The prognostic value of rapid shallow breathing index and physiologic dead space for weaning success in intensive care unit patients under mechanical ventilation.

BACKGROUND: Mechanical ventilation (MV) is a life-saving intervention that should be considered for patients with respiratory failure. This study was conducted to evaluate the predictive value of physiologic dead space for weaning success and compare it with rapid shallow breathing index (RSBI). MATERIALS AND METHODS: This cross-sectional study was conducted on 80 intensive care unit (ICU) patients who were under MV and candidate for weaning; among them, 68 patients experienced weaning success. RSBI was measured by dividing the respiratory rate by tidal volume. End-tidal CO2 (PETCO2) was obtained using caponometry, then dead-space was calculated as (VD/VT = (PaCO2 - PETCO2)/PaCO2). PaCO2 was also obtained from arterial blood gas recorded chart. RESULTS: Age, PaCO2, PETCO2, and RSBI were significantly different between those patients with and without weaning success (P < 0.05). RSBI ≤ 98 could predict the success of weaning with sensitivity 91.7%; specificity 76.5% and (AUC) area under the ROC curve (AUC = 0.87; 95% confidence interval [CI]: 0.78-0.94; P < 0.001). Dead space was not statistically significant prognostic index (AUC = 0.50; 95% CI: 0.31-0.69; P = 0.09). CONCLUSION: In our study, RSBI was an effective predictive index for weaning success in ICU patients under MV, but dead space did not show significant predictive value. Further studies with larger sample sizes for providing more evidence are recommended.

A Pilot Study of Nebulized Heparin for Prevention of Ventilator Induced Lung Injury: Comparative Effects with an Inhaled Corticosteroid.

BACKGROUND: Ventilator-induced lung injury (VILI) is a side effect of mechanical ventilation. Lung inflammation and pulmonary activation of coagulation are induced by mechanical stress. Clinical and preclinical studies show that heparin possesses anti-inflammatory properties. Therefore, we assessed the effects of nebulized heparin in VILI. METHODS: Sixty critically ill adult patients who require mechanical ventilation for more than 48 h were included in this prospective, nonrandomized controlled study. Patients received nebulized heparin (10,000 U every 6 h) for 5 days. The matched control group received nebulized budesonide as routine practice in our center. This study assessed changes in partial pressure of oxygen to inspired fraction of oxygen ratio (PaO2/FiO2) and rapid shallow breathing index (RSBI) during the study as primary endpoints. RESULTS: The average daily PaO2/FiO2 ratio was not statistically significant between both groups (187 ± 11.6 vs. 171 ± 11.6, P = 0.35). The RSBI also did not differ between groups (P = 0.58). Heparin administration was associated with a higher number of ventilator-free days among survivors but not significantly (7.7 ± 10.6 vs. 5.1 ± 8, 95% confidence interval - 2.2-7.5, P = 0.28). Successful weaning from mechanical ventilation was higher in the heparin group (P = 0.42). We did not observe any serious or increased adverse effects from nebulized heparin. CONCLUSION: The results of this study show that the overall effectiveness of nebulized heparin is at least as comparable with a potent corticosteroid (budesonide). Heparin could be a safe and effective modality for patients who at risk of VILI.

Association of irritable bowel syndrome and sleep apnea in patients referred to sleep laboratory.

BACKGROUND: Irritable bowel syndrome (IBS) is assumed as one of the most frequent gastrointestinal disorders, which decreases the patient's quality of life. IBS pathogenesis, however, is not clearly defined. It seems that sleep apnea induces or escalates IBS clinical symptoms. This study aims at evaluating of IBS prevalence in patients, who are afflicted or are not afflicted with sleep apnea. MATERIALS AND METHODS: This was a case-control study, which was implemented in a sleep laboratory located in Isfahan, Iran. We recruited 200 patients being more than 15 years from 2014 to 2015. Based on the apnea-hypopnea index (AHI), we recruited 100 patients in each of two groups: negative sleep apnea (NSA) (AHI ≤4) and positive sleep apnea (PSA) (AHI >4). IBS was diagnosed through a Rome III diagnostic questionnaire. RESULTS: Overall, the prevalence of IBS among patients referred to sleep laboratory was 17.6%. Indeed, IBS prevalence in NSA and PSA groups were 8.2% and 27.1%, respectively. Furthermore, odds ratio of IBS in PSA group versus NSA was 3.92 (95% confidence interval = 1.58-9.77, P = 0.003). Our results showed that the prevalence of IBS did not differ significantly between various severity of sleep apnea (P = 0.452). CONCLUSION: This study showed that there was a positive association between sleep apnea and IBS.

Relationship between obstructive sleep apnea and 30-day mortality among patients with pulmonary embolism.

BACKGROUND: Pulmonary embolism (PE) is the most life-threatening form of venous thrombosis which causes the majority of mortalities in this category. Obstructive sleep apnea (OSA) has been indicated as one of the risk factors for thromboembolism because of hemostatic alterations. The present study was designed to seek for the relationship between OSA and 30-day mortality of patients with PE. MATERIALS AND METHODS: This prospective cohort study was conducted among 137 consecutive patients referred to hospital with symptoms of PE and preliminary stable hemodynamic. Confirmation of PE was made by multislice computed tomography pulmonary angiography and in the case of contraindication; V/Q lung scan and Doppler sonography were done. A STOP-Bang Questionnaire was used to determine patients with high- and low-risk of OSA. Patients were followed up for 1-month, and their survivals were recorded. RESULTS: This study showed that there was no relationship between OSA and 30-day mortality (P = 0.389). Chronic kidney disease (P = 0.004), hypertension (P = 0.003), main thrombus (P = 0.004), and segmental thrombus (P = 0.022) were associated with 30-day mortality. In the logistic regression analysis, history of chronic kidney disease was diagnosed as a risk factor for 30-day mortality among the PE patients (P = 0.029, odds ratio = 4.93). CONCLUSION: Results of this study showed 30-day mortality was not affected by OSA directly. In fact, it was affected by complications of OSA such as hypertension and thrombus. Also, positive history of chronic kidney disease increased the risk of 30-day mortality.

Bilateral peripheric facial nerve palsy following SARS-CoV-2 infection: A case report and review of literature.

Neurologic complications of SARS-CoV-2 infection have been reported commonly. Peripheric facial nerve palsy is one of the most reported neurologic problems. However, idiopathic bilateral facial palsy is a very rare complication of SARS-CoV-2 infection. Herein, we present a case of a COVID-19 35-year-old man, which developed bilateral facial palsy.

Multiple Hydatid Cysts in Rare Locations Treated with Albendazole: A Case Report.

Hydatid cyst is a common disease between humans and animals. Foods that are contaminated with eggs of echinococcal species are the cause of hydatid disease. Although this parasite affects different organs, the liver and lungs are very susceptible but the cardiac hydatid disease is very rare. We report the case of a 33-year-old man admitted because of chest pain. Echocardiography had shown suspected round cyst in the myocardium. More diagnostic managements had demonstrated cystic lesion in the liver, spleen and lungs. There were also multiple cystic lesions in both lungs. He refused surgery and was taken to medical therapy. Myocardial involvement by hydatid cysts occurs very rarely. The main treatment approach for cardiac hydatid disease in patients should be surgery. The alternative treatment was done to those who refused surgical removal, adjuvant therapy such as albendazole for at least 1-6 months. Because myocardial involvement by hydatid cysts is uncommon, we decided to report this rare case.

Pulmonary Function, Anxiety, Depression, and Sleep Quality after Recovery from COVID-19.

Background: The COVID-19 pandemic has affected human beings worldwide. After recovery from the disease, the pulmonary function and physiological characteristics of COVID-19 patients are not well documented. The current study aims to assess post-COVID-19 lung function, anxiety, depression, and sleep quality within three months after recovery from the disease. Materials and Methods: Ninety-seven patients (21 outpatients and 76 inpatients) with COVID-19 were followed three months after recovery. They were divided into two groups according to the severity of the disease. The spirometric parameters included FEV1, FVC, and FEV1/FVC. A 6-minute walk test (6-MWT) was recorded. Besides, sleep quality using Pittsburgh Sleep Quality Index (PSQI) and mood status in two dimensions of anxiety and depression using the Hospital Anxiety and Depression Scale (HADS) were compared between the groups. Results: More than 70% of the studied population presented at least one of the COVID-19 infection-related symptoms within three months after recovery. spirometric measurements revealed non-significant differences between the patients with severe versus non-severe COVID-19 in terms of FVC (P=0.805), FEV1 (P=0.948), FEV1/FVC (P=0.616), and 6MWT (P=0.409). Based on PSQI, sleep quality was significantly associated with the severity of disease (P=0.031), but HADS assessments were not significant (P>0.05). Conclusion: This study demonstrated that a significant proportion of COVID-19 patients have corona symptoms and abnormal pulmonary function tests three months after recovery. Besides, sleep quality was considerably affected by the severity of the disease and was directly associated with the post-COVID-19 mood of the patients. It seems necessary to consider and control the long-term consequences of this infection regardless of the disease severity.

Efficacy and Safety Comparison of Two Different Doses of Dexamethasone in Hospitalized Patients with COVID-19: A Randomized Clinical Trial.

Objective: The current study aims to investigate high- versus low-dose dexamethasone administration to control the disease with minor complications. Methods: The current multicentric randomized clinical trial was conducted on 119 patients with COVID-19 pneumonia and assigned into two groups of low-dose (8 mg daily intravenous dose for at least 7 days or until discharge) (n = 61) versus high-dose dexamethasone (24 mg for 3 days followed by daily 8 mg for the at least 4 days later or until discharge) (n = 58) during 2020-2021. Oxygen saturation, dyspnea severity based on the Borg scale, and laboratory indices were assessed at 3, 5, and 7 days of corticosteroid therapy. Patients were compared regarding the length of hospitalization, intensive care unit (ICU) admission requirement, and noninvasive or invasive ventilation. The other investigations included corticosteroid-related adverse effects and mortality rates within a month after the medications. Findings: Oxygen saturation, Borg scale, and C-reactive protein levels were significantly altered by the time in both the groups (P < 0.05). In contrast, the trend of improvements in Borg scale (P = 0.007) and lactate dehydrogenase levels (P = 0.034) were superior in high-dose treated cases. Drug-related adverse (P = 0.809), mortality rate (P = 0.612), hospitalization duration (P = 0.312), ICU admission requirement (P = 0.483), and noninvasive (P = 0.396) and invasive ventilation (P = 0.420) did not differ between the groups. Conclusion: According to this study, low- versus high-dose dexamethasone therapy did not affect the outcomes, so low-dose dexamethasone is recommended for COVID-19 pneumonia to achieve optimal results and prevent potential adverse events.

Does cosmetic rhinoplasty affect sleep quality and/or contribute to the development of obstructive sleep apnea?

OBJECTIVE: Rhinoplasty can reduce nasal airways' resistance. This study evaluates the effects of rhinoplasty on sleep quality, daytime drowsiness, and obstructive sleep apnea (OSA). METHODS: In this prospective cohort study, 80 rhinoplasty candidates were examined before and six months after rhinoplasty to evaluate symptom changes. STOP-BANG, Pittsburgh Sleep Quality Index (PSQI), and Epworth Sleepiness Scale (ESS) questionnaires, and nocturnal polysomnography were used, respectively, to screen for OSA, assess sleep quality, assess daytime drowsiness, and confirm results. RESULTS: Seventeen men (21.2%) and 63 women (78.8%) were studied. PSQI results showed an increase only in post-operative sleep disturbance items (p = 0.04). STOP-BANG showed an increase in apnea (p = 0.06) and a decrease in snoring (p = 0.06), which were both insignificant. The polysomnography tests confirmed the results of the questionnaires. CONCLUSION: Contrary to popular belief, rhinoplasty does not increase snoring, sleep disorders, or apnea.

Effects of Laparoscopic Sleeve Gastrectomy and Roux-En-Y Gastric Bypass on the Improvement of Sleep Quality, Daytime Sleepiness, and Obstructive Sleep Apnea in a Six-Month Follow-up.

BACKGROUND: The number of bariatric surgeries has increased in recent years, and major attempts have been made to find the best surgical procedure. Laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB) are the most common bariatric surgery procedures. This study aimed to investigate the effects of these two procedures on improving sleep quality, daytime sleepiness, and obstructive sleep apnea. MATERIALS AND METHODS: This case-control study was performed on two groups of patients (n=60 per group). The case group included obese candidates for LSG or RYGB, and the control group consisted of obese patients without any surgical interventions. The sleep quality, obstructive sleep apnea (OSA) risk, and daytime sleepiness were examined, using the Pittsburgh Sleep Quality Index (PSQI), Stop-Bang questionnaire, and Epworth Sleepiness Scale (ESS), respectively. The results were recorded before and six months after the intervention and compared between the two groups. RESULTS: There was no significant difference in the mean scores of ESS, PSQI, and Stop-Bang questionnaire between the two groups before the intervention (P>0.05). However, the mean scores of PSQI and its dimensions, ESS, and Stop-Bang questionnaire significantly improved in patients undergoing surgery (P<0.05). The results of linear regression analysis also showed significant improvements in the ESS, PQSI and Stop-Bang scores in the intervention group. Body mass index (BMI) reduction improved the scores of PSQI, ESS, and Stop-Bang questionnaire in patients, with impact factors of 0.032, 0.700, and 0.025, respectively (P<0.05). CONCLUSION: LSG and RYGB surgeries significantly improved the patients' sleep quality, decreased daytime sleepiness, and reduced the risk of OSA. Overall, BMI reduction and lack of OSA can significantly affect sleep quality.

Precalcitonin and C-reactive protein as markers in response to antibiotic treatment in ventilator-associated pneumonia in intensive care unit-hospitalized patients.

BACKGROUND: Pneumonia due to ventilator is a prevalent nosocomial infection associated with high morbidity and mortality. This study aimed to determine the change in serum levels of precalcitonin (PCT) and C-reactive protein (CRP) in response to antibiotic treatment in patients hospitalized in intense care unit (ICU) suffering from ventilator-associated pneumonia (VAP). MATERIALS AND METHODS: This is an analytical and descriptive study performed in 2013 in Ayatollah Kashani Medical Training Center, Isfahan, Iran. The statistical sample includes patients hospitalized in ICU in 2013 suffering from VAP. In this study, 50 patients suffering from VAP were selected, and PCT and CRP levels were measured in them before antibiotic therapy and every 48 h until the end of therapy. The collected data were analyzed by SPSS software. RESULTS: CRP and PCT levels were high before the beginning of antibiotic therapy in all patients suffering from VAP and their CRP level had an increasing trend until 4 days after the beginning of therapy; however, from the 4(th) day, it turned into decreasing trend. PCT serum level was higher than normal before the treatment and until 48 h after the therapy, and then it was found to have a decreasing trend. According to variance analysis test with repetition of observations, the mean level of mentioned markers had a meaningful difference before the beginning of antibiotic therapy until the end of antibiotic therapy (P < 0.001). CONCLUSION: CRP and PCT serum levels can be used as an instrument for determining the effect of antibiotic therapy in patients with VAP.

Improving the Practice of Nutrition Therapy in the NRITLD Critically Ill Patients: An International Quality Improvement Project.

BACKGROUND: In previous decades several studies have been performed demonstrating that providing appropriate nutritional support to intensive care unit patients affects complications, time of mechanical ventilation, length of ICU stay, and risk of death. In this study we provided a report of nutrition statuses in Masih Daneshvari's ICU as compared to 156 ICUs from 20 countries that participated in an international nutrition survey. MATERIALS AND METHODS: All patients admitted to an intensive care unit during a specified one-month period who required artificial nutrition were included in this study. Characteristics of patients, performance of nutrition practices, and ICU outcomes were registered for all patients and compared with data from 156 other intensive care units from various countries around the world. RESULTS: Twenty patients, of which 11(55%) were males and 9(45%) were females, were included in this study. The median age was 50.5 yrs (IQR: 40.5-56.0). Seventeen (85%) of them had EN nutrition only, 2(10%) had PN nutrition only, and 1(5%) had both EN and PN nutrition during their stay in the ICU. The adequacy of calorie intake was 67.6% (vs. 61.1% in all 157 ICUs) and the adequacy of protein intake was 84.9% (vs. 56.7% in 157 ICUs). CONCLUSION: In our ICU, enteral feeding was superior to parenteral feeding. Also we considered early initiation of enteral feeding within 48 hours following ICU admission. We just used polymeric formula during this study. As a result of formula variation limits, we overestimated calories and protein needs. Glutamine and Selenium supplementations have not been used yet for patient in our ICU, regardless of their proven benefits in oxidative stress conditions like pulmonary diseases. Therefore, limited use of supplementations like selenium is inevitably among the disadvantages of Masih Daneshvari Hospital's ICU, which is a tertiary-care center for chronic pulmonary diseases.