Development Of Acute Respiratory Failure Research Articles

Age, comorbidity burden and late presentation are significant predictors of hospitalization length and acute respiratory failure in patients with influenza

Influenza viruses are responsible for a high number of infections and hospitalizations every year. In this study, we aimed to identify clinical and host-specific factors that influence the duration of hospitalization and the progression to acute respiratory failure (ARF) in influenza. We performed an analysis of data from a prospective active influenza surveillance study that was conducted over five seasons (2018/19 to 2022/23). A total of 1402 patients with influenza were included in the analysis, the majority of which (64.5%) were children (under 18 years), and 9.1% were elderly. At least one chronic condition was present in 29.2% of patients, and 9.9% of patients developed ARF. The median hospital stay was 4 days (IQR: 3, 6 days). The most important predictors of prolonged hospital stay and development of ARF were extremes of age (infants and elderly), presence of chronic diseases, particularly the cumulus of at least 3 chronic diseases, and late presentation to hospital. Among the chronic diseases, chronic obstructive pulmonary disease, cardiovascular disease, cancer, diabetes, obesity, and chronic kidney disease were strongly associated with a longer duration of hospitalization and occurrence of ARF. In this context, interventions aimed at chronic disease management, promoting influenza vaccination, and improving awareness and access to health services may contribute to reducing the impact of influenza not only in Romania but globally. In addition, continued monitoring of the circulation of influenza viruses is essential to limit their spread among vulnerable populations.

ТРУДНОСТИ ДИАГНОСТИКИ ПОВРЕЖДЕНИЯ ЛЕГКИХ, АССОЦИИРОВАННОГО С ВЕЙПИНГОМ И ЭЛЕКТРОННЫМИ СИГАРЕТАМИ, У ПОДРОСТКА С МИКОПЛАЗМЕННОЙ ПНЕВМОНИЕЙ

Electronic nicotine delivery systems’ popularity has increased rapidly over the past decade among both adults and children and especially adolescents. With the growing number of consumers, the number of research studies describing the negative effects of e-cigarettes on the respiratory system and the so-called “E-cigarette or Vaping Use-Associated Lung Injury” (EVALI) is growing Worldwide as well. EVALI that occurs simultaneously with a lower respiratory tract infection can be considered as ‘probable EVALI.’ Addition of an infectious agent can be clinically manifested with the development of acute respiratory failure thus complicating the EVALI diagnosis. This Article represents a clinical case observation of an adolescent patient with mycoplasma pneumonia coupled with EVALI.

Cardiogenic Pulmonary Edema in Emergency Medicine.

Cardiogenic pulmonary edema (CPE) is characterized by the development of acute respiratory failure associated with the accumulation of fluid in the lung's alveolar spaces due to an elevated cardiac filling pressure. All cardiac diseases, characterized by an increasing pressure in the left side of the heart, can cause CPE. High capillary pressure for an extended period can also cause barrier disruption, which implies increased permeability and fluid transfer into the alveoli, leading to edema and atelectasis. The breakdown of the alveolar-epithelial barrier is a consequence of multiple factors that include dysregulated inflammation, intense leukocyte infiltration, activation of procoagulant processes, cell death, and mechanical stretch. Reactive oxygen and nitrogen species (RONS) can modify or damage ion channels, such as epithelial sodium channels, which alters fluid balance. Some studies claim that these patients may have higher levels of surfactant protein B in the bloodstream. The correct approach to patients with CPE should include a detailed medical history and a physical examination to evaluate signs and symptoms of CPE as well as potential causes. Second-level diagnostic tests, such as pulmonary ultrasound, natriuretic peptide level, chest radiograph, and echocardiogram, should occur in the meantime. The identification of the specific CPE phenotype is essential to set the most appropriate therapy for these patients. Non-invasive ventilation (NIV) should be considered early in the treatment of this disease. Diuretics and vasodilators are used for pulmonary congestion. Hypoperfusion requires treatment with inotropes and occasionally vasopressors. Patients with persistent symptoms and diuretic resistance might benefit from additional approaches (i.e., beta-agonists and pentoxifylline). This paper reviews the pathophysiology, clinical presentation, and management of CPE.

A clinical case of acute methadone poisoning in an infant child

Introduction. The article considers a case of a favorable outcome of severe acute oral methadone poisoning complicated by the development of acute respiratory failure and toxic hypoxic encephalopathy.
 Clinical observation. A clinical case of acute oral (through breast milk) methadone poisoning of severe degree in a child of 9 months and 6 days with the development of toxicohypoxic encephalopathy is presented. The narcotic substance entered the body once, after breastfeeding from mother to child. Acute poisoning in the child was manifested by respiratory insufficiency with impaired consciousness (did not respond to pain stimuli, short-term apnea was noted, saturation of arterial blood with oxygen (SpO2) was 62%).
 Intensive therapy included infusion, antidote, detoxification therapy, correction of acid-base state disorders, water-electrolyte balance, hypoxic disorders.
 Conclusion. Methadone-induced respiratory failure is characterized by dose dependence and the possibility of relief after administration of naloxone.
 In our clinical case, a specific antidote was used at the prehospital and hospital stages and an activator of metabolic cellular processes – riboxin in combination with B vitamins: thiamine chloride (vitamin B1) and pyridoxine hydrochloride (vitamin B6).
 In conclusion, it should be noted that the relevance of acute methadone poisoning in childhood remains high. Taking into account the mechanisms of the toxic effect of methadone, it is possible to formulate the directions of intensive therapy: maintenance of life support systems, rational antidote therapy, the fight against hypoxia and its consequences.

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

A case of a favorable outcome of acute oral poisoning with a mixture of narcotic and psychoactive substances of severe degree, complicated by the development of acute respiratory failure and exotoxic shock (clinical observation)

Introduction. The article considers a case of a favorable outcome of acute oral poisoning with a mixture of narcotic and psychoactive substances of severe degree, complicated by the development of acute respiratory failure and exotoxic shock.
 Clinical observation. An episode of acute oral poisoning with a mixture of narcotic and psychoactive substances of severe degree (baclofen, (4-amino-3-(4-chlorophenyl) is presented-butyric acid – 
 ethylglucuronide >2000 mg/ml), methadone 83 mg/ml, methylenedioxypyrovaleron 57 ng/ml, complicated by the development of exotoxic shock in a 32-year-old patient. The clinical picture of acute poisoning was manifested by depression of consciousness to the level of coma II, acute respiratory failure, mixed respiratory and metabolic acidosis (pH 7.18; partial pressure of carbon dioxide 64.0 mmHg, lactic acidosis 
 up to 5 mmol/l), swelling of the brain, exotoxic shock (BP – 60/20 mmHg, heart rate – 110 beats per minute).
 Intensive therapy included: respiratory, infusion, detoxification, anticoagulation, antibacterial therapy, correction of acid-base state disorders, water-electrolyte balance, nutritional support, normalization 
 of metabolic disorders through the use of a substrate antihypoxant. The calculation of the required 
 amount of sodium bicarbonate was carried out according to the Mellengaard-Astrup formula: the amount of mmol of sodium bicarbonate is equal to the product of VE • body weight in kg • 0.3. According 
 to the calculation, the amount of required bicarbonate was 195 mmol, that is, in terms of 5% bicarbonate solution – 195 ml.
 Conclusion. As a result of basic resuscitation care in the form of artificial lung ventilation, correction of mixed respiratory and metabolic acidosis by using sodium bicarbonate, infusion therapy to correct hypovolemia, ensuring optimal perfusion of organs and tissues, elimination of key links of hypoxia by using cytoflavin, improvement of rheological properties of blood and symptomatic therapy allowed for a favorable outcome of severe poisoning with a mixture of narcotic and psychoactive substances complicated by the development of exotoxic shock.

ASSESSMENT OF SST2 BEHAVIORS TO EVALUATE SEVERITY/CLINICAL IMPACT OF ACUTE PULMONARY EMBOLISM

Objective: Pulmonary embolism (PE) is a potentially life-threatening disorder. Beyond its usefulness in the prognostic stratification of heart failure, sST2 can represent a biomarker with high utility in several acute conditions. Our study was aimed to investigate whether sST2 can be used as a clinical marker of severity and prognostic outcome in acute PE. Design and method: We enrolled 72 patients with documented PE and 38 healthy subjects; we measured the plasma concentrations of sST2 to evaluate the prognostic and severity performance of different levels of sST2 according to its association with the pulmonary embolism severity index (PESI) score and several parameters of respiratory function. Results: PE patients had significantly higher levels of sST2 compared with healthy subjects (87.74 ± 17.1 vs. 17.1 ± 0.4 ng/mL, p < 0.001); we found higher PESI scores and serum lactate values in the group of patients with sST2 > 35 ng/mL compared with patients with sST2 < 35 ng/mL (138.7 ± 14.9 vs. 103.7 ± 15.1 and 2.43 ± 0.69 vs. 1.025 ± 0.05 mmol/L, respectively; p < 0.05). Patients with sST2 > 35 ng/mL showed higher radiological severity of PE compared with patients with sST2 < 35 ng/mL. Moreover, sST2 was the strongest parameter with a discriminative capacity for the development of acute respiratory failure and a PESI score >106 with respect to C reactive protein (CRP), creatinine, d-dimer, and serum lactate. Conclusions: We clearly demonstrated that sST2 significantly increased in PE and that its elevation was associated with disease severity. Therefore, sST2 may be used as a clinical marker in the evaluation of PE severity. However, further studies with larger patient populations are required to confirm these findings.

Non-invasive respiratory support in patients with severe community-acquired pneumonia

Acute respiratory failure (ARF) is the leading cause of death in hospitalized patients with severe forms of COVID-19. At the beginning of COVID-19 pandemic the starting respiratory protocol suggested early use of intubation and artificial lung ventilation (ALV) in patients with severe pneumonia complicated by ARF. However, after the analysis of the published studies it was noted that the pathophysiology of the development of ARF in COVID-19 had features that determine the atypical clinical pattern – “silent hypoxemia”. This leads to the late onset of respiratory support (RS) and, as a result, to the lower effectiveness of non-invasive RS methods. This article discusses the creation of an algorithm for the early use of various non-invasive RS methods in patients with COVID-19 complicated by ARF, that will decrease the frequency of hospitalization to the Intensive care units, tracheal intubation and ALV, reduce the duration of treatment and improve prognosis.

No Difference in 30-day Mortality Between Patients Undergoing Bilateral Simultaneous Total Knee Arthroplasty With Technology Assistance Compared to Conventional Instrumentation.

Background: Bilateral simultaneous total knee arthroplasty (BSTKA) has decreased in frequency due to concerns about higher rates of early mortality and complications than unilateral or staged surgeries. Purpose: We sought to evaluate whether technology assistance (encompassing robotics and computer assistance) decreases early mortality following BSTKA. Methods: We conducted a retrospective cohort study using a national all-payer claims database. Patients who underwent BSTKA from October 2015 to December 2020 were identified. Univariate and multivariable analyses were conducted to compare outcomes in patients who underwent BSTKA with technology assistance compared to conventional instrumentation. The primary outcome was 30-day postoperative mortality. Secondary outcomes were respiratory failure and fat embolism. A post-hoc analysis was performed to evaluate length of stay, readmission, and other medical complications. Results: A total of 14,870 patients who underwent BSTKA were included in this study. Of these, 860 patients underwent technology-assisted BSTKA, and 14,010 patients underwent BSTKA without technology assistance. After a multivariable analysis, patients who underwent technology-assisted BSTKA had equivalent odds of 30-day mortality compared to those who underwent BSTKA without technology assistance. Technology assistance was not protective against the development of acute respiratory failure or fat embolism. Conclusion: This retrospective cohort study found no differences in the rates of 30-day mortality, respiratory failure, or fat embolism after technology-assisted BSTKA compared to conventional BSTKA. On the post-hoc analysis, technology use was associated with a decreased length of stay, lower readmission risk, and decreased rates of deep vein thrombosis, pulmonary embolism, and blood transfusion.

Gaceta Médica de México in SARS-CoV-2 pandemic times

December 2019 ended with the identification and development of an atypical pneumonia epidemic caused by an unknown pathogen in Wuhan, China. At the dawn of 2020, at first week, on January 7, the causative agent was isolated in bronchial lavage sam-ples from a critically ill patient. Five days later, on January 12, the Chinese health authorities made the whole genome sequence of a new strain of the Coro-naviridae family public: SARS-CoV-2, among whose relevant characteristics a high mortality rate stood out, as a consequence of the development of acute respi-ratory failure, and easy transmission.

Assessment of sST2 Behaviors to Evaluate Severity/Clinical Impact of Acute Pulmonary Embolism

Pulmonary embolism (PE) is a potentially life-threatening disorder. Beyond its usefulness in the prognostic stratification of heart failure, sST2 can represent a biomarker with high utility in several acute conditions. Our study was aimed to investigate whether sST2 can be used as a clinical marker of severity and prognostic outcome in acute PE. We enrolled 72 patients with documented PE and 38 healthy subjects; we measured the plasma concentrations of sST2 to evaluate the prognostic and severity performance of different levels of sST2 according to its association with the pulmonary embolism severity index (PESI) score and several parameters of respiratory function. PE patients had significantly higher levels of sST2 compared with healthy subjects (87.74 ± 17.1 vs. 17.1 ± 0.4 ng/mL, p < 0.001); we found higher PESI scores and serum lactate values in the group of patients with sST2 > 35 ng/mL compared with patients with sST2 < 35 ng/mL (138.7 ± 14.9 vs. 103.7 ± 15.1 and 2.43 ± 0.69 vs. 1.025 ± 0.05 mmol/L, respectively; p < 0.05). Patients with sST2 > 35 ng/mL showed higher radiological severity of PE compared with patients with sST2 < 35 ng/mL. Moreover, sST2 was the strongest parameter with a discriminative capacity for the development of acute respiratory failure and a PESI score >106 with respect to C reactive protein (CRP), creatinine, d-dimer, and serum lactate. We clearly demonstrated that sST2 significantly increased in PE and that its elevation was associated with disease severity. Therefore, sST2 may be used as a clinical marker in the evaluation of PE severity. However, further studies with larger patient populations are required to confirm these findings.

Sex differences and disparities in cardiovascular outcomes of COVID-19.

Previous analyses on sex differences in case fatality rates at population-level data had limited adjustment for key patient clinical characteristics thought to be associated with coronavirus disease 2019 (COVID-19) outcomes. We aimed to estimate the risk of specific organ dysfunctions and mortality in women and men. This retrospective cross-sectional study included 17 hospitals within 5 European countries participating in the International Survey of Acute Coronavirus Syndromes COVID-19 (NCT05188612). Participants were individuals hospitalized with positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from March 2020 to February 2022. Risk-adjusted ratios (RRs) of in-hospital mortality, acute respiratory failure (ARF), acute heart failure (AHF), and acute kidney injury (AKI) were calculated for women vs. men. Estimates were evaluated by inverse probability weighting and logistic regression models. The overall care cohort included 4499 patients with COVID-19-associated hospitalizations. Of these, 1524 (33.9%) were admitted to intensive care unit (ICU), and 1117 (24.8%) died during hospitalization. Compared with men, women were less likely to be admitted to ICU [RR: 0.80; 95% confidence interval (CI): 0.71-0.91]. In general wards (GWs) and ICU cohorts, the adjusted women-to-men RRs for in-hospital mortality were of 1.13 (95% CI: 0.90-1.42) and 0.86 (95% CI: 0.70-1.05; pinteraction = 0.04). Development of AHF, AKI, and ARF was associated with increased mortality risk (odds ratios: 2.27, 95% CI: 1.73-2.98; 3.85, 95% CI: 3.21-4.63; and 3.95, 95% CI: 3.04-5.14, respectively). The adjusted RRs for AKI and ARF were comparable among women and men regardless of intensity of care. In contrast, female sex was associated with higher odds for AHF in GW, but not in ICU (RRs: 1.25; 95% CI: 0.94-1.67 vs. 0.83; 95% CI: 0.59-1.16, pinteraction = 0.04). Women in GW were at increased risk of AHF and in-hospital mortality for COVID-19 compared with men. For patients receiving ICU care, fatal complications including AHF and mortality appeared to be independent of sex. Equitable access to COVID-19 ICU care is needed to minimize the unfavourable outcome of women presenting with COVID-19-related complications.

Abstract 11122: Sex Differences and Disparities in Cardiovascular Outcomes of Covid-19

Introduction: Previous analyses on sex differences in case-fatality rates at population-level data had limited adjustment for key patient clinical characteristics thought to be associated with COVID-19 outcomes. Hypothesis: We aimed to estimate the risk of specific organ dysfunctions and mortality in women and men. Methods: This retrospective cross-sectional study included 17 hospitals within 5 European countries participating in the International Survey of Acute Coronavirus Syndromes (ISACS) COVID-19 (NCT05188612). Participants were individuals hospitalized with positive SARS-CoV-2 from March 2020 to February 2022. Risk-adjusted ratios (RR) of in-hospital mortality, acute respiratory failure (ARF), acute heart failure (AHF), and acute kidney injury (AKI) were calculated for women versus men. Estimates were evaluated by inverse probability of weighting and logistic regression models Results: The overall care cohort included 4,499 patients with COVID-19 associated hospitalizations. Of these, 1,524 (33.9%) were admitted to ICU, and 1,117 (24.8%) died during hospitalization. Compared with men, women were less likely to be admitted to ICU (RR: 0.80; 95%CI: 0.71-0.91). In general wards and ICU cohorts, the adjusted women-to-men RRs for in-hospital mortality were of 1.13 (95%CI: 0.90-1.42) and 0.86 (95%CI: 0.70-1.05; p interaction =0.04). Development of AHF, AKI, and ARF was associated with increased mortality risk (OR: 2.27; 95%CI; 1.73-2.98, OR: 3.85; 95%CI: 3.21-4.63 and OR: 3.95; 95%CI: 3.04-5.14, respectively). The adjusted RRs for AKI and ARF were comparable among women and men regardless of intensity of care. By contrast, female sex was associated with higher odds for AHF in general wards, but not in ICU (RRs: 1.25;9 5%CI: 0.94-1.67 versus 0.83; 95%CI: 0.59-1.16, p interaction =0.04). Conclusions: Women in general wards were at increased risk of AHF and in-hospital mortality for COVID-19 compared with men. For patients receiving ICU care, fatal complications including AHF and mortality appeared to be independent of sex. Equitable access to COVID-19 ICU care is needed to minimize the unfavourable outcome of women presenting with COVID-19 related complications.

Lipopolysaccharide and ARDS caused by new coronavirus infection: hypotheses and facts

This review presents data from the literature that provide insight into the role of the lipopolysaccharide (LPS) of the Gram-negative bacteria in pathogenesis of acute respiratory distress syndrome (ARDS) caused by the novel SARS-CoV-2 coronavirus infection. ARDS is a syndrome of severe respiratory failure, an acutely occurring diffuse inflammatory lesion of lung tissue that develops as a nonspecific reaction to various direct (aspiration, inhalation of toxic gases), and systemic (sepsis, polytrauma) damaging factors and leading to development of acute respiratory failure (ARF), due to impaired structure of the lung parenchyma, disturbances in vascular permeability, decreased area of ventilated lung tissue. ARDS from coronavirus infection appears to have worse outcomes than ARDS from other causes. Mortality from typical ARDS at the intensive care units and hospitals is 35.3% and 40.0%, respectively, while the lethality rates for COVID-19-associated ARDS, ranged from 26% to 61.5%. Among patients who underwent artificial ventilation of the lungs, the mortality rates can range from 65.7% to 94%. Risk factors for poor outcomes include, e.g., older age, presence of concomitant diseases such as hypertension, cardiovascular disease and diabetes mellitus; decreased number of lymphocytes, kidney injury, and increased D-dimer levels. Death with ARDS in COVID-19 occurs as a result of respiratory failure (53%), respiratory failure combined with heart failure (33%), myocardial damage and circulatory failure (7%), or death from an unknown cause. A large number of studies show that bacterial LPS is directly or indirectly involved in all pathogenetic links of ARDS caused by the SARS-CoV-2 virus, i.e., worsening the course of inflammatory lung diseases due to decreased level of angiotensin-converting enzyme 2 (ACE2); increasing generation of reactive oxygen species (ROS) via NADPH oxidase and subsequent inactivation of endothelial nitric oxide synthase (eNOS) and decreasing bioavailability of endothelial NO, thus leading to endothelial dysfunction; interacting with proteins of surfactants. SP-A and SP-D, promoting early destruction of the cellular monolayers and lowering surface tension, interact with soluble CD14 receptor, which also has a pro-inflammatory effect on epithelial and endothelial cells, leading to p38MAPK activation via TLR4 receptors, causing degradation of IêBá protein and subsequent translocation of p65 NF-êB into the nucleus, thus inducing transcription of IL-6 and adhesion molecules (ICAM-1, VCAM-1 and E-selectin), and, as shown by Petruk et al. (2020), causing direct binding to the viral S protein in combination with LPS, thus enhancing activation of nuclear factor-kappa B (NF-êB) in monocytic THP-1 cells and cytokine responses in mononuclear blood cells. These pathophysiological mechanisms require further in-depth study in order to understand the nature of changes that occur in the patients with new SARS-CoV-2 infection.

Изменения инспираторного усилия при тяжелой гипоксии на фоне действия интерлейкина-6 и фактора некроза опухолей

Today, it is paramount to clarify the role of proinflammatory cytokines in the acute respiratory distress syndrome (ARDS) with severe hypoxemia and systemic inflammatory reaction (SIR). Previously, we found that an increase in the number of circulating IL-1ß and TNF-α suppressing the compensatory reaction of pulmonary ventilation to hypoxia is the main cause of respiratory failure and reduced survival after hypoxic apnea. IL-6 does not cause respiratory decompensation in severe hypoxia, instead, it increases the risk of mortality compared to IL-1ß and TNF-α. We suggested that this difference in the nature of respiratory reactions may be due to the opposite biological effects that cytokines have on the generation of inspiratory effort which is indicative of the activity of respiratory muscles. We conducted a comparative assessment of the effect of intravenous administration of IL-6 and TNF-α on the generation of inspiratory effort (intra-thoracic pressure) and the breathing pattern in hypoxia. In anesthetized rats hypoxia was reproduced by the rebreathing method from normoxia up to apnea. The data were analyzed at FIO2 8%. The recorded parameters include respiratory volume (Vt), breathing frequency (BF), minute lung ventilation (MLV), esophageal pressure (Pes), and survival after hypoxic apnea. It was found that in severe hypoxia IL-6 does not suppress the generation of inspiratory effort and the activity of the respiratory muscles, hence, it does not lead to decompensation of the respiratory function. TNF-α contributes to the development of acute respiratory failure due to the weakening of the inspiratory effort and its contribution to the formation of the breathing pattern.

Application aspects of medications for inhalation at the prehospital stage of medical evacuation

This study aimed to determine the aspects of inhalation application of drugs as medical means of protection against lesions by factors of radiation, chemical, and biological nature at the prehospital stage of medical evacuation. Advantages of inhalation administration of drugs and use of individual inhalers of portable type over parenteral and oral administration methods are described. The existing drugs that are most suitable for inhalation at the prehospital stage of medical evacuation include emergency prevention and treatment of toxic pulmonary edema, analgesics, antiradiation, drugs for arresting radiation primary reaction, agents for accelerated radionuclides elimination, and antibacterial and antiviral agents. This list is conditioned by the rapid achievement of the protective effect of the drug during inhalation, both due to the local action in the area of the entrance gate of the intake of damaging agents and the accelerated absorption and systemic action on target organs. This study presents data on existing and promising inhalation drugs (antidotes for warfare agents, recombinant forms of acetyl- and butyrylcholinesterase) and technical means of their delivery (a metered aerosol inhaler, a metered dry powder inhaler) in the Armed Forces of the European North Atlantic Treaty Organization bloc and the United States for the prevention and treatment of damage e to chemical agents, as well as the prospects of radiomitigator usage (granulocyte-macrophage colony-stimulating factor) by inhalations for acute radiation syndrome treatment and inhalation of complexones of radioactive isotopes. The prospects of inhalation in combination with bronchodilators in the development of acute respiratory failure and toxic pulmonary edema on the background of poisoning with the use of a metered-dose powder inhaler are described. The introduction and use of a metered-dose dry powder inhaler at the prehospital stage of medical evacuation determines the need for its development, taking into account the specifics of the drug usage, as well as the need to unify the dosage form of drugs in combination with one type of inhaler (single-dose or multi-dose).

Spontaneous Pneumomediastinum an Unusual Complication of Covid-19 Infection in a Non-intubated Patient With Diffuse Bilateral Ground-glass Opacity: A Case Report of Progression of Disease During Self-isolation

Background: Spontaneous pneumomediastinum or mediastinal emphysema is relatively a rare disease that occurs in viral and bacterial infections with the benign entity. Case: The patient was a 57-year-old man who, after a week of self-isolation at home, coming to the COVID-19 triage center of the hospital with severe shortness of breath. He was admitted to the Intensive Care Unit (ICU) due to acute respiratory failure. The patient was treated as the protocol designed and respiratory support with high flow nasal oxygen and Non-Invasive Positive Pressure Ventilation (NIPPV). Spontaneous pneumomediastinum was developed during viral pneumonia infection. The known risk factors included age, male sex, and abnormal laboratory finding. All the biochemical and hematological findings such as lymphopenia, thrombocytopenia, raised CRP, LDH, and ferritin were detected in our cases. They indicate a possible prognosis for the development of acute respiratory failure and adverse clinical outcomes. Conclusion: Spontaneous pneumomediastinum has usually a benign outcome in COVID-19 Pneumonia and its prognosis is related to background conditions in patients.

Efficacy and Safety of D-dimer, Weight, and Renal Function-Adjusted Thromboprophylaxis in Patients with Coronavirus Disease 2019 (COVID-19).

The activation of inflammatory and coagulation pathways, leading to hypercoagulability with reduced fibrinolysis, has emerged as pivotal mechanism in development of acute respiratory failure and thrombosis in patients with severe coronavirus disease 2019 (COVID-19).[1] Although thrombosis is a major complication in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, the optimal thromboprophylaxis regimen in these patients is unknown. High rates of thrombosis, especially in those admitted to intensive care, are usually reported despite standard or even intensified thromboprophylaxis with low molecular weight heparin (LMWH). The uncertainty has been reflected in the diverse recommendations in local, national, and international guidelines.[2] [3] [4] Early studies reported that elevated D-dimer values were associated with magnified risk of thrombosis,[5] and this has been confirmed in subsequent studies,[6] even in those in which the thrombosis rate was found to be low.[7] D-dimer has also been a reliable predictor of a poor outcome, and although it is not established that these two observations are linked, large and small vessel thrombosis is prominent in the pulmonary circulation both ante- and postmortem.[8] The prominence of large and small vessel thrombosis in the pathophysiology of COVID-19 and its high frequency despite standard or sometimes increased intensity LMWH suggests that intensified prophylaxis may be beneficial. However, any benefit from this approach would need to be balanced against a possible increase in bleeding complications. The use of intensified versus standard dose LMWH is being investigated in several clinical trials, although only recently initiated in the United Kingdom. Pending the results of such studies, individual National Health Service (NHS) Trusts have developed local thromboprophylaxis guidelines for COVID-19.

Pulmonary complications due to COVID-19 – a literature review

Introduction: irst cases of a disease called coronavirus disease 2019 (COVID-19), caused by a novel virus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) of the coronavirus family, were detected in December 2019. The disease is manifested by a variety of symptoms and can run a different course: from oligosymptomatic or asymptomatic to the development of acute respiratory failure and even death. Aim: The aim of this paper is to provide critical analysis of the potential pulmonary complications after COVID-19 infection. Material and methods: We have provided the systematic literature review based on which we have discussed the pathophysiology of COVID-19, its outcomes, risk factors and pulmonary complications. Results and discussion: The organs that are most often affected by a SARS-CoV-2 infection are the lungs. An infection with this virus can lead to a severe respiratory tract illness, both in the acute phase and as a complication after a relatively mild case. There are numerous observations of patients convalescing from COVID-19 who suffer from the interstitial pulmonary disease with fibrosis. There are also reported cases of spontaneous pneumothorax after COVID-19. Conclusions: It should be borne in mind that other late complications may appear with time.

Silent hypoxemia in a patient with severe SARS-CoV-2 pneumonia

Patients with COVID-19 are typically characterized by severe lung injury with the development of acute respiratory failure. However, in some patients, subjective well-being may remain relatively satisfactory for a long time and, despite severe hypoxemia, they do not complain of shortness of breath. Case report. We observed a 65-year-old man hospitalized with severe SARS-CoV-2 pneumonia, low level of blood oxygen saturation, but at the same time without complaints of shortness of breath. Only as the disease progressed with a decrease in oxygen saturation when breathing atmospheric air (SpO2 ) lower than 85% he began to notice a feeling of lack of air. The patient’s condition worsened and as a result, he died in the intensive care unit from multiple organ failure. Discussion. This case clearly illustrates one more feature of the course of pneumonia associated with the novel SARSCoV-2 coronavirus and shows that SpO2 measurement is one of the leading objective criterion that allows a doctor to assess the real severity of a patient’s condition with COVID-19.