Long-Term Acute Care Hospital Outcomes of Mechanically Ventilated Patients With Coronavirus Disease 2019.

OBJECTIVES: To describe the clinical characteristics and outcomes of adult patients with coronavirus disease 2019 requiring weaning from prolonged mechanical ventilation. DESIGN: Observational cohort study of patients admitted to two long-term acute care hospitals from April 1, 2020, to March 31, 2021. SETTING: Two long-term acute care hospitals specialized in weaning from prolonged mechanical ventilation in the Chicagoland area, Illinois, United States. PATIENTS: Adult (≥ 18 yr old) ICU survivors of respiratory failure caused by severe acute respiratory syndrome coronavirus 2 pneumonia receiving prolonged mechanical ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: During the study period, 158 consecutive patients were transferred to the long-term acute care hospitals for weaning from prolonged ventilation. Demographic, clinical, and laboratory data were collected and analyzed. Final date of follow-up was June 1, 2021. Prior to long-term acute care hospital transfer, median length of stay at the acute care hospital was 41.0 days and median number of ventilator days was 35. Median age was 60.0 years, 34.8% of patients were women, 91.8% had a least one comorbidity, most commonly hypertension (65.8%) and diabetes (53.2%). The percentage of weaning success was 70.9%. The median duration of successful weaning was 8 days. Mortality was 9.6%. As of June 1, 2021, 19.0% of patients had been discharged home, 70.3% had been discharged to other facilities, and 1.3% were still in the long-term acute care hospitals. CONCLUSIONS: Most patients with coronavirus disease 2019 transferred to two Chicago-area long-term acute care hospitals successfully weaned from prolonged mechanical ventilation.

A Case Report of Cystic Fibrosis Plus Tuberous Sclerosis: A Cautionary Tale Regarding Lung Transplantation.

BACKGROUND: Cystic fibrosis (CF) and tuberous sclerosis complex (TSC) are 2 rare genetic diseases that often affect the lungs. Pulmonary compromise in TSC or CF can be severe enough to require lung transplantation. In rare instances patients with CF undergo pneumonectomy to control recurrent lung infections and lung necrosis affecting one lung more than the other. Lung transplantation in these patients is exceedingly rare because preexistent pneumonectomy increases the risk of lung transplant-associated morbidity and mortality. CASE PRESENTATION: We present the case of a young woman with co-occurrence of TSC and CF, who underwent left-sided pneumonectomy and, approximately 2 years later, right-sided single lung transplant. The posttransplant clinical course was complicated by phrenic nerve injury, ventilator dependency, Aspergillus endocarditis with embolic shower, and death. Pretransplant pneumonectomy, Aspergillus colonization, and posttransplant phrenic nerve injury contributed to the complex postoperative course, ventilatory dependence, and poor outcome. CONCLUSION: This cautionary case should alert physicians on the challenges associated with single lung transplant in patients with preexistent pneumonectomy.

Ultrasound and non-ultrasound imaging techniques in the assessment of diaphragmatic dysfunction.

Diaphragm muscle dysfunction is increasingly recognized as an important element of several diseases including neuromuscular disease, chronic obstructive pulmonary disease and diaphragm dysfunction in critically ill patients. Functional evaluation of the diaphragm is challenging. Use of volitional maneuvers to test the diaphragm can be limited by patient effort. Non-volitional tests such as those using neuromuscular stimulation are technically complex, since the muscle itself is relatively inaccessible. As such, there is a growing interest in using imaging techniques to characterize diaphragm muscle dysfunction. Selecting the appropriate imaging technique for a given clinical scenario is a critical step in the evaluation of patients suspected of having diaphragm dysfunction. In this review, we aim to present a detailed analysis of evidence for the use of ultrasound and non-ultrasound imaging techniques in the assessment of diaphragm dysfunction. We highlight the utility of the qualitative information gathered by ultrasound imaging as a means to assess integrity, excursion, thickness, and thickening of the diaphragm. In contrast, quantitative ultrasound analysis of the diaphragm is marred by inherent limitations of this technique, and we provide a detailed examination of these limitations. We evaluate non-ultrasound imaging modalities that apply static techniques (chest radiograph, computerized tomography and magnetic resonance imaging), used to assess muscle position, shape and dimension. We also evaluate non-ultrasound imaging modalities that apply dynamic imaging (fluoroscopy and dynamic magnetic resonance imaging) to assess diaphragm motion. Finally, we critically review the application of each of these techniques in the clinical setting when diaphragm dysfunction is suspected.

Validity and reliability of rectus femoris ultrasound measurements: Comparison of curved-array and linear-array transducers.

Muscle-mass loss augers increased morbidity and mortality in critically ill patients. Muscle-mass loss can be assessed by wide linear-array ultrasound transducers connected to cumbersome, expensive console units. Whether cheaper, hand-carried units equipped with curved-array transducers can be used as alternatives is unknown. Accordingly, our primary aim was to investigate in 15 nondisabled subjects the validity of measurements of rectus femoris cross-sectional area by using a curved-array transducer against a linear-array transducer-the reference-standard technique. In these subjects, we also determined the reliability of measurements obtained by a novice operator versus measurements obtained by an experienced operator. Lastly, the relationship between quadriceps strength and rectus area recorded by two experienced operators with a curved-array transducer was assessed in 17 patients with chronic obstructive pulmonary disease (COPD). In nondisabled subjects, the rectus cross-sectional area measured with the curved-array transducer by the novice and experienced operators was valid (intraclass correlation coefficient [ICC]: 0.98, typical percentage error [%TE]: 3.7%) and reliable (ICC: 0.79, %TE: 9.7%). In the subjects with COPD, both reliability (ICC: 0.99) and repeatability (%TE: 7.6% and 9.8%) were high. Rectus area was related to quadriceps strength in COPD for both experienced operators (coefficient of determination: 0.67 and 0.70). In conclusion, measurements of rectus femoris cross-sectional area recorded with a curved-array transducer connected to a hand-carried unit are valid, reliable, and reproducible, leading us to contend that this technique is suitable for cross-sectional and longitudinal studies.