BACKGROUND:The Confusion, Urea > 7 mM, Respiratory Rate $ 30 breaths/min, BP < 90 mm Hg (Systolic) or < 60 mm Hg (Diastolic), Age $ 65 Years (CURB-65) score and the Pneumonia Severity Index (PSI) are well-established clinical prediction rules for predicting mortality in patients hospitalized with community-acquired pneumonia (CAP). SARS-CoV-2 has emerged as a new etiologic agent for CAP, but the role of CURB-65 score and PSI have not been established. RESEARCH QUESTION: How effective are CURB-65 score and PSI at predicting in-hospital mortality resulting from SARS-CoV-2 CAP compared with non-SARS-CoV-2 CAP? Can these clinical prediction rules be optimized to predict mortality in SARS-CoV-2 CAP by addition of procalcitonin and D-dimer? STUDY DESIGN AND METHODS: Secondary analysis of two prospective cohorts of patients with SARS-CoV-2 CAP or non-SARS-CoV-2 CAP from eight adult hospitals in Louisville, Kentucky. RESULTS:The in-hospital mortality rate was 19% for patients with SARS-CoV-2 CAP and 6.5% for patients with non-SARS-CoV-2 CAP. For the PSI score, receiver operating characteristic (ROC) curve analysis resulted in an area under the ROC curve (AUC) of 0.82 (95% CI, 0.78-0.86) and 0.79 (95% CI, 0.77-0.80) for patients with SARS-CoV-2 CAP and non-SARS-CoV-2 CAP, respectively. For the CURB-65 score, ROC analysis resulted in an AUC of 0.79 (95% CI, 0.75-0.84) and 0.75 (95% CI, 0.73-0.77) for patients with SARS-CoV-2 CAP and non-SARS-CoV-2 CAP, respectively. In SARS-CoV-2 CAP, the addition of D-dimer (optimal cutoff, 1,813 mg/mL) and procalcitonin (optimal cutoff, 0.19 ng/mL) to PSI and CURB-65 score provided negligible improvement in prognostic performance.INTERPRETATION: PSI and CURB-65 score can predict in-hospital mortality for patients with SARS-CoV-2 CAP and non-SARS-CoV-2 CAP comparatively. In patients with SARS-CoV-2 CAP, the inclusion of either D-dimer or procalcitonin to PSI or CURB-65 score did not improve the prognostic performance of either score. In patients with CAP, regardless of cause, PSI and CURB-65 score remain adequate for predicting mortality in clinical practice.

Purpose of Review A challenging aspect of the care for patients with acute respiratory failure is their nutrition management. This manuscript consists of a literature review on nutrition therapy in non-intubated patients with acute respiratory failure receiving high-flow nasal cannula oxygenation or non-invasive positive pressure ventilation. Recent Findings Studies show that non-intubated patients with acute respiratory failure either on non-invasive ventilation or high-flow nasal cannula are largely underfed in the initial phase of their hospitalization. Although data is limited, the available evidence suggests the feasibility of initiating oral diet in the majority of these patients in the early phase. Summary Initial evaluation includes mental status evaluation, the Yale swallowing screening protocol, and an assessment of severity of illness. The goal should be to initiate oral diet within 24 h. If patient cannot initiate oral diet, the reason for not initiating oral diet should dictate the next step. For instance, if the reason is failure of the swallow screening, further evaluation with fiberoptic endoscopy is warranted. The inability to provide oral diet for a patient in respiratory distress may a harbinger of failure of non-invasive oxygen therapy and should prompt consideration for endotracheal intubation. We suggest placement of a small-bore feeding tube for enteral nutrition if patient is unable receive oral diet after 48 h. Conclusions The nutrition management of these patients is better provided by a multidisciplinary team in a protocolized manner.

Travelers seen for pretravel health encounters are frequently prescribed new travel-related medications, which may interact with their previously prescribed medications. In a cohort of 76 324 travelers seen at 23 US clinics, we found that 2650 (3.5%) travelers were prescribed travel-related medications with potential for serious drug interactions.

INTRODUCTION:Endotracheal intubation provide a reliable method for airway access to allow for assistance with oxygenation and ventilation. Although intubation can be a life-saving measure, there are complications associated with intubation that can be fatal. Obstructive fibrinous tracheal pseudomembrane (OFTP) is a rare and potentially fatal complication that can result from superficial damage of the trachea secondary to intubation. CASE PRESENTATION:We present a case of a 23 year old male with no known past medical history that presented to our emergency department with a chief complaint of intermittent fevers for 10 days associated with exertional syncope. The patient was started on doxycycline for presumed tick-borne illness. His electrocardiogram had evidence of a right bundle branch block and atrioventricular dissociation. Several hours into his admission, his heart rhythm deteriorated into pulseless ventricular tachycardia requiring intubation and chest compression. Return of spontaneous circulation was achieved after approximately 20 minutes of cardiopulmonary resuscitation with multiple defbrillations. He spent the next two days in the ICU and was successfully extubated. On post extubation day two, the patient developed sudden onset respiratory distress after attempting to take a doxycycline pill. A rapid response was called and the ICU team found the patient to be stridorous with cyanotic lips and fingers. Pulse oximetry was <70% and telemetry showed a junctional rhythm with a heart rate in the 40s. The patient's mentation was rapidly deteriorating. Manual digital sweep of the mouth was attempted as emergent oral intubation was prepared. Rapid sequence intubation using direct laryngoscopy was performed successfully and airway access was achieved. The patients SpO2 immediately increased to > 90% with manual ventilation. Bedside bronchoscopy was performed immediately after intubation however no obvious obstruction was visualized; the airways appeared grossly unremarkable. The patient required minimal ventilator settings afterwards and after two hours, the patient was following commands. Positive cuff-leak test was noted indicating no significant airway edema was present. The patient was successfully extubated the same day. After extubation there was a large piece of fibrous tissue moulding the shape of the trachea around the endotracheal tube balloon.DISCUSSION: OFTP is a unusual and life threatening complication that carries a mortality as high as 33%. It is believed to result from tracheal irritation and may represent the first stage in the development of tracheal stenosis. Most common symptoms are hoarseness, stridor, and respiratory failure. Prompt diagnosis and intervention is imperative in order to avoid the associated high mortality.CONCLUSIONS: This case highlights the importance of early recognition and action in diagnosing and treating patients with OFTP.

INTRODUCTION: Pulmonary involvement in setting of common variable immunodeficiency (CVID) usually manifests as an airway disease and/or ILD. Development of severe pre-capillary PH is unusual. Herein, we present a case of severe PH associated with CVID ILD that was managed with combination therapy including inhaled treprostinil and was followed for 8 years.