Hypoxic Index Research Articles

The effect of nebulized heparin in the attenuation of coronavirus disease 2019-induced acute lung injury: a randomized controlled trial

Background Since the declaration of coronavirus disease 2019 (COVID-19) as a pandemic by the WHO in January 2020, efforts have been exerted by the scientific community to clarify the pathogenesis of severe acute respiratory syndrome-related coronavirus-induced acute lung injury. Corticosteroids, inhaled vasodilators, B2 agonists, surfactant therapy, antibiotics, and/or antiviral agents are used as a pharmacological treatment for acute respiratory distress syndrome. However, we studied whether prophylactic nebulized heparin could limit this form of lung injury. Patients and methods In all, 100 adult patients with COVID-19 suffering from moderate symptoms of the disease were randomized to prophylactic nebulized heparin (1000 IU/kg) every 6 h or placebo. The primary outcome of this study was the average daily ratio of partial pressure of PaO2 to FiO2 (P/F ratio), while the patient was on room air for 7 days. The secondary outcome was the levels of fibrin degradation products in the pulmonary lavage fluid measured at baseline and on study days 3 and 7 through minibronchoalveolar lavage (mini-BAL) fluid samples. Results We found nebulized heparin was accompanied by a better hypoxic index as it was linked to a lesser D-dimer change at the intermediate phase of the study (day 3). Moreover, nebulized heparin was not associated with bleeding complications. Conclusion In conclusion, prophylactic nebulized heparin may provide an adequate therapeutic approach in COVID-19 patients.

The safety and efficacy of imatinib a tyrosine kinase inhibitor for the treatment of SARS-COV-2 induced pneumonia: a pilot study

Introduction Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) results in a wide spectrum of disease, approximately 15–20% of affected patients present with severe phenotype that require supplemental oxygen, including up to 5% who may develop critical illness. The main therapeutic strategies proposed for the management of COVID-19 pneumonia are direct antiviral and immunomodulatory treatments aiming to prevent disease progression. In this pilot study we are testing the hypothesis of using imatinib a tyrosine kinase inhibitor (TKI) as an immunomodulatory treatment to prevent disease progression, based on encouraging data from cellular, animal models and clinical trials, showing a beneficial role of TKI in the regulation of inflammation and endothelial barrier integrity, as well as their antiviral properties. Aim The primary end point is to assess the effect of the imatinib treatment, in terms of safety and efficacy, to prevent the progression of patients with moderate to severe COVID-19 pneumonia into critical illness and need for invasive mechanical ventilation. The secondary end point is a composite of change in clinical, laboratory and radiological parameters, including: clinical parameters − the percentage of patients reaching normal hypoxic index (HI) at time of hospital discharge, hospital length of stay and days on mechanical ventilation (MV) in patient intubated and mechanically ventilated, the changes in the levels of laboratory inflammatory markers: serum ferritin, serum C reactive protein (CRP), serum interleukin 6 (IL6), viral clearance presented by the delta time till negative SARS-CoV-2 PCR results, as well as the change in the chest radiological parameters (Computed tomography chest or radiography). Methods Thirty SARS-COV-2 positive patients with moderate to severe respiratory symptoms, were enrolled and randomized into three groups: group 1 Control, group 2 Low dose Imatinib (receiving 200 mg Imatinib/day) and group 3 Standard dose Imatinib (receiving 400 mg Imatinib/day). Results There was no significant difference between the three groups regarding the severity of the disease at baseline, as assessed by clinical, laboratory and radiological parameters. There was a nonstatistically significant difference in the primary end point of the study, regarding the number of patients in need for invasive mechanical ventilation, between the control group and the intervention groups receiving imatinib. Conclusion Despite the negative results regarding the efficacy of imatinib to flatten the curve of the illness and the prevention of more severe phenotype of the disease, our study showed positive findings regarding the medication’s safety and patients’ tolerability. These finding would pave the way for further studies to assess the concept of immunomodulation in the treatment of immunity derived disease, like sepsis and acute respiratory distress syndrome (ARDS).

The incidence of aspiration pneumonia in acute ischemic stroke patients in relation to early insertion of nasogastric tube feeding

Background Stroke is the acute onset of cerebral ischemia. Dysphagia with difficult swallowing is one of the common complications during the course of acute stroke, its incidence varies between 29–67%. Pneumonia is the second most common cause of death during the acute phase of stroke, with up to 20% mortality rate. In patient with risk of dysphagia or deficient oral intake, enteral feeding will be recommended. Objective Study the effect of early insertion of nasogastric tube for feeding on incidence of aspiration pneumonia in acute ischemic stroke patients with abnormal water swallow test. Methods The study was carried out in Alexandria Main University Hospital on 40 patients with acute ischemic stroke. Patients with abnormal water swallow test were classified into two groups: Group A: Insertion of nasogastric tube on admission after diagnosis. Group B: Giving intravenous fluids, minerals and traces for the first 48 h then inserting nasogastric tube on the third day. Results By comparing the patients in both groups, there was no statistical significant difference between them as regards; age, gender, comorbidities, and APACHE II score on admission. There was a statistical significant difference between both groups regarding fever, CRP level, WBCs, hypoxic index and the length of hospital stay. Conclusion Inserting Nasogastric tube insertion on admission in acute stroke patients may increase the incidence of aspiration pneumonia than being non-oral for 48 h before insertion on the third day as it affects the duration of ICU and hospital stay.

Effect of Bronchoscopy on the Outcome of Patients with Severe Sepsis, Acute Respiratory Distress Syndrome and Complicated by Ventilator Associated Pneumonia from Prolonged Ventilation

Introduction: 65% of patients in Intensive Care Units (ICU) with severe sepsis and/or severe traumatic lung contusion are complicated with pneumonia and respiratory failure, which need long-term ventilation. Sepsis is a common finding in such patients; it is either a cause of ventilator associated pneumonia (VAP) or a complication of VAP. VAP is one of the most common complications of prolonged ventilation. Both diagnostic and therapeutic bronchoscopies could be used to improve the outcome in those patients by controlling septic reactions and improve lung mechanics through the clearing of the small airways from purulent discharge. Aims of Work: To evaluate the effect of the use of bronchoscopy in patients with Acute respiratory distress syndrome (ARDS), severe sepsis and complicated by VAP as regards, improve the general condition of those patients, improve lung mechanics, control all signs of both VAP and sepsis, accelerate weaning from the ventilator, shorten the duration of ICU stays and its effect on mortality rate in those patients. Materials and Methods: 200 patients were selected after 4 days of ventilation because of ARDS due to either severe traumatic lung contusion or a severe lung infection. Those who still showed unresolved ARDS (diagnosed by hypoxic index less than 200, bilateral parenchymatous lung infiltration on the chest X ray, ABG showed PH > 7.30), Severe sepsis diagnosed by >12 SOFA score (Sequential Organ Failure Assessment) and developed VAP diagnosed by >6 CPIS score (clinical pulmonary infection score) were included in two groups of 100 patients in each. Only patients of group B did three bronchoscopies and BAL was sent for culture, while patients of group A continued on the traditional way of management and sputum was sent for culture. Improvement of ARDS & VAP, weaning from ventilation, duration of ICU stay, improvement of one/all parameters of both SOFA & CPIS scores, morbidity, and mortality were recorded and compared within 14 days. Results: Patients of group B showed significant improvement in APACHII score (acute physiological assessment and chronic health evaluation score), GCS (Glasgow coma scale), parameters of both SOFA score and CPIS score, hemodynamics parameters, LDH (lactate dehydrogenase), and C-Reactive protein levels. A significantly higher number of patients were weaned from the ventilator and discharged from ICU. There was no significant difference between the two groups regarding the mortality rate. Conclusion: The use of bronchoscopy can improve general conditions, control all signs of severe sepsis, VAP, improve lung mechanics, improve ARDS, accelerate weaning from the ventilator, and shorten the ICU stay but has no effect on mortality rate in those patients with severe sepsis with ARDS and complicated by VAP from prolonged ventilation. Clinical Trial Registration Number: My study is already registered in the clinical trial, and all the information is present in this study. The clinical trial number is NCT04553367, and is registered by my name.

The Validity of Quantifying Pulmonary Contusion Extent by Lung Ultrasound Score for Predicting ARDS in Blunt Thoracic Trauma

Background Thoracic trauma comprises 20–25% of all traumas worldwide and constitutes the third most common cause of death after abdominal injury and head trauma in polytrauma patients. Pulmonary contusion (PC) is a common injury seen after blunt trauma that is associated with significant morbidity and mortality. The aim of this prospective study was to determine the value of PC extent measurements using lung ultrasound in predicting high risk patients for ARDS development. Methods In one year, 50 polytrauma patients with blunt chest trauma were admitted to the ICU at Damanhur Institute. Lung contusion extent was evaluated using a lung US score (LUS) and was compared to the CT contusion score. The ability of the LUS to predict ARDS was tested. The diagnostic accuracy of LUS was compared with chest radiography for lung contusion and pneumothorax with thoracic CT scan as a reference. Patients were restratified by LUS into two groups: severe and nonsevere contusion group. The two groups' data were compared with respect to difference in mortality and injury characteristics. Results Lung contusion assessed by LUS score was well correlated to thoracic CT scan measurements (r = 0.78). A LUS of 4 was defined as a cut-off value for predicting ARDS development within 72 hours of trauma with sensitivity and specificity (91.67% and 84.21%), respectively. Patients with severe lung contusions had a lower hypoxic index on admission, more ventilator days, a higher risk of ARDS development, more fractured ribs; higher rate of hemothorax and a higher ISS score than patients with nonsevere lung contusions. Conclusion LUS on admission can quantify lung contusion extent and the high risk of developing ARDS after blunt thoracic trauma.

Comparative Study Between Action Vitamin C vs. Action of Nitric Oxide in Prolonged Ventilation in Respiratory Failure Patients Due to ARDS

Introduction: Recent meta-analysis prove that vitamin C shorten the duration of mechanical ventilation and accelerate weaning from ventilator especially in prolonged ventilated patients. Nitric oxide considered a relatively old drug used for long time in this issue. Aim: To compare the effect of either vitamin C or nitric oxide on improvement of general condition of the patients, improvement lung mechanics, early weaning from prolonged ventilation and mortality rates. Material and Methods: This a prospective double-blind study done in King Abdul-Aziz specialist hospital between September 2020 and December 2021 in the intensive care unit on 60 patients had difficult weaning after ventilation for >10 days due to Acute Respiratory Distress Syndrome (ARDS) and still showing full criteria of ARDS. Allocated randomly in two groups 30 patients in each. All patients in both groups continued on the same protocol of ventilation. Group A received Nitric Oxide (NO) while group B received vitamin C intravenous. The duration of the study last 16 days. during this period, APCH II score, Hemodynamics, Chest X-ray, hypoxic index, lung compliance, Recruitment maneuver, arterial blood saturation, Lactic Acid Dehydrogenase (LDH), C-reactive protein used as indicator for improvement. Number of patients weaned from the ventilator and patients died also recorded. >Results: Showed significant improvement in the general condition between patients of group B compared to group A which monitored by number of patients had both APACH II score <10 and had normal core temperature. Significant improvement in lung condition between patients of group B compared to group A which monitored clinically by number of patients had arterial oxygen saturation >95, hypoxic index >300, better lung compliance, responder to recruitment maneuver. And monitored radiologically by significant higher number of patients in group B had parenchymatous lung infiltrate in chest X-ray less than one quadrant infiltration compared to group A. And monitored laboratory by significant higher number of patients had lower level of LDH from (100-200 U/L) and CRP (201-300) mg/L in group B compared to group A. There was significant higher number of patients weaned from the ventilator in group B compared to group A. There was significant lower morbidity between patients of group B compared to group A. No significant difference was found in mortality rates. Conclusion: Vitamin C significantly improve the general condition of the patients, improve all parameters of lung mechanics and accelerate weaning from ventilators in prolonged ventilated patients compared to nitric oxide.

Role of nebulized heparin in mechanically ventilated critically ill patients

Background Mechanical ventilation is a technique for supporting or substituting respiration. Fibrin deposition in the pulmonary microcirculation and alveolar sacs (hyaline membrane generation) is a major inflammatory route of lung injury, as it hinders both alveolar perfusion and ventilation. Heparin lowers fibrin deposition in the lungs and improves clinical outcomes in mechanically ventilated patients, according to clinical and experimental studies. Heparin nebulization may be more efficient than systemic delivery.Aim The purpose of this study was to evaluate how nebulized heparin affected both morbidity and mortality rates in mechanically ventilated patients.Patients and methods A total of 50 patients who required mechanical ventilation for more than 48 h were assigned into two groups: group 1 (control group) received 0.9% nebulized saline and group 2 (treatment group) received nebulized heparin. All patients were subjected to complete history taking, complete physical examination, routine laboratory investigations, daily arterial blood gas analysis and chest imaging, and Sequential Organ Failure Assessment score every 48 h. The primary end point was to evaluate lung functions such as airway resistance, static compliance, hypoxic index, and ventilator-free days. The development of acute respiratory distress syndrome after enrollment, tracheostomy rate, vasopressor-free days, length of ICU stay, and mortality rate at days 7 and 28 were all secondary end points.Results On days 2, 3, 4, 5, and 7, the mean static compliance in the treatment group was considerably higher than in the control group, with a statistically significant difference at days 2 and 4. The mean hypoxic index in the nebulized heparin group was significantly higher than in the control group. The nebulized heparin group had significantly more days without using vasopressors than the control group.Conclusion In patients needing mechanical ventilation for more than 48 h, nebulized heparin significantly improved lung static compliance and hypoxic index and was associated with more vasopressor-free days.

Goal-directed fluid therapy versus restrictive fluid therapy: A cardiomerty study during one-lung ventilation in patients undergoing thoracic surgery

ABSTRACT Background Fluid management during thoracic anaesthesia is a challenge for the anaesthesiologists. The “safe zone” between volume overload (pulmonary oedema risk) and hypovolemia (renal failure risk) remains to be narrow and hard to determine. Purpose The aim of the present study was to assess goal-directed fluid therapy using cardiometry versus restrictive fluid therapy during one-lung ventilation in patients planned for having thoracic surgery. Methods After receiving the Ethics Committee approval and taking an informed written consent, a prospective randomized study was conducted. Fifty adult patients of both genders were scheduled for thoracic surgery with one lung ventilation. Patients were randomly categorized using closed envelope technique into two equal groups (25 patients each). Group I: a number of 25 patients underwent thoracic surgery and were managed with goal directed fluid therapy using intraoperative cardiometry. Group II: a number of 25 patients underwent thoracic surgery and were managed with intraoperative restrictive fluid therapy. Results There was a significantly increased serum lactate level, serum creatinine with decreased urine output in restrictive therapy group (RT) by the end of the surgery, immediately postoperative and 6 h postoperative (p value of <0.001). The restrictive hypoxic index values were much higher than the goal directed group values, yet, both were of normal range and no patient suffered of lung injury. A significant increase in serum neutrophil gelatinase-associated lipocalin (Ngal) in the restrictive therapy group compared to the goal directed therapy group. (p value of <0.001). Conclusion From these results, we concluded that patients undergoing thoracic surgery are preferably to be maintained over goal directed therapy protocol using electrical cardiometry. Fluid restriction is better to be individualized and aided by new technologies based on beat-to-beat variations.

Acute kidney injury in ventilated patients with coronavirus disease-2019 pneumonia: A single-center retrospective study.

Background:Acute kidney injury (AKI) is repeatedly observed in ventilated critically ill patients with coronavirus disease-2019 (COVID-19) pneumonia. This study aimed to determine the incidence, risk factors, and consequences of AKI in the ventilated critically ill adult patients with COVID-19 pneumonia.Methods:This retrospective study included all the ventilated critically ill adult patients with COVID-19 pneumonia from March 1, 2020, to June 1, 2020. Data were collected from the electronic medical system. AKI was diagnosed using the Kidney Disease: Improving Global Outcomes 2012 Clinical Practice definition. Patients were followed 90 days from the intensive care unit (ICU) admission time or to the date when they were discharged from the hospital.Results:AKI occurred in 65.1% of patients, with 26.6% of these started on continuous renal replacement therapy (CRRT). Patients with AKI had higher comorbidity and illness severity scores (P < 0.001). Age and the vasopressor requirements were predictors of AKI (P= 0.016 and P = 0.041) and hypertension predicted AKI (P = 0.099) and its progression (P = 0.05). The renal recovery rate was 86.7% and was associated with the mean arterial pressure on ICU admission in the no-CRRT group (P = 0.014) and the hypoxic index in the CRRT group (P = 0.019). AKI was associated with higher mortality (P = 0.017) and significantly longer ICU length-of-stay (P = 0.001). Additionally, AKI patients were more often discharged to a long-term skilled nursing facility (P = 0.005).Conclusion:COVID-19-associated AKI was common and associated with poor outcome, with the specific mechanisms being the main driving factors.

Features of hypoxic resistance in children with bronchial asthma who have undergone a new coronavirus infection

Aim. To study the characteristics of resistance/sensitivity to normobaric hypoxia in 50 children with bronchial asthma (BA) from 9 to 12 years old, 24 of them after a previous coronavirus infection СOVID-19.&#x0D; Materials and methods. A normobaric hypoxic test (HT) was carried out by creating hypoxemia (threshold level SpO2 80%) during mask inhalation of a gas mixture with 1011% O2 by a child using a ReOxy Cardio apparatus (Ai Mediq S.A., Luxembourg). The data obtained were compared with the results in a group of healthy children the same age.&#x0D; Results. It was found that the integral level of hypoxic resistance of children with BA was generally lower in comparison with the group of healthy children, which was manifested in lower values of the hypoxic index (3.11.4, in the group of healthy children 4.92.8, p=0.005), a significantly increased level of tachycardia and a hypotonic response to dosed hypoxia.&#x0D; Conclusion. When typing reactions to HT, it was found that in children with BA, the type of low resistance to hypoxia is more common (to a greater extent in children with BA after a coronavirus infection), which confirms the need to involve such children in comprehensive rehabilitation programs.

Multiple genetic variations of chronic rhinosinusitis with nasal polyps are associated with respiratory parameters in men with obstructive sleep apnea

PurposePatients with chronic rhinosinusitis with nasal polyps (CRSwNP) have a higher risk of obstructive sleep apnea (OSA). However, the relationship between CRSwNP and OSA remains unclear. The aim of this research study was to evaluate the association of multiple single nucleotide polymorphism (SNP) variations in CRSwNP with sleep- and breath-related parameters in men with OSA.MethodsWe included eight CRSwNP SNPs in 2320 participants after strict screening. For each participant, the genetic risk score (GRS) was calculated based on the cumulative effect of multiple genetic variants of CRSwNP. A bivariate correlation analysis was used to assess the relationship between CRSwNP genetic polymorphisms and polysomnography parameters in men with OSA. Logistic regression analyses were used to assess the relationship between the risk of OSA and CRSwNP genetic polymorphisms.ResultsIn moderate OSA, rs28383314 was related to the oxygen desaturation index, and rs4807532 was positively associated with the microarousal index (r = 0.09, P = 0.03 and r = 0.11, P = 0.01, respectively). The CRSwNP GRS was positively correlated with the oxygen desaturation index and cumulative time percentage with SpO2 < 90% in moderate OSA (r = 0.13, P < 0.001 and r = 0.1, P = 0.01, respectively). There was no association between the CRSwNP GRS and the risk of OSA (OR = 1.007; 95% CI, 0.973–1.042; P = 0.702).ConclusionIn men with moderate OSA, single CRSwNP genetic variations correlated with sleep-related parameters, and the cumulative effects of CRSwNP genetic variations were associated with the hypoxic index. CRSwNP may be a predisposing condition for sleep disorders in men with moderate OSA.

Use of Early Bronchoscopy in Mechanically Ventilated Patients with Aspiration Pneumonitis

Background and objectivesAspiration-induced lung injury accounts for a significant proportion of acute pulmonary dysfunction. Few studies were conducted to study the use of early bronchoscopy in mechanically ventilated patients with aspiration pneumonitis. This study aimed at assessing the clinical impact of early bronchoscopy for removal of gastric fluid and solid particles in the first 24 hours of mechanical ventilation (MV) on the progression of aspiration, MV days, intensive care unit (ICU) stay, development of pneumonia, and ICU mortality.Materials and methodsThe study was an open-label randomized control trial and included 76 adult subjects mechanically ventilated due to aspiration pneumonitis, half the subjects received early bronchoscopy in the first 24 hours after aspiration for removal of aspirated material and bronchoalveolar lavage sampling, the other half received standard treatment.ResultsThe intervention group had a significant reduction in the rate of development of pneumonia at 60.5 vs 81.6%, p = 0.043 through the first week of admission, the intervention group has a significantly better hypoxic index (HI), white blood count, clinical pulmonary infection score, lung injury score, and sepsis-related organ failure assessment (SOFA) score compared to the control group. Although there was a reduction in mechanical ventilation days and ICU mortality in the intervention group vs control group that difference did not reach statistical significance.ConclusionsEarly bronchoscopy in mechanically ventilated patients with aspiration pneumonitis can be beneficial in improving respiratory functions and decreasing the incidence of development of aspiration pneumonia and may guide the de-escalation of antibiotic therapy.How to cite this articleMegahed MM, El-Menshawy AM, Ibrahim AM. Use of Early Bronchoscopy in Mechanically Ventilated Patients with Aspiration Pneumonitis. Indian J Crit Care Med 2021;25(2):146–152.

Опыт применения метода гипоксического кондиционирования в комплексной реабилитации детей с бронхиальной астмой, перенесших коронавирусную инфекцию

Objective. To evaluate the efficacy and safety controlled hypoxic stimulation in children after coronavirus infection, including those with BA. Patients and methods. This study included 72 children aged 9–12 years who had had COVID-19 at least 1.5–2 months before the enrollment; of them, 24 patients had mild to moderate BA. Study participants were randomized into two groups: ‘intermittent hypoxic training’ (IHT, n = 31) and ‘intermittent hypoxic-hyperoxic training’ (IHHT, n = 41). Before the procedures, we assessed hypoxic resistance of children using a hypoxic test. The following parameters were measured before and after the course, which included 10 procedures: hypoxic resistance (hypoxic index, time to desaturation, and reoxygenation time), spirometry parameters (forced expiratory volume in 1 second, peak expiratory flow, and airway resistance), changes in systolic/diastolic pressure, heart rate variability, tolerability of procedures (using a visual analog scale), and anxiety level (CMAS test). Results. We found no significant differences between BA and non-BA children in their spirometry parameters and hypoxic resistance. We observed good tolerability of the procedures in children from different groups. After the course of IHT/IHHT, patients demonstrated a significant increase in their resistance to hypoxic stimulation. IHHT procedures were more effective and safer than IHT according to spirometry parameters (RINTexp), tolerability, and anxiety level. Conclusion. Hypoxic conditioning procedures can be recommended as a part of comprehensive rehabilitation in BA children who had had COVID-19. Key words: intermittent hypoxic training, new coronavirus infection, bronchial asthma, children, rehabilitation

Efficacy of transalveolar pressure measurement as a monitoring parameter for lung recruitment in postcardiac surgery hypoxic patients

ABSTRACT Background: Lung atelectasis is a common complication post-cardiac surgery that can affect patient’s outcomes significantly. The current study aimed to evaluate the efficacy of transalveolar pressure measurement (PTA) using esophageal manometer as a monitoring parameter during a modified stepwise staircase lung recruitment employing adaptive ventilation mode (AVM) in postcardiac surgery hypoxic patients.Settings and Design: This study was a prospective case series study.Methods: The study was carried out on 62 adult patients who were undergone on-pump cardiac surgeries. After haemodynamic stabilization of the patient in ICU, esophageal manometer catheter had been inserted then a modified stepwise staircase alveolar recruitment maneuver was done with the use of the transalveolar pressure as the main parameter for the monitoring of the effectiveness and safety of the recruitment maneuver. Agreement between parameters was done and weighted kappa, standard error and confidence intervals at 95% (95% CI) were calculated.Results: During the alveolar recruitment maneuver, the PTA Insp detected 96.7% of the patients with alveolar overdistention and the PTA Exp detected 98.3% of the patients with alveolar optimum PEEP. Statistical significant improvement in both hypoxic index and ultrasound lung aeration score from before to after alveolar recruitment.Conclusion: Transalveolar pressure inspiratory and expiratory were accurate monitoring parameters for alveolar overdistention and optimum PEEP detection selectively. Abbreviations: ALI: Acute lung injury; ARDS: Adult respiratory distress syndrome; AVM: Adaptive ventilation mode; Cdyn: Compliance Dynamic; ETT: Endotracheal tube; IBW: Ideal body weight; ICU: Intensive care unit; MBP: Mean blood pressure; MVTarget:Minute volume target; PEEP: Positive end expiratory pressure; PES: Esophageal pressure; PLimit: Pressure limit; PPL: Pleural pressure; PTA: Transalveolar pressure measurement; PTA Exp: Expiratory transalveolar pressure; PTA Insp: Inspiratory transalveolar pressure; RM: Recruitment maneuvers; SpO2: Percutaneous Oxygen saturation

Does therapeutic plasma exchange have a role in resistant cytokine storm state of COVID-19 infection?

ABSTRACT Introduction Among the main causes of mortality in COVID-19 patients is cytokine storm (CS) state. Few treatment options with variable efficacy results are available for its management. We aimed to illustrate the efficacy of Therapeutic Plasma Exchange (TPE) treatment in COVID-19 patients with resistant CS. Material and methods This research is a prospective pilot study which included ten COVID-19 positive patients with CS state with no response after two doses of tocilizumab. Each patient received three to five TPE sessions according to his/her response. Respiratory status {oxygen (O2) requirements and data of mechanical ventilation} and laboratory markers (IL-6, CRP, ferritin, D dimer, LDH) were assessed before and after TPE. We reported mortality at 28 day of illness. Results Six males and four females were enrolled in the study with a mean age of (52.9 years). Seven patients (70%) were on mechanical ventilation (MV). After TPE, oxygenation parameters and most laboratory markers improved significantly in all patients (p < 0.05). Four patients survived and were discharged (40%). One was on MV and three were not. The four patients had better hypoxic index (PaO2/FiO2 ratio) (˃100 vs <100), started TPE sooner after tocilizumab failure (2–3 vs 5–6 days), needed fewer TPE sessions (3 vs 4–5, p = 0.03), and less duration in ICU (6.5 vs 12.5 days) compared to those who did not benefit. Conclusions In patients with CS state who did not respond well to tocilizumab and steroids, TPE could be a good option. Larger randomized clinical trials are needed to support its use. Clinical trials registration ClinicalTrials.gov Identifier:NCT04457349

Comparative Study between the Uses of High Dose Corticosteroid Therapy for Short Duration Versus Low Dose Corticosteroid for Long Duration in Severe Lung Contusion with ARDS

Introduction: Corticosteroids are used in ARDS to prevent lung fibrosis. The best dose, duration and regimen are still the points of debate among physicians. Aim of the Work: The aim of this study is to make a comparison between two corticosteroid regimens, i.e. short-duration high dose versus long- duration low dose corticosteroid use in ARDS due to lung contusion with VAP for lowering both morbidity and mortality rates and early weaning from ventilator. Patients and Methods: Patients who had &gt;3 on Murray score and &gt;6 on CPIS were allocated randomly in two groups of 120 patients each. Group A received 30 mg/kg methyl-prednisolone slowly intravenously in 250 ml normal saline every 8 hours for only 48 hours, while group B received 1 mg/kg/day methyl-prednisolone divided into three doses given every 8 hours for two weeks. The study lasted for 16 days; morbidity was considered if no improvement was observed in any or all clinical parameters of both Murray and CPIS scores and if there was failure in removing patients from the ventilator within the studied period. Results: Significant improvement was observed in patients of group B compared to group A with regard to APACH II &lt;10 score, arterial oxygen saturation&gt;95, hypoxic index &gt;300, lung infiltrate in chest X-ray, lung compliance, response of the lung to recruitment maneuver, the return of core temperature to normal, normal tracheal secretion, the return of leucocytic count to normal, negative qualitative sputum culture and a significantly higher number of patients were removed from the ventilator of group B compared to group A. However, mortality rate was not significant between the two groups. Conclusion: Low dose corticosteroid if used for a long duration significantly lowers morbidity and accelerates recovery, and in turn, accelerates weaning from ventilator compared to high dose corticosteroid used for a short duration. While the difference between the two regimens was not significant with regard to the mortality rate, still further studies are needed to emphasize a fixed corticosteroid dose and regimen in ARDS due to lung contusion.

Indicators of individual hypoxia resistance — a way to optimize hypoxic training for children

Objective. To develop a protocol for a normobaric hypoxic test and criteria of resistance assessment — normobaric hypoxia sensitivity in children. Characteristics of children and research methods . 56 healthy children aged from 8 to 12 years underwent a hypoxic test inhaling gas mixture with 10—11% of O 2 through mask to create hypoxemia conditions (SpO 2 = 80%). The authors used a normobaric hypoxic device (certified in the Russian Federation) to produce hypoxic and hyperoxic gas mixtures — ReOxy Cardio (S.A. Aimediq, Luxembourg) with an integrated pulse oximetry sensor (Masimo Rad-5, USA). During hypoxic test they monitored the arterial blood oxygen saturation (SpO 2 ) and heart rate (HR, bpm), and there were automatically recorded the individual minimum values of SpO 2 level (SpO 2 min) and maximum heart rate (HR max). A “hypoxic phase” was terminated in case of decrease in SpO2 to 80% or lower, or breathing with a hypoxic gas mixture during 9 minutes. An additional criterion for termination was an increase in HR by 30% and higher over the initial level. After reaching one of the described criteria, the teenagers began to breathe ambient air and the authors determined the recovery time of SpO 2 to 97%. In addition, the authors calculated the hypoxic index as desaturation/reoxygenation time ratio. Results. The authors developed a protocol for conductance and assessment of hypoxic resistance in children and adolescents. There were determined three types (phenotypes) of response to dosed normobaric hypoxia in adolescents: low, medium and high levels of dosed hypoxic stimulus resistance. Conclusion . The proposed hypoxic test protocol reflects the individual hypoxia tolerance and can be used to individualize hypoxic therapy courses, as well as additional diagnostic tool in assessing the adaptive capabilities and non-specific reactivity in children.

Activated Factor Seven (aFVII) versus Aminocaproic Acid for Treatment of Traumatic Retro-Peritoneal Hematoma

Introduction: Off-labelled use of activated Factor VII (aFVII) in severe traumatic bleeding has been used as an alternative to aminocaproic. Aim of Work: The aim of this study is to compare the efficacy of aFVII with aminocaproic acid in the medical treatment of retroperitoneal bleeding, treatment of hypovolemic shock and preventing complications of massive blood transfusion. Materials and Methods: 80 patients with traumatic retro-peritoneal hematoma were allocated into two groups of 40 patients each. Patients in Group A received aminocaproic acid, while patients of group B received aFVII. The number of packed RBCs given to achieve the target Hb level and time to get to this target Hb level (&gt;10 gm%) were recorded as indicators of control bleeding. Blood pressure, pulse, arterial blood gasses and urine output were recorded as indicators of successful treatment of hypovolemic shock. Hypoxic index, chest X-ray and coagulation profile were used as indicators for complications. Results: There was a significantly smaller number of packed RBCs given to patients of group B to achieve the target Hb level and this target Hb level was achieved in a shorter time. There was a significantly higher number of patients in group B compared to group A who had normal blood pressure, pulse and urine output, pH and bicarbonate concentration. There was a significantly smaller number of patients who developed DIC and TRALI in group B compared to group A. Conclusion: aFVII was more effective than aminocaproic acid and needed a shorter time to stop retroperitoneal bleeding, treat hypovolemic shock, restore adequate tissue perfusion and protect patients from complications of massive blood transfusion.

Ефективність комплексної програми фізичної реабілітації хворих на бронхіальну астму в поєднанні з патологією гепатобіліарної системи

Мета. Науково обґрунтувати, розробити і визначити ефективність комплексноїпрограми фізичної реабілітації хворих на бронхіальну астму в поєднанні з патологієюгепатобіліарної системи.Методи. Розрахунок індексу Робінсона (подвійного добутку) для оцінки обмінно-енергетичних процесів в міокарді; розрахунок адаптаційного потенціалу серцево-судинної системи, вегетативного індексу Кердо, експіраторного гіпоксичного індексу, інтенсивності болю за допомогою візуально-аналогової шкали ВАШ та психоемоційного стану за тестом САН. Результати. Обстежено 20 осіб віком від 36 до 60 років (з них 10 жінок і 10 чоловіків) з діагнозом бронхіальна астма і супутніми патологіями гепатобіліарної системи. У реабілітаційному комплексі використано лікувальну гімнастику, яка відрізнялась поєднаннямспеціальних фізичних вправ для бронхіальної астми та патології гепатобіліарної системи,способи вольового керування диханням для профілактики та купірування бронхоспазму,сегментарно-рефлекторний та точковий масаж, фізіотерапію, дієтотерапію. Висновки. Під впливом проведеного курсу фізичної реабілітації у експериментальній групі достовірно покращились показники психологічного тесту САН (з 40,2 ± 1,89 до 49,5 ± 2,01 ум. од.; р &lt; 0,01), за шкалою інтенсивності болю ВАШ (з 60,9 ± 2,12 % до 45,6 ± 2,3 %; p &lt; 0,001), адаптаційного потенціалу серцево-судинної системи (з 3,2 ± 0,16 до 2,8 ± 0,14 балів; p &lt; 0,05), а також індексу Робінсона (з 101,4 ± 3,4 до 93,2 ± 2,46 ум. од.; p &lt; 0,05) та експіраторного гіпоксичного індексу (з 3,42 ± 0,17 до 2,60 ± 014 ум. од.; р &lt; 0,01). Досліджені показники функціональних резервів організму хворих на бронхіальну астму, яка поєднується з патологією гепатобіліарної системи, у основній групі кращі, ніж у контрольній. В основній групібуло виявлено більш суттєвий реабілітаційний єфект, що доказує ефективність та перевагирозробленої реабілітаційної програми і дозволяє рекомендувати її до впровадження.

0721 Coronary Atherosclerotic Plaque Burden and Composition in Patients with Obstructive Sleep Apnea by Coronary CT Angiography

Abstract Introduction OSA is closely associated with increased risk of coronary artery disease. Although previous small studies have investigated coronary plaque in OSA patients, limited data are available regarding the association of OSA with plaque morphology and composition. Therefore, we aimed to quantitatively characterize and compare coronary plaque burden and composition between patients with no or mild obstructive sleep apnea (OSA) and moderate-severe OSA using coronary computed tomography angiography (CTA) in a large-scale study. Methods We retrospectively analyzed consecutive patients who underwent sleep monitoring and coronary CTA. Metrics reflecting coronary plaque characteristics were compared between patients with no or mild OSA with apnea hypoxic index (AHI) ≤15 and moderate-severe OSA (AHI&amp;gt;15). The associations of OSA with coronary plaque components were determined by logistic and linear regression analysis. Results A total of 854 patients were enrolled in the study. Of these, 162 did not meet the inclusion criteria and of the remaining 692 patients 400 (57.8%) had moderate-severe OSA and 292 had no or mild OSA. Patients with moderate-severe OSA had a significantly higher total plaque volume, total non-calcified plaque (NCP) volume and total low density non-calcified plaque (LD-NCP) volume, and corresponding burden than those with no or mild OSA (all with p&amp;lt;0.05). Multivariate logistic regression analysis revealed that moderate-severe OSA patients are more likely to have any plaque, NCP and LD-NCP than those without no or mild OSA (p&amp;lt;0.05). In addition, stepwise multivariate linear regression analysis further revealed an independent relationship between moderate OSA (15&amp;lt;AHI≤30) and more so between severe OSA (AHI&amp;gt;30) and, NCP volume, LD-NCP volume, NCP composition, and LD-NCP composition, following adjustment for traditional cardiovascular risk factors, compared to no or mild OSA (AHI&amp;lt;15) (all with a p&amp;lt;0.05). Moderate-severe OSA conferred a similar odds ratio for LD-NCPs (a high-risk plaque) as the usual cardiovascular risk factors. Conclusion In this large cross-sectional study, OSA severity was associated with high-risk plaque features independent of traditional cardiovascular risk factors, suggesting an increased risk for cardiovascular events. Support This study was supported by NSFC (Project 81870335), International Science &amp; Technology Cooperation Program of China (No.2015DFA30160), Beijing Municipal Science &amp; Technology Commission (No. Z141100006014057)