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High flow nasal cannula (HFNC) is used to treat acute hypoxemic respiratory failure (AHRF) even outside the ICU and the ROX index (pulse oximetry/fraction of inspired oxygen/respiratory rate) may predict HFNC failure. OBJECTIVE: The purpose of this investigation was therefore to verify whether the ROX index is an accurate predictor of HFNC failure for COVID-19 patients treated outside the intensive care unit (ICU) and to evaluate the validity of the previously suggested threshold. DESIGN: Multicenter study. Retrospective observational analysis of prospectively collected data. SETTING: 3 centres specialized in non-invasive respiratory support (Buenos Aires, Argentina; Bolzano and Treviso, Italy). Patients treated outside the ICU were analysed MEASUREMENTS: The variables to calculate the ROX index were collected during the first day of therapy at 2, 6, 12 and 24 hours and then recorded every 24 hours. HFNC failure was defined as escalation of respiratory support to invasive mechanical ventilation (IMV) or death. MAIN RESULTS: A total of 35 (29%) patients failed HFNC and required intubation. ROC analysis identified the 12-hour ROX index as the best predictor of intubation with an AUC of 0.7916[CI 95% 0.6905-0.8927] and the best threshold to be 5.99[Specificity 96% Sensitivity 62%]. In the survival analysis, a ROX value

Noninvasive ventilation (NIV) still has high failure rate when used for de novo acute respiratory failure (ARF). Delirium may impact the outcome, however data regarding its incidence, timing of occurrence and clinical predictors in this subset of patients are scarce.Consecutive patients with de novo ARF subjected to NIV were recruited in 10 Italian Respiratory Intensive Care Units (RICUs) and Intensive Care Units (ICUs). Demographics and clinical features, including tolerance to interface and NIV setting were recorded on admission and during stay, whereas delirium onset and type was assessed by the Confusion Assessment Method for ICU (CAM-ICU)-7 scale and Richmond Agitation Sedation Scale (RASS) twice/per day up to a week. The association between clinical variables and the occurrence of delirium and its influence on NIV failure and other clinical outcomes were analyzed.Thirty-two out of 90 enrolled patients (36%) developed delirium over seven days upon admission; median time to onset was 48 hours (24-60). Older age (OR=2.7 [1.9-9], P=0.01), the presence of cancer OR=3.7 [2-5.4], P=0.002), sepsis (OR=1.7 [1.1-3.4], P=0.01), SOFA Score (OR=1.8 [1.1-3.1], P=0.01), low tolerance to interface (OR=3.2 [2.1-5], P=0.002), use of helmet (OR=1.9 [1.2-4.3] P=0.04), and higher PRE-DELIRIC (OR=3.5 [1.3-15], P=0.03) and BORG (OR=1.7 [1.1-4.6], P=0.02] scores were significantly associated with delirium. Delirium had high risk for NIV failure (HR=3.5 95% CI: [1.4-8.6], P=0.0002) and it significantly associated with longer RICU/ICU stay and higher mortality.Delirium onset in acute hypoxic patients undergoing NIV is frequent and negatively affects the outcome. Multiple related clinical factors should be addressed early on admission to prevent the delirium-related risk of NIV failure in these patients.

RATIONALE The "Berlin definition" of acute respiratory distress syndrome (ARDS) does not allow inclusion of patients receiving high-flow nasal oxygen (HFNO). However, several articles proposed that criteria for defining ARDS should be broadened to allow inclusion of patients receiving HFNO. OBJECTIVE To compare the proportion of patients fulfilling ARDS criteria during HFNO and soon after intubation, and 28-day mortality between patients treated exclusively with HFNO and patients transitioned from HFNO to IMV. METHODS From previously published studies we analyzed COVID-19 patients who had PaO2/FiO2 ≤300 while treated with HFNO ≥40 L/min, or NIV with PEEP ≥5 cmH2O (comparator). In patients transitioned from HFNO/NIV to invasive mechanical ventilation (IMV), we compared ARDS severity during HFNO/NIV and soon after IMV. We compared 28-day mortality in patients treated exclusively with HFNO/NIV vs. transitioned to IMV. MEASUREMENTS AND MAIN RESULTS We analyzed 184 and 131 patients receiving HFNO or NIV, respectively. 112 HFNO, and 69 NIV patients transitioned to IMV. 104 (92.9%) HFNO patients and 66 (95.7%) NIV patients continued to have PaO2/FiO2 ≤300 under IMV. 28-day mortality in patients who remained on HFNO was 4.2% (3/72) while in patients transitioned from HFNO to IMV it was 28.6% (32/112) (p

RationalePulse glucocorticoid therapy is used in hyperinflammation related to coronavirus disease 2019 (COVID-19). We evaluated the efficacy and safety of pulse intravenous methylprednisolone in addition to standard treatment in COVID-19 pneumonia.MethodsIn this multicentre, randomised, double-blind, placebo-controlled trial, 304 hospitalised patients with COVID-19 pneumonia were randomised to receive 1 g of methylprednisolone intravenously for three consecutive days or placebo in addition to standard dexamethasone. The primary outcome was the duration of patient hospitalisation, calculated as the time interval between randomisation and hospital discharge without the need for supplementary oxygen. The key secondary outcomes were survival free from invasive ventilation with orotracheal intubation and overall survival.ResultsOverall, 112 (75.4%) out of 151 patients in the pulse methylprednisolone arm and 111 (75.2%) of 150 in the placebo arm were discharged from hospital without oxygen within 30 days from randomisation. Median time to discharge was similar in both groups (15 days, 95% CI 13.0–17.0 days and 16 days, 95% CI 13.8–18.2 days, respectively; hazard ratio (HR) 0.92, 95% CI 0.71–1.20; p=0.528). No significant differences between pulse methylprednisolone and placebo arms were observed in terms of admission to intensive care unit with orotracheal intubation or death (20.0%versus16.1%; HR 1.26, 95% CI 0.74–2.16; p=0.176) or overall mortality (10.0%versus12.2%; HR 0.83, 95% CI 0.42–1.64; p=0.584). Serious adverse events occurred with similar frequency in the two groups.ConclusionsMethylprenisolone pulse therapy added to dexamethasone was not of benefit in patients with COVID-19 pneumonia.

Introduction Up to fifteen percent of patients with novel pandemic coronavirus disease (Covid-19) have acute respiratory failure (ARF). Ratio between arterial partial pressure of oxygen (PaO2) and fraction of inspired oxygen (FiO2), P/F, is currently used as a marker of ARF severity in Covid-19. P/F does not reflect the respiratory efforts made by patients to maintain arterial blood oxygenation, such as tachypnea and hyperpnea, leading to hypocapnia. Standard PaO2, the value of PaO2 adjusted for arterial partial pressure of carbon dioxide (PaCO2) of the subject, better reflects the pathophysiology of hypoxemic ARF. We hypothesized that the ratio between standard PaO2 over FiO2 (STP/F) better predicts Covid-19 ARF severity compared to P/F. Methods Aim of this pilot prospectic observational study was to observe differences between STP/F and P/F in predicting outcome failure, defined as need of invasive mechanical ventilation and/or deaths in Covid-19 ARF. Accuracy was calculated using Receiver Operating Characteristics (ROC) analysis and areas under the ROC curve (AUROC) were compared. Results 349 consecutive subjects admitted to our respiratory wards due to Covid-19 ARF were enrolled. STP/F was accurate to predict mortality and superior to P/F with, respectively, AUROC 0.710 versus 0.688, p = 0.012.Both STP/F and PF were accurate to predict outcome failure (AUROC respectively of 0.747 and 0.742, p = 0.590). Discussion This is the first study assessing the role of STP/F in describing severity of ARF in Covid-19. According to results, STP/F is accurate and superior to P/F in predicting in-hospital mortality.

Background: Noninvasive ventilation (NIV) still has high failure rate when used for acute respiratory failure (ARF). Delirium may impact the outcome, however data regarding its incidence, timing of occurrence and clinical predictors are lacking. Methods: Consecutive patients with ARF subjected to NIV were recruited in 9 Respiratory Intensive Care Units (July 2019-January 2020). Individuals with neurological impairment, established psychiatric or neurological disease, need for immediate intubation, and use of home-NIV were excluded. Demographics and clinical features, including tolerance to interface and NIV setting were recorded on admission, whereas delirium was assessed by the CAM-ICU7 Scale twice/per day up to a week. The impact of baseline variables on the occurrence of delirium and its influence on NIV outcome were analysed. Results: Thirty-two out of 92 enrolled patients (34,7%) developed delirium over 7 days upon admission; time to onset was 32.6 hours (SD=12.6). Sepsis (OR=2.9[1.2-14.5] p=0.01), SOFA score>7 (OR= 3.5[1.6-19.4] p=0.002), low tolerance to interface (OR=1.9[1.1-21.4] p=0.002), use of helmet (OR=4.2[1.7-29] p=0.001), and higher pre-DELIRIC (OR=1.8 [1.1-14]p=0.03) and BORG (OR=2.6[1.4-11.6]p=0.002] scores were significantly associated with delirium. Delirium was highly related with NIV failure (HR=3.5[1.4-8.5] p=0.01). Conclusion: The occurrence of delirium in patients undergoing acute NIV is relevant and negatively affects the outcome. Multiple related clinical factors should be addressed early on admission to prevent the risk of NIV failure in these patients.

Introduction The Coronavirus 2(SARS-CoV-2) outbreak spread rapidly in Italy and the lack of intensive care unit(ICU) beds soon became evident, forcing the application of noninvasive respiratory support(NRS) outside the ICU, raising concerns over staff contamination. We aimed to analyse the safety of the hospital staff, the feasibility, and outcomes of NRS applied to patients outside the ICU. Methods In this observational study, data from 670 consecutive patients with confirmed COVID-19 referred to the Pulmonology Units in nine hospitals between March 1st and May 10th,2020 were analysed. Data were collected including medication, mode and usage of the NRS (i.e. high-flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), noninvasive ventilation(NIV)), length of stay in hospital, endotracheal intubation(ETI) and deaths. Results Forty-two health-care workers (11.4%) tested positive for infection, but only three of them required hospitalisation. Data are reported for all patients (69.3% male), whose mean age was 68 (sd 13) years. The PaO2/FiO2 ratio at baseline was 152±79, and the majority of patients (49.3%) were treated with CPAP. The overall unadjusted 30-day mortality rate was 26.9% with 16%, 30%, and 30%, while the total ETI rate was 27% with 29%, 25% and 28%, for HFNC, CPAP, and NIV, respectively, and the relative probability to die was not related to the NRS used after adjustment for confounders. ETI and length of stay were not different among the groups. Mortality rate increased with age and comorbidity class progression. Conclusions The application of NRS outside the ICU is feasible and associated with favourable outcomes. Nonetheless, it was associated with a risk of staff contamination., In patients with Coronavirus 2 infection and Acute Respiratory Failure, we demonstrated that the utilization of noninvasive respiratory support delivered outside the ICU, was feasible and effective, but associated with a risk of staff contamination

An 18-year-old adolescent male presented to our emergency department complaining of chest pain that started about 2 days earlier and remained unchanged. Chest x-rays revealed a right apical pneumothorax. The patient did not use any medication. Two months earlier he had presented to the emergency department with a similar episode that resolved spontaneously. Blood testing performed at the time of presentation showed severe hypokalemia with a potassium concentration of 2.5 mmol/L. He was admitted to our respiratory unit. He was 180 cm (70.9 in) tall and weighed 64 kg (141 lb, body max index 19.8 kg/m2). He was in good general health, and the physical examination was unremarkable. A renal ultrasound was normal. He noted an unintentional weight loss of 7 kg (15.4 lb) over the last 36 months. Furthermore, he reported fatigue and muscle weakness. His personal history and family history were unremarkable. He was delivered naturally at term and developed normally during childhood and puberty. Further blood tests revealed moderate hypomagnesemia of 1.2 mg/dL [0.5 mmol/L; reference interval 1.7–2.2 mg/dL (0.7–0.9 mmol/L)]. Arterial blood gas analysis showed metabolic alkalosis (pH 7.46, bicarbonate 28.9 mmol/L). Sodium, chloride, and calcium were within reference intervals. Renal function, fasting blood glucose, and a complete blood count were normal. Table 1 provides a selection of relevant laboratory results at presentation and during follow-up. View this table: Table 1. Laboratory results at presentation and on further investigation.a As recommended by the British Thoracic Society, the patient was scheduled for video-assisted thoracoscopic surgery (1). Before surgery, an endocrine specialist was consulted to further investigate the cause of the patient's hypokalemia and hypomagnesemia. The spontaneous pneumothorax was unrelated to the abnormal electrolyte results and is not further discussed here. ### QUESTIONS 1. What are the most common causes of hypokalemia? 2. Which laboratory tests can differentiate between renal and nonrenal causes of potassium …