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Objectives: Treatment of severe respiratory distress syndrome (ARDS) due to COVID-19 by veno-venous extracorporeal membrane oxygenation (VV-ECMO) had a mortality of up to 70% in Germany. Many patients with COVID-19 need VV-ECMO support longer than 28 days (long-term VV-ECMO). Evidence on mortality, complications during intensive care, functional status after discharge and mortality-predictors for patients supported with long-term VV-ECMO is lacking. Method(s): Retrospective study of 137 consecutive patients treated with VV-ECMO for ARDS due to COVID-19 at University Hospital Regensburg from March 2020 to March 2022. Result(s): 38% (n=52;87% male) of patients needed longterm VV-ECMO support. In these, SOFA score (median [IQR]) at ECMO initiation was 9 [8-11], age 58.2 [50.6- 62.5] years, PaO2/FiO2-ratio 67 [52-88] mmHg, pCO262 [52-74] mmHg, Murray-Score 3.3 [3.0-3.6] and PEEP 15 [13 - 16] cmH2O. Duration of long-term support was 45 [35-65] days. 26 (50%) patients were discharged from the ICU. Only one patient died after hospital discharge. At VVECMO initiation, baseline characteristics did not differ between deceased and survivors. Complications were frequent (acute kidney injury: 31/52, renal replacement therapy: 14/52, pulmonary embolism: 21/52, intracranial hemorrhage 8/52, major bleeding 34/52 and secondary sclerosing cholangitis: 5/52) and more frequent in the deceased. Karnofsky index (normal 100) after rehabilitation was 70 [57.5-82.5]. Twelve of the 18 patients discharged from rehabilitation had a satisfactory quality of life according to their own subjective assessment. Four patients required nursing support. Mortality-predictors within the first 30 days on VV-ECMO only observed in those who deceased later, were: Bilirubin >5mg/dl for > 7 days, pulmonary compliance <10ml/mbar for >14 days, and repeated serum concentrations of interleukin 8 >150ng/L. Conclusion(s): Long-term extracorporeal lung support in patients with COVID-19 resulted in 50 % survival and subsequently lead to a satisfactory quality of life and functionality in the majority of patients. It should preferably be performed in experienced centers because of a high incidence of complications. Several findings during the early course were associated with late mortality but need validation in large prospective studies.
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Objectives: Death from SARS-CoV-2 pneumonia resulted from progressive respiratory failure in most patients. Whenever accessible, venovenous extracorporeal membrane oxygenation (VVECMO) was implemented to rescue patients with refractory hypoxemia. Reported mortality in this population reached values from 20 to 50 percent, but the direct causes of death were not so widely acknowledged. The aim of our study was to characterize mortality in patients treated with VVECMO support. Method(s): Retrospective review of a prospectively collected database in an ECMO referral centre. All patients with diagnosis of SARS-CoV-2 infection treated with VVECMO support were included. Survivors and nonsurvivors were compared using t-student and chi2 methods. A Cox regression analysis was performed to identify predictors of mortality at admission. Result(s): Ninety-three patients were included (29% female). Median age was 54+/-12 years, mean SOFA was 5.7+/-2.9 and SAPS II was 35.6+/-13.6. Hospital mortality was 24.7%. Main causes of death were septic shock in 39.1% (9 patients), irreversible lung fibrosis 30.4% (7 patients) and catastrophic hemorrhage in 4.3% (4 patients). End-of-life care measures (withdrawal or withholding) were adopted in 65.2% of non-survivals. Patients who died were older (55 vs 48 years, p<0.05), had longer disease course (19 vs 15.3 days, p<0.05), longer invasive mechanical ventilation course before cannulation (8.5 vs 5 days, p<0.05), lower static lung compliance (25.5 vs 31.8 mL/cmH2O, p<0.05) and were ventilated with lower PEEP (8 vs 10 cmH2O, p<0.05) on cannulation. On a Cox-regression model, only prone ventilation before cannulation (HR 9,7;CI 95% 1,4- 68,6;p<0.05) and SAPS II (HR 1.04;CI 95% 1,001- 1,083;p<0.05) predicted mortality. Conclusion(s): Mortality in patients with severe SARSCoV-2 pneumonia treated with VVECMO was exceedingly low in our study, when compared with other series. Only one-third died from progressive lung disease, which suggests that protocol improvement can further reduce mortality.
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Chapter 1: COVID-19 pathogenesis poses paradoxes difficult to explain with traditional physiology. For instance, since type II pneumocytes are considered the primary cellular target of SARS-CoV-2;as these produce pulmonary surfactant (PS), the possibility that insufficient PS plays a role in COVID-19 pathogenesis has been raised. However, the opposite of predicted high alveolar surface tension is found in many early COVID-19 patients: paradoxically normal lung volumes and high compliance occur, with profound hypoxemia. That 'COVID anomaly' was quickly rationalised by invoking traditional vascular mechanisms-mainly because of surprisingly preserved alveolar surface in early hypoxemic cases. However, that quick rejection of alveolar damage only occurred because the actual mechanism of gas exchange has long been presumed to be non-problematic, due to diffusion through the alveolar surface. On the contrary, we provide physical chemical evidence that gas exchange occurs by an process of expansion and contraction of the three-dimensional structures of PS and its associated proteins. This view explains anomalous observations from the level of cryo-TEM to whole individuals. It encompasses results from premature infants to the deepest diving seals. Once understood, the COVID anomaly dissolves and is straightforwardly explained as covert viral damage to the 3D structure of PS, with direct treatment implications. As a natural experiment, the SARS-CoV-2 virus itself has helped us to simplify and clarify not only the nature of dyspnea and its relationship to pulmonary compliance, but also the fine detail of the PS including such features as water channels which had heretofore been entirely unexpected.Copyright ©
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Introduction: Coronavirus disease 2019 (COVID-19) pneumonia is reportedly associated with air leak syndrome (ALS), including mediastinal emphysema and pneumothorax, and has a high mortality rate. In this study, we compared values obtained every minute from the ventilator to clarify the relationship between ventilatory management and the risk of developing ALS. Method(s): This was a single-center, retrospective, observational study for a 21-months period. Patient background, ventilator data, and outcomes were collected from adult patients with COVID-19 pneumonia on ventilator-assisted respiratory management. The primary outcome was the development of ALS within 30 days of starting ventilator management. Result(s): Of the 105 patients, 14 (13%) developed ALS. The mean positive-end expiratory pressure (PEEP) difference was 0.33 cmH2O (95% confidence interval (CI) 0.31-0.33), and it was higher in the ALS than in the non-ALS group (9.18 +/- 2.20 versus 8.85 +/- 2.63, respectively). For peak pressure, the mean difference was -0.18 cmH2O (95% CI -0.20 to -0.15), (20.70 +/- 5.30 vs. 20.87 +/- 5.65) and the mean pressure difference of -0.05 cmH2O (95% CI -0.04 to -0.07) (12.80 +/- 3.13 vs. 12.85 +/- 3.55, respectively) was also higher in the non-ALS group. The difference in the single ventilation volume per ideal body weight was 0.65 ml/kg (95% CI 0.63-0.66) (7.83 +/- 3.16 vs. 7.18 +/- 2.96, respectively), and the difference in dynamic lung compliance was 8.57 mL/cmH2O (95% CI 8.43-8.70) (50.32 +/- 31.68 vs. 49.68 +/- 15.16, respectively), and both were higher in the ALS group. The percentage of times that the ventilation volume per body weight exceeded 8 was higher in the ALS group (53.7% vs. 38.6%, p < 0.001). Conclusion(s): There was no association between higher ventilator pressures and the development of ALS. The ALS group had higher dynamic lung compliance and higher tidal volumes, which may indicate a pulmonary contribution to ALS, and ventilatory management that limits tidal volume may prevent the development of ALS.
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Introduction: NIRS reduces intubation rate in COVID-19 pneumonia. Outcome is related to age, comorbidities, and baseline illness severity. Thoracic CT has prognostic value in COVID-19 pneumonia. Forced Oscillatory Technique (FOT) allows non-invasive assessment of respiratory reactance (Xrs) that is related to lung compliance. A pilot study showed FOT feasibility in patients with COVID-19 pneumonia receiving NIRS (1). Aim(s): Measuring Xrs in COVID19 patients receiving NIRS and correlate with CT. Method(s): The local ERB approved the study. 32 consecutive patients with moderate-severe COVID-19 ARDS were enrolled. Patients underwent non-invasive ventilation (NIV) alternated to High Flow Nasal Cannula (HFNC). In the first 24 hours of hospitalization triplicate FOT measurements were performed (Resmon ProFULL) according to current guidelines during HFNC. Within 1 week 28 patients underwent computed tomographic pulmonary angiography (CTPA) and collapsed, infiltrated and normally inflated areas were quantified (3D Slicer software). Result(s): 12 patients had altered Xrs-z score. Collapsed areas correlated with Xrs z-score (rho=0.37;p=0.046) and almost with inspiratory Xrs (rho=-0.36;p=0.055). Inflated areas correlated with inspiratory Xrs (rho=0.42;p=0.024) while infiltrated areas didn't. In our cohort CTPA and FOT parameters didn't discriminate outcomes but inflated areas were inversely related to hospitalization (rho=-0.43;p=0.04). Conclusion(s): FOT showed abnormal Xrs in a subset of patients. Xrs z-score is a noninvasive index of collapsed areas in COVID-19 pneumonia and could be useful in patients assessment and follow up.
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During acute respiratory distress syndrome (ARDS), the increase in pulmonary vascular permeability and lung water induced by pulmonary inflammation may be related to altered lung compliance. A better understanding of the interactions between respiratory mechanics variables and lung water or capillary permeability would allow a more personalized monitoring and adaptation of therapies for patients with ARDS. Therefore, our main objective was to investigate the relationship between extravascular lung water (EVLW) and/or pulmonary vascular permeability index (PVPI) and respiratory mechanic variables in patients with COVID-19-induced ARDS. This is a retrospective observational study from prospectively collected data in a cohort of 107 critically ill patients with COVID-19-induced ARDS from March 2020 to May 2021. We analyzed relationships between variables using repeated measurements correlations. We found no clinically relevant correlations between EVLW and the respiratory mechanics variables (driving pressure (correlation coefficient [CI 95%]: 0.017 [-0.064; 0.098]), plateau pressure (0.123 [0.043; 0.202]), respiratory system compliance (-0.003 [-0.084; 0.079]) or positive end-expiratory pressure (0.203 [0.126; 0.278])). Similarly, there were no relevant correlations between PVPI and these same respiratory mechanics variables (0.051 [-0.131; 0.035], 0.059 [-0.022; 0.140], 0.072 [-0.090; 0.153] and 0.22 [0.141; 0.293], respectively). In a cohort of patients with COVID-19-induced ARDS, EVLW and PVPI values are independent from respiratory system compliance and driving pressure. Optimal monitoring of these patients should combine both respiratory and TPTD variables.
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Background: Acute respiratory distress syndrome (ARDS) is one of the manifestations of severe coronavirus disease 2019 (COVID-19) with low respiratory compliance and poor oxygenation as main characteristics and mortality rate of 50%-94%. Surfactants, including surfactant protein D (SP-D), have a role in maintaining respiratory compliance. This study aimed to analyze the relationship between serum SP-D levels with respiratory compliance and ARDS in patients with critically ill COVID-19 pneumonia. Methods: This study was a cross-sectional study. Subjects were adult reverse transcription-polymerase chain reaction-confirmed COVID-19 patients who had ARDS treated with invasive mechanical ventilation. All data were obtained from medical records. Statistical analysis was done using Spearman test, Mann-Whitney test, and receiver operating characteristic curve. Results: Serum level of SP-D was significantly correlated with static respiratory compliance (P = 0.009; correlation coefficient [rs] = 0.467). Serum SP-D levels correlated with ARDS severity (P < 0.001). SP-D levels had a very strong diagnostic value for ARDS severity, with an optimal cutoff value of 44.24 ng/mL (sensitivity 92.3%; specificity 94.1%). ARDS severity also correlated significantly with respiratory compliance (P = 0.005; correlation coefficient 0.496). Conclusion: Higher serum SP-D levels were associated with lower respiratory compliance, ARDS severity, and may be utilized diagnostically to identify patients with severe ARDS.
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Introduction: Whether beach chair position can improve pulmonary compliance in mechanically ventilated subjects with Coronavirus disease 2019 (COVID-19) is unclear. This study aimed to investigate the impact of beach chair position on pulmonary compliance and oxygenation in mechanically ventilated patients with COVID-19. Material(s) and Method(s): Forty-four COVID-19 subjects admitted to intensive care unit (ICU) of our institute who receive invasive mechanical ventilation were enrolled in this observational study. Patients were initially placed in supine position. Following a couple of hours patients were then placed in beach-chair position (head of bed elevated to 30 degrees) at least 16 hours a day. Data from mechanical ventilator was recorded hourly in each position. Total compliance was defined as tidal volume (VT, milliliters) divided by the difference between plateau pressure (cm H2O) and positive end-expiratory pressure (PEEP, cm H2O) Blood gas analysis was performed bi-hourly. Mean values were taken for statistical analysis. The difference in lung compliance, airway resistance, and blood gas analysis between supine and beach chair position was the primary outcome measure of this study. Result(s): Positioning patients form supine to beach-chair led to a significant improvement in lung compliance (29.68+/-10.42 ml/cm H2O vs. 33.96+/-11.71 ml/cm H2O, p<0.001), reduction in airway resistance (17.51+/-8.44 H2O/L/sc vs. 16.73+/-8.06 H2O/L/sc, p<0.001) and led to a significant decline in plateau pressure (30.82+/-5.94 cm H2O vs. 29.98+/-5.68 cm H2O, p=0.001). Moreover a significant improvement in PaO2 was observed following positioning from supine to beach-chair (67.93+/-20.29 mm Hg vs. 87.83+/-27.33 mm Hg, p<0.001). Conclusion(s): Compared to supine position, beach chair positioning improves lung compliance and oxygenation in COVID-19 patients with acute respiratory distress syndrome (ARDS) who receive invasive mechanical ventilation. Copyright © 2022 A. CARBONE Editore. All rights reserved.
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Background and Aims: Coronavirus disease (COVID)-19 has spread across the globe. For a country like India with limited resources and a high population, it is worth knowing how these patients were managed. This prospective study was aimed to evaluate the patient characteristics and risk factors associated with mortality. Methods: The study was conducted from 15 June 2020 to 31 December 2020 in four centres across India. Patients above 18 years of age admitted in the intensive care unit (ICU) with severe COVID-19 pneumonia were included. Details of oxygen therapy and ventilator characteristics were collected for seven days. Results: Of 667 patients included in the study, the average age was 57 (standard deviation (SD) = 15) years and 70.46% were male. The ICU mortality was 60%. Acute physiology, age and chronic health evaluation (APACHE II) score was 29.8 (SD = 6.1). Among various significant risk factors, the need for invasive ventilator support on day 1 [odds ratio (OR): 3.11, 95% confidence interval (CI) (1.91-5.08)] and the development of arrhythmia [OR 3.85 CI (1.69,8.77) confidence interval (CI) (1.69, 8.77)] had higher odds of mortality. PF ratio [partial pressure of arterial oxygen/fraction of inspired oxygen] was 109.31 (77.79-187.26), maximum positive end-expiratory pressure was 10.29 (3.5) cmH2O, driving pressure was 18.22 (6.16) cmH2O, static compliance was 24.20 (8.57) ml/cmH2O and dynamic compliance was 17.55 (5.18) ml/cmH2O on day 1. Proning was used in 67 (22.41%) intubated patients and 44 (11.96%) awake patients. Conclusion: In this cohort of patients, ICU mortality was 60%. The reason for higher mortality could be the severity of illness as suggested by day 1 PF ratio and APACHE II score.
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SESSION TITLE: What Lessons Will We Take From the Pandemic? SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Since the emergence of COVID-19, many serious complications have arisen especially in the setting of Acute Respiratory Distress Syndrome (ARDS) in the intensive care unit. Historically, ARDS and mechanical ventilation is associated with higher rates of pneumothorax. It has been well described that ARDS is the result of inflammatory lung injury, with increased activation of circulating neutrophils, complement and proinflammatory mediators leading to loss of surfactant, alveolar atelectasis, and fibrin deposition. This leads to a less compliant lung parenchyma, and higher airway pressures, which has been attributed as a risk factor for pneumothorax. The management of pneumothorax varies depending on the etiology of the pneumothorax. In the case of iatrogenic pneumothorax (i.e. mechanical ventilation), tube thoracostomy is generally recommended, however the size of the chest tube inserted remains less clear. METHODS: This is a multi-center retrospective cohort study of 88 hospitalized patients with a diagnosis of COVID-19 and pneumothorax or pneumomediastinum between the dates of 3/11/2020 to 01/26/2021. Patient demographics, comorbidities, laboratory and hemodynamic data were collected as well as ventilator settings, lung mechanics, and clinical patient outcome data including type of intervention and rate of resolution of pneumothorax. Final statistical analysis is pending. RESULTS: Our preliminary results reveal that there was a higher rate of resolution of pneumothorax with a large bore chest tube (LBCT) compared to a small bore chest tube (SBCT). There was no significant difference in lung compliance or tidal volume in cc/kg between the patients with a resolving pneumothorax compared to the patients with a nonresolving pneumothorax. Overall mortality rate among all patients was 70.4%. CONCLUSIONS: Patients with a large bore chest tube placed are more likely to have resolution of pneumothorax compared to small bore chest tube or serial X-ray. Lung compliance and tidal volume were not significantly different between patients that had a resolving pneumothorax compared to nonresolving pneumothorax. It is important to manage a pneumothorax early on to reduce associated morbidity. CLINICAL IMPLICATIONS: The development of pneumothorax in COVID patients with ARDS has significant associated morbidity and mortality. Utilization of a large bore chest tube may result in improved rates of resolution of pneumothorax. DISCLOSURES: No relevant relationships by Nathalie Antonios No relevant relationships by Colby Baker No relevant relationships by Jessica Johnson No relevant relationships by Karen Sayad
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SESSION TITLE: ECMO and ARDS in COVID-19 Infections SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/17/2022 12:15 pm - 1:15 pm PURPOSE: The SARS-CoV-2 virus preferentially attacks alveolar Type 2 cells that have the membrane ACE2 receptors. Type 2 cells are the surfactant producing cells in the lung. Damage to Type 2 cells can result in decreased/abnormal surfactant production leading to ARDS and respiratory failure. Surfactant is further inactivated by inflammatory proteins during ARDS. We sought to evaluate the feasibility, safety and tolerability of surfactant therapy in COVID-19 associated ARDS using a synthetic surfactant, lucinactant. METHODS: Open-label, single arm, multicenter study (NCT04389671) in adults with COVID-19 associated ARDS, who have been intubated and on mechanical ventilation (MV) with a P/F ratio <= 300. COVID-19 infection was confirmed by PCR. Lucinactant at a dose of 160 ml (∼80 mg TPL/kg lean body weight) was delivered intratracheally within 7 days of intubation. Retreatment was allowed at >= 6-hour intervals if subjects remained on MV. Assessments included time to deliver the dose, physiologic parameters of oxygenation (P/F, OI, PaO2), FiO2, PaCO2, lung compliance (CL) from baseline (pre-dosing) through day 5 post-dosing. Safety parameters included peri-dosing (PD) events (bradycardia, desaturation, hypotension, regurgitation) and adverse events through 30 days post dosing. RESULTS: 20 subjects were enrolled and 19 received at least one dose. Five subjects received 2 doses of lucinactant. The mean age of subjects was 49 years, 80% were male, 60% were white. The mean time to administer the dose was 31 minutes. FiO2 requirements, PaO2 and PCO2 remained stable throughout the 5-day period post dosing. Baseline mean P/F ratio and standard deviation (SD) was 196 (68), 179 (57) at 12 hours and 193 (61) at day 1 post-dosing, followed by a gradual increase to 223 (105) at day 5. Mean CL increased from 40.5 (16) at baseline to 49.8 (23) at day 5. Seven subjects (37%) died, 6 due to secondary infection and sepsis > 13 days after dosing. Two subjects experienced transient PD events (desaturation, regurgitation). Lucinactant administration in severe ARDS due to COVID-19 was safe and generally well tolerated. The incidence of PD events was low. Stable to improved physiologic parameters of oxygenation were observed post dosing. Increasing the dose and number of administrations may provide additional benefit. CLINICAL IMPLICATIONS: The data support continued study of lucinactant in ARDS patients. DISCLOSURES: Consultant relationship with Windtree Therapeutics Please note: August 2000 Added 03/31/2022 by Carlos Guardia, value=Consulting fee Consultant relationship with Windtree Therapeutics Inc. Please note: August 2000 Added 03/31/2022 by Carlos Guardia, value=Consulting fee Removed 03/31/2022 by Carlos Guardia Advisory Committee Member relationship with Windtree, inc Please note: 4/2021-2/2022 Added 04/04/2022 by Yuh-Chin Huang, value=Grant/Research No relevant relationships Added 04/04/2022 by Peter Morris, value=Consulting fee Removed 04/04/2022 by Peter Morris Employee relationship with Windtree Therapeutics, Inc. Please note: 2008-2022 Added 04/04/2022 by Phillip Simmons, value=Salary Employee relationship with Windtree Therapeutics Please note: 2014 to present Added 04/14/2022 by Steven Simonson, value=Salary
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SESSION TITLE: COVID-19 Case Report Posters 3 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: One of the greatest challenges of the coronavirus (COVID-19) pandemic has been deciphering its unique properties, such as the propensity to infect and damage lung epithelium, thereby increasing susceptibility to pulmonary complications.(1, 2) A 2020 cohort study comparing patients with acute respiratory distress syndrome (ARDS) from COVID-19 and ARDS from other causes showed a significantly higher rate of subcutaneous emphysema and pneumomediastinum in the COVID-19 group, suggesting these diagnoses may be due to direct viral damage rather than exposure to positive pressure alone.(3) Presented here is a patient with no underlying lung pathology who was diagnosed with COVID-19 and developed severe subcutaneous emphysema, pneumomediastinum, and pneumothorax. CASE PRESENTATION: A 74 year old male with a history of hypertension presented to the emergency room with a 5-day history of difficulty breathing, cough, fever, chills, and weakness. He tested positive for COVID-19, required non-invasive positive pressure ventilation (NIPPV), and was started on ceftriaxone, doxycycline, and daily dexamethasone. He received a five-day course of remdesivir and one dose of convalescent plasma. By day 9, a chest x-ray revealed a left apical pneumothorax, bilateral subcutaneous emphysema, and pneumomediastinum. On day 12, his respiratory status deteriorated, necessitating invasive mechanical ventilation. A chest CT showed extensive subcutaneous emphysema involving the chest, supraclavicular and axillary regions, and abdominal wall, as well as extensive pneumomediastinum and a moderate left pneumothorax. A left-sided thoracostomy tube was placed and he was proned per ICU protocol. He required placement of a second left-sided chest tube due to persistent worsening pneumothorax. On day 28, despite all aggressive measures, he expired from acute hypoxemia. DISCUSSION: Although this patient was exposed to NIPPV, the severe degree of lung pathology was inconsistent with the amount of positive pressure administered. Furthermore, he lacked underlying pulmonary disease that would compromise his lung compliance to this magnitude. Combining evidence that COVID-19 can cause epithelial lung damage, the patient's absence of pulmonary risk factors, and his severe degree of lung damage incongruent with his exposure to positive pressure, is reasonable to extrapolate that a significant portion of his lung pathology was a result of direct damage from COVID-19. CONCLUSIONS: Patients with COVID-19 may be at higher risk for the development of subcutaneous emphysema, pneumomediastinum, and pneumothorax, likely due to direct viral effect. Lung damage seen may be disproportionate to exposure of positive pressure and may also be seen in the absence of any underlying pulmonary comorbidities. Awareness of this observed pathophysiology may help guide clinicians to optimize ventilator management as well as anticipate potential complications. Reference #1: Hu B, Guo H, Zhou P, Shi ZL. Characteristics of SARS-CoV-2 and COVID-19 [published correction appears in Nat Rev Microbiol. 2022 Feb 23;:]. Nat Rev Microbiol. 2021;19(3):141-154. doi:10.1038/s41579-020-00459-7 Reference #2: Miró Ò, Llorens P, Jiménez S, et al. Frequency, Risk Factors, Clinical Characteristics, and Outcomes of Spontaneous Pneumothorax in Patients With Coronavirus Disease 2019: A Case-Control, Emergency Medicine-Based Multicenter Study. Chest. 2021;159(3):1241-1255. doi:10.1016/j.chest.2020.11.013 Reference #3: Lemmers DHL, Abu Hilal M, Bnà C, et al. Pneumomediastinum and subcutaneous emphysema in COVID-19: barotrauma or lung frailty?. ERJ Open Res. 2020;6(4):00385-2020. Published 2020 Nov 16. doi:10.1183/23120541.00385-2020 DISCLOSURES: No relevant relationships by Shanaz Azad No relevant relationships by Sarah Monaghan No relevant relationships by Brandon Nance No relevant relationships by Samantha Peterson
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SESSION TITLE: Lessons Learned from Critical Care Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Local compression of the anterior chest wall (CACC) or abdomen has been shown to unexpectedly improve respiratory system compliance in patients with severe acute respiratory distress syndrome (ARDS). The mechanism is thought to be similar to prone positioning, causing a redistribution of transpulmonary pressures. Limited data exists regarding this topic, particularly as it applies to COVID-19. We describe two cases of improved compliance and oxygenation with CACC in individuals with COVID-19 related ARDS, including one with prior lung transplantation. CASE PRESENTATION: Case 1: The patient was an unvaccinated 79 year-old man diagnosed with COVID-19 on admission. One week later, he progressed to requiring CPAP therapy. He was intubated the following week. Prone ventilation was initially attempted, but this was discontinued due to hemodynamic instability. Despite neuromuscular blockade and lung-protective ventilation, the patient's respiratory mechanics continued to worsen. CACC was then initiated using a 10 lb sandbag on the upper thorax, resulting in improved compliance (8 to 11.4 mL/cmH2O) and driving pressure (30 to 21 cmH2O). While CACC allowed room to adjust PEEP, there was no significant change in oxygenation or paCO2. Case 2: The patient was a fully vaccinated 46 year-old man with a history of bilateral lung transplant for cystic fibrosis, who tested positive for COVID-19 and was treated with sotrovimab as an outpatient. Despite early treatment, the patient had worsening hypoxia necessitating admission, treatment with bilevel PAP therapy, and subsequent intubation. Prone ventilation was initiated, but discontinued after 1 day due to worsening hemodynamics and poor improvement. CACC was then employed using two 5 lb sandbags with an improvement in compliance (16.7 to 21.1 mL/cmH2O). There was also a significant improvement in oxygenation (P/F ratio 115 from 86) and a decrease in paCO2. Following this favorable response, prone positioning was resumed, demonstrating similar improvement in respiratory mechanics. DISCUSSION: These cases demonstrate improved respiratory mechanics with CACC, which may be due to a reduction in end-inspiratory over-distention. In the first case, CACC allowed for an increase in PEEP when prone ventilation was not tolerated. In the second case, it was a tool that directed clinicians to resume prone positioning, with favorable improvement in oxygenation. The decrease in paCO2 may signify improved V/Q matching and dead space ventilation. CONCLUSIONS: This case series illustrates CACC as a potential therapeutic and diagnostic tool for clinicians to make lung-protective ventilator adjustments in responders. Trials of CACC may improve compliance and oxygenation in these patients, and may indicate those who would benefit from further prone positioning. Additional investigation is needed to clarify the clinical role of CACC for the management of COVID-19 related ARDS. Reference #1: Marini JJ, Gattinoni L. Improving lung compliance by external compression of the chest wall. Crit Care. 2021;25(1):264. Published 2021 Jul 28. doi:10.1186/s13054-021-03700-8 DISCLOSURES: Speaker/Speaker's Bureau relationship with boehringer ingelheim Please note: $5001 - $20000 by Brad Bemiss, value=Travel and payment for lecture No relevant relationships by Anila Khan No relevant relationships by Rishi Mehta No relevant relationships by Jason Peng
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Pediatric acute respiratory distress syndrome (PARDS) is a life-threatening condition characterized by hypoxemia and is the most important cause of respiratory failure .It has been proposed that adult COVID-19 respiratory illness has two phenotypes: a low compliance ARDS- like phenotype and a normal compliance phenotype with low ventilation to perfusion ratio. The normal compliance phenotype is theorized to be due to a loss of hypoxic pulmonary vasoconstriction although the pediatric presentation in critical care has not been reported yet;the adult phenotype could be considered when managing pediatric patients with severe COVID-19. PARDS characterized by hypoxemia, radiographic haziness and decreased lung ,compliance per the criteria purposed by the pediatric acute lung injury consensus conference group (PALICC). High frequency nasal cannula or NIV by CPAP or BIPAP has been used successfully in pediatric patient with COVID-19 hypoxemia but increases risk of aerosolization and air born transmission that obligate strict airborne precautions. Management in ICU aims to maintain oxygenation while minimizing ventilation induced lung injury (VILI). For mechanical ventilation oxygen supplementation to maintain SPO2 > 92% and OI < 4 or OSI < 5 is recommended. Prone position and HFO ventilation (HFOV) are mostly utilized as rescue oxygenation. Prone position has been used as an adjunct therapy in adult patients with COVID 19 as chest computed tomography shows ground-glass appearance and depended lung injury. Pediatric evidence supp onorting prone position is scarce;however, there have been promising results with improved ventilation in dependent lung regions If HFOV is considered in patients with COVID-19, it should be used cautiously due to the high risk of aerosolization.
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Background: Lung protective ventilation plays a crucial role in the management of patients with COVID-19 ARDS treated with VV-ECMO. We hypothesized that increasingly protective ventilator settings may be associated with improved lung recovery by reducing ventilator induced lung injury. Method(s): We performed a retrospective cohort study of all patients treated with VV-ECMO for COVID-19 at NYU Langone Medical Center from March 2020 to June 2020. Ventilator data including tidal volume (cc/ kg predicted body weight), peak airway pressure, PEEP, Driving pressure (DP), Respiratory Rate, FiO2, lung compliance, and mechanical power were obtained. Pulmonary function test (PFT) results, 6-minute walk test results, and quantitative chest CT scores were obtained from the first outpatient follow up assessment. Bivariate and multivariate analysis correlating ventilator data with lung function and CT outcomes was performed. Result(s): 30 COVID-19 patients were treated with VV-ECMO during the study period, of which 26 survived without lung transplantation and 12 completed follow up assessment at a median of 106 days post ECMO decannulation. Multivariate LASSO regression model results;FEV1: DP (beta=-5.535), Respiratory Rate (beta=-0.370), compliance (beta=0.467), FVC: DP (beta=-4.08), compliance (beta=0.875), preECMO tidal volume (beta=-0.0008), TLC: DP (beta=-4.518), ECMO sweep (beta=-0.598), DLCO: peak airway presure (beta=-1.836), 6MWT distance: compliance (beta=1.436), Chest CT total opacity score: DP(beta=-0.60), preECMO tidal volume(beta=-0.0033). Conclusion(s): Driving pressure and peak airway pressure during VV-ECMO had the strongest associations with improved short-term follow up lung volumes, DLCO, and chest CT outcomes in VV-ECMO treated COVID-19 survivors.
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Introduction: Clinicians in retrieval and transfer medicine face increased diagnostic uncertainty by virtue of their operational environment.1 Integral to our quality improvement and clinical governance framework is individual case analysis, clinical incident interrogation and follow up of every single patient to the point of discharge from critical care. We describe a case where an adverse clinical incident several hours post patient handover was a driver for implementing process and diagnostic change within our own service. Objectives: Describe the translation of after-action review of a critical incident into service improvement. Methods: A 61-year-old patient with severe acute respiratory distress syndrome (ARDS) secondary to coronavirus disease 2019 (COVID-19) developed an ischaemic lower limb. A diagnosis of femoral artery thrombosis was confirmed by computed tomography angiography, necessitating transfer to the regional vascular centre. The transfer was undertaken following emergent intubation of the patient by the referring unit and patient followup proceeded as per our standard operating procedures. Results: The transition to invasive ventilation demonstrated low lung compliance and a poor alveolar-arterial (Aa) gradient in keeping with established ARDS secondary to COVID-19.2 Deterioration in oxygenation and respiratory mechanics was partially (falsely) attributed to switching from semi-recumbent to supine positioning. Within 3 hours of handover to the receiving team, a rapid deterioration in oxygenation and ventilation occurred with subsequent diagnosis of tension pneumothorax. This was managed with an intercostal drain which resulted in a significant drop in peak airway pressure (24cm H2O). Close collaboration between our service and the involved hospitals enabled a detailed multi-service review. A number of missed opportunities were identified for prevention of deterioration due to a tension pneumothorax: 1. Immediate post-intubation x-ray imaging regardless of time-critical nature of transfer 2. Lung POCUS post-intubation or at any point whilst transitioning care 3. Highlighting post-intubation imaging as an immediate post-arrival need at handover Pre-departure, post-intubation x-ray was added to our checklist as a cognitive aid. We further identified lung point of care ultrasound (POCUS), an established adjunct to clinical examination,3,4 as a potentially missing diagnostic safety-net. Consequently, we set out to introduce a lung POCUS operating policy. This includes a device optimised for the pre-hospital environment (VScan Air, GE Healthcare, USA), training package, decision-aid algorithm, and overarching governance. We will monitor the diagnostic impact of this tool and benchmark against previously published literature.3,4 Conclusion: Robust followup, governance, and stakeholder engagement allowed us to identify an adverse event detected several hours post patient disposition at the receiving site. With an increasing volume and complexity of transfers, diagnostic adjuncts formerly considered the exclusively the domain of in-hospital practice may well become core techniques in retrieval medicine.
ABSTRACT
Introduction: Acute Disseminated Encephalomyelitis (ADEM) is a rare, immune-mediated, demyelinating disorder of the central nervous system characterized by acute encephalopathy with neurologic deficits and MRI findings consistent with multifocal demyelination requiring immunosuppression for therapy.1,2 Patients seldom develop hypoxia during the course of the illness, requiring prone ventilation to improve oxygenation which is the first line of therapy and a proven standard of care in patients with ARDS.3,4We would like to present a case of ADEM where a patient developed unexplained hypoxia requiring prone ventilation. Case description: A 35-year-old male with no significant past medical history presented to our neuro-specialist centre with one day history of severe lower back pain associated with lower limb weakness and numbness. His symptoms, which commenced 10 days post his Covid vaccination, rapidly progressed over 2 days of hospital admission to involve right upper limb & facial weakness. MRI scan of brain and spine showed features of ADEM and pulse Methylprednisolone was initiated. CT thorax and abdomen on admission was unremarkable. He was transferred to the critical care unit in view of progressive ascending paralysis and was intubated on his 5th inpatient day due to involvement of respiratory muscles. Following 4 cycles of plasma exchange with albumin (day 6,7,9 and 10 of hospital admission), he developed unexplained hypoxic episodes which eventually resulted in sustained hypoxia, requiring 100% oxygen. Airway pressures and lung compliance were within normal range. Bedside ultrasound demonstrated good lung sliding in all lung fields and good left ventricular contractility with no evidence of right ventricular dilatation. There was no evidence of pericardial/pleural effusion. CT thorax repeated on day 9 showed no features of acute thromboembolic disease and there were no signs of lung parenchymal involvement. Formal echocardiography with bubble test showed normal heart with no evidence of patent foramen ovale. Multi-disciplinary discussions involving cardiology, respiratory, neurology teams and regional ECMO centre could not explain the enigma of impaired oxygenation. The patient responded well to 16 hours of prone ventilation on day 10 with decreasing oxygen requirements. In the subsequent 3 months of his inpatient stay, he was weaned off oxygen and was tracheostomised in view of his neurological illness. He continues to receive physiotherapy and neuro rehabilitation which had led to clinical improvement. Conclusion: The possible reason for hypoxia could be impaired tissue oxygenation post plasma exchange. However, it could be a coincidental finding and there is not much literature to explain this phenomenon and warrants further research.5.
ABSTRACT
Background: Coronavirus disease 2019 (COVID-19) has been frequently complicated by severe acute respiratory distress syndrome (ARDS) with prolonged invasive ventilation. While respiratory system compliance and lung recruitability have been described within the first days after ICU admission, data about their longitudinal changes are still limited. Therefore, we conducted this study to assess the evolution of respiratory system compliance and lung recruitability in patients with COVID-19-related ARDS. Method: We conducted a prospective single-center study in patients admitted for COVID-19-related ARDS during the first wave of the pandemic, from March 16, 2020 to April 10, 2020. Respiratory system compliance was calculated daily at clinical positive end-expiratory pressure (PEEP) during passive breathing. The potential for lung recruitment was assessed by measuring the volume derecruited between PEEP 15 cmH2O and 5 cmH2O, and using the calculation of the recruitment-to-inflation ratio (R/I ratio). Recruitable lung was considered when the R/I ratio was at least 0.5. The primary outcome was the evolution of respiratory mechanics over time. The secondary outcome was the evolution of lung recruitability over time. Results: Thirty-two patients were included in this study. The respiratory mechanics were assessed 222 times (7 ± 5 times per patient). Respiratory system compliance at clinical PEEP was 29.1 mL/cmH2O (interquartile range [IQR]: 24.1-33.9 mL/cmH2O) and decreased significantly over time (P <0.0001). Lung recruitability was assessed in 22 out of the 32 patients (60 assessments). The median volume derecruited between PEEP 15 cmH2O and 5 cmH2O was 246.8 mL (IQR: 180.8-352.2 mL) and the median R/I ratio was 0.56 (IQR: 0.39-0.73). Neither changed significantly over time. The proportion of patients with recruitable lung was 50.0% (6/12) within the first 3 days after intubation, 69.2% (9/13) between day 4 and day 7, and 66.7% (8/12) after day 7 (P=0.7934). Conclusions: In our cohort, respiratory system compliance was low and decreased over time. The potential for lung recruitment was high and persisted despite prolonged mechanical ventilation, suggesting that maintaining high PEEP levels in the later course of COVID-19 could be adequate.
ABSTRACT
Aim and background: Since the beginning of COVID-19 pandemic, we have come across a large number of ARDS patients with different presentations and clinical manifestations. The usual management is using a lung-protective ventilatory strategy followed by proning to improve oxygenation. Here, we present a case where the usual management failed to improve oxygenation which led us to think of co-existing alternative diagnosis. Case description: A 59-year-old male with a history of cardiovascular disease, presented with cough and breathing difficulty for 10 days and COVID RT PCR was positive. He was started on remdesivir, steroids, anti-coagulants, and other supportive measures but worsened and had to be intubated and mechanically ventilated. Lung-protective ventilation was initiated but the patient remained hypoxic even at 100% fiO2. Chest X-ray and HRCT did not show much severity and the measured lung compliance was also good. A transesophageal ECHO showed good LV function and no significant diastolic dysfunction. 2 sessions of proning were done and yet the oxygenation did not improve. Repeat HRCT + CTPA was done to look for pulmonary embolism but it instead revealed a pulmonary AV malformation. Coiling of the AV malformation was done. Oxygenation then substantially improved. Further sessions of proning were done and patient was gradually weaned off. Conclusion: There may be several co-existing causes of ventilation-perfusion mismatch which needs to be looked for. Pulmonary AV malformation, though rare, can cause shunting and hence persistent hypoxia.
ABSTRACT
Aim and background: Mechanical Power in ARDS has predictive value for both VILI and mortality. Driving pressure and mechanical power are two new targets in the mechanical ventilation of ARDS patients. COVID-19 pneumonia has two different phenotypes H type and L type which have different lung compliance, elasticity, and recrutability with different ventilatory strategies. We want to observe how Mechanical Power behaves in H type COVID-19 ARDS and its correlation with compliance and driving pressure. Objective: To study the correlation of Mechanical Power with Driving Pressure and Compliance in H type of COVID-19 pneumonia. Materials and methods: It is a prospective observational study conducted in COVID-19 patients admitted to the Medical Intensive Care unit. We included 65 adult COVID-19 patients aged between 18 and 70 years requiring invasive mechanical ventilation for at least 24 hours. Patients who developed spontaneous pneumothorax and pneumomediastinum before initiation of mechanical ventilation were excluded. Patients were categorised to H type based on lung compliance (<40 mL/cmH2O), recrutability, and lung weight. The Mechanical Power was calculated using the following equation, MP = 0.098 × TV × RR (Paw-1/2 ΔP). Paw-peak airway pressure, ΔP-driving pressure, TV-tidal volume, RR-respiratory rate. The variables are taken at 3 different time intervals in the first 24 hours of invasive mechanical ventilation. All patients are ventilated according to ARDSNET protocol. The Driving pressure and compliance were recorded. The correlation of Mechanical Power with Driving pressure and Compliance were analysed using Pearson Correlation. Results: The mean age of the patients was 57.04 ± 13.96 years (mean ± SD), gender distribution 75% were males and 25% were females. A positive correlation was observed between Mechanical power and Driving pressure (Pearson correlation 0.245) which is statistically significant p = 0.049. A negative correlation was observed between Mechanical power and Compliance (Pearson correlation 0.183) which is not statistically significant. Conclusion: The Mechanical Power and Driving pressure the new targets of Ventilator-Induced Lung Injury (VILI) and also predictors of mortality in ARDS patients. The positive correlation between Mechanical Power and Driving pressure was observed in H type of COVID-19 patients which behaves similar to other ARDS and independent risk factors of mortality in H type of COVID-19 ARDS too.