Journal of Anaesthesia and Pain. 2022. Vol.3(3):51-53 51
Management of Respiratory Failure in Patients with COVID-19 and Multiple Myeloma
Slamet Hadi Santoso
1, Arie Zainul Fatoni
21Anesthesiology and Intensive Care Specialist Program, Brawijaya University, Malang, Indonesia
2Department of Anesthesiology and Intensive Therapy, Faculty of Medicine Brawijaya University, Dr. Saiful Anwar General Hospital, Indonesia
INTRODUCTION
COVID-19 infection in patients with malignancy require more attention and often result in prolonged hospitalization. In the severe case, the mortality rate is high. The underlying cause of cancer patients is more at risk of contracting Covid 19, namely malignancy can induce immune response irregularities.1 The therapy given for COVID-19 affects the response to chemotherapy.2 SARS-CoV-2 can affect the underlying neoplastic disease. The effects of COVID-19 on cancer states require further investigation.3
Patients with multiple myeloma undergo immunosuppression as soon as their disease is identified. The average age of multiple myeloma patients is 65 years old, and many of them also have serious comorbid conditions like diabetes, kidney disease, or heart disease.4 As a result, these individuals are seen as being at increased risk. Consequently, a thorough inspection must be performed. COVID-19 infection may delay the malignancy treatment.4
COVID-19 patient management is primarily supportive care, e.g. fluid management, ventilation, and oxygenation.
Systematic combination treatment of low-dose and anti-viral corticosteroids and inhaled interferon atomization has been suggested as part of the critical management of COVID-19.5 This case we present the management of respiratory failure in COVID- 19 patient with multiple myeloma.
CASE
A 66-year-old man came with complaints of shortness of breath and desaturation. The patient then was intubated and treated in the COVID-19 Intensive Care Unit (ICU). Complaints of shortness of breath have been felt 2 days of before hospital admission and worsened since one day before admission. The patient also complained of cough and fever since the day before admission, but the patient's temperature was not measured.
While in the COVID-19 ICU, the patient uses the endotracheal tubeventilator breathing apparatus.
ABSTRACT
Background
:
Cancer patients have higher risk of getting COVID-19. Individuals with malignancy who infected COVID-19 often underwent prolonged hospitalization or death. Here, we report respiratory failure management of of COVID-19 patient with multiple myeloma (MM).Case: A 66-year-old man came with complaints of shortness of breath. The patient was intubated and treated in the intensive care COVID. Patients with a history of multiple myeloma and who have chemotherapy cycle. The laboratory results showed an increase in markers of inflammation, hypoalbuminemia, and bicytopenia. The results of the polymerase chain reaction swab were positive.
There are 4 managements in this patient, airway management: intubation and ventilator settings using the Lung Protective Strategy principle. Management Breathing: administration of antibiotics according to sputum culture results. Circulation Management: Fluid management using a non- invasive Contractility Index (ICON) monitor. Management of Disability: Spontaneous Awakening Trial (SAT) and Spontaneous Breathing Trial (SBT) when the aggravating disease has been handled.
Conclusion: Management of respiratory failure in patients with multiple myeloma and COVID-19 infection is primarily focused on supportive care such as airway management, breathing management, fluid management and disability management.
Keywords: COVID-19, multiple myeloma, respiratory failure Correspondence:
Slamet Hadi Santoso, MD*
Anesthesiology and Intensive Care Specialist Program, Brawijaya University, Malang, Indonesia
e-mail:
fab.noerudin@gmail.com
Received: April 2022, Revised: September 2022, Published: September 2022
How to cite this article: Santoso, S. AZ Fatoni. Management of respiratory failure in patients with COVID-19 and multiple myeloma. Journal of Anaesthesia and Pain. 2022:3(3):51-53. doi: 10.21776/ub.jap.2022.003.03.03
Case Report
Journal of Anaesthesia and Pain, 2022, Volume: 3, No.3: 51-53 P-ISSN : 2722-3167https://jap.ub.ac.id E-ISSN : 2722-3205
Journal of Anaesthesia and Pain. 2022. Vol.3(3):51-53 52
This patient had a history of multiple myeloma and was diagnosed one week ago with the results of bone marrow puncture (BMP) and had chemotherapy. Eight months ago, the patient underwent an open biopsy of the sacrum region, and the results were Multiple Myeloma. The diagnosis is supported by laboratory results (Table 1). From the laboratory results, while being treated in the COVID-19 intensive care unit, it was found that there was an increase in the markers of inflammation, hypoalbuminemia, and bicytopenia.
The patient was treated for 8 days in the COVID-19 intensive care unit. There are 4 managements done in this patient including airway management: intubation and ventilator settings using the Lung Protective Strategy principle. Management Breathing: administration of antibiotics according to sputum culture results. Circulation Management: Fluid management using a non-invasive Contractility Index (ICON) monitor.
Management of Disability: Spontaneous Awakening Trial (SAT) and Spontaneous Breathing Trial (SBT) when the aggravating disease has been handled. The detail of the patient’s management can be seen in table 2.
We also measure sepsis markers during ICU treatment.
On day 7, the patient’s Polymerase Chain Reaction (PCR) showed negative results and breathing improvement by spontaneous breathing with HNFC flow 60 FiO2 80%. Day 8 shows better improvement. Patients then transfer to the high care unit.
Table 1. Peripheral blood and bone marrow examination Peripheral blood Value
Hemoglobin Red blood cell Hematocrit MCV MCH RDW CV Reticulocytes WBC Platelet Count type
8.0 g/dl 2.82 x 1012/l 25.9%
91.8 fl 28.4 pg 17.2%
0.76%
6.97 x 109/l 135 x 109/ l
Eo Ba St Seg Ly Mo - - 25 54 13 3 Normoblast
Erythrocyte
Leukocyte Platelet
1/100 leucocyte; Metamyelocytes: 2%;
Plasma cell: 2%; Lymphoplasmacytic: 1%
Normochrome anisopoikilocytosis, rouleaux formation +, elliptocyte +, teardrop cell +, normoblast +
Impression normal count, plasma cell +, neutrophil hypersegmentation+
The impression of the number down Bone marrow Value
Cellularity Ratio M:E Erythrocyte Granulopoiesis Megakaryopoiesis Fe Reserve Other
Hypercellular 7.5:1
Activity down Activity down Activity down Down
There is a 45-50% plasma cell proliferation
MCV: mean corpuscular volume, MCH: mean corpuscular haemoglobin, RDW CV: red distribution width, Ratio M:E Ratio Myeloid:Erythroid, eo:
Eosinophil, ba: Basophil, St: Stab, Seg: Segment, Ly: Lymphocyte, Mo:
Monocyte
Table 2. Patient management
Time Ventilator Setting Leuk ocyte s
NLR Fibrin ogen
D- dime r
PCR
Day 1 NIV Mode PSIMV, PINSP 7, FiO2 100%, PEEP 7, RR 20, IE Ratio 1:1,5 MV 12,3 TV 450- 500 ml SaO2 99%
2750 5,92 514 2,82 Positive
Day 2 NIV Mode PSIMV, PINSP 11, PEEP 8, FiO2 70%, RR 24, IERatio 1:1,5, MV 10 TV 500-630 ml, SpO2 99% et CO2 27
4950 18,56
Day 3 ETT Mode PSIMV, PINSP 7 Pcont 7, FiO2 60%, PEEP 8, RR 17, IE Ratio 1:1,5 TV 460-520 ml SpO2 99% et CO2
36
5440 15 458,4 2,02
Day 4 ETT Mode PCAC PINSP 10 PEEP 8 RR 18 IE Ratio 1:1,5 FiO2 50% TV 340- 440 ml SpO2 99%
et CO2 32-34
6840 28,09
Day 5 ETT Mode PSIMV PINSP 8 Psupp 6 PEEP 5 RR 25 IE Ratio 1:1,5 FiO2 40% TV 458-499 ml MV 9,6 SpO2 99%
et CO2 28-31
8720 19,9
Day 6 ETT Mode Spontan PS psupp 5 PEEP 5 FiO2 40% trigger 2 TV 440 ml SpO2 98%
14.57 0
46.53
Day 7 Spontaneous breath HFNC flow 60 FiO2 80% + NRBM 10 lpm ->
RR 25 x/menit SpO2 100% ROX 5
17.55 0
58 Negative
Day 8 Airway patent, Spontaneous breath HFNC flow 40 FiO2 40% + NRBM 10 lpm ->
RR 21 x/menit SpO2 97% ROX 11.5
377.9 6.22 Negative
NIV: non-invasive ventilation, PSIMV: pressure synchronized intermitten mandatory ventilation, PINSP: pressure inspiration, PEEP: positive end expiratory pressure, ETT: endotracheal tube, PCAC: pressure control assist control, TV: tidal volume, HFNC: high flow nasal cannula, ROX:
ratio of pulse oximetry, PCR: Polymerase chain reaction DISCUSSION
SARS-CoV-2 has the ability to pathogenically and quickly spread, causing a pandemic and broad multidisciplinary effect.6 Coronavirus itself is a new type that has been discovered by humans since it emerged in Wuhan, China in December 2019, and was named Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV2). So, this disease is called Coronavirus Disease- 2019 (COVID-19).1
In a study of 1099 patients with confirmed COVID-19 symptoms, the median incubation period was four days.
Symptoms range from mild to critical. Mild COVID symptoms do not cause symptoms or mild pneumonia symptoms, while severe symptoms are associated with symptoms of dyspnea, hypoxia, or pulmonary involvement.3
Journal of Anaesthesia and Pain. 2022. Vol.3(3):51-53 53
The prevalence of COVID-19 in Indonesia is based on age, with the majority of positive patients, namely the 31-45- year-old (29%), followed by the 46-59-year-old (27.3%). The cure rate was dominated by the group of 31-45 years (32.21%), and followed by the group of 18-30 years (29.77%).The highest mortality rate occurred in geriatric patients >60 years (17.68%).6
The clinical manifestations of COVID-19 vary, such as asymptomatic, symptomatic, acute respiratory distress syndrome (ARDS), and pneumonia with varying degrees of severity.7 Patients with severe symptoms develop ARDS and severe complications in the heart and kidneys which potentially lead to death.8 A poor prognosis can be associated with older age, gender, and history of comorbidities such as cardiovascular disease, and diabetes.9
In 28 COVID-19 patients from Wuhan, China, the median age was 65, 17% of the patients were men, and lung cancer was the most prevalent kind of cancer (25%).1 The clinical course varies, but more than 50 percent of patients have severe diseases. COVID-19 patient conditions were worse in patients who had received immunotherapy, radiotherapy, and chemotherapy.10
Multiple myeloma patients developed
immunosuppression from the time they are diagnosed. If the patient is tested positive for COVID-19, all treatment must be postponed until the symptoms of COVID-19 are cured. Patient management is primarily supportive care, e.g. fluid management, ventilation, and oxygenation.4 Systematic combination treatment of low-dose corticosteroids and antivirals and inhaled interferon
atomization has become part of the critical management of COVID-19.11
If a patient with multiple myeloma and infected with COVID-19 and requires mechanical ventilation, the physician should always have proactive discussions with patients about treatment goals and planning for follow-up care, especially for those with advanced cancer who may be infected with COVID- 19. Patients who suffer from myeloma associated with severe COVID-19 infection. According to the recommendation, COVID- 19 symptoms must be alleviated first before starting or continuing the myeloma treatment.4 In this case, we present the successful respiratory failure management in COVID-19 patient with multiple myeloma.
CONCLUSION
The four management of respiratory failure in COVID- 19 with multiple myeloma, including airway management:
intubation, and ventilator settings using the Lung Protective Strategy principle. Management Breathing: administration of antibiotics according to sputum culture results. Circulation Management: Fluid management using a non-invasive Contractility Index (ICON) monitor. Management of Disability:
Spontaneous Awakening Trial (SAT) and Spontaneous Breathing Trial (SBT) when the aggravating disease has been handled. The best management is airway management with intubation and lung protective strategy.
ACKNOWLEDGMENT -
CONFLICT OF INTEREST None
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