Two-year outcome of extracorporeal membrane oxygenation in COVID-19 related severe respiratory failure

Objectives: We sought to evaluate 2-year outcome of V-V ECMO support for COVID-19 related severe respiratory failure in our center. Method(s): Retrospective analysis of 41 consecutive patients (73% male, mean age 51.6+/-14.2 years, mean BMI 35.1+/-12.5 kg/m2) with critical hypoxemic and/or hypercapnic refractory respiratory failure (mean P/F ratio 67.9+/-14.3 mmHg, mean pCO2 77.6.0+/-185.7 mmHg, Murray Score 3.71+/-0.4) on V-V ECMO support from October 2020 to January 2022 Results: With mean support duration of 234.4+/-63.2 hours, 29 patients (70.7%) were successfully weaned off. Finally, 19 of them (46.3%) were discharged home with good neurological outcome (CPC 1,2). During followup, 30-day, 6-, 12-, and 24 -month survival rate was 61.3%, 46.2%, 41.9%, and 41,9% respectively. In survivor group shorter symptoms onset to respiratory failure time (4+/-4.7 vs. 7+/-6.7 days, p=0.04), higher P/F ration (86+/-41.5 vs. 65+/-37.5 mmHg, p=0.04) and norepinephrine support (0.03+/-0.06 vs. 0.09+/-0.12 ug/kg/min, p=0.04), and lower IL-6 level (12.3+/-7.5 vs. 25.9+/-8.8 ng/l, p=0.03) p=0.01) were analysed before cannulation. Mean in-ICU stay and in-hospital stay in survivors;groups reached 32.5+/-27.7 days and 42.6+/-35.8 days, respectively. All long-term survivors (17 patients) complained about slight functional health limitation only with normal 6MWT (542.6+/- 89.2 min), near to normal spirometry parameters (FEV/VC 87+/-7.4%, DLCO 63.1+/-13.7%, KCO 82.,1+/-19.4%) and minimal neurological disability (CPC 1-2) Conclusion(s): 2-year outcome of V-V ECMO support in COVID-19 severe respiratory failure is acceptable even in the scope of low-volume ECMO centre. Reported functional status of long-term survivors was good despite the complicated and prolonged in-hospital stay. (Table Presented).

Tocilizumab Initiation based on Indicator in Patients Infected by Coronavirus-19 to Prevent Intubation

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has created severe medical and economic consequences worldwide since 2019. Tocilizumab is one of the therapies considered capable of improving the condition of patients with COVID-19. However, there is not much information about the best time to give tocilizumab. METHOD(S): This was an analytical study with a retrospective cohort design, using the data of 125 patients infected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with signs of acute respiratory distress syndrome in Dr. Moewardi Hospital, Surakarta, from March to August 2020. We analyzed various available clinical data to see which factors into clinical improvement with tocilizumab therapy. RESULT(S): Most patients showed clinical improvement after administration of tocilizumab. During the follow-up period, 21 patients died despite tocilizumab therapy. Significant risk factors associated with the need for intubation were heart rate, neutrophil, lymphocyte, pH, PaCO2, and PO2. The most influential variable on the need for intubation without being associated with other risk factors was PaO2 (p = 0.003, Confidence Intervals 95%). CONCLUSION(S): Tocilizumab has a role in treating patients infected by SARS-CoV-2, preventing the need for intubation when given to patients in good saturation condition with oxygen supplementation without positive pressure (PaO2 >65mmHg;SpO2 >93%).Copyright © 2023 Septian Adi Permana, Adhrie Sugiarto, Sidharta Kusuma Manggala, Muhammad Husni Thamrin, Purwoko Purwoko, Handayu Ganitafuri.

Role of telemedicine in anesthesia: Are we ready yet?

Telemedicine is a modality which utilizes technology to provide and support health care across large distances. It has redefined the practices of medicine in many specialties and continues to be a boon for clinicians on many frontiers. Its role in the branch of anesthesia remains largely unexplored but has shown to be beneficial in all the three phases: pre-operative, intra-operative, and post-operative. Now time has come that anesthesiologists across the globe reassess their strategies and utilize the telemedicine facilities in the field of anesthesia.Copyright © 2021 EDP Sciences. All rights reserved.

Early prone positioning under VV-ECMO in SARS- CoV-2-induced acute respiratory distress syndrome - a retrospective cohort study

Objectives: The effectiveness of prone positioning (PP) under VV-ECMO for severe COVID-19 still be unclear. Until now, PP under VV-ECMO was often performed as the trump card for refractory hypoxemia and weaning off ECMO. On the other hand, PP has the effect of promoting homogenization of Lung aeration and leading to prevention of VILI. Combine use of early prone positioning together VV-ECMO may have synergy effects of ultra-lung protective strategy. In this study, we analyzed early PP cases under VV-ECMO for severe COVID-19 in our hospital and examined their efficacy and feasibility. Method(s): We performed a retrospective study of patients with SARS-CoV-2-induced ARDS submitted to early PP during VV-ECMO. During VVECMO, PP was considered in case of "Type-H transition in imaging findings (CT / LUS) " and cases that the physician deemed necessary. The lung aeration is evaluated by LUS before and after each PP. If there is a finding that the dorsal collapsed lung is improved through PP, it is implemented as effective, and it continued. Result(s): From April 2021 to August 2021, there were a total of 10 early PP cases under ECMO, and the age was (average) 56 years. ECMO was implanted with P/F 98 and Murray score 3.3 points, and PP was started 14 hours after the ECMO implantation. The average PP duration is 17.4 hours and PP performed 5.8 times per patient. Comparing blood gas and respiratory mechanics before and after PP showed a significant difference in PaCO2 (before: 46 +/- 8 vs after: 42 +/- 9, p = 0.02). Finally, there were 10 ECMO successful weaning (100%) and 8 surviving discharges (80%). No major complications were observed. Conclusion(s): Early PP under VV-ECMO for severe COVID-19 can be safely performed, and it is suggested that the synergy effect of ultra-lung protective strategy may be associated with a reduction of hospital mortality.

Is COVID-19 a risk for postoperative delirium and death in elderly patients after emergency surgery?

Aim: While recent evidence describes atypical outcomes of coronavirus disease 2019 (COVID-19) in elderly patients, the frequency of delirium and associated outcomes in elderly patients with COVID-19 (coronavirus disease 2019) infection undergoing emergency surgery are not well defined. This study aims to determine the effect of COVID-19 on postoperative delirium and postoperative death in elderly patients undergoing emergency surgery. Material(s) and Method(s): This descriptive and cross-sectional study was conducted in general surgery, orthopedics, and cardiovascular surgery clinics of a public hospital, including 30 days of follow-up between April 1 and May 1, 2021. All patients who were admitted to these clinics for emergency surgery intervention on these dates constituted the study population, while a total of 140 patients aged >=65 years, who met the study criteria, formed the sample of the study. Descriptive Characteristics Form and Nursing Delirium Screening Scale (Nu-DESC) were used as data collection tools in the study. SPSS 25.0 statistical program was used for data analysis. Result(s): Thirty (42.85%) of the SARS-CoV-2 positive (n=70) patients developed delirium in the study. 12.9% (n=18) of the patients died within 30 days of follow-up after surgery. There were 30 (69.8) of 70 SARS-CoV-2 positive patients who developed delirium, and 12 patients (25.5) died after testing positive for COVID-19, with a mean of 8.08T1.56 days within 30 days of admission. Discussion(s): These findings may lead to a poor clinical prognosis for COVID-19 infection delirium and postoperative death in patients over 65 years of age undergoing emergency surgery.Copyright © 2023, Derman Medical Publishing. All rights reserved.

Clinical characteristics and risk factors of patients with COVID-19 developing barotrauma

Background: At our hospital, people with COVID-19 (coronavirus disease 2019) had a high rate of pulmonary barotrauma. Therefore, the current study looked at barotrauma in COVID-19 patients getting invasive and non-invasive positive pressure ventilation to assess its prevalence, clinical results, and features. Methodology: Our retrospective cohort study comprised of adult COVID-19 pneumonia patients who visited our tertiary care hospital between April 2020 and September 2021 and developed barotrauma. Result(s): Sixty-eight patients were included in this study. Subcutaneous emphysema was the most frequent type of barotrauma, reported at 67.6%;pneumomediastinum, reported at 61.8%;pneumothorax, reported at 47.1%. The most frequent device associated with barotrauma was CPAP (51.5%). Among the 68 patients, 27.9% were discharged without supplemental oxygen, while 4.4% were discharged on oxygen. 76.5% of the patients expired because of COVID pneumonia and its complications. In addition, 38.2% of the patients required invasive mechanical breathing, and 77.9% of the patients were admitted to the ICU. Conclusion(s): Barotrauma in COVID-19 can pose a serious risk factor leading to mortality. Also, using CPAP was linked to a higher risk of barotrauma.Copyright © 2021 Muslim OT et al.

Characteristics, management and outcomes of thirty COVID-19 ARDS patients supported with veno-venous extracorporeal membrane oxygenation at Rikshospitalet, Oslo University Hospital

Background: We reviewed patients with COVID-19 ARDS managed with VV-ECMO support at our center from March 2020 until February 2022. Material(s) and Method(s): We extracted data from electronic health records (Metavision and DIPS). We registered premorbid health status, ventilator-settings before initiation of ECMO, the time-course, and hospital mortality. Result(s): Thirty patients were managed at our hospital, with a median age of 57.2 years (28-65) and median BMI 28 (22-40). No patient had any serious comorbidity. Twenty-two patients received non-invasive ventilation prior to intubation (1-10 days). The median time on ventilator were 8.0 days (1-19) prior to ECMO and median tidal volume was 5.8 mL/kg PBW (3.1-7.5). Hypoxemia (median PaO2-FiO2 ratio 8 kPa, range 6-12 kPa) and hypercapnia (median PaCO2 11.9 kPa, range 4.2-18.5) [SEP1] despite lung protective ventilation were the main indications for VV-ECMO. Two patients had severe respiratory acidosis without hypoxemia. 18 patients developed serious complications while managed with ECMO (acute renal failure, clinically significant bleeding, sepsis, right ventricular heart failure, dislocation of cannulae). Seven patients received renal replacement therapy. Sixteen patients (53%) died. Thirteen patients (43%) died on ECMO, three (10%) after weaning, Twelve (40%) were discharged from hospital, two are currently in ICU (7%). The median duration of ECMO and ventilator treatment, was 27 (6-50) and 37 (9-78) days, respectively. Conclusion(s): Management of patients with COVID-19 ARDS with VV-ECMO is very resource-intensive, and accompanied by serious complications and high mortality. In-hospital mortality in our cohort was 53%, which is comparable with reports from other centers. However, the duration of ECMO, and pre-ECMO mechanical ventilation, were longer than typically reported.

The impact of prone episodes on oxygenation in COVID-19 mechanically ventilated patients

Introduction: Prone positions have been used extensively to improve oxygenation in patients with acute respiratory distress syndrome (ARDS). During the COVID-19 pandemic there was widespread adoption of proning in patients with acute severe hypoxic respiratory failure. Few studies explore the use of prone positioning in mechanically ventilated COVID-19 patients. Method(s): This study was part of the REACT COVID observational study at University Hospital Southampton (UHS) [1]. Eligibility included admission to UHS with a positive COVID-19 RT-PCR between 03/2020 and 03/2022. Data was collected from all available electronic clinical data sources using semi-automated and manual data extraction. Result(s): 184 patients received invasive mechanical ventilation with documented evidence for 931 prone episodes. We performed detailed analysis for 763 prone episodes. The rest were excluded due to insufficient data. The median duration of each cycle was 16 h (IQR 15-17 h). 459 cycles were done within 7 days of intubation (early), 202 in 7-14 days (intermediate) and 102 after 14 days (late). The change in oxygenation defined as delta PaO2/ FiO2 ratio (DELTAPF) for early, intermediate, and late cycles were 2.4 +/- 5.2 kPa, 1.6 +/- 3.7 kPa and 1.4 +/- 4.0 kPa, (p = 0.03) respectively. The overall DELTAPF for all groups after a cycle was 2.1 +/- 4.7 kPa. There was an increase in PaCO2 following proning with an overall change of 0.30 +/- 1.0, however, this was not statistically significant (p = 0.30). Conclusion(s): Following proning, there was significant improvement in oxygenation. Cycles lasted for 16 h consistent with current ARDS guidelines [2]. Although the results suggest a diminishing response in those proned at later times, the DELTAPF ratio was still significant. Overall, this suggests a beneficial effect on oxygenation. However, findings cannot be translated into survival benefit. Further research including randomised controlled trials is recommended.

Causes of mortality of severe COVID-19 patients receiving high-flow oxygen therapy

Introduction: High-flow oxygen therapy (HFOT) is used to provide oxygenation and reduce the need for intubation in severe pneumonia cases caused by SARS-CoV-2 virus. In this study, causes of mortality during hospitalization in the intensive care unit (ICU) in patients receiving HFOT therapy were investigated. Method(s): The data of 215 adult patients, who were admitted to ICU of a university hospital between April 2020 and October 2021, with severe COVID pneumonia and received HFOT were enrolled retrospectively in our study. Result(s): Total mortality among patients was 158 (73.4%). The overall mean age was 72 years, 61 in the survivor group and 73 in the mortality group (p < 0.001). It was determined that mortality rates decreased as the length of stay (LoS) in ICU and HFOT duration of the patients increased (p = 0.008 and < 0.001, respectively). The increase in respiratory rate on arrival was found to be significantly associated with increased mortality. Although the goal of HFOT is to improve oxygenation, no significant mortality-related difference was found in terms of pO2, pCO2 and P/F values calculated at the time of admission. The ROC curve was applied to examine the differential effect of Apache-II, SOFA, ROX and Procalcitonin measurements according to the survival. The area under the curve (AUC) and cut-off values were calculated as follows: APACHE-II (63.9%, 5,) SOFA (62.8%, 2), ROX index (66.8%, 4.72), Procalcitonin (65.7%, 0.23) (Fig. 1). Conclusion(s): Unlike reports in literature on mortality in ICU, LoS was found to have a decreasing effect on mortality rate [1]. In addition to the well-known scoring systems such as APACHE-II and SOFA, the ROX index, which is used to predict the success of HFOT, has emerged as a predictive value for mortality at admission to the intensive care unit [2].

Predictive value of central venous-to-arterial carbon dioxide tension in patients with ARDS treated with veno - venous extracorporeal membrane oxygenation (ECMO)

Introduction: Central venous-to-arterial carbon dioxide tension ( PvaCO2) can be useful for monitoring adequacy of tissue perfusion in patients with ARDS supported with veno-venous Extracorporeal Membrane Oxygenation (VV-ECMO). However, in theory, the unavoidable mixing of venous blood with blood after the oxygenator can affect PvaCO2 values by increasing central venous oxygen saturation and substantially decreasing CO2 concentration. This study aimed to evaluate acute changes in PvaCO2 after VV-ECMO installation and determine its association with patient outcomes. Method(s): Retrospectively evaluated coronavirus disease 2019 (COVID-19) ARDS patients with at least one concurrent arterial and central venous blood gas analysis before and after VV-ECMO installation as standard care. The primary outcome was intensive care unit (ICU) mortality at 28 days. Result(s): 29 patients were enrolled in the study. All the patients had a 25 F drainage multistage femoral cannula and a 21 F internal jugular infusion cannula. The median distance between the central venous sampling point and the tip of the infusion cannula was 39 [23-73] mm. No statistically significant changes in PvaCO2frelative changes calculated. After were observed 24-48 h after VV-ECMO installation (5 [4-7] mmHg to 6.5 [5-8.2] mmHg, p = 0.12). Hemoglobin concentration decreased 24 to 48 h after VVECMO installation (10.7 [9.5-12.7] g/dl to 9.6 [8.8-11.6] g/dl, p < 0.01) but neither central venous (75 [70-81]% to 73 [67-78]%, p = 0.46) nor arterial oxygen saturation (95 [92-97]% to 95 [93-96]%, p = 0.81) changed significantly. Elevated PvaCO2 after VV-ECMO installation had a good predictive value for 28 day ICU mortality (calculated area under the ROC curve 0.81) (Fig. 1 veno-venous). Conclusion(s): VV-ECMO support appears to have little effect on the PvaCO2 calculation. PvaCO2 can be used to evaluate patients with ARDS supported with VV-ECMO, as persistently elevated values can be associated with poor outcomes.

Increased shunt and dead space in recovered COVID-19 pneumonitis patients

Introduction/Aim: We previously reported impaired pulmonary gas exchange in acute COVID-19 patients resulting from both increased intrapulmonary shunt (SH) and increased alveolar dead space (AD) 1 . The present study quantifies gas exchange in recovered patients. Method(s): Unvaccinated patients diagnosed with acute COVID-19 infection (March-December 2020) were studied 15 to 403 days post first SARS-CoV-2 positive PCR test. Demographic, anthropometric, acute disease severity and comorbidity data were collected. Breathing room air, steady-state exhaled gas concentrations were measured simultaneously with arterial blood gases. Alveolar CO 2 and O 2 (P A CO 2 and P A O 2 ;mid-exhaled volume) determined;AaPO2, aAPCO2, SH% and AD% calculated. 2 Results: We studied 59 patients (33 males, Age: 52[38-61] years, BMI: 28.8[25.3-33.6] kg/m 2 ;median[IQR]). Co-morbibities included asthma (n = 2), cardiovascular disease (n = 3), hypertension (n = 12), and diabetes (n = 9);14 subjects smoked;44 had experienced mild-moderate COVID-19 (NIH category 1-2), 15 severe-critical disease (NIH category 3-5). PaCO 2 was 39.4[35.6-41.1] mmHg, PaO 2 92.1[87.1-98.2] mmHg;P A CO 2 32.8[28.6-35.3] mmHg, P A O 2 112.9[109.4-117.0] mmHg, AaPO 2 18.8[12.6-26.8] mmHg, aAPCO 2 5.9[4.3-8.0] mmHg, SH 4.3 [2.1-5.9]% and AD 16.6 [12.6-24.4]%. 14% of patients had normal SH (<5%) and AD (<10%);1% abnormal SH and normal AD;36% both abnormal SH and AD;49% normal shunt and abnormal AD. Previous severe-critical disease was a strong independent predictor for increased SH (OR 14.8[2.28-96], [95% CI], p < 0.01), increasing age weakly predicted increased AD (OR 1.18[1.01, 1.37], p < 0.04). Time since infection, BMI and comorbidities were not significant predictors (all p > 0.11). Conclusion(s): Prior COVID-19 was associated with increased intrapulmonary shunt and/or increased alveolar dead space in 86% of this cohort up to ~13 months post infection, with those with more severe acute disease, and older patients, at greater risk. Increased intrapulmonary shunt suggests persistent alveolar damage, while increased alveolar dead space may indicate persistent pulmonary vascular occlusion.

Efficacy of N-acetyl Cysteine in Severe COVID-19 Patients: A Randomized Controlled Phase III Clinical Trial

Background: Today, various drugs have been investigated as the primary or complementary treatment for coronavirus disease 2019 (COVID-19). N-acetylcysteine (NAC) has been used as a mucolytic in pulmonary diseases. This drug apparently contributes to the retrieval of the intracellular antioxidant system. Objective(s): This study aimed to determine the efficacy of NAC in severe COVID-19 patients admitted to the intensive care unit (ICU). Method(s): This single-blinded randomized controlled phase III clinical trial included 40 patients with confirmed COVID-19 (based on polymerase chain reaction) admitted to the Shahid Mohammadi Hospital's ICU, Bandar Abbas, Iran, in 2020. All cases had severe COVID-19. They were allocated randomly to two equal groups. Patients in the control group received standard drug therapy based on the treatment protocol of the national COVID-19 committee, while those in the NAC group received a single dose of intravenous NAC (300 mg/kg) upon admission to the ICU in addition to standard drug treatment. Clinical status and laboratory tests were done on admission to the ICU and then 14 days later or at discharge without knowing the patient grouping. Result(s): The two groups were comparable regarding age, gender, and other baseline laboratory and clinical parameters. At the final evaluation, respiratory rate (21.25 +/- 4.67 vs. 27.37 +/- 6.99 /min) and D-dimer (186.37 +/- 410.23 vs. 1339.04 +/- 2183.87 ng/mL) were significantly lower in the NAC group (P = 0.004 and P = 0.030, respectively). Also, a lower percentage of patients in the NAC group had lactate dehydrogenase (LDH) <= 245 U/L (0% vs. 25%, P = 0.047). Although the length of ward and ICU stay was shorter in the NAC group than in controls, the difference was statistically insignificant (P = 0.598 and P = 0.629, respectively). Mortality, on the other hand, was 75% in the control group and 50% in the NAC group, with no statistically significant difference (P = 0.102). Concerning the change in the study parameters, only the decrease in diastolic blood pressure (DBP) was significantly higher with NAC (P = 0.042). The intubation and mechanical ventilation rates were higher, while oxygen with mask and nasal oxygen rates were lower with NAC, but the difference was statistically insignificant. Conclusion(s): Based on the current research, NAC is related to a significant decrease in RR, D-dimer, and DBP in severe COVID-19. Also, LDH was significantly lower in the NAC group than in the controls. More research with larger sample sizes is needed to validate the current study results.Copyright © 2023, Author(s).

The Relationship between Wearing Protective Masks and Poor Oral Health

Since the beginning of the COVID-19 pandemic, the number of people wearing masks in everyday life has increased. At the same time, there has been a noticeable rise in the amount of patients with bad breath (foe-tor ex ore), gingivitis, caries, and xerostomia. The appearance of these symptoms and diseases caused by wearing a mask is designated by the term mask mouth. The aim of this article is to establish the link between wearing protective masks and deteriorating oral health. From the conducted research, it has been es-tablished that wearing a surgical mask over a long period of time leads to reduced air exchange in the mask and "recycling" of exhaled air. This leads to inhalation of air with increased CO2 content and increase in pCO2 in the blood, which is subsequently compensated by rapid and deep breathing in most cases through the mouth. The goal is to exhale the accumulated CO2. As the mask reduces air exchange, the level of CO2 in the mask remains relatively high. Prolonged breathing through the mouth often leads to xerostomia. Saliva is known to have protective functions against the development of bacteria in the oral cavity through its an-tibacterial properties. Xerostomia can be a prerequisite for the development of various diseases of bacterial origin, such as gingivitis. Furthermore, oral respiration leads to an increase in temperature and CO2 in the air in the mask and a decrease in pH in the oral cavity, which are optimal conditions for biofilm formation, plaque buildup, development of most bacteria, e.g., S. mutans, which is the main cause of caries.Copyright © 2022, Bulgarian-American Center. All rights reserved.

Relationship between blood gases and inflammatory markers with clinical outcomes in critically ill patients with COVID-19

Introduction: SARS - CoV mainly affects the airways and, although most cases of COVID-19 are mild or moderate, up to 30% of patients may have the severe form of the disease and be hospitalized due to the cytokine storm in response to viral infection (Milovanovic, L. et al. BMJ Open. 2021;11(1):e042008). Of these, up to a quarter need an Intensive Care Unit (ICU) and in this unit, data on partial pressure of oxygen (PaO2), carbon dioxide (PaCO2) and inflammatory markers are collected daily to assess respiratory function and assist in decision making. Aim(s): To analyze how these blood gas and inflammatory data are related to a greater need for invasive support and mortality in the ICU. Method(s): 79 patients admitted to an Intensive Care Unit with a mean age of 60 years, of whom 50 required invasive support and 44 died. Result(s): After comparing the groups, it was observed that the need for invasive ventilatory support and death were related to higher values of PaCO2 (p<0.001;p<0.001) and C-Reactive Protein (p=0.004;p=0.006), which did not occur with those with lower PaO2 levels (p=0.339;p=0.580). Furthermore, the inflammatory activity marker CRP correlated significantly and positively with PaCO2 (p=0.007;0.378), which did not happen with PaO2 (p=0.406;-0.121). Conclusion(s): Although the respiratory involvement caused by COVID-19 has hypoxemic characteristics, it is observed that, in critically ill patients, the assessment of CRP and carbon dioxide levels are more decisive for the clinical outcome, having more relevance for patient decisions and evaluations. serious hospitalized with COVID-19.

Exhaled gases and the potential of cross infection from NIV machines

Background: The indications for Long Term Ventilation (LTV) are expanding. Pneumonia is common in these patients and transmission of bacterial infections, and more recently COVID-19 infection, between users of ventilators is a concern. UK national standards recommend bacterial/viral filters for use with acute Non-Invasive Ventilation (NIV) to protect the ventilator from contamination. However, there are no recommendations made for LTV. UK National guidance also explicitly states that there is no airflow from the patient to the ventilator.1 Aims and objectives: To investigate whether exhaled gas reaches the ventilator outlet. Method(s): We conducted experiments on three ventilators with different circuits during NIV delivered to a member of the study team using standard clinical settings. We used a side-stream end tidal CO2 (EtCO2) analyser attached to the tubing adjacent to the ventilator outlet as shown in the figure. Result(s): Regardless of ventilator and circuit used we demonstrated that exhaled gas reaches the ventilator outlet during NIV. EtCO2 values were 1.6-3.7kPa. Conclusion(s): Exhaled gas reaches the ventilator outlet during NIV. This raises an urgent requirement within the LTV community to test ventilators for bacterial and viral colonisation, consider the use of bacterial/viral filters, and discuss routine decontamination of these devices between individual patient uses. (Figure Presented).

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.

Outcome of Long Term Ventilation (LTV) following remote initiation and monitoring in patients with Chronic Hypercapnic Respiratory Failure (CHRF) during the SARS-CoV-2 pandemic

Background: In the absence of LTV, CHRF leads to recurrent hospital admissions, poor quality of life and increased mortality. Anticipating a significant surge in SARS-CoV-2 our long term ventilation staff were redeployed to provide acute COVID service. NIV was considered as an aerosol generating procedure and due to lack of regular outpatient clinical activity, we implemented a remote LTV initiation and review service and have evaluated the clinical outcomes Method: Consecutive patients started on LTV over a 12 month period were included. Patient demographics, LTV indications, trial duration, remote review and clinical outcomes were evaluated Results: N=54, mean age;60+/-16, mean FEV1;45+/-24, mean BMI;39+/-18, males-54%. indications for LTV were OHS-56%, COPD-28%, NMD-7%, Chest wall disorders-6% and others (overlap syndromes and opioid induced)-3%. A third of patients needed supplemental oxygen therapy (2-4 lts/16-24 hours/day). The median (IQR) duration of LTV trial was 4.3 (1-5-4.5) months and mean (SD) NIV compliance was 5.5 (2.3) hours. Patients were regularly monitored remotely (via modem or telephone) due to clinical shielding advice and this prevented hospital admissions in 56% of patients. A significant improvement in pCO2 was noted (P -0.0009, mean pCO2 pre LTV: 9 +/- 2.85 v/s post LTV: 6.7 +/- 1.3, DELTA change 2.2 kpa, 95% CI: 1.2 -3.52). 9.3% had SARS-CoV-2 infection with all-cause mortality of 3.7% Conclusion(s): LTV can be initiated and monitored remotely & effectively. Adequate compliance and improvement of hypercapnia are key parameters of good outcome with LTV and remote monitoring may be cost effective.

SARS-CoV-2 infection, lung involvement and vitamin D-driven immune endocrine reactivity a Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology

Vitamin D is a hormone rather than a vitamin in the strict sense. In fact, the active form 1,25 dihydroxyvitamin D3 [1,25(OH)2D3] exerts several effects on the inflammatory response of autoimmune rheumatic and infectious diseases. Low serum concentrations (less than 20 ng/ml) of 25-hydroxyvitamin D3 [25(OH)D3], the precursor of 1,25(OH)2D3, are common in COVID-19 patients and are associated with an impairment of the innate (neutrophils, monocytes/macrophages, dendritic cells) and adaptive (T and B lymphocytes, antibodies production) immune responses. Respiratory parameters (partial pressure of arterial oxygen-PaO2, partial pressure of arterial carbon dioxide-PaCO2, pressure of arterial oxygen to fractional inspired oxygen concentration-PaO2/FiO2), radiological pulmonary involvement, and serum concentrations of 25(OH)D3 were evaluated in sixty-five hospitalized COVID-19 patients (mean age 76 +/- 13 years) and sixty-five sex- and age-matched control subjects (CNT). COVID-19 patients showed significant lower 25(OH)D3 serum concentrations than CNT (median 8 ng/ml vs 16 ng/ml, p=0.001). 25(OH)D3 serum concentrations correlated positively with PaO2 (p=0.03) and PaO2/FiO2 (p=0.02). Moreover, 25(OH)D3 serum concentrations were significantly lower in COVID-19 patients with diffuse/severe radiological lung involvement (p=0.05) or multiple lung consolidations (p=0.0001) than in those with mild radiological lung involvement. Finally, significantly lower 25(OH)D3 serum concentrations were found in COVID-19 patients who died during hospitalization, compared to those who survived (p=0.05). In conclusion, vitamin D deficiency is associated with a more severe lung involvement and a higher risk of death in old COVID-19 patients.

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.