Pneumothorax in hospitalized COVID-19 patients with severe respiratory failure: Risk factors and outcome.

PNX was described as an uncommon complication in COVID-19 patients but clinical risk predictors and the potential role in patient's outcome are still unclear. We assessed prevalence, risk predictors and mortality of PNX in hospitalized COVID- 19 with severe respiratory failure performing a retrospective observational analysis of 184 patients admitted to our COVID-19 Respiratory Unit in Vercelli from October 2020 to March 2021. We compared patients with and without PNX reporting prevalence, clinical and radiological features, comorbidities, and outcomes. Prevalence of PNX was 8.1% and mortality was >86% (13/15) significantly higher than in patients without PNX (56/169) (P < 0.001). PNX was more likely to occur in patients with a history of cognitive decline (HR: 31.18) who received non-invasive ventilation (NIV) (p < 0.0071) and with low P/F ratio (HR: 0.99, p = 0.004). Blood chemistry in the PNX subgroup compared to patients without PNX showed a significant increase in LDH (420 U/L vs 345 U/L, respectively p = 0.003), ferritin (1111 mg/dl vs 660 mg/dl, respectively p = 0.006) and decreased lymphocytes (HR: 4.440, p = 0.004). PNX may be associated with a worse prognosis in terms of mortality in COVID patients. Possible mechanisms may include the hyperinflammatory status associated with critical illness, the use of NIV, the severity of respiratory failure and cognitive impairment. We suggest, in selected patients showing low P/F ratio, cognitive impairment and metabolic cytokine storm, an early treatment of systemic inflammation in association with high-flow oxygen therapy as a safer alternative to NIV in order to avoid fatalities connected with PNX.

Sub-clinical left ventricular diastolic dysfunction in early stage of chronic obstructive pulmonary disease.

Sub-clinical cardiac dysfunction may be significantly associated with chronic obstructive pulmonary disease (COPD) with a different degree of severity. In a cross-sectional design we aimed to evaluate 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 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 the COPD group (70.9 percent) compared to controls (27.5 percent). 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 were also higher among COPD patients compared to controls. The results of the present study suggest that subclinical 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.

Exhaled nitric oxide as a marker of lung involvement in Crohn's disease.

Crohn's disease is an inflammatory bowel disease associated with a variety of systemic manifestations, including large and small airway involvement. The latter is most often a subclinical one, and requires expensive and invasive diagnostic approaches. Nitric oxide (NO) can be detected non-invasively in the exhaled air (eNO) and be considered as a surrogate marker of airway inflammation. eNO tested at multiple expiratory flows can be used to distinguish the alveolar concentration of NO (CalvNO) from the total amount of fractional eNO (FeNO). The aim of our study is to compare FeNO and concentration of alveolar nitric oxide (CalvNO) levels and to assess their relationship with pulmonary involvement in Crohn's patients differing in clinical stage and therapeutic regimens versus a group of healthy subjects. Thirty Crohn's patients not showing clinical evidence of pulmonary diseases and 21 non-smoking, non-atopic healthy controls were enrolled. FeNO (14.9±10.2 ppb vs 10.1±6.3 ppb, p=0.049) and CalvNO (4.4±2.2 ppb vs 2.6±1.9; p=0.006) values were found to be significantly higher in Crohn's patients than in healthy controls. Both FeNO and CalvNO correlated positively with the Crohn's Disease Activity Index. In conclusion, our results for FeNO and CalvNO confirm the presence of subclinical pulmonary involvement in Crohn's disease. eNO measurement may be of clinical value in the follow-up of Crohn's patients.

Upper extremity deep vein thrombosis as an uncommon complication of pacemaker implantation: a case report.

Venous complications of pacemaker implantation rarely cause immediate clinical problems. An 89-year-old man, without thrombophilia, 4 weeks after a pacemaker implantation experienced functional impotence of the left arm that appeared warm, reddened, oedematous and painful. Color Doppler Ultrasonography revealed a thrombosis of the axillary vein extended to the proximal third of the ulnar vein. In our opinion, upper extremity deep vein thrombosis (UEDVT) represents an important complication of post-surgical pacemaker implantation that should be suspected early, even without specific symptoms and thrombophilia.

Severe intravascular haemolysis as delayed manifestation of perivalvular leak in patients with mitral valve replacement: a report of two cases.

Haemolytic anaemia following mitral valve replacement is uncommon, however in patients who suffer from some degree of perivalvular leak, severe and potentially fatal recurrent intravascular haemolysis can be an annoying problem. We report the cases of two patients with severe haemolytic anaemia observed some years after mitral valve replacement. In one of the two patients the presence of an association between a valvular leak after mitral valve replacement and a calcific atrial wall produced severe and recurrent haemolysis that required multiple blood transfusions. In the second patient the presence of a single valvular leak after mitral valve replacement induced an episode of haemolytic anaemia some years after the operation. These cases point out that in case of unexplained worsening anaemia, a transthoracic (TT) and transesophageal (TE) echocardiogram should be performed, and the possibility of atrial wall alterations in the producing of anaemia should be kept in consideration. In these cases reoperation resolved the recurrence of anemization.

Exhaled nitric oxide levels in alpha-1-antitrypsin PiMZ subjects.

OBJECTIVES: Although the likelihood of intermediate alpha-1-antitrypsin deficiency (PiMZ) patients developing chronic obstructive pulmonary disease (COPD) remains uncertain, several investigators have suggested that a lack of antiprotease inhibitor activity may favour the development of airway inflammation with subsequent pulmonary tissue damage. The levels of exhaled nitric oxide (FeNO) in PiMZ subjects are unknown and polymorphisms in nitric oxide synthase have been linked to lung disease susceptibility in subjects with alpha-1-antitrypsin (AAT) deficiency. This study was aimed at assessing FeNO levels in a group of PiMZ subjects and comparing it with the concentrations found amongst groups of COPD and control patients. DESIGN: A group of 31 PiMZ subjects, 31 COPD patients and 30 controls underwent pulmonary function tests, AAT assay and phenotyping, and FeNO measurement in an ambulatory setting. RESULTS: FeNO values observed in the group of PiMZ subjects (21.6 +/- 8.9 ppb) showed a significant increase compared with COPD (14.5 +/- 8.7 ppb; P < 0.01) and the control groups (9.1 +/- 2.9 ppb; P < 0.01). Within the PiMZ population, a significant, negative correlation was observed between plasma AAT levels and FeNO readings. CONCLUSIONS: Not only did PiMZ subjects show increased FeNO levels compared with COPD patients and controls; FeNO levels proved to be related to the reduced concentration of plasma AAT. Such findings seem to suggest the importance of FeNO measurements on PiMZ subjects for monitoring a possible progression of airway inflammation to obstructive lung disease as observed in some of these patients.

Non-invasive methods to assess biomarkers of exposure and early stage of pulmonary disease in smoking subjects.

Cigarette smoking is the major factor implicated in the pathogenesis of chronic obstructive pulmonary disease (COPD), despite the fact that only susceptible smoking subjects develop this respiratory disease. In the last few years non-invasive techniques such as induced sputum (IS), exhaled nitric oxide (eNO) measurement and exhaled breath condensate (EBC) collection have been successfully established revealing an inflammatory status and oxidative stress indicators in the airways involved in the pathogenesis of several pulmonary diseases. Using these new non-invasive experimental tools recently, several efforts have been made to find new biomarkers in order to assess and monitor early lung damage induced by smoking. Tobacco smoke can acutely reduce eNO levels in healthy smokers and non-smoker subjects so it can play a role in anti-smoking programmes; its increase can be a positive parameter for subjects who are going to stop cigarette smoking and at the same time be used as an anti-smoking indicator. It can be useful to investigate the mechanism of cigarette-induced lung damage in an experimental setting and may potentially be useful for assessing of Environmental Tobacco Smoke (ETS) effects. Markers of oxidative stress have been detected in induced sputum of COPD subjects even though only few studies investigated the use of induced sputum to study smoke effects on the lungs of healthy subjects. Exhaled breath condensate (EBC) obtained by cooling exhaled air under conditions of spontaneous breathing is a promising biological fluid that could provide a real-time assessment of pulmonary pathobiology. The analysis of induced sputum and of exhaled air is feasible and non-invasive, can be useful to identify new biomarkers of exposure or susceptibility in COPD patients to enhance the understanding of airways changes due to current smoking and may be useful to find new biomarkers in order to assess and monitor early lung damage induced by smoke in order to prevent the progression of obstructive disease.