Minimally Invasive Coronary Artery Revascularization During Current Pandemics, New Hope! - Our Experience in a Third World Country

Objective: Since the last decade, the notion of minimally invasive cardiac surgery (MICS) has gained worldwide rapid popularity. Bangladesh is not far from mastering this technique due to the increasing interest of both patients and surgeons. Meanwhile, during this COVID-19 era could it help patients, remains the main question. In this context, we have operated on a total of 523 patients from October 2020 to November 2021 including, 89 patients who were MICS and among them, 17 were coronary artery bypass grafting. Method(s): We have included all patients who underwent minimally invasive coronary artery surgery in our hospital from October 2020 to November 2021 irrespective of single (MIDCAB) / multi-vessel disease (MICAS) or combined valve replacement with coronary revascularization. Data were collected from the hospital database, telephone conversations, and direct clinic visits. All data were analyzed statistically and expressed in the form of tables. Result(s): In the last 14 months of pandemics we have operated on a total of 89 MICS patients, among them 10 were Minimally Invasive Direct Coronary Artery Bypass (MIDCAB), 6 were double or triple vessels coronary artery surgery (MICAS), 1 patient underwent upper-mini aortic valve replacement along with coronary revascularization. One of our patients needed re-exploration for chest wall bleeding on the same day. Mean ICU and hospital stay in our series were less than conventional revascularization. There was no in-hospital or 30 days' mortality in our series. Conclusion(s): Cardiac surgery these days is headed toward less invasive approaches with the aid of technology, advanced instruments, and pioneer's lead. But from our in-hospital results we conclude that by avoiding median sternotomy, these minimal invasive revascularization techniques can provide hope to the patients by alleviating symptoms with restored vascularity, reduced morbidity, preventing sudden cardiac death. Health costs reduction with shorter hospital and ICU stay are the added benefits.

A Cost-effective, Patient-facing Electronic Stethoscope For Telemedical Cardiac Auscultation

Introduction: The COVID19 pandemic spurred an unprecedented growth in telehealth utilization across medical specialties which challenged providers to adapt their standard history and physical protocols for the virtual realm. Heart failure clinicians could readily translate some aspects of physical examination such as jugular venous distention and lower extremity edema assessment over video incorporating bendopnea to gain additional information. However, objective data for clinicians to rely on and guide therapy was often missing. A myriad of technology is available to bridge this gap ranging from simple wearables to invasive hemodynamic monitors though come with varying price tags and avenues of accessibility. Objective(s): We sought to develop an affordable, patient-facing electronic stethoscope of comparable quality to those existing that could seamlessly integrate with any telemedicine platform for real-time or asynchronous clinician review. Method(s): A rigorous design process guided by clinician and patient input generated nearly 100 concepts stratified through a pugh decision matrix in reference to an existing product, the Eko Core, to decide on the most suitable design - the AusculBand. With the form factor of a wrist-band, the AusculBand encases a custom bell with a high fidelity microphone and unique circuitry to sit comfortably in the palm of a user's hand to facilitate self-auscultation over the chest wall for real-time clinician review via telemedicine. Recognizing cardiac sounds to fall between 20 Hz and 2000 Hz, frequency response testing was conducted to determine the cut-off frequency of the AusculBand. With knowledge of an industry standard signal-to-noise ratio of 10.31 dB, a simple comparative study was devised between our novel AusculBand and the commercial Eko Core. With each device, a single-user in replicative fashion collected cardiac signals from the chest wall and background noise from the bicep to generate signal-to-noise ratio readouts and compare overall sound quality. Result(s): In response to frequency testing, the AusculBand was found to attenuate frequencies higher than 1997 Hz when testing a signal that swept through a range of 0 to 3,000 Hz at a constant amplitude. This result was within 0.2% of the 2000 Hz upper-limit of cardiac sounds and surpassing our design input goal of <= 1%. Signal-to-noise ratio analysis revealed 27.29 dB for the AusculBand and 24.02 dB for the Eko Core each exceeding the industry standard of 10.31 dB. Head-to-head comparison revealed the AusculBand achieved nearly double the loudness of the Eko Core. The projected price of the AusculBand is $80. The Eko Core is currently marketed at $350. Conclusion(s): The AusculBand is a cost-effective, patient-facing electronic stethoscope that surpasses industry standards in signal-to-noise ratio and is readily adaptable to popular telemedicine platforms. Additional modification is underway to add a single-lead electrocardiogram to bolster the device as an all-in-one, affordable and accessible telemedicine tool for cardiac analysis.Copyright © 2022

Occlusive Explosion

Clinical Information Patient Initials or Identifier Number: A Relevant Clinical History and Physical Exam: 47yr old man, suffered a blast injury at the workplace after an O2 tank exploded while he was transferring liquid gas into a tank for welding purposes. The impact has caused him to temporary loss of consciousness. Upon awakening, he had severe chest pain associated with shortness of breath. On examination, superficial partial thickness injury on the chest wall, and lungs: reduced breath sound bi-basally, no murmur heard. BP:106/77mmHg, HR:100/min, SPO2 100% on HFM 15L/min. [Formula presented] [Formula presented] [Formula presented] Relevant Test Results Prior to Catheterization: Serial ECGs were done and showed dynamic changes in the anterior leads Bedside echo before invasive coronary angiograms shows mild LVSD, normal valves, and no pericardial effusion [Formula presented] [Formula presented] Relevant Catheterization Findings: Right radial approach 6F system Opitorque catheter for diagnostic angiogram LMS: smooth LAD: ATO mid LAD, DG1 prox ATO LCx: smooth RCA: smooth Impression: ATO to LAD and Diagonal 1 ( Dual ATO) [Formula presented] [Formula presented] [Formula presented] Interventional Management Procedural Step: Right radial coronary angiogram via 6F system EBU 3.0 engaged with good support Sion blue wired into LAD, export catheter delivered, and aspirated red thrombus Pre-dilated with Sapphire 3 SC 2.5x15mm @ 6-10ATM Flow established in LAD, however, decided to interrogate DG1 as it shows ATO BMW wired into the DG1 and pre-dilated with Sapphire 3 SC 2.0x15mm Noted nonflow limiting dissection and decided to stent DG1 with 2.25x34mm@12ATM, dissection sealed and TIMI III flow established Stented mid LAD with 2.5x30mm @12ATM just before LAD/DG1 bifurcation, then stented proximal LAD with 2.5x 26mm@ 12ATM. Post-dilated LAD with 2.75x15mm@ 14-20ATM TIMI II-III flow IV Tirofiban has been given a loading dose due to a high thrombus burden and sluggish flow [Formula presented] [Formula presented] [Formula presented] Conclusion(s): Myocardial infarction is a rare complication of blunt chest trauma. This case demonstrates how blast shock waves result in the dissection of the coronary vessel leading to total occlusion of the two vessels. It also promotes red thrombus within the coronary vessels. Percutaneous coronary intervention is the most suitable way to treat this condition. Intravascular imaging such as IVUS or OCT would be beneficial to demonstrate the physiology behind this MI and would also be helpful in planning and optimizing the lesions. Unfortunately, intravascular imaging was not used for this patient to reduce procedural time as he was treated during the height of the COVID pandemic.Copyright © 2023

Outcome of Long Term Ventilation (LTV) following remote initiation and monitoring in patients with Chronic Hypercapnic Respiratory Failure (CHRF) during the SARS-CoV-2 pandemic

Background: In the absence of LTV, CHRF leads to recurrent hospital admissions, poor quality of life and increased mortality. Anticipating a significant surge in SARS-CoV-2 our long term ventilation staff were redeployed to provide acute COVID service. NIV was considered as an aerosol generating procedure and due to lack of regular outpatient clinical activity, we implemented a remote LTV initiation and review service and have evaluated the clinical outcomes Method: Consecutive patients started on LTV over a 12 month period were included. Patient demographics, LTV indications, trial duration, remote review and clinical outcomes were evaluated Results: N=54, mean age;60+/-16, mean FEV1;45+/-24, mean BMI;39+/-18, males-54%. indications for LTV were OHS-56%, COPD-28%, NMD-7%, Chest wall disorders-6% and others (overlap syndromes and opioid induced)-3%. A third of patients needed supplemental oxygen therapy (2-4 lts/16-24 hours/day). The median (IQR) duration of LTV trial was 4.3 (1-5-4.5) months and mean (SD) NIV compliance was 5.5 (2.3) hours. Patients were regularly monitored remotely (via modem or telephone) due to clinical shielding advice and this prevented hospital admissions in 56% of patients. A significant improvement in pCO2 was noted (P -0.0009, mean pCO2 pre LTV: 9 +/- 2.85 v/s post LTV: 6.7 +/- 1.3, DELTA change 2.2 kpa, 95% CI: 1.2 -3.52). 9.3% had SARS-CoV-2 infection with all-cause mortality of 3.7% Conclusion(s): LTV can be initiated and monitored remotely & effectively. Adequate compliance and improvement of hypercapnia are key parameters of good outcome with LTV and remote monitoring may be cost effective.

Thoracic ultrasound.

Ultrasound is an imaging technique based on the interaction of ultrasound with biological tissues, generated and received by a probe and processed by an ultrasound scanner into a two-dimensional image. Available ultrasound equipment is not designed to study lung paren-chyma, which due to its physical characteristics completely reflects the ultrasound, generating an artefactual picture. However, the presence of pathological conditions affecting the pleura and parenchyma unveils the organ, allowing an accurate study of superficial pathological changes and finding application in the pathology of the chest wall, pleura, lung parenchyma and in the study of diaphragmatic dynamics, adapting itself to multiple clinical contexts. Technological evolution and miniaturization have undoubtedly helped the method to spread widely, also helped by the COVID-19 pandemic. Artificial intelligence technologies are currently being studied to improve the diagnostic yield by supporting operators in interpreting pathological pictures, but the production of images of good quality remains a limit.Copyright © by Associazione Italiana Pneumologi Ospeda-lieri - Italian Thoracic Society (AIPO - ITS).

Effects of pulmonary rehabilitation in post-COVID syndrome

Introduction: Significant portion of the patients manifest symptoms, like coughing, dyspnoea, fatigue, exercise intolerance, sleep disorders or neuropsychological symptoms in post-COVID condition. It has influence on patients' quality of life and workability. Pulmonary rehabilitation (PR) has favourable effect on the cardiovascular system, metabolism, respiratory and peripheral muscles, lung mechanics and psychological condition of the patient. Aim(s): Our aim was to assess the effectiveness of a post-COVID PR program in terms of the improvement of patients' functional condition and quality of life. Method(s): 50 patients were involved (female:male=26:24, age 55+/-12 years, BMI: 31+/-8 kg/m2) at the Department of Pulmonology, Semmelweis University, Budapest, Hungary. At the onset of the program we measured lung function, 6-minute walking distance (6MWD), chest wall expansion (CWE), lung function and quality of life (EQ5D and postCovid Functional Scale (PCFS). The post-COVID rehabilitation included controlled breathing techniques, chest wall mobilization, strengthening of respiratory and peripheral muscle, endurance training for cycle and treadmill, dietetic, psychological health assessment and counselling. Result(s): Rehabilitation resulted in improvement in 6MWD (496.16 (80-780) vs. 526.32 (328-744) m;p<0.05), CWE (39.4 (15.2-98.9) vs. 47.4 (20.1-100.5) cm;p<0.05) and quality of life (EQ5D, PCFS). Statistically significant improvement was detected in IVC and FVC. No side effect was observed related to the PR program. Conclusion(s): There is an urgent need of an available PR for patients who suffer from post-COVID pulmonary symptoms to avoid serious medical, social and economic complications and it is safe for the patients.

LARGE BILATERAL PNEUMATOCELES COMPLICATING COVID-19 RECOVERY

SESSION TITLE: Using Imaging for Diagnosis Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Pulmonary clinicians are all too familiar with the ground-glass and consolidative pulmonary opacities that are the hallmark of COVID-19 pneumonia on imaging. As the pandemic continues, we encounter an ever-growing list of complications of SARS-CoV-2 infection. Pneumatoceles are thin-walled, gas-filled spaces within the lungs that occur in association with pneumonia or chest trauma and typically resolve spontaneously1 but may rupture and cause pneumothorax2. Reports of pneumatoceles due to COVID-19 are uncommon. In this case report, I describe a patient who developed large bilateral pneumatoceles as a complication of COVID-19. CASE PRESENTATION: A 25-year-old male non-smoker with no significant past medical history presented with dyspnea after a lab-confirmed diagnosis of COVID-19 nine days prior. Initial chest radiograph showed multifocal bilateral airspace infiltrates consistent with COVID-19 pneumonia. He was admitted for management of acute hypoxic respiratory failure and treated with dexamethasone, remdesivir, and tocilizumab. He required heated high-flow nasal cannula oxygen up to 60 LPM but did not require CPAP or mechanical ventilation. On hospital day 5 he developed increasing tachypnea and exertional desaturation. CT pulmonary angiogram (CTPA) ruled-out pulmonary embolus but revealed progression of bilateral infiltrates and extensive pneumomediastinum with subcutaneous air in the neck and chest wall, and no clear evidence for pneumothorax. The patient discharged on day 12 with oxygen but returned 2 days later with new onset hemoptysis. CTPA on admission showed new bilateral pneumothoraces and he was transferred to a quaternary hospital for intensive care where bilateral chest tubes were placed. Repeat CT Chest after lung expansion revealed bilateral cystic areas within the lungs initially concerning for necrotizing infection. Bacterial and fungal cultures were negative. Despite resolution of the pneumothoraces and removal of chest tubes, he continued to experience hemoptysis and chest pain. CT Chest demonstrated enlargement of now clearly very large pneumatoceles with air-fluid levels. After conservative management and discharge, a 6-week surveillance CT showed significant decrease in the pneumatoceles but a new moderate-to-large right pneumothorax. Ultimately after 2 more admissions and 90 days since COVID-19 diagnosis, he underwent wedge resection and mechanical pleurodesis for definitive management of secondary pneumothoraces. DISCUSSION: A pneumatocele, especially when large and containing an air-fluid level, may mimic hydropneumothorax, empyema, or pulmonary abscess among other diagnoses. Failure to recognize a pneumatocele and differentiate it from other conditions could lead to inappropriate treatment and cause patient harm3. CONCLUSIONS: It is important to recognize pneumatoceles as a potential complication in the post COVID-19 setting to guide appropriate management. Reference #1: Quigley, M. J., & Fraser, R. S. (1988). Pulmonary pneumatocele: pathology and pathogenesis. AJR. American journal of roentgenology, 150(6), 1275–1277. https://doi.org/10.2214/ajr.150.6.1275 Reference #2: Odackal, J., Milinic, T., Amass, T., Chan, E. D., Hua, J., & Krefft, S. (2021). A 28-Year-Old Man With Chest Pain, Shortness of Breath, and Hemoptysis After Recovery From Coronavirus Disease 2019 Pneumonia. Chest, 159(1), e35–e38. https://doi.org/10.1016/j.chest.2020.07.096 Reference #3: Jamil A, Kasi A. Pneumatocele. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556146/ DISCLOSURES: Speaker/Speaker's Bureau relationship with Boehringer Ingelheim Please note: 2018 to present Added 04/01/2022 by Erin Peterson, value=Honoraria

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

IMPROVING COMPLIANCE WITH CONTINUOUS ANTERIOR CHEST COMPRESSION IN ARDS CAUSED BY COVID-19: A CASE SERIES

SESSION TITLE: Lessons Learned from Critical Care Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Local compression of the anterior chest wall (CACC) or abdomen has been shown to unexpectedly improve respiratory system compliance in patients with severe acute respiratory distress syndrome (ARDS). The mechanism is thought to be similar to prone positioning, causing a redistribution of transpulmonary pressures. Limited data exists regarding this topic, particularly as it applies to COVID-19. We describe two cases of improved compliance and oxygenation with CACC in individuals with COVID-19 related ARDS, including one with prior lung transplantation. CASE PRESENTATION: Case 1: The patient was an unvaccinated 79 year-old man diagnosed with COVID-19 on admission. One week later, he progressed to requiring CPAP therapy. He was intubated the following week. Prone ventilation was initially attempted, but this was discontinued due to hemodynamic instability. Despite neuromuscular blockade and lung-protective ventilation, the patient's respiratory mechanics continued to worsen. CACC was then initiated using a 10 lb sandbag on the upper thorax, resulting in improved compliance (8 to 11.4 mL/cmH2O) and driving pressure (30 to 21 cmH2O). While CACC allowed room to adjust PEEP, there was no significant change in oxygenation or paCO2. Case 2: The patient was a fully vaccinated 46 year-old man with a history of bilateral lung transplant for cystic fibrosis, who tested positive for COVID-19 and was treated with sotrovimab as an outpatient. Despite early treatment, the patient had worsening hypoxia necessitating admission, treatment with bilevel PAP therapy, and subsequent intubation. Prone ventilation was initiated, but discontinued after 1 day due to worsening hemodynamics and poor improvement. CACC was then employed using two 5 lb sandbags with an improvement in compliance (16.7 to 21.1 mL/cmH2O). There was also a significant improvement in oxygenation (P/F ratio 115 from 86) and a decrease in paCO2. Following this favorable response, prone positioning was resumed, demonstrating similar improvement in respiratory mechanics. DISCUSSION: These cases demonstrate improved respiratory mechanics with CACC, which may be due to a reduction in end-inspiratory over-distention. In the first case, CACC allowed for an increase in PEEP when prone ventilation was not tolerated. In the second case, it was a tool that directed clinicians to resume prone positioning, with favorable improvement in oxygenation. The decrease in paCO2 may signify improved V/Q matching and dead space ventilation. CONCLUSIONS: This case series illustrates CACC as a potential therapeutic and diagnostic tool for clinicians to make lung-protective ventilator adjustments in responders. Trials of CACC may improve compliance and oxygenation in these patients, and may indicate those who would benefit from further prone positioning. Additional investigation is needed to clarify the clinical role of CACC for the management of COVID-19 related ARDS. Reference #1: Marini JJ, Gattinoni L. Improving lung compliance by external compression of the chest wall. Crit Care. 2021;25(1):264. Published 2021 Jul 28. doi:10.1186/s13054-021-03700-8 DISCLOSURES: Speaker/Speaker's Bureau relationship with boehringer ingelheim Please note: $5001 - $20000 by Brad Bemiss, value=Travel and payment for lecture No relevant relationships by Anila Khan No relevant relationships by Rishi Mehta No relevant relationships by Jason Peng

CAVITATORY LUNG RHIZOPUS INFECTION IN RENAL TRANSPLANT RECIPIENT: RARE CASE REPORT

Introduction: Mucormycosis is a life threatening fungal infection commonly seen in diabetics and immunocompromised individuals. It is caused by one of the members of mucoraceae family which includes mucor, rhizopus, rhizomucor, absidia and others. Its prevalence has become more common in covid pandemic. Methods: We report a rare case of large cavitatory Rhizopus infection in a renal transplant recipient. Patient was initiated on antitubercular therapy for tubercular lymphadenitis two months prior to transplant. He was given rabbit ATG as induction agent and was on triple maintenance immunosuppression with tacrolimus/ mycophenolate mofetil/ steroids. Patient developed post transplant Diabetes mellitus. Four months post transplant he presented with cough, fever and left sided chest and shoulder pain for 10 days. Covid RT PCR was done twice and it came out to be negative. High Resolution Computed tomography Chest revealed thick walled cavity abutting the chest wall (10.3 x 7.1cm) in left upper lobe. Blood culture was sterile after five days of incubation. Serum Beta galactomannan was negative. He was empirically started on broad spectrum antibiotics and antifungals (oral voriconazole). He underwent bronchoscopy on day 4 of admission. As tuberculosis was a differential, gene expert, tubercular culture and AFB stain was obtained on Bronchoalveolar(BAL) fluid which all came out to be negative. Microbiological sample from BAL Fluid revealed growth of Rhizopus species. He was started on Liposomal amphotericin B. Since the cavitatory lesion occupied almost the entire left lung, surgical resection was offered to the patient to which patient refused. Results: He improved symptomatically after 10 days of Liposomal amphotericin B. Total of 10 weeks of Liposomal amphotericin B was given. Follow up CT after 40 days showed significant reduction in size of cavity to 7.5cm. A surprising complete resolution of the lung cavity was seen after 4 months. Conclusions: This case is one of the very few reported cases of invasive pulmonary rhizopus infections. It emphasizes how medical treatment alone can lead to complete resolution of such large cavitatory lesions without surgical intervention. No conflict of interest

Stepwise Validation Program for Developing the Algorithm for Chronic Cough with Remote e-stethoscope Platform RESP

RATIONALE: There has been a sustained interest in chronic cough, defined as 8 to 12 weeks of daily coughing (adults) or 4 weeks (children). The interest was initially driven by discrimination of cough based on etiology and response to therapy, and the proposed diagnosis of refractory chronic cough when other major etiologies have been excluded. Perhaps not coincidentally, the convergence of cough counting as a valid method of assessing response to therapy (necessary and sufficient) with the clinical development of first generation P2X3 inhibitors has led to the emergence of a number of patient-oriented devices that claim to count coughs. The emergence of “COVID cough” and “post COVID cough” have heightened the interest in cough. METHODS: The Strados Labs RESPTM has been validated to count coughs. Presented are three methods to count coughs in a continuous recording, in order of increased automation. Each validated method has been confirmed to be within +/- 10% of the true cough count for the gold standard recordings. Each method is validated using >6 patients (>48 hours) of continuous recordings. Number of coughs are annotated by trained professionals and are then reviewed by clinical professionals. This is the gold standard cough count. Cough Counting Methods:1.Multiple trained labelers listen to the recordings and agree on if a sound is a cough or not. The number of agreed upon coughs are added together to determine a total cough count. 2.A highly sensitive machine learning algorithm highlights samples that have a probable likelihood of a cough. Multiple trained labelers listen to recordings and agree if a cough or not. 3.Fully automated machine learning algorithm. RESULTS: In comparison with the gold standard, the highly sensitive method was (>98% sensitivity, and the fully automated machine learning algorithm is >90% specific and >90% accurate and reports the number of coughs. CONCLUSIONS: The process shown here is both necessary and sufficient to validate cough data collection using the RESP. However, unlike other approaches, the RESP provides significant quantitative and qualitative data beyond counting coughs. The RESP provides spectrograms and chest wall motion as well as archival recordings so that parsing coughs into single, multiple and spasms can be reclassified as the data set and science expand. Cough architecture can be evaluated to differentiate intrathoracic from extra-thoracic cough, cough onset in inspiration versus expiration, and response to therapy in real time and with increased anatomic certainty.

RESPIRATORY DISTRESS IN A NEONATE - WHEN BOARDS MEET REAL LIFE

Case Report A male infant is born at 37w to a 34-year-old G3P2 mother by vaginal delivery after an uncomplicated pregnancy. Prenatal screens are negative. The patient had a birth weight of 2,620 g, with Apgar scores of 9 and 9. On day 2 after birth, had increased work of breathing which prompted transfer to a level II NICU for further management. On arrival to the unit, the infant is tachypneic with mild chest wall retractions and thick nasal secretions. A CBC and blood culture were collected and empiric antibiotic therapy was started. Respiratory viral panel and COVID test are negative. A chest radiograph shows a middle lobe opacity concerning for pneumonia (figure 1). His clinical status failed to improve and on day 4 after birth, supplemental oxygen was provided. The primary team consulted ENT and Pulmonology services. Flexible laryngoscopy showed a normal anatomy. Pulmonology recommended transferring to our NICU for a chest CT with bronchoscopy. Our differential diagnosis for this neonate with respiratory distress that fails to improve over time or with antibiotics was broad, but further testing revealed this infant's condition. A CBC, CRP and a blood gas were collected on admission and were normal. ID service was consulted. A Chest CT showed bilateral atelectasis. Bronchoscopy showed a normal anatomy. Bronchoalveolar lavage was sent. Umbilicus swab was positive for MRSA, nasal wash/sputum culture/bronchoalveolar fluid also grew moderate S. aureus. Nasal ciliary biopsy sent for electron microscopy. Positive umbilicus and nasal swab, and subsequently BAL for MRSA led to a diagnosis of MRSA neonatal rhinitis. Therapy with IV vancomycin was initiated and later changed to oral clindamycin to complete a total of 14 days of therapy. The neonate was weaned off oxygen support on day 11. His clinical symptoms improved. He was discharged on oral clindamycin with follow up appointments with pulmonology and ID clinics. His ciliary biopsy showed absence of outer and inner dynein arms, compatible with the diagnosis of primary ciliary dyskinesia (PCD) (figure 2). Genetic testing for PCD showed mutations in the DNAAF1 and CCDC40 genes. This neonate was diagnosed with primary ciliary dyskinesia (PCD) but his presentation at birth was nonspecific and the differential diagnosis was broad. There is no gold standard diagnostic test for PCD and high clinical suspicion is important. Since it is most likely an AR inheritance, screening of family members is essential. Initial management of neonates may include measures that manage the respiratory distress, airway clearance to prevent respiratory infections and treat bacterial infections. Chest physiotherapy may help if recurrent atelectasis. Flexible bronchoscopy and bronchoalveolar lavage may help both to diagnose and treat the underlying infection. Antibiotic therapy based on organism growth for exacerbations may prevent development of bronchiectasis. (Figure Presented).

Impact of chest wall perforator flap reconstruction on mastectomy in breast cancer

Introduction: Breast conserving surgery (BCS) has comparable or superior oncological safety when compared to mastectomy and is associated with improved cosmetic and psychological outcome. Previously patients with larger tumour to breast ratios were not suitable for BCS due to poor aesthetic outcomes and hence underwent total mastectomy with or without reconstruction. With the introduction of chest wall perforator flaps (CWPF), a significant proportion of these women who would have otherwise undergone mastectomy, can now qualify for BCS along with volume replacement. The objective of our study was to find out the impact of CWPFs on mastectomy and reconstruction. Methods: All patients who underwent surgery for breast cancer from January 2016 to December 2019 were included in the study to know the impact of CWPF on rates of mastectomy and other procedures. We excluded 2020-21 due to alterations in breast cancer treatment due to COVID-19 pandemic. The study was registered and approved by the local Clinical Governance department at the University Hospitals of North Midlands NHS Trust (CA12119). Results: Following the introduction of CWPF reconstruction, the mastectomy rate (including reconstruction) dropped by 10.69% (from 215 mastectomies in 2016 to 192 in 2019) and the mastectomy with reconstruction rate dropped by 23.29% (from 73 in 2016 to 56 in 2019). This change can be attributed to the use of CWPFs (from 1 in 2016 to 51 in 2019). Conclusion: CWPF reconstruction has reduced the rates of mastectomy +/- reconstruction and can potentially improve overall patient outcome.

Effects of anterior external chest wall compression on respiratory mechanics and gas exchange in COVID-19 ARDS patients

Introduction: Beneficial effects of prone position on outcome in ARDS may be related to decreased anterior chest wall compliance, which facilitates lung recruitment. The effects of anterior external chest wall compression (AEC) in supine position on respiratory mechanics and gas exchange are less well known [1]. We aimed to evaluate the effects of AEC in invasively ventilated COVID-19 patients. Methods: In 10 sedated and paralyzed COVID-19 patients ventilated in volume control mode, airway and esophageal pressures, driving pressure (DP) and lung compliance (Clung) were recorded before (baseline) and during (5 kg, 10 kg) AEC (10-min epochs). AEC was performed by placing one or two 5 l fluid bags on anterior chest. Repeated arterial blood gas analysis was available in 6 patients. Results: Patients' (9/1 M/F, age 65 [range 53-74] yrs, BMI 29.2 [range 23.2-50.5] kg/m2, PEEP median 11.8 (IQR 9.7-13.9) cmH2O), Clung at baseline (median 21.3;IQR 15.0-32.6 ml/cmH2O) increased > 10% with 5 kg AEC (mean 20.7 ± 7.3%, max. increase 30.9%) and additionally increased with 5.9% (range -2.9-19.3%) with 10 kg AEC (Fig. 1a, p < 0.001). Better response was related to an anteriorly located baby lung on CT imaging. At baseline, median transpulmonary DP (Pl DP) was 17.46 (IQR 11.50-25.07) cmH2O and decreased with 16.2 ± 4.9% and 20.6 ± 8.2% during 5 kg and 10 kg AEC, respectively (Fig. 1b, p < 0.001). pCO2 decreased in 4 patients and remained equal in 2 patients (Fig. 1c). The latter group also had minimal change in Pl DP and Clung. In all patients PO2 decreased with need for increasing FiO2. Median P/F ratio of 124 (IQR 104-143) mmHg at baseline decreased to 105 (IQR 92-124) mmHg and 86 (IQR 78-114) mmHg during 5 kg and 10 kg AEC respectively. Conclusions: This preliminary data demonstrates improved compliance of the aeriated lung by decreasing hyperinflation. No evidence for recruitment was found in contrast to existing literature showing improved oxygenation [2]. (Table Presented).

Post-COVID-19 optoelectronic plethysmography findings: Inspiratory muscle weakness linked to impaired breathing pattern

PURPOSE/HYPOTHESIS: Altered breathing patterns have been reported after SARS-CoV-2 infection, but it is unclear if they result from changes in chest wall kinematics, inspiratory muscle weakness, or both. Lung volumes can be estimated through chest wall motion via optoelectronic plethysmography (OEP). We hypothesized that poor inspiratory muscle performance would relate to impaired quiet breathing pattern as assessed by OEP in adults post COVID-19 infection. NUMBER OF SUBJECTS: 20. MATERIALS AND METHODS: A convenience sample of 20 subjects recovered from RT-PCR-confirmed COVID-19 (mean ± SD age = 52.45 ± 11.93 years and BMI = 30.89 ± 6.48 kg/m2) with no overt pulmonary disease underwent measures of maximal inspiratory pressure (MIP) using a digital manometer followed by OEP analysis to evaluate chest wall motion and its compartments during quiet breathing. All OEP data were collected with subjects in a seated position and with arms supported laterally. Eighty-nine reflective markers were distributed on the anterior surface, side and back of the participants' trunks, who were instructed to breathe normally for three minutes while the system was operated. The displacement of markers during the requested spontaneous quiet breathing was picked up by six synchronized cameras that recorded their coordinates, from which lung volumes were later estimated using algorithms. Statistical analyses included normality tests, descriptive statistics, Pearson's correlation and independent samples t-tests. RESULTS: The mean ± SD MIP and tidal volume (VT) of the sample were 82.15 ± 34.32 cmH2O and 369 ± 216.31 ml, respectively. 65% of the participants were below their predicted values for VT, and 70% had lower than predicted MIP values. MIP was significantly and positively associated with VT (r = 0.40, P=0.04), while a negative relationship was found between MIP and the percentage contribution of abdominal rib cage motion to VT (r=- 0.45, P=0.02). No further correlation was observed between MIP and other OEP variables. Additionally, subjects classified as having normal inspiratory muscle function (i.e. MIP > 80 cmH2O) had significantly greater VT when compared to those presenting with inspiratory muscle weakness (450.64 ± 262.57 versus 269.22 ± 67.67 ml, respectively;P = 0.04). CONCLUSIONS: The variability of post COVID-19 ventilatory impairment requires a complex screening process. In our sample, most subjects presented with lower than predicted VT and MIP. Moreover, a significant association existed between inspiratory muscle dysfunction and reduced tidal volume. Changes in abdominal rib cage motion were also observed and likely occurred to compensate for a less efficient diaphragm even during normal, regular breathing. CLINICAL RELEVANCE: Subjects recovering from COVID-19 may present with diaphragm myopathy and impairment, highlighting the need to screen for inspiratory muscle weakness which may help identify altered breathing patterns and guide management such as inspiratory muscle training to mitigate persistent symptoms related to abnormal ventilation.

Discussing results and breaking bad news in breast video consultations: A pilot questionnaire

Aim: Virtual consultations (VC) in Breast Surgery have become wellestablished during the COVID pandemic. They are successfully utilised in routine follow ups and low-risk new referrals. We aimed to assess the utility of VC in more complex clinical discussions. Methods: We collected feedback anonymously via electronic link from 20 consecutive patients who specifically had more challenging video- VC including: 12 diagnostic MDT results (10 patients received bad news of new cancer diagnosis, 2 had benign results);6 post-operative wound checks with therapeutic MDT outcomes;2 new consultations for chest wall reconstruction. Results: The time saved by patients was between 1 and 3 hours (median=2). All patients felt that booking and joining a VC was either very easy (12) or easy (8). 18 patients were satisfied with the quality of sound and picture and all 18 felt they were able to communicate everything to the clinician during their VCs. Compared to a face-to-face consultation, 14 patients felt that VC was better (70%), 4 felt it was similar (20%) and 2 thought it was worse (10%). Most received comments were themed around VC had allowed patients to get their results, discuss their management plans and ask questions while they were safely at home with other family members, at times when COVID restrictions applied to outpatient clinical settings. Conclusion: VC may be utilised selectively to provide complex consultations including discussing results, breaking bad news and wound inspections. Qualitative studies in this field can be beneficial.

A case report: Necrotising leukocytoclastic vasculitis (NLV) of the breast mimicking necrotising fasciitis (NF)

Leukocytoclastic vasculitis (LV) is an inflammation of the small vessels in the dermis characterised by the deposition of immunocomplexes in the involved vessel walls. It commonly manifests as palpable purpura, limited to the skin and predominantly of the lower limb. We report a rare case of necrotising LV (NLV) affecting bilateral breast, manifesting clinical features of necrotising fasciitis (NF), and emphasizes the potential diagnostic challenges that markedly influence the treatment and survival of patients. A 48-year-old female presented with an acute onset left breast skin necrosis and discolouration that rapidly progressed to the contralateral breast with surrounding erythema and oedema of the chest wall yet spared the intermammary cleft. Some non-blanching purpuric rash were also noted on upper abdomen and left lower limb. COVID-19 test was negative. CT scan showed extensive bilateral breast fat stranding and oedema. Patient became clinically septic with a moderately raised CRP and mild acute kidney injury. Radical mastectomies and chest wall excision were performed with intra-operative findings of cloudy fluid and easily peeled away subcutaneous tissue from fascia. Urgent gram stain and culture showed no organisms. Tissue biopsies subsequently showed the diagnosis of NLV. Chest wall defect was then reconstructed with split skin grafts, NLV treated with corticosteroids and patient made an uneventful recovery. This case highlights the incidence of a rare and aggressive manifestation of NLV on the breast that mimics NF, emphasizing the clinical differentiation that may lead to catastrophic results and significant cosmetic defect, if a differential diagnosis cannot be determined at the time.