Weaning is the process of withdrawing mechanical ventilation which starts with the first spontane... more Weaning is the process of withdrawing mechanical ventilation which starts with the first spontaneous breathing trial (SBT). Based on the degree of difficulty and duration, weaning is classified as simple, difficult and prolonged. Prolonged weaning, which includes patients who fail 3 SBTs or are still on mechanical ventilation 7 days after the first SBT, affects a relatively small fraction of mechanically ventilated ICU patients but these, however, requires disproportionate resources. There are several potential causes which can lead to prolonged weaning. It is nonetheless important to understand the problem from the point of view of each individual patient in order to adopt appropriate treatment and define precise prognosis. An otherwise stable patient who remains on mechanical ventilation will be considered for transfer to a specialized weaning unit (SWU). Though there is not a precise definition, SWU can be considered as highly specialized and protected environments for patients requiring mechanical ventilation despite resolution of the acute disorder. Proper staffing, well defined short-term and longterm goals, attention to psychological and social problems represent key determinants of SWU success. Some patients cannot be weaned, either partly or entirely, and may require longterm home mechanical ventilation. In these cases the logistics relating to caregivers and the equipment must be carefully considered and addressed.
Acupuncture and dry needling in the management of myofascial trigger point pain: a systematic rev... more Acupuncture and dry needling in the management of myofascial trigger point pain: a systematic review and meta-analysis of randomised controlled trials.
Additional file 1: Table E1. Data from the 4 subgroups of patients stratified according the amoun... more Additional file 1: Table E1. Data from the 4 subgroups of patients stratified according the amount of secretions and application of recruiting manoeuvres.
Background Besides airway suctioning, patients undergoing invasive mechanical ventilation (iMV) b... more Background Besides airway suctioning, patients undergoing invasive mechanical ventilation (iMV) benefit of different combinations of chest physiotherapy techniques, to improve mucus removal. To date, little is known about the clearance effects of oscillating devices on patients with acute respiratory failure undergoing iMV. This study aimed to assess (1) the effects of high-frequency chest wall oscillation (HFCWO) on lung aeration and ventilation distribution, as assessed by electrical impedance tomography (EIT), and (2) the effect of the association of HFCWO with recruitment manoeuvres (RM). Methods Sixty critically ill patients, 30 classified as normosecretive and 30 as hypersecretive, who received ≥ 48 h of iMV, underwent HFCWO; patients from both subgroups were randomized to receive RM or not, according to two separated randomization sequences. We therefore obtained four arms of 15 patients each. After baseline record (T0), HFCWO was applied for 10 min. At the end of the treatme...
There is a need of consensus about the pulmonary rehabilitation (PR) in patients with COVID-19 af... more There is a need of consensus about the pulmonary rehabilitation (PR) in patients with COVID-19 after discharge from acute care. To facilitate the knowledge of the evidence and its translation into practice, we developed suggestions based on experts’ opinion. A steering committee identified areas and questions sent to experts. Other international experts participated to a RAND Delphi method in reaching consensus and proposing further suggestions. Strong agreement in suggestions was defined when the mean agreement was >7 (1 = no agreement and 9 = maximal agreement). Panelists response rate was >95%. Twenty-three questions from 4 areas: Personnel protection equipment, phenotypes, assessments, interventions, were identified and experts answered with 121 suggestions, 119 of which received high level of concordance. The evidence-based suggestions provide the clinicians with current evidence and clinical experts opinion. This framework can be used to facilitate clinical decision maki...
Background: Non-specific low back pain (LBP) is the leading cause of disability worldwide. Acute ... more Background: Non-specific low back pain (LBP) is the leading cause of disability worldwide. Acute LBP usually has a good prognosis, with rapid improvement within the first 6 weeks. However, the majority of patients develop chronic LBP and suffer from recurrences. For clinical management, a plethora of treatments is currently available but evidence of the most effective options is lacking. The objective of this study will be to identify the most effective interventions to relieve pain and reduce disability in acute and sub-acute non-specific LBP. Methods/design: We will search electronic databases (MEDLINE, Embase, CENTRAL) from inception onwards. The eligible population will be individuals with non-specific LBP older than 18 years, both males and females, who experience pain less than 6 weeks (acute) or between 6 and 12 weeks (subacute). Eligible interventions and comparators will include all conservative rehabilitation or pharmacological treatments provided by any health professional; the only eligible study design will be a randomized controlled trial. The primary outcomes will be pain intensity and back-specific functional status. Secondary outcomes will be any adverse events. Studies published in languages other than English will also potentially be included. Two reviewers will independently screen the titles and abstracts retrieved from a literature search, as well as potentially relevant full-text articles. General characteristics, potential effect modifiers, and outcome data will be extracted from the included studies, and the risk of bias will be appraised. Conflicts at all levels of screening and abstraction will be resolved through team discussions. After describing the results of the review, if appropriate, a random effects meta-analysis and network meta-analysis will be conducted in a frequentist setting, assuming equal heterogeneity across all treatment comparisons and accounting for correlations induced by multi-arm studies using a multivariate normal model. Discussion: Our systematic review will address the uncertainties in the use of pharmacological or non-pharmacological treatments, and their relative efficacy, for acute and subacute LBP. These findings will be useful for patients, healthcare providers, and policymakers. Systematic review registration: PROSPERO CRD42018102527
Acupuncture and dry needling in the management of myofascial trigger point pain: a systematic rev... more Acupuncture and dry needling in the management of myofascial trigger point pain: a systematic review and meta-analysis of randomised controlled trials.
INTRODUCTION. Although a life-saving intervention, mechanical ventilation is apt to unwanted side... more INTRODUCTION. Although a life-saving intervention, mechanical ventilation is apt to unwanted side-effects and complications and should be interrupted as soon as possible. In acutely brain-injured patients, delaying weaning and liberation from mechanical ventilation increase the rate of ventilator-associated pneumonia, septic complications, and mortality. In neurologic and neurosurgical intubated patients, a systematic assessment of the patient\u2019s potential to be weaned off the ventilator has been demonstrated to reduce the risk of re- intubation following extubation failure, compared to the sole physician\u2019s clinical judgment. OBJECTIVES. We undertook this multicentre randomized controlled trial to evaluate whether a systematic approach to weaning is superior to the physician\u2019s judgment in pre- venting weaning failure occurring within 48 h, in neurologic patients undergoing mechanical ventilation through a tracheotomic cuffed tube. METHODS. Seventy-six neurosurgical and neurologic tracheotomized patients receiving mechanical ventilation were randomized to receive either protocolized weaning protocol (intervention group, IG) or a liberal weaning process according to the attending physicians\u2019 clinical judgment (control group, CG). Although in this last group the decision was left entirely to the discretion of the physicians, all the information collected and recorded for the IG were also available. The criteria for protocol failure were de\ufb01ned a priori. Patients were considered successfully weaned if they were not reconnected to the ventilator in the following 48 h. RESULTS. We included 38 patients in both groups. The average age of the patients enrolled was 54 \ub1 15 in IG, and 43 \ub1 17 in CG (p = 0.001), while the ratio between female and male was 11/27, and 17/21, respectively. The SAPII score at ICU admission was 41 \ub1 12 for IG, and 36 \ub1 17 for CG (p = 0.082). On study enrolment, the GCS was 9 \ub1 1 and 9 \ub1 2, for IG and CG, respectively (p = 0.14). There was no signi\ufb01cant difference with respect to weaning failure (7/38 in IG, 9/38 in CG); the days spent on mechanical ventilation were also no different between the two groups (17 \ub1 9 and 16 \ub1 8 days, for IG and CG, p = 0.66, respectively); the overall length of hospital stay was 22 \ub1 8 days in IG and 23 \ub1 9 days in CG (p = 0.64). CONCLUSIONS. In tracheotomized brain-injured patients receiving mechanical ventilation arranging physiologic and clinical data in a systematic fashion by means of a written \ufb02ow chart does not offer any advantage, as opposed to the sole clinical judgement
Objective: To evaluate patient comfort, skin breakdown and eye irritation when comparing a protot... more Objective: To evaluate patient comfort, skin breakdown and eye irritation when comparing a prototype face mask (PM) and conventional face masks (CMs) during non-invasive ventilation. Setting and design: Eight centers (intensive or intermediate care units). Multicenter randomized study. Populations: Patients with acute respiratory failure of different etiologies. Interventions: Patients were randomized to CMs or PM when ventilation was expected to last at least 12 consecutive hours a day for two consecutive days. Patient comfort, skin breakdown and eye irritation, assessed by means of standardized scoring systems, were measured after 24 and 48 h and before discontinuing ventilation. Results: Hundred ninety-four patients were randomized. Forty-seven patients were finally enrolled: PM (24) and CMs (23). Ventilator settings were similar in the two groups at the beginning of the treatment and after 24 and 48 h. Skin breakdown was significantly higher in the CMs group over the study period (p<0.001). Patient comfort was higher in the PM group after 24 and 48 h (p=0.008 and p<0.001, respectively). Eye irritation was absent in both groups after 24 h and did not differ significantly after 48 h (p=0.539). Before ventilation was discontinued skin breakdown and patient comfort were significantly higher in the CMs group, when compared to the PM group (p<0.001 and p=0.003, respectively). Eye irritation was slightly higher in the PM versus CMs group (p=0.21). The time on ventilation was not significantly different between the two groups (p=0.830). Conclusion: The PM significantly reduced skin breakdown while improving patient comfort, compared to the CMs.
On completion of this article, the reader should be able to: 1. Explain the protocol used in the ... more On completion of this article, the reader should be able to: 1. Explain the protocol used in the intervention group. 2. Explain the pros and cons identified related to protocol use. 3. Demonstrate this information in a clinical setting. The authors have disclosed that they have no financial relationships with or interests in any commercial companies pertaining to this educational activity. All faculty and staff in a position to control the content of this CME activity have disclosed that they have no financial relationship with, or financial interests in, any commercial companies pertaining to this educational activity. Lippincott CME Institute, Inc., has identified and resolved all faculty conflicts of interest regarding this educational activity. Visit the Critical Care Medicine Web Site (www.ccmjournal.org) for information on obtaining continuing medical education credit. Objective: To assess whether a systematic approach to weaning and extubation (intervention) is superior to the sole physician's judgment (control) in preventing reintubation secondary to extubation failure in patients with neurologic disorders. Design: Randomized controlled trial. Setting: Intensive care unit of a large teaching hospital. Patients: Three hundred eighteen intubated patients who had been receiving mechanical ventilation for at least 12 hrs and were able to trigger the ventilator. Interventions: Patients were randomized to the intervention (n ؍ 165) or control group (n ؍ 153). Measurements: Rate of reintubation after extubation failure occurring within 48 hrs (primary end point). Duration of mechanical ventilation, length of intensive care unit stay, mortality, rate of tracheotomy (secondary end points). The perception of the research protocol by the intensive care unit staff was also assessed. Main Results: The rate of reintubation was lower in the intervention (5%) than in the control (12.5%) group (p ؍ 0.047). There was no difference in any of the other outcome variables (secondary end points). Simplified Acute Physiologic Score II (adjusted odds ratio 1.042 per unit; 95% confidence interval 1.006-1.080; p ؍ 0.022) and inclusion in the control group (adjusted odds ratio 2.393; 95% confidence interval 1.000-5.726; p ؍ 0.05) were the only two independent predictive factors for the risk of extubation failure. The protocol was felt by the staff to determine an improvement in patients' clinical outcome, but to increase intensive care unit workload; nurses and physiotherapists considered its impact on their professional role more positively than physicians. Conclusions: In patients with neurologic diseases, a systematic approach to weaning and extubation reduces the rate of reintubation secondary to extubation failure without affecting the duration of mechanical ventilation, and is overall positively perceived by intensive care unit professionals.
The efficacy of noninvasive mechanical ventilation (NIMV) in improving breathing pattern and arte... more The efficacy of noninvasive mechanical ventilation (NIMV) in improving breathing pattern and arterial blood gases (ABG) in hypercapnic patients has been well documented; however, little attention has been given to the choice of the interface and the ventilatory mode. We evaluated the effects of three types of masks and two modes of ventilation on patients&#39; ABG, breathing pattern, and tolerance to ventilation. Prospective randomized study. Two respiratory weaning centers. A total of 26 stable hypercapnic patients (pH, 7.38 +/- 0.04; PaCO2, 59.2. +/- 10.9 torr) had not received NIMV and were affected by restrictive thoracic disease or obstructive pulmonary disease. Three 30-min runs of NIMV, delivered using volume-assisted (n = 13) or pressure-assisted modes of partial mechanical support (n = 13), were performed in random order with a full-face mask, a nasal mask, and nasal plugs. ABG, breathing pattern, and patients&#39; tolerance to ventilation. Compared with spontaneous breathing, the application of NIMV significantly improved ABG and minute ventilation, irrespective of the ventilatory mode, the underlying pathology or the type of mask. Overall, a nasal mask was better tolerated than the other two interfaces (p &lt; .005 vs. nasal plugs and full-face mask). PaCO2 was significantly lower (p &lt; .01) with a full-face mask or nasal plugs than with a nasal mask (49.5 +/- 9.4 torr, 49.7 +/- 8 torr, and 52.4 +/- 11 torr, respectively). Minute ventilation was significantly higher with a full-face mask than with a nasal mask because of an increase in tidal volume. No differences were observed in tolerance to ventilation, ABG, or breathing pattern, using assist control or pressure-assisted modes. In this physiologic study, we have shown that in patients with hypercapnic respiratory failure, irrespective of the underlying pathology, the type of interface affects the NIMV outcome more than the ventilatory mode.
To determine whether non-invasive ventilation (NIV) may be an effective and safe alternative to i... more To determine whether non-invasive ventilation (NIV) may be an effective and safe alternative to invasive mechanical ventilation in chronic obstructive pulmonary disease (COPD) patients with acute respiratory failure (ARF) meeting criteria for mechanical ventilation. Matched case-control study conducted in ICU. NIV was prospectively applied to 64 COPD patients with advanced ARF. Their outcomes were compared with those of a control group of 64 COPD patients matched on age, FEV(1), Simplified Acute Physiology Score II, and pH at ICU admission, previously treated in the same ICU with conventional invasive mechanical ventilation. NIV failed in 40 patients who required intubation. Mortality rate, duration of mechanical ventilation, and lengths of ICU and post-ICU stay were not different between the two groups. The NIV group had fewer complications ( P = 0.01) and showed a trend toward a lower proportion of patients remaining on mechanical ventilation after 30 days ( P = 0.056). Compared to the control group, the outcomes of the patients who failed NIV were no different. Compared to the patients who received intubation, those who succeeded NIV had reduced mortality rate and lengths of ICU and post-ICU stay. In COPD patients with advanced hypercapnic acute respiratory failure, NIV had a high rate of failure, but, nevertheless, provided some advantages, compared to conventional invasive ventilation. Subgroup analysis suggested that the delay in intubation was not deleterious in the patients who failed NIV, whereas a better outcome was confirmed for the patients who avoided intubation.
Purpose: To assess reporting completeness of the most frequent outcome measures used in randomize... more Purpose: To assess reporting completeness of the most frequent outcome measures used in randomized controlled trials (RCTs) of rehabilitation interventions for mechanical low back pain. Methods: We performed a cross-sectional study of RCTs included in all Cochrane systematic reviews (SRs) published up to May 2013. Two authors independently evaluated the type and frequency of each outcome measure reported, the methods used to measure outcomes, the completeness of outcome reporting using a eight-item checklist, and the proportion of outcomes fully replicable by an independent assessor. Results: Our literature search identified 11 SRs, including 185 RCTs. Thirty-six different outcomes were investigated across all RCTs. The 2 most commonly reported outcomes were pain (n=165 RCTs; 89.2%) and disability (n=118 RCTs; 63.8%), which were assessed by 66 and 44 measurement tools, respectively. Pain and disability outcomes were found replicable in only 10.3% (n=17) and 10.2% (n=12) of the RCTs,...
Background: The use of remote rehabilitation in children was limited before the COVID-19 pandemic... more Background: The use of remote rehabilitation in children was limited before the COVID-19 pandemic, due to culture, technology access, regulatory and reimbursement barriers.Methods: The study was conducted according to the STROBE (The Strengthening the Reporting of Observational Studies in Epidemiology) checklist in order to provide qualitative and quantitative data about experience of patients with disabilities and their caregivers during Phase 1 of the COVID-19 pandemic, and their level of satisfaction. An online survey was developed using Google Forms and sent via email. The outcome measures were rated using a 5-point Likert Scale. Two additional open-ended questions were used to collect qualitative data.Results: 128 out of 261 families responded to the survey: 80.5% of the caregivers reported they were satisfied with the remote rehabilitation. More than a half (53%) of the families reported a high level of satisfaction with the involvement they received in defining and sharing of...
Monaldi archives for chest disease = Archivio Monaldi per le malattie del torace, 2021
In February 2020 the first COVID-19 case was reported in Italy and afterwards the virus started s... more In February 2020 the first COVID-19 case was reported in Italy and afterwards the virus started spreading rapidly, increasing dramatically the number of infected subjects. To face the pandemic outbreak, hospitals converted wards to assure COVID-19 patients' care and adopted measures to reduce virus diffusion. The aim of this study was to determine how many physiotherapists, in the Lombardy region, worked during pandemic, whether they continued their usual practice or were employed in COVID-19 wards and in which tasks they were involved. The survey was submitted online by the national professional order. The response rate was 11.79%. During the pandemic, 648 (53.9%) respondents interrupted their services. Less than 20% of the physiotherapists that continued working were assigned to COVID-19 wards with the role of physiotherapist. Only a small proportion of respondents had advanced skills in respiratory physiotherapy. Moreover, this study showed a limited involvement of physiother...
Weaning is the process of withdrawing mechanical ventilation which starts with the first spontane... more Weaning is the process of withdrawing mechanical ventilation which starts with the first spontaneous breathing trial (SBT). Based on the degree of difficulty and duration, weaning is classified as simple, difficult and prolonged. Prolonged weaning, which includes patients who fail 3 SBTs or are still on mechanical ventilation 7 days after the first SBT, affects a relatively small fraction of mechanically ventilated ICU patients but these, however, requires disproportionate resources. There are several potential causes which can lead to prolonged weaning. It is nonetheless important to understand the problem from the point of view of each individual patient in order to adopt appropriate treatment and define precise prognosis. An otherwise stable patient who remains on mechanical ventilation will be considered for transfer to a specialized weaning unit (SWU). Though there is not a precise definition, SWU can be considered as highly specialized and protected environments for patients requiring mechanical ventilation despite resolution of the acute disorder. Proper staffing, well defined short-term and longterm goals, attention to psychological and social problems represent key determinants of SWU success. Some patients cannot be weaned, either partly or entirely, and may require longterm home mechanical ventilation. In these cases the logistics relating to caregivers and the equipment must be carefully considered and addressed.
Acupuncture and dry needling in the management of myofascial trigger point pain: a systematic rev... more Acupuncture and dry needling in the management of myofascial trigger point pain: a systematic review and meta-analysis of randomised controlled trials.
Additional file 1: Table E1. Data from the 4 subgroups of patients stratified according the amoun... more Additional file 1: Table E1. Data from the 4 subgroups of patients stratified according the amount of secretions and application of recruiting manoeuvres.
Background Besides airway suctioning, patients undergoing invasive mechanical ventilation (iMV) b... more Background Besides airway suctioning, patients undergoing invasive mechanical ventilation (iMV) benefit of different combinations of chest physiotherapy techniques, to improve mucus removal. To date, little is known about the clearance effects of oscillating devices on patients with acute respiratory failure undergoing iMV. This study aimed to assess (1) the effects of high-frequency chest wall oscillation (HFCWO) on lung aeration and ventilation distribution, as assessed by electrical impedance tomography (EIT), and (2) the effect of the association of HFCWO with recruitment manoeuvres (RM). Methods Sixty critically ill patients, 30 classified as normosecretive and 30 as hypersecretive, who received ≥ 48 h of iMV, underwent HFCWO; patients from both subgroups were randomized to receive RM or not, according to two separated randomization sequences. We therefore obtained four arms of 15 patients each. After baseline record (T0), HFCWO was applied for 10 min. At the end of the treatme...
There is a need of consensus about the pulmonary rehabilitation (PR) in patients with COVID-19 af... more There is a need of consensus about the pulmonary rehabilitation (PR) in patients with COVID-19 after discharge from acute care. To facilitate the knowledge of the evidence and its translation into practice, we developed suggestions based on experts’ opinion. A steering committee identified areas and questions sent to experts. Other international experts participated to a RAND Delphi method in reaching consensus and proposing further suggestions. Strong agreement in suggestions was defined when the mean agreement was >7 (1 = no agreement and 9 = maximal agreement). Panelists response rate was >95%. Twenty-three questions from 4 areas: Personnel protection equipment, phenotypes, assessments, interventions, were identified and experts answered with 121 suggestions, 119 of which received high level of concordance. The evidence-based suggestions provide the clinicians with current evidence and clinical experts opinion. This framework can be used to facilitate clinical decision maki...
Background: Non-specific low back pain (LBP) is the leading cause of disability worldwide. Acute ... more Background: Non-specific low back pain (LBP) is the leading cause of disability worldwide. Acute LBP usually has a good prognosis, with rapid improvement within the first 6 weeks. However, the majority of patients develop chronic LBP and suffer from recurrences. For clinical management, a plethora of treatments is currently available but evidence of the most effective options is lacking. The objective of this study will be to identify the most effective interventions to relieve pain and reduce disability in acute and sub-acute non-specific LBP. Methods/design: We will search electronic databases (MEDLINE, Embase, CENTRAL) from inception onwards. The eligible population will be individuals with non-specific LBP older than 18 years, both males and females, who experience pain less than 6 weeks (acute) or between 6 and 12 weeks (subacute). Eligible interventions and comparators will include all conservative rehabilitation or pharmacological treatments provided by any health professional; the only eligible study design will be a randomized controlled trial. The primary outcomes will be pain intensity and back-specific functional status. Secondary outcomes will be any adverse events. Studies published in languages other than English will also potentially be included. Two reviewers will independently screen the titles and abstracts retrieved from a literature search, as well as potentially relevant full-text articles. General characteristics, potential effect modifiers, and outcome data will be extracted from the included studies, and the risk of bias will be appraised. Conflicts at all levels of screening and abstraction will be resolved through team discussions. After describing the results of the review, if appropriate, a random effects meta-analysis and network meta-analysis will be conducted in a frequentist setting, assuming equal heterogeneity across all treatment comparisons and accounting for correlations induced by multi-arm studies using a multivariate normal model. Discussion: Our systematic review will address the uncertainties in the use of pharmacological or non-pharmacological treatments, and their relative efficacy, for acute and subacute LBP. These findings will be useful for patients, healthcare providers, and policymakers. Systematic review registration: PROSPERO CRD42018102527
Acupuncture and dry needling in the management of myofascial trigger point pain: a systematic rev... more Acupuncture and dry needling in the management of myofascial trigger point pain: a systematic review and meta-analysis of randomised controlled trials.
INTRODUCTION. Although a life-saving intervention, mechanical ventilation is apt to unwanted side... more INTRODUCTION. Although a life-saving intervention, mechanical ventilation is apt to unwanted side-effects and complications and should be interrupted as soon as possible. In acutely brain-injured patients, delaying weaning and liberation from mechanical ventilation increase the rate of ventilator-associated pneumonia, septic complications, and mortality. In neurologic and neurosurgical intubated patients, a systematic assessment of the patient\u2019s potential to be weaned off the ventilator has been demonstrated to reduce the risk of re- intubation following extubation failure, compared to the sole physician\u2019s clinical judgment. OBJECTIVES. We undertook this multicentre randomized controlled trial to evaluate whether a systematic approach to weaning is superior to the physician\u2019s judgment in pre- venting weaning failure occurring within 48 h, in neurologic patients undergoing mechanical ventilation through a tracheotomic cuffed tube. METHODS. Seventy-six neurosurgical and neurologic tracheotomized patients receiving mechanical ventilation were randomized to receive either protocolized weaning protocol (intervention group, IG) or a liberal weaning process according to the attending physicians\u2019 clinical judgment (control group, CG). Although in this last group the decision was left entirely to the discretion of the physicians, all the information collected and recorded for the IG were also available. The criteria for protocol failure were de\ufb01ned a priori. Patients were considered successfully weaned if they were not reconnected to the ventilator in the following 48 h. RESULTS. We included 38 patients in both groups. The average age of the patients enrolled was 54 \ub1 15 in IG, and 43 \ub1 17 in CG (p = 0.001), while the ratio between female and male was 11/27, and 17/21, respectively. The SAPII score at ICU admission was 41 \ub1 12 for IG, and 36 \ub1 17 for CG (p = 0.082). On study enrolment, the GCS was 9 \ub1 1 and 9 \ub1 2, for IG and CG, respectively (p = 0.14). There was no signi\ufb01cant difference with respect to weaning failure (7/38 in IG, 9/38 in CG); the days spent on mechanical ventilation were also no different between the two groups (17 \ub1 9 and 16 \ub1 8 days, for IG and CG, p = 0.66, respectively); the overall length of hospital stay was 22 \ub1 8 days in IG and 23 \ub1 9 days in CG (p = 0.64). CONCLUSIONS. In tracheotomized brain-injured patients receiving mechanical ventilation arranging physiologic and clinical data in a systematic fashion by means of a written \ufb02ow chart does not offer any advantage, as opposed to the sole clinical judgement
Objective: To evaluate patient comfort, skin breakdown and eye irritation when comparing a protot... more Objective: To evaluate patient comfort, skin breakdown and eye irritation when comparing a prototype face mask (PM) and conventional face masks (CMs) during non-invasive ventilation. Setting and design: Eight centers (intensive or intermediate care units). Multicenter randomized study. Populations: Patients with acute respiratory failure of different etiologies. Interventions: Patients were randomized to CMs or PM when ventilation was expected to last at least 12 consecutive hours a day for two consecutive days. Patient comfort, skin breakdown and eye irritation, assessed by means of standardized scoring systems, were measured after 24 and 48 h and before discontinuing ventilation. Results: Hundred ninety-four patients were randomized. Forty-seven patients were finally enrolled: PM (24) and CMs (23). Ventilator settings were similar in the two groups at the beginning of the treatment and after 24 and 48 h. Skin breakdown was significantly higher in the CMs group over the study period (p<0.001). Patient comfort was higher in the PM group after 24 and 48 h (p=0.008 and p<0.001, respectively). Eye irritation was absent in both groups after 24 h and did not differ significantly after 48 h (p=0.539). Before ventilation was discontinued skin breakdown and patient comfort were significantly higher in the CMs group, when compared to the PM group (p<0.001 and p=0.003, respectively). Eye irritation was slightly higher in the PM versus CMs group (p=0.21). The time on ventilation was not significantly different between the two groups (p=0.830). Conclusion: The PM significantly reduced skin breakdown while improving patient comfort, compared to the CMs.
On completion of this article, the reader should be able to: 1. Explain the protocol used in the ... more On completion of this article, the reader should be able to: 1. Explain the protocol used in the intervention group. 2. Explain the pros and cons identified related to protocol use. 3. Demonstrate this information in a clinical setting. The authors have disclosed that they have no financial relationships with or interests in any commercial companies pertaining to this educational activity. All faculty and staff in a position to control the content of this CME activity have disclosed that they have no financial relationship with, or financial interests in, any commercial companies pertaining to this educational activity. Lippincott CME Institute, Inc., has identified and resolved all faculty conflicts of interest regarding this educational activity. Visit the Critical Care Medicine Web Site (www.ccmjournal.org) for information on obtaining continuing medical education credit. Objective: To assess whether a systematic approach to weaning and extubation (intervention) is superior to the sole physician's judgment (control) in preventing reintubation secondary to extubation failure in patients with neurologic disorders. Design: Randomized controlled trial. Setting: Intensive care unit of a large teaching hospital. Patients: Three hundred eighteen intubated patients who had been receiving mechanical ventilation for at least 12 hrs and were able to trigger the ventilator. Interventions: Patients were randomized to the intervention (n ؍ 165) or control group (n ؍ 153). Measurements: Rate of reintubation after extubation failure occurring within 48 hrs (primary end point). Duration of mechanical ventilation, length of intensive care unit stay, mortality, rate of tracheotomy (secondary end points). The perception of the research protocol by the intensive care unit staff was also assessed. Main Results: The rate of reintubation was lower in the intervention (5%) than in the control (12.5%) group (p ؍ 0.047). There was no difference in any of the other outcome variables (secondary end points). Simplified Acute Physiologic Score II (adjusted odds ratio 1.042 per unit; 95% confidence interval 1.006-1.080; p ؍ 0.022) and inclusion in the control group (adjusted odds ratio 2.393; 95% confidence interval 1.000-5.726; p ؍ 0.05) were the only two independent predictive factors for the risk of extubation failure. The protocol was felt by the staff to determine an improvement in patients' clinical outcome, but to increase intensive care unit workload; nurses and physiotherapists considered its impact on their professional role more positively than physicians. Conclusions: In patients with neurologic diseases, a systematic approach to weaning and extubation reduces the rate of reintubation secondary to extubation failure without affecting the duration of mechanical ventilation, and is overall positively perceived by intensive care unit professionals.
The efficacy of noninvasive mechanical ventilation (NIMV) in improving breathing pattern and arte... more The efficacy of noninvasive mechanical ventilation (NIMV) in improving breathing pattern and arterial blood gases (ABG) in hypercapnic patients has been well documented; however, little attention has been given to the choice of the interface and the ventilatory mode. We evaluated the effects of three types of masks and two modes of ventilation on patients&#39; ABG, breathing pattern, and tolerance to ventilation. Prospective randomized study. Two respiratory weaning centers. A total of 26 stable hypercapnic patients (pH, 7.38 +/- 0.04; PaCO2, 59.2. +/- 10.9 torr) had not received NIMV and were affected by restrictive thoracic disease or obstructive pulmonary disease. Three 30-min runs of NIMV, delivered using volume-assisted (n = 13) or pressure-assisted modes of partial mechanical support (n = 13), were performed in random order with a full-face mask, a nasal mask, and nasal plugs. ABG, breathing pattern, and patients&#39; tolerance to ventilation. Compared with spontaneous breathing, the application of NIMV significantly improved ABG and minute ventilation, irrespective of the ventilatory mode, the underlying pathology or the type of mask. Overall, a nasal mask was better tolerated than the other two interfaces (p &lt; .005 vs. nasal plugs and full-face mask). PaCO2 was significantly lower (p &lt; .01) with a full-face mask or nasal plugs than with a nasal mask (49.5 +/- 9.4 torr, 49.7 +/- 8 torr, and 52.4 +/- 11 torr, respectively). Minute ventilation was significantly higher with a full-face mask than with a nasal mask because of an increase in tidal volume. No differences were observed in tolerance to ventilation, ABG, or breathing pattern, using assist control or pressure-assisted modes. In this physiologic study, we have shown that in patients with hypercapnic respiratory failure, irrespective of the underlying pathology, the type of interface affects the NIMV outcome more than the ventilatory mode.
To determine whether non-invasive ventilation (NIV) may be an effective and safe alternative to i... more To determine whether non-invasive ventilation (NIV) may be an effective and safe alternative to invasive mechanical ventilation in chronic obstructive pulmonary disease (COPD) patients with acute respiratory failure (ARF) meeting criteria for mechanical ventilation. Matched case-control study conducted in ICU. NIV was prospectively applied to 64 COPD patients with advanced ARF. Their outcomes were compared with those of a control group of 64 COPD patients matched on age, FEV(1), Simplified Acute Physiology Score II, and pH at ICU admission, previously treated in the same ICU with conventional invasive mechanical ventilation. NIV failed in 40 patients who required intubation. Mortality rate, duration of mechanical ventilation, and lengths of ICU and post-ICU stay were not different between the two groups. The NIV group had fewer complications ( P = 0.01) and showed a trend toward a lower proportion of patients remaining on mechanical ventilation after 30 days ( P = 0.056). Compared to the control group, the outcomes of the patients who failed NIV were no different. Compared to the patients who received intubation, those who succeeded NIV had reduced mortality rate and lengths of ICU and post-ICU stay. In COPD patients with advanced hypercapnic acute respiratory failure, NIV had a high rate of failure, but, nevertheless, provided some advantages, compared to conventional invasive ventilation. Subgroup analysis suggested that the delay in intubation was not deleterious in the patients who failed NIV, whereas a better outcome was confirmed for the patients who avoided intubation.
Purpose: To assess reporting completeness of the most frequent outcome measures used in randomize... more Purpose: To assess reporting completeness of the most frequent outcome measures used in randomized controlled trials (RCTs) of rehabilitation interventions for mechanical low back pain. Methods: We performed a cross-sectional study of RCTs included in all Cochrane systematic reviews (SRs) published up to May 2013. Two authors independently evaluated the type and frequency of each outcome measure reported, the methods used to measure outcomes, the completeness of outcome reporting using a eight-item checklist, and the proportion of outcomes fully replicable by an independent assessor. Results: Our literature search identified 11 SRs, including 185 RCTs. Thirty-six different outcomes were investigated across all RCTs. The 2 most commonly reported outcomes were pain (n=165 RCTs; 89.2%) and disability (n=118 RCTs; 63.8%), which were assessed by 66 and 44 measurement tools, respectively. Pain and disability outcomes were found replicable in only 10.3% (n=17) and 10.2% (n=12) of the RCTs,...
Background: The use of remote rehabilitation in children was limited before the COVID-19 pandemic... more Background: The use of remote rehabilitation in children was limited before the COVID-19 pandemic, due to culture, technology access, regulatory and reimbursement barriers.Methods: The study was conducted according to the STROBE (The Strengthening the Reporting of Observational Studies in Epidemiology) checklist in order to provide qualitative and quantitative data about experience of patients with disabilities and their caregivers during Phase 1 of the COVID-19 pandemic, and their level of satisfaction. An online survey was developed using Google Forms and sent via email. The outcome measures were rated using a 5-point Likert Scale. Two additional open-ended questions were used to collect qualitative data.Results: 128 out of 261 families responded to the survey: 80.5% of the caregivers reported they were satisfied with the remote rehabilitation. More than a half (53%) of the families reported a high level of satisfaction with the involvement they received in defining and sharing of...
Monaldi archives for chest disease = Archivio Monaldi per le malattie del torace, 2021
In February 2020 the first COVID-19 case was reported in Italy and afterwards the virus started s... more In February 2020 the first COVID-19 case was reported in Italy and afterwards the virus started spreading rapidly, increasing dramatically the number of infected subjects. To face the pandemic outbreak, hospitals converted wards to assure COVID-19 patients' care and adopted measures to reduce virus diffusion. The aim of this study was to determine how many physiotherapists, in the Lombardy region, worked during pandemic, whether they continued their usual practice or were employed in COVID-19 wards and in which tasks they were involved. The survey was submitted online by the national professional order. The response rate was 11.79%. During the pandemic, 648 (53.9%) respondents interrupted their services. Less than 20% of the physiotherapists that continued working were assigned to COVID-19 wards with the role of physiotherapist. Only a small proportion of respondents had advanced skills in respiratory physiotherapy. Moreover, this study showed a limited involvement of physiother...
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Papers by Pamela Frigerio