Your browser doesn't support javascript.
Show: 20 | 50 | 100
Results 1 - 20 de 98
Filter
1.
Can J Respir Ther ; 58: 151-154, 2022.
Article in English | MEDLINE | ID: covidwho-2091556

ABSTRACT

Introduction: The use of high-flow nasal oxygen (HFNO) is a simple method that can reduce intubation in patients with hypoxemic acute respiratory failure (ARF). Early and prolonged prone position has demonstrated benefits on mortality in mechanically ventilated patients and on intubation in awake patients with ARF. However, strategies to achieve adherence to awake prone positioning (APP) have not been previously described. Case and outcomes: We present six patients with ARF due to COVID-19 treated with HFNO and APP. The median (p25-75) of PaFiO2 upon admission was 121 (112-175). The average duration of APP on the first day was 16 h (SD 5 h). Duration (median p25-75) in APP for the following 20 days was 13 (10-18) h/day. Several strategies such as the presence of a health care team, recreational activities, adaptation of the circadian rhythm, oral nutritional support, and analgesics were used to improve prone tolerance. None of the patients suffered from delirium, all were ambulating on discharge from the ICU and none require intubation. Conclusion: The case series presented show the feasibility of prolonged use of HFNO and APP in patients with COVID-19 and severe persistent hypoxemia and described strategies to enhance adherence.

2.
Ann Thorac Med ; 17(4): 214-219, 2022.
Article in English | MEDLINE | ID: covidwho-2080627

ABSTRACT

CONTEXT: Early use of a high-flow nasal cannula (HFNC) provides positive outcomes for preventing the risk of intubation. However, the efficiency and usage of HFNC in the case of coronavirus disease 2019 (COVID-19) among adult patients with multiple risk factors remain debatable and require more investigation. AIMS: The aim of this study was to determine the efficiency of HFNC in preventing the possible risk of intubation. SETTINGS AND DESIGN: This study was an observational cross-sectional study that was conducted at a selected hospital in Jeddah, Saudi Arabia, from July 2020 to August 2021. METHODS: The data were collected from patients' medical records through the hospital health information system. Adult COVID-19 patients who used HFNC were included, while those who used bilevel positive airway pressure or continuous positive airway pressure without any trials of HFNC and neonatal or pediatric patients were excluded. The exposure of HFNC setting which included variables such as percentages of the fraction of inspired oxygen and the duration of using HFNC were measured to find the relation with respiratory rate oxygenation (ROX) index as a measurement of patient outcome. STATISTICAL ANALYSIS USED: The data were analyzed by using the online calculator socscistatistics. com for prevalence statistics, and correlation tests of significance. Prevalence statistics were presented in mean, median, frequencies, and percentages. Statistical tests were used to measure correlations of key variables. P < 0.05 of ANOVA and t-tests was considered statistically significant. RESULTS: A total of 159 adult COVID-19 patients using HFNC were included, and most of these patients were male. The median age was 64 years. Most of patients were reported to have hypertension and diabetes mellitus. The majority (94.34%) of patients were successfully weaned from HFNC and shows effective intervention with a mean of 7.53 of ROX score. Appropriate implementation of HFNC might be a successful intervention for preventing the risk of intubation. CONCLUSIONS: According to the success rate of HFNC, which was considered a positive outcome, there might be a promising intervention for HFNC to prevent the risk of intubation and decrease the mortality rate.

3.
Indian Journal of Critical Care Medicine ; 26(10):1120-1125, 2022.
Article in English | EMBASE | ID: covidwho-2067000

ABSTRACT

Aims and objectives: In coronavirus disease-2019 (COVID-19) pneumonia, guidelines on timing and method of tracheostomy are evolving. The aim of the study was to analyze the outcomes of moderate-to-severe COVID-19 pneumonia patients who required tracheostomy and the safety with regard to the risk of transmission to the healthcare workers. Material(s) and Method(s): We retrospectively analyzed 30-day survival outcome of a total of 70 moderate-to-severe COVID-19 pneumonia patients on a ventilator, wherein tracheostomy was performed only in 28 (tracheostomy group), and the remaining were with endotracheal intubation beyond 7 days (non-tracheostomy group). Besides demographics, comorbidities, and clinical data including 30-day survival, and complications of tracheostomy were analyzed in both groups with respect to the timing of tracheostomy from the day of intubation. Healthcare workers were monitored for COVID-19 symptoms by carrying out periodical COVID tests. Result(s): The 30-day survival of the tracheostomy group was 75% as compared to 26.2% of the non-tracheostomy group. The majority of the patients (71.4%) had severe disease with PaO2/FiO2 (P/F ratio) <100. The first wave showed an 80% (4/5) whiles the second wave 100% (8/8) thirty days survival in the tracheostomy group performed before 13 days. All patients during the second wave underwent tracheostomy before 13 days with a median of 12th day from the day of intubation. These tracheostomies were performed percutaneous at the bedside, without any major complications and no transmission of disease to healthcare workers. Conclusion(s): Early percutaneous tracheostomy within 13 days of intubation demonstrated a good 30-day survival rate in severe COVID-19 pneumonia patients. Copyright © The Author(s). 2022.

4.
Crit Care ; 26(1): 70, 2022 03 24.
Article in English | MEDLINE | ID: covidwho-2064832

ABSTRACT

BACKGROUND: Excessive inspiratory effort could translate into self-inflicted lung injury, thus worsening clinical outcomes of spontaneously breathing patients with acute respiratory failure (ARF). Although esophageal manometry is a reliable method to estimate the magnitude of inspiratory effort, procedural issues significantly limit its use in daily clinical practice. The aim of this study is to describe the correlation between esophageal pressure swings (ΔPes) and nasal (ΔPnos) as a potential measure of inspiratory effort in spontaneously breathing patients with de novo ARF. METHODS: From January 1, 2021, to September 1, 2021, 61 consecutive patients with ARF (83.6% related to COVID-19) admitted to the Respiratory Intensive Care Unit (RICU) of the University Hospital of Modena (Italy) and candidate to escalation of non-invasive respiratory support (NRS) were enrolled. Clinical features and tidal changes in esophageal and nasal pressure were recorded on admission and 24 h after starting NRS. Correlation between ΔPes and ΔPnos served as primary outcome. The effect of ΔPnos measurements on respiratory rate and ΔPes was also assessed. RESULTS: ΔPes and ΔPnos were strongly correlated at admission (R2 = 0.88, p < 0.001) and 24 h apart (R2 = 0.94, p < 0.001). The nasal plug insertion and the mouth closure required for ΔPnos measurement did not result in significant change of respiratory rate and ΔPes. The correlation between measures at 24 h remained significant even after splitting the study population according to the type of NRS (high-flow nasal cannulas [R2 = 0.79, p < 0.001] or non-invasive ventilation [R2 = 0.95, p < 0.001]). CONCLUSIONS: In a cohort of patients with ARF, nasal pressure swings did not alter respiratory mechanics in the short term and were highly correlated with esophageal pressure swings during spontaneous tidal breathing. ΔPnos might warrant further investigation as a measure of inspiratory effort in patients with ARF. TRIAL REGISTRATION: NCT03826797 . Registered October 2016.


Subject(s)
COVID-19 , Noninvasive Ventilation , Respiratory Distress Syndrome , Respiratory Insufficiency , Humans , Respiration, Artificial/methods , Respiratory Insufficiency/therapy
5.
Otolaryngology - Head and Neck Surgery ; 167(1 Supplement):P74-P75, 2022.
Article in English | EMBASE | ID: covidwho-2064505

ABSTRACT

Introduction: The purpose of this study is to evaluate longterm laryngotracheal outcomes in patients who required 10 or more days of invasive mechanical ventilation (IMV) for COVID-19. Method(s): This is a prospective cohort study of patients previously hospitalized for active COVID-19 infection between January 2020 and March 2021 who required intubation for 10+ days. Subjects who met criteria were enrolled at an outpatient laryngology clinic, where they underwent a clinical evaluation with head and neck exam, nasolaryngoscopy, and patient-reported outcome measures (Voice Handicap Index, EAT-10). Medical history was collected through electronic medical record review. Result(s): In total, 166 patients met criteria based on chart review. Of these patients, 31 (18.6%) were deceased since discharge. Enrolled subjects included 16 patients, 2 women and 14 men, with mean (SD) age of 57.4 (14.12) years. The mean duration (SD) of IMV was 36.8 (21.8) days. Fourteen of 16 patients underwent tracheostomy for prolonged endotracheal intubation. The mean time (SD) from hospital admission to intubation was 2.7 (3.2) days, intubation to tracheostomy or extubation was 13.9 (5.3) days, and tracheostomy to decannulation was 38.1 (22.6) days. Conclusion(s): Patients who required prolonged mechanical ventilation to treat COVID acute respiratory distress syndrome demonstrated significant laryngeal or tracheal pathology during laryngoscopy at 1-year follow-up, though subjectively, their self-reported voice and swallowing deficits were mild.

6.
Otolaryngology - Head and Neck Surgery ; 167(1 Supplement):P67, 2022.
Article in English | EMBASE | ID: covidwho-2064480

ABSTRACT

Introduction: Tracheostomy is often performed in patients with a prolonged course of endotracheal intubation to minimize sedation, facilitate ventilator weaning, or to address other clinical complexities. However, the clinical benefit of tracheostomy during severe COVID-19 infection is not fully understood. Method(s): A retrospective single-system, multicenter observational cohort study was performed on patients intubated in the setting of COVID-19 infection in the University of Pennsylvania Health System during 2020 and 2021. Patients who received intubation alone were compared with patients who received intubation and subsequent tracheostomy. Data analyses included patient demographics, comorbidities, and hospital course. Result(s): Of 777 patients, 452 were male (58.2%) and 325 were female (41.8%) with a mean age of 62.2+/-15.4 years. A total of 185 (23.8%) patients underwent tracheostomy, and the mean time from endotracheal intubation to tracheostomy was 17.3+/-9.7 days. Medical comorbidities were associated with undergoing tracheostomy, including immunocompromise (odds ratio [OR]=5.2;P<.0001), current smoker (OR=3.3;P=.0034), cardiovascular disease (OR=2.2;P<.0001), and diabetes mellitus (OR=1.5;P=.0344). Tracheostomy was associated with a significantly longer hospital length of stay (57.5+/-32.2 days vs 19.9+/-18.1 days;P<.0001). However, patients who underwent tracheostomy were significantly less likely to expire during their hospitalization than those who did not undergo tracheostomy (OR=2.79;P<.0001). Conclusion(s): The difference in in-hospital mortality between COVID-19 patients who received intubation and those who received both intubation and tracheostomy suggests an association between tracheostomy and improved outcomes in the setting of severe COVID-19 infection.

7.
Chest ; 162(4):A2099, 2022.
Article in English | EMBASE | ID: covidwho-2060898

ABSTRACT

SESSION TITLE: Pulmonary Procedures: Creativity and Complications SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Recent advances in the management of airway disorders have provided additional therapeutic options for pathology, such as central airway obstruction (CAO). Symptomatic CAO has been managed by bronchoscopic interventions with a high risk of airway compromise and respiratory failure. Other alternatives such as mechanical and jet ventilation may not ensure adequate respiratory support during the procedure and cause delays in life-saving treatments. Venovenous extracorporeal membrane oxygenation (VV ECMO) has been used as an adjunct to preserve safety during these airway interventions [1,2]. We present a case of complete tracheal occlusion successfully intervened using VV ECMO support. CASE PRESENTATION: The patient is a 55-year-old male with a history of ventilator-dependent respiratory failure s/p tracheostomy, secondary to post COVID-19 fibrosis, who presented from a long-term acute care facility with worsening hypoxemia. The patient was transferred to the intensive care unit, where he underwent flexible bronchoscopy via the tracheostomy lumen, which did not reveal a patent airway. Orotracheal intubation was unsuccessful as there was complete occlusion of the airway below the vocal cords with abundant granulation tissue. Interventional pulmonology was consulted, and emergent recanalization of the airway with rigid bronchoscopy-mediated debulking was performed. Due to the severity of hypoxemia, cardiothoracic surgery was consulted, and the patient was placed on VV ECMO to support further intervention. The patient was intubated with EFER-DUMON 13 mm rigid bronchoscope. Complete recanalization was achieved using a rigid barrel and forceps with patency of both mainstems and all segmental bronchi. There were no postprocedural complications, and the patient returned to his baseline ventilator settings. DISCUSSION: VV ECMO has been used as an adjunct to preserve safety during high-risk bronchoscopic interventions, primarily in CAO. Acute respiratory decompensation remains a feared complication during these interventions in cases of CAO. Initiating ECMO before these interventions may reduce the incidence of respiratory failure and airway compromise. In a case series, ECMO has been described by Stokes et al. as a supportive measure facilitating such interventions [3]. Further guidelines are required to standardize ECMO initiation as procedural support during airway interventions. CONCLUSIONS: Planned preprocedural ECMO initiation can prevent respiratory emergencies and allow therapeutic high-risk airway interventions. The choices for this patient were stark- either airway recanalization without ECMO bridge with a risk of hypoxic brain injury vs. VV ECMO support and curative airway intervention. In the absence of large-scale data and based on local availability of excellent ECMO support and Interventional Pulmonology, the latter approach was used, leading to successful and safe airway recanalization. Reference #1: Zapol WM, Wilson R, Hales C, Fish D, Castorena G, Hilgenberg A et al.Venovenous bypass with a membrane lung to support bilateral lung lavage. JAMA 1984;251:3269–71. Reference #2: Fung R, Stellios J, Bannon PG, Ananda A, Forrest P. Elective use of venovenous extracorporeal membrane oxygenation and high-flow nasal oxygen for resection of subtotal malignant distal airway obstruction. Anaesth Intensive Care 2017;45:88–91. Reference #3: Stokes JW, Katsis JM, Gannon WD, Rice TW, Lentz RJ, Rickman OB, Avasarala SK, Benson C, Bacchetta M, Maldonado F. Venovenous extracorporeal membrane oxygenation during high-risk airway interventions. Interact Cardiovasc Thorac Surg. 2021 Nov 22;33(6):913-920. doi: 10.1093/icvts/ivab195. PMID: 34293146;PMCID: PMC8632782 DISCLOSURES: No relevant relationships by Vatsal Khanna No relevant relationships by Anurag Mehrotra No relevant relationships by Trishya Reddy No relevant relationships by Bernadette Schmidt

8.
Chest ; 162(4):A1810, 2022.
Article in English | EMBASE | ID: covidwho-2060868

ABSTRACT

SESSION TITLE: Diagnosis of Lung Disease through Pathology Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Idiopathic pulmonary hemosiderosis (IPH) is a rare pulmonary disease often resulting in diffuse pulmonary fibrosis. The majority of diagnoses present in infanthood with limited studies demonstrating late onset disease in patients older than 30 years. The mainstay of treatment is immunosuppressive therapy including systemic corticosteroids. Here we present a unique case of IPH in an unvaccinated individual with COVID-19 pneumonia. CASE PRESENTATION: Our patient was a 31 year-old male with a history of IPH diagnosed in early childhood with past hospitalizations for DAH and progressive pulmonary fibrosis for which he was treated with corticosteroids and cyclophosphamide years prior to this admission. He presented with six days of progressive shortness of breath and respiratory distress. He tested positive for COVID-19 four days prior to presentation. He was unvaccinated for COVID-19. Initial oxygen saturation was found to be 56% and non-invasive mechanical ventilation was started. CT angiography of the chest revealed diffuse ground glass opacities, bilateral consolidative changes, and redemonstration of pulmonary fibrosis with extensive honeycombing. Lab results were remarkable for elevated inflammatory enzymes including ferritin 1,335 ng/mL, lactate dehydrogenase 1,369 units/L, and C-reactive protein 6.5 ml/dL. Patient was started on intravenous glucocorticoids, IL-6 inhibitor, remdesivir. Work up for bacterial superinfection was unremarkable. His hospitalization was complicated by acute kidney injury, elevated liver enzymes, and anxiety. Despite the immunosuppressive therapy, the patient continued to have refractory hypoxemia. Due to his persistent hypoxemia, the family was contacted regarding the impending need for endotracheal intubation. They ultimately declined and the patient succumbed to his respiratory failure. DISCUSSION: Idiopathic pulmonary hemosiderosis remains to be a largely unstudied and rare disease with catastrophic respiratory sequela. There remains a scarcity of evidence surrounding the most effective treatment of these patients, although limited studies have shown mortality benefit with immunosuppressive therapy. In patients with IPH an insult such as COVID-19 infection could prove fatal. Preventative measures such as vaccination is vital in the protection of these patients. Further research regarding pathogenesis and treatment mechanisms for IPH is an aim of future study. CONCLUSIONS: Idiopathic Pulmonary Hemosiderosis is a rare but deadly disease often complicated by diffuse alveolar hemorrhage and pulmonary fibrosis. Considering the underlying pulmonary compromise in these patients, secondary insult from infection can have catastrophic outcomes. Reference #1: Saha B. K. (2021). Idiopathic pulmonary hemosiderosis: A state of the art review. Respiratory medicine, 176, 106234. https://doi.org/10.1016/j.rmed.2020.106234 Reference #2: Ioachimescu, O. C., Sieber, S., & Kotch, A. (2004). Idiopathic pulmonary haemosiderosis revisited. The European respiratory journal, 24(1), 162–170. https://doi.org/10.1183/09031936.04.00116302 Reference #3: Thornton, G. & Alotaibi, M. (2016). 979: IDIOPATHIC PULMONARY HEMOSIDEROSIS IN ADULT PATIENTS: AN EPIDEMIOLOGIC ANALYSIS. Critical Care Medicine, 44 (12), 321-321. doi: 10.1097/01.ccm.0000509655.03624.6e. DISCLOSURES: No relevant relationships by Allison Kunze No relevant relationships by Mohammed Siddiqui

9.
Chest ; 162(4):A995, 2022.
Article in English | EMBASE | ID: covidwho-2060746

ABSTRACT

SESSION TITLE: Hot Topics in Critical Care SESSION TYPE: Original Investigations PRESENTED ON: 10/18/2022 02:45 pm - 03:45 pm PURPOSE: Recent data from the national American Heart Association Get with the Guidelines Resuscitation registry suggests substantial hospital-to-hospital variation in airway management during in-hospital cardiac arrest (IHCA), with most patients undergoing endotracheal intubation. Less than 5% of IHCA patients receive a supraglottic airway (SGA). Over the past several years, SGAs have been studied extensively in out-of-hospital cardiac arrests (OHCA) with promising results and are widely used in the OHCA setting. In this study, we describe factors and airway characteristics at a center encouraging either SGA or endotracheal intubation (ETI) for IHCA advanced airway management. METHODS: We performed a retrospective observational study examining all cardiac arrests occurring at a multi-campus academic medical center between August 3, 2020 to July 11, 2021. Locations studied included general medical wards, telemetry units, and intensive care units (both medical and specialty ICUs, such as surgical or cardiac). Patients were excluded if they possessed an invasive airway at time of arrest, suffered an arrest in the ED or procedural areas (e.g., operating room, catheterization lab), or were SARS-CoV-2 positive. Of note, SGAs were not specifically discouraged during the COVID-19 pandemic at this institution. We compared patient, arrest, and airway characteristics between the SGA and endotracheal intubation (ETI) groups using t-tests or Fisher’s exact tests where appropriate. Given risk for confounding by indication, we did not compare patient outcomes between groups. RESULTS: A total of 97 patients were included in the study, of whom 82 (84.5%) received an advanced airway during cardiopulmonary resuscitation. Of these the initial airway was ETI in 46 (56.1%) arrests and SGA in 36 (43.9%) arrests. As compared to SGA, patients receiving ETI were younger (66.1 [±2.0] vs. 71.2 [±2.1], p=0.08), more likely to be obese (11.0% vs. 5.6%), and more likely to have pre-existing lung conditions (19.6% vs 11.1%)—although no difference reached the a priori defined α<0.5 level of significance. Other hypothesized differences were not as extreme including for body mass index (28.3 [±1.4] vs. 28.4 [±1.6]) and respiratory cause of arrest (34.8% vs. 47.2%). First pass success rate was 84.8% for ETI. Complications of airway management were rare with one patient in each group suffering vomiting, one instance of oropharyngeal bleeding in the SGA group, and one pneumothorax in the ETI group. CONCLUSIONS: At a center using both SGA and ETI during IHCA response, patients who were younger, more obese, and more commonly had underlying lung disease tended to receive ETI—although these associations were not statistically significant. Complications of both advanced airway modalities were rare. CLINICAL IMPLICATIONS: DISCLOSURES: No relevant relationships by jonathan daich No relevant relationships by Alex Li No relevant relationships by Ari Moskowitz No relevant relationships by Aron Soleiman

10.
Chest ; 162(4):A963, 2022.
Article in English | EMBASE | ID: covidwho-2060742

ABSTRACT

SESSION TITLE: Post-COVID-19 Infection Complications SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) is the causative agent of coronavirus disease-2019 (COVID-19). Post-infectious encephalitis secondary to SARS-CoV-2 may present with delirium, seizures, or transient comatose state. The mechanism of encephalitis in patients with COVID-19 is multifactorial. Cytokine release syndrome, a systemic hyperinflammatory condition, might have an integral part in the pathophysiology of this manifestation. Beneficial effects of pulse dose glucocorticoid therapy, with and without plasma exchange or IVIG, have been described. (1, 2) In this case report, we disclose a case of a young healthy male that presented with acute encephalopathy after 10 days of contracting SARS-CoV-2 and aim to discuss the potential role of IVIG and pulse dose steroid. CASE PRESENTATION: A 37-year-old previously healthy Caucasian man initially presented to urgent care with fatigue and generalized weakness and was diagnosed with acute COVID-19 infection through positive PCR. Four days later, he developed shortness of breath, syncope and vomiting. He was taken to the ER, where he had a witnessed seizure complicated by status epilepticus requiring endotracheal intubation for airway protection. He was then airlifted to our University Hospital. Upon arrival, labs were notable for elevated troponin, leukocytosis, and mildly elevated liver enzymes. An echocardiogram revealed stress induced (Takotsubo) cardiomyopathy. CT head was normal and continuous EEG showed focal electrographic seizures of left temporal onset. MRI of brain with/without contrast showed subtle areas of cortical diffusion hyperintensity involving left cerebral hemisphere including left posterior temporal lobe, lateral occipital lobe, posterior lateral frontal lobe and posterior lateral parietal lobe with subtle patchy areas of cortical enhancement on postcontrast T1-weighted images. CSF analysis was benign and CSF PCR for SARS-CoV-2 was negative. One gram daily IV methylprednisolone and IVIG therapy was given for total 5 days. On Day 2 of therapy, seizures subsided, and patient was successfully extubated after. Repeat MRI brain with/without contrast done after day of therapy showed improvement in previously demonstrated findings. He improved clinically and was discharged home on hospitalization day. DISCUSSION: Post-infectious COVID-19 encephalitis falls under the spectrum of disease described under neurological syndromes related to SARS-CoV-2 infection.(3) Diagnosis is based on Clinical presentation, positive COVID PCR on nasopharyngeal swab and Imaging demonstrating cortical enhancement on post contrast T1-weighted imaging. Out of various treatment options described in literature (1,2), our patient responded well to pulse dose steroids and IVIG therapy for 5 days. CONCLUSIONS: Careful selection of patients and therapies should be considered when post-infectious COVID-19 encephalitis is suspected. Reference #1: Cao A, Rohaut B, Le Guennec L, et al. Severe COVID-19-related encephalitis can respond to immunotherapy. Brain. 2020;143(12):e102. doi:10.1093/brain/awaa337 Reference #2: Pugin D, Vargas MI, Thieffry C, et al. COVID-19-related encephalopathy responsive to high-dose glucocorticoids. Neurology. 2020;95(12):543-546. doi:10.1212/WNL.0000000000010354 Reference #3: Al-Ramadan A, Rabab'h O, Shah J, Gharaibeh A. Acute and Post-Acute Neurological Complications of COVID-19. Neurol Int. 2021;13(1):102-119. Published 2021 Mar 9. doi:10.3390/neurolint13010010 DISCLOSURES: No relevant relationships by Ali Ahmad No relevant relationships by Varun Halani No relevant relationships by Michael Lasky No relevant relationships by Posan Limbu

11.
Chest ; 162(4):A743, 2022.
Article in English | EMBASE | ID: covidwho-2060679

ABSTRACT

SESSION TITLE: Encounters with Mechanical Ventilation SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/17/2022 12:15 pm - 1:15 pm PURPOSE: Baseline radiographic edema on chest X-ray (CXR) in patients with COVID-19 presenting to the emergency department has been associated with need for hospital and intensive care unit (ICU) admission as well need for mechanical ventilation and 30-day mortality. Whether this is true for radiographic edema quantified after initiation of mechanical ventilation is unclear. We sought to evaluate this question using a well-validated scoring system (the Radiographic Assessment of Lung Edema [RALE] score) using data over 6 months from a large, multi-hospital healthcare system including all adult (age >= 18) patients. METHODS: We collected CXRs performed in patients after endotracheal intubation for COVID-19 associated hypoxemic respiratory failure between March and September 2020. We quantified severity of radiographic edema using the RALE score. Two independent reviewers quantified radiographic edema using the RALE scoring system. We examined the association of radiographic edema with time from hospital admission to intubation and 30-day mortality. RESULTS: 65 patients were identified (median age 68, 40% female). Inter-rate agreement for RALE score was excellent (ICC = 0.84, 95% CI 0.82 - 0.87, p < 0.0001). Mortality at 30 days was 54% (n = 35). There was no association between time to ICU admission from ED presentation (r = -0.14, p = 0.27). RALE scores were not different in survivors and non-survivors (8 [4-17] and 7 [5-15], p = 0.92 respectively). When adjusted for age and history of diabetes, there was no difference in 30-day mortality between the lowest and highest RALE quartiles (HR 0.67 [0.24 - 1.85], p = 0.44). CONCLUSIONS: In unvaccinated patients with COVID-19 hypoxemic respiratory failure requiring mechanical ventilation there is no association between baseline (time of intubation) radiographic edema as captured by CXR and 30-day mortality. Larger observational studies accounting for vaccination status, oxygenation strategies and medical therapy are needed. CLINICAL IMPLICATIONS: In small sample of unvaccinated patients requiring mechanical ventilation for COVID-19-associated hypoxemic respiratory failure, baseline radiographic edema on CXR does not provide prognostic value. DISCLOSURES: No relevant relationships by Samantha Gillenwater No relevant relationships by Christine Girard No relevant relationships by Anas Hadeh No relevant relationships by Andrew Kim No relevant relationships by Daniel Kotok No relevant relationships by Allen Lavina No relevant relationships by Jose Rivera No relevant relationships by Shruti Shettigar

12.
Chest ; 162(4):A663, 2022.
Article in English | EMBASE | ID: covidwho-2060662

ABSTRACT

SESSION TITLE: Challenging Cases of Hemophagocytic Lymphohistiocytosis SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Worsening respiratory disease is the most common complication of severe COVID-19. However, when patients develop multi-organ dysfunction, clinicians must have a high index of suspicion for rare syndromes such as hemophagocytic lymphohistiocytosis (HLH). CASE PRESENTATION: A 39-year-old male smoker presented with 1 week of shortness of breath and malaise. Initial physical examination revealed T 37.3 C, pulse 85 min-1, respiratory rate 18 breaths min-1, SPO2 96% and clear breath sounds without labored respirations. Chest X-ray showed bilateral patchy airspace opacities in the mid and lower lung fields. A SARS-COV2 PCR test was positive. The patient was prescribed antibiotics and discharged home. Subsequently, the patient's symptoms worsened and he presented 1 week later with SPO2 90% (O2 10 L/min via nasal cannula). He was admitted to the hospital with COVID-19 pneumonia and began remdesivir, barcitinib, systemic steroids, albuterol and IV antibiotics. On admission his complete blood count and complete metabolic panel were unremarkable. After 3 weeks of hospitalization, he developed multi-organ failure with acute liver injury, acute kidney injury, shock, pancytopenia and worsening hypoxemia leading to endotracheal intubation and mechanical ventilation. CT chest imaging showed bilateral ground glass opacities in the lungs with superimposed consolidation (figure 1). Blood cultures remained sterile, HIV, hepatitis B and C viral serologies were negative. Serum viral polymerase chain reaction detected Herpes Simplex Virus-1 (HSV-1) and Epstein Barr Virus (EBV) infections. Trans-jugular liver biopsy confirmed HSV-1 hepatitis and showed sub-massive hemorrhagic necrosis of the liver (figure 2). Bone marrow biopsy demonstrated phagocytic histiocytes engulfing red blood cells and platelets consistent with HLH (figure 3). The patient began HLH targeted therapy with anakinra and high dose steroids. Despite this, the patient continued to deteriorate, developed refractory shock and subsequently expired. DISCUSSION: HLH is a rare disease of the immune system in which a genetic or infectious trigger causes uncontrolled T cell activation. T cell activation triggers macrophage activation, cytokine storm and macrophage phagocytosis of erythrocytes, leukocytes, platelets and precursors in the bone marrow and other tissues. If the syndrome is unrecognized, it can quickly lead to multi-organ failure and death. EBV is the most common infectious trigger of HLH;however, infection with HSV-1 and SARS-COV-2 viruses have been identified as rare and independent causes. CONCLUSIONS: This case illustrates the high index of suspicion providers should have for HLH in patients with severe COVID-19 who develop multi-organ injuries. Once HLH is suspected, prompt initiation of HLH-94 protocol with etoposide and dexamethasone may be lifesaving. For those patients with liver failure, other agents (e.g. anakinra) may be provided. Reference #1: Ramos-Casals M, Brito-Zerón P, López-Guillermo A, et al.: Adult haemophagocytic syndrome. Lancet 2014;383:1503–1516 Reference #2: Risma K, Jordan MB: Hemophagocytic lymphohistiocytosis: updates and evolving concepts. Curr Opin Pediatr 2012;24:9–15 Reference #3: Trottestam H, Horne A, Aricò M, et al.: Chemoimmunotherapy for hemophagocytic lymphohistiocytosis: long-term results of the HLH-94 treatment protocol. Blood 2011;118:4577–4584 DISCLOSURES: No relevant relationships by Erin Biringen No relevant relationships by Christine Brennan No relevant relationships by Joann Hutto No relevant relationships by Daniel Puebla Neira

13.
Journal of the Intensive Care Society ; 23(1):61-62, 2022.
Article in English | EMBASE | ID: covidwho-2043017

ABSTRACT

Introduction: During the COVID-19 pandemic, mobile airway trollies formed an integral part of the emergency airway management. The AAGBI and ICS produced consensus guidelines recommending a COVID-19 airway trolley or pack;however, the maintenance guidance of these trollies is unclear.1 The pandemic placed severe pressure on all critical care staff, especially nursing staff. The airway trolley checks were transitioned to the junior doctors after wave one at Chelsea and Westminster Hospital. Unfortunately, trollies were not adequately checked and stocked. This created potential delays with emergency tracheal intubations, jeopardizing patient safety. Using a Plan Do Study Act (PDSA) approach we attempted to understand the factors affecting our compliance and ultimately improve patient safety. Objectives: 1. Identify which group of ICU professionals should check the airway trollies 2. Identify the barriers to safety checks? 3. Assess which targeted interventions improve compliance with checks? Methods: Single centre, prospective data collection (surveys n= 23 and trollies checklist compliance) over a 7 month period. Data on the frequency and accuracy of the checks was collected monthly. Surveys were used to identify appropriate and targeted interventions. Interventions were made at each cycle to address shortfalls in checks. Results: 1. 87% of staff believed that doctors (SHOs or SpRs) should check the airway trollies. 2. Barriers identified were 1. Lack of time or too busy 68% 2. Lack of organisation (finding stock or understanding equipment) 41% 3. Difficulty in finding the checklists 27% 3. Compliance improved from 34% to 77%, through various interventions (see graph below) At baseline (November) trolley check compliance was 34%. Changes were made to improve accessibility of checklists and equipment, and daily reminders were added to the morning operational handover. However, this only improved the check frequency to 38%. A staff survey highlighted recommendations for improvement: daily allocation of checks to a specific doctor and airway education. The trolley check allocation was built into the doctors' rota and airway trolley education was added to the departmental induction. There was minimal initial change in the following month but further applied education in the form of consultant-led airway skills sessions to engage the doctors in the process saw rates drastically improved to 75% and 77% over the following two months. Unpredictable challenges which negatively influenced the results were identified. These included surge rotas, including redeployed non-ICU doctors in checks and increased trolley numbers with increased ICU capacity. Conclusions: This quality improvement project, performed during the height of a pandemic, demonstrates the importance of adaptation and persistence to identify interventions that take into account the evolving clinical environment and human factors. It highlighted the difficulty in building new habits within the daily routine of junior doctors and the necessity of senior lead teaching to build the doctors' confidence, understanding and engagement with safety processes. Following the rigorous cycles, it is expected that the routine for the trolley checks is sufficient to withstand the rotations of junior doctors and expansion of the department in potential future waves of the pandemic.

14.
HemaSphere ; 6:2388-2389, 2022.
Article in English | EMBASE | ID: covidwho-2032150

ABSTRACT

Background: Intensive care unit (ICU) admission during hematopoietic stem cell transplant (HSCT) is associated with poor prognosis1,2. Published series report a range of ICU admission rates from 24-40% of transplant patients, most frequent reasons involving septic shock, respiratory failure and veno-occlusive disease3. In addition, patients undergoing HSCT are at a high risk of severe morbidity and mortality associated with COVID-194. Aims: The aim of this study was to analyze outcome of HSCT patients requiring ICU admission in our center. Methods: We retrospectively analysed outcome of 752 patients who underwent HSCT in our centre from January/2008 to June/2021. Data were collected from patients' clinical histories. Results: 103 (14%) patients required ICU admission (baseline and HSCT characteristics on table). Median time to ICU admission was 42 days (-2-1765). Seven of these patients were admitted to ICU on two occasions giving a total of 110 consecutive ICU admissions available for analysis. Main reason for ICU admission was respiratory distress (74;67%), mainly due to pneumonia (53%) including a 3% caused by COVID19, pulmonary edema (26%) and pulmonary haemorrhage (8%). Septic shock was second most common cause for ICU admission (26;24%) due to gram-negative bacilli (47%), fungal (15%) gram-positive bacteria (13%), virus (10%) and others/idiopathic (16%). Other less frequent causes were veno-occlusive disease (11;10%), hepatic failure/encephalopathy (8;7%), haemorrhagic complications (6;5%), cardiorespiratory arrest (2%), GVHD (2%), cardiogenic shock (2%). Of the 110 ICU admissions, 37 (34%) required hemofiltration, of which 30 (81%) died;and 77 (70%) required orotracheal intubation, of which 59 (77%) died. During the 110 ICU admissions, 67 patients (61%) died in the ICU;of these, 40 (37%) received unrelated donor HSCT, 36 (33%) sibling donor, 16 (15%) haploidentical and 17 (16%) autologous. Median ICU length of stay of these patients was 13 days (range 1-76). The cause of death was the same reason for ICU admission. Eighteen (16%) patients were discharged from ICU and died prior to Hospital discharge and 24 (22%) survived to Hospital discharge and were classified as post-discharge survivors. Of these 24 cases, 19 (79%) remain alive while the others (5;21%) succumbed to underlying disease or complications post-HSCT. Off note, both patients with COVID19 pneumonia (haploidentical and autologous HSCT respectively) were discharged from ICU and remain alive to date, without major complications. Summary/Conclusion: In our study 14% of transplant recipients required ICU admission, slightly lower than previous reports. Most common cause of admission was respiratory failure, consistent with reported. Mortality rate during ICU admission was 61%;higher death rate observed in allogeneic transplantation and those requiring aggressive ICU treatments such as mechanical ventilation or hemofiltration. Although patients with COVID19 pneumoniae who require ICU admission are usually associated with adverse outcome, in our series they responded successfully to intensive treatment. ICU admission following HSCT is associated with poor prognosis, but should not be considered futile. (Table Presented).

15.
Anaesthesia and Intensive Care Medicine ; 23(8):415-422, 2022.
Article in English | EMBASE | ID: covidwho-2031577

ABSTRACT

Failed intubation in obstetrics remains a topical issue, a rare but potentially devastating complication of obstetric general anaesthesia. The 2015 guidelines produced following several years of collaborative work between the Difficult Airway Society (DAS) and Obstetric Anaesthetists' Association (OAA) remain the definitive text. While deaths from failed intubation have declined significantly over 30 years, the incidence of failed intubation remains fairly constant at 1:300, with the latest studies showing a rate of 1:224. This reflects the significant decline in the use of general anaesthesia for caesarean section over the last three decades;however, it also highlights a decreased exposure for trainees to tracheal intubation in the obstetric population.

16.
Southern African Journal of Anaesthesia and Analgesia ; 28(1):S1-S2, 2022.
Article in English | EMBASE | ID: covidwho-2010609

ABSTRACT

Background: Before the COVID-19 pandemic, there was an increasing interest in the use of high-flow nasal oxygenation (HFNO) due to the way it delivers oxygen and because of its impact on respiratory mechanics. Its use extends from the operating room, e.g. pre-oxygenation, apnoeic oxygenation in ENT surgery, electroconvulsive therapy, to the emergency room and intensive care unit, e.g. acute respiratory failure, cardiogenic shock in adults and paediatrics. It has also been advocated as a useful method to prevent reintubation. However, it has not always shown to be a superior approach to other oxygenation methods. Currently, the medical literature is inundated with the use of HFNO in the management of COVID-19. Yet, the picture may differ outside this ambit. Methods: We describe two complex cases in which this therapy was used and was decisive toward a positive outcome. Results: We describe two complex cases in which HFNO therapy was used and was decisive toward a positive outcome. In our first described case, it was an effective tool to bypass the need of endotracheal intubation in a high-risk OSA patient. In the second case the traditional epidural with invasive or noninvasive ventilation was challenged. The higher tolerability of HFNO, absence of sedation, better mobility and easier access to enteral nutrition resulted in the quick, successful recovery of the patient despite the combination of chronic restrictive pulmonary disease and severe thoracic-abdominal trauma. Conclusion: In our opinion, both cases may illustrate a significant potential for the use of HFNO in different clinical scenarios.

17.
Indian Journal of Critical Care Medicine ; 26:S120-S123, 2022.
Article in English | EMBASE | ID: covidwho-2006411

ABSTRACT

Aim: To prevent endotracheal intubations in the COVID wards with early awake proning, allowing time for lung to recover, and decrease mortality in COVID-19 patients. Objectives: 1. To assess the effect of prone positioning on the requirement for invasive mechanical ventilation. 2. To calculate PaO2/FiO2 before prone position. 3. To measure PaO2/FiO2 after prone position. 4. To assess how much increase in PaO2 during prone. 5. To assess the length of time tolerating prone positioning. Materials and methods: Inclusion criteria: (1) Age >18 years. (2) Patient with confirmed COVID with or without chest X-ray infiltrates. (3) Isolated hypoxemic respiratory failure without substantial dyspnea (the paradoxically well appearing hypoxemic patient). Requiring >2 L of O2 to maintain SpO2 >92%. A reasonable candidate might meet the following criteria: • not in multi-organ failure, • expectation that patient has a fairly reversible lung injury and may avoid intubation, • no hypercapnia or substantial dyspnea, • normal mental status, able to communicate distress, • no anticipation of difficult airway. (4) Patients who do not wish to be intubated (DNI). The main risk of awake proning is that it could cause excessive delays in intubation. In the DNI patient who is failing other modes of ventilation, there is little to be lost by trialing awake proning. Exclusion criteria: (1) Signs of respiratory fatigue (RR > 40/minute, PaCO2 > 50 mm Hg/pH< 7.30, and obvious accessory respiratory muscle use), (2) immediate need for intubation (PaO2/FiO2 < 50 mm Hg, unable to protect airway or change of mental status), (3) unstable hemodynamic status, and (4) inability to collaborate with prone position with agitation or refusal. Also, it is observed that the mean O2 requirement is slightly higher in females (Baseline-7.74 L) as compared to males (Baseline-6.06 L), however, this difference is not statistically significant when observed using an independent sample t test (t value = -1.728, df = 48, p > 0.05). The mean reduction of O2 requirement from baseline to Day 3 post proning amongst male patients is 4.53 L, while in females it is 5.16 L. There is no statistically significant mean reduction of O2 requirement in males and females which was observed using independent sample t-test (t value = -0.675, df = 47, p > 0.05). SpaO2 increase after awake proning Overall, a total of 21 patients were followed up until Day 3 post proning and an increase in SpaO2 was observed in these patients. It is seen that the Mean Baseline SpaO2 in these 21 patients was 68.43 ± 2 (14.172) and after 3 days of awake proning it increased to 77.24 + 2 (17.023). However, this difference is not statistically significant using the paired sample t-test (t value = -1.819, df = 20, p > 0.05). Conclusion: It can be concluded from the study that 3 out of 50 patients (6.0%) required NIV or intubation after giving awake proning. The SpaO2 increases after awake proning but the increase is not statistically significant. However, the O2 requirement is reduced 4 to 6 times after awake proning and this reduction is statistically very highly significant. Thus, awake proning significantly helps in the reduction of the requirement of O2.

18.
Indian Journal of Critical Care Medicine ; 26:S80-S81, 2022.
Article in English | EMBASE | ID: covidwho-2006367

ABSTRACT

Aims and objectives: To establish that non-invasive ventilation (NIV) can be substituted by high flow nasal cannula (HFNC) for respiratory support during oral feeding of a patient with COVID-19 patients. Materials and methods: This prospective case series was conducted after taking informed and written consent from the patients. Ten patients with severe COVID-19 disease requiring NIV with inspiratory pressure of <10 cm H2O, positive end-expiratory pressure of <6 cm H2O and FiO2 <0.6 were included in this study. Patients with altered consciousness, circulatory failure, or worsening acidosis were not included in the study. Patients underwent HFNC trial for 10 minutes and were screened for risk of dysphagia and aspiration using a 3-ounce water swallowing test. The patients were given a trial of HFNC for 10 minutes with a flow of 60 L/minute and FiO2 of 0.1 more than their requirement on NIV. The patients were observed for hypoxemia (SpO2 <88%) or signs of respiratory distress, e.g., increase in respiratory rate (>35/minute), laboured breathing pattern, use of accessory muscle of respiration, heart rate (>20% change), blood pressure (>20% change), perspiration, and anxiety. Then, HFNC was used for supporting respiration during oral feeding for up to 20 minutes. Feeding was started with a hypocaloric target on starting day and was increased progressively as per European Society for Clinical Nutrition and Metabolism guidelines to the target estimated caloric requirement. Results: The HFNC support for oral feeding was successful with adequate diet intake in eight patients without desaturation/respiratory distress during oral feeding. Other than COVID-19, co-morbidities in these eight patients included diabetes mellitus, obesity, chronic obstructive pulmonary disease, coronary artery disease, and dilated cardiomyopathy. Six patients, previously on enteral nutrition using the nasogastric tube, were successfully switched to oral feeding with help of HFNC. Four patients were directly started on the oral diet with help of HFNC support. HFNC could not support respiration adequately in two of these four patients. The initial trial was successful for one of the patients and HFNC support for oral feeding was used for 3 days, but a progressive increase in ventilatory requirements resulted in failure of HFNC trial subsequent days and the patient was switched to nasogastric feeding. In another patient, the initial trial of HFNC failed due to rapid desaturation within a few minutes of the trial. The eight patients in whom HFNC was used successfully for feeding were switched to HFNC completely and discharged from the hospital after weaning off from oxygen support. The patients who failed the HFNC support for feeding required higher ventilatory requirements and needed endotracheal intubation. Conclusion: Based on our case series, using daily screening trial of oral feeds with HFNC support in selected patients of severe COVID-19 pneumonia on NIV seems thought-provoking and should be explored for its potential in improving patient's nutrition with a positive impact on the outcome.

19.
Indian Journal of Critical Care Medicine ; 26:S51-S52, 2022.
Article in English | EMBASE | ID: covidwho-2006347

ABSTRACT

Introduction: Macroglossia is defined as an enlargement of the tongue in the resting position, protruding beyond the teeth. Many cases have been reported secondary to patient positioning while under anesthesia, post oro-pharyngeal packing, trauma or surgery, and allergic or non-allergic angioedema. However, acute macroglossia in the ICU is a rare situation. In COVID-19 related severe ARDS, endotracheal intubation and prolonged proning is an important part of management of hypoxemic respiratory failure Prone positioning also has the potential to independently cause macroglossia. Awareness of this complication of proning could help mitigate morbidity in patients. Case report: A 53-year-old diabetic, hypertensive overweight female with OSA presented with progressive shortness of breath and productive cough. She was mechanically ventilated in ICU in view of respiratory distress secondary to COVID-19 pneumonia. Intubation was minimally traumatic with minimal oral bleeding settling over few minutes. Though managed with medications as per COVID-19 management protocol, she progressed to severe ARDS hence proned on hospital day 1 for 16 hours - PaO2/FiO2 ratio improved. She was not proned further. Acute macroglossia (3 inches outside the oral cavity) with lower facial edema was noted 4 days post proning. Saline moistened gauze was loosely wrapped around the tongue every hour. Circumferential ecchymosis was noticed around her neck on the 6th day. On day 8, macroglossia did not show signs of resolution. Hence, the tongue was pushed in manually every 2 hourly and the position was maintained manually for 10 minutes. The swelling decreased gradually with the tongue staying in a retracted position on treatment day 2. On day 3, there was a complete resolution of the swelling. However, she had persistent swallowing difficulty causing difficulty in weaning from tracheostomy. MRI of neck and chest showed large pre-vertebral collection from the upper border of C2 inferiorly across the thoracic inlet to the posterior mediastinum with thin linear extension up to the lower border of T4. Mass effect with airway compression, displacement, and compression of esophagus and neck vessels was seen. Trans-oral exploration revealed mucosal rent and bulge in the posterior pharyngeal wall. The hematoma was evacuated by ENT specialists. She was discharged on tracheostomy and feeding tube. Tracheostomy decannulation was done after 1 month. Discussion: In our practice of proning patients with ARDS for >10 years, this is the first case of macroglossia as a complication of proning that we encountered. Other factors that could have contributed to this patient are obesity and mildly traumatic intubation. Development of macroglossia 4 days after proning and resolution over a short period of time is rare and suggests lymphatic and vascular compression as the cause. Later development of ecchymosis and dysphagia may be due to the posterior pharyngeal injury. Conclusion: Proning, especially in obese patients, can be a challenge. Positioning of the face and avoidance of injury to any of the structures is vital to the care of the proned patient. Medical staff involved in patient care should be aware and vigilant to pick up this condition early to avoid further injury.

20.
Indian Journal of Critical Care Medicine ; 26, 2022.
Article in English | EMBASE | ID: covidwho-2002964

ABSTRACT

The proceedings contain 246 papers. The topics discussed include: nasotracheal vs orotracheal intubation and post-extubation airway obstruction in critically ill children: an open-label randomized controlled trial;prognostication of the outcomes in patients on mechanical ventilation due to severe ARDS in COVID-19 using neutrophil to lymphocyte ratio (NLR) at admission;prognostic role of different severity indexes in COVID-19 pneumonia: a retrospective study;monoclonal antibody for COVID treatment;fluid management 100% non-invasive for COVID patient in ICU by sterling stroke volume guided resuscitation;post-COVID double valve and bypass surgery one of 1st in world;terlipressin-induced skin necrosis;safety, feasibility, and outcome of percutaneous dilatational tracheostomy in critically ill COVID-19 Patients;Cisatracurium for Orgen failure patient in ICU;and is there association between trends of inflammatory marker to clinical course of critically ill COVID-19 patient require prolong hospitalization?.

SELECTION OF CITATIONS
SEARCH DETAIL