Use of front-door thoracic ultrasound to predict and improve outcomes in pleural infection in patients with community-acquired pneumonia

IntroductionThe incidence of parapneumonic effusions (PPE) in patients with community acquired pneumonia (CAP) is 20–57%, of which 5–10% develop into pleural infection. The role of early identification of PPE by thoracic ultrasound (TUS) and other presenting features in prediction of subsequent pleural infection is not clear. We explored the use of TUS in the front-door assessment of patients with CAP, particularly if this aided earlier identification of pleural infection.MethodsConsecutive patients admitted with CAP underwent TUS within 24 hours of admission. Appropriate sampling was performed in patients with effusions >2 cm depth. Final outcome including any subsequent development/worsening of effusion was recorded. CAP was defined as an ‘acute respiratory febrile illness with new consolidation on Chest X-Ray (CXR) or CT scan and not attributed to COVID-19’.ResultsOver a 4-week period, 39 patients with CAP were admitted, age range 40 to 90, median 74. 25/39 (64%) had a detectable pleural effusion on TUS, of which 19 (48.7%) had no visible effusion on the corresponding CXR. Most of these effusions were not amenable to sampling. Of the 6/39 (15.3%) patients who had a visible effusion on CXR, 3 were sampled, 1 of which was proven to be pleural infection. 2 patients that had a detectable effusion on TUS but not on CXR at admission subsequently developed an effusion visible on CXR. Of these, 1 patient was very unwell and died prior to sampling of pleural fluid whilst the other was discharged home without sampling.ConclusionsThe incidence of PPEs may be higher than previously estimated from previous cohorts where TUS was not used in routine assessment. The characteristics of this cohort which are associated with either resolution or development of pleural infection are not understood and warrant further evaluation. Our data from this small pilot evaluation did not identify any particular TUS features that predict development of pleural infection. A detailed prospective evaluation of the use of TUS in patients with pneumonia to further characterise the natural history of PPEs is required.

Utility of ultrasound-guided supraclavicular lymph node sampling in lung cancer diagnosis – remodelling the pathway in the era of COVID-19

Introduction: Ultrasound guided sampling (USGS) of supraclavicular lymph nodes (SCLN) is a minimally invasive method for obtaining cytological diagnosis in metastatic lung cancer. Same day USGS service may improve timeliness of investigations, minimise hospital visits and reduce invasive procedures. Methods: We performed a 3-year retrospective analysis of patients with SCLN amenable to biopsy detect-ed on 2 week-wait (2WW) CT. We identified those who underwent USGS or other procedures, diagnostic yield and their timeliness were determined. Results: 49 patients (26%) had amenable SCLN, of whom 37 (75.5%) had USGS. USGS alone sufficient for 27 (73%) patients. Diagnostic yield is better for larger nodes (<1cm 62.5% positive;≥1cm 86.2% positive, 95% CI 0.13-0.93, p=0.011). The overall diagnostic yield of USGS SCLN was 81% (30/37, 95% CI 65% to 92%). Al-though faster to obtain USGS, no statistically significant difference was reached between USGS and other methods (USGS median 15.5 days (IQR 11.2), other procedures median 17.5 days (IQR 26.5), Mann-Whitney U p=0.42). Conclusion: USGS SCLN has potential utility in early lung cancer diagnosis, even in lymph nodes <1cm, and is an underutilized diagnostic investigation. A prospective study of same day 2WW outpatient clinic and USGS procedure is now required to assess its effect on an accelerated diagnostic pathway. © 2022, Zita Medical Managent. All rights reserved.

THE ERA OF COVID-19: WILL CONVALESCENT PLASMA AND INTRAVENOUS IMMUNOGLOBULINS BE THE ANSWER

Since the World Health Organization (WHO) declared severe acute respiratory syndrome corona virus-2 (SARS-CoV-2) infection a pandemic in December 2019, observational and interventional studies have been underway to investigate potential therapeutic options to treat and prevent the progression of coronavirus disease (COVID-19). Most COVID-19 patients develop mild to moderate symptoms. However, elderly patients suffering from chronic comorbidities and immunocompromised patients are susceptible to more severe life-threatening presentations. Convalescent plasma and intravenous immunoglobulins (IVIg) are two attractive options for managing and preventing severe COVID-19. However, current literature does not confirm nor deny the efficacy of the convalescent plasma and IVIg against COVID-19. Moreover, there is much concern considering the safety of blood-derived immune products. For these reasons, the current clinical guidelines do not recommend for or against the use of blood-derived immune products for managing COVID-19 cases. This article summarizes recent evidence on the safety and efficacy of the convalescent plasma and IVIg in COVID-19 patients.

What can we Learn from Patients who Died from Covid-19 Following Escalation to a Respiratory High Dependency Unit for Trial of Non-Invasive Respiratory Support?

Background: Covid-19 infection is associated with significant risk of death, particularly in older, comorbid patients. Emerging evidence supports use of non-invasive respiratory support (CPAP and high-flow nasal oxygen [HFNO]) in this context, but little is known about its use in patients receiving end-of-life care. Methods: This was a retrospective study of 33 patients who died of Covid-19 on the Respiratory High Dependency Unit at the John Radcliffe Hospital, Oxford between 28/03/20 and 20/05/20. Data was sourced via retrospective review of electronic patient records and drug charts. Results: Patients dying from Covid-19 on the Respiratory HDU were comorbid with median Charlson Comorbidity Index 5 (IQR 4-6); median age 78 (IQR 72-85). Respiratory support was trialled in all but one case with CPAP being the most common form of first line respiratory support (84.8%) however, was only tolerated in 44.8% of patients. Median time to death was 10.7 days from symptom onset (IQR 7.5-14.6) and 4.9 days from hospital admission (IQR 3.1-8.3). 48.5% of patients remained on respiratory support at the time of death. Conclusions: End-of-life care for patients with Covid-19 remains a challenge. Patients tend to be frail and comorbid with a rapid disease trajectory. Non-Invasive Respiratory Support may play a key role in symptom management in select patients, however, further work is needed in order to identify patients who will most benefit from Respiratory Support and those for whom withdrawal may prevent unnecessary distress at the end of life or potential prolongation of suffering.

Mind the gap! Research experience of respiratory trainees- a national survey

P173 Figure 1Perceived barriers to undertaking research during respiratory training[Figure omitted. See PDF]ConclusionClinical research can significantly improve patient outcomes and is a core curriculum requirement for trainees. Unfortunately, our survey shows that most trainees who would like to engage with research have not had access. There is currently a unique opportunity to build upon the recent surge in research interest following widespread engagement in COVID-19 trials. There is a lack of accessible research experience for respiratory trainees. A potential solution would be a national trainee research network which could provide a unique opportunity for the creation of high-quality collaborative research spearheaded by trainees.

Improved COVID-19 outcomes in a large non-invasive respiratory support cohort despite new variants

P217 Table 1A comparison of first and second wave characteristics, treatment and outcome data First wave Second wave Mean difference (95%CI) X2 (df) P value Age (years) 69.0 (52.0, 80.0) 62.0 (52.0, 71.0) -3.4 (-7.8 to +1.1) - 0.14 Sex: - Male - Female 49 (69.0%) 22 (31.0%) 180 (65.0%) 97 (35.0%) - 0.4 (1) 0.52 BMI (kg/m2) 28.5 (24.9, 33.6) 29.6 (24.8, 34.9) +0.6 (-1.7 to +2.9) - 0.63 Clinical Frailty Score: - 1 to 2 (fit) 18 (25.4%) 132 (47.7%) - 15.6 (5) 0.008 CT severity score - Moderate/severe - Severe 11 (29.7%) 23 (62.2%) 131 (52.2%) 113 (45.0%) - 16.0 (3) 0.0012 CRP prior to rHDU admission (mg/L) 180.6 (118.0, 210.0) 124.1 (78.1, 175.6) -44.1 (-66.9 to -21.3) - 0.0002 Spike gene testing - VOC B.1.1.7 variant - Wild-type - Ambiguous - - - 143 (67.1%) 57 (26.8%) 13 (6.1%) - - - Dexamethasone 3 (4.2%) 266 (96.0%) - 271.4 (1) <0.0001 Remdesivir 4 (5.6%) 198 (71.5%) - 100.6 (1) <0.0001 CPAP as primary respiratory support 32 (45.1%) 248 (89.5%) - 71.1 (1) <0.0001 Able to adopt semi- or full- prone position 42 (59.2%) 237 (85.6%) - 24.8 (1) <0.0001 Admission outcome (all) - Died - Discharged 36 (50.7%) 35 (49.3%) 74 (26.7%) 201 (72.5%) - 14.7 (1) 0.0001 rHDU outcome (‘For Intubation’) - Died - Off respiratory support - Intubated 0 (0.0%) 14 (41.2%) 20 (58.8%) 7 (3.3%) 152 (72.4%) 51 (24.3%) - 17.3 (2) 0.0002 ConclusionOur single centre experience shows that rHDU mortality and intubation rates have improved over time in spite of the emergence of new variants. Improvements in outcome are likely to be multi-factorial. Our data support the benefit of pharmacological COVID-19 therapies in a rHDU population as well as the use of CPAP and awake proning. Other potential causes for improved outcomes are lower serological and radiological COVID-19 severity in our wave two cohort as well as reduced rates of frailty.Referencehttps://medrxiv.org/content/10.1101/2021.03.11.21253364v1

Potential utility of ultrasound guided supraclavicular lymph node biopsy in the diagnosis of lung cancer - Remodelling the pathway

Introduction: Ultrasound guided sampling (USGS) of supraclavicular lymph nodes (SCLN) with fine needle aspiration (FNA) or core biopsy is a well established, minimally invasive method for obtaining cytological diagnosis in metastatic lung cancer. It is recommended in the National Lung Cancer Optimal Pathway 'Direct to Biopsy' option for cases where further staging is not required to guide treatment. Re-modelling of the pathway to incorporate 'direct to biopsy' (same day Radiology or Respiratory service) may help improve timeliness of investigations whilst minimising hospital visits and reducing invasive procedures particularly given COVID-19 precautions. Method: We performed a retrospective analysis of patients with SCLN amenable to FNA or biopsy detected on 2 week wait (2WW) CT, timeliness of subsequent SCLN sampling and (Figure presented) diagnostic yield. Data was extracted from InfoFlex from January 2017 to December 2019. Inclusion criteria was at least N2 mediastinal lymphadenopathy >0.5 cm at initial staging with adequate lower neck CT coverage, and where the node was amenable to biopsy (determined by a radiologist). Review of patient records identified those who underwent USGS, whether this was diagnostic and which other procedures were performed. Statistical analysis was performed using IBM SPSS. Results: From 186 patients with suspected N2 or N3 lymphadenopathy at initial staging, 49 (26%) had SCLN amenable to sampling, of whom 37 (75.5%) had sampling performed. Diagnostic yield was 81.2%. Average timeline from 2WW CT to USGS was variable (M = 18 days, 95% CI[14.5, 21.5]) but shorter, on average, compared to other diagnostic procedures (M=22.81 days, 95% CI[13.02, 35.6]). SCLNs with positive biopsy are larger than those without, with AUC of 0.814 (see figure 1). SCLN size of ≥0.65 cm was highly associated with a diagnostic result. Conclusion: 2WW CT with lower neck coverage provided an early opportunity to identify any amenable SCLN especially in the presence of enlarged mediastinal nodes, for ultrasound guided sampling even when SCLN measured <1 cm, and may apply in up to 25% of patients, A prospective study of ultrasound assessment of all patients with N2 mediastinal lymphadenopathy is now required to assess its clinical utility and effect on an accelerated diagnostic pathway.

COVID-19 in the least developed, fragile, and conflict-affected countries - How can the most vulnerable be protected?

The relentless spread of coronavirus disease 2019 (COVID-19) and its penetration into the least developed, fragile, and conflict-affected countries (LDFCAC) is a certainty. Expansion of the pandemic will be expedited by factors such as an abundance of at-risk populations, inadequate COVID-19 mitigation efforts, sheer inability to comply with community mitigation strategies, and constrained national preparedness. This situation will reduce the benefits achieved through decades of disease control and health promotion measures, and the economic progress made during periods of global development. Without interventions, and as soon as international travel and trade resume, reservoirs of COVID-19 and other vaccine-preventable diseases in LDFCAC will continue 'feeding' developed countries with repeated infection seeds. Assuring LDFCAC equity in access to medical countermeasures, funds to mitigate the pandemic, and a paradigm change in the global development agenda, similar to the post-World War II Marshall Plan for Europe, are urgently needed. We argue for a paradigm change in strategy, including a new global pandemic financing mechanism for COVID-19 and other future pandemics. This approach should assist LDFCAC in gaining access to and membership of a global interdisciplinary pandemic taskforce to enable in-country plans to train, leverage, and maintain essential functioning and also to utilize and enhance surveillance and early detection capabilities. Such a task force will be able to build on and expand research into the management of pandemics, protect vulnerable populations through international laws/treaties, and reinforce and align the development agenda to prevent and mitigate future pandemics. Lifting LDFCAC from COVID-related failure will offer the global community the best economic dividends of the century.

All Hands on Deck: A synchronized whole-of-world approach for COVID-19 mitigation.

The COVID-19 pandemic can no longer be mitigated by a nationwide approach of individual nations alone. Given its scale and accelerating expansion, COVID-19 requires a coordinated and simultaneous Whole- of-World approach that galvanizes clear global leadership and solidarity from all governments of the world. Considering an 'all hands-on deck' concept, we present a comprehensive list of tools and entities responsible for enabling them, as well a conceptual framework to achieve the maximum impact. The list is drawn from pandemic mitigation tools developed in response to past outbreaks including influenza, coronaviruses, and Ebola, and includes tools to minimize transmission in various settings including person-to-person, crowd, funerals, travel, workplace, and events and gatherings including business, social and religious venues. Included are the roles of individuals, communities, government and other sectors such as school systems, health, institutions, and business. While individuals and communities have significant responsibilities to prevent person-to-person transmission, other entities can play a significant role to enable individuals and communities to make use of the tools. Historic and current data indicate the role of political will, whole-of-government approach, and the role of early introduction of mitigation measures. There is also an urgent need to further elucidate the immunologic mechanisms underlying the epidemiological characteristics such as the low disease burden among women, and the role of COVID-19 in inducing Kawasaki-like syndromes in children. Understanding the role of and development of anti-inflammatory strategies based on our understanding of pro-inflammatory cytokines (IL1, IL-6) is also critical. Similarly, the role of oxygen therapy as an anti-inflammatory strategy is evident and access to oxygen therapy should be prioritized to avoid the aggravation of COVID-19 infection. We highlight the need for global solidarity to share both mitigation commodities and infrastructure between countries. Given the global reach of COVID-19 and potential for repeat waves of outbreaks, we call on all countries and communities to act synergistically and emphasize the need for synchronized pan-global mitigation efforts to minimize everyone's risk, to maximize collaboration, and to commit to shared progress.