Intravenous Doxycycline, Azithromycin, or Both for Severe Scrub Typhus.

BACKGROUND: The appropriate antibiotic treatment for severe scrub typhus, a neglected but widespread reemerging zoonotic infection, is unclear. METHODS: In this multicenter, double-blind, randomized, controlled trial, we compared the efficacy of intravenous doxycycline, azithromycin, or a combination of both in treating severe scrub typhus. Patients who were 15 years of age or older with severe scrub typhus with at least one organ involvement were enrolled. The patients were assigned to receive a 7-day course of intravenous doxycycline, azithromycin, or both (combination therapy). The primary outcome was a composite of death from any cause at day 28, persistent complications at day 7, and persistent fever at day 5. RESULTS: Among 794 patients (median age, 48 years) who were included in the modified intention-to-treat analysis, complications included those that were respiratory (in 62%), hepatic (in 54%), cardiovascular (in 42%), renal (in 30%), and neurologic (in 20%). The use of combination therapy resulted in a lower incidence of the composite primary outcome than the use of doxycycline (33% and 47%, respectively), for a risk difference of -13.3 percentage points (95% confidence interval [CI], -21.6 to -5.1; P = 0.002). The incidence with combination therapy was also lower than that with azithromycin (48%), for a risk difference of -14.8 percentage points (95% CI, -23.1 to -6.5; P<0.001). No significant difference was seen between the azithromycin and doxycycline groups (risk difference, 1.5 percentage points; 95% CI, -7.0 to 10.0; P = 0.73). The results in the per-protocol analysis were similar to those in the primary analysis. Adverse events and 28-day mortality were similar in the three groups. CONCLUSIONS: Combination therapy with intravenous doxycycline and azithromycin was a better therapeutic option for the treatment of severe scrub typhus than monotherapy with either drug alone. (Funded by the India Alliance and Wellcome Trust; INTREST Clinical Trials Registry-India number, CTRI/2018/08/015159.).

Dynamic assessment of oropharynx with ultrasonography as a screening tool for obstructive sleep apnea.

Ultrasonography is an easily available and portable tool to assess the dynamic changes in the upper airway and surrounding soft tissue. This study aimed to evaluate the utility of oropharynx ultrasonography as a screening tool for obstructive sleep apnea (OSA). The study sequentially enrolled overweight individuals (body mass index >25 kg/m2 ) and subjected them to OSA screening tools (Berlin questionnaire, Epworth Sleepiness Scale and STOP-Bang scores), ultrasonography of the oropharynx followed by overnight polysomnography. A total of 30 healthy individuals were also recruited as controls. Detailed dynamic and static ultrasonography measurements of the oropharynx and surrounding tissue were done. The diagnostic ability of various ultrasonography parameters to detect OSA was determined using receiver operating characteristic curve analysis. A total of 63 subjects were enrolled, with 33 in the OSA group and 30 in non-OSA overweight group. All baseline characteristics were similar in the two groups. Except for the dynamic measurements of oropharynx (Retropalatal% change-inspiration, retropalatal% change-Muller manoeuvre, retroglossal% change-inspiration, and retroglossal% change-Muller manoeuvre) all other parameters were similar in the OSA and non-OSA overweight subjects. The area under the receiver operating characteristic curve was highest for retropalatal% change-inspiration: 0.989, followed by retropalatal% change-Muller manoeuvre: 0.988. Both were also significant predictors of OSA with odds ratios of 0.338 (p = 0.003; 95% confidence interval [CI] 0.164-0.696) and 0.346 (p = 0.018; 95% CI 0.143-0.837), respectively. Ultrasonography provides a near complete picture of the dynamic changes and collapsibility of the oropharynx and can be an effective tool in screening for OSA.

Utility and timing of the respiratory rate-oxygenation index in the prediction of high-flow oxygen therapy failure in acute hypoxemic respiratory failure of infective etiology: a prospective observational study.

During and following the COVID-19 pandemic, the world has witnessed a surge in high-flow oxygen therapy (HFOT) use. The ability to provide high oxygenation levels with remarkable comfort levels has been the grounds for the same. Despite the advantages, delays in intubation leading to poor overall outcomes have been noticed in subgroups of patients on HFOT. The respiratory rate-oxygenation (ROX) index has been proposed to be a useful indicator to predict HFOT success. In this study, we have examined the utility of the ROX index prospectively in cases of acute hypoxemic respiratory failure (AHRF) due to infective etiologies. A total of 70 participants were screened, and 55 were recruited for the study. The majority of participants were males (56.4%), with diabetes mellitus being the most common comorbidity (29.1%). The mean age of the study subjects was 46.27±15.6 years. COVID-19 (70.9%) was the most common etiology for AHRF, followed by scrub typhus (21.8%). 19 (34.5%) experienced HFOT failure, and 9 (16.4%) subjects died during the study period. Demographic characteristics did not differ between either of the two groups (HFOT success versus failure and survived group versus expired group). The ROX index was significantly different between the HFOT success versus failure group at baseline, 2, 4, 6, 12, and 24 hours. The best cut-offs of the ROX index at baseline and 2 hours were 4.4 (sensitivity 91.7%, specificity 86.7%) and 4.3 (sensitivity 94.4% and specificity 86.7%), respectively. The ROX index was found to be an efficient tool in predicting HFOT failure in cases of AHRF with infective etiology.

Nonsmoker COPD represents a clinically Distinct Phenotype: A Prospective Observational Study.

BACKGROUND: Chronic obstructive lung disease (COPD) has been characterized as a smoker's disease, which has resulted in the usual exclusion of never-smokers from COPD studies. It is now recognized that never-smokers account for nearly one-fourth of all COPD cases, and thus airflow limitation in never-smokers needs further evaluation. Our study aims to elucidate the clinical and physiological aspects of COPD in nonsmokers and to compare smokers and nonsmokers with COPD. MATERIALS AND METHODS: A total of 200 naïve sequential patients with COPD were recruited. The severity of airflow limitation in COPD patients was defined as per Global Initiative for COPD (GOLD) 2019 criteria, and the severity of breathlessness was assessed by the modified Medical Research Council (MRC) dyspnea scale. Data was collected using a patient pro forma, including risk factors for COPD and detailed clinical history. Phenotypic differences along with biomass exposure between never-smokers and smokers were analyzed. RESULTS: Compared to smokers, never-smokers presented at a younger age (55.69 ± 11.5 years; p < 0.001), with a longer duration of dyspnea (5.05 ± 4.96 vs 7.35 ± 6.98 years, p < 0.01). Chest radiographs revealed hyperinflation in a higher number of smokers as compared to never-smokers (82.9 vs 64.6%, p < 0.05). On spirometry evaluation, smokers were found to have significantly poorer lung function [forced expiratory volume in first second (FEV1) 40.36 ± 17.76%; forced vital capacity (FVC): 58.16 ± 17.02%] as compared to never-smokers (FEV1: 47.1 ± 16.47%; FVC: 67.38 ± 17.02%) with p < 0.05. With respect to severity at presentation, most (45.8%) never-smokers presented with stage 2 COPD as compared to the majority of smokers (46.7%) who presented with stage 3 COPD (p-value of <0.05). Absolute eosinophil count (AEC) and eosinophil proportion in total leucocyte count (TLC) was significantly higher in never-smokers as compared to the smokers (232 ± 204.2 vs 309 ± 238.8, p < 0.05). Risk factor analysis showed mean biomass exposure index was significantly higher in never-smokers as compared to smokers (56.02 vs 6.28; p-value of <0.001). CONCLUSION: Compared to smokers, COPD in never-smokers presents at a younger age, with a longer duration of dyspnea and higher eosinophil count. Biomass exposure is one of the major contributors to etiologies for COPD in nonsmokers.

In Response to: Corticosteroids in Non-severe COVID-19: Finding Window of Opportunity.

Nasa P, Chaudhry D. In Response to: Corticosteroids in Non-severe COVID-19: Finding Window of Opportunity. Indian J Crit Care 2022;26(3):405.

Guidelines for the Use of Procalcitonin for Rational Use of Antibiotics.

How to cite this article: Khilnani GC, Tiwari P, Zirpe KG, Chaudhary D, Govil D, Dixit S, et al. Guidelines for the Use of Procalcitonin for Rational Use of Antibiotics. Indian J Crit Care Med 2022;26(S2):S77-S94.

Recommendations for Evaluation and Selection of Deceased Organ Donor: Position Statement of ISCCM.

There is a wide gap between patients who need transplants and the organs that are available in India. Extending the standard donation criterion is certainly important to address the scarcity of organs for transplantation. Intensivists play a major role in the success of deceased donor organ transplants. Recommendations for deceased donor organ evaluation are not discussed in most intensive care guidelines. The purpose of this position statement is to establish current evidence-based recommendations for multiprofessional critical care staff in the evaluation, assessment, and selection of potential organ donors. These recommendations will give "real-world" criteria that are acceptable in the Indian context. The aim of this set of recommendations is to both increase the number and enhance the quality of transplantable organs. How to cite this article: Zirpe KG, Tiwari AM, Pandit RA, Govil D, Mishra RC, Samavedam S, et al. Recommendations for Evaluation and Selection of Deceased Organ Donor: Position Statement of ISCCM. Indian J Crit Care Med 2022;26(S2):S43-S50.

Renal Replacement Therapy in Adult Intensive Care Unit: An ISCCM Expert Panel Practice Recommendation.

Acute kidney injury (AKI) contributes significantly to morbidity and mortality in ICU patients. The cause of AKI may be multifactorial and the management strategies focus primarily on the prevention of AKI along with optimization of hemodynamics. However, those who do not respond to medical management may require renal replacement therapy (RRT). The various options include intermittent and continuous therapies. Continuous therapy is preferred in hemodynamically unstable patients requiring moderate to high dose vasoactive drugs. A multidisciplinary approach is advocated in the management of critically ill patients with multi-organ dysfunction in ICU. However, an intensivist is a primary physician involved in life-saving interventions and key decisions. This RRT practice recommendation has been made after appropriate discussion with intensivists and nephrologists representing diversified critical care practices in Indian ICUs. The basic aim of this document is to optimize renal replacement practices (initiation and management) with the help of trained intensivists in the management of AKI patients effectively and promptly. The recommendations represent opinions and practice patterns and are not based solely on evidence or a systematic literature review. However, various existing guidelines and literature have been reviewed to support the recommendations. A trained intensivist must be involved in the management of AKI patients in ICU at all levels of care, including identifying a patient requiring RRT, writing a prescription and its modification as per the patient's metabolic need, and discontinuation of therapy on renal recovery. Nevertheless, the involvement of the nephrology team in AKI management is paramount. Appropriate documentation is strongly recommended not only to ensure quality assurance but also to help future research as well. How to cite this article: Mishra RC, Sinha S, Govil D, Chatterjee R, Gupta V, Singhal V, et al. Renal Replacement Therapy in Adult Intensive Care Unit: An ISCCM Expert Panel Practice Recommendation. Indian J Crit Care Med 2022;26(S2):S3-S6.

ISCCM Guidelines on Acute Kidney Injury and Renal Replacement Therapy.

Acute kidney injury (AKI) is a complex syndrome with a high incidence and considerable morbidity in critically ill patients. Renal replacement therapy (RRT) remains the mainstay of treatment for AKI. There are at present multiple disparities in uniform definition, diagnosis, and prevention of AKI and timing of initiation, mode, optimal dose, and discontinuation of RRT that need to be addressed. The Indian Society of Critical Care Medicine (ISCCM) AKI and RRT guidelines aim to address the clinical issues pertaining to AKI and practices to be followed for RRT, which will aid the clinicians in their day-to-day management of ICU patients with AKI. How to cite this article: Mishra RC, Sodhi K, Prakash KC, Tyagi N, Chanchalani G, Annigeri RA, et al. ISCCM Guidelines on Acute Kidney Injury and Renal Replacement Therapy. Indian J Crit Care Med 2022;26(S2):S13-S42.

Competencies for Point-of-care Ultrasonography in ICU: An ISCCM Expert Panel Practice Recommendation.

How to cite this article: Srinivasan S, Kumar PG, Govil D, Gupta S, Kumar V, Pichamuthu K, et al. Competencies for Point-of-care Ultrasonography in ICU: An ISCCM Expert Panel Practice Recommendation. Indian J Crit Care Med 2022;26(S2):S7-S12.

Tuberculosis in Intensive Care Unit.

About 3.4% of the hospitalized tubercular patients need admission to the intensive care unit (ICU). Patients requiring ICU admission had a poor prognosis and high mortality rate (60 vs 25%) as compared to other causes of severe pneumonia. The most common indication for tuberculosis-related ICU admission is acute respiratory failure due to pneumonia or acute respiratory distress syndrome (ARDS) (with or without miliary tuberculosis) followed by septic shock with multiple organ dysfunction, adrenal insufficiency, and neurological involvement, especially tubercular meningitis. Tuberculosis patients who require admission to ICU are mostly immunocompromised [human immunodeficiency virus (HIV) coinfection] and have underlying miliary tuberculosis or disseminated tuberculosis. Pulmonary tuberculosis presenting as ARDS is a rare phenomenon, but a most common cause of admission of tuberculosis patients to ICU. Tuberculous meningitis is the most severe form of tuberculosis with mortality more than 60% and residual neurological disability in 25% cases. Tuberculosis-related septic shock has been found in only 1% of all septic shock patients admitted to ICU. Patients with tuberculosis with refractory shock should be suspected for adrenal insufficiency. A trial of physiologic stress replacement dose of hydrocortisone (200-300 mg) should be given to all critically ill patients with vasopressor-dependent shock after correcting other causes. Diagnosis and treatment of tuberculosis in critically ill patients has various challenges, namely appropriate sample collection, issues with the route of administration, drug absorption, bioavailability, dose modification in hepatic and renal dysfunction, and interaction with other drugs. How to cite this article: Chaudhry D, Tyagi D. Tuberculosis in Intensive Care Unit. Indian J Crit Care Med 2021;25(Suppl 2):S150-S154.

Epidemiology of Intensive Care Unit-acquired Infections in a Tertiary Care Hospital of North India.

BACKGROUND: The majority of nosocomial infections in the hospital setting are found in intensive care units (ICUs). The present study was undertaken to determine the incidence, risk factors, causative microorganisms, and outcome of various ICU-acquired infections. MATERIALS AND METHODS: The patients admitted to the ICU of a teaching hospital in North India were prospectively studied. Detailed history, clinical examination, acute physiology and chronic health evaluation score II, simplified acute physiology score II, sequential organ failure assessment score, and baseline investigations were recorded. Patients were assessed daily till 14th day for nosocomial infection as per Centers for Disease Control and Prevention (CDC) guidelines and were followed till death or discharge. Incidence, risk factors, and outcome parameters were calculated using Student t-test, Chi-square test, and stepwise multivariate logistic regression model. RESULTS: The overall incidence rate of ICU infections was 27.9%. The most common ICU-acquired infection was ventilator-associated pneumonia followed by catheter-related bloodstream infection and catheter-associated urinary tract infection. Pseudomonas aeruginosa, Acinetobacter baumannii, and Klebsiella pneumoniae were implicated in most of the infections. ICU length of stay (LOS) >7 days, neurological dysfunction, endotracheal intubation, ischemic heart disease, and use of antacids/H2 blockers were significantly associated with ICU-acquired infections. The mortality rate was 32.8 and 28.8% in patients with and without ICU infections, respectively (p = 0.531). The ICU LOS (19.23 ± 12.79 days) was significantly higher in the ICU infections group (p <0.001). CONCLUSION: Ventilator-associated pneumonia was the most common nosocomial infection in our study. Gram-negative microorganisms were the predominant causative agents for various ICU-acquired infections. Mortality was not found to be affected but ICU LOS was significantly prolonged as a consequence of the development of ICU-acquired infection. HOW TO CITE THIS ARTICLE: Kumar A, Chaudhry D, Goel N, Tanwar S. Epidemiology of Intensive Care Unit-acquired Infections in a Tertiary Care Hospital of North India. Indian J Crit Care Med 2021;25(12):1427-1433.

Correlation of PaCO2 and ETCO2 in COPD Patients with Exacerbation on Mechanical Ventilation.

Introduction: Chronic obstructive pulmonary disease (COPD) patients in hypercapnic respiratory failure require multiple arterial blood gas (ABG) analysis for monitoring. It is a painful, invasive, and expensive investigation. This study was aimed at finding an agreement between end-tidal carbon dioxide (ETCO2, a noninvasive modality) and arterial carbon dioxide (PaCO2) in COPD patients with acute exacerbation on mechanical ventilation. Materials and methods: A prospective observational study was conducted in COPD patients who required mechanical ventilation. ETCO2 was recorded by mainstream capnography along with ABG analysis. An agreement between PaCO2 and ETCO2 was assessed. The effect of various factors on correlation was also studied. Results: A total of 100 patients with COPD in hypercapnic respiratory failure were included. Seventy-three percentage of patients were managed on invasive mechanical ventilation (IMV). The mean ETCO2 and PaCO2 were 48.66 ± 15.57 mm Hg and 75.52 ± 21.9 mm Hg, respectively. There was a significant correlation between PaCO2 and ETCO2 values (r = 0.82, 95% confidence interval of r = 0.78-0.86, p <0.0001). The Bland-Altman analysis shows the mean bias as -19.4 (95% limits of agreement = -40.0-1.1). Pearson's correlation coefficient was 0.84 in intubated patients and 0.58 in patients on noninvasive ventilation (NIV). Pearson's correlation coefficient between PaCO2 and ETCO2 in subjects with consolidation, cardiomegaly, hypotension, and raised pulmonary artery pressures was 0.78, 0.86, 0.85, and 0.86, respectively. Conclusion: Mainstream ETCO2 measurement accurately predicts the PaCO2 in COPD patients on IMV. However, for patients on NIV, ETCO2 is insufficient in monitoring PaCO2 levels due to weak correlation. Clinical significance: ETCO2 can be used as a noninvasive modality in intensive care unit for monitoring the PaCO2 in COPD patients on IMV. This can reduce the requirement of arterial blood sampling to a minimum number, in turn, reducing the cost of the treatment and discomfort to the patients. How to cite this article: Tyagi D, Govindagoudar MB, Jakka S, Chandra S, Chaudhry D. Correlation of PaCO2 and ETCO2 in COPD Patients with Exacerbation on Mechanical Ventilation. Indian J Crit Care Med 2021;25(3):305-309.

Tofacitinib Associated with Reduced Intubation Rates in the Management of Severe COVID-19 Pneumonia: A Preliminary Experience.

BACKGROUND: The second wave of COVID-19 pandemic was not only associated with a rapid and severe surge in the number of cases but also limited availability of recommended medicines. Baricitinib has been known to reduce recovery time in COVID-19 pneumonia in association with remdesivir. Tofacitinib, with limited evidence, was used in severe COVID-19 pneumonia based on its similarity of action with baricitinib. METHODS: Data of all patients admitted to the COVID-19 intensive care unit in the month of April were accessed and analyzed. Data of patients who were on other immunomodulators, invasive ventilation, or suffering from end-stage organ diseases were excluded from the analysis. RESULTS: Out of 73 patients, data of 50 were analyzed. Twenty-five received tofacitinib and the other 25 were managed with standard of care. Age, comorbidities, and gender distribution between the two groups were similar. On day 7 of admission, the change in SpO2/FiO2 ratio was 1.26 ± 1 and 0.72 ± 1 in the tofacitinib group and control group, respectively. Similarly, a higher number of subjects in the control group showed worsening in the World Health Organization (WHO) ordinal scale (36 vs 12%, p = 0.01). The clinical objective improvement was similar in the two groups. The intubation rates in the tofacitinib group were significantly lower than that in the control group (32% vs 8%, p = 0.034). CONCLUSION: Tofacitinib, in this retrospective single-center experience, was found to be associated with reduced intubation rates and reduced worsening in the WHO ordinal scale. There was no difference in mortality in the two groups. HOW TO CITE THIS ARTICLE: Singh PK, Lalwani LK, Govindagoudar MB, Aggarwal R, Chaudhry D, Kumar P, et al. Tofacitinib Associated with Reduced Intubation Rates in the Management of Severe COVID-19 Pneumonia: A Preliminary Experience. Indian J Crit Care Med 2021;25(10):1108-1112.

Expert Consensus Statements on the Use of Corticosteroids in Non-severe COVID-19.

INTRODUCTION: There is strong evidence for the use of corticosteroid in the management of severe coronavirus disease-2019 (COVID-19). However, there is still uncertainty about the timing of corticosteroids. We undertook a modified Delphi study to develop expert consensus statements on the early identification of a subset of patients from non-severe COVID-19 who may benefit from using corticosteroids. METHODS: A modified Delphi was conducted with two anonymous surveys between April 30, 2021, and May 3, 2021. An expert panel of 35 experts was selected and invited to participate through e-mail. The consensus was defined as >70% votes in multiple-choice questions (MCQ) on Likert-scale type statements, while strong consensus as >90% votes in MCQ or >50% votes for "very important" on Likert-scale questions in the final round. RESULTS: Twenty experts completed two rounds of the survey. There was strong consensus for the increased work of breathing (95%), a positive six-minute walk test (90%), thorax computed tomography severity score of >14/25 (85%), new-onset organ dysfunction (using clinical or biochemical criteria) (80%), and C-reactive protein >5 times the upper limit of normal (70%) as the criteria for patients' selection. The experts recommended using oral or intravenous (IV) low-dose corticosteroids (the equivalent of 6 mg/day dexamethasone) for 5-10 days and monitoring of oxygen saturation, body temperature, clinical scoring system, blood sugar, and inflammatory markers for any "red-flag" signs. CONCLUSION: The experts recommended against indiscriminate use of corticosteroids in mild to moderate COVID-19 without the signs of clinical worsening. Oral or IV low-dose corticosteroids (the equivalent of 6 mg/day dexamethasone) for 5-10 days are recommended for patients with features of disease progression based on clinical, biochemical, or radiological criteria after 5 days from symptom onset under close monitoring. HOW TO CITE THIS ARTICLE: How to cite this article: Nasa P, Chaudhry D, Govil D, Daga MK, Jain R, Chhallani AA, et al. Expert Consensus Statements on the Use of Corticosteroids in Non-severe COVID-19. Indian J Crit Care Med 2021;25(11):1280-1285.

Tocilizumab and COVID-19.

The number of cases in COVID-19 pandemic is rising rapidly. There has not been a single effective proven medication for COVID-19 disease. Highest mortality has been reported among subjects who develop acute respiratory disease (ARDS). The histopathological analysis of lung specimens has given rise to theories that propose the major role of cytokine release syndrome in the development of ARDS. IL-6 has often been found to be raised in subjects having severe disease. Tocilizumab is a selective inhibitor of the IL-6 pathway and has been approved for various rheumatological diseases. Its use in COVID-19 has been evaluated following the success of other immunosuppressive drugs like steroids. The data in support of against its use in COVID19 are lacking. Similarly, the risk of early- and late-onset infections after tocilizumab in COVID-19 remains unknown. The study by Nasa et al. is a valuable addition to the evidence concerning its use. Despite multiple articles, its safety and efficacy in COVID-19 remain unknown. Caution must be used about its timing and role of IL-6 levels for disease monitoring. How to cite this article: Chaudhry D, Singh PK. Tocilizumab and COVID-19. Indian J Crit Care Med 2020;24(9):741-743.

Indications for Proning in Acute Respiratory Distress Syndrome: Expanding the Horizon!

BACKGROUND: Previously prone positioning (PP) was described in addition to invasive mechanical ventilation and it has been known to reduced mortality and improve oxygenation in patients of ARDS. Recently novel timing of prone positioning was described with the use of high-frequency nasal cannula (HFNC) and noninvasive ventilation (NIV) in patients of acute respiratory distress syndrome (ARDS) to avoid the intubation. Here we would like to share a case of severe ARDS where prone positioning was used in a step further ahead. CASE DESCRIPTION: A 38-year-old gentleman presented with the complaints of progressive breathlessness, dry cough and fever for 7 days. Patient was diagnosed as a case of H1N1 pneumonia with severe ARDS. Patient was initially managed with invasive mechanical ventilation according to ARDS-Net protocol. Despite persistent hypoxia he was put on prone positioning for consecutive 4 days. Patient was extubated after 10 days of mechanical ventilation and put on HFNC in view of persistent high oxygen requirement. At this point of time, we attempted prone positioning in addition to HFNC. Patient was comfortable on prone position and put himself in the same condition for prolonged periods. His oxygenation showed a remarkable improvement from PaO2 of 63 (before prone positioning) to 136 mm Hg (after prone positioning). Oxygen supplementation was later tapered off and subsequently, he improved and was shifted to ward. CONCLUSION: Prone positioning is a harmless and still extremely effective intervention which can and should be utilized at all steps of ARDS-management. HOW TO CITE THIS ARTICLE: Lalwani LK, Sharma V, Chaudhry D, Singh PK. Indications for Proning in Acute Respiratory Distress Syndrome: Expanding the Horizon! Indian J Crit Care Med 2020;24(7):589-591.

COVID-19: Winter is COMING!

Coronavirus disease-2019 (COVID-19) pandemic has battered the healthcare system of India recently. Though the mortality rate is low but the mortality itself is high. In this issue, dedicated to COVID-19, the authors have presented a concise and directed look at the pieces of evidence for COVID-19. Today, there is a plethora of information available on COVID-19 but the same does not translate into true knowledge. This issue serves as the one-point reference for pieces of evidence on various critical aspects of COVID-19. As winters are approaching and air pollution will again be bothering the healthcare system, these times are vital for preparing ourselves and resources for a long and exhaustive battle. How to cite this article: Chaudhry D, Kumar P, Singh PK, Govindagoudar MB. COVID-19: Winter is COMING! Indian J Crit Care Med 2020;24(Suppl 5):S223-S224.

Modified Barrier Enclosure for Noninvasive Respiratory Support in COVID-19 Outbreak.

AIM: To develop a device that can reduce the exposure of aerosols to healthcare workers (HCWs) who are working in coronavirus disease-2019 (COVID-19) critical units. BACKGROUND: Barrier enclosure has recently been proposed for use during intubations where the risk of aerosolization is high. In COVID-19 outbreak, use of noninvasive respiratory support is increasing. But at the same time, it is associated with high risk of aerosol generation, leading to infections among HCWs. We have made a modification in the intubation box and hence expanded its use with an aim to reduce COVID-19 exposure. TECHNIQUE: Vacuum suction tubing was attached to wall mount, and the other end of tubing was fixed, using adhesive surgical tapes, to the inside of the roof of barrier enclosure. Keeping the vacuum suction switched-on inside the box created a negative pressure while overall air flow is into the box from outside. This led us to believe that aerosols if generated are not contaminating patient's vicinity. Currently, we are using barrier enclosure boxes on all patients who are on noninvasive support (noninvasive ventilation or high-flow oxygen therapy). CONCLUSION AND CLINICAL SIGNIFICANCE: We believe that adding barrier enclosure with the above-mentioned negative-pressure modification will provide an opportunity to use noninvasive support widely, while at the same time, HCW's exposure to aerosols will be reduced. HOW TO CITE THIS ARTICLE: Kumar P, Chaudhry D, Lalwani LK, Singh PK. Modified Barrier Enclosure for Noninvasive Respiratory Support in COVID-19 Outbreak. Indian J Crit Care Med 2020;24(9):835-837.

Ultraviolet Box: An Innovative In-house Use of Ultraviolet Irradiation for Conservation of Respirators in COVID-19 Pandemic.

AIM: To use ultraviolet (UV) radiations in an indigenous method for sterilization of respirators for reuse during COVID-19 outbreak. BACKGROUND: COVID-19 outbreak has infected more than 200 countries. In India, till now, more than 100,000 cases have been reported. Healthcare workers are at high risk of developing infections being in the frontline of taking care of COVDI-19 cases. The demands of personal protective equipment (PPE) are increasing, but the same is not matched with supply due to various reasons. In such scenarios, reusing respirators and face shields is an alternative. UV radiations have quick action and are able to preserve the quality of respirators. We have developed a UV box for surface sterilization of respirators with an intention to reuse. TECHNIQUE: A thermocol box was taken from the central drug store and was fitted with two UV tubes of 254 nm wavelength procured from local service center of water purifiers. The position of the two tubes was such that one was near the base while other was fixed at the top. An aluminum mesh frame was placed in the middle of the box to act as a platform. The roof of the box was converted into a lid. The effectiveness of assembly was tested using culture of Escherichia coli and Staphylococcus aureus. In addition, a biological indicator tube containing test strip with spores of Bacillus atrophaeus was also exposed to UV light for a predefined duration, which did not show any color change after incubation for 48 hours. CONCLUSION: Our prototype assembly with supported efficacy from microbiological tests is an option for use of UV light within available resources for disinfection and reuse of scarce supplies of personal protective equipment. CLINICAL SIGNIFICANCE: UV box can help in meeting the demand supply deficit for respirators, face shields, and goggles that are paramount for the protection of HCW. HOW TO CITE THIS ARTICLE: Kumar P, Chaudhry D, Parmar A, Tyagi D, BG Manjunath, Singh PK. Ultraviolet Box: An Innovative In-house Use of Ultraviolet Irradiation for Conservation of Respirators in COVID-19 Pandemic. Indian J Crit Care Med 2020;24(8):713-715.