The inspiratory activity of respiratory center and respiratory muscles strength after COVID-19.

The respiratory pump that provides pulmonary ventilation includes the respiratory center, peripheral nervous system, chest and respiratory muscles. The aim of this study was to evaluate the activity of the respiratory center and the respiratory muscles strength after COVID-19 (COronaVIrus Disease 2019). Methods. The observational retrospective cross-sectional study included 74 post-COVID-19 patients (56 (76%) men, median age - 48 years). Spirometry, body plethysmography, measurement of lung diffusing capacity (DLCO), maximal inspiratory and expiratory pressures (MIP and MEP), and airway occlusion pressure after 0.1 sec (P0.1) were performed. In addition, dyspnea was assessed in 31 patients using the mMRC scale and muscle strength was assessed in 27 of those patients using MRC Weakness scale. Results. The median time from the COVID-19 onset to pulmonary function tests (PFTs) was 120 days. The total sample was divided into 2 subgroups: 1 - P0.1 <= 0.15 kPa (norm), 2 - > 0.15 kPa. The lung volumes, airway resistance, MIP, and MEP were within normal values in most patients, whereas DLCO was reduced in 59% of cases in both the total sample and the subgroups. Mild dyspnea and a slight decrease in muscle strength were also detected. Statistically significant differences between the subgroups were found in the lung volumes (lower) and airway resistance (higher) in subgroup 2. Correlation analysis revealed moderate negative correlations between P0.1 and ventilation parameters. Conclusion. Measurement of P0.1 is a simple and non-invasive method for assessing pulmonary function. In our study, an increase in P0.1 was detected in 45% of post-COVID-19 cases, possibly due to impaired pulmonary mechanics despite the preserved pulmonary ventilation as well as normal MIP and MEP values.Copyright © Savushkina O.I. et al., 2023.

Extracorporeal membrane oxygenation for airway emergencies

Objectives: Extracorporeal membrane oxygenation (ECMO) is well established in cardiorespiratory failure. Here we report the use of ECMO in an airway emergency to provide respiratory support. Method(s): Informed consent was obtained from patient at the time of admission. Result(s): A 48-year-old with COVID-19 requiring venovenous ECMO (VVECMO) for 32 days and tracheostomy for 47 days had developed tracheal stenosis three months after tracheostomy removal, and undergone tracheal resection and reconstruction. He presented two weeks later with acute dyspnea, bloody drainage and a bulge in his neck with coughing. A computerized tomography (CT) of the cervical spine and chest showed dehiscence of the tracheal wound and a gap in the trachea. He was managed with High Flow Nasal Canula and supported on VVECMO support using 25 Fr. right femoral drainage cannula and 23 Fr. left IJ return cannula. A covered stent was placed, neck wound was irrigated and debrided. Patient was decannulated after 10 days on ECMO. Future therapeutic considerations include mediastinal tracheostomy, aortic homograft interposition of the disrupted segment of trachea with stent placement and permanent self-expandable stent with internal silicone stent. Conclusion(s): ECMO is increasingly used in complex thoracic surgery as well as in the perioperative period as salvage support. One of the areas where it has shown promising results is traumatic main bronchial rupture, airway tumor leading to severe airway stenosis, and other complex airway problems. The ease of cannulation, the technological advances and growing confidence in the management of ECMO patients are the main reasons for the expansion of ECMO use beyond conventional indications. The case described above is an example of the use of ECMO in the perioperative management of impending respiratory failure due to airway obstruction or disconnection. (Figure Presented).

Clinical improvement 2 years after starting elexacaftor/tezacaftor/ivacaftor in patients with advanced lung disease

Background: With the introduction of new cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy (elexacaftor/tezacaftor/ ivacaftor), peoplewith CF experiencing severe lung disease can experience significant improvements in clinical symptoms. Method(s): This single-center institutional review board-approved retrospective chart review identified patients with advanced lung disease who met criteria for a compassionate use or expanded access program because of high risk of death or transplant need within 2 years. Clinical data collection for all patients began at baseline, 2 to 4 weeks after therapy initiation, and continued every 3 months for 2 years. Datawere collected on demographic characteristics, clinic progress notes, clinical labs, forced expiratory volume in 1 minute (FEV1),weight, body mass index, respiratory colonization, and hospitalizations after drug initiation. Patients also completed sinus and chest computed tomography (CT) to track clinical changes. Result(s): Eighteen people with CF (aged 15-49, 56% male) from a large midwestern CF center who initiated drug therapy between July and September 2019 in an inpatient hospital or clinic setting were identified. Clinical markers (Table 1) indicated that modulator therapy was well tolerated and not discontinued by any participant;safety lab values did not indicate medical concern or discontinuation. There were 90 admissions for the group in the 2 years before therapy and 17 admissions during the 2 years after, although seven of the posttherapy admissions were for nonrespiratory indications. Monitoring results indicated the safety of modulator therapy because there were no adverse clinical occurrences or laboratory events, and all patients presented with universal stabilization. There have been no deaths and no transplants. Unlike lumacaftor/ivacaftor, therewere no problems with chest tightness or any difficulty with troublesome increases in expectoration burden or choking during initiation of therapy. Most had significant reduction in or loss of spontaneous cough and sputum production. The impact on microbial colonization is unclear, because even in this severe group, inability to produce sputum on command led to considerable missing data in follow-up, leaving colonization status at follow-up unclear. Conclusion(s): This study focused on people with CF who qualified for modulator therapy based on advanced lung disease. Initiation of modulator therapy was deemed safe and resulted in objective positive changes in nutrition;cough;FEV1);and subjective reports of clinical status, level of activity, and reduction in burden of treatment. No evidence was found of difficulty managing the increased expectoration during initial therapy. Limitations were noted in missing data during the COVID-19 pandemic, small sample size, and delayed follow-up for drug monitoring.(Table Presented) Clinical indicators before and after modulator therapy *Completed post-drug initiation (earlier than 12 months), **24 months before and after therapy initiationCopyright © 2022, European Cystic Fibrosis Society. All rights reserved

The inspiratory activity of respiratory center and respiratory muscles strength after COVID-19.

The respiratory pump that provides pulmonary ventilation includes the respiratory center, peripheral nervous system, chest and respiratory muscles. The aim of this study was to evaluate the activity of the respiratory center and the respiratory muscles strength after COVID-19 (COronaVIrus Disease 2019). Methods. The observational retrospective cross-sectional study included 74 post-COVID-19 patients (56 (76%) men, median age - 48 years). Spirometry, body plethysmography, measurement of lung diffusing capacity (DLCO), maximal inspiratory and expiratory pressures (MIP and MEP), and airway occlusion pressure after 0.1 sec (P0.1) were performed. In addition, dyspnea was assessed in 31 patients using the mMRC scale and muscle strength was assessed in 27 of those patients using MRC Weakness scale. Results. The median time from the COVID-19 onset to pulmonary function tests (PFTs) was 120 days. The total sample was divided into 2 subgroups: 1 - P0.1 <= 0.15 kPa (norm), 2 - > 0.15 kPa. The lung volumes, airway resistance, MIP, and MEP were within normal values in most patients, whereas DLCO was reduced in 59% of cases in both the total sample and the subgroups. Mild dyspnea and a slight decrease in muscle strength were also detected. Statistically significant differences between the subgroups were found in the lung volumes (lower) and airway resistance (higher) in subgroup 2. Correlation analysis revealed moderate negative correlations between P0.1 and ventilation parameters. Conclusion. Measurement of P0.1 is a simple and non-invasive method for assessing pulmonary function. In our study, an increase in P0.1 was detected in 45% of post-COVID-19 cases, possibly due to impaired pulmonary mechanics despite the preserved pulmonary ventilation as well as normal MIP and MEP values.Copyright © Savushkina O.I. et al., 2023.

Treatable trait guided asthma management: A feasibility study

Introduction/Aim: Treatable traits based personalised medicine has been shown to improve outcomes in severe asthma clinic. We assessed the feasibility of a randomised controlled trial of protocolised 'focused' and 'extended' treatable trait guided asthma management in patients not under a severe asthma clinic. Method(s): Ten week single-group cohort study. Participants had a doctor's diagnosis of asthma, asthma control questionnaire (ACQ) score >1, and a history of exacerbation in the last year. Patients already under the care of a severe asthma clinic or receiving high-dose inhaled corticosteroids, biological therapy or maintenance oral corticosteroids were excluded. Intervention(s): asthma medication according to application of a 'focused' treatable trait algorithm, targeting type-2 inflammation and airflow obstruction. Feasibility outcomes: recruitment rates, acceptability of intervention, willingness to enrol in a full RCT, need for 'extended' trait assessment after 10 weeks, and estimation of trait prevalence. Result(s): Recruitment ceased after 14 months with 30/50 participants due to difficulties associated with COVID-19. 92% found the intervention acceptable and were willing to be randomised in a future study. 65% remained not well-controlled with an ACQ >1 after 10 weeks and would have required the 'extended' algorithm. Participants had a mean (SD) 4.8(2.3) of 13 traits assessed. Participation in the study was associated with clinically important improvements in ACQ, -1.0 (1.5) units;St George Respiratory Questionnaire, -15.1 (14.7) units;Asthma Quality of Life Questionnaire, +1.0 (1.1) units;and FEV1, +0.4 (0.4) L. Post-bronchodilator airflow obstruction reduced from 60% of participants at study commencement to 35%. 53% of participants were allocated continuous oral corticosteroids at some point during the study. Conclusion(s): Protocolised treatable trait management was acceptable, associated with significant clinical benefit and a full trial appears feasible. Targeting two traits was insufficient to control asthma in the majority of patients over the timeframe of this study, despite significant corticosteroid exposure.

Upper Airway Complications in COVID-19: A Case Series.

Prolonged intubation is associated with several complications leading to upper airway obstruction, including tracheal stenosis and tracheomalacia. Tracheostomy may potentially decrease the risk of tracheal injury in patients with upper airway obstruction. The ideal timing to perform tracheostomy remains controversial. Prolonged intubations were particularly common during the initial phase of the coronavirus disease 2019 (COVID-19) pandemic. This study aimed to present a series of five cases of upper airway complications in patients who underwent mechanical ventilation in the setting of COVID-19 and discuss their clinical aspects, risk factors, and therapeutic strategies.

Diagnosis of Nasal Breathing Using a Rhinomanometer in Patients with Osa Prescribed Conservative Treatment with Intraoral Devices

In recent years, diagnostics in the field of medicine has developed at an extremely rapid pace, thanks to the use and improvement of new medical devices and devices. The problem of timely and adequate diagnosis and treatment of the syndrome of obstructive sleep apnea (OSA) and snoring is particularly relevant world-wide. The disease has been proven to worsen the patients' quality of life, and may even threaten it. Obstructive sleep apnea and snoring syndrome (OSAS) is a widespread disease of social importance in which there is a reduction or cessation of airf low through the nose/mouth during sleep due to upper airway collapse. Obstructive sleep apnea affects the cardiovascular, endocrine, neurocognitive and other systems of the body. There are symptoms of loud snoring, choking, hypoxemia, and micro-awakenings, leading to sleep frag-mentation, daytime fatigue, and sleepiness. The latter greatly worsens the quality of life of patients. There are real risks to the life and health of the patient and others, given the possibility of falling asleep at the wheel in drivers with sleep apnea and participation in traffic accidents. To diagnose the syndrome, a poly-somnographic study is performed, which is still the gold standard. For a better diagnosis, it is recommend-ed to combine it with rhinomanometry. Treatment of OSA includes control of risk factors and removal of obstructive factors that make breathing difficult. Severe OSA syndrome is treated with continuous positive pressure ventilation (CPAP) during sleep, possibly in combination with intraoral devices. Rhinomanome-try can also be used to monitor the effectiveness of CPAP therapy in severe forms of the syndrome by deter-mining tissue resistance. The impact on patients with a milder form of OSA treated with intraoral devices is also monitored. The method can also be used in patients with allergic rhinitis, sinusitis of rhinogenic and other origin, and patients with orthodontic deformities. The correct choice of intraoral appliances for conservative treatment of OSA and timely diagnosis are key to successful treatment.Copyright © 2022, Bulgarian-American Center. All rights reserved.

Clinical Approaches to Minimize Readmissions of Patients with COPD: A Narrative Review

Chronic Obstructive Pulmonary Disease (COPD) is a progressive disease and also a lead-ing cause of morbidity and mortality worldwide. The frequent readmissions of patients with COPD may reduce lung function, mental health, and quality of life;it also increases the cost of treatment and mortality rate. Some common factors that may increase the readmission frequency of COPD patients include delay of diagnosis, advanced lung function decline, lack of adherence for COPD treatment, ineffective management of comorbidities, acute exacerbation or stable COPD, and infec-tions. However, these factors might be well controlled with appropriate approaches to minimize the readmission of patients with COPD. In this review, we propose a strategy with a seven-step approach to reduce the readmission in COPD patients, including early diagnosis of COPD, optimal treatment for stable COPD, targeted management of comorbidities, adequate therapy for acute ex-acerbations, individualized action plans for COPD patients, effective prevention of bacterial and viral infections, and adaptive program of pulmonary rehabilitation. Thus, implementing this approach may reduce the risk of readmission in patients with COPD.Copyright © 2023 Bentham Science Publishers.

Airway obstruction in respiratory viral infections due to impaired mucociliary clearance.

Respiratory viral infections, such as SARS-CoV-2 or influenza, can lead to impaired mucociliary clearance in the bronchial tree due to increased mucus viscosity and its hyper-secretion. We develop in this work a mathematical model to study the interplay between viral infection and mucus motion. The results of numerical simulations show that infection progression can be characterized by three main stages. At the first stage, infection spreads through the most part of mucus producing airways (about 90% of the length) without significant changes in mucus velocity and thickness layer. During the second stage, when it passes through the remaining generations, mucus viscosity increases, its velocity drops down, and it forms a plug. At the last stage, the thickness of the mucus layer gradually increases because mucus is still produced but not removed by the flow. After some time, the thickness of the mucus layer in the small airways becomes comparable with their diameter leading to their complete obstruction.

Sleep disturbances in post-Covid patients as a function of sex

Introduction: Within the post-Covid syndrome, sleep disturbances are one of the most persistent symptoms, in which women are more 50% vulnerable than men to insomnia. Objective(s): To compare the prevalence of sleep disorders in post-Covid patients according to sex. Method(s): A cross-sectional observational study was carried out. The participants were 264 post-Covid patients evaluated 3 months after hospital discharge, divided into men (n=156, G1) and women (n=108, G2). A general sleep habits survey and the Berlin SAOS questionnaire were used for sleep assessment. Statistical analyses were performed using SPSS v25. Result(s): Mean age was G1: 54.16 +/-11.751 and G2: 54.23 +/- 13.319. There were differences (p<0.05) between both sexes in the following disorders (G1 vs G2): snoring (73.1% vs 58.3%), primary snoring (45.6% vs 28.6%), unrefreshing sleep more than 3 times a week (28.2% vs 43.5%), tiredness or fatigue during the day at least 3 times a week (30.1% vs 51.9%), sudden movements in extremities: (37.2% vs 22.2%), onset insomnia: (34.0% vs 53.7%), intermediate insomnia (36.5% vs 58.3%), final insomnia: (39.7% vs 55.6%). No differences (p>0.05) were found in pauses in breathing, teeth grinding, feeling of paralysis and feeling of choking, with a prevalence greater than 20% in all cases. Conclusion(s): In our study, the affectation of most sleep disorders are more frequent in the female sex, with the predominance of different types of insomnia (onset, intermediate and final);which could be related to affective disorders. In men, the most prevalent disorders were snoring and sudden movements, mostly linked to respiratory disorders.

Choking Phobia in an Older Adult: A Telephone-Based CBT Case Study Informed by Gerontology

Fear of choking is a relatively understudied phenomenon in older adults, despite the higher incidence of choking to death in this population and the associated mental health burden. This case report presents the use of a cognitive-behavioral (CBT) approach to treating choking phobia in an older adult in her 80s, with sessions conducted over the telephone during the COVID-19 pandemic. A reliable change in self-reported avoidance of solid food was observed, although indices of general distress appeared to have remained stable. By placing a seemingly focal problem (choking phobia) within a comprehensive conceptualization framework using gerontology, we were able to consider additional complexity related to aging-related beliefs and experiences of distress to address therapeutic opportunities and challenges, including the COVID-19 context.Copyright © 2022 Hogrefe.

Lung function variability in one year after COVID-19 pneumonia

The SARS-CoV-2 virus causes pneumonia which can result in lung function (LF) impairment. Impaired LF shortly after the disease is not commonly observed, but the LF substantially fluctuates even when its value remains within the limits of the norm. The aim of the study was to determine the variability scope of LF during the first year after COVID-19 pneumonia. Material(s) and Method(s): LF measurements (spirometry, body-plethysmography, transfer factor) were conducted up to 1 month, 3, 6, and 12 months after hospitalization in a group of consecutive patients recovered from moderate to severe COVID-19 pneumonia requiring hospitalization. The coefficient of variation (CV) was calculated to assess the stability of LF. Result(s): 113 patients were included, with a lung involvement median of 40% (IQR:30-60%). Shortly after hospitalization, we detected 3.5% airway obstructions, 12.4% restrictions, and 26.5% lung transfer factor impairments. During one year significant changes were observed in lung volumes but not flow indices. The most pronounced improvements were observed in lung transfer factor (TLco) and they were associated with volume changes (VA), but not Kco improvements (figure 1). Stable LF (CV<4%) was observed only in 21% of patients. Conclusion(s): Impaired LF shortly after COVID-19 was detected in a quarter of patients with significant improvement in the next months. However, lung function remained unstable in the majority of examined patients.

The Role of Labacs in Long COVID-19 Patients in Pringsewu,Indonesia

Background: Severe covid-19 disease has led to many death. Some post mortem study has investigated the cause. The autopsy revealed occurrence of DVT and postmortem lung CT showed reticular infiltration, dense consolidation, while histologically showed diffuse alveolar damage. Through FOB conducted In mechanically ventilated COVID-19 patient, airway obstruction was seen due to hypersecretion and mucus plug in the bronchi. Inhaled budesonide in COVID-19 patient has showed faster recovery and the research focus in the administration of ICS is limited. Objective(s): This study aims to investigate the benefit of LABACS treatment in LONG COVID-19 patients in Pringsewu Indonesia. Method(s): The method of this research was cross sectional. Total subjects included in this study were 276 patients. 168 subjects were treated with Beclomethasone-Formoterol (61%), 49 subjects were treated with FluticasoneSalmeterol (17%), 59 subjects were treated with Budesonide-Formoterol (22%) during 3 months period. We assessed symptoms improvement, mMRC score and chest X-ray imaging. Spirometry of 34 subjects were measured. Result(s): There was a significant correlation between the incidence of lung obstruction and persistent symptom of long covid patients according to spirometry measurement (P value = 0.000). There was a significant correlation between symptoms improvement, mMRC score and chest X-ray imaging after treatment with Beclomethasoneformoterol (p-value = <0.05) Fluticasone-Salmeterol (P value = <0.05) Budesonide-Formoterol (P value = 0.002, P value = 0.007, P value = 0.049). Conclusion(s): LABACS treatment improved lung function and clinically benefit in managing obstruction due to COVID-19.

Diagnosis and rehabilitation of swallowing disorders.

Swallowing disorders are frequently encountered pathologies. There are numerous etiologies which can be responsible. The consequences of dysphagia may lead to choking, aspiration pneumonia, denutrition, dehydration or even fatal issue. These disorders are more commonly found after prolonged intubation, as commonly seen in severe Covid-19 patients. Early screening and adequate diagnostic testing are necessary in order to prevent these different complications. It is thus important to define the underlying etiology and to assess the severity of dysphagia. This allows an adequate rehabilitation to maintain the patient on a sufficient oral diet adapted to his disorders.Copyright © 2022 Association des Medecins anciens etudiats de l'Universite libre de Bruxelles (A.M.U.B.). All rights reserved.

A Novel Approach to Repair of Tracheal Occlusion Secondary to Percutaneous Tracheostomy Creation.

The number of endotracheal intubations increased in the United States during the COVID-19 pandemic with an associated rise in laryngotracheal injury. Our patient had a complete laryngeal occlusion just proximal to the first tracheal ring. The Neodymium-doped Yttrium Aluminum Garnet (Nd-YAG) laser is often used to resolve sub-laryngeal occlusions, and without access to the Nd-YAG laser, we had to find an alternative solution. Few centers have the access to an Nd-YAG laser, the optimal choice for sub-laryngeal occlusion and our novel approach allowed us to reestablish tracheal continuity and the patient's ability to speak.

Vocal Cord Dysfunction During the COVID-19 Pandemic.

BACKGROUND: Vocal cord dysfunction is an upper-airway disorder characterized by exaggerated and transient glottic constriction causing respiratory and laryngeal symptoms. Common presentation is with inspiratory stridor often in the context of emotional stress and anxiety. Other symptoms include wheezing (which may be on inspiration), frequent cough, choking sensation, or throat and chest tightness. This is seen commonly in teenagers, particularly in adolescent females. The COVID-19 pandemic has been a trigger for anxiety and stress with an increase in psychosomatic illness. Our objective was to find out if the incidence of vocal cord dysfunction increased during COVID-19 pandemic. METHODS: We performed a retrospective chart review of all the subjects with a new diagnosis of vocal cord dysfunction who were seen at the out-patient pulmonary practice at our children's hospital between January 2019-December 2020. RESULTS: The incidence of vocal cord dysfunction in 2019 was found to be 5.2%, (41/786 subjects seen) compared to 10.3% (47/457 subjects seen) in 2020, which is a nearly 100% increase in incidence (P < .001). CONCLUSIONS: It is important to recognize that vocal cord dysfunction has increased during the COVID-19 pandemic. In particular, physicians treating pediatric patients, as well as respiratory therapists, should be aware of this diagnosis. It is imperative to avoid unnecessary intubations and treatments with bronchodilators and corticosteroids as opposed to behavioral and speech training to learn effective voluntary control over the muscles of inspiration and the vocal cords.

Eosinophilic Oesophagitis in Children: A Single Uk Tertiary Centre Experience

The incidence of Eosinophilic Oesophagitis (EoE) is increasing worldwide in the paediatric population. Management of these children is complex, and includes elimination diet (2/4/6 food), steroids etc. It is recommended to perform endoscopies between each reintroduction to assess disease activity. In our centre dietary exclusion is the standard practice. Since 2019 we follow a step-up approach with regards to elimination diet starting with 2 food exclusion diet (FED) and building up as required. Food is reintroduced gradually with significant dietetic support and proactive monitoring including endoscopy. Objectives We looked at the outcomes of children with EoE referred to Maidstone and Tunbridge Wells NHS Trust from Kent and East Sussex. Methods Retrospective review of case notes of paediatric patients diagnosed with EoE between January 2015 and December 2020. Data collected included symptoms, endoscopy findings and histology at diagnosis and compared the same after dietary intervention. Results 21 patients were diagnosed with EoE between January 2015 and December 2020 between 5-16 yrs Median age at diagnosis 11years. Frequently seen in boys (65%). Dysphagia was the predominant symptom (76%) followed by vomiting (60%), abdominal pain (50%), and choking (20%). Features of EoE were seen during endoscopy in 71% and oesophagus looked endoscopically normal in 29% of patients. Diagnosis was made on eosinophil count as per ESPGHAN guidance. The frequency and timing of repeat endoscopies following dietary intervention varied due to a multitude of factors including COVID-19 restrictions (between 4-9 months median 4 months). Histological remission (Eosinophils <15 pHPF) was achieved in 15/21 (70%) of patients. 7/10 children on 2FED, 3/3 patients on 4FED and 5/5 children on 6FED achieved histological resolution. The 6FED group took significantly longer to identify the causative food, establish long term dietary management and required more endoscopies. Food was reintroduced gradually on an individual basis with the aim of introducing back all food groups. 13/15 continue to be on milk free diet, 5/15 remain on milk and wheat free diet, 1/15 on soya and egg free diet and the other patient remains on 4FED (parental choice). 2 patients have started steroids due to on-going symptoms findings on surveillance endoscopy and histological following re-introduction. Summary and Conclusion Dysphagia was the predominant symptom in our cohort of patients. Furrowing and oedema was the major finding during endoscopy. With dietary exclusion endoscopic resolution was seen in 62% and histological resolution seen in 70% of patients at first surveillance endoscopy. Re-introduction continues to remains a major challenge and we have not been able to introduce all the food groups in any of our patients due to either symptoms or recurrence on endoscopy/histology.