Exploring diaphragmatic response to high-flow nasal cannula in patients with COVID-19 pneumonia using ultrasound: a proof of concept study.

BACKGROUND: Recent studies have highlighted the recognition of diaphragmatic dysfunction as a significant factor contributing to respiratory disturbances in severely ill COVID-19 patients. In the field of noninvasive respiratory support, high-flow nasal cannula (HFNC) has shown effectiveness in relieving diaphragm dysfunction. This study aims to investigate the diaphragmatic response to HFNC in patients with COVID-19 pneumonia by utilizing ultrasound. METHODS: This retrospective study was conducted in a medical-surgical intensive care unit (ICU) at a tertiary care center in Buenos Aires, Argentina (Sanatorio de Los Arcos) over a 16-month period (January 2021-June 2022). The study included patients admitted to the ICU with a diagnosis of COVID-19 pneumonia who were deemed suitable candidates for HFNC therapy by the attending physician. Diaphragm ultrasound was conducted, measuring diaphragmatic excursion (DE) both before and during the utilization of HFNC for these patients. RESULTS: A total of 10 patients were included in the study. A statistically significant decrease in respiratory rate was observed with the use of HFNC (p = 0.02), accompanied by a significant increase in DE (p = 0.04). CONCLUSION: HFNC leads to a reduction in respiratory rate and an increase in DE as observed by ultrasound in patients with COVID-19 pneumonia, indicating promising enhancements in respiratory mechanics. However, further research is required to validate these findings.

Predicting mortality in severe Covid-19 Pneumonia: the role of right ventricular dysfunction.

PURPOSE: There is evidence that COVID-19 can have a clinically significant effect on the right ventricle (RV). Our objective was to enhance the efficiency of assessing RV dilation for diagnosing ACP by utilizing both linear measurements and qualitative assessment and its usefulness as an independent predictor of mortality. METHODS: This is an observational, retrospective and single-center study of the Intensive Care Unit of the Sanatorio de Los Arcos in Buenos Aires, Argentina from March 2020 to January 2022. All patients admitted with acute respiratory distress syndrome due to COVID-19 pneumonia (C-ARDS) on mechanical ventilation who were assessed by transthoracic echocardiography (TTE) were included. RESULTS: A total of 114 patients with C-ARDS requiring invasive mechanical ventilation were evaluated by echocardiography. 12.3% had RV dilation defined as a RV basal diameter greater than 41 mm, and 87.7% did not. Acute cor pulmonale (ACP) defined as RV dilation associated with paradoxical septal motion was found in 6.1% of patients. 7% had right ventricular systolic dysfunction according to qualitative evaluation. The different RV echocardiographic variables were studied with a logistic regression model as independent predictors of mortality. In the multivariate analysis, both the RV basal diameter and the presence of ACP showed to be independent predictors of in-hospital mortality with OR of 3.16 (95% CI 1.36-7.32) and 3.64 (95% CI 1.05-12.65) respectively. CONCLUSION: An increase in the RV basal diameter and the presence of ACP measured by TTE are independent predictors of in-hospital mortality in patients with C-ARDS.

The value of speckle tracking echocardiography in diagnosing minoxidil-induced cardiotoxicity: a case report.

Minoxidil is a drug designed for the treatment of arterial hypotension. Due to its secondary effect of hypertrichosis, it is also used for alopecia treatment. We present a case of a 50-year-old female patient who was orally consuming Minoxidil for medical reasons. She presented with severe hypotension, requiring vasoactive drugs, and evidence of myocardial injury was detected using speckle tracking echocardiography. It is worth noting that the patient did not have any coronary heart disease, and the myocardial injury was found to be associated with Minoxidil consumption. Remarkably, the patient showed signs of reversal 72 h after stopping the drug. To our knowledge, this is the first reported case of subendocardial injury associated with Minoxidil, using speckle tracking echocardiography. In the resolution of the case, it was essential to rule out differential diagnoses, administer vasopressors, and use the speckle tracking echocardiography, which allowed for the objective assessment of myocardial injury and the monitoring of the patient during their hospitalization.

A modified subcostal view: a novel method for measuring the LVOT VTI.

PURPOSE: The velocity time integral (VTI) of the left ventricular outflow tract (LVOT) obtained in the apical view by echocardiography can be regarded as a surrogate for the stroke volume. In critically ill patients it is often difficult to obtain an appropriate apical view to assess the VTI. The subcostal view is more accessible, but while it allows a qualitative assessment of the heart, is not adequate for estimating a reliable LVOT VTI, given the inappropriate angle between the Doppler signal and the flow through the LVOT. We present a new modified subcostal view that allows a proper LVOT VTI measurement. METHODS: This is a single-centre experimental, retrospective, and observational study using data from patients in a tertiary-care centre. We included adult patients admitted to the intensive care unit in the period from June 2020 to January 2022, who were evaluated by echocardiography and whose LVOT VTI was measured aligned with the Doppler signal in both the apical five-chamber view and the modified subcostal view. RESULTS: A total of 30 patients were evaluated in the study period by ultrasonography. The Bland-Altman method analysis of the LVOT VTI measured in the apical view compared with that obtained in the subcostal view showed a bias of 0.8 (95% CI 0.39-1.21) with a 95% limit of agreement between - 1.35 (95% CI - 2.06 to - 0.64) and 2.96 (95% CI 2.25-3.67). The percentage error was calculated to be 23%. The Pearson correlation coefficient for the two forms of measurements showed an R value of 0.98 (95% CI 0.96-0.99). CONCLUSION: The LVOT VTI measured in a modified subcostal view is useful for estimating the value of the LVOT VTI obtained in an apical view.

Transthoracic echocardiography of patients in prone position ventilation during the COVID-19 pandemic: an observational and retrospective study.

Mechanical ventilation in prone position is a strategy that increases oxygenation and reduces mortality in severe ARDS. The hemodynamic and cardiovascular assessment of these patients is essential. Transthoracic echocardiography (TTE) is a widely used tool to assess hemodynamics in critical care, but the prone position is thought to limit adequate TTE views and goal-oriented measurements. The aim of this study is to show the feasibility of the hemodynamic assessment by transthoracic echocardiography during prone position ventilation (PPV). This is a retrospective, observational study, carried out in the intensive care unit (ICU) of a tertiary-care center in Buenos Aires, Argentina. We included all the adult patients admitted to the ICU between March 2020 and August 2021 who had a TTE examination in PPV due to ARDS. During the study period, we evaluated by TTE a total of 35 patients requiring PPV. The vast majority of the patients had COVID-19 pneumonia (91.4%). In 33 out of 35 (94.3%) cases, it was able to achieve an adequate apical four chamber view. We assessed qualitatively the systolic function of left ventricle (LV) and right ventricle (RV) in all of the successfully evaluated patients. We measured the RV basal diameter (94.3%), RV/LV ratio (77.1%), tricuspid annular plane systolic excursion (TAPSE) (91.4%), and septal mitral annular plane systolic excursion (MAPSE) (88.5%) in most of them. Also, we quantified the left ventricle outflow tract velocity time integral (LVOT VTI) in a large part (68.5%) of the examinations. Transthoracic echocardiography is a useful tool for the hemodynamic assessment of patients in prone position under mechanical ventilation.

Effect of prone position on right ventricular dysfunction due to pulmonary embolism assessed by speckle tracking echocardiography.

Prone position has shown beneficial hemodynamic effects in patients with right ventricular dysfunction associated with acute respiratory distress syndrome decreasing the right ventricle afterload. We describe the case of a 57-year-old man with right ventricular dysfunction associated with pulmonary thromboembolism with severe hypoxemia that required mechanical ventilation in prone position. With this maneuver, we verified an improvement not only in his oxygenation, but also in his right ventricular function assessed with speckle tracking echocardiography. Our case shows the potential beneficial effect of the prone position maneuver in severely hypoxemic patients with right ventricular dysfunction associated with pulmonary thromboembolism.

Usefulness of ultrasound in the diagnosis of nosocomial maxillary sinusitis in patients with severe Covid-19 pneumonia: a retrospective study.

PURPOSE: Severe Covid-19 pneumonia frequently presents with infective complications as bacterial and fungal infections, nosocomial maxillary sinusitis is one of them. We describe the role of ultrasonography in the diagnosis of nosocomial maxillary sinusitis in patients undergoing mechanical ventilation due to severe Covid-19 pneumonia. METHODS: Patients with severe pneumonia due to Covid-19 requiring mechanical ventilation and had maxillary sinus occupation by ultrasonography were retrospectively enrolled at intensive care unit of Sanatorio De los Arcos, Buenos Aires, Argentina, between March 2020 and May 2021. RESULTS: We evaluated a total of 171 patients with severe Covid-19 pneumonia requiring mechanical ventilation during the study period. We included 26 patients that had maxillary sinus occupation by ultrasonography (15.2%). Out of the 26 patients, in 17 the diagnosis was confirmed by surgical drainage of the maxillary sinus with positive cultures with a positive predictive value of 85%. In 34.6% of the cases the maxillary sinus disease was unilateral and in 38.4% bilateral. A sinus computed tomography (CT) was performed in 30.7% of the patients. Most of the patients underwent to surgical drainage without a CT scan (66.7%). CONCLUSIONS: Ultrasonography is a useful tool for the detection of maxillary sinus infection in patients with severe Covid-19 pneumonia and avoids to perform a CT scan and, therefore, unnecessary transfers.