No abstract

Background: Airway Pressure Release Ventilation (APRV) is a pressure controlled intermittent mandatory mode of ventilation characterized by prolonged inspiratory time and high mean airway pressure. Several studies have demonstrated that APRV can improve oxygenation and lung recruitment in patients with Acute Respiratory Distress Syndrome (ARDS). Although most patients with COVID-19 meet the Berlin criteria for ARDS, hypoxic respiratory failure due to COVID-19 may differ from traditional ARDS as patients often present with severe, refractory hypoxemia and significant variation in respiratory system compliance. To date, no studies investigating APRV in this patient population have been published. The aim of this study was to evaluate the effectiveness of APRV as a rescue mode of ventilation in critically ill patients diagnosed with COVID-19 and refractory hypoxemia. Methods: We conducted a retrospective analysis of patients admitted with COVID-19 requiring invasive mechanical ventilation who were treated with a trial of APRV for refractory hypoxemia. PaO2/FIO2 (P/F ratio), ventilatory ratio and ventilation outputs before and during APRV were compared. Results: APRV significantly improved the P/F ratio and decreased FIO2 requirements. PaCO2 and ventilatory ratio were also improved. There was an increase in tidal volume per predicted body weight during APRV and a decrease in total minute ventilation. On multivariate analysis, higher inspiratory to expiratory ratio (I: E) and airway pressure were associated with greater improvement in P/F ratio. Conclusions: APRV may improve oxygenation, alveolar ventilation and CO2 clearance in patients with COVID-19 and refractory hypoxemia. These effects are more pronounced with higher airway pressure and inspiratory time.

Pulmonary hypertension is an uncommon disease that carries a significant morbidity and mortality. Pulmonary arterial hypertension is a subtype of pulmonary hypertension that describes a group of disease entities that lead to an elevation in precapillary pulmonary artery pressure. Despite advances in the diagnosis and treatment of pulmonary arterial hypertension, it remains a difficult disease to recognize and manage. In this review article, we will discuss the definition and diagnosis of pulmonary arterial hypertension. Additionally, we will discuss the ever-expanding management options, their mechanisms and strategies, including combination therapy and the most recent advances and future directions.

No abstract

BACKGROUND: SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) continues to be a global challenge due to the lack of definitive treatment strategies. We sought to determine the efficacy of early administration of anti-interleukin 6 therapy in reducing hospital mortality and progression to mechanical ventilation. METHODS: This was a retrospective chart review of 11,512 patients infected with SARS-CoV-2 who were admitted to a New York health system from March to May 2020. Tocilizumab was administered to subjects at the nasal cannula level of oxygen support to maintain an oxygen saturation of >88%. The Charlson comorbidity index was used as an objective assessment of the burden of comorbidities to predict 10-year mortality. The primary outcome of interest was hospital mortality. Secondary outcomes were progression to mechanical ventilation; the prevalence of venous thromboembolism and renal failure; and the change in C-reactive protein, D-dimer, and ferritin levels after tocilizumab administration. Propensity score matching by using a 1:2 protocol was used to match the tocilizumab and non-tocilizumab groups to minimize selection bias. The groups were matched on baseline demographic characteristics, including age, sex, and body mass index; Charlson comorbidity index score; laboratory markers, including ferritin, D-dimer, lactate dehydrogenase, and C-reactive protein values; and the maximum oxygen requirement at the time of tocilizumab administration. Mortality outcomes were evaluated based on the level of oxygen requirement and the day of hospitalization at the time of tocilizumab administration. RESULTS: The overall hospital mortality was significantly reduced in the tocilizumab group when tocilizumab was administered at the nasal cannula level (10.4% vs 22.0%; P 5 .002). In subjects who received tocilizumab at the nasal cannula level, the progression to mechanical ventilation was reduced versus subjects who were initially on higher levels of oxygen support (6.3% vs 18.7%; P < .001). There was no improvement in mortality when tocilizumab was given at the time of requiring non-rebreather, high-flow nasal cannula, noninvasive ventilator, or invasive ventilator. CONCLUSIONS: Early use of anti-interleukin 6 therapy may be associated with improved hospital mortality and reduction in progression to more severe coronavirus disease 2019.

Mechanical power of ventilation (MP) has been proposed as the variable that unifies factors correlated with ventilator-induced lung injury and a recent observational study suggested that MP can be used as predictor of mortality in critically ill patients. Aim of this study was to assess the association between the mechanical power of ventilation and in-hospital mortality and the ratio of PaO(2) to fraction of inspired oxygen (PF) after 48 hours of mechanical ventilation (MV) in patients with mild, moderate and severe ARDS. METHODS: We analyzed the Medical Information Mart for Intensive Care III (MIMIC-III v.1.4) database which comprises deidentified data of patients admitted to the ICU between 2001 and 2012. We selected patients aged 18 and older with mild (PF 300-200) moderate (PF 200-100) and severe (PF<100) ARDS requiring invasive mechanical ventilation for at least 48 hours. We calculated the average MP in the first 48 hours, initial PF (PF0) and PF after 48 hours of mechanical ventilation (PF48). Multivariate analysis was used to determine the effects of MP on mortality and PF48, after adjusting for patients' characteristics, APACHE and SAPS scores, and Exhauster's comorbidity index. RESULTS: We found 1,835 patients admitted to the ICU for ARDS requiring invasive mechanical ventilation. Mean age was 63, 39.72% were female, mean PF0 was 129.75, mean MP in the first 48 hours was 20.87 J/min. We found that MP was an independent predictor of mortality (OR per 5 J/min increase: 1.100 p¼0.012 CI [1.02-1.18]). Patients with severe ARDS who had PF48 >300 received significantly lower mechanical power in the first 48 hours (18.20 J/min [15.80-20.60]) compared to those with PF48<300 (23.34 J/min [22.64-24.04], p<0.001). Similar findings were observed in patients with moderate ARDS (16.75 J/ min [14.81-18.70] when PF48>300 vs 20.20 J/min [19.59-20.80] p¼0.001 when PF48<300) and mild ARDS (MP 15.29 J/min [13.81-16.77] when PF48>300 vs 17.98 J/min [17.17-18.78] p¼0.002 when PF48<300]). After adjusting for confounders, regression analysis revealed a negative association between MP and PF48 (Coef.-10.812 per 5 J/min increase, p<0.001 CI [-13.41-8.21]) CONCLUSIONS: Mechanical power of ventilation is a strong predictor of mortality in patients with ARDS and is associated with decreased PF48. Patients receiving higher MP are less likely to have a PF greater than 300 after 48 hours of mechanical ventilation. CLINICAL IMPLICATIONS: These findings support the increasing evidence that the mechanical power of ventilation can be useful in monitoring critically ill patients during mechanical ventilation.

BACKGROUND: Cataract is the leading cause of blindness in the world. An efficient and effective cataract surgical service is necessary to reduce the backlog of cataract blindness in the community. This study aims to determine the cataract surgical coverage among individuals aged 50 years and above residing in Esie and Arandun communities. This will serve as a measure of the impact of the cataract intervention programme provided by the University of Ilorin Teaching Hospital, Nigeria. METHODS: The study was a population-based, cross sectional survey conducted from November to December, 2013. Cataract surgical services are provided by the University of Ilorin Teaching Hospital, Nigeria, at Esie and Arandun communities as out-reach centres. Seven hundred and fifty-five individuals aged 50 years and above residing in these communities had basic ocular examination done. RESULT: Out of the 765 subjects registered, 755(98.7%) were examined. Out of these, 38.4% were males and 61.6% were females. The prevalence of bilateral cataract blindness was 1.6%. The Cataract Surgical Coverage (eyes) at visual acuity < 3/60 for males and females were 52.3% and 51.2% respectively (X2=19.30, p=0.001), while the Cataract Surgical Coverage (person) at visual acuity less < 3/60 for males and females were 80.6% and 68.4% respectively (X2=2.10, p=0.147). CONCLUSION: The Cataract Surgical Coverage was high with a correspondingly low prevalence of cataract blindness in these communities. The availability of cataract surgical services via out-reach programmes bridges the gap between eye care-givers and the community.

No abstract