Approach to dyspnoea in pregnancy in the COVID-19 era.

IMPORTANCE: Dyspnoea and hypoxia in pregnant women during the COVID-19 pandemic may be due to causes other than SARS Co-V-2 infection which should not be ignored. Shared decision-making regarding early delivery is paramount. OBJECTIVE: To highlight and discuss the differential diagnoses of dyspnoea and hypoxia in pregnant women and to discuss the risks versus benefit of delivery for maternal compromise. DESIGN, SETTING AND PARTICIPANTS: Case series of two pregnant women who presented with dyspnoea and hypoxia during the COVID-19 pandemic. RESULTS: Two pregnant women presented with dyspnoea and hypoxia. The first case had COVID-19 infection in the 3rd trimester. The second case had an exacerbation of asthma without concurrent COVID-19. Only the first case required intubation and delivery. Both recovered and were discharged home. Conclusion and relevance: Our two cases highlight the importance of making the correct diagnosis and timely decision-making to consider if delivery for maternal compromise is warranted. Whilst COVID-19 is a current healthcare concern other differential diagnoses must still be considered when pregnant women present with dyspnoea and hypoxia.

Acceptance and transfer to a regional severe respiratory failure and veno-venous extracorporeal membrane oxygenation (ECMO) service: predictors and outcomes.

The use of extracorporeal membrane oxygenation for respiratory failure is high risk and resource intensive. In England, five centres provide this service and patients who are referred have four possible outcomes: declined transfer due to perceived futility; accepted in principle but remain at the referring centre with ongoing surveillance; retrieved using conventional ventilation; or retrieved on extracorporeal support. The decision-making process leading to these outcomes has not previously been examined. We evaluated referrals to one centre and identified factors associated with each decision outcome. Five hundred and sixty-four patients were analysed from January 2012 to October 2015. One hundred and fifty-seven patients were declined; multivariate analysis demonstrated associated factors to be: age (odds ratio (95% confidence interval) 1.05 (1.04-1.07)); immunocompromise (4.95 (2.58-9.67)); lactate (1.11 (1.01-1.22)); duration of ventilation (1.08 (1.04-1.14)); and cardiac failure (3.22 (1.04-10.51)). Factors associated with the decision to retrieve an accepted patient were: plateau pressure (1.05 (1.01-1.10)); ratio of arterial oxygen partial pressure to fractional inspired oxygen (0.89 (0.85-0.93)); partial pressure of carbon dioxide in arterial blood (1.13 (1.03-1.25)); and the absence of non-pulmonary infection (0.31 (0.15-0.61)). Only pH was independently associated with the decision to transfer on extracorporeal support (0.020 (0.002-0.017)). Six-month survival in the declined, non-retrieved, conventionally retrieved and extracorporeal-retrieved groups was 16.6%, 71.1%, 76.7% and 72.1%, respectively, substantially supporting the decision-making model. Survival in the accepted group exceeds that reported previously. However, a proportion of those declined do survive and some remotely managed patients die. This suggests the approach does not account for some important survival-determining factors.

Capabilities of a mobile extracorporeal membrane oxygenation service for severe respiratory failure delivered by intensive care specialists.

We conducted a single-centre observational study of retrievals for severe respiratory failure over 12 months. Our intensivist-delivered retrieval service has mobile extracorporeal membrane oxygenation capabilities. Sixty patients were analysed: 34 (57%) were female and the mean (SD) age was 44.1 (13.6) years. The mean (SD) PaO2 /FI O2 ratio at referral was 10.2 (4.1) kPa and median (IQR [range]) Murray score was 3.25 (3.0-3.5 [1.5-4.0]). Forty-eight patients (80%) required veno-venous extracorporeal membrane oxygenation at the referring centre. There were no cannulation or extracorporeal membrane oxygenation-related complications. The median (IQR [range]) retrieval distance was 47.2 (14.9-77.0 [2.3-342.0]) miles. There were no major adverse events during retrieval. Thirty-seven patients (77%) who received extracorporeal membrane oxygenation survived to discharge from the intensive care unit and 36 patients (75%) were alive after six months. Senior intensivist-initiated and delivered mobile extracorporeal membrane oxygenation is safe and associated with a high incidence of survival.

Assessing the performance of the Whisperflow continuous positive airway pressure generator: a bench study.

BACKGROUND: There are few data describing the performance of the Whisperflow continuous positive airway pressure (CPAP) generator. METHODS: (i) (a) A static test of 11 Whisperflow devices examining maximum flow generation with no load and with 2.5, 5, 7.5, 10, 15, and 20 cm H2O valve loading, at varying Fi(O2). (b) CPAP valves (Accu-peep(R), Vital Signs, Totowa, NJ, USA) were tested by measuring mean upstream pressure at varying flows in five valves (2.5, 5, 7.5, 10, 15, and 20 cm H2O). (ii) We measured the mean and minimum inspiratory mask pressure generated by a representative Whisperflow device in a model of spontaneous respiration. Measurements were made with combinations of Fi(O2), ventilatory frequency, tidal volume, and valve loading similar to those encountered in clinical practice. RESULTS: (i) (a) The flow generated by the Whisperflow valves decreases with increasing valve load and increasing Fi(O2) (from 140 to 20 litre min(-1)). (b) The CPAP valves maintain the required pressure within acceptable limits against varying flow. (ii) At all permutations, the mean inspiratory mask pressure was significantly lower than that required. At high inspiratory flow rates, the minimum inspiratory pressure approached atmospheric pressure. CONCLUSIONS: The Whisperflow may not perform as expected. Clinicians should be cautious when using this device, particularly with high Fi(O2) and CPAP valve load. The flow setting should be set at maximum. Failure of CPAP therapy may be due to failure of the generator. Further in vivo data are required.

"Sneeze of a cancer from the lung": sternumentum carcinomae pulmonariae.

The protean manifestations of the clinical presentation of carcinoma of the lung are well known. In the following case report we describe an unusual presentation of such a carcinoma. We further describe this occurrence in Latin as befits what we believe to be a new presentation.

Synergistic necrotizing cellulitis resulting from peri-tonsillar abscess.

This case demonstrates the rare but potentially fatal condition of synergistic necrotizing cellulitis of the head and neck. Although similar to necrotizing fasciitis, this is more extreme as it also destroys muscle. Peri-tonsillar abscess is a recognized cause, but has not previously been described in this country, however it is a condition commonly referred to otolaryngologists and awareness of the complication of synergistic necrotizing cellulitis is necessary to allow early recognition and prompt treatment. This should be by broad-spectrum intravenous antibiotics with extensive surgical debridement and drainage procedures repeated as necessary. Although this case had a successful outcome, many patients do not survive, particularly if treatment is delayed or inadequate.

Facial palsy due to tuberculosis: the value of CT.

This case report demonstrates the value of CT in the investigation of facial palsy due to tuberculous mastoiditis. This is the best imaging modality available for identifying features suggestive of tuberculosis, the disease extent, presence of complications and demonstration of anatomy prior to surgery.

All that wheezes is not asthma.

Insidious upper airway obstruction may be misdiagnosed as asthma. This study illustrates such a case, highlighting the reason for confusion between asthma and upper airway obstruction and discussing investigations to differentiate between the two.

Necrotizing sialometaplasia.

Necrotizing sialometaplasia is a benign self-limiting disorder which can simulate malignancy. We report the third such case of nasal fossa involvement in the literature. The pathology of this condition is discussed.

Pneumoparotitis.

Pneumoparotitis is a rare cause of parotid enlargement. It is due to a reflux of air through Stensen's duct into the acini of the parotid gland with subsequent dilatation. We report a case which followed a long history of autoinflation of the middle ears by the Valsalva manoeuvre. The plain radiographic, sialographic and ultrasound findings are presented.

Kikuchi's necrotising lymphadenitis.

Three cases of Kikuchi's necrotizing lymphadenitis without granulocytic infiltration presented to the ENT department as cervical lymphadenopathy with neutropaenia. Differential diagnosis from malignant lymphoma was difficult both clinically and histopathologically. Two recovered spontaneously without treatment within three months, one improved initially but was lost to follow-up after one month.

Unusual lymphoproliferative oropharyngeal lesions in heart and heart-lung transplant recipients.

Three unusual cases of oropharyngeal lympho-proliferative lesions were seen in recipients of heart and heart-lung transplants. Two caused acute upper respiratory obstruction necessitating urgent ENT intervention. All patients were receiving immunosuppressive drugs including cyclosporin. The two obstructive cases were adenotonsillar enlargement in a 6-year-old, and a tumour of the tonsil and tongue base with cervical lymph node enlargement in a 32-year-old male. Both were caused by Epstein-Barr Virus-associated lymphoproliferative disorder. The third patient, a 32-year-old female, had a presumed low grade T-cell lymphoma that regressed spontaneously. Histopathological diagnosis of these lympho-proliferative disorders after transplantation usually requires immunocytochemistry to distinguish polyclonal proliferative disorders from true lymphoma. Polyclonal lymphoproliferative disorders after transplantation do not usually require aggressive cytoreductive therapy, but respond to simple measures such as the reduction of immunosuppression.