Pneumothorax in critically ill patients with COVID-19 infection: Incidence, clinical characteristics and outcomes in a case control multicenter study.

BACKGROUND: The clinical features and outcomes of mechanically ventilated patients with COVID-19 infection who develop a pneumothorax has not been rigorously described or compared to those who do not develop a pneumothorax. PURPOSE: To determine the incidence, clinical characteristics, and outcomes of critically ill patients with COVID-19 infection who developed pneumothorax. In addition, we compared the clinical characteristics and outcomes of mechanically ventilated patients who developed a pneumothorax with those who did not develop a pneumothorax. METHODS: This study was a multicenter retrospective analysis of all adult critically ill patients with COVID-19 infection who were admitted to intensive care units in 4 tertiary care centers in the United States. RESULTS: A total of 842 critically ill patients with COVID-19 infection were analyzed, out of which 594 (71%) were mechanically ventilated. The overall incidence of pneumothorax was 85/842 (10%), and 80/594 (13%) in those who were mechanically ventilated. As compared to mechanically ventilated patients in the non-pneumothorax group, mechanically ventilated patients in the pneumothorax group had worse respiratory parameters at the time of intubation (mean PaO2:FiO2 ratio 105 vs 150, P<0.001 and static respiratory system compliance: 30ml/cmH2O vs 39ml/cmH2O, P = 0.01) and significantly higher in-hospital mortality (63% vs 49%, P = 0.04). CONCLUSION: The overall incidence of pneumothorax in mechanically ventilated patients with COVID-19 infection was 13%. Mechanically ventilated patients with COVID-19 infection who developed pneumothorax had worse gas exchange and respiratory mechanics at the time of intubation and had a higher mortality compared to those who did not develop pneumothorax.

Ultrasound for Pleural Disease. Beyond a Pocket of Pleural Fluid.

The evolution of pleural disease imaging modalities through the years has helped the scientific community understand and treat various disease states. Ultrasound (US) has been an image modality that has reigned superior to those used in the past such as chest X-ray and computed tomographic scan in terms of cost effectiveness, portability, and reduction in unwarranted radiation exposure to patients. Here we provide a succinct review of US use in pleural disease including imaging techniques, identifying safe pleural space for access, and predicting pleural fluid volume and etiology along with specificities regarding trapped lung identification and pleural mass biopsy. We believe bedside chest US is an adjunct to the physical exam adding superior diagnostic abilities. Further research is warranted in more specific aspects of sonographic use such as in fibrinolytic therapy management, evaluation for trapped lung, and the utility of specific modes like the color flow Doppler.

An Infrequent Extraintestinal Manifestation of Ulcerative Colitis: Pulmonary Necrobiotic Nodules.

Pulmonary necrobiotic nodules are a rare extraintestinal manifestation (EIM) of inflammatory bowel disease (IBD), which are often overlooked when diagnosing cavitary pulmonary nodules. We present this case to highlight the importance of a thorough differential diagnosis, which includes EIMs of ulcerative colitis (UC), in this case as necrobiotic nodules. Herein, we present a 25-year-old male patient with a history of poorly controlled UC who presented with fevers, left-sided abdominal pain, and bloody diarrhea. Imaging revealed cavitary pulmonary nodules without an infectious or malignant etiology. Lung biopsy and pathology confirmed a diagnosis consistent with necrobiotic nodules.

Barrier Techniques to Reduce Aerosolization During Extubation.

Preventing exposure of virulent pathogens during aerosolizing procedures such as intubations has been a cause of concern during the coronavirus pandemic. As such, protocols have been adjusted and precautions implemented in order to minimize the risk to the proceduralist. As patients improve, we face another high-risk aerosolizing procedure-extubation. We illustrate a protocol to help minimize the exposure risk during extubation. We describe a barrier technique during extubation which contained aerosolized particulates into a non-rebreather mask at time of extubation. Our protocol allows providers to perform extubations while minimizing exposure to aerosolized particles.

Barrier Techniques to Reduce Aerosolization During Cardiopulmonary Resuscitation.

Preventing the dispersion of virulent particles during aerosol generating procedures has never been more relevant than during the current coronavirus pandemic. The American Heart Association released interim guidelines to assist in limiting exposure during advanced cardiovascular life support. These include maintaining a closed circuit on the ventilator for intubated patients and to use a high-efficiency particulate air filter during airway management of nonintubated patients. We developed additional modifications to the suggested guidelines such that providers are even further protected from unnecessary aerosolization, and illustrate a sample protocol for provider safety during advanced cardiovascular life support in the coronavirus pandemic. For the intubated patient, our protocol maintains the patient to the ventilator in addition to being draped with a plastic barrier over the mouth and nares. In the nonintubated patient, a plastic drape or a non-rebreather mask is used to help reduce aerosolization during manual chest compressions. Our modified protocol allows providers to perform advanced cardiac life support by further minimizing exposure risk.

Review of potential drug interaction between Oseltamivir and Warfarin and why it is important for emergency medicine physicians.

Oseltamivir is a very commonly prescribed anti-viral medication by the Emergency Medicine (EM) physicians for the prophylactic and therapeutic treatment of Influenza infection. While the drug interaction of Warfarin with various antibiotics is known, the drug interaction between Oseltamivir and Warfarin is not common. We present a case where an 83-year female patient, on Warfarin for Pulmonary Embolism, had worsening of coagulopathy after she was started on Oseltamivir. The INR was monitored daily in our patient and Warfarin was stopped when the INR became supra-therapeutic. Our patient did not have any minor or major bleeding complication. This is the first reported case of Oseltamivir related worsening coagulopathy in patient on Warfarin to the best of our knowledge. Keeping in mind the possible interaction between the two as it was evident in our case and few other published reports, we recommend monitoring the INR closely in patients using Warfarin after they are started on Oseltamivir therapy.