Rapid exchange of a percutaneous gastrostomy tube during an early episode of COVID-19

We retrospectively report a case of rapid exchange of a percutaneous radiologic gastrostomy tube (balloon-occluded type catheter) via off-label use of a pigtail catheter for nutrition supply during a very early episode of coronavirus disease 2019 (COVID-19) in an outpatient clinic. This case demonstrates that minimally invasive percutaneous procedures might be provided safely and effectively under appropriate precautions for preventing COVID-19 transmission during the pandemic.Copyright © 2023, Society of Gastrointestinal Intervention.

Autonomic Dysfunction after Covid-19 Immunization - Case Report

Background: The infection caused by the SARS-CoV-2 continues affecting millions of people worldwide and vaccines to prevent the coronavirus disease (COVID-19) are considered the most promising approach for curbing the pandemic. Otherwise, cardiovascular and neurological complications associated with the vaccines were speculated and some few case reports were published. Objective(s): We describe a case of postural orthostatic tachycardia syndrome (POTS) after viral vector COVID-19 vaccination and the possible autoimmune process of the syndrome. Method(s): A 35-year-old female, without previous symptoms or comorbidities, developed intermittent palpitation, intense fatigue and dyspnea, compromising her daily activities, triggered by upright position, seven days following the second dose of the Oxford vaccine. Physical examination was normal, except for a heart rate (HR) increase of 33 beats/min from supine to standing position, with no significant change in blood pressure and reproduction of symptoms. Result(s): A 24-hour Holter monitoring revealed episodes of spontaneous sinus tachycardia correlated with palpitation and fatigue. Extensive diagnostic investigations excluded primary cardiac, endocrine, infectious and rheumatologic etiologies. The patient underwent an autonomic function test which demonstrated normal baroreflex sensitivity, as well as normal cardiovagal and adrenergic scores. Head-up tilt test showed persistent orthostatic tachycardia (HR increase from a medium of 84 beats/min in supine position to 126 beats/min during upright tilt), without hypotension, consistent with the diagnostic criteria for POTS. According to the current guidelines, general behavior recommendations, pharmacotherapy with low dose of propranolol associated with the autonomic rehabilitation were oriented. Along three months of follow-up, the patient reported a gradually improvement in her symptoms. Conclusion(s): POTS is a heterogeneous disorder of the autonomic nervous system characterized by orthostatic tachycardia associated with symptoms of orthostatic intolerance. Although the physiopathology of COVID-19 vaccine and autonomic disorders remains speculative, autoimmune response is one of the possible mechanisms. Based on clinic presentation, the time frame of symptom onset is consistent with other well-known post-vaccination syndromes, which may be an indicator of an autoimmune process induced by immunization. Further studies are needed to assess causal relationship between immunization and autonomic dysfunction.Copyright © 2023

Lung inhomogeneities in COVID-19 related acute respiratory distress syndrome

Introduction: In acute respiratory distress syndrome (ARDS) inhomogeneities in lung aeration can act as local multipliers of pressure during inspiration (stress risers), increasing the risk of lung damage even in presence of airway pressures considered safe [1]. In this study we aimed to describe lung inhomogeneities in COVID-19 related ARDS (C-ARDS) and to relate these to disease severity and lung morphology. Method(s): We enrolled patients with C-ARDS within 3 days from mechanical ventilation start, deeply sedated and paralyzed. Lung CT scan was obtained at PEEP of 5 cmH2O to measure lung weight compartments (non-, poorly-, well- and over-aerated). Lung inhomogeneities were computed as the gas/tissue ratio of each voxel compared to the neighboring voxels. We considered values > 1.61 as pathologic lung inhomogeneities, as previously described [1]. The fraction of total lung volume with pathologic inhomogeneities (extent) and the average severity of inhomogeneities contained in that fraction (intensity) was calculated. Respiratory system compliance and blood gas analysis were obtained at the same PEEP level of the CT scan. Some results have been presented in another publication [2]. Result(s): Forty patients were studied in the supine position 1 (0-1) days after ICU admission. The extent of pathologic lung inhomogeneities represented 18 +/- 4% of total lung volume. The intensity of pathologic lung inhomogeneities was on average 2.53 +/- 0.12. Extent was positively correlated with the amount of poorly aerated lung weight ( r2 = 0.51, p < 0.001) (Fig. 1) and negatively correlated with the amount of non-aerated lung weight ( r2 = 0.22, p = 0.002). No correlation was found between extent and intensity and PaO2/ FiO2, dead space fraction or respiratory system compliance. Conclusion(s): In C-ARDS lung inhomogeneities represent roughly 20% of total lung volume. In these regions local stress is increased with risk of secondary lung damage.

Haemodynamic changes during prone versus supine position in patients with COVID-19 acute respiratory distress syndrome.

BACKGROUND: Prone positioning improves oxygenation in patients with acute respiratory distress syndrome (ARDS) secondary to COVID-19. However, its haemodynamic effects are poorly understood. OBJECTIVES: The objective of this study was to investigate the acute haemodynamic changes associated with prone position in mechanically ventilated patients with COVID-19 ARDS. The primary objective was to describe changes in cardiac index with prone position. The secondary objectives were to describe changes in mean arterial pressure, FiO2, PaO2/FiO2 ratio, and oxygen delivery (DO2) with prone position. METHODS: We performed this cohort-embedded study in an Australian intensive care unit, between September and November 2021. We included adult patients with severe COVID-19 ARDS, requiring mechanical ventilation and prone positioning for respiratory failure. We placed patients in the prone position for 16 h per session. Using pulse contour technology, we collected haemodynamic data every 5 min for 2 h in the supine position and for 2 h in the prone position consecutively. RESULTS: We studied 18 patients. Cardiac index, stroke volume index, and mean arterial pressure increased significantly in the prone position compared to supine position. The mean cardiac index was higher in the prone group than in the supine group by 0.44 L/min/m2 (95% confidence interval, 0.24 to 0.63) (P < 0.001). FiO2 requirement decreased significantly in the prone position (P < 0.001), with a significant increase in PaO2/FiO2 ratio (P < 0.001). DO2 also increased significantly in the prone position, from a median DO2 of 597 mls O2/min (interquartile range, 504 to 931) in the supine position to 743 mls O2/min (interquartile range, 604 to 1075) in the prone position (P < 0.001). CONCLUSION: Prone position increased the cardiac index, mean arterial pressure, and DO2 in invasively ventilated patients with COVID-19 ARDS. These changes may contribute to improved tissue oxygenation and improved outcomes observed in trials of prone positioning.

Amount and distribution of parenchymal abnormalities at CT-scan do not predict awake prone position outcome in Covid-19

Background: Even if definitive evidence is still missing, prone position in non-intubated hypoxemic patients with Covid-19 is largely used. The aim of the present study was to investigate whether the amount and distribution of lung abnormalities evaluated by CT-scan can predict the improvement of oxygenation when Covid-19 patients undergoing non-invasive ventilation (NIV) are turned prone. Method(s): Retrospective monocentric study of severe Covid-19 patients who underwent NIV and prone position, evaluated with a basal chest CT-scan. Result(s): Forty-five severe Covid-19 patients were considered. On average 50% of the overall lung volume was involved by pneumonia at CT-scan, with ground glass, and consolidation accounting for 44, and 4%, respectively. The parenchymal abnormalities were predominantly posterior, as demonstrated by a posterior/anterior ratio of ground glass and consolidation of 1.5, and 4.4, respectively. PaO2/FiO2, whose basal value under NIV in supine position was 140 [IQR 108;169] improved on average by 67% (+98) during prone position. Once supine position was resumed, improvement in oxygenation was maintained in 28 patients (62% of the overall population, categorized as "responders"). We did not find significant difference between responders and non-responders in terms of the amount and distribution of parenchymal abnormalities. No correlation emerged between the distribution of parenchymal abnormalies and changes in oxygenation in supine position before and after prone position (R2 = 0.009, p= 0.526). Conclusion(s): the amount and distribution of lung abnormalities evaluated by CT-scan do not predict the response to awake prone position in patients with severe Covid-19 pneumonia undergoing non-invasive ventilation.

Predictors of Non-invasive Respiratory Support Failure in COVID-19 Pneumonia (RUTIROX). Preliminary Results

The RUTIROX clinical trial aims to determine clinical predictors of respiratory failure using high-flow nasal cannula (HFNC) for acute respiratory failure (ARF) P/F ratio<200 due to COVID-19 pneumonia. Study protocol includes a change to NIV after HFNC failure, prior to endotracheal intubation (ETI). Local ethics committee approval NCT05094661. Method(s): Interventional randomized study in PICU during Mar-Nov 21. In supine position HFNC was started at 60l/min Fio2 0.9, ABG and analysis were controled. If respiratory failure (defined as RR>30 or Sat<92% or P/F<80) occurred, participants were randomized to CPAP/BPAP. At day 28 ETI and death were evaluated. Statistical analysis SPSS. Chi-square tests, U-Mann Whitney and ROC analysis. Result(s): n=128 63% Men. Mean age 62. Mean P/F 164. 49% required NIV (28 CPAP/35 BIPAP). 21.9% required ETI. Mortality 9.3%. Advanced age, diabetes, neoplasia, low P/F ratio, low pO2 and high initial LDH value, were significantly more frequent in HFNC failure group (p-value <0.05). Area Under the ROC curve (AUC) of initial LDH is 0,65 (level of 300 U/L) and LDH at 48h 0,67. AUC of P/F is 0,69 for survival. No differences were found between NIV groups. Conclusion(s): Older age, higher degree of ARF and high LDH value are factors associated with HFNC failure. Despite presenting high intragroup failure frequency values, ETI rate and mortality rate were lower than those reported in other series. (Figure Presented).

Lung perfusion assessment in Long-COVID children: a pilot study

Aim/Introduction: There is growing interest in the clinical management of children with persisting and debilitating symptoms after Sars-COV-2 infection (Long-COVID). Chronic effects could arise from residual clot burden and small vessel inflammation, both expressing endothelial damage that may lead to lung perfusion impairment. 99mTc-macroaggregated albumin (MAA) SPECT/ CT is a well-established tool to detect lung perfusion defects, even at the small-vessels level. This pilot study aimed at assessing lung perfusion in Long-COVID children with MAA SPECT/CT and at comparing functional patterns with clinical scenarios during acute infection and follow-up. Material(s) and Method(s): Clinical and biochemical data were collected during acute infection and follow-up in 10 children (6 males and 4 females, mean age: 13.6 years) fulfilling Long-COVID diagnostic criteria and complaining of chronic fatigue and post-exertional malaise after mild efforts. All patients underwent a cardiopulmonary test and MAA SPECT/CT scan. Dose activities were properly chosen according to the EANM guidelines for lung scintigraphy in children. Intravenous injections were administered to patients in the supine position immediately before the planar scan, which was followed by the lung SPECT/CT acquisition. Reconstructed studies were visually analyzed. Imaging results were compared with clinical scenarios during acute infection and follow-up. Result(s): The severity of acute disease was mild and moderate in 6/10 (60 %) and 2/10 (20 %) children, respectively;there were no significant symptoms in the remaining 2 cases. Persisting symptoms after the acute phase were observed in 7/10 (70%) patients. Five out of 10 (50.0%) children showed perfusion defects on MAA SPECT/CT scan, without morphological alterations on co-registered CT. In particular, 4/5 (80%) children with lung perfusion abnormalities were previously affected by a mild acute infection, whereas a single child (20%) was asymptomatic. However, during the follow-up, persisting symptoms (e.g., headache and dyspnea after the cardiopulmonary test) were detected in 5/5 (100%) patients. Conversely, among the five children without lung perfusion defects, only 2 (40%) showed persisting symptoms (in particular, headache), while 3 (60%) children had dyspnea after the cardiopulmonary test. Conclusion(s): This pilot study showed lung perfusion defects in Long-COVID children. Despite the small patient sample, perfusion abnormalities on MAA SPECT/CT seem to occur more frequently in children with persisting symptoms following the acute infection and dyspnea after the cardiopulmonary test. Larger cohort studies are needed to confirm these preliminary results, providing a better selection among children who can benefit the most from MAA SPECT/CT imaging.

Rapid recovery in a patient with severe COVID-19 after a low-load, high-frequency rehabilitation program using an ergometer in the supine position.

Background Rehabilitation therapy for patients with severe coronavirus disease 2019 (COVID-19) is crucial; however, studies regarding rehabilitation strategies for intensive care unit (ICU) patients with COVID-19 are limited. We report a case of severe COVID-19 in an ICU patient whose physical function and basic movement ability rapidly improved after the initiation of active aerobic exercise in the supine position.Case A 70-year-old man with hypertension and obesity was admitted to the ICU and managed with a ventilator because of severe COVID-19. Physical therapy started on postadmission day 34. Problems encountered during physical therapy included low saturation of percutaneous oxygen (SpO2; <90%), dyspnea with a light exercise load, advancing muscle weakness, and endurance decline. The rehabilitation program included getting out of bed and resistance training of the upper and lower limbs twice daily while maintaining SpO2 at ≥90%. After ventilator weaning, we initiated aerobic training using a supine ergometer with varying load volume. On discharge from the ICU on postadmission day 45, the patient' s physical function (handgrip strength, Medical Research Council score, and Borg scale) and basic movement ability (Functional Status Score for ICU) rapidly improved.Conclusion Rehabilitation therapy involving aerobic cycling training based on a quantitative load setting may be effective in treating COVID-19.

Vascular Response to a Cardiac Rehabilitation Program Adapted for COVID-19

Background: Cardiac Rehabilitation (CR) is a supervised exercise and risk factor modification program for patients with cardiac conditions. Endothelial dysfunction is often present and is associated with worsening cardiac prognosis, and several studies have indicated that standard onsite CR has improved endothelial function in heart disease patients. However, during the COVID-19 pandemic, many CR programs transitioned to a virtual or hybrid model of care to increase safety of CR programs. Objective(s): The objective of this study was to determine vascular function of patients with coronary artery disease (CAD) measured before and after 4 months of outpatient CR using a virtual model of care. Method(s): Virtual CR included 1 virtual group session/week by videoconferencing and hybrid CR included 1 session/week (4 on-site and 12 virtual group sessions) for a total of 16 weeks. CAD patients (6 females, 4 males) mean age 68.1+/-7.5 years rested in a supine position to measure 1) brachial artery flow-mediated dilation (FMD), 2) microvascular function, and 3) augmentation index (AI) using ultrasound sonography (n=8) and an EndoPAT 2000 (n=9). Two patients completed virtual CR and the rest underwent hybrid CR. These measurements were obtained concurrently using an ultrasound transducer at the brachial artery proximal to a blood pressure cuff on the forearm with EndoPAT cuffs on the index fingers during 5-minute intervals of baseline, occlusion, and recovery. FMD results were analyzed using automated Cardiovascular Suite software. AI and Reactive Hyperemia Index (LnRHI) were determined using automatic analysis via the EndoPAT 2000. Anthropometrics, blood pressure, and food intake were recorded at each visit. Patients were advised to refrain from strenuous exercise, alcohol, caffeine, and highly saturated foods at least 12 hours prior to the study appointment. One tailed paired t-tests were conducted between baseline and completion. Result(s): Adherence to CR averaged 10.3+/-3.2 out of 16 sessions. FMD improved from (2.75+/-1.71% to 5.63+/-4.37%, p=0.048) while there was no improvement in AI (14.2+/-18.8 to 13.2+/-19.6, p=0.45) or LnRHI (0.56+/-0.12 to 0.52+/-0.20, p=0.24). Conclusion(s): While there was no improvement in LnRHI or AI after CR, FMD improved in CAD patients after 4 months of adapted CR. Our results indicate that while virtual and hybrid models of CR may not be sufficient for improving microvascular function and aortic stiffness in CAD, there is an improvement of endothelial function. Future studies should examine the effects of adherence, duration and exercise intensity within these alternative models of CR on aortic and microvascular improvements.

Meeting nutritional requirements in critically-ill patients with COVID-19: Does the patient's position really matter?

Introduction: Prone positioning and veno-venous extracorporeal membrane oxygenation (VV-ECMO) can improve oxygenation in patients with COVID 19-induced acute respiratory distress syndrome (ARDS).1 Enteral feeding in the prone position has challenges, including possible aspiration risk of gastric contents and potential for disruption to enteral feeding.2 National guidelines2 were implemented locally;including a reduction in the maximum acceptable gastric residual volume (GRV) and the avoidance of bolus feeding while patients were in prone position. Objectives: • To explore the nutritional adequacy of patients in the prone position with COVID-19 on our critical care unit during the second surge (November 2020-April 2021) • To compare nutritional adequacy of days when patients were in prone versus supine position • To identify any factors that impacted on nutritional adequacy • To provide recommendations for improvement Methods: Patients with COVID-19 who required intubation, were placed in prone position at any time during their admission and had been assessed by the dietitian, were included. Total daily energy and protein intakes, from enteral (EN) and parenteral nutrition (PN), propofol and intravenous glucose were obtained from our computerised information system (Metavision) for each full day. If nutritional aims were not met then reasons for this were investigated. Nutritional adequacy was defined as ≥ 80% of energy and protein received per day.3 Results: Data for 34 patients was collected (see Table 1). A total of 1142 ICU days were included: 106 (9.3%) prone position days and 1036 (90.7%) supine position days. Patients received EN on 1098 days (96.1%) and PN on 44 days (3.9%). Only 4 of the 44 PN days occurred whilst a patient was in the prone position (0.4%). On prone position days, patients received an average 80% of their prescribed energy and 56% of their prescribed protein requirements, compared with 95% prescribed energy and 84% prescribed protein on supine position days. The average received across both prone and supine position days was 94% energy and 82% of protein. The 4 most frequent barriers to meeting protein requirements when in prone position were: • Reduction of NG feed rate when GRV's were higher than maximum acceptable volume • Use of a standard 4g protein/100ml 'Out of Hours' enteral feed • Fasting for procedures • Failure to give protein supplement boluses when patient returned to supine position Conclusion: Patient position affected nutritional intake, with energy and protein intake being lower on prone position days compared with supine position days. As only 9.3% of total ICU days were prone position days, average energy and protein received across all days still achieved nutritional adequacy. An increase in a patient's prone position days during ICU admission is likely to result in greater nutritional deficit, particularly for protein. Recommendations to improve nutritional adequacy on prone position days: • Consider use of post-pyloric feeding to increase feed tolerance • Use of a higher protein 'out of hours' enteral feed • Raised awareness of standard fasting times to ensure minimum disruption to feeding • Consider administration of protein supplement boluses in prone position when GRV's are within the accepted range .

Bedside diaphragmatic ultrasound used to diagnose an unexpected cause of weaning difficulty in a patient with COVID-19 pneumonitis

Introduction: Diaphragm dysfunction has been described as being responsible for weaning failure with an incidence of 23-80%. It has also been associated with difficult weaning from mechanical ventilation, prolonged intensive care unit (ICU) stay and increased ICU and hospital mortality.1 This case report describes the use of bedside ultrasound to diagnose diaphragm dysfunction, assess the severity of dysfunction, refer to specialist care and monitor disease progression in patient with COVID-19 pneumonitis with difficulty weaning from mechanical ventilation. Main body: A 59 year-oldmale with no known past medical history was admitted to our ICU with respiratory failure due to COVID-19 pneumonitis. He had received continuous positive pressure ventilation with oxygen supplementation on the medical high dependency unit for 15 days prior to deteriorating and requiring invasive ventilation in ICU. In ICU, the patient was mandatory ventilated using lung protective ventilation strategies for 26 days before he was switched to pressure support ventilation for attempts to wean him from mechanical ventilation. During the initial phase of his ICU admission, he was severely hypoxaemic and required deep sedation as well as muscle relaxation for a total of 370 hours. Prone positioning was required on 4 occasions before he was stable in the supine position. Once attempts to liberate him from mechanical ventilation were being made, pressure support was gradually reduced along with PEEP and FiO2. Progress with this reduction in support was slow due to marked tachypnoea and a dyssynchronous respiratory pattern. It was also noted that he had poor air entry in his right base with corresponding right lower zone opacities on his chest x-ray. At this stage a bedside ultrasound was used to investigate the cause of weaning difficulty and consequently, the diagnosis of right diaphragmatic paralysis was made. This was a new finding, as his admission chest x-ray did not show a raised hemidiaphragm. This diagnosis led to an increased focus on physical rehabilitation and mobilisation with tolerance of his tachypnoea and respiratory pattern as we now appreciated this didn't represent ongoing underlying parenchymal lung disease. We also made a referral to the respiratory team in order to facilitate longer-term rehabilitation and follow up. The patient was successfully extubated after intense physical rehabilitation, post extubation he remained tachypnoeic and still required supplemental oxygen at the point of hospital discharge. A follow up diaphragm ultrasound 6 months after discharge did not show any improvement in the right diaphragmatic function, he remains dyspnoeic on exertion and still occasionally uses ambulatory supplemental oxygen. Conclusion: Ultrasound assessment revealed an unexpected cause of weaning difficulty in our patient that allowed us to individualise his weaning plan and rehabilitation. This case shows that bedside intensivist performed ultrasound can accurately evaluate diaphragmatic function in patients who are difficult to wean from mechanical ventilation. Brief description of ultrasound video: The diaphragm was scanned using low frequency curvilinear ultrasound probe. There is lack of diaphragmatic excursion and absent thickening of the right hemidiaphragm on subcostal and intercostal views. M-mode evaluation and 'sniff test' confirms diaphragmatic paralysis.

Stereotactic Body Radiotherapy for Primary and Metastatic Lung Cancer, Cyberknife-M6 Experience

Introduction: It was aimed to evaluate the efficacy, local control and survival in patients with inoperable primary or metastatic lung cancer who underwent stereotactic body radiotherapy (SBRT) using the Cyberknife-M6 (CK-M6) with lung optimized treatment (LOT) module. Methods: Ethics committee (no: 2018-7/6) and scientific research project (OUAP (T) 2019/1) approval were obtained. 23 lesions of 21 patients were treated between April 2019 to December 2020 at our department. The patients were immobilized in the supine position by wearing a Synchrony vest, with the hands at their sides. A planning 4D-CT was obtained in a free breathing modality. The gross target volumes was created both on the full-inhale and full-exhale phases and internal target volume (ITV) was created. By taking an image of patients on the treatment device, tracking modality was selected according to the visibility of the target. Zero-View tracking was applied in 10 patients, 1-View in 10 patients, 2-View in 1 patients. 3 to 5 mm margin added for planning target volume (PTV) according to tracking method. Median ITV and PTV was 9,38 (2-52,34) and 20,27 (9,25-82,7) cc, respectively. An InCise2 multileaf collimator optimized by the Monte Carlo algoritm was used in all patients. A pair of the orthogonal kV X-ray imaging systems were used for simultaneous target tracking. Median prescribed dose was 48 Gy in 4 fractions (30-54 Gy in 3-6 fractions) administered consecutively or every other day. Prescription isodose covering 95% of PTV was 82,5% (77,4-99,3). Median conformity and homogeneity index was 1,17 (1,02-1,77) and 1,22 (1,09-1,29), respectively. Median BED10 was 100 Gy (53,62-151,2) and median beam on time was 26 minutes (12-42). Results: Patients were evaluated on January 2022. The median follow-up was 21 months (2-33). The median age was 68 (53-80) and 40% of the cases were adenocarcinoma. Two patients diagnosed with radiologically. Median lesion size was 13 mm (9-27). SBRT was applied to 13 primary tumors, 3 lung metastases and 7 lymph nodes. At initial evaluation, complete, partial and stable response was found 30%, 65% and 5%, respectively. During the follow-up, 3 patients locally recurred at a median of 11 months (9-14). The median and one-year local recurrence free survival was 22 months, and 89%. Acute and late grade 1-2 pulmonary complications was seen in 10 patients in a median of 7 months (2-13). While the cause of death in 6 cases was existent cardiac morbidity, covid19 pneumonia, lung infection (2) and progression (2), it was unknown in 1 patient. The median and one-year survival was 23 months and 95%. Conclusions: LOT module of the CK-M6 Xsight lung tracking system allows for the application of fiducial-free motion management strategies. The advantage of our study is that the most appropriate tracking modality can be selected prospectively before treatment. In our study, excellent local control with a median survival of 23 months for primary and metastatic lung cancer. With a median treatment time 26 minutes, noninvasive CK-M6 based SBRT was efficient, safe and comfortable treatment in lung cancer. Keywords: lung cancer, Cyberknife-M6, stereotactic body radiotherapy

Effect of Lateral Positioning on Oxygen Levels in An Obese Critically Hypoxic COVID-19 Patient: A Case Report ABS0174)

Aim and objective: To demonstrate the effectiveness of lateral positioning as a salvage for deteriorating PaO2/FiO2 ratio through a case report of a morbidly obese individual managed with lateral positioning. To demonstrate that the improvement of oxygenation was due to the recruitment of previously non-ventilated lung areas as demonstrated by Electrical impedance tomography. The study noted the evolution in SpO2, variations in regional distribution of ventilation (TV), and changes in end-expiratory lung volume/ FRC. Materials and methods: The patient was ventilated using the Carescape R860 GE ventilator. As per protocol, the transpulmonary pressure was monitored using an esophageal manometer using the Nutrivent. End expiratory lung volume (EELV) or the functional residual capacity (FRC) was measured using the nitrogen washout method. The patient was ventilated with a pressurecontrolled mode at a FiO2 of 80% of ventilated with the driving pressure (pressure control-peep) maintained at 15. The PEEP was progressively increased in steps of 5 (staircase maneuver). The staircase recruitment was continued to reach an inspiratory transpulmonary pressure of 25 or a peep of 40 (whichever reached earlier). At each step of the staircase manoeuvre, the end expiratory lung volume, compliance, and the electrical impedance tomography values were noted to avoid overdistension. Lateral (both left and right, ∼ 40° with pillows) and supine positions were performed (∼ 2 h for each position). At each position, an FRC calculation (average of three) was done and an EIT measurement was done. The strain was a calculation by the formula tidal volume/functional residual capacity and found to be <0.25 at all times. Results: The positional alteration (right and left lateral) consistently showed an improvement in the end-expiratory lung volume/FRC along with a clear demonstration of improvement of air redistribution in the lung maps by electrical impedance tomography. The findings of the case suggest recruitment of previously non-ventilated/ poorly ventilated lung areas. Conclusion: The case study results provide evidence of the effectiveness of a lateral positioning in the improvement of oxygenation in COVID ARDS. This case report would encourage the use of lateral positioning in those hypoxic patients who cannot be proned or in those units who have no expertise in proning.

Sensitivity and specificity of RT PCR and HRCT Thorax for Confirmed Diagnosis ofCOVID-19

Introduction:TheCOVID-19pandemichasrepeatedlyhittheplanetwithawaveofinfection.Clinicians are attempting to defend public health care ethics. Asymptomatic COVID-19 casesgounrecorded,andthemajorityofthemisolatethemselves.Significantradiologicalabnormalit ies have been discovered in RT-PCR positive asymptomatic COVID-19 cases,accordingto studies. Objective:Thegoalofthiscross-sectionalstudyistoevaluateasymptomaticRT-PCRpositivepatients'chest CT findingsin oneof India's COVID-designatedinstitutions in a tertiary care centre in Bihar. Methods: In three months, we did HRCT chest of diverse (200 patient case study) proved andprobableinstances of COVID-19 infection. All patients are underwent HRCT chest by multislice (128 slice) Toshiba CT scan (Aquilion) or 16 slice Toshiba CT scan. The following CT parameters were used: collimation 5mm;slice thickness, 0.5- 2.5 mm;reconstruction interval, 2.5 mm;table speed 13.5 mm per rotation;150 -250 mA effective current;tube potential 120kVp;and matrix size, 512 x 512. the patient was examined in supine position with both arms extended above the head. All CT chest were taken in caudocranial direction, covering entire chest from diaphragmatic dome up to lung apex, without intravenous contrast administration. The image finally send to PACS for reporting. Results: Positive HRCT chest results were detected in 196 of 200 scanned individuals withclinical complaints and suspicion, indicating clinical-radiological association and an accuracyof 98 percent. Based on positive RT-PCR data, the sensitivity of chest CT in suggestingCOVID-19was98.6%(146/148patients).90percent(18/20)ofpatientswithnegativeRTPCRresultsandsigni ficantclinicalsuspicionhadpositivechestCTfindings. Conclusion:InlaboratorynegativeRT-PCRcaseswithstrongclinicalsuspicionofCOVID-19infection,HRCTchestisparticularly sensitive and accurate in detecting up lung parenchymal abnormalities, as well asin all symptomatic patients whose RT-PCR was not done. In patients with a strong clinicalsuspicion,HRCTcanbeexceedinglysensitive,cost-effective,andtimeeffective.HRCT outperformsRTPCRintermsofprovidingimmediateresults,measuringdiseaseseverity,andprognosisprediction. InallpatientswithclinicalsymptomsandsuspicionofCOVIDinfection,regardlessoflaboratoryRTPCRstatus,werecommendHRCTchestforidentificationofearlyparenchymalabnormalities and determining diseaseseverity.

ORTHOSTATIC HYPOTENSION IN COVID 19 - CATCH IT IF YOU CAN!

Objective: The relationship between COVID-19 and blood pressure (BP) has raised great concern since the discovery of Angiotensin Convertase Enzyme 2 (ACE 2) - mediated mechanism of action for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV2). Hypertension (HTN) itself proved to be a risk factor for more severe Coronavirus Disease 19 (COVID -19). However less studies focus on the trend of blood BP for patients with COVID-19 during the initial phase of disease. Design and method: We present the case of a 71 years old woman with grade 2 HTN previously controlled with diuretic and betablocker therapy that came to our hospital with dyspnea, cough and debilitating fatigue progressively worsened in the last 10 days. The patient also related the first episode of syncope in her life the night before the presentation. Results: The clinical evaluation revealed a conscious, euvolemic, with polypnea and a peripheral saturation in oxygen of 86%, corrected to 95% with 9 liters oxygen/ minute via simple face mask and a BP of 110/70 mmHg with a ventricular rate of 45 beats per minute in supine position. The assessment of BP values while standing showed a value of 78/60 mmHg after 1 minute and 58/40 mmHg after 3 minutes, while the ventricular rate increased overall to 65 beats per minute. ECG was remarkable only for mild bradycardia and computed tomography pulmonary angiogram excluded pulmonary embolism. The patient was admitted with severe COVID-19 accompanied by severe orthostatic hypotension and bradycardia. Continuous telemonitoring showed only mild bradycardia. Under standard COVID 19 treatment, after 10 days, her symptoms had resolved with no residual orthostatic hypotension or bradycardia. Conclusions: In conclusion this case reflects the life-threatening dysautonomia caused by SARS-COV 2 infection. More concern should be placed on this type of fragile patients, taking into account both the macroscopic implications of being confined to bed for a long period of time and the microscopic butterfly effect caused by the binding of the virus on the widespread ACE 2 in the lungs, heart, kidneys and digestive tract.

Vestibular Dysfunctions Related to COVID-19 Infection: A Clinical Case Report

Objective: NA Introduction: Vertigo is an unusual presentation of COVID infection about which there have been only a few case reports focusing on peripheral vestibular dysfunctions. Accumulation of clinical experiences is needed to improve our knowledge and clinical practice. We report a recent encounter with predominant and persistent vestibular symptoms from COVID-19 infection. Design/Methods: NA Case Presentation: A 31 y/o otherwise healthy male suffered rapidly onset severe non-positional vertigo, disequilibrium, and nystagmus associated with nausea and vomiting, which were followed in a few hours with high fever, diarrhea, and generalized fatigue. He and his wife were then both tested positive for SARS CoV-2 by PCR. He denied having other common COVID-19 symptoms. All his systemic symptoms resolved in 2 weeks after treatments. However, he remained having persistent severe and subjectively progressive vertigo and disequilibrium upon the first office encounter 2 months later. Symptoms were enhanced by head pitching and were reduced by maintaining head stationary in supine position with eyes closed. Examination was unremarkable except the findings of slight left-sided peripheral vestibular weakness and mild deviation with Fukuda stepping. Further vestibular studies showed normal water caloric irrigation, impaired vertical gaze holding, abnormal subjective visual vertical testing, and delayed bilateral vestibular evoked myogenic potentials. COVID-19 infection-related peripheral and central vestibular complications were suspected. The patient was referred to vestibular rehabilitation. Discussion: COVID-19 virus is known to cause acute and long-term injuries of peripheral and central nervous systems. Although uncommon, COVID-19 infection can present with acute vestibular symptoms. Like the other reports, our case showed no profound peripheral vestibular losses after recovery from acute COVID-19 infection. However, his debilitating vestibular discomforts have persisted long after the recovery. Our observations suggest that the mechanisms for COVID-19-related vestibular dysfunctions are more complicated and may involve both peripheral and central vestibular systems.

DIAGNOSTIC AND MANAGEMENT PROBLEMS IN PULMONARY ASPERGILLOSIS

TYPE: Late Breaking TOPIC: Chest Infections INTRODUCTION: The gold standard for the definite diagnosis of opportunistic infections in the respiratory system is represented by the bronchial biopsy accompanied by the histopathological examination, thus eliminating the suspicion of other diseases at this level. CASE PRESENTATION: In January of this year, a 59-year-old patient presented to the pulmonology department, accusing the sensation of suffocation in supine position, accentuated during the evening, retrosternal embarrassment and epigastric pain. From the patient’s history we remember SARS-COV2 infection, sarcoidosis and cardiac pathology, with outpatient backgroung treatment. The objective examination shows pale, cold skin, sound chest, no bronchial rales. From laboratory data we note slight inflammation, mild neutropenia and anemia. Functional respiratory tests are normal. The sputum examination doesn’t show the pathogenic flora, the Galactomannan antigen is negative. Thus, fibrobronchoscopy with biopsy is performed, the cytohistological result highlighting septate hyphae with sharp-angled branches, conidia and metules of the genus Aspergillus Spp. The evolution during the hospitalization period is favorable under the antibiotic and symptomatic treatment, subsequently following the outpatient antifungal treatment. DISCUSSION: We are facing a case in which establishing an early diagnosis of pulmonary aspergillosis is a challenge, being known that a proper therapy can prevent further complications. CONCLUSIONS: Patients with pre-existing lung disease may contract various infections and the response of the immune system depends on the degree of damage. DISCLOSURE: No significant relationships. KEYWORD: pulmonary aspergillosis

Prone ventilation in intubated COVID-19 patients: a systematic review and meta-analysis.

BACKGROUND: The efficacy and safety profiles of prone ventilation among intubated Coronavirus Disease 2019 (COVID-19) patients remain unclear. The primary objective was to examine the effect of prone ventilation on the ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO₂/FiO₂) in intubated COVID-19 patients. METHODS: Databases of MEDLINE, EMBASE and CENTRAL were systematically searched from inception until March 2021. Case reports and case series were excluded. RESULTS: Eleven studies (n = 606 patients) were eligible. Prone ventilation significantly improved PaO₂/FiO₂ ratio (studies: 8, n = 579, mean difference 46.75, 95% CI 33.35‒60.15, p < 0.00001; evidence: very low) and peripheral oxygen saturation (SpO₂) (studies: 3, n = 432, mean difference 1.67, 95% CI 1.08‒2.26, p < 0.00001; evidence: ow), but not the arterial partial pressure of carbon dioxide (PaCO₂) (studies: 5, n = 396, mean difference 2.45, 95% CI 2.39‒7.30, p = 0.32; evidence: very low), mortality rate (studies: 1, n = 215, Odds Ratio 0.66, 95% CI 0.32‒1.33, p = 0.24; evidence: very low), or number of patients discharged alive (studies: 1, n = 43, Odds Ratio 1.49, 95% CI 0.72‒3.08, p = 0.28; evidence: very low). CONCLUSION: Prone ventilation improved PaO₂/FiO₂ ratio and SpO₂ in intubated COVID-19 patients. Given the substantial heterogeneity and low level of evidence, more randomized- controlled trials are warranted to improve the certainty of evidence, and to examine the adverse events of prone ventilation.

Effects of the prone position in the treatment of acute respiratory syndrome in patients with COVID-19

Objective: To measure the effects of the prone position on ventilatory parame-ters in the treatment of patients with acute respiratory syndrome secondary to COVID-19. Methods: Through a descrip-tive, cross-sectional, prospective study, a sample of 103 patients with acute respira-tory syndrome (ARDS) secondary to COVID-19 was studied. The patients were placed in the prone position indefinitely and clinical ventilatory pa-rameters were monitored such as blood pressure oxygen (PaO2), oxygen saturation (SatO2) and relationship between partial pressure of oxy-gen and inspired fraction of oxygen (PaO2/FiO2). Results: The concentration of FiO2 decreased from 100% in the su-pine position to 69% in the prone position, the PaO2/FiO2 increased from 74 to 122 millimeters of mercury (mmHg), the basal PaO2 was recorded at 51 mmHg and after the change in position it was of 89 mmHg, also the SatO2 improved from 84% to 93%. Conclusions: The prone position can significantly improve the PaO2, SatO2 values, as well as the PaO2/FiO2 ratio, and in general, the clinical status of the patient with ARDS.