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Dipasri Bhattacharya,1 Antonio M Esquinas,2 Mohanchandra Mandal3 1Department of Anaesthesiology, Pain Medicine and Critical Care, R.G.Kar Medical College & Hospital, Kolkata, West Bengal, India; 2Critical Care Specialist and Staff Physician, Intensive Care Unit, Hospital Morales, Murcia, Spain; 3Department of Anaesthesiology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, IndiaCorrespondence: Mohanchandra Mandal, Department of Anaesthesiology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India, Email drmcmandal@gmail.com

Introduction and case report: We described a case of primary spontaneous partial pneumothorax in a middle-aged man with COVID-19 pneumonia who presented with fever, loss of appetite, and malaise. Laboratory results revealed higher levels of inflammatory markers, as well as sterile urine and blood cultures. On admission, a chest X-ray revealed bilateral patchy consolidations in the lung parenchyma, as well as a left-sided partial pneumothorax. Throughout his hospitalization, the patient was closely examined by a thoracic surgeon, and a chest X-ray was taken on multiple occasions. There was spontaneous resorption of air from the pleural space. Conclusion: Pneumothorax is a rare but serious complication of the COVID-19 infection that has recently been documented in patients with no comorbidities, requiring various types of ventilatory support. The precise mechanism of primary spontaneous pneumothorax in COVID-19 infection is unknown, but it will undoubtedly pose a challenge to future researchers.

Jaber S Alqahtani,1,2 Renata G Mendes,3 Abdulelah Aldhahir,1,4 Daniel Rowley,5 Mohammed D AlAhmari,2,6 George Ntoumenopoulos,7 Saeed M Alghamdi,8,9 Jithin K Sreedharan,2 Yousef S Aldabayan,10 Tope Oyelade,11 Ahmed Alrajeh,10 Carlo Olivieri,12 Maher AlQuaimi,13 Jerome Sullivan,14 Mohammed A Almeshari,15 Antonio Esquinas16 1UCL Respiratory, University College London, London, UK; 2Department of Respiratory Care, Prince Sultan Military College of Health Sciences, Dammam, Saudi Arabia; 3Department of Physical Therapy, Cardiopulmonary Physiotherapy Laboratory, Federal University of São Carlos, São Paulo, Brazil; 4Respiratory Care Department, Faculty of Applied Medical Sciences, Jazan University, Jazan, Saudi Arabia; 5Pulmonary Diagnostics & Respiratory Therapy Services, University of Virginia Medical Center, Charlottesville, VA, USA; 6Dammam Health Network, Dammam, Saudi Arabia; 7Consultant Physiotherapist, Physiotherapy Department St Vincent’s Hospital Sydney, Sydney, NSW, Australia; 8National Heart and Lung Institute, Imperial College London, London, UK; 9Faculty of Applied Medical Sciences, Umm Al-Qura University, Makkah, Saudi Arabia; 10Respiratory Care, King Faisal University, Al-Ahsa, Saudi Arabia; 11UCL Institute for Liver and Digestive Health, London, UK; 12Emergency Department, Ospedale Sant’Andrea, Vercelli 13100, Italy; 13Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia; 14President, International Council for Respiratory Care, Professor Emeritus & Respiratory Care Program Director, The University of Toledo, Toledo, OH, USA; 15Rehabilitation Health Sciences Department, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia; 16Director International NIV School, Intensive Care Unit, Hospital Morales Meseguer, Murcia, SpainCorrespondence: Jaber S AlqahtaniUCL Respiratory, University College London, Rowland Hill Street, London NW3 2PF, UKEmail Alqahtani-Jaber@hotmail.comBackground: As the global outbreak of COVID-19 continues to ravage the world, it is important to understand how frontline clinicians manage ventilatory support and the various limiting factors.Methods: An online survey composed of 32 questions was developed and validated by an international expert panel.Results: Overall, 502 respondents from 40 countries across six continents completed the survey. The mean number (±SD) of ICU beds was 64 ± 84. The most popular initial diagnostic tools used for treatment initiation were arterial blood gas (48%) and clinical presentation (37.5%), while the national COVID-19 guidelines were the most used (61.2%). High flow nasal cannula (HFNC) (53.8%), non-invasive ventilation (NIV) (47%), and invasive mechanical ventilation (IMV) (92%) were mostly used for mild, moderate, and severe COVID-19 cases, respectively. However, only 38.8%, 56.6% and 82.9% of the respondents had standard protocols for HFNC, NIV, and IMV, respectively. The most frequently used modes of IMV and NIV were volume control (VC) (36.1%) and continuous positive airway pressure/pressure support (CPAP/PS) (40.6%). About 54% of the respondents did not adhere to the recommended, regular ventilator check interval. The majority of the respondents (85.7%) used proning with IMV, with 48.4% using it for 12– 16 hours, and 46.2% had tried awake proning in combination with HFNC or NIV. Increased staff workload (45.02%), lack of trained staff (44.22%) and shortage of personal protective equipment (PPE) (42.63%) were the main barriers to COVID-19 management.Conclusion: Our results show that general clinical practices involving ventilatory support were highly heterogeneous, with limited use of standard protocols and most frontline clinicians depending on isolated and varied management guidelines. We found increased staff workload, lack of trained staff and shortage of PPE to be the main limiting factors affecting global COVID-19 ventilatory support management.Keywords: COVID-19, ventilation, respiratory, clinical management, proning, mechanical ventilation, NIV, HFNC

Bshayer Ramadan Alhamad,1,2 Antonio M Esquinas3 1Department of Respiratory Therapy, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Al Ahsa, Saudi Arabia; 2King Abdullah International Medical Research Center, Al Ahsa, Saudi Arabia; 3Intensive Care Unit, Hospital Morales Meseguer, Murcia, SpainCorrespondence: Bshayer Ramadan Alhamad Email balhamad7@gmail.com View the original paper by Dr Asseri and colleagues

Gulsah Karaoren,1 Senay Goksu Tomruk,1 Antonio M Esquinas2 1Department of Anesthesiology and Reanimation, Istanbul Umraniye Research Hospital, Istanbul, Turkey; 2Intensive Care Unit, Hospital Morales Meseguer, Murcia, Spain We have read the article titled “Automated oxygen titration and weaning with FreeO2 in patients with acute exacerbation of COPD: a pilot randomized trial” by Lellouche et al with great interest; however, there are some key aspects to take into account for proper practical implications.1 First, regarding ethical aspects, there seem to be some confusing points about disclosure and researchers. Of the researchers, one is a co-inventor of company that developed the device and two are owners of free oxygen generator. We could not clarify whether any of the authors are medical doctors. With regard to other aspects in the manuscript, the study included COPD patients (aged .40 years) with exacerbation and resting saturation ,90% at room environment in whom SpO2 increased to ,92% by 8 L/min oxygen supplementation. It was mentioned that it was impossible to obtain informed consent from patients who stayed in the hospital for .24 h, those with antibiotic-resistant infection, those who underwent intermittent nonintensive ventilation, and those with cognitive dysfunction. Also, the authors did not mention comorbid conditions, body mass index, exercise capacity, duration of COPD, current therapies received, and, most importantly, whether there is comorbid heart failure in the patients.2 The authors performed pulmonary function tests by post-bronchodilator spirometry; however, they did not take COPD grade (mild/moderate/severe) into account during standardization.3 In addition, there were no data regarding concurrent therapies given at emergency department and during admission. Did all patients undergo a standard treatment protocol? Moreover, patients of a broad range of age were included in the study. Thus, it is impossible to have no variations in exercise capacity, cognitive functions, and treatment response in this wide range of age from 40 to 80 years. The finding that use of free oxygen device was only an effective factor in improved saturation and shortened length of hospital stay by neglecting many parameters arises some questions about the results obtained in this study. In the limitations, the authors mentioned that sample size per group was small. However, no power analysis was performed. View the original paper by Lellouche F and colleagues.

This research provides new empirical evidence of the gender gap in university studies in the economics-business area based on econometric analysis (mean difference, OLS, quantile regression, logit/probit). The sample includes 717 first-year students of the 2016-2020 economics, business administration and management, and marketing degree courses at the University of Seville, Spain. Gender differences favoring female students both in the variables prior to entering the university and in university academic success indicators are documented. The findings continue to indicate the underrepresentation of women in these studies (40.4%), even though better academic performance and retention results for women are documented in the estimated models. The dissemination of these results could encourage females to choose these studies, thereby helping to achieve more equality in the profession.

Subrata Kumar Singha,1 Habib MR Karim,1 Antonio Esquinas2 1Department of Anaesthesia, AIIMS Raipur, Raipur, India; 2ICU, Hospital Morales, Murcia, SpainCorrespondence: Subrata Kumar SinghaDepartment of Anaesthesia, AIIMS, 3rd Floor, Major OT, Trauma Building, PO: Tatibandh, Raipur 492099, CG, IndiaEmail subratsingh@gmail.com We have read the study by Liao et al published in your journal with great interest.1 The article evaluates the effects of COPD on the outcome of laparoscopic cholecystectomy. Although COPD is a well-known risk for postoperative pulmonary complications, it is interesting to know this association from this matched study with a relatively larger sample. The authors' findings and conclusions are relevant, but we consider that a few other aspects need to be taken into account from the practical point of view.Firstly, from the methodological point of view, although the cohort was matched for age and gender, their comorbidities were very much different and may have affected the outcome measures like use of supports, ie, vasopressors, hemodialysis (HD), mechanical ventilation (MV), intensive care unit (ICU) stay, etc. Inclusion of patients with only COPD in the COPD group or using multivariate analysis may have helped in determining the real impact caused by COPD. In addition, the time period considered, ie, 1997–2013, is too long and the management strategy, especially for COPD patients, has evolved/changed a lot, diluting the applicability in the current practice.View the original paper by Liao KM and colleaguesA response to the letter has been publshed

Antonio M Esquinas,1 Marco Confalonieri21Intensive Care Unit, Hospital Morales Meseguer, Murcia, Spain; 2Department of Pneumology, University Hospital of Trieste, Trieste, ItalyDetermination of prognosis of exacerbation of chronic obstructive pulmonary disease (AECOPD) is a key cornerstone for health cost, organization, systems, and influences determinations of rationale in the use of non-invasive ventilation (NIV).1 However, systemic complexity of AECOPD makes it difficult to establish a "gold and perfect" prognosis model.1 Recently, a growing number of biological parameters such as anemia and health performance score evaluations are becoming decisive factors for NIV decisions.2In an interesting study, Haja Mydin et al determined that anemia, and performance status based on World Health Organization performance status (WHO-PS) were independent prognostic markers in acute hypercapnic respiratory failure (AHRF) due to AECOPD.3 The authors considered the major findings were that WHO-PS >3, and anemia, were the best prognostic factors to identify patients unlikely to benefit from NIV.We believe that the study makes a useful contribution to the establishment of predictors of poor prognosis in patients with AECOPD and it may help to make appropriate decisions for rational use of NIV. However, there are some concerns related to this study.View original paper by Haja Mydin and colleagues.

Paulo Matos,1 Antonio M Esquinas2 1Pneumology Department, Hospitais da Universidade de Coimbra, Coimbra, Portugal; 2Intensive Care Unit, Hospital Morales Meseguer, Murcia, SpainNowadays non-invasive ventilation (NIV) is a common therapeutic option in chronic hypercapnic respiratory failure, especially in chronic obstructive pulmonary disease (COPD).1 Even though there is not robust data showing mortality or morbidity benefits, it appears to improve quality of life and reduce admissions for exacerbation.1,2 However, there will always be a group of patients where NIV is not an option, because of poor compliance or side effects. Read the original article

Antonio M Esquinas,1 Gherardo Siscaro,2 Enrico M Clini21Intensive Care Unit, Hospital Morales Meseguer, Murcia, 2Department of Medical and Surgical Sciences, University of Modena, Pavullo-Modena, ItalyWe read with great interest the original work by Murphy et al analyzing the effects of two treatment strategies for delivery of noninvasive mechanical ventilation in hypercapnic patients with chronic obstructive pulmonary disease.1 High pressure and high intensity noninvasive mechanical ventilation were compared in a short-term crossover trial to assess whether high intensity noninvasive mechanical ventilation (inspiratory pressure > 25 cm H2O associated with a high backup ventilator rate) may improve adherence, physiological, and subjective outcomes when compared with delivery of high pressure noninvasive mechanical ventilation (without elevated backup respiratory rate). The authors concluded that both strategies are equivalent in all the recorded outcomes, showing thus that driving pressure, but not backup respiratory rate, is essential to gain physiological and clinical benefits in this population when in a chronic stable condition.View original paper by Murphy and colleagues.

Huriye Berk Takir,1 Antonio M Esquinas21Department of Intensive Care Unit, Sureyyapasa Chest Disease and Research Hospital, Istanbul, Turkey; 2Intensive Care and Non Invasive Ventilatory Unit, Hospital Morales Meseguer, Murcia, SpainCommunity acquired pneumonia (CAP) leads to more than 1 million hospital admissions per year according to the severity of the disease or exacerbation of underlying comorbid conditions in the USA.1,2 COPD is the most frequent comorbidity in patients with pneumonia, which induces acute exacerbation of COPD and respiratory failure. In a recent study, pneumonia was the second cause (19.7%) for intensive care unit (ICU) admissions among COPD patients,3 and a long-term (12 months) follow-up showed that the mortality of the COPD patients who were admitted to ICU due to pneumonia was higher than patients admitted for other reasons.3View original paper by Lu et al.

Antonio M Esquinas,1 Yoshinori Matsuoka,2 Sven Stieglitz3 1Intensive Care Unit, Hospital Morales Meseguer, Murcia, Spain; 2Saga Medical School Hospital, Department of Anesthesiology and Intensive Care Medicine, Saga, Japan; 3Clinic for Pneumology and Allergology, Centre for Sleep and Ventilation Medicine, Solingen, Germany Patients with acute chronic obstructive pulmonary disease (ACOPD) admitted to an intensive care unit (ICU) still show substantial high hospital mortality (24%).1 After ICU discharge, long-term application noninvasive ventilation (NIV) may be a reasonable and effective indication.2 However, hospital mortality shows higher mortality rates for patients with COPD surviving their first episode after 2 and 5 years.2,3 View original paper by Titlestad and colleagues.

Antonio M EsquinasIntensive Care Unit, Hospital Morales Meseguer, Murcia, SpainWe read with interest the survival analysis of chronic obstructive pulmonary disease (COPD) patients who are admitted to critical care units with exacerbation, conducted in Saudi Arabia by Alaithan et al.1 This study makes an important contribution on the real practice of intensive care units (ICUs). The authors, in the overall results, provided some great information similar in some aspects to previous epidemiologic surveys where a low level of consciousness on admission, need for endotracheal intubation (ETI), being a current smoker, cardiopulmonary arrest, tracheostomy, and development of acute renal failure are associated with higher ICU and hospital mortality. Although, study design showed some limitations with respect to interpretation predictors of mortality, there are aspects that differ compared to previous studies in this area that could be taken into account for clinical and practical implications.View original paper by Alaithan and colleagues.

Antonio Esquinas,1 Ritesh Agarwal21Intensive Care Unit, Hospital Morales Meseguer, Murcia, Spain; 2Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, IndiaWe read with interest the paper by Rawat et al1 related to the role of bilevel positive airway pressure (BiPAP) delivered via endotracheal tube in unconscious patients suffering from acute exacerbations of chronic obstructive pulmonary disease in a real-world situation. Although the authors provide some justification for the use of BiPAP through an endotracheal tube, we believe that this technique is fraught with complications and should not be routinely employed. In fact, three patients failed BiPAP therapy, two patients received conventional invasive ventilation, and one patient failed to respond to BiPAP. Thus, almost 30% of patients either failed or showed no evidence for benefit of BiPAP. Further, the authors provide no data on the amount of leakage that was present while administering BiPAP therapy. The authors also do not provide details on whether the nurses/chest therapist administered intermittent manual bag ventilation. Ideally, the authors should have referred the patients on manual bag ventilation to another public health center where facilities for invasive ventilation are available free of cost.View original paper by Rawat and colleagues.

Angelo Petroianni,1 Antonio M Esquinas2 1Department of Cardiovascular and Respiratory diseases, Sapienza University of Rome, Rome, Italy; 2Intensive Care and Noninvasive Ventilatory Unit, Hospital General Universitario Morales Meseguer, Murcia, SpainWe read with interest the study by Yalcinsoy et al1 appreciating its relevance and clinical practice value. In the last decades, noninvasive ventilation (NIV) has revolutionized the management of acute respiratory failure (ARF) reducing the need for endotracheal intubation and its associated complications and also reducing the complications associated with a stay in the intensive care unit, the length of hospital stay, and mortality.2View the original paper by Yalcinsoy and colleagues.

Pedro Silva Santos,1 Antonio M Esquinas21Pulmonology Unit, Centro Hospitalar e Universitário de Coimbra – Hospitais da Universidade de Coimbra, Coimbra, Portugal; 2Internsive Care Unit, Hospital Morales Meseguer, Múrcia, SpainHigh-flow nasal cannula (HFNC) oxygen therapy is an innovative and useful mode for the treatment of patients with respiratory failure.1–3 It delivers heated and humidified air providing higher and more expected gas flow rates and fraction inspired oxygen (FiO2) than traditional oxygen therapy.2 We read the article by Bräunlich et al1 carefully and congratulate the authors on their study about the use of nasal high-flow therapy in COPD patients. There are, however, some limitations to the study that need to be considered. First, this study has a small number of patients, particularly in groups A and B, which in our opinion will affect the comparison of data with the group C that contains a greater variety of patients with more severe outcomes, including forced expiratory volume in 1 second and forced vital capacity. Second, as a study on mean airway pressure, it would be interesting to evaluate partial pressure of CO2 with higher flows. Third, one of the aims of this study was to characterize changes in hypercapnia, so it is not correct to include nonhypercapnic patients. Fourth, it would be interesting to know the FiO2 that was given and whether the patients had domiciliary oxygen or noninvasive ventilation, as most of them are hypercapnic patients. Finally, regarding comfort and dyspnea scale, HFNC showed better results, which may increase its use when intolerant to noninvasive ventilation. In short, HFNC is an interesting mode for the future treatment of COPD patients with respiratory failure, which may lead to larger and randomized trials to confirm this indication.View original paper by Bräunlich et al.