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1.  Can ultrasound guidance reduce the risk of pneumothorax following thoracentesis?*, **  
Thoracentesis is one of the bedside procedures most commonly associated with iatrogenic complications, particularly pneumothorax. Various risk factors for complications associated with thoracentesis have recently been identified, including an inexperienced operator; an inadequate or inexperienced support team; the lack of a standardized protocol; and the lack of ultrasound guidance. We sought to determine whether ultrasound-guided thoracentesis can reduce the risk of pneumothorax and improve outcomes (fewer procedures without fluid removal and greater volumes of fluid removed during the procedures). In our comparison of thoracentesis with and without ultrasound guidance, all procedures were performed by a team of expert pulmonologists, using the same standardized protocol in both conditions.
A total of 160 participants were randomly allocated to undergo thoracentesis with or without ultrasound guidance (n = 80 per group). The primary outcome was pneumothorax following thoracentesis. Secondary outcomes included the number of procedures without fluid removal and the volume of fluid drained during the procedure.
Pneumothorax occurred in 1 of the 80 patients who underwent ultrasound-guided thoracentesis and in 10 of the 80 patients who underwent thoracentesis without ultrasound guidance, the difference being statistically significant (p = 0.009). Fluid was removed in 79 of the 80 procedures performed with ultrasound guidance and in 72 of the 80 procedures performed without it. The mean volume of fluid drained was larger during the former than during the latter (960 ± 500 mL vs. 770 ± 480 mL), the difference being statistically significant (p = 0.03).
Ultrasound guidance increases the yield of thoracentesis and reduces the risk of post-procedure pneumothorax. (Chinese Clinical Trial Registry identifier: ChiCTR-TRC-12002174 [])
PMCID: PMC4075913  PMID: 24626264
Pneumothorax; Ultrasonography; Thoracic surgical procedures
2.  Predictors of Non-Invasive Ventilation Failure in Severe Respiratory Failure Due to Community Acquired Pneumonia 
Tanaffos  2014;13(4):20-28.
Non-invasive ventilation (NIV) has been used for acute respiratory failure to avoid endotracheal intubation and intensive care admission. Few studies have assessed the usefulness of NIV in patients with severe community acquired pneumonia (CAP). The use of NIV in severe CAP is controversial because there is a greater variability in success compared to other pulmonary conditions.
Materials and Methods
We retrospectively followed 130 patients with CAP and severe acute respiratory failure (PaO2/FiO2 < 250) admitted to a Respiratory Monitoring Unit (RMU) and underwent NIV. We assessed predictors of NIV failure and hospital mortality using univariate and multivariate analyses.
NIV failed in 26 patients (20.0%). Higher chest X-ray score at admission, higher heart rate after 1 hour of NIV, and a higher alveolar-arteriolar gradient (A-aDO2) after 24 hours of NIV each independently predicted NIV failure.
Higher chest X ray score, higher LDH at admission, higher heart rate after 24 hours of NIV and higher A-aDO2 after 24 hours of NIV were directly related to hospital mortality.
NIV treatment had high rate of success. Successful treatment is related to less lung involvement and to early good response to NIV and continuous improvement in clinical response.
PMCID: PMC4386012  PMID: 25852758
Community-acquired pneumonia; Severe respiratory failure; Non-invasive ventilation; Hospital mortality
3.  Effectiveness of treatment with high-frequency chest wall oscillation in patients with bronchiectasis 
High-frequency airway clearance (HFCWC) assist devices generate either positive or negative trans-respiratory pressure excursions to produce high-frequency, small-volume oscillations in the airways.
HFCWC can lead to changes in volume of 15–57 ml and in flow up to 1.6 L/s, which generate minimal coughing to mobilize secretions. The typical treatment lasts 20–30 minutes, and consists of short periods of compression at different frequencies, separated by coughing.
The aim of this study was to find the more efficacious treatment in patients with bronchiectasis: traditional techniques of chest physiotherapy (CPT) versus high frequency oscillation of the chest wall in patients with bronchiectasis.
37 patients were enrolled. Seven of them were excluded. Computer randomization divided the patients into three groups:
– 10 patients treated with HFCWO by using the Vest® Airway Clearance System;
– 10 patients treated with traditional techniques of air way clearance (PEP bottle, PEP mask, ELTGOL, vibratory positive expiratory pressure);
– 10 patients received medical therapy only (control group).
To be eligible for enrollment, participants had to be between 18 and 85 years old and have a diagnosis of bronchiectasis, confirmed on high resolution computed tomography. Exclusion criteria: lack of informed consent, signs of exacerbation, cystic fibrosis. Before the treatment, each patient had blood tests, sputum volume and cell count, pulmonary function tests and on the quality of life inventories (MMRC, CAT, BCSS). The results were processed through the covariance analysis, performed with the R-Project statistical program. It has been considered a positive result p <005.
Both treatments (traditional CPT and HFCWO) showed a significant improvement in some biochemical and functional respiratory tests as well as in the quality of life compared to the control group. The use of HFCWO compared to CPT also produced a significant improvement in blood inflammation parameter C-RP (p ≤0.019), parameters of lung functionality associated with bronchial obstruction (FVC, FEV1) (p ≤0.006 and p ≤0.001), and in the dyspnea. Improvement in quality of life scales was noted. (BCSS, CAT) (both p ≤0.001). No significant changes of total cell counts in sputum samples were observed in the two groups. In the HFCWO group a significant reduction of neutrophils percentage (p≤0.002) and a significant increase of macrophages percentage (p ≤0.012).
The HFCWO technique provides an improvement both in pulmonary function and quality of life related parameters in patients with chronic hypersecretive disease. Since those patients need daily airway clearance, this treatment should be included among the principal options in chest physiotherapy. The study was registered as ChiCTR-TRC-12002134 at
PMCID: PMC3623823  PMID: 23556995
Bronchiectasis; High frequency chest wall oscillation; Chest physiotherapy; Lung function; Sputum cell count; Dyspnea scales
4.  Use of positive expiratory pressure during six minute walk test: results in patients with moderate to severe chronic obstructive pulmonary disease 
The six-minute walk test (6MWT) is widely used because it is both simple and reliable as a measure of exercise capacity. Individuals with chronic obstructive pulmonary disease (COPD) usually show a limited capacity to perform exercise.
Our study is a prospective, randomized controlled trial which uses the 6MWT in one hundred consecutive in and out- patients with moderate to severe COPD to assess the benefit of a simple positive expiratory pressure (PEP) device. PEP device consisted of a PEP valve 5 cmH2O connected to 1-meter tube and a mouthpiece. All the enrolled patients performed a 6MWT before randomization. The following day PEP group patients performed the 6MWT using PEP device. Control group patients performed the 6MWT without this device. The primary outcome was the difference in distance (meters) walked.
Functional capacity assessed by the distance covered during 6MWT improved in the PEP group more than in the control group. The difference was statistically significant (p < 0.001).Oxygen saturation improved to a statistically significant level during 6MWT (p < 0.01). Heart rate was also reduced (p < 0.03).
There are few studies demonstrating that PEP devices enhance exercise capacity in COPD patients. Our results has been obtained using only a low positive expiratory pressure (5 cmH2O). In our opinion the strength of this study is the simplicity and the lower cost when compared to other devices and approaches. The study was registered as Chi CTR-ORC-12002173 at
PMCID: PMC3637106  PMID: 23497658
Moderate-severe chronic obstructive pulmonary disease; Positive expiratory pressure device; Six-minute walk test
5.  Short Term Effects of Tiotropium on COPD Patients Treated with Long Acting Bronchodilators 
Tanaffos  2012;11(1):26-31.
The results of bronchodilator therapy in chronic obstructive pulmonary disease (COPD) are not satisfactory and because of this, many drugs are administered for treatment of disease. We examined the short-term additive bronchodilator effects of tiotropium in patients with stable COPD already treated with salmeterol twice daily.
Materials and Methods
In a double-blind, double-dummy randomized study we evaluated the acute bronchodilator efficacy of a single 18 µg dose of tiotropium in patients with COPD under chronic treatment with a long acting beta-adrenergic (salmeterol 50µg twice a day). Measurements of forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1) and six-minute walking test (6 MWT) as indicator of daily activities were made before and after giving the drug. A total of 129 outpatients with stable COPD (Gold level 2 -3- 4) were enrolled and 92 completed the study.
Tiotropium elicited a significantly greater bronchodilation than the placebo. The action of the drug was elicited as increase in FEV1 (p ≤ 0.001) and FVC (p ≤ 0.001); 6-MWT increased 35 meters in patients treated with tiotropium compared to 2.5 meters in those receiving placebo (p ≤ 0.001).
Addition of tiotropium to chronic administration of a beta-adrenergic drug such as salmeterol induced an increase in pulmonary function parameters and in exercise capacity suggesting that association of the two drugs can be more efficient for treatment of disease and improvement of daily living activities than beta-adrenergics alone.
PMCID: PMC4153178  PMID: 25191397
Chronic obstructive pulmonary disease; Pulmonary function; Six-minute walk test; Tiotropium
6.  Evaluation of a transcutaneous carbon dioxide monitor in patients with acute respiratory failure 
Annals of Thoracic Medicine  2011;6(4):217-220.
Non-invasive measurement of oxygenation is a routine procedure in clinical practice, but transcutaneous monitoring of PCO2(PtCO2) is used much less than expected.
The aim of our study was to analyze the value of a commercially available combined SpO2/PtCO2 monitor (TOSCA-Linde Medical System, Basel, Switzerland) in adult non-invasive ventilated patients with acute respiratory failure. Eighty critically ill adult patients, requiring arterial blood sample gas analyses, underwent SpO2 and PtCO2 measurements (10 min after the probe was attached to an earlobe) simultaneously with arterial blood sampling. The level of agreement between PaCO2 - PtCO2 and SaO2 - SpO2was assessed by Bland-Altman analyses.
Both, SaO2 from blood gas analysis and SpO2 from the transcutaneous monitor, and PaCO2 and PtCO2 were equally useful. No measurements were outside of the acceptable clinical range of agreement of ± 7.5 mmHg.
The accuracy of estimation of the TOSCA transcutaneous electrode (compared with the “gold standard” blood sample gas analysis) was generally good. Moreover, TOSCA presents the advantage of the possibility of continuous non-invasive measurement. The level of agreement of the two methods of measurement allows us to state that the TOSCA sensor is useful in routine monitoring of adults admitted to an intermediate respiratory unit and undergoing non-invasive ventilation.
PMCID: PMC3183639  PMID: 21977067
Non-invasive measurement; PaCO2; PtCO2; respiratory failure; SaO2; SpO2; transcutaneous electrode
7.  Desmoplastic malignant mesothelioma of the pericardium: Description of a case and review of the literature 
Desmoplastic mesothelioma (DMM) is a rare and highly lethal subtype of diffuse malignant mesothelioma and is often difficult to distinguish from reactive pleural fibrosis. The term “desmoplastic” refers to the growth of fibrous or connective tissue. We report the clinical, radiological, and pathological features of a primary DMM of the pericardium and a short review of the literature. A 72-year-old man was admitted presenting shortness of breath, cough, and asthenia. Computed tomography scan showed thickenings and effusions both in the pleura and in the pericardium. Histopathological diagnosis was performed by surgical pericardial biopsy and confirmed by autopsy. The patient had a history of asbestos exposure. Primary mesothelioma of the pericardium is a rare tumor occurring in the fourth to seventh decades with nonspecific symptoms and a rapid clinical course. The diagnosis is difficult and often needing a surgical pericardial biopsy. The prognosis is poor although newer antiblastic drugs seem to prolong survival times.
PMCID: PMC3162765  PMID: 21886962
Asbestos exposure; desmoplastic malignant mesothelioma; involvement; pleura-pericardial
8.  Lobar flexible fiberoptic lung lavage: therapeutic benefit in severe respiratory failure in pulmonary alveolar proteinosis and influenza A H1N1 pneumonia 
Clinics and Practice  2011;1(3):e53.
Lobar fiberoptic lung lavage is a well-known procedure used in primary pulmonary alveolar proteinosis (PAP); the use of this procedure has increased in the recent years. This procedure has also been used in other pulmonary diseases such as desquamative interstitial pneumonia with good results. We describe a case of extremely severe respiratory failure due to concurrence of PAP and Influenza A H1N1 virus pneumonia which resolved with the help of this procedure. The patient, a 41-year-old woman, needed less mechanical ventilation after undergoing lobar fiberoptic bronchoscopic lavage. Moreover, a rapid and progressive improvement in the computed tomography of the lungs was observed. Flexibile fiberoptic bronchoscopic lobar lavage is a simple, safe procedure used not only in milder disease, but also in particular severe cases in which the physiological derangement of whole lung lavage would not be tolerated by patient or when extra-corporeal membrane oxygenation is not available.
PMCID: PMC3981374  PMID: 24765314
lexible fiberoptic lobar bronchoscopic lavage; pulmonary alveolar proteinosis; influenza A H1N1 pneumonia.

Results 1-8 (8)