Pulmonary sarcoidosis

The lung is the most common organ affected by sarcoidosis. Multiple tools are available to assist clinicians in assessing lung disease activity and in excluding alternative causes of respiratory symptoms. Improving outcomes in pulmonary sarcoidosis should focus on preventing disease progression and disability, and preserving quality of life, in addition to timely identification and management of complications like fibrotic pulmonary sarcoidosis. While steroids continue to be first-line therapy, other therapies with fewer long-term side-effects are available and should be considered in certain circumstances. Knowledge of common clinical features of pulmonary sarcoidosis and specific pulmonary sarcoidosis phenotypes is important for identifying patients who are more likely to benefit from treatment.Copyright © ERS 2022.

The long-COVID in the Czech Republic -interim analysis of population based survey

Introduction: The occurrence of the late effects of covid-19(long-covid)is a hot issue. Detailed data on its forms within the population are still lacking. Aim(s): We want to describe the long-covid in the population of the Czech Republic(CR)in relation to the covid severity. Method(s): Prospective collection of data on consecutive patients(pts)sent by GPs to pulmonologists started since June,21. The interim analysis concerns pts enrolled by February,22. The analysis was based on data collected in Information System of Infectious Diseases of the CR, especially its long-covid module. The 44 outpatient centers cover all 14regions of the CR and represent 13% of all(343)outpatient clinics of pulmonologists, they are responsible for the care of long-covid pts in the CR. Result(s): 3.489pts have been included in the study so far. After the removal of 40%pts with significant comorbidities,1.895"healthy"post-covid individuals (50%men,69%non-smokers)remained. Only a minority of these pts with long-covid 874(46%)were hospitalized due to covid severity. Inpatients were older, more often males/obese, less likely smokers. Inpatients had more severe post-covid residual CTchanges, more frequent diffusion capacity impairment, more restrictive ventilation pattern, and more oxygen desaturation during walking. Contrary nonhospitalized pts had more cough, and obstructive ventilation pattern. Hospitalized and non-hospitalized pts did not differ in incidence of resting desaturation, dyspnea, fatigue, expectoration, and chest pain. Despite the fact that 64%of the CR population is fully vaccinated, only 25(1.3%)were vaccinated among long-covid cohort. Conclusion(s): Previously hospitalized have more severe long-covid, however, most pts had only a mild acute COVID.

Validation of the one minute sit to stand test(1MSTS)for identification of exertional oxygen desaturation in chronic respiratory disease

Background: Despite limited validation data (Kalin et al Systematic Reviews 2021 Mar 16;10(1):77), the 1MSTS was widely used as a rapid exercise test to assess exertional oxygen desaturation during the COVID-19 pandemic. Aim(s): To assess the diagnostic accuracy of the 1MSTS to detect significant exertional oxygen desaturation in people with chronic respiratory disease. Method(s): 99 patients referred for pulmonary rehabilitation assessment were assessed for ambulatory oxygen requirements using a shuttle walk test according to British Thoracic Society Guidelines for Home Oxygen Use. Exertional oxygen desaturation was defined as a drop in oxygen saturations (SpO ) of >=4% with nadir <90%. 1MSTS was conducted in each participant by an assessor blinded to ambulatory oxygen assessment results. Result(s): Mean(SD) age 68.9(11.4) years, 59%COPD, 13%ILD. 21% demonstrated significant exertional oxygen desaturation. Using a drop of SpO >=4% to nadir <90% threshold, the 1MSTS only identified 6 out of 21 patients with exertional oxygen desaturation (sensitivity 29%). Simplifying the threshold to a drop in SpO of >=4% alone during 1MSTS improved sensitivity to 81% with specificity of 87%. Conclusion(s): Using a threshold of drop in SpO of >=4%, the 1MSTS test had reasonable sensitivity and specificity identifying significant exertional oxygen desaturation in patients with chronic respiratory disease.

Persistent oxygen desaturation during exercise in patients with long COVID

Background: An uncertain proportion of COVID-19 survivors may present persisting symptoms,referred to the term "Long COVID". The prevalence of exercise-induced oxygen desaturation (EID) in patients with Long COVID is still uncertain, ranging between 22% and 50%;moreover, the relationship of EID with exertional dyspnea and baseline Pulmonary Function Tests (PFTs) remains unclear. Aim(s): The study was designed to investigate the prevalence of EID in patients with "Long COVID" and assess its relationship to exertional dyspnea and PFTs. Method(s): A prospective cohort study was conducted including 194 consecutive "Long COVID" patients (M/F:132/62;age: 62.8+/-12.8 yrs) discharged from 2 university hospitals in North-Eastern Italy. At 6 month follow-up visit, patients underwent 6-min walking test (6MWT) and PFTs, including spirometry and diffusing capacity (DLco). The level of dyspnea was assessed by mMRC dyspnea scale. Result(s): Thirty-three (17%) patients showed early EID (SaO2 drop: 3.4 +/- 2.5;p<0.001) with a synchronous positive chronotropic response. Compared to non-desaturators, desaturators showed significantly reduced 6-min walk distance (420 [355-525] vs 500 [443.5-581] m;p=0.002) and DLco (70.6+/-24.7%pred vs 85.7+/-16.9%pred;p<0.001). The level of dyspnea didn't significantly differ between desaturators and non desaturators (mMRC dyspnea score: 1 [1-2] vs 1 [1-1];p=0.184). Conclusion(s): A significant proportion of survivors with "Long COVID" shows persistent oxygen desaturation during exercise which seems to be unrelated to the degree of dyspnea. 6MWT should be regularly performed after discharge from hospital to understand the extent and severity of EID and whether it may be associated with worse prognosis.

Cardiopulmonary exercise testing in patients with COVID19 at 3 months from hospital discharge

Introduction: The long-term COVID-19 effects are currently unknown. Whether and for how long symptoms extend beyond the acute phase of the disease is unresolved Aim: To determine the functional capacity of COVID-19 survivors by cardio- pulmonary exercise testing (CPET) and describe its association with dyspnoea and pulmonary function test (PFT). Methods and Results: All COVID-19 patients discharged from our tertiary care institution were enrolled in a prospective follow-up study which would assess clinical, instrumental and laboratory characteristics of COVID-19 survivors at 3months from hospital discharge (Careggi University Hospital, Florence). Clinical evaluation included: peripheral blood samples including inflammatory cytokines, pulmonary function test (functional respiratory and 6 minwalking test), lung ultrasound, ECG recording and echocardiographic exam. All patients with peripheral oxygen desaturation at 6 min-walking test (SpO2 < 92%), dyspnoea and with a history of hospitalization in critical care settings were referred for CPET. Dyspnoea was classified with the Medical Research Council (MRC) scale. From June 2020 to May 2021, 198 patients were enrolled;overall, 42% of patients presented with dyspnoea at 3 months from hospital discharge with no difference according to disease severity on hospital admission (P 1/4 0.233) Conclusion(s): At 3-months, almost 1 in 2 patients discharged for COVID-19 pneumonia presented with dyspnoea, irrespective of disease severity. We want to compare CPET and spirometry data (already performed in 110 patients), highlighting differences between ventilated patients (invasive or noninvasive) and patients admitted to the ward. The data are still being analyzed.

Pulmonary function and tomographic features in adult survivors of severe COVID-19 pneumonia: a prospective study of 12-month follow-up

Introduction: There is a lack of data on long-term sequelae of severe COVID-19 pneumonia beyond clinical followup at 6 months. Aim(s): To describe the evolution of pulmonary sequelae at 3, 6 and 12 months in severe COVID-19 survivors in terms of pulmonary function and high-resolution computed tomography (HRCT) of the chest. Method(s): 84 subjects (74% male, median age: 63 [49-70]) hospitalized for COVID-19 pneumonia (January 2021- January 2022) were evaluated at 3, 6 and 12 months after discharge with spirometry, lung diffusing capacity (DLCO), 6-minute walking test (6MWT) and HRCT. Result(s): At 3, 6 and 12 months, 64%, 70% and 80% of patients were found to have normal spirometry (FVC: 83+/-6%, 96+/-2%, 97+/-2%]);DLCO <80% was found in 66% (mean 77+/-1%), 63% (mean 74+/-2%) and 43% (mean 81+/-1%) of subjects;6MWT performance was normal in 70% (median 494 m [582-472]), 84% (median 552 m [487- 583]) and 100% (median 557 m [496-588]) of subjects. However, after 1 year of discharge, 50% of patients had persistent oxygen desaturation at the end of the 6MWT. HRCT abnormalities were detected at 3, 6 and 12 months in 87%, 60% and 43% of patients. The most prevalent HRCT patterns at 12 months were ground-glass opacities (71%), subpleural reticulation and atelectasis (35%) and bronchiectasis (10%). Conclusion(s): A high prevalence of persistent lung function and HRCT abnormalities was found in survivors of severe COVID-19 pneumonia. Evaluation at 3, 6 and 12 months showed progressively improving values of spirometry, DLCO and 6MWT over time. However, long-term HRCT anomalies and exercise-induced desaturation suggest persistent interstitial phenomena of unknown implications.

The utility of 1-minute sit-to-stand test to detect exerciseinduced oxygen desaturation in outpatient assessment of post COVID-19 patients

Introduction: The 6-min walk test (6MWT) is the gold standard for assessing exercise-induced impairment of gas exchange, but it is technically challenging in a busy outpatient clinic. The aim of this study was to compare the 1-min sit-to-stand test (1STST) with the 6MWT in assessment of exercise-induced oxygen desaturation in post COVID-19 patients in an outpatient setting. Method(s): A total of 447 outpatient post COVID-19 patients were recruited from post COVID-19 clinic. Both 6MWT and 1STST (a set) were performed on the same day including pulse oxygen saturation (SpO2) recording at baseline, nadir, and recovery stage. Result(s): A total of 447 sets were performed at a mean of 160 days post discharge. Majority were in category severe (n=251, 56%), critical (n=118, 26%) and moderate (n=6, 15%). At assessment, most patients were symptomatic (mMRC > 2) n= 258, 58%. There was no significant difference between nadir SpO2 for 6MWT and 1STST (p<0.075) with Bland-Altman plots showing good agreement, p<0.593 (figure 1). There was good correlation between SpO2 and 6MWT or 1STST at baseline;R=0.592 p<0.001, nadir;R=0.456 p<0.001, and recovery;R= 0.514 p<001. 1STST had 76.8% sensitivity and 42.4% specificity to detect > 4% oxygen desaturation compared with 6MWT (table 1). There was also correlation between 6MWT distance and 1STST repetition;R=0.144 p<0.002. Conclusion(s): Both 6MWT and 1STS have good agreement on nadir SpO2 and are sensitive to detect > 4% oxygen desaturation. Therefore, 1STST is an useful screening test to detect exercise-induced oxygen desaturation during outpatient assessment.

Spirometry outcomes in survivors of COVID-19 pneumonia

Introduction: Acute COVID-19 infection could lead to long COVID, a heterogenous condition which includes the respiratory system. But data on long-term respiratory complications are scarce and limited especially from our part of the world. Method(s): A total of 443 post COVID-19 patients were recruited from post COVID-19 clinic. The following assessments were performed in all patients;symptoms, 6-minute-walk-test (6MWT), 1-minute-sit-to-stand-test (1STST), spirometry, and chest radiograph. Result(s): Patient's mean age was 51 (13) years old, majority were male (60%), and Malay ethnicity (73%). Majority were in category severe (n=254, 57%), critical (n=122, 28%) and moderate (n=67, 15%). Abnormal spirometry (FVC <80%) were detected in 47% (n=209) of the patients. It was associated with older age groups (54 vs 49 years old, p 0.001), longer hospital admission (17 vs 13 days, p 0.016), shorter follow-up duration (140 vs 170 days, p 0.004), more likely to have oxygen desaturation >4% during 6MWT and 1STST, OR 1.8 (1.1-2.9) and OR 1.7 (1.1-2.6) respectively, and abnormal chest radiograph, OR 3.9 (2.5-6.2) compared to those with normal spirometry findings 125 patients have full lung function test and gas transfer done which showed reduced TLC (<80%) and DLCO (<80%), and normal KCO (>80%) in majority of cases;80% (n = 100), 86.4% (n = 108) and 94% (n = 117). Conclusion(s): Abnormal spirometry findings are common among post COVID-19 patients with pneumonia and are associated with poorer respiratory outcomes;exertional oxygen desaturation and abnormal chest radiograph. Therefore, these groups of patients should be referred for spirometry assessment.

Early initiation of remdesivir and its effect on oxygen desaturation: A clinical review study among high-risk COVID-19 patients in Myanmar.

Background: Although Remdesivir has been evaluated for the treatment of coronavirus disease 2019 (COVID-19), few study has yet shown effective mortality reduction. It might be because, in almost all those studies, remdesivir therapy was started beyond 7th days from the onset of symptoms when the active viral replications have already gone. Methods: This study reviewed the effectiveness of early remdesivir therapy during viral phase of COVID-19 and safety of its administration at home or community care during the outbreak of COVID-19 from July to September 2021 in Myanmar. We retrospectively reviewed clinical records of 204 high risk COVID-19 patients who had received remdesivir therapy within 7 days from the onset of illness and before oxygen desaturation. Findings: All patients received remdesivir therapy according to standard five days course of 200 mg loading dose on day 1, followed by 100 mg daily for up to 4 additional days. Out of 204 patients, 60.75% (124/204) were aged 60 years and above with comorbidity; 21.1% (43/204) aged under 60 years with comorbidity and 18.1% (37/204) were aged more than 60 years old without comorbidity. The patients who received RDSV therapy within 1-4 days and within 5-7 days were 50.5% (103/204) and 49.5% (101/204) respectively. All patients survived to 21 days without ICU admission or mechanical ventilation. Eighty six percent of patients had no hypoxia and only five percent had moderate to severe hypoxia, requiring oxygen. Those who received RDSV therapy within 1 to 4 days from the onset of symptoms had significantly lower rate of hypoxia compared to those who received remdesivir therapy on 5 to 7 days. After RDSV therapy, increased lymphocyte count and decreased CPR were observed in 74.5% (152/204) and 52.9% (108/204) of the patients respectively. There was no report of major adverse events. Conclusion: Remdesivir, if given within first 4 days from the onset of symptoms, is the most effective strategy for prevention of oxygen desaturation, further progression of COVID-19 and death although it is still beneficial if given later, days 5 to 7. It is a safe drug to be prescribed in hospital at home care. It may be cost-benefit if high-risk group of patients with COVID-19 were selected for early remdesivir therapy in the community.

THORACIC ULTRASOUND IN COVID-19: USE OF LUNG AND DIAPHRAGM ULTRASOUND IN EVALUATING DYSPNEA IN SURVIVORS OF CRITICAL ILLNESS FROM COVID-19 PNEUMONIA IN A POST-ICU CLINIC

SESSION TITLE: Long COVID: It Can Take Your Breath Away SESSION TYPE: Original Investigations PRESENTED ON: 10/16/2022 10:30 am - 11:30 am PURPOSE: Dyspnea is a common complaint in survivors of severe COVID-19 pneumonia, which may originate from intrinsic lung injury, diaphragmatic weakness, or other etiologies. Point-of-care ultrasound has revolutionized evaluation of acute respiratory failure in inpatient settings. Ultrasound however has seldomly been employed in ambulatory practice. We report on the use of thoracic ultrasound in evaluating dyspnea in survivors of critically ill COVID-19 pneumonia in a Post-ICU clinic. We aimed to determine how thoracic ultrasound (comprised of the lung ultrasound score (LUS) and diaphragm excursion during inspiration) correlate with patient-reported dyspnea (per the Borg Dyspnea Scale) during 6-minute walk test (6MWT). We hypothesize higher LUS and lower diaphragm excursion will correlate with severity of dyspnea. METHODS: Single-center cross-sectional study of survivors of critically ill COVID-19 pneumonia (requiring high-flow nasal cannula, or invasive- or non-invasive mechanical ventilation) seen in our Post-ICU clinic. All patients underwent standardized scanning protocols to compute LUS and diaphgram excursion (at quiet and deep inspiration). Pearson correlations were performed to detect association between LUS and diaphragm excursion with dyspnea at rest and exertion during 6MWT. RESULTS: Between 1/15/21-1/15/22, we enrolled n=45 patients. Average age was 61.5±13.9 years, 57.7% were male, with average BMI of 32.3±7.2. Higher LUS correlated significantly with dyspnea, at rest (r = +0.41, p = <0.01) and at exertion (r = +0.40, p = <0.01). Higher LUS correlated significantly with lower oxygen saturation during 6MWT (r = -0.55, p = <0.01) and lower 6MWT distance (r = -0.44, p = <0.01). Diaphragm excursion (on quiet and deep inspiration), correlated significantly with 6MWT distance (r = +0.33, p = 0.05;r = +0.37, p = 0.03), but did not correlate with dyspnea at rest or exertion. CONCLUSIONS: Higher LUS correlated positively and significantly with patient-reported dyspnea, both at rest and during exertion. Higher LUS significantly correlated with more exertional oxygen desaturation during 6MWT and lower 6MWT distance. While diaphragm excursion did not correlate with dyspnea, higher excursion (on quiet and deep inspiration) did correlate positively and significantly with 6MWT distance. CLINICAL IMPLICATIONS: Higher LUS reflect severity of lung injury following viral pneumonia in post-COVID-19 patients. LUS may thus predict which patients will desaturate during exertion, and which patients may require prolonged oxygen support during recovery. Hypoxemia from post-viral lung injury may limit exercise capacity, thus LUS may also guide clinicians in determining the role of physical or pulmonary rehabilitation. Diaphragm excursion correlated with 6MWT distance, and thus may provide insight for clinicians into the capacity of a patient's extra-pulmonary respiratory system in relation to patient exercise tolerance. DISCLOSURES: No relevant relationships by Seth Congdon No relevant relationships by Gerardo Eman No relevant relationships by Benjamin Galen no disclosure on file for Aluko Hope;No relevant relationships by Marjan Islam No relevant relationships by Shwe Synn

Dyspnea: neurobiological and clinical aspects

The aim. The presented material reflects the results of studies by Russian specialists conducted under the auspices of the Russian Respiratory Society over the past 15 years. The article also includes the main provisions set out in the III Guidelines for dyspnea. A significant part of the manual is devoted to the recent achievements in studying neurophysiological processes in the brain structures during the development of dyspnea. These achievements were driven by image-diagnosis methods. An important aspect of this series of works for the clinical practice was identifying dyspnea domains and developing the instruments to assess severity. Results. Analysis of the data on dyspnea from the clinical practice showed a highly heterogenic clinical picture, which must be taken into account in the management of individual patients. A diagnostic algorithm for long-term follow-up of patients with dyspnea syndrome is also discussed. The attention of doctors is drawn to the features of dyspnea during COVID-19;the disproportion between the sensory perception of respiratory discomfort and the degree of oxygen desaturation is emphasized. Conclusion. It was concluded that in the Russian-speaking environment of patients, doctors should actively use a verbal characteristic of dyspnea – the “language of dyspnea”. © 2021 Medical Education. All rights reserved.

Mesenchymal Stem/Stromal Cells: MESENCURE: A PROFESSIONALIZED CELL THERAPY FOR ARDS REDUCED THE MORTALITY OF SEVERE COVID-19 PATIENTS BY 68% ACCORDING TO A RECENTLY CONCLUDED MULTI-CENTER, CONTROLLED PHASE II STUDY

Background & Aim: The wide gap in severe Covid-19 management is increasingly addressed by mesenchymal cell (MSC) therapies, despite studies that failed to show significant efficacy in ARDS. To improve the therapeutic utility of MSCs in ARDS, Bonus BioGroup developed MesenCure: An allogeneic adipose-derived MSC product professionalized by a combination of culture conditions enhancing the cells’ potency and stability, producing unique transcriptomic, proteomic, and morphological signatures. Up to 100k fresh MesenCure doses with a shelf life sufficient for global supply can be produced from a single donor under 20 PDLs, further preventing potency loss due to cryopreservation and culture aging. Based on preclinical data presented during ISCT2021, demonstrating MesenCure’s advantages over non-professionalized MSCs, and its safety in a Phase I study, Bonus BioGroup initiated a multi-center Phase II trial in severe Covid-19 patients that was recently concluded. Methods, Results & Conclusion: The Phase II trial included 50 severe Covid-19 patients suffering from diffuse pneumonia and oxygen desaturation treated with up to 3 MesenCure doses (1.5x106 cells/kg on days 1, 3, and 5), on top of the Standard of Care (SoC), and 150 similar severe control patients treated by the SoC only and stratified according to gender, age, and comorbidities. A substantial 68% reduction in the mortality rate of the test patients was measured (Fig. 1A, p<0.05), along with a 57% drop in their risk of intubation relative to the control (Fig. 2A, p<0.05). Over 50% of the patients treated with MesenCure were released from the hospital within two days after treatment, and a 38% reduction was measured in the hospital length of stay (LoS) of patients having LoS>7 days (Fig. 1C, p<0.01). Starting from a similar baseline as the control, the median CRP and CK levels of the test patients, after MesenCure treatment, ended 52% (p<0.0001) and 33% (p<0.01) lower than their respective control levels. As shown in Fig. 2 [Figure Presented] Fig. 1 ( 25). (A) Mortality rates among test and control patients at Visit 8 (one month after the first MesenCure dose or the equivalent time points for the control). (B) Test and control patients’ risk of deteriorating to mechanical ventilation. (C) Average hospital length of stay (LoS) of patients having LoS > 7 days. Two-sided p values were calculated using the Fisher Exact test (A and B) or t-test (C). [Figure Presented Fig. 2 ( 25). (A) CRP and (B) CK levels measured at Visit 6, the earliest of two weeks after the first MesenCure dose (Visit 2) or upon hospital release, or the equivalent time points for the control. The test and control groups started from similar median CRP and CK levels. (C) Changes in control and test patients’ LDH levels from Visit 1 (screening) to Visit 6. (D) Area of test patients’ diffuse pneumonia during Visits 1, 6, and 8 (one month after Visit 2). (E) Blood oxygen saturation measured during test patients visits 1, 2-4 (upon or before receiving the first to third MesenCure dose), Visit 5 (the earliest of one week after Visit 2 or upon hospital release), and Visit 6. (F) Test patients’ blood lymphocytes levels (absolute) across Visits 1 and 6. Charts are presented as box-and-whiskers (according to the Tukey method). p values were calculated using the Mann-Whitney test (A, B, and C), Dunn’s multiple comparisons (D and E), or the Wilcoxon test (F). the more profound improvements in inflammatory and tissue damage markers observed in test patients were accompanied by a rapid recovery in pneumonia, respiratory functions, and lymphopenia, emphasizing MesenCure’s powerful effect. In conclusion, we show that MesenCure saves patients’ lives and accelerates their healing, possibly reducing the risk of long-term damages while freeing ICU beds allowing better care for other patients, and reducing the burden associated with hospitalization and additional long-term healthcare costs.

Intubation Performance with Stylet and Preloaded Bougie for Rapid Sequence Intubation in Patients Undergoing General Anaesthesia: A Randomised Clinical Trial

Introduction: Rapid sequence induction requires quick and single attempt intubation to secure airway without any untoward complications. As the number of attempts increase, risk of desaturation and aspiration increase which is potentially life threatening. In such circumstances, miscalculation may cost loss of time which may prove fatal. Various adjuncts and techniques have been devised to prevent such calamities. Aim: To compare ease of intubation with angulated stylet versus distally preloaded bougie for rapid sequence intubation in elective general anaesthesia procedures. Materials and Methods: This randomised trial was conducted in 100 patients belonging to 18-60 years of age from November 2019 to October 2020. Patients were intubated using rapid sequence including cricoid pressure by either styletted endotracheal tube (Group S) or distally preloaded bougie (Group B), for surgeries performed under general anaesthesia. The primary outcome was to determine mean time to intubation (TTI) and number of attempts, while secondary outcomes were haemodynamic responses to intubation and complications. Data comparison between independent groups in this normally distributed data was done using student -t test while intragroup analysis was done using chi-square test. Results: A total of hundred patients were randomized into two groups- group S (mean age: 41.12 years) and group B (mean age: 37.34 years), of 50 patients each. Number of intubation attempts with stylet were single in 82%, two in 18% cases while with preloaded bougie, it was 80% and 14%, respectively (p-value=0.196). Time to intubation was 22.16 seconds (group S) versus 33.78 seconds (group B) (p-value <0.05). The haemodynamic assessments revealed that tachycardia, hypertension and increased End tidal carbon dioxide (EtCO2) was seen for 10 minutes immediately post induction in both the groups, though the intergroup difference was non significant. The incidence of sore throat was higher with stylet than bougie, though non-significant (p-value=0.118). Conclusion: Stylet should be preferred for ease of intubation in rapid sequence inductions. However, the insertion and removal of stylet must be done cautiously to prevent postoperative sore throat.

Polysomnography performed in home during the pandemic as a diagnostic alternative for patients in research of respiratory sleep disorders

Introduction: Obstructive sleep apnea and hypopnea syndrome (OSAHS) is characterized by pauses in breathing during sleep, due to multiple collapses and/or narrowing of the upper airway, causing a drop in blood oxygen saturation and sleep fragmentation. Obesity, male gender, craniofacial abnormalities, tonsil hypertrophy, nasal obstruction, endocrine abnormalities, and family history are predictive factors for OSAHS. Objective: The aim of the study was to investigate OSAHS through home polysomnography during the COVID-19 pandemic. Methods: Data were collected between March 16, 2020, and June 25, 2021 in the city of Surubim-PE, totaling 191 subjects. The Apnea link Air portable polysomnographic device was used. With the following channels: respiratory effort, pulse, oxygen saturation, nasal flow and snoring. Data were analyzed using IBM SPSS 28.0 software. Results: The apnea and hypopnea index (AHI) was considered: Normal in 33 women (17.0%;2.1+1.3) and 41 men (21.2%;2.5+1.2);Mild on 18 women (9.3%;9.4+3.3) and 39 men (20.2%;8.8+3.1);Moderate in 5 women (2.5%;19.5+4.5) and 27 men (13.9%;21.4+4.7);and Severe in 8 women (4.1%;52.5+14.4) and 22 men (11.3%;51.5+17.4). The oxygen desaturation index (IDO) was, 32 women (16.5%;2.1 + 1.7) and 40 men (20.7%;2.6 + 1.1) were classified as normal;Mild in 18 women (9.3%;9.6 + 2.9) and 30 men (15.5%;8.8 + 2.8);Moderate in 6 women (3.1%;20.9 + 5.2) and 27 men (13.9%;21.4 + 4.4);and Severe in 7 women (3.6%;53.2 + 11.5) and 22 men (11.4%;50.2 + 17.3). A positive correlation was observed both between BMI and the apnea-hypopnea index (AHI) (r=0.527;p=<0.01), as well as the BMI and oxygen desaturation index (ODI) (r=0.516;p=<0.01). There is an effect of gender (p<0.008) and age (p<0.001) on the AHI, but there is no interaction between the variables gender and age (p=0.936) A similar result was observed for the ODI, in which there is an effect of gender (p<0.009) and age (p<0.001), but not in the interaction between the two variables (p=0.948) BMI had an effect on the AHI (p<0.001) and ODI (p<0.001) but not in the interaction between BMI and gender (p=0.250 and p=0.223 respectively). Conclusion: High BMI implies higher values of AHI and ODI in the study population. Although there is an effect of gender and age on the AHI and ODI, an interaction between these two variables is not maintained when analyzed.

SLEEPY IN THE MOUNTAINS

Introduction: Central sleep apnea (CSA) is a rare disorder caused by a reduction of airflow and ventilatory effort during sleep. CSA is rarely idiopathic and associated with medical conditions including heart failure, opioid medications, treatment emergent and high-altitude periodic breathing. At higher altitudes, hypoxemia induces periodic breathing with periods of deep and rapid breathing alternating with central apnea. Patients with high-altitude periodic breathing experience fragmented sleep, poor sleep quality, excessive daytime sleepiness, morning headaches and witnessed apnea. We discuss a patient with obstructive sleep apnea (OSA) who developed new-onset central sleep apnea after relocating to a higher altitude location. Report of Cases: A 75-year-old male with a history of moderate obstructive sleep apnea well controlled on CPAP for eight years, with no known cardiovascular or pulmonary disease, presented with new-onset excessive daytime sleepiness. He had recently relocated to an area in the Colorado mountains (7000 ft elevation) from his previous home in Los Angeles (sea level). His residual apneahypopnea index (r-AHI) displayed on his CPAP machine increased to 7-14/ hr from his normal of 1-2/hr after his relocation. Review of his compliance data revealed his central apnea index was elevated, contributing to his high r-AHI. A one-night nocturnal oximeter was mailed to the patient to use while on CPAP. Data revealed oxygen desaturation to less than 88% for about 2 hours of the night, worse during the early morning hours. The patient was advised to undergo a polysomnography and adaptive servo-ventilation titration if significant central sleep apnea was present. The patient declined due to concern about the COVID-19 pandemic. Supplemental nocturnal oxygen was initiated at 2L/min with normalization of the r-AHI. Conclusion: Patients with OSA who experience worsening symptoms or increased r-AHI despite excellent compliance with PAP therapy should be considered for repeat polysomnography or titration study. While it is expected that high-altitude central sleep apnea will improve with acclimatization, nocturnal supplemental oxygen in addition to PAP therapy is indicated for patients with high-altitude central sleep apnea to diminish hypoxemia and improve residual AHI and sleep quality.

Double-blind placebo-controlled randomized clinical trial to assess the efficacy of montelukast in mild to moderate respiratory symptoms of patients with long COVID: E-speranza COVID-19 Project study protocol

Objective: To evaluate the efficacy of 10-mg oral montelukast every 24 h for 28 days versus placebo in improving health-related quality of life in patients with long COVID and mild to moderate respiratory symptoms measured with the COPD Assessment Test (CAT) questionnaire. The secondary objectives will evaluate the effect of montelukast versus placebo on improving: exercise capacity and oxygen desaturation;COVID-19 related symptoms (asthenia, headache, mental, brain fog, ageusia and anosmia);functional status;and mortality. Material and/or methods: Phase III, randomized, double-blind clinical trial. We will include 18 to 80 year old patients with SARS-CoV-2 infection and mild to moderate respiratory symptoms lasting between 4 weeks and 12 months after the onset of infection. Participants will be randomly allocated in a 1:1 ratio to the experimental treatment with 10-mg/day montelukast or the placebo group, during a 28-day treatment. Follow-up will finish 56 days after starting of the treatment. The study will be carried out in primary healthcare centres in four health areas of Catalonia and Aragon, Spain, from 1 August 2021 to 1 March 2023. The primary outcome will be health-related quality of life associated with respiratory symptoms according to the COPD Assessment Test, assessed at 4 weeks after finishing of the treatment. Secondary outcomes: (a) Exercise capacity and oxygen saturation (1Min Sit-to-Stand test);(b) Post-COVID-19 Functional Status scale;(c) other symptoms: asthenia, headache, mental confusion (brain fog), ageusia and anosmia (Likert scale);(d) use of healthcare resources;(e) sick leave duration in days;(f) side effects of montelukast;(g) mortality. Ethics and dissemination: This study has been approved by the AEMPS and Clinical Research Ethics Committee of the IDIAPJGol (reference number 21/091-C). EudraCT number 2021-000605-24. ClinicalTrials.gov Identifier: NCT04695704.It is currently under peer-review process for publication. Results: Ongoing clinical trial. Conclusions: Ongoing clinical trial.

Deep sedation with dexmedetomidine administered by electrophysiologists during COVID-19 pandemic compared with propofol administered by anesthesiologists for ablation of atrial fibrillation

Background: COVID-19 pandemic, limiting the availability of anesthesiologists, has impacted heavily on the organization of invasive cardiac procedures such as transcatheter atrial fibrillation (AF) ablation. Purpose: We compared the safety and efficacy of deep sedation with dexmedetomidine administered by electrophysiologists without anesthesiologist supervision, against the standard protocol performed with propofol. Methods: We retrospectively included all AF ablation procedures performed in 2020: 23 patients sedated with 1% propofol (2 ml bolus followed by infusion starting at 1 mg/Kg/h), 26 patients with dexmedetomidine (infusion starting at 0.7 mcg/Kg/h). Both groups additionally received 1 mcg/Kg of midazolam as a single bolus and 0.05 mg single boluses of fentanyl prior to ablation on each pair of pulmonary veins (PV). Primary outcomes were oxygen desaturation (< 90%) or need for assisted ventilation/intubation, bradycardia (heart rate < 45 bpm) and persistent hypotension (systolic blood pressure < 90 mmHg). Results: Baseline characteristics and hemodynamic variables did not differ between the two groups (all p > 0.05). In 8/23 (35%) patients propofol infusion velocity reduction was necessary to maintain the hemodynamic values, compared to 7/26 (27%) with dexmedetomidine. Inter-group comparison of hemodynamic variables during the procedure showed no statistically significant difference, despite a trend in favor of dexmedetomidine (3 respiratory depressions and 3 persistent hypotension episodes with propofol vs. 0 with dexmedetomidine;p = 0.057). Conclusion: Deep sedation with dexmedetomidine administered by electrophysiologists without anesthesiologist supervision is safe and effective for AF transcatheter ablation. A trend towards a lower incidence of hypotension and respiratory depression was noted when compared to propofol.