ABSTRACT
Purpose of study The IMPACT DC Asthma Clinic is an intervention program designed to transition children who are heavily dependent on the emergency department for episodic care to more effective longitudinal asthma care in their primary medical homes. We sought to study the implementation of a telemedicine model for IMPACT DC during the COVID-19 pandemic in order to address barriers to care. Methods used A telemedicine model of IMPACT DC was implemented using rapid-cycle improvements and process mapping. Measures for adoption of services including visit completion, show rates, primary language, and patient satisfaction were collected for six months. Healthcare utilization data for the six months prior to the IMPACT DC clinical intervention was collected. This data was compared to in- person clinic visits over the same six-month period the previous year. Summary of results 360 patients successfully completed a telemedicine visit between April 2020 and September 2020 with an average visit show rate of 52%. Primary language was English in 89%. These patients were most frequently classified as having mild-persistent asthma and were assessed as well-controlled. Satisfaction survey response rate was 33%;overall average satisfaction was high. In the comparison group, 701 patients successfully completed an in-person clinic visit between April 2019 and September 2019 with a visit show rate of 39%. Primary language was English in 84%. These patients were most frequently classified as having mild-persistent asthma, not well-controlled. Healthcare utilization data for both groups six months prior to their visit are displayed Conclusions The use of telemedicine provides IMPACT DC a feasible and adoptable model to continue caring for children with asthma, with overall high patient satisfaction. This model addresses access barriers during the pandemic, and promises to be an adjunctive tool for reaching families with low show rates and high healthcare utilization. (Table Presented).
ABSTRACT
Case report Dust is a known mixture and carrier of multiple allergens and an epidemiologic study demonstrated the presence of peanut proteins in school cafeterias and classrooms, suggesting that schools may play an important role in exposure to environmental food allergens. While inhalation of food allergens is a known trigger of IgE-mediate acute respiratory reaction as rhinitis and wheezing, little is known about persistent allergic asthma and/or rhinitis induced by chronic inhalation of food allergens. Here we report two cases of teenagers with nuts allergy presenting with persistent respiratory symptoms when exposed to closed and dusty environments. The first case concerns a 12-year-old boy allergic to walnut and hazelnut (specific IgE > 100 and 81.70 kU/l, respectively). For some years he has had a persistent mild asthma, frequent nasal occlusion and rhinorrhea, without any allergic sensitization to aeroallergens. Symptoms occurred exclusively during school period when he required maintenance therapy with inhaled and nasal steroids. He was asymptomatic and did not need any treatment during summer. During the lockdown period due to Covid-19 pandemic, he did not attend school for several months and he was able to discontinue inhaled corticosteroid therapy without recurrence of asthma and rhinitis symptoms. Asthma recurred after he returned to school, but with only mild intermittent symptoms, probably thanks to the use of masks and the frequent airing of the classrooms. On a single occasion he experienced nasal occlusion and rhinorrhea after that a parent had eaten hazelnut cream in the same room where he was. The second case deals with a 17-year-old boy with a history of several food allergies (milk, egg, wheat, banana, nuts, hazelnuts) and mild persistent asthma in absence of sensitization to aeroallergens. He successfully underwent oral desensitization for milk, egg and wheat in previous years. Asthma symptoms improved over the years together with progressive development of oral tolerance to food allergens for which oral immunotherapy had been done. On the other hand, he referred persistence of allergic rhinitis especially during the school year and his symptoms got worse in classroom. Exhaled nitric oxide was quite increased with evidence of eosinophils in nasal smears. In-vitro and in-vivo tests only detected food allergens sensitizations, in particolar to walnuts and hazelnuts (specific IgE were 61.00 and 55.50 kU/l respectively). These two clinical cases suggest that food allergens might be causative agents of allergic persistent asthma and/or rhinitis as aeroallergens do.
ABSTRACT
IntroductionWe present a case of a rare but serious adverse consequence of Acute Respiratory Distress Syndrome (ARDS) secondary to COVID-19 infection: spontaneous pneumomediastinum and pneumopericardium resulting in cardiac tamponade. Case descriptionA 35 year old unvaccinated female with a history of degenerative disc disease, Sjogren's disease, and mild persistent asthma presented with COVID-19 pneumonia. On admission, she required near-maximum heated high flow oxygen, yet desaturated with minimal movement. Three days later, she noted sharp chest pain with worsening oxygenation. Chest radiograph revealed diffuse subcutaneous air with concern for bilateral pneumothoraces, and follow up CT revealed pneumomediastinum, pneumopericardium, and extensive subcutaneous emphysema. She was subsequently intubated. She ultimately developed signs of obstructive shock, and an emergent chest CT demonstrated tamponade physiology on the heart from the mediastinal air. Bedside echocardiogram was unable to be performed due to air surrounding the heart. At this time, her Murray score was 3.8, and discussions began regarding transfer to a referral center for Extracorporeal Membrane Oxygenation (ECMO). Given her tenuous hemodynamics and the prospect of transfer in a low-pressure aircraft, a mediastinotomy tube was placed with a large air leak, tidaling of the tube, and improvement in hemodynamics. On arrival at the ECMO center (Saint Joseph Hospital), her tamponade physiology had improved, but she was requiring progressively higher ventilator pressures due to her severe ARDS. Her extensive pneumomediastinum, pneumoperitoneum, and subcutaneous emphysema would likely only be worsened by higher positive end-expiratory pressures. Due to this complex physiology, she was deemed a VVECMO candidate and was cannulated the day after transfer. Following cannulation, her pneumomediastinum and pneumoperitoneum improved, and eventually her mediastinotomy tube no longer demonstrated an air leak or tidaling. As such, it was removed and her hemodynamics remained stable with no evidence of recurrent tamponade. DiscussionThis presented a unique case in which the choice for VVECMO was influenced not only by severity of ARDS, but also by the complicating factor of positive pressure ventilation causing worsening tamponade physiology due to spontaneous tension pneumomediastinum. Additionally, this case adds to the reports of spontaneous pneumomediastinum in COVID-19 infection, as our patient had no history of trauma or barotrauma before this occurred. On literature review, we have only found one other case report in which a tension pneumomediastinum in COVID-19 required bedside mediastinotomy. Physicians should be aware of this potentially fatal complication and expedite referral to an ECMO center.