ERS/ESTS statement on the management of pleural infection in adults.

Pleural infection is a common condition encountered by respiratory physicians and thoracic surgeons alike. The European Respiratory Society (ERS) and European Society of Thoracic Surgeons (ESTS) established a multidisciplinary collaboration of clinicians with expertise in managing pleural infection with the aim of producing a comprehensive review of the scientific literature.Six areas of interest were identified including the epidemiology of pleural infection, the optimal antibiotic strategy, diagnostic parameters for chest tube drainage, the status of intrapleural therapies, the role of surgery and the current place of outcome prediction in management.The literature revealed that recently updated epidemiological data continue to show an overall upwards trend in incidence, but there is an urgent need for a more comprehensive characterisation of burden of pleural infection in specific populations such as immunocompromised hosts. There is a sparsity of regular analyses and documentation of microbiological patterns at a local level to inform geographical variation and ongoing research efforts are needed to improve antibiotic stewardship. The evidence remains in favour of a small-bore chest tube optimally placed under image guidance as an appropriate initial intervention for most cases of pleural infection. With a growing body of data suggesting delays to treatment are key contributors to poor outcomes, this suggests that earlier consideration of combination intrapleural enzyme therapy (IET) with concurrent surgical consultation should remain a priority. Since publication of the MIST-2 study, there has been considerable data supporting safety and efficacy of IET, but further studies are needed to optimise dosing using individualised biomarkers of treatment failure. Pending further prospective evaluation, the MIST-2 regimen remains the most evidence based. Several studies have externally validated the RAPID score, but it requires incorporating into prospective intervention studies prior to adopting into clinical practice.

Outcomes of Early Versus Late Tracheostomy in Patients With COVID-19: A Multinational Cohort Study.

Timing of tracheostomy in patients with COVID-19 has attracted substantial attention. Initial guidelines recommended delaying or avoiding tracheostomy due to the potential for particle aerosolization and theoretical risk to providers. However, early tracheostomy could improve patient outcomes and alleviate resource shortages. This study compares outcomes in a diverse population of hospitalized COVID-19 patients who underwent tracheostomy either "early" (within 14 d of intubation) or "late" (more than 14 d after intubation). DESIGN: International multi-institute retrospective cohort study. SETTING: Thirteen hospitals in Bolivia, Brazil, Spain, and the United States. PATIENTS: Hospitalized patients with COVID-19 undergoing early or late tracheostomy between March 1, 2020, and March 31, 2021. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: A total of 549 patients from 13 hospitals in four countries were included in the final analysis. Multivariable regression analysis showed that early tracheostomy was associated with a 12-day decrease in time on mechanical ventilation (95% CI, -16 to -8; p < 0.001). Further, ICU and hospital lengths of stay in patients undergoing early tracheostomy were 15 days (95% CI, -23 to -9 d; p < 0.001) and 22 days (95% CI, -31 to -12 d) shorter, respectively. In contrast, early tracheostomy patients experienced lower risk-adjusted survival at 30-day post-admission (hazard ratio, 3.0; 95% CI, 1.8-5.2). Differences in 90-day post-admission survival were not identified. CONCLUSIONS: COVID-19 patients undergoing tracheostomy within 14 days of intubation have reduced ventilator dependence as well as reduced lengths of stay. However, early tracheostomy patients experienced lower 30-day survival. Future efforts should identify patients most likely to benefit from early tracheostomy while accounting for location-specific capacity.

Outcomes of Early Versus Late Tracheostomy in Patients With COVID-19: A Multinational Cohort Study

OBJECTIVES: Timing of tracheostomy in patients with COVID-19 has attracted substantial attention. Initial guidelines recommended delaying or avoiding tracheostomy due to the potential for particle aerosolization and theoretical risk to providers. However, early tracheostomy could improve patient outcomes and alleviate resource shortages. This study compares outcomes in a diverse population of hospitalized COVID-19 patients who underwent tracheostomy either “early” (within 14 d of intubation) or “late” (more than 14 d after intubation). DESIGN: International multi-institute retrospective cohort study. SETTING: Thirteen hospitals in Bolivia, Brazil, Spain, and the United States. PATIENTS: Hospitalized patients with COVID-19 undergoing early or late tracheostomy between March 1, 2020, and March 31, 2021. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: A total of 549 patients from 13 hospitals in four countries were included in the final analysis. Multivariable regression analysis showed that early tracheostomy was associated with a 12-day decrease in time on mechanical ventilation (95% CI, –16 to –8;p < 0.001). Further, ICU and hospital lengths of stay in patients undergoing early tracheostomy were 15 days (95% CI, –23 to –9 d;p < 0.001) and 22 days (95% CI, –31 to –12 d) shorter, respectively. In contrast, early tracheostomy patients experienced lower risk-adjusted survival at 30-day post-admission (hazard ratio, 3.0;95% CI, 1.8–5.2). Differences in 90-day post-admission survival were not identified. CONCLUSIONS: COVID-19 patients undergoing tracheostomy within 14 days of intubation have reduced ventilator dependence as well as reduced lengths of stay. However, early tracheostomy patients experienced lower 30-day survival. Future efforts should identify patients most likely to benefit from early tracheostomy while accounting for location-specific capacity.

Indoor Air Quality and Environmental Sampling as Support Tools to Detect SARS-CoV-2 in the Healthcare Setting.

OBJECTIVES: To evaluate severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spread inside the healthcare setting using environmental sampling and indoor air quality (IAQ) parameters. METHODS: Ward/ICU rooms had IAQ parameters monitored in real-time, including volatile organic compounds and particulate matter. Surface and three air samples with different exposure times were collected in each room and tested for SARS-CoV-2 using quantitative Rt-PCR. Environmental sampling and IAQ data were compared to provide information about viral spread. RESULTS: SARS-CoV-2 RNA was detected in 6/10 rooms and 9/30 air samples, which is proportionally higher than previous studies. Sampling time confirmed to be crucial to viral detection. No correlations between IAQ parameters could be associated with positive/negative samples even when aerosol-generating procedures were performed. CONCLUSION: Environmental sampling of SARS-CoV-2 RNA may be used as an indicator of occupational safety. IAQ is also a potential tool but requires further research.

Pneumomediastinum in COVID-19 disease: Outcomes and relation to the Macklin effect.

AIM: Pneumomediastinum (PM) is associated with several etiologies and mechanisms. Although it has been described more than 100 years ago, the literature is limited to small retrospective studies. This study aimed to follow patients with coronavirus disease (COVID-19) that developed PM during hospitalization and describe their clinical and radiological evolution. METHODS: A prospective cohort was developed with patients with PM, excluding those with aerodigestive trauma, inside a hospital COVID-19 dedicated hospital. Clinical variables including onset of symptoms, hemodynamic instability, associated complications, the need of interventions, and disease course were all recorded. Also, radiological findings such as the presence of the Macklin effect, extension of lung involvement by COVID-19, and characteristics of the PM were analyzed. RESULTS: Twenty-one patients with non-traumatic PM were followed, resulting in an overall incidence of 0.5% during the study period. Seven (33%) patients had associated pneumothorax and malignant/tension PM was observed in three (14%) cases. The Macklin effect could be found in 11 patients (52%) and the majority of them had more than 50% of lung involvement due to COVID-19. The mortality rate was 49%; however, no deaths were directly related to the PM. CONCLUSIONS: PM incidence is probably increased in the severe acute respiratory syndrome caused by COVID-19, especially in those with greater involvement of the lungs, and the Macklin effect may be an important underlying mechanism of this complication. Usually, PM has a benign course, but complications like tension/malignant PM may occur requiring prompt detection and intervention.

Standardization of elective tracheostomies at the Central Institute of the Hospital das Clínicas in São Paulo during the COVID-19 pandemic

ABSTRACT The COVID-19 Pandemic has resulted in a high number of hospital admissions and some of those patients need ventilatory support in intensive care units. The viral pneumonia secondary to Sars-cov-2 infection may lead to acute respiratory distress syndrome (ARDS) and longer mechanical ventilation needs, resulting in a higher demand for tracheostomies. Due to the high aerosolization potential of such procedure, and the associated risks of staff and envoirenment contamination, it is necesseray to develop a specific standardization of the of the whole process involving tracheostomies. This manuscript aims to demonstrate the main steps of the standardization created by a tracheostomy team in a tertiary hospital dedicated to providing care for patients with COVID-19. RESUMO A pandemia da COVID-19 tem gerado um número elevado de internações hospitalares e muitos pacientes são admitidos nas unidades de terapia intensiva para suporte ventilatório invasivo. A pneumonia viral provocada pelo Sars-cov-2 pode resultar na síndrome da disfunção respiratória aguda (SDRA) e em um tempo prolongado de ventilação mecânica, gerando uma demanda maior de traqueostomias. Diante do alto potencial de aerossolização desse procedimento, com risco de contaminação da equipe e do ambiente, é necessário criar uma padronização específica de todo o processo que envolve essa cirurgia. Este artigo visa demonstrar as principais etapas dessa padronização desenvolvida por um equipe dedicada à realização de traqueostomias em um hospital terciário dedicado ao atendimento de pacientes com suspeita ou confirmação de COVID-19.

Editoriale - L'emergenza Covid-19: riflessioni pedagogiche: Un'emergenza inquietante a più volti

As highlighted by this contribution, the "COVID-19" pandemic has dramatically recalled and universally established some transdisciplinary frontiers that also impose a pedagogical and philosophical-educational reflection.

Standardization of elective tracheostomies at the Central Institute of the Hospital das Clínicas in São Paulo during the COVID-19 pandemic.

The COVID-19 Pandemic has resulted in a high number of hospital admissions and some of those patients need ventilatory support in intensive care units. The viral pneumonia secondary to Sars-cov-2 infection may lead to acute respiratory distress syndrome (ARDS) and longer mechanical ventilation needs, resulting in a higher demand for tracheostomies. Due to the high aerosolization potential of such procedure, and the associated risks of staff and envoirenment contamination, it is necesseray to develop a specific standardization of the of the whole process involving tracheostomies. This manuscript aims to demonstrate the main steps of the standardization created by a tracheostomy team in a tertiary hospital dedicated to providing care for patients with COVID-19.