INTRODUCTION AND OBJECTIVES Subjects with severe acquired brain injury (sABI) require long-term m... more INTRODUCTION AND OBJECTIVES Subjects with severe acquired brain injury (sABI) require long-term mechanical ventilation and, as a consequence, the tracheostomy tube stays in place for a long time. In this observational study, we investigated to what extent the identification of late tracheostomy complications by flexible bronchoscopy (FBS) might guide clinicians in the treatment of tracheal lesions throughout the weaning process and lead to successful decannulation. SUBJECTS AND METHODS One hundred and ninety-four subjects with sABI admitted to our rehabilitation unit were enrolled in the study. All subjects received FBS and tracheal lesions were treated either by choosing a more suitable tracheostomy tube, or by laser therapy, or by steroid therapy, or by a combination of the above treatments. RESULTS Overall, 122 subjects (63%) were decannulated successfully. Our subjects received 495 FBSs (2.55 per subject) and as many as 270 late tracheostomy complications were identified. At lea...
Data from literature show that 60% of patients tracheostomized in intensive care unit are dischar... more Data from literature show that 60% of patients tracheostomized in intensive care unit are discharged without removing the tracheostomy tube (Marchese Respir Med 2010, 104:749). Further, in neurological patients the overall incidence of airway stenosis after decannulation is 20% (Richard Arch Phys Med Rehabil 1996, 77:493). Thus, identifying successful procedures for removing tracheostomy tubes has gained increasing interest among clinicians. In this observational study we tested the hypothesis that fiberbronchoscopy (FBS) might play a pivotal role in driving tracheostomy weaning in patients admitted to high intensity rehabilitation units following severe brain injury. After standard clinical assessment, we performed FBS in 129 patients. In 41 patients (32%) who fulfilled the clinical decannulation criteria, tracheostomy tube was removed during the first FBS. In 49 patients (38%) who did not fulfill the clinical decannulation criteria at first FBS, tracheostomy tube could also be removed after changing or downsizing the tube or after medical or laser therapy, based upon FBS findings. In 3 patients who successfully overcame all clinical evaluation, FBS pointed out stenosis >50% requiring laser therapy. In 39 patients (30%) tracheostomy tube was not removed due to cough ineffectiveness (7), inability to tolerate the deflated tube (10), low level of consciousness (10) or concurrent acute events (12 patients). In conclusion our data show that in patients with severe brain injury FBS drives successful tracheostomy weaning even in a relevant proportion of the patients who do not fulfill decannulation criteria on a purely clinical basis.
Assessment of needle electromyography (nEMG) may complement previous data on limb muscle dysfunct... more Assessment of needle electromyography (nEMG) may complement previous data on limb muscle dysfunction (LMD) in patients with chronic obstructive pulmonary disease (COPD). We attempted to quantify the prevalence of LMD and assess its impact on clinical outcomes in patients admitted to a rehabilitation programme. One hundred and thirty-two clinically stable patients were consecutively enrolled. They underwent spirometry and the following primary outcomes were evaluated: St. George respiratory questionnaire (SGRQ), functional independence measure (FIM) questionnaire and a 6-min walking test (6MWT). One hundred and fourteen patients underwent nEMG. The frequency of LMD was related to COPD stage and chronic dyspnoea. nEMG detected myopathic signs in 36.8% of the patients. LMD was found even in early stages of COPD. FIM and 6MWT were significantly lower, and SGRQ tended to be higher at each COPD stage in patients with LMD. However, the 6MWT rate of decay across the COPD stages was similar in patients with and without LMD. LMD might not be restricted to patients with severe airway obstruction and regardless of COPD stage, contributes to functional limitation of these patients. The putative role of LMD in motor limitations indicates the need to assess it early onto better organise a specific training programme as part of general pulmonary rehabilitation in COPD patients.
We hypothesised that chest wall displacement inappropriate to increased ventilation contributes t... more We hypothesised that chest wall displacement inappropriate to increased ventilation contributes to dyspnoea more than dynamic hyperinflation or dyssynchronous breathing during unsupported arm exercise (UAE) in COPD patients. We used optoelectronic plethysmography to evaluate operational volumes of chest wall compartments, the upper rib cage, lower rib cage and abdomen, at 80% of peak incremental exercise in 13 patients. The phase shift between the volumes of upper and lower rib cage (RC) was taken as an index of RC distortion. With UAE, no chest wall dynamic hyperinflation was found; sometimes the lower RC paradoxed inward while in other patients it was the upper RC. Phase shift did not correlate with dyspnoea (by Borg scale) at any time, and chest wall displacement was in proportion to increased ventilation. In conclusions neither chest wall dynamic hyperinflation nor dyssynchronous breathing per se were major contributors to dyspnoea. Unlike our prediction, chest wall expansion and ventilation were adequately coupled with each other.
It has yet to be determined whether the language of dyspnea responds to pulmonary rehabilitation ... more It has yet to be determined whether the language of dyspnea responds to pulmonary rehabilitation programs (PRP). We tested the hypothesis that PRP affect both the intensity and quality of exercise-induced dyspnea in patients with chronic obstructive pulmonary disease (COPD). We studied 49 patients equipped with a portable telemetric spiroergometry device during the 6-min walking test before and 4 weeks after PRP. In a first screening visit, appropriate verbal descriptors of dyspnea were chosen that patients were familiar with during daily living activities. Tidal volume, respiratory frequency, inspiratory capacity, inspiratory reserve volume (IRV) and dyspnea intensity were evaluated by a modified Borg scale every minute during the test. Qualitative descriptors of dyspnea were defined by three different sets of cluster descriptors (a-c) at the end of the exercise test, before and after PRP: a - work/effort (W/E); b - inspiratory difficulty (ID) and chest tightness (CT), and c - W/E, ID and/or CT. The three language subgroups exhibited similar lung function at baseline, and similar rating of dyspnea and ventilatory changes during exercise. The rehabilitation program shifted the Borg-IRV relationship (less Borg at any given IRV) towards the right without modifying the set of descriptors in most patients. Rehabilitation programs allowed patients to tolerate a greater amount of restrictive dynamic ventilatory defect by modifying the intensity, but not necessarily the quality of dyspnea.
Breathing pattern description and chest wall kinematics during phonation have not been studied in... more Breathing pattern description and chest wall kinematics during phonation have not been studied in male and female patients with chronic obstructive pulmonary disease. We used optoelectronic plethysmography to provide a quantitative description of breathing pattern and chest wall kinematics. Volumes of chest wall compartments (rib cage and abdomen) were assessed in 15 patients while reading aloud (R), singing (SI) and during high-effort whispering (HW). Relative to quiet breathing, tidal volume and expiratory time increased while inspiratory time decreased. The expiratory flow decreased during R and SI, but was unchanged during HW. In males, the end-expiratory volume decreased as a result of a decreased volume of rib cage during R, SI and HW and due to a decreased volume of abdomen during HW. In females, a decrease in end-expiratory volume was accomplished by a decrease in abdominal volume during R and HW. During R, the chest wall end-expiratory volume of the last expiration in females was to the left of the maximal expiratory flow volume curve (MEFV), with still substantial expiratory reserve volume available. In contrast, during SI and HW in females and during all types of phonation in males, chest wall end-expiratory volume of the last expiration was well to the right of the MEFV curve and associated with respiratory discomfort. Gender had a greater importance than physical characteristics in determining more costal breathing in females than in males under all conditions studied. Phonation imposes more abdominal breathing pattern changes in males and costal changes in females. Expiratory flow encroaches upon the MEFV curve with higher phonatory efforts and respiratory discomfort.
INTRODUCTION AND OBJECTIVES Subjects with severe acquired brain injury (sABI) require long-term m... more INTRODUCTION AND OBJECTIVES Subjects with severe acquired brain injury (sABI) require long-term mechanical ventilation and, as a consequence, the tracheostomy tube stays in place for a long time. In this observational study, we investigated to what extent the identification of late tracheostomy complications by flexible bronchoscopy (FBS) might guide clinicians in the treatment of tracheal lesions throughout the weaning process and lead to successful decannulation. SUBJECTS AND METHODS One hundred and ninety-four subjects with sABI admitted to our rehabilitation unit were enrolled in the study. All subjects received FBS and tracheal lesions were treated either by choosing a more suitable tracheostomy tube, or by laser therapy, or by steroid therapy, or by a combination of the above treatments. RESULTS Overall, 122 subjects (63%) were decannulated successfully. Our subjects received 495 FBSs (2.55 per subject) and as many as 270 late tracheostomy complications were identified. At lea...
Data from literature show that 60% of patients tracheostomized in intensive care unit are dischar... more Data from literature show that 60% of patients tracheostomized in intensive care unit are discharged without removing the tracheostomy tube (Marchese Respir Med 2010, 104:749). Further, in neurological patients the overall incidence of airway stenosis after decannulation is 20% (Richard Arch Phys Med Rehabil 1996, 77:493). Thus, identifying successful procedures for removing tracheostomy tubes has gained increasing interest among clinicians. In this observational study we tested the hypothesis that fiberbronchoscopy (FBS) might play a pivotal role in driving tracheostomy weaning in patients admitted to high intensity rehabilitation units following severe brain injury. After standard clinical assessment, we performed FBS in 129 patients. In 41 patients (32%) who fulfilled the clinical decannulation criteria, tracheostomy tube was removed during the first FBS. In 49 patients (38%) who did not fulfill the clinical decannulation criteria at first FBS, tracheostomy tube could also be removed after changing or downsizing the tube or after medical or laser therapy, based upon FBS findings. In 3 patients who successfully overcame all clinical evaluation, FBS pointed out stenosis >50% requiring laser therapy. In 39 patients (30%) tracheostomy tube was not removed due to cough ineffectiveness (7), inability to tolerate the deflated tube (10), low level of consciousness (10) or concurrent acute events (12 patients). In conclusion our data show that in patients with severe brain injury FBS drives successful tracheostomy weaning even in a relevant proportion of the patients who do not fulfill decannulation criteria on a purely clinical basis.
Assessment of needle electromyography (nEMG) may complement previous data on limb muscle dysfunct... more Assessment of needle electromyography (nEMG) may complement previous data on limb muscle dysfunction (LMD) in patients with chronic obstructive pulmonary disease (COPD). We attempted to quantify the prevalence of LMD and assess its impact on clinical outcomes in patients admitted to a rehabilitation programme. One hundred and thirty-two clinically stable patients were consecutively enrolled. They underwent spirometry and the following primary outcomes were evaluated: St. George respiratory questionnaire (SGRQ), functional independence measure (FIM) questionnaire and a 6-min walking test (6MWT). One hundred and fourteen patients underwent nEMG. The frequency of LMD was related to COPD stage and chronic dyspnoea. nEMG detected myopathic signs in 36.8% of the patients. LMD was found even in early stages of COPD. FIM and 6MWT were significantly lower, and SGRQ tended to be higher at each COPD stage in patients with LMD. However, the 6MWT rate of decay across the COPD stages was similar in patients with and without LMD. LMD might not be restricted to patients with severe airway obstruction and regardless of COPD stage, contributes to functional limitation of these patients. The putative role of LMD in motor limitations indicates the need to assess it early onto better organise a specific training programme as part of general pulmonary rehabilitation in COPD patients.
We hypothesised that chest wall displacement inappropriate to increased ventilation contributes t... more We hypothesised that chest wall displacement inappropriate to increased ventilation contributes to dyspnoea more than dynamic hyperinflation or dyssynchronous breathing during unsupported arm exercise (UAE) in COPD patients. We used optoelectronic plethysmography to evaluate operational volumes of chest wall compartments, the upper rib cage, lower rib cage and abdomen, at 80% of peak incremental exercise in 13 patients. The phase shift between the volumes of upper and lower rib cage (RC) was taken as an index of RC distortion. With UAE, no chest wall dynamic hyperinflation was found; sometimes the lower RC paradoxed inward while in other patients it was the upper RC. Phase shift did not correlate with dyspnoea (by Borg scale) at any time, and chest wall displacement was in proportion to increased ventilation. In conclusions neither chest wall dynamic hyperinflation nor dyssynchronous breathing per se were major contributors to dyspnoea. Unlike our prediction, chest wall expansion and ventilation were adequately coupled with each other.
It has yet to be determined whether the language of dyspnea responds to pulmonary rehabilitation ... more It has yet to be determined whether the language of dyspnea responds to pulmonary rehabilitation programs (PRP). We tested the hypothesis that PRP affect both the intensity and quality of exercise-induced dyspnea in patients with chronic obstructive pulmonary disease (COPD). We studied 49 patients equipped with a portable telemetric spiroergometry device during the 6-min walking test before and 4 weeks after PRP. In a first screening visit, appropriate verbal descriptors of dyspnea were chosen that patients were familiar with during daily living activities. Tidal volume, respiratory frequency, inspiratory capacity, inspiratory reserve volume (IRV) and dyspnea intensity were evaluated by a modified Borg scale every minute during the test. Qualitative descriptors of dyspnea were defined by three different sets of cluster descriptors (a-c) at the end of the exercise test, before and after PRP: a - work/effort (W/E); b - inspiratory difficulty (ID) and chest tightness (CT), and c - W/E, ID and/or CT. The three language subgroups exhibited similar lung function at baseline, and similar rating of dyspnea and ventilatory changes during exercise. The rehabilitation program shifted the Borg-IRV relationship (less Borg at any given IRV) towards the right without modifying the set of descriptors in most patients. Rehabilitation programs allowed patients to tolerate a greater amount of restrictive dynamic ventilatory defect by modifying the intensity, but not necessarily the quality of dyspnea.
Breathing pattern description and chest wall kinematics during phonation have not been studied in... more Breathing pattern description and chest wall kinematics during phonation have not been studied in male and female patients with chronic obstructive pulmonary disease. We used optoelectronic plethysmography to provide a quantitative description of breathing pattern and chest wall kinematics. Volumes of chest wall compartments (rib cage and abdomen) were assessed in 15 patients while reading aloud (R), singing (SI) and during high-effort whispering (HW). Relative to quiet breathing, tidal volume and expiratory time increased while inspiratory time decreased. The expiratory flow decreased during R and SI, but was unchanged during HW. In males, the end-expiratory volume decreased as a result of a decreased volume of rib cage during R, SI and HW and due to a decreased volume of abdomen during HW. In females, a decrease in end-expiratory volume was accomplished by a decrease in abdominal volume during R and HW. During R, the chest wall end-expiratory volume of the last expiration in females was to the left of the maximal expiratory flow volume curve (MEFV), with still substantial expiratory reserve volume available. In contrast, during SI and HW in females and during all types of phonation in males, chest wall end-expiratory volume of the last expiration was well to the right of the MEFV curve and associated with respiratory discomfort. Gender had a greater importance than physical characteristics in determining more costal breathing in females than in males under all conditions studied. Phonation imposes more abdominal breathing pattern changes in males and costal changes in females. Expiratory flow encroaches upon the MEFV curve with higher phonatory efforts and respiratory discomfort.
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Papers by Barbara Lanini