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Background: Severe COVID-19 pneumonitis in elderly frail patients is associated with poor outcomes, and therefore invasive mechanical ventilation is often deemed an inappropriate course of action. Some evidence suggests high-flow nasal oxygen (HFNO) may prevent the need for invasive ventilation in other groups of patients, but whether it is an appropriate ceiling of care for older frail patients is unknown. Methods: We retrospectively identified patients with severe COVID-19 pneumonitis requiring FiO2>60% who were deemed inappropriate for invasive ventilation or non-invasive continuous positive airway pressure ventilation (CPAP). Our local protocol based on national guidance suggested these patients should be considered for HFNO. We observed whether the patients received HFNO or standard oxygen therapy (SOT) and compared mortality and survival time in these groups. Results: We identified 81 patients meeting the inclusion criteria. From this group, 24 received HFNO and 57 received SOT. The HFNO group was similar in age, BMI and co-morbidities to the SOT group but less frail, as determined by the Clinical Frailty Scale (CFS). All 24 patients that received HFNO died in comparison to 46 patients (80.7%) in the SOT group. Mortality in the HFNO group was significantly higher than in the SOT group. Conclusion: Elderly frail patients with severe COVID-19 pneumonitis deemed inappropriate for invasive ventilation and did not benefit from HFNO. Further, HFNO may have been associated with harm in this group.

BackgroundThe optimum management of respiratory failure in COVID-19 patients has been a challenge for physicians across the globe. Many scientific societies have suggested the use of CPAP (continuous positive airway pressure) in severe cases, in an effort to reduce invasive ventilation. We investigated mortality outcomes in patients who needed CPAP but were not suitable for invasive ventilation.MethodsWe retrospectively evaluated the mortality outcomes of all consecutive COVID-19 cases with severe type 1 respiratory failure requiring FiO2 >0.6 who were admitted to our hospital between 12th March and 04th May’20. British Thoracic Society guidelines were followed for identifying patients needing CPAP. Their outcomes were recorded and compared with a similar group of patients who had oxygen as a ceiling of care. Prospectively collected data between 5th May and 7th June’20 in similar but smaller group of patients was also analysed.Results:A total of 104 COVID-19 patients with documented Do Not Attempt Resuscitation (DNAR) decision required high fraction of inspired oxygen (FiO2) >0.6 to maintain peripheral oxygen saturation (SpO2)> 92% (SpO2> 88% in COPD). 24 received CPAP as the ceiling of care with a mortality rate of 92.5%. The remaining 80 patients who were on oxygen as a ceiling of treatment had 91.7% mortality.Conclusion CPAP did not appear to improve survival of patients with severe respiratory failure due to COVID-19 who were not suitable for invasive ventilation. Further studies are warranted to adequately inform appropriate management strategies for this group of patients.KeywordsCPAP; non-invasive ventilation; COVID-19; critically ill; respiratory failure

Background Reliable differentiation between uncomplicated and self-limiting acute respiratory tract infections (ARIs) and more severe bacterial respiratory tract infections remains challenging, due to the non-specific clinical manifestations in both systemic bacterial or viral infections. The current COVID-19 pandemic is putting extraordinary strain on healthcare resources. To date, molecular testing is available but has a long turnaround time and therefore cannot provide results at the point-of-care, leading to a delay in results thereby exposing patients to cross-infection and delay in diagnosis (1-3). Methods We prospectively evaluated the utility of FebriDx®, a point-of-care fingerstick blood test that can differentiate viral from bacterial ARIs through simultaneous detection of both Myxovirus-resistance protein A (MxA) and C-reactive protein (CRP), in rapidly determining viral cases requiring immediate isolation and confirmatory molecular testing, from non-infectious patients or bacterial infections that require antibacterial therapy.Results 75 consecutive patients were assessed and 48 eligible cases were tested with FebriDx®. Overall, 35 patients had FebriDx® test viral positive. All 35 patients had either positive rt-PCR (n=30) for COVID-19 or clinical picture highly suggestive of COVID-19 infection (PPV of 100% in a pandemic situation)[AB1] . In the 13 cases it was viral negative, rRT-PCR was also negative in all cases. In one case of LRTI, it was not possible to determine the exact cause of infection and a viral infection couldn’t be excluded. Including this patient, the NPV was 12/13 (92%) exceeding the NPV of rRt-PCR at 71% (12/17). Sensitivity was conservatively calculated at 97% (35/36) compared to 85.7% (30[RS2] /35) for rRt-PCR. Similarly the specificity of both FebriDx®and rRt-PCR was 100% (12/12).Conclusions In the current COVID-19, FebriDx® shows potential as a reliable POC test and a proxy marker of COVID-19 infection amongst inpatients in a secondary care setting. [AB1]35/35 equates to a sensitivity and specificity of 100% for COVID, would you be willing to say that instead of ‘near 100% ppv)? [RS2]I believe PCR was 85.7% (30/35), because PCR only detects the COVID cases

Pulmonary endothelium dysfunction is a key characteristic of ARDS. The aim of this study was to investigate endothelium-derived markers, such as angiopoietin-2 (Ang-2) and endothelial cell-specific molecule-1 (endocan), at the vascular and alveolar compartments as outcome predictors in ARDS. Fifty-three consecutive ARDS patients were studied. The primary outcome was 28-day mortality. Secondary endpoints were days of unassisted ventilation and days with organ failure other than ARDS, during the 28-day study period. Nonsurvivors presented higher lung injury scores and epithelial lining fluid (ELF) Ang-2 levels compared to survivors, with no significant differences in plasma Ang-2, endocan, and protein C concentrations between the two groups. In logistic regression analysis, ELF Ang-2 levels > 705 pg/ml were the only independent variable for 28-day mortality among the previous four. Plasma endocan values > 13 ng/pg were the only parameter predictive against days of unassisted ventilation during the 28-day study period. Finally, lung injury score > 2.25 and ELF Ang-2 levels > 705 pg/ml were associated with increased number of days with organ failure, other than ARDS. Our findings suggest that Ang-2 levels are increased in the alveolar compartment of ARDS patients, and this may be associated both with increased mortality and organ failure besides lung.

A 54-year-old heavy smoker was admitted with a 2-week history of pleuritic chest pain, cough, shortness of breath and weight loss. He had not improved despite a course of antibiotics from his general practitioner. He was commenced on intravenous antibiotics for presumed pneumonia based on his chest X-ray, which seemed to show left middle zone opacification (figure 1), and after 2 days, he was discharged with a further oral antibiotic course. Figure 1 Posteroanterior chest X-ray …

Introduction: Current guidelines require a chest x-ray 1 hour post transcutaneous imaging-guided lung biopsy, in order to rule-out pneumothorax. This delays patient discharge, leads to longer waiting times and more radiation. Thoracic ultrasound (TUSS) is proven to be a safe and fast tool that has very high specificity in ruling-out pneumothorax, when performed by trained chest physicians. Objective: To assess the efficacy and safety of a TUSS-only protocol to rule-out post biopsy pneumothorax. Methods: 48 patients had US-guided biopsy (USGB) for peripheral lung/mediastinal lesions. Mean age 66.8 (SD± 12.0), mean FEV1 (Lts) was 1.61 (SD± 0.55), mean tumour size was 38.3mm (SD± 27.0) and mean distance from skin was 14.2mm (SD± 9.0). Tumours were located in lower lobes in 45.8% and in upper lobes in 54.2%. A bilateral 6-point TUSS (2D and M-mode) was performed before the biopsy as a baseline. Another 6-point TUSS was performed 10 minutes and 30 minutes post USGB, establishing presence of “sliding” and “seashore” signs. All patients were discharged home 30 minutes post biopsy and followed up with a phonecall later the same day. Results: Both “sliding” and “seashore” signs were present post USGB in 46/48 patients (95.8%). In 2 patients there was no clear “sliding” but there was “seashore” sign post biopsy. None of the patients reported shortness of breath or haemoptysis. One patient reported new pleuritic pain, had a repeat TUSS and chest x-ray and confirmed to have a small subcutaneous haematoma. Conclusions: TUSS performed by trained chest physicians can safely rule-out pneumothorax post USGB.

Introduction: Transthoracic ultrasound is an important tool in assessing pleural effusions and placement of chest drains. It also demonstrates pleural-based masses and lung tumours abutting the pleura, lesions usually suitable for US-guided biopsy (USGB). This procedure is not being widely performed by chest physicians. Objective: To assess safety and efficacy of USGB performed by chest physicians in outpatient setting. Methods: The procedures were carried out in outpatient setting between August 2015-January 2016. Apart from informed written consent, checking clotting and omitting antiplatelet/anticoagulants, no special preparations were undertaken. Under real-time US, lesions involving/abutting the pleura which were >15mm were sampled 1-3 times with a full-core biopsy needle (Biopince® 18G). Repeat US was done 10 minutes and 30 minutes post-biopsy, ruling-out pneumothorax. Patients were discharged home 30 minutes post-biopsy. Results: 48 patients had USGB for lung/mediastinal tumours. Biopsies were histologically deemed adequate in 97.9%, with overall yield 97.9% and yield for malignancy 91.6% (44/48), all in accordance with The Royal College of Radiologists. In 1 patient with a negative biopsy, malignancy was diagnosed at surgery. Complications were minimal with one case of minor haemoptysis (2%) and one case of small subcutaneous hematoma (2%). We had no pneumothoraces and no deaths (0%). After the introduction of the service the waiting list for tissue diagnosis has disappeared. Conclusion: USGB can be performed by trained chest physicians with excellent yield and very low complication rate in outpatients. When used appropriately, it reduces the waiting list for tissue diagnosis.

BACKGROUND Intensivists and nursing staff are often reluctant to admit patients with cancer to the intensive care unit even though these patients' survival rate has improved since the 1980s. OBJECTIVE To identify factors associated with mortality in cancer patients admitted to the intensive care unit and to assess and compare the effectiveness of 3 general prognostic models: the Acute Physiology and Chronic Health Evaluation (APACHE) II, the Simplified Acute Physiology Score (SAPS II), and the Sequential Organ Failure Assessment (SOFA). METHODS A prospective observational cohort study was performed in 2 general intensive care units. Discrimination was assessed by using area under the receiver operating characteristic curves, and calibration was evaluated by using Hosmer-Lemeshow goodness-of-fit tests. RESULTS A total of 126 patients were included during a 3-year period. The observed mortality was 46.8%. All 3 general models showed excellent discrimination (area under the curve >0.8) and good calibration (P = .17, .14, and .22 for APACHE II, SAPS II, and SOFA, respectively). However, discrimination was significantly better with APACHE II scores than with SOFA scores (P = .02). Multivariate analyses indicated that independent of the 3 severity-of-illness scores, unfavorable risk factors for mortality included a patient's preadmission performance status, source of admission (internal medicine vs surgery department), and the presence of septic shock, infection, or anemia. Combining SOFA and SAPS II scores with these variables created prognostic models with improved calibration and discrimination. CONCLUSIONS The general prognostic models seem fairly accurate in the prediction of mortality in critically ill cancer patients in the intensive care unit.

We report a case of severe ovarian hyperstimulation syndrome (OHSS) complicated by community-acquired methicillin-resistant Staphylococcus aureus-Panton-Valentine leukocidin positive (CAMRSA-PVL[+]) necrotizing pneumonia, sepsis and multiple organ failure (MOF) in a previously immunocompetent female. The patient required prolonged ventilatory support and intensive care unit (ICU) hospitalization. Multiple cavities and severely affected lung function persist 1 year after discharge.

The role of the D allele of the angiotensin-converting enzyme (ACE) gene I/D polymorphism in the clinical outcomes of patients with acute lung injury and acute respiratory distress syndrome (ALI/ARDS) remains controversial. We assessed simultaneously the effect of the ACE I/D polymorphisms as well as the serum and BALF ACE levels on prognosis of ARDS patients.

Several studies of critically ill patients have suggested an association of the D/D genotype of the insertion/deletion (I/D) angiotensin-converting enzyme (ACE) polymorphism with poor outcome probably by enhancing the inflammatory response and leading to a procoagulant state. Our aim was to evaluate the effect of both the ACE I/D polymorphism and its gene product, on the clinical outcome of critically ill septic patients.