Role of ultrasound in acute respiratory failure and in the weaning of mechanical ventilation

Comprehensive ultrasound assessment has become an essential tool to facilitate diagnosis and therapeutic management in critically ill patients with acute respiratory failure (ARF). There is evidence supporting the use of ultrasound for the diagnosis of pneumothorax, acute respiratory distress syndrome, cardiogenic pulmonary edema, pneumonia, acute pulmonary thromboembolism, and the patient with COVID-19. In addition, in recent years, the use of ultrasound to evaluate response to treatments in critically ill patients with ARF has been developed, providing a non-invasive tool for titrating positive end-expiratory pressure, monitoring recruitment maneuvers and response to prone, as well as to facilitate weaning from mechanical ventilation. The objective of this review is to summarize the basic concepts on the utility of ultrasound in the diagnosis and monitoring of critically ill patients with ARF.Copyright © 2023 Elsevier Espana, S.L.U. y SEMICYUC

Po251 / #854 Noninvasive Closed Loop Diaphragm Stimulation for Ventilated Icu Patients: E-Poster Viewing

Introduction: Many COVID-19 patients need prolonged artificial ventilation. Skeletal muscle wastes rapidly when deprived of neural activation, and in ventilated patients the diaphragm muscle begins to atrophy within 24 hours (ventilator induced diaphragmatic dysfunction, VIDD). This profoundly weakens the diaphragm, complicating the weaning of the patient off the ventilator, and increasing the risk of complications such as bacterial pneumonia. 40% of the total duration of mechanical ventilation in ITU patients is accounted for by the weaning period, after the initial illness has resolved. Prevention of VIDD would therefore both improve individual outcomes, and also release ITU capacity. We aim to prevent VIDD by exercising the diaphragm with electrical stimulation of the nerves that control it. Evidence suggests that muscle wasting can be prevented by quite low levels of exercise (e.g. 200 contractions per day). Materials / Methods: The diaphragm is activated by the phrenic nerves, formed from branches of the C3-C5 nerve roots in the neck. These nerves may be electrically stimulated in the lower neck. An electrode array is positioned on each side of the neck using surface landmarks. The system automatically determines the best electrode to use in each array. Sensors built into the ventilatory circuit are monitored both to match stimulation to the respiratory cycle and to determine the effects of stimulation. Result(s): We have designed and built a prototype system for unsupervised noninvasive phrenic nerve stimulation. The system delivers one contraction every 7 minutes, synchronised to early inspiration so as not to disrupt ventilation. Electrode impedances are measured before each stimulus, and the closed loop system continuously monitors the effects of stimulation on airflow and adjusts stimulation parameters to compensate for changes in coupling, for example due to head movement. Discussion(s): This stimulator system overcomes several limitations of existing solutions, namely the resource implications and risk profile of invasive electrodes, and the requirement for supervised operation. While invasive systems are applied selectively for these reasons, routine use of our system can be envisaged. This system was inspired by COVID-19 patients but is not limited to them, and has broad applicability to ventilated intensive care patients in general, for example patients with traumatic brain injury. Conclusion(s): Non-invasive stimulation of the phrenic nerves using pressure-free skin surface electrodes is feasible and safe. It offers the potential for prevention of VIDD and thereby faster ventilator weaning and shorter stay on ITU. Clinical trials are planned in 2022. Learning Objectives: After this presentation delegates should be aware of: 1. Ventilation induced diaphragm dysfunction (VIDD) and its importance in patients having lengthy periods of ventilation, as in many cases of COVID-19. 2. The fact that low levels of activity can maintain the condition of skeletal muscles including the diaphragm muscle 3. The potential for noninvasive stimulation of the phrenic nerves to provide 'diaphragm exercise' and prevent VIDD. Keywords: phrenic nerve stimulation, diaphragm, ventilation, COVID-19Copyright © 2022

Markedly prolonged compound muscle action potential duration in a patient with coronavirus disease 2019 related critical illness myopathy

A 56-year-old man admitted with coronavirus disease 2019 (COVID-19) became severely ill, required ventilator support and intensive care unit management. After ventilator weaning, he was found to have quadriparesis. Guillain-Barre syndrome (GBS) was suspected and administration of high-dose intravenous immunoglobulin (IVIg) was considered. However, markedly prolonged compound muscle action potential (CMAP) duration was observed, leading to a diagnosis of critical illness myopathy (CIM). Therefore, IVIg was not given at all, and supportive care was continued. A good functional recovery was obtained. Prolonged CMAP duration is a characteristic finding to CIM. CIM following severe COVID-19 infection is probably common, although the diagnostic value of prolonged CMAP duration is not widely recognized. This characteristic finding deserves more attention because it contributes to early differentiation between CIM and GBS and the use of IVIg in patients with COVID-19 may cause thrombotic complications and worsen the prognosis.Copyright © 2023 The Authors. Neurology and Clinical Neuroscience published by Japanese Society of Neurology and John Wiley & Sons Australia, Ltd.

Lung Transplantation in Patients with Irreversible Lung Injury Due to SARS-CoV-2: A Single-Center Experience

Background: Lung transplantation (LTx) has been demonstrated to be a feasible therapy in patients with irreversible lung injury due to SARS-CoV-2. Aim of this retrospective study was to present our experience with LTx in SARS-CoV-2 patients. Method(s): Records of the 136 patients who underwent LTx between January 2021 and August 2022 at our institution were retrospectively reviewed. LTx was performed in SARS-CoV-2 patients who showed radiological evidence of irreversible lung failure, after failed attempts of weaning off mechanical ventilation (MV) and ECMO;showed single-organ dysfunction;were SARS-CoV-2 negative, preferably <65 years old and awake under MV and ECMO support. Graft survival was compared between COVID-19 LTx patients and contemporary patients transplanted for other indications. Median follow-up amounted to 7.6 (5.2-14.5) months. Result(s): Among the 79 patients with SARS-CoV-2 lung failure referred for LTx, 9 (11%) patients were listed, 8 of them being transplanted between January 2021 and August 2022. One patient died while on the waiting list. All were on MV and ECMO support (awake in 6 cases) for a median ECMO support time of 75 (38.5-152.8) days. Four (50%) patients were male and median age was 52 (37-57) years. All patients underwent bilateral LTx on ECMO support that was weaned off in all patients at the end of Tx. After LTx, 2 (25%) patients showed a primary graft dysfunction (PGD) score grade 3 at 72 hours and required reinstitution of veno-venous (n = 1) and veno-arterial (n = 1) ECMO support that was successfully weaned after 7 and 6 days, respectively. One patient (12.5%) required rethoracotomy for bleeding, and two (25%) patients required new hemodialysis treatment, with recovery of renal function in all patients. Median MV time amounted to 8 days (1-30), median intensive care unit stay to 19 (13-26) days, and median hospital stay to 91 (62-103) days. No patient died in-hospital. At 1-year follow-up, graft survival was 100% in SARS-CoV-2 LTx patients and 95% for patients (n = 128) transplanted for other indications (p = 0.539). Conclusion(s): Lung transplantation in highly selected SARS-CoV-2 patients yielded excellent posttransplant results. Graft survival was comparable between patients transplanted for SARS-COV-2 pneumonia and patients transplanted for other indications. A multidisciplinary approach is of paramount importance to successfully bridge these patients to transplantation and to guarantee a complete patient functional recovery after transplantation.

Predictive indexes in prolonged weaning of mechanical ventilation due to tracheostomy in patients with COVID19 pneumonia

Introduction: In the pandemic, porlonged weaning(PW) of mechanical ventilation (wMV) of COVID patients in the intermediate respiratory care unit IRCU was performed. It was necessary to use predictive indexes for(wMV), which do not generate aerosolization of viral particles. Objetive: To develop a oredictive indexes for wMV and tracheostomy decannulation (TCHd) for COVID-19 pneumonia in IRCU. Method(s): The sample consists of 76 serial cases to the IRCU, in 2020 and 2021. Indexes were developed with an oxygenation variable (PaO2/FiO2) or (SatO2/FiO2), respiratory rate (RR) and corrected (C) in based alveolar ventilation (PCO2), the following indexes were developed as predictors of wMV;ventilation-oxygenation index IVOX= (PaFi/RR), IVOX corrected for PCO2 is IVOX-C=(IVOX x Oco2) and with SaFi the SIVOX-C= [(SaFi/RR) x PCO2]. The StatPlus 7.3 program forWindows was used of the Mann-Whitney U (M-WU) comparing their mean values, using binary logistic regression (BLR) and area under curve AUC ROC to compare their predictability. Result(s): Mean age 58,9 +/-14,4;male 53,7% and the stay in the IRCU was 16,7+/- 11 days, mortality of 28,3%(22);received MV (71,0%) 54. wMV was(70,4%)38 and TCHd was (67,3)35. The mean differrences in disconnected and non-diconnected from MV analyzed by M-WU are significante. An BLR model was built to analyze the predictive behavior ofIVOX, IVOX-C and SIVOX-C for wMV. It was observed that the three indexes are predictive, but IVOX-C and SIVOX-C have the highest predictive weight. In turn the AUC ROC was significance. Conclusion(s): The construction of a predictive indexes of wMV and TCHd in this sample the patients who reached the objective.

VACCINE-INDUCED THROMBOCYTOPENIA AND THROMBOSIS: SAILING CLOSE TO THE WIND IN A PANDEMIC

SESSION TITLE: Issues After COVID-19 Vaccination Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Ever since the global introduction of adenovirus-vector COVID-19 vaccines, cases of cerebral venous sinus thrombosis and thrombocytopenia after immunization has been reported, posing a challenge to global effects on vaccine implementation. CASE PRESENTATION: A previously healthy 33 year old male presented to emergency room with altered mental status after a left sided seizure episode at home. Patient had a 1week history of occipital headache after receiving Ad26.COV2·S Johnson and Johnson vaccine 2 weeks prior. MRI showed superior sagittal sinus thrombosis and right high frontal hemorrhage 8.6x4.7x4.9 cm. CT angiography confirmed nearly occlusive thrombosis of superior sagittal sinus with extension to right transverse sinus. Noted to have a hemoglobin of 15, platelet count of 74000, PT/INR 16/1.2 and PTT of 28. Started on intravenous heparin and intubated for GCS of 4. Heparin was stopped due to supra therapeutic PTT of 200 overnight, drop in platelet count to 55 and hemoglobin to 13. Repeat ct head done for change in neurological exam of dilated right pupil, showed frontoparietal hemorrhage 9.3 cmx4.1 cm and 7 mm midline shift. Heparin was reversed with protamine and transfused 1 unit platelets prior to emergent decompressive craniectomy and thrombectomy. Heparin induced platelet antibody and SRA came back positive confirming vaccine induced thrombocytopenia and thrombosis. Treatment was initiated with argatroban and IVIG. Platelet count improved with no further propagation of thrombus. Patient underwent feeding tube and tracheostomy placement after 10 days due to prolonged ventilator weaning period and poor mental status. Patient's neurological status continued to improve significantly over subsequent months in acute rehabilitation facility with only residual left sided hemiparesis. Patient was successfully decannulated and anticoagulation switched to apixaban DISCUSSION: Possible pathophysiology is thought to be due to a trigger in spike protein production after biodistribution of adenovirus vaccine and a subsequent autoimmune response resulting in thrombosis. Similar to HIT, platelet consumption leads to thrombocytopenia and the continued platelet and monocyte activation increases thrombin generation, resulting in thrombosis. CDC advices to maintain a high suspicion of cases with symptoms that may indicate an underlying thrombotic event along with simultaneous thrombocytopenia. Heparin use is discouraged, unless HIT testing is negative. The International Society on Thrombosis and Hemostasis (ISTH), recommend considering non-heparin anticoagulants and high-dose intravenous immunoglobulin (IVIG). While platelet transfusions are avoided, rapid progression with rising ICP may necessitate transfusion to enable neurosurgical intervention CONCLUSIONS: Management of complications including seizures and elevated intracranial pressure (ICP) is essential to reduce morbidity and mortality risk. Reference #1: Greinacher A, Thiele T, Warkentin TE, Weisser K, Kyrle PA, Eichinger S. Thrombotic thrombocytopenia after ChAdOx1 nCov-19 vaccination. N Engl J Med 2021;384:2092–101. Reference #2: Muir KL, Kallam A, Koepsell SA, Gundabolu K. Thrombotic thrombocytopenia after Ad26.COV2.S vaccination. N Engl J Med 2021;384:1964–5 Reference #3: Pavord S, Scully M, Hunt BJ, et al. Clinical Features of Vaccine-Induced Immune Thrombocytopenia and Thrombosis. N Engl J Med 2021;385:1680–9 DISCLOSURES: No relevant relationships by Axel Duval No relevant relationships by Nadish Garg No relevant relationships by ARCHANA SREEKANTAN NAIR

A FOUR-BODING FUTURE: POLYVIRAL INFECTION WITH SARS-COV-2, PARAINFLUENZA VIRUS TYPE 3, INFLUENZA A, AND ADENOVIRUS

SESSION TITLE: COVID-19 Co-Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Over the past 2 years, SARS-CoV-2 has been undergoing research regarding its immunopathology, with its understanding continuously evolving. We present a case of severe respiratory failure from viral co-infection with SARS-CoV-2, parainfluenza virus III, influenza A, and adenovirus. CASE PRESENTATION: A 42-year-old female with no respiratory or immunological comorbidities, was admitted with respiratory failure that progressed within days to severe septic shock and refractory hypoxemia requiring venovenous extracorporeal membrane oxygenation (VV-ECMO). On initial laboratory evaluation, her nasopharyngeal swab sample tested positive for SARS-CoV-2, Parainfluenza virus III, Influenza A, and Adenovirus on our institute's ROCHE PCR detection test. This was then confirmed with an endotracheal sample and a BAL sample, each of which tested positive for the above 4 viruses. The patient had no prior history of lung disease, autoimmune disorder, immunodeficiency, or malignancy. Serum immunoglobulin levels were within normal range, and the patient tested negative for HIV. She was not on any immunomodulators, and had no known contacts with individuals with polyviral infection. Her presentation had been usual, with 6 days of fever, shortness of breath, extreme fatigue, coughing, and diarrhea. She had initially received treatment with remdesivir, tocilizumab, and dexamethasone. But these tests were noted to be positive prior to her receiving any therapies. Her hospital course was complicated by septic shock, refractory hypoxemia, secondary ventilator associated pneumonia, and fungemia, requiring invasive mechanical ventilation, inhaled nitric oxide, vasopressors, broad spectrum antimicrobials, and eventually rescue by VV-ECMO. She slowly recovered over 6 weeks, received a tracheostomy and was discharged to a long-term acute care hospital for continued rehabilitation and weaning from mechanical ventilation. At 1 year follow up, she has made a full recovery with no residual respiratory limitation. DISCUSSION: Co-infection is defined as infection at diagnosis within 7 days of initial primary infection, whereas, secondary infection develops after 7 days. Co-infection of respiratory viruses, though uncommon, has been reported. Their detection has improved with the use of PCR testing. Simultaneous infection of COVID-19 and usual respiratory viruses has also been documented. Effect of co-infection on disease severity is a result of interaction of viruses among themselves and with the host. CONCLUSIONS: COVID-19 research has mainly focused on SARS-CoV-2 effects on the human host, but with it evolving into an endemic, its interaction and co- and superinfection with other pathogens is imperative. Further research into such interactions of SARS-CoV2 are required to help develop preventative and therapeutic measures. Reference #1: Lansbury L, Lim B, Baskaran V, Lim WS. Co-infections in people with covid-19: A systematic review and meta-analysis. SSRN Electronic Journal. 2020. Reference #2: Kim D, Quinn J, Pinsky B, Shah NH, Brown I. Rates of co-infection between SARS-COV-2 and other respiratory pathogens. JAMA. 2020;323(20):2085. Reference #3: DaPalma T, Doonan BP, Trager NM, Kasman LM. A systematic approach to virus–virus interactions. Virus Research. 2010;149(1):1-9. DISCLOSURES: No relevant relationships by Vinita Kusupati No relevant relationships by Jyoti Lenka No relevant relationships by Rachel Tan

Convalescent Plasma Therapy in the Management of a Pediatric Patient with COVID-19 Infection

Introduction: In 2020, coronavirus rapidly became a global pandemic leading to high mortality rates. Extensive studies done have yet to provide consistent and successful treatment options to improve disease progression and mortality. Convalescent plasma is being studied in adults with very minimal studies in the pediatric population. Here we report a case of a 16 year old with COVID-19 infection resulting in ARDS who showed drastic improvement after convalescent plasma therapy. Case Description: A 16 year old female with morbid obesity, presented to our pediatric emergency department (ED) for a 5 day history of fever, cough, congestion and respiratory distress, along with vomiting, diarrhea and diffuse abdominal pain. Patient arrived on 3 LPM (or litres/min) of oxygen, vitals stable and in no acute respiratory distress, with bilateral coarse breath sounds and diffuse abdominal pain. She tested positive on PCR test for SARSCoV-2 done via nasopharyngeal swab, otherwise unremarkable blood count and comprehensive metabolic panel. Imaging showed chest x-ray with multifocal pneumonia and an electrocardiogram was normal. She was admitted and treated Remdesivir and IV immunoglobulin (IVIG) due to the concern for multi system inflammatory syndrome in children (MIS-C). She was started on a 5 day course of low dose steroids. However, by the third day of hospitalisation, patient's respiratory status rapidly declined, eventually requiring intubation and mechanical ventilation. She was placed on Synchronised Intermittent Mandatory Ventilation (SIMV) mode, volume control with autoflow, tidal volume 550ml, requiring up to FiO2 of 80-90% and peak inspiratory pressure was ranging from 36-45. Following Mayo clinic protocol and attaining emergent FDA approval, she received Covid-19 convalescent plasma, following which she showed significant improvement in peak inspiratory pressure (ranging 20-30), within 24-36 hours of plasma therapy. Through the course of the next few days, the patient tolerated successful weaning of respiratory support and was extubated and gradually weaned to room air. She showed tremendous recovery and was discharged home. Discussion: COVID-19 infection continues to show high mortality rates. Studies show that obesity is a risk factor for severe illness as seen in case. The use of convalescent plasma along with significantly improved this patient's clinical status which is also seen on imaging. Convalescent plasma has previously been used successfully for the treatment of other viral infections including SARS-CoV, Middle East respiratory syndrome, influenza A (H1N1), and Ebola. Data from these infections also suggest that convalescent plasma is most effective when given early in the disease process. Conclusion: COVID-19 is a serious infection leading to multifocal pneumonia, ARDS and death, even in children. This case report shows the beneficial use of convalescent plasma therapy in a pediatric patient. There continues to be a need for further studies on pediatric patients on management, of which convalescent plasma is a considerable option.

Pulmonary rehabilitation in post-acute COVID-19 critical patients

Respiratory rehabilitation (RR) in pulmonary rehabilitation units with expertise in weaning from mechanical ventilation (MV) may have a significant role in the management of post-acute critical COVID-19 patients with a prolonged dependance from MV. Although these patients have a very severe functional impairment, they show in general a more significant and faster recovery of spontaneous ventilation and exercise capacity than patients undergo-ing rehabilitation after discharge from ICUs due to non-COVID respiratory problems.

Impact of tracheostomy in patients with severe acute respiratory syndrome due to coronavirus infection

OBJECTIVE. To estimate the effect of tracheostomy on ventilation in patients with COVID-19. MATERIAL AND METHODS. An observational, retrospective, analytical, longitudinal study of a consecutive series of cases was carried out between April 2020 and March 2021. The study included data about different variables, such as age, sex, comorbidities, time of orotracheal intubation, place of surgery, complications and death, ventilatory parameters, blood gas and time of the weaning after tracheostomy. Descriptive statistics were used with measures of central tendency, measures of dispersion and the Wilcoxon test to see differences in the ventilatory parameters. RESULTS. The study was performed on 130 patients admitted to the ICU with intubation to manage their critical condition. From these patients, the study group included 31 who underwent tracheostomy, 25 males (80.64%) with a mean age of 57.1±13.395 years and with 20.52±6.722 days in orotracheal intubation. Among the most frequent comorbidities, we encountered: arterial hypertension (51.6%), obesity (35.4%), diabetes mellitus (22.5%), hypothyroidism (6.4%), asthma (3.2%), pregnancy (3.2%), chronic obstructive pulmonary disease (3.2%) and obstructive sleep apnea syndrome (3.2%). The main complications were bleeding (12.9%) and decannulation (3.2%). The survival rate was 90.32%. Comparing the pre-surgical and postoperative outcomes of the ventilatory parameters and blood gas, statistically significant differences were found only in case of PEEP (p = 0.033), FiO2 (p = 0.001) and O2 saturation (p = 0.001). The average removal of the ventilator was 4.3±2.437 days. CONCLUSION. There were no significant changes in the ventilatory parameters, however, they were sufficient to wean the patients from the ventilation team and discharge them to the internal medicine department to continue their management outside the intensive care unit. [ FROM AUTHOR] Copyright of Romanian Journal of Rhinology is the property of Romanian Rhinologic Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Subclavian Cannulation Strategy

Background: For patients with acute respiratory distress requiring veno-venous (VV) extracorporeal membrane oxygenation (ECMO), there are several cannulation strategies that may be used. The typical cannulation strategy for VV ECMO is either femoral-femoral or a femoral-internal jugular due to the advantage of using larger vessels to access and can typically be done at the bedside under ultrasound and x-ray guidance. However, there is concern for limited mobility and an increased risk of infection due to the location of the cannulas. VV ECMO with a dual-lumen cannula placed via the subclavian approach is an effective cannulation strategy. Case Review: 38-year-old male with a past medical history of childhood asthma and depression. He was hospitalized for respiratory failure due to COVID-19 and intubated on hospital day 2. Despite heavy sedation, paralytics, and prone positioning, his P/F ratio remained less than 50 with peak pressures in the 40s. The multidisciplinary team decided to proceed with cannulation for VV ECMO on day four of intubation. He was cannulated using a 25 French multistage cannula via the left common femoral vein and a 21 French single-stage return cannula via the right common femoral vein. He underwent a tracheostomy on ECMO day four and was able to tolerate weaning of the ventilator over the next few days. Despite only requiring a sweep gas flow of 0.5L/min on ECMO day six, the patient had worsening oxygenation and was unable to achieve a blood flow of more than 3L/min due to chatter. The chest x-ray (CXR) revealed the drainage cannula was now too high and his PaO2 decreased from 101 to 50 despite the same ventilator settings. The drainage cannula was pulled back 6cm at the bedside and flows were increased from 3L/min to 4 L/min with an increase in the PaO2 to 83. On ECMO day seven, oxygenation remained suboptimal and the CXR demonstrated a worsening pneumomediastinum, so the decision was made to transition the patient to a dual-lumen cannula in order to optimize ECMO flow and allow for more aggressive weaning of the ventilator. By ECMO day 12, he was weaned off sedation, out of bed with physical therapy, tolerating CPAP and able to Facetime with his family. ECMO support was utilized to allow for more aggressive ventilator weaning given the pneumomediastinum and increase rehab and nutrition. On ECMO day 16, he was weaned off sweep while on a T-piece with 20L 60%. He remained off sweep for 24 hours and tolerated physical therapy without requiring additional support. By day 17, he was decannulated at bedside. Discussion: By transitioning the ECMO cannulation strategy to optimize oxygenation, facilitate weaning of mechanical ventilation and allow for increased mobility, patients may be decannulated at a higher functional status than if they continued with the original cannulation strategy. Since 2020, our institution has performed 137 dual-lumen subclavian cannulations for patients on VV ECMO with a survival rate of 63%.

Trends in home mechanical ventilation in the first year of the COVID-19 pandemic in Germany: a routine data analysis

Background: Routine data have shown a stark increase in home mechanical ventilation (HMV) in Germany in recent years. However, the development of HMV in the first year of the COVID-19 pandemic is unknown. Methods: Case numbers of initiations, control examinations, and terminations of invasive and non-invasive HMV in 2017-2020 were analysed. ICD-10 diagnoses of cases with an initiation of invasive HMV in 2017- 2020 were examined (data from the German Federal Statistical Office). Expenses of the statutory health insurances for ambulatory intensive care in 2017-2020 were analysed (data from the German Federal Ministry of Health). Results: Contrary to the trend in recent years, HMV initiations declined by 14.9 % in 2020, from n = 17,958 (2019) to n = 15,279 (2020). This development was due to a 15.9 % decline in initiations of non-invasive HMV. In contrast, initiations of invasive HMV remained stable in 2020, despite regional differences. For invasive and non-invasive HMV, control examinations (-28 % and -24 %, respectively) and ventilation terminations (-45.3 % and -15.1 %, respectively) dropped in 2020. Patients for whom invasive HMV was initiated had numerous comorbidities and care needs. Expenses of statutory health insurances for ambulatory intensive care increased from EUR 1.52 billion (2017) to EUR 2.16 billion (2020;+42.3 %). Conclusions: After an increase in control examinations and terminations of HMV in recent years, we observe a trend reversal in 2020. Additionally, initiations of non-invasive HMV decreased in 2020. Future studies need to explore the association between this development and the COVID-19 pandemic.

Respiratory drive, inspiratory effort, and work of breathing: review of definitions and non-invasive monitoring tools for intensive care ventilators during pandemic times. / Impulso, esfuerzo y trabajo respiratorio: revisión de definiciones y herramientas no invasivas de ventiladores de cuidados intensivos durante tiempos de pandemia.

Technological advances in mechanical ventilation have been essential to increasing the survival rate in intensive care units. Usually, patients needing mechanical ventilation use controlled ventilation to override the patients respiratory muscles and favor lung protection. Weaning from mechanical ventilation implies a transition towards spontaneous breathing, mainly using assisted mechanical ventilation. In this transition, the challenge for clinicians is to avoid under and over assistance and minimize excessive respiratory effort and iatrogenic diaphragmatic and lung damage. Esophageal balloon monitoring allows objective measurements of respiratory muscle activity in real time, but there are still limitations to its routine application in intensive care unit patients using mechanical ventilation. Like the esophageal balloon, respiratory muscle electromyography and diaphragmatic ultrasound are minimally invasive tools requiring specific training that monitor respiratory muscle activity. Particularly during the coronavirus disease pandemic, non invasive tools available on mechanical ventilators to monitor respiratory drive, inspiratory effort, and work of breathing have been extended to individualize mechanical ventilation based on patients needs. This review aims to identify the conceptual definitions of respiratory drive, inspiratory effort, and work of breathing and to identify non invasive maneuvers available on intensive care ventilators to measure these parameters. The literature highlights that although respiratory drive, inspiratory effort, and work of breathing are intuitive concepts, even distinguished authors disagree on their definitions.

Los avances tecnológicos de la ventilación mecánica han sido parte esencial del aumento de la sobrevida en las unidades de cuidados intensivos. Desde la conexión a la ventilación mecánica, comúnmente se utiliza ventilación controlada sin la consecuente participación de los músculos respiratorios del paciente, con el fin de favorecer la protección pulmonar. El retiro de la ventilación mecánica implica un periodo de transición hacia la respiración espontánea, utilizando principalmente ventilación mecánica asistida. En esta transición, el desafío de los clínicos es evitar la sub y sobre asistencia ventilatoria, minimizando el esfuerzo respiratorio excesivo, daño diafragmático y pulmonar inducidos por la ventilación mecánica. La monitorización con balón esofágico permite mediciones objetivas de la actividad muscular respiratoria en tiempo real, pero aún hay limitaciones para su aplicación rutinaria en pacientes ventilados mecánicamente en la unidad de cuidados intensivos. Al igual que el balón esofágico, la electromiografía de los músculos respiratorios y la ecografía diafragmática son herramientas que permiten monitorizar la actividad muscular de la respiración, siendo mínimamente invasivas y con requerimiento de entrenamiento específico. Particularmente, durante la actual pandemia de enfermedad por coronavirus se ha extendido el uso de herramientas no invasivas disponibles en los ventiladores mecánicos para monitorizar el impulso (drive), esfuerzo y trabajo respiratorio, para promover una ventilación mecánica ajustada a las necesidades del paciente. Consecuentemente, el objetivo de esta revisión es identificar las definiciones conceptuales de impulso, esfuerzo y trabajo respiratorio utilizadas en el contexto de la unidad de cuidados intensivos, e identificar las maniobras de medición no invasivas disponibles en los ventiladores de cuidados intensivos para monitorizar impulso, esfuerzo y trabajo respiratorio. La literatura destaca que, aunque los conceptos de impulso, esfuerzo y trabajo respiratorio se perciben intuitivos, no existe una definición clara. Asimismo, destacados autores los definen como conceptos diferentes.

Addressing Diaphragm Dysfunction in Lung Transplant Recipients: The Expanding Role of Diaphragm Pacing

Purpose: Diaphragmatic dysfunction is documented after lung transplantation and can affect up to 62% patients. Diaphragm pacing (DP) prevents ventilator induced diaphragm dysfunction (VIDD) while on mechanical ventilation (MV) and has been shown via functional electrical stimulation to improve phrenic nerve recovery. We report the largest experience of DP in lung transplantation recipients. Methods: This is a retrospective analysis of an IRB approved prospective, non-randomized interventional experience at a single institution with two DP systems. A chronic DP system [NeuRx, Synapse Biomedical] was implanted laparoscopically in those with phrenic nerve injury or difficulty with weaning from MV remotely after their transplant. A temporary DP system [TransAeris, Synapse Biomedical] was implanted at the time of transplantation or laparoscopically. In both types of implantation, diaphragm stimulation ensued if needed to wean from MV or for nerve recovery. Results evaluated radiographically and with diaphragm electromyography (dEMG). Results: DP was utilized in16 patients with no device adverse events. Of those, 5 patients had chronic DP system: a) 1 patient one year post transplant shows no recovery of phrenic nerve injury, still pacing;b) 3 patients showed recovery of phrenic nerve/diaphragm function through pacing;c) 1 patient 2 years post-transplant sustained hip fracture requiring surgery, developed pneumonia and became tracheostomy MV dependent;DP allowed complete diaphragm recovery, decanullation of tracheostomy and removal of DP wires. 11 patients had temporary DP electrodes placed: a) 1 recipient(two months post-transplant) had DP use during ECMO for COVID- 19 sepsis and respiratory failure and subsequently expired when family withdrew therapy;b) 10 implanted at time of lung transplant. Of those 10, 3 patients had bilateral dEMG identified post-operatively with uneventful recovery and removal of electrodes;7 patients had diaphragm abnormalities identified post-operatively and underwent DP. Of those 7, 5 showed recovery and DP electrodes removed and 2 are still pacing 1 and 9 months post-transplant. Conclusion: DP was safely used in lung transplantation to identify and improve recovery of phrenic nerve injuries, wean from MV and prevent VIDD. DP shows promise in addressing diaphragm dysfunction after lung transplantation and improving outcomes.

Design of a Clinical Practice Guideline in Nurse-Led Ventilator-Weaning for Nursing Training.

Cardiothoracic intensive care unit (CICU) nurses have shared the role and responsibility for ventilator-weaning to expedite decision-making in patient care. However, the actions taken are based on individual's unstructured training experience as there is no clinical practice guideline (CPG) for nurses in Malaysia. Hence, this study aims to design a CPG for the process of weaning from mechanical ventilation (MV) for a structured nursing training in a CICU at the National Heart Institute (Institut Jantung Negara, IJN) Malaysia. The Fuzzy Delphi Method (FDM) was employed to seek consensus among a panel of 30 experts in cardiac clinical practice on the guidelines. First, five experts were interviewed and their responses were transcribed and analyzed to develop the items for a FDM questionnaire. The questionnaire, comprising of 73 items, was distributed to the panel and their responses were analyzed for consensus on the design of the CPG. The findings suggested that the requirements expected for the nurses include: (a) the ability to interpret arterial blood gases, (b) knowledge and skills on the basics of mechanical ventilation, and (c) having a minimum 1-year working experience in the ICU. On the other hand, the CPG should mainly focus on developing an ability to identify criteria of patient eligible for weaning from MV. The learning content should focus on: (a) developing the understanding and reasoning for weaning and extubating and (b) technique/algorithm for extubating and weaning. Also, the experts agreed that the log book/competency book should be used for evaluation of the program. The CPG for structured nursing training at IJN in the context of the study is important for developing the professionalism of CICU nurses in IJN and could be used for training nurses in other CICUs, so that decision for ventilator-weaning from postcardiac surgery could be expedited.

Diaphragm dysfunction induced by mechanical ventilation – pathophysiology and treatment options

Majority of mechanically ventilated patients in intensive care units (ICU) suffer from diaphragm dysfunction. It occurs in approximately 60 to 80 % of such patients. Early after the initiation of mechanical ventilation pathophysiological processes leading to diaphragm dysfunction are triggered. Inadequate diaphragm function significantly contributes to difficult weaning, prolonged mechanical ventilation as well as increased morbidity and mortality. Etiology of ventilation induced diaphragm dysfunction (VIDD) is complex and multifactorial. Metabolic and inflammatory changes in muscular tissue are one of the hallmarks of critical illness and together with patient-ventilator asynchrony and prolonged vasopressor support play a key role in VIDD pathophysiology. Treatment of primary cause of respiratory insufficiency is of utmost importance, but besides this, adequate titration of sedatives and muscle relaxants, monitoring of respiratory mechanics and deployment of proportional modes of ventilation are of great significance in prevention and treatment of VIDD. Proportional modes offer support to spontaneous breathing. However, unlike the conventional modes, this support is not constant, it changes with every breath, offering assistance that is proportional to activity of respiratory muscles. The aim of this article was to offer an insight into latest data from scientific literature to healthcare providers. The electronic search of Pubmed, Medline and Google Scholar was conducted by using MeSH (Medical Subject Headings) terms. Our search was limited to randomized controlled trials and review articles written in English, which were published from 2016 to 2021 and conducted on adult patients. Conclusion: During the pandemic of SARS-CoV-2, the importance of mechanical ventilation with all its aspects came into the focus of medical community. Mechanical ventilation is considered as a life saving method of treatment, but serious adverse effects such as dysfunction of diaphragm can be encountered. There are ongoing developments of new strategies and modes of mechanical ventilation aiming at protection of lungs and diaphragm. Diaphragm protective mechanical ventilation reduces the duration of mechanical ventilator support, decreases the incidence of severe complications such as multiple organ failure and consequntely mortality. © 2022 Hrvatski Lijecnicki Zbor. All rights reserved.

Inspiratory muscle training immediately following lung transplantation due to COVID-19: A report of two cases

BACKGROUND AND PURPOSE: Covid-19 is a novel respiratory disease leading to high rates of acute respiratory distress syndrome (ARDS) and causes adverse effects on both the peripheral and respiratory muscles. Despite optimal medical management some patients with severe Covid-19 develop irreversible lung injury. Patients who cannot be weaned from mechanical ventilation (MV) or extracorporeal life support, lung transplantation (LTX) may be the only life-saving option. Inspiratory muscle training (IMT) has been extensively studied in a variety of non-LTX population with results indicating improvements in exercise capacity, diaphragmatic thickness, reduced dyspnea with ADL's and improved quality of life. Several previous studies found that IMT is a feasible and safe modality in ICU patients. A recent study showed significant improvements in the dyspnea index and quality of life following 2 weeks of IMT in Covid-19 patients after weaning from MV. To the best of our knowledge, no studies have investigated the use of IMT immediately after lung transplantation due to Covid-19 in addition to physical therapy intervention. This report describes the effects of IMT on inspiratory muscle strength, perceived dyspnea and physical performance over the course of 22 weeks in two patients post lung transplantation. CASE DESCRIPTION: Two males (45 ± 9 yr, BMI 33.6 ± 0.1 kg/m2) admitted to the hospital with ARDS secondary to Covid-19 underwent double lung transplantation and performed IMT (2 sessions/day;30 breathes, 50% maximal inspiratory pressure, (MIP);5 days/week) in addition to physical therapy immediately following surgery. Inspiratory muscle strength (MIP), perceived dyspnea (Modified Borg Dyspnea Scale, MBS) and physical performance (4- meter walking speed and 5 times sit to stand) were assessed at baseline and weekly for a total of 22 weeks. Length of hospital stay (LOS) was 58 ± 22 days and both patients participated in a 12 week Pulmonary Rehab Program upon hospital discharge. OUTCOMES: There were no adverse events associated with the intervention. IMT resulted in an increase MIP from -25.7 ± 13 cmH2O to -79.8 ± 7 cmH2O (22% to 66% of predicted normal). MBS improved 4 and 2, to 3 and 0 respectively. Baseline physical performance: 4-meter walking speed and 5-time sit to stand test were 0.40 ± 0.3 m/sec and 60 seconds, and improved to 1.28 ± 0.1 m/s and 7 ± 3 seconds, respectively, after IMT. Activity Measure for Post-Acute Care mobility score (AM-PAC) 7 improved from 7.5 ± 0.7 at evaluation to 18 ± 6.4 upon discharge. DISCUSSION: The present case report describes the integration of IMT to physical therapy intervention in two patients immediately following double lung transplantation due to Covid-19. Improvements in inspiratory muscle strength, perceived dyspnea and functional performance following IMT were present in both cases after a 22 week intervention. These results indicate that IMT program should be encouraged in the rehabilitation of patients post Covid-19. Further research is needed to investigate the benefits of IMT for patients requiring lung transplantation and/or post-Covid-19.

Successful Recovery of a Child with COVID-19-Induced Secondary Hemophagocytic Lymphohistiocytosis

The coronavirus disease 2019 (COVID-19) pandemic has imposed a significant burden worldwide, manifesting as a severe disease and causing mortality even in children. Severe COVID-19 disease is characterized by cytokine storm with progression to secondary hemophagocytic lymphohistiocytosis (sHLH). We describe an 18-month-old boy in Iran, previously healthy, diagnosed with COVID-19-induced sHLH. Three weeks after close contact with COVID-19 confirmed cases, he was admitted with high fever, lethargy, mild respiratory distress, skin rash, and conjunctivitis with swollen eyelids and lips. Laboratory data revealed elevated levels of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and liver enzymes, and mild thrombocytopenia. His clinical condition rapidly deteriorated, with septic shock, hepatosplenomegaly, and respiratory failure. Laboratory tests showed cytopenia, coagulopathy, hy-perferritinemia, and hypertriglyceridemia, which met the criteria for sHLH diagnosis. Chest computed tomography (CT) revealed bilateral infiltrations that suggested acute respiratory distress syndrome (ARDS) of COVID-19 that was confirmed by a positive real-time polymerase chain reaction (RT-PCR) test. Therefore, the child was treated with intravenous immunoglobulin (IVIG), glucocorti-coid, hydroxychloroquine, lopinavir/ritonavir, and interferonβ-1a. This therapeutic strategy enabled complete recovery from fever, regaining consciousness, weaning from respiratory support, and resolving shock. Serial chest radiographs showed diminishing infiltrations. Sequential physical examinations revealed an overall significant reduction in spleen and liver span. Laboratory data showed rapid improvement from cytopenia and coagulopathy, normalization of liver enzyme levels, and reduction in hyperinflam-mation markers. Although ARDS is the most common cause of death from COVID-19, other complications such as sHLH may be lethal;thus, early diagnosis and appropriate treatment are necessary for saving patients’ lives.

P.0811 Factors and outcomes associated with delirium in critically ill COVID-19 patients

Introduction: Evidence demonstrates that 25-33% of hospitalized patients with COVID-19 develop delirium [1,2], with rates up to 65% in critically ill patients [3]. Several potential reasons, including the use of deep sedation and invasive mechanical ventilation (IMV), as well as the restrictions to limit infection transmission, such as prohibition of family visits and minimal contact with health staff were identified [4]. Although factors and outcomes associated with delirium are well documented, limited data are available regarding severe COVID-19 patients. Aims: This study aims to estimate the rates of delirium in critically ill COVID-19 patients and to analyze factors that may be associated with its development, as well as to examine long-term outcomes. Methods: From March to May 2020 (in COVID-19 first wave), all adult patients (≥18y.o.) admitted due to COVID-19, in the Intensive Care Medicine Department (ICMD) of a University Hospital (CHUSJ), in Porto, Portugal, were assessed, unless they had a ICMD length of stay (LoS) ≤24h, terminal illness or major sensory loss or inability to communicate at the time of follow-up. Participants were evaluated during a scheduled telephone follow-up appointment with a comprehensive protocol, including: Six-item Cognitive Impairment Test (6CIT) (cognitive impairment);Patient Health Questionnaire (PHQ-9) (symptoms of depression);General Anxiety Disorder (GAD-7) (symptoms of anxiety);and EuroQol five-dimension five-level questionnaire (EQ-5D-5L) (health-related quality of life-HRQoL), which includes EQ-Visual Analogue Scale (EQ-VAS) (global health status patient perception). Data on acute illness severity, sedative/analgesic drugs use, respiratory support and major complications (including delirium, nosocomial infections and difficulty weaning from mechanical ventilation) during ICMD stay, were obtained from hospital electronic records review. Patients with and without delirium were compared, using Mann-Whitney test for continuous variables, and Chi-square or Fisher tests for paired categorical variables (significance level of 0.05). This study is part of an ongoing larger multidisciplinary research project (MAPA-Mental Health in Critically ill patients with COVID-19). Results: The sample included 59 patients (median age=65 years;66.1% male). Delirium was registered in almost half of the sample (49.2%). Patients with delirium were significantly older (median=72 vs. 62;p=0.010) and presented more nosocomial infections (82.8% vs 53.3%;p=0.032) particularly ventilator-associated pneumonia (75.9% vs. 33.3%;p=0.003). Also, they were significantly more likely to be deeply sedated (89.7% vs 60%;p=0.021), more often required IMV (89.7% vs 60%;p=0.021). Moreover, those with delirium stayed longer in the hospital (median=67 vs 37 days;p=0.014). Concerning HRQoL, assessed at follow-up appointment, patients who have developed delirium reported more problems in self-care (48.3% vs 10%;p=0.003) and in everyday activities (79.3% vs 53.3%;p=0.035) after hospital discharge. Nevertheless, no statistically significant differences were found for cognitive impairment, symptoms of anxiety and depression. Conclusions: Delirium was common in this critically ill COVID-19 sample, namely in older patients, who have been deeply sedated, invasively ventilated or had major ICU complications. It was associated with longer hospital stay and worse HRQoL. Recognizing potential associated factors will allow the identification of high-risk patients that should be targeted for early screening with preventive interventions to minimize the adverse outcomes associated to delirium in critical COVID-19 patients. No conflict of interest

Revised recommendations from the CSO-HNS taskforce on performance of tracheotomy during the COVID-19 pandemic - what a difference a year makes.

BACKGROUND: During the early part of the COVID-19 pandemic, the Canadian Society of Otolaryngology - Head & Neck Surgery (CSO-HNS) task force published recommendations on performance of tracheotomy. Since then, our understanding of the virus has evolved with ongoing intensive research efforts. New literature has helped us better understand various aspects including patient outcomes and health care worker (HCW) risks associated with tracheotomy during the COVID-19 pandemic. Accordingly, the task force has re-evaluated and revised some of the previous recommendations. MAIN BODY: Based on recent evidence, a negative reverse transcription polymerase chain reaction (RT-PCR) COVID-19 swab status is no longer the main deciding factor in the timing of tracheotomy. Instead, tracheotomy may be considered as soon as COVID-19 swab positive patients are greater than 20 days beyond initial symptoms and 2 weeks of mechanical ventilation. Furthermore, both open and percutaneous surgical techniques may be considered with both techniques showing similar safety and outcome profiles. Additional recommendations with discussion of current evidence are presented. CONCLUSION: These revised recommendations apply new evidence in optimizing patient and health care system outcomes as well as minimizing risks of COVID-19 transmission during aerosol-generating tracheotomy procedures. As previously noted, additional evidence may lead to further evolution of these and other similar recommendations.