Severe Acute Respiratory Failure Research Articles

Safety and efficacy of airway stent placement following bronchial artery embolization: A retrospective study at a single institute

BackgroundAirway stenting is an established procedure for treating oncological emergencies in patients with airway disorders. In patients with airway hemorrhage, respiratory conditions may worsen during stenting. Bronchial artery embolization (BAE) is useful to prevent bleeding from the bronchus. We aimed to evaluate the efficacy and safety of airway stenting after BAE in patients with malignant airway disorders. MethodsThe medical records of all patients who underwent airway stenting following BAE at the National Hospital Organization Okayama Medical Center between 2016 and 2023 were retrospectively reviewed. ResultsThirteen procedures (11 silicone Y stents, one hybrid stent, and one self-expandable metallic stent) were performed. The median duration from BAE to airway stenting was one day (range: 1–5 days). Nine patients experienced tumor shrinkage, and none experienced severe bleeding after BAE during the stent procedure. No other major complications were associated with the stent placement. The median survival time after stenting was 169 days (range; 24–1086). No serious complications caused by BAE, such as spinal cord infarction, were observed. ConclusionsAirway stent placement was safely performed after BAE without severe bleeding or acute respiratory failure. BAE, followed by airway stenting, is useful.

Cerebral hemodynamics and optic nerve sheath diameter acquired via neurosonology in critical patients with severe coronavirus disease: experience of a national referral hospital in Peru

AimWe aimed to describe the neurosonological findings related to cerebral hemodynamics acquired using transcranial Doppler and to determine the frequency of elevated ICP by optic nerve sheath diameter (ONSD) measurement in patients with severe coronavirus disease (COVID-19) hospitalized in the intensive care unit of a national referral hospital in Peru.MethodsWe included a retrospective cohort of adult patients hospitalized with severe COVID-19 and acute respiratory failure within the first 7 days of mechanical ventilation under deep sedoanalgesia, with or without neuromuscular blockade who underwent ocular ultrasound and transcranial Doppler. We determine the frequency of elevated ICP by measuring the diameter of the optic nerve sheath, choosing as best cut-off value a diameter equal to or >5.8 mm. We also determine the frequency of sonographic patterns obtained by transcranial Doppler. Through insonation of the middle cerebral artery. Likewise, we evaluated the associations of clinical, mechanical ventilator, and arterial blood gas variables with ONSD ≥5.8 mm and pulsatility index (PI) ≥1.1. We also evaluated the associations of hemodynamic findings and ONSD with mortality the effect size was estimated using Poisson regression models with robust variance.ResultsThis study included 142 patients. The mean age was 51.39 ± 13.3 years, and 78.9% of patients were male. Vasopressors were used in 45.1% of patients, and mean arterial pressure was 81.87 ± 10.64 mmHg. The mean partial pressure of carbon dioxide (PaCO2) was elevated (54.08 ± 16.01 mmHg). Elevated intracranial pressure was seen in 83.1% of patients, as estimated based on ONSD ≥5.8 mm. A mortality rate of 16.2% was reported. In the multivariate analysis, age was associated with elevated ONSD (risk ratio [RR] = 1.07). PaCO2 was a protective factor (RR = 0.64) in the cases of PI ≥ 1.1. In the mortality analysis, the mean velocity was a risk factor for mortality (RR = 1.15).ConclusionsA high rate of intracranial hypertension was reported, with ONSD measurement being the most reliable method for estimation. The increase in ICP measured by ONSD in patients with severe COVID-19 on mechanical ventilation is not associated to hypercapnia or elevated intrathoracic pressures derived from protective mechanical ventilation.

Ideal Post-Discharge Follow-up after Severe Pneumonia or Acute Respiratory Failure: A Qualitative Study of Primary Care Clinicians in Diverse Settings

Ideal Post-Discharge Follow-up after Severe Pneumonia or Acute Respiratory Failure: A Qualitative Study of Primary Care Clinicians in Diverse Settings

Severe Community-Acquired Pneumonia: Noninvasive Mechanical Ventilation, Intubation, and HFNT.

Severe acute respiratory failure (ARF) is a major issue in patients with severe community-acquired pneumonia (CAP). Standard oxygen therapy is the first-line therapy for ARF in the less severe cases. However, respiratory supports may be delivered in more severe clinical condition. In cases with life-threatening ARF, invasive mechanical ventilation (IMV) will be required. Noninvasive strategies such as high-flow nasal therapy (HFNT) or noninvasive ventilation (NIV) by either face mask or helmet might cover the gap between standard oxygen and IMV. The objective of all the supporting measures for ARF is to gain time for the antimicrobial treatment to cure the pneumonia. There is uncertainty regarding which patients with severe CAP are most likely to benefit from each noninvasive support strategy. HFNT may be the first-line approach in the majority of patients. While NIV may be relatively contraindicated in patients with excessive secretions, facial hair/structure resulting in air leaks or poor compliance, NIV may be preferable in those with increased work of breathing, respiratory muscle fatigue, and congestive heart failure, in which the positive pressure of NIV may positively impact hemodynamics. A trial of NIV might be considered for select patients with hypoxemic ARF if there are no contraindications, with close monitoring by an experienced clinical team who can intubate patients promptly if they deteriorate. In such cases, individual clinician judgement is key to choose NIV, interface, and settings. Due to the paucity of studies addressing IMV in this population, the protective mechanical ventilation strategies recommended by guidelines for acute respiratory distress syndrome can be reasonably applied in patients with severe CAP.

Evaluating the diagnostic and prognostic ability of ischemia modified albumin in COVID-19

BackgroundPatients with COVID-19 can rapidly deteriorate and develop acute hypoxic respiratory failure. Prominent features of the disease include severe inflammation, endotheliitis, and thrombosis. ObjectivesThe aim of the study was to evaluate the diagnostic and prognostic effectiveness of ischemia modified albumin (ΙΜΑ) in a cohort of COVID-19 patients. MethodsThis prospective observational study included adults with SARS-CoV-2 infection confirmed by reverse transcription polymerase chain reaction test, who were hospitalized specifically for COVID-19. The outcomes of interest were progression to severe acute respiratory failure during the index hospitalization defined as partial pressure of oxygen/fraction of inspired oxygen lower or equal to 150, admission to the intensive care unit (ICU) and in-hospital mortality. Admission IMA levels were determined using the commercially available “IMA Assay Kit” method (Abbexa LTD, Cambridge, UK). Adults without SARS-CoV-2 infection were used as controls. Results135 COVID-19 patients and 64 controls were included. Admission IMA levels were significantly higher in COVID-19 patients compared to controls [[24.38 (11.94) ng/ml vs. 14.69 (3.52) ng/ml, p < 0.01]. Receiver operating characteristic analysis of admission IMA showed an area under the curve (AUC) of 94% (p < 0.0001) for COVID-19 diagnosis (cut-off value: 17.5 ng/ml; sensitivity: 90.37%; specificity: 87.5%). Admission IMA was also associated with mortality (AUC: 68%, p = 0.01). However, it was not associated with severe acute respiratory failure (AUC: 47%, p = 0.53) or ICU admission (AUC: 58%, p = 0.41). ConclusionAdmission IMA was significantly increased in COVID-19 patients and was associated with in-hospital mortality.

Airway stenting for liberation from positive pressure ventilation in patients with central airway obstruction presenting with acute respiratory failure

BackgroundCentral airway obstruction (CAO) can lead to acute respiratory failure (RF) necessitating positive pressure ventilation (PPV). The efficacy of airway stenting to aid liberation from PPV in patients with severe acute RF has been scarcely published. We present a systematic review and our recent experience. MethodsA systematic review of PubMed was performed, and a retrospective review of cases performed at our two institutions from 2018 to 2022 in adult patients who needed stent insertion for extrinsic or mixed CAO complicated by RF necessitating PPV. ResultsFifteen studies were identified with a total of 156 patients. The weighted mean of successful liberation from PPV post-stenting was 84.5% and the median survival was 127.9 days. Our retrospective series included a total of 24 patients. The most common etiology was malignant CAO (83%). The types of PPV used included high-flow nasal cannula (HFNC) (21%), non-invasive ventilation (NIV) (17%) and Invasive Mechanical Ventilation (62%). The overall rate of successful liberation from PPV was 79%, with 55% of HFNC and NIV cases being liberated immediately post-procedure. The median survival of the patients with MCAO that were successfully liberated from PPV was 74 days (n = 16, range 3–893 days), and for those with that failed to be liberated from PPV, it was 22 days (n = 4, range 9–26 days). ConclusionIn patients presenting with acute RF from extrinsic or mixed morphology CAO requiring PPV, airway stenting can successfully liberate most from the PPV. This may allow patients to receive pathology-directed treatment and better end-of-life care.

Concurrent use of continuous kidney replacement therapy during extracorporeal membrane oxygenation: what pediatric nephrologists need to know-PCRRT-ICONIC practice points.

Extracorporeal membrane oxygenation (ECMO) provides temporary cardiorespiratory support for neonatal, pediatric, and adult patients when traditional management has failed. This lifesaving therapy has intrinsic risks, including the development of a robust inflammatory response, acute kidney injury (AKI), fluid overload (FO), and blood loss via consumption and coagulopathy. Continuous kidney replacement therapy (CKRT) has been proposed to reduce these side effects by mitigating the host inflammatory response and controlling FO, improving outcomes in patients requiring ECMO. The Pediatric Continuous Renal Replacement Therapy (PCRRT) Workgroup and the International Collaboration of Nephrologists and Intensivists for Critical Care Children (ICONIC) met to highlight current practice standards for ECMO use within the pediatric population. This review discusses ECMO modalities, the pathophysiology of inflammation during an ECMO run, its adverse effects, various anticoagulation strategies, and the technical aspects and outcomes of implementing CKRT during ECMO in neonatal and pediatric populations. Consensus practice points and guidelines are summarized. ECMO should be utilized in patients with severe acute respiratory failure despite the use of conventional treatment modalities. The Extracorporeal Life Support Organization (ELSO) offers guidelines for ECMO initiation and management while maintaining a clinical registry of over 195,000 patients to assess outcomes and complications. Monitoring and preventing fluid overload during ECMO and CKRT are imperative to reduce mortality risk. Clinical evidence, resources, and experience of the nephrologist and healthcare team should guide the selection of ECMO circuit.

The impact of ECPELLA on haemodynamics and global oxygen delivery: a comprehensive simulation of biventricular failure

BackgroundECPELLA, a combination of veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) and Impella, a percutaneous left ventricular (LV) assist device, has emerged as a novel therapeutic option in patients with severe cardiogenic shock (CS). Since multiple cardiovascular and pump factors influence the haemodynamic effects of ECPELLA, optimising ECPELLA management remains challenging. In this study, we conducted a comprehensive simulation study of ECPELLA haemodynamics. We also simulated global oxygen delivery (DO2) under ECPELLA in severe CS and acute respiratory failure as a first step to incorporate global DO2 into our developed cardiovascular simulation.Methods and resultsBoth the systemic and pulmonary circulations were modelled using a 5-element resistance‒capacitance network. The four ventricles were represented by time-varying elastances with unidirectional valves. In the scenarios of severe LV dysfunction, biventricular dysfunction with normal pulmonary vascular resistance (PVR, 0.8 Wood units), and biventricular dysfunction with high PVR (6.0 Wood units), we compared the changes in haemodynamics, pressure–volume relationship (PV loop), and global DO2 under different VA-ECMO flows and Impella support levels.ResultsIn the simulation, ECPELLA improved total systemic flow with a minimising biventricular pressure–volume loop, indicating biventricular unloading in normal PVR conditions. Meanwhile, increased Impella support level in high PVR conditions rendered the LV–PV loop smaller and induced LV suction in ECPELLA support conditions. The general trend of global DO2 was followed by the changes in total systemic flow. The addition of veno-venous ECMO (VV-ECMO) augmented the global DO2 increment under ECPELLA total support conditions.ConclusionsThe optimal ECPELLA support increased total systemic flow and achieved both biventricular unloading. The VV-ECMO effectively improves global DO2 in total ECPELLA support conditions.

Noninvasive Ventilation Before Intubation and Mortality in Patients Receiving Extracorporeal Membrane Oxygenation for COVID-19: An Analysis of the Extracorporeal Life Support Organization Registry.

Bilevel-positive airway pressure (BiPAP) is a noninvasive respiratory support modality which reduces effort in patients with respiratory failure. However, it may increase tidal ventilation and transpulmonary pressure, potentially aggravating lung injury. We aimed to assess if the use of BiPAP before intubation was associated with increased mortality in adult patients with coronavirus disease 2019 (COVID-19) who received venovenous extracorporeal membrane oxygenation (ECMO). We used the Extracorporeal Life Support Organization Registry to analyze adult patients with COVID-19 supported with venovenous ECMO from January 1, 2020, to December 31, 2021. Patients treated with BiPAP were compared with patients who received other modalities of respiratory support or no respiratory support. A total of 9,819 patients from 421 centers were included. A total of 3,882 of them (39.5%) were treated with BiPAP before endotracheal intubation. Patients supported with BiPAP were intubated later (4.3 vs. 3.3 days, p < 0.001) and showed higher unadjusted hospital mortality (51.7% vs. 44.9%, p < 0.001). The use of BiPAP before intubation and time from hospital admission to intubation resulted as independently associated with increased hospital mortality (odds ratio [OR], 1.32 [95% confidence interval {CI}, 1.08-1.61] and 1.03 [1-1.06] per day increase). In ECMO patients with severe acute respiratory failure due to COVID-19, the extended use of BiPAP before intubation should be regarded as a risk factor for mortality.

Proportion of COVID-19 survivors in 2020-2022 in the Russian population (according to the ESSE-RF3 study)

Aim. To study the proportion of coronavirus disease 2019 (COVID-19) survivors and hospitalization cases of the Russian population for the period 2020-2022, depending on socio-demographic characteristics.Material and methods. The work was performed on random samples of the population aged 35-74 years from 15 regions participating in the Epidemiology of Cardiovascular Diseases and their Risk Factors in Regions of Russian Federation-3 (ESSE-RF3) study. The examination was carried out from February 2020 to March-April 2022 (n=28718, 47% men).Results. According to a survey of sample participants, the proportion of respondents who had COVID-19 by the spring of 2022 among all surveyed was 26,0%. Among 45-54-year-old respondents, this parameter was maximum (28,0%), while among those aged 65-74-year-old — minimal (22,3%). The following categories of people were more likely to have COVID-19: women (27,9 vs 23,9% of men, p&lt;0,001), persons with higher education (30 vs 22,6% persons without higher education, p&lt;0,001), persons with high income (30,0 vs 24,3% low-income, p=0,002), persons with family (26,6 vs 24,8% single, p&lt;0,001), employed persons (28,4 vs 21,7% non-employed, p&lt;0,001), as well as those living in urban areas (26,5 vs 24,5% country people, p=0,003). But those less likely to have COVID-19 (men, people without higher education, low-income, single, unemployed or rural residents) had more severe disease course. The following categories of people had higher hospitalization rates: men (26,0 vs 20,9% women, p&lt;0,001), patients without higher education (27,1 vs 19,6% those with higher education, p&lt;0,001), non-employed (34,3 vs 18,4% workers), p&lt;0,001) and rural residents (27,2 vs 22,0% of city residents, p&lt;0,001). Hospitalization rate was not associated with the level of income and marital status. However, low-income and single people were more likely to require mechanical ventilation.Conclusion. The results obtained by survey reflect the following population data: the proportion of patients after COVID-19, hospitalization rate and the development of severe acute respiratory failure requiring mechanical ventilation among Russians for the period 2020-2022. This can complement the population data demonstrated by state statistics. Special attention from the healthcare system, both during treatment and prevention of COVID-19, requires males, people aged ≥65 years, low-income people, single people (widowers, divorced), unemployed people (pensioners, disabled people, nonemployed), rural residents and people without higher education.

Impact of Center of Admission on Receipt of Extracorporeal Membrane Oxygenation Among Patients With Hypoxemic Respiratory Failure: A Secondary Analysis of the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure and Reseau Europeen de Recherche en Ventilation Artificielle Influenza A(H1N1) Studies

BackgroundGiven the resources and specialized training required to deliver extracorporeal membrane oxygenation (ECMO), the provision of ECMO is often centralized within expert centres. Spurred by recent evidence the use of ECMO has increased dramatically. However, given the centralized nature of ECMO it is possible that inequities in access exist. Research QuestionDoes centre of admission impact the likelihood of receiving ECMO among adults with moderate or severe acute hypoxemic respiratory failure (PaO2/FiO2 ratio ≤ 200mmHg within 48hrs of ventilation). Study Design and MethodsWe performed a retrospective cohort study using data from the LUNG SAFE and REVA influenza A (H1N1) databases. Using modified log-Poisson analysis we estimated the likelihood of receiving ECMO (initiation at the admitting hospital or transfer for initiation), adjusting for disease severity over time. To explore unmeasured confounding, we evaluated the association between centre of admission on three negative controls: neuromuscular blockade, prone positioning, and dialysis. ResultsAmong 1,581 patients (37.7% female, mean age 60.7 years), 76 (4.8%) received ECMO. Longitudinal analysis, adjusted for trends in disease severity, demonstrated that patients admitted to ECMO centres were two-times more likely to receive ECMO than those admitted to non-ECMO centres (RR 2.00; 95% CI 1.17-3.41). Patients at ECMO centres received ECMO two days earlier than those at non-ECMO centres, median (IQR) time to initiation 1 (1-5) vs 3 (2-5) days (p=0.04). Centre of admission was not associated with neuromuscular blockade (RR 1.08; 95% CI 0.90-1.30), prone positioning (RR 0.93; 95% CI 0.68-1.28), or dialysis (RR 1.04; 95% CI 0.84-1.27). InterpretationAdults with hypoxemic respiratory failure admitted to ECMO centres were twice as likely to receive ECMO as those admitted to non-ECMO centres. These finding raise concerns regarding equity in access to care and suggest a potential lower threshold among clinicians at ECMO centres to initiate ECMO.

Historical Perspectives of SARS-CoV-2 Viral Subversion of Host Cell: Biochemical and Pathological Aspects

The pandemic of coronavirus disease-19 (COVID-19) was a worldwide health crisis affecting many more people than 221 countries causing life-threatening complications and indirectly affecting even more individuals through disruption of daily living. COVID-19 is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is a member of beta-coronavirus having RNA as a genetic material sharing 79% similarity with the bat SARS-CoV genome. The SARS-CoV-2 enters the host cells by binding specifically to the angiotensin-converting enzyme-2 (ACE-2) which is expressed on the surface of epithelial cells in the respiratory tract, intestine, kidneys, and others causing severe acute respiratory failure and other complications. In addition to respiratory symptoms, uncontrolled SARS-CoV-2 infection can induce a cytokine storm, whereby pro-inflammatory cytokines and chemokines such as IL-6, TNF-α, and IL-1β are increased, which in turn leads to multiorgan damage. Herein, we described the history and classification of coronaviruses, geographical distribution of COVID-19, SARS-CoV-2 structure and genomic organization, life cycle, immunopathological responses, symptoms, and finally pulmonary and extra-pulmonary complications of SARS-CoV-2 infection.

Vitamin C deficiency in critically ill COVID-19 patients admitted to intensive care unit.

To determine vitamin C plasma kinetics, through the measurement of vitamin C plasma concentrations, in critically ill Coronavirus infectious disease 2019 (COVID-19) patients, identifying eventually the onset of vitamin C deficiency. Prospective, observational, single-center study. Intensive Care Unit (ICU), Vall d'Hebron University Hospital, Barcelona. Study period from November 12th, 2020, to February 24th, 2021. Patients who had a severe hypoxemic acute respiratory failure due to COVID-19 were included. Plasma vitamin C concentrations were measured on days 1, 5, and 10 of ICU admission. There were no vitamin C enteral nor parenteral supplementation. The supportive treatment was performed following the standard of care or acute respiratory distress syndrome (ARDS) patients. Plasma vitamin C concentrations were analyzed using an ultra-performance liquid chromatography (UPLC) system with a photodiode array detector (wavelength set to 245 nm). We categorized plasmatic levels of vitamin C as follows: undetectable: < 1,5 mg/L, deficiency: <2 mg/L. Low plasma concentrations: 2-5 mg/L; (normal plasma concentration: > 5 mg/L). Forty-three patients were included (65% men; mean age 62 ± 10 years). The median Sequential Organ Failure Assessment (SOFA) score was 3 (1-4), and the Acute Physiology and Chronic Health disease Classification System (APACHE II) score was 13 (10-22). Five patients had shock. Bacterial coinfection was documented in 7 patients (16%). Initially all patients required high-flow oxygen therapy, and 23 (53%) further needed invasive mechanical ventilation during 21 (± 10) days. The worst PaO2/FIO2 registered was 93 (± 29). ICU and hospital survival were 77 and 74%, respectively. Low or undetectable levels remained constant throughout the study period in the vast majority of patients. This observational study showed vitamin C plasma levels were undetectable on ICU admission in 86% of patients with acute respiratory failure due to COVID-19 pneumonia requiring respiratory support. This finding remained consistent throughout the study period.

An 8-Year Retrospective Review of Human Albumin Solution (HAS) Use August 2015 to March 2023; Guy's and St Thomas' NHS Foundation Trust (GSTFT)

Abstract Background: HAS is widely used in clinical practice for a variety of haematological, renal, neurological, respiratory and metabolic conditions. A United Kingdom shortage in 2015 prompted a demand management guideline incorporating the American Society for Apheresis (ASFA) indications 1 and GSTFT criteria 2 for other indications. Objectives:The objective of this study was to evaluate the indications for HAS usage following the introduction of the GSTFT demand management guideline. Methods: We audited HAS usage from August 2015 to March 2023 at GSTFT. Data was entered in SPSS version 20, with categorical variables described as frequencies and percentages. Results: 4816 patients received HAS during the study period, totaling 21,231 infusions. We recorded 16,772 (79%) infusions for 20% HAS in 4,145 patients. The indications for 20% HAS included; volume resuscitation for hypovolaemia 5237 (31%), severe sepsis/septic shock 3528 (21%), acute lung injury and severe respiratory failure 2987 (18%), paracentesis 2402 (14%), hepatorenal syndrome 1710 (10%), childhood nephrotic syndrome 685 (4.1%) and spontaneous bacterial peritonitis 223 (1.3%) (Table 1). According to GSTFT criteria infusions were recorded in the following indication categories: Red 7099 (42.3%), Blue 4436 (26.4%) and Grey 5237 (31.2%). A total of 4459 (21%) infusions were recorded for 4.5 and 5% HAS. A total of 3628 (81%) infusions were used for plasma exchange (PEX) in 305 patients; 2817(76.99%) ASFA category I, 445(12.03%) category II, 290(7.97%) category III and 92 (2.5%) for indications not specified according to ASFA; 826 infusions (18.5%) were for volume resuscitation for hypovolaemia (Grey indication) in 389 patients, the remaining 5 infusions (0.1%) were in 3 patients for burns and thermal injuries (Table 1). Major indications for PEX included post-transplant focal segmental glomerulosclerosis 911 infusions (20%) in 9 patients, familial hypercholesterolaemia 738 infusions (16%) in 5 patients, antibody mediated rejection 439 infusions (10%) in 71 patients (Table 2). Conclusions: This report provides a rare long term retrospective review of total albumin usage in a large UK tertiary referral center. The majority (97.5%) of PEX HAS indications were within ASFA guidelines. Aside from apheresis the main indication for HAS was volume resuscitation, a grey indication, where evidence is weak. REFERENCES (1) Padmanabhan A, Connelly-Smith L, Aqui N, Balogun RA, Klingel R, Meyer E, Pham HP, Schneiderman J, Witt V, Wu Y, Zantek ND, Dunbar NM, Schwartz GEJ. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher. 2019 Jun;34(3):171-354. doi: 10.1002/jca.21705. PMID: 31180581 (2) Yazdani MS, Retter A, Maggs T, Li P, Robson MG, Reid C, Holmes P, Garood T, Robinson SE. Where does the Albumin go? Human Albumin Solution usage following the implementation of a demand management programme. Transfus Med. 2017 Jun;27(3):192-199. doi: 10.1111/tme.12406. Epub 2017 Apr 3. PMID: 28370709.

A 16-year-old man with leptospirosis and atypical disseminated intravascular coagulation: a case report

BackgroundLeptospirosis is known for its pulmonary form characterized by intra-alveolar hemorrhage, exhibiting a high mortality rate. Management by venous–venous extracorporeal membrane oxygenation has been reported in a small number of cases.Case presentationWe report herein the case of a 16-year-old Caucasian male who was admitted with rapidly deteriorating respiratory and digestive complaints. He developed severe acute respiratory distress syndrome secondary to disseminated intravascular coagulation and intra-alveolar hemorrhage, requiring initiation of venous–venous extracorporeal membrane oxygenation. Initial infectious and immunological assessments were inconclusive, but repeat serology on the tenth day of admission confirmed a diagnosis of leptospirosis. The patient received multiple transfusions, and upon favorable response to treatment with corticosteroids and antibiotics, he was successfully weaned off venous–venous extracorporeal membrane oxygenation, which was discontinued after 12 days.ConclusionLeptospirosis is a rare cause of severe acute respiratory failure following pulmonary hemorrhage. It is typically diagnosed by serology, with detectable IgM antibodies 5–7 days after the onset of symptoms. We report that early support with respiratory extracorporeal membrane oxygenation favors timely clearance of endobronchial clotting, parenchymal recovery, and prevention of ventilator-induced lung injury. Major hypofibrinogenemia, which did not seem to worsen during extracorporeal membrane oxygenation application, was managed by repeated transfusions. Further studies investigating the pathogenesis of this coagulopathy are required to further optimize the management of this rare and severe complication.

Cardiovascular effects of COVID-19 in children

Introduction: Although severe acute respiratory failure is the primary cause of morbidity and mortality in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, this viral infection leads to cardiovascular disease in some individuals. Cardiac effects of the virus include myocarditis, pericarditis, arrhythmias, coronary aneurysms and cardiomyopathy, and can result in cardiogenic shock and multisystem organ failure. Method: This review summarises cardiac manifestations of SARS-CoV-2 in the paediatric population. We performed a scoping review of cardiovascular disease associated with acute coronavirus disease 2019 (COVID-19) infection, multisystem inflammatory syndrome in children (MIS-C), and mRNA COVID-19 vaccines. Also examined are special considerations for paediatric athletes and return to play following COVID-19 infection. Results: Children presenting with acute COVID-19 should be screened for cardiac dysfunction and a thorough history should be obtained. Further cardiovascular evaluation should be considered following any signs/symptoms of arrhythmias, low cardiac output, and/or myopericarditis. Patients admitted with severe acute COVID-19 should be monitored with continuous cardiac monitoring. Laboratory testing, as clinically indicated, includes tests for troponin and B-type natriuretic peptide or N-terminal pro-brain natriuretic peptide. Echocardiography with strain evaluation and/or cardiac magnetic resonance imaging should be considered to evaluate diastolic and systolic dysfunction, coronary anatomy, the pericardium and the myocardium. For patients with MIS-C, combination therapy with intravenous immunoglobulin and glucocorticoid therapy is safe and potentially disease altering. Treatment of MIS-C targets the hyperimmune response. Supportive care, including mechanical support, is needed in some cases. Conclusion: Cardiovascular disease is a striking feature of SARS-CoV-2 infection. Most infants, children and adolescents with COVID-19 cardiac disease fully recover with no lasting cardiac dysfunction. However, long-term studies and further research are needed to assess cardiovascular risk with variants of SARS-CoV-2 and to understand the pathophysiology of cardiac dysfunction with COVID-19.

Cardiovascular effects of COVID-19 in children

Introduction: Although severe acute respiratory failure is the primary cause of morbidity and mortality in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, this viral infection leads to cardiovascular disease in some individuals. Cardiac effects of the virus include myocarditis, pericarditis, arrhythmias, coronary aneurysms and cardiomyopathy, and can result in cardiogenic shock and multisystem organ failure. Method: This review summarises cardiac manifestations of SARS-CoV-2 in the paediatric population. We performed a scoping review of cardiovascular disease associated with acute coronavirus disease 2019 (COVID-19) infection, multisystem inflammatory syndrome in children (MIS-C), and mRNA COVID-19 vaccines. Also examined are special considerations for paediatric athletes and return to play following COVID-19 infection. Results: Children presenting with acute COVID-19 should be screened for cardiac dysfunction and a thorough history should be obtained. Further cardiovascular evaluation should be considered following any signs/symptoms of arrhythmias, low cardiac output, and/or myopericarditis. Patients admitted with severe acute COVID-19 should be monitored with continuous cardiac monitoring. Laboratory testing, as clinically indicated, includes tests for troponin and B-type natriuretic peptide or N-terminal pro-brain natriuretic peptide. Echocardiography with strain evaluation and/or cardiac magnetic resonance imaging should be considered to evaluate diastolic and systolic dysfunction, coronary anatomy, the pericardium and the myocardium. For patients with MIS-C, combination therapy with intravenous immunoglobulin and glucocorticoid therapy is safe and potentially disease altering. Treatment of MIS-C targets the hyperimmune response. Supportive care, including mechanical support, is needed in some cases. Conclusion: Cardiovascular disease is a striking feature of SARS-CoV-2 infection. Most infants, children and adolescents with COVID-19 cardiac disease fully recover with no lasting cardiac dysfunction. However, long-term studies and further research are needed to assess cardiovascular risk with variants of SARS-CoV-2 and to understand the pathophysiology of cardiac dysfunction with COVID-19.

Physiological effects of lung-protective ventilation in patients with lung fibrosis and usual interstitial pneumonia pattern versus primary ARDS: a matched-control study

BackgroundAlthough patients with interstitial pneumonia pattern (ILD-UIP) and acute exacerbation (AE) leading to severe acute respiratory failure may require invasive mechanical ventilation (MV), physiological data on lung mechanics during MV are lacking. We aimed at describing the physiological effect of lung-protective ventilation in patients with AE-ILD-UIP compared with primary ARDS.MethodsPartitioned lung and chest wall mechanics were assessed in a series of AE-ILD-UIP patients matched 1:1 with primary ARDS as controls (based on BMI and PaO2/FiO2 ratio). Three PEEP levels (zero = ZEEP, 4–8 cmH2O = PEEPLOW, and titrated to achieve positive end-expiratory transpulmonary pressure PL,EE = PEEPTITRATED) were used for measurements.ResultsTen AE-ILD-UIP patients and 10 matched ARDS were included. In AE-ILD-UIP median PL,EE at ZEEP was − 4.3 [− 7.6– − 2.3] cmH2O and lung elastance (EL) 44 [40–51] cmH2O/L. At PEEPLOW, PL,EE remained negative and EL did not change (p = 0.995) versus ZEEP. At PEEPTITRATED, PL,EE increased to 0.8 [0.3–1.5] cmH2O and EL to 49 [43–59] (p = 0.004 and p < 0.001 compared to ZEEP and PEEPLOW, respectively). ΔPL decreased at PEEPLOW (p = 0.018) and increased at PEEPTITRATED (p = 0.003). In matched ARDS control PEEP titration to obtain a positive PL,EE did not result in significant changes in EL and ΔPL.ConclusionsIn mechanically ventilated AE-ILD-UIP patients, differently than in patients with primary ARDS, PEEP titrated to obtain a positive PL,EE significantly worsened lung mechanics.

Acute and subchronic exposure to urban atmospheric pollutants aggravate acute respiratory failure in infants

Urban air pollution is a major factor that affects the respiratory health of children and adolescents. Less studied is exposure during the first two years of life. This study analyzed the influence of acute and subchronic exposure to urban air pollutants on the severity of acute respiratory failure (ARF) in the first two years of life. This population-based study included 7364 infants hospitalized with ARF. Acute exposure was considered to have occurred 1, 3 and 7 days before hospitalization and subchronic exposure was considered the mean of the last 30 and 60 days. We found that for acute exposure, significant increases in days of hospitalization (LOS) occurred at lag 1 day for NO2 (0.24), SO2 (6.64), and CO (1.86); lag 3 days for PM10 (0.30), PM2.5 (0.37), SO2 (10.8), and CO (0.71); and lag 7 days for NO2 (0.16), SO2 (5.07) and CO (0.87). Increases in the risk of death occurred at lag 1 day for NO2 (1.06), SO2 (3.64), and CO (1.28); and lag 3 days for NO2 (1.04), SO2 (2.04), and CO (1.19). Subchronic exposures at 30 and 60 days occurred for SO2 (9.18, 3.77) and CO (6.53, 2.97), respectively. The associations were more pronounced with higher temperatures and lower relative humidity levels. We concluded that acute and subchronic exposure to higher atmospheric concentrations of all the pollutants studied were associated with greater severity of ARF. The greatest increases in LOS and risk of death occurred with hot and dry weather.

High-Flow Nasal Cannula oxygen therapy in COVID-19: retrospective analysis of clinical outcomes - single center experience.

High-Flow Nasal Cannula (HFNC) oxygen therapy emerged as the therapy of choice in COVID-19-related pneumonia and moderate to severe acute hypoxemic respiratory failure (AHRF). HFNC oxygen therapy in COVID-19 has been recommended based its use to treat AHRF of other etiologies, and studies on assessing outcomes in COVID-19 patients are highly needed. This study aimed to examine outcomes in COVID-19 patients with pneumonia and severe AHRF treated with HFNC. The study included 235 COVID-19 patients with pneumonia treated with HFNC. Data extracted from medical records included demographic characteristics, comorbidities, laboratory parameters, clinical and oxygenation status, clinical complications, as well as the length of hospital stay. Patients were segregated into two groups based on their oxygen therapy needs: HDU group, those who exclusively required HFNC and ICU group, those whose oxygen therapy needed to be escalated at some point of hospital stay. The primary outcome was the need for respiratory support escalation (noninvasive or invasive mechanical ventilation) and the secondary outcome was the in-hospital all-cause mortality. The primary outcome was met in 113 (48%) of patients. The overall mortality was 70%, significantly higher in the ICU group [102 (90.2%) vs. 62 (50.1%), p < 0.001]. The rate of intrahospital infections was significantly higher in the ICU group while there were no significant differences in the length of hospital stay between the groups. The ICU group exhibited significant increases in D-dimer, NLR, and NEWS values, accompanied by a significant decrease in the SaO2/FiO2 ratio. The multivariable COX proportional regression analysis identified malignancy, higher levels of 4C Mortality Score and NEWS2 as significant predictors of mortality. High-Flow Nasal Cannula oxygen therapy is a safe type of respiratory support in patients with COVID-19 pneumonia and acute hypoxemic respiratory failure with significantly less possibility for emergence of intrahospital infections. In 52% of patients, HFNC was successful in treating AHRF in COVID-19 patients. Overall, mortality in COVID-19 pneumonia with AHRF is still very high, especially in patients treated with noninvasive/invasive mechanical ventilation.