Capnography-Assisted Learned, Monitored (CALM) breathing therapy for dysfunctional breathing in COPD: A bridge to pulmonary rehabilitation.

BACKGROUND: Although dyspnea is a primary symptom of chronic obstructive pulmonary disease (COPD), its treatment is suboptimal. In both COPD and acute anxiety, breathing patterns become dysregulated, contributing to abnormal CO2, dyspnea, and inefficient recovery from breathing challenges. While pulmonary rehabilitation (PR) improves dyspnea, only 1-2% of patients access it. Individuals with anxiety who use PR have worse outcomes. METHODS: We present the protocol of a randomized controlled trial designed to determine the feasibility and acceptability of a new, four-week mind-body intervention that we developed, called "Capnography-Assisted Learned, Monitored (CALM) Breathing," as an adjunct to PR. Eligible participants are randomized in a 1:1 ratio to either CALM Breathing program or Usual Care. CALM Breathing consists of 10 core, slow breathing exercises combined with real time biofeedback (of end-tidal CO2, respiratory rate, and airflow) and motivational interviewing. CALM Breathing promotes self-regulated breathing, linking CO2 changes to dyspnea and anxiety symptoms and targeting breathing efficiency and self-efficacy in COPD. Participants are randomized to CALM Breathing or a Usual Care control group. RESULTS: Primary outcomes include feasibility and acceptability metrics of recruitment efficiency, participant retention, intervention adherence and fidelity, PR facilitation, patient satisfaction, and favorable themes from interviews. Secondary outcomes include breathing biomarkers, symptoms, health-related quality of life, six-minute walk distance, lung function, mood, physical activity, and PR utilization and engagement. CONCLUSION: By disrupting the cycle of dyspnea and anxiety, and providing a needed bridge to PR, CALM Breathing may address a substantive gap in healthcare and optimize treatment for patients with COPD.

A 52-Year-Old Man With Chest Pain and Dyspnea.

CASE PRESENTATION: A 52-year-old man came to the cardiac surgery clinic for pulmonary thromboendarterectomy (PTE) evaluation. He had initially appeared at an outside hospital 1 year earlier, with chest pain and shortness of breath. He had no known chronic conditions. A CT pulmonary angiogram (CTPA) at that time showed a filling defect at the bifurcation of the main pulmonary artery. A transthoracic echocardiogram revealed mild mitral valve regurgitation, but otherwise the results were normal. As he was hemodynamically stable and not hypoxemic, he was treated solely by anticoagulation. Despite adhering to prescribed apixaban, he developed progressive dyspnea and reduced exercise tolerance over the subsequent year. A repeat CTPA performed 12 months after the initial presentation showed a persistent filling defect at the level of the pulmonary artery bifurcation, with a new extension now completely occluding the right main pulmonary artery. A pulmonary angiogram confirmed this complete occlusion, and right heart catheterization revealed precapillary pulmonary hypertension, with a mean pulmonary artery pressure of 50 mm Hg. His anticoagulation was transitioned to enoxaparin for presumed apixaban treatment failure, and an investigation for hypercoagulable conditions was initiated. His lupus anticoagulant test result was positive, but he did not meet the criteria for antiphospholipid syndrome because he was negative for anticardiolipin and ß2-glycoprotein antibodies. Assays for antithrombin III, protein C, prothrombin gene, and factor V Leiden mutations produced normal results.

In COVID-19 Patients Who Suffer In-Hospital Cardiac Arrest, Cardiopulmonary Resuscitation Outcomes May Be Impacted by Arrest Etiology and Local Pandemic Conditions.

OBJECTIVES: The utility and risks to providers of performing cardiopulmonary resuscitation after in-hospital cardiac arrest in COVID-19 patients have been questioned. Additionally, there are discrepancies in reported COVID-19 in-hospital cardiac arrest survival rates. We describe outcomes after cardiopulmonary resuscitation for in-hospital cardiac arrest in two COVID-19 patient cohorts. DESIGN: Retrospective cohort study. SETTING: New York-Presbyterian Hospital/Columbia University Irving Medical Center in New York, NY. PATIENTS: Those admitted with COVID-19 between March 1, 2020, and May 31, 2020, as well as between March 1, 2021, and May 31, 2021, who received resuscitation after in-hospital cardiac arrest. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: Among 103 patients with coronavirus disease 2019 who were resuscitated after in-hospital cardiac arrest in spring 2020, most self-identified as Hispanic/Latino or African American, 35 (34.0%) had return of spontaneous circulation for at least 20 minutes, and 15 (14.6%) survived to 30 days post-arrest. Compared with nonsurvivors, 30-day survivors experienced in-hospital cardiac arrest later (day 22 vs day 7; p = 0.008) and were more likely to have had an acute respiratory event preceding in-hospital cardiac arrest (93.3% vs 27.3%; p < 0.001). Among 30-day survivors, 11 (73.3%) survived to hospital discharge, at which point 8 (72.7%) had Cerebral Performance Category scores of 1 or 2. Among 26 COVID-19 patients resuscitated after in-hospital cardiac arrest in spring 2021, 15 (57.7%) had return of spontaneous circulation for at least 20 minutes, 3 (11.5%) survived to 30 days post in-hospital cardiac arrest, and 2 (7.7%) survived to hospital discharge, both with Cerebral Performance Category scores of 2 or less. Those who survived to 30 days post in-hospital cardiac arrest were younger (46.3 vs 67.8; p = 0.03), but otherwise there were no significant differences between groups. CONCLUSIONS: Patients with COVID-19 who received cardiopulmonary resuscitation after in-hospital cardiac arrest had low survival rates. Our findings additionally show return of spontaneous circulation rates in these patients may be impacted by hospital strain and that patients with in-hospital cardiac arrest preceded by acute respiratory events might be more likely to survive to 30 days, suggesting Advanced Cardiac Life Support efforts may be more successful in this subpopulation.

Impact of a Critical Care Specialist Intervention on First Pass Success for Emergency Airway Management Outside the ICU.

BACKGROUND: There has been limited investigation into the procedural outcomes of patients undergoing emergent endotracheal intubation (EEI) by a critical care medicine (CCM) specialist outside the intensive care unit (ICU). We hypothesized that EEI outside an ICU would be associated with lower rates of first pass success (FPS) as compared to inside an ICU. METHODS: We performed a retrospective cohort study of all adult patients admitted to our academic medical center between January 1, 2016, and July 31, 2018, who underwent EEI by a CCM practitioner. The primary outcome of FPS was identified in the EEI procedure note. Secondary outcomes included difficult intubation (> 2 attempts at laryngoscopy) and mortality following EEI. RESULTS: In total, 1958 patients (1035 [52.9%] inside ICU and 923 [47.1%]) outside an ICU) were included in the final cohort. Unadjusted rate of FPS was not different between patients intubated out of the ICU and patients intubated inside of the ICU (689 [74.7%] vs 775 [74.9%]; P = .91). There was also no difference in FPS between groups after adjusting for predictors of difficult intubation and baseline covariates (odds ratio: 0.95; 95% confidence interval, 0.75-1.2, P = .65). Mortality of patients undergoing EEI out of the ICU was higher at each examined time interval following EEI. DISCUSSION: For EEI done by CCM practitioners, rate of FPS is not different between patients undergoing EEI outside an ICU as compared to inside an ICU. Despite the lack of difference between rates of procedural success, patient mortality following EEI outside an ICU is higher than EEI inside an ICU at all examined time points during hospitalization.

Inferior vena cava filters do not increase the risk of blood stream infections in patients with newly diagnosed VTE.

BACKGROUND: The association between inferior vena cava (IVC) filter presence and subsequent bloodstream infection (BSI) is unknown. We hypothesized among patients with a new diagnosis of venous thromboembolism (VTE), incidence of BSI after 1 year would be higher in patients who had presence of an IVC filter. METHODS: We performed a retrospective cohort study of patients with newly diagnosed VTE but no IVC filter (N = 4,053) and patients with IVC filter (N = 635) admitted to a metropolitan hospital system from 2006 to 2009 comparing incidence of BSI within 1 year of inclusion. Multivariable regression modeling was used to evaluate the association of IVC filter placement with BSI 1 year after placement. RESULTS: Patients with an IVC filter placed were more likely to be older with higher Charlson co-morbidity score (median 4 vs 1; P < .001). The incidence of BSI was not different between the group with IVC filter and the group without (10.7% vs 8.8%; P = .12). There was no association with IVC filter placement and BSI before or after multivariable adjustment. CONCLUSIONS: In patients newly diagnosed with VTE, we found no association between IVC filter placement and increased incidence of BSI after 1 year.

Influenza: diagnosis and management in the emergency department.

Emergency clinicians must be aware of the current diagnostic and therapeutic recommendations for influenza and the available resources to guide management. This comprehensive review outlines the classification of influenza viruses, influenza pathophysiology, the identification of high-risk patients, and the importance of vaccination. Seasonal variations of influenza are discussed, as well as the rationale for limiting testing during periods of high prevalence. Differences between strains of influenza are discussed, as well as the challenges in achieving optimal vaccine effectiveness. Recommendations for use of the currently available oral, intranasal, and intravenous antiviral treatments are provided, as well as utilizing shared decision-making with patients regarding risks and benefits of treatment.

Clinical predictors of occult pneumonia in the febrile child.

BACKGROUND: The utility of chest radiographs (CXRs) for detecting occult pneumonia (OP) among pediatric patients without lower respiratory tract signs has been previously studied, but no predictors other than white blood cell count (WBC) and height of fever have been investigated. OBJECTIVES: To identify predictors of OP in pediatric patients in the postconjugate pneumococcal vaccination era. METHODS: This was a retrospective cross sectional study that was conducted in a large urban pediatric hospital. Physician records of emergency department (ED) patients of age 10 years or less who presented with fever (38 degrees C) and had a CXR obtained for suspected pneumonia were reviewed. Patients were classified into two groups: "signs of pneumonia" and "no signs of pneumonia" on the basis of the presence or absence of respiratory distress, tachypnea, or lower respiratory tract findings. Occult pneumonia was defined as radiographic pneumonia in a patient without signs of pneumonia. RESULTS: Two thousand one hundred twenty-eight patients were studied. Among patients categorized as having no signs of pneumonia (n = 1,084), 5.3% (95% CI = 4.0% to 6.8%) had OP. Presence of cough and longer duration of cough (greater than 10 days) had positive likelihood ratios (LR+) of 1.24 (95% CI = 1.15 to 1.33) and 2.25 (95% CI = 1.21 to 4.20), respectively. Absence of cough had a negative likelihood ratio (LR-) of 0.19 (95% CI = 0.05 to 0.75). The likelihood of OP increased with increasing duration of fever (LR+ for more than three days and more than five days of fever, respectively: 1.62; 95% CI = 1.13 to 2.31 and 2.24; 95% CI = 1.35 to 3.71). When obtained (56% of patients), WBC was a predictor of OP, with a LR+ of 1.76 (95% CI = 1.40 to 2.22) and 2.17 (95% CI = 1.58 to 2.96) for WBC of >15,000/mm3 and >20,000/mm3, respectively. CONCLUSIONS: Occult pneumonia was found in 5.3% of patients with fever and no lower respiratory tract findings, tachypnea, or respiratory distress. There is limited utility in obtaining a CXR in febrile children without cough. The likelihood of pneumonia increased with longer duration of cough or fever or in the presence of leukocytosis.