The Multi Split Ventilator System: Performance Testing of Respiratory Support Shared by Multiple Patients

Ventilator sharing has been proposed as a method of increasing ventilator capacity during instances of critical shortage. We sought to assess the ability of a regulated, shared ventilator system (Multi Split Ventilator System, MSVS) to individualize support to multiple simulated patients using one ventilator. We employed simulated patients of varying size, compliance, minute ventilation requirement, and PEEP requirement. Performance tests were performed to assess the ability of the QSVS, versus control, to achieve individualized respiratory goals to clinically disparate patients sharing a single ventilator following ARDSNet guidelines. Resilience tests measured the effects of simulated adverse events occurring to one patient on another patient sharing a single ventilator. The QSVS met individual oxygenation and ventilation requirements for multiple simulated patients with a tolerance similar to a single ventilator. Abrupt endotracheal tube occlusion or extubation occurring to one patient resulted in modest, clinically tolerable changes in ventilation parameters for the remaining patients. The QSVS is a regulated, shared ventilator system capable of individualizing ventilatory support to clinically dissimilar simulated patients. It is also resilient to common adverse events. The QSVS represents a feasible option to ventilate multiple patients during a severe ventilator shortage.

Opioids in COVID-19: Two Sides of a Coin

Introduction: The treatment of most severe COVID-19 patients included the large-scale use of sedatives and analgesics–possibly in higher doses than usual–which was reported in the literature. The use of drugs that decrease mortality is necessary and opioids are important agents in procedures such as orotracheal intubation. However, these drugs seem to have been overestimated in the COVID-19 pandemic. We performed a review of the PubMed-Medline database to evaluate the use of opioids during this period. The following descriptors were used to enhance the search for papers: “Opioids”, “COVID-19,” “COVID-19 pandemic,” “SARS-CoV-2,” “Opioid use disorder,” “Opioid dependence” and the names of the drugs used. We also evaluated the distribution of COVID-19 patients in Brazil and the applicability of opioids in our country during the COVID-19 pandemic.Results: Several positive points were found in the use of opioids in the COVID-19 pandemic, for instance, they can be used for analgesia in orotracheal intubation, for chronic pain management, and as coadjutant in the management of acute intensification of pain. However, high doses of opioids might exacerbate the respiratory depression found in COVID-19 patients, their chronic use can trigger opioid tolerance and the higher doses used during the pandemic might result in greater adverse effects. Unfortunately, the pandemic also affected individuals with opioid use disorder, not only those individuals are at higher risk of mortality, hospitalization and need for ventilatory support, but measures taken to decrease the SARS-CoV-2 spread such as social isolation, might negatively affect the treatment for opioid use disorder. In Brazil, only morphine, remifentanil and fentanyl are available in the basic health care system for the treatment of COVID-19 patients. Out of the 5,273,598 opioid units used in this period all over the country, morphine, fentanyl, and remifentanil, accounted for, respectively, 559,270 (10.6%), 4,624,328 (87.6%), and 90,000 (1.8%) units. Many Brazilian regions with high number of confirmed cases of COVID-19 had few units of opioids available, as the Southeast region, with a 0.23 units of opioids per confirmed COVID-19 case, and the South region, with 0.05 units. In the COVID-19 pandemic scenario, positive points related to opioids were mainly the occurrence of analgesia, to facilitate intubation and their use as coadjutants in the management of acute intensification of pain, whereas the negative points were indiscriminate use, the presence of human immunosuppressor response and increased adverse effects due to higher doses of the drug.Conclusion: The importance of rational and individualized use of analgesic hypnotics and sedative anesthetics should be considered at all times, especially in situations of high demand such as the COVID-19 pandemic.

Interventional Bronchus Occlusion Using Amplatzer Devices – A Promising Treatment Option for Children with Persistent Air Leak

Background: Persistent air leak (PAL) is a severe complication of secondary spontaneous pneumothorax (SSP). Surgical interventions are usually successful when medical treatment fails, but can be associated with significant complications and loss of potentially recoverable lung parenchyma. Methods: Retrospective analysis of efficacy and safety of interventional bronchus occlusions (IBO) using Amplatzer devices (ADs) in children with PAL secondary to SSP. Results: Six patients (four males, 4–15 years of age) underwent IBO using ADs as treatment for PAL. Necrotizing pneumonia (NP) was the most common cause (n=4) of PAL. Three patients were previously healthy and three suffered from chronic lung disease. All patients required at least two chest tubes prior to the intervention for a duration of 15–43 days and all required oxygen or higher level of ventilatory support. In three cases, previous surgical interventions had been performed without success. All children improved after endobronchial intervention and we observed no associated complications. All chest tubes were removed within 5–25 days post IBO. In patients with PAL related to NP (n=4), occluders were removed bronchoscopically without re-occurrence of pneumothorax after a mean of 70 days (IQR: 46.5–94). Conclusion: IBO using ADs is a safe and valuable treatment option in children with PAL independent of disease severity and underlying cause. A major advantage of this procedure is its less invasiveness compared to surgery and the parenchyma- preserving approach.

Sildenafil for treating patients with COVID-19 and perfusion mismatch: a pilot randomized trial

Background SARS-CoV-2 seems to affect the regulation of pulmonary perfusion. Hypoperfusion in areas of well-aerated lung parenchyma results in a ventilation–perfusion mismatch that can be characterized using subtraction computed tomography angiography (sCTA). This study aims to evaluate the efficacy of oral sildenafil in treating COVID-19 inpatients showing perfusion abnormalities in sCTA. Methods Triple-blinded, randomized, placebo-controlled trial was conducted in Chile in a tertiary-care hospital able to provide on-site sCTA scans and ventilatory support when needed between August 2020 and March 2021. In total, 82 eligible adults were admitted to the ED with RT-PCR-confirmed or highly probable SARS-COV-2 infection and sCTA performed within 24 h of admission showing perfusion abnormalities in areas of well-aerated lung parenchyma; 42 were excluded and 40 participants were enrolled and randomized (1:1 ratio) once hospitalized. The active intervention group received sildenafil (25 mg orally three times a day for seven days), and the control group received identical placebo capsules in the same way. Primary outcomes were differences in oxygenation parameters measured daily during follow-up (PaO2/FiO2 ratio and A-a gradient). Secondary outcomes included admission to the ICU, requirement of non-invasive ventilation, invasive mechanical ventilation (IMV), and mortality rates. Analysis was performed on an intention-to-treat basis. Results Totally, 40 participants were enrolled (20 in the placebo group and 20 in the sildenafil group); 33 [82.5%] were male; and median age was 57 [IQR 41–68] years. No significant differences in mean PaO2/FiO2 ratios and A-a gradients were found between groups (repeated-measures ANOVA p = 0.67 and p = 0.69). IMV was required in 4 patients who received placebo and none in the sildenafil arm (logrank p = 0.04). Patients in the sildenafil arm showed a significantly shorter median length of hospital stay than the placebo group (9 IQR 7–12 days vs. 12 IQR 9–21 days, p = 0.04). Conclusions No statistically significant differences were found in the oxygenation parameters. Sildenafil treatment could have a potential therapeutic role regarding the need for IMV in COVID-19 patients with specific perfusion patterns in sCTA. A large-scale study is needed to confirm these results. Trial Registration: Sildenafil for treating patients with COVID-19 and perfusion mismatch: a pilot randomized trial, NCT04489446, Registered 28 July 2020, https://clinicaltrials.gov/ct2/show/NCT04489446.

Pneumoperitoneum Secondary to Pneumothorax Post-Intubation in a Patient with Difficult Airway

The use of mechanical ventilation can be performed in situations where patients need ventilatory support to maintain adequate oxygenation. Its inappropriate use can cause some complications, among them: pneumothorax and pneumoperitoneum. Our report describes a 28-year-old man admitted to the ICU with a diagnosis of Covid-19 requiring mechanical ventilation with orotracheal intubation due to acute respiratory failure. During the patient’s clinical evolution he presented bilateral pneumothorax with evolution and progression to secondary pneumoperitoneum, where we sought to understand the relationship between the two conditions.

Ocorrência de Lesão Pulmonar Aguda relacionada à Transfusão em Hospital de Referência do Ceará: Relato de Caso / Occurrence of Transfusion-related Acute Lung Injury in a Reference Hospital of Ceará: Case Report

Lesão pulmonar aguda relacionada à transfusão (TRALI –Transfusion Related Acute Lung Injury) é uma complicação grave da transfusão sanguínea que cursa essencialmente com desconforto respiratório durante ou dentro de 6 horas depois de completada a transfusão. Apesar de ser considerada rara e a lesão pulmonar ser geralmente transitória, traz preocupação aos profissionais da área da saúde, visto que está associada à alta morbidade dos pacientes que necessitaram de suporte ventilatório, assim como a alta mortalidade. Sua incidência não está bem estabelecida, muito devido à falta de preparo para identificar os casos suspeitos. Assim, os relatos de casos ganham relevância tanto para contribuir que o diagnóstico desta patologia seja alcançado com mais facilidade quanto para estimular que os casos sejam notificados. O presente relato descreve a ocorrência de TRALI em paciente no segundo dia de pós-operatório de cesárea por pré- eclâmpsia e síndrome Hellp que evoluiu com suspeita de hemoperitônio sendo submetida a laparotomia exploratória (LE).---Transfusion related acute lung injury (TRALI) is a serious complication of blood transfusion that evolves mainly with respiratory distress during or within 6 hours after transfusion. Although considered rare and is usually transient lung injury, she brings concern to health professionals, as it is associated with high morbidity of patients requiring ventilatory support, as well as the high mortality. Its incidence is not well established, much due to lack of preparation to identify suspected cases. Thus, case reports gain relevance to contribute to the diagnosis of this condition is more easily achieved as to stimulate the cases are reported. This report describes the occurrence of TRALI in a patient on the second day after surgery by cesarean preeclampsia and HELLP syndrome who developed suspected hemoperitoneum and underwent exploratory laparotomy (LE).

A Case Report on Post COVID -19 Vaccine Associated Guillain–Barré Syndrome

Guillain–Barré syndrome (GBS) is an autoimmune demyelinating illness in which a patient’s immune system attacks and cause deterioration of peripheral nervous system leading to progressive paralysis and polyneuropathy. The exact cause of the GBS is unclear but the main mechanism of behindis the demyelination of nerves especially the motor, sensory, and autonomic nerves which can be triggered by any immunologic or infectious agent. The infectious agent elicits the humoral and cellular mediated immune response due to their molecular mimicry in which the antibodies created against the infection matches with the proteins on the nerve. The characteristic features of Guillain–Barré syndrome are ascending flaccid paralysis, paresthesia, impairment of muscle reflexes, respiratory failureetc. The GBS is diagnosed via nerve conduction studies, lumbar puncture (Cerebrospinal fluid analysis), electromyography, Brighton criteria. Treatments like intravenous immunoglobulin therapy, plasma exchange can ease the symptoms and reduce the duration of the illness. This case report focusing on a 43-year-old female patient admitted seeking ventilatory support for respiratory distress caused by Guillain–Barré Syndrome in a tertiary hospital. Patient had developed limb weakness with ascending paralysis along with facial weakness within a couple of weeks after receiving the COVID -19 vaccination (COVISHIELD)one month back. Patient underwent nerve conduction study and routine monitoring of vital parameters. After conservative management with physiotherapy, ventilation, intravenous immunoglobulins and prophylaxis for pain and DVT patient gradually started improving the muscle power and was discharged to continue the rehabilitation care at home.

Pediatric Inflammatory Multisystem Syndrome Temporally Associated with SARS-CoV-2—Case Series of a Pediatric Intensive Care Unit in Portugal

Pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (PIMS-TS) is a novel condition with persistent fever, inflammation, and single or multiorgan dysfunction. We aimed to describe the characteristics of children more severely affected and our clinical approach. We retrospectively collected clinical, treatment, and early outcomes data during a 3-month period in a pediatric intensive care unit (PICU) of a tertiary university hospital in Portugal. Twelve children who fulfilled the Royal College of Pediatrics and Child Health case definition were hospitalized, seven needed PICU admission. Median age was 13 years and three were overweight, with no other comorbidity. All had positive immunoglobulin G antibodies for SARS-CoV-2. All presented with prolonged fever, asthenia, hypotension, and shock. Other prominent symptoms were abdominal complaints and rash. All patients had leukocytosis, neutrophilia, and marked elevation of inflammatory markers. Cardiac involvement was observed in all patients with elevated levels of troponin and B-type natriuretic peptide along with left ventricular hypokinesis. Depressed left ventricular function was observed in four patients. All patients received broad-spectrum antibiotics, intravenous immunoglobulin, methylprednisolone, low-dose aspirin, and vasoactive medications. Four patients received prophylactic enoxaparin. All patients needed supplementary oxygen; however, high-flow oxygen therapy and noninvasive ventilatory support with positive end-expiratory pressure were required in three and two patients, respectively. Five patients required invasive mechanical ventilation. The mean duration of PICU stay was 7.1 days. The median Pediatric Risk of Mortality-III score was 9 and no mortality was observed. PIMS-TS demands a prompt and multidisciplinary approach. Risk factors, best clinical pathway, and long-term complications are still unknown.