The initiation of mechanical ventilation in the setting of profound metabolic acidosis can be a particular challenge in the transport environment. The classic teaching is that patients with severe acidemia should not be intubated, if possible, because they are often able to better maintain their own compensatory minute ventilation compared with clinician management with the mechanical ventilator. In this case, a patient had profound metformin-associated lactic acidosis with a pH of 6.51 and required intubation for deteriorating mental status with an inability to protect her airway. Maintaining adequate minute ventilation can be directly in conflict with the evidence-based approach of low tidal volume ventilation for all patients. When patients have profound metabolic acidosis without evidence of acute respiratory distress syndrome, increasing the tidal volume slightly to allow for more efficient respiration can be an effective strategy to maintain acid-base status.

Neuromuscular diseases (NMD) are indications for long-term home mechanical ventilation (HMV). Noninvasive ventilation is preferred to HMV. However, invasive mechanical ventilation (IMV) is more appropriate if the patient has uncontrollable airway secretions, the possibility of aspiration, failure to wean, or severe weakness of the respiratory muscles. But if the patient undergoes multiple intubation or tracheotomy, it will be more painful and unbearable. For some end-stage NMD patients who need long-term tracheostomy, HMV using noninvasive ventilator via tracheotomy may be a conservative care option. An 87-year-old male with myasthenia gravis underwent repeated IMV and failed to wean. We used a noninvasive ventilator connected to a tracheostomy tube for mechanical ventilation. One and a half years later, the patient weaned successfully. However, there was a lack of evidence-based medicine and standardized guidelines in such areas as indications, contraindications, and ventilator parameter setting. For the systematic review, a literature search was performed in PubMed, Embase, Cochrane, and CNKI (China National Knowledge Infrastructure) to identify reported cases of using noninvasive ventilator in patients undergoing tracheostomy. A total of 72 cases who performed ventilation via tracheotomy tube were identified. The main diagnoses included NMD, chronic obstructive pulmonary disease (COPD), pneumonia, and congenital central hypoventilation syndrome (CCHS). Indications included dysfunctional ventilatory weaning response (DVWR), apnea and cyanosis. Clinical outcome was as follows: 33 patients were weaned, and 24 patients underwent HMV. A total of 288 cases who performed ventilation through the mask after blocking the tracheostomy tube were identified. The primary diagnoses included COPD, NMD, thoracic restriction, spinal cord injured (SCI), and CCHS. Indications included DVWR, apnea and cyanosis, routine weaning. Clinical outcome was as follows: successful tracheostomy tube decannulations were performed in 254 patients and failed in 33 patients. So, in patients requiring HMV, selection of noninvasive ventilation (NIV) or IMV should be individualized. Tracheostomy preservation should be considered in some patients with advanced NMD if there is respiratory muscle weakness or the risk of aspiration. And attempts can be made to use a noninvasive ventilator because of its advantages of portability, ease of operation, and low cost. Noninvasive ventilators can be used in patients with tracheotomy, whether direct connection tracheotomy or mask ventilation after the tube is capped, especially in weaning and tracheostomy tube decannulation.

This study aimed to assess the factors associated with medical device incidents.
In this mixed-methods study, we used incident reporting data from the Japan Council for Quality Health Care. Of the 232 medical device-related reports that were downloaded, 34 (14.7%) were ventilator-associated incidents. Data related to patients, situations, and incidents were collected and coded.
The frequencies of ventilator-associated accidents were 20 (58.8%) during the daytime and 14 (41.2%) during the night/early morning. Ventilator-associated accidents occurred more frequently in the hospital room (n = 22 [64.7%]) than in the intensive care unit (n = 4 [11.8%]). Problems with ventilators occurred in only 4 cases (11.8%); in most cases, medical professionals experienced difficulty with the use or management of ventilators (n = 30 [88.2%]), and 50% of them were due to misuse/misapplication of ventilators (n = 17 [50.0%]). Ventilator-associated accidents were caused by an entanglement of complex factors-hardware, software, environment, liveware, and liveware-liveware interaction. Communication and alarm-related errors were reported to be related, as were intuitiveness or complicated specifications of the device.
Our study revealed that ventilator-associated accidents were caused by an entanglement of complex factors and were related to inadequate communication among caregivers and families. Moreover, alarms were overlooked owing to inattentiveness. Mistakes were generally caused by a lack of experience, insufficient training, or outright negligence. To reduce the occurrence of ventilator-associated accidents, hospital administrators should develop protocols for employment of new devices. Medical devices should be developed from the perspective of human engineering, which could be one of the systems approaches.

Rehabilitation of patients with high cervical spinal cord injury (CSCI) to improve activities of daily living (ADL) is challenging due to severe paralysis. In addition, pediatric patients with CSCI are rare, and literature describing ADL changes as the patient grows are limited. In this case report, we present the long-term change in ADL over time in a girl with severe high CSCI from an injury during infancy.
A 2 years and 6 months old girl, who was injured in a traffic accident, was diagnosed with C3 CSCI, resulting in complete quadriplegia and respiratory paralysis below C3. Thus, she was managed with a ventilator. Rehabilitation for quadriplegia, respiratory dysfunction, and autonomic neuropathy was started on the fifth day after the injury while she was in the intensive care unit. Six months after the injury, the patient was transferred to a hospital. Thereafter, she was discharged with nursing and care guidance provided to her family and environmental changes at home. Afterwards, she continued to acquire skills through writing training using a mouse stick, computer operation training, and electric wheelchair operation training, which enabled her to improve her ADL despite her severe disability. In terms of education, she was able to go through a regular elementary school, a regular junior high school, and then to a senior high school of a support school.
We believe that training that utilizes current technology and changes in the environment that are appropriate for daily life are important for improving the ADL of children with severe CSCI.

An 8-year-old boy recently sustained a cerebellar arteriovenous malformation rupture, and subsequently suffered from severe neurological injury and became ventilator-dependent through a tracheostomy. During a routine clinic visit, the parents reported that a loose baby tooth had fallen out and disappeared 7 days earlier. The physical examination was unremarkable, but a chest X-ray demonstrated a foreign body in the left lung and secondary atelectasis. A rigid bronchoscopy extracted what turned out to be a tooth from the left lower lobe bronchus, with no associated sequelae. Aspiration of a tooth is rare, and it is mostly seen in children and elderly patients following trauma, endotracheal intubation, and dental procedures. Only a few previous studies emphasized the increased risk of foreign body aspiration among neurological impaired children. This unique report describes a child in his physiological exfoliation period, which is characterized by the spontaneous shedding of 20 teeth over the course of several years. In severely neurologically impaired children, this period carries a risk of aspiration of teeth and secondary pulmonary damage. Therefore, treating physicians and caregivers must be aware of this risk, and routine dental check-ups are advised in a neurological impaired child during this period.

BACKGROUND: Neuromuscular pathologies must be considered when caring for patients with persistent or progressive respiratory failure. Pertinent disease states may involve skeletal muscles of respiration or associated neurologic structures including motor neurons, peripheral neurons and the neuromuscular junction. Diagnosis may require pulmonary function testing, neurophysiologic studies, imaging, and/or muscle biopsy.
METHODS: A 68-year-old male was transferred to our intensive care unit (ICU) for management of ventilator dependent respiratory failure. Upon further historical review, he described gradually worsening gait instability and muscle weakness, which was previously attributed to vascular Parkinsonism in the setting of known cerebrovascular disease. Upon arrival to our hospital, he was found to have elevated muscle specific enzymes, prompting evaluation for neuromuscular causes of respiratory failure. He was also found to have elevated HMG-CoA Reductase (HMGCR) antibodies. Ultimately, a right quadriceps muscle biopsy was performed and electron microscopy identified nemaline bodies within skeletal myofibers. Given the clinical course and other histopathologic findings, he was diagnosed with Sporadic late-onset nemaline myopathy (SLONM).
CONCLUSIONS: The diagnosis of neuromuscular disease in patients with ventilator dependent respiratory failure is challenging. A detailed history of a patient\'s clinical course prior to hospitalization is key and may raise suspicion for underlying neuromuscular pathology. Further evaluation in non-critically ill patients may include pulmonary function, electromyography and confirmatory muscle biopsy. Sporadic late onset nemaline myopathy remains a rare disease entity which rarely presents with respiratory failure and lacks effective treatment.

We present here the case of a ventilator-dependent 76-year-old man with C3 complete spinal cord injury (SCI) who presented with recurrent left lung atelectasis managed with manual hyperinflation (MH). Atelectasis was primarily assessed with chest X-ray (CXR). Additional monitoring included blood gas analysis, serum procalcitonin, and the Modified Borg Dyspnea Scale (MBS), as an objective measure of reported dyspnea. We found that MH successfully reversed the radiographic appearance of atelectasis after the first treatment and maintained this effect for the duration of the 2-week intervention period as well as at 2 weeks of follow-up post-intervention. Furthermore, MH decreased the patient\'s oxygen requirements and was associated with a decrease in serum procalcitonin. Clinically, the patient reported reduced subjective dyspnea post-MH, which was reflected as an improvement on the MBS. We conclude that MH may represent a therapeutic modality for consideration in the routine management of recurrent atelectasis in mechanically ventilated patients.

Pneumothoraces are not an uncommon finding in the newborn period. Recurrent pneumothoraces can be associated with complications of prematurity or use of ventilators but can be seen in rapidly progressive cystic lung disease. We report a case of recurrent pneumothoraces in an infant with the rapidly progressive cystic disease in the setting of an absent right pulmonary artery. The patient ultimately underwent pneumonectomy for definitive management of the recurrent unilateral pneumothoraces.

BACKGROUND: The spectrum of clinical manifestations and differential diagnosis associated with coronavirus disease 2019 is broad, ranging from fever and cutaneous eruptions to respiratory distress or even neurological disorders. Coexisting multipathogen infections significantly increase the complexity of the proper diagnostic and therapeutic approach and correlate with the rate of intensive care unit admissions and in-hospital mortality.
METHODS: We present a case of multipathogen respiratory infection with severe acute respiratory syndrome coronavirus 2, varicella zoster virus, and polymicrobial tracheobronchitis in a 48-year-old Caucasian male hospitalized after traumatic brain injury. The patient tested positive for severe acute respiratory syndrome coronavirus 2 infection upon admission. During his stay in the intensive care unit, the patient developed a vesicular exanthema along with respiratory failure and signs of septic shock.
CONCLUSIONS: This case of an adult presenting with severe acute respiratory syndrome coronavirus 2 infection and simultaneous primary varicella zoster virus infection illustrates the importance of considering coinfections in patients with coronavirus disease 2019 with unusual clinical manifestations.

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a valuable treatment option for chest trauma individuals and some patients required surgery. A 35-year-old female patient with severe chest trauma was admitted to Affiliated Hospital of Zunyi Medical University on February 27, 2020. The patient was hospitalized with chest pain and dyspnea due to fall from a height. Emergency chest CT revealed a right fluid pneumothorax (60% of right lung compression), left hemothorax, little pericardial effusion, and multiple emphysemas in the lower neck, chest, back and mediastinum. Invasive ventilator was difficult to maintain oxygen saturation. After evaluation, the VV-ECMO was established, then, she received a thoracotomy. There was a 1.2 cm trachea rupture observed during operation, and the trachea was repaired. The operation lasted 4 hours with the continuous support of VV-ECMO. When the patient\'s haemodynamics and oxygenation was stable, ECMO was removed. Sixteen days later, the patient\'s chest CT showed that, the chest wall subcutaneous emphysema was reduced, and the exudative lesions of both lungs were absorbed, indicating that the patient was treated effectively and reached the discharge standard with no complication. During the treatment of this patient, VV-ECMO was applied rapidly and lasted for a short period, which provided the patient with the opportunity of emergency operation and finally the patient was fully recovered. VV-ECMO can provide support for patients with severe trauma and refractory hypoxemia.