Treating COVID-19 Acute Severe Hypoxemic Respiratory Failure: First Case Report Utilizing Dexamethasone, Remdesivir, and Convalescent Plasma in Operation Inherent Resolve.

Coronavirus 2019 (COVID-19) has spread across the globe with a concerningly high infectivity resulting in the World Health Organization deeming it a pandemic. It has resulted in thousands of deaths and placed enormous strain on communities, healthcare systems and healthcare workers as they battle shortages of ventilators, supplies, and difficulties in protecting patients and hospital staff alike. Challenges in managing the disease have led to new treatment and management strategies as healthcare teams struggle to adapt. We present the first case of COVID-19 managed in the austere deployed environment of Operation Inherent Resolve in which the patient was treated with dexamethasone, remdesivir, COVID-19 convalescent plasma, positive pressure ventilation, and proning. We discuss some of the inherent and unique challenges of caring for a patient in this resource constrained environment with a brief review of the literature on the treatment and management.

Secondary Spontaneous Pneumothorax Mimicking Lung Herniation.

Patients with chronic obstructive pulmonary disease (COPD) are at an increased risk for numerous pulmonary complications, including secondary spontaneous pneumothorax (SSP) and lung herniation. We describe the case of a 66-year-old female patient with severe COPD and previous lingula-sparing left upper lobectomy from adenocarcinoma who presented to the emergency department with a painful anterior chest wall mass that varied in size with respiration. This finding, in a patient with a prior history of an invasive thoracic procedure, is suggestive of lung herniation. Further investigation revealed an SSP mimicking the classic physical exam finding of a lung herniation. The patient was deemed a poor surgical candidate; therefore, talc pleurodesis was administered with resolution of the pneumothorax.

The use of lobectomy for management of clinically significant pulmonary vein stenosis and occlusion refractory to percutaneous intervention.

Pulmonary vein stenosis (PVS) is a serious complication of radiofrequency ablation (RFA) for the treatment of atrial fibrillation. The prevalence of this complication was reported to be as high as 42% in 1999 when RFA was first implemented [1]. However, with improvements in operator technique including wide area circumferential ablation, antral isolation, and the use of intracardiac ultrasound, the incidence of symptomatic severe PVS following RFA ranges from 0% to 2.1% while the incidence of symptomatic pulmonary vein occlusion (PVO) following RFA was found to be 0.67% [2-8]. Despite a decrease in the incidence of clinically significant PVS following RFA, there have been increased reports of complications associated with PVS to include hemoptysis, scarring, lung infarction, and intraparenchymal hemorrhage [9]. Studies have shown that PVS is often misdiagnosed as pneumonia, pulmonary embolism, and lung cancer and as a result, patients are often subjected to unnecessary diagnostic procedures [2,10]. The current first line treatment for this condition is percutaneous balloon angioplasty with stenting; however, there are studies that have shown that there is a relatively high rate of restenosis despite optimal medical therapy [2-3,10,11]. Three case reports have described the use of lobectomy to treat patients with persistent respiratory symptoms in the setting of severe PVO with good outcomes [12-14]. We present a case of iatrogenic PVO and ipsilateral severe PVS following RFA who underwent attempted lobectomy for persistent exertional dyspnea and persistent hypoperfusion of the left upper lung lobe despite percutaneous intervention and six months of optimal medical therapy. The lobectomy was aborted due to the presence of a significant fibrothorax, and the patient continues to have significant exercise limitation despite participation in pulmonary rehabilitation.

Comparison of Forced and Slow Vital Capacity Maneuvers in Defining Airway Obstruction.

BACKGROUND: Obstructive lung disease is diagnosed by a decreased ratio of FEV1 to the vital capacity (VC). Although the most commonly used VC is FVC, American Thoracic Society guidelines suggest alternative VCs, for example, slow VC (SVC), may offer a more-accurate evaluation of breathing capacity. There is recent evidence that using only FEV1/FVC underrecognizes obstruction in subjects at high risk and who are symptomatic. Previous studies have indicated that healthy individuals show a minimum difference between FVC and SVC; however, testing of individuals with asthma and who are symptomatic indicates that SVC can be markedly larger than FVC. OBJECTIVE: To evaluate the differences among SVC, FVC, and SVC-based measurements in the diagnosis of symptomatic obstructive lung disease. METHODS: A retrospective analysis was performed of spirometry and plethysmography measurements from studies conducted between 2011 to 2015. We established a pulmonary function database that incorporated predictive equations from the National Health and Nutrition Examination Survey III (NHANES III). The SVC to FVC difference was calculated. FEV1/SVC was compared with FEV1/FVC by using NHANES III lower limit of normal values. RESULTS: A total of 2,710 studies with 2,244 subjects were reviewed. Spirometric obstruction, as defined by NHANES III, was identified in 26.1% of the studies (707/2,710). The mean (± SD) difference between SVC and FVC was 375.0 ± 623.0 mL and 258.8 ± 532.5 mL in those with and those without obstruction, respectively. Subgroup and multivariate analysis demonstrated age, body mass index, and FEV1 associated contributions to the difference between SVC and FVC. By using FEV1/SVC, the prevalence of obstruction increased from 26.1 to 45.0% (1,219/2,710) and identified 566 additional studies of subjects with obstruction. Fifty-four percent of the subjects with newly-identified obstructive lung disease (305/566) had smoking histories, and 67.4% (345/512) received medications for obstructive lung disease. CONCLUSIONS: The isolated use of FVC-based diagnostic algorithms did not recognize individuals with symptomatic obstructive lung disease. Recognizing the difference between SVC and FVC measurements in subjects will improve testing and diagnosis of obstructive lung disease.

Admission chest CT complements fiberoptic bronchoscopy in prediction of adverse outcomes in thermally injured patients.

In burned patients, inhalation injury can result in progressive pulmonary dysfunction, infection, and death. Although bronchoscopy is the standard for diagnosis, it only assesses the proximal airway and does not provide a comprehensive analysis of pulmonary insult. Chest radiographs have not been proven helpful in diagnosis of inhalation injury. Our hypothesis is that a CT scan alone or in conjunction with bronchoscopy can be used as a prognostic tool for critically ill burn patients, especially those with inhalation injury. The authors performed a retrospective study of all patients admitted to the U.S. Army Institute of Surgical Research Burn Center between 2002 and 2008 with chest CT within 24 hours of admission. They divided subjects into two groups, those with evidence of inhalation injury on bronchoscopy and those without. They used a radiologist's score to assess the degree of damage to the pulmonary parenchyma. The primary endpoint was a composite of pneumonia, acute lung injury/acute respiratory distress syndrome, and death. The inhalation injury group consisted of 25 patients and the noninhalation injury group of 19 patients. Groups were not different in age, TBSA burned, and percentage full-thickness burn. By multiple logistic regression, detection of inhalation injury on bronchoscopy was associated with an 8.3-fold increase in the composite endpoint. The combination of inhalation injury on bronchoscopy and a high radiologist's score was associated with a 12.7-fold increase in the incidence of the composite endpoint. Admission CT assists in predicting future lung dysfunction in burn patients.