Prevalence and Incidence of Pediatric Acute Respiratory Distress Syndrome in a Tertiary Academic PICU in South Africa.

OBJECTIVES: To determine the prevalence and incidence of pediatric acute respiratory distress syndrome (pARDS) among infants and children admitted to the PICU. DESIGN: A single-center descriptive point prevalence study with twice weekly data collection over a 6 months (August 2020 to February 12, 2021). SETTING: Red Cross War Memorial Children's Hospital, Cape Town, South Africa. PATIENTS: All infants and children admitted to the PICU on study days were included. INTERVENTIONS: Data were captured electronically on a standardized case record form using a Research Electronic Data Capture electronic database. MEASUREMENTS AND MAIN RESULTS: The Pediatric Acute Lung Injury Consensus Conference criteria were used to define pARDS cases. Prevalence was calculated as the total number of pARDS cases/1,000 PICU bed days. The study included 354 patients (median [interquartile range]) 10.1 months old (1.5-61.3 mo old), with 204 males (57.6%), who occupied 879 bed days. Of these 879 bed days, 266 (30.3%; 95% CI, 27.2-33.3%) were occupied by pARDS cases, with a calculated prevalence and incidence of 302.6 of 1,000 bed days (30.3%) and 29.7% (95% CI, 26.7-32.7%), respectively. Three cases from the cohort were defined using the oxygen saturation index calculation. In cases receiving invasive ventilation ( n = 494; 56.2%), pARDS severity was classified as mild ( n = 143; 16.3%), moderate ( n = 44; 5.0%), and severe ( n = 29, 3.3%). A further 205 beds (23.3%) were occupied by patients classified as being at risk of pARDS. CONCLUSIONS: The prevalence and incidence of pARDS in a South African PICU appears substantially higher than findings described in international reports. Further investigation of risk factors and outcomes is warranted.

Measurement of hand grip strength: A cross-sectional study of two dynamometry devices.

Background: Grip strength has been identified as an important indicator of health status and predictor of clinical outcomes. The gold standard for measuring grip strength is the JAMAR® Hydraulic Hand Dynamometer. Less expensive dynamometers are available but have not been validated within a hospital setting. Objectives: To validate the Camry Digital Handgrip Dynamometer (Model EH101) against the validated JAMAR® Dynamometer (Model J00105) in a hospital population. Methods: A cross-sectional observational study with a randomised single-blind cross-over component was conducted on consenting adult patients admitted to general hospital wards. The best of three measurements taken using the dominant hand was used for analysis. Results: Fifty-one participants (median [interquartile range] age 42 [30-58] years; n = 27 [52.9%] female) were included. The mean difference between the Jamar® and Camry measurements was 1.9 kg ± 3.6 kg (t-value 0.9; p = 0.4). There was a strong positive correlation between the Jamar® and the Camry devices (R = 0.94; r² = 0.88; p < 0.0001). Excellent agreement was found between Jamar® and Camry measurements (interclass correlational coefficient 0.97, 95% CI 0.94-0.99, p < 0.0001). Hand dominance significantly affected the agreement between devices (p = 0.002). Conclusions: The Camry Digital Handgrip Dynamometer is a valid tool for assessing grip strength in hospitalised adult patients. Clinical implications: The Camry Digital Handgrip Dynamometer could be used as an inexpensive tool to measure grip strength.

Persistent Symptoms among Frontline Health Workers Post-Acute COVID-19 Infection.

Growing evidence shows that a significant number of patients with COVID-19 experience persistent symptoms, also known as long COVID-19. We sought to identify persistent symptoms of COVID-19 in frontline workers at Right to Care South Africa, who are past the acute phase of illness, using a cross-sectional survey. We analysed data from 207 eligible COVID-19 positive frontline workers who participated in a two-month post-COVID-19 online self-administered survey. The survey response rate was 30%; of the 62 respondents with a median age of 33.5 years (IQR= 30-44 years), 47 (76%) were females. The majority (n = 55; 88.7%) self-isolated and 7 (11.3%) were admitted to hospital at the time of diagnosis. The most common comorbid condition reported was hypertension, particularly among workers aged 45-55 years. The most reported persistent symptoms were characterised by fatigue, anxiety, difficulty sleeping, chest pain, muscle pain, and brain fog. Long COVID-19 is a serious phenomenon, of which much is still unknown, including its causes, how common it is especially in non-hospitalised healthcare workers, and how to treat it. Given the rise in COVID-19 cases, the prevalence of long COVID-19 is likely to be substantial; thus, the need for rehabilitation programs targeted at each persistent COVID-19 symptom is critical.

Exercise-based rehabilitation for major non-communicable diseases in low-resource settings: a scoping review.

INTRODUCTION: While there is substantial evidence for the benefits of exercise-based rehabilitation in the prevention and management of non-communicable disease (NCD) in high-resource settings, it is not evident that these programmes can be effectively implemented in a low-resource setting (LRS). Correspondingly, it is unclear if similar benefits can be obtained. The objective of this scoping review was to summarise existing studies evaluating exercise-based rehabilitation, rehabilitation intervention characteristics and outcomes conducted in an LRS for patients with one (or more) of the major NCDs. METHODS: The following databases were searched from inception until October 2018: PubMed/Medline, Embase, CINAHL, Cochrane Library, PsycINFO and trial registries. Studies on exercise-based rehabilitation for patients with cardiovascular disease, diabetes, cancer or chronic respiratory disease conducted in an LRS were included. Data were extracted with respect to study design (eg, type, patient sample, context), rehabilitation characteristics (eg, delivery model, programme adaptations) and included outcome measures. RESULTS: The search yielded 5930 unique citations of which 60 unique studies were included. Study populations included patients with cardiovascular disease (48.3%), diabetes (28.3%), respiratory disease (21.7%) and cancer (1.7%). Adaptations included transition to predominant patient-driven home-based rehabilitation, training of non-conventional health workers, integration of rehabilitation in community health centres, or triage based on contextual or patient factors. Uptake of adapted rehabilitation models was 54%, retention 78% and adherence 89%. The majority of the outcome measures included were related to body function (65.7%). CONCLUSIONS: The scope of evidence suggests that adapted exercise-based rehabilitation programmes can be implemented in LRS. However, this scope of evidence originated largely from lower middle-income, urban settings and has mostly been conducted in an academic context which may hamper extrapolation of evidence to other LRS. Cost-benefits, impact on activity limitations and participation restrictions, and subsequent mortality and morbidity are grossly understudied.

An investigation into the use of ultrasound as a surrogate measure of diaphragm function.

PURPOSE: Sonographic assessment of the diaphragm may be a surrogate for interpretation of diaphragm function in mechanically ventilated patients. This study aimed to determine the correlation between respiratory muscle function and diaphragm thickness in a healthy population. METHODS: A descriptive study was conducted. Diaphragm thickness was determined by sonographic measurement. Respiratory muscle strength, fatigue and endurance was determined using a mouth pressure manometer. RESULTS: 55 subjects with a mean (SD) age 21.16 ± 1.55 years were studied. Diaphragm thickness was moderately correlated with strength (r = 0.52; r2=0.27; p < 0.001). Respiratory muscle fatigue was not correlated with thickness (r=-0.15; r2=0.02; p = 0.29) or strength (r=-0.19; r2=0.04; p = 0.16). CONCLUSION: Diaphragm thickness was moderately correlated to strength but not to fatigue or endurance in healthy individuals. Sonography may be a surrogate measure of volitional respiratory muscle strength and requires confirmation in critically ill patients.

Prone Positioning Improves Ventilation Homogeneity in Children With Acute Respiratory Distress Syndrome.

OBJECTIVES: To determine the effect of prone positioning on ventilation distribution in children with acute respiratory distress syndrome. DESIGN: Prospective observational study. SETTING: Paediatric Intensive Care at Red Cross War Memorial Children's Hospital, Cape Town, South Africa. PATIENTS: Mechanically ventilated children with acute respiratory distress syndrome. INTERVENTIONS: Electrical impedance tomography measures were taken in the supine position, after which the child was turned into the prone position, and subsequent electrical impedance tomography measurements were taken. MEASUREMENTS AND MAIN RESULTS: Thoracic electrical impedance tomography measures were taken at baseline and after 5, 20, and 60 minutes in the prone position. The proportion of ventilation, regional filling characteristics, and global inhomogeneity index were calculated for the ventral and dorsal lung regions. Arterial blood gas measurements were taken before and after the intervention. A responder was defined as having an improvement of more than 10% in the oxygenation index after 60 minutes in prone position. Twelve children (nine male, 65%) were studied. Four children were responders, three were nonresponders, and five showed no change to prone positioning. Ventilation in ventral and dorsal lung regions was no different in the supine or prone positions between response groups. The proportion of ventilation in the dorsal lung increased from 49% to 57% in responders, while it became more equal between ventral and dorsal lung regions in the prone position in nonresponders. Responders showed greater improvements in ventilation homogeneity with R improving from 0.86 ± 0.24 to 0.98 ± 0.02 in the ventral lung and 0.91 ± 0.15 to 0.99 ± 0.01 in the dorsal lung region with time in the prone position. CONCLUSIONS: The response to prone position was variable in children with acute respiratory distress syndrome. Prone positioning improves homogeneity of ventilation and may result in recruitment of the dorsal lung regions.

The effect of positioning and diaphragmatic breathing exercises on respiratory muscle activity in people with chronic obstructive pulmonary disease.

BACKGROUND: Body positioning and diaphragmatic breathing may alter respiratory pattern and reduce dyspnoea in people with chronic obstructive pulmonary disease (COPD). OBJECTIVES: To determine the effect of positioning and diaphragmatic breathing on respiratory muscle activity in a convenience sample of people with COPD, using surface electromyography (sEMG). METHODS: This prospective descriptive study recorded sEMG measurements at baseline, after upright positioning, during diaphragmatic breathing and 5 minutes thereafter. Vital signs and levels of perceived dyspnoea were recorded at baseline and at the end of the study. Data were analysed using repeated measures ANOVAs with post hoc t-tests for dependent and independent variables. RESULTS: Eighteen participants (13 male; mean ± standard deviation age 59.0 ± 7.9 years) were enrolled. Total diaphragmatic activity did not change with repositioning (p = 0.2), but activity increased from 7.3 ± 4.2 µV at baseline to 10.0 ± 3.3 µV during diaphragmatic breathing (p = 0.006) with a subsequent reduction from baseline to 6.1 ± 3.5 µV (p = 0.007) at the final measurement. There was no change in intercostal muscle activity at different time points (p = 0.8). No adverse events occurred. Nutritional status significantly affected diaphragmatic activity (p = 0.004), with participants with normal body mass index (BMI) showing the greatest response to both positioning and diaphragmatic breathing. There were no significant changes in vital signs, except for a reduction in systolic/diastolic blood pressure from 139.6 ± 18.7/80.4 ± 13.0 to 126.0 ± 15.1/75.2 ± 14.7 (p < 0.05). CONCLUSION: A single session of diaphragmatic breathing transiently improved diaphragmatic muscle activity, with no associated reduction in dyspnoea.

The effects of prone and supine positions on the regional distribution of ventilation in infants and children using electrical impedance tomography.

BACKGROUND: Positioning of ill children is often used to optimise ventilation-perfusion matching, thereby improving oxygenation. OBJECTIVES: To determine the effects of supine and prone positions, and different head positions, on the distribution of ventilation in healthy, spontaneously breathing infants and children between the ages of 6 months and 9 years. METHODS: Electrical impedance tomography measurements were recorded from participants in supine and prone positions. Head positions included the head turned to the left and right in supine and prone positions, and in the midline in the supine position. Distribution of ventilation was described using end-expiratory-end-inspiratory relative impedance change. RESULTS: A total of 56 participants (boys = 31 [55%]; girls = 25 [45%]) were studied. The dorsal lung was significantly better ventilated than the ventral lung (P < 0.001) in both body positions. The majority of participants (83%) had greater ventilation in the dorsal lung in both positions, whilst five participants (10%) demonstrated consistently better ventilation in the non-dependent lung in both positions. Head position had no effect on the distribution of ventilation. CONCLUSIONS: This study demonstrates that the distribution of ventilation in healthy, spontaneously breathing infants and children in supine and prone positions is not as straightforward as previously thought, with no clear reversal of the adult pattern evident.

Challenging a paradigm: positional changes in ventilation distribution are highly variable in healthy infants and children.

RATIONALE: Current understanding is that infants and children preferentially ventilate non-dependent lungs, a reversal of that of adults, based on studies using krypton-81m ventilation scanning. Participants in these studies had lung disease and were either sedated or ventilated. There is little understanding of the distribution of ventilation in spontaneous breathing healthy infants and children. OBJECTIVES: This study aimed to determine the effects of side lying on the distribution of ventilation in healthy, spontaneously breathing infants and children between the ages of 6 months and 9 years. METHODS AND MEASUREMENTS: Measurements were taken using electrical impedance tomography (EIT) in supine, left and right side lying. Distribution of ventilation was described using end-expiratory to end-inspiratory relative impedance change. RESULTS: Fifty-six (31, 55% male) participants were studied. Nineteen (35%) participants consistently showed greater ventilation in the non-dependent lung, eight (15%) consistently showed greater ventilation in the dependent lung and 28 (51%) showed a varied pattern between left and right side lying. Overall, left side lying resulted in significantly better mean ventilation of the right (non-dependent) lung (P < 0.01). Distribution of ventilation in right side lying was relatively equal between left and right lungs. CONCLUSIONS: This study demonstrates that the distribution of ventilation in spontaneously breathing infants and children is not as straightforward as previously described. The distribution of ventilation was variably affected by body position with no clear reversal of the adult pattern evident.