Hypoxemic Patients Research Articles

Predictors of intubation and mortality in COVID-19 patients: a retrospective study

BackgroundEstimating the risk of intubation and mortality among COVID-19 patients can help clinicians triage these patients and allocate resources more efficiently. Thus, here we sought to identify the risk factors associated with intubation and intra-hospital mortality in a cohort of COVID-19 patients hospitalized due to hypoxemic acute respiratory failure (ARF).ResultsWe included retrospectively a total of 187 patients admitted to the subintensive and intensive care units of the University Hospital “Maggiore della Carità” of Novara between March 1st and April 30th, 2020. Based on these patients’ demographic characteristics, early clinical and laboratory variables, and quantitative chest computerized tomography (CT) findings, we developed two random forest (RF) models able to predict intubation and intra-hospital mortality. Variables independently associated with intubation were C-reactive protein (p < 0.001), lactate dehydrogenase level (p = 0.018) and white blood cell count (p = 0.026), while variables independently associated with mortality were age (p < 0.001), other cardiovascular diseases (p = 0.029), C-reactive protein (p = 0.002), lactate dehydrogenase level (p = 0.018), and invasive mechanical ventilation (p = 0.001). On quantitative chest CT analysis, ground glass opacity, consolidation, and fibrosis resulted significantly associated with patient intubation and mortality. The major predictors for both models were the ratio between partial pressure of arterial oxygen and fraction of inspired oxygen, age, lactate dehydrogenase, C-reactive protein, glycemia, CT quantitative parameters, lymphocyte count, and symptom onset.ConclusionsAltogether, our findings confirm previously reported demographic, clinical, hemato-chemical, and radiologic predictors of adverse outcome among COVID-19-associated hypoxemic ARF patients. The two newly developed RF models herein described show an overall good level of accuracy in predicting intra-hospital mortality and intubation in our study population. Thus, their future development and implementation may help not only identify patients at higher risk of deterioration more effectively but also rebalance the disproportion between resources and demand.

Optimizing high-flow nasal cannula flow settings in adult hypoxemic patients based on peak inspiratory flow during tidal breathing

BackgroundOptimal flow settings during high-flow nasal cannula (HFNC) therapy are unknown. We investigated the optimal flow settings during HFNC therapy based on breathing pattern and tidal inspiratory flows in patients with acute hypoxemic respiratory failure (AHRF).MethodsWe conducted a prospective clinical study in adult hypoxemic patients treated by HFNC with a fraction of inspired oxygen (FIO2) ≥ 0.4. Patient’s peak tidal inspiratory flow (PTIF) was measured and HFNC flows were set to match individual PTIF and then increased by 10 L/min every 5–10 min up to 60 L/min. FIO2 was titrated to maintain pulse oximetry (SpO2) of 90–97%. SpO2/FIO2, respiratory rate (RR), ROX index [(SpO2/FIO2)/RR], and patient comfort were recorded after 5–10 min on each setting. We also conducted an in vitro study to explore the relationship between the HFNC flows and the tracheal FIO2, peak inspiratory and expiratory pressures.ResultsForty-nine patients aged 58.0 (SD 14.1) years were enrolled. At enrollment, HFNC flow was set at 45 (38, 50) L/min, with an FIO2 at 0.62 (0.16) to obtain an SpO2/FIO2 of 160 (40). Mean PTIF was 34 (9) L/min. An increase in HFNC flows up to two times of the individual patient’s PTIF, incrementally improved oxygenation but the ROX index plateaued with HFNC flows of 1.34–1.67 times the individual PTIF. In the in vitro study, when the HFNC flow was set higher than PTIF, tracheal peak inspiratory and expiratory pressures increased as HFNC flow increased but the FIO2 did not change.ConclusionMean PTIF values in most patients with AHRF were between 30 and 40 L/min. We observed improvement in oxygenation with HFNC flows set above patient PTIF. Thus, a pragmatic approach to set optimal flows in patients with AHRF would be to initiate HFNC flow at 40 L/min and titrate the flow based on improvement in ROX index and patient tolerance.Trial registration: ClinicalTrials.gov (NCT03738345). Registered on November 13th, 2018. https://clinicaltrials.gov/ct2/show/NCT03738345?term=NCT03738345&draw=2&rank=1

Protective ventilation in patients with acute respiratory distress syndrome related to COVID-19: always, sometimes or never?

Purpose of reviewTo review current evidence on the pathophysiology of COVID-19-related acute respiratory distress syndrome (ARDS) and on the implementation of lung protective ventilation.Recent findingsAlthough multiple observations and physiological studies seem to show a different pathophysiological behaviour in COVID-19-ARDS compared with ‘classical’ ARDS, numerous studies on thousands of patients do not confirm these findings and COVID-19-ARDS indeed shares similar characteristics and interindividual heterogeneity with ARDS from other causes. Although still scarce, present evidence on the application of lung protective ventilation in COVID-19-ARDS shows that it is indeed consistently applied in ICUs worldwide with a possible signal towards better survival at least in one study. The levels of positive end-expiratory pressure (PEEP) usually applied in these patients are higher than in ‘classical’ ARDS, proposing once again the issue of PEEP personalization in hypoxemic patients. In the absence of robust evidence, careful evaluation of the patient is needed, and empiric settings should be oriented towards lower levels of PEEP.SummaryAccording to the present evidence, a lung protective strategy based on low tidal volume and plateau pressures is indicated in COVID-19-ARDS as in ARDS from other causes; however, there are still uncertainties on the appropriate levels of PEEP.

Tracheal intubation in the critically ill patient.

Tracheal intubation is among the most commonly performed and high-risk procedures in critical care. Indeed, 45% of patients undergoing intubation experience at least one major peri-intubation adverse event, with cardiovascular instability being the most common event reported in 43%, followed by severe hypoxemia in 9% and cardiac arrest in 3% of cases. These peri-intubation adverse events may expose patients to a higher risk of 28-day mortality, and they are more frequently observed with an increasing number of attempts to secure the airway. The higher risk of peri-intubation complications in critically ill patients, compared with the anaesthesia setting, is the consequence of their deranged physiology (e.g. underlying respiratory failure, shock and/or acidosis) and, in this regard, airway management in critical care has been defined as "physiologically difficult". In recent years, several randomised studies have investigated the most effective preoxy-genation strategies, and evidence for the use of positive pressure ventilation in moderate-to-severe hypoxemic patients is established. On the other hand, evidence on interventions to mitigate haemodynamic collapse after intubation has been elusive. Airway management in COVID-19 patients is even more challenging because of the additional risk of infection for healthcare workers, which has influenced clinical choices in this patient group. The aim of this review is to provide an update of the evidence for intubation in critically ill patients with a focus on understanding peri-intubation risks and evaluating interventions to prevent or mitigate adverse events.

Oxygen Administration under Surgical Face Mask in COVID-19 Patients: A Game Changer.

ABSTRACTCOVID-19 is a multifaceted infectious disease. The development of hypoxemic respiratory failure is not uncommon during the course of illness in some of them. The objectives of the present study were to assess the effect of the addition of a surgical face mask while delivering oxygen via nasal cannula in hypoxemic COVID-19 patients and highlight on the advantages and patient's comforts. We prospectively assessed 30 consecutive conscious and hypoxemic COVID-19 patients, requiring oxygen via nasal cannula. The mean PaO2 without and with surgical face mask were 52 (+9) and 83 (−12) mm Hg respectively in the cohort, and the elevation in oxygen saturation was statistically significant (p <0.001). The present results encourage the delivery of oxygen under the surgical face mask in symptomatic COVID-19 patients, as it improves oxygen saturation and prevents aerosol dispersion with no change in PaCO2. The other advantages of this method are a reduction in the total requirement of oxygen per patient, better utilization of scarce resources, and lessening of the expenses incurred for oxygen.How to cite this articleSenthilkumaran S, Koushik M, Meenakshisundaram R, Jena NN, Thirumalaikolundusubramanian P. Oxygen Administration under Surgical Face Mask in COVID-19 Patients: A Game Changer. Indian J Crit Care Med 2021;25(11):1286–1287.

Lack of Medical Criteria for Long-Term Oxygen Therapy Usage According to International Guidance in Outpatients With Chronic Hypoxemia.

BackgroundBenefits of long-term oxygen therapy (LTOT) have been observed in hypoxemic respiratory patients. Reports have shown the lack of observance among healthcare professionals of LTOT. Thus, this study aimed to determine the demographic characteristics and observance of the medical indication of LTOT according to the international guidelines.MethodologyA cross-sectional study was conducted on patients who attended the Medical Unit in Aguascalientes, Mexico to re-evaluate the need for LTOT. Data are presented as mean ± standard deviation. Statistical analyses were performed using the chi-square test or unpaired t-tests. P-values of <0.05 were considered statistically significant.ResultsFrom 813 outpatients attended to re-evaluate whether they met the medical criteria to use LTOT, 93 outpatients were excluded, and the remaining 714 outpatients were enrolled. The mean age of the patients was 70.0 ± 15.1 years, with a female gender predominance (59.1 %). The mean PaO2 level in room air was 7.9 ± 2.3 kPa. Hemoglobin and hematocrit levels were 14.9 ± 4.1 g/dL and 44.7 ± 8.4%, respectively. The mean levels of PaO2 were higher in female patients (8.1 ± 2.5 kPa vs. 7.6 ± 1.9 kPa; p = 0.01). The most common diagnosis was chronic obstructive pulmonary disorder (60.5%). Moreover, the specialty that most indicated the use of LTOT was pulmonology (57.8%); however, 36.8% of patients who used LTOT did not have any criteria according to international guidelines.ConclusionsAlthough a significant percentage of patients do not use LTOT correctly, the most important finding is that the medical indication of LTOT by physicians is not always correct, leading to an excessive prescription of oxygen.

Abstract 11986: A Safety Study of Intermittent versus Continuous Inhaled NO Therapy in Spontaneously Breathing COVID-19 Patients: A Randomized Controlled Trial

Introduction: Nitric oxide (NO) inhalation (iNO) therapy has been approved as a salvage therapy in patients with acute respiratory distress syndrome. However, the optimal patterns of therapeutic administration and iNO efficacy in COVID-19 patients with hypoxemia have not been studied so far. Hypothesis: A combination of high-concentration intermittent iNO treatment with continuous low-concentration NO gas supplementation between therapeutic high-dose iNO sessions may be a safe approach in COVID-19 patients with hypoxemia compared with the high-dose spike therapy alone. Methods: A single-center randomized controlled trial examined the safety of administration of intermittent high-dose iNO therapy versus the intermittent therapy in the presence of continuous low-dose iNO in spontaneously breathing COVID-19 patients (www.clinicaltrials.gov #NCT04476992). The study comprised adult patients tested positive for the COVID-19 by RT-PCR, who required oxygen and was admitted to the respiratory hospital. After attrition, a total of 20 patients were enrolled and randomized to the group of intermittent high-dose iNO treatment combined with continuous low-dose NO supplementation (group 1) or the group of intermittent high-dose iNO treatment(group 2). Control group (group 3) comprised retrospective patients who received conventional treatment for COVID-19 in hospital. Results: Administration of intermittent high-dose iNO therapy combined with continuous low-dose NO supplementation significantly improved physiological interactions in the heart-lung blood circulation system and was not associated with the extrapulmonary organ dysfunction. Safety parameters are presented in Table 1. Conclusions: High-dose intermittent iNO therapy combined with continuous low-dose NO gas supplementation may be considered a safe adjuvant modality of treatment for COVID-19 in spontaneously breathing hypoxemic patients.

Association Between Metformin Use and Mortality among Patients with Type 2 Diabetes Mellitus Hospitalized for COVID-19 Infection.

IntroductionMetformin has known mechanistic benefits on COVID-19 infection due to its anti-inflammatory effects and its action on the ACE2 receptor. However, some physicians are reluctant to use it in hypoxemic patients due to potential lactic acidosis. The primary purpose of the study was to determine whether metformin use is associated with survival. We also wanted to determine whether there is a difference in outcomes in subcategories of metformin use, whether at home, in-hospital, or mixed home/in-hospital use.ObjectivesThis study aimed to determine an association between metformin use and mortality among patients with type 2 diabetes mellitus hospitalized for COVID-19 infection.MethodologyThis was a cross-sectional analysis of data acquired from the COVID-19 database of two tertiary hospitals in Cebu from March 1, 2020, to September 30, 2020. Hospitalized adult Filipino patients with type 2 diabetes mellitus who tested positive for COVID-19 via RT-PCR were included and categorized as either metformin users or metformin non-users.ResultsWe included 355 patients with type 2 diabetes mellitus in the study, 186 (52.4%) were metformin users. They were further categorized into home metformin users (n=109, 30.7%), in-hospital metformin users (n=40, 11.3%), and mixed home/in-hospital metformin users (n=37, 10.4%). Metformin use was associated with a lower risk for mortality compared to non-users (p=0.001; OR=0.424). In-hospital and mixed home/in-hospital metformin users were associated with lower mortality odds than non-users (p=0.002; OR=0.103 and p=0.005; OR 0.173, respectively). The lower risk for mortality was noted in metformin, regardless of dosage, from 500 mg to 2 g daily (p=0.002). Daily dose between ≥1000 mg to <2000 mg was associated with the greatest benefit on mortality (p≤0.001; OR=0.252). The survival distributions between metformin users and non-users were statistically different, showing inequality in survival (χ2=5.67, p=0.017).ConclusionMetformin was associated with a lower risk for mortality in persons with type 2 diabetes mellitus hospitalized for COVID-19 disease compared to non-users. Use of metformin in-hospital, and mixed home/in-hospital metformin use, was also associated with decreased risk for mortality. The greatest benefit seen was in those taking a daily dose of ≥1000 mg to <2000 mg.

On the Treatment of Pneumocystis jirovecii Pneumonia: Current Practice Based on Outdated Evidence.

Pneumocystis jirovecii pneumonia (PCP) is a common opportunistic infection causing more than 400000 cases annually worldwide. Although antiretroviral therapy has reduced the burden of PCP in persons with human immunodeficiency virus (HIV), an increasing proportion of cases occur in other immunocompromised populations. In this review, we synthesize the available randomized controlled trial (RCT) evidence base for PCP treatment. We identified 14 RCTs that were conducted 25–35 years ago, principally in 40-year-old men with HIV. Trimethoprim-sulfamethoxazole, at a dose of 15–20 mg/kg per day, is the treatment of choice based on historical practice rather than on quality comparative, dose-finding studies. Treatment duration is similarly based on historical practice and is not evidence based. Corticosteroids have a demonstrated role in hypoxemic patients with HIV but have yet to be studied in RCTs as an adjunctive therapy in non-HIV populations. The echinocandins are potential synergistic treatments in need of further investigation.

Predictors and outcomes of COVID-19 patients with hypoxemia in Lagos, Nigeria

Objectives: The coronavirus disease 2019 (COVID-19) pandemic is the current public health concern. Hypoxemia has been identified as an independent risk factor for mortality in COVID-19 patients regardless of age or sex. This study therefore aimed to assess the profile of COVID-19 patients with hypoxemia in Lagos, Nigeria and identify their associated socio-demographic and clinical risk factors, predictors, and outcomes. Materials and Methods: This was a retrospective cohort study in which data were extracted from medical records of real-time polymerase chain reaction confirmed COVID-19 positive patients admitted between April and October 2020. Data extracted included age, sex, comorbidities, disease category/classification, symptoms, lowest oxygen saturation (SPO2), and outcomes. Bivariate analysis was done to test associations between hypoxemia and other variables. Multivariate analysis was done to determine significant predictors of hypoxemia. Results: A total of 266 patients were included in the study; mean (SD) 49.80 (± 16.68) years. Hypoxemia (lowest SPO2 ≤ 90 in adults and &lt; 92% in children) was found in 102 (38.3 %) of the cases. SPO2 of hypoxemic patients ranged from 33% to 90%, Mean ±SD of 77±13%. About half of the hypoxemic cases, 53 (52%) were ≥ 60 years and mostly male 70 (68.6%). Difficulty breathing was present in 56 (55%), while the common comorbidities were hypertension 86 (32.3%) and diabetes mellitus 47 (17.7%). Age ≥ 60, difficulty breathing, and fever were independent predictors of hypoxemia. Hypoxemia was significantly associated with death (X2-42.13; P &lt; 0.001); odds ratio 14.5 (95% CI: 5.4–38.8). Conclusion: Hypoxemia occurred in 1 out of every 3 COVID-19 patients with poor prognosis. SPO2 monitoring and early presentation in hospital for those 60 years and above or with dyspnea may be essential for early identification and treatment of hypoxemia to reduce mortality.

Noninvasive respiratory support for acute respiratory failure due to COVID-19.

Purpose of reviewNoninvasive respiratory support has been widely applied during the COVID-19 pandemic. We provide a narrative review on the benefits and possible harms of noninvasive respiratory support for COVID-19 respiratory failure.Recent findingsMaintenance of spontaneous breathing by means of noninvasive respiratory support in hypoxemic patients with vigorous spontaneous effort carries the risk of patient self-induced lung injury: the benefit of averting intubation in successful patients should be balanced with the harms of a worse outcome in patients who are intubated after failing a trial of noninvasive support.The risk of noninvasive treatment failure is greater in patients with the most severe oxygenation impairment (PaO2/FiO2 < 200 mmHg).High-flow nasal oxygen (HFNO) is the most widely applied intervention in COVID-19 patients with hypoxemic respiratory failure. Also, noninvasive ventilation (NIV) and continuous positive airway pressure delivered with different interfaces have been used with variable success rates. A single randomized trial showed lower need for intubation in patients receiving helmet NIV with specific settings, compared to HFNO alone.Prone positioning is recommended for moderate-to-severe acute respiratory distress syndrome patients on invasive ventilation. Awake prone position has been frequently applied in COVID-19 patients: one randomized trial showed improved oxygenation and lower intubation rate in patients receiving 6-h sessions of awake prone positioning, as compared to conventional management.SummaryNoninvasive respiratory support and awake prone position are tools possibly capable of averting endotracheal intubation in COVID-19 patients; carefully monitoring during any treatment is warranted to avoid delays in endotracheal intubation, especially in patients with PaO2/FiO2 < 200 mmHg.

Treatment of pulmonary hypertension associated with COPD: a systematic review.

Chronic obstructive pulmonary disease-associated pulmonary hypertension (COPD-PH) is an increasingly recognised condition which contributes to worsening dyspnoea and poor survival in COPD. It is uncertain whether specific treatment of COPD-PH, including use of medications approved for pulmonary arterial hypertension (PAH), improves clinical outcomes. This systematic review and meta-analysis assesses potential benefits and risks of therapeutic options for COPD-PH.We searched Medline and Embase for relevant publications until September 2020. Articles were screened for studies on treatment of COPD-PH for at least 4 weeks in 10 or more patients. Screening, data extraction, and risk of bias assessment were performed independently in duplicate. When possible, relevant results were pooled using the random effects model.Supplemental long-term oxygen therapy (LTOT) mildly reduced mean pulmonary artery pressure (PAP), slowed progression of PH, and reduced mortality, but other clinical or functional benefits were not assessed. Phosphodiesterase type 5 inhibitors significantly improved systolic PAP (pooled treatment effect −5.9 mmHg; 95% CI −10.3, −1.6), but had inconsistent clinical benefits. Calcium channel blockers and endothelin receptor antagonists had limited haemodynamic, clinical, or survival benefits. Statins had limited clinical benefits despite significantly lowering systolic PAP (pooled treatment effect −4.6 mmHg; 95% CI −6.3, −2.9).This review supports guideline recommendations for LTOT in hypoxaemic COPD-PH patients as well as recommendations against treatment with PAH-targeted medications. Effective treatment of COPD-PH depends upon research into the pathobiology and future high-quality studies comprehensively assessing clinically relevant outcomes are needed.

Effect of Automated Oxygen Titration during Walking on Dyspnea and Endurance in Chronic Hypoxemic Patients with COPD: A Randomized Crossover Trial

The need for oxygen increases with activity in patients with COPD and on long-term oxygen treatment (LTOT), leading to periods of hypoxemia, which may influence the patient’s performance. This study aimed to evaluate the effect of automated oxygen titration compared to usual fixed-dose oxygen treatment during walking on dyspnea and endurance in patients with COPD and on LTOT. In a double-blinded randomised crossover trial, 33 patients were assigned to use either automated oxygen titration or the usual fixed-dose in a random order in two walking tests. A closed-loop device, O2matic delivered a variable oxygen dose set with a target saturation of 90–94%. The patients had a home oxygen flow of (mean ± SD) 1.6 ± 0.9 L/min. At the last corresponding isotime in the endurance shuttle walk test, the patients reported dyspnea equal to median (IQR) 4 (3–6) when using automated oxygen titration and 8 (5–9) when using fixed doses, p < 0.001. The patients walked 10.9 (6.5–14.9) min with automated oxygen compared to 5.5 (3.3–7.9) min with fixed-dose, p < 0.001. Walking with automated oxygen titration had a statistically significant and clinically important effect on dyspnea. Furthermore, the patients walked for a 98% longer time when hypoxemia was reduced with a more well-matched, personalised oxygen treatment.

THE BAD AND THE UGLY: A CASE OF COVID-19 AND TB CO-INFECTION

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: For the last 100 years, the leading infectious cause of death has been tuberculosis (TB) – until 2020, when SARS-CoV2 became a global pandemic. As the incidence of COVID-19 rises, co-infection with TB is expected. CASE PRESENTATION: A 49-year-old Nepali male presented to the emergency room with cough, dyspnea, and lower extremity weakness. He reported anorexia and weight loss over several months. On presentation, he was afebrile with a heart rate of 118 beats/min, respiratory rate of 20 breaths/min, blood pressure of 156/115 mmHg, and oxygen saturation of 89%. Initial examination demonstrated an ill-appearing male with epidermoid cysts of the neck and cervical lymphadenopathy. Auscultation revealed diminished breath sounds bilaterally with intercostal retractions with breathing. Laboratory results included elevated transaminase, CRP, ferritin, and LDH levels. CT imaging showed large bilateral effusions, bilateral lung atelectasis and pleural thickening with no peripheral ground-glass pattern. The patient was screened for COVID-19 and subsequently tested for TB following the findings on imaging. SARS-CoV2 PCR and QuantiFERON gold test were positive on admission. The patient underwent serial diagnostic and therapeutic thoracentesis for his effusions, and the bilateral fluid AFB cultures were positive.Pleural thickening on the CT scan suggested a chronic disease process, without typical COVID-19 findings. Remdesivir, convalescent plasma and steroids were held following TB diagnosis as his presentation supported a more chronic disease trajectory rather than an acute progression of illness. The patient was initially placed on a high-flow nasal cannula and eventually weaned to room air throughout the hospital course with RIPE treatment. After 65 days, he was discharged to a rehab facility. DISCUSSION: The patient's hypoxemia was likely a result of chronic TB given imaging did not reveal typical findings of COVID-19. The presentation of bilateral pleural effusions caused by TB is a rare phenomenon as most cases demonstrate unilateral effusions. Pleural effusions in COVID-19 infection are usually found as a complication of prolonged illness or bacterial superinfections. Blunting the inflammatory response in COVID-19 with steroids can endanger a patient with active TB because it interferes with cellular immunity essential to containing mycobacteria. Although recent evidence suggests that COVID-19 infection severity is higher in the setting of TB co-infection, our patient demonstrated a mild COVID-19 infectious course. Despite his prolonged hospital course, he did not require intubation and his hypoxemia steadily improved. CONCLUSIONS: Our case demonstrates a previously undescribed case of COVID-19 superimposed on TB complicated by bilateral pulmonary effusions. When indicated, it is crucial to screen for both infections due to overlapping symptomatology and the prevalence of these diseases. REFERENCE #1: Mousquer GT, Peres A, Fiegenbaum M. Pathology of TB/COVID-19 Co-Infection: The phantom menace. Tuberculosis (Edinb) 2021;126:102020. REFERENCE #2: Bandyopadhyay A, Palepu S, Bandyopadhyay K, Handu S. COVID-19 and tuberculosis co-infection: a neglected paradigm. Monaldi Arch Chest Dis 2020;90(3). REFERENCE #3: Vorster MJ, Allwood BW, Diacon AH, Koegelenberg CFN. Tuberculous pleural effusions: advances and controversies. J Thorac Dis 2015;7(6):981–991. DISCLOSURES: No relevant relationships by Saad Ahmad, source=Web Response No relevant relationships by Klaus Meinhof, source=Web Response No relevant relationships by Reiichiro Obata, source=Web Response

UNILATERAL CRYSTAL METHAMPHETAMINE LUNG

TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Methamphetamine is a drug manufactured from ephedrine and pseudoephedrine mixed with ingredients such as ammonia, lithium, iodine, and phosphorous but adulterants such as alcohol, acetone, and energy drinks have also been used. Smoking is the most common form of abuse with complications such as eosinophilic pneumonia, alveolar hemorrhage, acute interstitial pneumonia, and pulmonary fibrosis. We present an atypical methamphetamine-induced lung injury. CASE PRESENTATION: A 57-year-old female with a 40-pack year smoking history and polysubstance abuse presented with acute onset shortness of breath. On admission, she was hypoxic requiring 25 liters of high flow oxygen. On examination, the patient was afebrile with normal blood pressure. Chest auscultation revealed wheezing, most prominent in the left lung fields, while the rest of the systemic examination was unremarkable. Laboratories showed leukocytosis, normal liver, and renal function test. Sputum culture had no bacterial growth and Covid-19 PCR negative. Urine toxicology was positive for methamphetamine. Contrast CT chest showed diffuse interstitial thickening and ground-glass opacities throughout the right lung but normal left lung parenchyma with narrowing of the distal left mainstem bronchus by an endobronchial mass. The patient's hypoxemia improved with Methylprednisolone. Bronchoscopy showed a left mainstem lesion with near-complete obstruction of the left upper and lower lobes with biopsy revealing squamous cell carcinoma. There was normal airway mucosa on the right lung segments and scant inflammation without malignant cells on biopsy. The patient underwent successful tumor debulking with follow-up PET CT demonstrating decreased but persistence of alveolar septal thickening on the right lung with FDG positive mediastinal lymph nodes. The patient was weaned off supplemental oxygen 4 weeks later. DISCUSSION: Diagnosis of Methamphetamine-induced lung injury depends on the history of recent use, ground-glass opacities on imaging, and exclusion of other infections which was fulfilled by our patient but with the question of left lung sparing. Crystalline particles range in size from less than 250 nm-10 μm, with clusters as large as 80 μm where the obstructing mass may have prevented the flow of the drug vapor. Methamphetamine has also been postulated to release early response cytokines including TNF-alpha and IL-6 leading to recruitment of neutrophils and free radicals release causing acute lung injury. The management is mainly supportive with empiric steroids with improvement via impeding this inflammatory cascade. CONCLUSIONS: Our case demonstrates multiple learning points including particle size factor in passage through an obstructed airway, response to steroids supporting in settings of acute inflammation, and the persistence of residual lung disease on imaging in contrast to clinical improvement 4 weeks post-exposure. REFERENCE #1: Javed A, Nasrullah A, Malik K (February 08, 2021) A Rare Case of Methamphetamine-Induced Lung Injury During the Ongoing COVID-19 Pandemic. Cureus 13(2): e13215. doi:10.7759/cureus.13215 REFERENCE #2: Kinner SA, Degenhardt L. Crystal methamphetamine smoking among regular ecstasy users in Australia: increases in use and associations with harm. Drug Alcohol Rev. 2008 May;27(3):292-300. doi: 10.1080/09595230801919452. PMID: 18368611. REFERENCE #3: Lin SS, Chen YC, Chang YL, Yeh DY, Lin CC. Crystal amphetamine smoking-induced acute eosinophilic pneumonia and diffuse alveolar damage: a case report and literature review. Chin J Physiol. 2014 Oct 31;57(5):295-8. doi: 10.4077/CJP.2014.BAC201. PMID: 25241990. DISCLOSURES: No relevant relationships by Uchit Thapa, source=Web Response

VAPING CAN BREAK YOUR HEART

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Electronic cigarette or vaping product use-associated lung injury (EVALI) is potentially life-threatening disease that has become increasingly recognized over the last years. However, the extra-pulmonary manifestations of this disease are not as well described. We present a patient who simultaneously developed acute EVALI and stress induced cardiomyopathy. CASE PRESENTATION: A 35-year-old female with a recent heavy vaping history presented to hospital via EMS due to disorganized behavior. Her past medical history was notable for polysubstance abuse and an extensive neuropsychiatric history. Her vital signs were notable for sinus tachycardia, hypotension and hypoxia with an oxyhemoglobin saturation 65%. Her physical exam was notable for cyanosis, rales to pulmonary auscultation and use of accessory muscles. She was intubated and started on empiric antibiotics for community acquired pneumonia, and vasopressors. A computer tomography pulmonary angiography (CTPE) was negative for acute pulmonary embolism but showed scattered bilateral airspace opacities with dependent consolidations (fig 1.). Relevant laboratory on admission included procalcitonin 28.17, WBC count 12.9 and troponin 1.58. SARs-COV-2, serum blood cultures, legionella antigen, streptococci pneumoniae antigen and HIV were negative. Urine toxicology was positive for cannabinoids. Bronchoalveolar lavage later demonstrated 50,000 TNC with neutrophil predominance. EKG showed sinus tachycardia and nonspecific ST depression. Echocardiogram revealed severe diffuse hypokinesis with left ventricular ejection fraction (LVEF) of 13%. During her ICU course she continued on mechanical ventilation with lung protective strategy, systemic glucocorticoids and antibiotics. Vasopressors were subsequently weaned off. Repeated echocardiogram on ICU day five demonstrated a recovered LVEF at 55%. Patient's hypoxemia improved, and she was successfully extubated on ICU day eight. DISCUSSION: Pulmonary injury is the most well described clinical manifestation of EVALI, however a large majority of these patients also present with gastrointestinal symptoms and malaise, suggesting a systemic disease process. Our patient had newly reduced LVEF suggestive of stress induced cardiomyopathy which consequently improved with standard and supportive care. CONCLUSIONS: It is important to maintain a high index of suspicion of secondary organ damage, as prompt diagnosis and treatment of EVALI associated cardiac dysfunction can have an impact in short- and long-term prognosis. REFERENCE #1: Kligerman S, Raptis C, Larsen B, Henry TS, Caporale A, Tazelaar H, Schiebler ML, Wehrli FW, Klein JS, Kanne J. Radiologic, Pathologic, Clinical, and Physiologic Findings of Electronic Cigarette or Vaping Product Use-associated Lung Injury (EVALI): Evolving Knowledge and Remaining Questions. Radiology. 2020 Mar;294(3):491-505. doi: 10.1148/radiol.2020192585. Epub 2020 Jan 28. PMID: 31990264. DISCLOSURES: No relevant relationships by David barounis, source=Web Response No relevant relationships by Xavier Fonseca, source=Web Response No relevant relationships by Dana Mueller, source=Web Response

Efficacy and safety of hyperbaric oxygen treatment in SARS-COV-2 (COVID-19) pneumonia: a systematic review.

The need for intubation and mechanical ventilation among COVID-19 patients is associated with high mortality rates and places a substantial burden on the healthcare system. There is a strong pathophysiological rationale suggesting that hyperbaric oxygen treatment (HBOT), a low-risk and non-invasive treatment, may be beneficial for COVID-19 patients. This systematic review aimed to explore the potential effectiveness and safety of HBOT for treating patients with COVID-19. Medline, Embase, Scopus, and Google Scholar were searched from December 2019 to February 2021, without language restrictions. The grey literature was searched via an internet search engine and targeted website and database searches. Reference lists of included studies were searched. Independent reviewers assessed studies for eligibility and extracted data, with disagreements resolved by consensus or a third reviewer. Risk of bias was assessed using the Newcastle Ottawa Scale. Data were summarised descriptively. Six publications (one cohort study, five case reports/series) met the inclusion criteria with a total of 37 hypoxaemic COVID-19 patients treated with HBOT. Of these 37 patients, the need for intubation and mechanical ventilation and in-hospital survival were assessed for 26 patients across three studies. Of these 26 patients, intubation and mechanical ventilation were not required for 24, and 23 patients survived. No serious adverse events of HBOT in COVID-19 patients were reported. No randomised trials have been published. Limited and weak evidence from non-randomised studies including one propensity-matched cohort study suggests HBOT is safe and may be a promising intervention to optimise treatment and outcomes in hypoxaemic COVID-19 patients. Randomised controlled studies are urgently needed.

Early the diagnosis, intervention and treatment is key for Covid-19 induced Mucormycosis

The novel corona virus (COVID-19) outbreak declared as a global pandemic. Glucocorticoids are inexpensive, widely available, and have been shown to reduce mortality in hypoxemic patients with COVID-19. With increasing risk of new strains of covid virus infections and now the latest dreadful fungal infection Mucormycosis, the situation is becoming more and more devastating. Survival in mucormycosis depends on early diagnosis, alleviation of basic predisposing factors, aggressive debridement of necrotic tissues, and appropriate systemic antifungal agents.

Comparison of SpO2 and heart rate values on Apple Watch and conventional commercial oximeters devices in patients with lung disease

Lung diseases have high mortality and morbidity, with an important impact on quality of life. Hypoxemic patients are advised to use oxygen therapy to prolong their survival, but high oxygen saturation (SpO2) levels can also have negative effects. Pulse oximeters are the most common way to assess oxygen levels and guide medical treatment. This study aims to assess whether wearable devices can provide precise SpO2 measurements when compared to commercial pulse oximeters. This is a cross-section study with 100 patients with chronic obstructive pulmonary disease and interstitial lung disease from an outpatient pneumology clinic. SpO2 and heart rate data were collected with an Apple Watch Series 6 (Apple) and compared to two commercial pulse oximeters. The Bland–Altman method and interclass correlation coefficient were used to compare their values. We observed strong positive correlations between the Apple Watch device and commercial oximeters when evaluating heart rate measurements (r = 0.995, p < 0.001) and oximetry measurements (r = 0.81, p < 0.001). There was no statistical difference in the evaluation of skin color, wrist circumference, presence of wrist hair, and enamel nail for SpO2 and heart rate measurements in Apple Watch or commercial oximeter devices (p > 0.05). Apple Watch 6 is a reliable way to obtain heart rate and SpO2 in patients with lung diseases in a controlled environment.

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

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