Correction Of Hypoxemia Research Articles

2023 Year in Review: Home Oxygen Therapy.

Long-term oxygen therapy (LTOT) is a treatment that involves the provision of supplemental oxygen to individuals with respiratory disease to correct hypoxemia in the post-acute care environment. Over 1.5 million adults in the United States use supplemental oxygen for various respiratory disorders. This paper explores literature published on LTOT from September 2022-September 2023. Upon the conclusion of this literature review, 4 distinct categories emerged. This paper highlights the significant findings associated with the 4 categories: supplemental oxygen and COVID-19, telemonitoring, LTOT equipment, and in-home high-flow nasal cannula.

Effectiveness of Continuous Positive Airway Pressure in Alleviating Hypoxemia and Improving Exertional Capacity at Altitude.

Strickland, Brian, Elan Small, Mary Ryan, and Ryan Paterson. Effectiveness of continuous positive airway pressure in alleviating hypoxemia and improving exertional capacity at altitude. High Alt Med Biol. 00:000-000, 2024. Introduction: Decreased oxygen saturation and exercise tolerance are commonly experienced at high altitude. Continuous positive airway pressure (CPAP) devices have become increasingly portable and battery powered, providing a potentially unique new therapeutic modality for treatment of altitude-related illnesses. This study evaluated the potential use of CPAP devices to improve and maintain oxygen saturation at altitude, both at rest and with exertion, to evaluate the feasibility of using this device at altitude. Methods: Subjects were taken to Mount Blue Sky and monitored while they hiked to the summit (4,350 m), maintaining a consistent level of exertion. Subjects hiked for 0.7 km both with and without CPAP set to 10 cmH2O pressure. Continuous vital signs were collected during the hike and recovery period. Results: All subjects completed the hike wearing CPAP devices at a vigorous level of exertion. Mean oxygen saturation of the CPAP group (M = 83.8%, SD = 3.72) was significantly higher than that of the control group during exertion (M = 78.7%, SD = 2.97); p = 0.005. Recovery after exertion was quicker in the CPAP group than the control group. Three subjects experienced claustrophobia requiring a brief pause, but were able to complete their exercise trial without removing equipment or experiencing adverse events. When pauses from claustrophobia were excluded, there was no difference in completion time between the groups (p = 0.06). Conclusion: CPAP reliably improved oxygen saturation at rest and during vigorous exertion at high altitude. Its ability to correct hypoxemia, even with physical exertion, may prove useful after further study as a portable self-carried device to prevent and treat altitude-related illness, or to improve safety in high-altitude rescues.

Pathophysiological features of neuroendocrine tumors in cyanotic congenital heart disease: a systematic review

Abstract Background Patients with cyanotic congenital heart disease (CCHD) have an increased risk to develop pheochromocytomas or paragangliomas (PPGL), which are rare neuroendocrine tumours molecularly driven by the activation of the hypoxia-inducible factor 2-alpha (HIF-2α ). Purpose To define the clinical characteristics of CCHD-PPGL patients. Methods An international multicentre CCHD-PPGL consortium from 8 countries was stablished. The group performed a systematic review of clinic-pathological features of 149 CCHD-PPGL cases and compared to 1559 CCHD non-PPGL patients. Results CCHD-PPGL were predominantly women (56.4%) with univentricular heart (UVH) (55.0%), followed by tetralogy of Fallot (23.5%). Most patients remained unoperated (28.6%) or had only undergone a palliative procedure (25.8%), and the mean saturation at diagnosis was 84.0%. The median age at PPGL diagnosis was 27.0 yo [20-38]. Pheochromocytoma (PCC) occurred in 36.9% of patients, abdominal or thoracic paraganglioma (TA-PGL) in 40.3%, carotid body paraganglioma (CB-PGL) in 14.7% and a combination in 8.0%. Most CB-PGLs were non-secreting, non-symptomatic tumors while PCC and TA-PGL were mostly noradrenalin-secreting and symptomatic tumors. Metastatic disease was documented in 10.3% of non-CB and none in CB-PGL . Comparing to patients with PCC or TA-PGL, CB-PGL patients were predominantly female (81.8% vs 52.0%), older at time of diagnosis (43 yo [36.0 – 52.0] vs 25.0 yo [19.0-35.0], p<0.01) and with a longer period of cyanosis at diagnosis (37.0 [23-47] vs 23.0 [13-46], p<0.01). Patients with Fontan procedure were mostly men (63.3%) who developed a noradrenalin-secreting PCC or a TA-PGL (42.0% and 58.0% respectively) at an earlier age than non-Fontan patients (22.0yo [18.0-27.0] vs 29.0yo [21.0-41.0], p<0.01). Patients with Eisenmenger physiology were female patients (100%) who developed mostly CB-PGL, non-secreting tumors (54.5%) and were older at diagnosis (48.0 yo [42-58]). Compared to a cohort of 1599 CCHD non- PPGL patients, CCHD-PPGL were predominantly women (57.7% vs 44.8%, p<0.01), with forms of UVH (53.7% in CCHD-PPGL vs 14.1% in CCHD, p <0.01 ) and were mainly unoperated and palliated patients (27.1% and 26.4% respectively vs 10.0% and 5.3% in CCHD, p <0.01). CCHD-PPGL patients showed lower levels of oxygen saturation (80.0% [76.0-85.0] vs 84.0% [80.0-88.0], p<0.01) and higher haematocrit levels (60.0% [52.0-66.5] vs 53.3% [46.3-62.0], p<0.01) than CCHD without PPGL. Conclusions Patients with CCHD and lifelong cyanosis, and especially those with Eisenmenger physiology, probably develop CB-PGL as an adaptive response to chronic systemic hypoxemia, present a good clinical course, and usually do not require an initial surgical approach. In patients with Fontan circulation, the risk of developing a sympathetic thoracic-abdominal PPGL persists, despite correction of hypoxemia, possibly due to the initial hypoxemia during adrenal medulla post-natal development.

Herramientas docentes en medicina intensiva: chatGPT

Asthma exacerbations can be life-threatening, with 25,000 to 50,000 such patients per year requiring admission to an ICU in the United States. Appropriate triage of life-threatening asthma is dependent on both static assessment of airway function and dynamic assessment of response to therapy. Treatment strategies focus on achieving effective bronchodilation with inhaled β2-agonists, muscarinic antagonists, and magnesium sulphate while reducing inflammation with systemic corticosteroids. Correction of hypoxemia and hypercapnia, a key in managing life-threatening asthma, occasionally requires the incorporation of noninvasive mechanical ventilation to decrease the work of breathing. Endotracheal intubation and mechanical ventilation should not be delayed if clinical improvement is not achieved with conservative therapies. However, mechanical ventilation in these patients often requires controlled hypoventilation, adequate sedation, and occasional use of muscle relaxation to avoid dynamic hyperinflation, which can result in barotrauma or volutrauma. Sedation with ketamine or propofol is preferred because of their potential bronchodilation properties. In this review, we outline strategies for the assessment and management of patients with acute life-threatening asthma focusing on those requiring admission to the ICU.

The role of microbial biofilms in the development of respiratory system complications in patients with COVID-19: A literature review

One of the complications of COVID-19 is the development of acute respiratory failure, which may require artificial ventilation using an endotracheal tube to correct hypoxaemia. However, the establishment of biofilms during intubation of patients can pose a risk of microbial growth that can cause severe complications. Therefore, the research on the microbial composition of biofilms that causes such diseases becomes an urgent issue. The purpose of the research was to analyse and summarise the data from current studies on the role of microbial biofilms and their impact on the development of respiratory system complications in patients with COVID-19. After reviewing the literature, it was determined that Staphylococcus epidermidis, Enterococcus faecalis, Pseudomonas aeruginosa and Candida albicans accounted for the majority of biofilms isolated from endotracheal tubes in patients with COVID-19. The level of antimicrobial resistance among the isolated strains was almost 70%. The examination of samples from endotracheal tubes identified representatives of the lung microbiome, Prevotella spp. and some species of Streptococcus, Veillonella. However, in the research on the microbial composition of biofilms isolated from endotracheal tubes, pathogenic representatives dominated, such as Pseudomonas spp., Staphylococcus spp., Streptococcus spp., Stenotrophomonas spp., Enterobacterales, Haemophilus spp. and Actinomyces spp. Changes in the composition of the lung microbiome in patients with COVID-19 can lead to the development of severe complications accompanied by the establishment of biofilms. Microorganisms in biofilms can be a reservoir for secondary pulmonary infections, which affects the duration of mechanical ventilation and the admission of patients with COVID-19 to intensive care units. The development and implementation of effective measures for the prevention and treatment of biofilm-related infections is an important task for modern medical practice

Comparison of the efficacy of high-flow oxygen insufflations and continuous positive airway pressure during one-lung ventilation undergoing video-assisted thoracoscopic surgery

Isolation of one-lung leads to ventilation-perfusion mismatch and increases intrapulmonary shunt, which in some cases may lead to clinically significant hypoxemia.The objective was to compare the efficacy of hypoxemia correction and the convenience of surgical work during one-lung ventilation with the use of high-flow oxygen insufflation (HFI) and continuous positive airway pressure (CPAP) in the non-ventilated lung during video-assisted thoracoscopic surgery (VATS).Materials and methods. The study included 60 patients who underwent surgical intervention in the form of VATS lobectomy. All studied patients were randomly divided into two groups: group 1 included patients who received HFI into non-ventilated lung to correct hypoxemia, and group 2 – CPAP into non-ventilated lung. The study was divided into four stages. Stage I – two-lung ventilation. Stage II – one-lung ventilation. At stage III, HFI of 60 L/min (FiO2 = 0,5) into non-ventilated lung was used to correct hypoxemia in group 1, and CPAP of 5 cm H2O into non-ventilated lung was used in group 2. At stage IV, HFI of 30 L/min (FiO2 = 0,5) into non-ventilated lung was used to correct hypoxemia in group 1, and CPAP of 2 cm H2O into non-ventilated lung was used in group 2. The following parameters were recorded during the stages of the study: PaO2, PaCO2, SpO2, Qs/Qt, and surgical team satisfaction with lung collapse by 10-point visual analogue scale (VAS).Results. At stages I and II, there was no statistically significant difference between groups in such parameters as PaO2, PaCO2, SaO2, and SpO2 (p > 0.05). Starting from stage III, a statistically significant difference between the two groups was found for a parameter PaO2 (U 26.0; Z = –6.27; p < 0.001). For group 1, it was equal to 134.5 (126.0; 141.75) and for group 2 – 108.5 (104.0; 114.5) correspondingly. At stage IV, the values of PaO2 were higher in group 1: 118.5 (113.0; 122.25) vs 92.5 (89.0; 98.25) in group 2 (U 0.0; Z = –6.66; p < 0.001). When comparing PaCO2 between the two groups, there were no statistically significant differences at all stages (p > 0.35). When comparing SaO2 at stages I (U 450.0; Z = 0.0; p = 1.0), II (U 422.5; Z = –0.4; p = 0.69), III (U 339.0; Z = –1.8; p = 0.69), no statistically significant differences were indicated between the two groups. However, at stage IV, the value of SaO2 was higher (97 (96; 97)) in group 1 than in group 2 (94 (94; 95)), U 69.5; Z = –5.75; p < 0.001. When comparing SpO2 between the two groups, there was no statistical difference at all stages (p > 0.69). Comparing the two groups by such indicator as Qs/Qt, no statistically significant differences were found at the first three stages (p > 0.4). A comparison of Qs/Qt at stage IV revealed statistically significant differences (U 69.0; Z = –5.6; p < 0.001). This parameter was equal to 10.7% (9.5; 15.7) in group 1 and 21.3% (18.4; 23.9) in group 2 correspondingly. When assessing surgical team satisfaction levels with surgical field visualization by VAS, there were statistically significant differences between group 1 and group 2 at stage III (p < 0.001) and stage IV (p < 0.001). The satisfaction level was significantly higher in group 1.Conclusions. The usage of high-flow oxygen insufflation during one-lung ventilation undergoing VATS allows to effectively correcting hypoxemia similar to the CPAP method, but as opposed to CPAP, it can provide comfortable conditions for carrying out the surgical procedures.

Effect of remimazolam tosilate on the incidence of hypoxemia in elderly patients undergoing gastrointestinal endoscopy: A bi-center, prospective, randomized controlled study.

Background: Remimazolam tosilate is a new ultra-short-acting benzodiazepine sedative medicine. In this study, we evaluated the effect of remimazolam tosilate on the incidence of hypoxemia during sedation in elderly patients undergoing gastrointestinal endoscopy. Methods: Patients in the remimazolam group received an initial dose of 0.1mg/kg and a bolus dose of 2.5mg of remimazolam tosilate, whereas patients in the propofol group received an initial dose of 1.5mg/kg and a bolus dose of 0.5mg/kg of propofol. Patients received ASA standard monitoring (heart-rate, non-invasive blood pressure, and pulse oxygen saturation) during the entire examination process. The primary outcome was the incidence of moderate hypoxemia (defined as 85%≤ SpO2< 90%, >15s) during the gastrointestinal endoscopy. The secondary outcomes included the incidence of mild hypoxemia (defined as SpO2 90%-94%) and severe hypoxemia (defined as SpO2< 85%, >15s), the lowest pulse oxygen saturation, airway maneuvers used to correct hypoxemia, patient's hemodynamic as well as other adverse events. Results: 107 elderly patients (67.6 ± 5.7years old) in the remimazolam group and 109 elderly patients (67.5 ± 4.9years old) in the propofol group were analyzed. The incidence of moderate hypoxemia was 2.8% in the remimazolam group and 17.4% in the propofol group (relative risk [RR] = 0.161; 95% confidence interval [CI], 0.049 to 0.528; p < 0.001). The frequency of mild hypoxemia was less in the remimazolam group, but not statistically significant (9.3% vs. 14.7%; RR = 0.637; 95% CI, 0.303 to 1.339; p = 0.228). There was no significant difference in the incidence of severe hypoxemia between the two groups (4.7% vs. 5.5%; RR = 0.849; 95% CI, 0.267 to 2.698; p = 0.781). The median lowest SpO2 during the examination was 98% (IQR, 96.0%-99.0%) in patients in the remimazolam group, which was significantly higher than in patients in the propofol group (96%, IQR, 92.0%-99.0%, p < 0.001). Patients in the remimazolam group received more drug supplementation during endoscopy than patients in the propofol group (p = 0.014). There was a statistically significant difference in the incidence of hypotension between the two groups (2.8% vs. 12.8%; RR = 0.218; 95% CI, 0.065 to 0.738; p = 0.006). No significant differences were found in the incidence of adverse events such as nausea and vomiting, dizziness, and prolonged sedation. Conclusion: This study explored the safety of remimazolam compared with propofol during gastrointestinal endoscopy in elderly patients. Despite the increased supplemental doses during sedation, remimazolam improved risk of moderate hypoxemia (i.e., 85%≤ SpO2 < 90%) and hypotension in elderly patients.

A novel strategy to reduce the recirculation of venovenous extracorporeal membrane oxygenation: Inferior vena cava closure technology.

The recirculation of venovenous extracorporeal membrane oxygenation (VV-ECMO) will decrease the efficiency of respiratory support. We report a patient with refractory severe acute respiratory distress syndrome (ARDS). Even with the support of ECMO and mechanical ventilation (MV), it is still difficult to correct hypoxemia. In this case, we placed a balloon catheter above the ECMO drainage cannula in inferior vena cava (IVC), and then occlusion the IVC with the water-filled balloon. After the occlusion, the patient's hypoxemia was quickly improved, and angiography proved that the recirculation has been significantly reduced. In this case, IVC occlusion technology greatly reduces recirculation. Its advantages lie in simple operation, low cost, short term safety, which probably act as an innovative method to reduce recirculation.

Insuficiencia respiratoria crónica

The term chronic respiratory failure denotes a failure in the basic functions of gas exchange: the oxygenation of arterial blood and/or elimination of carbon dioxide. It can be classified as acute or chronic according to its time of onset, although the true difference is that compensatory mechanisms for tissue hypoxia are activated in the chronic form. The diagnosis is made by means of an arterial blood gas test and the possible etiologies comprise a very broad differential diagnosis which includes respiratory, cardiological, oncological, and neuromuscular diseases. The treatment of chronic respiratory failure is based on three fundamental pillars: general measures (among which stopping smoking is of note); optimization of the treatment for underlying disease and its complications; and the correction of hypoxemia and hypercapnia, mainly through oxygen therapy and mechanical ventilation.

Exome sequencing contributes to identify comorbidities in a rare case of infant ARDS induced by the CD40LG mutation

BackgroundAcute respiratory distress syndrome (ARDS) causes significant mortality in young children with certain diseases. Early diagnosis and treatment can reduce infant mortality. Here, we report a rare case of exome sequencing in the early diagnosis of immunodeficiency in an infant.Case presentationA four-month-old full-term male infant presented with severe shortness of breath, hypoxemia, and unexplained parenchymal lung lesions. A series of examinations were performed to search for potential culprit viruses but negative results were obtained with the only exception being the rhinovirus that tested positive. The child’s family history revealed he had a brother who died of severe infection at the age of two years. We performed an exome sequencing analysis and a mutation analysis of CD40LG to obtain genetic data on the patient. Besides, we used flow cytometry to measure the CD40LG expression levels of activated T cells. A retrospective review of all the CD40LG mutant-induced X-linked hyper IgM syndromes (XHIGM) had been conducted to assess the differences between clinical and genetic molecular features. Finally, a regular intravenous immunoglobulin (IVIG) regimen led to steady breathing, the correction of hypoxemia, and a progressive improvement of lung CT scans. During follow-up, the patient received an IVIG regimen and his CT images improved. Moreover, his parents took advantage of pre-implantation genetic testing with in vitro fertilization to have a healthy twin offspring who did not carry such a mutation according to the early exome sequencing for the proband. Compared with other CD40LG mutant cases in our center, this proband displayed a normal plasma immunoglobulin level and he should be the youngest infant to have a molecular diagnosis of XHIGM.ConclusionUsually, XHIGM would not be suspected with a normal plasma immunoglobulin concentration. However, as we could not identify a potential comorbidity or risk factor, exome sequencing helps target this patient's real facts. Thus, this case report calls for exome sequencing to be performed in the case of unexplained infections when immunodeficiency is suspected after general immunological tests, especially for cases with a contributive family history among infants as the maternal transfused immunoglobulin might mask immune deficiency.

Microbial diversity and antimicrobial susceptibility in endotracheal tube biofilms recovered from mechanically ventilated COVID-19 patients

In patients with acute respiratory failure, mechanical ventilation through an endotracheal tube (ET) may be required to correct hypoxemia and hypercarbia. However, biofilm formation on these ETs is a risk factor for infections in intubated patients, as the ET can act as a reservoir of microorganisms that can cause infections in the lungs. As severely ill COVID-19 patients often need to be intubated, a better knowledge of the composition of ET biofilms in this population is important. In Spring 2020, during the first wave of the COVID-19 pandemic in Europe, 31 ETs were obtained from COVID-19 patients at Ghent University Hospital (Ghent, Belgium). Biofilms were collected from the ET and the biofilm composition was determined using culture-dependent (MALDI-TOF mass spectrometry and biochemical tests) and culture-independent (16S and ITS1 rRNA amplicon sequencing) approaches. In addition, antimicrobial resistance was assessed for isolates collected via the culture-dependent approach using disc diffusion for 11 antimicrobials commonly used to treat lower respiratory tract infections. The most common microorganisms identified by the culture-dependent approach were those typically found during lung infections and included both presumed commensal and potentially pathogenic microorganisms like Staphylococcus epidermidis, Enterococcus faecalis, Pseudomonas aeruginosa and Candida albicans. More unusual organisms, such as Paracoccus yeei, were also identified, but each only in a few patients. The culture-independent approach revealed a wide variety of microbes present in the ET biofilms and showed large variation in biofilm composition between patients. Some biofilms contained a diverse set of bacteria of which many are generally considered as non-pathogenic commensals, whereas others were dominated by a single or a few pathogens. Antimicrobial resistance was widespread in the isolates, e.g. 68% and 53% of all isolates tested were resistant against meropenem and gentamicin, respectively. Different isolates from the same species recovered from the same ET biofilm often showed differences in antibiotic susceptibility. Our data suggest that ET biofilms are a potential risk factor for secondary infections in intubated COVID-19 patients, as is the case in mechanically-ventilated non-COVID-19 patients.

STUDY OF OXYGEN DELIVERY METHODS USE IN THE COVID-19 PATIENTS

Background: The oxygen crisis globally during the Corona virus disease-19 (COVID-19) pandemic reflected the need of appropriate and economic use of oxygen in its management. There is scarce report of the use of different oxygen delivery methods (ODMs) in COVID-19 patients in our region. Methods: This was a hospital-based observational study conducted from July 2021 to October 2021. We studied various ODMs used by 100 COVID-19 patients, aged 18 years or above admitted to Chitwan Medical College and Teaching Hospital during July to October 2021 and the trend of how the ODMs changed during the hospital stay. Data analysis was done by SPSS version 20 for Windows. Fisher’s exact and Kruskal Wallis tests were used to analyze the data of the participants. Results: In our study, oxygen supplementation at presentation using nasal cannula was required by 74% of patients, face mask by 13%, Venturi mask 34%, non-rebreathing mask 25%, high-flow nasal cannula 27%, non-invasive ventilation 6%, and invasive mechanical ventilation by 21%. There was significant difference in the use of ODMs at presentation among the moderate, severe and critical COVID-19 groups (P&lt;0.001). There was a wide range of switching between various ODMs during the treatment course. Conclusions: Nasal cannula was the most common ODM followed by venturi devices and invasive mechanical ventilation. Despite varying oxygen flow requirements, aerosol risks, merits and limitations of different ODMs, they can be appropriately used in various COVID-19 management situations. Besides inspired oxygen concentration and oxygen flow, patients’ condition, tolerance and availability of the resource also affected the choices of ODMs to achieve the correction of hypoxemia.

Optimizing Physiology During Prehospital Airway Management: An NAEMSP Position Statement and Resource Document

Airway management is a critical component of resuscitation but also carries the potential to disrupt perfusion, oxygenation, and ventilation as a consequence of airway insertion efforts, the use of medications, and the conversion to positive-pressure ventilation. NAEMSP recommends: Airway management should be approached as an organized system of care, incorporating principles of teamwork and operational awareness. EMS clinicians should prevent or correct hypoxemia and hypotension prior to advanced airway insertion attempts. Continuous physiological monitoring must be used during airway management to guide the timing of, limit the duration of, and inform decision making during advanced airway insertion attempts. Initial and ongoing confirmation of advanced airway placement must be performed using waveform capnography. Airway devices must be secured using a reliable method. Perfusion, oxygenation, and ventilation should be optimized before, during, and after advanced airway insertion. To mitigate aspiration after advanced airway insertion, EMS clinicians should consider placing a patient in a semi-upright position. When appropriate, patients undergoing advanced airway placement should receive suitable pharmacologic anxiolysis, amnesia, and analgesia. In select cases, the use of neuromuscular blocking agents may be appropriate.

Hyperbaric oxygen as an adjuvant treatment for patients with COVID-19 severe hypoxaemia: a randomised controlled trial

BackgroundHyperbaric oxygen (HBO2) therapy has been proposed to treat hypoxaemia and reduce inflammation in COVID-19. Our objective was to analyse safety and efficacy of HBO2 in treatment of hypoxaemia in...

Oxygen use and saturation targets in patients with COVID-19: Are we giving too much or aiming too low?

Oxygen use and saturation targets in patients with COVID-19: Are we giving too much or aiming too low?

Application of Continuous Positive Airway Pressure During Video-Assisted Thoracoscopic Surgery.

Purpose of ReviewVideo-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS) are used for anatomic resection of early stage cancer. These surgical techniques require the use of one-lung ventilation (OLV). During OLV, an obligatory intrapulmonary shunt may produce hypoxemia. One method to correct hypoxemia is with the use of continuous positive airway pressure (CPAP). This review focuses on 1) the lung physiology of OLV; 2) application of CPAP in VATS or RATS during supine and lateral position; and 3) the application of CPAP in COVID-19 patients during OLV.Recent FindingsStudies have shown the beneficial effects of CPAP to improve oxygenation during OLV while the patient is in the lateral decubitus position. In contrast, studies have shown no benefit on improving oxygenation with CPAP in patients undergoing OLV in supine position.SummaryThe application of CPAP to the non-dependent lung is one of the options to treat hypoxemia during VATS or RATS.

Pathogenesis-directed therapy of 2019 novel coronavirus disease.

The 2019 novel coronavirus disease (COVID-19) now is considered a global public health emergency. One of the unprecedented challenges is defining the optimal therapy for those patients with severe pneumonia and systemic manifestations of COVID-19. The optimal therapy should be largely based on the pathogenesis of infections caused by this novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Since the onset of COVID-19, there have been many prepublications and publications reviewing the therapy of COVID-19 as well as many prepublications and publications reviewing the pathogenesis of SARS-CoV-2. However, there have been no comprehensive reviews that link COVID-19 therapies to the pathogenic mechanisms of SARS-CoV-2. To link COVID-19 therapies to pathogenic mechanisms of SARS-CoV-2, we performed a comprehensive search through MEDLINE, PubMed, medRxiv, EMBASE, Scopus, Google Scholar, and Web of Science using the following keywords: COVID-19, SARS-CoV-2, novel 2019 coronavirus, pathology, pathologic, pathogenesis, pathophysiology, coronavirus pneumonia, coronavirus infection, coronavirus pulmonary infection, coronavirus cardiovascular infection, coronavirus gastroenteritis, coronavirus autopsy findings, viral sepsis, endotheliitis, thrombosis, coagulation abnormalities, immunology, humeral immunity, cellular immunity, inflammation, cytokine storm, superantigen, therapy, treatment, therapeutics, immune-based therapeutics, antiviral agents, respiratory therapy, oxygen therapy, anticoagulation therapy, adjuvant therapy, and preventative therapy. Opinions expressed in this review also are based on personal experience as clinicians, authors, peer reviewers, and editors. This narrative review linking COVID-19 therapies with pathogenic mechanisms of SARS-CoV-2 has resulted in six major therapeutic goals for COVID-19 therapy based on the pathogenic mechanisms of SARS-CoV-2. These goals are listed below: 1. The first goal is identifying COVID-19 patients that require both testing and therapy. This is best accomplished with a COVID-19 molecular test from symptomatic patients as well as determining the oxygen saturation in such patients with a pulse oximeter. Whether a symptomatic respiratory illness is COVID-19, influenza, or another respiratory pathogen, an oxygen saturation less than 90% means that the patient requires medical assistance. 2. The second goal is to correct the hypoxia. This goal generally requires hospitalization for oxygen therapy; other respiratory-directed therapies such as prone positioning or mechanical ventilation are often used in the attempt to correct hypoxemia due to COVID-19. 3. The third goal is to reduce the viral load of SARS-CoV-2. Ideally, there would be an oral antiviral agent available such as seen with the use of oseltamivir phosphate for influenza. This oral antiviral agent should be taken early in the course of SARS-CoV-2 infection. Such an oral agent is not available yet. Currently, two options are available for reducing the viral load of SARS-CoV-2. These are post-Covid-19 plasma with a high neutralizing antibody titer against SARS-CoV-2 or intravenous remdesivir; both options require hospitalization. 4. The fourth goal is to identify and address the hyperinflammation phase often seen in hospitalized COVID-19 patients. Currently, fever with an elevated C-reactive protein is useful for diagnosing this hyperinflammation syndrome. Low-dose dexamethasone therapy currently is the best therapeutic approach. 5. The fifth goal is to identify and address the hypercoagulability phase seen in many hospitalized COVID-19 patients. Patients who would benefit from anticoagulation therapy can be identified by a marked increase in d-dimer and prothrombin time with a decrease in fibrinogen. To correct this disseminated intravascular coagulation-like phase, anticoagulation therapy with low molecular weight heparin is preferred. Anticoagulation therapy with unfractionated heparin is preferred in COVID-19 patients with acute kidney injuries. 6. The last goal is prophylaxis for persons who are not yet infected. Potential supplements include vitamin D and zinc. Although the data for such supplements is not extremely strong, it can be argued that almost 50% of the population worldwide has a vitamin D deficiency. Correcting this deficiency would be beneficial regardless of any impact of COVID-19. Similarly, zinc is an important supplement that is important in one's diet regardless of any effect on SARS-CoV-2. As emerging therapies are found to be more effective against the SARS-CoV-2 pathogenic mechanisms identified, they can be substituted for those therapies presented in this review.

Oxygen and pulmonary arterial hypertension: effects, mechanisms, and therapeutic benefits.

Oxygen is a pulmonary vasodilator. Although treatment of pulmonary arterial hypertension (PAH) is focused on pulmonary vasodilation, treatment guidelines do not recommend O2 therapy for patients unless they develop hypoxaemia. These guidelines point to a lack of evidence of benefit of O2 therapy from randomized controlled trials (RCTs) and to evidence of lack of benefit in a single RCT involving patients with Eisenmenger syndrome. These guidelines did not identify major limitations with the Eisenmenger study or consider other evidence of therapeutic benefit. Recent advances in mechanistic understanding of O2 effects on pulmonary vascular tone, along with substantial evidence of acute effects of O2 in PAH patients, challenge the view that benefits of O2 arise only through correction of hypoxaemia. Evidence presented in this review shows that O2 acts as a pulmonary vasodilator in patients who are normoxaemic; that this probably involves an alveolar mechanism in addition to a blood-borne (oxyhaemoglobin) mechanism; and that therapeutic benefit of O2 does not depend on arterial O2 levels. This suggests that O2 has potential therapeutic benefit for all patients with PAH. Clinical guidelines and practice related to O2 therapy need to be reassessed, and further research is needed.

Association between detectable SARS-COV-2 RNA in anal swabs and disease severity in patients with coronavirus disease 2019.

BackgroundSevere acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) RNA was found in the intestines and feces, but its clinical significance is not completely clear. We aim to characterize the longitudinal test results of SARS‐CoV‐2 RNA in anal swabs and to explore the association with disease severity.MethodsWe included laboratory‐confirmed coronavirus disease 2019 (COVID‐19) patients, who were hospitalized in Guangzhou Eighth People's Hospital and excluded those who had not received anal swabs for SARS‐COV‐2 RNA testing. Epidemiological, clinical, and laboratory data were obtained. Throat swabs and anal swabs were collected periodically for SARS‐COV‐2 RNA detection.ResultsTwo hundred and seventeen eligible patients (median aged 50 years, 50.2% were females) were analyzed. 21.2% (46/217) of the patients were detected with SARS‐CoV‐2 RNA in anal swabs. The duration of viral RNA was longer, but the viral load was lower in anal swabs than throat swabs in the early stage of the disease. During a median follow‐up of 20 days, 30 (13.8%) patients were admitted to the intensive care unit (ICU) for high‐flow nasal cannula or higher‐level oxygen support measures to correct hypoxemia. Detectable viral RNA in anal swabs (adjusted hazard ratio [aHR], 2.50; 95% confidence interval [CI], 1.20‐5.24), increased C‐reactive protein (aHR, 3.14; 95% CI, 1.35‐7.32) and lymphocytopenia (aHR, 3.12; 95% CI, 1.46‐6.67) were independently associated with ICU admission. The cumulative incidence of ICU admission was higher among patients with detectable viral RNA in anal swabs (26.3% vs 10.7%, P = .006).ConclusionDetectable SARS‐CoV‐2 RNA in the digestive tract was a potential warning indicator of severe disease.

Management of hospitalized patients with pulmonary arterial hypertension and COVID-19 infection.

Management of hospitalized patients with pulmonary arterial hypertension and COVID-19 infection.