This report describes the case of a 46-year-old non-smoker housewife. She presented to our attention having a diagnosis of "difficult asthma" from another center in the previous two years. She had no allergies and had not been exposed to an excessive amount of noxious stimuli. Her chronic respiratory symptoms (dyspnea on exertion with wheezing) remained uncontrolled despite maximal anti-asthmatic inhaled therapy. An HRCT scan was performed to further investigate other pulmonary diseases that mimic asthma. It revealed a pedunculated endotracheal lesion with regular borders that obstructed 90% of the tracheal lumen. The lesion was removed via rigid bronchoscopy with laser endobronchial; histological examination revealed the presence of atypical carcinoid. Atypical carcinoids are a rare subtype of neuroendocrine lung tumor that accounts for 2% of all thoracic malignancies. They frequently arise from the central airways and cause obstructive symptoms such as coughing, wheezing, chest pain, or recurrent obstructing pneumonia, which is caused by central airway obstruction. Clinical onset is gradual and characterized by non-specific symptoms, which frequently result in misdiagnosis. As a result, in a young patient with progressive dyspnea, chronic cough, and wheezing that is not responding to anti-asthmatic treatment, second-level investigations are required and may lead to a definite diagnosis, allowing the appropriate course of treatment to begin.

SARS-CoV-2 may lead to a large spectrum of respiratory manifestations, including pulmonary sequelae. We conducted a single-center longitudinal study of survivors from severe COVID-19 cases who underwent a chest CT during hospitalization (CTH). Three months after being discharged, these patients were evaluated by a clinical examination, pulmonary function tests and a chest-CT scan (CTFU). Sixty-two patients were enrolled. At follow-up, 27% complained of exertional dyspnoea and 12% of cough. Dyspnoeic patients had a lower forced expiratory flow (FEF)25–75 (p = 0.015), while a CT scan (p = 0.016 showed that patients with cough had a higher extent of bronchiectasis. Lung volumes and diffusion of carbon monoxide (DLCO) at follow-up were lower in patients who had been invasively ventilated, which correlated inversely with the length of hospitalization and ground-glass extension at CTH. At follow-up, 14.5% of patients had a complete radiological resolution, while 85.5% presented persistence of ground-glass opacities, and 46.7% showed fibrotic-like alterations. Residual ground-glass at CTFU was related to the length of hospitalization (r = 0.48; p = 0.0002) and to the need for mechanical ventilation or high flow oxygen (p = 0.01) during the acute phase. In conclusion, although patients at three months from discharge showed functional impairment and radiological abnormalities, which correlated with a prolonged hospital stay and need for mechanical ventilation, the persistence of respiratory symptoms was related not to parenchymal but rather to airway sequelae.

Pneumothorax (PNX) and pneumomediastinum (PNM) are potential complications of COVID-19, but their influence on patients’ outcomes remains unclear. The aim of the study was to assess incidence, risk factors, and outcomes of severe COVID-19 complicated with PNX/PNM. Methods: A retrospective multicenter case-control analysis was conducted in COVID-19 patients admitted for respiratory failure in intermediate care units of the Treviso area, Italy, from March 2020 to April 2021. Clinical characteristics and outcomes of patients with and without PNX/PNM were compared. Results: Among 1213 patients, PNX and/or PNM incidence was 4.5%. Among these, 42% had PNX and PNM, 33.5% only PNX, and 24.5% only PNM. COVID-19 patients with PNX/PNM showed higher in-hospital (p = 0.02) and 90-days mortality (p = 0.048), and longer hospitalization length (p = 0.002) than COVID-19 patients without PNX/PNM. At PNX/PNM occurrence, one-third of subjects was not mechanically ventilated, and the respiratory support was similar to the control group. PNX/PNM occurrence was associated with longer symptom length before hospital admission (p = 0.005) and lower levels of blood lymphocytes (p = 0.017). Conclusion: PNX/PNM are complications of COVID-19 associated with a worse prognosis in terms of mortality and length of hospitalization. Although they are more frequent in ventilated patients, they can occur in non-ventilated, suggesting that mechanisms other than barotrauma might contribute to their presentation.

Introduction: Mepolizumab is an anti-IL5 humanized antibody approved for severe eosinophilic uncontrolled asthma. Long term safety has been assessed in registration studies, but few data are available on patients with echinococcus hepatic cyst (EHC) or other comorbidities i.e. lung cancer requiring chemotherapy (CT). Aim: analysis of one-year treatment outcomes in 30 patients on treatment with Mepolizumab, including one patient with known EHC and hepatic cyrrosis and one patient on treatment with cisplatin-gemcitabine for lung cancer (stage IV adenocarcinoma ). Methods: All patients were evaluated for blood eosinophylic count, oral corticosteroids (OCS) use and comorbidities in a single-center cohort case-note analysis. Results: Mepolizumab reduced OCS use (p<0.05), decreased blood eosinophils compared to baseline (p<0.01). No impairment of hepatic function or relapse of echinococcus infection was reported in the patients with EHC. No interaction with CT were observed, and lung cancer is actually in clinical stability. Conclusions: Mepolizumab treatment improved asthma outcomes and was not related with hepatic impairment, relapse of EHC and did not affected chemotherapy at one year follow up.

BACKGROUND:Some patients with idiopathic pulmonary fibrosis (IPF) develop acute exacerbation (AE-IPF) leading to severe acute respiratory failure (ARF); despite conventional supportive therapy, the mortality rate remains extremely high. The aim of this study was to assess how a treatment algorithm incorporating high-flow nasal cannula (HFNC) oxygen therapy affects the short-term mortality of patients with AE-IPF who develop ARF.METHOD AND DESIGN:A retrospective cohort analysis was conducted.PATIENTS AND INTERVENTIONS:The study consisted of 17 patients with AE-IPF admitted to a respiratory intensive care unit (RICU) for ARF managed using a treatment algorithm incorporating HFNC. The outcome measure was mortality rate during their stay in the RICU.RESULTS:Implementation of the treatment algorithm led to a successful outcome in nine patients and to a negative one in eight patients (47.1%) who died within 39 days of being admitted to the RICU. The survival rate was 70.6% (±0.1 %) at 15 days, 52.9% (±0.1%) at 30 days, 35.3% (±0.1%) at 90 days, and 15.6% (±9.73 %) at 365 days. Overall, 4 out of 10 patients who did not respond to conventional oxygen therapy showed a satisfactory response to HFNC.CONCLUSIONS:Short-term mortality fell to below 50% when a treatment algorithm incorporating HFNC was implemented in a group of patients with AE-IPF admitted to a RICU for ARF. Patients not responding to conventional oxygen therapy seemed to benefit from HFNC. The reviews of this paper are available via the supplementary material section.

Convex probe-endobronchial ultrasound (CP-EBUS) has been proven to be safe and accurate for identifying malignancy and granulomatous disease affecting the mediastinum and hilum. CP-EBUS can be used for intraparenchymal lesions also and has been shown to be efficacious. A subset of lesions particularly suited for CP-EBUS are those completely surrounded by lung parenchyma, centrally located, and typically close to but without an airway leading directly to them. We report a case of transbronchial needle aspiration (TBNA) done from a nodule of size 11 mm in the superior segment of the right lower lobe. EBUS-TBNA was done from this lesion, which was 5 mm away from the bronchus in the lung parenchyma with intervening normal lung tissue in between. TBNA was performed by compressing the abutting normal lung tissue, thus causing compression collapse of the intervening normal lung. We labeled this Zealous Unique Trans Arterial Maneuver as the “ZUTAM” technique.

A 46-year-old female patient with severe Muscular Dystrophy (MD) was admitted to our Unit with a 7-day history of progressive dyspnea, nausea and abdominal distension. The patient was diagnosed at 6 years of age with MD, but she had declined undergoing DNA analysis; she became wheelchair bound at 12 years of age. At the time of admission, the patient reported a long-standing history of abdominal bloating and constipation. She had been receiving, during the 32 month period prior to admission, home Non-Invasive Positive Pressure Ventilation (NPPV) administered via a nasal mask. On admission, the patient's abdomen was extremely distended but soft (Fig. 1); bowel tones were diminished and the abdomen was diffusely tender to palpation. A postero-anterior radiograph of the chest and upper abdomen revealed elevation of both hemidiaphragms and marked gaseous distension of the large bowel loops. There was no free air or evidence of mechanical obstruction. Given these findings, a diagnosis of exacerbated chronic colonic pseudo-obstruction was made and the patient was assigned conventional management. Although she showed transient benefit, her clinical condition and pulmonary gas exchange status worsened progressively, leading to a severe, uncompensated respiratory acidosis and the need for intubation. Following intubation tracheostomy, the patient's PaCO2 progressively normalized during ventilatory assistance and her abdominal distension decreased. Due to an inability to adequately protect the airways causing extubation failure, the patient was then tracheostomized. On the seventh day, the patient's bowel transit returned to usual and on day 10, she was discharged from hospital. Due to a persistent requirement for round-the-clock ventilatory support, she was prescribed home ventilation via a tracheostomy.

Background: Long-term Tracheostomy Ventilation (TV) is utilized to prolong survival of individuals with Amyotrophic Lateral Sclerosis (ALS). Due to the potential risk of CO2 rebreathing and the lack of direct measurement of Tidal Volume, the use of a passive exhalation port in this setting remains uncommon. AIMS AND OBJECTIVES: To investigate the use of a passive exhalation port in comparison to an active exhalation valve for long-term TV in ALS patients. Methods: Following tracheostomy for progressive ventilatory failure, 20 consecutive, clinically stable ALS pts were randomly assigned to receive Volume-Assured Pressure Support (VAPS) (Trilogy 100, Philips Respironics) using a passive exhalation port (Whisper Swivel II) (group A) or Pressure Support Ventilation +Target Volume (Vivo 50, Breas GE) using a nonrebreathing expiratory valve (group B). Primary study end-point was PaCO2 level after a 60-day follow-up; the level of dyspnea and care-giver burden were also assessed. Results: Optimal ventilator setting was established within the first 8 hrs of treatment in 8/10 pts in group A. No significant differences in PaCO2 level (38.5±1.34 vs 42.8±1.77 mmHg; p=0.2239), Borg Dyspnea Scale (2±0.29 vs1.5±0.26; p=0.296), and Relative Stress Scale (48±3.87 vs 52±9.42; p=0.316) were apparent at the end of follow-up period, regardless of the exhalation system used. One patients in group A reported minor technical problems with the ventilator. Conclusions: The use of a passive exhalation port had a similar effect on gas exchange, dyspnea and care-giver burden compared to an active exhalation valve in ALS patients receiving long-term TV.

Objectives: The real incidence of pneumomediastinum (PNM) in adult patients with severe acute asthma exacerbation continues to be unknown. The current study aims to investigate the occurrence of PNM in an adult population of patients presenting a severe asthma attack and to evaluate the risk factors associated to its development. Methods: The 45 consecutive subjects who were admitted to our Division between January 1, 2015 and December 31, 2016 for severe acute asthma exacerbation underwent a diagnostic protocol including a standard chest X-ray and continuous monitoring of arterial oxygen saturation (SaO(2)) during the first 24 hours following admission. The patients showing persistence or deterioration of oxyhemoglobin desaturation were prescribed a chest Computed Tomographic (CT) scan. Results: Five out of the 45 patients (11.1%) with severe acute asthma exacerbation were diagnosed with PNM, in one case on the basis of an X-ray image and in four on the basis of a chest CT scan. Data analysis showed that the PNM patients were younger [21 (17-21) vs 49.5 (20-73) yrs; p < 0.001] and more likely to show sensitization to Alternaria (2/5 vs 0/40; p = 0.0101) with respect to their non-PNM counterparts. The duration of hospital stay was similar in the two groups [8 (4-12) vs 7 (3-15) days; p = 0.6939]. Conclusions: PNM is a common clinical entity in young adults with severe acute asthma exacerbation, particularly in those with unsatisfactory response to initial medical therapy. Although generally benign, patients with suspected PNM should be closely monitored because of the risk of developing severe hypoxemia.

Background: The clinical course of IPF is heterogeneous however it is recognized that patients can have a slow (S) or rapid (R) progression of the disease and that R is related to worse prognosis. Aims: By using a HRCT alveolar score (AS) as an index of alveolar inflammation and an interstitial score (IS) as an index of fibrosis we wanted to investigate: 1) If AS and IS could differentiate S from R at a time close to diagnosis; 2) The behavior of the AS and IS over time; 3)The relation of FVC decline to the progression of AS and IS. Methods: 28 IPF patients (17S, 11R) followed longitudinally with FVC had a HRCT close to diagnosis (HRCT1). 13 of these patients (7S and 6R) had a second HRCT2 after 30±25 months of follow up. Ground glass (AS) and fibrosis (IS) % extension (0-100) were scored in each lobe. HRCT1 and HRCT2 scores were computed, the rate of progression calculated and compared to the FVC change between the interval from HRCT1 to HRCT2. Results: In the 28 patients examined at diagnosis, HRCT1 AS in R (23.4±22%) was higher than in S (8.4±14.1%, p< 0.03) while IS was similar (42.2±21% in R vs 41.1±24% in S). In the 13 patients in whom HRCT2 was available, AS significantly increased in S (5.7±8 to 15.4±17%, p<0.05) and R (22±29 to 30±30%, p<0.05) while IS did not increase significantly. The rate of decline of FVC between HRCT1 and HRCT2 correlated strongly with the combined AS and IS change/month (r=0.80, p<0.005). Conclusion: At diagnosis HRCT AS differentiates R from S progressors. The combination of progressive inflammation (AS) and fibrosis (IS) by HRCT seems to drive the functional decay in IPF.