Obstructive Sleep Apnea and Risk of COVID-19 Infection, Hospitalization and Respiratory Failure.

PURPOSE: To study the relationship between OSA and risk of COVID-19 infection and disease severity, identified by the need for hospitalization and progression to respiratory failure. METHODS: We queried the electronic medical record system for an integrated health system of 10 hospitals in the Chicago metropolitan area to identify cases of COVID-19. Comorbidities and outcomes were ascertained by ICD-10-CM coding and medical record data. We evaluated the risk for COVID-19 diagnosis, hospitalization, and respiratory failure associated with OSA by univariate tests and logistic regression, adjusting for diabetes, hypertension, and BMI to account for potential confounding in the association between OSA, COVID-19 hospitalization, and progression to respiratory failure. RESULTS: We identified 9405 COVID-19 infections, among which 3185 (34%) were hospitalized and 1779 (19%) were diagnosed with respiratory failure. OSA was more prevalent among patients requiring hospitalization than those who did not (15.3% versus 3.4%, p < 0.0001; OR 5.20, 95% CI (4.43, 6.12)), and among those who progressed to respiratory failure (19.4% versus 4.5%, p < 0.0001; OR 5.16, 95% CI (4.41, 6.03)). After adjustment for diabetes, hypertension, and BMI, OSA was associated with increased risk for hospitalization (OR 1.65; 95% CI (1.36, 2.02)) and respiratory failure (OR 1.98; 95% CI (1.65, 2.37)). CONCLUSIONS: Patients with OSA experienced approximately 8-fold greater risk for COVID-19 infection compared to a similar age population receiving care in a large, racially, and socioeconomically diverse healthcare system. Among patients with COVID-19 infection, OSA was associated with increased risk of hospitalization and approximately double the risk of developing respiratory failure.

Comparison between Two Inspiratory Muscle Training Protocols, Low Loads versus High Loads, in Institutionalized Elderly Women: A Double-Blind Randomized Controlled Trial.

BACKGROUND: Aging results in a decline in the function of the respiratory muscles. Inspiratory muscle training is presented as a possible solution to attenuate the loss of respiratory function in the elderly. The objective of the study was to evaluate and compare the efficacy of 2 protocols with inspiratory muscle training (IMT), low loads and high loads, to improve respiratory strength, functional capacity and dyspnea in institutionalized elderly women, over 65 years. METHODS: The study was a controlled, randomized, double-blind trial and with allocation concealment performed on 26 institutionalized elderly women distributed in 2 groups, the high-intensity group (HIG) and low-intensity group (LIG). Over an 8-week period an IMT protocol was followed 5 days/week, 15 min/day. The HIG trained with a load of 40% of the maximum inspiratory pressure (MIP) and the LIG with 20%. MIP, maximum expiratory pressure (MEP), functional capacity and dyspnea were evaluated. RESULTS: After training, in the HIG MIP, MEP and functional capacity increased 52, 16 and 7%, respectively (p = 0.000, p = 0.001, p = 0.001) and in the LIG 30, 18 and 9%, respectively (p = 0.002, p = 0.014, p = 0.001). The improvement in MIP was significantly higher in the HIG than in the LIG (p = 0.042). CONCLUSION: IMT with low and high loads improves respiratory muscle strength and functional capacity in institutionalized elderly women. In addition, high loads were significantly more effective to improve MIP.

Micronutrients as immunomodulatory tools for COVID-19 management.

COVID-19 rapidly turned to a global pandemic posing lethal threats to overwhelming health care capabilities, despite its relatively low mortality rate. The clinical respiratory symptoms include dry cough, fever, anosmia, breathing difficulties, and subsequent respiratory failure. No known cure is available for COVID-19. Apart from the anti-viral strategy, the supports of immune effectors and modulation of immunosuppressive mechanisms is the rationale immunomodulation approach in COVID-19 management. Diet and nutrition are essential for healthy immunity. However, a group of micronutrients plays a dominant role in immunomodulation. The deficiency of most nutrients increases the individual susceptibility to virus infection with a tendency for severe clinical presentation. Despite a shred of evidence, the supplementation of a single nutrient is not promising in the general population. Individuals at high-risk for specific nutrient deficiencies likely benefit from supplementation. The individual dietary and nutritional status assessments are critical for determining the comprehensive actions in COVID-19.

Safe chest tube placement in a patient with tension pneumothorax receiving rivaroxaban therapy for non-valvular atrial fibrillation.

The number of patients treated with direct oral anticoagulants is increasing worldwide. Although bleeding complications associated with direct oral anticoagulants are lower than those associated with vitamin K antagonists, the increased number of patients treated with these anticoagulants suggests that a higher absolute number of patients are at risk. Tube thoracostomy is an invasive procedure with a high risk of bleeding. To date, among direct oral anticoagulants, only dabigatran has a well-studied antidote to reverse its effects during emergency procedure or surgery. This report describes a case in which emergency placement of a tube thoracostomy, in a patient with type 2 respiratory failure due to left tension pneumothorax and receiving the anticoagulant rivaroxaban, in the pharmacokinetics phase with greater anticoagulant effect, did not result in bleeding greater than that typically encountered during such interventions. The procedure ended successfully with no acute complications.

Vaping-Associated Acute Respiratory Failure Due to Acute Lipoid Pneumonia.

Electronic cigarettes, pens, cartridges and other devices were developed as nicotine delivery systems not requiring combustion of tobacco leaves. This technology was subsequently employed to deliver the cannabis component tetrahydrocannabinol (THC) via products often manufactured without adequate quality oversight and sold illegally. Recently, five patients presenting within a 2-month period with acute respiratory failure due to acute lipoid pneumonia after inhaling THC-containing concentrates or oils have been described. We report a 28-year-old previously healthy man who presented in acute respiratory failure 2 weeks after initiating use of a street-purchased THC-containing vape cartridge. Bronchoalveolar lavage cytology with oil red O staining confirmed the diagnosis of acute lipoid pneumonia. Diffuse alveolar hemorrhage and eosinophilic pneumonia were excluded. Evolving evidence supports a clinical entity of acute respiratory failure due to acute, exogenous lipoid pneumonia induced by THC-containing concentrates or oils inhaled through a variety of vaping products. All six patients reported to date received intravenous corticosteroids and survived to hospital discharge.

Acquired acrodermatitis enteropathica due to zinc-depleted parenteral nutrition.

Well-known causes of zinc deficiency, also referred to as acrodermatitis enteropathica (AE), include defects in intestinal zinc transporters and inadequate intake, but a rare cause of acquired zinc deficiency discussed here is an iatrogenic nutritional deficiency caused by parenteral nutrition administered without trace elements. While zinc-depleted parenteral nutrition causing dermatosis of acquired zinc deficiency was first reported in the 1990s, it is now again relevant due to a national vitamin and trace element shortage. A high index of suspicion may be necessary to diagnose zinc deficiency, particularly because early clinical findings are nonspecific. We present this case of acquired zinc deficiency in a patient admitted to a pediatric intensive care unit for respiratory distress and atypical pneumonia, who subsequently developed a severe bullous eruption due to iatrogenic zinc deficiency but was treated effectively with enteral and parenteral zinc supplementation, allowing for rapid re-epithelialization of previously denuded skin.

Interhospital ECMO Transport: Regional Focus.

Utilization of extracorporeal membrane oxygenation (ECMO) has increased dramatically over the last decade. Despite this trend, many medical centers have limited, if any, access to this technology or the resources necessary to manage these complex patients. In an effort to improve the current infrastructure of regional ECMO care, ECMO centers of excellence have an obligation to partner with facilities within their communities and regions to increase access to this potentially life-saving technology. While the need for this infrastructure is widely acknowledged in the ECMO community, few reports describe the actual mechanisms by which a successful interfacility transport program can operate. As such, the purpose of this document is to describe the elements of and methods for providing safe and efficient mobile ECMO services from the perspective of an experienced, high-volume tertiary ECMO center of excellence in the Southeastern United States.

Temporary transvenous diaphragm pacing vs. standard of care for weaning from mechanical ventilation: study protocol for a randomized trial.

BACKGROUND: Mechanical ventilation (MV) is a life-saving technology that restores or assists breathing. Like any treatment, MV has side effects. In some patients it can cause diaphragmatic atrophy, injury, and dysfunction (ventilator-induced diaphragmatic dysfunction, VIDD). Accumulating evidence suggests that VIDD makes weaning from MV difficult, which involves increased morbidity and mortality. METHODS AND ANALYSIS: This paper describes the protocol of a randomized, controlled, open-label, multicenter trial that is designed to investigate the safety and effectiveness of a novel therapy, temporary transvenous diaphragm pacing (TTVDP), to improve weaning from MV in up to 88 mechanically ventilated adult patients who have failed at least two spontaneous breathing trials over at least 7 days. Patients will be randomized (1:1) to TTVDP (treatment) or standard of care (control) groups. The primary efficacy endpoint is time to successful extubation with no reintubation within 48 h. Secondary endpoints include maximal inspiratory pressure and ultrasound-measured changes in diaphragm thickness and diaphragm thickening fraction over time. In addition, observational data will be collected and analyzed, including 30-day mortality and time to discharge from the intensive care unit and from the hospital. The hypothesis to be tested postulates that more TTVDP patients than control patients will be successfully weaned from MV within the 30 days following randomization. DISCUSSION: This study is the first large-scale clinical trial of a novel technology (TTVDP) aimed at accelerating difficult weaning from MV. The technology tested provides the first therapy directed specifically at VIDD, an important cause of delayed weaning from MV. Its results will help delineate the place of this therapeutic approach in clinical practice and help design future studies aimed at defining the indications and benefits of TTVDP. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03096639 . Registered on 30 March 2017.

Thyrotoxic periodic paralysis complicated by life-threatening acute hypercapnic respiratory failure in a Chinese male with painless thyroiditis.

CONTEXT: Thyrotoxic periodic paralysis (TPP) is a relatively common complication seen in Asian hyperthyroid patients. However, it is a rare occurrence to find a TPP case comprised of acute hypercapnic respiratory failure in patients with painless thyroiditis. PATIENT: A 29-year-old Chinese man presented with flaccid paralysis of all four limbs and he was brought to emergency room. Severe hypokalemia was found on admission. Although treatment had been initiated with potassium chloride supplementation, he went on to develop acute hypercapnic respiratory failure likely due to muscle fatigue. The patient was intubated for mechanical ventilatory support. Once his serum potassium levels were normalized, he was able to be weaned off ventilator support. Thyroid function tests showed elevated free thyroxine concentration and low thyroid-stimulating hormone concentration. He underwent a thyroid uptake scan with 131I which revealed decreased uptake rate of thyroid area. Based on the patient's clinical presentation and associated findings, we diagnosed him with TPP due to painless thyroiditis. We have reviewed TPP cases caused by painless thyroiditis and TPP cases associated with acute hypercapnic respiratory failure. CONCLUSION: It is important to note that potentially fatal complications such as acute hypercapnic respiratory failure might occur in acute attacks of TPP even in cases of TPP due to painless thyroiditis.

Anticoagulant rodenticide toxicosis causing tracheal collapse in 4 small breed dogs.

OBJECTIVE: To describe 4 cases of tracheal narrowing attributed to tracheal mucosal hemorrhage caused by anticoagulant rodenticide toxicity in breeds predisposed to tracheal collapse. CASE SUMMARY: Over the years 2005-2014, 4 dogs were presented for respiratory distress secondary to diffuse tracheal narrowing. All dogs had possible anticoagulant rodenticide ingestion and prolonged prothrombin time. All dogs received fresh-frozen plasma transfusions, vitamin K1 supplementation, and supportive care. Tracheal narrowing improved on follow-up radiographs in 3 of 4 patients. One of 4 did not have follow-up radiographs performed. All dogs survived. NEW OR UNIQUE INFORMATION PROVIDED: Anticoagulant rodenticide toxicity causing clinical signs consistent with tracheal collapse is a rare but recognized phenomenon that has not been previously reported in breeds prone to tracheal collapse.

How New Support Devices Change Critical Care Delivery.

Mechanical support devices are used to support failing cardiac, respiratory, or both systems. Since Gibbon developed the cardiopulmonary bypass in 1953, collaborative efforts by medical centers, bioengineers, industry, and the National Institutes of Health have led to development of mechanical devices to support heart, lung, or both. These devices are used as a temporary or long-term measures for acute collapse of circulatory system and/or respiratory failure. Patients are managed on these support devices as a bridge to recovery, bridge to long term devices, or bridge to transplant. The progress in development of these devices has improved mortality and quality of life in select groups of patients. Care of these patients requires a multidisciplinary team approach, which includes cardiac surgeons, critical care physicians, cardiologists, pulmonologists, nursing staff, and perfusionists. Using a team approach improves outcomes in these patients.

Analytic Morphomics Predict Outcomes After Lung Transplantation.

BACKGROUND: The purpose of this study was to identify morphomic factors on standard, pretransplantation computed tomography (CT) scans associated with outcomes after lung transplantation. METHODS: A retrospective review of 200 patients undergoing lung transplantation at a single institution from 2003 to 2014 was performed. CT scans obtained within 1 year before transplantation underwent morphomic analysis. Morphomic characteristics included lung, dorsal muscle group, bone, and subcutaneous and visceral fat area and density. Patient data were gathered from institutional and United Network for Organ Sharing databases. Outcomes, including initial ventilator support greater than 48 hours, length of stay, and survival, were evaluated using univariate and multivariable analyses. RESULTS: On multivariable Cox regression, subcutaneous fat/total body area (hazard ratio [HR] 0.60, p = 0.001), lung density 3 volume (HR 0.67, p = 0.013), and creatinine (HR 4.37, p = 0.010) were independent predictors of survival. Initial ventilator support more than 48 hours was associated with decreased vertebral body to linea alba distance (odds ratio [OR] 0.49, p = 0.002) and Zubrod score 4 (OR 14.0, p < 0.001). Increased bone mineral density (p < 0.001) and increased cross-sectional body area (p < 0.001) were associated with decreased length of stay, whereas supplemental oxygen (p < 0.001), bilateral transplantation (p = 0.002), cardiopulmonary bypass (p < 0.001), and Zubrod score 3 (p < 0.001) or 4 (p = 0.040) were associated with increased length of stay. CONCLUSIONS: Morphomic factors associated with lower metabolic reserve and frailty, including decreased subcutaneous fat, bone density, and body dimensions were independent predictors of survival, prolonged ventilation, and increased length of stay. Analytic morphomics using pretransplantation CT scans may improve recipient selection and risk stratification.

Diaphragm Dysfunction in Critical Illness.

The diaphragm is the major muscle of inspiration, and its function is critical for optimal respiration. Diaphragmatic failure has long been recognized as a major contributor to death in a variety of systemic neuromuscular disorders. More recently, it is increasingly apparent that diaphragm dysfunction is present in a high percentage of critically ill patients and is associated with increased morbidity and mortality. In these patients, diaphragm weakness is thought to develop from disuse secondary to ventilator-induced diaphragm inactivity and as a consequence of the effects of systemic inflammation, including sepsis. This form of critical illness-acquired diaphragm dysfunction impairs the ability of the respiratory pump to compensate for an increased respiratory workload due to lung injury and fluid overload, leading to sustained respiratory failure and death. This review examines the presentation, causes, consequences, diagnosis, and treatment of disorders that result in acquired diaphragm dysfunction during critical illness.

Nasal high flow therapy: a novel treatment rather than a more expensive oxygen device.

Nasal high flow is a promising novel oxygen delivery device, whose mechanisms of action offer some beneficial effects over conventional oxygen systems. The administration of a high flow of heated and humidified gas mixture promotes higher and more stable inspiratory oxygen fraction values, decreases anatomical dead space and generates a positive airway pressure that can reduce the work of breathing and enhance patient comfort and tolerance. Nasal high flow has been used as a prophylactic tool or as a treatment device mostly in patients with acute hypoxaemic respiratory failure, with the majority of studies showing positive results. Recently, its clinical indications have been expanded to post-extubated patients in intensive care or following surgery, for pre- and peri-oxygenation during intubation, during bronchoscopy, in immunocompromised patients and in patients with "do not intubate" status. In the present review, we differentiate studies that suggest an advantage (benefit) from other studies that do not suggest an advantage (no benefit) compared to conventional oxygen devices or noninvasive ventilation, and propose an algorithm in cases of nasal high flow application in patients with acute hypoxaemic respiratory failure of almost any cause.

Acute Hypoxemic Respiratory Failure With Hemoptysis in a Dog Exposed to Copper Sulfate Powder.

A 2-year-old male mongrel dog was presented because of the onset of dry cough. About 16 hours before, the dog had been exposed to the pesticide that the owner was spraying in the vineyard. Approximately 3 hours later an acute respiratory failure, with a rapid evolution, began. Hemoptysis and regenerative normocytic normochromic anemia arose within hours, and a pulmonary hemorrhage was diagnosed. Pulmonary hemorrhage fast led to pneumonia, as evidenced by the serial CXR findings and the developing of leukocytosis. The hypothesis that we believe more likely is that the dog inhaled an amount of copper sulfate powder enough to determine respiratory tree damage, extending from the trachea to the pulmonary alveoli. Oxygen supplementation, antibiotics, antioxidant, and gastroprotective medications had been administered. After 4 days of hospitalization the dog was discharged. After a follow-up of more than 2 years later, the dog is still alive and in good health. To the authors knowledge no evidences of acute pulmonary involvement after copper sulfate inhalation exist in any species. This report is a contribution to the knowledge of copper poisoning, scarcely mentioned both in human and veterinary literature, and which has never been described in companion animals.

Intravenous Poison Hemlock Injection Resulting in Prolonged Respiratory Failure and Encephalopathy.

BACKGROUND: Poison hemlock (Conium maculatum) is a common plant with a significant toxicity. Data on this toxicity is sparse as there have been few case reports and never a documented poisoning after intravenous injection. OBJECTIVES: We present a case of intravenous poison hemlock injection encountered in the emergency department. CASE REPORT: We describe a 30-year-old male who presented to the emergency department after a brief cardiac arrest after injecting poison hemlock. The patient had return of spontaneous circulation in the emergency department but had prolonged muscular weakness and encephalopathy later requiring tracheostomy. CONCLUSION: Intravenous injection of poison hemlock alkaloids can result in significant toxicity, including cardiopulmonary arrest, prolonged weakness, and encephalopathy.

Using a Sniff Controller to Self-Trigger Abdominal Functional Electrical Stimulation for Assisted Coughing Following Cervical Spinal Cord Lesions.

Individuals with cervical spinal cord lesions (SCLs) typically depend on caregivers to manually assist in coughing by pressing against their abdominal wall. Coughing can also be assisted by functional electric stimulation (FES) applied to abdominal muscles via surface electrodes. Efficacy of FES, however, depends on precise temporal synchronization. The sniff controller is a trigger that enables paralyzed individuals to precisely control external devices through alterations in nasal airflow. We hypothesized that FES self-triggering by sniff controller may allow for effective cough timing. After optimizing parameters in 16 able-bodied subjects, we measured peak expiratory flow (PEF) in 14 subjects with SCL who coughed with or without assistance. Assistance was either manual assistance of a caregiver, caregiver activated FES, button self-activated FES (for SCL participants who could press a button), or sniff-controlled self-activated FES. We found that all assisted methods provided equally effective improvements, increasing PEF on average by 25 ± 27% (F[4,52] = 7.99, p = 0.00004 ). There was no difference in efficacy between methods of assistance ( F[3,39] = 0.41, p = 0.75 ). Notably, sniff-controlled FES was the only method of those tested that can be activated by all paralyzed patients alone. This provides for added independence that is a critical factor in quality of life following SCL.