Deterioration Of Respiratory Status Research Articles

Pulmonary Nocardiosis as an Opportunistic Infection in COVID-19.

Secondary bacterial pneumonia infection is frequent in COVID-19 patients. Nocardia are responsible for opportunistic pulmonary infections especially after steroid treatment. We describe a case of pulmonary nocardiosis following critical COVID-19 pneumonia in an 83-year-old male. Two weeks after initiation of dexamethasone 6 mg/L, the patient developed a new episode of acute dyspnea. The sputum cultures identified Nocardia cyriacigeorgica. In spite of intravenous imipenem and cotrimoxazole treatment the patient died. Physicians should be aware of the possibility of nocardiosis in case of deterioration of respiratory status of severe COVID-19 inpatients and perform Nocardia evaluation. This evaluation requires prolonged culture.LEARNING POINTSNocardia are responsible for opportunistic pulmonary infections after steroid treatment.We describe a case of pulmonary nocardiosis following critical COVID-19 pneumonia.Physicians should be aware of the possibility of secondary nocardiosis in COVID-19 inpatients.

Association between ABO blood types and the prognosis and mortality rates in patients with severe COVID-19 admitted in the intensive care unit of a tertiary-level hospital in Turkey

Objectives There is limited number of data showing possible correlation between ABO blood types and prognosis and mortality of COVID-19 patients. It was aimed to investigate whether ABO blood group type affects the prognosis and mortality rates in patients with severe COVID-19 hospitalized in the ICU (intensive care unit) of a tertiary-level hospital in Turkey. Methods The data of 273 patients with diagnosis of severe COVID-19 who were admitted to ICU from April 2020 through June 2021 and in an age range between 25–93 years were evaluated in this retrospective study. Results Blood group distribution was 47.3, 13.2, 10.6 and 28.9% for groups A, B, AB, and O, respectively. As a respiratory status at admission to ICU, the ratio of intubation patients with blood type O was significantly higher than of other groups while most of patients in group A achieved spontaneous respiration without any mechanical ventilator (p = .0168). The mean neutrophil ratio, NLR, concentrations of procalcitonin, lactate, urea and ferritin significantly increased in the serum of patients with type O (p < .01 for all except p = .016 for the ferritin). The weaning duration was longest among patients with blood group O while the hospitalization duration was longest among patients with group AB; however, there was not significant difference (p > .05). The highest mortality rate was calculated in group AB as 68.97% and lowest was 47.2% in group B without any statistical difference (p > .05). Conclusion ABO blood types carry different association risk factors for the prognosis of severe COVID-19 patients hospitalized in ICU. Specifically, blood group O was correlated with an increased risk of deterioration of respiratory status including intubation and elevation of laboratory findings whereas it did not affect the risk of increased mortality.

Can Deep Learning-Based Volumetric Analysis Predict Oxygen Demand Increase in Patients with COVID-19 Pneumonia?

Background and Objectives: This study aimed to investigate whether predictive indicators for the deterioration of respiratory status can be derived from the deep learning data analysis of initial chest computed tomography (CT) scans of patients with coronavirus disease 2019 (COVID-19). Materials and Methods: Out of 117 CT scans of 75 patients with COVID-19 admitted to our hospital between April and June 2020, we retrospectively analyzed 79 CT scans that had a definite time of onset and were performed prior to any medication intervention. Patients were grouped according to the presence or absence of increased oxygen demand after CT scan. Quantitative volume data of lung opacity were measured automatically using a deep learning-based image analysis system. The sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) of the opacity volume data were calculated to evaluate the accuracy of the system in predicting the deterioration of respiratory status. Results: All 79 CT scans were included (median age, 62 years (interquartile range, 46–77 years); 56 (70.9%) were male. The volume of opacity was significantly higher for the increased oxygen demand group than for the nonincreased oxygen demand group (585.3 vs. 132.8 mL, p < 0.001). The sensitivity, specificity, and AUC were 76.5%, 68.2%, and 0.737, respectively, in the prediction of increased oxygen demand. Conclusion: Deep learning-based quantitative analysis of the affected lung volume in the initial CT scans of patients with COVID-19 can predict the deterioration of respiratory status to improve treatment and resource management.

Possibility of deterioration of respiratory status when steroids precede antiviral drugs in patients with COVID-19 pneumonia: A retrospective study.

Coronavirus disease (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2. Although most patients with COVID-19 develop asymptomatic or mild disease, some patients develop severe disease. The effectiveness of various therapeutic agents, including antiviral drugs, steroids, and anti-inflammatories for COVID-19, have been being confirmed. The effect of administering steroids in early disease is unclear. This study therefore aimed to evaluate the effectiveness and risk of exacerbation of steroids administered preceding antiviral drugs in patients with COVID-19 pneumonia. This retrospective, single-center, observational study included consecutive patients with COVID-19 between March 2020 and March 2021. Patients were divided into a steroids-first group and antiviral-drugs-first group. Mortality, duration of hospitalization, incidence rate and duration of intensive care unit (ICU) admission, intubation, and extracorporeal membrane oxygenation (ECMO) induction of the two groups were compared. A total of 258 patients were admitted during the study period. After excluding patients who received symptomatic treatment only, who were taking immunosuppressive drugs, or who were administered antiviral drugs only, 68 patients were included in the analysis, 16 in the steroids-first group and 52 in the antiviral-drugs-first group. The rate of intubation, ICU admission and ECMO induction were significantly higher in the steroids-first group than in the antiviral-drugs-first group (81.3% vs. 33.3, p<0.001, 75.0% vs. 29.4%, p = 0.001, and 31.3% vs. 7.8%, p = 0.017, respectively). Furthermore, patients who received steroids within ten days after starting antiviral drugs had significantly lower rates of ICU admission, intubation, and ECMO induction. (81.3% vs. 42.9% p = 0.011, 75.0% vs. 37.1% p = 0.012, and 31.3% vs. 8.6% p = 0.039, respectively). Administering steroids prior to antiviral drugs soon after symptom onset can aggravate disease severity. When administration of steroids is considered soon after symptom onset, it may be safer to initiate antiviral drugs first.

Factors Affecting Energy Metabolism and Prognosis in Patients with Amyotrophic Lateral Sclerosis

Background/Aims: Nutritional status is a factor affecting prognosis in patients with amyotrophic lateral sclerosis (ALS). Here, we aimed to clarify the factors associated with hypermetabolism and the prognosticators of ALS. Methods: Forty-two inpatients (22 men, 20 women) diagnosed with ALS according to the revised El-Escorial criteria were investigated. The following data were retrospectively analyzed: anthropometric measurements, blood biochemistry, disease severity, basal energy expenditure (BEE), resting energy expenditure (REE) measured by indirect calorimetry, spirometry, and bioelectrical impedance analysis. Single and multiple regression analysis was performed to examine factors affecting REE and metabolic changes (defined as the ratio of REE to fat-free mass [FFM]). The Kaplan-Meier method was used to examine factors associated with the occurrence of cumulative events (death or tracheostomy). Results: Among the 42 inpatients, REE was significantly higher than BEE, indicating hypermetabolism in ALS. Multiple regression analysis revealed that REE/FFM is strongly associated with the skeletal muscle index (−3.746 to −1.532, p < 0.0001) and percent forced vital capacity (%FVC) (−0.172 to −0.021, p = 0.013). Moreover, both the skeletal muscle index and %FVC were significant prognosticators associated with the occurrence of cumulative events. Conclusions: Energy metabolism was elevated in ALS, and respiratory status and muscle mass were associated with the hypermetabolism and poor prognosis. Adequate nutritional support may improve outcomes in ALS by preventing deterioration of respiratory status and reduction in muscle mass.

Adverse events experienced with intrahospital transfer of critically ill patients: A national survey.

Research that focuses on transfers to and from the intensive care unit (ICU) could highlight important patients’ safety issues. This study aims to describe healthcare workers’ (HCWs) practices involved in patient transfers to or from the ICU.This cross-sectional study was conducted among HCWs during the Saudi Critical Care Society's annual International Conference, April 2017. Responses were assessed using Likert scales and frequencies. Bivariate analysis was used to evaluate the significance of different indicators.Overall, 312 HCWs participated in this study. Regarding transfer to ICUs, the most frequently reported complications were deterioration in respiratory status (51.4%), followed by deterioration in hemodynamic status (46.5%), and missing clinical information (35.5%). Regarding transfers from ICUs to the general ward, the most commonly reported complications were changes in respiratory status (55.6%), followed by incomplete clinical information (37.9%), and change in hemodynamic conditions (29%). The most-used models for communicating transfers were written documents in electronic health records (69.3%) and verbal communication (62.8%). One-fourth of the respondents were not aware of the Situation, Background, Assessment, Recommendation (SBAR) method of patients’ handover. Pearson's test of correlation showed that the HCW's perceived satisfaction with their hospital transfer guidelines showed significant negative correlation with their reported transfer-related complications (r = −0.27, P < .010).Hemodynamic and respiratory status deterioration is representing significant adverse events among patients transferred to or from the ICU. Factors controlling the perceived satisfaction of HCWs involved in patients, transfer to and from the ICU need to be addressed, focusing on their compliance to the hospital-wide transfer and handover policies. Quality improvement initiatives could improve patient safety to transfer patients to and from the ICU and minimize the associated adverse events.

PNEUMOMEDIASTINUM AND PNEUMOTHORAX DUE TO NONINVASIVE POSITIVE PRESSURE VENTILATION IN COVID-19 PNEUMONIA

SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Barotrauma as a consequence of high alveolar pressures is well described in invasive mechanically ventilated (IMV) patients with pneumonia or pneumonitis. Limited data exists on the incidence of barotrauma in patients with Coronavirus Disease 19 pneumonia (COVID-19). We present a case of barotrauma occurring in a non-intubated patient with COVID-19 receiving noninvasive positive pressure ventilation (NPPV). CASE PRESENTATION: A 43-year-old male with obesity presented with 2 days of cough and dyspnea. Polymerase chain reaction (PCR) testing confirmed COVID-19. He initially required 5L of oxygen (O2) per minute by nasal cannula. Due to worsening hypoxemic respiratory failure (HRF) on day 3, the patient was placed on high-flow nasal cannula (HFNC) at 90% FiO2 at a flow rate of 30 L/min . By day 7, the patient had worsening HRF and increased work of breathing. He was transitioned to continuous positive airway pressure (CPAP) at 100% FiO2 with continuous pressure set at 12 cm H2O. On day 13, he developed tachycardia and desaturation. Chest CT found gas dissecting along the axial interstitium resulting in pneumomediastinum, bilateral pneumothoraces, and extensive subcutaneous emphysema. The lung parenchyma exhibited coarse ground glass opacities and early evidence of fibrotic changes. Chest tubes were placed in each hemithorax with resolution of his pnemothoraces after 5 days. His O2 requirements decreased, and he was transferred to a rehabilitation hospital on 10 L/min O2 by facemask on day 25. DISCUSSION: Barotrauma leading to pneumomediastinum and pneumothoraces are a well-documented complication of mechanical ventilation.1 In an effort to mitigate the morbidity and mortality associated with mechanical ventilation, many clinicians have shifted toward using NPPV in HRF in COVID-19, however NPPV may not necessarily protect patients against a complication more commonly associated with IMV.2,3 Progressive and cumulative alveolar injury may predispose COVID-19 patients to barotrauma regardless of mode of ventilation.3 CONCLUSIONS: Due to the mortality associated with IMV in COVID-19, many clinicians have shifted toward using NPPV to manage HRF. However, patients receiving NPPV may still be subject to complications such as barotrauma. Additionally, given our evolving understanding of COVID-19 and the pulmonary parenchymal distortion seen in many patients, a deterioration in respiratory status should prompt clinicians to search for evidence of barotrauma, even in patients receiving NPPV. Reference #1: Mentzer SJ, Tsuda A, Loring SH. Pleural mechanics and the pathophysiology of air leaks. J Thorac Cardiovasc Surg. 2018;155(5):2182-2189. Reference #2: Xu XP, Zhang XC, Hu SL, et al. Noninvasive Ventilation in Acute Hypoxemic Nonhypercapnic Respiratory Failure: A Systematic Review and Meta-Analysis. Crit Care Med. 2017;45(7):e727-e733. Reference #3: Sun R, Liu H, Wang X. Mediastinal Emphysema, Giant Bulla, and Pneumothorax Developed during the Course of COVID-19 Pneumonia. Korean J Radiol. 2020;21(5):541-544. DISCLOSURES: no disclosure on file for Nikhil Barot; No relevant relationships by Michael Kahn, source=Web Response No relevant relationships by Nader Kamangar, source=Web Response No relevant relationships by Jay Thetford, source=Web Response

Visual Diagnosis: Rapid Deterioration of Respiratory Status and Lower Limb Hypotonia in a 6-month-old Infant.

1. Guillaume J. LimFat, BMSc* 2. Vinay Kukreti, MD†,‡ 1. *Undergraduate Medicine, Queen’s University School of Medicine, Kingston, ON, Canada 2. †Department of Pediatrics, Queen’s University School of Medicine, Kingston General Hospital, Kingston, ON, Canada 3. ‡Department of Pediatrics, Lakeridge Health Oshawa, Oshawa, ON, Canada A 6-month-old previously healthy boy presents to the local emergency department with a 1-week history of progressive lethargy, irritability, and anorexia. Two days before presentation he developed an unusual breathing pattern and worsening respiratory distress, and he had a fever of 101.3°F (38.5°C). There was no rhinorrhea, coryza, cough, vomiting, or diarrhea. He appears unwell, with respiratory distress, tachypnea, and grunting. His blood pressure is 80/45 mm Hg, heart rate is 200 beats/min, respiratory rate is 60 breaths/min, and oxygen saturation is 77% in room air. He is afebrile. There is significantly decreased air entry bilaterally, most impressively over the right lung field. His neurologic examination reveals a mild right-sided ptosis. Although he moves both arms normally, there is a noticeable paucity of movements in his lower limbs, with decreased tone in both legs. The remainder of his examination findings are normal. On further questioning the parents clarify that for the past 2 months there has been a relative decrease in leg movements, and he had stopped attempting to bear weight when made to stand with support. His respiratory status does not improve, and he requires supplemental oxygen to maintain appropriate oxygen saturation. Clinical laboratory tests reveal a white blood cell count of 18,800/ μ L (18.8×109/L) (neutrophil count, 6,200/ μ L [6.2×109/L]; lymphocyte count, 11,100/ μ L [11.1×109/L]; and monocyte count, 1,100/ μ L [1.1×109/L]) and normal electrolyte levels. A chest radiograph reveals a large right paravertebral mass with significant left mediastinal shift associated with rib and vertebral destruction and moderate right-sided pleural effusion (Fig 1). Given these findings and worsening …

Clinical Mortality in a Large COVID-19 Cohort: Observational Study.

BackgroundNorthwell Health, an integrated health system in New York, has treated more than 15,000 inpatients with COVID-19 at the US epicenter of the SARS-CoV-2 pandemic.ObjectiveWe describe the demographic characteristics of patients who died of COVID-19, observation of frequent rapid response team/cardiac arrest (RRT/CA) calls for non–intensive care unit (ICU) patients, and factors that contributed to RRT/CA calls.MethodsA team of registered nurses reviewed the medical records of inpatients who tested positive for SARS-CoV-2 via polymerase chain reaction before or on admission and who died between March 13 (first Northwell Health inpatient expiration) and April 30, 2020, at 15 Northwell Health hospitals. The findings for these patients were abstracted into a database and statistically analyzed.ResultsOf 2634 patients who died of COVID-19, 1478 (56.1%) had oxygen saturation levels ≥90% on presentation and required no respiratory support. At least one RRT/CA was called on 1112/2634 patients (42.2%) at a non-ICU level of care. Before the RRT/CA call, the most recent oxygen saturation levels for 852/1112 (76.6%) of these non-ICU patients were at least 90%. At the time the RRT/CA was called, 479/1112 patients (43.1%) had an oxygen saturation of <80%.ConclusionsThis study represents one of the largest reviewed cohorts of mortality that also captures data in nonstructured fields. Approximately 50% of deaths occurred at a non-ICU level of care despite admission to the appropriate care setting with normal staffing. The data imply a sudden, unexpected deterioration in respiratory status requiring RRT/CA in a large number of non-ICU patients. Patients admitted at a non-ICU level of care suffered rapid clinical deterioration, often with a sudden decrease in oxygen saturation. These patients could benefit from additional monitoring (eg, continuous central oxygenation saturation), although this approach warrants further study.

Immunization practices and adverse events following vaccination in infants admitted to the Neonatal Intensive Care Unit

Objective: To determine if vaccinations administered in the neonatal intensive care unit (NICU) were administered following Centers for Disease Control and Prevention guidelines while assessing for adverse reactions in the 48 hours post-vaccination. Study Design: Retrospective cohort study of infants who received Diphtheria-Tetanus-Pertussis, inactivated Polio, Hepatitis B vaccines during NICU admission from February 2016 to January 2017 with a total of 337 immunization events reviewed. Data were assessed to determine vaccination delay according to recommended schedules as well as rate of adverse events. Knowledge base and attitudes were evaluated through a questionnaire administered over a three-week period to NICU care providers. Results: Of the 337 immunization events reviewed, 256 vaccines were administered within 7 days of the recommended vaccination schedule, leaving 24% (n=81) administered outside of this schedule. Taking into account weaning of respiratory support and deterioration of respiratory status in the 48 hours prior to vaccination, total adverse event rates for the remaining 312 immunization events were 2% (n=7). Questionnaire showed many providers felt adverse events are commonplace following vaccination and highlighted a possible gap in knowledge of recommended vaccination guidelines. Conclusions: This study suggests neonates admitted to the NICU are at risk for vaccination delay. Immunizations have a low rate of adverse events, thus confirming safety. Factors that may increase adverse events post-immunization include coincidental worsening of overall status and recent wean in respiratory support. Further studies are needed to examine best practices to promote improved vaccination in the NICU.

USE OF CORTICOSTEROIDS IN SEVERE PULMONARY BLASTOMYCOSIS IN A CONSTRUCTION WORKER IN NEW YORK STATE

SESSION TITLE: Monday Fellow Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Pulmonary blastomycosis, endemic to the midwestern, southcentral and southeastern regions of United States, is a rare occurrence with only a few cases reported in non-endemic areas. The mortality rate can be as high as 50 to 89% with significant pulmonary involvement. In non-endemic areas, such as New York, it is often overlooked as a potential pathogen. A few cases have been reported in New York along the St. Lawrence River. Here, we present a rare case of an immunocompetent patient with severe pulmonary blastomycosis without any significant travel history outside New York who required treatment with Amphotericin B and Methylprednisone. CASE PRESENTATION: 22 year-old male with history of cocaine and marijuana use presented to the hospital with 2 weeks of cough and pleuritic chest pain. He worked as a roofer without any personal protective equipment. On arrival, he was febrile (103˚ F) in mild respiratory distress with rales auscultated in the left upper lobe. CT thorax showed extensive consolidation of left upper lobe and lingula with left hilar adenopathy. He was HIV negative. Bronchial alveolar lavage (BAL) showed Aspergillus EIA was 0.90 units (normal < 0.5). Empiric IV Voriconazole was started initially and then switched to liposomal amphotericin B when patient was clinically deteriorating. Since his oxygen requirements were increasing with further deterioration of respiratory status, Methylprednisone 60mg IV every 6 hours was started and tapered to off after a 12 day course. Later, BAL fungal culture was found to be positive for Blastomyces Dermatitidis. He eventually showed improvement and was discharged home. DISCUSSION: Blastomycosis is rare with a yearly incidence rate of 1 to 2 cases per 100,000 population in states where it is reportable. This is an unusual case of Blastomycosis occurring without any travel or camping history, suggesting Marijuana from infected soil or a roofing occupation as a possible source. Treatment depends on disease severity. An azole is preferred for mild to moderate disease not involving the central nervous system. Amphotericin B is used for moderate to severe pulmonary infection or disseminated blastomycosis. Some immunocompetent patients may not require treatment, whereas all immunocompromised patients require treatment. No clear guidelines exist for the use of corticosteroids in fungal pneumonia. The use of steroids in case reports of ARDS from blastomycosis showed some improvement. In our case, corticosteroids proved to be of clinical benefit. CONCLUSIONS: This case urges clinicians to include blastomycosis on the differential even in non-endemic areas from unusual sources. Further research is needed regarding the use of corticosteroids in Blastomycosis. Reference #1: Bariola, J., and Keyur Vyas. “Pulmonary Blastomycosis.” Seminars in Respiratory and Critical Care Medicine, vol. 32, no. 06, 13 Dec. 2011, pp. 745–753., https://doi.org/10.1055/s-0031-1295722. Reference #2: Goldman, Mitchell, et al. “Fungal Pneumonias.” Clinics in Chest Medicine, vol. 20, no. 3, 1 Sept. 1999, pp. 507–519., https://doi.org/10.1016/s0272-5231(0570232-x). Reference #3: Permpalung, Nitipong, et al. “Pulmonary Blastomycosis: a New Endemic Area in New York State.” Mycoses, vol. 56, no. 5, 18 Mar. 2013, pp. 592–595., https://doi.org/10.1111/myc.12073. DISCLOSURES: No relevant relationships by Jagadish Akella, source=Web Response No relevant relationships by Artur Alaverdian, source=Web Response No relevant relationships by Ashlie Arthur, source=Web Response No relevant relationships by Javed Iqbal, source=Web Response No relevant relationships by Dolly Patel, source=Web Response No relevant relationships by Pranay Srivastava, source=Web Response

ガス供給と電源容量の問題が解決されhigh flow nasal cannula呼吸補助下に施設間陸路搬送した1例(A case of interhospital ground transport with a high flow nasal cannula for respiratory support enabled by the resolution of gas and power supply capacity problems)

要旨High flow nasal cannula（HFNC）療法は様々な医療場面での使用が増加しているが，HFNCを用いた施設間搬送の報告は少ない。これまで当院では，HFNCシステムへの酸素・混合ガス供給とドクターカーの電源容量の問題によりHFNC呼吸補助下の施設間陸路搬送が実施できなかった。しかし，新たなHFNCシステムの導入と，ドクターカーの電源容量増加と補助電源の確保により，HFNCを用いた施設間搬送が可能となった。今回，我々はHFNC呼吸補助下に施設間陸路搬送した症例を経験したので報告する。症例は11か月の男児。Respiratory syncytial virus（RSV）細気管支炎による急性呼吸不全のため当院へ転院し，pediatric intensive care unit（PICU）でHFNC療法が導入された。その後症状が軽快しHFNC呼吸補助下に医療機関へ転院搬送となった。搬送中，呼吸状態の悪化や重篤な副作用を認めず，安全に搬送が行われた。搬送にHFNCを用いる場合，デバイスによっては呼吸器設定に限界があること，屋外使用時はデバイスへの外気温の影響を考慮すること，および複数の医療機器を同時に使用する場合の総電源容量と搬送車両の電源容量を把握するなど留意すべき点がある。今後，症例を蓄積し施設間搬送におけるHFNC療法の安全性と有効性を評価する必要がある。

Oligonucleotide Therapies for the Lung: Ready to Return to the Clinic?

The most promising targets for treating lung diseases are often intracellular molecules recalcitrant to conventional pharmacotherapy. In this respect, antisense oligonucleotides (ASO) would be valuable tools to treat airways disease, as the plurality of their potential mechanisms of action is well-established, their efficiency has been extensively validated in-vitro, and their potential clinical value has been demonstrated with numerous regulatory approvals. Yet in spite of high confidence in the treatment rationale and mechanism of action, it appears that oligonucleotides delivered topically to the lung either rapidly access circulation via epithelial transcytosis or are removed by alveolar macrophages, exerting minimal if any action in the cytosol of cells relevant to lung disease. Moreover, use of cell penetrating peptides, liposomes or nanoparticle delivery systems has not so far been shown to eliminate circulatory clearance, may activate immune responses, or drive macrophage phenotypic changes that, together or in isolation, may present risks to patients.

Transesophageal lung ultrasonography: a novel technique for investigating hypoxemia.

Acute deterioration in respiratory status commonly occurs in patients who cannot be transported for imaging studies, particularly during surgical procedures and in critical care settings. Transthoracic lung ultrasonography has been developed to allow rapid diagnosis of respiratory conditions at the bedside. Nevertheless, the thorax is not always accessible, especially in the perioperative setting. Transesophageal lung ultrasonography (TELU) can be used to circumvent this problem. The aim of this narrative review is to provide a complete description of the TELU technique by summarizing the existing literature on the subject and describing our own experience that extrapolates from transthoracic lung ultrasonography. The use of TELU can provide point-of-care real-time information for quickly establishing the etiology of acute hypoxemia. The transesophageal probe is placed in close proximity to the posterior regions of the lungs where lung consolidation and pleural effusions are most often seen; however, most of the artefacts relied on by transthoracic ultrasound have yet to be validated with TELU. Moreover, the relative invasiveness of TELU compared with transthoracic ultrasonography may limit its use to specific situations when the probe is already in place, as during cardiac anesthesia or when the anterior thorax is inaccessible. The main advantage of TELU may lie in the ability to integrate both cardiac and pulmonary assessments in one single examination. Anesthesiologists and intensivists who already use transesophageal echocardiography on a regular basis should consider adding TELU to their clinical assessment of hypoxemia and related pulmonary pathologies. Nevertheless, the literature specifically supporting TELU is relatively limited, and further validation studies are needed.

Partial Obstruction of the Endotracheal Tube by the Plastic Coating Sheared from a Stylet.

A preterm with gestational age of 24 weeks was intubated at day of life 16. The intubation was done in a routine manner with the use of a stylet. It took a significant effort from the clinician to pull the stylet out after intubation. After intubation the respiratory status of the neonate deteriorated requiring significantly greater support. When ventilating and oxygenating the infant was getting progressively difficult, the decision was made to change the endotracheal tube (ETT). The cause for deterioration of respiratory status was then determined to be a sheared piece of plastic from the sheath of the stylet which was lodged in the lumen of the ETT. After removal of the plastic particle, the condition of the infant improved significantly.

Clinical features of late-onset circulatory dysfunction in premature infants

Background: Sudden unpredictable hypotension during the post-transitional period, termed late-onset circulatory dysfunction (LCD) of premature infants, has been reported in low birthweight infants who overcame major problems during the early neonatal period. We investigated the clinical features of LCD and factors associated with the occurrence of LCD. Methods: A multicenter retrospective case-control study. The clinical records of 1,004 children born at less than 32 weeks of gestation were reviewed. Patients with LCD were compared with age-matched non-LCD controls. Results: Of the 1,004 infants, 73 (7.3%) were diagnosed with LCD, with the incidence differing significantly among institutions ( P,0.0001). The median age of diagnosis was 16 days of age (range: 4–50 days) and 29 weeks of postmenstrual age (range: 25–35 weeks). The incidence of LCD was inversely correlated with gestational age at birth, except at 22 and 23 weeks. Compared with the control infants, the LCD infants had significantly higher incidences of birth by cesar ean section (61/73 versus 48/73, P,0.05); hyponatremia (sodium ,130 mEq/L) at the time of diagnosis (24/66 versus 3/39, P,0.01); deterioration of respiratory status within 24 hours before diagnosis (36/73 versus 6/73, P,0.0001); and periventricular leukomalacia (14/73 versus 4/73, P,0.05). Corticosteroids were effective in 52 infants who were unresponsive to volume expansion or inotropic agents. None of these infants died of LCD. Conclusion: LCD is common but worthy of attention due to its association with periventricular leukomalacia. A review of institutional differences in treatment policies may contribute to the prevention of LCD.

Congenital Diaphragmatic Hernia: Not Quite There Yet

Congenital Diaphragmatic Hernia: Not Quite There Yet

AngioJet rheolytic thrombectomy in a neonate with pulmonary artery thrombus

A newborn infant with obstructed supracardiac total anomalous pulmonary venous return underwent emergent surgical correction on day of life 0. A surgically placed transthoracic pulmonary artery catheter was used to monitor pulmonary artery pressure and removed on postoperative day 3. Following acute deterioration in respiratory status requiring reintubation, echocardiographic assessment demonstrated findings consistent with pulmonary hypertension and diminished flow to the left lung. Cardiac catheterization confirmed elevated pulmonary artery pressure and near complete occlusion of his left pulmonary artery due to a thrombus. He underwent successful percutaneous catheter-based thrombectomy using the AngioJet rheolytic catheter, recovered fully, and was discharged home on postoperative day 30. Although thrombotic events resulting in respiratory and hemodynamic compromise are rare in infants, recognition is important and treatment using mechanical thrombectomy can be life saving.

CT analysis of the effect of pirfenidone in patients with idiopathic pulmonary fibrosis

PurposePirfenidone is a new, anti-fibrotic drug used for the treatment of idiopathic pulmonary fibrosis (IPF). The aim of this study was to evaluate the utility of computed tomography (CT) in the imaging assessment of the response to pirfenidone therapy. Materials and methodsSubjects were 78 patients with IPF who underwent CT on two occasions with one-year interval (38 consecutive patients treated with pirfenidone and 40 age-matched control). Changes in the fibrous lesion on sequential CTs were assessed as visual score by two radiologists. We measured the volume and change per year of fibrous pattern (F-pattern) quantitatively using a computer-aided system on sequential CTs. ResultsThe baseline vital capacity (%pred VC) was 74.0±14.0% in the pirfenidone group and 74.6±16.6% in controls (p=NS). Deterioration of respiratory status was defined as 10% or greater decline in %pred VC value after 12-month treatment. A significantly larger proportion of pirfenidone-treated patients showed stable respiratory status (21 of 38, 65.6%) than the control (15 of 40, 37.5%). The change in fibrous lesion was significantly smaller in the pirfenidone group than the control in both of visual score (p=0.006) and computer analysis (p<0.001). The decline in VC correlated significantly with the increase in fibrotic lesion (p<0.001). ConclusionCT can be used to assess pirfenidone-induced slowing of progression of pulmonary fibrosis.

Fundoplication in Ventilator-Dependent Infants with Gastro-oesophageal Reflux

In ventilator-dependent infants with complex comorbidities, severe gastro-oesophageal reflux (GOR) may contribute to prolonging the period of ventilation. It is often difficult to predict whether antireflux surgery will improve the respiratory status of an infant and assist with weaning off the ventilator. The aim of this study was to review the outcomes in a cohort of ventilator-dependent infants who underwent fundoplication to help wean them off ventilation. Between January 2006 and December 2010, out of 596 infants who underwent fundoplication for symptoms of GOR, 26 were ventilator dependent before surgery; 13 patients had an emergency fundoplication following an acute life-threatening event (n = 5, 19%) or an acute deterioration of respiratory status (n = 8, 31%). Fundoplication was planned in the rest of the group (n = 13, 50%) with the aim of improving respiratory status and weaning from ventilation. The median age at surgery was 5.8 months (range: 0.8 to 19.4 months). The median weight at surgery was 6.3 kg (range: 4 to 15.1 kg). Data were collected for each infant on comorbidities, pre- and postoperative ventilation status, pre- and postoperative GOR symptoms, and survival. All infants underwent a Nissen fundoplication with no intraoperative morbidity or mortality. Of these, 12 infants had a laparoscopic fundoplication; 14 infants had an open fundoplication. Postoperatively, all infants received invasive positive pressure ventilation in the intensive care unit (ICU). All infants were successfully weaned from ventilation. The median time to extubation was 4 days (range: 2 to 18 days). The median postoperative ICU stay was 9 days (range: 3 to 52 days). Of the patients, 9 (34%) had a recurrence of symptoms following fundoplication; 5 (19%) subsequently underwent revision of fundoplication and 1 (3.8%) underwent oesophago-gastric dissociation; and 10 (38%) died within the study period. In infants with severe GOR, ventilator dependence, and complex comorbidities, fundoplication may be a useful procedure to assist weaning off ventilator dependence. Rates of symptom recurrence, of revision of fundoplication, and of mortality within this cohort were higher than expected. These data reflect the challenges of patient selection in high-risk groups.