Octreotide as a novel agent for the management of bronchorrhea in mechanically ventilated patients: A case series and review of literature.

Excessive bronchial secretions pose a challenge in mechanically-ventilated patients and may prolong the time to extubation, increasing the risk for pneumonia. Octreotide, a somatostatin analog, has been used to decrease bronchial secretions especially for the symptomatic management of patients with lung cancer. We describe three patients in the form of a case series and discuss effect of octretotide on bronchial secretions and management of bronchorrhea in the intensive care unit. Similar to reports of its utilization in palliative care in patients with lung cancer, we observed a clinically significant decrease in the rate of bronchial secretions.

Upper Airway Complications in COVID-19: A Case Series.

Prolonged intubation is associated with several complications leading to upper airway obstruction, including tracheal stenosis and tracheomalacia. Tracheostomy may potentially decrease the risk of tracheal injury in patients with upper airway obstruction. The ideal timing to perform tracheostomy remains controversial. Prolonged intubations were particularly common during the initial phase of the coronavirus disease 2019 (COVID-19) pandemic. This study aimed to present a series of five cases of upper airway complications in patients who underwent mechanical ventilation in the setting of COVID-19 and discuss their clinical aspects, risk factors, and therapeutic strategies.

Clinical Outcomes With the Use of Prophylactic Versus Therapeutic Anticoagulation in Coronavirus Disease 2019.

OBJECTIVES: To determine the impact of anticoagulation on inhospital mortality among coronavirus disease 2019-positive patients with the a priori hypothesis that there would be a lower risk of inhospital mortality with use of preemptive therapeutic over prophylactic dose enoxaparin or heparin. DESIGN SETTING: Retrospective cohort study from April 1, 2020, to April 25, 2020. The date of final follow-up was June 12, 2020 Two large, acute-care hospitals in Western Connecticut. PATIENTS: Five hundred and one inpatients were identified after discharge as 18 years or older and positive for severe acute respiratory syndrome coronavirus 2. The final sample size included 374 patients after applying exclusion criteria. Demographic variables were collected via hospital billing inquiries, whereas the clinical variables were abstracted from patients' medical records. EXPOSURE: Preemptive enoxaparin or heparin at a therapeutic or prophylactic dose. MAIN RESULTS: When comparing treatments through multivariable analysis, risk of inhospital mortality was 2.3 times greater in patients receiving preemptive therapeutic anticoagulation (95% CI = 1.0-4.9; p = 0.04). Additionally, the average treatment effects were higher (ß = 0.11, p = 0.01) in the therapeutic group. CONCLUSIONS: An increase in inhospital mortality was observed among patients on preemptive therapeutic anticoagulation. Thus, in the management of coronavirus disease 2019 and its complications, we recommend further research and cautious use of preemptive therapeutic over prophylactic anticoagulation.

The Effects of a Comprehensive Care Management Program on Readmission Rates After Acute Exacerbation of COPD at a Community-Based Academic Hospital.

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is one of the leading causes of hospitalization in the United States. Prior investigations suggest clinical and physiological parameters are important determinants for AECOPD readmissions. Strategies aimed at addressing these factors have not resulted in a major reduction of readmissions. We compared patients readmitted after an index AECOPD admission with non-readmitted patients. Patients' age, gender, body mass index, comorbidities (obstructive sleep apnea, chronic hypercapnia, congestive heart failure, lung cancer, pulmonary arterial hypertension, pneumonia, interstitial lung disease, atrial fibrillation, musculoskeletal disorders, cognitive disorders, and anxiety disorders), substance abuse and smoking status were assessed. Some 272 patients were included: 20 patients were readmitted within 30 days of their index hospitalization; 252 patients were not readmitted within 30 days of their index admission. Readmitted patients were significantly more likely to have pneumonia than non-readmitted patients (30.0% versus 13.1%, p<0.05). No statistically significant difference was seen with respect to other clinical comorbidities. Patients readmitted within 30 days were significantly more likely than non-readmitted patients to have safety issues at home (80.0% versus. 39.3%, p<0.001), anxiety (60.0% versus 29.8%, p<0.01), and lack of transportation (35.0% versus 15.5%, p<0.05). Implementation of a comprehensive care management program (CCMP) was associated with a reduction in readmissions from 21.5% to 13.6% (p<0.01, 95% confidence interval [CI] 2.08-12.45). A CCMP can reduce readmissions through attention to social variables, optimization of in-hospital care, improved coordination of pre- and post-discharge, a system to better identify problems after discharge, and an office setup that accommodates same-day visits.

Perioperative Risks of Untreated Obstructive Sleep Apnea in the Bariatric Surgery Patient: a Retrospective Study.

BACKGROUND: The use of continuous positive airway pressure (CPAP) perioperatively in bariatric surgery patients with obstructive sleep apnea (OSA) has been controversial. Although studies have demonstrated that CPAP use is safe in bariatric patients, prior studies have not shown improvement in outcomes in these patients. METHODS: A retrospective review of patients who underwent bariatric surgery from 2005 to 2009 was performed. All patients underwent polysomnography preoperatively. Patient age, sex, BMI, comorbidities, polysomnogram data, type of bariatric procedure, length of hospital stay, and postoperative complications were reviewed. The Fisher exact test was used for statistical analysis. RESULTS: Among the 352 patients studied, 47 with apnea-hypopnea index (AHI) ≥5 did not receive CPAP postoperatively. A total of 7/47 (14.9 %) developed postoperative pulmonary complications. There were no non-pulmonary complications. Some 9/305 (2.95 %) with CPAP developed pulmonary complications. There were 26/305 patients with all-cause complications (8.52 %). The AHI was higher in the group receiving treatment. There was a statistically significant difference in pulmonary complications between patients with and those without treatment (p value 0.0002). The average length of stay was 3.0 and 3.2 days in treatment and comparison groups, respectively, a difference that did not reach statistical significance. CONCLUSIONS: Patients who did not receive CPAP postoperatively developed more pulmonary complications than those with CPAP, suggesting that CPAP might be beneficial in decreasing pulmonary complications in patients undergoing bariatric surgery. However, further investigation is warranted to better delineate other risk factors due to small sample size in our study group.

Unusual Case of Isolated Pleural B-Cell Lymphoma.

Pleural involvement in lymphoma is rare as the initial presentation of disease in the immunocompetent patient. We describe a rare case of primary, isolated pleural B-cell lymphoma in a 75-year-old female, previously treated for adenocarcinoma of the left lung with lobectomy and chemotherapy, who presented with shortness of breath. A CT scan of the chest revealed a right-sided pleural effusion and pleural thickening. She underwent multiple nondiagnostic thoracenteses. A subsequent surgical biopsy was diagnostic of large B-cell lymphoma.

Acute upper extremity arterial thrombosis and stroke in an unresected pheochromocytoma.

Pheochromocytoma is a rare cause of hypertension in the general population. Only isolated reports show an association with acute obstructive arterial thrombosis. A 50-year-old chronically noncompliant woman with a known unresected pheochromocytoma presented to the emergency department with ataxia. Imaging confirmed a right-sided ischemic stroke. During her hospital stay, the patient developed signs consistent with acute right upper extremity ischemia resulting from occlusion in the distal right subclavian, axillary, and proximal brachial arteries. Emergent open thrombectomy was successfully performed. In patients with an unresected pheochromocytoma, one must consider acute arterial thrombosis as a rare but potentially limb-threatening and even life-threatening complication.