Comparative Evaluation of Vibratory Physiotherapy Methods in the Early Period after Cardiac Surgery

Postoperative respiratory complications in patients undergoing cardiac surgery occur in 20‒30% cases, and the most of them can be associated with ineffective cough and bronchial mucus evacuation.The objective. Comparative assessment of effectiveness and safety of methods for stimulating the evacuation of bronchial secretions using oscillatory PEP-therapy (Acapella Duet), oscillatory chest compression insufflator-aspirator “Comfort Cough Plus”, and the traditional method of manual chest percussion in the early period after cardiac surgery.Subjects and Methods. The prospective study included 120 cardiac surgery patients. They were divided into 3 groups (40 in each), depending on the type of the applied respiratory procedure. Distribution into groups was carried out by random selection. All procedures were performed 10‒12 hours after tracheal extubation. Before the procedure and 20 minutes after it, the efficiency of sputum discharge was assessed, gas exchange indices on room air breathing and maximum inspiratory lung capacity (MILC) were measured.Results. Ineffective bronchial mucus evacuating in the early period after tracheal extubation was observed in 86.7% of the patients. A single procedure of both PEP-therapy (Group 1) and mechanical cough stimulation (Group 2) led to improved sputum passage, as evidenced by an increase in the number of patients with productive cough by 4.25 times (p < 0.0009) and 5.3 times (p < 0.0007), respectively. In patients of Groups 1 and 2, an increase in MILC was observed (by 42.2% and 60.0%, respectively, p = 0.000001), the difference between the groups was statistically significant. In Control Group 3, with manual physiotherapy, the average increase in MILC was only 11.6%. Mechanical respiratory therapy procedures led to significant improvement in gas exchange variables, as evidenced by an increase in SpO2 in Groups 1 and 2 (p = 0.000009 and 0.000001, respectively) and a decrease in the proportion of patients with impaired oxygenating lung function (SpO2 below 92%) by 11 and 12 times, respectively (p < 0.01). The most significant changes were revealed in case of mechanical stimulation with aspirator-insufflator due to combination of two methods (oscillatory chest compression and lung inflation). In Control Group, no significant changes of gas exchange variables were observed.Conclusion: Mechanical vibratory methods for stimulating the bronchial secretion evacuation have significant advantages over classical manual chest massage in patients after cardiac surgery. Their positive effect on sputum passage, ventilatory parameters and gas exchange was noted, and the most pronounced effect was observed after oscillatory chest compression with insufflator-aspirator. The procedures were well tolerated and there were no complications associated with them.

Changes in lung inflation in asthma in patients with osmotic airway hyperresponsiveness

The scientific literature does not provide enough information on whether bronchial hyperresponsiveness to hypoosmotic stimulus in patients with asthma can lead to more pronounced disturbances of regional lung ventilation.Aim. to characterize lung inflation in asthma patients with osmotic airway hyperresponsiveness.Methods. The lung inflation was studied by body plethysmography, as well as by three-dimensional volumetry, planimetry, and multispiral CT densitometry in 24 patients (group 1) with persistent mild asthma and osmotic airway hyperresponsiveness, identified by the bronchoprovocation test with inhalation of distilled water (IDW) (the average ДРБУ1 was —21.1 ± 3.2%). The comparison group (group 2) consisted of 49 patients with no response to IDW (the average ДББУ1 was —3.7 ± 0.5%; p = 0.00001).Results. Group 1 had lower lung function (FEVj was 83.6 ± 4.5%; FEF50 was 58.1 ± 5.8%) at baseline in comparison with the group 2 (96.7 ± 2.2%, p = 0.0042 and 75.5 ± 2.2%, p = 0.016, respectively) and higher indices of lung inflation at body plethysmography (RV was 153.2 ± 12.5 and 127.5 ± 4.0%, respectively; p = 0,027; RV/TLC was 128.8 ± 5.5 and 109.9 ± 2.8%, respectively; p = 0.015). According to three-dimensional volumetry, the indicators of expiratory lung inflation (526.0 ± 117.8 vox) and average residual inflation of both lungs (13.1 ± 2.6 vox) in group 1 were significantly higher than in group 2 (301.5 ± 55.8 vox, р < 0.05 and 9.1 ± 1.6 vox,р < 0,05, respectively). The patients with osmotic airway hyperresponsiveness also showed higher values of the expiratory area in the middle zone (235.3 ± 29.4 and 149.2 ± 14.9 pix, respectively; p = 0.00 47) and the lower zone (292.3 ± 37.9 and 178.6 ± 18.6 pix, respectively; p = 0.0034) of the lungs.Conclusion. Asthma patients with osmotic airway hyperresponsiveness have lung hyperinflation with impaired lung ventilation predominantly in the middle and lower zones.

STATE OF THE PROBLEM OF ORGANIZATION OF RESPIRATORY CARE FOR NEWBORN CHILDREN IN TODAY’S RUSSIA: SURVEY RESULTS OF A OF NEONATOLOGISTS AND INTENSIVE CARE SPECIALISTS

Objective of the study: to study the current situation regarding the introduction of modern methods of respiratory therapy in neonatal practice in the Russian Federation, on the basis of the results of the questionnaire, and to assess the dynamics of changes from 2013 to 2021. Materials and methods of research: the article analyzes the results of the survey of neonatologists and anesthesiologistsresuscitators from 163 settlements in 81 regions of the Russian Federation on various issues of providing respiratory care to newborns for the period from January 18, 2021 to May 7, 2021. The questionnaire included 82 question. Results: 489 Russian specialists took part in the survey. More than 90% of respondents were trained in respiratory therapy, most of whom worked in level 2 medical organizations (191 doctors) and level 3a perinatal centers (192 doctors). The main changes in respiratory therapy over the past 9 years have been mainly work in the delivery room: the proportion of doctors (from 9,4% to 54,7%) increased statistically significantly (p<0,001) (from 9,4% to 54,7%) who, according to indications, used CPAP as a starting method of respiratory therapy in premature infants at birth, oxygen mixers were used statistically significantly (p<0,001) (from 44,2% to 62,5%), statistically significant (p<0.001) increased the proportion of doctors (from 46,3% to 92, 1%) who performed the first administration of surfactant in the delivery room, introduced new respiratory strategies, 57% of doctors refused from «prolonged lung inflation» in the delivery room. Conclusion: a survey of specialists from almost all regions of the Russian Federation made it possible to obtain a clear picture of the problem of respiratory care for newborn children. The material obtained objectively demonstrated the evolution in the development and implementation of the most modern neonatal respiratory strategies in the Russian Federation over the past decade.

Bronchitis obliterans after severe pneumonia in children: a review of 34 cases

Background: This study aimed to describe the clinical characteristics, pathogeny and bronchoscopic findings of 34 children with bronchitis obliterans after severe pneumonia. Methods: Thirty-four children diagnosed with bronchitis obliterans were retrospectively studied at the Children’s Hospital of Chongqing Medical University in China between January, 2014 and October, 2020. The clinical manifestations, pathogeny, lung computed tomography imaging and bronchoscopic findings of the 34 children were reported. Results: In children with bronchitis obliterans, repeated coughing, fever, wheezing, tachypnea, and lung rales were common clinical manifestations. Mycoplasma pneumoniae (M. pneumoniae) was the most common etiologic agent, followed by adenovirus. The CT scan images included uneven lung inflation(12/34), lung consolidation( 27/34), pulmonary atelectasis(23/34), and pleural effusion(22/34). All children underwent flexible bronchoscopy, and major types of airway findings were identified: mucosal congestion, luminal longitudinal folds, mucosal erosion or necrosis, hyperplastic changes, sputum emboli, bronchiectasis and obliterative-like lesions. Conclusion: In conclusion, severe M. pneumoniae pneumonia and adenovirus pneumonia appeared to have a higher risk of development of bronchitis obliterans. Bronchoscopy can be used as the main criterion for the diagnosis of bronchitis obliterans. Bronchoscopy interventional treatment is an effective measure to quickly recanalize the occluded lumen, but there is a risk of recurrence after treatment. Children with severe pneumonia should undergo regular follow-up and bronchoscopy to detect possible lumen occlusion in time.

Lung Inflation With Hydrogen During the Cold Ischemia Phase Alleviates Lung Ischemia-Reperfusion Injury by Inhibiting Pyroptosis in Rats

Background: Lung inflation with hydrogen is an effective method to protect donor lungs from lung ischemia-reperfusion injury (IRI). This study aimed to examine the effect of lung inflation with 3% hydrogen during the cold ischemia phase on pyroptosis in lung grafts of rats.Methods: Adult male Wistar rats were randomly divided into the sham group, the control group, the oxygen (O2) group, and the hydrogen (H2) group. The sham group underwent thoracotomy but no lung transplantation. In the control group, the donor lungs were deflated for 2 h. In the O2 and H2 groups, the donor lungs were inflated with 40% O2 + 60% N2 and 3% H2 + 40% O2 + 57% N2, respectively, at 10 ml/kg, and the gas was replaced every 20 min during the cold ischemia phase for 2 h. Two hours after orthotopic lung transplantation, the recipients were euthanized.Results: Compared with the control group, the O2 and H2 groups improved oxygenation indices, decreases the inflammatory response and oxidative stress, reduced lung injury, and improved pressure-volume (P-V) curves. H2 had a better protective effect than O2. Furthermore, the levels of the pyroptosis-related proteins selective nucleotide-binding oligomerization domain-like receptor protein 3 (NLRP3), cysteinyl aspartate specific proteinase (caspase)-1 p20, and the N-terminal of gasdermin D (GSDMD-N) were decreased in the H2 group.Conclusion: Lung inflation with 3% hydrogen during the cold ischemia phase inhibited the inflammatory response, oxidative stress, and pyroptosis and improved the function of the graft. Inhibiting reactive oxygen species (ROS) production may be the main mechanism of the antipyroptotic effect of hydrogen.

Use of Continuous Positive Airway Pressure (CPAP) to Limit Diaphragm Motion—A Novel Approach for Definitive Radiation Therapy for Inoperable Pleural Mesothelioma: A Pilot Study

Malignant pleural mesothelioma (MPM) is a deadly disease and radiotherapy (RT) plays an important role in its management. Recent developments in technique have made it is possible to deliver RT to MPM in the intact lung. However, it is imperative to reduce normal lung doses. We present a pilot study examining the use of CPAP and VMAT radiotherapy to reduce toxicity when treating MPM, involving three consecutive patients with MPM, not amenable to surgery, who were treated according to Helsinki committee approval. Patients were simulated using four-dimentional CT simulation with the assistance of CPAP lung inflation, then were treated using both IMRT and VMAT techniques. Radiation lung dose was optimized based on accepted lung dose constraints. Patients were followed for toxicity as well as local control and survival. Results: Three patients were treated with CPAP-based IMRT treatment. These patients tolerated the treatment and DVH constraints were able to be met. The comparison plans among the four VMAT arcs and the IMRT static field treatment were able to accomplish the treatment planning objectives without significant advantages with either technique. The treatment combined with CPAP reduced the normal lung dose in MPM patients with intact lungs. This technique is worthy of further investigation.

Anesthesia considerations to reduce motion and atelectasis during advanced guided bronchoscopy

Partnership between anesthesia providers and proceduralists is essential to ensure patient safety and optimize outcomes. A renewed importance of this axiom has emerged in advanced bronchoscopy and interventional pulmonology. While anesthesia-induced atelectasis is common, it is not typically clinically significant. Advanced guided bronchoscopic biopsy is an exception in which anesthesia protocols substantially impact outcomes. Procedure success depends on careful ventilation to avoid excessive motion, reduce distortion causing computed tomography (CT)-to-body-divergence, stabilize dependent areas, and optimize breath-hold maneuvers to prevent atelectasis. Herein are anesthesia recommendations during guided bronchoscopy. An FiO2 of 0.6 to 0.8 is recommended for pre-oxygenation, maintained at the lowest tolerable level for the entire the procedure. Expeditious intubation (not rapid-sequence) with a larger endotracheal tube and non-depolarizing muscle relaxants are preferred. Positive end-expiratory pressure (PEEP) of up to 10–12 cm H2O and increased tidal volumes help to maintain optimal lung inflation, if tolerated by the patient as determined during recruitment. A breath-hold is required to reduce motion artifact during intraprocedural imaging (e.g., cone-beam CT, digital tomosynthesis), timed at the end of a normal tidal breath (peak inspiration) and held until pressures equilibrate and the imaging cycle is complete. Use of the adjustable pressure-limiting valve is critical to maintain the desired PEEP and reduce movement during breath-hold maneuvers. These measures will reduce atelectasis and CT-to-body divergence, minimize motion artifact, and provide clearer, more accurate images during guided bronchoscopy. Following these recommendations will facilitate a successful lung biopsy, potentially accelerating the time to treatment by avoiding additional biopsies. Application of these methods should be at the discretion of the anesthesiologist and the proceduralist; best medical judgement should be used in all cases to ensure the safety of the patient.

The evaluation of non-anesthetic computed tomography for detection of pulmonary parenchyma in feline mammary gland carcinoma: a preliminary study

Background Thoracic radiography in awake cats is a common procedure for the evaluation of pulmonary metastasis in feline mammary gland carcinoma (MGC). However, due to poor sensitivity, computed tomography (CT) is progressively taking its place. To perform CT in animals, general anesthesia is normally preferred but can cause lung atelectasis, affecting lung interpretation. Besides, MGC is often found in senile cats that are concurrently affected with other diseases, increasing anesthetic risk. Therefore, this study was aimed at comparing the effect of anesthesia on lung atelectasis observed through CT in clinically healthy cats and comparing the feasibility of non-anesthetic CT with non-anesthetic radiography in the detection of lung lesions in feline MGC. Thoracic CTs from anesthetized, clinically healthy cats and non-anesthetized either clinically healthy cats or MGC-affected cats were reviewed. In clinically healthy cats, motion artifacts and characteristics of lung atelectasis were observed and compared. In MGC-affected cats, motion artifacts were observed and compared to clinically healthy cats, and the number of MGC-affected cats, the number and characteristics of lung lesions were compared between non-anesthetic thoracic CT and radiography. Results Anesthesia significantly increased lung CT attenuation (P = 0.0047) and was significantly correlated with lung atelectasis (OR = 15; CI 2.02–111.18; P = 0.0081), particularly of the cranial lung lobe. Nonetheless, significantly higher motion artifacts in the caudal thoracic area were found in non-anesthetized healthy cats (P = 0.0146), but comparable low motion artifacts were observed in anesthetized healthy and MGC-affected cats. Non-anesthetic CT revealed higher numbers of MGC-affected cats and pulmonary nodules with a significantly lower nodular diameter (P = 0.0041) than those observed on radiographs. The smallest nodular diameters detected on radiographs and CT were 2.5 and 1.0 mm, respectively. Furthermore, CT showed additional information such as intra-thoracic lymphadenopathy, that could not be seen on radiographs. Conclusions Despite the motion artifacts, CT without anesthesia is a sensitive technique as it provides better lung inflation. Furthermore, compared to non-anesthetic radiography, non-anesthetic CT provided more information such as higher number of pulmonary nodules of a smaller size, including more distinct intra-thoracic lesions, such as lymphadenopathy, in MGC-affected cats.

Paradoxical Response of Pulmonary Slowly Adapting Units During Constant Pressure Lung Inflation

Typically, unit discharge of slowly adapting receptors (SARs) declines slowly when lung inflation pressure is constant, although in some units it increases instead-a phenomenon hereinafter referred to as creeping. These studies characterize creeping behavior observed in 62 of 137 SAR units examined in anesthetized, open-chest and mechanically ventilated rabbits. SAR units recorded from the cervical vagus nerve were studied during 4 seconds of constant lung inflation at 10, 20 and 30 cmH2O. Affected SAR units creep more quickly as inflation pressure increases. SAR units also often deactivate after creeping, i.e., their activity decreases or stops completely. Creeping likely results from encoder switching from a low discharge to a high discharge SAR, because it disappears in SAR units with multiple receptive fields after blocking a high discharge encoder in one field leaves low discharge encoders intact. The results support that encoder switching is a common mechanism operating in lung mechanosensory units.