Temporal and geographical variation in low carbon inhaler dispensing in England, 2016 to 2021: an ecological study.

OBJECTIVES: In 2019-2020, four national recommendations were published in the United Kingdom to encourage use of low carbon inhalers. This study aimed to investigate whether these were associated with a change in primary care dispensing in England and to explore associations between geographical variation and clinical commissioning group (CCG) characteristics. DESIGN: Ecological study using aggregated publicly available data. SETTING: All CCGs in England (March 2016 to February 2021). PARTICIPANTS: not applicable. MAIN OUTCOME MEASURES: Percentage of low carbon inhalers dispensed. RESULTS: The percentage of low carbon inhalers dispensed was 26.3% in 2020-2021 (of 8.8 million inhalers). This decreased over the study period for short-acting beta-agonist (SABA), inhaled corticosteroid (ICS) and ICS+long-acting beta-agonist (LABA) inhalers. The same trend was seen for LABA and ICS+LABA+long-acting muscarinic antagonist inhalers from 2019. The SABA and ICS classes were less often dispensed as low carbon inhalers (⁓6% versus 35-45%). Interrupted time series analyses found slight increases in low carbon inhaler percentage in the SABA, LABA and ICS classes after April 2019, which were soon erased by the long-term trend. There was also geographical variation, with the north-west, Birmingham and London consistently dispensing more low carbon inhalers. The presence of advice on climate change in CCG formularies/guidelines, the prevalence of asthma and population age profile were associated with significant variation in low carbon inhaler percentage for some classes. CONCLUSIONS: The percentage of low carbon inhalers dispensed in England remains low and continues to decrease. Greater use of low carbon inhalers is achievable, but is more likely with locally implemented initiatives.

Tube thoracostomy surgery among COVID-19 positive patients in a tertiary care hospital in Bangladesh

Background: Acute respiratory distress syndrome requiring invasive mechanical ventilation may occur in COVID-19 patients. Barotrauma causes clinically severe pneumothorax, necessitating a chest tube thoracostomy. Acute respiratory syndrome coronavirus 2 is aerosolized during the process, hence specific precautions must be taken to minimize exposure risks to health care workers. Objectives: The objective of the study to diagnosis of Tube thoracostomy during the COVID-19 pandemic to detect and diagnose patients who are positive with the virus. Material & Methods: In Bangladesh, researchers from a tertiary care hospital's thoracic surgery section did a retrospective analysis. In total, we had 34 participants. All COVID-19 cases requiring thoracic surgery consultation and management that were admitted to the ICU between July 2020 and January 2022 were included in this study. Iatrogenic pneumothorax and other critical cases not associated with COVID-19 were also eliminated.

Pneumothorax, pneumomediastinum and subcutaneous emphysema in patients with COVID-19 pneumonia: evaluation of 26 cases

Objective: The study aims to contribute to the literature by sharing the treatment process and results of patients who develop pneumothorax, pneumomediastinum, and subcutaneous emphysema, which are rarely seen in COVID-19 pneumonia, and to reveal the possible high mortality situation.

Spontaneous Pneumo-Mediastinum in a Post-COVID-19 Patient with Systemic Sclerosis.

Pulmonary involvement is the most common cause of death among patients with systemic sclerosis (SSc). The current coronavirus disease 2019 (COVID-19) is particularly problematic to manage in SSc patients since they may experience a more severe evolution of COVID-19 due to the pre-existent interstitial lung disease (ILD) and the administration of immunosuppressive treatments. In addition, the remarkable radiological similarities between SSc-ILD and COVID-19 complicate the differential diagnosis between these two entities. Herein, we present the first case of spontaneous pneumo-mediastinum in a post-COVID-19 patient with SSc. In our patient, both smoking and pulmonary fibrosis could lead to cyst formation, which possibly spontaneously broke and caused pneumo-mediastinum. Moreover, megaesophagus perforation due to the smooth muscle atrophy, replacement with fibrosis, and achalasia may extend into the mediastinum or pleural space and has also been described as a rare case of spontaneous pneumo-pericardium. Finally, spontaneous pneumo-mediastinum and pneumothorax have been recently reported as an established complication of severe COVID-19 pneumonia and among COVID-19 long-term complication. This case report underlines that the worsening of respiratory symptoms in SSc patients, especially when recovered from COVID-19, requires further investigations for ruling out other tentative diagnoses besides the evolution of the SSc-ILD.

Pneumorrhachis associated with COVID-19: a rare observation

This paper describe a case of a 46-year-old male with a background of diabetes presented with a week's history of fever followed by breathlessness. On initial evaluation his oxygen saturation was found to be 82 % on ambient air. His chest X-ray showed bilateral peripheral heterogeneous opacities. COVID-19 PCR from nasopharyngeal swab was positive. He was started on high flow nasal cannula and was cared for in the intensive care unit (ICU) as a case of severe COVID-19 pneumonia. He received broad spectrum antibiotics, corticosteroids, low molecular weight heparin, remdesivir, convalescent plasma and off label tocilizumab. A week later, he developed worsening hypoxia, a CT Pulmonary angiogram was done to rule out possible pulmonary embolism but demonstrated extensive pneumomediastinum with surgical emphysema extending in neck, bilateral chest walls and air in the spinal canal, known as pneumorrhachis. He was managed conservatively on high flow nasal cannula and recovered after a long course of hospitalization.

Successful use of endobronchial valve for persistent air leak in a patient with COVID-19 and bullous emphysema.

Patients with SARS-CoV-2 pneumonia can suffer from pneumothorax and persistent air leak (PAL). The pneumothorax occurs with or without pre-existing lung disease. PAL refers to air leak lasting more than 5-7 days and arises due to bronchopleural or alveolopleural fistula. The management of PAL can be challenging as a standard management guideline is lacking. Here we present the case of a 42-year-old smoker with COVID-19 who presented to the hospital with fever, cough, acute left-sided chest pain and shortness of breath. He suffered from a large left-sided pneumothorax requiring immediate chest tube drainage. Unfortunately, the air leak persisted for 13 days before one-way endobronchial valve (EBV) was used with complete resolution of the air leak. We also review the literature regarding other cases of EBV utilisation for PAL in patients with COVID-19.

Pulmonary emphysema, bullae, and pneumothorax in COVID-19 pneumonia.

In this paper, we described 2 cases with COVID-19 pneumonia, who developed pulmonary emphysema, bullae, and pneumothorax during therapy. In a 48-year-old man with mechanical ventilation, parts of ground glass opacities and consolidations transformed into emphysema and giant bulla, and bilateral pneumothorax were also observed. In a 35-year-old man, localized emphysema and pulmonary bullae were seen in subpleural area in bilateral upper lobes, where no previous lesions were presented. In conclusion, pulmonary emphysema, bullae, and pneumothorax could be complications of COVID-19. On one hand, surgical emphysema in ventilated COVID-19 patients was observed as in SARS patients. On the other hand, more serious destruction of lung parenchyma was found in COVID-19 patients.

Fatal pulmonary fibrosis complicating COVID-19 infection in preexistent emphysema.

Only a few earlier clinical radiologic reports exist describing post-COVID-19 pulmonary fibrosis. We report a case of 74-year-old woman referred with dizziness and hypoxemic respiratory failure with chest high resolution computer tomography (HRCT) showing ground glass opacities and emphysema. The patient was tested for Sars-CoV-2 and resulted positive, she was treated with medical therapy and supported with mechanical ventilation. Despite initial clinical and radiological improvements, subsequently the respiratory failure worsened as ground glass opacities evolved, with the appearance of combined pulmonary fibrosis and emphysema and the patient eventually died. Development of pulmonary fibrosis after SARS-CoV-2 infection and the overlap with preexistent emphysema could be a fatal complication.