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The role of high-frequency oscillatory ventilation in the treatment of acute respiratory failure in adults.

High-frequency oscillatory ventilation (HFOV) is increasingly used in adults with the acute respiratory distress syndrome (ARDS), who remain hypoxemic during conventional mechanical ventilation. In this review, we will summarize the trials evaluating HFOV in adults with ARDS and discuss issues relevant to the clinician regarding the use of HFOV.

RECENT FINDINGS: Several observational and randomized trials support the safety of HFOV and improvements in oxygenation in adult patients with severe ARDS, who remain hypoxemic during conventional mechanical ventilation.

SUMMARY: HFOV theoretically meets the goals of lung-protective ventilation. On the basis of the current evidence, HFOV is associated with improvements in oxygenation in severe, adult ARDS. However, whether HFOV influences mortality, length of ICU stay, ventilator-free days, quality-of-life factors and is cost-effective remains to be determined. Large, prospective, randomized controlled trials such as the ongoing OSCAR and OSCILLATE trials will help further define the role of HFOV in adult ARDS.

Inhaled Fentanyl Citrate Improves Exercise Endurance During High-Intensity Constant Work Rate Cycle Exercise in Chronic Obstructive Pulmonary Disease.

Activity limitation and dyspnea are the dominant symptoms of chronic obstructive pulmonary disease (COPD). Traditionally, efforts to alleviate these symptoms have focused on improving ventilatory mechanics, reducing ventilatory demand, or both of these in combination. Nevertheless, many patients with COPD remain incapacitated by dyspnea and exercise intolerance despite optimal therapy.

OBJECTIVES: To determine the effect of single-dose inhalation of nebulized fentanyl citrate (a μ-opioid agonist drug) on exercise tolerance and dyspnea in COPD.

METHODS: In a randomized, double-blind, placebo-controlled, crossover study, 12 stable patients with COPD (mean±standard error of the mean post-β(2)-agonist forced expiratory volume in one second [FEV(1)] and FEV(1) to forced vital capacity ratio of 69%±4% predicted and 49%±3%, respectively) received either nebulized fentanyl citrate (50mcg) or placebo on two separate days. After each treatment, patients performed pulmonary function tests and a symptom-limited constant work rate cycle exercise test at 75% of their maximum incremental work rate.

RESULTS: There were no significant postdose differences in spirometric parameters or plethysmographic lung volumes. Neither the intensity nor the unpleasantness of perceived dyspnea was, on average, significantly different at isotime (5.0±0.6 minutes) or at peak exercise after treatment with fentanyl citrate vs. placebo. Compared with placebo, fentanyl citrate was associated with 1) increased exercise endurance time by 1.30±0.43 minutes or 25%±8% (P=0.01); 2) small but consistent increases in dynamic inspiratory capacity by ∼0.10L at isotime and at peak exercise (both P≤0.03); and 3) no concomitant change in ventilatory demand, breathing pattern, pulmonary gas exchange, and/or cardiometabolic function during exercise. The mean rate of increase in dyspnea intensity (1.2±0.3 vs. 2.9±0.8 Borg units/minute, P=0.03) and unpleasantness ratings (0.5±0.2 vs. 2.9±1.3 Borg units/minute, P=0.06) between isotime and peak exercise was less after treatment with fentanyl citrate vs. placebo.

CONCLUSION: Single-dose inhalation of fentanyl citrate was associated with significant and potentially clinically important improvements in exercise tolerance in COPD. These improvements were accompanied by a delay in the onset of intolerable dyspnea during exercise near the limits of tolerance.

Nasal disease and asthma.

Nasal disease and asthma.

Int J Immunopathol Pharmacol. 2011 Oct;24(4 Suppl):7-12

Authors: Marseglia GL, Merli P, Caimmi D, Licari A, Labó E, Marseglia A, Ciprandi G, La Rosa M

Abstract
The nose plays a primary role within the airways, working as a filter and air-conditioner, together with other important functions. Thus, it is not surprising that nasal diseases are associated with several other comorbidities, including both upper and lower airways, such as bronchial hyperresponsiveness (BHR) and asthma. Several studies have investigated the relationship existing between the upper and the lower airways and new insights are rising. Nevertheless, some uncertainties still remain, mainly because nasal disorders are quite heterogeneous, overlapping (i.e. rhinitis-rhinosinusitis-sinusitis, acute or chronic, allergic or non-allergic) and difficult to diagnose, so that, frequently, many studies don’t differentiate between the various conditions. For this reason, the purpose of this review is to systematically analyze present epidemiological, pathophysiological and clinical data on the relationship between nasal diseases and asthma, splitting up three main conditions: allergic rhinitis, chronic rhinosinusitis and nasal polyposis.

PMID: 22032779 [PubMed - indexed for MEDLINE]

Fractional exhaled nitric oxide measurements in rhinitis and asthma in children.

Fractional exhaled nitric oxide measurements in rhinitis and asthma in children.

Int J Immunopathol Pharmacol. 2011 Oct;24(4 Suppl):29-32

Authors: Miraglia Del Giudice M, Marseglia GL, Leonardi S, Tosca MA, Marseglia A, Perrone L, Ciprandi G

Abstract
Exaled nitric oxide (FeNO) is considered a good noninvasive marker to assess airway inflammation in asthma and allergic rhinitis. In asthma, exhaled NO is very useful to verify adherence to therapy, and to predict upcoming asthma exacerbations. It has been also proposed that adjusting anti-inflammatory drugs guided by the monitoring of exhaled NO, could improve overall asthma control. Other studies showed increased FeNO levels in subjects with allergic rhinitis.

PMID: 22032784 [PubMed - indexed for MEDLINE]

Inhalation therapy in asthmatic and not asthmatic children.

Inhalation therapy in asthmatic and not asthmatic children.

Int J Immunopathol Pharmacol. 2011 Oct;24(4 Suppl):61-7

Authors: Lo Valvo L, Leonardi S, Marseglia GL, Miraglia Del Giudice M, Salpietro C, Ciprandi G, La Rosa M

Abstract
The use of inhaled aerosols allows selective treatment of the lungs directly by achieving high drug concentrations in the airway while reducing systemic adverse effects by minimizing systemic drug levels. Aerosol drug delivery is painless and often convenient, but the proliferation of inhaler devices has resulted in a confusing number of choices for clinicians who are selecting a delivery device for aerosol therapy. There are advantages and disadvantages associated with each device category. Several factors can guide clinicians to choose a device for a specific patient. This choice has to be tailored according to the patient's needs, situation and preference. Whatever the chosen inhaler, inhaler technique is the critical factor in the correct use of delivery devices and patient education has a key-role for improving technique and compliance.

PMID: 22032789 [PubMed - indexed for MEDLINE]

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