Severe COVID 19 In Children and Young Adults

Here is a look at pediatric and young adult cases of COVID 19 from Washington, DC.  Note the higher percentage of cases in infants and older teenagers, in addition to asthma as the most common comorbidity.  Other chronic conditions more likely to be associated with ICU admission.

Children and young adults in all age groups can develop severe illness after SARS-CoV-2 infection, but the oldest and youngest appear most likely to be hospitalized and possibly critically ill, based on data from a retrospective cohort study of 177 pediatric patients seen at a single center.

“Although children and young adults clearly are susceptible to SARS-CoV-2 infection, attention has focused primarily on their potential role in influencing spread and community transmission rather than the potential severity of infection in children and young adults themselves,” wrote Roberta L. DeBiasi, MD, chief of the division of pediatric infectious diseases at Children’s National Hospital, Washington, and colleagues.

In a study published in the Journal of Pediatrics, the researchers reviewed data from 44 hospitalized and 133 non-hospitalized children and young adults infected with SARS-CoV-2. Of the 44 hospitalized patients, 35 were noncritically ill and 9 were critically ill. The study population ranged from 0.1-34 years of age, with a median of 10 years, which was similar between hospitalized and nonhospitalized patients. However, the median age of critically ill patients was significantly higher, compared with noncritically ill patients (17 years vs. 4 years). All age groups were represented in all cohorts. “However, we noted a bimodal distribution of patients less than 1 year of age and patients greater than 15 years of age representing the largest proportion of patients within the SARS-CoV-2–infected hospitalized and critically ill cohorts,” the researchers noted. Children less than 1 year and adolescents/young adults over 15 years each represented 32% of the 44 hospitalized patients.

Read article here.

What About COVID 19 and Asthma?

As data continues to stream in regarding possible risk factors for COVID 19, one missing population besides children in general seems to be .... asthma.  COVID 19 and other SARS type viruses are known to enter lung cells (type 2 pneumocytes) through a cell surface receptor known as ACE2.  According to this study, there appears to be reduced cell surface expression in people with allergic diseases.  This is of course, not enough to clear children with asthma from significant risk, but warrants investigation.  Incidentally, nonatopic individuals did NOT have reduced ACE2 expression.

  

Viral respiratory infections are the most common trigger of severe asthma exacerbations in children and adults. Unexpectedly, large epidemiological studies of the COVID-19 pandemic in China did not identify asthma as a risk factor of severe COVID19 related illnesses.(2) Here, we report that respiratory allergy and controlled allergen exposures are each associated with significant reductions in ACE2 expression. ACE2 expression was lowest in those with both high levels of allergic sensitization and asthma. Importantly, non-atopic asthma was not associated with reduced ACE2 expression. Given that ACE2 serves as the receptor for SARS-CoV-2, our findings suggest a potential mechanism of reduced COVID-19 severity in patients with respiratory allergies. However, it is likely that additional factors beyond ACE2 expression modulate the response to COVID-19 in allergic individuals, and elucidation of these factors may also provide important insights into COVID-19 disease pathogenesis. Strengths of our study include carefully phenotyped cohorts of children and adults. Further, the allergen challenge studies included both upper and lower airway samples, with each demonstrating a consistent impact on ACE2 expression. Limitations include lack of clinical information to directly link ACE2 expression to SARS-CoV-2 infection and illness severity in our study populations. In addition, we do not have data on the ACE2 protein levels to confirm the gene expression data, though previous work suggests a direct association between ACE2 mRNA levels and ACE2 protein levels in the lung.(8)

 Read article here.

Telemedicine , The Right Way

An emergency declaration from the State of Texas has made it easier for physicians to take care of patients during a time where routine clinic visits pose substantial risk of infection spread.  A host of well marketed telemedicine organizations, some promoted by your insurance company have swooped in, attempting to fill the gap.  They are missing one crucial element - YOUR doctor.  

Adapted from the Texas Medical Association, here are answers to common questions on the patient side:

1. What technology do I need for telemedicine?

Texas law says that  telemedicine services can occur through:

• Real-time audiovisual interaction between you and the doctor (for example, a simple digital camera on a laptop or a desktop with secure broadband internet);
• For many, a "Facetime like" interaction can take place with your doctor using a simple downloadable app on your smart phone
• A telephone only consultation for new or follow-up patients may be appropriate in some circumstances

2. Are initial in-person visits mandatory?

No.  For some medical conditions, the standard of care has always been in office visits.  In office, we have the opportunity for a more comprehensive exam and additional testing to evaluate lung disease.  However, given the risk of infection spread in offices, emergency rooms, and urgent cares, even initial visits can take place through telemedicine.

3. Can the patient be at home for a telemedicine visit?

In short, yes. The new state law removed the requirement for a clinical place of service, as long as the standard of care is uncompromised.  Keeping you at home improves the chance of flattening the curve while still providing you access to a board certified medical specialist.

 See TMA information here.

Schedule a telemedicine visit here.

One Ventilator and Multiple Patients?

Economy does not equal quality.

An anticipated shortage of hospital ventilators has led some organizations to look at potential innovative ways to maximum the use of available hospital equipment.  Undoubtedly, these are trying times for critical care docs.

However, numerous organizations have highlighted major potential risks associated with these measures, including this list provided by the Society for Critical Care Medicine:

• Volumes would go to the most compliant lung segments.
• Positive end-expiratory pressure, which is of critical importance in these patients, would be impossible to manage.
• Monitoring patients and measuring pulmonary mechanics would be challenging, if not impossible.
• Alarm monitoring and management would not be feasible.
• Individualized management for clinical improvement or deterioration would be impossible.
• In the case of a cardiac arrest, ventilation to all patients would need to be stopped to allow the change to bag ventilation without aerosolizing the virus and exposing healthcare workers. This circumstance also would alter breath delivery dynamics to the other patients.
• The added circuit volume defeats the operational self-test (the test fails). The clinician would be required to operate the ventilator without a successful test, adding to errors in the measurement.
• Additional external monitoring would be required. The ventilator monitors the average pressures and volumes.
• Even if all patients connected to a single ventilator have the same clinical features at initiation, they could deteriorate and recover at different rates, and distribution of gas to each patient would be unequal and unmonitored. The sickest patient would get the smallest tidal volume and the improving patient would get the largest tidal volume.
• The greatest risks occur with sudden deterioration of a single patient (e.g., pneumothorax, kinked endotracheal tube), with the balance of ventilation distributed to the other patients.
• Finally, there are ethical issues. If the ventilator can be lifesaving for a single individual, using it on more than one patient at a time risks life-threatening treatment failure for all of them.

See article linked here.

Clinic Update During COVID 19 Pandemic

We have stepped up to protect our patients, our staff and the community during the coronavirus (COVID-19) pandemic.  Houston Specialty Clinic has CHANGED almost all clinic office visits to telemedicine, effective immediately due to the urgent need for all of us to reduce the risk of infection. 

   We will still be OPEN for the following patient visit types: 

• Patients requiring regular injections for asthma management  
• Urgent visits

Fortunately, the State of Texas has issued an emergency declaration waiving many restrictions on telemedicine.  Therefore, our providers are available during office hours for telemedicine consultation for both new AND existing patients. 

Please see the following links for useful resources infection prevention: 

https://www.cdc.gov/coronavirus/2019-nCoV/index.html 

https://www.thoracic.org/patients/patient-resources/resources/coronavirus-patient.pdf 

CPAP , A Medical Aesthetic?

 

Coronary artery disease, cerebrovascular events, cardiac arrhythmias... What about fine lines and wrinkles?  Looks like we have the whole sleep apnea marketing approach wrong.

Patients With OSA Are Perceived as Younger Following Treatment With CPAP.

Yagihara F1, Lorenzi-Filho G2, Santos-Silva R3.

Abstract

BACKGROUND: 

The aim of this study was to compare the effects of CPAP treatment and placebo intervention on the facial appearance of patients with OSA.

METHODS: 

Patients with severe OSA were randomized to receive either CPAP treatment or nasal dilator (placebo) intervention for 1 month. The sequence was interposed by 15 days of washout with no treatment. Patients were evaluated by using questionnaires, polysomnography, and facial photographs at baseline and at the end of both interventions. In an electronic survey, the photographs were presented in a randomized order to 704 observers who rated the perceived age, health, attractiveness, and tiredness of the patients. Observers were unaware of the patients' conditions.

RESULTS: 

Thirty patients (age, 46 ± 9 years; 21 men; apnea-hypopnea index, 61.8 ± 26.2) were evaluated. During each intervention period, patients used CPAP 6.0 ± 1.7 h per night on 94% of the nights and the placebo intervention on 98% of the nights. After CPAP treatment, patients were rated younger (47.9 ± 3.5 years) than they appeared at baseline (53.9 ± 4.0 years) and following the placebo treatment (49.8 ± 3.7 years) (P < .001). Linear regression analysis identified that CPAP adherence, total sleep time, and percentage of total sleep time with oxyhemoglobin saturation < 90% were predictors of a decreased age rating following CPAP treatment.

CONCLUSIONS: 

Patients with severe OSA had a younger appearance following 1 month of CPAP treatment. This benefit can serve as an additional source of motivation for patients with OSA to comply with CPAP treatment and may facilitate OSA management.

Read abstract here.

Good Sleep Hygiene in Adolescents With Asthma Linked to Improved Attention

A real world comparison of this study seems to fit what we know.  Child and adolescent sleep patterns are woefully bad.  It's no surprise then that attentiveness and other quality of life factors can improve immensely when we "clean up" our sleep habits. Dr. Susarla

Adolescents with asthma who practice good sleep hygiene may experience improvements in sleep and attention span, better quality of life in school, and lower rates of dysfunction during the daytime, according to a study published in the Journal of Asthma. 

This study included 41 participants with persistent asthma (mean age, 14.83±1.28 years; 51.2% male adolescents). Measures included demographic information (sex, age, race/ethnicity, education, caregiver marital status, and family income), information on asthma, sleep hygiene via the adolescent sleep hygiene scale (ASHS), quality of sleep via the Adolescent Sleep Wake Scale (ASWS), quality of life via the Pediatric Quality of Life Index (PedsQL), and attention span via the psychomotor vigilance task (PVT).

To investigate associations among variables related to asthma, as well as between demographic features and dependent variables, Pearson product-moment correlations were used. The predictive power of sleep hygiene on sleep quality, quality of life (school-related or otherwise), and attention span was calculated using linear regressions. Because the sample size was smaller than the recommended 73 participants, effect sizes were used to interpret results. Cohen's f² effect sizes were categorized as large (0.35), medium (0.15), or small (0.02).

Read article here.