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With the rapid pandemic spread of the novel coronavirus (SARS-CoV2), Emergency Departments of affected countries are facing an increasing number of patients presenting with hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19). Providing mechanical support and endotracheal intubation can be challenging due to a number of patients larger than usual, often exceeding available resources. Considering the lack of recommendations available, we developed a flowchart to standardize the first approach to patients presenting to the Emergency Department with hypoxemic respiratory failure due to COVID-19.

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Nursing triage was characterised by a low predictive accuracy in identifying high-risk individuals.

Background During COVID-19 outbreak, with the increasing number of patients presenting with acute respiratory failure, a large use of non-invasive positive pressure ventilation was done in the emergency departments and medical wards despite the lack of recommendations. This study describes the clinical characteristics of patients presenting to the hospital with acute respiratory failure due to COVID-19 related pneumonia undergoing treatment with helmet CPAP with a strict nursing evaluation and monitoring. Methods A case series study enrolling adult patients admitted to an emergency department of an Italian hospital with acute respiratory failure due to COVID-19 pneumonia from March 18 th to April 18 th , 2020, was conducted. Only patients who strictly followed a local CPAP protocol were enrolled. Results A total of 52 patients were included in this study. 38 patients (73%) were judged eligible for endotracheal intubation (ETI). Eight-teen (34.6%) were intubated. Six-teen (30.8%) patients died: 7 (38.9%) and 9 (26.5%) in the eligible and non-eligible for ETI group, respectively. The median hospital length of stay was different in ETI and non-ETI group: 26 days [IQR 16-37] vs 15 days [IQR 9-17] (p = 0.005). The median invasive mechanical ventilation time was 11 days [IQR 7-21] with an ICU length of stay of 14.5 days [IQR 10-28]. During the CPAP trial, among patients eligible for ETI variations over time for positive end-expiratory pressure (p = 0.003) and respiratory rate (p = 0.059) were found between intubated and non-intubated patients. Conclusions A short closed monitored CPAP trial could be considered for acute respiratory failure due to COVID-19 pneumonia before considering ETI. A progressive positive end-expiratory pressure titration should target patient’s respiratory rate reduction. More studies are needed to evaluate the efficacy and predictors of failure of CPAP and non-invasive positive pressure ventilation in patients with acute respiratory failure due to COVID-19 pneumonia.

Pacing in elderly recurrent fallers with carotid sinus hypersensitivityTo the editor: We read with great interest the article by Parry and co-workers regarding pacing in elderly recurrent fallers with carotid sinus hypersensitivity. 1 However, we believe that there are some issues deserving clarification.We wonder whether the results of the study could have been influenced by a patient selection different from other studies. This hypothesis could be supported by the 11.7% mortality rate that was almost twice as high as that reported in other studies. 2 3 Moreover, the fall in systolic blood pressure during carotid sinus massage in this study is much more than that observed in the study by Kenny et al. 3 By the same line of reasoning, while pacing in cardioinhibitory hypersensitivity syncope is of obvious efficacy, in the mixed one with a prevalent vasodepressor response, pacing could be less useful. In this regard, it would be more helpful to analyse separately cardioinhibitory (CI) or mixed (Mx) patient outcomes.Finally, a relative risk of falling when the pacemaker is switched off compared with when the pacemaker is turned on of 0.82 has been reported in the abstract, while the relative risk of 0.82 reported in the text referred to the opposite ratio.

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Case presentation Dr Montano: A 60-year-old-man was admitted to our Emergency Department (ED) for worsening dyspnea, and recurrent episodes of oppressive chest pain that resolved within a few minutes with rest. He had a history of benign prostatic hypertrophy (in therapy with Finasteride 5 mg/day), mild chronic renal failure, a prior episode of