COVID-19 Acute Respiratory Distress Syndrome: Treatment with Helmet CPAP in Respiratory Intermediate Care Unit by Pulmonologists in the Three Italian Pandemic Waves.

COVID-19 Acute Respiratory Distress Syndrome (CARDS) is the most serious complication of COVID-19. The SARS-CoV-2 outbreaks rapidly saturated intensive care unit (ICU), forcing the application of non-invasive respiratory support (NIRS) in respiratory intermediate care unit (RICU). The primary aim of this study is to compare the patients' clinical characteristics and outcomes (Helmet-Continuous Positive Airway Pressure (H-CPAP) success/failure and survival/death). The secondary aim is to evaluate and detect the main predictors of H-CPAP success and survival/death. A total of 515 patients were enrolled in our observational prospective study based on CARDS developed in RICU during the three Italian pandemic waves. All selected patients were treated with H-CPAP. The worst ratio of arterial partial pressure of oxygen (PaO2) and fraction of inspired oxygen (FiO2) PaO2/FiO2 during H-CPAP stratified the subjects into mild, moderate and severe CARDS. H-CPAP success has increased during the three waves (62%, 69% and 77%, respectively) and the mortality rate has decreased (28%, 21% and 13%). H-CPAP success/failure and survival/death were related to the PaO2/FiO2 (worst score) ratio in H-CPAP and to steroids' administration. D-dimer at admission, FiO2 and positive end expiratory pressure (PEEP) were also associated with H-CPAP success. Our study suggests good outcomes with H-CPAP in CARDS in RICU. A widespread use of steroids could play a role.

Erector spine plane block as single loco-regional anesthesia in non-intubated video-assisted thoracic surgery for unfit patients: a case-match study.

In the present study, we analyzed the safety and efficacy of non-intubated video-assisted thoracoscopy (NI-VATS) for the diagnosis and palliation of malignant pleural effusion in the elderly population using erector-spinae plane block (ESPB) as single loco-regional anesthesia. From January 2016 to December 2020 a consecutive series of 158 patients who underwent surgery for malignant pleural effusion was analyzed. Of these, 20 patients were operated using ESPB NI-VATS, while 138 were operated under general anesthesia (GA). After propensity score matching, the NI-VATS population was older (81 vs. 76 years p 0.006), and had more severe pre-existing comorbidities, evaluated using Charlson Comorbidity Index (p = 0.029) and ASA score (p < 0.001). GA and NI-VATS patients did not differ in terms of postoperative opioid consumption, complication rate and postoperative hospitalization. Both short- and long-term efficacy of talc poudrage was equal in the two populations. The overall length of stay in the operative room was significantly shorter for the NI-VATS than for the GA-VATS group (67.5 vs. 105 min, p < 0.001), and operative time significantly differed in the two groups (35 vs. 47.5 min, respectively, p < 0.001). ESPB NI-VATS can be a safe and effective option for the diagnosis and palliation of malignant pleural effusion for elderly and frail patients.

Spontaneous pneumothorax as unusual presenting symptom of COVID-19 pneumonia: surgical management and pathological findings.

BACKGROUND: Spontaneous pneumothorax has been reported as a possibile complication of novel coronavirus associated pneumonia (COVID-19). We report two cases of COVID-19 patients who developed spontaeous and recurrent pneumothorax as a presenting symptom, treated with surgical procedure. An insight on pathological finding is given. CASE PRESENTATION: Two patients presented to our hospital with spontaneous pneumothorax associated with Sars-Cov2 infection onset. After initial conservative treatment with chest drain, both patients had a recurrence of pneumothorax during COVI-19 disease, contralateral (patient 1) or ipsilateral (patient 2) and therefore underwent lung surgery with thoracoscopy and bullectomy. Intraoperative findings of COVID-19 pneumonia were parenchymal atelectasis and vascular congestion. Lung tissue was very frail and prone to bleeding. Histological examination showed interstitial infiltration of lymphocytes and plasma cells, as seen in non specific interstitial pneumonia, together with myo-intimal thicknening of vessels with blood extravasation and microthrombi. CONCLUSIONS: Although rarely, COVID-19 may present with spontaneous pneumothorax. Lung surgery for pneumothorax in COVID-19 patients can be safely and effectively performed when necessary.

Salvage Surgery After Definitive Chemoradiotherapy for Non-small Cell Lung Cancer.

Following definitive chemoradiation therapy, 24%-35% of patients with locally advanced non-small cell lung cancer have recurrence. We aimed to evaluate the feasibility of salvage surgery after definitive chemoradiotherapy and perioperative morbidity and mortality rates to determine long-term survival. From June 2003 to June 2013, 35 patients were eligible for lung cancer resection owing to relapse after definitive chemoradiation therapy. All patients received cisplatin-based chemotherapy and definitive radiotherapy (mean Gy: 58) with curative intent and all underwent total body computed tomography scan and 18-fluoro-deoxyglucose positron emission tomography scan after the end of medical treatment and before surgery. Cyto-histologic confirmation was attempted in 20 (57%) patients. Six patients had exploratory thoracotomies. Twenty-nine patients underwent lung cancer resection: 11 lobectomies, 1 bilobectomy, and 17 pneumonectomies (7 right, 10 left). Complete resection was obtained in 27 of 35 (77%) patients. Thirteen (45%) patients underwent extended resection: intrapericardial pneumonectomy in 5 patients, vascular or bronchial sleeve resection in 2, atrial resection in 1, tracheal sleeve in 1, superior vena cava resection and reconstruction in 2 (1 with tracheal-sleeve resection), and chest wall resection in 2. Median time from chemoradiation therapy to resection was 7 months (range: 1-39). Viable tumor was found in 26 of 29 (89.6%) patients. Major complications occurred in 9 patients (25.7%). There were 2 (5.7%) perioperative deaths within 30 days. With a median follow-up of 13 months, postoperative 2- and 3-year survival rates after complete resection were 46% and 37%, respectively. Salvage lung resection after definitive chemoradiation therapy is feasible, with acceptable postoperative survival and complication rates.

Superior vena cava resection in thoracic malignancies: does prosthetic replacement pose a higher risk?

BACKGROUND: After superior vena cava (SVC) resection, the need for reconstruction varies among tangential resection, pericardial patch repair and prosthetic replacement. Patients undergoing complete prosthetic replacement often require a different surgical approach, intra-operative SVC cross-clamping and anticoagulation when polytetrafluoroethylene (PTFE) prosthesis is used. This study tested the hypothesis that PTFE replacement may interfere with perioperative outcome. MATERIALS AND METHODS: Clinical records from a series of 72 consecutive SVC resections performed between 1998 and 2008 were reviewed. Complications were classed into five categories: surgical, respiratory, cardiac, SVC system thrombosis and nerve damage. Each category of postoperative complications was considered as an outcome variable in a univariate analysis testing 12 covariates as risk factors. Covariates considered clinically relevant or statistically significant were included in the multivariate model. RESULTS: During the considered period, 28 patients underwent total SVC resection with PTFE prosthetic replacement and 44 patients underwent SVC repair by the use of direct running suture (nine patients), stapling (30 patients) or autologous pericardial patch (five patients). Two patients died postoperatively (2.8%). Major complications were mainly due to respiratory failure, which occurred in nine cases (acute respiratory failure in five cases, recurrent atelectasis in three cases, acute respiratory distress syndrome (ARDS) in one case). In terms of overall mortality and morbidity, univariate analysis did not confirm a detrimental effect of SVC replacement as compared with SVC repair, as major postoperative complications occurred in similar proportion in both groups (respectively, 6/28, 21.4% vs 7/44, 15.9%, p=0.54). No other risk factor was identified by univariate analysis. CONCLUSIONS: Complete prosthetic replacement does not increase overall postoperative morbidity in patients undergoing SVC resection and can be safely performed when other reconstruction techniques preclude sufficient tumour-free resection margin or compromise adequate blood flow.