ABSTRACT
Patients hospitalised due to infection with SARS-CoV-2 frequently require admission to the ICU for organ support. Most of these admissions are due to acute respiratory failure, often fulfilling the criteria for ARDS. This chapter will review current evidence-based management of this patient population. We discuss how oxygenation can be supported via noninvasive and invasive methods, and describe how invasive ventilation should be set to provide lung protection. We discuss how there is no place for routine antiviral, antibiotic and therapeutic anticoagulation in ICU patients with COVID-19-related ARDS, but there is a place for steroids and immunomodulation via anti-IL-6. Finally, we provide an overview of the complications and long-term consequences of critical illness caused by COVID-19.Copyright © ERS 2021.
ABSTRACT
Background: Day case local anaesthetic thoracoscopy (LAT) with indwelling pleural catheter (IPC) insertion is currently being advocated to mininize length of stay in the Covid pandemic. As part of this innovation, continuous service reviews are warranted. All local procedures are performed in theatre. Rapid pleurodesis with talc is not performed due to staffing problems. All patients receive erector spinae catheters to control post-op pain. Method(s): All patients undergoing day case LAT between Dec 2019-Jan2022 were analysed. Basic demographics and outcomes were collected for a descriptive analysis of data. Result(s): 32 patients underwent day case LAT. All had negative pre-op Covid-19 swabs: mean age 72.4 years (range 34-83);22M/10M. Diagnoses were 9 lung cancers, 11 mesotheliomas and 9 fibrinous pleuritis (1 of those went for VATS and proved mesothelioma). The lung did not deflate, not enabling biopsies in 3 (Non-malignant diagnoses). 28 IPCs and 2 large bore drains were inserted due to surgical emphysema. 1 patient developed an empyema and 1 had cellulitis within 30 days. 28 IPCs have already been removed due to pleurodesis (median 54 range 21-197). All were discharged the same day except the 2 requiring a large bore drains. Mean length of stay is 0 days. Diagnostic sensitivity of LAT is 96.5%. Pain scores at day 0,1,2 of surgery were consistently low. No patient caught Covid in the 30 days post surgery. Conclusion(s): Day case LAT is feasible with our current set up and should be widely adopted. The health economics of preventing admission are considerable.
ABSTRACT
Introduction: We have previously described pneumothorax (PTX) and pneumomediastinum (PM) in COVID-19. Incidence is approx. 1%, and usually associated with a poor prognosis. Method(s): With Caldicott approval, all patients with Covid-19 with PTX and PM are flagged to the pleural service for ongoing analysis. Demographics and outcomes are collected. Result(s): 46 were identified (Total: 4506, 01/03/20-02/01/22): mean age 57.5 years (range 19-91). 37 (82%) male, 45 white Caucasian, 1 South East Asian, 20 ex-smokers, 8 never smokers, 1 current smoker & the rest unknown. Respiratory comorbidity was most commonly COPD (12), asthma (4), combined pulmonary fibrosis and emphysema (1), previous TB (1), & active lung cancer (1). Average estimated frailty score was 2 (range 1-6). Mean BMI was 28 (range 18.5-46.7), mean height 1.72m (range 1.55-1.84). Average number of days to air leaks is 13.29 patients had PTX [16 isolated PTX (including 6 bilateral)] & 22 had PM (4 isolated PNM). 18 patients had concurrent surgical emphysema. 10 patients were intubated at the time of air leak, 16 on CPAP or HFNC, 13 on oxygen, the rest on air. 32 were managed conservatively. Others had a variety of small, large bore and subcutaneous drains and 1 was transferred for ECMO. There were 10 deaths with 1 directly due to PTX in a 91 yr old, CFS of 6 and intercurrent stroke. 1 was associated with PM, CFS 2 & lung cancer, 1 85 yr old with CFS 4 & COPD, 1 82 yr old with CFS 3 on CPAP & the rest were on mechanical ventilation). Conclusion(s): Inpatient incidence of PTX and PM is still approximately 1%. Survival is better as overall Covid19 survival improves(direct mortality from air leak approx. 21 %) with mortality due to other factors rather than the air leak.
ABSTRACT
BACKGROUND: Coronavirus disease 2019 has had a dramatic impact on the delivery of acute care globally. Accurate risk stratification is fundamental to the efficient organisation of care. Point-of-care lung ultrasound offers practical advantages over conventional imaging with potential to improve the operational performance of acute care pathways during periods of high demand. The Society for Acute Medicine and the Intensive Care Society undertook a collaborative evaluation of point-of-care imaging in the UK to describe the scope of current practice and explore performance during real-world application. METHODS: A retrospective service evaluation was undertaken of the use of point-of-care lung ultrasound during the initial wave of coronavirus infection in the UK. We report an evaluation of all imaging studies performed outside the intensive care unit. An ordinal scale was used to measure the severity of loss of lung aeration. The relationship between lung ultrasound, polymerase chain reaction for SARS-CoV-2 and 30-day outcomes were described using logistic regression models. RESULTS: Data were collected from 7 hospitals between February and September 2020. In total, 297 ultrasound examinations from 295 patients were recorded. Nasopharyngeal swab samples were positive in 145 patients (49.2% 95%CI 43.5-54.8). A multivariate model combining three ultrasound variables showed reasonable discrimination in relation to the polymerase chain reaction reference (AUC 0.77 95%CI 0.71-0.82). The composite outcome of death or intensive care admission at 30 days occurred in 83 (28.1%, 95%CI 23.3-33.5). Lung ultrasound was able to discriminate the composite outcome with a reasonable level of accuracy (AUC 0.76 95%CI 0.69-0.83) in univariate analysis. The relationship remained statistically significant in a multivariate model controlled for age, sex and the time interval from admission to scan Conclusion: Point-of-care lung ultrasound is able to discriminate patients at increased risk of deterioration allowing more informed clinical decision making.
Subject(s)
COVID-19 , Humans , COVID-19/diagnostic imaging , Point-of-Care Systems , Retrospective Studies , SARS-CoV-2 , Lung/diagnostic imaging , United Kingdom/epidemiologyABSTRACT
Background: Immunogenicity and safety of SARS-CoV-2 vaccines have been widely investigated in patients (pts) with cancer. However, their effectiveness against Coronavirus disease 2019 (COVID-19) and the additional protective effect of a booster dose in this population are yet to be defined. Methods: Using OnCovid study data (NCT04393974), a European registry enrolling consecutive pts with cancer and COVID-19, we evaluated morbidity and 14 days case fatality rates (CFR14) from COVID-19 in pts who were unvaccinated, vaccinated (either partially/full vaccinated but not boosted) and those who had received a third dose. Analyses were restricted to pts diagnosed between 17/11/2021 (first breakthrough infection in a boosted pt) and the 31/01/2022. Pts with unknown vaccination status were excluded. Results: By the data lock of 22/02/2022, out of 3820 consecutive pts from 36 institutions, 415 pts from 3 countries (UK, Spain, Italy) were eligible for analysis. Among them, 51 (12.3%) were unvaccinated, 178 (42.9%) were vaccinated and 186 (44.8%) were boosted. Among vaccinated pts, 26 (14.6%) were partially vaccinated (1 dose). Pts with haematological malignancies had more likely received a booster dose prior to infection (25.4% vs 13.6% and 11.8%, p = 0.02). We found no other associations between vaccination status and pts' characteristics including sex, age, comorbidities, smoking history, tumour stage, tumour status and receipt of systemic anticancer therapy. Compared to unvaccinated pts, boosted and vaccinated pts achieved improved CFR14 (6.8% and 7.0% vs 22.4%, p = 0.01), COVID-19-related hospitalization rates (26.1% and 20.6% vs 41.2%, p = 0.01) and COVID-19-related complications rates (14.5% and 15.7% vs 31.4%). Using multivariable Inverse Probability of Treatment Weighting (IPTW) models adjusted for sex, comorbidities, tumour status and country of origin we confirmed that boosted (OR 0.21, 95%CI: 0.05-0.89) and vaccinated pts (OR 0.19, 95%CI: 0.04-0.81) achieved improved CFR14 compared to unvaccinated pts, whilst a significantly reduced risk of COVID-19 complications (OR 0.26, 95%CI: 0.07-0.93) was reported for vaccinated pts only. Conclusions: SARS-CoV-2 vaccines protect from COVID-19 morbidity and mortality in pts with cancer. Accounting for the enrichment of haematologic pts in the boosted group, the observation of comparable mortality outcomes between boosted and vaccinated pts is reassuring and suggests boosting to be associated with reduced mortality in more vulnerable subjects, despite evidence of adverse features in this group.
ABSTRACT
Background and aims: Cerebral venous sinus thrombosis with thrombosis with thrombocytopenia syndrome (CVST-TTS) is a serious adverse drug reaction after adenoviral SARS-CoV-2 vaccinations. CVST-TTS patients may need decompressive surgery to avoid fatal brain herniation, but despite this intervention, many CVST-TTS patients die during the initial hospital admission. Here, we describe the characteristics and outcomes of CVST-TTS patients who underwent decompressive surgery and explore predictors of mortality in CVST-TTS patients. Methods: We used data from an ongoing international registry collecting data from patients who developed CVST within 28 days of SARS-CoV-2 vaccination, reported between 29 March and 9 December 2021. TTS was defined in accordance with the Brighton Collaboration case definition. Results: Out of 97 CVST-TTS patients, 29 (30%) underwent decompressive surgery. All operated patients had an intracerebral haemorrhage before the surgery. In-hospital mortality was 19/29 (66%) in the operated and 23/68 (34%) in the non-operated group. In the operated group, the highest mortality rate was among patients who were in coma before the surgery (14/15, 93% vs 4/12, 33% in those not in coma), had bilateral absence of the pupillary response (7/7, 100% vs 8/16, 50% in patients with uni/bilateral pupillary response) and platelet count <50 x103/μL (11/14, 79% vs 6/12, 50% in cases with a platelet count ≥50 x103/μL). Conclusion: Mortality rate of CVST-TTS patients who underwent decompressive surgery is extremely high. Among the operated patients, coma before the surgery, bilateral absence of the pupillary response, and platelet count <50 x103/μL were the predictors of mortality.
ABSTRACT
Background: Northumbria Healthcare NHS Foundation Trust runs a large pleural service. Local anaesthetic medical thoracoscopy (LAT) is a well-established procedure in undiagnosed pleural effusions. Patients were traditionally admitted for a mean of 3.4 days and had a large bore drain inserted post LAT with pleurodesis. The Covid-19 pandemic has forced day case LAT provision with IPC placement without pleurodesis to minimise transmission risk. We describe our experience. LAT is performed in theatre under conscious sedation. Methods: All notes of patients requiring day case LAT between July 2020-Feb 2021 were analysed. Basic demographics and outcomes were collected. A descriptive analysis of the data was performed. Results: 17 patients underwent day case LAT. All had negative preoperative Covid-19 swabs: mean age 70.8 years (range 34-82), 12 male,5 female. Diagnoses included 5 lung cancers, 6 mesotheliomas and 4 fibrinous pleuritis. The lung did not deflate, not enabling biopsies in 2. Non-malignant diagnoses are currently presumed. 14 IPCs and 2 large bore drain were inserted due to 2 immediate complication (surgical emphysema). 1 patient developed an empyema within 30days. 9 out of the 11 IPCs have already been removed due to pleurodesis occurring (mean number days 60. All were discharged on the same day except the two requiring further drain insertion. Conclusions: We have thus transformed our service after more than a decade of providing LAT as an inpatient service. This is a small cohort of patients but proves the feasibility and safety of day case LAT with massive reduction in inpatient stay. The Covid-19 pandemic has transformed our service but for the better. Further qualitative work should elucidate the acceptability of such a pathway for patients. Disclosure: No significant relationships.
ABSTRACT
Introduction: Pleural disease requires additional training for procedural competencies and research. We have a well-established pleural service. After a business case application, we have offered a yearly pleural fellowship (PF) through open applications, funded from respiratory and acute medicine budgets in our NHS Foundation Trust. There have been four fellows in 5 years;one has continued their fellowship post since the first Covid-19 outbreak in the UK. Methods: A quantitative review of the PF using an electronic questionnaire was done. Descriptive statistical methodology was applied and thematic analysis evaluated free-text responses. Results: Response rate was 100%. Mean time in PF was 12.5 months (range 9-17). Two were appointed before respiratory speciality training, one during and one after. Competency and autonomy at advanced pleural procedures was achieved by all. 31 scientific s/publications were achieved {mean 6 (range 1-24)}. New services developed were ambulatory pneumothorax and day-case medical thoracoscopy. Three developed similar services elsewhere and one is a service lead. Common themes in the free text were service and procedural skills development and research opportunities. All delivered regional thoracic ultrasound and pleural teaching. Average number of procedures per fellow, per year is 82.6. Conclusions: PF provides trainees with a valuable opportunity to develop their clinical and academic competencies, irrespective of level of training. A PF post is beneficial for an NHS foundation trust and associated with cost-saving through service development of day case procedures in line with the NHS Best Practice Tariffs and the fellows performing many procedures which would otherwise consume consultant time. Disclosure: No significant relationships.
ABSTRACT
IntroductionFalls cause 75% of trauma in patients above 65 years of age and thoracic trauma is the second commonest injury;rib fractures are the commonest thoracic injury. There is wide variation in care. Older trauma patients are less likely to have trauma assessments. Rib fractures carry up to 12% mortality with up to 31% developing pneumonia.1 The number of fractures correlates with morbidity. Northumbria Healthcare has a team of respiratory consultants, physiotherapists, specialist nurses and anaesthetists for rib fracture management on a respiratory support unit.MethodsWith Caldicott approval, basic demographics and clinical outcomes of patients admitted with thoracic trauma between Aug 20-Apr 21 were analysed. Descriptive statistical methodology was applied.Results119 patients were identified. Mean age was 71.1 years (range 23–97). 53 were male, 66 female. Mechanism of injury were falls from standing (65), falls down stairs/bed or in the bath (18), ladders (4), cycling (12), assault (3), road accidents (8) and 9 others (for example off horses). LOS was 7.3 days (range 1–54). 85 patients had more than 1 co-morbidity. 26 had a full trauma assessment and 75 had pan CTs. Mean number of rib fractures was 3.6. 31 (26%) had a pneumothorax and/or haemothorax. 18 chest drains were inserted (all small bore) and 1 needle aspiration done. No cardiothoracic input was required. Isolated chest trauma was present only in 45 patients. All had pain team review, 22 erector spinae catheters were inserted with 2 paravertebral blocks. 82 patients did not require oxygen, 1 required CPAP and 1 HFNC. 7 needed intensive care transfer. 20 (17%) developed pneumonias.16 (14%) deaths occurred within 30 days (1 heart failure and cancer progression, 2 Covid and 14 pneumonias)- all were in those with falls from standing. There was no correlation between number of fractured ribs, length of stay and mortality.ConclusionsHigh level care for thoracic trauma can be performed by the respiratory team with analgesia managed by the pain team. 42% of pneumothoraces/haemothoraces were observed. Falls from standing are associated with significant mortality and morbidity. The service is now complemented by a frailty assessment service.Referencehttps://academic.oup.com/ageing/article/49/2/161/5673134
ABSTRACT
Introduction: Northumbria Healthcare NHS Foundation Trust runs a large pleural service. Local anaesthetic medical thoracoscopy (LAT) is a well-established procedure in undiagnosed pleural effusions. Patients were traditionally admitted for a mean of 3.4 days and had a large bore drain inserted post LAT with pleurodesis. The Covid-19 pandemic has forced day case LAT provision with IPC placement without pleurodesis to minimise transmission risk. We describe our experience. LAT is performed in theatre under conscious sedation. Methods: All notes of patients requiring day case LAT between July 2020-Feb 2021 were analysed. Basic demographics and outcomes were collected. A descriptive analysis of the data was performed. Results: 17 patients underwent day case LAT. All had negative pre-operative Covid-19 swabs: mean age 70.8 years (range 34-82), 12 male,5 female. Diagnoses included 5 lung cancers, 6 mesotheliomas and 4 fibrinous pleuritis. The lung did not deflate, not enabling biopsies in 2. Non-malignant diagnoses are currently presumed. 14 IPCs and 2 large bore drain were inserted due to 2 immediate complication (surgical emphysema). 1 patient developed an empyema within 30days. 9 out of the 11 IPCs have already been removed due to pleurodesis occurring (mean number days 60. All were discharged on the same day except the two requiring further drain insertion. Conclusion: We have thus transformed our service after more than a decade of providing LAT as an inpatient service. This is a small cohort of patients but proves the feasibility and safety of day case LAT with massive reduction in inpatient stay. The Covid-19 pandemic has transformed our service but for the better. Further qualitative work should elucidate the acceptability of such a pathway for patients. Keywords: medical thoracoscopy, lung cancer, covid-19
ABSTRACT
Background: Northumbria Healthcare NHS Foundation Trust runs a very successful pleural service catering for patients with malignant pleural fluid, pleural infection and pneumothorax. Local anaesthetic medical thoracoscopy (LAT) is a well-established diagnostic, therapeutic and preventative procedure in undiagnosed pleural effusions. Patients were traditionally admitted for a mean of 3.4 days and had a large bore drain inserted post LAT and pleurodesis was performed. The Covid-19 pandemic has forced us to provide day case LAT with IPC placement without pleurodesis to minise transmission risk. We thus describe our local experience. LAT is performed in theatre under conscious sedation. Methods: All the notes of patients requiring day case LAT between July 2020-Dec 2020 were analysed. Basic demographics were collected as well as diagnoses and what interventions were performed. A descriptive analysis of the data was performed. Results: 13 patients underwent day case LAT. All had negative preoperative Covid-19 swabs. Mean age was 69.7 years (range 24–82). 10 were male and 3 female. Definite diagnoses included 5 lung cancers, 4 mesotheliomas and 2 fibrinous pleuritis. The lung did not deflate, not allowing for biopsies in 2 patients. Non-malignant diagnoses are currently presumed. 10 IPCs and 1 large bore drain were inserted due to 1 immedidate complication (surgical emphysema). 1 patient developed an empyema within 30days. 8 out of the 10 IPCs have already been removed due to pleurodesis occuring (mean number of days 27.5, range 16–72). All patients were discharged on the same day except 1 patient who required a large bore drain and stayed overnight. Conclusions: We have thus transformed our service after more than a decade of providing LAT as an inpatient service. This is a small cohort of patients but proves the feasibility and safety of day case LAT with massive reduction in inpatient stay. The Covid-19 pandemic has transformed our service but for the better. Further qualitative work should elucidate the acceptability of such a pathway for patients. Legal entity responsible for the study: The authors. Funding: Has not received any funding. Disclosure: All authors have declared no conflicts of interest.