Severe COVID-19 pneumonia can be defined by low oxygen levels, respiratory distress, and lung infiltrates. It has two phenotypes - Type L has low lung recruitability while Type H is similar to classic ARDS. Pathogenesis involves cytokine storm and microvascular thrombosis. Treatment involves oxygen support with HFNC or NIV initially. For respiratory failure, low tidal volume ventilation is used along with prone positioning. Corticosteroids, remdesivir, tocilizumab and anticoagulants may provide benefit. Discharge requires symptom resolution and negative PCR test. Managing the different phenotypes and supporting oxygenation while preventing lung injury are keys to treatment.
This is an ARDS case study presentation done by a group of Respiratory care students in UOD:
Aziza AlAmri, Fay AlBuainain, Mashail AlRayes, Nora AlWohayeb, Salma Almakinzi .
The original case study:(http://www.researchgate.net/publication/50399037_Acute_Respiratory_Distress_SyndromeA_Case_Study)
This is an ARDS case study presentation done by a group of Respiratory care students in UOD:
Aziza AlAmri, Fay AlBuainain, Mashail AlRayes, Nora AlWohayeb, Salma Almakinzi .
The original case study:(http://www.researchgate.net/publication/50399037_Acute_Respiratory_Distress_SyndromeA_Case_Study)
Lung contusion is when, as a result of chest trauma, there is direct or indirect damage of the parenchyma of the lung that leads to oedema or alveolar haematoma and loss of physiological structure and function of the lung.
Acute respiratory distress syndrome (ARDS) is an acute, diffuse, inflammatory form of lung injury that is associated with a variety of etiologies.
Lung contusion is when, as a result of chest trauma, there is direct or indirect damage of the parenchyma of the lung that leads to oedema or alveolar haematoma and loss of physiological structure and function of the lung.
Acute respiratory distress syndrome (ARDS) is an acute, diffuse, inflammatory form of lung injury that is associated with a variety of etiologies.
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Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
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Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
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2 Case Reports of Gastric Ultrasound
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
2. INTRODUCTION
The ongoing outbreak of the coronavirus disease
2019 (covid-19) has posed immense challenges for the
research and medical communities.
3.
4. SEVERE
COVID
PNEUMONIA
Severe covid-19 pneumonia as defined by the National Institutes
of Health, referring to individuals with SARS-CoV-2 infection
confirmed by polymerase chain reaction (PCR) testing who have
SpO2 < 90% on room air at sea level
A ratio of arterial partial pressure of oxygen to fraction of
inspired oxygen (PaO2/FiO2) <300 mm Hg,
Respiratory frequency >30 breaths/min, or
Lung infiltrates >50%.
7. Pathogenesis
Clinical and serologic evidence points to high
levels of serum IL-6, IL-1β, and TNF-α
which are associated with clinical instability
Compared with classic ARDS, autopsy studies
also indicate higher thrombus burden in
pulmonary capillaries
A greater pathogenic role of thrombotic and
microangiopathic vasculopathy in covid-19
related ARDS
Clinical observation of lymphopenia may be
associated with worsening disease
8. Pathogenesis
contd
Several unique pathophysiological
processes are postulated to be at play for
CARDS, such as
Intravascular thrombosis caused by loss
of endothelial barrier,
Prominent loss of hypoxic pulmonary
vasoconstriction resulting from
endothelial dysfunction, and
Excessive blood flow to collapsed lung
tissue
12. RESPIRATORY
MANAGEMENT
Titration of oxygen therapy to
avoid hyperoxemia and hypoxemia
is strongly recommended for acute
hypoxemic respiratory failure.
A range of 90-96% oxygen
saturation is a reasonable target
13. The second goal of mechanical
ventilation in ARDS is to prevent
the constant opening and closing
of alveoli which may be injurious
to the lung(atelectrauma).
Positive end expiratory
pressure(PEEP) is titrated to keep
alveolar units open throughout the
respiratory cycle
14. PHENOTYPES OF COVID PNEUMONIA
Patients who had low elastance, low ventilation perfusion matching, low
recruitability and lung weight were named the “L type.”
May not require low tidal volume ventilation and attempts at recruitment
could bring harm
Should be placed on mechanical ventilation earlier to prevent spontaneous
high tidal volumes generated by the patients
15. • More consistent with classic ARDS (high
elastance, high ventilation/perfusion ratio, high
recruitability and lung weight) was referred to as
the “H type.”
• Treated like classic ARDS.
17. HIGH FLOW
NASAL
CANULA
HFNC oxygen therapy refers to the delivery of humidified
and heated oxygen at high flows,
Typically 20-60 L/min, which is titrated to a precise fraction
of inspired oxygen (FiO2).
Improved comfort by satisfying patient flow demand
Creates an oxygen reservoir in the upper airway thereby
reducing physiological dead space (reduced CO2
rebreathing), and
Provides a modest PEEP that could help recruit collapsed
alveoli with consequent reduction in work of breathing
18. ROX index (ratio of oxygen saturation by
pulse oximetry/FiO2 to respiratory rate) is
a bedside tool for predicting HFNC failure.
Patients with a ROX index ≥4.88 after 2, 6,
and 12 hours of treatment had low risk of
intubation,
Whereas a ROX index <3.85 at the same
time points was associated with a high risk
of failure.
19. NON INVASIVE
VENTILATION
Non-invasive ventilation (NIV) is delivered
through a face mask or a helmet that is
placed over the patient’s head
Application of NIV in the setting of acute
hypoxemic respiratory failure excluding
COPD and cardiogenic pulmonary edema
has been controversial
NIV was associated with higher intensive
care unit mortality among ARDS patients
with PaO2/FiO2 <150 mm Hg on
presentation
20. After 1 hour of initiation of NIV, expired tidal volumes >9 mL/kg of predicted
body weight and PaO2/FiO2 ≤200 mmHg independently predicted NIV failure
In the absence of concomitant COPD or pulmonary edema, the benefits of NIV
are uncertain in the management of CARDS
HFNC is the initial non-invasive support in severely hypoxemic patients with
CARDS.
21. Invasive
mechanical
ventilation
( IMV)
Endotracheal intubation should be done in
patients
Requiring vasopressor support or clinical
signs of shock
With altered mentation
Failure of HFNC or NIV
Neuromuscular blockade should be done early
to prevent patient ventilator dyssynchrony
22. Once intubated and deeply sedated, the Type L patients, if hypercapnic, can be ventilated
with volumes greater than 6 ml/kg (up to 8-9 ml/kg).
Prone positioning should be used only as a rescue maneuver
The PEEP should be reduced to 8-10 cmH2O, given that the recruitability is low and the
risk of hemodynamic failure increases at higher levels.
An early intubation may avert the transition to Type H phenotype.
23. The type H phenotype should be managed as classical ARDS with
Low tidal volume and High PEEP as per ARDSnet protocol.
OXYGENATION GOAL: PaO2 55-80 mmHg or SpO2 88-95%
PLATEAU PRESSURE GOAL: ≤ 30 cm H2O
pH GOAL: 7.30-7.45
24.
25.
26. • Time spent proning
should be ideally 16
hrs/day
27. V-V ECMO may be considered in patients with
refractory hypoxemia on invasive mechanical
ventilation, who do not respond to other
adjuvant therapies.
29. CORTICOSTEROIDS
Corticosteroids are the only therapeutic agents that have demonstrated a clear
mortality benefit in the treatment of severe covid-19.
While the evidence is most robust for dexamethasone , no evidence exists at
present to believe one steroid is superior to the other
However, recent evidence suggests that methyl prednisolone has better lung
penetration , making it a better choice
30. Inj Dexamethasone 6mg iv od, the dose can be escalated to 12 to 24 mg/day if
there is clinical worsening and patient is non diabetic.
Inj methyl prednisolone 1 – 2 mg/kg body weight
Should be initiated early in the pulmonary phase to counter immune dysregulation
Ideal time day 8 of symptoms when virus has a low tendency to replicate and
inflammatory response is persistent
However it must be emphasized that steroids should not be used in mild
asymptomatic patients or early on in the course of covid 19 if not indicated.
31. Anticoagulation
All moderate and severe symptomatic patients with
Age >18 yrs with no bleeding manifestations or thrombocytopenia
Spo2 <94%
RR>24/min
Pulse rate> 110/min
Evidence of pneumonia on CXR or CT
Should receive anticoagulation
32. Dosage
Unless contraindicated, FULL anticoagulation (on
admission to the ICU) with enoxaparin, i.e., 1 mg kg s/c
q 12 hourly (dose adjust with Cr Cl < 30mls/min) in
those patients with a D-dimer > 3-5 X ULN and those
with a rising D-dimer.
Heparin is suggested with CrCl < 15 ml/min.
In all other ICU patients medium dose anticoagulation;
enoxaparin 0.5 mg/kg q 12 hourly
33. REMDESIVIR
Remdesivir is an antiviral drug that acts by inhibiting viral RNA transcription
Consider Remdesivir in Patients who are within 10 days of symptom onset and are
RT-PCR positive for SARS-CoV-2, >18 yrs. Old,
Pneumonia confirmed by chest imaging,
Oxygen saturation of 94% or lower on room air, or
A ratio of arterial oxygen partial pressure to fractional inspired oxygen (PF Ratio) of 300 mm Hg or less
34. Avoid Remdesivir if
known severe renal impairment (estimated
glomerular filtration rate estimated GFR
<30ml/min per 1.73 m2)
alanine aminotransferase or aspartate
aminotransferase more than five times the
upper limit of normal;
hepatic cirrhosis;
35. Dose: Inj Remdesivir 200 mg IV on day 1.
Then, 100 mg IV daily for next 4 days (can be extended up to 10 days in case of
progressive disease)
Only reduces days of hospitalization without significant improvement in mortality
rates
36. TOCILIZUMAB
Tocilizumab is a monoclonal antibody that blocks IL-6 receptors
May be considered within 24 to 48 hours of progression to severe disease when all of the below criteria are met
Severe disease
Significantly raised inflammatory markers (CRP &/or IL-6)
Not improving despite use of steroids
No active bacterial/ fungal infections
37. • The recommended dose is 4 to 8mg/kg (with a
maximum dose of 800 mg at one time) in 100
ml NS over 1 hour (dose can be repeated once
after 12 to 24 hours depending on clinical
response
38. • Itolizumab -Very small study -30 patient study.
• Dose-1.6 mg/kg in 250 ML NS over 6 hours.
(- 25 mg in the first hour and the remaining
dose over 5 hours)
• If well tolerated and improvement in patient
observed, clinician has the discretion to repeat
a dose (after 1 week for itolizumab or after 12
hours for tocilizumab only after expert
opinion)
• Informed consent is mandatory.
• Bevacizumab and Sarlijumab are other options
39. CYTOKINE STORM
Unremitting fever
Cytopenia, Hyper ferritinemia
If the patient in the second week having SOB (even with previous normal CT),
rising CRP above 50, CT worsening, fever onset in the second week, etc. points
towards impending cytokine storm.
40. • Daily CRP monitoring and steroid dose adjustments are crucial here
• Methylprednisolone pulse 250 mg to 1000 mg per day for 3 days
• Tocilizumab
42. Tofacitinib/baricitinib
Start after 48 hours of initiation of steroid therapy,
where CRP fails to decrease by 50% from baseline, or
signs of clinical deterioration like persistence of fever or hypoxemia are noted on close follow
up.
43. Dosage
• Tab Baricitinib 4 mg once daily for 10 days
(*Renal modification - 2mg once daily if GFR
is between 30 to 60ml/min, avoid if GFR <
30 ml/min)
• Tablet Tofacitinib 10 mg twice daily for 10
days (* avoid if GFR < 30 ml/min)
44. Bevacizumab - (Avastin 400mg
single dose vial) –
It is an anti VEGF recombinant
humanized monoclonal antibody
It is being tried with severe Covid-
19,
Bevacizumab 7.5mg/kg body weight
+ 0.9% NaCl 100ml, intravenous drip
45. 2 Deoxy Glucose
The 2 DG drug, like glucose, spreads through the body, reaches the virus-infected cells and prevents virus
growth by stopping viral synthesis and destroys the virus energy production.
The drug also works on virus infection spread into lungs which help us to decrease patient’s dependability
on oxygen."
Has been developed in powder form and is ingested orally by dissolving it in water.
Phase III trial on (40 patients) report led to DCGI approval - 8th May 2021
46. Dose and Regimen: 2-DG: 45 mg/kg body weight AM + 45 mg/kg body
weight PM, twice daily for not more than 10 days.
DO NOT USE the reconstituted dose solution for further dosing of the
patient. Each dose of 2-DG should be prepared using a fresh sachet.
Monitoring of QTc interval on ECG, Blood glucose levels are essential.
47. Colchicine
Colchicine use: Except few studies, most of studies did
not find any significant improvement.
It is now being used in mild, moderate and severe cases
despite any recommendations by standard guidelines.
It is considered if fever persists despite paracetamol
Loading dose: 1.5 mg followed by 0.5 mg of colchicine 60
minutes later if no adverse gastrointestinal effects
Maintenance dosage: 0.5 mg BD until discharge or a
maximum of 21 days (reduce to OD if body weight <60 kg)
Contraindicated if eGFR<30mL/min/1.73m2
48. Discharge criteria
Severe covid pneumonia patients should be
discharged only after
• Clinical resolution of symptoms
• Patient tested negative by RTPCR once ( after resolution
of symptoms)
49. Conclusion
For people hospitalized with covid-19, 15-30% will go on to develop covid-19 associated
acute respiratory distress syndrome (CARDS).
Patients who died of severe SARS CoV-2 infection reveal presence of diffuse alveolar
damage consistent with ARDS but with a higher thrombus burden in pulmonary capillaries.
When used appropriately, high flow nasal cannula (HFNC) may allow CARDS patients to
avoid intubation
During invasive mechanical ventilation, low tidal volume ventilation and positive end
expiratory pressure (PEEP) titration to optimize oxygenation are recommended.
50. Corticosteroid treatment improves mortality for the
treatment of severe and critical covid-19
Remdesivir may have modest benefit in time to recovery in
patients with severe disease but no significant benefit in
mortality or other clinical outcomes