1
|
Routaray S, Prasad C, Rajagopalan V. Non-invasive ventilation (NIV) induced bilateral subcutaneous emphysema in SARS COV-2 patient: A rare occurrence. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2021; 38:18-20. [PMID: 38620754 PMCID: PMC8006496 DOI: 10.1016/j.tacc.2021.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/07/2020] [Accepted: 03/19/2021] [Indexed: 11/22/2022]
Abstract
A patient with coronavirus disease-2019 (COVID-19) developed bilateral subcutaneous emphysema involving the neck and upper chest following the institution of non-invasive ventilation (NIV) for worsening hypoxia. We discuss the various causes, differentials and successful management of this patient.
Collapse
Affiliation(s)
- Sunil Routaray
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Chandrakant Prasad
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Vanitha Rajagopalan
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| |
Collapse
|
2
|
Kahn MR, Watson RL, Thetford JT, Wong JI, Kamangar N. High Incidence of Barotrauma in Patients With Severe Coronavirus Disease 2019. J Intensive Care Med 2021; 36:646-654. [PMID: 33722090 PMCID: PMC7967021 DOI: 10.1177/0885066621989959] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objective.: To report the high incidence of barotrauma in critically ill patients admitted to the intensive care unit (ICU) with coronavirus disease 2019 (COVID-19) and to discuss its implications. Design.: Retrospective cohort study. Setting.: ICU of an academic county hospital in Los Angeles, CA admitted from March 15-June 20, 2020. Patients.: 77 patients with COVID-19 pneumonia. 75 patients met inclusion criteria. Results.: 21% of patients with severe COVID-19 sustained barotrauma (33% of patients receiving IMV, 8% of patients receiving (NIV). There were no differences between the barotrauma and non-barotrauma groups regarding demographics, illness severity, or medications received, nor tidal volume or average/peak airway pressures in those receiving IMV. In the barotrauma group there was a greater proportion of patients receiving therapeutic anticoagulation (81% vs. 47%, p = 0.023) and ventilated using airway pressure release ventilation mode (13% vs. 0%, p = 0.043). Barotrauma was associated with increased likelihood of receiving a tracheostomy (OR 2.58 [0.23-4.9], p = 0.018]), longer median ICU length of stay (17 days vs. 7 days, p = 0.03), and longer median length of hospitalization (26 days vs. 14 days, p < 0.001). There was also a trend toward prolonged median duration of IMV (12.5 days vs 7 days, p = 0.13) and higher average mortality (56% vs 37%, p = 0.25). Conclusions.: Barotrauma is seen in 5-12% of patients with ARDS receiving IMV and is exceedingly rare in patients receiving NIV. We report a high incidence of barotrauma observed in critically ill patients with COVID-19 requiring either NIV or IMV. While there was a trend toward increased mortality in patients with barotrauma, this did not reach statistical significance. The increased incidence of barotrauma with COVID-19 may be a product of the pathophysiology of this disease state and a heightened inflammatory response causing rampant acute lung injury. Evidence-based medicine and lung-protective ventilation should remain the mainstay of treatment.
Collapse
Affiliation(s)
- Michael R Kahn
- Department of Medicine, 12222UCLA-Olive View Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Richard L Watson
- Division of Pulmonary and Critical Care Medicine, Ronald Reagan 12222UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jay T Thetford
- Department of Medicine, 12222UCLA-Olive View Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Joseph Isaac Wong
- Department of Medicine, 12222UCLA-Olive View Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Nader Kamangar
- Division of Pulmonary and Critical Care Medicine, 12222UCLA-Olive View Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| |
Collapse
|
3
|
Recurrent Pneumothorax with CPAP Therapy for Obstructive Sleep Apnea. Case Rep Pulmonol 2020; 2020:8898621. [PMID: 33520324 PMCID: PMC7816758 DOI: 10.1155/2020/8898621] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 11/19/2020] [Accepted: 11/24/2020] [Indexed: 02/05/2023] Open
Abstract
Pulmonary barotrauma such as pneumothorax (PTX) is a known complication of invasive mechanical ventilation. However, it is uncommonly reported with the use of noninvasive positive pressure ventilation (NPPV) and CPAP (continuous positive airway pressure) therapy. We present a case of a 66-year-old female who presented with chronic dyspnea on exertion secondary to right-sided diaphragmatic hernia. The patient also underwent a home sleep study which suggested obstructive sleep apnea (OSA) for which she was initiated on CPAP. She then underwent surgical repair of her right diaphragmatic hernia. The patient developed pneumothorax three times over the course of the following several months, once on the right side and twice on the left side. The patient's incidences of PTX had a temporal association with the CPAP initiation. Her CPAP therapy was discontinued permanently after the third occurrence of PTX. With this case report, we highlight the risk of barotrauma with the use of CPAP for OSA. There are very few reported cases of PTX in association with NPPV therapy for OSA. The lung-protective ventilation strategies and limiting the positive airway pressures can help reduce the risk of pulmonary barotrauma with CPAP.
Collapse
|
4
|
Meade MJ, Tumati A, Chantachote C, Huang EC, Rutigliano DN, Rubano JA, Vosswinkel JA, Jawa RS. Antithrombotic Agent Use in Elderly Patients Sustaining Low-Level Falls. J Surg Res 2020; 258:216-223. [PMID: 33032140 DOI: 10.1016/j.jss.2020.08.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 08/19/2020] [Accepted: 08/25/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Elderly patients who are injured from a low-level fall comprise an increasing percentage of trauma admissions. We sought to evaluate the prevalence of antithrombotic (anticoagulant or antiplatelet) agent use, injury patterns, and outcomes in this population, focusing on intracranial hemorrhage (ICH). METHODS We retrospectively reviewed the trauma registry at an American College of Surgeons-verified Level I trauma center for all patients aged 65 y or older admitted between 2007 and 2016 following a low-level fall. Medical records of patients on antithrombotic agents were examined in detail. Patients were divided into four groups based on the presence/absence of ICH and presence/absence of preadmission antithrombotic medication use. RESULTS There were 4074 elderly patients admitted after a low-level fall, of which 1153 (28.3%) had a traumatic ICH, and 1238 (30.4%) were on antithrombotic agents. Notably, 35.9% of patients on antithrombotics had an ICH, as compared to 25.0% of 2836 patients not on antithrombotics other than aspirin (P < 0.001). The overall distribution of antithrombotic agent use differed significantly between the ICH and non-ICH groups; the ICH group had more coumadin usage. The mortality rate was significantly different across groups, with the group having ICH and a history of antithrombotics having the highest mortality at 14.2% (P < 0.001). Excluding the 27.8% of patients who were transferred into our hospital demonstrated that significantly more admissions on antithrombotics had ICH (22.4%) versus ICH admissions not on antithrombotics (14.7%, P < 0.001). The mortality rate was significantly different across groups, with the group having ICH and a history of antithrombotics having the highest mortality at 12.0% (P < 0.001). On multivariable analysis, anticoagulants, antiplatelets, and aspirin were all significantly associated with ICH; but only anticoagulants were significantly associated with mortality. CONCLUSIONS Antithrombotic agent use was common in admitted elderly patients sustaining a low-level fall and is associated with an elevated rate of ICH. Anticoagulants were also associated with increased mortality.
Collapse
Affiliation(s)
- Michael J Meade
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York
| | - Abhinay Tumati
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York
| | - Chanak Chantachote
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York
| | - Emily C Huang
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York
| | - Daniel N Rutigliano
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York
| | - Jerry A Rubano
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York
| | - James A Vosswinkel
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York
| | - Randeep S Jawa
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York.
| |
Collapse
|
5
|
Cho HE, Byun J, Choi WA, Kim M, Kim KY, Kang SW. Analysis of Pneumothorax in Noninvasive Ventilator Users With Duchenne Muscular Dystrophy. Chest 2020; 159:1540-1547. [PMID: 32956714 DOI: 10.1016/j.chest.2020.09.086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 09/09/2020] [Accepted: 09/11/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND With the advancement of cardiorespiratory interventions, the survival rate among patients with Duchenne muscular dystrophy (DMD) has increased. Subsequently, pneumothorax has become a significant problem in patients with prolonged ventilatory support. RESEARCH QUESTION What are the frequency, recurrence rate, risk factors, and prognosis of pneumothorax in patients with DMD requiring noninvasive ventilation (NIV)? Also, are there known risk factors of pneumothorax on chest CT scans? STUDY DESIGN AND METHODS This retrospective longitudinal cohort study included 176 patients treated between 2006 and 2019. We collected information regarding location, severity, treatment methods, recurrence frequency, abnormal findings on CT scanning, and date of death. We compared the pneumothorax and nonpneumothorax groups. We calculated the estimated survival probabilities from the age at NIV application according to pneumothorax occurrence. RESULTS Sixteen of the 176 patients (9.0%) experienced pneumothorax (median age at diagnosis, 24.6 years; range, 20.7-33.7 years). Among the 16 patients, 15 demonstrated pneumothorax after NIV application (median time between diagnosis and initial NIV application, 5.6 years; range, 3 days-9.6 years). Sixteen patients experienced 31 episodes of pneumothoraces (range, one-five episodes); among them, seven episodes (22.6%) were asymptomatic. Known risk factors not clearly visible by radiography scans were found in chest CT scan in 11 patients (68.8%). Seven of 16 patients (43.8%) eventually sustained severe lung damage with pulmonary fibrosis. No significant between-group differences were found in body weight, BMI, and age at NIV application; however, the pneumothorax group showed a significantly higher mortality rate after NIV application. INTERPRETATION On pneumothorax occurrence in patients with DMD, recurrences and severe lung damage are common; moreover, these patients show higher mortality rates than patients without pneumothorax. Chest CT scans should be performed to identify risk factors, and treatment should be initiated accordingly. In addition, physicians should consider chest CT scanning in the case of suspected pneumothorax, even if no radiographic abnormality is found.
Collapse
Affiliation(s)
- Han Eol Cho
- Department of Rehabilitation Medicine, Gangnam Severance Hospital and Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Justin Byun
- Department of Rehabilitation Medicine, Gangnam Severance Hospital and Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Won Ah Choi
- Department of Rehabilitation Medicine, Gangnam Severance Hospital and Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Myungsang Kim
- Department of Rehabilitation Medicine, Gangnam Severance Hospital and Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Kyeong Yeol Kim
- Department of Rehabilitation Medicine, Gangnam Severance Hospital and Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Seong-Woong Kang
- Department of Rehabilitation Medicine, Gangnam Severance Hospital and Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea.
| |
Collapse
|
6
|
Lee BR, Shin SH, Kim MJ, Kim E, Choi YJ, Park JD, Suh DI. Clinical characteristics of pediatric pneumothorax during a noninvasive positive pressure ventilation. ALLERGY ASTHMA & RESPIRATORY DISEASE 2019. [DOI: 10.4168/aard.2019.7.1.51] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Bo Ra Lee
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - So Hyun Shin
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Min Jung Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Eunji Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | | | - June Dong Park
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Dong In Suh
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| |
Collapse
|
7
|
Fraser KL, Wong S, Foley AR, Chhibber S, Bönnemann CG, Lesser DJ, Grosmann C, Rutkowski A. Pneumothoraces in collagen VI-related dystrophy: a case series and recommendations for management. ERJ Open Res 2017; 3:00049-2017. [PMID: 28660205 PMCID: PMC5482316 DOI: 10.1183/23120541.00049-2017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 05/14/2017] [Indexed: 01/07/2023] Open
Abstract
Collagen VI-related dystrophy (collagen VI-RD) is a rare neuromuscular condition caused by mutations in the COL6A1, COL6A2 or COL6A3 genes. The phenotypic spectrum includes early-onset Ullrich congenital muscular dystrophy, adult-onset Bethlem myopathy and an intermediate phenotype. The disorder is characterised by distal hyperlaxity and progressive muscle weakness, joint contractures and respiratory insufficiency. Respiratory insufficiency is attributed to chest wall contractures, scoliosis, impaired diaphragmatic function and intercostal muscle weakness. To date, intrinsic parenchymal lung disease has not been implicated in the inevitable respiratory decline of these patients. This series focuses on pneumothorax, an important but previously under-recognised disease manifestation of collagen VI-RD. We describe two distinct clinical presentations within collagen VI-RD patients with pneumothorax. The first cohort consists of neonates and children with a single pneumothorax in the setting of large intrathoracic pressure changes. The second group is made up of adult patients with recurrent pneumothoraces, associated with chest computed tomography scan evidence of parenchymal lung disease. We describe treatment challenges in this unique population with respect to expectant observation, tube thoracostomy and open pleurodesis. Based on this experience, we offer recommendations for early identification of lung disease in collagen VI-RD and definitive intervention. Collagen VI-RD patients may experience unprovoked or recurrent pneumothorax from parenchymal lung changeshttp://ow.ly/ZL3h30ce0Bk
Collapse
Affiliation(s)
| | - Scott Wong
- The Congenital Muscle Disease International Registry, Torrance, CA, USA
| | - A Reghan Foley
- Neuromuscular and Neurogenetic Disorders of Childhood Section, National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD, USA
| | | | - Carsten G Bönnemann
- Neuromuscular and Neurogenetic Disorders of Childhood Section, National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD, USA
| | - Daniel J Lesser
- Division of Respiratory Medicine, Rady Children's Hospital San Diego, University of California San Diego, San Diego, CA, USA
| | - Carla Grosmann
- Division of Neurosciences, University of California San Diego, San Diego, CA, USA
| | | |
Collapse
|
8
|
Plasma Krebs von den Lungen glycoprotein, lung injury, and noninvasive ventilation in Duchenne muscular dystrophy. Am J Phys Med Rehabil 2012; 91:831-5. [PMID: 22760105 DOI: 10.1097/phm.0b013e31825f1414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE There have been few reports of ventilator-induced lung injury associated with noninvasive ventilation (NIV), but many with invasive mechanical ventilation. The purpose of this study was to detect subclinical NIV-associated lung injury by monitoring Krebs von den Lungen glycoprotein plasma levels. DESIGN Forty-one Duchenne muscular dystrophy patients were divided into three categories: group 1, asymptomatic and not using ventilators; group 2, NIV use less than 24 hrs/day at full ventilatory support settings; and group 3, continuous NIV dependence. Plasma Krebs von den Lungen glycoprotein level was measured by electrochemical luminescent immunoassay using Krebs von den Lungen glycoprotein antibodies. One-way analysis of variance, followed by the Tukey-Kramer test, was used as appropriate to compare intergroup differences. RESULTS Extent of ventilator dependence correlated with age (P < 0.05). Intergroup plasma Krebs von den Lungen glycoprotein levels were not significantly different. CONCLUSIONS NIV used at volumes and pressures of full (invasive) ventilatory support may not induce the alveolar septal barrier injury commonly seen with invasive mechanical ventilation.
Collapse
|
9
|
Carron M, Gagliardi G, Michielan F, Freo U, Ori C. Occurrence of pneumothorax during noninvasive positive pressure ventilation through a helmet. J Clin Anesth 2007; 19:632-5. [DOI: 10.1016/j.jclinane.2007.04.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2006] [Revised: 04/13/2007] [Accepted: 04/23/2007] [Indexed: 10/22/2022]
|
10
|
Sleep-Related Breathing Disorders of Childhood: Description and Clinical Picture, Diagnosis, and Treatment Approaches. Sleep Med Clin 2007. [DOI: 10.1016/j.jsmc.2007.05.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
|
11
|
Abstract
Despite increasing recognition of childhood obstructive sleep apnea syndrome (OSAS) as a significant public health problem, treatment of the condition remains inconsistent. Some children are screened using polysomnography and treated only when objective respiratory disturbances are identified. Many others receive adenotonsillectomy based only on signs and symptoms of upper airway obstruction without ever having a formal sleep study. Outcome-based data regarding the effectiveness of adenotonsillectomy, continuous positive airway pressure, and other treatments for childhood OSAS remain extremely limited. In this article, the major therapeutic options for treatment of childhood OSAS are reviewed. Adenotonsillectomy remains the most frequently used treatment for uncomplicated OSAS in children, but residual airway obstruction persists in a notable minority of patients. Nasal continuous positive airway pressure is used for children who are not good surgical candidates or who have failed previous surgical treatment, but is sometimes not tolerated by young children or their parents. Various alternative treatments are used on an individualized basis for children who cannot use the two first-line therapies for sleep apnea.
Collapse
Affiliation(s)
- Timothy F Hoban
- Department of Pediatrics, L3227, Women's Hospital, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
| |
Collapse
|