A Case of Severe COVID-19 Infection in a Patient with Acute Myeloid Leukaemia: Critical Care Management and a Review of the Literature

Acute myeloid leukaemia (AML) is a highly heterogeneous disorder and is characterised by the proliferation of poorly differentiated myeloid cells due to underlying mutation, eventually causing bone marrow failure. Accounting for approximately 25% of cases, AML is the most frequent form of leukaemia in the world yet has the lowest survival rate among all leukaemias. Patients with haematological malignancy are more susceptible to severe acute respiratory syndrome coronavirus-2 infection and further development of severe infection, including pneumonia with poor blood oxygenation. The management of such patients is more challenging than expected. Successful management of one such case is discussed in this report. COVID-19 infection can cause great harm to a patient with underlying leukaemia and increase the mortality risk. It has a major impact on the physical and psychological health of the patient. Therefore, these patients need special care and attention. The authors emphasise the importance of supportive management (oxygen with bilevel positive airway pressure, prone positioning, and physiotherapy) to prevent complications.

Deleterious Facial Effects Caused by Noninvasive Ventilation Mask Early Treatment, in Congenital Muscular Dystrophy

Neuromuscular disorders is a general term that encompasses a large number of diseases with different presentations. Progressive muscle weakness is the predominant condition of these disorders. Respiratory failure can occur in a significant number of diseases. The use of devices to assist ventilation is quite frequent in these types of patients. Noninvasive ventilation can be applied by various means, including nasal, oronasal, or facial masks. Masks, type bilevel positive airway pressure, continuous positive airway pressure, and similar are generally supported on the maxilla. Oral health in pediatric neuromuscular diseases has some peculiar aspects that we must consider in these patients’ follow-up. Based on a clinical case, this chapter provides a better understanding of these patients. It will focus on the oral and maxillofacial morphological alterations and preventive measures and strategies for oral pathologies management in this population. Despite always aiming at esthetics, treating these patients should always prioritize the possibilities of improving the oral and general functions of the body.

Passive Tracer Visualization to Simulate Aerodynamic Virus Transport in Noninvasive Respiratory Support Methods

<b><i>Background:</i></b> Various forms of noninvasive respiratory support methods are used in the treatment of hypoxemic CO­VID-19 patients, but limited data are available about the corresponding respiratory droplet dispersion. <b><i>Objectives:</i></b> The aim of this study was to estimate the potential spread of infectious diseases for a broad selection of oxygen and respiratory support methods by revealing the therapy-induced aerodynamics and respiratory droplet dispersion. <b><i>Methods:</i></b> The exhaled air-smoke plume from a 3D-printed upper airway geometry was visualized by recording light reflection during simulated spontaneous breathing, standard oxygen mask application, nasal high-flow therapy (NHFT), continuous positive airway pressure (CPAP), and bilevel positive airway pressure (BiPAP). The dispersion of 100 μm particles was estimated from the initial velocity of exhaled air and the theoretical terminal velocity. <b><i>Results:</i></b> Estimated droplet dispersion was 16 cm for unassisted breathing, 10 cm for Venturi masks, 13 cm for the nebulizer, and 14 cm for the nonrebreathing mask. Estimated droplet spread increased up to 34 cm in NHFT, 57 cm in BiPAP, and 69 cm in CPAP. A nonsurgical face mask over the NHFT interface reduced estimated droplet dispersion. <b><i>Conclusions:</i></b> During NHFT and CPAP/BiPAP with vented masks, extensive jets with relatively high jet velocities were observed, indicating increased droplet spread and an increased risk of droplet-driven virus transmission. For the Venturi masks, a nonrebreathing mask, and a nebulizer, estimated jet velocities are comparable to unassisted breathing. Aerosols are transported unboundedly in all these unfiltered therapies. The adequate use of protective measures is of vital importance when using noninvasive unfiltered therapies in infectious respiratory diseases.

Airway management in the adult patient with COVID-19: High flow nasal oxygen or not? A summary of evidence and local expert opinion

The use of high flow nasal oxygen in the care of COVID-19-positive adult patients remains an area of contention. Early guidelines have discouraged the use of high flow nasal oxygen therapy in this setting due to the risk of viral spread to healthcare workers. However, there is the need to balance the relative risks of increased aerosol generation and virus transmission to healthcare workers against the role high flow nasal oxygen has in reducing hypoxaemia when managing the airway in high-risk patients during intubation or sedation procedures. The authors of this article undertook a narrative review to present results from several recent papers. Surrogate outcome studies suggest that the risk of high flow nasal oxygen in dispersing aerosol-sized particles is probably not as great as first perceived. Smoke laser-visualisation experiments and particle counter studies suggest that the generation and dispersion of bio-aerosols via high flow nasal oxygen with flow rates up to 60 l/min is similar to standard oxygen therapies. The risk appears to be similar to oxygen supplementation via a Hudson mask at 15 l/min and significantly less than low flow nasal prong oxygen 1–5 l/min, nasal continuous positive airway pressure with ill-fitting masks, bilevel positive airway pressure, or from a coughing patient. However, given the limited safety data, we recommend a cautious approach. For intubation in the COVID-positive or suspected COVID-positive patient we support the use of high flow nasal oxygen to extend time to desaturation in the at-risk groups, which include the morbidly obese, those with predicted difficult airways and patients with significant hypoxaemia, ensuring well-fitted high flow nasal oxygen prongs with staff wearing full personal protective equipment. For sedation cases, we support the use of high flow nasal oxygen when there is an elevated risk of hypoxaemia (e.g. bariatric endoscopy or prone-positioned procedures), but recommend securing the airway with a cuffed endotracheal tube for the longer duration procedures when theatre staff remain in close proximity to the upper airway, or considering the use of a surgical mask to reduce the risk of exhaled particle dispersion.

Role of esophageal manometry in polysomnography of patients with chronic respiratory failure

Esophageal pressure (Pes) monitoring is performed during polysomnography (PSG) with a thin, water-filled catheter connected to a transducer. The resulting quantitative assessment of respiratory effort can aid in the accurate diagnosis of sleep-related breathing disorders. This was a prospective observational study using Pes in PSG for thirty patients with chronic respiratory failure (CRF) conducted in the Department of Pulmonary, Critical Care and Sleep Medicine at a tertiary care center of North India. Sleep Scoring was done by conventional method and using esophageal manometry and compared- Polysomnography normal without esophageal manometry recording (PSGN) and polysomnography with esophageal manometry scoring (PSGE). AHI index was similar in both groups. However, RERAs were diagnosed easily using Pes resulting in significant increase in RDI and even reclassification in terms of severity of sleep apnea. Besides, Pes was also useful to distinguish obstructive from central hypopnea which cannot be distinguished by routine PSG which can help guide therapy particularly in chronic respiratory failure patients with hypoventilation. Such patients with hypoventilation often require bilevel positive airway pressure as ventilatory support. Central hypopneas and apneas with hypercapnia may require a higher-pressure support, a backup rate or even advanced volume assured modes of ventilation. Thus, it can be concluded that Pes in PSG remains a safe and generally well-tolerated procedure. Use of Pes aids to detect RERA and thereby respiratory disturbance index (RDI); a better marker of Sleep related breathing disorder rather than AHI. It also helps in differentiate between obstructive and central hypopnea.

Synopsis on Non-invasive Ventilation in Neonatology

Non-invasive ventilation (NIV) is a mode of respiratory support commonly used on the neonatal unit. Since the advent of NIV, it has evolved from being used as a mode of respiratory support to wean infants from mechanical ventilation (MV) to a primary mode of respiratory support. NIV improve the functional residual capacity in the newborn (at term or preterm) avoiding invasive actions such as tracheal intubation. Newer methods of NIV support such as nasal bilevel positive airway pressure (BiPAP) and humidified high flow nasal cannula oxygen therapy (HHFNC) have emerged in attempts to reduce intubation rates and subsequent MV in preterm infants. With this synopsis, we aim to discuss various available NIV modes of ventilation in Neonatology, including indications, physiological principle, practical aspects and effects on important short and long-term morbidities associated with the use of NIV.

Clinical usage of non-invasive ventilation by physical therapists in cystic fibrosis centres across Australia: A cross-sectional survey study

BACKGROUND: This study investigated clinical usage of non-invasive ventilation during physical therapy for people with cystic fibrosis. Specific research questions were: 1. What are the clinical indications, contraindications and patient selection criteria for non-invasive ventilation use as an adjunct to physical therapy in people with cystic fibrosis? 2. Who implements non-invasive ventilation, what settings are used and how are they determined? 3. What outcome measures are used to determine the effectiveness of non-invasive ventilation as an adjunct to physical therapy and what are the main benefits and complications? METHODS: A purpose-designed survey was sent to 23 Australian cystic fibrosis centres. RESULTS: Fifteen centres (65%) responded, with 13 reporting current utilization of non-invasive ventilation to assist physical therapy. Non-invasive ventilation was most commonly (85%) used in patients with lung function <40% predicted. Physical therapy clinical indications included shortness of breath at rest (100%) and during airway clearance (100%), and fatigue during airway clearance (100%). Physical therapists were responsible for initiating non-invasive ventilation (62%), setting up (85%) and determining settings (62%). Bi-level ventilation was the only chosen ventilation mode. Benefits reported included improved ease of airway clearance (100%), reduced fatigue (92%) and decreased dyspnoea (85%). Only one complication of haemoptysis was reported. CONCLUSIONS: Non-invasive ventilation was used during physical therapy in people with cystic fibrosis who had severe disease, mostly during airway clearance to improve tolerability of treatment. Australian physical therapists initiated non-invasive ventilation when people with cystic fibrosis experienced shortness of breath or fatigue during treatment, aligning with current clinical guidelines. Clinical usage was largely consistent across centres, with numerous benefits and few complications reported. Further research is required to explore benefits of non-invasive ventilation use during physical therapy. Keywords: Cystic Fibrosis, Noninvasive Ventilation, Bilevel Positive Airway Pressure, Physical Therapy, Airway Clearance, Exercise

Tracheomalacia after thyroidectomy for retrosternal goitres requiring sternotomy– a myth or reality?

Introduction Tracheomalacia after thyroidectomy is not well understood. Reports on tracheomalacia are conflicting, with some suggesting a high rate and other large cohorts in which no tracheomalacia is reported. The aim of our study was to assess the incidence and factors associated with tracheomalacia after thyroidectomy in patients with retrosternal goitres requiring sternotomy at a high-volume tertiary care referral centre. Methods A longitudinal cohort study was conducted from January 2011 to December 2019. All adult patients who underwent thyroidectomy with sternotomy were included. Tracheomalacia was considered when tracheal rings were soft compared with other parts (proximal or distal) of the trachea and required either tracheostomy or resection with anastomosis. The decision to perform a tracheostomy or to administer continuous or bilevel positive airway pressure postoperatively was made depending on the degree of tracheomalacia. Logistic regression analysis was used to assess factors associated with tracheomalacia. Results We evaluated 40 patients who underwent thyroidectomy with sternotomy. The mean age of our cohort was 48.7 ± 11.3 years and the population was predominantly female (67.5%). One patient required tracheal resection with anastomosis, and two patients required tracheostomy. Multivariable logistic regression analysis did not reveal any patient- or thyroid-related factor significantly associated with the development of tracheomalacia in our cohort. Conclusions The incidence of tracheomalacia after thyroidectomy with sternotomy appears to be very low. However, the occurrence of tracheomalacia after thyroidectomy in cases of large goitre is possible and hence worrisome.