Clinical Medicine Insights-Circulatory Respiratory and Pulmonary Medicine最新文献

Aims: To study the respiratory variation of right atrial (RA) pressures at baseline and during atrioventricular nodal reentry tachycardia (AVNRT).

Methods: Of the 23 patients screened, 16 participants with typical AVNRT were included in the study. After ensuring adequate hydration, baseline RA pressures were measured as the height of 'a' and 'v' waves. The patients were asked to take deep breaths, and the measurements were taken in both inspiration and expiration.

Results: Of the 16 participants, 14(87.5%) showed a normal fall in the height of 'a' and 'v' waves with inspiration, 1(6.25%) showed no change and 1(6.25%) showed a rise in height at baseline, p <0.01. During induced AVNRT, the 'a' and 'v' wave heights increased in 8(50%), remained same in 6(37.5%) and showed a normal fall in 2(12.5%), p = 0.07 for 'a' waves and p = 0.09 for 'v' waves. When the magnitude and direction of change in 'a' and 'v' wave height at baseline was compared with AVNRT, it showed a significant difference with 13(81.25%) participants demonstrating positive Pseudo-Kussmaul's sign, p <0.01. Mean age was numerically higher in those with a more considerable inspiratory rise in RA pressures but was not statistically significant, χ²(2) = 3.1, p = 0.21.

Conclusions: Pseudo-Kussmaul's sign does occur in a substantial number of patients during AVNRT. Clinical appreciation of this phenomenon is possible in half to three-fourth of patients, provided the mean RA pressures are low enough for the variation to be visible in the neck.

Background: COVID-19 placed a significant burden on the global healthcare system. Strain in critical care capacity has been associated with increased COVID-19-related ICU mortality. This study evaluates the impact of an early warning system and response team implemented on medical floors to safely triage and care for critically ill patients on the floor and preserve ICU capacity.

Methods: We conducted a multicenter, retrospective cohort study, comparing outcomes between intervention and control hospitals within a US eight-hospital urban network. Patients hospitalized with COVID-19 pneumonia between April 13^th, 2020 and June 19^th, 2020 were included in the study, which was a time of a regional surge of COVID-19 admissions. An automated, electronic early warning protocol to identify patients with moderate-severe hypoxemia on the medical floors and implement early interventions was implemented at one of the eight hospitals ("the intervention hospital").

Results: Among 1024 patients, 403 (39%) were admitted to the intervention hospital and 621 (61%) were admitted to one of the control hospitals. Adjusted for potential confounders, patients at the intervention hospital were less likely to be admitted to the ICU (HR = 0.73, 95% CI 0.53, 1.000, P = .0499) compared to the control hospitals. Patients admitted from the floors to the ICU at the intervention hospital had shorter ICU stay (HR for ICU discharge: 1.74; 95% CI 1.21, 2.51, P = .003). There was no significant difference between intervention and control hospitals in need for mechanical ventilation (OR = 0.93; 95% CI 0.38, 2.31; P = .88) or hospital mortality (OR = 0.79; 95% CI 0.52, 1.18; P = .25).

Conclusion: A protocol to conserve ICU beds by implementing an early warning system with a dedicated response team to manage respiratory distress on the floors reduced ICU admission and was not associated with worse outcomes compared to hospitals that managed similar levels of respiratory distress in the ICU.

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are the most devastating events in the course of the disease. Our aim was to investigate the value of early warning scoring systems: National Early Warning Score (NEWS) and Modified Early Warning Score (MEWS) in AECOPD. This is a prospective observational study of patients with AECOPD who were admitted at hospital. The NEWS and MEWS scores were registered at admission (NEWS-d1, MEWS-d1) and on the second day (NEWS-d2, MEWS-d2). A nasopharyngeal and sputum sample was taken for culture. Follow-up was done at 3 and 6 months after hospitalization. Any possible correlations between NEWS and MEWS and other parameters of COPD were explored. A cohort of 64 patients were included. In-hospital mortality was 4.7% while total mortality at 6 months was 26%. We did not find any significant correlation between in-hospital mortality and any of the scores but we could show a higher mortality and more frequent AECOPD at 6 months of follow-up for those with higher NEWS-d2. NEWS-d2 was associated with higher pCO₂ at presentation and a more frequent use of NIV. Higher NEWS-d1 and NEWS-d2 were predictive of a longer hospital stay. The presence of pathogens in the nasopharyngeal sample was related with a higher reduction of both scores on the second day. We therefore support the superiority of NEWS in the evaluation of hospitalized patients with AECOPD. A remaining high NEWS at the second day of hospital stay signals a high risk of hypercapnia and need of NIV but also higher mortality and more frequent exacerbations at 6 months after AECOPD.

There are few reports on sepsis caused by infection with Nocardia in people with normal immune function, and there is no report on bronchial tumor caused by Nocardia. This paper describes a case of Nocardia farcinica pneumonia with sepsis and a bronchial neoplasm in a healthy patient.

Background: Atherosclerosis, which is one of the leading causes of death all over the world, can create major or minor thromboembolic complications with the exponentially increasing diabetic status. Despite all the studies, the mechanism by which endothelial damage in atherosclerosis is triggered in diabetic setting is still not fully understood.

Methods: In this study, tissue factor (TF), which is thought to act together in the formation of vasular endothelial growth factor (VEGF-A) and coagulopathy in diabetic atherosclerotic patients, may be an important indicator in this regard, a total of 100 cases who were undergone off-pump coronary artery bypass (OPCAB) which were at same risk group examined by dividing into diabetic status. Early postoperative process and biochemical parameters analyzed in terms of TF and VEGF-A levels measured before and after the operation.

Results: TF and VEGF-A expression of the T1DM group were statistically high compared to non-diabetics. Significantly longer hospital stays with changes in TF and VEGF-A were found in patients in the diabetic group compared to pre- and postoperatively, respectively; TF (95% CI: 0.879-0.992; p = 0.025), VEGF-A (95% CI: 0.964-0.991; p = 0.001) and hospital stay (95% CI: 1.96-7.49; p = 0.0001). Preoperatively measured carotid intima-media thickness (CT) was higher in diabetics and was significantly associated with atrial fibrillation (AF), (r = 0.873). Surgical team and protocols were same and OPCAB procedures were routinely applied to all patients in our clinic. No minor or major events were observed in any of the cases.

Conclusion: TF and VEGF-A values in patients with diabetic atherosclerosis may be important in the early detection of thromboembolic complications.

Introduction: A frequent cause of weaning and extubation failure in critically ill mechanically ventilated patients is diaphragm muscle dysfunction. Ultrasound (US) evaluation of the diaphragm yields important data regarding its thickness (diaphragm thickening fraction [TFdi]) and its movement or excursion (diaphragmatic dynamics) that reveal the presence of diaphragmatic dysfunction.

Methods: Cross-sectional study, which included patients older than 18 years with invasive mechanical ventilation with an expected duration of more than 48 h, in a tertiary referral center in Colombia. The excursion of the diaphragm, inspiratory and expiratory thickness, and TFdi were evaluated by US. Prevalence and use of medications were evaluated, and the association with failure in ventilatory weaning and extubation was analyzed.

Results: Sixty-one patients were included. The median age and APACHE IV score were 62.42 years and 78.23, respectively. The prevalence of diaphragmatic dysfunction (assessed by excursion and TFdi) was 40.98%. The sensibility, specificity, positive predictive value, and negative predictive value for TFdi < 20% was 86%, 24%, 75%, and 40%, respectively, with an area under the receiver operating characteristic (ROC) curve of 0.6. The ultrasonographic analysis of excursion of the diaphragm, inspiratory and expiratory thickness, and TFdi (>20%) allow in its set and with normal values, predict success or failure for the extubation with an area under the ROC curve of 0.87.

Conclusion: Diaphragmatic dynamics and thickness parameters together assessed by ultrasonography could predict the success of extubation in critically ill patients in Colombia, based on the finding of diaphragmatic dysfunction.

Background: Angiotensin-converting enzyme 2 (ACE2) is not only the entry route of SARS-CoV-2 infection but also triggers a major mechanism of COVID-19 aggravation by promoting a hyperinflammatory state, leading to lung injury, hematological and immunological dysregulation. The impact of ACE2 inhibitors on the course of COVID-19 is still unclear. The effect of ACE2 inhibitors on the course of acute respiratory distress syndrome (ARDS) during COVID-19 and other severe respiratory infections in conditions of hyperferritinemia (HF) was investigated.

Methods: A cohort study of critically ill patients with COVID-19 and other respiratory diseases (widespread infection, pneumonia) who underwent treatment in The Critical Care Unit of the First University Clinic (Tbilisi, Georgia) during the 2020-2021 years was conducted. The impact of the ACE2 inhibitors on the course of the ARDS developed during COVID-19 and other severe respiratory infections in conditions of different severity of HF was evaluated.

Results: In COVID-19-infected (I) and uninfected (II) patients with ARDS, ACE2 inhibitors reduce the levels of Ang II, C reactive protein (CRP) and D-dimer (I: from 1508.07  ±  26.68 to 48.51  ±  24.35, from 233.92  ±  13.02 to 198.12  ±  11.88, from 7.88  ±  0.47 to 6.28  ±  0.43; II: from 1000.14  ±  149.49 to 46.23  ±  88.21, 226.48  ±  13.81 to 183.52  ±  17.32, from 6.39  ±  0.58 to 5.48  ±  0.69) at moderate HF and Ang II, CRP levels (I: from 1845.89  ±  89.37 to 49.64  ±  51.05, from 209.28  ±  14.41 to 175.37  ±  9.84; II: from 1753.29  ±  65.95 to 49.76  ±  55.74, 287.10  ±  20.50 to 214.71  ±  17.32) at severe HF, reduce interleukin-6 (IL-6) expression at moderate HF (I: from 1977.23  ±  354.66 to 899.36  ±  323.76) and cause reduction of pCO₂ index at severe HF (I: from 69.80  ±  3.22 to 60.44  ±  2.20) in COVID-19-infected patients.

Conclusion: Study results show that the ACE2 inhibitors play an important role in the regulation of inflammatory processes in both COVID-19-infected and uninfected patients with ARDS. ACE2 inhibitors decrease immunological disorders, inflammation, and lung alveoli dysfunction, especially in COVID-19-infected patients.

Background: Severe COVID-19-associated Acute Respiratory Distress Syndrome (ARDS) may warrant extracorporeal membrane oxygenation (ECMO). We evaluated the safety and physiologic changes in oxygenation and hemodynamic profile during ECMO, prone positioning, and the two modalities combined in patients receiving veno-venous (VV) ECMO.

Methods: Cohort study of consecutive adult patients with COVID-19-associated ARDS requiring VV-ECMO, classified into three groups: ECMO support only; Prone positioning only; and Prone positioning during ECMO. We collected hemodynamic, respiratory and ventilation variables as follows: pre-treatment, 1, 6, and 24 h post-treatment, and documented treatment-related complications. On-treatment variables were compared with pre-treatment using one-sample paired t-test with Bonferroni correction.

Results: Fourteen patients (mean age 48.1 [SD 9.3] years, male [100%]) received VV-ECMO. Of those, 10 patients had data during prone positioning alone and seven had data while proned on ECMO. While on ECMO, patients had improvement in oxygen saturation, PaO₂/FiO₂ ratio, and minute ventilation up to 24 h post-treatment. Vasopressor requirements increased with ECMO at 1 h and 24 h post-treatment. Prone positioning was not associated with clinically significant hemodynamic or respiratory changes, either alone or during ECMO support. All patients sustained deep tissue injuries, but only those on the face or chest were related to prone positioning. Three patients required cannula replacement. In-hospital mortality was 43%.

Conclusions: VV-ECMO and prone positioning in patients with COVID-19 ARDS was overall well-tolerated; however, physiologic improvements were marginal, and patients sustained deep tissue injuries. Although this was a selected population with high mortality, our data call into question the benefits of these management modalities in this severe COVID-19 population.

Spontaneous pneumomediastinum (SPM) is defined as free air in the mediastinum thought to be due to non-traumatic rupture of marginal alveoli without evidence of underlying lung disease. Secondary causes must be excluded, including perforations of the esophagus, trachea, and bronchi, due to their propensity for unfavorable outcomes. Infectious etiologies have been documented to cause pneumomediastinum, but this is most frequently observed in the setting of mechanical and noninvasive positive-pressure ventilation (NIPPV). Here we present a case of asymptomatic spontaneous pneumomediastinum in a patient with COVID-19 in absence of mechanical ventilation.