Mechanical ventilation and prone positioning in pregnant patients with severe COVID-19 pneumonia: experience at a quaternary referral center

BackgroundWe present the care of 17 consecutive pregnant patients who required mechanical ventilation for Coronavirus Disease 2019 (COVID-19) pneumonia at a quaternary referral center in the United States. We retrospectively describe the management of these patients, maternal and fetal outcomes, as well as the feasibility of prone positioning and delivery.MethodsBetween March 2020 and June 2021, all pregnant and postpartum patients who were mechanically ventilated for COVID-19 pneumonia were identified. Details of their management including prone positioning, maternal and neonatal outcomes, and complications were noted.ResultsSeventeen pregnant patients required mechanical ventilation for COVID-19. Thirteen patients received prone positioning, with a total of 49 prone sessions. One patient required extracorporeal membrane oxygenation. All patients in this series survived until at least discharge. Nine patients delivered while mechanically ventilated, and all neonates survived, subsequently testing negative for SARS-CoV-2. There was one spontaneous abortion. Four emergent cesarean deliveries were prompted by refractory maternal hypoxemia or non-reassuring fetal heart rate after maternal intubation.ConclusionsOverall, maternal and neonatal survival were favorable even in the setting of severe COVID-19 pneumonia requiring mechanical ventilation. Prone positioning was well tolerated although the impact of prone positioning or fetal delivery on maternal oxygenation and ventilation are unclear.     

无创呼吸机辅助通气对重症哮喘患者的临床效果观察

目的:探讨无创呼吸机辅助通气对重症哮喘患者的临床疗效。方法:选择2018年1月~2019年5月本院收治的86例重症哮喘患者作为研究对象,根据随机数字表法将86例患者分为观察组(n=43例)和对照组(n=43例),对照组患者采用β2受体激动药、糖皮质激素、茶碱类药物、鼻导管吸氧、纠正水电解质及酸碱失衡等对症处理,观察组在对照组对照对症处理基础上加以无创呼吸机辅助通气治疗,对比分析两组患者的咳嗽、胸闷、喘息缓解时间,测定治疗前后两组患者的肺功能指标[第1秒用力呼气量(FEV1)、第1秒呼气容积与用力肺活量比值(FEV1/PVC)]变化情况,同时比较两组患者的治疗疗效。结果:观察组的咳嗽缓解时间、胸闷缓解时间、喘息缓解时间均明显短于对照组,P<0.05。治疗前,观察组及对照组的FEV1、FEV1/PVC比较,P>0.05。治疗后,观察组的FEV1、FEV1/PVC均明显高于对照组,P<0.05。观察组总有效率为90.70%(39/43),对照组总有效率为67.44%(29/43),两组比较,P<0.05。结论:在重症哮喘患者中应用无创呼吸机辅助通气治疗,可有效改善患者的临床症状及肺功能,并能有效提高药物治疗效果,具有重要的临床意义。     

Acute rhabdomyolysis following viral infection with coxsackie A4 in a 50-day-old infant with Fukuyama congenital muscular dystrophy

BackgroundFukuyama congenital muscular dystrophy (FCMD), which is characterized by generalized muscle weakness, hypotonia, and motor delay during early infancy, gradually progresses with advanced age. Although acute rhabdomyolysis following infection in patients with FCMD has occasionally been reported, no studies have investigated rhabdomyolysis following viral infection in FCMD patients during early infancy.Case reportWe report the case of a 50-day-old girl with no apparent symptoms of muscular dystrophy who developed severe acute rhabdomyolysis caused by viral infection, resulting in quadriplegia and respiratory failure therefore requiring mechanical ventilation. Brain magnetic resonance imaging incidentally showed the typical characteristics of FCMD, and FCMD was confirmed by genetic analysis, which revealed a 3-kb retrotransposon insertion in one allele of the fukutin gene and a deep intronic splicing variant in intron 5 in another allele. The virus etiology was confirmed to be Coxsackie A4.ConclusionWe report a severe case of acute rhabdomyolysis with the earliest onset of symptoms due to the Coxsackie A4 virus in a patient with FCMD. The present findings indicate that physicians should consider FCMD with viral infection a differential diagnosis if the patient presents with acute rhabdomyolysis following a fever.     

Effects of deep sedation on sleep in critically ill medical patients on mechanical ventilation

Atypical EEG patterns not consistent with standard sleep staging criteria have been observed in medical intensive care unit (ICU) patients. Our aim was to examine the relationship between sleep architecture and sedation in critically ill mechanically ventilated patients pre‐ and post‐extubation. We performed a prospective observational repeated measures study where 50 mechanically ventilated patients with 31 paired analyses were examined at an academic medical centre. The sleep efficiency was 58.3 ± 25.4% for intubated patients and 45.6 ± 25.4% for extubated patients (p = .02). Intubated patients spent 76.33 ± 3.34% of time in non‐rapid eye movement (NREM) sleep compared to 64.66 ± 4.06% of time for extubated patients (p = .02). REM sleep constituted 1.36 ± 0.67% of total sleep time in intubated patients and 2.06 ± 1.09% in extubated patients (p = .58). Relative sleep atypia was higher in intubated patients compared to extubated patients (3.38 ± 0.87 versus 2.79 ± 0.42; p < .001). Eleven patients were sedated with propofol only, 18 patients with fentanyl only, 11 patients with fentanyl and propofol, and 10 patients had no sedation. The mean sleep times on “propofol”, “fentanyl”, “propofol and fentanyl,” and “no sedation” were 6.54 ± 0.64, 4.88 ± 0.75, 6.20 ± 0.75 and 4.02 ± 0.62 hr, respectively. The sigma/alpha values for patients on “propofol”, “fentanyl”, “propofol and fentanyl” and “no sedation” were 0.69 ± 0.04, 0.54 ± 0.01, 0.62 ± 0.02 and 0.57 ± 0.02, respectively. Sedated patients on mechanical ventilation had higher sleep efficiency and more atypia compared to the same patients following extubation. Propofol was associated with higher sleep duration and less disrupted sleep architecture compared to fentanyl, propofol and fentanyl, or no sedation.     

How to use noninvasive positive airway pressure device data reports to guide clinical care

There has been a significant increase in the past few decades in the number of children receiving noninvasive positive airway pressure (PAP) therapy at home. At present, PAP therapy can be successfully used in children of all ages, for a variety of indications. Data acquired from PAP devices is clinically useful, providing objective information regarding adherence, leak, and efficacy of PAP therapy. However, guidelines outlining a standardized approach to interpretation of PAP device data in pediatrics is currently lacking. Given the rapidly expanding use of PAP therapy in pediatric practice, we aim to provide an overview of the interpretation of data reports, otherwise called “data downloads,” from PAP devices and illustrate how they can be used to guide clinical care.     

Principles of artificial ventilation

The application of intermittent positive pressure ventilation (IPPV) during the 1952 Copenhagen polio epidemic led to the development of the world’s first intensive care unit. The requirement for ventilatory support is the most common indication for intensive therapy unit (ITU) admission and is a defining feature of the specialty. Ventilator technology continues to develop and there are many ways to deliver IPPV. The variety of modes of ventilation is increasingly complex and expanding, without evidence that any one mode is associated with improved outcome. Ventilatory support is part of the treatment for a range of conditions including acute respiratory failure, raised intracranial pressure (ICP) and circulatory shock. Ventilator-associated lung injury is reduced by using low tidal volumes and limiting plateau airway pressure to less than 30 cmH₂O. Prolonged artificial ventilation has an associated morbidity and mortality and thus should be reviewed by an expert clinician on a daily basis. Weaning aims to identify those patients who will be able to breathe spontaneously. Protocols exist to facilitate timely extubation without the need for re-intubation.     

Chest Radiograph Reporting: Public Preferences and Perceptions

PurposeTo assess public preferences and perceptions regarding negative chest radiograph reports.MethodsUsing Amazon Mechanical Turk (Amazon Inc, Seattle, Washington), paid US English-speaking volunteers completed an 18-question survey. Participants were presented with the same two chest radiograph reports—one each in a freestyle and structured format—but randomized to one of four impression statements commonly used in our community. Participants were asked about content comprehension and confidence in the hypothetical interpreting radiologist.ResultsOver 15 days, 5,155 eligible participants completed the survey (of 6,363 respondents). Most reported prior chest radiography (68.9%) or any imaging (93.8%). Of those who underwent chest radiography, 77.6% reviewed their reports. Participants indicated structured reports were easier to comprehend (P < .001) but no difference in perceived confidence in the radiologist with freestyle versus structured reports (P = .21). No differences in comprehension were noted between different impressions with either freestyle (P = .077) or structured (P = .083) reports. Participants indicated higher confidence in radiologists when structured reports indicated “no acute disease” versus “unremarkable” (P = .049). When impressions stated “no acute disease,” participants indicated they would be more likely to do nothing, versus “negative chest” for which they indicated a higher likelihood of taking some action (P = .013, P = .04). Participant responses were similar for subgroups who previously underwent chest or other imaging and previously reviewed their imaging reports.ConclusionFor negative chest radiographs, structured reports are better comprehended by the public and less likely to prompt unnecessary follow-up. As patients increasingly access their medical records online, radiologist reporting should consider patient needs and behavior.     

Incidencia,pronóstico y factores asociados al infarto estriatocapsular aislado tras trombectomía mecánica

ObjectivesTo describe baseline and procedural characteristics and clinical outcomes of isolated striatocapsular infarct (iSCI) after mechanical thrombectomy in patients with large-vessel occlusion of the anterior cerebral circulation andits clinical outcome.MethodsWe performed a longitudinal study including all patients treated with mechanical thrombectomy at our centre between 2015 and 2017; patients were divided into 2 groups (iSCI and non-iSCI) according to whether they presented iSCI in a control CT scan at 24 h.ResultsOf the 83 patients identified, 22.9% developed an iSCI. There were no statically significant differences in baseline characteristics or in reperfusion times. Patients presenting iSCI showed better collateral circulation and better reperfusion rates in the bivariate analysis. No significant difference was observed for mortality at discharge or at 3 months, or for functional prognosis at 3 months.ConclusionsEven if successful reperfusion is achieved, iSCI is a common sequela, independently of reperfusion time, especially in patients with good collateral circulation.