A Case of Complex Pulmonary Hypertension: the Importance of Diagnostic Investigation

Pulmonary hypertension (PH) encompasses several heterogeneous groups of multiple diseases characterized by abnormal pulmonary arterial blood pressure elevation. Unrepaired atrial septal defect (ASD) may be associated with pulmonary arterial hypertension (PAH), indicating pulmonary vascular remodeling. Furthermore, unrepaired ASD could also be associated with other conditions, such as left heart disease or thromboembolism, contributing to the disease progression. We present a case of a 61-years-old woman with complex PH comprising several etiologies, which are PAH due to unrepaired Secundum ASD, mitral regurgitation caused by mitral valve prolapse as a group 2 PH, pulmonary embolism (PE) which progress to chronic thromboembolism PH (CTEPH) and post-acute sequelae of SARS Cov-2. We highlighted the importance of diagnostic investigation in PH, which is crucial to avoid misdiagnosis and inappropriate treatment that could be detrimental for the patient.

Forty-One-Year-Old Man with Pulmonary Embolism 5 Months After COVID-19

Background: Hypercoagulation is one of the striking features of COVID-19. Patients hospitalized with COVID-19 are at high risk for venous thromboembolism. However, it is unknown if the risk for venous thromboembolism persists after discharge. Case Summary: We report a case with pulmonary embolism 5 months after COVID-19. No risk factors for venous thrombosis have been identified. Conclusion: In COVID-19 related hospitalization, large studies are needed to identify the risk of venous thromboembolism after discharge.

Continuous Lower Abdominal Compression as a Therapeutic Intervention in COVID-19 ARDS

We report the case of a patient with severe COVID-19 ARDS, suggesting a possible therapeutic intervention by applying a continuous lower abdominal compression. In order to assess ventilation distribution, a lung CT scan was performed with and without lower abdominal compression.

V.I.T.A.M. in COVID 19: A Systematic Approach to a Global Pandemic

Introduction In the unprecedented era of COVID-19, ongoing research and evolution of evidence has led to ever-changing guidelines for clinical monitoring and therapeutic options. Formulating treatment protocols requires the understanding and application of the evolving research. Objective The primary objective of this study is to present a systematic evidence-based approach to synthesize the necessary data in order to optimize the management of COVID-19. Methods At Mayo Clinic Florida, we developed a multidisciplinary centralized COVID Treatment Review Panel (TRP) of expert pulmonologists, intensivists, infectious disease specialists, anesthesiologists, hematologists, rheumatologists, and hospitalists that in real-time reviews the latest evidence in peer-reviewed journals, the available clinical trials, and help guide the rapid application of therapeutics or interventions to the patient and the bedside provider. Results/Conclusions The multi-disciplinary team approach of synthesizing clinical data and coordinating care is effective in responding to rapidly evolving and changing evidence. Systematic data collection and evidence-based treatment algorithms enable physicians to rapidly translate the current literature to clinical practice, and improve care and outcomes of patients.

A Quick Review on the Multisystem Effects of Prone Position in Acute Respiratory Distress Syndrome (ARDS) Including COVID-19

Objective: The purpose of this review is to highlight the multisystem effects of prone position in ARDS patients with a focus on current findings regarding its use in COVID-19 patients. Methods: Two reviewers comprehensively searched PubMed database for literature regarding pathophysiology and efficacy of prone position in ARDS patients as well as specific data regarding this approach in COVID-19 patients. Conclusion: Prone positioning is well-documented to improve oxygenation and cardiac function in ARDS patients and might confer increased survival, with benefits that outweigh risks such as facial edema, endotracheal tube displacement, and intraabdominal organ dysfunction in obese patients. Severe COVID-19 pneumonia, while meeting ARDS criteria, differs from typical ARDS in several ways. Data would suggest that advantages of prone position would become limited after significant disease progression and fibrosis. The use of this technique in COVID-19 requires prolonged sessions that are unprecedented in the treatment of ARDS patients. New data regarding COVID-19 pathophysiology and patients continues to evolve daily. More frequently, patients are proned while maintaining spontaneous breathing—the results of this intervention are an area for future studies. There is more to learn about the appropriate use of prone position in COVID-19 patients. The multisystem risks and benefits require clinicians to adopt a patient centered decision-making algorithm when employing this technique in COVID-19 patients. Level of evidence: NA

COVID-19 Related Cardiovascular Comorbidities and Complications in Critically Ill Patients: A Systematic Review and Meta-analysis

Objective: This systematic-review and meta-analysis aimed to assess the prevalence of cardiovascular comorbidities and complications in ICU-admitted coronavirus disease 2019 (COVID-19) patients. Data sources: PubMed and Web of Science databases were referenced until November 25, 2020. Data extraction: We extracted retrospective and prospective observational studies on critically ill COVID-19 patients admitted to an intensive care unit. Only studies reporting on cardiovascular comorbidities and complications during ICU therapy were included. Data synthesis: We calculated the pooled prevalence by a random-effects model and determined heterogeneity by Higgins’ I2 test. Results: Of the 6346 studies retrieved, 29 were included in this review. The most common cardiovascular comorbidity was arterial hypertension (50%; 95% confidence interval [CI], 0.42-058; I2 = 94.8%, low quality of evidence). Among cardiovascular complications in the ICU, shock (of any course) was most common, being present in 39% of the patients (95% CI, 0.20-0.59; I2 = 95.6%; 6 studies). Seventy-four percent of patients in the ICU required vasopressors to maintain target blood pressure (95% CI, 0.58-0.88; I2 = 93.6%; 8 studies), and 30% of patients developed cardiac injury in the ICU (95% CI, 0.19-0.42; I2 = 91%; 14 studies). Severe heterogeneity existed among the studies. Conclusions: Cardiovascular complications are common in patients admitted to the intensive care unit for COVID-19. However, the existing evidence is highly heterogeneous in terms of study design and outcome measurements. Thus, prospective, observational studies are needed to determine the impact of cardiovascular complications on patient outcome in critically ill COVID-19 patients.

Assessment of Ventilation and Perfusion in Patients with COVID-19 Discloses Unique Information of Pulmonary Function to a Clinician: Case Reports of V/P SPECT

V/P SPECT from 4 consecutive patients with COVID-19 suggests that ventilation and perfusion images may be applied to diagnose or exclude pulmonary embolism, verify nonsegmental diversion of perfusion from the ventilated areas (dead space ventilation) that may represent inflammation of the pulmonary vasculature, detect the reversed mismatch of poor ventilation and better preserved perfusion (shunt perfusion) in bilateral pulmonary inflammation and indicate redistribution of lung perfusion (antigravitational hyperperfusion) due to cardiac congestion. V/P mismatch and reversed mismatch may be extensive enough to diminish dramatically preserved matching ventilation/perfusion and to induce severe hypoxemia in COVID-19.

Correlation and Predicted Equations of MIP/MEP from the Pulmonary Function, Demographics and Anthropometrics in Healthy Thai Participants aged 19 to 50 Years

Objective: To identify the correlations and possible predicted equations of maximal inspiratory (MIP) and expiratory mouth pressure (MEP) values from pulmonary function test (PFT), demographics, and anthropometrics. Methods: This study involved 217 healthy participants (91 males and 126 females) aged 19 to 50 years. The PFT (forced vital capacity; FVC, forced expiratory volume in 1 second; FEV1, maximal mid-expiratory flow; MMEF, and peak expiratory flow; PEF) was performed by spirometry, whereas MIP and MEP were evaluated by a respiratory pressure meter. Pearson correlation and multiple linear regression, with the stepwise method, were used for statistical analysis. Results: The MIP and MEP had a significant positive correlation with weight, height, body mass index (BMI), and waist circumference. MIP had a significant positive correlation with FVC (%) and PEF (L/s and %), as well as a negative correlation with FEV1/FVC (ratio and %) and MMEF (%). Whereas, MEP showed a significant positive correlation with PEF (L/s and %) and negative correlation with FEV1/FVC (ratio and %) and MMEF (L/s). Finally, the predicted MIP and MEP equations were 103.988−97.70 × FEV1/FVC + 31.292 × Sex (male = 1 and female = 0) + 0.662 × PEF (%) and 47.384 + 3.603 × PEF (L/s)−9.514 × MMEF(L/s) + 30.458 × Sex (male = 1 and female = 0) + 0.534 × PEF (%), respectively. Conclusion: The respiratory muscle strengths can be predicted from the pulmonary function test, and gender data.

Lung Adenocarcinoma with Paraneoplastic Hyper-Eosinophilia Not Responding To Pembrolizumab

Background: Paraneoplastic hyper-eosinophilia associated with metastatic lung adenocarcinoma is a rare finding and has been associated with a poor prognosis when present. Early hyper-eosinophilia appearing following non-small cell lung cancer (NSCLC) treatment with immune checkpoint inhibitors (ICI) has been previously reported with contradictory outcomes. Case summary: We present the case of an elderly man with newly diagnosed metastatic lung adenocarcinoma and baseline hyper-eosinophilia, treated with pembrolizumab, and showing evidence of significant and rapid disease progression suggestive of hyper-progressive disease, worsening baseline hyper-eosinophilia, and a fatal outcome within 1 month of therapy initiation. Conclusion: Pre-treatment hyper-eosinophilia could represent a predictive factor of an unfavorable response to ICI treatment in cases of NSCLC. Additional similar cases are needed to draw a more conclusive relationship.

Inflammatory Mechanism and Clinical Implication of Asthma in COVID-19

Asthma is a chronic inflammatory disease of the respiratory tract that has become a public health problem in various countries. Referring to the Global Initiative for Asthma, the prevalence of asthma continues to increase especially in children. Coronavirus Disease 2019 (COVID-19) is an infectious disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) that has declared a pandemic by the world health organization on March 2020. For many years, it has been known that people with asthma have a worse impact on respiratory viral infections. Asthma has been listed by the centers for disease control and prevention as one of the risk factors for COVID-19, although several studies have different results. SARS-CoV-2 utilizes angiotensin-converting enzyme 2 (ACE2) as its cellular receptor, and it has been known that the expression of the ACE2 receptor is reduced in asthma patients. This reduced expression could also be accounted from the therapy of asthma. This paper aims to discuss the pathophysiology of asthma and COVID-19 and the susceptibility of asthma patients in contracting COVID-19.