Flow Nasal Cannula Oxygen Therapy Research Articles

High flow Nasal Cannula oxygen therapy: the Columbus egg that helps us understand the clinical meaning of dyspnea.

High flow Nasal Cannula oxygen therapy: the Columbus egg that helps us understand the clinical meaning of dyspnea.

Clinical research progress in non-invasive positive pressure ventilation in 2023

Non-invasive positive pressure ventilation (NPPV) is a widely used method of providing respiratory support in a variety of clinical settings, including emergency departments, general wards, and intensive care units. The relevant research articles on NPPV published between 1st October 2022 and 30th September 2023 were retrieved from Medline and reviewed. In the management of acute respiratory failure (ARF) associated with COVID-19, studies have highlighted the significant influence of regional economic status on the choice of respiratory support strategies. It has been observed that NPPV is more suitable for patients with mild to moderate acute respiratory distress syndrome (ARDS) than for those with severe ARDS, as the latter group has an increased risk of delayed intubation. In addition, patients with severe dyspnea tended to benefit more from NPPV compared with high flow nasal cannula (HFNC) and conventional oxygen therapy, with a reduced risk of self-induced lung injury. For non-COVID-19-related ARF, research shows no significant differences in mortality and intubation rates between HFNC and NPPV in patients with hypercapnic ARF. The updated HACOR score and ROX score have been validated to have a high predictive value for clinical outcomes in patients receiving NPPV for hypoxemic ARF. With regard to weaning from invasive mechanical ventilation, immediate application of NPPV after extubation showed a lower mortality rate compared to continued invasive weaning. Moreover, NPPV with active humidification significantly decreased the reintubation rate within 7 days after extubation compared with HFNC. The choice between using NPPV and HFNC should be based on the specific etiology of the patient's condition. The potential effect of noninvasive high-frequency oscillatory ventilation on CO2 clearance was also investigated.

Clinical characteristics and mortality prediction of patients admitted to the Hong Kong East Cluster intensive care units in the COVID‐19 fifth wave

AbstractIntroductionCOVID‐19 has been threatening global public health since 2019. To address the overwhelming caseload, several tools were developed to predict prognosis and aid triage of critically ill patients for intensive care. Currently, there is a lack of local data on the validity of such tools.ObjectiveThe objective of this study is to identify the predictors of intensive care unit (ICU) mortality in COVID‐19 patients in Hong Kong and externally validate the different scoring systems.MethodsA retrospective cohort analysis of patients admitted to the HKEC ICUs from 1 January 2022 to 30 April 2022 was performed. We collected data on patient demographics, vaccination status, laboratory parameters, and clinical outcomes including need for organ support and mortality. Clinical severities were estimated by Sequential Organ Failure Score, 4C Mortality Score, COVID‐Gram score, and Acute Physiology and Chronic Health Evaluation (APACHE) IV score based on the original studies. Comparison between individual scoring systems' performance on hospital mortality was conducted and summarized.ResultsIn these four months, 137 patients with COVID‐19 admitted to ICUs of Ruttonjee Hospital and Pamela Youde Nethersole Eastern Hospital were recruited. 64 patients (46.7%) were admitted for COVID‐19 related respiratory failure, among which mortality was 66.7%. The overall hospital and ICU mortality were 21.9% and 13.1%, respectively. Invasive mechanical ventilation (IMV) (OR 3.221, p 0.034), high flow nasal cannula (HFNC) oxygen therapy (OR 3.107, p 0.039), and higher APACHE IV score (OR 1.043, p < 0.001) were independent predictors of hospital mortality using multivariate analysis. The scoring systems had good performance in mortality prediction in our population. The APACHE IV score (AUROC 0.79, 95% CI 0.698–0.894) and 4C Mortality Score (AUROC 0.751, 95% CI 0.657–0.844) outperformed other scoring systems in predicting hospital mortality.ConclusionIn patients with COVID‐19, the use of IMV or HFNC and APACHE IV score were independent risk factors for hospital mortality. The APACHE IV and the 4C Mortality Score were most useful in our population for predicting ICU and hospital mortality.

Clinical study of NFNC in the treatment of acute exacerbation chronic obstructive pulmonary disease patients with respiratory failure

BACKGROUND Most patients with acute exacerbation chronic obstructive pulmonary disease (AECOPD) have respiratory failure that necessitates active correction and the improvement of oxygenation is particularly important during treatment. High flow nasal cannula (HFNC) oxygen therapy is a non-invasive respiratory aid that is widely used in the clinic that improves oxygenation state, reduces dead space ventilation and breathing effort, protects the loss of cilia in the airways, and improves patient comfort. AIM To compare HFNC and non-invasive positive pressure ventilation in the treatment of patients with AECOPD. METHODS Eighty AECOPD patients were included in the study. The patients were in the intensive care department of our hospital from October 2019 to October 2021. The patients were divided into the control and treatment groups according to the different treatment methods with 40 patients in each group. Differences in patient comfort, blood gas analysis and infection indices were analyzed between the two groups. RESULTS After treatment, symptoms including nasal, throat and chest discomfort were significantly lower in the treatment group compared to the control group on the 3rd and 5th days (P < 0.05). Before treatment, the PaO2, PaO2/FiO2, PaCO2, and SaO2 in the two groups of patients were not significantly different (P > 0.05). After treatment, the same indicators were significantly improved in both patient groups but had improved more in the treatment group compared to the control group (P < 0.05). After treatment, the white blood cell count, and the levels of C-reactive protein and calcitonin in patients in the treatment group were significantly higher compared to patients in the control group (P < 0.05). CONCLUSION HFNC treatment can improve the ventilation of AECOPD patients whilst also improving patient comfort, and reducing complications. HFNC is a clinically valuable technique for the treatment of AECOPD.

SARS-CoV-2 pneumonia and Eisenmenger’s Syndrome: doubling the challenge

Eisenmenger’s syndrome (ES) is the most severe phenotype of pulmonary arterial hypertension (PAH) secondary to congenital heart disease. In these cases, a significant systemic-to-pulmonary (left-to-right) shunting triggers the development of pulmonary vascular disease (PVD) and pulmonary hypertension. In cases of acute hypoxemic respiratory failure in patients with ES, high flow nasal cannula (HFNC) oxygen therapy should be considered as a first-line approach in order to avoid pulmonary complications and right ventricular overload related to positive pressure ventilation. Here, we report a case of HFNC use in a patient with COVID-19 infection and ES.

The Momentum Battle in an Upper Airway During High Flow Nasal Cannula Oxygen Therapy

Abstract Two types of high flow nasal cannula (HFNC) oxygen therapy were tested using computational models of the human upper airway to investigate cannula geometry's effect on CO2 flush. Models were run with a generic HFNC geometry, two High Velocity Nasal Insufflation (HVNI) cannula geometries, and without any cannula, each for open and closed mouth patient scenarios. For the open mouth scenario, models included either an inflamed left nasal passageway or a healthy (uninflamed) left nasal passageway. With a healthy left nasal passageway and open mouth, the CO2 remaining in the airway at end-exhale was 1.88 mg and 1.84 mg for the HVNI cannulas, 2.56 mg for HFNC, and 10.0 mg for the model with no cannula. With an inflamed left nasal passageway and open mouth, the CO2 remaining was 1.97 mg, 1.95 mg, 4.24 mg, and 10.5 mg for the same sequence of therapy types. For the closed mouth models, the distinction between therapy types was negligible. It was found that the higher momentum from the HVNI cannulas created a higher resistance against the infiltration of exhaled CO2 into the upper airway. The HVNI cannulas also began flushing the airway (reducing total CO2 mass) earlier in the exhalation cycle than both the HFNC and no-cannula models. The higher resistance to expiratory flow entering the upper airway and earlier transition to flush led to HVNI therapy having the lowest values of CO2 remaining in the airway.

Performance of the ROX index in predicting high flow nasal cannula failure in COVID-19 patients: a systematic review and meta-analysis

COVID-19 patients with acute hypoxemic respiratory failure (AHRF) benefit from high flow nasal cannula (HFNC) oxygen therapy. However, delays in initiating invasive ventilation after HFNC failure are associated with poorer outcomes. The respiratory oxygenation (ROX) index, combining SpO2/FiO2 and respiratory rate, can predict HFNC failure. This meta-analysis evaluated the optimal ROX index cut-offs in predicting HFNC failure among COVID-19 patients at different measurement timings and clinical settings. Three databases were searched for eligible papers. From each study, we reconstructed the confusion matrices at different cut-offs, fitted linear mixed models to estimate the ROX index distribution function, and derived the area under the summary receiver operator characteristic curve (sAUC) and optimal cut-offs to predict HFNC failure. 24 studies containing 4790 patients were included. Overall sAUC was 0.771 (95% CI: 0.666–0.847) (optimal cut-off: 5.23, sensitivity: 0.732, specificity: 0.690). The cut-off values to achieve 80%, 90% sensitivity, 80%, 90% specificity were 5.70, 6.69, 4.45, 3.37, respectively. We stratified the analysis by ROX measurement time and estimated optimal cut-offs and cut-offs to achieve 80% sensitivity and specificity. For 2–6 h and 6–12 h post-HFNC initiation, we propose the use of 80% specific cut-offs to rule in HFNC failure of < 5.33 and < 3.69, respectively. For 12–24 h post-HFNC initiation, we propose the use of the 80% sensitive cut-off of > 6.07 to rule out HFNC failure. Our analysis confirms the overall utility of the ROX index in risk stratification of COVID-19 patients with AHRF receiving HFNC and provides potentially useful cut-offs for different times from HFNC initiation.

High flow nasal cannula for respiratory support in term infants.

High flow nasal cannula for respiratory support in term infants.

Use of high flow nasal cannula oxygen therapy for patients infected with SARS-CoV-2 outside intensive care setting.

In early 2022, there was a sudden surge of patients infected by the Omicron variant of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in Hong Kong (HK), resulting in 9,163 deaths as of 29 May 2022. Many of the local population had not been vaccinated before this wave. The number of patients who developed coronavirus disease 2019 (COVID-19) related respiratory failure outnumbered the capacity of intensive care unit (ICU) beds. Some of these patients had to be supported with high flow nasal cannula (HFNC) therapy outside ICU setting. HK was in crisis situation. The primary objective of this study is to assess the 28-day mortality of this group of patients. The secondary objective is to explore any predictors of non-survivors to help clinical decision-making in future crisis. This is a retrospective observational study of patients suffering from COVID-19 related respiratory failure who received HFNC therapy in general medical wards of two hospitals during the period of 17 Mar to 30 Apr 2022. Survival and risk factors were reviewed. Forty-nine patients were recruited. Twenty-six patients (53%) survived at 28-day after initiation of HFNC support. Three clinical parameters were found to be significantly associated with mortality at 28-day: (I) SpO2/FiO2 (SF) ratio <160 at 48 hours; (II) SF ratio <191 at 72 hours; (III) serial SF ratio at 48 or 72 hours showing no improvement over that at the time of initiation of HFNC therapy. Use of HFNC outside ICU setting showed benefit to patients suffering from COVID-19 related acute hypoxemic respiratory failure (AHRF). Serial SF ratio monitoring at 48 and 72 hours after therapy initiation might serve as predictors of outcome and thus guide clinical decision-making for medical resource allocation in outbreak situation.

Analysis of the clinical features and the risk factors of severe human metapneu movirus-associated community acquired pneumonia in children

Objective: To investigate the clinical characteristics and the risk factors of severe human metapneumovirus (hMPV)-associated community acquired pneumonia (CAP) in children. Methods: A retrospective case summary was conducted. From December 2020 to March 2022, 721 children who were diagnosed with CAP and tested positive for hMPV nucleic acid by PCR-capillary electrophoresis fragment analysis of nasopharyngeal secretions at the Yuying Children's Hospital, the Second Affiliated Hospital of Wenzhou Medical University were selected as the research objects. The clinical characteristics, epidemiological characteristics and mixed pathogens of the two groups were analyzed. According to CAP diagnostic criteria, the children were divided into the severe group and the mild group. Chi-square test or Mann-Whitney rank and contrast analysis was used for comparison between groups, while multivariate Logistic regression was applied to analyze the risk factors of the severe hMPV-associated CAP. Results: A total of 721 children who were diagnosed with hMPV-associated CAP were included in this study, with 397 males and 324 females. There were 154 cases in the severe group. The age of onset was 1.0 (0.9, 3.0) years, <3 years old 104 cases (67.5%), and the length of hospital stay was 7 (6, 9) days. In the severe group, 67 children (43.5%) were complicated with underlying diseases. In the severe group, 154 cases (100.0%) had cough, 148 cases (96.1%) had shortness of breath and pulmonary moist rales, and 132 cases (85.7%) had fever, 23 cases (14.9%) were complicated with respiratory failure. C-reactive protein (CRP) was elevated in 86 children (55.8%), including CRP≥50 mg/L in 33 children (21.4%). Co-infection was detected in 77 cases (50.0%) and 102 strains of pathogen were detected, 25 strains of rhinovirus, 17 strains of Mycoplasma pneumoniae, 15 strains of Streptococcus pneumoniae, 12 strains of Haemophilus influenzae and 10 strains of respiratory syncytial virus were detected. Six cases (3.9%) received heated and humidified high flow nasal cannula oxygen therapy, 15 cases (9.7%) were admitted to intensive care unit, and 2 cases (1.3%) received mechanical ventilation. In the severe group, 108 children were cured, 42 children were improved, 4 chlidren were discharged automatically without recovery and no death occurred. There were 567 cases in the mild group. The age of onset was 2.7 (1.0, 4.0) years, and the length of hospital stay was 4 (4, 6) days.Compared with the mild group, the proportion of children who age of disease onset <6 months, CRP≥50 mg/L, the proportions of preterm birth, congenital heart disease, malnutrition, congenital airway malformation, neuromuscular disease, mixed respiratory syncytial viruses infection were higher (20 cases (13.0%) vs. 31 cases (5.5%), 32 cases (20.8%) vs. 64 cases (11.3%), 23 cases (14.9%) vs. 44 cases (7.8%), 11 cases (7.1%) vs. 18 cases (3.2%), 9 cases (5.8%) vs. 6 cases (1.1%), 11 cases (7.1%) vs. 12 cases (2.1%), 8 cases (5.2%) vs. 4 cases (0.7%), 10 cases (6.5%) vs. 13 cases (2.3%), χ2=0.42, 9.45, 7.40, 4.94, 11.40, 8.35, 3.52, 6.92, all P<0.05). Multivariate Logistic regression analysis showed that age<6 months (OR=2.51, 95%CI 1.29-4.89), CRP≥50 mg/L (OR=2.20, 95%CI 1.36-3.57), prematurity (OR=2.19, 95%CI 1.26-3.81), malnutrition (OR=6.05, 95%CI 1.89-19.39) were the independent risk factors for severe hMPV-associated CAP. Conclusions: Severe hMPV-associated CAP is most likely to occur in infants under 3 years old and has a higher proportion of underlying diseases and co-infection. The main clinical manifestations are cough, shortness of breath and pulmonary moist rales, fever. The overall prognosis is good. Age<6 months, CRP≥50 mg/L, preterm birth, malnutrition are the independent risk factors for severe hMPV-associated CAP.

Effects of aerosolized inhalation of N-acetylcysteine combined with high flow nasal cannulae oxygen therapy on inflammation, oxidative stress, and cognitive function in patients with severe pulmonary infection complicated with respiratory failure

Purpose: To investigate the effects of aerosolized inhalation of N-acetylcysteine (NAC) combined with high-flow nasal cannulae oxygen therapy on serum inflammation, oxidative stress, and cognitive function in patients with severe pulmonary infection complicated with respiratory failure.&#x0D; Methods: A total of 50 patients diagnosed with severe pulmonary infection complicated with respiratory failure were randomly divided into the study and control groups, respectively. Serum oxidative stress, inflammation, and cognitive function were determined after treatment intervention. The effect of aerosol inhalation of NAC combined with high flow-nasal cannulae oxygen therapy was assessed.&#x0D; Results: General clinical data such as age, lung function, etc, did not show any difference between the study and control groups (p &gt; 0.05). Dyspnea was scored in the Study group after treatment. Serum malondialdehyde (MDA), tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6) decreased (p &lt; 0.05), while cognitive scores and serum total antioxidant capacity of the Study group increased (p &lt; 0.05); There was no significant difference in serum superoxide dismutase levels between the two groups (p &gt; 0.05).&#x0D; Conclusion: Aerosolized inhalation of NAC combined with high-flow nasal cannulae oxygen therapy has anti-inflammatory and antioxidant effects, which can improve cognitive dysfunction in patients with severe pulmonary infection complicated with respiratory failure, and may provide a new clinical treatment strategy for severe pulmonary infection complicated with respiratory failure.

HIGH FLOW NASAL CANNULA OXYGEN THERAPY IN PEDIATRIC PATIENTS

With the spread of clinical applications, the interest in the use of high-flow nasal cannula, which warms and humidifies oxygen with the help of traditional nasal cannula, has increased. Many international protocols on the use of high-flow nasal cannula oxygen therapy (HFNC) are available. This study was conducted to evaluate the oxygen therapy methods used in pediatric services and to specify the roles and responsibilities of nurses in the application of HFNC, one of these methods. Because nurses are responsible for the use of HFNC, monitoring the effectiveness of the treatment, monitoring children during HFNC and helping them to carry out the activities of daily living, HFNC-related nursing approach is of importance.

Clinical outcomes of high-flow nasal cannula oxygen therapy in acute heart failure patients with hypoxemia: A retrospective cohort study.

Acute heart failure (AHF) is life-threatening medical condition requiring hospital admission and appropriate oxygen therapy. High flow nasal cannula oxygen therapy (HFNC) has gained its popularity in treatment of AHF, however, there were less studies have demonstrated the physiological efficacy of HFNC. Purpose of this study was to evaluated the physiological responses and clinical outcomes of HFNC by comparing with noninvasive positive pressure ventilation (NPPV) therapy. A retrospective cohort investigation was conducted at emergency intensive care unit (EICU) and cardiovascular center of our hospital from June 2019 to March 2022, AHF patients with hypoxemia were reviewed. According to the received oxygen therapy model, patients were divided into HFNC and NPPV groups. Demographic data, arterial blood gas (ABG) parameter, echocardiography findings, complications and other related variables were extracted and collected from the electronic medical records (EMRs) by well-trained investigators. Physiological responses and clinical outcomes within and between 2 groups were analyzed. Finally, 156 patients with a mean age of 69.3 ± 7.1 years were reviewed, there were 82 (52.6%) male and 74 (47.4%) female patients in the sample and 70 (44.9%) and 86 (55.1%) patients classified III and IV score were included in this study, 80 patients received HFNC and 76 underwent NPPV oxygen therapy. There were no significant differences of baseline characteristics for the 2 groups patients. Changes of left ventricular function parameters, ABG and clinical outcomes were all improved satisfactorily after 24 h medical interventions in both group, what's more, patients underwent HFNC therapy could acquire a better amelioration when compared with NPPV groups (P < .05). HFNC may be an ideal model for patients with AHF, particularly those with hypoxemia. HFNC therapy could significantly improve several objective parameters of physiological responses and clinical outcomes.

Analysis of the Effects of Humidified High Flow Nasal Oxygen Therapy Combined with Noninvasive Mechanical Ventilation on Treatment Outcomes.

Objective To investigate the effects of humidified high flow nasal cannula (HFNC) oxygen therapy combined with noninvasive mechanical ventilation (NIV) on blood gas indexes, complications, and respiratory function in patients with AECOPD. Method 100 patients with AECOPD admitted to the Department of Respiratory and Critical Medicine of Pukou District Central Hospital of Nanjing from March 2020 to February 2021 were selected. The patients were randomly divided into study group (50 cases) and control group (50 cases); both groups were given routine treatment such as bronchodilators, low-dose glucocorticoids, and antibiotics. During the treatment, the vital signs, inflammatory response indexes, fluid balance, and nutrition were continuously monitored; the body position was changed every 2 hours; and the curative effect was evaluated one week after treatment. On this basis, the control group received routine oxygen therapy combined with NIV (low flow conventional oxygen therapy + NIV), and the study group received HFNC combined with NIV (HFNC + NIV). The oxygen partial pressure (PaO2), peak expiratory flow rate (PEFR), arterial oxygen saturation (SaO2), first-second forced expiratory volume (FEV1), and mixed venous oxygen saturation (SvO2) level were compared between the two groups before and after treatment. Moreover, SECS scores before ventilation and 2, 4, 6, and 12 hours after ventilation were collected and analyzed. In addition, complications during oxygen therapy were compared. Result Before treatment, there was no significant difference in the levels of PaCO2, FEV1, SaO2, PEFR, and SvO2 between the two groups (P > 0.05). After treatment, the levels of PaCO2 in the study group were lower than those in the control group, and the levels of FEV1, SaO2, PEFR, and SvO2 in the study group were higher than those in the control group P < 0.05(P < 0.05). There was no significant difference in SECS scores between the two groups before ventilation and 2 hours after ventilation (P > 0.05). The SECS scores of the study group at 4, 6, and 12 hours after ventilation were higher than those of the control group P < 0.05(P < 0.05). The total complication rate in the study group (8.00% vs. 24.00%) was lower than that in the control group (P < 0.05). Compared with low flow conventional oxygen therapy, NIV combined with HFNC can effectively reduce the incidence of complications in AECOPD patients during oxygen therapy, improve patients' ventilation comfort, and effectively improve blood gas indexes and respiratory function, with simple operation and high safety, which is worthy of clinical promotion and application.

Factors affecting the failure of High Flow Nasal Cannula Oxygen therapy in Intensive Care follow-up of COVID-19 Severe Respiratory Failure.

Acute respiratory distress syndrome is the primary clinical problem that requires follow-up at the intensive care units. High Flow Nasal Cannula Oxygen Therapy has become an increasingly popular method by reducing the need for intubation but determining which patient will benefit from High Flow Nasal Cannula Oxygen Therapy is an important issue. Seventy patients who followed up with acute respiratory distress syndrome related COVID-19 treated with High Flow Nasal Cannula Oxygen Systems as initial treatment at the intensive care units were retrospectively review. The primary endpoint of this study is to identify factors correlating with failure (mortality and invasive mechanical ventilator requirement) of High Flow Nasal Cannula Oxygen Therapy in the treatment of COVID-19-related severe ARDS. The secondary aim of this study is to determine the ROX index measured at the 12th hour, which will indicate the need for intubation in critically ill patients followed up with HFNC. Advanced age, male gender, and low ROX index were independent variables affecting High Flow Nasal Cannula Oxygen Therapy failure. While mortality was lowest in patients who completed the process with High Flow Nasal Cannula Oxygen Therapy treatment, patients who were intubated early (12-24h) had lower mortality than those who were intubated later (>24h) (Mortality rates were %4,3 ,%65,6 ,%93,3 respectively). The cut-off value for ROX index, which will indicate the need for intubation, was found to be 2.84. High Flow Nasal Cannula Oxygen Therapy can be an effective treatment method in the follow-up of patients with COVID-19-related severe respiratory failure. Despite this, the requirement for intubation develops in two third of the patients. Early intubation reduces mortality in patients who fail High Flow Nasal Cannula Oxygen Therapy, and the easily calculated ROX index is a useful parameter to determine the need for intubation.

Clinical Characteristics and Risk Factors for Mortality in Critical Coronavirus Disease 2019 Patients 50 Years of Age or Younger During the Delta Wave: Comparison With Patients > 50 Years in Korea.

BackgroundNumerous patients around the globe are dying from coronavirus disease 2019 (COVID-19). While age is a known risk factor, risk analysis in the young generation is lacking. The present study aimed to evaluate the clinical features and mortality risk factors in younger patients (≤ 50 years) with a critical case of COVID-19 in comparison with those among older patients (> 50 years) in Korea.MethodsWe analyzed the data of adult patients only in critical condition (requiring high flow nasal cannula oxygen therapy or higher respiratory support) hospitalized with PCR-confirmed COVID-19 at 11 hospitals in Korea from July 1, 2021 to November 30, 2021 when the delta variant was a dominant strain. Patients’ electronic medical records were reviewed to identify clinical characteristics.ResultsDuring the study period, 448 patients were enrolled. One hundred and forty-two were aged 50 years or younger (the younger group), while 306 were above 50 years of age (the older group). The most common pre-existing conditions in the younger group were diabetes mellitus and hypertension, and 69.7% of the patients had a body mass index (BMI) > 25 kg/m2. Of 142 younger patients, 31 of 142 patients (21.8%, 19 women) did not have these pre-existing conditions. The overall case fatality rate among severity cases was 21.0%, and it differed according to age: 5.6% (n = 8/142) in the younger group, 28.1% in the older group, and 38% in the ≥ 65 years group. Age (odds ratio [OR], 7.902; 95% confidence interval [CI], 2.754–18.181), mechanical ventilation therapy (OR, 17.233; 95% CI, 8.439–35.192), highest creatinine > 1.5 mg/dL (OR, 17.631; 95% CI, 8.321–37.357), and combined blood stream infection (OR, 7.092; 95% CI, 1.061–18.181) were identified as independent predictors of mortality in total patients. Similar patterns were observed in age-specific analyses, but most results were statistically insignificant in multivariate analysis due to the low number of deaths in the younger group. The full vaccination rate was very low among study population (13.6%), and only three patients were fully vaccinated, with none of the patients who died having been fully vaccinated in the younger group. Seven of eight patients who died had a pre-existing condition or were obese (BMI > 25 kg/m2), and the one remaining patient died from a secondary infection.ConclusionAbout 22% of the patients in the young critical group did not have an underlying disease or obesity, but the rate of obesity (BMI > 25 kg/m2) was high, with a fatality rate of 5.6%. The full vaccination rate was extremely low compared to the general population of the same age group, showing that non-vaccination has a grave impact on the progression of COVID-19 to a critical condition. The findings of this study highlight the need for measures to prevent critical progression of COVID-19, such as vaccinations and targeting young adults especially having risk factors.

The role of high flow nasal cannula oxygen therapy in patients with acute exacerbation of interstitial pneumonia

The role of high flow nasal cannula oxygen therapy in patients with acute exacerbation of interstitial pneumonia

Airway hitches and management in Maroteaux-Lamy syndrome.

Dear Editor, Maroteaux-Lamy Syndrome (mucopolysaccharidosis type VI [MPS VI]) is caused by deficiency of N-acetylgalactosamine-4-sulfatase resulting in accumulation of dermatan sulfate which evokes the varied spectra of clinical symptoms.[1] Dysmorphic facial features with multi-systemic involvement pose a formidable challenge to anesthetists. We present a case of an 8-year-old female child with progressive bilateral flexion deformity of fingers, mouth breathing and snoring. She was posted for cervical (C1-C2) fixation surgery. Child had coarse facial features, macrocephaly (head circumference: 60 cm), macroglossia, short neck (thyromental distance: 4.5 cm, sternomental distance: 7 cm) and restricted neck mobility [Figure 1a]. Our plan A was C-MAC videolaryngoscopic (C-MAC®VL)-guided intubation with backup plans of fiber-optic bronchoscope (FOB)-guided intubation, retrograde intubation, and front of neck access as plans B, C, and D respectively. Consent of the mother was obtained. ASA standard monitors were attached. Continuous high flow nasal cannula (HFNC) oxygen therapy was started [Figure 1b]. Fentanyl 2mcg/kg (IV) was given and inhalational induction with sevoflurane was started. There was difficulty in mask ventilation even after oral airway insertion. So, immediate insertion of supreme laryngeal mask airway (LMA) size-2 enabled adequate ventilation [Figure 2a]. Injection rocuronium 1 mg/kg (IV) was administered. LMA was removed and endotracheal intubation was performed using C-MAC®VL at second attempt using bougie. Apneic oxygenation with HFNC and manual in-line stabilization was ensured until endotracheal intubation was achieved. When the patient was turned from prone to supine position after surgery, we noticed edema of the lips and tongue [Figure 2b]. Videolaryngoscopy revealed edema of posterior commissure which resolved with intravenous steroids and then extubated 24 hours later in ICU.Figure 1: (a) shows facial and airway profile in this child with MPS. (b) shows continuous HFNC therapyFigure 2: (a) Supreme LMA inserted to facilitate ventilation before endotracheal intubation. (b) Edematous tongue and lips noted when patient turned supine after surgeryMaroteaux–Lamy syndrome is a type of mucopolysaccharidosis characterized by learning difficulties, mental retardation, coarse facial features, frontal bossing, depressed nasal bridge, macroglossia, adeno-tonsillar hypertrophy, narrowed airway, short, stiff neck and temporomandibular joints leading to difficult airway.[2,3] Multi-systemic involvement includes obstructive or, restrictive lung disease, valvular heart disease and cardiomyopathy. Instability of the atlantoaxial joint requires special care during intubation to prevent further compression of the cervical spinal cord.[4] Difficulty in maintaining adequate ventilation may be due to obstructive and restrictive lung disease. Intraoperative hemodynamic instability may occur due to underlying cardiac disease. Prone position can further aggravate existing airway narrowing as it can lead to airway edema which may pose difficulty during extubation. In our case, we chose inhalational induction over intravenous induction as it was anticipated difficult airway. We could overcome the difficulty of mask ventilation by expeditious insertion of LMA. C-MAC®VL-guided intubation was chosen over the fiber-optic technique as it provides fixed wide view of the glottis that aids in quick recognition of airway landmarks.[5] FOB-guided intubation would be difficult as the patient had poor comprehension and, airway collapse leads to difficulty in maneuvering and advancement. HFNC oxygen therapy prevented desaturation. Thus, from this case, we infer that in a child with mucopolysaccharidosis, inhalational induction, ventilation with LMA followed by intubation with C-Mac videolaryngoscope would be a logical method of airway management. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Spontaneous pneumomediastinum – a rare cause of chest pain and dyspnoe in children

Introduction. Spontaneous pneumomediastinum is a very rare condition in children. Nevertheless it should be considered in the differential diagnosis in patients who present with chest pain and dyspnoe.Aim. The aim of our study was to describe clinical presentation, management and outcomes of the paediatric patients with spontaneous pneumomediastinumMaterial and Methods. This was a retrospective analysis of the charts of all the patients who were admitted to the Department of Pneumonology, Paediatric Allergy and Clinical Immunology in a ten year period from 01.01.2011 till 31.12.2020 in whom spontaneous pneumomediastinum was diagnosed.Results. There were 11 children (7 females) with spontaneous pneumomediastinum. The median age of the children was 11 years (range 3 to 17.5 years). Most of the children presented to the hospital with chest pain, three children complained of the neck swelling and four children developed dyspnoe. Three children with the primary spontaneous pneumomediastinum had a history of physical exercise prior to the onset of symptoms. The secondary spontaneous pneumomediastinum occurred in two children with asthma and 4 children with pneumonia. Genetic material of human Bocavirus was identified in 3 cases. In 81.8% of children pneumomediastinum was accompanied by subcutaneous emphysema and in one case, in a child with severe pneumonia and respiratory insufficiency caused by Bocavirus with pneumorrhachis. In 10 children computed tomography was performed, bronchoscopy in 4 and esophagoscopy in two children. There was no evidence of esophageal rupture or bronchial tree rupture in any of our patients. Three children with pneumonia and pneumomediastinum developed respiratory insufficiency, two of these were treated with mechanical ventilation and one with High Flow Nasal Cannula oxygen therapy. All the children received oxygen. In one child surgical procedure was performed and the drain was inserted into mediastinal space in order to decompress it. Outcome was favourable in all children. Mean time to recovery was 10.6 ± 1.2 days. There was no recurrence of symptoms in any of our patients.Conclusions. Spontaneous pneumomediastinum in most cases is a benign condition, sporadically however it may progress rapidly, leading to respiratory insufficiency and warrant invasive management.

LEAKY LUNGS: A COMPLICATION OF COVID-19 PNEUMONIA

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: COVID-19 pneumonia can result in complications such as ARDS, septic shock, thromboembolic events, and kidney failure. Spontaneous pneumothorax, pneumomediastinum and subcutaneous emphysema are rare complications. CASE PRESENTATION: A 72-year-old African American female presented with a four day history of dyspnea. She was tachypneic with respiratory rate of 25/min with O2 saturation of 67% on room air, oxygen therapy via nonrebreather mask improved the O2 saturation to 92%. PCR test for SARS-CoV-2 was positive. Laboratory studies revealed a D-dimer-1121 ng/ml, C-reactive protein-15.97mg/dl, ferritin-356.8 and lactate dehydrogenase-337 U/L. Chest X-ray showed focal areas of interstitial and alveolar opacities. A CT scan of chest showed multiple focal ground glass opacities in the bilateral lung fields. She was treated with dexamethasone, remdesivir and supplemental oxygen. Two days later she became more hypoxic and chest X-ray showed increased interstitial opacities and a small pneumomediastinum. She was placed on high flow nasal cannula oxygen therapy. On the fourth day, her condition acutely worsened and she was emergently intubated without any complications and placed on mechanical ventilation with tidal volume of 6ml/kg ideal body weight. Post intubation chest-X-ray showed extensive pneumomediastinum, subcutaneous emphysema and right sided pneumothorax. Bilateral chest tubes were placed. Ultimately the patient passed away. DISCUSSION: COVID-19 pneumonia presents with a wide spectrum of symptoms, ranging from febrile illness to complications like ARDS, respiratory failure, and septic shock. Spontaneous pneumothorax, subcutaneous emphysema and pneumomediastinum are relatively rare complications. We presented a case of COVID-19 pneumonia who developed these complications while getting appropriate treatment. COVID-19 pneumonia can cause diffuse alveolar damage, desquamation of pneumocytes and cellular fibromyositis [1,2]. Increase in alveolar pressure by coughing or Valsalva maneuver can cause marginal alveoli to rupture and leak air into the interstitial space. The air then dissects between the perivascular and the peri-bronchial sheath into the mediastinum, pleural space and subcutaneous tissue causing pneumomediastinum, pneumothorax and subcutaneous emphysema respectively. Higher level of LDH is associated with increased risk of air leak from the lungs [3]. Small pneumothoraces can resolve on their own, but larger require chest tubes. Pneumomediastinum and subcutaneous emphysema are usually self-limiting benign conditions which resolve with bed rest, analgesics, and oxygen therapy [3]. CONCLUSIONS: Sudden deterioration in the oxygenation in COVID-19 patient should prompt clinicians to think of possible air leakage. Management of pneumomediastinum, subcutaneous emphysema and smaller spontaneous pneumothorax is conservative but large and tension pneumothoraces require chest tube. REFERENCE #1: Quincho-Lopez A, Quincho-Lopez DL, Hurtado-Medina FD. Case Report: Pneumothorax and Pneumomediastinum as Uncommon Complications of COVID-19 Pneumonia-Literature Review. Am J Trop Med Hyg. 2020;103(3):1170-1176. doi:10.4269/ajtmh.20-0815 REFERENCE #2: Shan S, Guangming L, Wei L, Xuedong Y. Spontaneous pneumomediastinum, pneumothorax and subcutaneous emphysema in COVID-19: case report and literature review. Rev Inst Med Trop Sao Paulo. 2020;62:e76. Published 2020 Oct 9. doi:10.1590/S1678-9946202062076 REFERENCE #3: Elhakim TS, Abdul HS, Pelaez Romero C, Rodriguez-Fuentes Y. Spontaneous pneumomediastinum, pneumothorax and subcutaneous emphysema in COVID-19 pneumonia: a rare case and literature review. BMJ Case Rep. 2020;13(12):e239489. Published 2020 Dec 12. doi:10.1136/bcr-2020-239489 DISCLOSURES: No relevant relationships by Prakash Adhikari, source=Web Response No relevant relationships by Nikhil Madala, source=Web Response