Both influenza and respiratory syncytial virus (RSV) cause epidemics of respiratory illness of variable severity during the winter season. Influenza in particular has been blamed for hospital winter bed pressures, although it is thought that RSV may also play a role. Human metapneumovirus (hMPV) is a new respiratory virus reported to be important in children; only a limited number of studies are available for adult populations. We aimed to determine initially the burden of virologically confirmed infections, i.e. influenza, RSV and hMPV using polymerase chain reaction (PCR) technology and, in addition, to assess the feasibility of this approach as a surveillance tool for these respiratory viruses. Adult patients admitted to hospital in the previous 24 hours with onset of acute respiratory symptoms in the last 14 days were asked to participate. Informed written consent was obtained and nose and throat swabs taken. Multiplex PCR for influenza A (H1N1 and H3N2), influenza B and RSV A and B were carried out together with a separate PCR for hMPV. A total of 219 patients in 2001-2002 and 216 in 2002-2003 were tested and the combined results for both seasons were: 8 positive for influenza A/H1N1, 14 for influenza A/H3N2, 2 for influenza B, 14 for RSV A and 6 for RSV B. Most patients (261/435) were >65 years and most positives (30/44) were found within this age group. A number of patients aged >65 years who were positive for influenza (12/15) reported having had vaccine. In total, 373 samples were tested for hMPV and 20 were found positive across all age groups except the 45-54 years age group. As influenza activity was low during the study period the impact of infection on admissions could not be assessed. Nevertheless the viruses studied accounted for 15% of hospital admissions for respiratory infection. Most patients were aged >65 years, as expected. In the two years studied RSV and hMPV were each responsible for as many hospitalized cases of respiratory infection as influenza. Influenza infection must be considered even in those who give a history of vaccination. The molecular methods used in this study showed that surveillance of these respiratory viruses can be conducted and may help in the management of patients.

Acute respiratory distress syndrome (ARDS) is a clinically and biologically heterogeneous disorder associated with a variety of disease processes that lead to acute lung injury with increased non-hydrostatic extravascular lung water, reduced compliance, and severe hypoxemia. Despite significant advances, mortality associated with this syndrome remains high. Mechanical ventilation remains the most important aspect of managing patients with ARDS. An in-depth knowledge of lung protective ventilation, optimal PEEP strategies, modes of ventilation and recruitment maneuvers are essential for ventilatory management of ARDS. Although, the management of ARDS is constantly evolving as new studies are published and guidelines being updated; we present a detailed review of the literature including the most up-to-date studies and guidelines in the management of ARDS. We believe this review is particularly helpful in the current times where more than half of the acute care hospitals lack in-house intensivists and the burden of ARDS is at large.

ImportanceUse of non-invasive respiratory modalities in COVID-19 has the potential to reduce rates of intubation and mortality in severe disease however data regarding the use of high-flow nasal cannula (HFNC) in this population is limited.ObjectiveTo interrogate clinical and laboratory features of SARS-CoV-2 infection associated with high-flow failure.DesignWe conducted a retrospective cohort study to evaluate characteristics of high-flow therapy use early in the pandemic and interrogate factors associated with respiratory therapy failure.SettingMultisite single centre hospital system within the metropolitan Detroit region.ParticipantsPatients from within the Detroit Medical Center (n=104, 89% African American) who received HFNC therapy during a COVID-19 admission between March and May of 2020.Primary outcomeHFNC failure is defined as death or intubation while on therapy.ResultsTherapy failure occurred in 57% of the patient population, factors significantly associated with failure centred around markers of multiorgan failure including hepatic dysfunction/transaminitis (OR=6.1, 95% CI 1.9 to 19.4, p<0.01), kidney injury (OR=7.0, 95% CI 2.7 to 17.8, p<0.01) and coagulation dysfunction (OR=4.5, 95% CI 1.2 to 17.1, p=0.03). Conversely, comorbidities, admission characteristics, early oxygen requirements and evaluation just prior to HFNC therapy initiation were not significantly associated with success or failure of therapy.ConclusionsIn a population disproportionately affected by COVID-19, we present key indicators of likely HFNC failure and highlight a patient population in which aggressive monitoring and intervention are warranted.

Background: Knowledge of the factors that predispose to postdural puncture headache in children may help reduce the occurrence of this complication. Materials and Methods: A retrospective cohort study of children who presented to the study institution between 2010 and 2018 was conducted. Children were divided into 2 groups: those who experienced postdural puncture headache and those who did not. The 2 groups were compared with respect to certain demographic, technical, and personnel-related factors. Only children who had opening pressure documented during the procedure were included in the core study group. Results: In univariate analysis, children aged ≥10 years, female gender, children with higher body mass index, standard blinded lumbar puncture procedure, use of sedation, higher opening pressure, and presence of pseudotumor cerebri increased the probability of postdural puncture headache. In multivariable logistic regression analysis, presence of pseudotumor cerebri was the only factor that attained statistical significance when the opening pressure was measured and documented. Conclusions: The risk factors for postdural puncture headache in a pediatric cohort varied from risk factors that are classically implicated in adults.

Burkholderia cepacia complex (B. Cepacia), an obligate aerobic gram-negative rod, is frequently isolated in immunocompromised hosts, notably those with cystic fibrosisjane or chronic granulomatous disease. It is associated with accelerated decline in pulmonary function, especially in those with advanced lung disease or lung transplant, and higher mortality in these patients [1]. Here, we present a case of B. Cepacia in an immunocompetent patient with COVID-19. B. Cepacia in COVID-19 has not yet been reported in the medical literature. CASE PRESENTATION: A 51-year old female with a past medical history of diabetes mellitus type II, hypertension, and hypothyroidism was admitted to the medical intensive care unit for acute hypoxic respiratory failure requiring intubation and mechanical ventilation. Patient was found to be COVID-19 positive. She continued to spike fevers and her white blood cell count continued to rise, as high as 36.6/mm3 with a neutrophilic predominance, suggesting a superimposed bacterial infection. Respiratory culture was repeated 4 days into the patient's hospital stay and B. Cepacia was isolated. Patient then developed B. Cepacia bacteremia secondary to pneumonia. She completed a 2 week course of linezolid and meropenem, followed by a course of ceftazidime. However, she remained ventilator dependent for approximately 8 weeks and continued to have bilateral infiltrates on chest x-ray so a decision was made to perform bronchoscopy with bronchoalveolar lavage (BAL) in order to facilitate ventilator weaning. BAL fluid culture grew B. cepacia once again, however with increased resistance this time, so the patient was initiated on minocycline. Two consecutive repeat COVID-19 tests were found to be negative however she still remains on a mechanical ventilator. DISCUSSION: Our case highlights that B. cepacia may complicate COVID-19 even in immunocompetent patients. To our knowledge, this is the first reported case of B. cepacia pneumonia in a patient with COVID-19. However, infections caused by B. cepacia should be taken into consideration because of their high mortality in ICU settings. The combination of 2 or more antibiotics usually is recommended for the treatment of B. cepacia infections. B. Cepacia is intrinsically resistant to antipseudomonal penicillins, aminoglycosides and polymyxin B thus determining antimicrobial susceptibility is crucial [2]. CONCLUSIONS: Early diagnosis and aggressive treatment of patients with confirmed B. cepacia sepsis is critical to increase the probability of survival.