The use of the heated and humidified high-flow nasal cannula has become increasingly popular in the treatment of patients with respiratory failure through all age groups. This article will examine the main mechanisms of actions attributed to the use of the high-flow nasal cannula and review the indications in adult and pediatric populations (outside of the neonatal period). It is unclear which of the mechanisms of action is the most important, but it may depend on the cause of the patient’s respiratory failure. This article describes the mechanism of action in an easy to remember mnemonic (HIFLOW); Heated and humidified, meets Inspiratory demands, increases Functional residual capacity (FRC), Lighter, minimizes Oxygen dilution, and Washout of pharyngeal dead space. We will also examine some of the main indications for its use in both the adult and pediatric age groups. The data for the use of high-flow nasal cannula is growing, and currently, some of the main adult indications include hypoxemic respiratory failure due to pneumonia, post-extubation, pre-oxygenation prior to intubation, acute pulmonary edema, and use in patients who are "do not resuscitate or intubate". The main pediatric indication is in infants with bronchiolitis, but other indications are being studied, such as its use in asthma, croup, pneumonia, transport of a critically ill child, and post-extubation.

Early warning systems are tools proposed by the Institute of Medicine to decrease morbidity and mortality for inpatients. At Geisinger, we utilize the MEWS (Modified Early Warning System), which is integrated into our Electronic Health Record (EHR). MEWS uses vital signs to calculate a score to serve as a surrogate marker for clinical deterioration and prompts varying clinical responses. Our current model fails to account for baseline patient characteristics, disease process, or effects of therapy into consideration. We argue that the change in MEWS score ("delta MEWS") is a better marker for hospital acuity (length of stay (LOS), intensive care unit (ICU) transfer, or mortality) instead of our current static, baseline MEWS score. METHODS: This is a retrospective cohort study which includes all patients aged 18 or older who were admitted to a specific unit in our hospital from 1/1/2018 to 12/31/2018. Data collected included demographics, admission diagnosis, MEWS scores throughout hospitalization, and overall outcome, including rapid response (RR), ICU transfer, date of discharge, and if death occurred while inpatient. For each baseline MEWs score, mortality and ICU transfer rate are compared between delta MEWS 2 vs 3 vs 4+ using chi-square test, and LOS was compared using Kruskal-Wallis Test. Statistical analysis is performed using SAS (Version 9.4, SAS Inst. Cary, NC). RESULTS: There were 1,196 patients identified. The majority were white male smokers with a mean age of 68 years. The most common comorbidities were renal disease (39.5%), diabetes (38.2%), congestive heart failure (34.4%), chronic obstructive pulmonary disease (30.3%), and neoplasm (25%). The overall mortality was 27.5%. The rate of needing an RR was 4.1%. ICU admission occurred in 4.7% of patients. The average LOS was 4 days. For those with a baseline MEWS of 1, there was statistically significant increases in LOS with increasing delta MEWS score (4 days for Delta MEWS of 2, 5 days for Delta MEWS of 3 and 6 days for Delta MEWS of 4, P 0.0002). Likewise, the incidence of ICU transfers increased significantly with increasing delta MEWS score (3.2% for Delta MEWS of 2, 8.4% for Delta MEWS of 3 and 22.1% for Delta MEWS of 4+, P< 0.001). Similar findings were noted for length of stay and ICU admission for all baseline MEWs scores. For patients with baseline MEWS of 1 or greater, there was a trend towards increase in mortality between Delta MEWS of 2,3 and $4 but this was not statistically significant. CONCLUSIONS: This study validates the utility of using an objective scoring system to identify declining clinical status of admitted patients. Delta MEWS was better able to identify these patients and will therefore facilitate interventions which decrease LOS, or prevent ICU transfer and mortality. CLINICAL IMPLICATIONS: Delta-MEWS is a better predictor of adverse outcomes for inpatients, regardless of their baseline MEWS score.

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Babesiosis is an emerging health risk and a nationally notifiable disease in the United States.1 It can present as shock and multi-organ dysfunction in immunocompromised host. As babesiosis prophylaxis in patients with splenectomy is not common, it should be considered in post-splenectomy sepsis syndrome.1 This case describes a post-splenectomy patient with severe babesiosis presenting with refractory Acute Respiratory Distress Syndrome (ARDS).CASE PRESENTATION: 59-year-old man presented to emergency department with 2 weeks of worsening generalized weakness, fever, and headaches, not getting better on oral antibiotics prescribed outpatient. His Computed Tomography (CT) head, lumbar puncture was normal. He developed severe respiratory distress and was emergently intubated. Chest imaging revealed bilateral pulmonary infiltrates. Arterial blood gas analysis confirmed severe ARDS with a PaO2/FiO2 (P/F) ratio <100. The patient was managed with lung protective ventilation and prone positioning. Peripheral smear revealed intraerythrocytic ring inclusions consistent with Babesia microti trophozoites (Figure1). Testing for other bacterial infections, viral pathogens, and tick-borne illnesses were negative. Labs were significant for hemoglobin (Hb) 10.8 g/dl, platelet count 170 K/uL, haptoglobin <10 mg/dl, lactate dehydrogenase 373 U/L, aspartate aminotransferase 68 U/L and alanine aminotransferase 71 U/L. He was treated with atovaquone and azithromycin. Doxycycline was initiated for possible co-infection with other tick-borne illnesses. The patient also had red cell exchange transfusion given his critical condition and history of splenectomy. He was evaluated for Veno-venous extracorporeal membrane oxygenation (ECMO), but cannulation was deferred due to initial improvement with prone positioning. Though there was initial improvement, his hemodynamic status continued to decline requiring initiation of vasopressor support and was transitioned to comfort care after prolonged intubation with goals of care discussions with family.DISCUSSION: Early recognition and diagnosis of babesia, especially in patients with asplenia, is imperative as babesiosis can progress to refractory ARDS, shock and multi-organ dysfunction. Clinicians should have a high index of suspicion for a patient living in an endemic area who presents with unexplained nonspecific symptoms and laboratory findings including thrombocytopenia, hemolytic anemia, and/or elevation of liver enzymes. If clinical suspicion is high, sever real-time PCR assays are useful to detect low-grade parasitemia and are more sensitive than blood smears.2 Prone positioning has been shown to improve outcomes with ARDS if used early and for longer sessions and may help patients avoid need for ECMO.3 CONCLUSIONS: Our case reveals the importance of early recognition of babesiosis in immunocompromised patients living in endemic areas for preventing refractory ARDS.

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