Clinical Significance of Pleural Lactate Measurement in Critically Ill Patients with Parapneumonic Pleural Effusion.

OBJECTIVE: Pleural fluid pH measurement is recommended for tube thoracostomy decisions in complicated parapneumonic pleural effusions. However, pleural fluid pH may be affected by blood pH in critically ill patients with common systemic acid-base disorders. We aimed to investigate the use of pleural fluid lactate to distinguish culture-positive parapneumonic effusions from other pleural effusions. MATERIAL AND METHODS: This prospective observational study included 121 eligible patients (51 female and 70 male). All patients with pleural effusion who underwent thoracentesis were assessed. Pleural fluid lactate was measured by a blood gas analyzer. RESULTS: Of the 121 patients, 30 (24.8%) were transudate and 91 (75.2%) were exudate. Of the 91 patients with exudative pleural effusion, 61 were diagnosed as culture-negative parapneumonic, 13 as culture-positive parapneumonic, 9 as malignant, and 8 as other exudative effusion. There was a strong positive linear association between serum pH and pleural fluid pH (R = 0.77, P < .001). The post hoc tests for pleural fluid lactate revealed there was a significant difference between culture-positive parapneumonic versus culture-negative parapneumonic groups (P = .004), culture-positive parapneumonic versus transudative effusion groups (P < .001), culture-negative parapneumonic versus transudative effusion groups (P = .008) and lastly; malignant effusion versus transudative effusion groups (P = .001). Receiver operating characteristics curve analysis for culture-positive parapneumonic indicated a cutoff of 4.55 mmol/L for pleural fluid lactate to have a sensitivity of 76.9% and a specificity of 84.3% (positive predictive value: 37%, negative predictive value: 96.8%). CONCLUSION: A cutoff of 4.55 mmol/L of pleural fluid lactate can be used as a useful tool to distinguish culture-positive parapneumonic effusions from other effusions in critically ill patients.

Incidência e fatores de risco para hipotensão pós-intubação em pacientes críticos com COVID-19 / Incidence of and risk factors for postintubation hypotension in critically ill patients with COVID-19

RESUMO Objetivo: Avaliar a incidência de fatores de risco para hipotensão pósintubação em pacientes críticos com COVID-19. Metódos: Foi realizado um estudo retrospectivo com 141 pacientes com COVID-19 que foram intubados na unidade de terapia intensiva. Hipotensão pós-intubação foi definida como a necessidade de qualquer dose de vasopressor a qualquer momento em até 60 minutos após a intubação. Pacientes com parada cardiorrespiratória relacionada à intubação e hipotensão antes da intubação foram excluídos do estudo. Resultados: Dos 141 pacientes incluídos, 53 pacientes (37,5%) e 43,6% dos pacientes (n = 17) eram do sexo feminino. A idade mediana do grupo com hipotensão pós-intubação foi de 75 anos (amplitude interquartil: 67,0 - 84,0). Na análise multivariada, índice de choque ≥ 0,90 (RC = 7,76; IC95% 3,14 - 19,21; p < 0,001), níveis de albumina < 2,92g/dL (RC = 3,65; IC95% 1,49 - 8,96; p = 0,005) e níveis de procalcitonina (RC = 1,07, IC95% 1,01 - 1,15; p = 0,045) foram fatores de risco independentes para hipotensão pós-intubação. A mortalidade hospitalar foi semelhante em pacientes com hipotensão pós-intubação e pacientes sem hipotensão pós-intubação (92,5% versus 85,2%; p = 0,29). Conclusão: A incidência de hipotensão pós-intubação foi de 37,5% em pacientes críticos com COVID-19. Um índice de choque ≥ 0,90 e níveis de albumina < 2,92g/ dL foram independentemente associados à hipotensão pós-intubação. Além disso, índice de choque ≥ 0,90 pode ser uma ferramenta do leito antes da intubação endotraqueal. Neste estudo, a hipotensão pós-intubação não esteve associada ao aumento da mortalidade hospitalar em pacientes com COVID-19.

ABSTRACT Objective: To evaluate the incidence of risk factors for postintubation hypotension in critically ill patients with COVID-19. Methods: We conducted a retrospective study of 141 patients with COVID-19 who were intubated in the intensive care unit. Postintubation hypotension was defined as the need for any vasopressor dose at any time within the 60 minutes following intubation. Patients with intubation-related cardiac arrest and hypotension before intubation were excluded from the study. Results: Of the 141 included patients, 53 patients (37.5%) had postintubation hypotension, and 43.6% of the patients (n = 17) were female. The median age of the postintubation hypotension group was 75.0 (interquartile range: 67.0 - 84.0). In the multivariate analysis, shock index ≥ 0.90 (OR = 7.76; 95%CI 3.14 - 19.21; p < 0.001), albumin levels < 2.92g/dL (OR = 3.65; 95%CI 1.49 - 8.96; p = 0.005), and procalcitonin levels (OR = 1.07, 95%CI 1.01 - 1.15; p = 0.045) were independent risk factors for postintubation hypotension. Hospital mortality was similar in patients with postintubation hypotension and patients without postintubation hypotension (92.5% versus 85.2%; p = 0.29). Conclusion: The incidence of postintubation hypotension was 37.5% in critically ill COVID-19 patients. A shock index ≥ 0.90 and albumin levels < 2.92g/dL were independently associated with postintubation hypotension. Furthermore, a shock index ≥ 0.90 may be a practical tool to predict the increased risk of postintubation hypotension in bedside scenarios before endotracheal intubation. In this study, postintubation hypotension was not associated with increased hospital mortality in COVID-19 patients.

Clinical characteristics and risk factors for 28-day mortality in critically ill patients with COVID-19: a retrospective cohort study

Background: To date, the coronavirus disease 2019 (COVID-19) caused more than 2.6 million deaths all around the world. Risk factors for mortality remain unclear. The primary aim was to determine the independent risk factors for 28-day mortality. Materials and methods: In this retrospective cohort study, critically ill patients (≥ 18 years) who were admitted to the intensive care unit due to COVID-19 were included. Patient characteristics, laboratory data, radiologic findings, treatments, and complications were analyzed in the study. Results: A total of 249 patients (median age 71, 69.1% male) were included in the study. 28-day mortality was 67.9% (n = 169). The median age of deceased patients was 75 (66­81). Of them, 68.6% were male. Cerebrovascular disease, dementia, chronic kidney disease, and malignancy were significantly higher in the deceased group. In the multivariate analysis, sepsis/septic shock (OR, 15.16, 95% CI, 3.96­58.11, p < 0.001), acute kidney injury (OR, 4.73, 95% CI, 1.55­14.46, p = 0.006), acute cardiac injury (OR, 9.76, 95% CI, 1.84­51.83, p = 0.007), and chest CT score higher than 15 (OR, 4.49, 95% CI, 1.51-13.38, p = 0.007) were independent risk factors for 28-day mortality. Conclusion: Early detection of the risk factors and the use of chest CT score might improve the outcomes in patients with COVID-19.

Effects of Oral pH Changes on Smoking Desire.

BACKGROUND: Nicotine addiction is associated with nicotine absorption from the buccal mucosa, and it is stated that the main factor that determines nicotine absorption is saliva pH. In the literature, the effects of changes in saliva pH values after eating and drinking on smoking desire in smokers were not questioned. AIM: To show the effect of saliva pH changes on smoking desire. The secondary aim was to show the impact of coffee and water drinking on saliva pH and smoking on oral-dental health (oral hygiene and gingival bleeding). STUDY DESIGN: Case-control study. METHODS: A questionnaire was administered that included "Sociodemographic Data Form" and smoking history and Fagerström Test for Nicotine Dependence (FTND). Oral and dental examinations were performed with mirror sonds and using oral hygiene standard Silness and Leöe plaque index and DMFT Index (Index of Decayed Missing or Filled Teeth). Untreated saliva samples were taken, and baseline saliva flow rate and pH values were measured. To assess pH changes, saliva pH was remeasured after sugar-free instant coffee and water consumption. Smoking desire was evaluated with the Visual Analog Scale (VAS). RESULTS: In this study, 24 (55.8%) females and 19 (44.2%) males were among the 43 smoking and 39 nonsmoking cases. Smoking was significantly associated with poor oral hygiene (in smokers 4.71 (±1.40), in non-smokers 2.30 (±1.59); P < .01). DMFT index was higher in smokers than in non-smokers (in smokers 6.45 (±3.69), in non-smokers 3.87 (±2.67); P < .01). Gingival bleeding was more prevalent in smokers (0.68 (±0.76)) than non-smokers (1.20 (±0.90); P = .009). Salivary flow rates were lower in smokers (in smokers 2.56 (±1.34), in non-smokers 3.00 (±1.22), P = .06). In both groups, pH values increased after coffee consumption and decreased after water; in smokers basal: 6.67 (±0.41), pH coffee: 6.93 (±0.36), pH water: 6.85 (±0.33); in non-smokers pH basal: 6.84 (±0.37), pH coffee: 7.02 (±0.37), pH water: 6.97 (±0.31), P < .01. The VAS values of smokers at basal 4.73 (±3.21); P < 0.01, after coffee consumption 4.91 (±3.08); P < .01, and after water 3.15 (±2.72); P < .01. CONCLUSION: The saliva pH increased after coffee consumption and decreased after drinking water. Besides, VAS values decreased significantly after drinking water. The results suggest that a simple behavior such as drinking water may be used in conjunction with behavioral and cognitive therapies to pursue smoking cessation.

The predictors of COVID-19 mortality in a nationwide cohort of Turkish patients.

The COVID-19-related death rate varies between countries and is affected by various risk factors. This multicenter registry study was designed to evaluate the mortality rate and the related risk factors in Turkey. We retrospectively evaluated 1500 adults with COVID-19 from 26 centers who were hospitalized between March 11 and July 31, 2020. In the study group, 1041 and 459 cases were diagnosed as definite and highly probable cases, respectively. There were 993 PCR-positive cases (66.2%). Among all cases, 1144 (76.3%) were diagnosed with non-severe pneumonia, whereas 212 (14.1%) had severe pneumonia. Death occurred in 67 patients, corresponding to a mortality rate of 4.5% (95% CI:3.5-5.6). The univariate analysis demonstrated that various factors, including male sex, age ≥65 years and the presence of dyspnea or confusion, malignity, chronic obstructive lung disease, interstitial lung disease, immunosuppressive conditions, severe pneumonia, multiorgan dysfunction, and sepsis, were positively associated with mortality. Favipiravir, hydroxychloroquine and azithromycin were not associated with survival. Following multivariate analysis, male sex, severe pneumonia, multiorgan dysfunction, malignancy, sepsis and interstitial lung diseases were found to be independent risk factors for mortality. Among the biomarkers, procalcitonin levels on the 3rd-5th days of admission showed the strongest associations with mortality (OR: 6.18; 1.6-23.93). This study demonstrated that the mortality rate in hospitalized patients in the early phase of the COVID-19 pandemic was a serious threat and that those patients with male sex, severe pneumonia, multiorgan dysfunction, malignancy, sepsis and interstitial lung diseases were at increased risk of mortality; therefore, such patients should be closely monitored.

Remdesivir for severe covid-19: a clinical practice guideline.

CLINICAL QUESTION: What is the role of remdesivir in the treatment of severe covid-19? This guideline was triggered by the ACTT-1 trial published in the New England Journal of Medicine on 22 May 2020. CURRENT PRACTICE: Remdesivir has received worldwide attention as a potentially effective treatment for severe covid-19. After rapid market approval in the US, remdesivir is already being used in clinical practice. RECOMMENDATIONS: The guideline panel makes a weak recommendation for the use of remdesivir in severe covid-19 while recommending continuation of active enrolment of patients into ongoing randomised controlled trials examining remdesivir. HOW THIS GUIDELINE WAS CREATED: An international panel of patients, clinicians, and methodologists produced these recommendations in adherence with standards for trustworthy guidelines using the GRADE approach. The recommendations are based on a linked systematic review and network meta-analysis. The panel considered an individual patient perspective and allowed contextual factors (such as resources) to be taken into account for countries and healthcare systems. THE EVIDENCE: The linked systematic review (published 31 Jul 2020) identified two randomised trials with 1300 participants, showing low certainty evidence that remdesivir may be effective in reducing time to clinical improvement and may decrease mortality in patients with severe covid-19. Remdesivir probably has no important effect on need for invasive mechanical ventilation. Remdesivir may have little or no effect on hospital length of stay. UNDERSTANDING THE RECOMMENDATION: Most patients with severe covid-19 would likely choose treatment with remdesivir given the potential reduction in time to clinical improvement. However, given the low certainty evidence for critical outcomes and the fact that different perspectives, values, and preferences may alter decisions regarding remdesivir, the panel issued a weak recommendation with strong support for continued recruitment in randomised trials.

The use of bronchoscopy in critically ill patients: considerations and complications.

INTRODUCTION: Flexible bronchoscopy has been well established for diagnostic and therapeutic purposes in critically ill patients. Areas covered: This review outlines the clinical evidence of the utility and safety of flexible bronchoscopy in the intensive care unit, as well as specific considerations, including practical points and potential complications, in critically ill patients. Expert commentary: Its ease to learn and perform and its capacity for bedside application with relatively few complications make flexible bronchoscopy an indispensable tool in the intensive care unit setting. The main indications for flexible bronchoscopy in the intensive care unit are the visualization of the airways, sampling for diagnostic purposes and management of the artificial airways. The decision to perform flexible bronchoscopy can only be made by trade-offs between potential risks and benefits because of the fragile nature of the critically ill. Flexible bronchoscopy-associated serious adverse events are inevitable in cases of a lack of expertise or appropriate precautions.

Occupational Risk Factors and the Relationship of Smoking with Anxiety and Depression.

OBJECTIVES: The aim of the present study was to evaluate the relation of smoking with anxiety and depression in workers who were exposed to occupational risk factors. For this purpose, working time, smoking status, nicotine dependence, and respiratory functions of the workers who were exposed to physical and/or chemical harmful substances were evaluated and the presence of anxiety/depression was investigated. MATERIAL AND METHODS: Male workers who were exposed to occupational risk factors such as solvents, heavy metals, and dust and visited the outpatient clinic for occupational diseases within a one-year period were included. Pulmonary Function Test and Fagerström Test for Nicotine Dependence were performed. Anxiety and depression statuses of the workers were assessed using the Hospital Anxiety and Depression Scale. RESULTS: The mean age of 665 male workers was 45 y (range, 38-48 y), and they were most commonly exposed to solvents (45.9%), followed by heavy metal fume/dust (20.9%). Of the workers, 252 (37.9%) had anxiety, 294 (44.2%) had depression, and 171 (25.7%) had both. More than half of the workers in each occupation/exposure group were smokers. Respiratory complaints were present in 34% of the workers. According to the regression analysis, the presence of respiratory system complaints was found to be a significant risk factor for anxiety, depression, and anxiety plus depression. CONCLUSION: In conclusion, smoking and anxiety/depression were found to be the conditions affecting more than half of the workers with occupational exposure.

Long-Term Oxygen Therapy in COPD Patients Who Do Not Meet the Actual Recommendations.

Chronic respiratory failure due to chronic obstructive pulmonary disease (COPD) is an increasing problem worldwide. Many patients with severe COPD develop hypoxemic respiratory failure during the natural progression of disease. Long-term oxygen therapy (LTOT) is a well-established supportive treatment for COPD and has been shown to improve survival in patients who develop chronic hypoxemic respiratory failure. The degree of hypoxemia is severe when partial pressure of oxygen in arterial blood (PaO2) is ≤55 mmHg and moderate if PaO2 is between 56 and 69 mmHg. Although current guidelines consider LTOT only in patients with severe resting hypoxemia, many COPD patients with moderate to severe disease experience moderate hypoxemia at rest or during special circumstances, such as while sleeping or exercising. The efficacy of LTOT in these patients who do not meet the actual recommendations is still a matter of debate, and extensive research is still ongoing to understand the possible benefits of LTOT for survival and/or functional outcomes such as the sensation of dyspnea, exacerbation frequency, hospitalizations, exercise capacity, and quality of life. Despite its frequent use, the administration of "palliative" oxygen does not seem to improve dyspnea except for delivery with high-flow humidified oxygen. This narrative review will focus on current evidence for the effects of LTOT in the presence of moderate hypoxemia at rest, during sleep, or during exercise in COPD.

High-Resolution Computed Tomography and Pulmonary Function Findings of Occupational Arsenic Exposure in Workers.

BACKGROUND: The number of studies where non-malignant pulmonary diseases are evaluated after occupational arsenic exposure is very few. AIMS: To investigate the effects of occupational arsenic exposure on the lung by high-resolution computed tomography and pulmonary function tests. STUDY DESIGN: Retrospective cross-sectional study. METHODS: In this study, 256 workers with suspected respiratory occupational arsenic exposure were included, with an average age of 32.9±7.8 years and an average of 3.5±2.7 working years. Hair and urinary arsenic levels were analysed. High-resolution computed tomography and pulmonary function tests were done. RESULTS: In workers with occupational arsenic exposure, high-resolution computed tomography showed 18.8% pulmonary involvement. In pulmonary involvement, pulmonary nodule was the most frequently seen lesion (64.5%). The other findings of pulmonary involvement were 18.8% diffuse interstitial lung disease, 12.5% bronchiectasis, and 27.1% bullae-emphysema. The mean age of patients with pulmonary involvement was higher and as they smoked more. The pulmonary involvement was 5.2 times higher in patients with skin lesions because of arsenic. Diffusing capacity of lung for carbon monoxide was significantly lower in patients with pulmonary involvement. CONCLUSION: Besides lung cancer, chronic occupational inhalation of arsenic exposure may cause non-malignant pulmonary findings such as bronchiectasis, pulmonary nodules and diffuse interstitial lung disease. So, in order to detect pulmonary involvement in the early stages, workers who experience occupational arsenic exposure should be followed by diffusion test and high-resolution computed tomography.

A rare cause of noninvasive ventilation failure: tracheal stenosis.

Noninvasive ventilation is the first line treatment of choice in acute respiratory failure in many diseases including post-extubation respiratory failure. Herein we report a case unresponsive to noninvasive ventilation due to tracheal stenosis. A 49- year -old female was admitted to intensive care unit after successful resuscitation of cardiac arrest. During the follow-up, she was extubated on 16th day and then transferred to the coronary ward. Four days later, she started to have progressive dyspnea and difficulty in breathing. Arterial blood gas evaluation showed respiratory acidosis with moderate hypercapnia. Noninvasive ventilation was initiated with the diagnosis of cardiogenic pulmonary edema however she did not respond to noninvasive ventilation therapy. Pulmonary consultation revealed that she had a new onset stridor. She had an urgent fiberoptic bronchoscopy which revealed severe tracheal stenosis. Tracheal stenosis should be considered in patients who do not respond to noninvasive ventilation after extubation like in our case.