively) were lower, although not significantly, in COPD patients than in control subjects. In both groups, FENO significantly decreased whereas VNO significantly increased during exercise. Both variables returned to baseline during the recovery time. Peak exercise VNO, but not FENO, was significantly lower in COPD patients than in control subjects (7.9 +/- 5.4 and 12.7 +/- 6.0 nmol/min, respectively, p < 0.05). The rise in VNO was weakly correlated to oxygen consumption VO(2)) both in control subjects (r = 0.31, p = 0. 002) and in COPD patients (r = 0.22, p = 0.03). FENO showed an inverse correlation to VO(2) in both groups (r = -0.53, p = 0.000; r = -0.31, p = 0.003 in control subjects and COPD patients, respectively). CONCLUSIONS: In patients with mild and moderate COPD, eNO during exercise parallels that observed in normal control subjects. VNO, but not FENO, is significantly reduced at peak exercise in COPD patients as compared with control subjects. The long-term effects of exercise training on eNO has to be evaluated by further studies.

N. Ambrosino, E. Clini ( 2000 ) - Noninvasive ventilation in COPD patients with chronic respiratory failure--pro - MONALDI ARCHIVES FOR CHEST DISEASE - n. volume 55 - pp. da 54 a 57 ISSN: 1122-0643 [Articolo su rivista - Articolo su rivista]
Abstract

nd

M. Vitacca, E. Clini, M. Pagani, L. Bianchi, A. Rossi, N. Ambrosino ( 2000 ) - Physiologic effects of early administered mask proportional assist ventilation in patients with chronic obstructive pulmonary disease and acute respiratory failure. - CRITICAL CARE MEDICINE - n. volume 28 - pp. da 1791 a 1797 ISSN: 0090-3493 [Articolo su rivista - Articolo su rivista]
Abstract

OBJECTIVE: To evaluate the physiologic short-term effects of noninvasive proportional assist ventilation (PAV) in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD). DESIGN: Prospective, physiologic study. SETTING: Respiratory intermediate intensive care unit. PATIENTS: Seven patients with acute respiratory failure requiring noninvasive mechanical ventilation because of exacerbation of COPD. INTERVENTIONS: PAV was administered by nasal mask as first ventilatory intervention. The setting of PAV involved a procedure to adjust volume assist and flow assist to levels corresponding to patient comfort. Volume assist was also set by means of the "run-away" procedure. Continuous positive airway pressure (CPAP) amounting to 2 cm H2O was always set by the ventilator. This setting of assistance (PAV) was applied for 45 mins. Thereafter, CPAP was increased to 5 cm H2O (PAV + CPAP-5) without any change in the PAV setting and was administered for 20 mins. Oxygen was delivered through a port of the mask in the attempt to maintain a target SaO2 >90\%. MEASUREMENTS AND MAIN RESULTS: Arterial blood gases, breathing pattern, and inspiratory effort were measured during unsupported breathing and at the end of PAV, and breathing pattern and inspiratory effort were measured after 20 mins of PAV + CPAP-5. PAV determined a significant increase in tidal volume and minute ventilation (+64\% and +25\% on average, respectively) with unchanged breathing frequency and a significant improvement in arterial blood gases (PaO2 with the same oxygen supply, from 65 +/- 15 torr to 97 +/- 36 torr; PaCO2, from 80 +/- 11 torr to 76 +/- 13 torr; pH, from 7.30 +/- 0.02 to 7.32 +/- 0.03). The pressure-time product calculated over a period of 1 min (from 318 +/- 87 to 205 +/- 145 cm H2O x sec x min(-1)) was significantly reduced. PAV + CPAP-5 resulted in a further although not significant decrease in the pressure-time product calculated over a period of 1 min (to 183 +/- 110 cm H2O x sec x min(-1)), without additional changes in the breathing pattern. CONCLUSIONS: Noninvasive PAV is able to improve arterial blood gases while unloading inspiratory muscles in patients with acute exacerbation of COPD.

M. Vitacca, E. Clini, R. Porta, N. Ambrosino ( 2000 ) - Preliminary results on nursing workload in a dedicated weaning center. - INTENSIVE CARE MEDICINE - n. volume 26 - pp. da 796 a 799 ISSN: 0342-4642 [Articolo su rivista - Articolo su rivista]
Abstract

OBJECTIVE: To evaluate the nursing time required for difficult-to-wean patients in a dedicated weaning center (WC) and to examine the correlation of the nursing time with nursing workload (NW) scores and with clinical severity and dependency. SETTING: Four-bed WC of a pulmonary rehabilitation department. INTERVENTION: None. DESIGN AND MEASUREMENT: Prospective, observational study of 46 consecutive patients admitted to a long-term WC. Time required by items of the Time Oriented Score System (TOSS) and other tasks specific to respiratory intermediate intensive care units were evaluated for all the activities performed on each patient in the first 2 days after admission. Patient dependency and level of nursing care at admission were measured using the Dependence Nursing Scale (DNS) and the Intermediate Therapeutic Intervention Score System (TISS-int). The Acute Physiology and Chronic Health Evaluation (APACHE) II score was also recorded at admission. RESULTS: On the first day each patient needed 45 +/- 15\% (63 +/- 23\%, 45 +/- 22\%, and 29 +/- 14\% for the three nursing shifts) of allocated single nursing time. On the TOSS on the first day patients required a daily mean 28 +/- 10\% of total available nursing time; on the second day the results did not change. Time of care in the first 24 h was only weakly related to DNS, APACHE II score, and TISS-int; only DNS was able (although weakly; r = 0.45) to predict minutes of nursing care. CONCLUSIONS: In difficult-to-wean patients from mechanical ventilation the nursing time in the first 2 days after admission is high. The use of TOSS may underestimate NW by about 38\%. Although only DNS showed the ability to predict minutes of care, the weak relationship limits its value in clinical practice.

E. Clini, G. Cremona, M. Campana, C. Scotti, M. Pagani, L. Bianchi, A. Giordano, N. Ambrosino ( 2000 ) - Production of endogenous nitric oxide in chronic obstructive pulmonary disease and patients with cor pulmonale. Correlates with echo-Doppler assessment - AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE - n. volume 162 - pp. da 446 a 450 ISSN: 1073-449X [Articolo su rivista - Articolo su rivista]
Abstract

Exhaled nitric oxide (NO) production in stable chronic obstructive pulmonary disease (COPD) has been loosely related to the severity of illness, being significantly reduced in the most severe cases. Pulmonary hypertension is associated with lower NO output from the lung. In this study expired NO was measured in patients with severe stable COPD with or without cor pulmonale (CP). Echocardiographic estimates of right heart function, lung function, diffusion capacity, respiratory muscle strength, and arterial blood gases were obtained in 34 consecutive patients with stable COPD (mean age, 68 +/- 7 yr). Expired NO was measured by chemiluminiscence to obtain fractional exhaled concentrations at peak (FENOp) and at plateau (FENOpl) points of the single-breath curve and resting NO output (V NO). All measurements of expired NO output, FENOp, FENOpl and V NO showed a negative correlation with both systolic pulmonary artery pressure (Pspa) (r = -0.51, -0.63, and -0.63, respectively, p < 0.01 for all) and right ventricle wall dimension (r = -0.41, -0.59, and -0.43, respectively, p < 0.05 for all), but not with any measurement of lung function. When the patients were divided according to the Pspa using a cutoff limit of 35 mm Hg, those subjects with CP showed lower FENOp (13.2 +/- 4.0 versus 36.7 +/- 30.8 ppb, p < 0.05), FENOpl (5.7 +/- 1.9 versus 8.9 +/- 4.7 ppb, p < 0.05), and V NO (69. 2 +/- 5.6 versus 107.6 +/- 14.6 nl/ min, p = 0.02) than did those with a normal resting Pspa. NO production from the airways was significantly lower and inversely related to development of CP in patients with severe COPD. Impaired endothelial release may account for the reduced levels of expired NO.

M. Vitacca, S. Nava, M. Confalonieri, L. Bianchi, R. Porta, E. Clini, N. Ambrosino ( 2000 ) - The appropriate setting of noninvasive pressure support ventilation in stable COPD patients. - CHEST - n. volume 118 - pp. da 1286 a 1293 ISSN: 0012-3692 [Articolo su rivista - Articolo su rivista]
Abstract

STUDY OBJECTIVE: To evaluate the short-term physiologic effects of two settings of nasal pressure-support ventilation (NPSV) in stable COPD patients with chronic hypercapnia. DESIGN: Randomized controlled physiologic study. SETTING: Lung function units and outpatient clinic of two affiliated pulmonary rehabilitation centers. PATIENTS: Twenty-three patients receiving domiciliary nocturnal NPSV for a mean (+/- SD) duration of 31 +/- 20 months. METHODS: Evaluation of arterial blood gases, breathing pattern, respiratory muscles, and dynamic intrinsic positive end-expiratory pressure (PEEPi,dyn) during both unassisted and assisted ventilation. Two settings of NPSV were randomly applied for 30 min each: (1) usual setting (U), the setting of NPSV actually used by the individual patient at home; and (2) physiologic setting (PHY), the level of inspiratory pressure support (IPS) and external positive end-expiratory pressure (PEEPe) tailored to patient according to invasive evaluation of respiratory muscular function and mechanics. RESULTS: All patients tolerated NPSV well throughout the procedure. Mean U was IPS, 16 +/- 3 cm H(2)O and PEEPe, 3.6 +/- 1.4 cm H(2)O; mean PHY was IPS, 15 +/- 3 cm H(2)O and PEEPe, 3.1 +/- 1.6 cm H(2)O. NPSV was able to significantly (p < 0.01) improve arterial blood gases independent of the setting applied. When compared with spontaneous breathing, both settings induced a significant increase in minute ventilation (p < 0.01). Both settings were able to reduce the diaphragmatic pressure-time product, but the reduction was significantly greater with PHY (by 64\%; p < 0.01) than with U (56\%; p < 0.05). Eleven of 23 patients (48\%) with U and 7 of 23 patients (30\%) with PHY showed ineffective efforts (IE); the prevalence of IE (20 +/- 39\% vs 6 +/- 11\% of their respiratory rate with U and PHY, respectively) was statistically different (p < 0.05). CONCLUSION: In COPD patients with chronic hypercapnia, NPSV is effective in improving arterial blood gases and in unloading inspiratory muscles independent of whether it is set on the basis of patient comfort and improvement in arterial blood gases or tailored to a patient's respiratory muscle effort and mechanics. However, setting of inspiratory assistance and PEEPe by the invasive evaluation of lung mechanics and respiratory muscle function may result in reduction in ineffective inspiratory efforts. These short-term results must be confirmed in the long-term clinical setting.

E. CLINI; VITACCA M; AMBROSINO N ( 1999 ) - Dependence Nursing Scale: a new method to assess the effect of nursing workload in a respiratory intermediate intensive care unit. - RESPIRATORY CARE - n. volume 44 - pp. da 29 a 37 ISSN: 0020-1324 [Articolo su rivista - Articolo su rivista]
Abstract

Non disponibile

M. Bernareggi, G. Rossoni, E. Clini, E. Pasini, T. Bachetti, G. Cremona, N. Ambrosino, F. Berti ( 1999 ) - Detection of nitric oxide in exhaled air of different animal species using a clinical chemiluminescence analyser. - PHARMACOLOGICAL RESEARCH - n. volume 39 - pp. da 221 a 224 ISSN: 1043-6618 [Articolo su rivista - Articolo su rivista]
Abstract

The aim of the present study was to evaluate the nitric oxide (NO) concentrations present in end-expired gas (FENO) of different animal species under basal and stimulated conditions using a clinical chemiluminescence analyser, which has been developed for measurement of single exhalations in humans. Anaesthetised, tracheotomised and artificially ventilated guinea pigs, rats and rabbits were prepared for recording systemic blood pressure and FENO. Stable levels of FENO were detected in expired air over a 1-h observation period in the three animal species tested. Rabbits exhibited the highest concentrations and output (FENO 12.9+/-1.0 ppb, VNO 9.0+/-0.7 nl min-1), followed by guinea pigs (FENO 6.2+/-0.70 ppb, VNO 1.7+/-0.19 nl min-1) and rats (FENO 0.9+/-0.01 ppb, VNO 0.25+/-0.00 nl min-1). L-arginine (1 g kg-1 i.v.) evoked significant increments in VNO in guinea pigs and rabbits but was ineffective in rats. However, L-arginine showed a direct effect on blood pressure in all the animal species tested, causing a rapid fall in the mean arterial blood pressure (MABP; 38, 48 and 50\% decrease in rabbits, guinea pigs and rats, respectively; P<0.05). An inhibitor of endogenous NO synthesis, NG-nitro-L-arginine methyl ester (L-NAME, 20 mg kg-1 i.v.), decreased both basal and L-arginine-induced VNO in guinea pigs and rabbits, but was ineffective in rats. L-NAME increased MABP in all the animal species tested (58\% in guinea pigs, 43\% in rats and 18\% in rabbits; P<0.05). The results indicate that it is possible to detect NO in the exhaled air of different animal species using a clinical chemiluminescence analyser and that different species exhibit striking differences in the levels of basal and stimulated NO output.

M. Vitacca, R. Porta, L. Bianchi, E. Clini, N. Ambrosino ( 1999 ) - Differences in spontaneous breathing pattern and mechanics in patients with severe COPD recovering from acute exacerbation. - EUROPEAN RESPIRATORY JOURNAL - n. volume 13 - pp. da 365 a 370 ISSN: 0903-1936 [Articolo su rivista - Articolo su rivista]
Abstract

The aims of this study were to assess spontaneous breathing patterns in patients with chronic obstructive pulmonary disease (COPD) recovering from acute exacerbation and to assess the relationship between different breathing patterns and clinical and functional parameters of respiratory impairment. Thirty-four COPD patients underwent assessment of lung function tests, arterial blood gases, haemodynamics, breathing pattern (respiratory frequency (fR), tidal volume (VT), inspiratory and expiratory time (tI and tE), duty cycle (tI/ttot), VT/tI) and mechanics (oesophageal pressure (Poes), work of breathing (WOB), pressure-time product and index, and dynamic intrinsic positive end-expiratory pressure (PEEPi,dyn)). According to the presence (group 1) or absence (group 2) of Poes swings during the expiratory phase (premature inspiration), 20 (59\%) patients were included in group 1 and 14 (41\%) in group 2. Premature inspirations were observed 4.5+/-6.4 times x min(-1) (range 1-31), i.e. 20+/-21\% (3.7-100\%) of total fR calculated from VT tracings. In group 1 the coefficient of variation in VT, tE, tI/ttot, PEEPi,dyn, Poes and WOB of the eight consecutive breaths immediately preceding the premature inspiration was greater than that of eight consecutive breaths in group 2. There were no significant differences in the assessed parameters between the two groups in the overall population, whereas patients with chronic hypoxaemia in group 1 showed a more severe impairment in clinical conditions, mechanics and lung function than hypoxaemic patients in group 2. In spontaneously breathing patients with chronic obstructive pulmonary disease recovering from an acute exacerbation, detectable activity of inspiratory muscles during expiration was found in more than half of the cases. This phenomenon was not associated with any significant differences in anthropometric, demographic, physiological or clinical characteristics.

T. Bachetti, E. Pasini, E. Clini, G. Cremona, R. Ferrari ( 1999 ) - High-dose heparin impairs nitric oxide pathway and vasomotion in rats. - CIRCULATION - n. volume 99 - pp. da 2861 a 2863 ISSN: 0009-7322 [Articolo su rivista - Articolo su rivista]
Abstract

BACKGROUND: Platelet-activating effects have been reported with high-dose heparin in acute thrombotic disorders. Recent studies have shown that increased platelet aggregation is due to reduced nitric oxide (NO) production in endothelial cells cultured in the presence of high-dose heparin. The aim of this study was to determine whether heparin can affect the NO pathway and the regulation of the vascular tone in vivo. METHODS AND RESULTS: Anesthetized and mechanically ventilated Sprague-Dawley rats were treated with high-dose heparin. After 4 hours, the endothelial constitutive NO synthase (ecNOS) protein content in the aorta decreased (36\% reduction, P<0.05), as detected by immunoblotting, and NO-dependent vascular reactivity was impaired. In fact, the increase in mean arterial blood pressure after inhibition of ecNOS with NG-nitro-L-arginine methyl ester (30 mg/kg) was smaller in heparin-treated animals than in controls (+26. 9+/-4.8 versus +48.3+/-9.1 mm Hg, P<0.05), and further infusion of the biological ecNOS substrate L-arginine (0.5 g/kg) was ineffective in reversing systemic vasoconstriction (-1\% versus 28\% vasodilatation, P<0.001). CONCLUSIONS: High-dose heparin can significantly affect vascular reactivity in vivo by downregulation of ecNOS protein expression.

E. CLINI; VITACCA M; BIANCHI L; PORTA R; AMBROSINO N ( 1999 ) - Long-term tracheostomy in severe COPD patients weaned from mechanical ventilation. - RESPIRATORY CARE - n. volume 44 - pp. da 415 a 420 ISSN: 0020-1324 [Articolo su rivista - Articolo su rivista]
Abstract

Background- It has been shown that Chronic Obstructive Pulmonary Disease (COPD) patients undergoing an episode of acute respiratory failure (ARF) requiring mechanical ventilation are at risk of relapses. Therefore it might be conceivable to maintain, at least temporarily, the tracheostomy after discharge from the ICU also in spontaneously breathing patients. The aim of this study was to evaluate the six month effects of chronic tracheostomy in severe COPD patients after weaning from mechanical ventilation.Setting- An adult four beds respiratory intermediate ICU in an Italian Respiratory Rehabilitation Department.Patients-Twenty tracheotomized COPD patients, recovering from an episode of ARF and weaned from mechanical ventilation were randomly allocated into two groups: group 1 (10 patients) maintaining their tracheal cannula, and group 2 (10 patients) having the tracheal cannula removed and their cutaneous fistula spontaneously closed. Measurements- Breathing pattern, forced lung volumes, respiratory muscle force and arterial blood gases were evaluated at discharge (T0) and at 1 (T1), 3 (T3) and 6 months (T6) after discharge; days spent in the hospital (HS), mortality rate and number of new exacerbations requiring antibiotic use were also recorded.Results- Maximal Expiratory Pressure (MEP) but not other lung function parameters significantly improved over time in both groups. Two out of 10 patients (20%) in both groups died due to respiratory causes after 5.0±0.8 months since discharge. During the follow up exacerbations (0.8 ± 0.1 vs. 0.4 ± 0.5 n/patient; p < 0.005 in group 1 and 2 respectively) but not HS were significantly greater in patients of group 1.Conclusions- Chronic tracheostomy in severe COPD patients may be associated to more frequent exacerbations requiring antibiotic treatment. When free from absolute indications of tracheostomy, COPD patients weaned from mechanical ventilation should undergo early decannulation.

R. Porta, M. Vitacca, E. Clini, N. Ambrosino ( 1999 ) - Physiological effects of posture on mask ventilation in awake stable chronic hypercapnic COPD patients. - EUROPEAN RESPIRATORY JOURNAL - n. volume 14 - pp. da 517 a 522 ISSN: 0903-1936 [Articolo su rivista - Articolo su rivista]
Abstract

Stable chronic hypercapnic patients are often prescribed long-term mask noninvasive pressure support ventilation (NPSV). There is a lack of information on the effects of posture on NPSV. Therefore posture induced changes in physiological effects of NPSV in awake stable chronic hypercapnic patients were evaluated. In 12 awake chronic obstructive pulmonary disease (COPD) patients breathing pattern, respiratory muscles, mechanics and dyspnoea (by visual analogue scale: VAS) were evaluated during spontaneous breathing (SB) in sitting posture and during NPSV in sitting, supine and lateral positions randomly assigned. Arterial blood gases were evaluated during SB and at the end of the last NPSV session (whatever the posture). As expected NPSV resulted in a significant improvement in carbon dioxide tension in arterial blood (Pa,CO2) (from 7.4+/-0.85 to 6.9+/-0.7 kPa). When compared with SB, sitting NPSV resulted in a significant increase in tidal volume and minute ventilation and in a significant decrease in breathing frequency. Inspiratory muscle effort as assessed by oesophageal pressure swings and pressure-time product per minute (from 14+/-4.8 to 6.2+/-3.5 cmH2O, and from 240+/-81 to 96+/-60 cmH2O x s x min(-1) respectively), intrinsic dynamic positive end expiratory pressure (from 2.7+/-2.3 to 1.4+/-1.3 cmH2O) and expiratory airway resistance (from 18+/-7 to 5+/-3 cmH2O x L x s(-1)) decreased during sitting NPSV, whereas VAS did not change. Changing posture did not significantly affect any parameter independently of the patients weight, whether obese or not. In awake stable hypercapnic chronic obstructive pulmonary disease patients changing posture does not significantly influence breathing pattern and respiratory muscles during noninvasive pressure support ventilation suggesting that mask ventilation may be performed in different positions without any relevant difference in its effectiveness.

M. Vitacca, E. Clini, L. Bianchi, N. Ambrosino ( 1998 ) - Acute effects of deep diaphragmatic breathing in COPD patients with chronic respiratory insufficiency. - EUROPEAN RESPIRATORY JOURNAL - n. volume 11 - pp. da 408 a 415 ISSN: 0903-1936 [Articolo su rivista - Articolo su rivista]
Abstract

This study investigated the impact of deep diaphragmatic breathing (DB) on blood gases, breathing pattern, pulmonary mechanics and dyspnoea in severe hypercapnic chronic obstructive pulmonary disease (COPD) patients recovering from an acute exacerbation. Transcutaneous partial pressure of carbon dioxide (Ptc,CO2) and oxygen (Ptc,O2) and arterial oxygen saturation (Sa,O2), were continuously monitored in 25 COPD patients with chronic hypercapnia, during natural breathing and DB. In eight of these patients, breathing pattern and minute ventilation (V'E) were also assessed by means of a respiratory inductance plethysmography. In five tracheostomized patients, breathing pattern and mechanics were assessed by means of a pneumotachograph/pressure transducer connected to an oesophageal balloon. Subjective rating of dyspnoea was performed by means of a visual analogue scale. In comparison to natural breathing deep DB was associated with a significant increase in Ptc,O2 and a significant decrease in Ptc,CO2, with a significant increase in tidal volume and a significant reduction in respiratory rate resulting in increased V'E. During DB, dyspnoea worsened significantly and inspiratory muscle effort increased, as demonstrated by an increase in oesophageal pressure swings, pressure-time product and work of breathing. We conclude that in severe chronic obstructive pulmonary disease patients with chronic hypercapnia, deep diaphragmatic breathing is associated with improvement of blood gases at the expense of a greater inspiratory muscle loading.

E. Clini, L. Bianchi, M. Pagani, N. Ambrosino ( 1998 ) - Endogenous nitric oxide in patients with stable COPD: correlates with severity of disease. - THORAX - n. volume 53 - pp. da 881 a 883 ISSN: 0040-6376 [Articolo su rivista - Articolo su rivista]
Abstract

BACKGROUND: Increased levels of exhaled nitric oxide (eNO) have been reported in asthmatic subjects but little information is available on eNO in patients with advanced chronic obstructive pulmonary disease (COPD). A study was undertaken to evaluate the levels of eNO in patients with stable COPD of different degrees of severity. METHODS: Peak and plateau values of eNO (PNO and PLNO, respectively) were evaluated in 53 patients with COPD and analysed according to the level of forced expiratory volume in one second (FEV1) and the presence of cor pulmonale (CP) (group 1, FEV1 < 35\% predicted with CP, n = 15; group 2, FEV1 < 35\% predicted without CP, n = 15; group 3, FEV1 > 35\% predicted, n = 23). Seventeen normal subjects served as controls. RESULTS: All the patients with COPD had reduced levels of PLNO compared with the controls (mean (SD) 6.3 (3.0) and 9.4 (2.8) ppb, respectively). In groups 1 and 2 PLNO levels were significantly lower than in subjects in group 3 (5.5 (2.9), 5.7 (3.5), and 7.1 (2.7) ppb, respectively; p < 0.01 ANOVA). In all subjects \% predicted FEV1 correlated slightly with PLNO but not with PNO. CONCLUSION: Patients with severe stable COPD have reduced levels of eNO compared with normal subjects. eNO levels are slightly related to the severity of airflow obstruction.

E. Clini, M. Vitacca ( 1998 ) - If and when to close tracheostomy. - MONALDI ARCHIVES FOR CHEST DISEASE - n. volume 53 - pp. da 377 a 380 ISSN: 1122-0643 [Articolo su rivista - Articolo su rivista]
Abstract

Non disponibile

M. Gasperini, E. Clini, S. Zaccaria ( 1998 ) - Mechanical ventilation in chronic respiratory insufficiency: report on an Italian nationwide survey. The Italian Telethon Committee and the AIPO Study Group on Pulmonary Rehabilitation and Intensive Care. - MONALDI ARCHIVES FOR CHEST DISEASE - n. volume 53 - pp. da 394 a 399 ISSN: 1122-0643 [Articolo su rivista - Articolo su rivista]
Abstract

Respiratory home care is an important aspect of rehabilitation programmes designed for patients needing long-term mechanical ventilation. Many differences have emerged between countries in the long-term care of these patients, depending on the different ways of supplying material, managing patients and providing equipment. The results of analysis of the data obtained in a preliminary survey carried out in 1995-1996 among 115 Italian centres operating in the field of home mechanical ventilation are presented. A questionnaire (all closed-circuit items) consisting of two sections (the first epidemiological, and the second methodological and economic) was sent to all centres. Fifty-seven out of 115 (50\%) centres responded to the questionnaire, with a prevalence of responses from the north of Italy (37 centres). The responding centres had been working in this field for a mean period of 6 +/- 3 yrs, and a total of 1,842 patients were surveyed. The analysis focuses on the prevalence of treated diseases, methods of mechanical ventilation, regulation of prescription, evaluations carried out during follow-up, supply of equipment, costs and reimbursement, and relations with volunteer associations. A more thorough approach to all the problems emerging from this Italian survey regarding candidates for home mechanical ventilation is warranted. A more detailed comparative analysis of indications, management and costs vis-à-vis other countries should contribute towards achieving maximum uniformity of standards throughout Europe.

S. Nava, N. Ambrosino, E. Clini, M. Prato, G. Orlando, M. Vitacca, P. Brigada, C. Fracchia, F. Rubini ( 1998 ) - Noninvasive mechanical ventilation in the weaning of patients with respiratory failure due to chronic obstructive pulmonary disease. A randomized, controlled trial. - ANNALS OF INTERNAL MEDICINE - n. volume 128 - pp. da 721 a 728 ISSN: 0003-4819 [Articolo su rivista - Articolo su rivista]
Abstract

BACKGROUND: In patients with acute exacerbations of chronic obstructive pulmonary disease, mechanical ventilation is often needed. The rate of weaning failure is high in these patients, and prolonged mechanical ventilation increases intubation-associated complications. OBJECTIVE: To determine whether noninvasive ventilation improves the outcome of weaning from invasive mechanical ventilation. DESIGN: Multicenter, randomized trial. SETTING: Three respiratory intensive care units. PATIENTS: Intubated patients with chronic obstructive pulmonary disease and acute hypercapnic respiratory failure. INTERVENTION: A T-piece weaning trial was attempted 48 hours after intubation. If this failed, two methods of weaning were compared: 1) extubation and application of noninvasive pressure support ventilation by face mask and 2) invasive pressure support ventilation by an endotracheal tube. MEASUREMENTS: Arterial blood gases, duration of mechanical ventilation, time in the intensive care unit, occurrence of nosocomial pneumonia, and survival at 60 days. RESULTS: At admission, all patients had severe hypercapnic respiratory failure (mean pH, 7.18+/-0.06; mean PaCO2, 94.2+/-24.2 mm Hg), sensory impairment, and similar clinical characteristics. At 60 days, 22 of 25 patients (88\%) who were ventilated noninvasively were successfully weaned compared with 17 of 25 patients (68\%) who were ventilated invasively. The mean duration of mechanical ventilation was 16.6+/-11.8 days for the invasive ventilation group and 10.2+/-6.8 days for the noninvasive ventilation group (P = 0.021). Among patients who received noninvasive ventilation, the probability of survival and weaning during ventilation was higher (P = 0.002) and time in the intensive care unit was shorter (15.1+/-5.4 days compared with 24.0+/-13.7 days for patients who received invasive ventilation; P = 0.005). Survival rates at 60 days differed (92\% for patients who received noninvasive ventilation and 72\% for patients who received invasive ventilation; P = 0.009). None of the patients weaned noninvasively developed nosocomial pneumonia, whereas 7 patients weaned invasively did. CONCLUSIONS: Noninvasive pressure support ventilation during weaning reduces weaning time, shortens the time in the intensive care unit, decreases the incidence of nosocomial pneumonia, and improves 60-day survival rates.

E.Clini, N.Ambrosino ( 1998 ) - Nursing e fisiokinesiterapia. (L.Gattinoni, A.Rossi, D.Olivieri - L’insufficienza respiratoria: terapia intensiva e semintensiva. - Scientific Press s.r.l. Firenze ITA) - n. volume 4. - pp. da 465 a 474 ISBN: 8802049882 [Contributo in volume (Capitolo o Saggio) - Capitolo/Saggio con ISBN]
Abstract

Not available

E. Clini, C. Sturani, R. Porta, C. Scarduelli, V. Galavotti, M. Vitacca, N. Ambrosino ( 1998 ) - Outcome of COPD patients performing nocturnal non-invasive mechanical ventilation. - RESPIRATORY MEDICINE - n. volume 92 - pp. da 1215 a 1222 ISSN: 0954-6111 [Articolo su rivista - Articolo su rivista]
Abstract

The role of non-invasive nocturnal domiciliary ventilation (NNV) in chronic obstructive pulmonary disease (COPD) patients with chronic hypercapnia is still discussed. The aims of this study were to evaluate the long-term survival, the clinical effectiveness and side-effects of NNV in these patients. Forty-nine stable hypercapnic COPD patients on long-term oxygen therapy (LTOT) were assigned to two groups: in Group 1, 28 patients performed NNV by pressure support modality in addition to LTOT; in Group 2, 21 patients continued their usual LTOT regimen. Treatment was assigned according to the compliance to NNV, after an in hospital period. Mortality rate, hospital stay (HS) and ICU admissions (IA) were recorded in the two groups. HS and IA were compared to those recorded in a similar period of follow-back. Lung and respiratory muscle function, dyspnoea, and exercise capacity (by 6-min walk test) were evaluated baseline and every 3-6 months up to 3 yr. Mean follow-up time was 35 +/- 7 months. Mortality rate was not different between the two groups: 16, 33, 46\% and 13, 28, 50\% at 1, 2 and 3 yr in Groups 1 and 2 respectively. Lung and respiratory muscle function did not significantly change over time. A significant increase in 6-min walk test (from 245 +/- 78 to 250 +/- 88, 291 +/- 75, 284 +/- 89 m after 1, 2 and 3 yr respectively, P < 0.01) was observed only in patients undergoing NNV. In comparison to the follow back HS significantly decreased in both groups (from 37 +/- 29 to 15 +/- 12 and from 32 +/- 18 to 17 +/- 11 days/pt/yr in Groups 1 and 2 respectively, P < 0.001) whereas IA significantly decreased only in patients performing also NNV (from 1.0 +/- 0.7 to 0.2 +/- 0.3/pt/yr, P < 0.0001). Addition of NNV by pressure support modality to LTOT does not improve long term survival but significantly reduces ICU admissions and improves exercise capacity in severe COPD with hypercapnia.

M. Vitacca, G. Natalini, S. Cavaliere, E. Clini, P. Foccoli, A. Candiani, N. Ambrosino ( 1997 ) - Breathing pattern and arterial blood gases during Nd-YAG laser photoresection of endobronchial lesions under general anesthesia: use of negative pressure ventilation: a preliminary study. - CHEST - n. volume 112 - pp. da 1466 a 1473 ISSN: 0012-3692 [Articolo su rivista - Articolo su rivista]
Abstract

STUDY OBJECTIVE: To evaluate the efficacy of negative pressure ventilation (NPV) in avoiding or reducing apneas and related hypoxemia and respiratory acidosis during laser therapy (LT) of endobronchial lesions. DESIGN: A prospective, controlled, randomized study. SETTING: An operating theater of a respiratory endoscopy and laser therapy unit. POPULATION AND INTERVENTION: Twenty-seven consecutive patients referred to LT were entered into the study. Fourteen patients were randomly assigned to LT under general anesthesia and spontaneous assisted ventilation (control group) whereas in 13 cases, NPV by a poncho-wrap ventilator (NPV group) was added to the procedure. MEASUREMENTS AND RESULTS: The prevalence and the duration of apnea/hypopnea periods assessed by respiratory inductive plethysmography during LT were significantly reduced under NPV, compared to the control group. As compared to baseline, during LT, all control patients developed mild to severe hypercapnia (PaCO2 ranging from 55 to 76 mm Hg) and respiratory acidosis (pH from 7.33 to 7.19), whereas only three patients undergoing NPV (23\%) developed hypercapnia (PaCO2 from 52 to 68 mm Hg) and related acidosis (pH from 7.29 to 7.21). Optimal oxygenation was achieved in all of the patients; nevertheless, patients under NPV needed a lower mean oxygen supply; five of them (38\%) could be treated at a fraction of inspired oxygen of 0.21 for the whole procedure. CONCLUSION: NPV may be useful in reducing apneas during laser therapy under general anesthesia, thus reducing hypercapnia, related acidosis, and need of oxygen supplementation.

M. Vitacca, E. Clini, R. Porta, N. Ambrosino ( 1997 ) - Breathing pattern and respiratory mechanics in chronically tracheostomized patients with chronic obstructive pulmonary disease breathing spontaneously through a hygroscopic condenser humidifier. - RESPIRATION - n. volume 64 - pp. da 263 a 267 ISSN: 0025-7931 [Articolo su rivista - Articolo su rivista]
Abstract

Hygroscopic condenser humidifiers (HCHs) have been proposed to artificially condition gases breathed by intubated and mechanically ventilated patients. These devices may improve viscosity and coloring of secretions, preventing further bacterial colonization, and heat inspiratory flow in chronically tracheostomized (CT) patients during spontaneous breathing. The aim of this study was to evaluate the effects of HCH on respiratory mechanics and breathing pattern in CT patients with chronic obstructive pulmonary disease (COPD) breathing spontaneously during quiet breathing and maximal voluntary ventilation (MVV). In a prospective, randomized, controlled study on 21 stable spontaneously breathing CT COPD patients, breathing pattern and respiratory mechanics were evaluated by means of a flow sensor and an esophageal pressure (Pes) catheter during quiet breathing in random order either with or without a HCH connected to the tracheostomy. Six of the patients were also studied during maximal voluntary ventilation (MVV). In comparison to without HCH, the application of HCH did not induce changes in the breathing pattern and respiratory mechanics during quiet breathing. As expected, in comparison to quiet breathing, MVV in 6 patients with HCH induced significant changes in respiratory frequency, minute ventilation, mean inspiratory flow, Pes, work of breathing, pressure time product and index. These changes were not significantly different without the application of HCH. In CT COPD patients spontaneously breathing. HCHs have no significant effects on the breathing pattern and respiratory mechanics both during quiet breathing and MVV.

M. Vitacca, E. Clini, D. Facchetti, M. Pagani, M. Poloni, R. Porta, N. Ambrosino ( 1997 ) - Breathing pattern and respiratory mechanics in patients with amyotrophic lateral sclerosis. - EUROPEAN RESPIRATORY JOURNAL - n. volume 10 - pp. da 1614 a 1621 ISSN: 0903-1936 [Articolo su rivista - Articolo su rivista]
Abstract

The aim of this study was to evaluate the time course of breathing pattern and respiratory mechanics in patients with amyotrophic lateral sclerosis (ALS). A study was conducted on 25 out of 38 eligible ALS patients. Neurological status, arterial blood gases (ABGs), spirometry, breathing pattern (minute ventilation (V'E), tidal volume (VT), respiratory frequency (fR), duty cycle (duration of inspiration/duration of total breathing cycle (tI/ttot)), respiratory drive (P0.1)), respiratory mechanics (oesophageal pressure (Ppl), dynamic compliance (CL,dyn), pressure time product (PTP) and index (PTI), work of breathing (WOB)), and respiratory muscle (RM) strength as assessed by maximal oesophageal pressure (Ppl,max) were evaluated at presentation (to) in all patients and after 6 months (t6) in 11 patients. At to, the mean values of the degree of neurological impairment were 60+/-20 and 103+/-30 as assessed by the Norris scale and Medical Research Council (MRC) score, respectively. From the time of the first neurological symptom, survival time ranged 7-50 months. Diurnal ABGs were normal. A mild restrictive pattern was observed, a forced vital capacity (FVC) <70\% of predicted being present in 45\% of patients, only FVC \% pred (r=0.59; p<0.05), forced expiratory volume in one second (FEV1) \% pred (r=0.53; p<0.05) and survival (r=0.64; p<0.05) showing a significant correlation with the Norris scale. A Ppl,max <30 cmH2O was associated with a significantly greater mortality, Ppl,max being correlated with survival (r=0.79, p<0.05). At t6, fR, fR/VT, P0.1/Ppl,max, were significantly increased in comparison to to, while FVC \% pred, vital capacity (VC) \% pred, FEV1 \% pred, VT and Ppl,max were significantly reduced. These results suggest a progressive deterioration in breathing pattern and in respiratory muscle strength with progression of disease.

S. Marangoni, M. Vitacca, A. Quadri, M. Schena, E. Clini ( 1997 ) - Non-invasive haemodynamic effects of two nasal positive pressure ventilation modalities in stable chronic obstructive lung disease patients. - RESPIRATION - n. volume 64 - pp. da 138 a 144 ISSN: 0025-7931 [Articolo su rivista - Articolo su rivista]
Abstract

The aim of this study was to compare the haemodynamic effects of a 45-min session of two modalities of non-invasive positive pressure ventilation (nPPV), by means of cardiac echo-Doppler and right heart catheterization, in chronic obstructive lung disease (COPD) patients with chronic respiratory insufficiency. Fourteen patients with stable COPD (11 males, mean age 62.9 +/- 9.8 years) underwent right heart catheterization using a floating Grandjean catheter and simultaneous echo-Doppler measurements before and during two randomly applied 45-min ventilatory sessions, consisting of nasal intermittent positive pressure ventilation in assist/control mode (nIPPV) and nasal pressure support ventilation (nPSV). Blood gases improved significantly during both modalities of ventilation. A significant increase during ventilatory sessions was found in invasive pulmonary right atrial pressure and cardiac output. A statistically significant decrease was found in the flow velocity peak of the superior vena cava and hepatic vein, and in systodiastolic flow velocity integral of the superior vena cava and hepatic vein. The inferior vena cava collapsibility index also decreased significantly during both ventilations. Right atrium diameter and area significantly decreased while right ventricular diameter significantly increased. The echo-Doppler cardiac output decreased significantly while systolic pulmonary artery pressure increased. A short session of both nIPPV and nPSV even without PEEP can induce significant haemodynamic changes in patients with stable COPD. Two-dimensional Doppler echocardiography is a non-invasive device with sufficient reliability to monitor the haemodynamic effects of nPPV. Further studies are needed to assess the effects of nPPV on vascular peripheral flows.

E. Clini ( 1997 ) - Patient ventilator interfaces: practical aspects in the chronic situation. - MONALDI ARCHIVES FOR CHEST DISEASE - n. volume 52 - pp. da 76 a 79 ISSN: 1122-0643 [Articolo su rivista - Articolo su rivista]
Abstract

In the ventilator-dependent patient, the nonpsychological problems of the chronic phase relate mainly to aspects of the patient ventilator interface. Humidification, suctioning of secretions, and ventilatory circuit and monitoring are the three most important aspects to which careful attention is needed. Good humidification can be obtained by means of various devices, which can provide humidity directly or indirectly: in the tracheostomized patient, the heat and moisture exchanger appears to be a good method because of its antibacterial properties. Airway suctioning is frequently needed in patients receiving ventilation invasively. Suctioning of secretions might possibly be associated with the risk of major cardiorespiratory complications: bacterial colonization of the airways and the subsequent increased risk of infection should be carefully considered. Problems concerning the ventilatory circuit and monitoring can be specific in patients with a tracheal cannula and those with a nasal/facial interface. Long-term tracheostomy in itself represents a real risk for bacterial colonization, damage to the tracheal mucosa, and to functioning of the vocal cords (both for speech and swallowing): therefore, a switch from invasive to noninvasive ventilatory interface may be proposed. Most problems with the nasal mask interface concern air leakage and the skin mucosal lesions. Two major aspects must be taken into account when considering the long-term effects of noninvasive ventilatory support monitoring: the possible effect of CO2 rebreathing, and the inadequate volume/pressure delivery, so that proper ventilation cannot be achieved. Use of an oral/mouth interface is of limited interest in subjects with restrictive disorders: air gastric distension and orthodontic problems are the most common side-effects in chronic use.

M. Vitacca, E. Clini, R. Porta, K. Foglio, N. Ambrosino ( 1996 ) - Acute exacerbations in patients with COPD: predictors of need for mechanical ventilation. - EUROPEAN RESPIRATORY JOURNAL - n. volume 9 - pp. da 1487 a 1493 ISSN: 0903-1936 [Articolo su rivista - Articolo su rivista]
Abstract

Predictive factors in mechanically-ventilated patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) have been extensively studied but not in spontaneously breathing patients. The aim of this retrospective study was to evaluate the contribution of parameters of respiratory mechanics, clinical and nutritional status in predicting the need for mechanical ventilation (MV) in COPD patients treated with medical therapy for an acute exacerbation. Anthropometric data, Acute Physiology and Chronic Health Evaluation (APACHE) II score, bedside spirometry, breathing pattern, respiratory mechanics and blood gases were measured in 39 COPD patients upon hospital admission for exacerbation of their disease. Fourteen patients in whom MV was necessary were compared with 25 patients in whom medical therapy was enough for a good outcome. The discriminant analysis showed, with decreasing order of power, that nutritional prognostic index (NPI), APACHE II score, forced expiratory volume in one second/forced vital capacity (FEV1/FVC) ratio, vital capacity (VC) (\% predicted) and FVC (\% pred) provided a significant distinction between the two groups. The discriminant equation considering NPI, and FVC (\% pred) could correctly predict the success in 76\% of the patients. A multiparametric stepwise regression analysis showed that APACHE II score was significantly correlated with NPI, VC (\% pred), pressure time index (PTI) and duty cycle, i.e. fraction of inspiration to duration of total breathing cycle (tl/ttot). In conclusion, underlying general conditions as assessed by malnutrition and APACHE II score were shown to be unfavourable indices of outcome for chronic obstructive pulmonary disease patients who experienced an exacerbation of their disease and were treated with medical therapy. Flow limitation data as assessed by the forced expiratory manoeuvre may provide additional information.

M. Vitacca, E. Clini, W. Spassini, L. Scaglia, P. Negrini, A. Quadri ( 1996 ) - Does the supine position worsen respiratory function in elderly subjects? - GERONTOLOGY - n. volume 42 - pp. da 46 a 53 ISSN: 0304-324X [Articolo su rivista - Articolo su rivista]
Abstract

The aim of our study was to test whether the supine position or the sitting position worsens static, forced expiratory flows and measurements of lung mechanics in a group of aged subjects living in a nursing home who were clinically stable and without clinical evidence of cardiorespiratory diseases. Seventeen subjects (mean age 80 +/- 7 years; 16 f) were studied under baseline conditions. Spirometric, breathing pattern and mechanics data by means of an esophageal balloon were measured in sitting and supine positions. Analysis of sitting results showed aged subjects to have a slight flow limitation in peripheral airways, an increase in expiratory airways resistance and mild hyperinflation index (PEEPi = 2.2 +/- 1.9 cm H2O). Pressure time index did not reach the fatigue level in hardly any patient. Maximal inspiratory pressure values (42 +/- 15 cm H2O) were reduced by about 50\% in comparison with our normal laboratory standards. Arterial blood gas analysis revealed no pathological data in any subject. When supine, subjects revealed a significant decrease in forced expiratory volume at the first second (p < 0.005), in forced vital capacity (p < 0.01) and in peak expiratory flow (p < 0.05). Moreover, mechanics and breathing pattern data showed a significant decrease in tidal volume (Vt) and dynamic lung compliance (Cld) (p < 0.05) and an increase in respiratory rate/Vt ratio (p < 0.05). Our data confirm the results of previous reports about Cld decrease in supine posture in young normal people. Although our aged subjects showed a significant decrease in forced expiratory volumes and Vt when the supine position was adopted, static mechanics data did not appear modified by the gravitational effect of this posture.

M. Schena, E. Clini, D. Errera, A. Quadri ( 1996 ) - Echo-Doppler evaluation of left ventricular impairment in chronic cor pulmonale. - CHEST - n. volume 109 - pp. da 1446 a 1451 ISSN: 0012-3692 [Articolo su rivista - Articolo su rivista]
Abstract

The effects of acute right ventricular (RV) pressure and volume overloads on left ventricular (LV) filling are well known, while the significance of chronic RV pressure overload on LV function has been less studied. To evaluate the LV impairment, 30 patients with chronic cor pulmonale and pulmonary arterial hypertension secondary to chronic obstructive lung diseases (COLDs) were studied. All patients underwent respiratory tests and arterial blood gas assessment. An echo-Doppler examination was made to measure LV ejection fraction (EF), RV and LV end-diastolic and end-systolic diameters and areas, RV/LV area indexes, LV diastolic and systolic eccentricity indexes, mitral and tricuspid flow patterns, and mitral flow velocity in late and early diastole (A/E) indexes. A right heart catheterization was carried out to determine the resting mean pulmonary arterial pressure (mPAP). The data showed a marked enlargement of RV, compressing the left through a leftward shift of interventricular septum. A linear regression analysis detected a significant correlation between mPAP and the following parameters: RV/LV diastolic and systolic area indexes (r=0.75, p<0.0001; r=0.84, p<0.000, respectively), mitral A/E index (r=0.61, p<0.0005), and LV diastolic and systolic eccentricity indexes (r=0.93, p<0.0001; and r=0.83, p<0.0001). No correlations were found between echo-Doppler data and functional respiratory parameters. From these results, we conclude that chronic RV pressure overload induces LV filling impairment despite a normal systolic phase, due to septal leftward shift. In fact, chronic RV pressure overload distorts early diastolic LV geometry delaying LV filling phase, and the functional diastolic impairment of the LV is closely correlated to pulmonary hypertension levels.

N. Ambrosino, E. Clini ( 1996 ) - Evaluation in pulmonary rehabilitation. - RESPIRATORY MEDICINE - n. volume 90 - pp. da 395 a 400 ISSN: 0954-6111 [Articolo su rivista - Articolo su rivista]
Abstract

Non disponibile

M. Vitacca, E. Clini, R. Porta, D. Sereni, N. Ambrosino ( 1996 ) - [Experience of an intermediate respiratory intensive therapy in the treatment of prolonged weaning from mechanical ventilation] - MINERVA ANESTESIOLOGICA - n. volume 62 - pp. da 57 a 64 ISSN: 0375-9393 [Articolo su rivista - Articolo su rivista]
Abstract

109 patients who suffered from an episode of acute respiratory failure, necessitated mechanical ventilation (MV) in a general Intensive Care Unit (ICU) and admitted to our Respiratory Intermediate Intensive Unit (RIIU), were retrospectively evaluated for outcome and weaning success. The patients, 69 +/- 9 years old, presented the following diseases: COLD (70\%), cardiovascular (15\%) and neuromuscular (15\%). A relapse of underlying disease (62\%), pneumonia (20\%), thoraco-muscular pump failure (15\%) and pulmonary embolism (3\%) were the relapsing causes needing the ICU admission. Patients remained intubated for 12 +/- 6 days and ventilated for 25 +/- 10 days. They were transferred to RIIU on pressure support ventilation (70\%); the causes of prolonged and/or difficult weaning were as following: lung failure (48\%), pump failure (12\%), cardiac and haemodynamic instability (28\%) others (12\%). Apache II score was 18 +/- 5. Maximal inspiratory pressure (31 +/- 7 cmH2O) and respiratory rate/tidal volume (83 +/- 34) were measured within 48 hours after RIIU admission. 82 subjects (75\%) were weaned after 6 +/- 4 days of MV using in 87\% of patients pressure support technique with spontaneous breathing cycles with oxygen supplementation. 8 patients on 109 (7\%) died; 20 patients on 109 (18\%) were discharged after 40 +/- 9 days of stay in RIIU necessitating home MV more than 18 hours/day by means of a tracheostomy. All patients stay in RIIU for 17 +/- 7 days with a mean cost per die of 750 thousands lire. Our data suggest that a RIIU institution for prolonged weaning in chronic diseases may be a useful solution to decrease superfluous stays in ICU decreasing costs without ba worsening in quality of care.

E. Clini, M. Vitacca, K. Foglio, P. Simoni, N. Ambrosino ( 1996 ) - Long-term home care programmes may reduce hospital admissions in COPD with chronic hypercapnia. - EUROPEAN RESPIRATORY JOURNAL - n. volume 9 - pp. da 1605 a 1610 ISSN: 0903-1936 [Articolo su rivista - Articolo su rivista]
Abstract

Long-term oxygen therapy (LTOT) has been shown to improve survival in chronic obstructive pulmonary disease (COPD) patients. The clinical effectiveness of long-term home mechanical ventilation (HMV) is still discussed, nevertheless both LTOT and HMV are often included in the home care programmes of these patients. To evaluate the effectiveness of home care programmes including either HMV or LTOT, 34 COPD patients were studied. They were admitted to either HMV (Group A: 12 males and 5 females, aged 62 +/- 5 yrs), or LTOT (Group B: 9 males and 8 females, aged 62 +/- 8 yrs). They were compared to a historical group (Group C: 19 males and 10 females, aged 67 +/- 16 yrs) performing only their usual standard LTOT during the same period. Spirometry, maximal inspiratory pressure and arterial blood gas values were assessed at baseline and at 6, 12 and 18 months of follow-up. Mortality rate and number of hospital and intensive care unit (ICU) admissions and days of hospitalization were also assessed. Four out of 17 (23\%) patients in Group A, 3 out of 17 (18\%) in Group B, and 5 out of 29 (17\%) in Group C died within 18 months. Of the lung function tests, only maximal inspiratory pressure in Group A showed a significant increase in the 18th month (50 +/- 4 to 56 +/- 7 cmH2O; p<0.01). In comparison to 18 months prior to the study, hospital admissions (from 2.2 +/- 0.6 to 1.3 +/- 1.1 and from 2.0 +/- 0.7 to 1.0 +/- 0.9 for Group A and B, respectively; p<0.005 for both), and days of hospitalization (from 60 +/- 34 to 34 +/- 40 and from 55 +/- 23 to 18 +/- 20 days in Group A and B, respectively; p<0.005 for both) significantly decreased only in the two groups submitted to the home care programme. We conclude that home care programmes may be effective in the long-term treatment of chronically hypercapnic chronic obstructive pulmonary disease patients in reducing hospital admissions.

E. Clini, M. Vitacca, S. Scalvini, A. Quadri, K. Foglio ( 1996 ) - Methacholine inhaled challenge: study of correlation among different indices expressing the result. - MONALDI ARCHIVES FOR CHEST DISEASE - n. volume 51 - pp. da 194 a 198 ISSN: 1122-0643 [Articolo su rivista - Articolo su rivista]
Abstract

We tested measures of specific airway conductance (sGaw) and forced expiratory volume in one second (FEV1) versus transcutaneous oxygen tension (Ptc,O2) during inhaled methacholine bronchial challenge in 60 out-patients (38 males 22 females, mean age 33 +/- 13 yrs). The provocative doses of methacholine needed to produce a 35\% decrease of sGaw (PD35,sGaw), a 20\% fall in FEV1 (PD20,FEV1) and a 20\% decrease in Ptc,O2 (PD20,O2) were simultaneously derived from the dose-response curves. Two groups were identified according to the PD20,FEV1 result ("responders" with a PD20,FEV1 < 2,000 micrograms methacholine and "nonresponders" with PD20,FEV1 > 2,000 micrograms methacholine). All three indices derived from the dose-response curves differed significantly between the groups (p < 0.00005). The relationship analysis showed a significantly better value for PD20,O2 versus PD35,sGaw (r = 0.98) than versus PD20, FEV1 (r = 0.62). We observed similar baseline levels and variations in arterial oxygen tension (Pa,O2) and Ptc,O2 during methacholine challenge (-25 and -27\%, respectively) in 14 randomly studied responders. Thus, inhaled methacholine-induced hypoxaemia (PD20,O2) seems to reflect PD35,sGaw better than changes in FEV1. Our investigation supports the hypothesis that PD20,O2 could be useful in interpreting the methacholine inhaled challenge. It could be of help in clarifying the pathophysiological meaning of the concurrent hypoxaemia during this challenge, which should be further elucidated.

M. Vitacca, E. Clini, F. Rubini, S. Nava, K. Foglio, N. Ambrosino ( 1996 ) - Non-invasive mechanical ventilation in severe chronic obstructive lung disease and acute respiratory failure: short- and long-term prognosis. - INTENSIVE CARE MEDICINE - n. volume 22 - pp. da 94 a 100 ISSN: 0342-4642 [Articolo su rivista - Articolo su rivista]
Abstract

OBJECTIVE: To evaluate the short- and long-term prognosis of patients with chronic obstructive lung disease (COLD) who had noninvasive mechanical ventilation (NMV) for acute respiratory failure (ARF). DESIGN: Retrospective study. SETTING: Two respiratory intermediate intensive care units. PATIENTS: Two groups of patients suffering from COLD and an ARF episode requiring mechanical ventilation. Group 1 (30 patients) was given NMV using face masks (aged 64 +/- 9 years; pH = 7.28 +/- 0.05; PaCO2 = 83 +/- 18 mmHg; PaO2/FIO2 = 141 +/- 61). Group 2 (27 patients) was composed of control patients (aged = 65 +/- 8 years; pH = 7.26 +/- 0.05; PaCO2 = 75 +/- 17 mmHg; PaO2/FIO2 = 167 +/- 41) given MV using endotracheal intubation (EI) when clinical and functional conditions had further deteriorated because the medical therapy failed and NMV was not available at the time. Causes of ARF were in group 1 and 2 respectively: pneumonia in 8 (27\%) and 11 (41\%), acute exacerbation of COLD in 19 (63\%) and 14 (52\%) and pulmonary embolism in 3 (10\%) and 2 (7\%) patients. MEASUREMENTS AND RESULTS: Success rate, mortality during stay in ICU (at 3 months and at 1 year), and the need for rehospitalization during the year following ARF were measured in this study. Group 1 showed a success rate of 74\%, only 8/30 patients needing EI and conventional MV. In group 2, the weaning success was 74\% (20/27 patients). The mortality for group 1 was 20\% in IICU, 23\% at 3 months and 30\% at 1 year; and 26\% for group 2 in ICU, 48\% at 3 months and 63\% at 1 year. Within each group 1-year mortality was greater (p < 0.01) in patients with pneumonia. The number of new ICU admissions during the follow-up at 1 year was 0.12 versus 0.30 in groups 1 and 2 respectively (p < 0.05). CONCLUSION: For patients suffering from COLD who have undergone ARF, avoiding EI by early treatment with NMV is associated with better survival in comparison to patients bound to invasive MV. Pneumonia as a cause of ARF may worsen the prognosis in both groups of patients.

N. Ambrosino, K. Foglio, F. Rubini, E. Clini, S. Nava, M. Vitacca ( 1995 ) - Non-invasive mechanical ventilation in acute respiratory failure due to chronic obstructive pulmonary disease: correlates for success. - THORAX - n. volume 50 - pp. da 755 a 757 ISSN: 0040-6376 [Articolo su rivista - Articolo su rivista]
Abstract

BACKGROUND--Non-invasive mechanical ventilation is increasingly used in the treatment of acute respiratory failure in patients with chronic obstructive pulmonary disease (COPD). The aim of this study was to identify simple parameters to predict the success of this technique. METHODS--Fifty nine episodes of acute respiratory failure in 47 patients with COPD treated with non-invasive mechanical ventilation were analysed, considering each one as successful (78\%) or unsuccessful (22\%) according to survival and to the need for endotracheal intubation. RESULTS--Pneumonia was the cause of acute respiratory failure in 38\% of the unsuccessful episodes but only in 9\% of the successful ones. Success with non-invasive mechanical ventilation was associated with less severely abnormal baseline clinical and functional parameters, and with less severe levels of acidosis assessed during an initial trial of non-invasive mechanical ventilation. CONCLUSIONS--The severity of the episode of acute respiratory failure as assessed by clinical and functional compromise, and the level of acidosis and hypercapnia during an initial trial of non-invasive mechanical ventilation, have an influence on the likelihood for success with non-invasive mechanical ventilation and may prove to be useful in deciding whether to continue with this treatment.

M. Vitacca, E. Clini, D. Facchetti, K. Foglio, S. Scalvini, A. Quadri, G. F. Levi ( 1994 ) - An unusual increase in haemodynamic values in a sleep apnoea syndrome patient with prolonged apnoea. - MONALDI ARCHIVES FOR CHEST DISEASE - n. volume 49 - pp. da 22 a 24 ISSN: 1122-0643 [Articolo su rivista - Articolo su rivista]
Abstract

This case report shows the results of a right heart catheterisation in a patient with sleep apnoea syndrome (SAS). Arterial oxygen saturation (SaO2), heart rate, oronasal flow, and monitoring of electroencephalographic (EEG), sovrayoidal electromyographic (EMG) and thoracoabdominal movements were recorded simultaneously. A mixed apnoea of 180 s was registered, SaO2 fell to 54\% and systolic pulmonary artery pressure (sPAP) increased to 130 mmHg. Slowly, haemodynamic values began to normalise with the reappearance of respiratory acts. We can hypothesize that this patient's nocturnal apnoeas may cause frequent and deep negative pleural pressure swings, with severe continuous action on pulmonary circulation. This case report has shown that a SAS patient is capable of developing an adaptative response to an unusual and remarkable systolic pulmonary artery pressure increase, which is mainly due to hypoxic vasoconstriction.

E. Pogliani, E. Clini ( 1994 ) - Association therapy as a prognostic factor in deep fungal infection complicating oncohaematological diseases. - HAEMATOLOGICA - n. volume 2 - pp. da 385 a 388 ISSN: 0390-6078 [Articolo su rivista - Articolo su rivista]
Abstract

A group of 31 oncohaemopathic patients (17 male, mean age 44 +/- 6 years), diagnosed as having primary deep fungal infection involving the lungs, were retrospectively evaluated. When infection was suspected on a clinical basis the major associated risks for death were the duration of bone marrow aplasia (12 +/- 7 versus 21 +/- 6 days, P < 0.001), increase in white blood cells and, in particular, prolonged granulocytopenia (11 +/- 5 versus 24 +/- 8 days, P < 0.001) when survivors were compared with patients, who died. Our therapeutic empirical approach was based on the association of i.v. amphotericin B, 1 mg kg-1 day-1, with oral 5-fluorocytosine (5-FC) 150 mg kg-1 day-1. Only 9 subjects received combination therapy for more than 7 days. For majority of them, oral 5-FC was interrupted because of altered compliance or sustained liver damage. A chi 2 test for independent parameters showed (P = 0.0021) a concentration of deaths among patients who received amphotericin B alone (15/22); none of the patients treated with amphotericin B + 5-FC (9 cases) died. Results generally suggest that a more favourable outcome was statistically associated with empirical antifungal combination therapy in deep fungal infection, although both treatment regimens showed effectiveness in terms of survival. Nevertheless the low 5-FC compliance and the small sample do not indicate the safe use of this drug in a large population.

K. Foglio, E. Clini, M. Vitacca ( 1994 ) - Different modes of noninvasive intermittent positive pressure ventilation (IPPV) in acute exacerbations of COLD patients. - MONALDI ARCHIVES FOR CHEST DISEASE - n. volume 49 - pp. da 556 a 557 ISSN: 1122-0643 [Articolo su rivista - Articolo su rivista]
Abstract

Patients with chronic obstructive lung disease may suffer from acute exacerbations of their disease, which may lead to acute respiratory failure necessitating endotracheal intubation and mechanical ventilation. We have compared retrospectively the results obtained with nasal positive pressure ventilation and those of standard medical therapy in acute relapses of severe COLD. The study showed that nasal IPPV (NIPPV) in control mode delivered for approximately 1 h, four times daily, six days a week over a 21 day period, does not result in independent improvement of acute exacerbation of COLD. In the next study the data seem to indicate, in apparent contrast, a marked reduction in the need for endotracheal intubation using noninvasive ventilation, both with assist-control and pressure support noninvasive modes, in comparison with an historical control group. We did not find a significant difference in the success rate of the two modes, but compliance to noninvasive ventilation was better with pressure support. In the former study patients showing neurological signs and requiring mechanical ventilation were excluded, while in the last study patients were selected on the basis of necessity of mechanical ventilation. The fact that in the last study, ventilation was applied by face mask instead of nasal mask may have influenced results. Further efforts are required to determine whether non-invasive ventilation is more a preventive measure to avoid endotracheal intubation, or is another means of delivering ventilatory support.

E. Clini, M. Vitacca ( 1994 ) - From intermediate intensive unit to home care. - MONALDI ARCHIVES FOR CHEST DISEASE - n. volume 49 - pp. da 533 a 536 ISSN: 1122-0643 [Articolo su rivista - Articolo su rivista]
Abstract

The procedure of discharging the chronically ill respiratory patient from an intermediate intensive care unit (IICU) is always difficult and requires multidisciplinary intervention. A complete clinical and functional evaluation is necessary during the period of hospitalization to determine the weaning possibilities and the respiratory performance of the patient in care. In-hospital management should also be able to produce an accurate plan for home care, especially in those subjects for whom ventilatory support cannot be denied. Appropriate instruction for the care-givers involved must be provided. Funding requirements should be carefully evaluated. Four hundred and sixty five chronically, critically ill respiratory patients were admitted to our cardiopulmonary IICU (34\% of the total patients admitted) coming from intensive care units (ICUs) or other departments. The death rate was 6\%. Six patients were transferred to an ICU due to urgent necessity. Three hundred and thirty eight subjects were mechanically-ventilated (115 invasively), and 23 were finally admitted to a long-term home-care programme. Nowadays, the respiratory IICU can be considered a new hospital ward, where appropriate monitoring can be performed and accurate evaluation for discharge should be planned. Knowledge of worldwide experience is necessary to establish the best way to discharge patients from a respiratory IICU and to eventually recommend them for a home-care programme.

M. Vitacca, E. Clini, K. Foglio, S. Scalvini, S. Marangoni, A. Quadri, N. Ambrosino ( 1994 ) - Hygroscopic condenser humidifiers in chronically tracheostomized patients who breathe spontaneously. - EUROPEAN RESPIRATORY JOURNAL - n. volume 7 - pp. da 2026 a 2032 ISSN: 0903-1936 [Articolo su rivista - Articolo su rivista]
Abstract

The aim of this study was to test the usefulness of hygroscopic condenser humidifiers on secretion and on inspired gas temperature in tracheostomized patients. Forty spontaneously breathing chronically tracheostomized patients were divided into two groups: Group 1 received a hygroscopic condenser humidifier connected to the tracheostomy, 24 h daily for 10 days; Group 2, without any protection system, was chosen as the control group. The daily number of tracheal suctions, quantity of aspirate and thickness and colouring of secretions was evaluated. At baseline, and at days 5 and 10, patients were submitted to blood gas analysis, respiratory function tests and sputum analysis. The temperature of gases breathed was measured at rest and during a hyperventilation test, with and without the hygroscopic condenser humidifier. Statistically significant differences were found in thickness and colouring of secretions between the two groups during the period of 10 days. Group 2 showed a significantly greater trend in number of bacteria than Group 1. The group with the hygroscopic condenser humidifier showed respiratory function improvement over time for forced expiratory volume in one second (FEV1) and tidal volume (VT), maximal inspiratory pressure (MIP), and maximal voluntary ventilation (MVV) in comparison to the control group, who did not. Significant differences in the temperature between rest and hyperventilation, with and without a hygroscopic condenser humidifier were also found. In conclusion, a hygroscopic condenser humidifier may be useful in chronically tracheostomized patients who breathe spontaneously, improving viscosity and colouring of secretions, preventing further bacterial colonization, heating inspiratory flow, and helping to improve the functional outcome.

A. Quadri, P. Simoni, E. Clini, D. Errera, K. Foglio, M. Vitacca, M. Schena ( 1994 ) - Professional figures in intermediate intensive units. - MONALDI ARCHIVES FOR CHEST DISEASE - n. volume 49 - pp. da 544 a 546 ISSN: 1122-0643 [Articolo su rivista - Articolo su rivista]
Abstract

In Italy, respiratory intermediate intensive care units (IICUs) are not yet considered as autonomous hospital departments. The IICU of the Rehabilitation Department of the Medical Centre of Gussago (12 monitored beds) provides care for respiratory and cardiac patients. Ventilatory assistance and noninvasive modalities both in treatment and monitoring suggest a multidisciplinary approach to the patient. Highly professional figures should, therefore, be singled out to provide care in a respiratory IICU. The medical staff is composed of one anaesthesiologist, one cardiologist and one pulmonologist, who can integrate care when respiratory complications occur in a cardiological patient, or when cardiac events affect a respiratory patient. Nurses are capable of specific activities, especially when ventilatory assistance is required. The presence of a physiotherapist reduces the nursing workload, especially for ventilated individuals. The psychological aspect is undertaken by a specialist. Finally, an expert in nutrition provides an individualized dietary regimen. Our 4 year experience encourages such a multidisciplinary approach. An ideal integration of the professional activities should provide adequate and individual care for patients admitted to an IICU.

M. Vitacca, E. Clini ( 1994 ) - Respiratory monitoring in an intermediate intensive unit. - MONALDI ARCHIVES FOR CHEST DISEASE - n. volume 49 - pp. da 508 a 512 ISSN: 1122-0643 [Articolo su rivista - Articolo su rivista]
Abstract

The major goal of monitoring is continuous recording of indices that enhance our understanding of the underlying pathophysiology, in order to improve diagnosis and guide management, and identify trends that assist in assessing the therapeutic response and predicting prognosis. Nowadays, technology has made it possible to automatically sense and display a wide variety of physiological indices. An ideal monitoring system should be pertinent to patient management, propose interpretable data, show high technical accuracy, high sensitivity, good reproducibility, be practical to use. The international literature, our personal experience, and cost considerations have proposed the following monitoring standards as the best for a noninvasive respiratory intermediate intensive care unit (RIICU): 1) mandatory indices: respiratory rate, oxygen saturation, haemogas-analysis, tidal volume, minute ventilation, maximum voluntary ventilation, forced expiratory volume in one second, forced vital capacity, vital capacity, maximal inspiratory pressure, heart rate and blood pressure; 2) second choice indices: capnometry, respiratory inductive plethysmography, transcutaneous monitoring of gases, haemodynamic monitoring, mechanics data by means of an oesophageal balloon, and central drive. Pulmonary monitoring devices shorten the time for patients who remain on mechanical ventilators; a reduction both in the risk of associated complications and the costs involved is a natural consequence. Continuous monitoring of significant physiological indices has the potential for predicting a critical event, and providing an opportunity for the institution of lifesaving measures.

K. Foglio, E. Clini, D. Facchetti, M. Vitacca, S. Marangoni, M. Bonomelli, N. Ambrosino ( 1994 ) - Respiratory muscle function and exercise capacity in multiple sclerosis. - EUROPEAN RESPIRATORY JOURNAL - n. volume 7 - pp. da 23 a 28 ISSN: 0903-1936 [Articolo su rivista - Articolo su rivista]
Abstract

Patients with multiple sclerosis (MS) show a poor exercise tolerance. A reduction in respiratory muscle strength has also been reported. The purpose of this study was to evaluate whether reduction in exercise tolerance was related to respiratory muscle dysfunction. Twenty four multiple sclerosis patients (mean +/- SD age: 48 +/- 9 yrs, duration of illness 12.2 +/- 6 yrs, severity of illness as assessed by Expanded Disability Scale Score (EDSS) 5.3 +/- 2), underwent detailed evaluation of lung function tests, arterial blood gas analysis, respiratory muscle strength and endurance, and exercise test on an arm ergometer. Sixteen of the 24 patients were able to perform the exercise test (Group I), whilst the other eight were not (group II). Arterial blood gases and lung function tests were normal for both groups. Respiratory muscle strength as assessed both by maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) was significantly reduced (MIP 18-76 cmH2O; MEP 16-82 cmH2O) compared to predicted values. Inspiratory muscle endurance time was significantly reduced in Group II in comparison to Group I (247 +/- 148 vs 397 +/- 154 s, respectively). Both MIP and MEP were significantly related to inspiratory muscle endurance time. Endurance time, MIP and MEP were inversely significantly related to duration of illness, whilst only endurance time was significantly related to Expanded Disability Scale Score.

E. Clini, K. Foglio, M. Vitacca, A. Quadri, F. Tana ( 1994 ) - Transcutaneous partial oxygen tension and lung mechanics during methacholine inhaled challenge. - CHEST - n. volume 105 - pp. da 1905 a 1905 ISSN: 0012-3692 [Articolo su rivista - Articolo su rivista]
Abstract

Non disponibile

M. Vitacca, E. Clini, S. Scalvini, K. Foglio, A. Quadri, G. Levi ( 1993 ) - Cardiopulmonary intermediate intensive unit: time course of two years activity. - MONALDI ARCHIVES FOR CHEST DISEASE - n. volume 48 - pp. da 296 a 300 ISSN: 1122-0643 [Articolo su rivista - Articolo su rivista]
Abstract

Intermediate intensive care may be defined as a post comprehensive programme, where monitoring, combined with necessary treatment, improves and maintains physiological functions to complete the cure of underlying diseases. The aims of this paper are: 1) to describe the caring activity that patients admitted to our 12 bed Cardiopulmonary Intermediate Intensive Unit (CPIIU) experience and, 2) to demonstrate that a noninvasive choice does not worsen mortality and the quality of care needed to improve patient outcome. From September 1st 1990 to September 30th 1992, 775 patients (135 respiratory subjects) were admitted. The majority of these patients came from Coronary Intensive Units or Medical and Surgical Intensive Care Units. Noninvasive cardiorespiratory monitoring was assessed in these patients, to obtain their clinical improvement. After this post acute observance, our patients were followed during a stabilization programme in the cardiopulmonary rehabilitation division until a day-hospital or home care programme was carried out. By implementing the CPIIU principles in our department we have reduced the number of deaths and the necessity for Intensive Care Unit admission (from 19 to 9.6\%). The estimated risk of death proposed by Apache score was higher than that recorded in our patients (estimated Apache = 25 and 6\% for respiratory and cardiac patients, respectively; actual Apache = 10.4 and 3.1\% for the same patients, respectively). Average hospitalisation days in our CPIIU was 18 +/- 9. Our CPIIU showed a mean daily cost for each patient of $370.6.

E. Pogliani, E. Clini ( 1990 ) - Fungal infection and haematological malignancies: a report about association therapy with amphotericin B and 5-flucytosine in primary lung involvement. - HAEMATOLOGICA - n. volume 75 - pp. da 304 a 305 ISSN: 0390-6078 [Articolo su rivista - Articolo su rivista]
Abstract

Non disponibile

E. Clini, P. Maffé, E. Pogliani, E. E. Polli ( 1989 ) - [Pulmonary mycosis as a complication of acute leukemia in the adult. Diagnostic study] - RECENTI PROGRESSI IN MEDICINA - n. volume 80 - pp. da 113 a 118 ISSN: 0034-1193 [Articolo su rivista - Articolo su rivista]
Abstract

Pulmonary fungal infections complicating hematological malignancies are difficult to diagnose antemortem because clinical findings are actually considered to be not specific. From December 1984 to June 1986 we documented the clinical findings in sixteen patients, 9 with ANLL, 6 with ALL and 1 with CML + BC; all patients were diagnosed as pulmonary fungal infection and treated for this complication. Pulmonary infiltrates occurred after severe aplasia (range 5-90 days) or during bone marrow relapse. We studied pulmonary signs and symptoms (pleuritic pain, cough, hemoptysis, shortness of breath, rales, rub, bronchial murmur) both at the beginning and during the management of this infectious complication and we related them to chest x-ray findings, the duration of granulocytopenia, and fever. Our purpose was to identify clinical characteristics for these episodes and establish roentgenological criteria for prognosis. These findings should improve the possibilities for an early diagnosis and prompt treatment.