BackgroundTracheostomy is a commonly performed procedure in patients requiring prolonged mechanical ventilation (MV) in Intensive Care Units (ICUs), including COVID-19-related ARDS. However, limited data exist on the timing and predictors of decannulation.AimTo compare time to decannulation between COVID-19 and non-COVID-19 ARDS patients and to identify predictive factors.MethodsA retrospective study including 96 COVID-19 ARDS and 32 non-COVID-19 ARDS tracheostomized patients admitted to step-down units after ICU stay from March 2020 to May 2021. Clinical, demographic data and comorbidities were analysed as well as predictors for decannulation delay.ResultsTiming of decannulation was similar between the two groups. Multivariate analysis identified limb weakness assessed by the Medical Research Council (MRC) scale, duration of steroids therapy, clinical complications, PaO2/FiO2 ratio and smoking history as independent predictors of decannulation timing.ConclusionsCOVID-19 did not affect timing of decannulation compared to non-COVID-19 ARDS. ICU-acquired weakness, assessed through the MRC scale, was the strongest predictor of delayed decannulation.

This retrospective study assessed the impact of SARS-CoV-2 infection on patients with interstitial lung disease (ILD) at two tertiary centers in Southern Italy between January 2022 and December 2023. The cohort included 282 ILD patients (mean age 69.6 years; 54.9% male), with common diagnoses such as idiopathic pulmonary fibrosis (33.3%) and connective tissue disease-associated ILD (18.7%). SARS-CoV-2 infection occurred in 130 patients (46%), mostly with mild or asymptomatic cases. Pneumonia developed in 18 cases, with 72.2% requiring hospitalization and 5 COVID-19-related deaths. Patients with pneumonia had higher rates of ILD progression (27.7%) and incidental post-infection ILD diagnoses (22.2%) than those with mild infection. Vaccination rates were high, correlating with favorable outcomes in most cases. Importantly, pneumonia cases were often associated with incomplete vaccination or complex comorbidities. Differentiating COVID-19-related lung changes from ILD progression proved challenging, highlighting the importance of specialized radiologic assessment. Excluding COVID-related deaths, mortality rates were similar regardless of infection status, suggesting a degree of resilience among ILD patients. The study concludes that with high vaccine coverage and careful follow-up, most ILD patients had stable outcomes after SARS-CoV-2 infection. However, pneumonia remains a risk factor for adverse outcomes, underscoring the need for long-term, specialized ILD care.

Telemedicine (TM) is increasingly recognised as a valuable tool in the management of interstitial lung diseases (ILDs). Despite its potential, its integration and application still remain limited. Our work aimed to assess pulmonologists' (physicians and trainees) perception regarding the use of TM in ILDs management. This national survey was created and distributed to all pulmonologists, both physicians and trainees, affiliated with Società Italiana di Pneumologia/Italian Respiratory Society (SIP/IRS). Responses were collected anonymously and analysed by using descriptive statistical analysis and the chi-square test. Results: Among 2,906 invited participants, 44 completed the survey. While 95.5% of respondents considered TM useful in ILDs monitoring, only 36% reported its use in clinical practice. Current barriers included reduced availability of TM services (64%) and limited knowledge of TM software (56.8%). Moreover, the majority of participants referred a supportive but not substitutive role of TM in-person consultations, especially in monitoring and patient education. A significant proportion of repliers (over 50%) claimed that it may reduce waiting lists and enhance patient satisfaction (63.6%). However, concerns regarding data security and absence of standardised protocols were also reported. Conclusions: TM is positively perceived by both physicians and trainees' pulmonologist for ILDs follow-up and educational purposes in ILD management. Nevertheless, its integration and application are still hindered by some concerns such as limited infrastructure and digital literacy as well as lack of standardisation of reimbursement protocols and evolving regulatory frameworks. Broader integration of TM will require to address these challenges through investments in technology, structured protocols, and training initiatives.

Pulmonary alveolar proteinosis (PAP) has an unpredictable clinical course. Although usually benign, an association with pulmonary fibrosis is described in literature, with troubling therapeutic and prognostic implications. We report the case of a patient affected by autoimmune PAP who developed pleuro-parenchymal fibroelastosis (PPFE) after 6 years of disease and underwent bilateral lung transplantation due to end stage respiratory failure. Punctual descriptions of pulmonary fibrosis in PAP are still lacking and no predictors of fibrotic evolution of PAP are known. It is necessary to ensure a strict follow up in order to promptly recognize signs of fibrotic evolution and early refer patients with evolutive disease to lung transplant center. Moreover, an extended genetic analysis by targeted next-generation sequencing could provide high-resolution information that may allow the identification of susceptible patients in a pre-fibrotic stage of disease.

Indoor environments, particularly in schools, are a significant source of bacterial exposure, posing a public health risk. The aim of this study was to investigate the bacterial load and associated factors in the indoor environments of governmental and private primary schools in Hawassa, City, Ethiopia, 2023. A comparative cross-sectional study design was used in March, 2023; in 56 randomly selected classrooms focusing in five governmental and five private primary schools in Hawassa, City. The bacterial load was estimated using the settle-plate method of passive air sampling. Differences in the mean bacterial load between government and private primary schools were evaluated using a non-parametric test. Multiple linear regression analysis using log-transformed data was performed. The average bacterial load in government primary schools was 8684.84 CFU/m3; while in private schools, it was 4396.43 CFU/m3. The isolated bacterial species included coagulase-negative Staphylococcus species (CoNS), gram-negative Bacillus species, gram-positive Bacillus species, and Staphylococcus aureus. A significant difference in the mean bacterial load (p=0.002) was observed between government and private primary schools with private primary schools showing lower levels. In government schools, the bacterial load was significantly associated with classroom cleanliness, occupant density, cleaning frequency, and classroom area. Conversely, the bacterial load in private schools showed strong association with the occupant density, cleaning frequency, relative humidity, and ventilation conditions. In government and private primary schools, the level of bacterial loads exceeded the WHO -criteria. This study revealed significant differences in indoor bacterial loads between government and private primary schools, with private schools showing lower levels. The correlation between bacterial load and environmental factors was distinct in each setting. As a recommendation; improving cleanliness, layout optimization, ventilation improvement, and hygiene education for both sectors, with regular air quality monitoring are crucial for tracking progress.

Reviewer acknowledgement 2024 The editors and staff of Multidisciplinary Respiratory Medicine would like to warmly thank the reviewers whose comments helped to shape the journal, for their invaluable assistance with review of manuscripts in Volume 19 (2024).

A cough persisting beyond eight weeks is referred as chronic cough (CC) and is a common symptom of many respiratory conditions and non-respiratory conditions. The role of a speech language pathologist (SLP) in CC is emerging and this study aimed to profile the awareness and practice patterns of SLPs practicing in India. Cross-sectional study. An online survey was used to profile the assessment, treatment and counselling practices in CC among SLPs working in India. It sought to identify the awareness levels among SLPs regarding their role and availability of behavioural interventions for CC. Only SLPs who dealt with CC could complete the entire survey while other SLPs, filled regarding awareness and availability of behavioural interventions. 127 eligible responses obtained from SLPs working across clinical settings in India were analysed. 75.59% (n=96) of them had not seen patients with CC in their career. 47.24% (n=60) of them were aware that behavioural interventions were available for CC. Thirty-one SLPs completed the entire survey and their practice patterns indicated that few clinicians used cough-specific protocols while largely relying on voice and swallowing related assessment and treatment for CC. This survey the lack of awareness of SLPs' role in CC and that their practices are dominated by existing procedures for voice and swallowing disorders. Increasing the awareness of SLP's role in CC may increase the caseload of patients referred and expand the SLP's scope of practice. Development of guidelines in CC practice and inclusion in coursework/curriculum are future considerations.

BackgroundLung ultrasound (LUS) is a bedside imaging tool that has proven useful in identifying and assessing the severity of pulmonary pathology. The aim of this study was to determine LUS patterns, their clinical significance, and how they compare to CT findings in hospitalized patients with coronavirus infection.MethodsThis observational study included 62 patients (33 men, age 59.3±15.9 years), hospitalized with pneumonia due to COVID-19, who underwent chest CT and bedside LUS on the day of admission. The CT images were analyzed by chest radiographers who calculated a CT visual score based on the expansion and distribution of ground-glass opacities and consolidations. The LUS score was calculated according to the presence, distribution, and severity of anomalies.ResultsAll patients had CT findings suggestive of bilateral COVID-19 pneumonia, with an average visual scoring of 8.1±2.9%. LUS identified 4 different abnormalities, with bilateral distribution (mean LUS score: 26.4±6.7), focal areas of non-confluent B lines, diffuse confluent B lines, small sub-pleural micro consolidations with pleural line irregularities, and large parenchymal consolidations with air bronchograms. LUS score was significantly correlated with CT visual scoring (rho = 0.70; p<0.001). Correlation analysis of the CT and LUS severity scores showed good interclass correlation (ICC) (ICC =0.71; 95% confidence interval (CI): 0.52–0.83; p<0.001). Logistic regression was used to determine the cut-off value of ≥27 (area under the curve: 0.97; 95% CI: 90-99; sensitivity 88.5% and specificity 97%) of the LUS severity score that represented severe and critical pulmonary involvement on chest CT (CT: 3-4).ConclusionWhen combined with clinical data, LUS can provide a potent diagnostic aid in patients with suspected COVID-19 pneumonia, reflecting CT findings.

BackgroundThe use of cytokine-blocking agents has been proposed to modulate the inflammatory response in patients with COVID-19. Tocilizumab and anakinra were included in the local protocol as an optional treatment in critically ill patients with acute respiratory distress syndrome (ARDS) by SARS-CoV-2 infection. This cohort study evaluated the effects of therapy with cytokine blocking agents on in-hospital mortality in COVID-19 patients requiring mechanical ventilation and admitted to intensive care unit.MethodsThe association between therapy with tocilizumab or anakinra and in-hospital mortality was assessed in consecutive adult COVID-19 patients admitted to our ICU with moderate to severe ARDS. The association was evaluated by comparing patients who received to those who did not receive tocilizumab or anakinra and by using different multivariable Cox models adjusted for variables related to poor outcome, for the propensity to be treated with tocilizumab or anakinra and after patient matching.ResultsSixty-six patients who received immunotherapy (49 tocilizumab, 17 anakinra) and 28 patients who did not receive immunotherapy were included. The in-hospital crude mortality was 30,3% in treated patients and 50% in nontreated (OR 0.77, 95% CI 0.56-1.05, p=0.069). The adjusted Cox model showed an association between therapy with immunotherapy and in-hospital mortality (HR 0.40, 95% CI 0.19-0.83, p=0.015). This protective effect was further confirmed in the analysis adjusted for propensity score, in the propensity-matched cohort and in the cohort of patients with invasive mechanical ventilation within 2 hours after ICU admission.ConclusionsAlthough important limitations, our study showed that cytokine-blocking agents seem to be safe and to improve survival in COVID-19 patients admitted to ICU with ARDS and the need for mechanical ventilation.

BackgroundIn patients with obstructive lung disease, maintaining adequate ventilation during exercise may require greater contraction of the respiratory muscles, which may lead to a compression of muscle capillaries. Furthermore, dynamic hyperinflation (DH) is frequent during exercise in these patients, as it allows to reach higher expiratory flows and to satisfy respiratory demand. However, in such situation, intercostal muscles are likely to be stretched, which could affect the diameter of their capillaries. Thus, in a context of high level of expiratory resistance, intercostal muscle oxygenation may be disturbed during exercise, especially if DH occurs.MethodsTwelve participants (22±2 years) performed two sessions of moderate exercise (20 min) by breathing freely with and without a 20-cmH2O expiratory threshold load (ETL). Tissue saturation index (TSI) and concentration changes from rest (Δ) in oxygenated ([O2Hb]) and total haemoglobin ([tHb]) were measured in the seventh intercostal space using near-infrared spectroscopy. Respiratory, metabolic and cardiac variables were likewise recorded.ResultsThroughout exercise, dyspnea was higher and TSI was lower in ETL condition than in control (p<0.01). After a few minutes of exercise, Δ [O2Hb] was also lower in ETL condition, as well as Δ [tHb], when inspiratory capacity started to be reduced (p<0.05). Changes in [O2Hb] and dyspnea were correlated with changes in expiratory flow rate (Vt/Te) (r = -0.66 and 0.66, respectively; p<0.05).ConclusionDuring exercise with ETL, impaired muscle oxygenation could be due to a limited increase in blood volume resulting from strong muscle contraction and/or occurrence of DH.