Continuous Positive Pressure Research Articles

PRS29 Health Technology Assessment Report on Clinical Effectiveness of Continuous Positive Pressure Ventilation with Helmet Versus Standard Therapy in Patients with Respiratory Failure

To evaluate the clinical effectiveness continuous positive airway pressure (CPAP) with helmet in patients with acute respiratory failure. A computerized search of PubMed, Google Scholar and Cochrane was done from 1966 through August 2020, followed by analysis of the text words contained in the title and abstract. Secondly search using all identified keywords and index terms was done across all included databases. Thirdly, the reference list of all identified reports and articles was searched for additional studies. Studies in English language, were considered. Quantitative data was pooled in statistical meta-analysis using Cochrane Review Manager (RevMan). Effect sizes expressed as risk ratio with 95% confidence intervals was calculated for analysis. A total of 15 studies were included in this analysis. Use of the helmet was associated with lower hospital mortality, intubation rate, complications, increased oxygenation and reduces average length of stay. Risk Ratio for mortality {0.57, 95% CI (0.42 to 0.78) p=0.0004)}, for intubation {0.43, 95% CI (0.33 to 0.55), p=0.00001)}, for complications {0.79, 95%CI (0.59 to 1.04), p=0.09)}. The application of CPAP with the helmet can represent a valid pulmonary support in the adequate setting and with simple monitoring tools. A careful CPAP titration can optimize the recruitment of unventilated lung regions and improve hypoxemia, making it a suitable bridge to ICU or a supportive treatment to improve patients’ outcomes. A better tolerability of the helmet and a reduced room contamination compared with oronasal masks may also improve patients’ clinical management, increasing the safety of the healthcare workers involved in the assistance during the COVID-19 pandemic. The use of CPAP with helmet interface, when compared to the other standard therapies in the management of patients with ARDS, reduces intubation rates, mortality, complications, increases oxygenation and reduces and hospital costs.

MO167AN UNUSUAL COURSE OF A 2,8 DHA CRYSTAL INDUCED NEPHROPATHY

Abstract Background and Aims 2, 8 dihydroxyadenine (DHA) deposition is a less known etiology of crystal-induced nephropathy, caused by a deficiency in a purine salvage enzyme, the adenine phosphoribosyl transferase (APRT). DHA is an insoluble molecule in urine leading to crystal formation, tubular obstruction or stone formation. The disease manifests as a history of urolithiasis, chronic kidney disease and even loss of renal allograft when the disease is undiagnosed in native kidneys. The cornerstone of treatment is the inhibition of xanthine dehydrogenase reducing thus the formation of 2,8-DHA and its renal excretion. Method A 59-year-old obese Lebanese male patient, born to a consanguineously married couple, was admitted to another hospital with desaturation, a history of progressive shortness of breath and a creatinine level of 2,8 mg/dl. He had no hypertension nor diabetes. His family history was positive for a sister with ESRD of unknown etiology. He was discharged on oxygen and continuous airway positive pressure therapy for severe obstructive sleep apnea. His renal function deteriorated leading to a creatinine level of 9.8 mg/dl three months later. There were no signs of systemic disease, no gross hematuria, no fluid overload. His blood pressure was normal. Laboratory work up showed anemia, low grade proteinuria, intermittent microscopic hematuria and negative serological and immunological workup. Kidney ultrasound showed normal size kidneys with no evidence of collecting system dilatation or urolithiasis. Due to this atypical presentation, the patient was admitted for a renal biopsy with a creatinine level of 11 mg/dl upon admission. Results The renal biopsy showed tubulo-interstitial nephritis associated with numerous brown-green crystals by Haematoxylin and eosin of various shapes birefringent under polarized light with the characteristic “maltese cross”. Crystals were found within tubular lumens and cytoplasm, interstitium, and macrophages. These findings were characteristic of 2,8 DHA crystals deposition in the kidney. The patient was started on 120 mg of Febuxostat with a low purine and high fluid diet. A genetic testing showed a pathogenic homozygous variant in the APRT gene which causes an amino acid change from Glycine to Aspartate at position 63. Two weeks later the patient was admitted to the ICU with pneumonia, respiratory failure, a creatinine of 9 mg/dl and severe metabolic encephalopathy. He received 4 sessions of hemodialysis followed by an improvement in his kidney function with a creatinine level down to 3.2 mg/dl a month after his discharge and he remains off dialysis until now. Conclusion Around 400 cases are currently recognized worldwide, emphasizing the under recognition of this autosomal recessive disease. Considering that the homozygoty causing a complete APRT deficiency should range between 1/50 000 and 1/100 000 cases, this would translate in at least 80 000 cases worldwide. The variant found in our patient has previously been described as disease causing for APRT deficiency in four cases. Reviewing the phenotype of these cases we find differences in terms of presentation and evolution, highlighting the variability in the APRT deficiency phenotype and underlining the fact that no correlation between phenotype and genotype was reported to date even for the same type of mutation. This case report shows us that the initiation of an adequate therapy is necessary even at advanced stages of the disease since it can improve our kidney outcome.

Need for Screening Triglyceride Levels in Women on Oral Contraceptives

Introduction: Oral contraceptive pills (OCPs) are the most used form of reversible contraceptives by women. Major risks are cardiovascular but OCPs also cause secondary hypertriglyceridemia (HTG) through effects of estrogen, which decreases hepatic triglyceride lipase and lipoprotein lipase activity. This causes increased triglycerides, cholesterol and free fatty acids,1 which then in turn can lead to life-threatening acute pancreatitis. Case Description: A 23-year-old morbidly obese (BMI 38.2 mg/kg2) female presented with severe epigastric pain, nausea and vomiting. She had a history of mild intermittent asthma, recently diagnosed pre-diabetes and recently started on OCPs. Initial labs were consistent with diabetic ketoacidosis with glucose 528 mg/dL (65-115 mg/dL), anion gap 21 mEq/L (5-15 mEq), and beta-hydroxybutyrate 2.00 mmol/L (0.02-0.27 mmol/L); and acute pancreatitis with triglyceride 4,425 mg/dL (30-200 mg/dL) and lipase >600 U/L (8-78 UL), confirmed on imaging.She rapidly deteriorated, developing acute hypoxemic respiratory distress requiring intubation and distributive shock requiring three vasopressors. She progressed into multi-organ failure with acute respiratory distress syndrome, ischemic liver and acute renal failure despite insulin drip, colloidal fluid resuscitation, continuous veno-venous hemofiltration and high positive end-exploratory pressures. She developed rhabdomyolysis, followed by abdominal compartment syndrome requiring decompressive laparotomy that resulted in large volume blood loss and retroperitoneal necrosis needing multiple laparotomies. Ultimately, she became non-responsive off sedation, attributed to malignant cerebral edema that progressed to brain herniation.While HTG was likely the cause of her pancreatitis, she had normal triglyceride levels on prior routine lab work while not on OCPs. Discussion: Severe acute pancreatitis is a life-threatening complication of HTG which may be precipitated by use of OCPs. We believe that there is a need for more research in this field and even propose periodic monitoring of HTG in women taking OCPs given the severity of the consequences. While there are currently no guidelines for monitoring lipid levels in women on OCP, appropriate clinical awareness of physicians prescribing OCPs to patients may prevent fatal outcomes.

SARS-CoV-2 Trigger in Severe Insulin Resistance With Acute Haemolytic Crisis in Diabetes and Glucose-6-phosphate Dehydrogenase Deficiency

Background: We report a case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection as trigger for increased insulin resistance and severe haemolytic crisis in a male with type 2 diabetes mellitus and glucose-6-phosphate dehydrogenase (G6PD) deficiency. Clinical Case: A 64-year-old man (BMI 25kg/m2, weight 75kg) with past medical history of type 2 diabetes mellitus (on metformin and sitagliptin; glycated haemoglobin 51 mmol/mol, n<42mmol/mol), hypertension, G6PD deficiency and gout was admitted to hospital with COVID pneumonitis and type 1 respiratory failure giving 5 days’ history of cough, shortness of breath, fatigue and tiredness. As per hospital guidelines, the patient was treated with amoxicillin/clavulanate 625mg three times daily and doxycycline 100mg once daily. Hydroxycholoroquine was not given in view of G6PD deficiency. There was no evidence of diabetic ketoacidosis and a short-acting insulin sliding scale was initiated at 2U/hr. Continuous positive pressure ventilation was offered for next 72 hours, however the patient failed to improve and required transfer to intensive care unit for intubation and mechanical ventilation. Computer tomography scan of pulmonary artery excluded embolism. The patient was fed via nasogastric tube post intubation. On day 8, the patient experienced a sudden drop in haemoglobin levels from 132 g/dl on day 1 to 68 g/dl, requiring multiple blood transfusions. The blood results demonstrated evidence of haemolysis with a rise in total and direct bilirubin and lactate dehydrogenase levels. The peripheral blood smear showed numerous bite cells with polychromasia suggesting an acute haemolytic crisis in the context of G6PD deficiency. A medication review revealed no evidence of drug-induced haemolysis. Later the patient was started on dexamethasone 6mg once daily (day 11) and on remdesivir 100mg once daily (day 15). During this time, the patient’s insulin infusion requirements had progressively increased from 2U/hr to 8U/hr (equivalent to 192 units/24 hr). On day 22, the patient’s clinical condition deteriorated with septicaemia requiring extended course of antibiotics. At this time, continuous insulin infusion was stopped and intermediate acting insulin (insulatard 36U twice daily; later increased to 48U twice daily) was started. In the next 10 days, the patient made good clinical recovery from sepsis with stable haemoglobin and blood sugar levels. He was extubated and transferred for rehabilitation. The patient was successfully weaned off insulin in the community with optimal diabetes control. Conclusion: This is a case demonstrating the possible role of SARS-CoV-2 in increased insulin resistance and severe haemolytic crisis on background of diabetes and G6PD deficiency.

A narrative review of the experience and decision‐making for children on home mechanical ventilation

Technological advances in mechanical ventilation have made home care possible for children requiring long-term ventilation. However, there are ethical and logistical challenges to transitioning home. The aim of this narrative review is to identify the experiences of the children and their families and the decision-making process to embark on home mechanical ventilation. A systematic review of the literature using Medline and OVID databases was conducted. Children <18 years requiring non-invasive ventilation or tracheostomy with ventilation or continuous positive pressure ventilation were included. The initial search yielded 1351 results, 1017 after duplications were removed and 111 after abstracts were reviewed. After applying inclusion and exclusion criteria to full text analysis, 48 references were analysed. The children and families described home ventilation as facilitating better health and functional status. However, they concurrently described social isolation, stigma, financial stress and loss of independence. The decision-making process to embark on home ventilation needs more research.

Sleep-Based Interventions in Alzheimer's Disease: Promising Approaches from Prevention to Treatment along the Disease Trajectory.

The multifactorial nature of Alzheimer’s disease (AD) has led scientific researchers to focus on the modifiable and treatable risk factors of AD. Sleep fits into this context, given the bidirectional relationship with AD confirmed by several studies over the last years. Sleep disorders appear at an early stage of AD and continue throughout the entire course of the pathology. Specifically, sleep abnormalities, such as more fragmented sleep, increase in time of awakenings, worsening of sleep quality and primary sleep disorders raise with the severity and progression of AD. Intervening on sleep, therefore, means acting both with prevention strategies in the pre-clinical phase and with treatments during the course of the disease. This review explores sleep disturbances in the different stages of AD, starting from the pre-clinical stage. Particular attention is given to the empirical evidence investigating obstructive sleep apnea (OSA) disorder and the mechanisms overlapping and sharing with AD. Next, we discuss sleep-based intervention strategies in the healthy elderly population, mild cognitive impairment (MCI) and AD patients. We mention interventions related to behavioral strategies, combination therapies, and bright light therapy, leaving extensive space for new and raising evidence on continuous positive air pressure (CPAP) treatment effectiveness. Finally, we clarify the role of NREM sleep across the AD trajectory and consider the most recent studies based on the promising results of NREM sleep enhancement, which use innovative experimental designs and techniques.

ROLE OF HYPERTENSION, CARDIOVASCULAR DISEASE AND CARDIOVASCULAR RISK FACTORS ON OUTCOME IN HOSPITALIZED COVID-19 PATIENTS

Objective: Emerging data show that hypertension as well as other cardiovascular risk factors may have a major role on outcome in terms of death on patients with COVID-19. We analysed a population of 258 consecutive patients admitted to General Medicine ward of the Hospital of Montichiari (Brixia, Italy) from 29 February to 30 April 2020. Design and method: A group of 258 consecutive patients (173 males and 85 females, aged 71 ± 14) was enrolled. In 168 patients, high-flow oxygen was required (Venturi mask), 20 patients needed orotracheal intubation and 11 were given continuous positive pressure oxygen therapy (CPAP). Patients were treated with the best approach according to available evidence during pandemic period: anti-malaria agents, anti-viral drugs, antibiotics (azithromycin and others), tocilizumab and low molecular weight heparin (LMWH). As of June 10th, 65 deaths had been observed. Survival curves were calculated according to Kaplan-Meier method. Comparison between groups was performed with Breslow and Mantel-Cox test. Results: As shown in the table, a significant raise in mortality was observed in patients older than 65 years (p &lt; 0.001), of male sex (p &lt; 0.001), hypertensives (p &lt; 0.001) as well as in patients with heart disease (picture 1; p &lt; 0.001), COPD (picture 2; p = 0.004), diabetes (p &lt; 0.001) and neoplasms (p = 0.03) compared with patients with no comorbidities or different diseases, both at discharge and at standard follow-up. The number of comorbidities impacted on survival as well. Conclusions: Hypertension, heart disease and cardiovascular risk factors play a significant role as a negative prognostic factor in patients affected by SARS-CoV-2 pneumonia. This confirms previous observations (Pol Arch Intern Med 2020;130(4):304–309) and outlines the importance of prevention of contagion in population with cardiovascular risk factors or established cardiovascular disease.

LOW MOLECULAR WEIGHT HEPARIN AT HIGH DOSE IMPACTS ON OUTCOME OF COVID-19 HOSPITALIZED PATIENTS, WHILE STANDARD DOSE DOESN’T

Objective: COVID-19 is a new disease caused by pandemic SARS-CoV-2, that involves multiple organs and can cause a potentially fatal respiratory distress syndrome. Accumulating evidence point out that an “endothelitis” due to a cytokines storm causes intravascular thrombosis, especially in the lungs, and is related to the poor outcome. We tested possible relationships between anticoagulant treatment and/or administration of low molecular weight heparin (LMWH) at different doses and outcome in a population of 258 COVID-19 patients admitted from February 28th to April 30th, 2020 to General Medicine ward of the Hospital of Montichiari (Brixia, Italy). Design and method: A group of 258 consecutive patients (174 males and 84 females, mean age 71 years +/- 14) was included in the present study. In 168 patients, high-flow oxygen was required (Venturi mask), 6 patients needed orotracheal intubation and 20 were given continuous positive pressure oxygen therapy (CPAP). Patient were treated (unless a pulmonary embolism was detected) with different doses of prophylactic LMWH, according to emerging evidence during pandemic period. As of June 10th, 65 deaths had been observed. Survival curves were calculated according to Kaplan-Meier method. Comparison between groups was performed with Breslow and Mantel-Cox test. Results: LMWH at standard dose (4000 IU once daily) didn’t reduce mortality compared to no treatment (p = ns), while LMWH at a higher dose than usual prophylactic dose (enoxaparin 6000 IU once daily or 4000 IU bid) was associated with better outcome (p &lt; 0.001 vs untreated and treated with standard dose). Significance was confirmed adding patients treated with oral anti-coagulant (OAC)for any reason. None of the patients treated with LMWH at higher doses or OAC died. Conclusions: The administration of subcutaneous LMWH at a higher dose than indicated for deep vein thrombosis prophylaxis is associated with a better outcome in patients with SARS-CoV-2 pneumonia, confirming some emerging evidence.

Obstructive sleep apnea in microtia children with maxillofacial dysostosis

Children with microtia are often associated with maxillofacial dysostosis, such as Treacher Collins syndrome, Goldenhar syndrome, and Nager syndrome, and they are prone to suffer from obstructive sleep apnea（OSA）. Obstruction widely occurred in the upper airway is the main mechanism of OSA in these children, and dysplasia of the pharynx and neurodevelopmental abnormalities may also participate. Early diagnosis requires symptom screening and polysomnography. Imaging techniques and endoscopy can be adopted to fully assess the upper airway status to guide further treatment. According to the child's condition and the main obstruction site, treatment methods include maxillofacial deformity correction, continuous positive pressure ventilation and tracheotomy. OSA in microtia children with maxillofacial dysostosis needs to be identified and treated in time to reduce the adverse effects on the growth and development of children.

Veno-Venous Extracorporeal Membrane Oxygenation - Rapid Recovery for Post-Surgical Negative Pressure Pulmonary Edema

Introduction Postoperative pulmonary edema can be cardiogenic, non-cardiogenic or a combination of both. A major cause of noncardiogenic edema is negative pressure pulmonary edema (NPPE) due to inspiration against a closed glottis. Within minutes, patients can develop dyspnea and pink tinged frothy sputum. Risk factors include a short neck, obstructive sleep apnea, and previous ENT surgeries. There have also been a few case reports that demonstrate NPPE after the use of sevoflurane. Below we present a case of a young female who developed post-surgical NPPE which was managed with short-term veno-venous extracorporeal membrane oxygenation (V-V ECMO). Case Report A 30-year-old female with minimal past medical history was airlifted to the cardiovascular intensive care unit four hours after a condyloma removal under sevoflurane anesthesia with a laryngeal mask airway. The patient developed post-operative hypoxia and hemoptysis requiring intubation. A computerized tomography (CT) scan of the chest with contrast revealed ground-glass opacities concerning for diffuse alveolar hemorrhage (DAH). Upon arrival, a bronchoscopy with sequential lavages revealed persistently sanguineous fluid which pointed away from active alveolar hemorrhage. The ECMO team was consulted due to concerns for acute lung injury. Given the preserved cardiac function, the patient was placed on V-V ECMO for two days with rapid recovery of lung function. The patient was maintained on ventilator support for two additional days before being discharged on the fifth day. Summary The mainstay of treatment for NPPE is supportive care. Most patients require prolonged monitoring in the postanesthesia care unit and usually recover within a few hours with supplemental oxygen and continuous positive end-expiratory pressure. Occasionally, patients will need to be intubated. In this case, the post-procedural CT scan showed no signs of cardiogenic pulmonary edema, but rather DAH. Given ventilation difficulties with adequate cardiac function, the patient was an appropriate candidate for V-V ECMO. The DAH could possibly be due to sevoflurane but was more likely a consequence of NPPE. Regardless of the cause, the use of V-V ECMO is highly effective in allowing patients to rapidly recover respiratory function without long-term complications.

Effect of smoking on glucose, lipid metabolism and sleep structure in postoperative patients with obstructive sleep apnea

Objective:The aim of this study is to investigate the effect of smoking on the glucose, lipid metabolism and sleep structure in patients with moderate and severe obstructive sleep apnea （OSA） after operation. Methods:A retrospective analysis of 103 adult male patients with moderate to severe OSA who were diagnosed and treated from January 2016 to December 2017. All of them could not tolerate continuous positive pressure ventilation. After evaluation by an otolaryngologist, they underwent modified uvulapalatopharyngoplasty surgery. All participants were grouped according to smoking status（non-smokers, smokers） for analysis. Laboratory-based polysomnographic variables, anthropometric measurements, biochemical indicators, and smoking history, Epworth sleepiness score（ESS） were collected preoperatively and postoperatively. And the difference of each variable preoperatively and postoperatively was demonstrated as delta（Δ, calculated as postoperative value minus preoperative value）. Results:Fifteen patients with preoperative moderate OSA and 88 patients with severe OSA. The overall successful rate of surgery was 55.3%（18.4% cured, 23.3% markedly effective and 13.6% effective）, and there was no statistical difference between the non-smokers and the smokers（59.7% vs 48.9%, P=0.276）. After surgery, AHI, mean oxygen saturation, ODI, MAI, TC, FBG, fasting insulin, BMI, ESS, N1 and N3 were significantly improved（P<0.05）. The amelioration of glucose or lipid metabolism related traits（including ΔTC, ΔFBG, Δfasting insulin） were not significantly different between smokers and non-smokers. However, as to sleep structure, ΔN3 was significantly higher in non-smoker as compared to smokers（P=0.039）. Conclusion:Upper airway surgery is helpful to improve the glucose and lipid metabolism disorder and sleep structure in OSA patients. Postoperative smoking was associated with worse sleep structure, but not glycolipid metabolism. The postoperative improvement of sleep structure in non-smoking OSA patients was better than smokers.

Impact of CPAP treatment for a short period in moderate-to-severe OSAS patients: a randomized double-blind clinical trial

IntroductionObesity is the most frequent reversible agravating factor of obstructive sleep apnea syndrome, with physical activity very important for its control. Continuous positive air pressure during sleep is the “gold standard” treatment for obstructive sleep apnea syndrome. Objectivewe aimed to investigate if the use of continuous positive air pressure for a short period (7 days), would improve sleep quality, daytime sleepiness, and the disposition for physical activity. MethodsEighty obstructive sleep apnea syndrome patients were randomly assigned as follows: group I – continuous positive air pressure with a steady pressure of 4 cm H2O; group II – ideal therapeutic pressure. After filling out the questionnaires related to the studied variables (International physical activity questionnaire long-form, Epworth sleepiness scale, Pittsburgh sleep quality index), patients underwent a baseline pulmonary function test and continuous positive air pressure titration. After continuous positive air pressure therapy for 4≥ hours a night for 7 consecutive days, patients returned and filled out new (International physical activity questionnaire long-form, Epworth sleepiness scale, Pittsburgh sleep quality index) forms. New spirometry was carried out. Results39 patients completed the study. The mean age was 52 ± 11 years old and 28 patients (71.79%) were obese. Both groups were similar for all variables studied at baseline. After Continuous positive air pressure use, patients of group II presented more significant improvements (p < 0.05) for sleep quality and diurnal sleepiness. Time spent with physical activities did not change. Spirometric data were at normal range at baseline. Solely the variable FEF 25%–75% was significantly enhanced (p < 0.05) in group II. ConclusionContinuous positive air pressure therapy for 1 week, with ideal pressure, improves daytime sleepiness and sleep quality, enhances pulmonary function, but does not change the mean time spent with physical activities.

Reversibility of retinochoroidal vascular alteration in patients with obstructive sleep apnea after continuous positive air pressure and surgical intervention.

Purpose:The aim of this work was to study various retinochoroidal parameters in patients with obstructive sleep apnea syndrome (OSAS) and the effect of interventions on these parameters at 6 months follow-up.Methods:A total of 36 patients were recruited prospectively from the otorhinolaryngology clinics of a large tertiary center between September 2018 to March 2020. The subjects were divided into three groups depending upon intervention chosen for OSAS: Group A (surgery, i.e., uvulopalatopharyngoplasty), group B (medical therapy, i.e., continuous positive air pressure) and group C (no intervention). Various retinochoroidal parameters which were studied included retinal thickness (RT), choroidal thickness (CT), choroidal vascularity index (CVI), arteriovenous ratio (AVR), capillary density index (CDI) in superficial and deep retina, at baseline and 6 months of follow-up after the intervention.Results:In group A, CT increased significantly at 6 months (332.76 ± 86.41 um) compared to baseline (306.28 ± 78.19) (P = 0.0004). Similarly, CDI at both superficial and deep capillary plexus increased significantly at 6 months (superficial CDI: 0.65 ± 0.04, deep CDI: 0.38 ± 0.01) compared to baseline (superficial CDI: 0.62 ± 0.03, deep CDI: 0.36 ± 0.02) (P = 0.004 and 0.002 respectively). In group B, CT increased significantly at 6 months (361.38 ± 78.63 um) compared to baseline (324.21 ± 76.97 um) (P = 0.008). Also, CVI showed a significant decrease at 6 months (65.74 ± 1.84%) compared to baseline (67.36 ± 1.57%) (P = 0.019). In group C, all except CDI in deep capillary plexus showed a significant decrease at 6 months (0.35 ± 0.01) compared to baseline (0.36 ± 0.02) (P = 0.003).Conclusion:OSAS alters various retinochoroidal parameters and timely intervention in patients with OSAS can prevent these alterations. Also, these retinochoroidal parameters could serve as one of the markers to monitor the disease progression.

Correlation between continuous Positive end-expiratory pressure (PEEP) values and occurrence of Pneumothorax and Pneumomediastinum in SARS-CoV2 patients during non-invasive ventilation with Helmet.

Background:Acute Hypoxemic Respiratory Failure is a common complication of SARS-CoV2 related pneumonia, for which non-invasive ventilation (NIV) with Helmet Continuous Positive Airway Pressure (CPAP) is widely used. The frequency of pneumothorax in SARS-CoV2 was reported in 0.95% of hospitalized patients in 6% of mechanically ventilated patients, and in 1% of a post-mortem case series.Objectives:Aim of our retrospective study was to investigate the incidence of pneumothorax and pneumomediastinum (PNX/PNM) in SARS-CoV2 pneumonia patients treated with Helmet CPAP. Moreover, we examined the correlation between PNX/PNM and Positive end-expiratory pressure (PEEP) values.Methods:We collected data from patients admitted to “Luigi Sacco” University Hospital of Milan from 2 February to 5 May 2020 with SARS-CoV2 pneumonia requiring CPAP. Patients, who need NIV with bi-level pressure or endotracheal intubation (ETI) for any reason except those who needed ETI after PNX/PNM, were excluded. Population was divided in two groups according to PEEP level used (≤10 cmH2O and >10 cmH20).Results:154 patients were enrolled. In the overall population, 42 patients (27%) were treated with High-PEEP (>10 cmH2O), and 112 with Low-PEEP (≤10 cmH2O). During hospitalization 3 PNX and 2 PNM occurred (3.2%). Out of these five patients, 2 needed invasive ventilation after PNX and died. All the PNX/PNM occurred in the High-PEEP group (5/37 vs 0/112, p<0,001).Conclusion:The incidence of PNX appears to be lower in SARS-CoV2 than SARS and MERS. Considering the association of PNX/PNM with high PEEP we suggest using the lower PEEP as possible to prevent these complications.

A review of respiratory manifestations and their management in Ehlers-Danlos syndromes and hypermobility spectrum disorders.

Background:Ehlers-Danlos Syndromes (EDS) and Hypermobility Spectrum Disorders (HSD) are a heterogeneous group of heritable genetic connective tissue disorders with multiple characteristics including joint hypermobility, tissue fragility, and multiple organ dysfunction. Respiratory manifestations have been described in EDS patients, but have not been systematically characterized. A narrative review was undertaken to describe the respiratory presentations and management strategies of individuals with EDS and HSD.Methods:A broad literature search of Medline, Embase, Cochrane Database of Systematic Reviews, and Cochrane CENTRAL was undertaken from inception to November 2020 of all study types, evaluating EDS/ HSD and pulmonary conditions. This narrative review was limited to adult patients and publications in English.Results:Respiratory manifestations have generally been described in hypermobile EDS (hEDS), classical and vascular EDS subtypes. Depending on EDS subtype, they may include but are not limited to dyspnea, dysphonia, asthma, sleep apnea, and reduced respiratory muscle function, with hemothorax and pneumothorax often observed with vascular EDS. Respiratory manifestations in HSD have been less frequently characterized in the literature, but exertional dyspnea is the more common symptom described. Respiratory symptoms in EDS can have an adverse impact on quality of life. The respiratory management of EDS patients has followed standard approaches with thoracotomy tubes and pleurodesis for pleural manifestations, vocal cord strengthening exercises, continuous positive pressure support for sleep apnea, and exercise training. Reduced respiratory muscle function in hEDS patients responds to inspiratory muscle training.Conclusion:Respiratory symptoms and manifestations are described in EDS and HSD, and have generally been managed using conservative non-surgical strategies. Research into the prevalence, incidence and specific respiratory management strategies in EDS and HSD is needed to mitigate some of the associated morbidity.

Design of powered air purifying respirator used for healthcare workers in isolation room

From December 2019, the COVID-19 outbreak has rapidly spread throughout the whole world and become a devastating infectious diseases, with the risk of cross infection quickly and no drug treatment is available. Some countries have been facing shortage of medical equipment, which leads to millions of deaths and may put healthcare workers at risk of infection when they caring for patients sicked with COVID-19 in isolation room, so need to ensure their occupational health and safety. In order to solve this problem, the paper presents a design of Powered Air Purifying Respirator (PAPR) to prevent cross-contamination COVID-19 infection in isolation room, protect for occupational health and safety of healthcare workers. That is specialized equipment for medical industry using ambient air as energy source to operate, the device removes contaminated air through the filters and UVC germicidal light bulbs, then provides clean air to the user's face through blower. It creates continuous positive pressure, and this positive pressure prevents outside contaminated air to a face, but it must be com ply with the safety standards of NIOSH. Especially, this design can be used in case of an emergency, lack of medical supplies and equipment because it can be connected to commercially available masks through a hose connector and a respiratory hose. In case the device does not work or out of battery, a mask accompanied by a hose connector can be connected to the breathing tubes placed in isolation room, all these breathing tubes use clean air from heating, ventilating, and air conditioning (HVAC) of isolation room. Simulations and experiments are attached below to compare the difference between ideal parameters and actual results. From which to draw conclusions and development directions of the research.

The prognostic value of chest X-ray in patients with COVID-19 on admission and when starting CPAP

The objective was to explore if chest X-ray severity, assessed using a validated scoring system, predicts patient outcome on admission and when starting continuous positive pressure ventilation (CPAP) for COVID-19. The study was a retrospective case-controlled study. There were 163 patients with COVID-19 deemed candidates for CPAP on admission, including 58 who subsequently required CPAP. On admission, we measured the proportion of patients meeting a composite 'negative' outcome of requiring CPAP, intubation or dying versus successful ward-based care. For those escalated to CPAP, 'negative' outcomes were intubation or death versus successful de-escalation of respiratory support. Our results were stratified into tertiles, those with 'moderate' or 'severe' X-rays on admission had significantly higher odds of negative outcome versus 'mild' (odds ratio (OR) 2.32; 95% confidence interval (CI) 1.121-4.803; p=0.023; and OR 3.600; 95% CI 1.681-7.708; p=0.001, respectively). This could not be demonstrated in those commencing CPAP (OR 0.976; 95% CI 0.754-1.264; p=0.856). We outline a scoring system to stratify X-rays by severity and directly link this to prognosis. However, we were unable to demonstrate this association in the patients commencing CPAP.

Alternative CPAP methods for the treatment of secondary serious respiratory failure due to pneumonia by COVID-19

IntroductionThe use of devices that provide continuous positive pressure in the airway has shown improvement in various pathologies that cause respiratory failure. In the COVID 19 pandemic episode the use of these devices has become widespread, but, due to the shortage of conventional CPAP devices, alternative devices have been manufactured. The objective of this study is to describe the use of these devices, as well as their efficacy. Material and methodsData are collected from patients admitted for Pneumonia due to COVID 19 at the IFEMA Field Hospital. Data are collected from 23 patients with respiratory failure and need for ventilatory support. ResultsStudy carried out on a total of 23 patients, dated admission to IFEMA. Alternative CPAP was used in five patients (21.7%), while ventilatory support with a reservoir mask or Ventimask Venturi effect was used in the remaining 18 patients (78.3%). A progressive increase in saturation is observed in those patients in whom alternative CPAP was used (from 94% on average to 98% and 99% on average after 30 and 60 min with the mask, respectively), although this change was not significant (p = 0.058 and p = 0.122 respectively). No significant change in RF was observed at the beginning and end of the measurement in patients who used alternative CPAP (p = 0.423), but among those who did not use alternative CPAP (p = 0.001). A statistically significant improvement in the variable oxygen saturation / fraction inspired by oxygen is observed in patients who used alternative CPAP (p = 0.040) ConclusionThe use of these devices has helped the ventilatory work of several patients by improving their oxygenation parameters. To better observe the evolution of patients undergoing this therapy and compare them with patients with other types of ventilatory support, further studies are necessary.

Abstract 205: Effect of Prehospital Noninvasive Positive Pressure Ventilation for Rescue of Acute Respiratory Distress

Background: Emergency medical services (EMS) patients in respiratory distress require prompt rescue treatment. Only limited data describe the outcomes of prehospital rescue treatment with non-invasive positive pressure ventilation (NIPPV), including continuous positive airway pressure (CPAP) or bilevel positive air pressure (BiPAP). We sought to characterize the outcomes of prehospital CPAP/BiPAP in a national EMS cohort. Methods: We analyzed 2018 cross-sectional data on 1289 EMS agencies from ESO Solutions, Inc. (Austin, Texas). We included adult (age ≥18 years) patients with respiratory distress (respiratory rate (RR) ≥30 breaths/min. We divided the patients between those receiving NIPPV and standard care (SC). The primary outcome was change in RR during EMS care. We censored the analysis at 40 minutes of treatment. We compared baseline characteristics between NIPPV and SC. Using mixed linear, fractional polynomial and multiple spline models, we determined the associations of prehospital NIPPV with changes in RR. Results: Of the 6,156,846 adult 911 cases, we included 87,219 with respiratory distress, including 11,271 (12.9%) NIPPV (11,206 CPAP and 65 BiPAP) and 75,948 (87.1%) SC. Median treatment duration were: NIPPV 20.0 minutes (IQR 13.5-29.2 minutes), SC 18.5 minutes (IQR 11.1-27.6 minutes). Common concurrent treatments for NIPPV and SC included: Albuterol (48.6%, 20.9%), Ipratropium (27.9%, 11.2%) and Methylprednisolone (23.7%, 7.8%). At 20 minutes, mean RR change was greater for SC than NIPPV; SC -7.8 breaths/min vs. NIPPV -6.0 breaths/min, difference 2.3 (95% CI 1.9-2.6), p&lt;0.001. At 40 minutes, mean RR change was greater for SC than NIPPV; SC -9.5 breaths/min vs. NIPPV -8.2 breaths/min, difference 1.6 (95% CI 0.8 - 2.5), p&lt;0.001. On linear mixed modeling adjusted for age, sex, incident location, race, ethnicity, agency type, initial RR, and medication use, SC was associated with a larger decrease in respiratory rate across time than NIPPV; [NIPPV X time] interaction p&lt;0.001. Conclusions: In this multicenter series of prehospital respiratory distress, SC was associated with greater reductions in RR than NIPPV.

Abstract 12728: Untreated Sleep Apnea Syndrome is Associated With Higher Incidence of Cardiovascular Events After Percutaneous Coronary Intervention

Introduction: Sleep apnea syndrome (SAS) is a risk factor of cardiovascular disease. However, the impact of SAS on the clinical course after percutaneous coronary intervention (PCI) remains to be elucidated. Methods: A total of 206 consecutive patients who underwent PCI were included. The incidence of major adverse cardiovascular events (MACE) at 3-year was compared among patients with untreated SAS (untreated SAS group; n=60), those with SAS treated by continuous positive alveolar pressure (CPAP group; n=20) and those without SAS (non-SAS group; n=96). MACE included cardiac death, non-fatal myocardial infarction, target vessel revascularization (TVR), and non-TVR (NTVR). Results: There was no significant difference in baseline clinical characteristics among the untreated SAS group, the CPAP group and the non-SAS groups, other than in age (74.1 ± 9.6 vs. 71.2 ± 0.33 vs. 68.2 ± 10.7, p = 0.002) and hemoglobin A1c levels (6.54 ± 0.87 vs. 6.61 ± 0.58 vs. 6.09 ± 0.70 %, p &lt; 0.001). The incidence of MACE, TLR and TVR was significantly higher in the untreated SAS group than in the CPAP group and the Non-SAS group although there was no significant difference in the incidence of NTVR among the three groups (Figure). The untreated SAS was independently associated with the incidence of 3-year MACE (odds ratio 3.24, 95% confidence interval 1.36-8.20, p = 0.008). Conclusions: The incidence of MACE was significantly higher in patients with untreated SAS than in those treated with CPAP and those without SAS after PCI. The present findings may highlight the importance of SAS management in patients requiring PCI.