Purpose Acute exacerbation of chronic obstructive pulmonary disease (COPD) is a major cause of mortality and morbidity. Noninvasive ventilation (NIV) is proven to be effective in the majority of patients with acute exacerbation COPD (AECOPD) complicated with respiratory failure. NIV could be lifesaving but also can delay mechanical ventilation if its efficacy is not assessed in a timely manner. In this study, we analyzed potential predictors of NIV failure in AECOPD in a tertiary medical intensive care unit (MICU). In particular, we wondered whether duration of NIV among those who eventually failed was associated with poor outcomes. Methods A retrospective review of consecutive patients with a primary diagnosis of AECOPD requiring NIV admitted to the MICU was conducted for the period between 2012 and 2017. Baseline data included demographics, APACHE III score, albumin level, blood lactate, and blood gas elements. Additional chart review was performed to collect NIV setting parameters on presentation to the MICU. Clinical outcome variables collected included outcome and duration of NIV, duration of invasive mechanical ventilation, MICU length of stay, hospital length of stay, and in-hospital mortality. Multivariate regression analysis was performed to determine independent variables associated with clinical outcomes. Results There were 370 patients who met the inclusion criteria; 53.2% were male. Mean age was 64.7 ± 11.2 years old. Mean baseline FEV 1 was 34 ±17% of predicted. Patients had mean pH of 7.20 ± 0.54 and P a CO 2 of 70.3 ± 28.7 on presentation; 323 patients (87.3%) were successfully weaned off NIV; 47 patients (12.7%) failed NIV and required invasive mechanical ventilation. APACHE III score was higher among patients who failed NIV (68.3±18.9 versus 48.8± 15.2, P < 0.001). In the subset of 47 patients who failed NIV requiring intubation, duration of NIV was 25.0 ± 58.8 h. Multivariate regression analysis yielded a model consisting of APACHE III score and body mass index as predictive variables for NIV failure (C-statistic = 0.809). Duration of NIV was not associated with worse clinical outcomes among patients who failed NIV. Conclusions NIV is successful in preventing invasive mechanical ventilation in majority of patients with acute respiratory failure due to COPD. Patients with worse clinical status at presentation are more likely to fail NIV and require mechanical ventilation. In the subgroup of patients who failed NIV, duration of NIV prior to intubation was not associated with poor clinical outcomes.

SummaryWaterbuck were darted with the new “Hypodart” fired from the crossbow, and with the “Cap‐Chur” gun.Eleven waterbuck were successfully immobilised with M.99 alone. The remaining 37 received M.99 in conjunction with an ataractic, acetylpromazine maleate. Hyoscine hydrobromide, a parasympatholytic drug, never formed part of the immobilising dose and was given to only five of the immobilised animals. Not only is this drug unnecessary; its use is a positive disadvantage and was responsible for the death of one waterbuck. Three other waterbuck died, two of these probably from heat stroke, a consequence of using acepromzine on a hot day. The remaining animal damaged a leg when trying to get up and was killed by lion five days later.This paper gives justification for combining M.99 and acepromazine in the approximate ratio of 1:1 for the immobilisation of this species, and suggests that the losses experienced by other workers through torticollis may well have been the result of the acepromazine.

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Table 1. (continued) A. Adenoma Detection a Predictors Odds Ratios 95% CI P-value (Intercept) 0.1 (0.08, 0.14) , 0.001 Withdrawal Time (minutes) 1.36 (1.32, 1.39) , 0.001 Gender [female] 0.59 (0.51, 0.68) , 0.001 Serrated Adenoma Detection c Predictors Odds Ratios 95% CI P-value (Intercept) 0.02 (0.02, 0.03) , 0.001 Withdrawal Time (minutes) 1.11 (1.09, 1.13) , 0.001 Gender [female] 1.07 (0.82, 1.39) 0.624 [0332] Figure 1. Indications for FIT testing in the inpatient and emergency setting

Case Summary: A 31-year-old female presented to a regional hospital at 27 weeks pregnant and was found to have COVID-19 ARDS. She underwent intubation and caesarian section for worsening hypoxia and non-reassuring fetal heart tones. Hypoxemia was refractory to proning requiring ECMO and transfer to a tertiary care center. Admission chest radiography showed a new right lower lobe cavitating lesion with computed tomography scan revealing a large multi-loculated cavity in the right lung and extensive bilateral ground-glass opacities. The patient was started on amphotericin and posaconazole, with final respiratory cultures growing Lichtheimia spp. Source control was discussed via possible open thoracostomy, but medical management alone was continued. Total ECMO support was 3 weeks. At the time of discharge to acute rehab, 1 month of amphotericin and posaconazole had been completed, with continuation of posaconazole. At last update, she had been discharged from rehab and was back home with her infant. Conclusion: Pulmonary mucormycosis, even in the non-ECLS population, carries a high mortality. Treatment in pulmonary disease with surgery improves mortality but is not always feasible. Salvage therapy with extended course antifungal medications may be an option for those not amendable