Asthma and COPD management during the COVID-19 pandemic.

Numerous patients with asthma or COPD are likely to be infected with SARS-CoV-2 virus. Although data is limited, patients with severe and/or uncontrolled asthma and those with COPD appear to be at increased risk of a more severe course of COVID-19 infection. Usual recommendations for management of asthma and COPD remain valid despite the ongoing epidemic. However, lung function testing and nebulisers should be performed with caution during the COVID-19 pandemic due to a potential risk of virus aerosolisation and contagion during the procedure. Particular care must be taken to identify and protect patients who are particularly vulnerable to COVID-19 infection. Asthma and COPD treatments should be pursued and adapted to ensure optimal control of the lung disease throughout the epidemic, thus reducing the risk of severe COVID-19 disease.Copyright © 2020 Editions Medecine et Hygiene. All rights reserved.

Aerosol Medication Use in COVID-19 Pandemic

Administration of aerolized drugs to patients diagnosed with COVID-19 leads to the risk of transmission of patient-generated infectious aerosols to healthcare providers.While the COVID-19 pandemic is ongoing, in order to provide the best treatment for patients and at the same time to protect healthcare providers at the highest level, it is necessary to increase access to information and pay maximum attention to preventive measures.Copyright © 2020 Bilimsel Tip Yayinevi. All rights reserved.

Tolerance of ETD001, a long-acting inhaled epithelial sodium channel blocker, in humans

Background: To assess the safety, tolerability, and pharmacokinetic (PK) profile in humans of the novel inhaled epithelial sodium channel blocker ETD001. Method(s): Inhaled ETD001 or placebo, delivered via nebulizer, have been administered in a 3:1 ratio to 96 healthy subjects in a blinded, first-inhuman clinical trial (ClinicalTrials.gov Identifier: NCT04926701). The study consisted of two parts. Part A evaluated single ascending doses (SADs) up to 10.8 mg, and Part B evaluated multiple ascending doses (MADs) up to 3.1 mg once daily (QD) for 7 days and 4.65 mg twice daily (BID) for 14 days. Safety was assessed by monitoring for adverse events (AEs), laboratory safety tests (including blood potassium monitoring), vital signs, 12-lead electrocardiogram (ECG), and spirometry. Systemic exposurewas assessed using serial pharmacokinetic blood draws. Result(s): Therewere no serious AEs. Twenty-four subjects reported 38 AEs, all of mild to moderate intensity and all resolved. There were no clinically relevant changes in laboratory safety tests, vital signs, ECGs, or spirometry measurements. All blood potassium assessments were within normal range at all doses. Three subjects withdrew in Part B;all withdrawals were considered unrelated to study drug: one on day 6 from the 3.1-mg QD cohort for personal reasons, one after the first dose of the 3.1-mg BID cohort because of vasovagal syncope at time of venipuncture triggering atrial fibrillation that spontaneously resolved, and one on Day 4 of the 3.1- mg BID cohort because of a positive COVID-19 test. Pharmacokinetic parameters were approximately dose proportional in Part A, with peak concentrations 1 to 2 hours after dose and exposure out to 12 to 24 hours at all doses, indicating good lung retention. Part B plasma concentrations displayed dose-independent kinetics and showed minimal accumulation, with a mean of 1.11-fold observed over 14 days. Conclusion(s): ETD001 was well tolerated at single doses up to 10.8 mg and multiple doses of 3.1 mg QD for 7 days and 4.65 mg BID for 14 days. The wide safety margin is predicted to enable doses capable of durable target engagement in the lung, which are expected to enhance mucociliary clearance in people with cystic fibrosis.Copyright © 2022, European Cystic Fibrosis Society. All rights reserved

A Medical Nebulizer as a Substitute for the OSHA-Approved Nebulizer for Qualitative Fit testing of Respirators During the Respiratory Infectious Pandemics: An Experimental Feasibility Study.

OBJECTIVE: The qualitative fit testing procedure would be challenging due to severe shortages, high cost, and unavailability of commercial fit test kits in the marketplaces during pandemics of respiratory infectious diseases. Assessment of alternatives for commercial fit test kits to be prepared for emergencies is critically required. This study aimed to investigate the feasibility of an alternative of the Accumed NF60 nebulizer for the OSHA-approved Allegro one. METHODS: Thirty-two participants were randomly allocated to six filtering facepiece respirators (FFRs). They were qualitatively fit tested by both manual Allegro and automated Accumed NF60 nebulizers. RESULTS: There was no statistically significant difference between the Allegro and Accumed NF60 nebulizers by passing rates. The odds for passing fit testing using the Accumed NF60 nebulizer was similar to that of the Allegro one [OR=1.0, 95% CI (0.58-1.74)]. CONCLUSIONS: The Accumed NF60 nebulizer could be used as a cost-benefit substitute for the standard fit test nebulizers in the pandemic situation where there is a shortage and difficulty of access. It is more convenient, decreases the time investment, and reduces the contact stress in the operators' hands as it does not require squeezing the nebulizer bulb frequently. The test solutions' preparation and fit testing procedures on many personnel are more straightforward, efficient, and hygienic than the Allegro one.

Efficacy and Safety of Inhalation of Nebulized Ethanol in COVID-19 Treatment: A Randomized Clinical Trial.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a pandemic caused by the SARS-CoV-2 virus. Many efforts have been made and are currently being made to prevent and treat this global disease. OBJECTIVES: This study was designed to evaluate the efficacy and safety of nebulized ethanol (EtOH) in treating COVID-19. METHODS: A randomized clinical trial (RCT) of 99 symptomatic and real-time polymerase chain reaction (RT-PCR)-positive patients admitted to a hospital receiving remdesivir-dexamethasone was conducted. They were randomly assigned to receive distilled water spray (control group (CG)) or 35% EtOH spray (intervention group (IG)). Both groups inhaled three puffs of spray (nebulizer) every six hours for a week. The primary outcome included Global Symptomatic Score (GSS) between the two groups at the first visit and on days three, seven, and 14. Secondary outcomes included the Clinical Status Scale (CSS; a seven-point ordinal scale ranging from death to complete recovery) and readmission rate. RESULTS: A total of 44 and 55 patients were enrolled in the IG and CG, respectively. Although there was no difference at admission, the GSS and CSS improved significantly in the IG (p = 0.016 and p = 0.001, respectively). The IG readmission rate was considerably lower (0% vs. 10.9%; p = 0.02). CONCLUSIONS: Inhaled-nebulized EtOH is effective in rapidly improving the clinical status and reducing further treatment. Due to its low cost, availability, and absent/tolerable adverse events, it could be recommended as an adjunctive treatment for moderate COVID-19. Further research on curative effects in more serious cases and in prevention is advisable.

Effect of a barrier on spatial distribution of respiratory particles in a room

Barriers have been widely used to mitigate transmission of Covid-19 and other diseases. Their efficacy for aerosol particles is not well established. The objective of this study was to quantify the impact of a barrier on the spatial distribution of particles released by speaking in a room with a low air-change rate (0.6 +/- 0.2 h-1). The source was a nebulizer that released fluorescent microspheres of diameters 0.5, 1, 6, 10, or 20 microm for 20 min, and the room was outfitted with 108 passive sampling sites. We counted the number of microspheres deposited on slides at sampling locations after >1 h. The presence of a barrier 0.46 m in front of the source resulted in an increase in 0.5 microm particles deposited on the source-side of the barrier and an increase in 0.5 microm particles around the sides of the barrier laterally and at certain locations 4-6 m from the source. The barrier had a minor effect on the distribution of 1 microm particles. There was no observable effect of the barrier on the distribution of 6, 10, and 20 microm particles. Most 10 and 20 microm particles deposited within 0.3 m of the source, although some were found at locations >3 m from the source. These results indicate that barriers may not serve as adequate protection to others in the room, depending on their location relative to the barrier and the exposure timescale. A limitation is that our study utilized only one barrier configuration at one air-change rate.Copyright © 2023 The Author(s). Published with license by Taylor & Francis Group, LLC.

Safety and tolerability of inhaled molgramostim in autoimmune pulmonary alveolar proteinosis (aPAP)

Background: aPAP is a rare lung disease characterized by surfactant build-up for which there is no approved pharmacologic treatment. aPAP patients typically present with shortness of breath due to impaired oxygen transfer in the lung . Objective(s): To report the long-term safety of inhaled molgramostim nebulizer solution (MOL) administered intermittently in aPAP patients: open-label IMPALA-X extension study (NCT03482752). Method(s): Patients who completed IMPALA (NCT02702180) were eligible for IMPALA-X. MOL (300 mug;once daily) was administered in cycles of 7 days on/7 days off treatment. The primary endpoint included adverse events (AEs), serious AEs (SAEs), adverse drug reactions (ADRs), and discontinuations. Result(s): Safety data from 59 patients were analyzed;44 (74.6%) and 15 (25.4%) patients had >=12 and >=24 months of exposure, respectively. Forty (67.8%) patients reported 165 AEs;138 AEs in 38 (64.4%) patients were treatmentemergent AEs (TEAEs). Eight patients had SAEs that were considered unlikely related to treatment. Seven patients had severe TEAEs and 3 were considered treatment-related/ADRs. Most common AEs (7 patients each, 11.9%) were cough and nasopharyngitis. Respiratory tract infection, arthralgia, alveolar proteinosis, and COVID-19 were each reported by 6.8% patients. No TEAEs led to treatment discontinuation/withdrawal. One subject died following COVID-19 infection 24 days after the last MOL dose. Conclusion(s): IMPALA-X was discontinued early as intermittent dosing did not show a benefit vs placebo in the IMPALA study. The phase 3 IMPALA-2 study of continuous daily MOL vs placebo in patients with aPAP is ongoing.

Nebulization and COVID-19:Is the risk of spread actual?

The airborne transmission of SARS-CoV-2 has been quickly suggested based on the stability of SARS-CoV-2 in aerosol for 3 hours. Nebulization, by a possible microorganisms contamination and/or by the aerosolization of contaminated particles, may expose health care workers. Thus, various guidelines on nebulization emerged during the SARS-CoV-2 pandemic to ensure a maximal protection. This study aimed to address the risk of airborne transmission in patients hospitalized with severe COVID-19. Ten severe COVID-19 patients were recruited at the admission in the hospital. They were treated by nebulization with a standard single-use jet nebulizer operating at 8 L/min with a T piece connected to a mouthpiece and a filter. Immediately after the first nebulization, the residual solution of each nebulizer was sampled. Then, the nebulizers were refilled with isotonic saline solution to complete the residual volume. The filter was replaced by a BioSampler (SKC 20-mL) loaded with 20 mL phosphatebuffered saline and 0.5% bovine serum albumin. The nebulizer was driven by a compressed air supply, and a 10minnebulization was performed again on the bench. The emitted aerosol was continuously collected during the nebulization. The nominal and emitted dose were sampled. The SARS-CoV-2 viral load was quantified in all samples by RT-PCR. No SARS-CoV-2 RNA was found in any sample for all nebulizations. The result of this study shows no SARS-CoV-2 nebulizers contamination by COVID-19 patients at hospital and does not support the role of nebulizers in terms of aerosol virus dissemination in air. Nevertheless, exhaled virus by the patient itself remains and must be considered independently to the nebulizer.

A novel negative pressure isolation device reduces aerosol exposure: A randomized controlled trial

Background and aim: The COVID-19 pandemic has led to a proliferation of intubation barriers designed to protect healthcare workers from infection. We developed the Suction-Assisted Local Aerosol Containment Chamber (SLACC) and tested it in the operating room. The primary objectives were to determine the ease and safety of airway management with SLACC, and to measure its efficacy of aerosol containment to determine if it significantly reduces exposure to health care workers. Method(s): In this randomized clinical trial, adult patients scheduled to undergo elective surgery with general endotracheal anesthesia were screened and informed consent obtained from those willing to participate. Patients were randomized to airway management either with or without the SLACC device. Patients inhaled nebulized saline before and during anesthesia induction to simulate the size and concentration of particles seen with severe symptomatic SARS-CoV-2 infection. Result(s): 79 patients were enrolled and randomized. Particle number concentration (PNC) at the patients' and healthcare workers' locations were measured and compared between the SLACC vs. control groups during airway management. Ease and success of tracheal intubation were recorded for each patient. All intubations were successful and time to intubation was similar between the two groups. Healthcare workers were exposed to significantly lower particle number concentrations (#/cm3) during airway management when SLACC was utilized vs. control. The particle count outside SLACC was reduced by 97% compared to that inside the device. Conclusion(s): The SLACC device does not interfere with airway management and significantly reduces healthcare worker exposure to aerosolized particles during airway management.Copyright © 2023 Elsevier Ltd

Viral Preservation with Protein-Supplemented Nebulizing Media in Aerosols.

The outbreak of SARS-CoV-2 has emphasized the need for a deeper understanding of infectivity, spread, and treatment of airborne viruses. Bacteriophages (phages) serve as ideal surrogates for respiratory pathogenic viruses thanks to their high tractability and the structural similarities tailless phages bear to viral pathogens. However, the aerosolization of enveloped SARS-CoV-2 surrogate phi6 usually results in a >3-log10 reduction in viability, limiting its usefulness as a surrogate for aerosolized coronavirus in "real world" contexts, such as a sneeze or cough. Recent work has shown that saliva or artificial saliva greatly improves the stability of viruses in aerosols and microdroplets relative to standard dilution/storage buffers like suspension medium (SM) buffer. These findings led us to investigate whether we could formulate media that preserves the viability of phi6 and other phages in artificially derived aerosols. Results indicate that SM buffer supplemented with bovine serum albumin (BSA) significantly improves the recovery of airborne phi6, MS2, and 80α and outperforms commercially formulated artificial saliva. Particle sizing and acoustic particle trapping data indicate that BSA supplementation dose-dependently improves viral survivability by reducing the extent of particle evaporation. These data suggest that our viral preservation medium may facilitate a lower-cost alternative to artificial saliva for future applied aerobiology studies. IMPORTANCE We have identified common and inexpensive lab reagents that confer increased aerosol survivability on phi6 and other phages. Our results suggest that soluble protein is a key protective component in nebulizing medium. Protein supplementation likely reduces exposure of the phage to the air-water interface by reducing the extent of particle evaporation. These findings will be useful for applications in which researchers wish to improve the survivability of these (and likely other) aerosolized viruses to better approximate highly transmissible airborne viruses like SARS-CoV-2.

Aerosol delivery through high-flow nasal therapy: Technical issues and clinical benefits.

High-flow nasal cannula (HFNC) therapy is an oxygen delivery method particularly used in patients affected by hypoxemic respiratory failure. In comparison with the conventional "low flow" oxygen delivery systems, it showed several important clinical benefits. The possibility to nebulize drugs via HFNC represents a desirable medical practice because it allows the administration of inhaled drugs, mostly bronchodilators, without the interruption or modification of the concomitant oxygen therapy. HFNC, by itself has shown to exert a small but significant bronchodilator effect and improves muco-ciliary clearance; thus, the nebulization of bronchodilators through the HFNC circuit may potentially increase their pharmacological activity. Several technical issues have been observed which include the type of the nebulizer that should be used, its position within the HFNC circuit, and the optimal gas flow rates to ensure an efficient drug delivery to the lungs both in "quiet" and "distressed" breathing patterns. The aim of this review has been to summarize the scientific evidence coming from "in vitro" studies and to discuss the results of "in vivo" studies performed in adult subjects, mainly affected by obstructive lung diseases. Most studies seem to indicate the vibrating mesh nebulizer as the most efficient type of nebulizer and suggest to place it preferentially upstream from the humidifier chamber. In a quite breathing patterns, the inhaled dose seems to increase with lower flow rates while in a "distressed" breathing pattern, the aerosol delivery is higher when gas flow was set below the patient's inspiratory flow, with a plateau effect seen when the gas flow reaches approximately 50% of the inspiratory flow. Although several studies have demonstrated that the percentage of the loaded dose nebulized via HFNC reaching the lungs is small, the bronchodilator effect of albuterol seems not to be impaired when compared to the conventional inhaled delivery methods. This is probably attributed to its pharmacological activity. Prospective and well-designed studies in different cohort of patients are needed to standardize and demonstrate the efficacy of the procedure.

Optimizing Respiratory Therapy Resources by De-Implementing Low-Value Care.

BACKGROUND: Our institution was experiencing a respiratory therapy staffing crisis during the COVID-19 pandemic, in part due to excessive workload. We identified an opportunity to reduce burden by limiting use of 3% hypertonic saline and/or N-acetylcysteine nebulizer therapies (3%HTS/NAC). METHODS: Leveraging the science of de-implementation, we established a policy empowering respiratory therapists to discontinue 3%HTS/NAC not meeting the American Association for Respiratory Care (AARC) Clinical Practice Guideline: Effectiveness of Pharmacologic Airway Clearance Therapies in Hospitalized Patients. After a 3-month period of educating physicians and advanced practice practitioners the policy went to into effect. Outcomes measured included monthly number of treatments, orders, and full-time employees associated with administering nebulized 3%HTS/NAC. RESULTS: Post policy activation, the monthly mean 3%HTS/NAC treatments were significantly reduced to 547.5 ± 284.3 from 3,565.2 ± 596.4 (P < .001) as were the associated monthly mean of full-time employees, 0.8 ± 0.41 from 5.1 ± 0.86 (P < .001). The monthly mean 3%HTS/NAC orders also fell to 93.8 ± 31.5 from 370.0 ± 46.9 (P < .001). Monthly mean non-3%HTS/NAC treatments remained stable; post policy was 3,089.4 ± 611.4 and baseline 3,279.6 ± 695.0 (P = 1.0). CONCLUSIONS: Implementing a policy that empowers respiratory therapists to promote adherence to AARC Clinical Guidelines reduced low-value therapies, costs, and staffing needs.

Study omicronf Commodity Aspects omicronf Compressor Nebulizers in Ukraine

Nebulizer therapy is an effective and safe treatment for respiratory diseases. Since the delivery of the pharmacologic agents to the lungs depends on the correct use of the inhalation device, the pharmacist, like the doctor must have all the skills in choosing a nebulizer, namely to be informed about the modern range of nebulizers, know the basic technical characteristics of these devices, their configuration, features of use, caveats for their use, as well as labeling and storage. Materials and methods. The following compressor devices were used as materials: nebulizer "Turbo Flow", trademark "Dr. Frei" (Great Britain), nebulizer "C102 TOTAL (NE-C102-E)" and "A3 Complete" of the trademark "OMRON" (Japan), nebulizer "LD-221 C" of the trademark "Little Doctor" (Singapore). Results and discussion. The article presents studies devoted to the research and analysis of the main technical parameters of modern compression nebulizers (nebulizer volume, speed spraying, the ability to adjust the size of particles in the aerosol cloud). The resulting knowledge will help working in tandem doctors and pharmacists to choose the right device for the effective delivery of the drug in the human the respiratory tract to achieve maximum therapeutic effect. Conclusions. Commodity analysis of compressor nebulizers available in Ukrainian pharmacies has been conducted. Analysis concern the range of nebulizers, the basic technical characteristics of these devices, their configuration, features of use, caveats for their use and conditions of storage. A comparative analysis of nebulizer chambers from different manufacturers was carried out and their main parameters were established. Labeling was studied and drew attention was drawn to the special information symbols that relate exclusively to nebulizers. Copyright © 2022, Zita Medical Managent. All rights reserved.

Pharmacy services provided by clinical pharmacists for COVID-19 patients

Background: In December 2019, a respiratory illness due to a novel coronavirus, SARS-CoV-2, was first identified in Wuhan, China. SARS-CoV-2, termed COVID-19, is now a worldwide pandemic and has been identified in 216 countries and areas or territories (WHO, 2020). As of May 15th, 2020, there have been more than 4.2 million confirmed cases and 294,190 deaths worldwide. Purpose(s): Ensure patient safety, drug availability, and therapeutic efficacy for all COVID-19 patients. Implement a number of changes to urgently meet the institution's patient care needs. Method(s): Data were collected from a 62-year-old male patient admitted with severe COVID-19 to the intensive care unit in April 2020. The following pharmacy services were then provided: first, constant review and interpretation of new clinical data;second, patient eligibility assessment and obtaining medication through compassionate use protocols;third, evidence-based interventions (e.g. drug-drug interaction, drug-disease interaction, and dose adjustments);fourth, limit unnecessary nebuliser use. Last but not least, educate patients and the public on effective strategies to prevent acquisition and further spread of infection (e.g. social distancing, optimal hand hygiene, and personal protective equipment). Result(s): With standard care and the compassionate use of Hydroxychloroquine, Azithromycin, Zn supplements, and Tocilizumab under close monitoring, the patient successfully recovered and was discharged on May 4th, 2020. Conclusion(s): Pharmacists play a vital role within a multi-disciplinary healthcare team to optimise patient care during this COVID-19 pandemic.

Safety, Tolerability, and Pharmacokinetics of Nebulized Hydroxychloroquine: A Pilot Study in Healthy Volunteers.

Background: Early in the coronavirus disease 2019 (COVID-19) pandemic, hydroxychloroquine (HCQ) drew substantial attention as a potential COVID-19 treatment based on its antiviral and immunomodulatory effects in vitro. However, HCQ showed a lack of efficacy in vivo, and different groups of researchers attributed this failure to the insufficient drug concentration in the lung following oral administration (HCQ is only available in the market in the tablet form). Delivering HCQ by inhalation represents a more efficient route of administration to increase HCQ exposure in the lungs while minimizing systemic toxicity. In this pilot study, the safety, tolerability, and pharmacokinetics of HCQ nebulizer solution were evaluated in healthy volunteers. Methods: Twelve healthy participants were included in this study and were administered 2 mL of HCQ01 solution (equivalent to 25 mg of HCQ sulfate) through Aerogen® Solo, a vibrating mesh nebulizer. Local tolerability and systemic safety were assessed by forced expiratory volume in the first and second electrocardiograms, clinical laboratory results (e.g., hematology, biochemistry, and urinalysis), vital signs, and physical examinations. Thirteen blood samples were collected to determine HCQ01 systemic exposure before and until 6 hours after inhalation. Results: The inhalation of HCQ01 was well tolerated in all participants. The mean value of Cmax for the 12 participants was 9.66 ng/mL. Tmax occurred at around 4.8 minutes after inhalation and rapidly decreased thereafter. The reported systemic exposure was very low with a mean value of 5.28 (0.6-15.6) ng·h/mL. Conclusion: The low systemic concentrations of HCQ01 of 9.66 ng/mL reported by our study compared with 1 µg/mL previously predicted after 200 mg BID oral administration, and the safety and tolerability of HCQ01 administered as a single dose through nebulization, support the assessment of its efficacy, safety, and tolerability in further studies for the treatment of COVID-19.

EFFICIENCY OF A NEBULIZER FILTER KIT TO PREVENT ENVIRONMENTAL CONTAMINATION DURING NEBULIZER THERAPY

SESSION TITLE: Respiratory Care: Oxygen, Rehabilitation, and Inhalers SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: The SARS-CoV-2 pandemic has highlighted the need to avoid environmental contamination with aerosols. To aid in this, the addition of a filter kit is intended to capture any exhaled aerosol. To determine the aerosol amounts emitted to the environment during nebulizer therapy several nebulizers were evaluated to test the efficiency of the nebulizer filter system. METHODS: The MaxiNeb® Duo, Circulaire® II and AeroEclipse® II BAN™ Nebulizer were operated at 50PSIG with their optional filter kits (n=5). Each device was evaluated with 2.5mg/3.0mL fill of albuterol and connected to a simulator mimicking adult tidal breathing. In addition to inspiratory and expiratory filters, the nebulizer was placed under an extraction system to capture any aerosol emitted through leakages or exhalation. Albuterol assay was undertaken by HPLC-UV spectrophotometry. RESULTS: The mass of albuterol captured from the extraction system with the MaxiNeb® Duo, Circulaire® II and AeroEclipse® II BAN™ Nebulizer was found to be 0.5±0.2, 1.5±0.6 and 0.0±0.0% of the initial dose respectively. CONCLUSIONS: The BAN™ Nebulizer without filter kit has previously reported environmental losses of just under 3%ꝉ so it is in keeping that the addition of the filter kit eliminated all losses for this device. The other two nebulizers emitted small amounts of aerosol even when a filter kit was used. CLINICAL IMPLICATIONS: If the laboratory results for the nebulizer / filter systems which did not eliminate all environmental emissions were replicated in a clinical setting, there would likely need to be an assessment performed into the potential risk to staff and patients. ꝉ Efficiency of a Nebulizer Filter Kit to Prevent Environmental Contamination During Nebulizer Therapy – presented at European Respiratory Society Meeting 2021 DISCLOSURES: Employee relationship with Trudell Medical International Please note: 27 years by Mark Nagel, value=Salary Employee relationship with Trudell Medical International Please note: >$100000 by Jason Suggett, value=Salary

FINGERNAIL CLIPPING AS A FOREIGN BODY CAUSING SEVERE EMPYEMA

SESSION TITLE: Chest Infections with Pleural Involvement Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Foreign body aspiration (FBA) is an uncommon cause of dyspnea and respiratory infection. 80% of cases occur in children under 15-years-old, with the highest mortality in children under 1 and adults over 75. We present an unusual case of a fingernail clipping causing severe empyema in a middle-aged male. CASE PRESENTATION: A 44-year-old male with diabetes mellitus presented with a 3-day history of dyspnea, productive cough, and anorexia, and a 1-day history of fevers and substernal chest pain. Exam was notable for fever, tachypnea, tachycardia, and hypoxemia requiring a non-rebreather mask. Labs were significant for a negative COVID-19 polymerase chain reaction (PCR) test, white blood cell (WBC) count 17,000 μL, and lactate 3.4 mmol/L. He was given albuterol-ipratropium nebulizer treatments and methylprednisolone 125 mg. Chest x-ray revealed a large right-sided air-fluid level, dense consolidation of the lung base, and complicated pleural effusion. Computed Tomography (CT) of the chest revealed a large right mid-lung abscess, right middle lobe (RML) and right lower lobe (RLL) consolidations, and loculated pleural effusion with hydropneumothorax. A surgical chest tube was placed that drained purulent fluid. The effusion grew Klebsiella pneumoniae, which was treated with ampicillin-sulbactam. Repeat CT chest revealed improved loculated effusion, but persistent RML and RLL consolidations with concern for endobronchial obstruction. Flexible bronchoscopy was performed, which identified and removed a human fingernail clipping obstructing the RML. Post-procedure, his oxygen requirements, cough, and dyspnea improved remarkably. He was discharged with a 4-week course of amoxicillin-clavulanate. On outpatient follow-up 6 weeks later, he was asymptomatic. DISCUSSION: In our patient, a fingernail clipping was lodged in the opening of the RML, resulting in a post-obstructive pneumonia complicated by empyema. Post-bronchoscopy, the patient admitted to anxiety-induced nail-biting. FBA most commonly occurs in the right bronchial tree (71.5%) as compared to the left bronchial tree (22.8%) and trachea (5.7%). Objects were most commonly lodged in the bronchus intermedius (27%) and right lower lobe (33%). Foreign bodies can be removed via rigid or flexible bronchoscopy, with a 90% success rate in the latter. Instruments such as forceps and baskets can be used to remove the foreign body, and Trendelenberg positioning can be useful in moving the object proximally. In up to 76% of cases, granulation tissue caused by a localized reaction to the foreign body may occur and can be minimized with systemic steroids for 24 hours. CONCLUSIONS: FBA in a middle-aged patient is an unusual cause of respiratory infection, but should be on the differential diagnosis for post-obstructive pneumonia. Reference #1: Hsu Wc, Sheen Ts, Lin Cd, Tan Ct, Yeh Th, Lee Sy. Clinical experiences of removing foreign bodies in the airway and esophagus with a rigid endoscope: a series of 3217 cases from 1970 to 1996. Otolaryngol Head Neck Surg. 2000 Mar;122(3):450-4. doi: 10.1067/mhn.2000.98321. PMID: 10699826. Reference #2: Blanco Ramos M, Botana-Rial M, García-Fontán E, Fernández-Villar A, Gallas Torreira M. Update in the extraction of airway foreign bodies in adults. J Thorac Dis. 2016;8(11):3452-3456. doi:10.21037/jtd.2016.11.32. Reference #3: Fang YF, Hsieh MH, Chung FT, Huang YK, Chen GY, Lin SM, Lin HC, Wang CH, Kuo HP. Flexible bronchoscopy with multiple modalities for foreign body removal in adults. PLoS One. 2015 Mar 13;10(3):e0118993. doi: 10.1371/journal.pone.0118993. PMID: 25768933;PMCID: PMC4358882. DISCLOSURES: No relevant relationships by Nuzhat Batool No relevant relationships by Lisa Glass No relevant relationships by Alice Mei No relevant relationships by Daisy Young

Abstracts of the RCPCH Conference

The proceedings contain 839 papers. The topics discussed include: parental attitudes regarding safe handling of hand sanitizers and management of children with sanitizer poisoning amongst a cohort of children admitted to a tertiary care center in Sri Lanka;pediatric major incident triage and the use of machine learning techniques to develop an alternative triage tool with improved performance characteristics;unfair and unequal: comparing the experiences and outcomes of children with acute mental health and acute physical health presentations to the pediatric emergency department;tackling child inequality in a UK emergency department: a pilot early intervention service on the shop floor;introducing a new pediatric clerking proforma in a tertiary pediatric emergency department - a quality improvement project;changing patterns of bronchiolitis attendances to the emergency department in the COVID-19 pandemic;investigating prescribing errors in salbutamol nebulizers for acute asthma patients aged 5 and above in a district general hospital;assessment for testicular torsion in a DGH hospital- a service review;and changing spectrum of children presenting with asthma and viral induced wheeze in the COVID -19 pandemic.

Compassionate use of pulmonary vasodilators in acute severe hypoxic respiratory failure due to COVID-19

Introduction: There have been over 200 million cases and 4.4 million deaths from Covid-19 worldwide. In the UK over half a million have required hospitalisation, with over 130,000 deaths. Although most experience a mild illness the mortality can be over 50% for those requiring mechanical ventilation.1 One potential treatment for severe hypoxaemia is inhaled pulmonary vasodilator (IPVD) therapy, either as nitric oxide (NO) or prostaglandin analogues. Despite the lack of robust evidence IPVDs are often considered recue treatments for refractory hypoxaemia.2,3 Given the disease severity in COVID-19 we implemented a protocol for the use of IPVDs on a compassionate basis for patients with severe hypoxaemia receiving otherwise maximal support. In this study we detail our findings and assess differences between survivors and non-survivors. Objectives: The primary outcome of this study was percentage changes in PaO2/FiO2 (PF) ratio and Alveolararterial (A-a) gradient at 2, 6, 12, 24, 48 and 72 hours following initiation of IPVD therapy. Secondary outcomes were differences in characteristics and response to therapy between survivors and non-survivors who received an IPVD. Methods: Data from a prospectively maintained research database of patients with SARS-CoV-2 admitted to the ICU at a large teaching hospital were analysed for the time period 14 March 2020 -11 February 2021. Patients aged 18 years or older who received an IPVD during their admission were eligible for inclusion. An IPVD was considered if the PF ratio was less than 13.3kPa despite rescue therapies (prone positioning, neuromuscular blockade, airway pressure release ventilation). Nitric oxide was commenced at 20ppm and titrated to response. If oxygenation improved Iloprost nebulisers were commenced at 10-30mcg four hourly and NO weaned. Results: Three-hundred eight patients with SARS-Cov-2 were admitted during the study period of whom 59 (19.2%) received IPVD therapy. Patients receiving an IPVD had a lower PF ratio (14.37 vs. 16.37kPa, p=0.002) and higher APACHE-II score (17 vs. 13, p=0.028) at admission compared to those who did not. Survival to ICU discharge was lower in patients receiving an IPVD (55.9% vs. 81.9%, p<0.001). The median PF ratio at commencing IPVD therapy was 11.33kPa (9.93-12.91) with a median of 6 days from admission to receiving an IPVD. At 72 hours the median improvement in PF ratio was 33.9% (-4.3-84.1). In patients receiving IPVDs there were no differences in other therapies received (steroids, prone ventilation, ECMO) between survivors (n=33) and non-survivors (n=26), with the exception of renal replacement therapy. At 72 hours changes in PF ratio (70.8 vs. -4.1%) and reduction in A-a gradient (44.7 vs. 14.8%) differed significantly between survivors and non-survivors (both p <0.001). Conclusion: The response to the compassionate use of IPVDs for patients with acute hypoxic respiratory failure due to Covid-19 differs significantly between survivors and non-survivors. Both NO and inhaled prostaglandins may offer therapeutic options for severe hypoxaemia due to COVID-19, with prostaglandins particularly attractive as they do not require specialist delivery systems. The use of inhaled prostaglandins, and NO where feasible, should be studied in both isolation and combination in adequately powered prospective randomised trials.

SURVIVING COVID UNDER HOSPICE

CASE: This is a 68 year old female who presented to the emergency room with progressively worsening fatigue, malaise, fever, nonproductive cough, nausea, and vomiting after testing positive for COVID-19 the week prior. Her past medical history was significant for obesity, fibromyalgia, chronic pain, osteoarthritis, hypertension, lymphedema, hypothyroidism, and GERD. She was admitted and started on remdesivir, IV methylprednisolone, supplemental oxygen, and nebulizer treatments. The patient's respiratory status deteriorated and her SpO2 dropped to 60%. She was escalated to high flow nasal cannulaadministered oxygen and a goals of care discussion was held. She refused both BiPaP and intubation and elected to not escalate her care further, instead focusing on comfort. Her high flow oxygen was weaned to 4L via nasal cannula and she was started on a morphine infusion, with as needed morphine for comfort. She desaturated to 65% SpO2, but did not exhibit respiratory distress or tachypnea. After twelve hours, she remained relatively stable and requested to go home. After twenty-four hours she was discharged with home hospice with a fentanyl patch, liquid morphine, and a benzodiazepine as needed. After two weeks, she survived and was discharged from hospice care. IMPACT/DISCUSSION: This case raises two key points of discussion. First, one must acknowledge the silent hypoxia that this patient experienced when she elected to go hospice. This phenomenon has been seen in multiple COVID19 patients around the world at various points during their treatment course. Some of these patients have survived, while others did not. Tobin et al. explored possible mechanisms for this including, but not limited to: a change in the baseline CO2 causing a diminished response to hypoxia as well as a change in oxygen dissociation due to fever. Rahman et al. suggested an additional mechanism with interplay between the patient's hypoxia, hypoxia-induced factor-1 (HIF-1), and angiotensin-converting enzyme receptor creating and exacerbating a cycle of inflammation that is difficult for a patient to overcome. Second, one must review the role of opioids in this patient's recovery. Both ASCO and the ACP have made recommendations for offering systemic opioids for patients who are experiencing dyspnea at the end of life or in advanced lung disease. CONCLUSION: Given the positive outcome that this patient experienced, one would hope that there will be less reluctance to introduce patients to a palliative care team earlier in their care. The appropriate practice of palliative medicine should not be equated to denial of active treatment against the patient's wishes. Rather, it is an attempt to maintain the dignity of those with advanced disease and safely ameliorate somatic symptoms, including breathlessness and pain. In addition, further research is needed on the phenomenon of silent hypoxia and its implications for what is deemed a safe oxygen saturation range for patients who require supplemental oxygenation.