Surfactant therapy using vibrating-mesh nebulizers in adults with COVID-19-induced ARDS: A case series.

Coronavirus adult respiratory distress syndrome, characterized by decreased surfactant due to lysis of type II pneumocytes and hyaline membrane formation, contributes to severe hypoxemia. The administration of surfactant via high-flow nasal cannula (HFNC) may positively affect lung structure and function in this context. In this study, we report on five clinical cases, encompassing patients aged 40-60 years of both sexes, who tested positive for coronavirus disease 2019 via real-time polymerase chain reaction and exhibited significant pulmonary compromise with elevated inflammatory biomarkers. These patients were treated with aerosol therapy using surfactant delivered through vibrating-mesh nebulizers alongside HFNC. Of these patients, four demonstrated positive responses to the treatment, suggesting that aerosol therapy with surfactant through vibrating-mesh nebulizers could be a viable rescue therapy in adults receiving HFNC oxygen therapy for hypoxemic respiratory failure caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Unfortunately, one patient had a negative outcome and succumbed. The findings from these cases indicate that the use of aerosol therapy with vibrating-mesh nebulizers as rescue therapy might offer an alternative approach for managing adults with hypoxemic respiratory failure due to SARS-CoV-2, as evidenced by the positive outcomes in four out of the five cases presented.

An Unusual Case of Severe Pneumonia Caused Due Candida Tropicalis With a Favorable Clinical Response to Antifungals in a Nonimmunocompromised Patient From the Community.

Severe pneumonia due to Candida tropicalis infection mainly occurs in immunosuppressed patients or those currently receiving broad-spectrum antibiotics. Herein, we report a case of severe pneumonia caused due to C tropicalis in an elderly patient. A 72-year-old man with a previous history of hypertension, ischemic stroke, and facial paralysis sequelae treated with the botulinic toxin, was admitted to the hospital for dyspnea. Severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) infection was negative. Computed tomography of the chest revealed bilateral consolidation with left predominance. A bronchoalveolar lavage sample was sent to molecular biology, but no microorganisms were detected using a FilmArray respiratory panel. However, mamanocandidas test for candida was 166 pg/mL (positive), and fungal structures were identified by the MALDI-TOF Biotyper mass spectrometry and attributed to C tropicalis. Antifungal therapy was started using caspofungin 75 mg as the initial dose followed by 50 mg daily. After 10 days of treatment, ventilatory weaning was achieved. By day 14, the patient was decannulated from the tracheostomy. Oral antifungal treatment with voriconazole was continued, and he was discharged from intensive care in good clinical condition. Severe pneumonia due to C tropicalis might occur in specific cases, especially in those patients with risk factors, and must thus be considered when approaching such cases.

Use of threshold PEP with an adult non-rebreather oxygen mask plus prone positioning in acute hypoxemic respiratory failure due to SARS-CoV-2 infection during the collapse of the health system in a low-income country.

During the coronavirus disease 2019 pandemic, Ecuador reported a collapse of the healthcare system, in which intensive care unit beds were lacking. Therefore, we sought to determine whether the use of threshold expiratory positive pressure with an adult non-rebreather oxygen mask plus prone positioning is useful for improving oxygenation. Twelve patients were included. Eight patients (66.7%) survived, while four patients (33.3%) died. Baseline arterial oxygen saturation (%) prior placement median (interquartile range) 85.5% (80%-89%) and arterial oxygen saturation (%) post placement of the device was median (interquartile range) (93%-96%) (P = 0.0001). Respiratory rate before placement was median (interquartile range) 38 (36-42) and post placement of the device was median (interquartile range) 24 (22-30) (P = 0.0005). The use of an adapted device might be useful for the management of acute hypoxemic respiratory failure due to severe acute respiratory syndrome coronavirus 2 pneumonia, particularly when mechanical ventilators and high-flow oxygen systems are unavailable.

A 71-Year-Old Man From Ecuador With a History of Type 2 Diabetes Mellitus and Severe COVID-19 Pneumonia and Lung Cavitation Associated With Triple Infection With Trichosporon Asahii, Klebsiella Pneumoniae, and Pseudomonas Aeruginosa.

Unvaccinated patients with comorbidities that impair the immune function, such as type 2 diabetes mellitus, are more likely to develop severe COVID-19. The COVID-19-associated acute respiratory distress syndrome has raised new concerns in intensive care units globally owing to the presence of secondary fungal infections. We report the case of a 71-year-old man from Ecuador with a history of type 2 diabetes mellitus, severe COVID-19 pneumonia, and lung cavitation associated with triple infections with Trichosporon asahii, Klebsiella pneumoniae, and Pseudomonas aeruginosa. The patient with a history of high blood pressure and type 2 diabetes was admitted to our hospital from a private care center with a diagnosis of COVID-19-associated acute respiratory distress syndrome. On arrival, the patient presented with signs of hypoxemic respiratory failure. During his stay at another hospital, he had received tocilizumab and corticosteroid therapy. Therefore, intubation was performed and mechanical ventilation was initiated. The patient developed a septic shock and renal failure with a glomerular filtration rate of 27.5 mL/min/1.73 m2; therefore, two hemodiafiltration sessions were started. The bronchoalveolar lavage revealed erythematous lesions in the bronchial tree and abundant purulent secretions and erosions in the bronchial mucosa, with a cavitary lesion in the right bronchial tree. The bronchoalveolar lavage samples were used to isolate Trichosporon asahii, Klebsiella pneumoniae, and Pseudomonas aeruginosa carbapenemase class A. Matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) Biotyper mass spectrometry and polymerase chain reaction (PCR) molecular identification were performed. This case report suggested that patients with severe COVID-19 pneumonia, with or without comorbidities, are more susceptible to opportunistic infections.

Noninvasive Mechanical Ventilation with Average Volume-Assured Pressure Support versus BiPAP S/T in De Novo Hypoxemic Respiratory Failure.

Background: Bilevel positive airway pressure in spontaneous/time and average volume-assured pressure support (BiPAP·S/T-AVAPS) could maintain an adequate tidal volume by reducing the patient's inspiratory effort; however, this ventilatory strategy has not been compared with other ventilatory modes, especially the conventional BiPAP S/T mode, when noninvasive mechanical ventilation (NIMV) is used. The primary objective of this study was to determine the rate of success and failure of the use of BiPAP·S/T-AVAPS versus BiPAP·S/T alone in patients with mild-to-moderate "de novo" hypoxemic respiratory failure. Methods: This was a matched-cohort study. Subjects with mild-to-moderate de novo hypoxemic respiratory failure were divided into two groups according to the ventilatory strategy used. The subjects in the BiPAP·S/T group were paired with those in the BiPAP·S/T-AVAPS group. Results: A total of 58 subjects were studied. Twenty-nine subjects in the BiPAP·S/T group were paired with 29 subjects in the BiPAP·S/T-AVAPS group. Twenty patients (34.5%) presented with "failure of NIMV," while 38 (65.5%) patients did not. In addition, 13 (22.4%) patients died, while 45 (77.6%) recovered. No differences were found in the percentage of intubation (P=0.44) and mortality (P=0.1). Conclusion: The BiPAP S/T-AVAPS ventilator mode was not superior to the BiPAP·S/T mode. A high mortality rate was observed in patients with NIMV failure in both modes. This trial is registered with https://doi.org/10.1186/ISRCTN17904857.

Use of high-flow nasal cannula and intravenous propofol sedation while performing flexible video bronchoscopy in the intensive care unit: Case reports.

Flexible video bronchoscopy is a procedure that plays an important role in diagnosing various types of pulmonary lesions and abnormalities. Case 1 is a 68-year-old male patient with a lesion in the right lung apex of approximately 4 mm × 28 mm with atelectasis bands due to a crash injury. High-flow system with 35 L/min and fraction of inspired oxygen (FiO2) 0.45 and temperature of 34 °C was installed prior to the video bronchoscopy. SpO2 was maintained at 98%-100%. The total dose of sedative was 50 mg of propofol. In Case 2, a 64-year-old male patient with bronchiectasis, cystic lesions and pulmonary fibrosis of the left lung field was placed on a high-flow system with 45 L/min and 0.35 FiO2 at a temperature of 34 °C. SpO2 was maintained at 100%. The total duration of the procedure was 25 min; SpO2 of 100% was sustained with oxygenation during maintenance time with the flexible bronchoscope within the airway. The total dose of propofol to reach the degree of desired sedation was 0.5-1 mg/kg. Both patients presented hypotension. For the patient of case 1, a vasopressor (norepinephrine at doses of 0.04 µg/kg/min) was given, and for the patient of case 2, only saline volume expansion was used. The video bronchoscopy with propofol sedation and high-flow nasal cannula allows adequate oxygenation during procedure in the intensive care unit.

Apnea-Hypopnea Index in Chronic Obstructive Pulmonary Disease Exacerbation Requiring Noninvasive Mechanical Ventilation with Average Volume-Assured Pressure Support.

INTRODUCTION: This study intends to determine the Apnea-Hypopnea Index in patients hospitalized with acute hypercapnic respiratory failure from chronic obstructive pulmonary disease exacerbation, who require noninvasive ventilation with average volume-assured pressure support (AVAPS), as well as describes the clinical characteristics of these patients. MATERIALS AND METHODS: We designed a single-center prospective study. The coexistence of Apnea-Hypopnea Index and clinical, gasometric, spirometric, respiratory polygraphy, and ventilatory characteristics were determined. The clinical characteristics found were categorized and compared according to the Apnea-Hypopnea Index (AHI) < 5, AHI 5-15, and AHI >15. A p value <0.05 was considered statistically significant. RESULTS: During the study period, a total of 100 patients were admitted to the ICU with a diagnosis of acute hypercapnic respiratory failure due to COPD exacerbation. 72 patients presented with acute respiratory failure and fulfilled criteria for ventilatory support. Within them, 24 received invasive mechanical ventilation and 48 NIV. After applying the inclusion criteria for this study, 30 patients were eligible. An AHI >5 was present in 24 of the 30 patients recruited (80%). Neck circumference (cm), Epworth scale, and Mallampati score evidenced significant differences when compared to the patient's AHI <5, AHI 5-15, and AHI >15 (p < 0.05). Furthermore, patients with an AHI >5 had longer hospital admissions, prolonged periods on mechanical ventilation, and a higher percentage of intubation rates. CONCLUSION: Apnea-Hypopnea Index and chronic obstructive pulmonary disease exacerbation are a frequent association found in patients with acute hypercapnic respiratory failure and COPD exacerbations that require NIV. This association could be a determining factor in the response to NIV, especially when AVAPS is used as a ventilatory strategy.

Management of COVID-19 at the pandemic's first wave in Ecuador.

During March and April 2020, Ecuador was the country with the highest death toll in Latin America due to the coronavirus disease 2019 pandemic. Simultaneously, research was being developed and published globally, and to a certain extent, guided therapeutic approaches in real time, mostly in under-resourced settings. We present the case of a 59-year-old male physician residing in Guayaquil, who presented with severe coronavirus disease 2019, in which mechanical ventilation, prone position, and pulmonary protective ventilatory strategy were used. We discuss the clinical management of the first reported case in the literature of a physician in Ecuador who survived severe acute respiratory syndrome coronavirus 2 infection, as well as the topic of self-medication within health professionals, the management approach that was emerging at the moment in scientific publications and guiding treatment, the role of responsible research and its worldwide impact, and the emotional burdens of the care team who had to make very difficult decisions in extremely adverse circumstances.

Cavitary Pneumonia Due to Methicillin-Resistant Staphylococcus aureus in a Non-Immunocompromised Patient After an Endoscopy: A Case Report.

BACKGROUND Methicillin-resistant Staphylococcus aureus (MRSA) pneumonia has well-defined characteristics. We present a case of cavitary pneumonia due to MRSA in a patient who had undergone a recent outpatient gastroscopic procedure. CASE REPORT A 32-year-old man presented at the Emergency Department with tonic-clonic seizures of 2 min durations. He had a history of seizures without current treatment or use of psychostimulant drugs. His personal history referred to hypothyroidism treated with levothyroxine, morbid type 3 obesity, gastritis with a gastric ulcer, penicillin allergies, and an ambulatory endoscopy with a biopsy (7 days ago) for erosive gastropathy. On the 3rd day of admission to the Intensive Care Unit (ICU), a bronchoscopy was performed, which showed a reddened mucosa with hemorrhagic points and a cavitary area in the right main bronchus. Multiple polymerase chain reaction and mass spectrometry analyses of samples of bronchioalveolar lavage from the bronchus revealed MRSA with a mechanism of resistance to the mecA gene (1×105 colony-forming unit/mL). The laboratory results for the cerebrospinal fluid were negative for bacterial growth. CONCLUSIONS This is a rare case of cavitary pneumonia due to MRSA of clinical and epidemiological characteristics, which is unusual after an outpatient endoscopic procedure.

Telemedicine and Home-Based Treatment of COVID-19 in Resource-Limited Countries. Report of 3 Cases.

Ecuador, despite having taken aggressive and early measures to stop the progression of the pandemic (COVID-19), ended up becoming an epicenter of the pandemic in Latin America, and with the collapse of its health care system. The authors describe three patients who had confirmed COVID-19 and met the criteria for hospital admission but could not be assigned a hospital bed in a resource-limited country. The patients included a 72-year-old male, an 82-year-old female, and a 56-year-old male. They typically presented with fever, dyspnea, loss of taste and smell, diarrhea, and abdominal pain. Oxygen saturation during the initial evaluation ranged from 80-89%. Laboratory results reported lymphopenia and neutrophilia, with leukocytosis in two patients. Inflammatory markers were also elevated for all three patients. CT scan findings showed bilateral ground-glass pulmonary opacities. SARS-CoV-2 was confirmed in all three patients by real time polymerase chain reaction (RT-PCR) testing. Home-based treatment was established. At the time of writing this report, all patients remain asymptomatic and with negative COVID-19 testing. Telemedicine and home-based treatment were essential assets in the care of these severely ill patients living in a low-resource setting where not all patients who have criteria to be admitted into the hospital are able to find a place in a collapsed health care system.

Invasive Subacute Pulmonary Aspergillosis After Puerperal Sepsis: Case Report.

Subacute invasive aspergillosis is an infection that locally destroys lung parenchyma, and it affects patients with mild immunocompromise. The diagnosis is made by clinical symptoms, imaging, and laboratory results related to the infection. Early diagnosis and treatment is imperative for a favorable patient outcome. In this article, we present the case of a 19-year-old woman who was admitted to the intensive care unit for puerperal sepsis where a hysterectomy was performed. During her hospitalization, she presented atelectasis of the left lung and hemodynamic instability. Chest X-ray and chest computed tomography scan were performed and showed round opacities. It was decided to perform flexible bronchoscopy with bronchoalveolar lavage. An unusual subacute form of implementation of aspergillosis was confirmed by a bronchoalveolar lavage culture that showed the presence of Aspergillus. Images taken during bronchoscopy revealed Aspergillus implantation in the lung and serum galactomannan antigen test was positive. Voriconazole was introduced, 200 mg daily. The patient showed clinical improvement and was discharged from our hospital. We conclude that subacute invasive aspergillosis is a serious infection that can lead to high mortality. Bronchoscopy with bronchoalveolar lavage allows access and effective visualization of the airway as well as sampling for Aspergillus identification.

Early Pulmonary Metastasis After a Surgical Resection of Glioblastoma Multiforme. A Case Report.

BACKGROUND Glioblastoma multiforme is one of the most aggressive types of tumors that affect the central nervous system. It has an extremely high morbidity and mortality rate despite immediate treatment and advances in chemotherapy, radiotherapy, and surgery. In the natural history of the disease, extracranial metastases of glioblastoma multiforme are a rare complication that can be localized in the lungs, bone, liver, and lymph nodes. CASE REPORT A 66-year-old male presented with pulmonary metastasis after the surgical resection of a primary glioblastoma multiforme tumor. Seventeen days after surgery while in the intensive care unit, the patient had leukocytosis with a predominance of neutrophils. An exploratory bronchoscopy evidenced a white lesion that prevented the visualization of the bronchus. Consequently, a sample was taken for pathological study that demonstrated pulmonary metastasis due to glioblastoma multiforme. CONCLUSIONS Surgical resection of the tumor can precipitate the appearance of extracranial metastases, especially pulmonary metastases.

Mendelson's Syndrome: Chemical Pneumonitis After Pesticide Intake.

BACKGROUND Mendelson's syndrome consists of pulmonary aspiration of acidic gastric contents that results in acute lung injury (chemical pneumonitis). CASE REPORT We present the case of a 15-year-old girl who was admitted to the Emergency Department 1 h after ingestion of an organophosphate pesticide. The patient had abundant emesis of aqueous, transparent content, accompanied by drowsiness and moderate sialorrhea. We observed drooling and foaming at the mouth and tachycardia, and her oxygen saturation dropped to 75%, requiring immediate invasive ventilation. Computed tomography (CT) revealed opacities in both lung bases, while bronchoscopy evidenced burn lesions along the airway. A bronchoalveolar lavage (BAL) was performed and microbiological results were negative. Following the BAL, the patient showed a satisfactory evolution and full recovery. CONCLUSIONS This case report describes chemical pneumonitis due to pulmonary aspiration of sterile gastric contents following ingestion of a pesticide. We discuss the importance of timely diagnosis, the characteristic burn lesions found in bronchoscopy, and the role of bronchoalveolar lavage, which most likely allowed for a rapid recovery with favorable results.

Azygos Vein Aneurysm with Thrombosis and Aspergillus fumigatus Diagnosed Using Bronchoscopy: Case Report.

BACKGROUND The venous system of the posterior thoracic wall merges into a single trunk called the azygos vein, located in the posterior mediastinum, before draining into the superior vena cava. An aneurysm in the azygos vein is extremely rare. Such aneurysms are discovered as incidental radiology findings or while investigating a mediastinal mass. Visualization via bronchoscopy is atypical. CASE REPORT An 86-year-old female patient presented to the Emergency Department with a 5-day complaint of dyspnea and chest pain. She was admitted because of worsening condition leading to respiratory failure and paresthesias. She underwent endotracheal intubation and invasive mechanical ventilatory support. A chest X-ray showed a thickened mediastinum, tortuous thoracic aorta, and bilateral perihilar infiltrate with right predominance. Bronchoscopy revealed bleeding along the right bronchus and a blue protrusion coated with white material at the entrance of the main right bronchus. A pulmonary computed tomography angiography confirmed the presence of an azygos vein dilatation. Culture of bronchoalveolar lavage revealed Aspergillus fumigatus. CONCLUSIONS Bronchoscopy as a diagnostic method allows clinicians to verify the state and permeability of the airways during investigation of azygos vein aneurysms, which are rare entities but should be considered in the differential diagnosis of mediastinal masses and may be complicated by fungal pathogens such as Aspergillus fumigatus mostly in immunocompromised patients.

Bronchial Visualization of Tetanic Contractions: A Case Report.

BACKGROUND Tetanus is a potentially fatal infectious disease which, during its evolution, creates multiple complications, usually requiring intensive management and care. CASE REPORT We present a clinical case of a 59-year-old male patient with generalized tetanus admitted to the intensive care unit. Flexible bronchoscopy revealed contraction of the bronchial demonstrating that tetany existed at the respiratory level, which rarely becomes evident. The clinical manifestations included trismus, facial paralysis, neck stiffness, and compromised respiratory function. The patient presented a state of respiratory failure that required invasive mechanical ventilation which was evaluated by bronchoscopy and that showed spasms of the bronchial musculature. The patient presented generalized tetanus in which the bronchial affectation was evaluated by bronchoscopy in the intensive care unit. In developed countries, the anti-tetanus toxoid vaccine has ostensibly decreased its incidence, while it is endemic in developing countries, and although there are measures such as vaccination that try to reduce its incidence, in Ecuador there is an increase in incidences. In this patient case, contraction of the bronchial rings was observed, demonstrating that tetany existed at the respiratory level, which rarely becomes evident. CONCLUSIONS Although muscular contractions are widespread, this clinical case evidences bronchial spams reported and visualized by bronchoscopy.

Ischemic Stroke and Disseminated Tuberculosis in Intensive Care: A Case Report.

BACKGROUND Tuberculosis (TB) continues to be a major public health problem worldwide. Extrapulmonary tuberculosis at the level of the central nervous system is the most devastating and deadly form of tuberculosis. CASE REPORT We present the case of a 73-year-old male Ecuadorian patient with no history of contact with tuberculosis and with a clinical picture of 4 days of evolution characterized by aphasia, deviation of the labial commissure, and deterioration of the level of consciousness with a Glasgow coma score of 7/15. A brain tomography showed evidence of indirect signs of cerebral ischemia; the patient was therefore diagnosed with non-specific cerebrovascular disease. Due to the critical nature of his clinical picture, the patient entered the Intensive Care Unit (ICU), where a chest x-ray was performed and bilateral perihilar alveolar opacities with a reticular and nodular pattern were visualized. These results, combined with the bronchoalveolar brushing, evidenced the presence of Mycobacterium tuberculosis. Adenosine of deaminase (ADA) was also detected in the cerebrospinal fluid with 30.7 µ/L and a molecular biology technique was used with high-multiplex real-time polymerase matrix MALDI-TOF mass spectrometry (Brucker Daltonics) for rapid identification of the causative agent. DNA/polymerase chain reaction (PCR) analyses were used for detection of M. tuberculosis, subsequently confirming the presence of cerebral tuberculosis. CONCLUSIONS This case illustrated an infrequent form of disseminated tuberculosis in a critically ill patient. Timely diagnosis and appropriate management are essential to reducing mortality.

Spontaneous Pneumothorax After Rupture of the Cavity as the Initial Presentation of Tuberculosis in the Emergency Department.

BACKGROUND Spontaneous pneumothorax can be secondary to a wide variety of lung diseases. Spontaneous pneumothorax secondary to pulmonary tuberculosis occurs in rare cases of residual fibrosis with retractions and bullae. CASE REPORT We present the case of a 65-year-old male patient from a rural area in the province of Los Ríos in Babahoyo, Ecuador, with no history of contact with tuberculosis. The patient arrived at the Emergency Department of the Regional Hospital of the Instituto Ecuatoriano de Seguridad Social (IESS), Babahoyo, due to acute respiratory failure, preceded by 10 days of evolution due to cough accompanied by greenish expectoration, chest pain, asthenia, and weight loss. On chest radiography, a left pneumothorax and interstitial pulmonary infiltrate were reported. A chest tube was placed, and the patient was intubated and was placed on invasive mechanical ventilation due to severe respiratory failure. Use of the GeneXpert MTB/RIF System detected Mycobacterium tuberculosis without resistance to rifampicin. Ziehl-Neelsen (ZN) staining for the identification of bacillus acid-resistant alcohol was positive in alveolar bronchial lavage. MALDI-TOF mass spectrometry and phenotypic analysis showed the presence of Pseudomonas aeruginosa and Klebsiella pneumonia with carbapenemases resistance mechanism, and the KPC type enzyme was identified. The culture for Mycobacterium tuberculosis was positive from the fourth week. CONCLUSIONS Secondary pneumothorax due to rupture of the polymicrobial cavity and especially of tuberculous origin is a very special form of acute respiratory failure in patients with previous structural pulmonary lesions in the Emergency Department.