There is no effective drug therapy for the treatment of acute respiratory distress syndrome (ARDS) due to novel coronavirus disease 2019 (COVID-19) pneumonia. Lung protective strategies for severe ARDS to prevent ventilatorassociated and/or patient self-inflicted lung injuries are the main treatment measures. However, it is still unclear how to use neuromuscular blocking agent (NMBA) for lung protection on ARDS due to COVID-19. A 60s-year-old male diagnosed as ARDS due to COVID-19 was referred to our hospital. On the second day following hospitalization, the extracorporeal membrane oxygenation (ECMO) and prone positioning were implemented for the lung protection. Even under deep sedation, strong spontaneous inspiratory effort was observed, and we decided to use continuous infusion of NMBA to reduce the risk of the patient self-inflicted lung injury. We daily evaluated the necessity for the use of NMBA using physical examination and airway occlusion pressure measurement as the indicators of inspiratory effort. As lung function gradually recovered, the inspiratory effort also decreased. Eventually 19 days of prone positioning and 26 days of continuous infusion of NMBA for preventing the lung injuries were required. The patient was weaned from the ECMO on the 47th day. After further stay at our ICU and general ward, he was discharged home with an oxygen therapy. Preparing for upcoming similar cases, we report the case with a literature review to share our experience and the feasibility of the airway occlusion pressure on the necessity for NMBA.

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This is a case report regarding the utility of lung ultrasonography for the postoperative respiratory management of esophagectomy. Herein, we reported a 50-year-old male who developed severe oxygenation disorder following esophagectomy. Lung ultrasonography was helpful in bilateral pneumothorax diagnosis and allowed us to judge the eligibility of thoracic drainage.

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This is a case report of bridging to lung transplantation using high frequency oscillatory ventilation (HFOV) in pediatric non-specific interstitial pneumonitis (IP). A 6-year-old boy was transferred to our hospital due to dry cough and oxygen desaturation. He had been treated with chemotherapy and radiation for bladder rhabdomyosarcoma until two years prior. No symptoms of tumor relapse were observed after the therapy. Chest computed tomography and lung biopsy findings revealed non-specific IP, which was probably due to the past chemotherapy. Following biopsy, the patient developed acute respiratory failure and was subsequently provided with intubation and conventional mechanical ventilator management, including continuous intravenous analgesic, muscle relaxants, and sedative drugs. However, his ventilation had not sustained an optimal PaCO₂ level, prompting initiation of HFOV. Thereafter, his ventilation improved, and he was judged to be eligible for lung transplantation due to untreatable respiratory dysfunction. With the continuation of HFOV for bridging to transplantation, living-related lung transplantation from his mother was successfully performed, and the patient was successfully discharged from the hospital. Although there is no consensus regarding HFOV eligibility in IP, this case report demonstrates the possibility of HFOV for bridging to lung transplantation in cases of IP.

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A woman in her 50s who had hyperthyroidism and antiphospholipid antibody syndrome, was brought to our hospital with a painful muscle spasm in her right thigh. She was unable to walk due to her painful muscle spasm and complained of anxiety about the muscle spasm. She was admitted to our hospital. On the fifth hospital day, she developed acute heart failure with suspected takotsubo cardiomyopathy. She was sedated with propofol and placed on a ventilator in the ICU. After she received intensive care and diazepam was administered, her muscle spasm disappeared, and the patient was extubated and discharged from the ICU. We diagnosed her with stiff-person syndrome (SPS) based on her clinical findings and strong positivity for anti-glutamic acid decarboxylase antibodies (anti-GAD antibodies) in her blood. SPS is a rare and intractable neurological disease characterized by muscle rigidity and muscle spasm. SPS can be caused by an autoimmune disorder associated with anti-GAD antibodies. In this case, the hyperexcitability of the sympathetic nervous system caused by anti-GAD antibodies and the psychological stress caused by anxiety and fear led to takotsubo cardiomyopathy. Our rigorous diagnostic approach and intensive care led to her good outcome.

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