Paediatric headbox as aerosol and droplet barrier

BACKGROUND

High-flow nasal oxygen (HFNO) is frequently used in hospitals, producing droplets and aerosols that could transmit SARS-CoV-2.

AIM

To determine if a headbox could reduce droplet and aerosol transmission from patients requiring HFNO.

METHODS

The size and dispersion of propylene glycol (model for patient-derived infectious particles) was measured using a spectrometer and an infant mannequin receiving 10-50 L/min of HFNO using (1) no headbox, (2) open headbox, (3) headbox-blanket or (4) headbox with a high-efficiency particulate (HEP) filter covering the neck opening.

RESULTS

All headbox set-ups reduced the dispersal of droplets and aerosols compared with no headbox. The headbox-blanket system increased aerosol dispersal compared with the open headbox. The fraction of aerosols retained in the headbox for HFNO of 10 and 50 L/min was, respectively, as follows: (1) open headbox: 82.4% and 42.2%; (2) headbox-blanket: 56.8% and 39.5%; (3) headbox-HEP filter: 99.9% and 99.9%.

CONCLUSION

A HEP-filter modified headbox may serve as an effective droplet and aerosol barrier adjunct for the protection of staff caring for children receiving HFNO.

New-onset haemoptysis and associated lung mass in the setting of dental care avoidance during the COVID-19 pandemic

We present a case of new-onset haemoptysis and associated lung lesion on chest imaging in the setting of the COVID-19 pandemic. This was believed to be due to dental care avoidance after tooth fracture and long-term use of temporary dental filler, with subsequent aspiration and bronchial injury. Our patient underwent bronchoscopy due to persistent haemoptysis with findings of mild traumatic injury. She responded to conservative management with no pharmacologic intervention. With time, there was resolution of symptoms and radiographic improvement of the lung lesion. We include a brief discussion on the influence of the COVID-19 pandemic on healthcare avoidance, complications of tooth fracture and the differential diagnosis of a new solitary lung lesion on chest imaging.

Hypogammaglobulinemia following COVID-19 infection in a patient on maintenance rituximab

Hypogammaglobulinemia is a known side-effect of rituximab use. It is typically asymptomatic and transient, although certain factors, such as maintenance dosing and concomitant glucocorticoid use can lead to symptomatic or prolonged hypogammaglobulinemia. Patients with symptomatic hypogammaglobulinemia leading to recurrent infections may be treated with intravenous immunoglobulin therapy. Herein, we report a case of a 49-year-old male on maintenance rituximab without prior respiratory symptoms with new onset recurrent pneumonia after COVID-19 pneumonia and treatment with glucocorticoids.

Rhinovirus induced bronchiolitis and ARDS in pregnancy: a case report

A 25-year-old woman in her 30th week of pregnancy presented with a 3-day history of fevers, productive cough and dyspnoea. On presentation she was tachypnoeic, tachycardic and hypoxic. Auscultation of the chest revealed widespread wheeze and crepitations at the right mid-zone. Despite initial treatment with intravenous antibiotics, nebulised bronchodilators and oral corticosteroids, the patient continued to deteriorate and required transfer to intensive care. Serial chest radiographs showed increasing bilateral alveolar densities consistent with acute respiratory distress syndrome (ARDS). The only positive investigation was a nasopharyngeal swab which revealed rhinovirus RNA. With supportive management, the patient made a full recovery and went on to deliver a healthy infant at 36 weeks gestation. This case explores human rhinoviruses-induced ARDS and highlights the clinical and diagnostic challenges posed by pregnancy in the critically unwell patient.

Complete splenic infarction in association with COVID-19

COVID-19 predominantly affects the respiratory system. As a novel disease, understanding of its management and complications continues to grow. Herein, we present a case of almost complete splenic infarction in a patient with COVID-19 pneumonia. This case highlights the need to maintain diagnostic vigilance whilst investigating secondary complications of COVID-19. It is also important to stress the high incidence of thromboembolic complications in patients with COVID-19, which may occur anywhere in the vasculature.

Microalbuminuria on admission for acute exacerbation of COPD as a predictor of all-cause mortality and future exacerbations

OBJECTIVES

Microalbuminuria (MAB) is a sensitive biomarker of cardiovascular risk that is directly associated with cardiovascular events and mortality. Recent studies have evaluated the presence of MAB in patients with stable chronic obstructive pulmonary disease (COPD) or hospitalised for acute exacerbation of COPD (AECOPD).

METHODS

We evaluated 320 patients admitted for AECOPD in respiratory medicine departments of two tertiary hospitals. On admission, demographic, clinical and laboratory values and COPD severity were assessed. Patients were evaluated monthly for 1 year, recording new AECOPD and death from any cause.

RESULTS

Patients with documented MAB (urinary albumin excretion of 30-300 mg/24 hours) on admission had worse lung function (forced expiratory volume in 1 s, %) (mean (SD) 34.2 (13.6)% vs 61.5 (16.7)%), higher modified Medical Research Council (3.6 (1.2) vs 2.1 (0.8)), lower 6 min walk test (171 (63) vs 366 (104)) and more hospitalisation days (9 (2.8) vs 4.7 (1.9)) (p < 0.001 for all comparisons). MAB was also correlated with Global Initiative for Chronic Obstructive Lung Disease 2020 COPD stages (p < 0.001). In multivariate regression analysis, MAB was a significant predictor of longer hospitalisation duration (OR 6.847, 95% CI 3.050 to 15.370, p < 0.0001). Twelve-month follow-up revealed that patients with MAB experienced more AECOPDs (4.6 (3.6) vs 2.2 (3.5), p < 0.0001) and deaths, n (%) (52 (36.6) vs 14 (7.8), p < 0.001). Kaplan-Meier survival curves demonstrated that patients with MAB presented with increased mortality, AECOPD and hospitalisation for AECOPD risk at 1 year (p < 0.001 for all comparisons).

CONCLUSIONS

The presence of MAB on admission for AECOPD was associated with more severe COPD and prolonged hospitalisation, as well as with higher rates of AECOPD and mortality risk at 1-year follow-up.

Microalbuminuria on admission for acute exacerbation of COPD as a predictor of all-cause mortality and future exacerbations

OBJECTIVES

Microalbuminuria (MAB) is a sensitive biomarker of cardiovascular risk that is directly associated with cardiovascular events and mortality. Recent studies have evaluated the presence of MAB in patients with stable chronic obstructive pulmonary disease (COPD) or hospitalised for acute exacerbation of COPD (AECOPD).

METHODS

We evaluated 320 patients admitted for AECOPD in respiratory medicine departments of two tertiary hospitals. On admission, demographic, clinical and laboratory values and COPD severity were assessed. Patients were evaluated monthly for 1 year, recording new AECOPD and death from any cause.

RESULTS

Patients with documented MAB (urinary albumin excretion of 30-300 mg/24 hours) on admission had worse lung function (forced expiratory volume in 1 s, %) (mean (SD) 34.2 (13.6)% vs 61.5 (16.7)%), higher modified Medical Research Council (3.6 (1.2) vs 2.1 (0.8)), lower 6 min walk test (171 (63) vs 366 (104)) and more hospitalisation days (9 (2.8) vs 4.7 (1.9)) (p<0.001 for all comparisons). MAB was also correlated with Global Initiative for Chronic Obstructive Lung Disease 2020 COPD stages (p<0.001). In multivariate regression analysis, MAB was a significant predictor of longer hospitalisation duration (OR 6.847, 95% CI 3.050 to 15.370, p<0.0001). Twelve-month follow-up revealed that patients with MAB experienced more AECOPDs (4.6 (3.6) vs 2.2 (3.5), p<0.0001) and deaths, n (%) (52 (36.6) vs 14 (7.8), p<0.001). Kaplan-Meier survival curves demonstrated that patients with MAB presented with increased mortality, AECOPD and hospitalisation for AECOPD risk at 1 year (p<0.001 for all comparisons).

CONCLUSIONS

The presence of MAB on admission for AECOPD was associated with more severe COPD and prolonged hospitalisation, as well as with higher rates of AECOPD and mortality risk at 1-year follow-up.

Miracles in my time: Reflections of a pediatric respiratory physician

Miracles, like London buses, just seem to come along. The truth is, there are no miracles, just lots of hard work behind the scenes, minds open to opportunity, serendipity, and possibly a little luck. In my time as a pediatric respiratory physician, I have borne witness to remarkable advances in treatment that have changed patients' fortunes overnight. Examples of these include artificial surfactant replacement for premature newborns, conjugate Haemophilus influenzae type b vaccination, propranolol for infants with subglottic haemangiomas, mandibular distraction for babies with micrognathia, cystic fibrosis transmembrane conductance regulator modulators therapy for patients with cystic fibrosis, and antisense oligonucleotide therapy for infants with spinal muscular atrophy. There are lessons to be learned from reflection upon these life-transforming treatments, and perhaps it is a good time just to pause and wonder.

Idiopathic subglottic stenosis and the consequences in cardiopulmonary exercise testing

A 15-year-old male patient with progressive dyspnoea and exercise-related wheezing was analysed with spirometry, ECG and a cardiopulmonary exercise test with blood gas analysis. Earlier analysis by a paediatrician concluded no abnormalities. However, the previously performed spirometry test may have clarified the diagnosis in an earlier stage.Severe hypoventilation was seen during the exercise test with hypercapnia and hypoxaemia while hearing a stridor during exercise. Eventually, a circular subglottic stenosis was seen on a CT scan of the chest. No malignancy or granulomatosis with polyangiitis was seen in biopsy and pathologic examination. There was no history of trauma, intubation or infection. Therefore, the diagnosis idiopathic subglottic stenosis was established. Bronchoscopic balloon dilation followed several times, leading to full recovery.

Antimicrobial prescribing and outcomes of community-acquired pneumonia in Australian hospitalized patients: a cross-sectional study

Objective

We aimed to assess prescribing practices, compliance with guidelines, and outcomes for patients who were admitted to the authors’ institution with community-acquired pneumonia (CAP).

Methods

We performed a single-center retrospective cross-sectional study of adults with CAP presenting during the 2019 influenza season. CAP severity was assessed using the CURB-65 risk score. The effect of CURB-65 risk score use on the rate of appropriate antimicrobial prescribing was assessed using the chi-square test and reported as odds ratio (OR). Fisher’s exact test was used to assess the relationship between prescribing appropriateness and patient outcomes.

Results

Patients with low-risk CAP were most likely to be inappropriately prescribed antimicrobials (OR: 4.77; 95% confidence interval: 2.44–10.47). In low-risk CAP, the most common prescribing error was overuse of ceftriaxone. In high-risk CAP, the most common errors were ceftriaxone underdosing and missed atypical coverage with azithromycin. Overall, 80% of patients were considered to have been inappropriately prescribed antimicrobials. No effect on mortality was observed.

Conclusions

In this study, we found low use of CAP risk scores and low adherence to antimicrobial prescribing guidelines for CAP at the authors’ institution.

Case of positional dyspnoea and hypoxia secondary to intracardiac shunting

Platypnea-orthodexia syndrome (POS) is a rare but well-characterised condition where hypoxaemia and breathlessness occur while upright but resolve once recumbent. Early recognition can result in excellent outcomes for patients and can prevent unnecessary investigations for patients, especially if they present repeatedly to hospital after missed diagnosis. We present a case of a 75-year-old woman with a chronic history of breathlessness who was picked up after observations at a routine outpatient clinic. Early recognition of the POS allowed for appropriate investigations to take place identifying a patent foramen ovale (PFO). She was referred to the tertiary centre for closure of her PFO with complete resolution of her symptoms.

Non-nuberculous mycobacteria infection treated with intermittently inhaled high-dose nitric oxide

Mycobacterium abscessus is an emerging multidrug-resistant non-tuberculous mycobacterium (NTM) with high prevalence in patients with cystic fibrosis. However, studies on antimicrobial susceptibilities and effective treatments against M. abscessus are still limited. Nitric oxide (NO) is important in innate immune response to various infections, including mycobacterial infections. In this case study, we describe a compassionate treatment of inhaled NO (iNO) at 150–250 ppm for 4 weeks. The dosing strategy proposed for this treatment was selected to minimise the potential of adverse events, while maximising the antibacterial effectiveness of NO, and was found to be safe, well tolerated and resulted in positive clinical findings including improvement in patient well-being, CT scan values, quality of life and bacterial load. Taken together, these observations may indicate that iNO could play a crucial role and potentially serve as a reliable option in the treatment of patients with chronic refractory NTM lung infection.

Late diagnosis of pulmonary agenesis

Pulmonary agenesis is defined as the complete absence of one or both lungs, including the bronchi, bronchioles, vasculature and lung parenchyma. Most of these malformations are detected in early childhood. A residual number remains asymptomatic and undiagnosed until adulthood. The clinical presentation is wide, ranging from asymptomatic to respiratory complaints like dyspnoea, respiratory distress and a history of recurrent lung infections. This case presents a 54-year-old woman with complaints of coughing, dyspnoea for medium exertion and wheezing for a couple of months. Based on the results of complementary diagnosis methods, right pulmonary agenesis was diagnosed without other malformations. Simultaneously, an asthma diagnosis was also performed. The treatment of pulmonary agenesis is symptomatic. Simultaneous cardiovascular malformations could require surgical interventions. This case demonstrates that pulmonary agenesis may remain undiagnosed, be identified incidentally, and have a good and long prognosis.

Use of opioids for refractory dyspnoea in hospitalised patients with serious illness: a narrative review

Refractory dyspnoea can be a challenging symptom to manage. Palliative care specialists are not always available for consultation, and while many clinicians may undergo training in palliative care, this education is not universal. Opioids are the most studied and prescribed pharmacological intervention for refractory dyspnoea; however, many clinicians hesitate to prescribe opioids due to regulatory concerns and fear of adverse effects. Current evidence suggests that rates of severe adverse effects, including respiratory depression and hypotension, are low when opioids are administered for refractory dyspnoea. Therefore, systemic, short-acting opioids are a recommended and safe option for the palliation of refractory dyspnoea in patients with serious illness, especially in a hospital setting that facilitates close observation. In this narrative review, we discuss the pathophysiology of dyspnoea; facilitate an evidence-based discussion on the concerns, considerations and complications associated with opioid administration for refractory dyspnoea; and describe one approach to managing refractory dyspnoea.

Use of opioids for refractory dyspnoea in hospitalised patients with serious illness: a narrative review

Refractory dyspnoea can be a challenging symptom to manage. Palliative care specialists are not always available for consultation, and while many clinicians may undergo training in palliative care, this education is not universal. Opioids are the most studied and prescribed pharmacological intervention for refractory dyspnoea; however, many clinicians hesitate to prescribe opioids due to regulatory concerns and fear of adverse effects. Current evidence suggests that rates of severe adverse effects, including respiratory depression and hypotension, are low when opioids are administered for refractory dyspnoea. Therefore, systemic, short-acting opioids are a recommended and safe option for the palliation of refractory dyspnoea in patients with serious illness, especially in a hospital setting that facilitates close observation. In this narrative review, we discuss the pathophysiology of dyspnoea; facilitate an evidence-based discussion on the concerns, considerations and complications associated with opioid administration for refractory dyspnoea; and describe one approach to managing refractory dyspnoea.

Lung cancer patient who had declined conventional cancer treatment: could the self-administration of 'CBD oil' be contributing to the observed tumour regression?

Conventional lung cancer treatments include surgery, chemotherapy and radiotherapy; however, these treatments are often poorly tolerated by patients. Cannabinoids have been studied for use as a primary cancer treatment. Cannabinoids, which are chemically similar to our own body's endocannabinoids, can interact with signalling pathways to control the fate of cells, including cancer cells. We present a patient who declined conventional lung cancer treatment. Without the knowledge of her clinicians, she chose to self-administer 'cannabidiol (CBD) oil' orally 2-3 times daily. Serial imaging shows that her cancer reduced in size progressively from 41 mm to 10 mm over a period of 2.5 years. Previous studies have failed to agree on the usefulness of cannabinoids as a cancer treatment. This case appears to demonstrate a possible benefit of 'CBD oil' intake that may have resulted in the observed tumour regression. The use of cannabinoids as a potential cancer treatment justifies further research.

Platypnoea-orthodeoxia syndrome due to a right-to-left interatrial shunt following pneumonectomy

A 62-year-old man presents with breathlessness 6 months following right pneumonectomy for lung adenocarcinoma. Previous investigations had not yielded a diagnosis and his symptoms were progressing. The patient described worsened symptoms when stood up (platypnoea), with profound hypoxia until laid supine (orthodeoxia). Platypnoea-orthodeoxia syndrome due to a right-to-left interatrial shunt was diagnosed on contrast-enhanced transoesophageal echocardiography with the patient undergoing successful percutaneous patent foramen ovale closure. Patent foramen ovale is often asymptomatic with a population prevalence of around 20%-30%. Anatomical shifts postpneumonectomy can open, or worsen a previously closed interatrial communication leading to right-to-left shunting of blood. Platypnoea-orthodeoxia is under-recognised, impairing quality of life and patient outcome. Investigations can be falsely reassuring, or poorly sensitive for the causative pathology. Percutaneous closure is safe with high success rates and this case highlights the need for a high index of suspicion for shunts, particularly in postpneumonectomy patients.

Thirty-day unplanned readmission in hospitalised asthma patients in the USA

INTRODUCTION

Hospital quality improvement and hospital performance are commonly evaluated using parameters such as average length of stay (LOS), patient safety measures and rates of hospital readmission. Thirty-day readmission (30-DR) rates are widely used as a quality indicator and a quantifiable metric for hospitals since patients are often readmitted for the exacerbation of conditions from index admission. The quality of patient education and postdischarge care can influence readmission rates. We report the 30-DR rates of patients with asthma using a national dataset for the year 2013.

OBJECTIVES

The aim of our study was to assess the 30- day readmission (30-DR) rate as well as, the causes and predictors of readmissions.

STUDY DESIGNS/METHODS

Using the Nationwide Readmission Database (NRD) (2013), we identified primary discharge diagnoses of asthma by using International Classification of Diseases, Ninth Revision, Clinical Modification code '493'. Categorical and continuous variables were assessed by a χ² test and a Student's t-test, respectively. The independent predictors of unplanned 30-DR were detected by multivariate analysis. We used sampling weights, which are provided in the NRD, to generate the national estimates.

RESULTS

There were 130 490 (weighted N=311 173) inpatient asthma admissions during 2013. The overall 30-DR for asthma was 11.9%. The associated factors for 30-DR were age 45-84 years (40.32% vs 29.05%; p<0.001), enrolment in Medicare (49.33% vs 30.61% p<0.001), extended LOS (mean, 4.40±0.06 vs 3.25±0.04 days; p<0.001), higher mean cost (US$8593.91 vs US$6741.31; p<0.001) and higher disposition against medical advice (DAMA) (4.14% vs 1.51%; p<0.001). The factors that increased the chance of 30-DR were advanced age (≥45-64 vs ≤17 years; OR 4.61, 95% CI 4.04 to 5.27, p<0.0001), male sex (OR 1.19, 95% CI 1.13 to 1.26, p<0.0001), a higher Charlson Comorbidity Index (CCI) (OR 1.16, 95% CI 1.14 to 1.18, p<0.0001), DAMA (OR 2.32, 95% CI 2.08 to 2.59, p<0.0001), non-compliance with medication (OR 1.34, 95% CI 1.24 to 1.46, p<0.0001), post-traumatic stress disorder (OR 1.48, 95% CI 1.22 to 1.79, p<0.0001), alcohol use (OR 1.45, 95% CI 1.27 to 1.65, p<0.0001), gastro-oesophageal reflux disease (OR 1.20, 95% CI 1.14 to 1.27, p<0.0001), obstructive sleep apnoea (OR 1.11, 95% CI 1.03 to 1.18, p<0.0042) and hypertension (OR 1.11, 95% CI 1.06 to 1.17, p<0.0001).

CONCLUSIONS

We found that the overall 30-DR rate for asthma was 11.9% all-cause readmission. Major causes of 30-DR were asthma exacerbation (36.74%), chronic obstructive pulmonary disease (11.47%), respiratory failure (6.46%), non-specific pneumonia (6.19%), septicaemia (3.61%) and congestive heart failure (3.32%). One-fourth of the revisits occurred in the first week, while half of the revisits took place in the first 2 weeks. Education regarding illness and the importance of medicine compliance could play a significant role in preventing asthma-related readmission.