Characteristics and Outcomes of In-Hospital Cardiac Arrest Events During the COVID-19 Pandemic: A Single-Center Experience From a New York City Public Hospital.

BACKGROUND: Patients hospitalized for severe coronavirus disease 2019 (COVID-19) infection are at risk for in-hospital cardiac arrest (IHCA). It is unknown whether certain characteristics of cardiac arrest care and outcomes of IHCAs during the COVID-19 pandemic differed compared with a pre-COVID-19 period. METHODS: All patients who experienced an IHCA at our hospital from March 1, 2020 through May 15, 2020, during the peak of the COVID-19 pandemic, and those who had an IHCA from January 1, 2019 to December 31, 2019 were identified. All patient data were extracted from our hospital's Get With The Guidelines-Resuscitation registry, a prospective hospital-based archive of IHCA data. Baseline characteristics of patients, interventions, and overall outcomes of IHCAs during the COVID-19 pandemic were compared with IHCAs in 2019, before the COVID-19 pandemic. RESULTS: There were 125 IHCAs during a 2.5-month period at our hospital during the peak of the COVID-19 pandemic compared with 117 IHCAs in all of 2019. IHCAs during the COVID-19 pandemic occurred more often on general medicine wards than in intensive care units (46% versus 33%; 19% versus 60% in 2019; P<0.001), were overall shorter in duration (median time of 11 minutes [8.5-26.5] versus 15 minutes [7.0-20.0], P=0.001), led to fewer endotracheal intubations (52% versus 85%, P<0.001), and had overall worse survival rates (3% versus 13%; P=0.007) compared with IHCAs before the COVID-19 pandemic. CONCLUSIONS: Patients who experienced an IHCA during the COVID-19 pandemic had overall worse survival compared with those who had an IHCA before the COVID-19 pandemic. Our findings highlight important differences between these 2 time periods. Further study is needed on cardiac arrest care in patients with COVID-19.

Room air entrainment during beta-agonist delivery with heliox.

Studies of the efficacy of heliox in patients with severe asthma have shown mixed results. Among the factors that are responsible for variable outcomes, the failure of heliox delivery systems to prevent room air entrainment (RAE) during beta-agonist delivery is probably the most critical. While keeping the rotameter flow rate (FR) of heliox mixed 70:30 to a nebulizer at 10 L/min, the FR of heliox from a second gas source to a T-connector (TC) was increased during the delivery of the beta-agonist with a conventional T-nebulizer delivery system (TNDS). A negative peak inspiratory flow (pneumotachometer reading) or a helium concentration of < 70% (quadralizer reading) were indicators of RAE. RAE was tested during spontaneous tidal breathing and acute asthma. A rotameter FR of 10 L/m to the nebulizer with no flow from a second gas source to a TC (conventional TNDS) resulted in a significant drop in helium concentration during tidal breathing (46.2%) and acute asthma (27.5%) due to RAE. This degree of helium dilution can negate the beneficial effects of heliox to lung mechanics almost completely. A rotameter FR of 10 L/m each to a nebulizer and a TC resulted in a helium concentration 69.8% during tidal breathing (no RAE), but 49% (significant RAE) during asthma events. A rotameter FR of 15 L/m (pressure regulator setting, 100 lbs per square inch) to a TC, while maintaining a rotameter FR of 10 L/m to a nebulizer prevented RAE during asthma (helium concentration, 69.9%). Conventional TNDS may be used to deliver the beta-agonist with heliox during asthma without RAE.

Regular vs ad-lib albuterol for patients hospitalized with acute asthma.

STUDY OBJECTIVES: Inhaled, short-acting beta-agonists and systemic corticosteroids form the mainstay of therapy in acute asthma exacerbation. Asthma, however, is an inflammatory disease of the airways, and its underlying pathology is not impacted by short-acting beta-agonists. While the efficacy of ad-lib beta-agonist administration in outpatient management of asthma symptoms is well established, little data exist to support this strategy in patients with acute, severe asthma. We postulate that as long as patients hospitalized with severe asthma exacerbation receive systemic corticosteroids, regular, scheduled administration of short-acting beta-agonists is unnecessary. Similar therapeutic outcomes can be achieved with the ad-lib administration of the short-acting beta-agonists. DESIGN: Prospective, randomized, double-blind, placebo-controlled trial. SETTING: Pulmonary floor of a 600-bed municipal hospital. PATIENTS OR PARTICIPANTS: Sixty-two patients hospitalized for acute asthma. INTERVENTIONS: Patients were randomized to receive either albuterol nebulizations (regular albuterol group) or saline solution nebulizations (ad-lib group) every 4 h with management of breakthrough symptoms with albuterol metered-dose inhaler or nebulizations for both groups. All patients received systemic corticosteroids. Peak expiratory flows, asthma symptoms, and need for rescue bronchodilator were followed up on each patient until discharge. RESULTS: There was no significant difference in the length of hospitalization (median length, 48 h for ad-lib group vs 57.5 h for regular albuterol group, p = 0.82), rate of improvement in peak flow, or symptoms between the two groups. Ad-lib beta-agonist use compared to regular albuterol scheduled use resulted in a significant reduction in the total number of albuterol treatments administered (median, 7 treatments vs 19 treatments, p = 0.001) during hospitalization. CONCLUSIONS: In the management of asthma exacerbation, ad-lib administration of albuterol is therapeutically as effective as regular, scheduled administration. This method of drug administration also reduces the total dose of beta-agonists received by the hospitalized patient.

Profile of near-fatal asthma in an inner-city hospital.

STUDY OBJECTIVES: Patients requiring mechanical ventilation for asthma are at a high risk of similar attacks and death in the future. Early recognition and treatment with systemic corticosteroids (SC) can influence outcome in near-fatal asthma (NFA). We studied the ability of patients to recognize the severity of asthma, implement SC therapy, and seek timely help from a health-care provider (HCP). DESIGN: Retrospective review of patient histories and medical records. SETTING: Medical ICU and inpatient medical ward of an inner-city university hospital. PATIENTS: Asthma patients requiring mechanical ventilation. METHODS: Seventy episodes of NFA requiring endotracheal intubation (intubation group [IG]) and 523 hospital admissions with acute asthma (nonintubation group [NIG]) were analyzed over a 4-year period from January 1997 to September 2000. Prior intubation(s), duration of symptoms, steroid dependence, and knowledge and use of inhaled corticosteroids and SC were noted. Indications for mechanical ventilation, ventilatory parameters using permissive hypercapnia, sedation/paralysis, duration, extubation criteria, complications, and outcome were analyzed. RESULTS: Twenty-nine of 70 patients (41.4%) in the IG had at least one prior episode of NFA requiring mechanical ventilation, compared to 123 of 523 patients (23.5%) in the NIG (p < 0.005). Ten of 70 patients (14.3%) in the IG were steroid dependent, compared to 40 of 523 patients (7.6%) in the NIG (p < 0.05). Forty of 70 patients (57%) in the IG compared to 308 of 523 patients (59%) in the NIG reported noncompliance with prescribed inhaled corticosteroids (not significant). All received aerosolized beta-agonist therapy, but only 11 of 70 patients (15.7%) initiated SC therapy in the IG compared to 145 of 523 patients (27.7%) in the NIG (p < 0.05). Even with symptoms > 48 h, 34 of 43 patients (79%) in the IG did not receive SC. Three patients died and four patients acquired myopathy in the IG. CONCLUSION: History of intubation and steroid dependence were identified as risk factors for future intubation. Our patients with asthma in both the IG and NIG were noncompliant with inhaled corticosteroids. Despite a long duration of symptoms and knowledge of SC, the majority neither implemented self-management with SC nor contacted an HCP. Early initiation of SC (symptoms < 48 h) might have averted intubation in the high-risk group. Most of our patients were extubated successfully in < 48 h. Incidence of barotrauma was very low, probably due to utilization of permissive hypercapnia.

Bronchial leiomyoma, a case report and review of literature.

A 44 year old male former smoker from Ecuador presented with productive cough for 3 weeks, positive tuberculin skin test, 40 lbs weight loss and right lower lobe collapse. He denied wheezing or hemoptysis. He was treated with antibiotics and ruled out for tuberculosis with negative sputum smear. Bronchoscopy showed an endobronchial lesion at the distal end of bronchus intermedius as cause of the collapse. Endobronchial biopsy of the lesion revealed an endobronchial leiomyoma, a rare cause of endobronchial tumor. The patient underwent bilobectomy as definite therapy for the leiomyoma due to its large size and possible extra-luminal extension, which made it not amenable to bronchoscopic resection or bronchoplasty. Differential diagnoses of endobronchial lesions are discussed along with clinical, radiographic, pathologic characteristics and various treatment modalities for endobronchial leiomyomas.

Emergency department as the main source of asthma care.

Many asthma patients use the emergency department (ED) as the sole source of asthma care. This is considered inadequate and poor practice. This prospective study revealed that young age, lack of evening clinic, forgetting to keep the appointment, conflicting priorities of daily life, and easy access to the ED on an as-needed basis for urgent care, medications, and prescriptions, and failure to use inhaled corticosteroids were significant while lack of insurance or access to asthma clinic were not significant factors in exclusive use of the ED. Establishing ED asthma education programs or an after hours asthma clinic may alleviate the practice.