COVID-19, Chronic Obstructive Pulmonary Disease and Pneumothorax: A Frightening Triad.

We describe the case of a male patient admitted to our emergency department during the Italian COVID-19 epidemic, for progressive worsening dyspnoea. A diagnosis of pneumothorax and diffuse interstitial lung involvement was promptly made by lung ultrasound and confirmed by an HRCT scan. A chest CT scan also showed diffuse emphysema, as observed in chronic obstructive pulmonary disease (COPD), and small consolidations in the lower lobes, suggestive for COVID-19 pneumonia. A chest tube was immediately inserted in the emergency room with complete resolution of the dyspnoea. A nasopharyngeal swab for 2019-nCoV was positive. Unfortunately, the patient died from COVID-19-related acute respiratory distress syndrome after 48 days of hospitalization. LEARNING POINTS: Coronavirus disease (COVID-19) can cause death from severe acute respiratory distress syndrome (ARDS).Pneumothorax is a common complication of chronic obstructive pulmonary disease (COPD).The combination of COVID-19, COPD and pneumothorax can prove fatal.

From the Triage to the Intermediate Area: A Simple and Fast Model for COVID-19 in the Emergency Department.

INTRODUCTION: The early identification of patients with SARS-CoV-2 infection is still a real challenge for emergency departments (ED). First, we aimed to develop a score, based on the use of the lung ultrasonography (LUS), in addition to the pre-triage interview, to correctly address patients; second, we aimed to prove the usefulness of a three-path organization (COVID-19, not-COVID-19 and intermediate) compared to a two-path organization (COVID-19, non-COVID-19). METHODS: We retrospectively analysed 292 patients admitted to our ED from 10 April to 15 April 2020, with a definite diagnosis of positivity (93 COVID-19 patients) or negativity (179 not-COVID-19 patients) for SARS-COV-2 infection. Using a logistic regression, we found a set of predictors for infection selected from the pre-triage interview items and the LUS findings, which contribute with a different weight to the final score. Then, we compared the organization of two different pathways. RESULTS: The most informative factors for classifying the patient are known nasopharyngeal swab positivity, close contact with a COVID-19 patient, fever associated with respiratory symptoms, respiratory failure, anosmia or dysgeusia, and the ultrasound criteria of diffuse alveolar interstitial syndrome, absence of B-lines and presence of pleural effusion. Their sensitivity, specificity, accuracy, and AUC-ROC are, respectively, 0.83, 0.81, 0.82 and 0.81. The most significant difference between the two pathways is the percentage of not-COVID-19 patients assigned to the COVID-19 area, that is, 10.6% (19/179) in the three-path organization, and 18.9% (34/179) in the two-path organization (p = 0.037). CONCLUSIONS: Our study suggests the possibility to use a score based on the pre-triage interview and the LUS findings to correctly manage the patients admitted to the ED, and the importance of an intermediate area to limit the spread of SARS-CoV-2 in the ED and, as a consequence, in the hospital.

Prone positioning in patients treated with non-invasive ventilation for COVID-19 pneumonia in an Italian emergency department.

We report the experience of prone ventilation in selected patients treated with helmet non-invasive ventilation (NIV) continuous positive airway pressure (CPAP) for acute respiratory failure in COVID-19 pneumonia. Preliminary results showed an improvement in the PaO2 value and PaO2/FiO2 ratio after 1 hour of prone ventilation. No variation of the lung ultrasound pattern before and after prone ventilation has been detected. At the time of writing, we attempted proning with helmet NIV CPAP in 10 patients. In 4 out of 10 patients, the attempt failed due to lack of compliance of the patient, scarce pain control even with ongoing treatment and refusal by the patient to prone positioning.

COVID-19 pandemic, Piacenza calling. The survival strategy of an Italian Emergency Department.

CoVID-19 is a global health emergency, which has paralyzed most of the worldwide health systems. Italy is struggling hard with CoVID-19 pandemic since the end of February 2020, to avoid the collapse of its health  system. The number of CoVID-19 patients and deaths are increasing day by day. At time of writing, in Italy there are 102253 infected patients and 19899 deaths. Despite being a relatively small city, Piacenza is one of the epicentres of the Italian epidemic, and our own hospital - Guglielmo da Saliceto - has quickly become a "CoVID-19 hospital". Fully 80% of beds in our hospital are reserved for ill CoVID-19 patients and ICU has tripled the number of beds. All these changes have required a great effort for all the medical staff to avoid the collpase of the local health system. We struggled to maintain our normal standard of care for each patient, but the severity of the disease and the high number of critically ill patients frustrated our efforts. Here we report our experience and challenge with managing such a disaster. We hope it could be useful for other Emergency Departments trapped in this global pandemic.