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This study aimed at investigating the effects of nasal cleansing and massage maneuvers on upper airway patency in mouth-breathing children. This is a case report on eight children, aged 7 to 10 years, with a speech-language-hearing diagnosis of mouth breathing and otorhinolaryngological assessment and clinical diagnosis of rhinitis. Nasal airflow and patency were respectively assessed with the Glatzel mirror and Peak Nasal Inspiratory Flow (PNIF). Then, they were submitted to nasal cleansing and massage maneuvers with a saline solution, followed by reassessment with the Glatzel mirror and PNIF to compare results. The medians of total nasal airflow quantification were significant. Data on unilateral nasal cavity measurement indicated a sharp increase in nasal airflow in each nostril, with statistically significant differences between before and after nasal cleansing and massage maneuvers. The medians of the total PNIF were significant after the cleansing. It is concluded that the nasal airflow increased in PNIF after the cleansing maneuver. RESUMO Esse estudo objetivou investigar o efeito da manobra de limpeza e massagem nasal na permeabilidade da via aérea superior de crianças com respiração oral. Trata-se de um relato de caso no qual foram selecionadas oito crianças com idade entre 7 a 10 anos apresentando diagnóstico fonoaudiológico de respiração oral, com avaliação otorrinolaringológica e diagnóstico clínico de rinites. Realizou-se as avaliações da aeração nasal e permeabilidade nasal, utilizando o espelho milimetrado de Altmann e o Peak Nasal Inspiratory Flow (PNIF), respectivamente. Em seguida, executou-se as manobras de limpeza e massagem nasal com soro fisiológico. Ao término, utilizou-se novamente o espelho de Altmann e o PNIF para comparar os resultados. Os resultados obtidos pelas medianas na quantificação da aeração nasal total foram significantes. Os dados da mensuração das cavidades nasais unilateralmente indicaram aumento acentuado na aeração nasal em cada narina, tendo diferenças estatisticamente significante quando comparados com os valores antes e depois das manobras de limpeza e massagem nasal. Os valores obtidos pelas medianas no Fluxo Nasal Máximo Inspiratório Total foram significantes após a limpeza. Concluiu-se que houve aumento da aeração nasal no fluxo nasal máximo inspiratório após manobra de limpeza.

Objectives To design and evaluate 3D‐printed nasal swabs for collection of samples for SARS‐CoV‐2 testing. Design An iterative design process was employed. Laboratory evaluation included in vitro assessment of mock nasopharyngeal samples spiked with two different concentrations of gamma‐irradiated SARS‐CoV‐2. A prospective clinical study compared SARS‐CoV‐2 and human cellular material recovery by 3D‐printed swabs and standard nasopharyngeal swabs. Setting, participants Royal Melbourne Hospital, May 2020. Participants in the clinical evaluation were 50 hospital staff members attending a COVID‐19 screening clinic and two inpatients with laboratory‐confirmed COVID‐19. Intervention In the clinical evaluation, a flocked nasopharyngeal swab sample was collected with the Copan ESwab and a mid‐nasal sample from the other nostril was collected with the 3D‐printed swab. Results In the laboratory evaluation, qualitative agreement with regard to SARS‐CoV‐2 detection in mock samples collected with 3D‐printed swabs and two standard swabs was complete. In the clinical evaluation, qualitative agreement with regard to RNase P detection (a surrogate measure of adequate collection of human cellular material) in samples collected from 50 hospital staff members with standard and 3D‐printed swabs was complete. Qualitative agreement with regard to SARS‐CoV‐2 detection in three pairs of 3D‐printed mid‐nasal and standard swab samples from two inpatients with laboratory‐confirmed SARS‐CoV‐2 was also complete. Conclusions Using 3D‐printed swabs to collect nasal samples for SARS‐CoV‐2 testing is feasible, acceptable to patients and health carers, and convenient.

Background Snoring source analysis is essential for an appropriate surgical decision for both simple snorers and obstructive sleep apnea/hypopnea syndrome (OSAHS) patients. Objective As snoring sounds carry significant information about tissue vibrations within the upper airway, a new feature entitled compressed histogram of oriented gradients (CHOG) is proposed to recognize vibration patterns of the snoring source acoustically by compressing histogram of oriented gradients (HOG) descriptors via the multilinear principal component analysis (MPCA) algorithm. Methods Each vibration pattern corresponds to a sole or combinatorial vibration among the four upper airway soft tissues of soft palate, lateral pharyngeal wall, tongue base, and epiglottis. 1037 snoring events from noncontact sound recordings of 76 simple snorers or OSAHS patients during drug-induced sleep endoscopy (DISE) were evaluated. Results With a support vector machine (SVM) as the classifier, the proposed CHOG achieved a recognition accuracy of 89.8% for the seven observable vibration patterns of the snoring source categorized in our most recent work. Conclusion The CHOG outperforms other single features widely used for acoustic analysis of sole vibration site.

The past decade has witnessed escalating legal and ethical challenges to the diagnosis of death by neurologic criteria (DNC). The legal tactic of demanding consent for the apnea test, if successful, can halt the DNC. However, US law is currently unsettled and inconsistent in this matter. Consent has been required in several trial cases in Montana and Kansas but not in Virginia and Nevada. In this paper, we analyze and evaluate the legal and ethical bases for requiring consent before apnea testing and defend such a requirement by appealing to ethical and legal principles of informed consent and battery and the right to refuse medical treatment. We conclude by considering and rebutting two major objections to a consent requirement for apnea testing: (1) a justice-based objection to allocate scarce resources fairly and (2) a social utility objection that halting the diagnosis of brain death will reduce the number of organ donors.

International audience; Introduction The new 2018 international guidelines for diagnosing usual interstitial pneumonia (UIP)/idiopathic pulmonary fibrosis (IPF) by CT scan split the old pattern possible UIP (2011 IPF guidelines) into two new patterns probable UIP and indeterminate for UIP. However, the proportions and prognoses of these new CT-scan patterns are not clear.Methods We used a monocentric retrospective cohort of 322 patients suspected of having IPF (University Hospital of Rennes; Competence Center for Rare Lung Diseases; 1 January 2012-31 December 2017). All patients initially diagnosed by CT scan as possible UIP were included. The chest CT-scans were then reclassified according to the new 2018 international guidelines by 3 observers. These data were then subjected to survival analysis with multivariate Cox regression using a composite endpoint of death, lung transplantation, a decline of ≥ 10% in forced vital capacity (FVC), or hospitalization.Results Of the 89 possible UIP patients included, 74 (83%) were reclassified as probable UIP and 15 (17%) as indeterminate for UIP. Probable UIP patients were more likely to meet the composite endpoint (56/74 [75.7%] vs. 5/15 [33%] patients; HR [IC 95%] = 3.12 [1.24; 7.83], P = 0.015). Multivariate analysis indicated that the probable UIP pattern was associated with significantly increased risk of reaching the composite endpoint (HR [95% CI] = 2.85[1.00; 8.10], P = 0.049).Conclusion The majority of possible UIP diagnoses corresponded to probable UIP, which was associated with a significantly worse prognosis than indeterminate for UIP. This distinction between these two CT patterns emphasizes the relevance of the new international guidelines for the diagnosis of IPF. © 2020 SPLF and Elsevier Masson SAS

Drug-induced sleep endoscopy (DISE) is useful in children with obstructive sleep apnea (OSA) that persists after adenotonsillectomy (AT), but its utility in surgically naive children is unclear. We report polysomnography outcomes of surgically naive children who underwent DISE-directed intervention because they were considered high risk for persistent OSA after adenotonsillectomy. This study is a case series of 62 surgically naive children with OSA who were considered high risk for persistence after AT and underwent DISE-directed intervention with pre- and postoperative polysomnography between 2012 and 2016. Analysis was performed with the paired t test. Children were on average 5.9 (± 5.5, 0.2–18.6) years old at the time of surgery, 68% male, 18% obese, and 60% white. Thirty-eight percent had a syndromic diagnosis: 19% trisomy 21, 11% hypotonic neuromuscular disorder, and 8% craniofacial condition. The remaining 62% were non-syndromic but underwent DISE because they had at least one risk factor for OSA persistence after AT (age > 7 years, black race, 1+ tonsils, obesity, and/or severe OSA). Forty-two percent underwent AT, while 58% underwent treatment other than AT, including 18% who had multilevel surgery. Children improved significantly in 4 out of 5 polysomnography parameters tested, including obstructive apnea-hypopnea index (oAHI; 22.2 to 7.2, p

Objective: to investigate the most frequent radiological findings in the international literature in the respiratory system of patients infected with Sars-CoV-2. Methodology: This is a Systematic Literature Review (RSL), a search being performed in the Pubmed and Cochrane Library databases, using a comprehensive search for the following terms and their correlates based on the Medical Subject Headings (MeSH): Coronavirus Infection, Respiratory Systems, Imaging, Diagnostic. Observational studies published from 2020 in any language were included. Results: After screening, 8 studies were included, with a total population of 1,089 patients from 6 different countries. Discussion: patients infected by Sars-CoV-2 were obtained by two categories of imaging tests: Computed Tomography and Pulmonary Ultrasonography, and pulmonary involvement is closely related to the severity and presence of risk factors. Conclusion: the results show the importance of radiological findings as a complementary tool in the diagnosis and prognosis of COVID-19, although they should not replace laboratory tests in confirming the diagnosis. Objetivo: investigar los hallazgos radiológicos más frecuentes en la literatura internacional en el sistema respiratorio de pacientes infectados por Sars-CoV-2. Metodología: Se trata de una revisión sistemática de la literatura (RSL), una búsqueda que se realiza en las bases de datos de Pubmed y Cochrane Library, utilizando una búsqueda integral de los siguientes términos y sus correlatos basados en Medical Subject Headings (MeSH): Coronavirus Infection, Respiratory Systems, Imaging, Diagnostic. Se incluyeron estudios observacionales publicados a partir de 2020 en cualquier idioma. Resultados: después del cribado, se incluyeron 8 estudios, con una población total de 1.089 pacientes de 6 países diferentes. Discusión: los pacientes infectados por Sars-CoV-2 se obtuvieron mediante dos categorías de exámenes de imagen: tomografía computarizada y ecografía pulmonar, y la afectación pulmonar está estrechamente relacionada con la gravedad y presencia de factores de riesgo. Conclusión: los resultados muestran la importancia de los hallazgos radiológicos como herramienta complementaria en el diagnóstico y pronóstico de COVID-19, aunque no deben reemplazar las pruebas de laboratorio en la confirmación del diagnóstico. Objetivo: investigar na literatura internacional os achados radiológicos mais frequentes no sistema respiratório de pacientes infectados pelo Sars-CoV-2. Metodologia: Trata-se de uma Revisão Sistemática de Literatura (RSL), a busca sendo realizada nas bases de dados Pubmed e Cochrane Library, sendo utilizadas estratégias de busca abrangentes dos seguintes termos e seus correlatos baseados no Medical Subject Headings (MeSH): Coronavirus Infection, Respiratory Systems, Imaging, Diagnostic. Foi incluído estudos observacionais publicados a partir de 2020 em qualquer idioma. Resultados: após a triagem, 8 estudos foram detectados, com população total de 1.089 pacientes de 6 países diferentes. Discussão: os pacientes infectados pelo Sars-CoV-2 foram avaliados por duas categorias de exames de imagem: Tomografia Computadorizada e Ultrassonografia Pulmonar, e o comprometimento pulmonar está intimamente relacionado com a gravidade e a presença de fatores de riscos. Conclusão: os resultados evidenciam a importância dos achados radiológicos como ferramenta complementar no diagnóstico e prognóstico da COVID-19, embora não deva substituir os exames laboratoriais na confirmação diagnóstica.

Purpose of review To discuss the proposed pathophysiology of empty nose syndrome (ENS), summarize and evaluate the role of validated diagnostic tools in the diagnosis of ENS, and review the medical and surgical treatment strategies for patients with ENS. Recent findings Historically, ENS has been associated with a reduction in nasal turbinate size; new data suggest that impaired trigeminal nerve function may also play a role in the pathophysiology of the disease. The newly validated empty nose syndrome 6 item questionnaires and Cotton test are steps forward to standardize the diagnosis of ENS. Finally, there has been a marked increase in surgical treatment strategies to reconstitute turbinate volume with various implant materials. Summary The diagnosis of ENS remains controversial but the last several years have seen a rejuvenation of interest in this disease entity. The validated empty nose syndrome 6 item questionnaires and Cotton test provide a standardized and objective means by which to characterize ENS. Prevention of iatrogenic ENS through avoidance of excessive turbinate reduction remains critical in preventing paradoxical nasal obstruction. Nasal humidification, patient education, and treatment of possible concomitant medical conditions (e.g., depression) constitute first lines of treatment. We support the cautious use of these screening tools as adjuncts to clinical decision-making. Although injectable implants to augment turbinate volume show promise as a therapeutic surgical technique, there is insufficient data to fully support their use at this time.

Background: We obtain summary estimates of the accuracy of additional objective tests for the diagnosis of adult asthma using systematic review and meta-analysis of diagnostic test accuracy studies. Methods: Medline, Embase, and other relevant electronic databases were searched for papers published between January 1989 and December 2016. Studies were included if they evaluated the diagnostic accuracy of objective tests, including airway reversibility (AR), airway hyperresponsiveness (AHR), and fractionated exhaled nitric oxide (FeNO) for the diagnosis of adult asthma in patients with symptoms suggestive of asthma. If papers were assessed appropriate using the adapted QUADAS-2 tool, meta-analysis was conducted using the hierarchical bivariate model. This hierarchical model accounts for both within and between study variability. Results: Sixteen studies reported the performance of the evaluated objective tests at presentation. For diagnosis of adult asthma, overall sensitivity and specificity for AR were 0.39 (95% confidence interval [CI] 0.18 to 0.66) and 0.95 (95% CI 0.86 to 1.00); for AHR, 0.86 (95% CI 0.61 to 1.00) and 0.95 (95% CI 0.77 to 1.00); for FeNO, 0.65 (95% CI 0.53 to 0.77) and 0.83 (95% CI 0.75 to 0.90). Comprehensive comparison of three diagnostic tools for adult asthma using the back-calculated likelihood rate (LR) showed that AR and AHR corresponded to a higher LR+, and AHR gave a lower LR-. Conclusions: In the current situation of no gold standard for diagnosis of adult asthma, AR and AHR are appropriate for ruling-in the true diagnosis, and AHR is superior for ruling-out a diagnosis. Since each objective test had a specific characteristic, it should be chosen depending on the situation, such as the capacity of the institution and the conditions of patients. Keywords: Airway hyperresponsiveness, Airway reversibility, Asthma, Fractionated exhaled nitric oxide, Meta-analysis

Background: Preoperative airway evaluation in children is an important part of routine preanesthetic evaluation before surgery. External airway measurements, viz., thyromental, mentohyoid, and sternomental distances, while being growth dependent, could identify pediatric patients with potentially difficult airways. Objectives: This study was conducted to validate the age- and height-based formulae, derived from a previous study conducted in our institute, to predict thyromental distance, sternomental distance, and mentohyoid distance in relation with the height and age of pediatric patients. Design: Prospective cross-sectional single arm observational study. Setting: Tertiary level university teaching hospital from July 2015 to December 2016. Patients: Children (202) in the age group of 3-15 years with no obvious external airway anomaly scheduled for elective surgery under general anesthesia. Outcomes Measured: The thyromental, mentohyoid, and sternomental distances were measured preoperatively. The same parameters were then calculated based on age- and height-related formulae derived in the earlier study. Results: Bland-Altman analysis of the sample patients showed a mean difference (bias) between measured and calculated values ranging from 0.14 to –0.60 (3 - 13%). Overall agreement in terms of bias were found to be more with height-based equation for mentohyoid distance and thyromental distance and age-based equation for sternomental distance. Conclusion: Our study validates the formulae derived in the earlier study to predict thyromental, mentohyoid, and sternomental distances in children with no obvious external airway anomalies. Further studies are needed to extend the applicability of these formulae in obese children and those with craniofacial anomalies coming for general anesthesia and surgery.

Background We aimed to estimate and compare the ability of clinical tools for dengue diagnosis in a pediatric population. Methods We prospectively evaluated episodes of acute febrile syndrome identified during the follow-up of a population-based cohort of children and adolescents residing in a dengue endemic city. We estimated the area under the receiver operating characteristic curve (AU-ROC) for dengue diagnosis of three clinical tools: the summation of manifestations of the WHO case definition, a predefined clinical scale and a logistic regression model obtained in this study. Results We compared 219 dengue cases (confirmed by laboratory) and 286 patients with other febrile illnesses. In a multiple model, variables independently associated with dengue included the duration of fever, sleepiness and exanthema. Rhinorrhea, cough and minimal leukocyte count were inversely associated with dengue. This model reached an accuracy of 84.2% (for a cut-off of >0.5, sensitivity: 79.5%, specificity: 87.9%, positive predictive value: 83.7%, negative predictive value: 84.6%). The AU-ROC of this model (89.8%) was significantly higher than that obtained with either the predefined scale (82.1%) or the WHO definition manifestations (77%). Conclusion We validated a predefined scale and identified a multiple model suitable for the clinical diagnosis of dengue in the pediatric population.

The Control of Allergic Rhinitis and Asthma Test (CARAT10), developed by Portuguese experts, is the only questionnaire assessing asthma control under additional consideration of a frequently concurrent allergic rhinitis (AR), providing sub-scores for both diseases. Aims of this study were the translation and validation of its German version. Asthma patients both with and without AR were included at three primary care pulmologists´ practices in Southern Germany. After translation process, patients completed the CARAT10, the Asthma Control Questionnaire (ACQ), the Asthma Control Test (ACT), and the Standardised Asthma Quality of Life Questionnaire (AQLQ(S)). Item and scale characteristics as well as measures of reliability and validity of the CARAT10 were determined. A confirmatory factor analysis was conducted to test factorial validity. Data of 213 patients were analysed, 101 (47%) of them with concurrent AR. Missing responses were minimal and unsystematic. Cronbach´s α was 0.87 for the CARAT10 total score (TS) and 0.84 for each sub-score. Spearman´s correlation coefficients for the association of the CARAT10 TS with ACQ, ACT and AQLQ(S) were moderate to high and slightly higher in patients with AR. Higher correlations were found for its lower airway sub-score than the upper airway sub-score (all around 0.8 to all around 0.3). Confirmatory factor analysis confirmed the two-factorial scale structure of the CARAT10, with a two-factor model showing a better fit to the data than a one-factor model. The German version of the CARAT10 is an acceptable, reliable and valid tool. Our results suggest a recommended use in asthma patients with AR., Allergic rhinitis and asthma: German version of control test verified A newly-translated German version of a two-factor asthma test shows promise as a reliable tool for assessing disease control. Asthma frequently co-exists with allergic rhinitis (AR), a condition in which allergies cause irritation and inflammation of the nasal passages. To verify asthma control under AR, a Portuguese team developed the Control of Allergic Rhinitis and Asthma Test (CARAT10). Now, Christoph Ulrich Werner at the Technical University of Munich in Germany and co-workers have translated CARAT10 into German and verified its reliability and validity for use in the German population. The team trialed their CARAT10 version with 213 patients, 101 of whom had concurrent AR, and compared the results with three standardised asthma questionnaires. They found that CARAT10 was a better fit to verify disease control for patients with co-existing AR than in such.

Background Immunocompromised children are at high risk of rapid deterioration and of developing life-threatening pulmonary infections. Etiologies in this setting are diverse, including those that are infectious and noninfectious, and many etiologies may coexist. Accurate diagnosis is required for the rational use of medications. Fiberoptic bronchoscopy (FOB) with bronchoalveolar lavage (BAL) can identify infectious causes in this population. Objectives The aims of this study were to evaluate diagnostic rate, safety, and changes in treatment following FOB with BAL, when applied with advanced laboratory diagnostic techniques. Patients and methods We reviewed the records of children who underwent FOB with BAL during the period spanning from 2006 to 2014 in the Hematology-Oncology Department. BAL samples were processed in microbiology, virology, cytology, and molecular laboratories. Results Antimicrobials were initiated in 91 of 117 children. BAL yielded an infectious etiology in 55 episodes. Management was altered in 74 patients following a positive (40/55) or a negative (30/54) result (4 patients had missing data). No severe complications associated with the procedures occurred. Conclusions Most immunocompromised patients with pulmonary manifestations are treated empirically with multiple medications. Evaluation FOB/BAL is a useful diagnostic tool, and seems to have changed the course of therapy in more than half of patients, by initiation or cessation of treatment. FOB/BAL is a safe diagnostic tool for the evaluation of pulmonary manifestations in this setting.

The Japanese Respiratory Society (JRS) has recommended spirometry for the diagnosis of respiratory diseases. It is indispensable for the confirmation of airflow obstruction by spirometry in chronic obstructive pulmonary disease (COPD) diagnosis. However, the coronavirus disease 2019 (COVID-19) pandemic has made it difficult for many clinics to perform spirometry as it may lead to possible aerosol infections. Thus, the diagnosis of COPD, especially in the early stage, has become difficult. To overcome this situation, JRS issued a "Flowchart of Working Diagnosis and Management of COPD during the COVID-19 Pandemic". This flowchart may help physicians provisionally diagnose COPD patients without performing spirometry, offering them appropriate intervention even in epidemic and pandemic situations.

Noninvasive sampling of the distal airspace in patients with acute respiratory distress syndrome (ARDS) has long eluded clinical and translational researchers. We recently reported that fluid collected from heat moisture exchange (HME) filters closely mirrors fluid directly aspirated from the distal airspace. In the current study, we sought to determine fluid yield from different HME types, optimal HME circuit dwell time, and reliability of HME fluid in reflecting the distal airspace. We studied fluid yield from four different filter types by loading increasing volumes of saline and measuring volumes of fluid recovered. We collected filters after 1, 2, and 4 h of dwell time for measurement of fluid volume and total protein from 13 subjects. After identifying 4 h as the optimal dwell time, we measured total protein and IgM in HME fluid from 42 subjects with ARDS and nine with hydrostatic pulmonary edema (HYDRO). We found that the fluid yield varies greatly by filter type. With timed sample collection, fluid recovery increased with increasing circuit dwell time with a median volume of 2.0 mL [interquartile range (IQR) 1.2–2.7] after 4 h. Total protein was higher in the 42 subjects with ARDS compared with nine with HYDRO [median 708 µg/mL (IQR 244–2017) vs. 364 µg/mL (IQR 136–578), P = 0.047], confirming that total protein concentration in HME is higher in ARDS compared with hydrostatic edema. These studies establish a standardized HME fluid collection protocol and confirm that HME fluid analysis is a novel noninvasive tool for the study of the distal airspace in ARDS.

COVID 19 pandemic has brought about a sea change in health care practices across the globe. All specialities have changed their way of working during the pandemic. In this study, we evaluated the impact of COVID-19 on the practice of interventional pulmonology at our centre. All interventional pulmonology procedures done during the three months after implementation of lockdown were evaluated retrospectively for patient demographics, clinical diagnosis, indication for procedure and diagnostic accuracy. The changes in practices, additional human resources requirement, the additional cost per procedure and impact on resident training were also assessed. Procedures done during the month of January 2020 were used as controls for comparison. Twenty-two flexible bronchoscopies (75.8%), four semirigid thoracoscopies (13.7%) and three EBUS-TBNAs (10.3%) were carried out during three month lockdown period as compared to 174 during January 2020. Twenty-three of the procedures were for the diagnostic indication (79%), and six were therapeutic (20.6%). The diagnostic yield in suspected neoplasm was 100% while for suspected infections was 58.3%. The percentage of independent procedures being done by residents reduced from 45.4% to 0%. The workforce required per procedure increased from 0.75 to 4-8, and the additional cost per procedure came out to be 135 USD. To conclude, COVID 19 has impacted the interventional pulmonology services in various ways and brought about a need to reorganize the services, while also thinking of innovative ideas to reduce cost without compromising patient safety.

Interventional treatment of emphysema offers a wide range of surgical and endoscopic options for patients with advanced disease. Multidisciplinary collaboration of pulmonology, thoracic surgery, and imaging disciplines in patient selection, therapy, and follow-up ensures treatment quality. The present joint statement describes the required structural and quality prerequisites of treatment centres. This is a translation of the German article “Positionspapier der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin und der Deutschen Gesellschaft für Thoraxchirurgie in Kooperation mit der Deutschen Röntgengesellschaft: Strukturvoraussetzungen von Zentren für die interventionelle Emphysemtherapie” Pneumologie. 2020;74:17–23.

Objective: describe the experience of working in a diagnostic testing center for Covid-19, from the perspective of nursing professionals. Method: experience report on conducting material collection for Reverse Transcriptase - Polymerase Chain Reaction testing to detect Covid-19. The experience took place from March to May 2020, at a federal public university, in the state of Rio de Janeiro, Brazil. Results: are presented from two sections: Service Flow at the Diagnostic Testing Center and; Perceptions and confrontations while working at the Diagnostic Testing Center. Conclusion: experience has shown that it is a challenge to be at the forefront in the fight against coronavirus due to the risk related to the activity, the scarcity of personal protective equipment and the high demand for work. But, it is possible for nurses, even in this context, to use basic care tools, apply the nursing process and interact with the patient. Objetivo: Describa la experiencia de trabajar en un centro de pruebas de diagnóstico para Covid-19, desde la perspectiva de los profesionales de enfermería. Método: informe de experiencia sobre la realización de la recolección de material para pruebas de Reacción en cadena de la polimerasa de transcriptasa inversa para detectar Covid-19. La experiencia tuvo lugar de marzo a mayo de 2020, en una universidad pública federal, en el estado de Río de Janeiro, Brasil. Resultados: se presentan a partir de dos secciones: flujo de servicio en el Centro de pruebas de diagnóstico y; Percepciones y confrontaciones mientras trabajaba en el Centro de Pruebas de Diagnóstico. Conclusión: La experiencia ha demostrado que es un desafío estar a la vanguardia en la lucha contra el coronavirus debido al riesgo relacionado con la actividad, la escasez de equipos de protección personal y la gran demanda de trabajo. Pero, es posible que las enfermeras, incluso en este contexto, utilicen herramientas de atención básica, apliquen el proceso de enfermería e interactúen con el paciente. Objetivo: descrever a experiência de atuação em um centro de testagem diagnóstica para a Covid-19, na perspectiva de profissionais enfermagem. Método: relato de experiência sobre a realização de coleta de material para teste de Transcrição Reversa - Reação em Cadeia da Polimerase para detecção da Covid-19. A vivência ocorreu no período de março a maio de 2020, em uma Universidade pública federal, no estado do Rio de Janeiro, Brasil. Resultados: são apresentados a partir de duas seções: Fluxo de Atendimento no Centro de Testagem Diagnóstica e; Percepções e enfrentamentos durante a atuação no Centro de Testagem Diagnóstica. Conclusão: a experiência demonstrou que é um desafio estar na linha de frente no combate ao coronavírus em função do risco relacionado à atividade, da escassez de equipamentos de proteção individual e da alta demanda de trabalho. Mas, é possível ao enfermeiro, mesmo nesse contexto, utilizar instrumentos básicos do cuidar, aplicar o processo de enfermagem e interagir com o paciente.

BACKGROUND AND OBJECTIVES: International patterns of antibiotic use and laboratory testing in bronchiolitis in emergency departments are unknown. Our objective is to evaluate variation in the use of antibiotics and nonindicated tests in infants with bronchiolitis in 38 emergency departments in Pediatric Emergency Research Networks in Canada, the United States, Australia and New Zealand, the United Kingdom and Ireland, and Spain and Portugal. We hypothesized there would be significant variation, adjusted for patient characteristics. METHODS: We analyzed a retrospective cohort study of previously healthy infants aged 2 to 12 months with bronchiolitis. Variables examined included network, poor feeding, dehydration, nasal flaring, chest retractions, apnea, saturation, respiratory rate, fever, and suspected bacterial infection. Outcomes included systemic antibiotic administration and urine, blood, or viral testing or chest radiography (CXR). RESULTS: In total, 180 of 2359 (7.6%) infants received antibiotics, ranging from 3.5% in the United Kingdom and Ireland to 11.1% in the United States. CXR (adjusted odds ratio [aOR] 2.3; 95% confidence interval 1.6–3.2), apnea (aOR 2.2; 1.1–3.5), and fever (aOR 2.4; 1.7–3.4) were associated with antibiotic use, which did not vary across networks (P = .15). In total, 768 of 2359 infants (32.6%) had ≥1 nonindicated test, ranging from 12.7% in the United Kingdom and Ireland to 50% in Spain and Portugal. Compared to the United Kingdom and Ireland, the aOR (confidence interval) results for testing were Canada 5.75 (2.24–14.76), United States 4.14 (1.70–10.10), Australia and New Zealand 2.25 (0.86–5.74), and Spain and Portugal 3.96 (0.96–16.36). Testing varied across networks (P < .0001) and was associated with suspected bacterial infections (aOR 2.12; 1.30–2.39) and most respiratory distress parameters. Viral testing (591 of 768 [77%]) and CXR (507 of 768 [66%]) were obtained most frequently. CONCLUSIONS: The rate of antibiotic use in bronchiolitis was low across networks and was associated with CXR, fever, and apnea. Nonindicated testing was common outside of the United Kingdom and Ireland and varied across networks irrespective of patient characteristics.

BACKGROUND Local tissue eosinophilia and Th2 cytokines are characteristic features of seasonal allergic rhinitis. Airway remodelling is a feature of asthma whereas evidence for remodelling in allergic rhinitis (AR) is conflicting. OBJECTIVE By use of a novel human repetitive nasal allergen challenge (RAC) model, we evaluated the relationship between allergic inflammation and features of remodelling in AR. METHODS Twelve patients with moderate-severe AR underwent 5 alternate day challenges with diluent which after 4 weeks were followed by 5 alternate day challenges with grass pollen extract. Nasal symptoms, Th1/Th2 cytokines in nasal secretion and serum were evaluated. Nasal biopsies were taken 24 hours after the 1st and 5th challenges with diluent and with allergen. Sixteen healthy controls underwent a single challenge with diluent and with allergen. Using immunohistochemistry, epithelial and submucosal inflammatory cells and remodelling markers were evaluated by computed image analysis. RESULTS There was an increase in early and late-phase symptoms after every allergen challenge compared to diluent (both P

Objective: To investigate the coronavirus disease 2019 (COVID-19) status of patients with initial sudden olfactory anosmia (ISOA) through nasopharyngeal swabs for reverse transcription–polymerase chain reaction (RT-PCR) analysis and to explore their olfactory dysfunctions with psychophysical olfactory evaluation. Methods: A total of 78 ISOA patients were recruited from April 6, 2020, to April 10, 2020, through a public call of University of Mons (Mons, Belgium). Patients benefited from nasopharyngeal swabs and fulfilled the patient-reported outcome questionnaire. Among them, 46 patients performed psychophysical olfactory evaluation using olfactory identification testing. Based on the duration of the ISOA, 2 groups of patients were compared: patients with olfactory dysfunction duration ≤12 days (group 1) and those with duration >12 days (group 2). Results: In group 1, 42 patients (87.5%) had a positive viral load determined by RT-PCR and 6 patients (12.5%) were negative. In group 2, 7 patients (23%) had a positive viral load and 23 patients (77%) were negative. The psychophysical olfactory evaluation reported that anosmia and hyposmia occurred in 24 (52%) and 11 (24%) patients, respectively. Eleven patients were normosmic. The viral load was significantly higher in patients of group 1 compared with those of group 2. Conclusions: Coronavirus disease 2019 was detected in a high proportion of ISOA patients, especially over the first 12 days of olfactory dysfunction. Anosmia is an important symptom to consider in the detection of COVID-19 infection.

There has been an explosion of use for quantitative image analysis in the setting of lung disease due to advances in acquisition protocols and postprocessing technology, including machine and deep learning. Despite the plethora of published papers, it is important to understand which approach has clinical validation and can be used in clinical practice. This paper provides an introduction to quantitative image analysis techniques being used in the investigation of lung disease and focusses on the techniques that have a reasonable clinical validation for being used in clinical trials and patient care.

Objective Structured light plethysmography (SLP) is a novel and noncontact respiratory assessment technique. It provides tidal breathing measurement in patients difficult to cooperate. In this study, we aimed to determine data for tidal breathing parameters measured by SLP in newborns. Study Design Infants between 2 and 5 days of life without having any respiratory symptoms were eligible for this observational study. In total, 5 minutes of tidal breathing was recorded using SLP (Thora-3Di, PneumaCare Ltd, Cambridge, U.K.) in each infant. Various tidal breathing parameters including timing indices, flow-based parameters, and regional parameters were obtained from SLP data. Results A total of 57 infants underwent measurements in the study. Evaluable recordings from 42 term and 11 late preterm infants were analyzed. Median gestational age and birthweight of the infants were 38 (37–39) weeks and 3,195 (2,790–3,585) g, respectively. In terms of flow-based parameters, “tidal inspiratory flow at 50% of inspiratory volume divided by tidal expiratory flow at 50% of expiratory volume” was 1.29 (1.13–1.53). Relative contribution of the thorax to each breath in percentage was measured as 38.67 (28.21–43.60). Median values of left–right hemithoracic asynchrony and thoraco-abdominal asynchrony were 6.92 (5.35–9.04) and 17.96 (12.98–36.44) degrees in the study population, respectively. There were no differences in tidal breathing parameters except “hemithoracic asynchrony” between term and late preterm infants. Hemithoracic asynchrony was significantly lower in term neonates than late preterms. Conclusion SLP was found to be feasible to obtain measures of tidal breathing parameters in newborns and it could be performed successfully even in the first days of life.

Multiple problems may be encountered during the diagnosis of sarcoidosis: at first diagnose sarcoidosis in an appropriate clinical setting, secondly, identify any manifestation to be linked to sarcoidosis at diagnosis work-up and during evolution; thirdly, recognize "danger" in sarcoidosis and parasarcoidosis syndromes, and finally, diagnose sarcoidosis recovery. Diagnosis is often delayed as presentation may be diverse, non-specific, or atypical. Diagnosis of sarcoidosis is based on three criteria: a compatible presentation; evidence of non-caseating granulomas and exclusion of any alternative diagnosis. However, even when all criteria are fulfilled, the probability of sarcoidosis diagnosis varies from definite to only possible depending upon the presence of more or less characteristic radio-clinical and histopathological findings and on the epidemiological context. Bilateral hilar lymphadenopathy and/or diffuse lung micronodules mainly along lymphatics are the most frequent highly suggestive findings. Evidence of granulomas relies on superficial biopsies of clinically suspected lesion when present or most often by bronchial endoscopy. The diagnosis of sarcoidosis may be difficult in absence of thoracic or skin manifestations and may require the benefit of hindsight before being definitive. Differential diagnoses, mainly tuberculosis, must be considered. The diagnosis of events during evolution relies on serial clinical, pulmonary function, radiographic evaluation and on extrapulmonary manifestations work-up, including electrocardiogram and blood biology. Affected organs need to be related to sarcoidosis using an appropriate diagnostic assessment instrument. To declare the recovery of sarcoidosis, all manifestations must have disappeared spontaneously or after 3-5 years post-treatment without relapse.

The aim of the present study was to evaluate in a sample of 200 patients diagnosed with COPD and selected from the physician database of 15 general practices from Valle Telesina (Benevento, Italy) if the diagnostic-therapeutic algorithm adopted by GPs operating in a non-urban district in Southern Italy adhered to GOLD 2018 recommendations for COPD. Each patient underwent a specialist visit by an experienced chest physician that collected anamnesis, assessed mMRC and CAT scores, and performed a spirometry. In case of diagnostic doubt, a second visit was performed at the Pulmonary Rehabilitation Unit of the Istituti Clinici Scientifici Maugeri IRCCS in Telese Terme where other diagnostic tests were performed. Our results showed that GPs participating in the study often diagnosed and empirically treated COPD without a confirmative spirometry or even despite a spirometry that was not diagnostic of obstructive lung disease. Furthermore, real-life implementation of GOLD strategy, as regards patients’ ABCD categorization, was poor and many patients belonging to groups A and B (39% and 48%, respectively) were over-treated and 19% of those belonging to group D were under-treated. The discrepancy between guidelines and daily clinical practice present also in this study supports the opinion of many that those who develop guidelines for the management of COPD must seriously try to understand if and why the guidelines might not reflect real life and therefore how it could be improved.

Background Eosinophilic chronic rhinosinusitis (ECRS) is often complicated by asthma and can be difficult to diagnose. This study aimed to clarify the usefulness of the self-administered odor questionnaire (SAOQ) and visual analog scale (VAS) to identify olfactory disorders in patients with asthma. Methods This retrospective study was conducted on patients with asthma who were referred to the Otolaryngology clinic between May and September 2018. The treatment step of asthma, asthma control test (ACT), pulmonary function test, peripheral blood eosinophils, and fractional exhaled nitric oxide (FeNO) were analyzed. ECRS was diagnosed based on the Japanese Epidemiological Survey of Refractory Eosinophilic Chronic Rhinosinusitis Study score. Olfactory dysfunction was evaluated using the SAOQ and VAS for olfactory disorders. Results The study included 56 patients (18 males and 38 females), who were divided into two groups; those with ECRS (n = 18) and those without ECRS (n = 38). Age, sex, treatment step, ACT score, and pulmonary function were not significantly different between the groups. The ECRS group had a significantly higher FeNO value (89.1 ppb vs. 39.1 ppb) and a significantly lower SAOQ score (40.1% vs. 96.1%). The area under the receiver operating characteristic curve for the efficacy of ECRS diagnosis was 0.88, 0.889, 0.799, and 0.757 for SAOQ, VAS, blood eosinophil count, and FeNO, respectively. Conclusion The SAOQ and VAS scores were useful tools that presented similar results to the blood eosinophil count and FeNO, and may help to improve the diagnosis of ECRS in patients with asthma.

The COPD Assessment Test (CAT) is in widespread use for the evaluation of patients with chronic obstructive pulmonary disease (COPD). We assessed whether the CAT items carry additional information beyond the sum score regarding COPD characteristics including emphysema. Patients of GOLD grades 1 to 4 from the COPD cohort COSYCONET (German COPD and Systemic Consequences - Comorbidities Network) with complete CAT data were included (n = 2270), of whom 493 had chest CT evaluated for the presence of emphysema. Comorbidities and lung function were assessed following standardised procedures. Cross-sectional data analysis was based on multiple regression analysis of the single CAT items against a panel of comorbidities, lung function, or CT characteristics (qualitative score, 15th percentile of mean lung density), with age, BMI and gender as covariates. This was supported by exploratory factor analysis. Regarding the relationship to comorbidities and emphysema, there were marked differences between CAT items, especially items 1 and 2 versus 3 to 8. This grouping was basically confirmed by factor analysis. Items 4 and 5, and to a lower degree 1, 2 and 6, appeared to be informative regarding the presence of emphysema, whereas the total score was not or less informative. Regarding comorbidities, similar findings as for the total CAT score were obtained for the modified Medical Research Council scale (mMRC) which was also informative regarding emphysema. Our findings suggest that the usefulness of the CAT can be increased if evaluated on the basis of single items which may be indicating the presence of comorbidities and emphysema.

Background In adult patients with bronchiectasis (BE) the identification of the underlying aetiology may be difficult. In a new patient with BE the performance of a panel of tests is recommended, even though this practice may be expensive and the level of evidence supporting is low. We aimed to identify a panel of variables able to predict the aetiological diagnosis of BE. Methods Our prospective study derived from our real-life experience on the management of adult stable BE outpatients. We recorded variables concerning clinical, radiological, microbiological and laboratory features. We identified five groups of aetiological diagnosis of BE (idiopathic, post-infective, COPD, asthma and non-common diseases [immunodeficiency or other rare conditions]). Multivariate models were used to identify predictors of each aetiological diagnosis. The suitability of performing a specific test for the diagnosis was also considered. Results We enrolled 354 patients with a new diagnosis of BE. Patients with different aetiological causes differed significantly with regard to age, sex, smoking habit, comorbidities, dyspnoea perception, airflow obstruction and severity scores. Various predictors were assessed, including sex, previous respiratory infections, diffuse localization of BE, risk scores, and laboratory variables (sodium and eosinophils). The levels of autoantibodies or immunoglobulins were reserved for the diagnosis of non-common disease. Conclusion Our research confirms that some predictors are specific for the aetiological diagnosis of BE. The possibility of integrating this information may represent a useful tool for the diagnosis. The execution of certain specific tests should be reserved for patients with a non-common disease.