Complicated extubation in a patient with an obstructing tracheobronchial thrombus

Endotracheal intubation is an effective and rapid technique used as a standard practice for airway management. Airway injury or complications could be a significant cause of morbidity and mortality for patients. Tracheobronchial obstruction secondary to thrombus formation are life threatening complications of traumatic intubations. We present a case of complicated extubation resulting in cardiac arrest in a patient with an obstructing tracheobronchial thrombus. The patient, an 83-year-old female, with atrial fibrillation presented for neck pain. During CT imaging, she developed ventricular fibrillation cardiac arrest. Return of spontaneous circulation (ROSC) was achieved after three cycles of compressions and defibrillation and the patient was intubated. After stabilization of the patient and passing of spontaneous breathing trials, the patient was extubated. The patient rapidly developed hypoxic respiratory failure and progressed to pulseless electrical activity. ROSC was achieved again after 3 rounds of compressions. The following days, after passing her SBT yet again, extubation was attempted. She had an audible stridor and visible respiratory distress. Bedside Yankauer suction of the oropharynx resulted in retrieval of a large 6x2cm thrombus. Immediate resolution of stridor and improved oxygenation occurred. Tracheobronchial clots are a cause of cardiac arrest and potentially fatal cause of endotracheal intubation. Physicians and respiratory therapists must be aware of optimizing pre-extubation conditions in the setting of TB obstruction as it can lead to arrest and death

The impact of physical activity on lung function in patients with Cystic Fibrosis

Compared to healthy individuals, patients with Cystic Fibrosis (CF) experience frequent pulmonary exacerbations (PE) and are associated with a reduced forced expiratory volume in 1 second (FEV1), the main prognostic measure of lung function in CF. Physical activity has been shown to attenuate the rate of decline in FEV1 in CF patients. Although CF patients have been shown to perform a similar amount of mild physical activity as their healthy counterparts, they have been shown to spend less time performing moderate to vigorous physical activity. These results were supported from baseline data collected for the local component of the international randomized control trial, ACTIVATE-CF, for which CF patients were shown to be somewhat active, but spent minimal time as very active. Using data collected from a study published by McIlwaine et al. (2013), we aimed to determine the predictors of lung function and physical activity in patients with CF. Using the local component of the ACTIVATE-CF study, we also aimed to determine if a 6-month partially supervised exercise-training program consisting of a motivational feedback component can motivate patients with CF to increase their physical activity levels and result in an improved lung function. We hypothesize that seasonality and lung function will have an impact on physical activity levels in patients with CF. We also hypothesize that the ACTIVATE-CF training program will motivate CF patients to increase their levels of physical activity and will improve their lung function. From the analysis of the McIlwaine et al. (2013) dataset, age was shown to predict time spent as somewhat active while lung function and seasonality were shown to predict time spent as very active in CF patients. Furthermore, time spent as very active, type of airway clearance technique, and age were shown to predict lung function. The results of this study suggest that in patients with CF, seasonal changes and lower lung function may be impacting their participation in intense physical activity and that spending more time as very active may increase their lung function. Following 3-months of training, the ACTIVATE-CF training program successfully increased physical activity levels for the two participants randomized to the intervention group. In addition, one of the two participants in the intervention group was associated with improvements in lung function and body composition. These results provide further support that intense physical activity may improve lung function in patients with CF.Par rapport aux personnes en bonne santé, les patients atteints de la Fibrose Kystique (FK) subissent des exacerbations pulmonaires fréquentes et sont affectés par un volume expiratoire réduit de 1 seconde (FEV1), qui est la principale mesure pronostique de la fonction pulmonaire. Il a été démontré que l'activité physique atténue le taux de déclin de FEV1 chez les patients FK. Malgré le fait que les patients atteints de FK aient montré de l'activité physique d'intensité légère semblable à celle de leurs homologues en bonne santé, il a été démontré qu'ils passaient moins de temps à pratiquer de l'activité physique d'intensité modérée à vigoureuse. Ces résultats ont été soutenus grâce à la base de données recueillies pour la composante locale lors de l'essai international de contrôle aléatoire, ACTIVATE-CF, pour lequel les patients atteints de FK ont été quelque peu actifs, mais ont passé un temps minimal à être très actif. En utilisant des données recueillies à partir d'une étude réalisée par McIlwaine et al. (2013), nous avons visé à déterminer les prédicteurs de la fonction pulmonaire et de l'activité physique dans des patients atteints de FK. En utilisant le composant local de l'étude ACTIVATE-CF, nous avons aussi visé à déterminer si un programme d'exercice de 6-mois partiellement surveillé consistant d'un composant de motivation peut motiver des patients atteints de FK d'augmenter leurs niveaux d'activité physique et améliorer leur fonction pulmonaire. Nous formulons l'hypothèse que la saisonnalité et la fonction pulmonaire auront un impact sur les niveaux d'activités physique des patients atteints de FK. Nous formulons aussi l'hypothèse que le programme d'exercice motivera les patients atteints de FK d'augmenter leurs niveaux d'activité physique et améliorera leur fonction pulmonaire. Les résultats de l'analyse des données recueillies par l'étude de McIlwaine et al. (2013) ont déterminé que l'âge permet de prédire le temps passé comme plus ou moins actif alors que la fonction pulmonaire et les changements saisonniers permettent de prévoir le temps passé comme très actif chez les patients FK. D'ailleurs, le temps passé comme très actif, le type de technique de dégagement de voies aériennes, et l'âge permettent de prédire la fonction pulmonaire. Les résultats de cette étude démontrent que chez les patients atteints de FK, les changements saisonniers et la diminution de la fonction pulmonaire peuvent avoir une incidence sur leur participation à l'activité physique intense et que passer plus de temps comme très actif peut augment leur fonction pulmonaire. Après 3-mois d'entrainement, le programme d'exercice d'ACTIVATE-CF augmenté les niveaux d'activité physique pour les deux participants randomisés au groupe d'intervention. De plus, un des deux participants au groupe d'intervention a connu des améliorations au niveau de sa fonction pulmonaire et de sa composition corporelle. Ces résultats fournissent un soutien supplémentaire à la théorie que l'activité physique intense peut améliorer la fonction pulmonaire chez les patients atteints de FK

Inflammatory bowel disease patient concerns and experiences on transition to home-based infusions during the COVID-19 pandemic.

BACKGROUND: In response to the COVID-19 pandemic, the CDC issued guidance advising patients and providers to adopt social distancing practices such as home-based infusions (H-BI). METHODS: We performed a mixed methods evaluation to summarize perceptions, concerns, and experiences with H-BI among all inflammatory bowel disease patients 18-90 years of age who transitioned to home-based infliximab or vedolizumab infusions between March to July 2020 at a tertiary care center. Semi-structured interviews were conducted and analyzed using an iterative, inductive thematic approach. Baseline characteristics and outcome on safety, COVID-19 transmission, delays in infusions, and H-BI persistence were collected. RESULTS: Of the 57 participants who transitioned to H-BI, 20 (33%) responded. Four major categories and six major themes related to expectations, experience, perceived safety, and logistical factors were identified. Initial perceptions were mixed, however these resolved. One patient developed COVID-19, one patient experienced an adverse event, 12 (21%) patients experienced an infusion delay, and 6 (11%) patients transitioned from H-BI. DISCUSSION: Despite mixed initial perceptions, respondents had a positive experience with most respondents planning to continue H-BI after the pandemic resolves. Several real-world actionable barriers were identified related to scheduling, communication between stakeholders, and nursing quality. No major safety concerns were identified