Baloch et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Objectives: This study describes three surges of COVID-19 hypoxemic respiratory failure and our experience with using iCPAP in patients with cardiovascular diseases at a tertiary cardiac care centre. Methodology: This observational study was conducted from March 23rd 2020 to May 31st 2021, at The National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan. This is an analysis of data from the PRICE Network Registry. Data was collected for all adult patients with cardiovascular diseases admitted with acute hypoxemic respiratory failure and a confirmed diagnosis of SARS CoV-2. Results: Among 362 patients with 'severe’ or 'critical’ COVID-19 were hospitalized; 163 (45%) in the 1st surge, 92 (25.4%) in the 2nd and 107 (29.6 %) in the 3rd surge. All-cause mortality was 118 (32.6%). iCPAP was used in 39% (141) patients, 19% (69) patients required oxygen only, 25.4% (92) were on BiPAP support and 16.6% (60) were intubated. ‘iCPAP failure’ occurred in 48/141 (34%) patients. iCPAP failure occurred in patients with higher APACHE II scores (16.3 ±5.7 v/s 21.3±6, p ≤0.001), lower ROX index on admission (5.0±2.2 vs. 10.4±5.4, p≤0.001), lesser degree of improvement in ROX index at 48 hours (Day 3 ROX 18.7±8.9 vs. 9.9±6.3, p≤0.001). Mortality rate on iCPAP was 44 (31.2%). Conclusion: COVID-19 outcomes in a resource-limited setting in patients having cardiovascular diseases, appear comparable to global reports. A modification of standard CPAP (iCPAP) appeared to be safe and effective. This modification of standard CPAP (iCPAP) identifies an option for resource-limited or resource-exhausted critical care units.

Background: We hypothesize that a change in lung ultrasound score (LUS) can assist in the early diagnosis of weaning-induced respiratory failure (RF). The objective of this study was to determine the utility of LUS in weaning patients with mitral regurgitation (MR) from mechanical ventilation (MV). Methods: This prospective observational study included patients with acute coronary syndrome (ACS) who required invasive MV after angiography/angioplasty. Echocardiography was performed and MR was recorded. When the patient was considered ready for extubation, a spontaneous breathing trial (SBT) was performed and pre- and post-SBT LUS was calculated. Patients who successfully passed the SBT were extubated and followed up for 48 hours for the signs of RF and outcomes. Results: We enrolled 215 patients, out of which MR occurred in 51(23.7%) patients. On post-SBT lung ultrasound, patients with MR were more likely to have B2 lines compared to those without MR; 15.7% vs. 3.7%; p=0.002 and mean LUS was significantly higher for patients with MR as compared to patients without MR; 2.75±3.21 vs. 1.37± 2.02; p<0.001. Post-extubation RF and mean CCU stay were significantly higher in MR patients, 49.0% (25) vs. 32.3% (53); p=0.030 and 3.53±1.54 days vs. 2.41±1.1 days; p<0.001 respectively. However, re-intubation and coronary care unit (CCU) mortality rate were not significantly different between patients with and without MR; 7.8% (4/51) vs. 3.7% (6/164); p=0.215, and 5.9% (3/51) vs. 3% (5/164); p=0.35 respectively. Conclusions: Bedside LU is a convenient tool to detect changes in cardiopulmonary interactions during weaning for patients with MR post-ACS.

Objective: To determine whether an educational program on personal protective measures can reduce anxiety and depression in Hospital workers exposed to COVID-19. Study Design: Quasi-experimental study. Place and Duration of Study: COVID Units & Emergency Room, from May to Jul 2020. Methodology: Educational tool based on World Health Organization and Pan American Health Organization guidelines including videos on Personal Protective Equipment usage was delivered to hospital staff assigned to areas with COVID-19 patients. Likert scale, Generalised Anxiety Disorder-7 score and Major Depression Inventory were used. Results: 100 hospital staff were included. About 40% doctors, 41% Nurses. None had preexisting anxiety or depression. 11% reported COVID-19, 46% reported quarantine, and 91% reported contact. About 93% stated insufficient knowledge of usage of personal protective equipment and 35% reported inadequate provision of personal protective equipment. Median score on the likert scale was 5 (IQR 4-7). Mean generalized anxiety disorder score was 6.48 ± 3.4, which improved to 4.65 ± 2.7 post session, p-value <0.001. 41% reported minimal, 34% mild, 24% moderate and 1% severe anxiety. Post session, 62% reported minimal Anxiety, 33% mild, 5% moderate and 0% severe anxiety. Mean major depression inventory score was 16.10 ± 7.05 which reduced to 13.58 ± 5.84, p-value <0.001. Pre-session 59% reported „no/doubtful depression‟, 40% mild, 1% moderate depresssion, while post-session 85% reported „no/doubtful‟, 15% mild and none had moderate/severe depression. Conclusion: We found an educational program that provided information on personal protective measures significantly reduced anxiety and depression in front-line workers during COVID-19 pandemic.

Background: The Rapid Shallow Breathing Index (RSBI) has been hypothesized to have discriminating power for categorizing patients at higher risk of post-extubation respiratory failure (RF). Hence aim of this study was to determine the predictive value of RSBI for post-extubation RF in patients after acute myocardial infarction (AMI). Methods: Consecutive, intubated patients admitted post-revascularization were included. RSBI and lung ultrasound score (LUS) were measured and post-extubation RF within 48 hours was recorded. Results: RF was observed in 36.3% (78/215) patients. For the prediction of RF, RSBI and LUS had area under the curve of 0.670 and 0.635, respectively. The sensitivity, specificity, negative predictive value, and positive predictive value of RSBI >50.5 were 75.6%, 54.7%, 79.8%, and 48.8% respectively, while, the accuracy measures for the combination of RSBI with LUS >1.5 were 44.9%, 84.7%, 73.0%, and 62.5% respectively. Conclusion: Combined RSBI and LUS measured during spontaneous breathing trial in patients after an AMI, have high predictive abilities for identifying post-extubation RF.