High-Flow Nasal Cannula Combined with Prone Positioning as an Intubation Alternative in Covid-19: A Case Report and Review of the Literature

The use of high-flow nasal cannula (HFNC) in COVID-19 patients is a contro-versial topic due to the benefits and risks which may occur in patients and healthcare workers. The goal of this treatment modality is potential avoidance of invasive mechanical ventilation, but generation of aerosol and increased healthcare professional infection risk must be considered. We present a case of a SARS-CoV-2-positive 71-year-old male with acute hypoxemic respiratory failure, who was success-fully treated with HFNC combined with prone positioning. Furthermore, we discuss recent literature concerning potential issues of HFNC treatment in COVID-19 patients.

Analgosedation of patients with severe COVID-19 associated respiratory failure supported with extracorporeal membrane oxygenation: A retrospective, single-center analysis

Objectives: Analgosedation of patients with severe respiratory failure due to coronavirus disease 2019 (COVID-19) proved to be challenging. Patients supported with venovenous extracorporeal membrane oxygenation (VV ECMO) seemed to require analgosedative drugs in high doses. This study reviews analgosedation practices in patients with COVID-19 associated severe respiratory failure supported with VV ECMO. Method(s): This is a retrospective, single-center registry study including all patients with COVID-19 associated severe respiratory failure that were supported with VV ECMO at our center. All sedative and analgetic drugs administered intravenously or via inhalation to patients for at least two hours were recorded and analyzed. Result(s): Between March 2020 and January 2022, 88 patients with COVID-19 associated severe respiratory failure were supported with VV ECMO at our center. Propofol and sufentanil were used most frequently for analgosedation in this cohort. Both drugs were co-administered following treatment standards established prior to the emergence of COVID-19 at our center. Sedative and analgetic drugs were switched to alternative regimens after a median time of 3 and 12.5 days. Alternative regimens included Isofluran, alpha-2- agonists (clonidine or dextomidine) or esketamine. Alpha-2- agonists were initiated at a median time of 2 days after starting VV ECMO support. Benzodiazepines were used primarily as last resort treatment option for sedation at our center. During the four waves of the pandemic experienced at our center, we experienced an increased average number of drugs needed for analgosedation. Conclusion(s): Analgosedation in critically ill COVID-19 patients supported with ECMO is challenging. It remains unclear, whether the standard analgosedation regimen with sufentanil and propofol established at our center prior to the COVID-19 pandemic is optimal for this patient cohort. Further studies are needed to determine optimal and long term safe analgosedation regimens in critically ill patients supported by VV ECMO. Furthermore, changes experienced during the course of the pandemic need to be scrutinized in comparison to other cohorts. (Table Presented).

Impact of Post-Visit Outreach on Inhaled Corticosteroid Refill Persistence in Children and Young Adults With Asthma.

BACKGROUND: Inhaled corticosteroids (ICSs) are a fundamental pillar of most regimens for long-term control of persistent asthma. Poor adherence to ICS medication is a common problem in the asthma population that can lead to poor asthma control. We hypothesized that conducting a follow-up telephone call after general pediatric clinic visits for asthma would improve refill persistence. METHODS: We conducted a prospective cohort analysis of pediatric and young adult subjects followed in our pediatric primary care clinic for asthma on ICS medication found to have poor ICS refill persistence. This cohort received a follow-up telephone outreach call 5-8 weeks after the clinic visit. The primary outcome measure was refill persistence with regard to ICS therapy. RESULTS: There were 289 subjects who met the inclusion criteria and did not meet any exclusion criteria for the study (n = 131 in the primary cohort, n = 158 in the post-COVID cohort). The mean ICS refill persistence increased significantly for subjects in the primary cohort (39.4 ± 30.8% post intervention vs 32.4 ± 19.7% pre intervention) (P = .02) but not in the post-COVID cohort (36.4 ± 25.6% post intervention vs 38.9 ± 21.0% pre intervention) (P = .26). There was not a statistically significant change in hospitalizations after the intervention in either the primary or the post-COVID cohorts (P = .08 and .07, respectively). Systemic corticosteroid courses and emergency department visits decreased significantly post intervention (P = .01 and P = .004, respectively) in the primary group but not in the post-COVID group (P = .75 and P = .16, respectively). CONCLUSIONS: These results suggest that telephone outreach after out-patient clinic visits for asthma may have short-term benefit in ICS refill persistence; however, the effect size was small.

Inhalation Pneumonitis Caused by Nebulized Hydrogen Peroxide.

Hydrogen peroxide is a chemical commonly used as a household antiseptic for cleaning and disinfecting. No cases of acute hydrogen peroxide inhalation-induced lung injury are previously described. We present a case of acute chemical pneumonitis caused by mixing hydrogen peroxide in a nighttime continuous positive airway pressure device's humidifier used for obstructive sleep apnea to prevent COVID-19 infection. The patient endorsed mixing hydrogen peroxide with distilled water in his nighttime continuous positive airway pressure device's humidifier at a ratio of 1:3-1:2 for the previous week before admission based on a friend's advice in preventing COVID-19. The presenting chest X-ray showed new multifocal consolidations with interstitial markings and alveolar edema throughout both lungs. Chest computed tomography (CT) imaging demonstrated multifocal, bilateral, hazy consolidations with increased interstitial markings and bilateral pleural effusions. The patient was subsequently initiated on systemic glucocorticoid therapy, significantly improving hypoxemia and dyspnea. Inhalation of hydrogen peroxide may produce acute pneumonitis distinct from what has been described previously with chronic inhalation. Given this case, systemic glucocorticoid therapy may be considered a viable treatment option for acute hydrogen peroxide-associated inhalation lung injury causing pneumonitis.

Enhancing respiratory comfort with fan respirators: Computational analysis of carbon dioxide reduction, temperature regulation, and humidity control

Respirators provide protection from inhalation exposure to dangerous substances, such as chemicals and infectious particles, including SARS-COVID-laden droplets and aerosols. However, they are prone to exposure to stale air as masks create a microclimate influenced by the exhaled air. As a result, exhaled air from lungs accumulating in the mask produces a warm and humid environment that has a high concentration of carbon dioxide (CO2), unsuitable for re-inhalation. Fans are a favorable option for respirators to ventilate the mask and remove the stale air. This study utilized computational fluid dynamics simulation consisting of a hybrid Reynolds-averaged Navier-Stokes-large eddy simulation turbulence method to compare the inhalation flow properties for different fan locations (bottom, top, and side) with regular respirator breathing. Three mask positions, top, side, and bottom, were evaluated under two breathing cycles (approximately 9.65 s of breathing time). The results demonstrated that adding a fan respirator significantly decreased internal mask temperature, humidity, and CO2 concentration. The average CO2 concentration decreased by 87%, 67%, and 73% for locations bottom, top, and side, respectively. While the top and side fan locations enhanced the removal of the exhaled gas mixture, the bottom-fan respirator was more efficient in removing the nostril jet gas mixture and therefore provided the least barrier to respiratory function. The results provide valuable insight into the benefits of fan respirators for long-term use for reducing CO2 concentration, mask temperature, and humidity, improving wearer safety and comfort in hazardous environments, especially during the COVID-19 pandemic.

Coupling Tracer Derived ACH with Risk Calculators to Calculate Risk of COVID-19 Infection

Risk calculators have been utilised to predict the risk of infection from SARS-CoV-2. Inputs include the dimensions of the indoor space, number of infected persons and activity, and inhalation rate of susceptible persons. The compartment model requires an estimate of the Air Changes per Hour (ACH) in the space, as the concentration is changing as a result of the dynamic balance between the generation and removal of exhaled quanta. ACH can be estimated using CO2, engineering drawings, or airflow measurements, but these estimates are often incorrect due to mechanical anomalies and mixing inefficiencies, or in the case of CO2, an absence of continuous occupancy for a sufficient amount of time. SF6 as a tracer gas to establish ACH has been used extensively for many decades to measure air exchange. This approach was utilised to assist a school in managing risk of infection in their facility during an exam period. © 2022 17th International Conference on Indoor Air Quality and Climate, INDOOR AIR 2022. All rights reserved.

Phytochemical Characterization and Screening of the Anti-Pneumonia (Anti-COVID-19, Anti-Fungal, and Anti-Bacterial) Activities of Cuscuta Campestris Extract

Introduction: Although, several vaccines are being approved, no effective antiviral drug has been developed for COVID-19 infectious. The present investigation was aimed to increase the essential oils of Cuscuta campestris using far-red light treatment and examine the potential of crude extracts of C. campestris against selected pneumonia pathogens and COVID-19.Methods: Anti-COVID-19 activity was determined in human lung cell lines and COVID-19 positive patients.Results: Results demonstrated that the aqueous extract had the highest amount of anti-COVID-19, antibiotic and antioxidant activity. The far-red light treatment increased Scoparone, cineole, Benzofuran, 2, 3- dihydro, Cinnamic acid, and Benzo[h]quinoline, 2, 4-dimethyl, which are mainly effective components against COVID-19 inflammation and pneumonia microbes. CT scan and clinical laboratory tests in a clinical case study, a 30-year-old woman who presented with severe 2019-nCoV, demonstrated that inhalation of 30 mg extract nebulized/day for seven days resulted in significant improvement in consolidation and ground-glass opacity in lungs on the seventh day of treatment.Conclusion: It is hoped that this study leads to the introduction of some compounds that could be used to formulate new and more potent anti-COVID-19 antibiotics, or other drugs of natural origin in medicine.

Stratifying risk outcomes among adult COVID-19 inpatients with high flow oxygen: The R4 score.

BACKGROUND: High flow oxygen therapy (HFO) is a widely used intervention for pulmonary complications. Amid the coronavirus infectious disease 2019 (COVID-19) pandemic, HFO became a popular alternative to conventional oxygen supplementation therapies. Risk stratification tools have been repurposed -and new ones developed- to estimate outcome risks among COVID-19 patients. This study aims to provide a simple risk stratification system to predict invasive mechanical ventilation (IMV) or death among COVID-19 inpatients on HFO. METHODS: Among 529 adult inpatients with COVID-19 pneumonia, we selected unadjusted clinical risk factors for developing the composite endpoint of IMV or death. The risk for the primary outcome by each category was estimated using a Cox proportional hazards model. Bootstrapping was used to validate the results. RESULTS: Age above 62, eGFR under 60 ml/min, room air SpO2 ≤89 % upon admission, history of hypertension, history of diabetes, and any comorbidity (cancer, cardiovascular disease, COPD/ asthma, hypothyroidism, or autoimmune disease) were considered for the score. Each of the six criteria scored 1 point. The score was further simplified into 4 categories: 1) 0 criteria, 2) 1 criterion, 3) 2-3 criteria, and 4) ≥4 criteria. Taking the first category as the reference, risk estimates for the primary endpoint were HR; 2.94 [1.67 - 5.26], 4.08 [2.63 - 7.05], and 6.63 [3.74 - 11.77], respectively. In ROC analysis, the AUC for the model was 0.72. CONCLUSIONS: Our score uses simple criteria to estimate the risk for IMV or death among COVID-19 inpatients with HFO. Higher category reflects consistent increases in risk for the endpoint.

Inhalation adherence for asthma and COPD improved during the COVID-19 pandemic: a questionnaire survey at a university hospital in Japan.

Background: Good adherence to an inhaled medication protocol is necessary for the management of asthma and chronic obstructive pulmonary disease (COPD), and several interventions to improve adherence have been reported. However, the impact of patient life changes and psychological aspects on treatment motivation is obscure. Here, we investigated changes in inhaler adherence during the COVID-19 pandemic and how lifestyle and psychological changes affected it.Methods: Seven-hundred sixteen adult patients with asthma and COPD who had visited Nagoya University Hospital between 2015 and 2020 were selected. Among them, 311 patients had received instruction at a pharmacist-managed clinic (PMC). We distributed one-time cross-sectional questionnaires from January 12 to March 31, 2021. The questionnaire covered the status of hospital visits, inhalation adherence before and during the COVID-19 pandemic, lifestyles, medical conditions, and psychological stress. The Adherence Starts with Knowledge-12 (ASK-12) was used to assess adherence barriers.Results: Four-hundred thirty-three patients answered the questionnaire. Inhalation adherence was significantly improved in both diseases during the COVID-19 pandemic. The most common reason for improved adherence was fear of infection. Patients with improved adherence were more likely to believe that controller inhalers could prevent COVID-19 from becoming more severe. Improved adherence was more common in patients with asthma, those not receiving counseling at PMC, and those with poor baseline adherence.Conclusions: Inhalation adherence for asthma and COPD improved in the COVID-19 pandemic. The patients seemed to realize the necessity and benefits of the medication more strongly than before the pandemic, which motivated them to improve adherence.

Identification of effective ventilation strategies to reduce the risk of COVID-19 infections inside buildings, using the INDALO (R) digital multizone model

Faced with epidemic risks, ensuring an exchange of air and sufficient direction of airflow is essential to reduce the air-borne transmission of infectious agents in buildings. In this study, we strove to identify effective ventilation strategies to reduce the risk of infection by COVID-19 inside buildings. To do so, we developed a multi-route transmission model of SARS-CoV-2 (INDALO (R)-COVID) which estimates a risk of infection.This study enabled us to quantify the impact of two preventive measures (installation of a mobile air purifier and increase in the renewal of air by the air purification unit) on the risk of COVID-19 infection in a nursing home. In the configuration used in this study, the use of an air purifier in the rooms of residents with COVID-19 appears to be the most effective measure to reduce the viral load potentially transported to other areas of the building, and thus to reduce the risk of COVID-19 infection among all residents.The digital model developed is a versatile and ready-to-use solution, which can compare preventive measures and design/renovation choices for different types of buildings and uses.

Comparison of disinfectants-induced gene expression profile: Potential adverse effects.

Despite their importance in combating the spread of the COVID-19 pandemic, adverse effects of disinfectants on human health, especially the respiratory system, have been of continuing concern to researchers. Considering that bronchi are the main target of sprayed disinfectants, we here treated the seven major active ingredients in disinfectant products accepted by the US EPA to human bronchial epithelial cells and determined the subtoxic levels. Then, we performed microarray analysis using total RNA obtained at the subtoxic level and designed a network representing disinfectant-induced cellular response using the KEGG pathway analysis technique. Polyhexamethylguanidine phosphate, a lung fibrosis inducer, was used as a reference material to verify the relationship between cell death and pathology. The derived results reveal potential adverse effects along with the need for an effective application strategy for each chemical.

Efficacy and Safety of Inhalation of Nebulized Ethanol in COVID-19 Treatment: A Randomized Clinical Trial.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a pandemic caused by the SARS-CoV-2 virus. Many efforts have been made and are currently being made to prevent and treat this global disease. OBJECTIVES: This study was designed to evaluate the efficacy and safety of nebulized ethanol (EtOH) in treating COVID-19. METHODS: A randomized clinical trial (RCT) of 99 symptomatic and real-time polymerase chain reaction (RT-PCR)-positive patients admitted to a hospital receiving remdesivir-dexamethasone was conducted. They were randomly assigned to receive distilled water spray (control group (CG)) or 35% EtOH spray (intervention group (IG)). Both groups inhaled three puffs of spray (nebulizer) every six hours for a week. The primary outcome included Global Symptomatic Score (GSS) between the two groups at the first visit and on days three, seven, and 14. Secondary outcomes included the Clinical Status Scale (CSS; a seven-point ordinal scale ranging from death to complete recovery) and readmission rate. RESULTS: A total of 44 and 55 patients were enrolled in the IG and CG, respectively. Although there was no difference at admission, the GSS and CSS improved significantly in the IG (p = 0.016 and p = 0.001, respectively). The IG readmission rate was considerably lower (0% vs. 10.9%; p = 0.02). CONCLUSIONS: Inhaled-nebulized EtOH is effective in rapidly improving the clinical status and reducing further treatment. Due to its low cost, availability, and absent/tolerable adverse events, it could be recommended as an adjunctive treatment for moderate COVID-19. Further research on curative effects in more serious cases and in prevention is advisable.

Measurement of Phthalates in Settled Dust in University Dormitories and Its Implications for Exposure Assessment

Six phthalates: dimethyl phthalate (DMP), diethyl phthalate (DEP), di(n-butyl) phthalate (DnBP), butyl benzyl phthalate (BBzP), di(2-ethylhexyl) phthalate (DEHP), and di(n-octyl) phthalate (DOP) in settled dust on different indoor surfaces were measured in 30 university dormitories. A Monte Carlo simulation was used to estimate college students' exposure via inhalation, non-dietary ingestion, and dermal absorption based on measured concentrations. The detection frequencies for targeted phthalates were more than 80% except for DEP (roughly 70%). DEHP was the most prevalent compound in the dust samples, followed by DnBP, DOP, and BBzP. Statistical analysis suggested that phthalate levels were higher in bedside dust than that collected from table surfaces, indicating a nonuniform distribution of dust-phase phthalates in the sleep environment. The simulation showed that the median DMP daily intake was 0.81 μg/kg/day, which was the greatest of the targeted phthalates. For the total exposures to all phthalates, the mean contribution of exposures during the daytime and sleeping time was 54% and 46%, respectively.

Ensayo clínico aleatorizado en pacientes COVID- 19 sobre el efecto de la fisioterapia precoz en su acondicionamiento físico

Introduction: The WHO recommends early rehabilitation and mobilization interventions in patients hospitalized for COVID-19. The benefits of early physiotherapy, during the hospital stay, have not been proven in clinical trials. Objective: To evaluate the effects of early physiotherapy and health education in hospitalized COVID-19 patients, in relation to the symptoms described in previous studies, analyzing differences between groups regarding their physical conditioning, need for oxygen therapy and hospital stay. Methodology: Randomized clinical trial with two arms, developed in hospitalization and intermediate respiratory care units, with COVID-19 patients. Sixty-four patients included in the experimental group (implementation of an early physiotherapy program after 48–72 h of admission) and 62 patients in the control group (usual treatment of the center). Sociodemographic and clinical variables: mMRC, oxygen therapy, MRC-SS, 30 s-STST, FPM, Tinetti, FRAIL Scale and PCFS. They were evaluated on admission, discharge and two months after discharge. Results: The experimental patients had fewer days of admission and conventional oxygen therapy. At discharge, they present a lower risk of falling (72.9% vs. 95.8%) and less weakness in MRC-SS (2.1% vs. 14.6%). At two months they had less frailty (5.0% vs. 14.5%), greater hand grip strength, less dyspnea, better results in 30s-STST and fewer post-COVID limitations (86.5% vs. 96.4%). Conclusión: The intervention of early physiotherapy in COVID-19 patients and the health education received, prevents muscle weakness during admission, improves physical conditioning at discharge and two months later, and reduces the days of hospital stay. ClinicalTrials.gov (NCT05032885). © 2023 Asociación Española de Fisioterapeutas

Transmission of droplet aerosols in an elevator cabin: Effect of the ventilation mode.

The recent outbreak of COVID-19 has threatened public health. Owing to the relatively sealed environment and poor ventilation in elevator cabins, passengers are at risk of respiratory tract infection. However, the distribution and dispersion of droplet aerosols in elevator cabins remain unclear. This study investigated the transmission of droplet aerosols exhaled by a source patient under three ventilation modes. Droplet aerosols produced by nose breathing and mouth coughing were resolved using computational fluid dynamics (CFD) simulations. We adopted the verified renormalization group (RNG) k-ε turbulence model to simulate the flow field and the Lagrangian method to track the droplet aerosols. In addition, the influence of the ventilation mode on droplet transmission was evaluated. The results showed that droplet aerosols gathered in the elevator cabin and were difficult to discharge under the mixed and displacement ventilation modes with specific initial conditions. The inhalation proportion of droplet aerosols for air curtain was 0.016%, which was significantly lower than that for mixed ventilation (0.049%) and displacement ventilation (0.071%). The air curtain confined the transmission of droplet aerosols with the minimum ratios of inhalation, deposition, and suspension and is thus recommended to reduce the exposure risk.

Corticosteroid outcome may be dependent of duration of use in severe COVID-19.

BACKGROUND/AIMS: For patients hospitalized with coronavirus disease 2019 (COVID-19) who require supplemental oxygen, the evidence of the optimal duration of corticosteroid is limited. This study aims to identify whether long-term use of corticosteroids is associated with decreased mortality. METHODS: Between February 10, 2020 and October 31, 2021, we analyzed consecutive hospitalized patients with COVID-19 with severe hypoxemia. The patients were divided into short-term (≤ 14 days) and long-term (> 14 days) corticosteroid users. The primary outcome was 60-day mortality. We performed propensity score (PS) analysis to mitigate the effect of confounders and conducted Kaplan-Meier curve analysis. RESULTS: There were 141 (52%) short-term users and 130 (48%) long-term corticosteroid users. The median age was 68 years and the median PaO2/FiO2 at admission was 158. Of the patients, 40.6% required high-flow nasal cannula, 48.3% required mechanical ventilation, and 11.1% required extracorporeal membrane oxygenation. The overall 60-day mortality rate was 23.2%, and that of patients with hospital-acquired pneumonia (HAP) was 22.9%. The Kaplan-Meier curve for 60- day survival in the PS-matched cohort showed that corticosteroid for > 14 days was associated with decreased mortality (p = 0.0033). There were no significant differences in bacteremia and HAP between the groups. An adjusted odds ratio for the risk of 60-day mortality in short-term users was 5.53 (95% confidence interval, 1.90-18.26; p = 0.003). CONCLUSION: For patients with severe COVID-19, long-term use of corticosteroids was associated with decreased mortality, with no increase in nosocomial complications. Corticosteroid use for > 14 days can benefit patients with severe COVID-19.

Machine learning approach for predicting inhalation injury in patients with burns.

BACKGROUND: The coronavirus disease pandemic has had a tangible impact on bronchoscopy for burn inpatients due to isolation and triage measures. We utilised the machine-learning approach to identify risk factors for predicting mild and severe inhalation injury and whether patients with burns experienced inhalation injury. We also examined the ability of two dichotomous models to predict clinical outcomes including mortality, pneumonia, and duration of hospitalisation. METHODS: A retrospective 14-year single-centre dataset of 341 intubated patients with burns with suspected inhalation injury was established. The medical data on day one of admission and bronchoscopy-diagnosed inhalation injury grade were compiled using a gradient boosting-based machine-learning algorithm to create two prediction models: model 1, mild vs. severe inhalation injury; and model 2, no inhalation injury vs. inhalation injury. RESULTS: The area under the curve (AUC) for model 1 was 0·883, indicating excellent discrimination. The AUC for model 2 was 0·862, indicating acceptable discrimination. In model 1, the incidence of pneumonia (P < 0·001) and mortality rate (P < 0·001), but not duration of hospitalisation (P = 0·1052), were significantly higher in patients with severe inhalation injury. In model 2, the incidence of pneumonia (P < 0·001), mortality (P < 0·001), and duration of hospitalisation (P = 0·021) were significantly higher in patients with inhalation injury. CONCLUSIONS: We developed the first machine-learning tool for differentiating between mild and severe inhalation injury, and the absence/presence of inhalation injury in patients with burns, which is helpful when bronchoscopy is not available immediately. The dichotomous classification predicted by both models was associated with the clinical outcomes.

Ethanol vapor inhalation treatment inhibits lethal respiratory viral infection with Influenza A.

Ethanol (EtOH) effectively inactivates enveloped viruses in vitro, including influenza and SARS-CoV-2. Inhaled EtOH vapor may inhibit viral infection in mammalian respiratory tracts, but this has not yet been demonstrated. Here we report that unexpectedly low EtOH concentrations in solution, approximately 20% (v/v), rapidly inactivate influenza A virus (IAV) at mammalian body temperature (37°C) and are not toxic to lung epithelial cells upon apical exposure. Furthermore, brief exposure to 20% (v/v) EtOH decreases production of infectious progeny viruses in IAV-infected cells. Using an EtOH vapor exposure system that is expected to expose murine respiratory tracts to 20% (v/v) EtOH solution by gas-liquid equilibrium at 37°C, we demonstrate that brief EtOH vapor inhalation twice a day protects mice from lethal IAV respiratory infection by reducing viruses in the lungs without harmful side effects. Our data suggest that EtOH vapor inhalation may provide a versatile therapy against various respiratory viral infectious diseases.