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AIMS: Comprehensive echocardiography assessment of right ventricular (RV) impairment has not been reported in critically ill patients with COVID-19. We detail the specific phenotype and clinical associations of RV impairment in COVID-19 acute respiratory distress syndrome (ARDS). METHODS: Transthoracic echocardiography (TTE) measures of RV function were collected in critically unwell patients for associations with clinical, ventilatory and laboratory data. RESULTS: Ninety patients (25.6% female), mean age 52.0 ± 10.8 years, veno-venous extracorporeal membrane oxygenation (VVECMO) (42.2%) were studied. A significantly higher proportion of patients were identified as having RV dysfunction by RV fractional area change (FAC) (72.0%,95% confidence interval (CI) 61.0-81.0) and RV velocity time integral (VTI) (86.4%, 95 CI 77.3-93.2) than by tricuspid annular plane systolic excursion (TAPSE) (23.8%, 95 CI 16.0-33.9), RVS' (11.9%, 95% CI 6.6-20.5) or RV free wall strain (FWS) (35.3%, 95% CI 23.6-49.0). RV VTI correlated strongly with RV FAC (p ≤ 0.01). Multivariate regression demonstrated independent associations of RV FAC with NTpro-BNP and PVR. RV-PA coupling correlated with PVR (univariate p

Background Corona Virus Disease 2019 (COVID-19) pneumonitis associated with severe respiratory failure carries a high mortality. Coagulopathy has emerged as a significant contributor to thrombotic complications. Case summary We describe two cases of severe COVID-19 pneumonitis refractory to conventional mechanical ventilation and proning position, transferred to our specialist centre for cardiorespiratory failure. Cross-sectional imaging demonstrated concurrent venous and aortic thrombosis with end-organ ischaemic changes. One patient received thrombolysis with a partial response. This could not be offered to the other patient due to a recent haemorrhagic event. Both patients died of multi-organ failure in the hospital. Discussion Concurrent aortic and venous thromboses are rare. This finding in COVID-19 cases, who were both critically ill patients, likely reflects the strongly thrombogenic nature of this illness which ultimately contributed to poor outcomes. The absence of deep vein thrombosis or a potential systemic source of embolism suggests in situ thrombosis. Further, the management of anticoagulation and thrombolysis is challenging in patients where an attendant bleeding risk exists.

Comprehensive echocardiography assessment of right ventricular (RV) impairment has not been reported in critically ill patients with COVID-19. We detail the specific phenotype and clinical associations of RV impairment in COVID-19 acute respiratory distress syndrome (ARDS).Transthoracic echocardiography (TTE) measures of RV function were collected in critically unwell patients for associations with clinical, ventilatory and laboratory data.Ninety patients (25.6% female), mean age 52.0 ± 10.8 years, veno-venous extracorporeal membrane oxygenation (VVECMO) (42.2%) were studied. A significantly higher proportion of patients were identified as having RV dysfunction by RV fractional area change (FAC) (72.0%,95% confidence interval (CI) 61.0-81.0) and RV velocity time integral (VTI) (86.4%, 95 CI 77.3-93.2) than by tricuspid annular plane systolic excursion (TAPSE) (23.8%, 95 CI 16.0-33.9), RVS' (11.9%, 95% CI 6.6-20.5) or RV free wall strain (FWS) (35.3%, 95% CI 23.6-49.0). RV VTI correlated strongly with RV FAC (p ≤ 0.01). Multivariate regression demonstrated independent associations of RV FAC with NTpro-BNP and PVR. RV-PA coupling correlated with PVR (univariate p 0.01), as well as RVEDAi (p 0.01), and RVESAi (p 0.01), and was associated with P/F ratio (p 0.026), PEEP (p 0.025), and ALT (p 0.028).Severe COVID-19 ARDS is associated with a specific phenotype of RV radial impairment with sparing of longitudinal function. Clinicians should avoid interpretation of RV health purely on long-axis parameters in these patients. RV-PA coupling potentially provides important additional information above standard measures of RV performance in this cohort.

Tracheobronchopathia osteochondroplastica (TO) is a large airway disorder, characterised by bony nodule growth on the anterior and lateral walls of the trachea and bronchi. Its diagnosis is based on the ‘rock garden’ appearance on bronchoscopy.[1–3][1] However, as an uncommon condition with

Antibiotic use in intensive care units (ICUs) can promote antimicrobial resistance. Outbreaks of multi-resistant bacteria significantly affect patient outcomes and delivery of care. Antibiotic stewardship programmes (ASPs), combining root-cause analyses and multi-faceted prevention strategies, are necessary, often at significant cost and time. Which elements of such strategies have the largest impact on antibiotic usage following an outbreak is unclear. The aim of this study was to investigate how antibiotic usage in a university hospital ICU changed with a non-protocolised ASP following a disruptive outbreak of multi-resistant Acinetobacter baumannii (MRAB). This was a three time-period observational cohort study. The primary endpoint was the change in overall antibiotic usage (daily defined dose, DDD, antibiotic-days, antibiotic-courses) for consecutive ICU patients staying >48 h, over three 6-month study time periods pre-MRAB (2008, n = 84) and post-MRAB (2010, n = 88; 2012, n = 122). Secondary endpoints were changes in antibiotic usage and patient demographics, in predefined admission categories (Medical Emergency, ME; Surgical Elective, SEL; and Surgical Emergency, SE). The mean age (54.6 ± 17.7, 58.1 ± 17.9, 62.8 ± 19.1 years*) and severity of illness (APACHE 14.8 ± 8.0, 16.7 ± 6.8, 18.3 ± 6.1*) increased, particularly medical admissions. There was a sustained reduction in DDD antibiotic usage [1895.1 (2008), 1224.2 (2010), 1236.6 (2012) per 1000 patient-days] but no overall change in antibiotic-days or antibiotic-courses. Antibiotic usage (antibiotic-days) fell significantly in surgical emergency admissions [20.2 ± 32.1, 4.6 ± 7.4*, 5.9 ± 7.3]. There was a sustained drop in beta-lactam, quinolone, glycopeptide and macrolide usage. Following an MRAB outbreak, and subsequent operational changes including enhanced ASPs (non-protocolised), there was a sustained overall fall in antibiotic usage in spite of an increase in disease severity over 5 years.

Purpose This survey investigated current practice in intensive care unit radiology reporting using a survey tool. We ascertained physician attitudes regarding best practice. Methods A national survey was sent by email to a sample of intensive care units throughout UK between March and October 2014. The questionnaire determined current practice in reporting chest X-ray in intensive care units. It also identified differences between ‘routine’ and emergency and out-of-hours service. Further, it investigated how reports were documented and physician preferences for perceived best practice. Results Of 146 intensive care units contacted, 55% completed the survey. Of the sample, radiologists were solely responsible for chest X-ray reporting in 43.7%, intensive care unit clinicians in 33.7% and joint reporting in 25% of intensive care units. The reporting clinician on intensive care unit was a consultant in 67% of the centres. Written reports by radiologists were provided in 71.7% of cases. This was only 54.5% when intensive care unit clinicians reported chest X-rays. For all routine and emergency films, written reports by radiologists occurred in 63.1% of responders. Out-of-hours, 54.9% of clinicians described different reporting practice to normal hours. Regarding perceived best practice, 64.8% of clinicians preferred joint daily reporting, whilst 27% preferred a radiologist’s formal report. For emergencies, 55.2% of the survey recipients preferred a joint report. Conclusion Based on this cohort of UK intensive care units, at present, there appears to be a lack of a standardised system for image reporting. There are discrepancies in who reports chest X-rays, written documentation and the timing of reports, more so out-of-hours. Clinicians suggest that joint reporting should be the standard.

Diagnostic error has implications for both clinical outcome and resource utilisation, and may often be traced to impaired data gathering, processing or synthesis because of the influence of cognitive bias. Factors inherent to the intensive/acute care environment afford multiple additional opportunities for such errors to occur. This article illustrates many of these with reference to a case encountered on our intensive care unit. Strategies to improve completeness of data gathering, processing and synthesis in the acute care environment are critically appraised in the context of early detection and amelioration of cognitive bias. These include reflection, targeted simulation training and the integration of social media and IT based aids in complex diagnostic processes. A framework which can be quickly and easily employed in a variety of clinical environments is then presented.

According to the British Thoracic Society (BTS) guidelines,[1][1] extracorporeal membrane oxygenation (ECMO) may be considered in near-fatal asthma exacerbations refractory to conventional ventilator treatment. However, there is currently no clear criteria for accepting such patients for ECMO

Owing to complexities of measuring dead space, ventilatory failure is difficult to quantify in critical care. A simple, novel index called ventilatory ratio (VR) can quantify ventilatory efficiency at the bedside. The study objectives were to evaluate physiological properties of VR and examine its clinical applicability in acute respiratory distress syndrome (ARDS) patients.A validated computational model of cardiopulmonary physiology [Nottingham Physiology Simulator (NPS)] was used to evaluate VR ex vivo in three virtual patients with varying degrees of gas exchange defects. Arterial P(CO₂) and mixed expired P(CO₂) were obtained from the simulator while either dead space or CO₂ production was altered in isolation. VR and deadspace fraction was calculated using these values. A retrospective analysis of a previously presented prospective ARDS database was then used to evaluate the clinical utility of VR. Basic characteristics of VR and its association with mortality were examined.The NPS showed that VR behaved in an intuitive manner as would be predicted by its physiological properties. When CO₂ production was constant, there was strong positive correlation between dead space and VR (modified Pearson's r 0.98, P0.01). The ARDS database had a mean VR of 1.47 (standard deviation 0.58). Non-survivors had a significantly higher VR compared with survivors [1.70 vs 1.34, mean difference 0.35, 95% confidence interval (CI) 0.16-0.56, P0.01]. VR was an independent predictor of mortality (odds ratio 3.05, CI 1.35-6.91, P0.01).VR is influenced by dead space and CO₂ production. In ARDS, high VR was associated with increased mortality.

Tracheal rupture is an infrequent, severe complication of endotracheal intubation, which can be difficult to diagnose. Post-intubation tracheal rupture (PiTR) is distinct from non-iatrogenic causes of tracheobronchial trauma and often requires different treatment. The increasing adoption of pre-hospital emergency services increases the likelihood of such complications from emergency intubations. Effective management strategies for PiTR outside specialist cardiothoracic units are possible. Two cases of severe PiTR, successfully managed non-operatively on a general medical-surgical intensive care unit, illustrate a modified approach to current standards. The evidence base for PiTR is reviewed and a pragmatic management algorithm presented.

Summary Inhalation injury may result from numerous noxious triggers and in association with other injuries, the most common being cutaneous burns. While patients with severe burns often require transfer to a regional unit for specialist management, this is not the case for those with inhalation injury associated with minor burns or occurring in isolation. These latter patients may require management in a general intensive care unit and yet they present some unique challenges to the clinician that may otherwise go unnoticed. The aim of this review is to provide an overview of the pathophysiology, presentation and management of patients with inhalation injury by way of a guide to those who manage such patients on an infrequent basis.

Transbronchial fine needle aspiration (TBNA) is a simple technique for sampling mediastinal lymph nodes and may provide additional information in patients with suspected lung cancer. However, the technique is still under-utilized, and the objective of this study was to evaluate the value of TBNA as part of an integrated pathway for the assessment of patients with suspected lung cancer. All patients referred to the lung cancer services of our institutions were prospectively evaluated. TBNA was performed in all patients with evidence of mediastinal lymphadenopathy. TBNA of one or more lymph node sites were performed in 129 of these patients. TBNA was the sole diagnostic modality in 23% of patients and provided positive staging information for 49% of patients, with adequate sampling in 71% of patients. Among patients with mediastinal adenopathy, the number of patients who required a TBNA performed to diagnose one patient with malignancy in patients suspected with lung cancer (number needed to diagnose) was 1.47 (95% confidence interval, 1.47–1.76). No complications were observed in patients who underwent TBNA. TBNA improves the diagnostic yield and staging of patients with lung cancer. Moreover, it is a simple, low-cost, and safe test, which should be incorporated into the diagnostic pathway of patients with suspected lung cancer.

lence, the susceptibility factors of the affected patient groups, the predictive clinical features and the impact of vaccinations and available pharmaceutical and supportive treatments have provided lessons for preparedness for pandemics in the future [7] . Against this backdrop, we are reminded that, at an individual level, the diagnosis of viral pneumonia with particular reference to the demonstration of viral pathogenicity is difficult. More specifically, in patients with a critical illness and severe respiratory failure not primarily suspected to be due to a virus, the challenges of recognizing viral etiology, diagnostic sampling, testing and treatment of viral pneumonitis remain complex. The herpesvirus family is a group of viruses (Herpesviridae) characterized by their ability to remain latent within tissues following initial infection and a tendency to reactivate at mucocutaneous sites [8] . The most common forms involved in the respiratory tract are herpes simplex virus (HSV) 1, cytomegalovirus (CMV), Epstein-Barr virus (EBV) and human herpes virus (HHV) 6 and 8. The prevalence of oropharyngeal HSV1 in healthy adults is 2–3% [9, 10] . This is similar to the prevalence in hospitalized non-intensive care unit (ICU) patients [11] . A reactivation of herpesviruses may occur due to local Acute viral respiratory infections are the most common illnesses experienced by people worldwide. Most notable amongst these are rhinoviruses, influenza (Flu A and B), adenoviruses, picornaviruses, respiratory syncytial virus, parainfluenza viruses 1–3, human metapneumovirus, human coronaviruses and the herpesviruses. Their reported frequency ranges from 0 to 7 per annum, and this diminishes with increasing age [1] . At least one such virus is isolated in up to 53% of patients attending an emergency department with acute respiratory tract infections [2] . Respiratory viruses are usually self-resolving in the immunocompetent host. In those who are immunocompromised as well as in a proportion of otherwise well individuals, however, they can pose potentially lifethreatening consequences. This situation is perhaps best epitomized by the influenza pandemic of 1918 that had a fatality rate of millions [3] . In recent years, the world has experienced equally fearful but less catastrophic pandemics; accurate population data from these have provided insights into risk factors, outcomes and confounding factors. The epidemics of severe acute respiratory syndrome (SARS), swine flu (H1N1) and the so-called Middle East respiratory syndrome have challenged populations and global healthcare systems over the last decade [4–6] . Fortunately, the careful retrospective analysis of their viruPublished online: February 28, 2014

Chest drain insertion (tube thoracostomy) is an essential skill for hospital doctors dealing with certain pleural diseases. While aspiration may be appropriate in spontaneous pneumothorax and uncomplicated pleural effusions, it is often inadequate. In such cases, and for other indications (Table 1), it may be necessary to insert a chest drain. Traditionally, this is inserted in the pleural space percutaneously through blunt dissection and connected to a drainage device with an underwater seal. The procedure may be image-directed. Newer chest drains based on a guide-wire technique have been developed with the dual aims of safety and ease of appropriate placement.

This new guideline covers the rapidly advancing field of interventional bronchoscopy using flexible bronchoscopy. It includes the use of more complex diagnostic procedures such as endobronchial ultrasound, interventions for the relief of central airway obstruction due to malignancy and the recent development of endobronchial therapies for chronic obstructive pulmonary disease and asthma. The guideline aims to help all those who undertake flexible bronchoscopy to understand more about this important area. It also aims to inform respiratory physicians and other specialists dealing with lung cancer of the procedures possible in the management and palliation of central airway obstruction. The guideline covers transbronchial needle aspiration and endobronchial ultrasound-guided transbronchial needle aspiration, electrocautery/diathermy, argon plasma coagulation and thermal laser, cryotherapy, cryoextraction, photodynamic therapy, brachytherapy, tracheobronchial stenting, electromagnetic navigation bronchoscopy, endobronchial valves for emphysema and bronchial thermoplasty for asthma.

Introduction Biomarkers have been investigated in order to speed up diagnosis of VAP, a common condition in ICU patients. TREM-1 is a protein involved in amplification of immune responses to bacterial and fungal infection and exists as soluble and surface forms.1 2 The diagnostic value of soluble TREM-1 in broncho-alveolar lavage fluid (BALF) in VAP is controversial.[3][1] Therefore the utility of surface TREM-1 for diagnosing VAP in a two-compartment model (BALF and blood) was investigated. Methodology Paired blood and BALF were obtained in consenting patients in the following groups: (1) Ventilated patients with VAP diagnosed on semi-quantitative microbiology and Clinical Pulmonary Infection Score (CPIS); (2) Ventilated patients without sepsis; (3) Day-case bronchoscopy patients without evidence of infection. Flow cytometry was performed on cell pellets derived from simultaneous BALF and blood samples. Surface TREM-1, CD11b (immune cell activation marker) and L-selectin (immune cell migration marker) levels were measured on monocytes and neutrophils. At the same time an inflammatory cytokine panel (comprising IL-1β, IL-6, IL-8 and soluble TREM-1) was measured by ELISA in the paired blood and BALF samples. Results Expression of TREM-1 and CD11b on monocytes were significantly elevated in BALF samples obtained from the VAP patient group. There was no change in blood surface TREM-1 and CD11b levels between the different patient groups. The BALF/blood ratio of monocytic TREM-1 increased the discrimination between the VAP and non-VAP groups ([Abstract S77 Figure 1][2]). Soluble TREM-1 levels were not significantly different between the groups. There was no difference in peripheral blood white cell count, CRP, expression of CD11b, L-selectin and inflammatory cytokines between VAP and disease controls. ![Abstract S77 Figure 1][3] Abstract S77 Figure 1 The ratio monocytic surface TREM-1 between BALF and blood (flow cytometry). 16 patients with VAP are compared with 8 ventilated non-septic control (VC) and 17 non-ventilated non-infected control patients (NVC). The median levels and IQRs are: VAP (0.92, 0.66–1.77), VC (0.21, 0.12–0.28) and NVC (0.36, 0.22–0.41). * and # p=0.0001. Conclusion The BALF/blood ratio of monocytic surface TREM-1 discriminates between the VAP and non-VAP groups. Measurement of surface TREM-1 using a two-compartment index may have utility in diagnosing VAP. [1]: #ref-3 [2]: #F1 [3]: pending:yes

Sampling from blood has been performed for over 200 years. However clinically useful arterial blood gas sampling became a reality after the development of robust methods for measuring oxygen tension from humans in the 1940s. Thus the development of the Clark electrode and subsequent safe tools for sampling plasma, heralded an era of blood sampling, and analysis from which we have not looked back. [1] As with many new medical technologies of their time, it was borne out of a combination of the need for investigational improvements, inventive spirit and serendipity. Arterial Blood gas sampling has been the standard of care for monitoring acid-base disturbance for decades - a testimony to its value in diverse settings. Despite this, concerns remain regarding its risks to the patient from repeated same site sampling. [2] This in part led to the alternative approach of arterialized blood samples (AzB), using either an earlobe or Þ nger pulp skin prick. [3] In theory AzB are more easily obtained than ABG, repeatable with better patient tolerance, and accurate. Thus it was surprising to know of the relatively poor uptake of this technique in the ambulatory setting. [4] Despite better utilisation in the UK, ongoing concerns regarding equipment, reliability and accuracy hamper its wider use. [5]