Omicron driven ECMO in a vaccinated critically ill patient

Objectives: Reporting a case of a COVID-19 vaccinated patient admitted to our intensive care unit with severe acute respiratory failure due to SARSCoV2 - Omicron variant, rapidly deteriorating requiring intubation, prone ventilation, and ECMO support. Method(s): A 62 years old Caucasian male was admitted in ICU for rapidly deranging respiratory failure and fever which occurred over the previous 24h. The patient received two doses of SARS-CoV2 vaccine (Oxford, AstraZeneca), the last one over five months before onset of symptoms. The patient was admitted to the intensive care unit (ICU) with tachypnea, low peripheral saturation (80%), elevated serum creatinine (2.4 mg/dl), and mild obesity (BMI 34,6). Pressure support ventilation trial (2 hours) failed carryng out to orotracheal intubation and protective ventilation. Worsening of respiratory exchanges (5 th day from the admission) required a rescue prone ventilation cycle, in the meantime an indication was given to the placement of veno-venous ECMO. The cannulation site was femoro-femoral and the configuration used was Vivc25- Va21, according to the current ELSO nomenclature;ECMO flow was progressively increased until a peripheral saturation of 95% was obtained. Result(s): The patient passed out after 2 month of extracorporeal support with no sign of recovery of pulmonary and renal function. Conclusion(s): Unlike evidences showing a lower symptomatic engagement of the Omicron variant SARSCoV2 positive patients, we have witnessed a rapid and massive pulmonary involvement. The short time that passed from the onset of symptoms and the rapid decay of respiratory function required rapid escalation of the intensity of care up to extracorporeal support. The patient showed previous pathologies that can lead to suspicion of a loss of immune coverage given by the vaccine, in addition to the long time elapsed since the last dose. (Figure Presented).

Extracorporeal cytokine hemadsorption in severe COVID-19 respiratory failure

Background: At least 20% of coronavirus disease 2019 (COVID-19) patients develop acute hypoxemic respiratory failure requiring admission to intensive care unit in 5-32% of the cases. Hyper-inflammatory activation characterized by immune cell infiltration and elevated levels of cytokines was reported as the main mechanism leading to critical illness and severe acute respiratory distress syndrome (ARDS). CytoSorb is currently used for all the conditions where elevated levels of cytokines are present. Along with the beneficial effect on systemic inflammation, CytoSorb can be easily integrated with all extracorporeal circulation systems. Case Presentation: Here, we present the laboratory and clinical outcomes of 11 patients with microbiological confirmed SARS-CoV-2 infection. These patients were treated with CytoSorb to remove the excess of cytokine. All patients were male, overweight and only 3 (27%) were over 70 years old. Median age was 62 years and median body mass index was 28. Best supportive care was provided according to hospital guidelines of that moment and included antibiotic therapy, antiretroviral therapy and protective ventilation. Result(s): Cytokines levels were evaluated before and after treatment. A significant reduction of IL-6, IL-8, IL-10 and IL-1beta was observed. A significant drop of C-reactive protein (CRP) median levels was observed starting from 48 hours after treatment start levels. The decrease in the inflammatory status was associated with a progressive improvement in the respiratory function, with a significant increase in P/F from the first day after the end of the therapy. A similar trend was observed for procalcitonin. Conclusion(s): CytoSorb therapy proved to be safe in COVID-19 patients. A clinical improvement was observed in most of the treated patients despite the severity of the disease. In this study CytoSorb was used empirically for 24- 48 hours based on previous experience in septic shock. The persistence of significant levels of IL-6 and CRP after CytoSorb treatment may suggest that a prolonged treatment can improve the efficacy in controlling COVID-19 hyperinflammatory status.

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.

Mechanical Ventilation in ARDS

Acute respiratory distress syndrome (ARDS) is a form of hypoxemic respiratory failure, which requires supplemental oxygen delivered by mechanical ventilation, either noninvasively or more commonly by invasive mechanical ventilation. Although not currently meeting the definition for ARDS, these patients may also use heated high-flow nasal cannula and can sometimes avoid invasive mechanical ventilation as a result. The avoidance of worsening acute lung injury using lung-protective ventilation is the first principle of invasive mechanical ventilation in these patients. Conventionally, this involves keeping the plateau pressure below 30 cm H2O by using low tidal volume ventilation, based on ideal body weight. Multiple observational series suggest that targeting a low driving pressure concurrently is also important. The determination of the optimal setting for positive end-expiratory pressure (PEEP) remains controversial. The mode of ventilation utilized may be either volume or pressure limited. It has been suggested that vigorous respiratory efforts can worsen lung injury and are best avoided whenever possible. Modes of ventilation such as airway pressure release ventilation lack evidence to support use and should not be used. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Veno-venous ECMO

Extracorporeal membrane oxygenator support can be performed in a veno-arterial configuration to support cardiopulmonary dysfunction, or veno-venous configuration if cardiac function is satisfactory but pulmonary function is limiting. In this case you are asked to cannulate an obese 36-year-old man with ARDS for veno-venous ECMO at the bedside. Initially planning to use a double-lumen catheter from the neck, the patient's ventricular dysrhythmias associated with passing a wire convinced you that an alternate approach will be safer and you proceed with cannulating the right internal jugular vein and right femoral vein for inflow and outflow respectively. The options for cannulating for veno-venous ECMO and associated complexities are reviewed. © The Author(s), 2022. All rights reserved.

Combined extracorporeal CO2 removal and renal replacement therapy in a pregnant patient with COVID-19: a case report.

Background. Pregnant women are at high risk of Coronavirus disease 2019 (COVID-19) complications, including acute respiratory distress syndrome. Currently, one of the cornerstones in the treatment of this condition is lung-protective ventilation (LPV) with low tidal volumes. However, the occurrence of hypercapnia may limit this ventilatory strategy. So, different extracorporeal CO2 removal (ECCO2R) procedures have been developed. ECCO2R comprises a variety of techniques, including low-flow and high-flow systems, that may be performed with dedicated devices or combined with continuous renal replacement therapy (CRRT). Case description. Here, we report a unique case of a pregnant patient affected by COVID-19 who required extracorporeal support for multiorgan failure. While on LPV, because of the concomitant hypercapnia and acute kidney injury, the patient was treated with an ECCO2R membrane inserted in series after a hemofilter in a CRRT platform. This combined treatment reducing hypercapnia allowed LPV maintenance at the same time while providing kidney replacement and ensuring maternal and fetal hemodynamic stability. Adverse effects consisted of minor bleeding episodes due to the anticoagulation required to maintain the extracorporeal circuit patency. The patient's pulmonary and kidney function progressively recovered, permitting the withdrawal of any extracorporeal treatment. At the 25th gestational week, the patient underwent spontaneous premature vaginal delivery because of placental abruption. She gave birth to an 800-gram female baby, who three days later died because of multiorgan failure related to extreme prematurity. Conclusions. This case supports using ECCO2R-CRRT combined treatment as a suitable approach in the management of complex conditions, such as pregnancy, even in the case of severe COVID-19.

Prone Ventilation in Patients with Ards

Introduction: Prone ventilation has been a a tool that has been shown to improve oxygenation and ventilatory mechanics in patients with Down syndrome acute respiratory distress (ARDS). Although be a technique that has been performed for decades in the field of intensive care has been with the pandemic generated by COVID-19 when it has returned to be in the spotlight. However, the lack of standardized protocols make it difficultestablish when ventilation should be performed in the prone position, so this little review tries to outline some indications of when it should be done. Methodology: Two recent meta-analyses have been reviewed. about the effects of prone ventilation based on randomized controlled clinical trials of ventilation in the prone position. Result(s): The results of the meta-analyses show that there are certain circumstances which must be given to maximize the beneficial effect of pronation and that it has a beneficial effect on survival of patients with ARDS. First of all, when separated the groups according to whether they had performed lung-protective ventilation or not, the OR of the group prone was 0.58 (95% CI 0.38-0.87) and 0.70 (95% CI 0.47-1.04), so prone ventilation does achieve a decrease in mortality when it is associated with lung-protective ventilation. Another variable that observed in this meta-analysis was the length of time prone, since when this was greater than 12 hours a day the OR of the prone group in terms of mortality vs. supine was 0.60 (95% CI 0.43-0.83) and 0.74 (95% CI 0.56-0.99). When the time was less than 12 hours these beneficial effects on mortality are they dissipated Thirdly, the "timing" was also studied. Of pronation since when it was established in the first 48 hours after ARDS diagnosis, the OR was 0.49 (95% CI 0.35-0.68), beneficial effect that was lost when it started after the first 48 hours. Finally, the severity of ARDS was also assessed (measured in PaFi), observing that patients with severe ARDS (PaFi < 100) achieved a decrease in mortality with an OR of 0.51 (95% CI 0.36-0.72), and this effect the benefit was not achieved in moderate ARDS (PaFi 100-200). The second meta-analysis shows results similar, although this compares the mortality of Moderate-severe ARDS (PaFi <200) with the rest of ARDS, obtaining a reduction in mortality With an OR 0.74 (95% CI 0.56-0.99) Conclusion(s): Prone ventilation can have effects beneficial in the survival of patients with ARDS and it is important to know what conditions you should to have to achieve this effect. If we rely on the results of the latest meta-analyses, it should be recommended its use in patients with moderate-severe ARDS (PaFi < 200), associated with low tidal volumes (ventilation of lung protection with VC < 8cc/kg of ideal weight), for more than 12 hours a day and establishing it in the first 48 hours from the diagnosis of ARDS.Copyright © 2022

[6]-Gingerol: A narrative review of its beneficial effect on human health

Ginger rhizome, a common spice that has been traditionally used in various health aspects. The rhizome contains volatile oil and nonvolatile oil compounds, including oleoresin. Chemical constituents of ginger are numerous and vary depending on the geographic origin, harvest process, and storage conditions. [6]-Gingerol, a major bioactive constituent of ginger, has been reported to possess anti-inflammatory, antiviral, antitumor, antioxidant, and antiemetic effects. Therefore, it is a valuable food molecule with benefits for human health. This review summarized current findings on [6]-gingerol with regards to its beneficial effects on human health, encompassing the biological activities, mechanisms of action and toxicity assessment. In addition, relevant evidence in support of the application of [6]-gingerol towards the promotion health and vitality, as well as methods for extraction, identification and quantitative determination of [6]-gingerol are also provided.Copyright © 2022 The Author(s)

Can Pneumothorax Developing in COVID-19 Patients be a Mortality Marker?

Objectives: The purpose of this study is to investigate the effects of pneumothorax (PX), a rare complication of COVID-19, on mortality. Method(s): All patients admitted to our hospital with the diagnosis of COVID-19 were screened, and patients who developed PX were included in the study. Patient demographics data, number of days of hospitalization for comorbidities, day and duration of thorax tube insertion, and laboratory findings during hospitalization were recorded by scanning the hospital automation system and patient records. Result(s): For our study, 7485 patients hospitalized with the diagnosis of COVID-19 were screened in intensive care unit. PX was detected in 32 (0.296%) of the patients. About 59.4% of these patients included in the study were male. DM was the most common comorbid condition at 56.3%. In these patients, the mortality rate was found to be 90.6%. Conclusion(s): The data obtained indicate that PX, a COVID-19 complication, leads to a serious increase in mortality. We believe that using protective ventilation methods to avoid the development of pneumotarax will help to reduce mortality.© Copyright 2022 by The Cardiovascular Thoracic Anaesthesia and Intensive Care - Available online at www.gkdaybd.org.

Pneumomediastinum in COVID-19 critically ill patients

Pneumomediastinum in COVID-19 critically ill patients Introduction: Pneumomedisatinum(PM) is an uncommon potentially life-threatening complication of COVID-19 and can be an aggravating factor. This study aimed to determine the incidence and outcomes of PM in critically ill COVI19 patients. Method(s): A retrospective study carried out in a 9-bed intensive care unit from October 1st, 2020 to February 28, 2021 including patients with confirmed COVID19 related acute respiratory distress syndrome (ARDS) with confirmed PM on Chest computed tomography (CT). Were recorded patients characteristics, management and outcomes. Result(s): 7 cases of PM were reported : 5 men, 2 women, aged between 47 and 70 years-old. None of them had underlying lung disease. 4 patients were under invasive mechanical ventilation (IMV), 2 under non-invasive ventilation (NIV) and one had a spontaneous PM at the time of the event. Chest CT scan showed : pulmonary involvement, moderate (n=4/7) to severe (n=3/7), PM (n=7/7), subcutaneous emphysema (n=5/7) and pneumothorax (n=2/7). The highest positive end-expiratory pressure (PEEP) for patients receiving IMV and NIV were respectively 10cmH2O and 6cmH2O. Urgent mediastinal decompression wasn't immediately indicated, conservative therapy with reduced airway pressure was adopted. Patients with NIV were intubated after NIV failure. Despite protective ventilation with lower pressure, needle aspiration and chest drainage, all patients expired during their hospital stay. Conclusion(s): Our findings suggest that PM is secondary to inflammatory response due to COVID-19 and mostly triggered by the use of positive pressure ventilation and it is associated with poor outcome in critically ill COVID-19 patients.

Early Veno-Venous Extracorporeal Membrane Oxygenation after Intubation Increases Outcome in Critically Ill COVID-19 Patients

Background: Since March 2020, COVID-19 pandemic has tremendously challenged the global health care system. In patients with severe therapy-refractory acute respiratory distress syndrome (ARDS), veno-venous extracorporeal membrane oxygenation (vv-ECMO) remains the ultimo ratio therapy;however, the outcome is still not satisfying. Prolonged mechanically ventilation of ARDS patients, especially with high driving pressure, may further damage the lung and contributes to impaired outcome. Method(s): Between 2020 and 2022, a total of 82 patients were treated with vv-ECMO for severe COVID-19-related ARDS in our department. The patients were prospectively enrolled into an institutional database and subsequent retrospectively reviewed. Patients were divided Patients were divided in regard to the duration of pre-ECMO mechanically ventilation (Group 1 [<=2 days]: n = 40;Group 2 [>2 days]: n = 36). The remaining n = 6 patients were excluded due to awake ECMO implantation. Result(s): Except gender (Group 1: 22.5% female, Group 2: 58.3% female, p < 0.01), baseline characteristics such as demographic data and concomitant diseases were comparable between the two groups. The mean duration between the onset of the first COVID-19 related symptoms and ECMO implantation was 14 +/- 7 days and between intubation and ECMO implantation 0.8 +/- 0.8 days for Group 1 compared with 18 +/- 7 days (p = 0.04), respectively, 7.6 +/- 4.3 days (p < 0.001) for Group 2. We did not observed differences regarding the incidence of severe ECMO-related adverse events in regard to the pre-ECMO mechanical ventilation time. However, successful ECMO weaning rate was numerically increased in Group 1 (42.5%) compared with Group 2 (25.0%, p = 0.15) with shorter support time until weaning (Group 1: 16 +/- 13 days, Group 2: 44 +/- 44 days, p = 0.08). A similar trend was also found for in-hospital death (Group 1: 60.0%, Group 2: 77.8%, p = 0.08). Conclusion(s): Early ECMO implantation after orotracheal intubation for severe COVID-19-related ARDS did not affect the peri-interventional morbidity. However, we observed a numerically increased weaning rate as well as increased survival in patients with early ECMO implantation after intubation. As lung-protective ventilation can be achieved by early ECMO implantation in COVID-19 patients, it potentially decreases the ventilator-associated lung damage.

Analysis of combined non-invasive respiratory support in the first six waves of the COVID-19 pandemic. Outcome according to the first respiratory support

Introduction: COVID-19 can lead to acute respiratory failure (ARF) requiring admission to intensive care unit (ICU). This study analyzes COVID-19 patients admitted to the ICU, according to the initial respiratory support. Its main aim is to determine if the use of combination therapy: high-flow oxygen system with nasal cannula (HFNC) and non-invasive ventilation (NIV), is effective and safe in the treatment of these patients. Methods: Retrospective observational study with a prospective database. All COVID-19 patients, admitted to the ICU, between March 11, 2020, and February 12, 2022, and who required HFNC, NIV, or endotracheal intubation with invasive mechanical ventilation (ETI-IMV) were analyzed. HFNC failure was defined as therapeutic escalation to NIV, and NIV failure as the need for ETI-IMV or death in the ICU. The management of patients with non-invasive respiratory support included the use of combined therapy with different devices. The study period included the first six waves of the pandemic in Spain. Results: 424 patients were analyzed, of whom 12 (2.8%) received HFNC, 397 (93.7%) NIV and 15 (3.5%) ETI-IMV as first respiratory support. PaO2/FiO2 was 145 ± 30, 119 ± 26 and 117 ± 29 mmHg, respectively (p = 0.003). HFNC failed in 11 patients (91.7%), who then received NIV. Of the 408 patients treated with NIV, 353 (86.5%) received combination therapy with HFNC. In patients treated with NIV, there were 114 failures (27.9%). Only the value of SAPS II index (p = 0.001) and PaO2/FiO2 (p < 0.001) differed between the six analyzed waves, being the most altered values in the 3rd and 6th waves. Hospital mortality was 18.7%, not differing between the different waves (p = 0.713). Conclusions: Severe COVID-19 ARF can be effectively and safely treated with NIV combined with HFNC. The clinical characteristics of the patients did not change between the different waves, only showing a slight increase in severity in the 3rd and 6th waves, with no difference in the outcome. © 2022 Elsevier Ltd

COVID-19-induced acute respiratory distress syndrome and challenges faced in management of young morbidly obese patient

In 2020, the World Health Organization described the SARS-CoV-2 virus (severe acute respiratory distress syndrome [ARDS]) for the first time. Millions of people were affected by the COVID virus worldwide, and many of them lost their lives too. Our center was also one health-care center that has played a significant role in managing severe ARDS patients secondary to COVID-19 infection. We want to outline the challenges faced by the respiratory therapist in managing a 24-year-old morbidly obese young male with severe ARDS due to COVID-19.

Extracorporeal Carbon Dioxide Removal: From Pathophysiology to Clinical Applications; Focus on Combined Continuous Renal Replacement Therapy.

Lung-protective ventilation (LPV) with low tidal volumes can significantly increase the survival of patients with acute respiratory distress syndrome (ARDS) by limiting ventilator-induced lung injuries. However, one of the main concerns regarding the use of LPV is the risk of developing hypercapnia and respiratory acidosis, which may limit the clinical application of this strategy. This is the reason why different extracorporeal CO2 removal (ECCO2R) techniques and devices have been developed. They include low-flow or high-flow systems that may be performed with dedicated platforms or, alternatively, combined with continuous renal replacement therapy (CRRT). ECCO2R has demonstrated effectiveness in controlling PaCO2 levels, thus allowing LPV in patients with ARDS from different causes, including those affected by Coronavirus disease 2019 (COVID-19). Similarly, the suitability and safety of combined ECCO2R and CRRT (ECCO2R-CRRT), which provides CO2 removal and kidney support simultaneously, have been reported in both retrospective and prospective studies. However, due to the complexity of ARDS patients and the limitations of current evidence, the actual impact of ECCO2R on patient outcome still remains to be defined. In this review, we discuss the main principles of ECCO2R and its clinical application in ARDS patients, in particular looking at clinical experiences of combined ECCO2R-CRRT treatments.

Acute respiratory distress syndrome

Acute respiratory distress syndrome (ARDS) is a heterogeneous lung disease that is triggered by pulmonary and non-pulmonary pathol-ogies. It predominantly causes hypoxaemic respiratory failure and can lead to significant morbidity and mortality. Although ARDS re-mains underdiagnosed, 24% of mechanically ventilated patients in intensive care units and 33% of coronavirus disease (COVID-19) pa-tients admitted to the hospital are reported to have ARDS. Despite recent advances in treatment, mortality remains at more than 30% for all ARDS patients and 43% for severe ARDS. The pathophysiology is complex and involves acute pulmonary and systemic inflammation, alveolar oedema, and de-recruitment which lead to ventilation-perfusion mismatch, reduced lung compliance and hypoxaemia. Similarities in the pathophysiology of COVID-19 ARDS outnumber differences from non-COVID-19 ARDS. Inhomoge-neous distribution of transpulmonary pressure variation throughout the lungs in ARDS increases the risk of patient self-inflicted lung injury and ventilator-associated lung injury. Stratifying ARDS patients as per Berlin definition can help to recog-nize ARDS early, identify resource requirements and plan appropriate management. Treating the underlying cause, lung-protective ventila-tion and supportive care are the mainstays of clinical management. Multiple rescue therapies, novel treatments, and methods of facili-tating individualized ventilation have been described but many require further validation;and appropriate patient selection is warranted.

Spontaneous pneumomediastinum in Covid-19 : a case of complete resolution despite invasive positive pressure ventilation

We present the case of a 65-year-old patient who was admitted to the intensive care unit (ICU) due to Covid-19 respiratory failure. During his hospital stay, he developed a spontaneous pneumomediastinum (SP). To date, there have been few reports of SP associated with Covid-19 and even less is known about the impact of positive pressure ventilation on these patients. Our patient was first treated with high-flow nasal cannula oxygen therapy (HFNC). Because of further respiratory deterioration, he was supported with non-invasive ventilation (NIV). Later, he required intubation and ventilation with invasive positive pressure ventilation. Despite this, a complete spontaneous resolution of the pneumomediastinum was observed 13 days after the initial diagnosis. Copyright © Acta Anaesthesiologica Belgica, 2021.

Incidence of Barotrauma in COVID-19 Patients Requiring Mechanical Ventilation: A Retrospective Study in a Community Hospital.

Background and aim Acute respiratory distress syndrome (ARDS) is a severe complication of COVID-19 and traditional ventilation strategies using ARDSNet protocol, including low tidal volumes, appear to cause barotrauma in COVID-19 patients at a higher rate than non-COVID-19 ARDS patients. The purpose of our study was to determine if COVID-19 patients with ARDS undergoing mechanical ventilation at St. Joseph's Medical Center (SJMC) developed barotrauma at a higher rate than non-COVID-19 ARDS patients. Methods and materials This study was a retrospective chart review of all patients admitted to critical care units at SJMC with COVID-19 infection and requiring mechanical ventilation from March 1, 2020 to September 30, 2020. The sample included adult patients (aged 18 and above) with the International Classification of Diseases (ICD) 10 code for COVID-19 (U07.1) and patients who were placed on mechanical ventilation for longer than 24 hours, from March 1, 2020 to September 30, 2020. Barotrauma was confirmed via radiographic imaging including chest X-ray, CT, or CT angiography (CTA).  Results One hundred and forty COVID-19 patients underwent mechanical ventilation for longer than 24 hours from March 1, 2020 to September 30, 2020 at our facility. Twenty-six COVID-19 patients (18.6%) met our inclusion criteria (development of barotrauma during hospital admission) of which 25 patients (17.9%) underwent mechanical (invasive and/or non-invasive) ventilation prior to the development of barotrauma. Around 80% of the patients were on non-invasive mechanical ventilation prior to intubation and invasive mechanical ventilation. The categorical breakdown of barotrauma was as follows: pneumothorax 65.4%, subcutaneous emphysema 61.5%, pneumomediastinum 34.6%, and pneumoperitoneum 7.7%. None of the included patients had any previous history of documented barotrauma. Prior to the time of barotrauma, 17 patients were on volume control, seven were on pressure control, and one was not on mechanical ventilation. Of the 17 patients on volume control, only one patient was above the ARDSNet guideline of 6-8 mL/kg ideal body weight (IBW). In comparison to ARDS patients at SJMC in 2019, only two out of 28 patients (7.14%) developed barotrauma during mechanical ventilation.  Conclusions Patients with COVID-19 who underwent mechanical ventilation developed barotrauma at a higher rate than traditional non-COVID-19 patients with ARDS.

ABDOMINAL COMPRESSION IN END-STAGE FIBROTIC INTERSTITIAL LUNG DISEASE (ILD) IMPROVES RESPIRATORY COMPLIANCE

SESSION TITLE: Critical Thinking SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 09:15 am - 10:15 am INTRODUCTION: Compressive therapies to improve respiratory mechanics, such as abdominal compression, have been described in literature in patients with COVID-19 induced acute respiratory distress syndrome (COVID-19 ARDS) 1–3. These compressive therapies minimize the risk of barotrauma by equal distribution of pressure across the alveoli. Hence, they help with lung protective ventilation. This phenomenon of paradoxical improvement in respiratory compliance with increase in intraabdominal pressure (IAP) has not been described in ILD population. We describe a case of end-stage fibrotic ILD, secondary to hypersensitivity pneumonitis (HP), exhibiting a paradoxical improvement in respiratory compliance with sustained abdominal compression. CASE PRESENTATION: 56-year-old female with history of NASH-related cirrhosis was transferred to our hospital for expedited work-up of lung transplant due to rapid progression of biopsy-proven steroid-unresponsive fibrotic HP. Due to worsening hypoxic respiratory failure, she was intubated on arrival to our hospital. Following intubation, she was sedated and paralyzed and was found to have high peak and plateau pressures in supine and reverse Trendelenburg positions. However, on application of abdominal pressure, her peak and plateau pressure showed a dramatic reduction in absolute values. This reduction was sustained during the entire duration of the maneuver. Overall, it reduced driving pressures and improved the static compliance of the respiratory system. We subsequently applied abdominal binder (table 1) and found a similar decrease in pressures (see images). Unfortunately, due to functional disability, patient was not deemed a candidate for lung and liver transplant and was transitioned to comfort measures. DISCUSSION: Paradoxical improvement in respiratory compliance has been demonstrated in late-stage COVID ARDS1,2. The mechanism behind this is unclear. In theory, increase in IAP increases intrapleural pressures, reduces end-expiratory volume and overdistention of aerated lung1,2. We hypothesize that patients with end-stage ILD behave similarly to patients with COVID-ARDS. However, this is purely exploratory as our observations are limited by lack of intrapleural measurements. Use of abdominal compression is a simple maneuver, which can be performed at the bedside to assess for the paradoxical phenomenon. Even though we postulate that long-term abdominal compression is well tolerated, we do not know the effects of sustained long-term abdominal compression on gas-exchange and chest wall dynamics. CONCLUSIONS: Patients with end-stage fibrotic lung disease, exhibiting high-driving pressures on mechanical ventilator in supine and reverse Trendelenburg positions, can be screened for reduction in peak and plateau pressures with abdominal compression. Use of this maneuver may help in lung-protective ventilation and minimize ventilator-induced lung injury. Reference #1: Elmufdi FS, Marini JJ. Dorsal Push and Abdominal Binding Improve Respiratory Compliance and Driving Pressure in Proned Coronavirus Disease 2019 Acute Respiratory Distress Syndrome. Crit Care Explor. 2021;3(11):e0593. doi:10.1097/cce.0000000000000593 Reference #2: Julia Cristina Coronado. Paradoxically Improved Respiratory Compliance With Abdominal Compression in COVID-19 ARDS. Is COVID-19 a risk factor Sev preeclampsia? Hosp Exp a Dev. 2020;(January):2020-2022. Reference #3: Stavi D, Goffi A, Shalabi M Al, et al. The Pressure Paradox: Abdominal Compression to Detect Lung Hyperinflation in COVID-19 Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2022;205(2):245-247. doi:10.1164/rccm.202104-1062IM DISCLOSURES: No relevant relationships by Abhishek Bhardwaj No relevant relationships by Brandon Francis no disclosure on file for Marina Freiberg;No relevant relationships by Simon Mucha No relevant relationships by Arsal Tharwani