Unexpected pulmonary mechanics during positive pressure mechanical ventilation in fibrotic lung disease with concomitant flail chest.

Understanding of pulmonary mechanics is essential to understanding mechanical ventilation. Typically, clinicians are mindful of peak and plateau pressures displayed on the ventilator and lung compliance, which is decreased in lung disease such as idiopathic pulmonary fibrosis (IPF). Decreased lung compliance leads to elevated peak and plateau pressures. We present a patient with IPF undergoing mechanical ventilation after cardiac arrest. Despite low lung compliance, he had normal peak and plateau pressures due to the presence of flail chest and increased chest wall compliance. This case highlights the role chest wall compliance plays in total respiratory system compliance and pulmonary mechanics.

Left atrial mass found on cardiac ultrasound leading to emergent thrombectomy.

Atrial myxomas, though the most common primary cardiac neoplasm, remain a rare disease occurring in about 0.03% of the population. While clinically benign, they are considered functionally malignant as they can cause life-threatening embolic events. Here we present a patient with a high-risk intermediate pulmonary embolism where bedside ultrasound revealed significant right ventricular dysfunction with an associated large left atrial mass. These findings combined with the patient's instability allowed her to be rushed to surgery for definitive treatment.

Safety of hybrid bronchial stents in transplant airway complications: a single center experience.

Background: Tracheobronchial stents are often used to manage lung transplant airway complications. In 2005, the Food and Drug Administration (FDA) issued a warning against the use of metallic stents for benign airway disease. Since that time, fully covered hybrid metallic stents have been developed and are increasingly used due to their ease of insertion and removal. There is limited data to support their safe utilization for transplant airway complications. This is the largest analysis to date of the safety of hybrid metallic stents for transplant airway complications. Methods: We performed a retrospective study of patients who had covered metallic stents placed for transplant airway complications between April 2016 to April 2021. Information obtained from chart review included demographics, procedure notes and stent data including indication for placement, type, size, location, duration, and complications. Results: We identified 50 patients who had a combined 376 stents placed for a total of 15,711 stent days. The most common minor complication and reason for removal was mucus plugging affecting 193 stents.There were only two cases of major stent associated complications. Among minor complications, there was a increased risk of stent fracture with Bonastent® (P=0.04). Conclusions: Our data shows that hybrid metallic stents are a safe intervention for patients with transplant airway complications. Most complications were minor and managed with repeat bronchoscopy. There were only two major complications over a 5-year period. Given the wide spectrum of possible airway complications, further research is needed to determine the optimal use of stents for patients with transplant airway complications.

Bleeding risk by intensity of anticoagulation in critically ill patients with COVID-19: A retrospective cohort study.

BACKGROUND: Studies report hypercoagulability in coronavirus disease 2019 (COVID-19), leading many institutions to escalate anticoagulation intensity for thrombosis prophylaxis. OBJECTIVE: To determine the bleeding risk with various intensities of anticoagulation in critically ill patients with COVID-19 compared with other respiratory viral illnesses (ORVI). PATIENTS/METHODS: This retrospective cohort study compared the incidence of major bleeding in patients admitted to an intensive care unit (ICU) within a single health system with COVID-19 versus ORVI. In the COVID-19 cohort, we assessed the effect of anticoagulation intensity received on ICU admission on bleeding risk. We performed a secondary analysis with anticoagulation intensity as a time-varying covariate to reflect dose changes after ICU admission. RESULTS: Four hundred and forty-three and 387 patients were included in the COVID-19 and ORVI cohorts, respectively. The hazard ratio of major bleeding for the COVID-19 cohort relative to the ORVI cohort was 1.26 (95% confidence interval [CI]: 0.86-1.86). In COVID-19 patients, an inverse-probability treatment weighted model found therapeutic-intensity anticoagulation on ICU admission had an adjusted hazard ratio of bleeding of 1.55 (95% CI: 0.88-2.73) compared with standard prophylactic-intensity anticoagulation. However, when anticoagulation was assessed as a time-varying covariate and adjusted for other risk factors for bleeding, the adjusted hazard ratio for bleeding on therapeutic-intensity anticoagulation compared with standard thromboprophylaxis was 2.59 (95% CI: 1.20-5.57). CONCLUSIONS: Critically ill patients with COVID-19 had a similar bleeding risk as ORVI patients. When accounting for changes in anticoagulation that occurred in COVID-19 patients, therapeutic-intensity anticoagulation was associated with a greater risk of major bleeding compared with standard thromboprophylaxis.

Determination of cardiovascular dysfunction before initiation of extracorporeal membrane oxygenation in septic shock.

Extracorporeal membrane oxygenation (ECMO) is being increasingly used in patients having sepsis-induced cardiovascular dysfunction. We report successful use of venovenous ECMO in septic shock secondary to pneumonia in the presence of severe left ventricular dysfunction. We also discuss the quantitative evaluation of cardiovascular dysfunction, which provides important input in choosing the type of ECMO in septic shock. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s12055-020-01119-4.