Proposed quality indicators and recommended standard reporting items in performance of EBUS bronchoscopy: An official World Association for Bronchology and Interventional Pulmonology Expert Panel consensus statement.

BACKGROUND: Since their introduction, both linear and radial endobronchial ultrasound (EBUS) have become an integral component of the practice of Pulmonology and Thoracic Oncology. The quality of health care can be measured by comparing the performance of an individual or a health service with an ideal threshold or benchmark. The taskforce sought to evaluate quality indicators in EBUS bronchoscopy based on clinical relevance/importance and on the basis that observed significant variation in outcomes indicates potential for improvement in health care outcomes. METHODS: A comprehensive literature review informed the composition of a comprehensive list of candidate quality indicators in EBUS. A multiple-round modified Delphi consensus process was subsequently performed with the aim of reaching consensus over a final list of quality indicators and performance targets for these indicators. Standard reporting items were developed, with a strong preference for items where evidence demonstrates a relationship with quality indicator outcomes. RESULTS: Twelve quality Indicators are proposed, with performance targets supported by evidence from the literature. Standardized reporting items for both radial and linear EBUS are recommended, with evidence supporting their utility in assessing procedural outcomes presented. CONCLUSION: This statement is intended to provide a framework for individual proceduralists to assess the quality of EBUS they provide their patients through the identification of clinically relevant, feasible quality measures. Emphasis is placed on outcome measures, with a preference for consistent terminology to allow communication and benchmarking between centres.

Utility of the FebriDx point-of-care test for rapid triage and identification of possible coronavirus disease 2019 (COVID-19).

OBJECTIVES: The Coronavirus disease 2019 (COVID-19) pandemic is straining healthcare resources. Molecular testing turnaround time precludes having results at the point-of-care (POC) thereby exposing COVID-19/Non-COVID-19 patients while awaiting diagnosis. We evaluated the utility of a triage strategy including FebriDx, a 10-minute POC finger-stick blood test that differentiates viral from bacterial acute respiratory infection through detection of Myxovirus-resistance protein A (MxA) and C-reactive protein (CRP), to rapidly isolate viral cases requiring confirmatory testing. METHODS: This observational, prospective, single-center study enrolled patients presenting to/within an acute care hospital in England with suspected COVID-19 between March and April 2020. Immunocompetent patients ≥16 years requiring hospitalisation with pneumonia or acute respiratory distress syndrome or influenza-like illness (fever and ≥1 respiratory symptom within 7 days of enrolment, or inpatients with new respiratory symptoms, fever of unknown cause or pre-existing respiratory condition worsening). The primary endpoint was diagnostic performance of FebriDx to identify COVID-19 as a viral infection; secondary endpoint was SARS-CoV-2 molecular test diagnostic performance compared with the reference standard COVID-19 Case Definition (molecular or antibody detection of SARS-CoV-2). RESULTS: Valid results were available for 47 patients. By reference standard, 35 had viral infections (34/35 COVID-19; 1/35 non-COVID-19; overall FebriDx viral sensitivity 97.1% (95%CI 83.3-99.9)). Of the COVID-19 cases, 34/34 were FebriDx viral positive (sensitivity 100%; 95%CI 87.4-100); 29/34 had an initial SARS-CoV-2 positive molecular test (sensitivity 85.3%; 95%CI 68.2-94.5). FebriDx was viral negative when the diagnosis was not COVID-19 and SARS-Cov-2 molecular test was negative (negative predictive value (NPV) 100% (13/13; 95%CI 71.7-100)) exceeding initial SARS-CoV-2 molecular test NPV 72.2% (13/19; 95%CI 46.4-89.3). The diagnostic specificity of FebriDx and initial SARS-CoV-2 molecular test was 100% (13/13; 95%CI 70-100 and 13/13; 95%CI 85.4-100, respectively). CONCLUSIONS: FebriDx could be deployed as part of a reliable triage strategy for identifying symptomatic cases as possible COVID-19 in the pandemic.

Ovarian hyperstimulation syndrome complicated by severe community-acquired pneumonia due to methicillin-resistant Staphylococcus aureus positive for Panton-Valentine leukocidin.

We report a case of severe ovarian hyperstimulation syndrome (OHSS) complicated by community-acquired methicillin-resistant Staphylococcus aureus-Panton-Valentine leukocidin positive (CAMRSA-PVL[+]) necrotizing pneumonia, sepsis and multiple organ failure (MOF) in a previously immunocompetent female. The patient required prolonged ventilatory support and intensive care unit (ICU) hospitalization. Multiple cavities and severely affected lung function persist 1 year after discharge.

Outcomes from a virtual ward delivering oxygen at home for patients recovering from COVID-19: a real world observational study.

BACKGROUND: There is a lack of data on the safety of providing oxygen at home to stable patients recovering from COVID-19. METHODS: A retrospective analysis of patients discharged to a COVID-19 virtual ward (CVW) between January 2021 and March 2021 at a UK district general hospital was performed. Patients with improving clinical trajectories and oxygen requirements up to 4 L/minute were eligible. Outcomes measured were 30-day mortality and readmission rate. RESULTS: From 02 January 2021 to 16 March 2021 (74 days), 147 patients discharged to the CVW were included: 71 received continuous or ambulatory oxygen, and 76 received pulse oximetry monitoring only. Five patients were readmitted within 30 days and two patients died. There were no significant differences between readmission and mortality rates between those discharged with or without oxygen. CONCLUSION: Provision of oxygen at home for selected patients recovering from COVID-19 is safe with low risk of readmission and death.

Lack of Benefit of High Flow Nasal Oxygen Therapy as Ceiling of Treatment for Severe COVID-19 Pneumonitis in Elderly Frail Patients: A Single Centre Observational Study.

Background: Severe COVID-19 pneumonitis in elderly frail patients is associated with poor outcomes, and therefore invasive mechanical ventilation is often deemed an inappropriate course of action. Some evidence suggests high-flow nasal oxygen (HFNO) may prevent the need for invasive ventilation in other groups of patients, but whether it is an appropriate ceiling of care for older frail patients is unknown. Methods: We retrospectively identified patients with severe COVID-19 pneumonitis requiring FiO2>60% who were deemed inappropriate for invasive ventilation or non-invasive continuous positive airway pressure ventilation (CPAP). Our local protocol based on national guidance suggested these patients should be considered for HFNO. We observed whether the patients received HFNO or standard oxygen therapy (SOT) and compared mortality and survival time in these groups. Results: We identified 81 patients meeting the inclusion criteria. From this group, 24 received HFNO and 57 received SOT. The HFNO group was similar in age, BMI and co-morbidities to the SOT group but less frail, as determined by the Clinical Frailty Scale (CFS). All 24 patients that received HFNO died in comparison to 46 patients (80.7%) in the SOT group. Mortality in the HFNO group was significantly higher than in the SOT group. Conclusion: Elderly frail patients with severe COVID-19 pneumonitis deemed inappropriate for invasive ventilation and did not benefit from HFNO. Further, HFNO may have been associated with harm in this group.

Life-threatening aortic thrombosis in a trauma patient homozygous for factor V Leiden mutation: Case report.

We report a case of near fatal aortic thrombosis in a trauma patient homozygous for mutation of Factor V Leiden. He responded well to vascular surgery and intensive care unit management and was discharged successfully from the hospital one month later.

Angiopoietin-2 Levels as Predictors of Outcome in Mechanically Ventilated Patients with Acute Respiratory Distress Syndrome.

Pulmonary endothelium dysfunction is a key characteristic of ARDS. The aim of this study was to investigate endothelium-derived markers, such as angiopoietin-2 (Ang-2) and endothelial cell-specific molecule-1 (endocan), at the vascular and alveolar compartments as outcome predictors in ARDS. Fifty-three consecutive ARDS patients were studied. The primary outcome was 28-day mortality. Secondary endpoints were days of unassisted ventilation and days with organ failure other than ARDS, during the 28-day study period. Nonsurvivors presented higher lung injury scores and epithelial lining fluid (ELF) Ang-2 levels compared to survivors, with no significant differences in plasma Ang-2, endocan, and protein C concentrations between the two groups. In logistic regression analysis, ELF Ang-2 levels > 705 pg/ml were the only independent variable for 28-day mortality among the previous four. Plasma endocan values > 13 ng/pg were the only parameter predictive against days of unassisted ventilation during the 28-day study period. Finally, lung injury score > 2.25 and ELF Ang-2 levels > 705 pg/ml were associated with increased number of days with organ failure, other than ARDS. Our findings suggest that Ang-2 levels are increased in the alveolar compartment of ARDS patients, and this may be associated both with increased mortality and organ failure besides lung.

Pulmonary hypertension in parenchymal lung disease.

Idiopathic pulmonary arterial hypertension (IPAH) has been extensively investigated, although it represents a less common form of the pulmonary hypertension (PH) family, as shown by international registries. Interestingly, in types of PH that are encountered in parenchymal lung diseases such as interstitial lung diseases (ILDs), chronic obstructive pulmonary disease (COPD), and many other diffuse parenchymal lung diseases, some of which are very common, the available data is limited. In this paper, we try to browse in the latest available data regarding the occurrence, pathogenesis, and treatment of PH in chronic parenchymal lung diseases.

General prognostic scores in outcome prediction for cancer patients admitted to the intensive care unit.

BACKGROUND: Intensivists and nursing staff are often reluctant to admit patients with cancer to the intensive care unit even though these patients' survival rate has improved since the 1980s. OBJECTIVE: To identify factors associated with mortality in cancer patients admitted to the intensive care unit and to assess and compare the effectiveness of 3 general prognostic models: the Acute Physiology and Chronic Health Evaluation (APACHE) II, the Simplified Acute Physiology Score (SAPS II), and the Sequential Organ Failure Assessment (SOFA). METHODS: A prospective observational cohort study was performed in 2 general intensive care units. Discrimination was assessed by using area under the receiver operating characteristic curves, and calibration was evaluated by using Hosmer-Lemeshow goodness-of-fit tests. RESULTS: A total of 126 patients were included during a 3-year period. The observed mortality was 46.8%. All 3 general models showed excellent discrimination (area under the curve >0.8) and good calibration (P = .17, .14, and .22 for APACHE II, SAPS II, and SOFA, respectively). However, discrimination was significantly better with APACHE II scores than with SOFA scores (P = .02). Multivariate analyses indicated that independent of the 3 severity-of-illness scores, unfavorable risk factors for mortality included a patient's preadmission performance status, source of admission (internal medicine vs surgery department), and the presence of septic shock, infection, or anemia. Combining SOFA and SAPS II scores with these variables created prognostic models with improved calibration and discrimination. CONCLUSIONS: The general prognostic models seem fairly accurate in the prediction of mortality in critically ill cancer patients in the intensive care unit.