Impact of Chronic Obstructive Pulmonary Disease and Emphysema on Outcomes of Hospitalized Patients with Coronavirus Disease 2019 Pneumonia

Comparison of Azvudine and Nirmatrelvir/Ritonavir and Combined Use in Patients with COVID-19

Purpose

To compare the effectiveness of azvudine and nirmatrelvir/ritonavir for the treatment of coronavirus disease (COVID-19).

Patients and Methods

We conducted a retrospective analysis of data from 576 patients with COVID-19, comprising 195 patients without antiviral therapy, 226 patients treated with azvudine, 114 patients treated with nirmatrelvir/ritonavir, and 41 patients were treated with azvudine and nirmatrelvir/ritonavir concurrently. We compared their symptoms, mortality rates, and the length and cost of hospitalization.

Results

The incidence of symptoms was similar in patients treated with azvudine and in those treated with nirmatrelvir/ritonavir. However, among patients experiencing weakness, the duration of weakness was significantly shorter in the azvudine group than in the nirmatrelvir/ritonavir group (P=0.029). Mortality did not differ significantly between the azvudine group and the nirmatrelvir/ritonavir group (18.14% vs.10.53%, P=0.068). Among "severe patients", the mortality rate was markedly lower in patients treated with nirmatrelvir/ritonavir than in patients treated with azvudine (16.92% vs.32.17%, P=0.026). In patients with hepatic insufficiency, those treated with nirmatrelvir/ritonavir had substantially lower mortality than those treated with azvudine (15.09% vs.34.25%, P=0.016). In addition, patients treated with nirmatrelvir/ritonavir had longer hospital stays (P=0.002) and higher hospital costs (P<0.001) than those receiving azvudine. Compared with patients treated with nirmatrelvir/ritonavir or azvudine alone, patients taking nirmatrelvir/ritonavir and azvudine concurrently had no significant improvement in survival (P>0.05), length of stay (P>0.05), or hospital costs (P>0.05).

Conclusion

Azvudine is recommended for patients with non-severe COVID-19 with weakness. Nirmatrelvir/ritonavir is recommended for patients with severe COVID-19, to reduce mortality, and it could be the best choice for patients with hepatic insufficiency. The concurrent use of nirmatrelvir/ritonavir and azvudine in patients with COVID-19 could be not recommended.

Respiratory Interventions, Hospital Utilization, and Clinical Outcomes of Persons with COPD and COVID-19

Purpose

Coronavirus disease 2019 (COVID-19) impacted outcomes of persons with chronic respiratory diseases such as chronic obstructive pulmonary disease (COPD). This study investigated the differences in respiratory interventions, hospital utilization, smoking status, and 30-day readmission in those with COPD and COVID-19 based on hospital survival status.

Methods

A retrospective cross-sectional study was conducted from February 2020 to October 2020 and included persons with COPD and COVID-19 infection. We examined respiratory interventions, hospital utilization and outcomes, and 30-day hospital readmission. Chi-square test analysis was used to assess categorical variables, and t-test or Mann-Whitney was used to analyze continuous data based on normality.

Results

Ninety persons were included in the study, 78 (87%) were survivors. The most common comorbidity was hypertension 71 (78.9%) (p = 0.003). Twenty-two (24%) persons were intubated, from whom 12 (15%) survived (p < 0.001). There were 25 (32.1%) and 12 (100%), (p < 0.001) persons who required an ICU admission from the survivor and non-survivor groups, respectively. Among the survivor group, fifteen (19%) persons required 30-day hospital readmission.

Conclusion

Persons with COPD and COVID-19 had a lower mortality rate (13%) compared to other studies in the early pandemic phase. Non-survivors had increased ICU utilization, endotracheal intubation, and more frequent application of volume control mode. Discharging survivors to long-term acute care facilities may reduce 30-day hospital readmissions.

Healthcare Utilization in Patients with Chronic Obstructive Pulmonary Disease Discharged from Coronavirus 2019 Hospitalization

Rationale

There is concern that patients with chronic obstructive pulmonary disease (COPD) are at greater risk of increased healthcare utilization (HCU) following Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-COV-2) infection.

Objective

To assess whether COPD is an independent risk factor for increased post-discharge HCU.

Methods

We conducted a retrospective cohort study of patients with COPD discharged home from a hospitalization due to Coronavirus Disease 2019 (COVID-19) between April 1, 2020, and March 31, 2021, using Optum's de-identified Clinformatics® Data Mart Database (CDM). COVID-19 was identified by an International Classification of Diseases, tenth revision, clinical modification (ICD-10-CM) diagnosis code of U07.1. The primary outcome was HCU (ie, emergency department (ED) visits, readmissions, rehabilitation/skilled nursing facility (SNF) visits, outpatient office visits, and telemedicine visits) nine months post-discharge after COVID-19 hospitalization (from here on "post-discharge") in patients with COPD compared to HCU of patients without COPD. Poisson regression modeling was used to calculate relative risk (RR) and confidence interval (CI) for COPD, adjusted for the other covariates.

Results

We identified a cohort of 160,913 patients hospitalized with COVID-19, with 57,756 discharged home and 14,622 (25.3%) diagnosed with COPD. Patients with COPD had a mean age of 75.48 years (±9.49); 55.5% were female and 70.9% were White. Patients with COPD had an increased risk of HCU in the nine months post-discharge after adjusting for the other covariates. Risk of ED visits, readmissions, length of stay during readmission, rehabilitation/SNF visits, outpatient office visits, and telemedicine visits were increased by 57% (RR 1.57; 95% CI 1.53-1.60), 50% (RR 1.50; 95% CI 1.46-1.54), 55% (RR 1.55; 95% CI 1.53-1.56), 18% (RR 1.18; 95% CI 1.14-1.22), 16% (RR 1.16; 95% CI 1.16-1.17), and 28% (RR 1.28; 95% CI 1.24-1.31), respectively. Younger patients (ages 18 to 65 years), women, and Hispanic patients with COPD showed an increased risk for post-discharge HCU.

Conclusion

Patients with COPD hospitalized with COVID-19 experienced increased HCU post-discharge compared to patients without COPD.

Risk of hospitalization in a sample of COVID-19 patients with and without chronic obstructive pulmonary disease

BACKGROUND AND OBJECTIVE

Patients with chronic obstructive pulmonary disease (COPD) may have worse coronavirus disease-2019 (COVID-19)-related outcomes. We compared COVID-19 hospitalization risk in patients with and without COPD.

METHODS

This retrospective cohort study included patients ≥40 years, SARS-CoV-2 positive, and with Kaiser Permanente Northern California membership ≥1 year before COVID-19 diagnosis (electronic health records and claims data). COVID-19-related hospitalization risk was assessed by sequentially adjusted logistic regression models and stratified by disease severity. Secondary outcome was death/hospice referral after COVID-19.

RESULTS AND DISCUSSION

Of 19,558 COVID-19 patients, 697 (3.6%) had COPD. Compared with patients without COPD, COPD patients were older (median age: 69 vs 53 years); had higher Elixhauser Comorbidity Index (5 vs 0) and more median baseline outpatient (8 vs 4), emergency department (2 vs 1), and inpatient (2 vs 1) encounters. Unadjusted analyses showed increased odds of hospitalization with COPD (odds ratio [OR]: 3.93; 95% confidence interval [CI]: 3.40-4.60). After full risk adjustment, there were no differences in odds of hospitalization (OR: 1.14, 95% CI: 0.93-1.40) or death/hospice referral (OR: 0.96, 95% CI: 0.72-1.27) between patients with and without COPD. Primary/secondary outcomes did not differ by COPD severity, except for higher odds of hospitalization in COPD patients requiring supplemental oxygen versus those without COPD (OR: 1.84, 95% CI: 1.02-3.33).

CONCLUSIONS

Except for hospitalization among patients using supplemental oxygen, no differences in odds of hospitalization or death/hospice referral were observed in the COVID-19 patient sample depending on whether they had COPD.

Explainable emphysema detection on chest radiographs with deep learning

We propose a deep learning system to automatically detect four explainable emphysema signs on frontal and lateral chest radiographs. Frontal and lateral chest radiographs from 3000 studies were retrospectively collected. Two radiologists annotated these with 4 radiological signs of pulmonary emphysema identified from the literature. A patient with ≥2 of these signs present is considered emphysema positive. Using separate deep learning systems for frontal and lateral images we predict the presence of each of the four visual signs and use these to determine emphysema positivity. The ROC and AUC results on a set of 422 held-out cases, labeled by both radiologists, are reported. Comparison with a black-box model which predicts emphysema without the use of explainable visual features is made on the annotations from both radiologists, as well as the subset that they agreed on. DeLong’s test is used to compare with the black-box model ROC and McNemar’s test to compare with radiologist performance. In 422 test cases, emphysema positivity was predicted with AUCs of 0.924 and 0.946 using the reference standard from each radiologist separately. Setting model sensitivity equivalent to that of the second radiologist, our model has a comparable specificity (p = 0.880 and p = 0.143 for each radiologist respectively). Our method is comparable with the black-box model with AUCs of 0.915 (p = 0.407) and 0.935 (p = 0.291), respectively. On the 370 cases where both radiologists agreed (53 positives), our model achieves an AUC of 0.981, again comparable to the black-box model AUC of 0.972 (p = 0.289). Our proposed method can predict emphysema positivity on chest radiographs as well as a radiologist or a comparable black-box method. It additionally produces labels for four visual signs to ensure the explainability of the result. The dataset is publicly available at https://doi.org/10.5281/zenodo.6373392.

Impact of COPD on clinical and CT characteristics of COVID-19-associated pneumonia: single tertiary center experience

Background

The severe acute respiratory syndrome-related coronavirus 2 pandemic continues to this day worldwide. Individuals with COPD are at increased risk of contracting SARS-CoV-2. Most of the conducted studies are based on the clinical assessment of COVID-19 infection with different comorbidities. The specific contribution of COPD to the severity of the disease and outcome still remains the point of investigation. The main goals of our study are to assess COPD’s influence on the severity of clinical and CT characteristics of COVID-19 pneumonia and associated in-hospital mortality.

Results

This is a retrospective study on 281 patients with RT-PCR-confirmed COVID-19 infection and CT spectrum of COVID-19 pneumonia. Fifty patients have COPD based on CT criteria. No significant difference was observed in the mean hospital length of stay, arterial oxygen saturation on admission or in-hospital mortality between COPD and non-COPD groups. Patients with COPD were two times less likely to have fever less than 37.9 °C (RR = 2.037; 95% CI 1.114–3.724, p = 0.016), but higher absolute neutrophil count (p = 0.033) and median level of neutrophil/lymphocyte ratio (p = 0.029). The COPD group was presented with milder CT severity score (especially CT1, less than 25% of lung involvement) (p = 0.022), less likely to have bilateral (RR = 2.601; 95% CI: 1.341–5.044, p = 0.023) or central (RR = 1.754; 95% CI 1.024–3.003, p = 0.046) distribution of ground-glass opacities, right lower lobe (RR = 2.887; 95% CI 1.574–5.293, p = 0.008) or left lung (RR = 2.627; 95% CI 1.448–4.765, p = 0.009) involvement, and “crazy-paving” pattern (RR = 2.208; 95% CI 1.292–3.774, p = 0.003). Both moderate positive and negative relationship was observed between CT1, CT4, hypoxia and in-hospital mortality in the COPD group (r = − 0.383, p = 0.033; r = 0.486, p = 0.007; r = − 0,354, p = 0,022, respectively).

Conclusion

The presence of COPD by imaging criteria in the settings of COVID-19-associated pneumonia did not significantly influence the clinical or imaging performance of the patients, nor was it linked to the increased in-hospital mortality.

Impact of SARS-CoV-2 Infection Among Non-Invasive Ventilated ALS Patients

BACKGROUND

The impact of SARS-CoV-2 infection among neuromuscular diseases with respiratory involvement, including amyotrophic lateral sclerosis (ALS), is still to be elucidated.

OBJECTIVES

We aim to characterize the clinical outcome of ALS patients non-invasive ventilated (NIV), following SARS-CoV-2 infection.

METHODS

We analyzed retrospectively our patients followed regularly at our ALS clinic, from the beginning of the COVID-19 pandemic (middle March 2020) to March 2021. We included patients on NIV with a documented SARS-CoV-2 infection. We recorded demographic and clinical data, including from the acute infectious illness.

RESULTS

Three men with spinal-onset ALS are described, mean age of onset was 55±9.1 years (45-61), and mean disease duration was 17.5±15.9 months (6.1-41). All of them were wheelchair-bounded, with a mean ALSFRS-R of 15.3±0.6 (15-16). One patient used NIV 15 hours/day, 2 between 4 to 7 hours/day, and all used assisted coughing twice daily. None had coexistent comorbidities. They were managed for SARS-CoV-2 infection as outpatients with fluticasone, bronchodilators, azithromycin and increasing frequency of assisted coughing. Supplemental oxygen (mean of 2 liters per minute) was needed in two patients, and one required NIV also during the daytime. Total recovery from SARS-CoV-2 infection was observed in all, despite being in an advanced stage of their disease, with severe respiratory involvement.

CONCLUSIONS

Prompt medical treatment is recommended for ALS patients with severe disease infected by SARS-CoV-2.

Outcomes of Patients with COPD Hospitalized for Coronavirus Disease 2019

RATIONALE

There is controversy concerning the association of chronic obstructive pulmonary disease (COPD) as an independent risk factor for mortality in patients hospitalized with Coronavirus Disease 2019 (COVID-19). We hypothesize that patients with COPD hospitalized for COVID-19 have increased mortality risk.

OBJECTIVE

To assess whether COPD increased the risk of mortality among patients hospitalized for COVID-19.

METHODS

We conducted a retrospective cohort analysis of patients with COVID-19 between February 10, 2020, and November 10, 2020, and hospitalized within 14 days of diagnosis. Electronic health records from U.S. facilities (Optum COVID-19 data) were used.

RESULTS

In our cohort of 31,526 patients, 3030 (9.6%) died during hospitalization. Mortality in patients with COPD was higher than that of patients without COPD, 14.02% and 8.8%, respectively. Univariate (odds ratio [OR] 1.68; 95% confidence interval [CI] 1.54 to 1.84) and multivariate (OR 1.33; 95% CI 1.18 to 1.50) analysis showed that patients with COPD had greater odds of death due to COVID-19 than patients without COPD. We found significant interactions between COPD and sex and COPD and age. Specifically, the increased mortality risk associated with COPD was observed among female (OR 1.62; 95% CI 1.36 to 1.95) but not male patients (OR 1.14; 95% CI 0.97 to 1.34); and in patients aged 40 to 64 (OR 1.42; 95% CI 1.07 to 1.90) and 65 to 79 (OR 1.48; 95% CI 1.23 to 1.78) years.

CONCLUSIONS

COPD is an independent risk factor for death in adults aged 40 to 79 years hospitalized with COVID-19 infection.

Pulmonary adverse drug event data in hypertension with implications on COVID-19 morbidity

Hypertension is a recognized comorbidity for COVID-19. The association of antihypertensive medications with outcomes in patients with hypertension is not fully described. However, angiotensin-converting enzyme 2 (ACE2), responsible for host entry of the novel coronavirus (SARS-CoV-2) leading to COVID-19, is postulated to be upregulated in patients taking angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs). Here, we evaluated the occurrence of pulmonary adverse drug events (ADEs) in patients with hypertension receiving ACEIs/ARBs to determine if disparities exist between individual drugs within the respective classes using data from the FDA Spontaneous Reporting Systems. For this purpose, we proposed the proportional reporting ratio to provide a statistical summary for the commonality of an ADE for a specific drug as compared to the entire database for drugs in the same or other classes. In addition, a statistical procedure, multiple logistic regression analysis, was employed to correct hidden confounders when causative covariates are underreported or untrusted to correct analyses of drug-ADE combinations. To date, analyses have been focused on drug classes rather than individual drugs which may have different ADE profiles depending on the underlying diseases present. A retrospective analysis of thirteen pulmonary ADEs showed significant differences associated with quinapril and trandolapril, compared to other ACEIs and ARBs. Specifically, quinapril and trandolapril were found to have a statistically significantly higher incidence of pulmonary ADEs compared with other ACEIs as well as ARBs (P < 0.0001) for group comparison (i.e., ACEIs vs. ARBs vs. quinapril vs. trandolapril) and (P ≤ 0.0007) for pairwise comparison (i.e., ACEIs vs. quinapril, ACEIs vs. trandolapril, ARBs vs. quinapril, or ARBs vs. trandolapril). This study suggests that specific members of the ACEI antihypertensive class (quinapril and trandolapril) have a significantly higher cluster of pulmonary ADEs.