Effects of pulmonary rehabilitation on functional and psychological parameters in post-acute sequelae of SARS-CoV-2 infection (PASC) patients.

BACKGROUND: COVID-19 survivors may develop long-term symptoms of fatigue, dyspnea, mental health issues, and functional limitations: a condition termed post-acute sequelae of COVID-19 (PASC). Pulmonary rehabilitation (PR) is a recommended treatment for PASC; however, there is a lack of data regarding PR's effect on multiple health indices and the factors that influence patient outcomes. The aim of our study is to evaluate the impact of pulmonary rehabilitation on functional and psychological parameters in patients diagnosed with Post-Acute Sequelae of SARS-CoV-2 Infection (PASC), thereby offering insights into the efficacy of such interventions in improving the quality of life and clinical outcomes for these individuals. METHODS: We extracted patient demographic, comorbidity, and outcome data from Allegheny Health Network's electronic medical records. Functionality test results were compared before and after PR, including 6-minute walk test (6MWT), chair rise repetitions (CR reps), timed up and go test (TUG), gait speed (Rehab gait), modified medical research council scale (MMRC), shortness of breath questionnaire (SOBQ), hospital anxiety and depression scale (HADS) and chronic obstructive pulmonary disease assessment test (CAT) scores. Multiple regression analysis was done to evaluate the effect of comorbidities and patient factors on patient responses to PR. RESULTS: The 55 patients included in this study had a mean time of 4 months between the initial COVID-19 diagnosis and the subsequent PASC diagnosis. Following pulmonary rehabilitation (PR), significant improvements were observed across various metrics. The distance covered in the 6-minute walk test (6MWT) increased markedly from a pre-rehabilitation average of 895 feet (SD 290) to 1,300 feet (SD 335) post-rehabilitation, with a mean change of 405 feet (95% CI [333, 477]). Chair rise repetitions (CR reps) saw an increase from 9 (SD 3) reps to 13 (SD 3) reps, with a change of 4 reps (95% CI [3.7, 4.9]). The timed up and go test (TUG) time decreased significantly from 13 s (SD 5) to 10 s (SD 2), reflecting a mean reduction of 3 s (95% CI [-4.5, -2.5]). Rehabilitation gait speed improved from 1.0 m/s to 1.3 m/s, changing by 0.3 m/s (95% CI [0.2, 0.3]). The Modified Medical Research Council (MMRC) dyspnea scale showed a notable decrease from a mean of 2 (SD 1) to 1 (SD 1), a change of -1 (95% CI [-1.5, -1]). The Shortness of Breath Questionnaire (SOBQ) scores reduced significantly from 51 (SD 21) to 22 (SD 18), with a change of -29 (95% CI [-34, -23]). The Hospital Anxiety and Depression Scale (HADS) scores decreased from 11 (SD 7) to 8 (SD 7), a reduction of -4 (95% CI [-5, -2]). Lastly, the Chronic Obstructive Pulmonary Disease (COPD) Assessment Test (CAT) scores significantly dropped from 18 (SD 7) to 9 (SD 7), changing by -10 (95% CI [-11, -8]). However, the presence of hypertension, diabetes, chronic lung diseases, outpatient status, and receipt of specific pharmacologic treatments (decadron, decadron + remdesivir, and decadron + remdesivir + tocilizumab) were identified as factors associated with a poor response to PR. CONCLUSION: Our study supports PR as an integrated model of care for PASC patients to improve several physical and mental health indices. The long-term effects of PR on patients' functional status should be investigated in the future.

Idiopathic Bilateral Pulmonary Vein Thrombosis.

A 52-year-old female with a history of chronic lymphoedema and untreated deep vein thrombosis, presented with non-specific right-sided chest pain. A CT angiogram confirmed bilateral inferior pulmonary vein thromboses (PVT). A comprehensive hypercoagulable workup and age-appropriate cancer screening were unremarkable; the lack of associated risk factors confirmed idiopathic PVT. The management strategy of systemic anticoagulation with apixaban and multidisciplinary follow-up underscores the treatment challenges of rare presentations. This case accentuates the importance of considering PVT in differential diagnoses of atypical chest pain and contributes valuable insights into the diagnosis, understanding and management of this uncommon condition. LEARNING POINTS: Pulmonary vein thrombosis (PVT) may present as chest pain, especially in patients with a history of prior blood clots and can occur without an underlying malignancy or coagulation disorder.Utilising a chest CT angiogram with delayed contrast timing is effective in detecting pulmonary vein thrombus.Systemic anticoagulation proves effective in managing pulmonary vein thrombus; however, further data on dosage and duration are required for better guidance.

Extracorporeal Carbon Dioxide Removal to Avoid Invasive Ventilation During Exacerbations of Chronic Obstructive Pulmonary Disease: VENT-AVOID Trial - A Randomized Clinical Trial.

Rationale: It is unclear whether extracorporeal CO2 removal (ECCO2R) can reduce the rate of intubation or the total time on invasive mechanical ventilation (IMV) in adults experiencing an exacerbation of chronic obstructive pulmonary disease (COPD). Objectives: To determine whether ECCO2R increases the number of ventilator-free days within the first 5 days postrandomization (VFD-5) in exacerbation of COPD in patients who are either failing noninvasive ventilation (NIV) or who are failing to wean from IMV. Methods: This randomized clinical trial was conducted in 41 U.S. institutions (2018-2022) (ClinicalTrials.gov ID: NCT03255057). Subjects were randomized to receive either standard care with venovenous ECCO2R (NIV stratum: n = 26; IMV stratum: n = 32) or standard care alone (NIV stratum: n = 22; IMV stratum: n = 33). Measurements and Main Results: The trial was stopped early because of slow enrollment and enrolled 113 subjects of the planned sample size of 180. There was no significant difference in the median VFD-5 between the arms controlled by strata (P = 0.36). In the NIV stratum, the median VFD-5 for both arms was 5 days (median shift = 0.0; 95% confidence interval [CI]: 0.0-0.0). In the IMV stratum, the median VFD-5 in the standard care and ECCO2R arms were 0.25 and 2 days, respectively; median shift = 0.00 (95% confidence interval: 0.00-1.25). In the NIV stratum, all-cause in-hospital mortality was significantly higher in the ECCO2R arm (22% vs. 0%, P = 0.02) with no difference in the IMV stratum (17% vs. 15%, P = 0.73). Conclusions: In subjects with exacerbation of COPD, the use of ECCO2R compared with standard care did not improve VFD-5. Clinical trial registered with www.clinicaltrials.gov (NCT03255057).

Efficacy of bronchial thermoplasty in a patient panel with uncontrolled severe persistent asthma.

BACKGROUND: Bronchial thermoplasty (BT) is an approved procedure to manage uncontrolled severe persistent asthma. Many insurance providers are reluctant to pay for BT without proven benefit among their specific patient panel. OBJECTIVE: Determine if BT is effective in a panel patient panel with uncontrolled severe persistent asthma. STUDY DESIGN AND METHODS: This was an unblinded prospective study of adult subjects with uncontrolled severe persistent asthma who underwent BT. Outcomes were assessed at baseline and then 3-, 6-, 12-, 18- and 24-months post-BT. The primary metric was an improved Asthma Quality of Life Questionnaire (AQLQ) score. Other metrics included improved Asthma Control Test (ACT), peak expiratory flow rates (PEFR), spirometry, fractional excretion of nitric oxide (FeNO), number of unscheduled medical visits, and lost days of work/activity. Respiratory adverse events were assessed during the BT treatment period and at each post-BT visit. RESULTS: Twenty-nine subjects completed the study; the median interquartile range (IQR) age was 47 (42-61), and the majority were female (69%), white (93%), and non-Hispanic (90%). After BT, mean (±std) AQLQ scores improved by 1.6(±1.1) at 3 months (p < 0.0001), 1.6(±1.2) at 6 months (p < 0.0001), 1.4(±1.0) at 12 months (p < 0.0001), 1.8(±1.1) at 18 months (p < 0.0001), and 1.6 (±1.5) at 24 months (p < 0.0001). There were significant improvements in ACT, PEFR, unscheduled medical visits and lost days of work and activity. Spirometry and FeNO metrics were unchanged. The average cost for subjects completing all 3 BT procedures was approximately $15,000. CONCLUSION: BT is an effective adjunctive therapeutic modality in subjects with uncontrolled severe persistent asthma.

Impact of COVID-19 on Pregnancy Outcomes across Trimesters in the United States.

BACKGROUND: Current knowledge regarding the association between trimester-specific changes during pregnancy and COVID-19 infection is limited. We utilized the National Inpatient Sample (NIS) database to investigate trimester-specific outcomes among hospitalized pregnant women diagnosed with COVID-19. RESULTS: Out of 3,447,771 pregnant women identified, those with COVID-19 exhibited higher in-hospital mortality rates in their third trimester compared with those without the virus. Notably, rates of mechanical ventilation, acute kidney injury, renal replacement therapy, and perinatal complications (preeclampsia, HELLP syndrome, and preterm birth) were significantly elevated across all trimesters for COVID-19 patients. COVID-19 was found to be more prevalent among low-income, Hispanic pregnant women. CONCLUSIONS: Our findings suggest that COVID-19 during pregnancy is associated with increased risk of maternal mortality and complications, particularly in the third trimester. Furthermore, we observed significant racial and socioeconomic disparities in both COVID-19 prevalence and pregnancy outcomes. These findings emphasize the need for equitable healthcare strategies to improve care for diverse and socioeconomically marginalized groups, ultimately aiming to reduce adverse COVID-19-associated maternal and fetal outcomes.

Fetal and Maternal Monitoring.

Fetal monitoring in the intrapartum and peripartum periods is important for the well-being of both baby and mother. Electronic fetal monitoring was first designed over 50 years ago in an attempt to improve perinatal outcomes. Its purpose is to assess fetal oxygenation and acid-base status during the antepartum course when indicated and during labor. Maternal assessment begins early in gestation with blood pressure monitoring and urine protein excretion to diagnose potential complications, such as severe hypertension and preeclampsia/eclampsia.

Asthma in Pregnancy.

Asthma is a common chronic respiratory condition that affects approximately 10% of adult women in the United States. Pregnancy can present unique challenges for women with asthma, as changes in the body can alter the severity and management of asthma-related respiratory symptoms. In this article, we review the current understanding of asthma during pregnancy, including the direct effects of the disease state on the pregnant woman and fetus, risk factors for poor control of disease, as well as current treatment recommendations.

Comparing Clinical Outcomes of COVID-19 and Influenza-Induced Acute Respiratory Distress Syndrome: A Propensity-Matched Analysis.

Acute respiratory distress syndrome (ARDS) is one the leading causes of mortality and morbidity in patients with COVID-19 and Influenza, with only small number of studies comparing these two viral illnesses in the setting of ARDS. Given the pathogenic differences in the two viruses, this study shows trends in national hospitalization and outcomes associated with COVID-19- and Influenza-related ARDS. To evaluate and compare the risk factors and rates of the adverse clinical outcomes in patients with COVID-19 associated ARDS (C-ARDS) relative to Influenza-related ARDS (I-ARDS), we utilized the National Inpatient Sample (NIS) database 2020. Our sample includes 106,720 patients hospitalized with either C-ARDS or I-ARDS between January and December 2020, of which 103,845 (97.3%) had C-ARDS and 2875 (2.7%) had I-ARDS. Propensity-matched analysis demonstrated a significantly higher in-hospital mortality (aOR 3.2, 95% CI 2.5-4.2, p < 0.001), longer mean length of stay (18.7 days vs. 14.5 days, p < 0.001), higher likelihood of requiring vasopressors (aOR 1.7, 95% CI 2.5-4.2) and invasive mechanical ventilation (IMV) (aOR 1.6, 95% CI 1.3-2.1) in C-ARDS patients. Our study shows that COVID-19-related ARDS patients had a higher rate of complications, including higher in-hospital mortality and a higher need for vasopressors and invasive mechanical ventilation relative to Influenza-related ARDS; however, it also showed an increased utilization of mechanical circulatory support and non-invasive ventilation in Influenza-related ARDS. It emphasizes the need for early detection and management of COVID-19.

Gastrointestinal Emergencies in the ICU.

Gastrointestinal (GI) emergencies and disorders are among the most common reasons to be admitted to an intensive care unit (ICU). In addition, critically ill patients admitted to the ICU for non-GI-related diseases are frequently at risk of developing GI complications during their hospitalization. This article details the epidemiology/etiology, clinical presentation, diagnostic assessment, and management of the following GI emergencies: upper and lower GI bleed, acute pancreatitis, and ascending cholangitis.

Toxicological Emergencies.

Poisoning, drug overdose, and adverse drug effects continue to be a common encounter, especially in the intensive care unit (ICU). Patients are often critically ill or have a potential to rapidly deteriorate and warrant ICU admission. Adults suffering from overdoses rarely give a complete and accurate description of the quantity or type of medications ingested. In most adult cases, multiple substances are involved. A tentative diagnosis in most overdose and poisoning cases can be made by physical examination and simple laboratory tests (electrolyte panel, creatinine, serum osmolarity, urinalysis, etc). Supportive care, with particular attention to airway management, oxygenation, and circulation, is the mainstay of treatment. Basic treatment principles include limiting the amount of toxin absorbed, enhancing the elimination of ingested toxin, and preventing the conversion of non-toxic compounds to toxic metabolites. Drugs or poisons, where specific antidotes or effective therapies exist (especially acetaminophen, salicylates, methanol, ethylene glycol, and digitalis), should be aggressively sought and treated after initial stabilization has been accomplished. For those drugs or poisons where specific quantitative tests are available, levels should be obtained before treatment and may be repeated as clinically indicated.

Effect of Recent Exacerbation History on the Efficacy of Once-Daily Single-Inhaler Fluticasone Furoate/Umeclidinium/Vilanterol Triple Therapy in Patients with Chronic Obstructive Pulmonary Disease in the FULFIL Trial.

Background: In the FULFIL trial, once-daily single-inhaler triple therapy with fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) resulted in reduced moderate/severe exacerbation rates and conferred significant improvements in lung function and health status in patients with chronic obstructive pulmonary disease (COPD) versus twice-daily budesonide/formoterol (BUD/FOR) dual therapy. Methods: FULFIL was a Phase III, randomized, double-blind, double-dummy, parallel-group study. Patients ≥40 years of age with symptomatic COPD were randomized 1:1 to FF/UMEC/VI 100/62.5/25 mcg or BUD/FOR 400/12 mcg. In this post hoc analysis, patients were categorized by exacerbation history in the year prior to study entry (≥1 moderate/severe exacerbation [recent exacerbation] versus no recent exacerbation). Endpoints included annual rate of on-treatment moderate/severe exacerbations up to Week 24, annual rate of on-treatment severe exacerbations up to Week 24, change from baseline in trough forced expiratory volume in 1 second at Week 24, and change from baseline in health status as measured by St George's respiratory questionnaire total score at Week 24. Results: Of the 1810 patients in the intent-to-treat population, 1180 (65%) had one or more moderate/severe exacerbation in the year prior to entry, while 630 (35%) patients did not. FF/UMEC/VI versus BUD/FOR significantly reduced moderate/severe exacerbation rates in the recent exacerbation subgroup (mean annualized rate: 0.19 vs 0.29; rate ratio [95% confidence interval [CI]]: 0.64: [0.45, 0.91]; p=0.014) and numerically reduced moderate/severe exacerbation rates in the no recent exacerbation subgroup (mean annualized rate: 0.29 vs 0.43; rate ratio [95% CI]: 0.67 [0.43, 1.04]; p=0.073). Severe exacerbation rates were numerically reduced with FF/UMEC/VI versus BUD/FOR treatment across both subgroups. FF/UMEC/VI conferred significant improvements in lung function and health status versus BUD/FOR, regardless of recent exacerbation history. Conclusion: FF/UMEC/VI reduced moderate/severe and severe exacerbation rates and improved lung function and health status versus BUD/FOR in patients with symptomatic COPD, regardless of recent exacerbation history.

Acute Cardiac Emergencies.

Acute cardiac emergencies are life threatening. The initial responses to acute cardiac emergencies must be rapid, efficient, skillful, and well-planned. The goal of this article is to provide information that can be used to facilitate the prompt recognition and treatment of the most common acute cardiac emergencies.

Learning Clinical Concepts for Predicting Risk of Progression to Severe COVID-19.

With COVID-19 now pervasive, identification of high-risk individuals is crucial. Using data from a major healthcare provider in Southwestern Pennsylvania, we develop survival models predicting severe COVID-19 progression. In this endeavor, we face a tradeoff between more accurate models relying on many features and less accurate models relying on a few features aligned with clinician intuition. Complicating matters, many EHR features tend to be under-coded degrading the accuracy of smaller models. In this study we develop two sets of high-performance risk scores: (i) an unconstrained model built from all available features; and (ii) a pipeline that learns a small set of clinical concepts before training a risk predictor. Learned concepts boost performance over the corresponding features (C-index 0.858 vs. 0.844) and demonstrate improvements over (i) when evaluated out-of-sample (subsequent time periods). Our models outperform previous works (C-index 0.844-0.872 vs. 0.598-0.810).

Lemierre's Syndrome: A Case Series.

Lemierre's syndrome (LS) is a potentially fatal complication of oropharyngeal infection, resulting in contiguous suppurative thrombosis of the internal jugular vein (IJV) and septic emboli. It is most commonly associated with Fusobacterium necrophorum (F. necrophorum), though other pathogens have also been implicated in its pathogenesis. The incidence of LS had so significantly decreased that it was referred to as "the forgotten disease." However, cases of LS have shown a resurgence, which may be partly attributed to an overreliance on a negative group A beta-hemolytic streptococcal rapid antigen detection test (RADT), commonly referred to as "rapid strep test." Clinicians must maintain a very high index of suspicion for LS in patients with persistent sequelae from tonsillopharyngitis who have a negative RADT.

Pathophysiology of COPD.

This article provides an overview of the pathophysiology of chronic obstructive pulmonary disease including the physiological mechanisms that are known precursors. The roles of environmental and genetic causes are considered. α1-Antitrypsin deficiency is also discussed as it relates to the development of airflow obstruction.

Chronic Obstructive Pulmonary Disease: Diagnosis and GOLD Classification.

This article describes the various steps required to confirm the diagnosis of chronic obstructive pulmonary disease (COPD). The GOLD Criteria developed by the Global Initiative for COPD will be outlined as they relate to the diagnosis and management of COPD. Pulmonary function testing, imaging, and symptom assessment will be explored.

COPD Maintenance Pharmacotherapy.

Chronic obstructive pulmonary disease (COPD) is currently the fourth leading cause of death worldwide and will likely be the third most common cause by the end of 2020. It is felt to be caused by repetitive noxious stimuli to the lung, most commonly from smoking, with persistent symptoms of cough, wheeze, and shortness of breath. Most patients will have these baseline symptoms, with periodic flare-ups known as exacerbations. This article focuses on pharmacological therapy in a stable COPD patient. Pharmacological treatment of a stable COPD patient focuses on minimizing symptoms, improving exercise tolerance, and preventing exacerbations. Nonpharmacological management of stable COPD, smoking cessation, and treatment of exacerbations are covered in other sections.

Nonpharmacological Therapies in COPD.

Chronic obstructive pulmonary disease has recently been gaining more attention, as beyond impacting roughly 10% of the world's population, it also carries high morbidity and mortality. The mainstay of management is optimizing pharmacological therapy, but various nonpharmacological therapies have shown benefits in providing symptom improvement and relief, prevention and mitigation of exacerbations, quality of life, and even mortality rate. Such modalities include supplemental oxygen therapy, pulmonary rehabilitation, viral and bacterial vaccinations, and noninvasive positive pressure ventilation therapy.