Respiratory Support Research Articles

Neuroendoscopic surgery for brainstem hemorrhage: Technical notes and preliminary clinical results

BackgroundBrainstem hemorrhage accounts for a relatively small proportion of spontaneous intracerebral hemorrhages (∼10 %) but tends to occur earlier in life and has poorer prognosis. Numerous studies support the therapeutic potential of minimally invasive hematoma evacuation for intracerebral hemorrhage; however, there have been few assessments of the benefits for brainstem hemorrhage. MethodsWe evaluated the safety and efficacy of a minimally invasive approach under neuroendoscopic guidance with pneumatic arm fixation for removing the hematoma in severe brainstem hemorrhage patients. 14 patients diagnosed with primary brainstem hemorrhage and treated by neuroendoscopy-assisted evacuation at Suzhou Ninth Hospital affiliated to Soochow University were included in the study. Relevant clinical and prognostic date were collected and analyzed. ResultsHematoma volume ranged from 8 to 13 mL according to preoperative CT, while GCS at admission ranged from 4 to 6. The average operative time was 157 min and average intraoperative blood loss was 86 mL. All patients achieved satisfactory hematoma evacuation (over 90 %) according to immediate postoperative CT. Postoperative intensive care unit stay averaged 9.5 days and respiratory support averaged 7.5 days. 11 patients required tracheotomy due to pulmonary infection and absence of pharyngeal reflexes. 9 patients achieved satisfactory functional recovery (GOS score of 4 and 3), while 5 remained in a vegetative state (GOS score of 2). ConclusionNeuroendoscopy provides excellent direct visualization of brainstem hematomas for safe and reliable evacuation. Patients with a new PPH score of 2 or 3 are more likely to benefit from surgical treatment. Large-scale studies are required to identify patients most likely to benefit from this technique.

Risk factors and outcomes of pediatric non-invasive respiratory support failure in Latin America

BackgroundNoninvasive respiratory support (NRS) is standard in pediatric intensive care units (PICUs) for respiratory diseases, but its failure can lead to complications requiring invasive mechanical ventilation (IMV). This study aimed to identify risk factors for NRS failure in children with acute respiratory failure (ARF) in PICUs, and compare complications and outcomes between IMV-only and NRS failure patients. MethodsWe conducted a cohort study using data from the LARed Network prospective registry (April 2017–November 2022), in children under 18 years admitted to PICUs for ARF. Cases were divided into subgroups: those managed with IMV only, those who experienced NRS failure requiring IMV, those who received NRS successfully, and those who did not require NRS or IMV. Exclusions included patients with home respiratory support prior to admission and those with incomplete data. Multivariate mixed models analyzed NRS failure risk factors, and complications between the IMV-only and NRS failure groups, using centers as a random effect. ResultsA total of 7374 children met the inclusion criteria, with 6208 in the NRS group and 1166 in the IMV-only group. The NRS success rate was 85.3 %. Risk factors for NRS failure included age (median of 4.6 months, interquartile range of 2.1–14.2 months), history of prematurity (adjusted odds ratio [aOR]=1.53, 95 % confidence interval [CI]: 1.20 to 1.95) or malnutrition (aOR=1.85, 95 % CI: 1.18 to 2.91), suspected bacterial infection (aOR=5.12, 95 % CI: 4.05to 6.49), FiO2 >30 % (aOR=1.52, 95 % CI: 1.18 to 1.97), severe hypoxemia with SpO2/FiO2 ≤150 (aOR=1.85, 95 % CI: 1.48 to 2.30), tachypnea (aOR=1.42, 95 % CI: 1.18 to 1.72), tachycardia (aOR=1.77, 95 % CI: 1.47 to 2.12), and lung consolidations (aOR=1.45, 95 % CI: 1.14 to 1.85) or interstitial infiltrates (aOR=1.29, 95 % CI: 1.05 to 1.58) on chest X-ray. There were no significant differences in morbidity, mortality, duration of IMV, or PICU length of stay between patients who received IMV only and those who experienced NRS failure. However, patients who experienced NRS failure were more likely to develop withdrawal symptoms related to sedative or opioid discontinuation and/or delirium (aOR=2.57, 95 % CI: 1.85 to 2.57). ConclusionThis study identified key risk factors for predicting NRS failure in children with acute ARF in PICUs, including younger age, prematurity, malnutrition, suspected bacterial infection, FiO2 >30 %, severe hypoxemia (SpO2/FiO2 ≤150), tachypnea, tachycardia, and radiological findings such as lung consolidation and interstitial infiltrates. Compared to patients managed with IMV from the start, those who experienced NRS failure were more likely to develop withdrawal symptoms and/or delirium, although clinical outcomes such as mortality, IMV duration, and PICU length of stay were similar in both groups.

A Chart Review for Epidemiology and Outcome of Fungal Bloodstream Infections Among Neonates in a Tertiary Care Hospital at North India

Background and Aims The risk of fungal bloodstream infection (BSI) and accompanying mortality in neonates varies widely in between centres depending on the region, the population characteristics and the risk factors. Methods This chart review of neonatal cases with fungal BSI admitted in a tertiary care teaching hospital in North India aimed to comprehensively investigate the epidemiology, profile of fungal species (and their susceptibility to various antifungal agents), risk factors, clinical profile and outcomes in these neonates. The study spanned over a one-year period, from September 2022 to August 2023, included all symptomatic neonates with positive blood cultures for fungal pathogen. Results Over one year, 24 out of 1,174 neonates at risk were diagnosed with fungal BSI, with a cumulative risk of 2.0 per 100 neonates. A peak in cases occurred in February. Candida pelliculosa was the predominant species (75% of isolates), while Candida albicans constituted 4.2%. Most isolates were sensitive to fluconazole, except for some fluconazole-resistant Candida pelliculosa (5.5%) and Candida tropicalis (25.0%), which remained susceptible to amphotericin-B and voriconazole. Around 60% of neonates were preterm, 40% had very low birth weight and 37% were small for gestational age. Nearly all had received prior broad-spectrum antibiotics, with 92% receiving prolonged courses over five days. Respiratory support, including intubation and mechanical ventilation, was used in 83% before onset of fungal sepsis. Intriguingly, all neonates had some invasive device in place for more than seven days. Mortality rate of 25% was observed, with preterm birth and gastrointestinal anomalies contributing to adverse outcomes. Conclusions This study confirms the ongoing shift in trend from albicans to non-albicans Candida infections in our region as well. A seasonal peak of fungal sepsis noted in the month of February hinted at potential seasonal variation or lapses in infection control practices during colder months. The analysis of trends in fungal BSI might hold a significance within neonatal intensive care units (NICUs) for the prompt detection of outbreaks. Simultaneously, understanding and analysing risk factors associated with fungal BSI are essential for targeted prevention.

Dexamethasone Dose for COVID-19 in a Large U.S. Hospital Network From April 2020 to May 2023.

While potential harm from high doses of systemic dexamethasone for clinical management of COVID-19 is an important concern, little is known about real world dexamethasone dosing in patients hospitalized with COVID-19 in the United States. Descriptive study to assess dexamethasone daily dose in adults with COVID-19 in a large US hospital network, overall and by respiratory support requirements, extracted using semi- structured nursing notes. Of 332 430 hospitalizations with a COVID-19 diagnosis, 201 637 (60.7%) hospitalizations included dexamethasone administration. The mean age of recipients was 63 years, 53.0% were male, and 64.5% White. Median time from admission to dexamethasone administration was 0 day (interquartile range [IQR], 0-1 days) and median duration of use was 5 (IQR, 3-9) days. Almost 80% of hospitalizations received standard daily doses (≤ 6 mg daily), 12.7% moderately high daily doses (> 6- ≤ 10 mg daily), and 8.1% high (> 10- ≤ 20 mg daily) or very high daily dose (> 20 mg daily). Over 20% of COVID-19 hospitalizations requiring no oxygen or simple oxygen received high doses of systemic dexamethasone. Given the findings from the UK RECOVERY trial, and the general uncertainty around safety of higher dexamethasone doses in those requiring more intense respiratory support, standard daily dexamethasone doses of 6 mg or less for hospitalized COVID-19 requiring supplemental oxygen are recommended.

Providing Education on Basic Life Support to Increase Student Knowledge

Background: Basic Life Support (BLS) is an essential first aid action performed on individuals experiencing cardiac or respiratory arrest. The primary goal of BLS is to restore and maintain vital organ function through interventions like chest compressions and respiratory support. Knowledge, which arises from experience and observation, is enhanced through education. This process aims to improve understanding and, consequently, decision-making abilities. Purpose: The aim of this Community Service (PkM) project is to increase the knowledge of students at MAN 1 Banyumas regarding Basic Life Support. Method: The methods used in this PkM included lectures and discussions. The students' knowledge was assessed before and after the educational intervention using a structured knowledge questionnaire. Findings: The participants of this PkM were predominantly middle adolescents aged 15-17 years, with 29 participants (96.7%) falling within this age range. The majority were female, comprising 26 participants (86.7%). Most of the participants were in grade 11, accounting for 22 participants (73.3%). Before the educational intervention, the knowledge levels were as follows: Good: 2 participants (6.7%), Sufficient: 12 participants (40.0%), Poor: 16 participants (53.3%). After the BLS education, there was a marked improvement in knowledge, with all 30 participants (100%) achieving a "Good" level of knowledge. Conclusions: Education on basic life support at MAN 1 Banyumas significantly improved students' knowledge, with a higher percentage achieving a good understanding after the training.

Clinical Factors Related to Abnormal General Movements Trajectories: Development of a Multicriteria Index.

To create a multicriteria index with clinical factors associated with abnormal general movements (GMs) trajectories during a stay in the neonatal intensive care unit. A longitudinal study assessed abnormal GMs trajectories in preterm infants in the neonatal intensive care unit. The multicriteria index included clinical factors such as intraventricular hemorrhage, respiratory support, gestational age, patent ductus arteriosus, and infection based on multi-attribute utility theory. A total of 52 preterm newborns, 57.7% male, were evaluated. The multicriteria index correlated with abnormal GMs trajectories and explained 26.5% of the variance in these trajectories. The developed multicriteria index, with the inclusion of combined clinical factors, allowed the identification of part of the abnormal trajectories of GMs in preterm infants. The multicriteria analysis can help clinicians to identify infants who have a greater chance of poor developmental trajectories before hospital discharge.

Incidence of Long COVID-19 at 12-18 Months Following Delta Wave of Coronavirus Disease 2019: Hospital-based Prospective Registry.

Long coronavirus disease 2019 (COVID-19) has emerged as an important consequence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). To identify its incidence 12-18 months following hospitalization in patients with COVID-19, we performed a prospective study. Virologically confirmed successive patients with moderate-to-severe COVID-19, hospitalized during the delta wave in India, were recruited. Data on clinical features, investigations, and outcomes were obtained. Long COVID-19 was diagnosed using the European quality of life questionnaire (EQ-5D) and Birmingham symptom burden questionnaire (SBQ) at 12-18-month follow-up. During the study period (January-July 2021), we evaluated 8,680 suspected COVID-19 patients, of whom 1,641 were confirmed virologically and 388 were hospitalized. Men accounted for 64.4%, individuals aged >60 years for 41.5%, hypertension for 42.8%, diabetes for 38.4%, and cardiovascular disease for 17.3%. At admission, there was a high prevalence of cough (71.1%), fever (86.6%), and oxygen requirement (38.6%). Proning was deployed in 89.2% of cases, nasal cannula in 36.3%, nonrebreather masks in 15.7%, noninvasive ventilation in 14.4%, and invasive ventilation in 16.2%. In-hospital deaths totaled 75 (19.3%), with 310 discharged for home care and eligible for follow-up. At a median follow-up of 15 months, 9 patients had died, 40 were lost to follow-up, and 264 were evaluated. The incidence of Long COVID-19 was 45 [17.0%, 95% confidence of interval (CI) 12.6-21.9%]. The median EQ-5D score was 5.0, with >5 observed in only 11 patients (0.6%). Using the SBQ, new-onset dyspnea on exertion was noted in 13 (4.9%), rest dyspnea in 7 (2.6%), fatigue in 31 (11.7%), feverishness in 18 (6.8%), and low energy in 16 (6.1%). Long COVID-19 was significantly more prevalent in women and older individuals. In Long COVID-19 compared to controls, the mean duration of oxygen requirement (5.46 ± 9.8 vs 2.46 ± 4.5 days, p = 0.002), use of nonrebreather masks (17.8 vs 7.3%, p = 0.026), noninvasive ventilation (11.1 vs 3.2%, p = 0.020), and duration of intensive care unit (ICU) stay (13.5, 8.7-17.3 vs 8.0, 5.0-11.0 days, p = 0.028) were significantly higher. The incidence of Long COVID-19 at 12-18 months follow-up is 17.0%. It is significantly higher in women, older age groups, and patients requiring longer oxygenation, nonrebreather oxygen masks, noninvasive respiratory support, and extended stays in the ICU.

Infants Born at Late Preterm Gestation: Management During the Birth Hospitalization

To examine the admission practices, frequency of common clinical morbidities, and rates of medical intervention in infants born at 34-36 weeks gestational age (GA, late preterm). This retrospective, single institution, cohort study analyzed electronic health records of infants born late preterm from 2019 through 2021. Infants with anomalies necessitating neonatal intensive care unit admission were excluded. Analysis included descriptive and inferential statistics. The study included 1022 infants: 209 (21%) 34 weeks GA; 263 (26%) 35 weeks GA; and 550 (54%) 36 weeks GA. Sixty-three percent of infants at 35 weeks GA and 78% of infants of 36 weeks GA remained in well newborn care throughout the birth hospitalization; infants born at 34 weeks GA were ineligible for well newborn care. The need for respiratory support was 32%, 18% and 11% in infants of 34, 35, and 36 weeks GA, respectively. Supplemental tube feeds were administered in 55%, 24%, and 8% of infants of 34, 35, and 36 weeks GA, respectively. Most infants born at 34 weeks GA (91%) were placed in an incubator; this was less frequent in infants at 35 (37%) and 36 weeks (16%). Tachypnea, hypoglycemia, and hypothermia were noted in 40%, 61%, and 57% of infants, respectively. A subset of these infants (30% with tachypnea, 23% with hypoglycemia, 46% with hypothermia) required medical intervention for these abnormalities. This single center study provides an outlook on the care of infants born late preterm. Multi-center studies can contextualize these findings in order to develop clinical benchmarks and quality markers for this large population of infants.

Obesity and COVID-19 Severity: Dissecting the Combined Relationship, Mechanisms, Diagnostic Obstacles, Management Approaches, and Treatment Plans

Background: This review delves into the intricate relationship between obesity and COVID-19 severity, uncovering mechanistic insights such as immunological dysregulation, inflammation, and metabolic complexities. It addresses challenges in diagnosis and treatment, advocating for tailored approaches. Emphasis is placed on proper management and customized dietary interventions to mitigate severity. Methodology: Scientific data related to obesity and COVID-19 was obtained from data bases like PubMed, Scopus, google, and google scholar. The search words employed for the data search were “Mechanisms linking obesity and COVID-19”, “Inflammatory milieu,” “Immune dysregulation”, “Impact of obesity on COVID-19 Severity”, and “Dual relationship between obesity and COVID- 19”. Only relevant data related to the intricate relationship between obesity and COVID-19 severity and its management was included. Results: This paper explores the multifaceted mechanisms linking obesity to increased COVID-19 severity, including immunological dysregulation, inflammatory responses, and metabolic comorbidities. This review highlights complex problems that arise in the diagnosis and treatment of obese people with COVID-19. These problems range from precise diagnosis to individualized treatment plans. Management approaches for obese individuals with COVID-19 encompass lifestyle interventions, pharmacotherapy, and dietary considerations, each tailored to mitigate risks and improve outcomes. Additionally, treatment plans integrating multidisciplinary care, including personalized respiratory support, antiviral therapy, and thromboprophylaxis, are proposed to address the unique needs of obese patients battling COVID-19. Conclusion: The abstract underscores the complexity of this interaction, emphasizing the need for comprehensive information to guide clinical care and future research effectively.

National review of end-of-life care withdrawal guidelines for non-invasive advanced respiratory support using document analysis

ObjectivesThis study aims to understand the breadth of practice around end-of-life withdrawal of non-invasive advanced respiratory support (encompassing both continuous positive airway pressure and non-invasive ventilation) by analysing NHS-published guidelines...

Prongs or Mask for Nasal Continuous Positive Airway Pressure in Neonates: Which One Is More Comfortable?

Nasal continuous positive airway pressure (NCPAP) is a common mode of respiratory support in neonatal intensive care units. Our objective was to compare whether NCPAP given with nasal prongs compared with a nasal mask reduces the pain scores in preterm infants with respiratory distress. Preterm infants on NCPAP due to respiratory distress were included in the study. All infants received NCPAP via the Infant Flow SiPAP. The COVERS pain scale was used to score the infants' pain. Each infant was studied alternating between nasal prongs and a nasal mask. Heart rate, respiratory rate, oxygen saturation, and transcutaneous CO 2 (tcCO 2 ) were monitored. Blood pressure and the infants' pain scores were determined every 30 minutes and the average of measurements was taken. The median (interquartile range) values of pain scores, respiratory rates, oxygen saturations, tcCO 2 levels, and systolic blood pressures differed significantly and favored the nasal mask. This study demonstrates that continuous positive airway pressure via a nasal mask leads to a significant reduction in pain scores without altering the respiratory parameters of babies. On the basis of this study, it is possible to conclude that NCPAP applied via nasal mask may be a good alternative to NCPAP applied via nasal prongs.

Umbilical Catheter Extravasation Mimicking Necrotizing Enterocolitis in a Preterm Neonate: A Diagnostic Challenge.

Managing acute abdomen in very low birth weight (VLBW) and premature infants presents a diagnostic challenge, often necessitating a thorough assessment to discern underlying causes. Umbilical venous catheters (UVCs), commonly used in neonatal intensive care, are essential but not without risks. A 29-week premature male infant, born to a 23-year-old mother, was referred to our clinic on the 16th day of life with a suspected diagnosis of necrotizing enterocolitis (NEC). The infant had spent the first day intubated and received non-invasive respiratory support for 15 days. A 5 French UVC was inserted at the 2nd hour of life, and by the 3rd day of life, the infant transitioned to minimal enteral feeding. Between the 12th and 16th days of life, the infant initially diagnosed with NEC due to symptoms such as decreased stool passage and abdominal distension. The patient had been on a continuous course of antibiotic treatment throughout the entirety of his life, commencing on the very first day due to suspected early neonatal sepsis, followed by nosocomial sepsis during the hospitalization, and persisting with antibiotic therapy for suspected NEC. The case took a unique turn upon further evaluation after being referred to our unit. Despite a preliminary NEC diagnosis, further evaluation revealed umbilical catheter complications, leading to total parenteral nutrition extravasation. Removal of the catheter, drainage, and antibiotic adjustment resulted in improved clinical outcomes. In neonatal care, cautious management is vital when dealing with infants exhibiting abdominal symptoms. A nuanced approach, including differential diagnosis and careful antibiotic use, is essential.

Association of antenatal steroid administration with neonatal morbidities among late preterm multiple gestation infants.

There is limited evidence on the efficacy of antenatal steroids (ANS) among women with multiple gestations at risk of late preterm delivery. This retrospective study included multiple gestation, late preterm infants (340/7-366/7 weeks' gestational age), born between January 2013 and December 2022. The primary outcome was composite respiratory outcome, defined as the need for respiratory support by 72 hours of age. Logistic and linear regressions were performed to compare the primary and secondary outcomes with and without exposure to any ANS, adjusted for gestational age, sex of infant, histologic chorioamnionitis, and intrauterine growth restriction. The composite respiratory outcome was significantly lower in any ANS group compared to no ANS group (28.6% vs. 33.7%) [adjusted odds ratio 0.50, 95% CI, 0.33-0.75, p < 0.001]. In late preterm multiple gestation infants, any ANS exposure was associated with lower risk of composite respiratory outcome.

Respiratory Syncytial Virus and US Pediatric Intensive Care Utilization

Bronchiolitis is the most common diagnosis necessitating respiratory support and pediatric intensive care, and respiratory syncytial virus (RSV) is the most common cause of bronchiolitis. In 2023, the monoclonal antibody nirsevimab and the maternal RSVpreF vaccine were implemented to prevent RSV in infants. To determine the potential association of novel RSV prevention strategies with pediatric intensive care unit (ICU) utilization. This retrospective cross-sectional study examined US pediatric ICU encounters with and without RSV from January 1, 2017, to June 1, 2023. Data were from Oracle Cerner RealWorld Data, a national electronic health record database. All children (aged >1 day and <18 years) admitted to an ICU during the study period were included in the analysis. Statistical analysis was performed from February to May 2024. The primary outcomes were ICU encounters with RSV and ICU encounters with RSV eligible for RSV prevention. There were 119 782 ICU encounters from 53 hospitals; 65 757 encounters (54.9%) were male; median (IQR) age was 4.5 (1.1-12.5) years, median (IQR) ICU length of stay was 1.8 (1.0-3.9) days; 13 702 ICU encounters (11.4%) had RSV, of which 38.6% (5217) were eligible for prevention (4.4% of total ICU encounters). Encounters with RSV accounted for 21.1% (109 334) of ICU days, of which 43.8% (47 888) were eligible for prevention (9.2% of total ICU days). Encounters with RSV were associated with a greater use of positive pressure ventilation (4074 [29.7%] vs 18 821 [17.7%]; P < .001) and vasoactive medications (3057 [22.3%] vs 18 570 [17.5%]; P < .001) compared with those without RSV. The findings of this retrospective cross-sectional study of RSV and US pediatric intensive care utilization suggest that if 65% to 85% of eligible children received RSV prevention, an estimated 2.1% to 2.8% reduction in pediatric ICU encounters and an estimated 4.5% to 5.9% reduction in pediatric ICU days could be achieved.

Cohen vs Pfannenstiel cesarean skin incision for body mass index ≥35 kg/m2: a randomized controlled trial

Background: Maternal obesity is recognized as a significant risk factor for adverse pregnancy outcomes, including increased cesarean delivery rates and heightened surgical complications. It is unclear if the Cohen or Pfannenstiel skin incisions at cesarean delivery are associated with different outcomes. Objective: To evaluate the impact of either Cohen or Pfannenstiel cesarean skin incision type on maternal morbidity. Study Design: Pregnant individuals with a BMI of ≥35 kg/m2, carrying either singleton or multiple gestations, were consented prenatally and in labor. Eligible participants who underwent a cesarean delivery between 24 and 41 weeks of gestation were randomized to either Pfannenstiel or Cohen skin incisions at Thomas Jefferson University Hospital from October 2016 to March 2020. The study aimed to recruit 284 participants based on a sample size calculation assuming a 50% reduction in wound complications with Cohen versus Pfannenstiel incisions (80% power, α=0.05), but recruitment was terminated early after 72 participants were randomized. The primary outcome was a composite maternal morbidity within six weeks, which consisted of the following: wound infection, hematoma, seroma, separation of skin ≥1 cm, readmission for wound complications, endometritis, and postpartum hemorrhage. Statistical analyses included bivariate tests, t-tests, and non-parametric analyses. Results: Of 331 pregnant individuals consented prenatally and in labor, 72 eventually underwent cesarean delivery and were randomized, 34 to Cohen and 38 to Pfannenstiel skin incisions. The mean BMI was >42 kg/m2, about two thirds of the patients had a pannus, 56% were Black, 47% had diabetes, and 56% hypertensive disorders. The primary outcome of composite maternal morbidity occurred in 47.1% in the Cohen and 36.8% in the Pfannenstiel groups (RR 1.24, 95% CI 0.71-2.08), and was also similar regardless of the presence of a pannus, or by degree of obesity. Surgical site infection, hematoma, seroma, wound separation/dehiscence, endometritis, and postpartum hemorrhage were each similar between Cohen and Pfannenstiel participants. Neonatal outcomes were also similar between the Cohen and Pfannenstiel groups, except that the Cohen group was found to have statistically significant lower Apgar score at 5 minutes and higher need for respiratory support compared to the Pfannenstiel group, possibly related to the trend for a longer time from skin incision to delivery. Physicians were found to be significantly less satisfied with the Cohen compared to the Pfannenstiel incision. Conclusion: In pregnant patients with BMI of ≥35 kg/m2, obstetrical providers can chose from either a Cohen or an Pfannenstiel skin incision, as they are associated in general with similar outcomes, except for lower Apgar scores and lower physician satisfaction associated with the Cohen incision. The findings of this study are limited by its early cessation for logistical reasons, leading to an underpowered analysis. It is crucial to acknowledge that these results must be interpreted cautiously due to the reduced sample size and the circumstances surrounding the study's termination. These data can inform future trial design and implementation as well as fuel individual patient level meta-analyses on this topic.

Propranolol As a Treatment Option for Chylous Effusions and Chylous Ascites in Fetuses and Neonates: A Systematic Review.

Chylous effusion and chylous ascites are rare but serious conditions that affect both fetuses and neonates. Previous studies have documented chylous effusions or chylous ascites treatment with medications as an adjunct to respiratory support and dietary modifications, but no formal recommendations have been made. New literature suggests propranolol as an effective and safe treatment option, though no randomized clinical studies have been published to date. This review aims to assess the efficacy and safety of propranolol in the treatment of chylous effusion and chylous ascites in fetuses and newborns from case reports. A comprehensive search of 10 databases and grey literature was completed. The inclusion criteria for articles were age at diagnosis less than 40 days old and case report/series. Articles were excluded if they were animal studies or not published in English. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 4 articles were ultimately included in the study for a total of 10 reported cases. Propranolol administered to mother and neonates was effective in 100% of cases. The most common oral dose for mothers was 20 mg, 4 times daily, titrated to 40 mg, 4 times daily. The maximum dosage varied for administration orally to neonates, with the median being 3 mg/kg/day. Side effects, including bradycardia and transient hypoglycemia, were seen in 20% of the cases and resolved with dose adjustment. Propranolol is a relatively effective and safe treatment option for chylous effusion and chylous ascites that can be administered prenatally or to neonates.

Association of dietary insulinemic potential with disease severity and symptoms in patients with COVID-19

AimCOVID-19 has threatened people's lives in world. Studies showed that level of insulin is related to function of immune system and level of inflammation in body. In this study we aimed to evaluate the association between dietary insulinemic potential and level of inflammatory biomarkers, severity and symptoms of COVID-19. MethodsParticipants of this cross-sectional study were 684 people who recovered from COVID-19. Dietary intake of participants was assessed using 168-item food frequency questionnaire during telephone interview, then dietary insulinemic index and load (DII and DIL) calculated for each participants. Data related to study outcomes, include levels of inflammatory biomarkers, disease symptoms, lung infection, saturation of peripheral oxygen, Respiratory Rate, need for respiratory support, duration of disease, hospitalization, recovery from disease and need for respiratory support and score of life satisfaction were collected through an interview with participants and review of their medical records. ResultsAfter controlling for confounders, participants in the highest quartile of DIL had a significantly higher risk of severe COVID-19 (OR: 2.66, 95% CI: 1.01–7.04, Ptrend=0.035), risk of hospitalization (OR: 3.44, 95% CI: 2.27-7.64, Ptrend>0.001), fever (OR: 2.91, 95% CI: 8.08–1.05, Ptrend=0.042), chills (OR: 4.68, 95% CI: 1.77–12.37, Ptrend=0.002) and lower risk of weakness (OR: 0.28, 95% CI: 0.10–0.74, Ptrend=0.012) and myalgia (OR:0.26, CI: 0.10–0.45, Ptrend=0.006) compared to the lowest quartile. In addition our findings showed a significant positive association between DII and risk of fever (OR: 1.71 95% CI: 2.84–1.03, Ptrend=0.049). Our finding failed to find a significand association between DII and risk of sever COVID-19 and hospitalization. Moreover we did not find significant association between DII/DIL and duration of disease, other symptoms and outcomes. ConclusionsOur findings showed that higher DIL was associated with greater risk of sever COVID-19 and hospitalization. More detailed cohort studies are needed to confirm the findings.

The role of extradiaphragmatic muscles’ ultrasound on the diagnosis and follow-up of diaphragmatic dysfunction associated with cervical septic arthritis: A case report and literature review

Cervical septic arthritis can lead to complications such as epidural abscess, which may result in respiratory failure. We present a case of a 78-year-old male with cervical septic arthritis complicated by epidural abscess, leading to severe diaphragm dysfunction. Ultrasound evaluation revealed dysfunction of the left hemidiaphragm and compensatory activation of accessory respiratory muscles. Treatment included antibiotic therapy and corticosteroids, alongside respiratory support. After 21 days, improvements were observed in diaphragmatic function and respiratory muscle activation. Our findings highlight the importance of assessing both diaphragm and accessory respiratory muscles in cases of cervical septic arthritis with respiratory complications.

Management of protective lung ventilation in children with a critical course of acute respiratory distress syndrome caused by SARS-CoV-2 coronavirus infection

the pandemic of coronavirus disease COVID-19 has created a serious threat to the public health system worldwide. With the beginning of the pandemic, it became clear that children infected by SARS-CoV-2, for unknown reasons, have a milder course compared to adults. In some cases, children are asymptomatic carriers of the infection. In light of today's scientific discoveries, contrary to initial reports, recent studies have shown that children are just as likely to contract the virus as adults, while vague symptoms and a milder course more often characterize the disease itself. However, it is worth noting that the true prevalence of asymptomatic SARS-CoV-2 infection is most likely underestimated since children are not tested for COVID-19 without obvious clinical symptoms. This fact has been confirmed by multiple blood tests indicating high titers of IgG to SARS-CoV-2. Compared to adults, the typical clinical manifestations of COVID-19 in children are fever, runny nose, cough, and general weakness. The laboratory test results indicate a normal level of leukocytes, lymphopenia, and an increased level of aspartate aminotransferase, alanine aminotransferase, D-dimer, and MB creatine kinase. Currently, there is no sufficient evidence that the etiotropic therapy is 100% successful. Yet a course of action such as respiratory system protection, control of fluids and electrolyte homeostasis, anti-cytokine therapy, preventative measures for thrombosis, and treatment for bacterial superinfection proved to be efficient at preventing the development of possible complications caused by SARS-CoV-2. Therefore, it is important to collect and accumulate new experiences\cases of respiratory system protection management of an acute respiratory syndrome with a critical course of acute respiratory distress syndrome caused by COVID-19 and implement practical treatment plans for healthcare facilities. The results were analyzed using clinical epidemiology methods. Children were admitted to the intensive care unit on an average of 6,6±0,62 days of illness and were more associated with systemic disorders and water-electrolyte imbalance, which required prosthetic respiratory function, correction of hemodynamics and water-electrolyte disorders, which was carried out in the infectious diseases department of anesthesiology and intensive care for an average of 5,2±0,7 days. In children in the clinical group, SARS-CoV-2 was verified by reverse transcription polymerase chain reaction of a nasopharyngeal swab and/or exhaled air condensate based on its positive results. Comprehensive treatment of patients with severe and extremely severe respiratory distress syndrome in coronavirus disease included respiratory and hemodynamic support, antiviral and antibacterial therapy, parenteral glucocorticosteroids and anticoagulants, which was in line with current national regulatory guidelines and local protocols. According to the criteria for choosing a method of respiratory function prosthetics, in more than half of the patients (62,2%) with hemoglobin oxygen saturation of less than 92%, while maintaining active respiratory capacity, respiratory support was provided by supplementing humidified oxygen through a face mask or nasal cannulas. In another 29,7% of patients, non-invasive ventilation was performed by constant positive airway pressure, with an oxygenation index of 0,4-0,5 and a positive end-expiratory pressure of 4-5 cm of water column. Children who had a critical course of acute respiratory syndrome caused by coronavirus infection COVID-19 (8,1%) and in whom non-invasive methods of respiratory support did not bring the desired therapeutic result were on invasive ventilation in the mode of auxiliary controlled ventilation or in the mode of synchronized intermittent forced ventilation. It should be noted that children who received respiratory support in the form of non-invasive ventilation by means of constant positive airway pressure required a lower concentration of oxygen in the inhalation mixture compared to patients on free-flow oxygen supplementation. The need for admission to the intensive care unit of children with COVID-19 is primarily associated with respiratory disorders caused by interstitial pneumonia. Oxygen supplementation was of paramount importance in patient management, primarily through noninvasive ventilation with constant positive airway pressure or free flow. The use of a pulmonary protective strategy in the treatment of acute respiratory distress syndrome caused by coronavirus disease COVID-19 in children requiring invasive ventilation was accompanied by a pronounced positive result, as it was not accompanied by side effects and resulted in a rapid recovery of patients.

The illness severity scores can predict the need for respiratory and inotropic support in newborns with critical congenital heart malformations

Background and objectives. The illness severity scoring systems have been developed and validated to assess mortality risks based on clinical conditions and aid critical patient decision-making. Dextro-transposition of the great arteries (D-TGA) and coarctation of the aorta (CoA) are critical congenital heart defects that require medical treatment from birth and surgical repair in the neonatal period. The study aimed to compare the values of three scoring systems in predicting the need for respiratory and inotropic support for newborns with D-TGA and CoA. Materials and methods. An observational study was conducted on inborn infants diagnosed with D-TGA and CoA admitted to the newborn intensive care unit (NICU) within 12 hours of birth at a referral unit for congenital heart disease between January 2018 and December 2020. Newborns with D-TGA and CoA who died within the first 24 hours of birth, outborn infants, and those with a late diagnosis were excluded. For each patient, the Clinical Risk Index of Babies (CRIB-II), Score for Neonatal Acute Physiology-II (SNAP-II), and Score for Neonatal Acute Physiology-Perinatal Extension-II (SNAPPE-II) were calculated. Results. A total of 69 newborns were included in the current study, 30 (43.48 %) of whom were infants with D-TGA (D-TGA Group) and 39 (56.52 %) with CoA (CoA group). Newborns who required respiratory support had significantly higher CRIBII scores (3.03 ± 0.63 vs. 1.34 ± 0.19; p = 0.001), SNAP-II scores (26.61 ± 13.96 vs. 12.43 ± 9.98; p = 0.001), and SNAPPE-II scores (33.04 ± 2.91 vs. 14.47 ± 12.35; p = 0.001) compared to those who did not require it. Significantly higher CRIB-II (3.22 ± 0.67 vs. 1.56 ± 0.23; p = 0.003), SNAP-II (22.91 ±14.57 vs. 14.28 ± 1.58; p = 0.003), and SNAPPE-II (28.82 ± 17.95 vs. 16.58 ± 13.85; p = 0.003) scores were also associated with the need for inotropic support. When comparing the predictive efficiency of illness severity scores for detecting the risk of needing respiratory and inotropic support, they are more effective at predicting the need for ventilation and less effective at predicting the need for inotropes. Conclusions. The illness severity scores can effectively predict the need for pre-surgery interventions. Their simplicity makes them suitable for routine use.