[Nursing Experience of Using Caring Theory in Caring for an Patient in Isolation Facing Bereavement].

A nursing experience using caring theory to care for the grief experienced by a patient with COVID-19 during their period of isolation from June 4 to June 15, 2021 is described in this article. The patient was assessed using physical, psychological, social, and spiritual framework assessments. Data were collected using care, observation, interviews, and medical records. The healthcare problems were identified as inefficient breathing patterns, anxiety, and grief. The patient transmitted COVID-19 to her father, who subsequently died of related respiratory failure. During the nursing process, we used a mobile application (app) to provide the patient with information about novel coronavirus pneumonia to relieve her anxiety. When the patient was physically unwell, we delivered drugs and oxygen, and provided comfortable prone position and breathing training to resolve her low-efficiency breathing patterns. Also, we cooperated with the psychological and spiritual team to resolve the patient's psychological problems, used hand-painted illustrations and words to provide encouragement, and provided information on the hospital's funeral services provider to help complete her father's funeral arrangements to reduce her sense of grief. It is suggested that, in the clinical care of similar patients, nurses should pay more attention to their psychological problems. In addition, nurses may use the concepts of caring theory to integrate a holistic approach, provide patient-specific resources, and accompanying the patient through the process of grief. This nursing experience may be used as a reference in the future care of similar patients to improve the quality of clinical nursing care.

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

Effects of face masks on cardiopulmonary performance in a partly double-blinded randomized cross-over study

Background: The use of face masks in the public and at work became mandatory as a result of the SARS-CoV-2 pandemic in many countries. Wearing masks under physical work or for a prolonged time may lead to complaints of labored breathing and increased stress. The influence of three types of masks on cardiopulmonary performance was investigated in a randomized cross-over design. Method(s): Forty volunteers (20 women, 19-65 years) underwent bodyplethysmography, spiroergometric and ergometric exercise tests without mask, with a surgical mask, a community mask and a FFP2 mask. Additionally, a 4hour mask wearing period was investigated during regular work (office or laboratory). Cardiopulmonary, physical, capnometric, and blood gas-related parameters were recorded. Result(s): Breathing resistance and work of breathing were increased when wearing a mask. During physical exercise minute ventilation was lower and the breathing cycle time was extended with mask. Wearing a mask caused minimal decreases in blood oxygen partial pressure (pO2) and oxygen saturation (sO2) and an initial slight rise in blood carbon dioxide partial pressure (pCO2) during exercise. All effects were most pronounced with FFP2. Temperature, humidity, and inspiratory CO2 concentration slightly increased behind the mask. No changes in pO2, sO2, and pCO2 were observed during the 4-hour wearing period at work. Conclusion(s): Wearing face masks at rest and under workload changed the breathing pattern in the sense of physiological compensation. Wearing a mask for 4 hours during light work had no effect on blood gases and no adverse effects were observed throughout all testing.

Designing Hybrid Mechanical Ventilator System Based on Arduino and Raspberry Pi 4

Mechanical ventilators are advanced life-supporting machines in this century. The ventilator needs to be safe, flexible, and easy for competent clinicians to use. Since ventilators supply the patient with gas, they need pneumatic components to be present. First technology ventilators were typically powered by pneumatic energy. Gas pressure is used to power ventilators as well as ventilate patients. Nowadays, ventilators are operated electronically with the useful microprocessor tool. This proposal aims to design a simple portable mechanical ventilator that includes measuring some important physiological variables such as respiratory rate, heart rate, and O2 saturation, which can be utilized in hospital and at home. The proposed system includes Arduino, Raspberry pi4, touch screen, and graphical user interface. This study showed a significant individual performance for measuring some important parameters such as flow rate, tidal volume, and minute ventilation. The accuracy of measuring the flow rate was 72%. The Cohen's kappa (CK) was estimated to be 0.61. The accuracy of calculated the tidal volume was estimated at 83% with 0.80 CK. The accuracy of measuring the O2 saturation was estimated at 99% with 0.99 CK. The advantages of the proposed design are cost-effective, safe, flexible, and easy to use. Also, this system is smart and can control its transactions, so it can be used at home without the need for professional help. The operating parameters can also be set by the user with a simple user interface.Copyright © 2022 by ASME.

Dysfunctional breathing after COVID-19: symptoms, functional impact and quality of life

Background: Dysfunctional breathing (DB) is increasingly recognized in long COVID. Associated symptoms, functional impact and quality of life (QoL) have not been systematically studied. Objective(s): We aimed to measure symptoms, functional impact and QoL in long COVID patients with new onset DB. Method(s): We included 55 patients (47.9 yr (14.4), female sex 72.7%) from our long COVID clinic with DB diagnosis based on compatible symptoms and abnormal breathing pattern during CPET. Questionnaires including mMRC scale, Nijmegen, short form 36 (SF-36), hospital anxiety and depression scale (HADS), post COVID functional scale (PFCS) and specific long COVID symptoms were administered. Result(s): Most patients had mild acute COVID-19 (admission rate 16.4%). Median time from SARS-CoV-2 diagnosis to CPET was 213 days (IQR 127), mean V'O2 was 90.4% (SD 20.2) pred. Hyperventilation, periodic sigh breathing and mixed types of DB were diagnosed in respectively 21.8%, 47.3%, 30.9% of patients. Mean (SD) Nijmegen score, PCFS and global HADS were 27.9 (11.9), 2.1 (0.8) and 16.6 (7.8) respectively. In addition to dyspnoea, most frequent symptoms on Nijmegen scale (cut-off >=3) were: faster or deeper breath (75.6%), unable to breath deeply (48.9%), sighs (53.5%), yawning (46.5%) and tight feeling in the chest (40.0%). SF36 scores were lower than population reference value. Conclusion(s): Long COVID patients living with DB have a high burden of symptom, functional impact and a low QoL despite normal exercise capacity.

Does virtual group treatment improve symptoms of breathlessness in the post COVID-19 patient population?

Introduction: British Thoracic Society (BTS) guidelines recommend assessment of breathing pattern disorder (BPD) for ongoing breathlessness post COVID-19 infection. 23.7% of patients attending post covid clinic were referred for breathing pattern retraining (BPR) (Heightman et al, 2021) and evidence suggests that BPR can improve breathlessness arising from BPD (British Thoracic Guidance, 2020). Due to large referral numbers and limited specialist work force, virtual group treatment (VGT) was trialled as an alternative to 1:1 intervention. Aim(s): To determine if a VGT improves breathlessness in patients with BPD following COVID-19 infection. Method(s): Data were collected from patients referred for BPR following completion of post Covid-19 multidisciplinary clinic assessment. Breathlessness (Dyspnoea 12- D12) and breathing pattern (Brompton Breathing Pattern Assessment Tool - BPAT) were assessed by a specialist Physiotherapist on referral and on completion of VGT. VGT consisted of 6, 1 hour, physiotherapist led sessions run fortnightly using a virtual platform. The programme included BPR at rest and on exertion, fatigue management and relaxation. Group size was 6-7 participants. A Wilcoxon Sign Rank test was used to compare pre and post treatment data. Result(s): Complete data sets (n=12) were analysed (11 female, 1 male, median age= 52) Improvement in BPAT was statistically significant (median pre 6, post 1, (z=-2.955, p=0.003)). Improvement in D12 was statistically significant (median pre 15, post 7, (z=-2.023, p=0.043)). Conclusion(s): Virtual group BPR treatment improves breathing pattern and breathlessness in the post covid population.

Outcomes from treating rhinitis in patients with refractory breathlessness

Background: In our multi-disciplinary airways service, we assess refractory breathlessness due to suspected inducible laryngeal obstruction (ILO) and/or breathing pattern disorder (BPD). A significant proportion of patients have evidence of uncontrolled co-morbidity, including rhinitis and asthma, which aggravate airway symptoms. Aim(s): To identify the impact of rhinitis management on i) nasal symptoms ii) asthma control and iii) cough control, for individuals referred with suspected ILO +/- BPD and evidence of rhinitis. Method(s): Patient demographics/clinical data were collected between January 2021 and January 2022. Symptoms were recorded using the Total Nasal Symptom Score (TNSS), Asthma Control Questionnaire (ACQ) in those with asthma and a 10-point self-rating scale in chronic refractory cough (CRC). Result(s): Data were available for 43 patients [72% female, 18% atopic, median (IQR) age 54 (41-64) years] with symptoms of rhinitis, confirmed by nasendoscopy in 41% (not all patients had nasendoscopy due to COVID-19 pandemic). Co-morbidities included asthma 54% (39%, of whom were on biologic treatment), CRC (21%), ILO (35%) and BPD (35%). Rhinitis management comprised education (100%), nasal corticosteroids (91%), saline nasal douche (49%) and antihistamines (10%). TNSS scores improved [from 5 (4-6) to 3 (2-4), p<0.001] following intervention. In those with asthma, there was improvement in ACQ [2.98 (2.15-3.70) to 2.00 (0.95-3.05), p<0.001], and in those with chronic refractory cough in self-rating score [8 (4-9) to 2 (2-6), p=0.11]. Conclusion(s): Optimisation of medical treatment for individuals with rhinitis is important and can improve outcomes in patients with asthma, CRC, ILO and BPD.

Persisting exertional dyspnea and perceived exercise intolerance after mild Covid-19: a critical role for breathing dysregulation?

Background: After mild Covid-19, a subgroup of patients reports post-acute sequelae of Covid-19 (PASC), in which exertional dyspnea and perceived exercise intolerance are common. Underlying pathophysiological mechanisms remain incompletely understood. We studied outcomes from cardiopulmonary exercise test (CPET) in these patients. Method(s): In this observational study, we included patients referred for the analysis of PASC after mild Covid-19 in whom CPET was performed after standard clinical work-up turned out unremarkable. Cardiocirculatory, ventilatory and metabolic response to, and breathing patterns during exercise at physiological limits were analyzed. Result(s): Twenty-one patients (76% female, mean age 40y) who reported severe fatigue (CIS-fatigue >= 35), dyspnea (mMRC 2 (IQR1-2)) and disability in physical role functioning (SF-36) underwent CPET at 32 weeks (IQR 22-52) after Covid-19. Mean peak oxygen uptake was 99% (SD13) of predicted with normal anaerobic thresholds at 62% (SD11) of predicted oxygen uptake. No cardiovascular or gas exchange abnormalities were detected. Twenty out of the 21 patients (95%) demonstrated breathing dysregulation, existing of ventilatory inefficiency (29%), abnormal course of breathing frequency and tidal volume (57%), and acute or chronic respiratory alkalosis in resting blood gases (67%). Conclusion(s): In the absence of deconditioning, breathing dysregulation may explain the experienced exertional dyspnea and exercise intolerance in patients with PASC after mild Covid-19.

The first-year experience of a long covid clinic in a UK district general hospital

Introduction: The impact of prolonged covid illness has been devastating for many people worldwide. Aim(s): We analysed the characteristics of patients referred to our Long Covid clinic. Method(s): Preliminary data;retrospective analysis from electronic and paper case notes. Result(s): 317 patients were included;majority were female (68%) & white (83%). Median age was 49 years (range 16-86 yrs). Wide range of symptoms experienced, most commonly fatigue & dyspnoea. 74% of patients were not admitted to hospital with their original covid illness. Majority had only 1-2 long term medical comorbidities. 43% had a history of previous/current mental health illness. Lung function results showed mild asthma (13%), significant asthma (6%), ILD (3%) and were normal in 63%. 41% had potentially treatable causes for fatigue (e.g. low Vitamin D or hypothyroidism). 82% of patients were referred to rehabilitation and physiotherapy for fatigue and/or breathing pattern disorder. The mean Body Mass Index (BMI) was 30, with 30% of patients overweight, 38.5% obese and 9% morbidly obese. 28% had abnormal overnight oximetry - 16% were mild and 4% severe. Conclusion(s): Long covid has predominantly affected young, middle-aged white women. We have noted many patients with high BMI, previous mental illness, breathing pattern disorder, asthma and abnormal overnight oximetry. More than 80% needed rehabilitation, physiotherapy and psychological support. More data is being collected.

Inappropriate Ventilatory Homeostatic Responses in Hospitalized COVID-19 Patients.

Background: The clinical presentation of COVID-19 suggests altered breathing control - tachypnoea, relative lack of dyspnoea, and often a discrepancy between severity of clinical and radiological findings. Few studies characterize and analyse the contribution of breathing drivers and their ventilatory and perceptual responses. Aim: To establish the prevalence of inappropriate ventilatory and perceptual response in COVID-19, by characterizing the relationships between respiratory rate (RR), dyspnoea and arterial blood gas (ABG) in a cohort of COVID-19 patients at presentation to hospital, and their post-Covid respiratory sequelae at follow-up. Methods: We conducted a retrospective cohort study including consecutive adult patients admitted to hospital with confirmed COVID-19 between 1st March 2020 and 30th April 2020. In those with concurrent ABG, RR and documented dyspnoea status on presentation, we documented patient characteristics, disease severity, and outcomes at hospital and 6-week post-discharge. Results: Of 492 admissions, 194 patients met the inclusion criteria. Tachypnoea was present in 75% pronounced (RR>30) in 36%, and persisted during sleep. RR correlated with heart rate (HR) (r = 0.2674), temperature (r = 0.2824), CRP (r = 0.2561), Alveolar-arterial (A-a) gradient (r = 0.4189), and lower PaO2/FiO2 (PF) ratio (r = -0.3636). RR was not correlated with any neurological symptoms. Dyspnoea was correlated with RR (r = 0.2932), A-a gradient (r = 0.1723), and lower PF ratio (r = -0.1914), but not correlated with PaO2 (r = -0.1095), PaCO2 (r = -0.0598) or any recorded neurological symptom except for altered consciousness. Impaired ventilatory homeostatic control of pH/PaCO2 [tachypnoea (RR>20), hypocapnia (PaCO2 <4.6 kPa), and alkalosis (pH>7.45)] was observed in 29%. This group, of which 37% reported no dyspnoea, had more severe respiratory disease (A-a gradient 38.9 vs. 12.4 mmHg; PF ratio 120 vs. 238), and higher prevalence of anosmia (21 vs. 15%), dysgeusia (25 vs. 12%), headache (33 vs. 23%) and nausea (33 vs. 14%) with similar rates of new anxiety/depression (26 vs. 23%), but lower incidence of past neurological or psychiatric diagnoses (5 vs. 21%) compared to appropriate responders. Only 5% had hypoxia sufficiently severe to drive breathing (i.e. PaO2 <6.6 kPa). At 6 weeks post-discharge, 24% (8/34) showed a new breathing pattern disorder with no other neurological findings, nor previous respiratory, neurological, or psychiatric disorder diagnoses. Conclusions: Impaired homeostatic control of ventilation i.e., tachypnoea, despite hypocapnia to the point of alkalosis appears prevalent in patients admitted to hospital with COVID-19, a finding typically accompanying more severe disease. Tachypnoea prevalence was between 12 and 29%. Data suggest that excessive tachypnoea is driven by both peripheral and central mechanisms, but not hypoxia. Over a third of patients with impaired homeostatic ventilatory control did not experience dyspnoea despite tachypnoea. A subset of followed-up patients developed post-covid breathing pattern disorder.

A Quantitative Approach and Preliminary Application in Healthy Subjects and Patients with Valvular Heart Disease for 24-h Breathing Patterns Analysis Using Wearable Devices

The 24-h breathing patterns may be closely related to health status as well as disease progression. However, there is no consistent and widely accepted approach for mining the potential value in 24-h respiratory signals based on wearable device monitoring. This study presented a reference approach including signal quality assessment, calibration of tidal volume, and breathing patterns parameters based on a wearable continuous physiological parameter monitoring system for 24-h breathing patterns analysis, including time domain, frequency domain and nonlinear domain. 70 healthy subjects and 76 patients undergoing heart valve surgery were enrolled in this study. The normal reference range of breathing patterns was calculated based on healthy subjects. A subgroup study was conducted based on whether patients developed postoperative pulmonary complications (PPCs). Compared with non-PPCs group, the coefficient of variation of breathing rate in the recumbent position was smaller in the PPCs group. During the daytime, the kurtosis of breathing rate and contribution of the abdomen was smaller in PPCs group. During the nighttime, the coefficient of variation of breathing rate and SD2 was smaller in the PPCs group. The quantitative method proposed in this study fills the gap in the field of quantifying 24-h breathing patterns which is effective in discriminating different populations and is expected to be used widely in the context of COVID-19 epidemic. © 2022 IEEE.

MiniVent: A low-cost pressure-controlled ventilator system for emergency use

Objective: To address the issue of ventilator shortages due to the COVID-19 pandemic, our group developed the proof-of-concept of a low-cost and rapidly scalable open-source mechanical ventilator system for emergency use. Method(s): A simplified architecture of MiniVent was designed to meet the low-cost and easy-to-produce pre-established properties of our device. To carry out such an approach, we decided to use only components commonly available in the market or components of easy production with usual manufacturing techniques, such as 3D printing. The design of MiniVent comprises a pneumatic unit that controls the quality of the air and oxygen mixture and maintains the pressure on the patient's lungs at the desired preset value, along the respiratory cycle. The control unit was programmed on a microcontroller and is responsible for ensuring the respiratory rate and the inspiratory-expiratory ratio, selected by the user. To ensure the fulfilment of all the security and specification requirements of pandemic ventilators, we followed the mandatory specifications presented in the document - Rapidly Manufactured Ventilator System (RMVS) - published by the Medicines & Healthcare products Regulatory Agency (MHRA). A set of tests was performed using different ventilatory parameters for instrumental verification of MiniVent's physical and biological performance. A stability test was also carried out during 35 hours of uninterrupted operation to analyse whether the expected dynamics of the output pressure were maintained over this time. Result(s): The ventilator system developed allows prescribing different breathing rates, fractions inspired of oxygen (FiO2), inspiratory-expiratory ratios (I: E), positive inspiratory pressures (PIP) and positive end-expiratory pressures (PEEP), which can be easily adjustable to the patient's condition. The results of a set of tests assured the reliability of all the ventilatory parameters set by the user. Furthermore, MiniVent showed a good performance over 35 hours of uninterrupted operation, which pointed out the stability of this device. In addition, the device was tested in a porcine model showing good mechanical performance and adequate arterial blood gas throughout all test periods. When compared with commercial ventilators, MiniVent exhibited a similar performance of ventilation. Conclusion(s): MiniVent could be a reliable solution to overcome the shortage of commercial ventilators in emergencies, such as the recent COVID-19 pandemic. This device presents a production cost of under 1000 and does not need specialized technical assistance so it might be a viable solution even in lowerincome countries.

Detection of COVID-19 Through Thermal and Voice Sensing Using Smartphone

Since the end of 2019, the world has been caught in the crisis of the COVID-19 which is a serious epidemic disease. This paper seeks to come up with a fast and efficient COVID-19 detection and monitoring easy to use system which can be used in the facilities of densely populated areas, such as community centers and school clinics, to quickly identify suspected COVID-19 patients. This system could detect the probability of a person getting infected by COVID-19 using an android smartphone and thermal camera. Three types of data are collected from users: breathe sound, thermal video, and health status. Generally, the breathe audio and thermal video are preprocessed into two-time series, which indicate the breath status of the user. Then, the two series are inputted into the Bidirectional Gated Recurrent Unit (BI-GRU) neural network model separately to get the infection rates. Since the real data is difficult to get due to privacy reasons, a synthetic dataset is generated based on mathematical equations to train the model. For health status, the application requires the user to fill a questionnaire and calculates an infection rate through a medical prediction model. Finally, the two values from the machine learning model and the infection rate from the user report are added together with weight to calculate the final predictive infection rate. © 2022 IEEE.

ATYPICAL PRESENTATION OF MUCORMYCOSIS IN A NONSEVERE COVID-19 PATIENT

SESSION TITLE: COVID-19 Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Coronavirus Disease 2019 (COVID-19) infection ranges from asymptomatic to severe disease as defined by WHO. Emerging fungal infections such as mucormycosis and aspergillosis have been described in critically ill patients, most notably in India, when treated with steroids due to severe COVID-19 [1]. We present a unique case of an atypical presentation of mucormycosis in a non-severe COVID-19 patient not treated with corticosteroids. CASE PRESENTATION: A 19-year-old male with type 1 diabetes mellitus presented to the emergency room for evaluation of shortness of breath, nausea and fatigue. History was significant for insulin noncompliance with home blood glucose in the 300s and a positive COVID-19 test one day prior to arrival. Initial vitals positive for tachycardia, tachypnea and hypertension while on room air. Labs showed leukocytosis 14,000 cells/uL, bicarbonate 7.2 mmol/L, anion gap 24.8, glucose 428 mg/dL, beta-hydroxybutyrate 58 mg/dL and nucleic acid amplification COVID-19 positive. Physical exam showed left eyelid and facial swelling, nasal congestion without sinus tenderness or other deformity, and kussmaul breathing pattern. CT face confirmed left periorbital cellulitis. Transfer to tertiary center for Ophthalmology evaluation was attempted but refused due to capacity. He was started on diabetic ketoacidosis treatment as well as broad spectrum antibiotics with the assistance of Infectious Disease, however COVID-19 treatments were held due to mild illness. Despite these interventions, he became stuporous and amphotericin was started. MR Brain showed findings suggestive of cavernous sinus thrombosis, acute ischemia and local mass effect. ENT then performed an endoscopic antrostomy with ethmoidectomy and biopsies were taken. Pathology resulted as invasive fungal sinusitis with 90° branching hyphae confirming mucormycosis and a lumbar drain was placed with intrathecal amphotericin started for concern of mucormycosis meningitis. The patient was ultimately transferred to a tertiary care center where he expired. DISCUSSION: Mucormycosis, an angioinvasive fungal infection affecting the immunocompromised and diabetics, is rare but deadly. The estimated prevalence in the United States is 0.16 per 10,000 hospital discharges [2] and bears a mortality rate of 46%. Recent systematic reviews report 275 cases of COVID associated mucormycosis with 233 in India [1] with 76.3% receiving corticosteroids prior to diagnosis [3], likely contributing to an immunocompromised state. Our case demonstrates that despite not receiving corticosteroids, even those with mild COVID-19 are at risk for this disease. CONCLUSIONS: Patients with diabetes, immunocompromised states, and now COVID-19, presenting with orbital symptoms warrant consideration of mucormycosis. Prompt management of the underlying condition, IV amphotericin, and possible debridement may increase survival. Reference #1: John TM, Jacob CN, Kontoyiannis DP. When Uncontrolled Diabetes Mellitus and Severe COVID-19 Converge: The Perfect Storm for Mucormycosis. J Fungi (Basel). 2021 Apr 15;7(4):298. doi: 10.3390/jof7040298. PMID: 33920755;PMCID: PMC8071133. Reference #2: Kontoyiannis DP, Yang H, Song J, et al. Prevalence, clinical and economic burden of mucormycosis-related hospitalizations in the United States: a retrospective study. BMC Infect Dis. 2016;16(1):730. Published 2016 Dec 1. doi:10.1186/s12879-016-2023-z Reference #3: Singh AK, Singh R, Joshi SR, Misra A. Mucormycosis in COVID-19: A systematic review of cases reported worldwide and in India. Diabetes Metab Syndr. 2021 Jul-Aug;15(4):102146. doi: 10.1016/j.dsx.2021.05.019. Epub 2021 May 21. PMID: 34192610;PMCID: PMC8137376 DISCLOSURES: No relevant relationships by james abraham No relevant relationships by christian ALMANZAR ZORRILLA No relevant relationships by Grace Johnson No relevant relationships by Thanuja Neerukonda No relevant relationships by Blake Spain No relevant re ationships by Michael Su No relevant relationships by Steven Tran No relevant relationships by Margarita Vanegas No relevant relationships by Alexandra Witt

PERICARDITIS EVOLVING INTO CARDIAC TAMPONADE IN A 76-YEAR-OLD PATIENT WITH COVID-19

SESSION TITLE: Cardiovascular Complications in Patients with COVID-19 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Cardiac tamponade is a medical emergency that requires rapid diagnosis and intervention to prevent hemodynamic collapse. Although COVID-19 typically manifests with pulmonary symptoms, cardiac involvement is becoming better studied through increasingly frequently reported cases [1]. We present a case of COVID-19 cardiac involvement presenting as a rapidly progressive pericardial effusion turning into tamponade. This highlights the importance of a high index of suspicion for patients who develop sudden and atypical respiratory compromise with hypotension in the setting of COVID-19 infection. CASE PRESENTATION: A 76-year-old male with a history of ESRD presented with fatigue after missing hemodialysis. Laboratory investigations revealed a mild troponin elevation and positive SARS-CoV-2 PCR. Initial TTE demonstrated an EF of 60-65% with a small pericardial effusion and thickened calcified pericardium. After a few days, the patient was noted to be encephalopathic and hypotensive. Labs revealed leukocytosis, lactic acidosis as well as an elevated troponin and D-dimer. Chest CTA was significant for a large pericardial effusion with reduced size of the right ventricle, concerning for cardiac tamponade. Repeat TTE had a moderate pericardial effusion and right atrial collapse, consistent with tamponade. Given significantly elevated INR in the setting of anticoagulation, pericardiocentesis was deferred while the patient was transfused FFP. The patient subsequently suffered PEA arrest and expired despite attempted hemodynamic stabilization. DISCUSSION: Cardiac tamponade is a result of accumulating pericardial fluid culminating in decreased cardiac output and shock. Clinicians should be prompted by characteristic findings, including Beck’s triad (JVD, hypotension, and muffled heart sounds) and Kussmaul’s sign of paradoxically elevated JVP with inspiration [2]. However, the diagnosis of tamponade based solely on clinical finding is difficult and may lead to unnecessary intervention [3]. Ultimately, a diagnosis of tamponade requires both hemodynamic instability and pericardial effusion. Echocardiography, including TTE and POCUS, plays a central role in the identification of cardiac tamponade. While it is essential to note the presence of a pericardial effusion, it is important to be familiar with core echocardiographic signs of tamponade: systolic RA collapse (earliest sign), diastolic RV collapse, IVC with minimal respiratory variation, and exaggerated respiratory cycle changes in MV and TV in-flow velocities (a surrogate for pulsus paradoxus) [3]. CONCLUSIONS: Despite the classic association between COVID-19 and pulmonary manifestation, pericardial involvement has been noted in 20% of COVID-19 patients. It is therefore imperative to maintain a high index of suspicion and familiarity of characteristic echocardiogram findings of tamponade to prompt intervention and curtail cardiac hemodynamic collapse. Reference #1: Lala A, Johnson KW, Januzzi JL, et al. Prevalence and Impact of Myocardial Injury in Patients Hospitalized With COVID-19 Infection. J Am Coll Cardiol. 2020;76(5):533-546. doi:10.1016/j.jacc.2020.06.007 Reference #2: Stashko E, Meer JM. Cardiac Tamponade. [Updated 2021 Dec 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431090/ Reference #3: Alerhand S, Carter JM. What echocardiographic findings suggest a pericardial effusion is causing tamponade?. Am J Emerg Med. 2019;37(2):321-326. doi:10.1016/j.ajem.2018.11.004 DISCLOSURES: No relevant relationships by Christopher Allahverdian No relevant relationships by John Javien No relevant relationships by Vishal Patel No relevant relationships by Sarah Youkhana

Drowning: A practical review of prehospital intervention

Despite a recent decrease in drowning deaths, the number of drownings in Australia remains too high. Being reminded of key considerations for a drowning emergency is helpful preparation for health professionals who may take control at the scene © 2021 Medicine Today Pty Ltd. All rights reserved.

Role of High Flow Nasal Cannula for Respiratory Support During Oral Feeding for COVID-19 Patients on Non-invasive Ventilation: A Case Series

Aims and objectives: To establish that non-invasive ventilation (NIV) can be substituted by high flow nasal cannula (HFNC) for respiratory support during oral feeding of a patient with COVID-19 patients. Materials and methods: This prospective case series was conducted after taking informed and written consent from the patients. Ten patients with severe COVID-19 disease requiring NIV with inspiratory pressure of <10 cm H2O, positive end-expiratory pressure of <6 cm H2O and FiO2 <0.6 were included in this study. Patients with altered consciousness, circulatory failure, or worsening acidosis were not included in the study. Patients underwent HFNC trial for 10 minutes and were screened for risk of dysphagia and aspiration using a 3-ounce water swallowing test. The patients were given a trial of HFNC for 10 minutes with a flow of 60 L/minute and FiO2 of 0.1 more than their requirement on NIV. The patients were observed for hypoxemia (SpO2 <88%) or signs of respiratory distress, e.g., increase in respiratory rate (>35/minute), laboured breathing pattern, use of accessory muscle of respiration, heart rate (>20% change), blood pressure (>20% change), perspiration, and anxiety. Then, HFNC was used for supporting respiration during oral feeding for up to 20 minutes. Feeding was started with a hypocaloric target on starting day and was increased progressively as per European Society for Clinical Nutrition and Metabolism guidelines to the target estimated caloric requirement. Results: The HFNC support for oral feeding was successful with adequate diet intake in eight patients without desaturation/respiratory distress during oral feeding. Other than COVID-19, co-morbidities in these eight patients included diabetes mellitus, obesity, chronic obstructive pulmonary disease, coronary artery disease, and dilated cardiomyopathy. Six patients, previously on enteral nutrition using the nasogastric tube, were successfully switched to oral feeding with help of HFNC. Four patients were directly started on the oral diet with help of HFNC support. HFNC could not support respiration adequately in two of these four patients. The initial trial was successful for one of the patients and HFNC support for oral feeding was used for 3 days, but a progressive increase in ventilatory requirements resulted in failure of HFNC trial subsequent days and the patient was switched to nasogastric feeding. In another patient, the initial trial of HFNC failed due to rapid desaturation within a few minutes of the trial. The eight patients in whom HFNC was used successfully for feeding were switched to HFNC completely and discharged from the hospital after weaning off from oxygen support. The patients who failed the HFNC support for feeding required higher ventilatory requirements and needed endotracheal intubation. Conclusion: Based on our case series, using daily screening trial of oral feeds with HFNC support in selected patients of severe COVID-19 pneumonia on NIV seems thought-provoking and should be explored for its potential in improving patient's nutrition with a positive impact on the outcome.

MODELING OF PRE-TRAINED NEURAL NETWORK EMBEDDINGS LEARNED FROM RAW WAVEFORM FOR COVID-19 INFECTION DETECTION

COVID-19 is a respiratory system disorder that can disrupt the function of lungs. Effects of dysfunctional respiratory mechanism can reflect upon other modalities which function in close coupling. Audio signals result from modulation of respiration through speech production system, and hence acoustic information can be modeled for detection of COVID-19. In that direction, this paper is addressing the second DiCOVA challenge that deals with COVID-19 detection based on speech, cough and breathing. We investigate modeling of (a) ComParE LLD representations derived at frame- and turn-level resolutions and (b) neural representations obtained from pre-trained neural networks trained to recognize phones and estimate breathing patterns. On Track 1, the ComParE LLD representations yield a best performance of 78.05% area under the curve (AUC). Experimental studies on Track 2 and Track 3 demonstrate that neural representations tend to yield better detection than ComParE LLD representations. Late fusion of different utterance level representations of neural embeddings yielded a best performance of 80.64% AUC. © 2022 IEEE

IN VITRO INVESTIGATION INTO FUGITIVE AEROSOL FROM A NOVEL 4TH GENERATION ADAPTIVE AEROSOL DELIVERY (AAD) SYSTEM

The recent Covid-19 pandemic has drawn attention to the amount of fugitive aerosol that is emitted by nebulizers. The novel I-neb Advance Adaptive Aerosol Delivery (AAD) System incorporates an improved AAD algorithm intended to reduce treatment times compared with earlier AAD devices. We conducted an in vitro test to determine the amount of fugitive aerosol that is emitted from the I-neb Advance (AAD) System. Three production equivalent investigational I-neb Advance nebulizers fitted with nonmetering chambers were filled with 1.7mL of 2mg/mL salbutamol solution. The delivered dose was collected on a filter during operation into a simulated breathing pattern (Tv=500mL, I:E=1:1, f 15 bpm). A second filter was fixed 1 cm away from the exhalation port of the nebulizer with an extraction flow of 60 L/min. Each nebulizer was run in triplicate. Salbutamol on filters was quantitated by high performance liquid chromatography. The delivered doses had low co-efficients of variation, intra-nebulizer=0.83 to 3% and inter-nebulizer=0.77%. The fugitive aerosol was lower than the limit of quantification of the assay (0.18% of fill) in 2/3 of the tests. Measurable exhaled doses were all below 0.3% of the fill volume. The improved AAD algorithm used in the I-neb Advance (AAD) System delivered precise, reproducible doses with minimal fugitive aerosol emissions into a simulated breathing pattern. The minimization of fugitive aerosol emissions demonstrated by AAD nebulizers likely has an added relevance to aerosol treatment following the emergence of the Covid-19 pandemic. Key Message: The novel I-neb Advance (AAD) System was shown to deliver reproducible doses of drug with minimal (<0.3% of the nominal dose) fugitive aerosol emissions. This observation could be important in clinical situations where there is a need to minimise escaping aerosol from nebuliser devices during use.