Predictors of exercise-induced bronchoconstriction in subjects with mild asthma.

BACKGROUND: Physical effort is capable of triggering airway obstruction in asthmatics, the so-called exercise-induced bronchoconstriction in asthma (EIBa). This study was performed in subjects with mild persistent asthma, aiming to find predictors for developing EIBa. METHODS: In 20 subjects with mild asthma, measurements of baseline functional respiratory parameters and airways responsiveness by a methacholine challenge were obtained on the first day. A maximal, symptom-limited incremental cardiopulmonary exercise test (CPExT) was performed the day after, with subsequent, repeated maneuvers of maximal full forced expiration to monitor the FEV1 change at 1,3,5,7,10 and 15 min after the end of the exercise. RESULTS: 19 subjects completed the two-days protocol. No functional parameters both at rest and during effort were useful to predict EIBa after stopping exercise. In asthmatics with EIBa, mean Inspiratory Capacity (IC) did not increase with increasing ventilatory requirements during CPExT because 6 of them (50%) displayed dynamic pulmonary hyperinflation (DH), as documented by their progressive increase of end-expiratory lung volume. This subgroup, showing earlier post-exercise FEV1 fall, had significantly lower forced mean expiratory flow between 25% and 75% of forced vital capacity (FEF25-75%) at rest (p < 0.05) and higher airways responsiveness, expressed as PD20FEV1 (p < 0.05) as compared with other asthmatics with EIBa. CONCLUSIONS: No functional respiratory parameters seem to predict EIBa in mild asthmatics. However, in those with EIBa, a subgroup developed DH during exercise, and this was associated with a baseline reduced forced expiratory flow rates at lower lung volumes and higher airway hyperresponsiveness, suggesting a prominent small airways impairment.

Hyperimmune plasma infusion in an immunocompromised Covid-19 patient previously treated for follicular lymphoma.

Covid-19 in immunocompromised patients shows a prolonged course and may lead to a poor prognosis. Although data on hyperimmune plasma for treatment of Covid-19 suggest an improved outcome in immunocompetent patients, limited data are currently available in immunocompromised patients. We present the case of a 62-year-old Caucasian woman, who was previously treated with obinutuzumab and bendamustine for follicular lymphoma and showed a prolonged positive test for Covid-19. Since no improvement was observed with standard of care (including remdesivir), the possibility of hyperimmune plasma infusion was discussed. A first dose of hyperimmune plasma was administered, with subsequent onset of fever, increasing inflammatory indexes and worsening radiological findings. Three days later a second dose of plasma was administered. Within twelve hours cough and fever disappeared, and oxygen at rest was discontinued. The patient was discharged 5 days later, and nasopharyngeal swabs resulted negative 16 days after discharge.

"Elasto-lung point": A new tool for the sonographic confirmation of pneumothorax.

INTRODUCTION: Standard ultrasound gives the operator a dynamic morphology of the investigated anatomy, whereas ultrasound elastography (USE) provides quantitative and qualitative information about the elastic properties of the tissues. OBJECTIVES: We designed a single-arm prospective study in order to investigate the feasibility of USE in the diagnosis of pneumothorax if a lung point sign is present. METHODS: Thirty patients were enrolled in this protocol, from January 2017 to December 2018 at the Pneumology Department of the Azienda Socio-Sanitaria Territoriale Spedali Civili (Brescia, Italy). Patients who were suspected of having pneumothorax were previously evaluated with standard ultrasonography, and then, in the presence of lung point, we performed strain elastography. All patients were evaluated in supine and sitting positions with a linear probe (7.5 MHz). USE enhanced the air-tissue interface dividing the normal parenchyma from the air column of pneumothorax with a sharp line. We called this sign "elasto-lung point." RESULTS AND CONCLUSION: The "elasto-lung point" was able to confirm the diagnosis of pneumothorax in every investigated patient. USE is a simple, reproducible and inexpensive technique that can contribute to the diagnosis of pneumothorax, such as the classic "stratosphere" or "Bar Code" sign in M-mode. No false negative cases were observed.

Ultrasound Evaluation of Hemidiaphragm Function Following Thoracentesis: A Study on Mechanisms of Dyspnea Related to Pleural Effusion.

BACKGROUND: Dyspnea is the major symptom caused by pleural effusion. The pathophysiological pathways leading to dyspnea are poorly understood. Dysfunction of respiratory mechanics may be a factor. We aimed to study the change in diaphragmatic function following thoracentesis. METHODS: Patients undergoing thoracentesis at a highly specialized pleural center, underwent ultrasound evaluation of hemidiaphragm movement, before and after thoracentesis was performed. The change was compared to the reduction of dyspnea measured at the modified Borg scale. RESULTS: Thirty-two patients were included. Dyspnea was reduced from 5.01 [95% confidence interval (CI): 4.12-6.04] to 2.6 (95% CI: 1.87-3.4, P<0.0001). Low hemidiaphragmatic movement before thoracentesis on the side of pleural effusion was improved by 17.4 cm (95% CI: 13.04-21.08), equalizing movement to the side without pleural effusion. On average, 1283 mL (SD: 469) fluid was drained. Multiple linear regression analysis showed that prethoracentesis ultrasound evaluation of hemidiaphragmatic function was correlated with successful thoracentesis. CONCLUSION: Hemidiaphragm function is reduced on the side of pleural effusion, and thoracentesis restores function. Improvement in diaphragm movement is related to a reduction in dyspnea.

Internal Mammary Lymph Node Visualization as a Sentinel Sonographic Sign of Tuberculous Pleurisy.

BACKGROUND: Tuberculous pleurisy is one of the primary sites of extrapulmonary tuberculosis, but clinicians currently lack the diagnostic tools necessary for early recognition in the absence of typical signs and symptoms. With this study, we aimed to test the association between internal mammary adenopathies and tuberculous pleurisy (TP). METHODS: 60 patients with a post-thoracoscopic histological diagnosis of granulomatosis or acute infective pleurisy were retrospectively enrolled. All of them had chest sonography and/or CT scan data available. At least two expert chest sonography physicians re-analyzed the sonography images to look for any internal mammary adenopathy. Such findings were compared to the CT data. RESULTS: Chest sonography showed internal mammary adenopathy ipsilateral to the pleural effusion in 97 % of 29 patients who had a diagnosis of TP, and in 13 % of those with an acute infective pleurisy (p < 0.001). Receiver operator characteristic analysis revealed 97 % sensitivity and 87 % specificity for this technique in predicting TP (area under curve 0.92 ± 0.04, p < 0.001). CT detection power and node measures were significantly similar (p < 0.001). CONCLUSION: Sonographic internal mammary node visualization ipsilateral to the pleural effusion may become a sentinel sign for TP, contributing to early diagnosis or orienting the diagnostic management towards invasive procedures in uncertain cases.

New insights in the use of pleural ultrasonography for diagnosis and treatment of pleural disease.

The use of transthoracic ultrasound (US) has acquired a wide consensus among respiratory physicians during the last few years. The development of portable devices promotes patient's bedside evaluation providing rapid, real-time and low-cost diagnostic information. The different acoustic impedance between different tissues and organs produces artifacts known as A lines, B lines, sliding sign, lung point, etc. The identification of such artifacts is essential to discriminate normal pleural appearance from the presence of pleural effusion, pneumothorax, thickenings and tumors. Ultrasounds are also a valuable tool during interventional procedures, such as thoracentesis, chest tube insertion and transcutaneous biopsy. Its use is recommended before medical thoracoscopy in order to assess the best site of trocar insertion according to presence, quantity and characteristics of pleural effusion. The aim of this review is to provide practical tips on chest ultrasound in clinical and interventional respiratory practice.

Methods for Measuring Lung Volumes: Is There a Better One?

BACKGROUND: Accurate measurement of lung volumes is of paramount importance to establish the presence of ventilatory defects and give insights for diagnostic and/or therapeutic purposes. OBJECTIVES: It was the aim of this study to measure lung volumes in subjects with respiratory disorders and in normal controls by 3 different techniques (plethysmographic, dilutional and radiographic methods), in an attempt to clarify the role of each of them in performing such a task, without any presumptive 'a priori' superiority of one method above others. Patients andMethods: In different groups of subjects with obstructive and restrictive ventilatory defects and in a normal control group, total lung capacity, functional residual capacity (FRC) and residual volume were measured by body plethysmography, multi-breath helium (He) dilution and radiographic CT scan method with spirometric gating. RESULTS: The 3 methods gave comparable results in normal subjects and in patients with a restrictive defect. In patients with an obstructive defect, CT scan and plethysmography showed similar lung volumes, while on average significantly lower lung volumes were obtained with the He dilution technique. Taking into account that the He dilution technique does primarily measure FRC during tidal breathing, our data suggest that in some patients with an obstructive defect, a number of small airways can be functionally closed at end-expiratory lung volume, preventing He to reach the lung regions subserved by these airways. CONCLUSION: In all circumstances, both CT scan with spirometric gating and plethysmographic methods provide similar values of lung volumes. In contrast, the He dilution method can measure lower lung volumes in some patients with chronic airflow obstruction.