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Rocha de Souza L, Ramos Amorim MM, Souza AS, Carvalho Pinto de Melo B, Tiné Cantilino C, de Oliveira Saunders MA, Jucá de Petribú M, Soares Lúcio L, Rodrigues Marinho J, de Oliveira Correia MEV, Katz L. Association between maternal and perinatal outcomes and histological changes in the placenta of patients with Covid-19: A cohort study. Medicine (Baltimore) 2024; 103:e38171. [PMID: 38788031 PMCID: PMC11124646 DOI: 10.1097/md.0000000000038171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 04/17/2024] [Indexed: 05/26/2024] Open
Abstract
Although studies evaluated placental involvement in Covid-19 patients, few have assessed its association with clinical repercussions. The study aimed to determine the association between the clinical status and maternal and perinatal outcomes of patients with Covid-19 at delivery and changes in placental histology. It is so far the largest cohort evaluating placentas of patients infected by the SARS-CoV-2. A secondary analysis was conducted of a database from which a cohort of 226 patients, who tested real-time polymerase chain reaction-positive for Covid-19 at delivery and whose placentas were collected and submitted to pathology, was selected for inclusion. One or more types of histological changes were detected in 44.7% of the 226 placentas evaluated. The most common abnormalities were maternal vascular malperfusion (38%), evidence of inflammation/infection (9.3%), fetal vascular malperfusion (0.8%), fibrinoid changes and intervillous thrombi (0.4%). Oxygen use (P = .01) and need for admission to an intensive care unit (ICU) (P = .04) were less common in patients with placental findings, and hospital stay was shorter in these patients (P = .04). There were more fetal deaths among patients with evidence of inflammation/infection (P = .02). Fetal death, albeit uncommon, is associated with findings of inflammation/infection. Oxygen use and need for admission to an ICU were less common among patients with placental findings, probably due to the pregnancy being interrupted early. None of the other findings was associated with maternal clinical status or with adverse perinatal outcome.
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Affiliation(s)
- Luiza Rocha de Souza
- Master’s Program of Comprehensive Health at IMIP, Recife, Brazil
- High Risk Pregnancy Unit at IMIP, Recife, Brazil
| | | | - Alex Sandro Souza
- Professor of the Postgraduate Program at IMIP, Recife, Brazil
- Department of Fetal Medicine at IMIP, Recife, Brazil
| | - Brena Carvalho Pinto de Melo
- High Risk Pregnancy Unit at IMIP, Recife, Brazil
- Simulation Center at Faculdade Pernambucana de Saúde (Csim), Recife, Brazil
| | | | | | | | | | | | | | - Leila Katz
- Professor of the Postgraduate Program at IMIP, Recife, Brazil
- Obstetric Intensive Care Unit at IMIP, Recife, Brazil
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Fisher JM, Subbian V, Essay P, Pungitore S, Bedrick EJ, Mosier JM. Acute Respiratory Failure From Early Pandemic COVID-19: Noninvasive Respiratory Support vs Mechanical Ventilation. CHEST CRITICAL CARE 2024; 2:100030. [PMID: 38645483 PMCID: PMC11027508 DOI: 10.1016/j.chstcc.2023.100030] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
BACKGROUND The optimal strategy for initial respiratory support in patients with respiratory failure associated with COVID-19 is unclear, and the initial strategy may affect outcomes. RESEARCH QUESTION Which initial respiratory support strategy is associated with improved outcomes in patients with COVID-19 with acute respiratory failure? STUDY DESIGN AND METHODS All patients with COVID-19 requiring respiratory support and admitted to a large health care network were eligible for inclusion. We compared patients treated initially with noninvasive respiratory support (NIRS; noninvasive positive pressure ventilation by facemask or high-flow nasal oxygen) with patients treated initially with invasive mechanical ventilation (IMV). The primary outcome was time to in-hospital death analyzed using an inverse probability of treatment weighted Cox model adjusted for potential confounders. Secondary outcomes included unweighted and weighted assessments of mortality, lengths of stay (ICU and hospital), and time to intubation. RESULTS Nearly one-half of the 2,354 patients (47%) who met inclusion criteria received IMV first, and 53% received initial NIRS. Overall, in-hospital mortality was 38% (37% for IMV and 39% for NIRS). Initial NIRS was associated with an increased hazard of death compared with initial IMV (hazard ratio, 1.42; 95% CI, 1.03-1.94), but also an increased hazard of leaving the hospital sooner that waned with time (noninvasive support by time interaction: hazard ratio, 0.97; 95% CI, 0.95-0.98). INTERPRETATION Patients with COVID-19 with acute hypoxemic respiratory failure initially treated with NIRS showed an increased hazard of in-hospital death.
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Affiliation(s)
- Julia M Fisher
- Statistics Consulting Laboratory, The University of Arizona College of Medicine, Tucson, AZ; College of Engineering, the BI05 Institute, The University of Arizona College of Medicine, Tucson, AZ
| | - Vignesh Subbian
- Department of Systems and Industrial Engineering, The University of Arizona College of Medicine, Tucson, AZ; Department of Biomedical Engineering, The University of Arizona College of Medicine, Tucson, AZ; College of Engineering, the BI05 Institute, The University of Arizona College of Medicine, Tucson, AZ
| | - Patrick Essay
- Department of Systems and Industrial Engineering, The University of Arizona College of Medicine, Tucson, AZ
| | - Sarah Pungitore
- Program in Applied Mathematics, The University of Arizona College of Medicine, Tucson, AZ
| | - Edward J Bedrick
- Statistics Consulting Laboratory, The University of Arizona College of Medicine, Tucson, AZ; College of Engineering, the BI05 Institute, The University of Arizona College of Medicine, Tucson, AZ
| | - Jarrod M Mosier
- The University of Arizona, the Department of Emergency Medicine, The University of Arizona College of Medicine, Tucson, AZ; Division of Pulmonary, Allergy, Critical Care, and Sleep, The University of Arizona College of Medicine, Tucson, AZ; Department of Medicine, The University of Arizona College of Medicine, Tucson, AZ
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Aretha D, Kefala S, Nikolopoulou A, Karamouzos V, Valta M, Mplani V, Georgakopoulou A, Papamichail C, Sklavou C, Fligou F. Intubation Time, Lung Mechanics and Outcome in COVID-19 Patients Suffering Acute Respiratory Distress Syndrome: A Single-Center Study. J Clin Med Res 2024; 16:15-23. [PMID: 38327390 PMCID: PMC10846488 DOI: 10.14740/jocmr4984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 01/17/2024] [Indexed: 02/09/2024] Open
Abstract
Background We examined the effect of intubation time and the lung mechanics on clinical outcomes in coronavirus disease 2019 (COVID-19) patients. Methods Based on the patient's hospital admission, intubation time was defined as early (≤ 2 days) or late (> 2 days). Patients were further divided into three groups; early (≤ 3 days), late (4 - 6 days), and very late (> 6 days) intubated. Results A total of 194 patients were included; 66.5% male, median age 65 years. Fifty-eight patients (29.9%) were intubated early and 136 (70.1%) late. Early intubated patients revealed lower mortality (44.8% vs. 72%, P < 0.001), were younger (60 vs. 67, P = 0.002), had lower sequential organ failure assessment (SOFA) scores (6 vs. 8, P = 0.002) and higher lung compliance on admission days 1, 6 and 12 (42 vs. 36, P = 0.006; 40 vs. 33, P < 0.001; and 37.5 vs. 32, P < 0.001, respectively). Older age (adjusted odds ratio (aOR) = 1.15, P < 0.001), intubation time (aOR = 1.15, P = 0.004), high SOFA scores (aOR = 1.81, P < 0.001), low partial pressure of oxygen (PaO2)/fractional inspired oxygen tension (FiO2) ratio (aOR = 0.96, P = 0.001), and low lung compliance on admission days 1 and 12 (aOR = 1.12, P = 0.012 and aOR = 1.14, P < 0.001, respectively) were associated with higher mortality. Very late and late intubated patients had higher mortality rates than patients intubated early (78.4% vs. 63.4% vs. 44.6%, respectively, P < 0.001). Conclusions Among COVID-19 intubated patients, age, late intubation, high SOFA scores, low PaO2/FiO2 ratio, and low lung compliance are associated with higher intensive care unit (ICU) mortality.
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Affiliation(s)
- Diamanto Aretha
- Department of Anesthesiology and Intensive Care Medicine, School of Medicine, University Hospital of Patras, Rion, 26504 Patras, Greece
| | - Sotiria Kefala
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Patras, Rion, 26504 Patras, Greece
| | - Alexandra Nikolopoulou
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Patras, Rion, 26504 Patras, Greece
| | - Vasilios Karamouzos
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Patras, Rion, 26504 Patras, Greece
| | - Maria Valta
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Patras, Rion, 26504 Patras, Greece
| | - Virginia Mplani
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Patras, Rion, 26504 Patras, Greece
| | - Alexandra Georgakopoulou
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Patras, Rion, 26504 Patras, Greece
| | - Chrysavgi Papamichail
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Patras, Rion, 26504 Patras, Greece
| | - Christina Sklavou
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Patras, Rion, 26504 Patras, Greece
| | - Fotini Fligou
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Patras, Rion, 26504 Patras, Greece
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Bianchi M. The effects of high-flow oxygen therapy on mortality in patients with COVID-19. J Am Assoc Nurse Pract 2023; 35:183-191. [PMID: 36729579 DOI: 10.1097/jxx.0000000000000821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 11/15/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND High-flow oxygen therapy (HFOT) has been successful in treating acute hypoxic respiratory failure (AHRF) and acute respiratory distress syndrome (ARDS). Successful treatment with noninvasive ventilation and avoidance of mechanical ventilation (MV) has been associated with decreased mortality and positive patient outcomes. It is unclear whether the evidence supports the use of HFOT to treat coronavirus disease 2019 (COVID-19)-induced AHRF and ARDS. OBJECTIVES To determine whether the use of HFOT decreases the need for intubation or decreases mortality compared with MV in patients with AHRF due to COVID-19. DATA SOURCES A literature search was conducted in March 2022 using CINAHL, Embase, PubMed, and Scopus bibliographic databases. Ten studies comparing HFOT and MV in COVID-19 respiratory failure met inclusion criteria. CONCLUSIONS Nine studies found a statistically significant reduction in the need for intubation; eight studies found significantly decreased morality in patients who received HFOT. Study design and methodologies limited the findings. IMPLICATIONS FOR PRACTICE Based on the available evidence, the use of HFOT positively affected mortality and incidence of the need for intubation and MV. Further research needs to be conducted before HFOT is adopted as the standard of care for COVID-19-induced AHRF and ARDS. Nurse practitioners should be informed regarding the various respiratory support modalities and evaluate risk versus benefit when caring for patients with COVID-19-induced AHRF and ARDS.
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Affiliation(s)
- Mia Bianchi
- University of Pennsylvania, School of Nursing, Adult Gerontology Acute Care Nurse Practitioner Program, Philadelphia, Pennsylvania
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Crimi C, Murphy P, Patout M, Sayas J, Winck JC. Lessons from COVID-19 in the management of acute respiratory failure. Breathe (Sheff) 2023; 19:230035. [PMID: 37378059 PMCID: PMC10292773 DOI: 10.1183/20734735.0035-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 04/17/2023] [Indexed: 06/29/2023] Open
Abstract
Accumulated evidence supports the efficacy of noninvasive respiratory support therapies in coronavirus disease 2019 (COVID-19)-related acute hypoxaemic respiratory failure, alleviating admissions to intensive care units. Noninvasive respiratory support strategies, including high-flow oxygen therapy, continuous positive airway pressure via mask or helmet and noninvasive ventilation, can be alternatives that may avoid the need for invasive ventilation. Alternating different noninvasive respiratory support therapies and introducing complementary interventions, like self-proning, may improve outcomes. Proper monitoring is warranted to ensure the efficacy of the techniques and to avoid complications while supporting transfer to the intensive care unit. This article reviews the latest evidence on noninvasive respiratory support therapies in COVID-19-related acute hypoxaemic respiratory failure.
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Affiliation(s)
- Claudia Crimi
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
- Respiratory Medicine Unit, Policlinico “G. Rodolico-San Marco” University Hospital, Catania, Italy
| | - Patrick Murphy
- Lane Fox Respiratory Service, Guy's and St Thomas’ Hospitals NHS Trust, London, UK
- Centre for Human and Applied Physiological Sciences (CHAPS), King's College London, London, UK
| | - Maxime Patout
- Service des Pathologies du Sommeil (Département R3S), Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Paris, France
- UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, INSERM, Paris, France
| | - Javier Sayas
- Pulmonology Service, Hospital Universitario 12 de Octubre, Madrid, Spain
- Facultad de Medicina Universidad Complutense de Madrid, Madrid, Spain
| | - Joao Carlos Winck
- Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
- Centro De Reabilitação Do Norte, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova De Gaia, Portugal
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Fisher JM, Subbian V, Essay P, Pungitore S, Bedrick EJ, Mosier JM. Outcomes in Patients with Acute Hypoxemic Respiratory Failure Secondary to COVID-19 Treated with Noninvasive Respiratory Support versus Invasive Mechanical Ventilation. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2022:2022.12.19.22283704. [PMID: 36597544 PMCID: PMC9810223 DOI: 10.1101/2022.12.19.22283704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Purpose The goal of this study was to compare noninvasive respiratory support to invasive mechanical ventilation as the initial respiratory support in COVID-19 patients with acute hypoxemic respiratory failure. Methods All patients admitted to a large healthcare network with acute hypoxemic respiratory failure associated with COVID-19 and requiring respiratory support were eligible for inclusion. We compared patients treated initially with noninvasive respiratory support (noninvasive positive pressure ventilation by facemask or high flow nasal oxygen) with patients treated initially with invasive mechanical ventilation. The primary outcome was time-to-in-hospital death analyzed using an inverse probability of treatment weighted Cox model adjusted for potential confounders. Secondary outcomes included unweighted and weighted assessments of mortality, lengths-of-stay (intensive care unit and hospital) and time-to-intubation. Results Over the study period, 2354 patients met inclusion criteria. Nearly half (47%) received invasive mechanical ventilation first and 53% received initial noninvasive respiratory support. There was an overall 38% in-hospital mortality (37% for invasive mechanical ventilation and 39% for noninvasive respiratory support). Initial noninvasive respiratory support was associated with an increased hazard of death compared to initial invasive mechanical ventilation (HR: 1.61, p < 0.0001, 95% CI: 1.33 - 1.94). However, patients on initial noninvasive respiratory support also experienced an increased hazard of leaving the hospital sooner, but the hazard ratio waned with time (HR: 0.97, p < 0.0001, 95% CI: 0.96 - 0.98). Conclusion These data show that the COVID-19 patients with acute hypoxemic respiratory failure initially treated with noninvasive respiratory support had an increased hazard of in-hospital death.
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Affiliation(s)
- Julia M Fisher
- Statistics Consulting Laboratory, The University of Arizona, Tucson, AZ
- BIO5 Institute, The University of Arizona, Tucson, AZ
| | - Vignesh Subbian
- Department of Systems and Industrial Engineering, College of Engineering, The University of Arizona, Tucson, AZ
- Department of Biomedical Engineering, College of Engineering, The University of Arizona, Tucson, AZ
- BIO5 Institute, The University of Arizona, Tucson, AZ
| | - Patrick Essay
- Department of Systems and Industrial Engineering, College of Engineering, The University of Arizona, Tucson, AZ
| | - Sarah Pungitore
- Program in Applied Mathematics, The University of Arizona, Tucson, AZ
| | - Edward J Bedrick
- Statistics Consulting Laboratory, The University of Arizona, Tucson, AZ
- BIO5 Institute, The University of Arizona, Tucson, AZ
| | - Jarrod M Mosier
- Department of Emergency Medicine, The University of Arizona College of Medicine, Tucson, AZ
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Department of Medicine, The University of Arizona College of Medicine, Tucson, AZ
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Bruno TW, Janwadkar R, Clayton LM, Hughes PG, Solano JJ, Shih RD, Bilello LA, Hughes MJ, Alter SM. Impact of COVID-19 on emergency medicine resident procedure performance. AEM EDUCATION AND TRAINING 2022; 6:e10832. [PMID: 36562022 PMCID: PMC9763965 DOI: 10.1002/aet2.10832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 10/31/2022] [Accepted: 11/07/2022] [Indexed: 06/17/2023]
Abstract
Background As a result of the COVID-19 pandemic, patterns of patient presentations and medical education have changed, potentially resulting in fewer and different types of patient encounters. Procedural proficiency is a cornerstone of emergency medicine (EM) training, and residents must meet Accreditation Council for Graduate Medical Education (ACGME) requirements to graduate. It is feared there may have been a pandemic-induced decrease in opportunities for residents to perform procedures. This study investigates the change in procedures performed by EM residents during the initial year of the pandemic. Methods This study utilized a multicenter retrospective design. Across three EM residency programs, logs of 14 ACGME-required procedures performed by residents were reviewed. For each procedure, counts were compared prepandemic year (March 2019 to February 2020) to during pandemic year (March 2020 to February 2021). Procedures were further grouped into 4-month periods: March to June, July to October, and November to February. Results A total of 113 EM resident physicians were included in this study. Procedures performed by EM residents tended to decrease during the COVID-19 pandemic. There were statistically significant decreases in number of annual cricothyrotomies (2.4 vs. 0.9, p < 0.001) and pediatric trauma resuscitations (5.7 vs. 3.9, p = 0.024). Comparing the first 4-month periods of each year, there were significant decreases in cardiac pacing (6.3 vs. 5.4, p = 0.038), chest tubes (2.2 vs. 1.0, p < 0.001), cricothyrotomies (0.6 vs. 0.1, p = 0.001), intubations (8.2 vs. 4.4, p = 0.002), and pericardiocenteses (1.7 vs. 0.2, p < 0.001). Conclusions The COVID-19 pandemic has led to a decrease in the number of procedures performed per EM resident in many of the domains required by the ACGME. Although only some procedures had statically significant decreases, it remains to be seen if this will lead to decreased resident procedural competency. Further research may be required in this area to determine any such effect.
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Affiliation(s)
- Tony W. Bruno
- Department of Emergency MedicineFlorida Atlantic University Charles E. Schmidt College of MedicineBoca RatonFloridaUSA
| | - Rohan Janwadkar
- Department of Emergency MedicineFlorida Atlantic University Charles E. Schmidt College of MedicineBoca RatonFloridaUSA
| | - Lisa M. Clayton
- Department of Emergency MedicineFlorida Atlantic University Charles E. Schmidt College of MedicineBoca RatonFloridaUSA
| | - Patrick G. Hughes
- Department of Emergency MedicineFlorida Atlantic University Charles E. Schmidt College of MedicineBoca RatonFloridaUSA
| | - Joshua J. Solano
- Department of Emergency MedicineFlorida Atlantic University Charles E. Schmidt College of MedicineBoca RatonFloridaUSA
| | - Richard D. Shih
- Department of Emergency MedicineFlorida Atlantic University Charles E. Schmidt College of MedicineBoca RatonFloridaUSA
| | - Leslie A. Bilello
- Department of Emergency MedicineBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
| | - Mary J. Hughes
- Department of Osteopathic Medical SpecialtiesMichigan State University College of Osteopathic MedicineEast LansingMichiganUSA
| | - Scott M. Alter
- Department of Emergency MedicineFlorida Atlantic University Charles E. Schmidt College of MedicineBoca RatonFloridaUSA
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Kronibus N, Seiler F, Danziger G, Muellenbach RM, Reyher C, Becker AP, Kamphorst M, Rixecker TM, Metz C, Bals R, Lepper PM, Mang S. Respiratory Physiology of COVID-19 and Influenza Associated Acute Respiratory Distress Syndrome. J Clin Med 2022; 11:6237. [PMID: 36362465 PMCID: PMC9657360 DOI: 10.3390/jcm11216237] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/16/2022] [Accepted: 10/19/2022] [Indexed: 09/25/2024] Open
Abstract
Background: There is ongoing debate whether lung physiology of COVID-19-associated acute respiratory distress syndrome (ARDS) differs from ARDS of other origin. Objective: The aim of this study was to analyze and compare how critically ill patients with COVID-19 and Influenza A or B were ventilated in our tertiary care center with or without extracorporeal membrane oxygenation (ECMO). We ask if acute lung failure due to COVID-19 requires different intensive care management compared to conventional ARDS. Methods: 25 patients with COVID-19-associated ARDS were matched to a cohort of 25 Influenza patients treated in our center from 2011 to 2021. Subgroup analysis addressed whether patients on ECMO received different mechanical ventilation than patients without extracorporeal support. Results: Compared to Influenza-associated ARDS, COVID-19 patients had higher ventilatory system compliance (40.7 mL/mbar [31.8-46.7 mL/mbar] vs. 31.4 mL/mbar [13.7-42.8 mL/mbar], p = 0.198), higher ventilatory ratio (1.57 [1.31-1.84] vs. 0.91 [0.44-1.38], p = 0.006) and higher minute ventilation at the time of intubation (mean minute ventilation 10.7 L/min [7.2-12.2 L/min] for COVID-19 vs. 6.0 L/min [2.5-10.1 L/min] for Influenza, p = 0.013). There were no measurable differences in P/F ratio, positive end-expiratory pressure (PEEP) and driving pressures (ΔP). Respiratory system compliance deteriorated considerably in COVID-19 patients on ECMO during 2 weeks of mechanical ventilation (Crs, mean decrease over 2 weeks -23.87 mL/mbar ± 32.94 mL/mbar, p = 0.037) but not in ventilated Influenza patients on ECMO and less so in ventilated COVID-19 patients without ECMO. For COVID-19 patients, low driving pressures on ECMO were strongly correlated to a decline in compliance after 2 weeks (Pearson's R 0.80, p = 0.058). Overall mortality was insignificantly lower for COVID-19 patients compared to Influenza patients (40% vs. 48%, p = 0.31). Outcome was insignificantly worse for patients requiring veno-venous ECMO in both groups (50% mortality for COVID-19 on ECMO vs. 27% without ECMO, p = 0.30/56% vs. 34% mortality for Influenza A/B with and without ECMO, p = 0.31). Conclusion: The pathophysiology of early COVID-19-associated ARDS differs from Influenza-associated acute lung failure by sustained respiratory mechanics during the early phase of ventilation. We question whether intubated COVID-19 patients on ECMO benefit from extremely low driving pressures, as this appears to accelerate derecruitment and consecutive loss of ventilatory system compliance.
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Affiliation(s)
- Niklas Kronibus
- Interdisciplinary COVID-19-Center, University Medical Centre, Saarland University, 66421 Homburg, Germany
- Department of Internal Medicine V–Pneumology, Allergology, Critical Care and ECMO/ECLS Center Saar, University Medical Centre, Saarland University, 66421 Homburg, Germany
| | - Frederik Seiler
- Interdisciplinary COVID-19-Center, University Medical Centre, Saarland University, 66421 Homburg, Germany
- Department of Internal Medicine V–Pneumology, Allergology, Critical Care and ECMO/ECLS Center Saar, University Medical Centre, Saarland University, 66421 Homburg, Germany
| | - Guy Danziger
- Interdisciplinary COVID-19-Center, University Medical Centre, Saarland University, 66421 Homburg, Germany
- Department of Internal Medicine V–Pneumology, Allergology, Critical Care and ECMO/ECLS Center Saar, University Medical Centre, Saarland University, 66421 Homburg, Germany
| | - Ralf M. Muellenbach
- Department of Anesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, 34125 Kassel, Germany
| | - Christian Reyher
- Department of Anesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, 34125 Kassel, Germany
| | - André P. Becker
- Interdisciplinary COVID-19-Center, University Medical Centre, Saarland University, 66421 Homburg, Germany
- Department of Internal Medicine V–Pneumology, Allergology, Critical Care and ECMO/ECLS Center Saar, University Medical Centre, Saarland University, 66421 Homburg, Germany
| | - Maren Kamphorst
- Interdisciplinary COVID-19-Center, University Medical Centre, Saarland University, 66421 Homburg, Germany
- Department of Internal Medicine V–Pneumology, Allergology, Critical Care and ECMO/ECLS Center Saar, University Medical Centre, Saarland University, 66421 Homburg, Germany
| | - Torben M. Rixecker
- Interdisciplinary COVID-19-Center, University Medical Centre, Saarland University, 66421 Homburg, Germany
- Department of Internal Medicine V–Pneumology, Allergology, Critical Care and ECMO/ECLS Center Saar, University Medical Centre, Saarland University, 66421 Homburg, Germany
| | - Carlos Metz
- Interdisciplinary COVID-19-Center, University Medical Centre, Saarland University, 66421 Homburg, Germany
- Department of Internal Medicine V–Pneumology, Allergology, Critical Care and ECMO/ECLS Center Saar, University Medical Centre, Saarland University, 66421 Homburg, Germany
| | - Robert Bals
- Interdisciplinary COVID-19-Center, University Medical Centre, Saarland University, 66421 Homburg, Germany
- Department of Internal Medicine V–Pneumology, Allergology, Critical Care and ECMO/ECLS Center Saar, University Medical Centre, Saarland University, 66421 Homburg, Germany
| | - Philipp M. Lepper
- Interdisciplinary COVID-19-Center, University Medical Centre, Saarland University, 66421 Homburg, Germany
- Department of Internal Medicine V–Pneumology, Allergology, Critical Care and ECMO/ECLS Center Saar, University Medical Centre, Saarland University, 66421 Homburg, Germany
| | - Sebastian Mang
- Interdisciplinary COVID-19-Center, University Medical Centre, Saarland University, 66421 Homburg, Germany
- Department of Internal Medicine V–Pneumology, Allergology, Critical Care and ECMO/ECLS Center Saar, University Medical Centre, Saarland University, 66421 Homburg, Germany
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9
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Rehman S, Shahiman MA, Khaleel MA, Holý O. Does the intubation timeline affect the in-hospital mortality of COVID-19 patients? A retrospective cohort study. Front Med (Lausanne) 2022; 9:1023229. [PMID: 36275820 PMCID: PMC9582598 DOI: 10.3389/fmed.2022.1023229] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 09/13/2022] [Indexed: 11/18/2022] Open
Abstract
Background Effective strategies for managing coronavirus disease 19 (COVID-19) patients suffering from acute respiratory distress are constantly evolving. The timeline and threshold for transitioning from non-invasive ventilation to intermittent mandatory ventilation in critical cases who develop COVID-19-related respiratory distress are undetermined. The present research intends to investigate if emergency room intubations in COVID-19 patients affect mortality. Methods Between January 1, 2021 and June 30, 2021, we retrospectively reviewed chart analysis on all patients with confirmed positive COVID-19 screening and who underwent endotracheal intubation. Depending on when the intubation was performed; early in the emergency room or delayed outside the emergency room, patients were separated into two cohorts. In addition to comorbid clinical manifestations, the quick sequential organ failure assessment (qSOFA) score, and in-hospital mortality were all recorded as demographic and clinical information. Results Fifty-eight of the 224 corona-positive patients who underwent intubation had their intubations performed in the emergency room. Age, sex, alcohol use, and smoking status did not significantly differ between the two categories at the baseline. The mean qSOFA score was higher in the early intubation cohort (3.5; p < 0.000) along with more underlying comorbidities (3.0; p < 0.000). When compared to the late intubation cohort (45.78%), patients treated with early intubation had a significantly greater death rate (67.24%). Conclusion In summary, we discovered that patients who underwent intubation in the emergency units exhibited a high quick SOFA score as well as maximum co-morbid conditions than patients intubated somewhere else in the hospital. The findings of our investigation imply that intubating patients too early might be risky.
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Affiliation(s)
- Shazia Rehman
- Department of Biomedical Sciences, Pak-Austria Fachhochschule, Institute of Applied Sciences and Technology, Haripur, Pakistan
| | - Muhammad Ali Shahiman
- Department of Urology, and Renal Transplantation, Benazir Bhutto Hospital, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Mundher A. Khaleel
- Department of Mathematics, College of Computer Science and Mathematics, Tikrit University, Tikrit, Iraq
| | - Ondřej Holý
- Science and Research Center, Faculty of Health Sciences, Palacký University Olomouc, Olomouc, Czechia,*Correspondence: Ondřej Holý
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Posición prono en respiración espontánea: una lección más del COVID-19. ACTA COLOMBIANA DE CUIDADO INTENSIVO 2022. [PMCID: PMC8841222 DOI: 10.1016/j.acci.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Con la pandemia se implementaron diversas estrategias para evitar la intubación y la ventilación mecánica invasiva. La posición prona tiene claros efectos benéficos en mejorar la oxigenación por diversos mecanismos al tiempo que genera cambios hemodinámicos que pueden optimizar la función del ventrículo derecho. La evidencia de la posición prona en pacientes con síndrome de dificultad respiratoria aguda en ventilación mecánica invasiva es contundente y obliga a considerarla en las primeras 24 h de pacientes con PaO2/FiO2 ≤ 150 mmHg. La posición prona en respiración espontánea puede mejorar la oxigenación en pacientes con falla respiratoria y si se implementa mediante un protocolo que incluya una adecuada selección de pacientes puede evitar la intubación de pacientes en falla respiratoria. La presente revisión resume los antecedentes históricos, las bases fisiológicas de la posición prona en el paciente despierto, así como la evidencia que evalúa su aplicación en el paciente con COVID-19 al tiempo que resume el protocolo y la experiencia de un centro con esta estrategia como propuesta para estudios multicéntricos.
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11
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Yamamoto R, Kaito D, Homma K, Endo A, Tagami T, Suzuki M, Umetani N, Yagi M, Nashiki E, Suhara T, Nagata H, Kabata H, Fukunaga K, Yamakawa K, Hayakawa M, Ogura T, Hirayama A, Yasunaga H, Sasaki J. Early intubation and decreased in-hospital mortality in patients with coronavirus disease 2019. Crit Care 2022; 26:124. [PMID: 35524282 PMCID: PMC9073819 DOI: 10.1186/s13054-022-03995-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/27/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Some academic organizations recommended that physicians intubate patients with COVID-19 with a relatively lower threshold of oxygen usage particularly in the early phase of pandemic. We aimed to elucidate whether early intubation is associated with decreased in-hospital mortality among patients with novel coronavirus disease 2019 (COVID-19) who required intubation. METHODS A multicenter, retrospective, observational study was conducted at 66 hospitals in Japan where patients with moderate-to-severe COVID-19 were treated between January and September 2020. Patients who were diagnosed as COVID-19 with a positive reverse-transcription polymerase chain reaction test and intubated during admission were included. Early intubation was defined as intubation conducted in the setting of ≤ 6 L/min of oxygen usage. In-hospital mortality was compared between patients with early and non-early intubation. Inverse probability weighting analyses with propensity scores were performed to adjust patient demographics, comorbidities, hemodynamic status on admission and time at intubation, medications before intubation, severity of COVID-19, and institution characteristics. Subgroup analyses were conducted on the basis of age, severity of hypoxemia at intubation, and days from admission to intubation. RESULTS Among 412 patients eligible for the study, 110 underwent early intubation. In-hospital mortality was lower in patients with early intubation than those with non-early intubation (18 [16.4%] vs. 88 [29.1%]; odds ratio, 0.48 [95% confidence interval 0.27-0.84]; p = 0.009, and adjusted odds ratio, 0.28 [95% confidence interval 0.19-0.42]; p < 0.001). The beneficial effects of early intubation were observed regardless of age and severity of hypoxemia at time of intubation; however, early intubation was associated with lower in-hospital mortality only among patients who were intubated later than 2 days after admission. CONCLUSIONS Early intubation in the setting of ≤ 6 L/min of oxygen usage was associated with decreased in-hospital mortality among patients with COVID-19 who required intubation. Trial Registration None.
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Affiliation(s)
- Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582 Japan
| | - Daiki Kaito
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582 Japan
| | - Koichiro Homma
- Department of Emergency and Critical Care Medicine, Nippon Medical School Musashikosugi Hospital, Kawasaki, Kanagawa Japan
| | - Akira Endo
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Musashikosugi Hospital, Kawasaki, Kanagawa Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Morio Suzuki
- Department of Emergency and Critical Care Medicine, Kawakita General Hospital, Tokyo, Japan
| | - Naoyuki Umetani
- Department of Emergency and Critical Care Medicine, Kawakita General Hospital, Tokyo, Japan
| | - Masayuki Yagi
- Emergency Medicine and Acute Care Surgery, Matsudo City General Hospital, Chiba, Japan
| | - Eisaku Nashiki
- Department of Emergency and Critical Care Medicine, Yokohama City Minato Red Cross Hospital, Yokohama, Kanagawa Japan
| | - Tomohiro Suhara
- Department of Anesthesiology, Keio University School of Medicine, Tokyo, Japan
| | - Hiromasa Nagata
- Department of Anesthesiology, Keio University School of Medicine, Tokyo, Japan
| | - Hiroki Kabata
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Koichi Fukunaga
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kazuma Yamakawa
- Department of Emergency Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Hokkaido Japan
| | - Takayuki Ogura
- Department of Emergency Medicine and Critical Care Medicine, Tochigi Prefectural Emergency and Critical Care Centre, Imperial Foundation Saiseikai Utsunomiya Hospital, Tochigi, Japan
| | - Atsushi Hirayama
- Public Health, Department of Social Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582 Japan
| | - the J-RECOVER study group
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582 Japan
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital, Tokyo, Japan
- Department of Emergency and Critical Care Medicine, Nippon Medical School Musashikosugi Hospital, Kawasaki, Kanagawa Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
- Department of Emergency and Critical Care Medicine, Kawakita General Hospital, Tokyo, Japan
- Emergency Medicine and Acute Care Surgery, Matsudo City General Hospital, Chiba, Japan
- Department of Emergency and Critical Care Medicine, Yokohama City Minato Red Cross Hospital, Yokohama, Kanagawa Japan
- Department of Anesthesiology, Keio University School of Medicine, Tokyo, Japan
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
- Department of Emergency Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Hokkaido Japan
- Department of Emergency Medicine and Critical Care Medicine, Tochigi Prefectural Emergency and Critical Care Centre, Imperial Foundation Saiseikai Utsunomiya Hospital, Tochigi, Japan
- Public Health, Department of Social Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
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12
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Chao KY, Wang JS, Liu WL. Role of helmet ventilation during the 2019 coronavirus disease pandemic. Sci Prog 2022; 105:368504221092891. [PMID: 35404163 PMCID: PMC9006090 DOI: 10.1177/00368504221092891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Coronavirus disease 2019 (COVID-19) has been declared a pandemic by the World Health Organization; it has affected millions of people and caused hundreds of thousands of deaths. Patients with COVID-19 pneumonia may develop acute hypoxia respiratory failure and require noninvasive respiratory support or invasive respiratory management. Healthcare workers have a high risk of contracting COVID-19 while fitting respiratory devices. Recently, European experts have suggested that the use of helmet continuous positive airway pressure should be the first choice for acute hypoxia respiratory failure caused by COVID-19 because it reduces the spread of the virus in the ambient air. By contrast, in the United States, helmets were restricted for respiratory care before the COVID-19 pandemic until the Food and Drug Administration provided the ‘Umbrella Emergency Use Authorization for Ventilators and Ventilator Accessories’. This narrative review provides an evidence-based overview of the use of helmet ventilation for patients with respiratory failure.
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Affiliation(s)
- Ke-Yun Chao
- Department of Respiratory Therapy, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City, Taiwan
- School of Physical Therapy, Graduate Institute of Rehabilitation Sciences, Chang Gung University, Taoyuan, Taiwan
| | - Jong-Shyan Wang
- Department of Physical Medicine and Rehabilitation, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
- Department of Physical Therapy, College of Medicine, Graduate Institute of Rehabilitation Science, Chang Gung University, Taoyuan, Taiwan
- Research Center for Chinese Herbal Medicine, College of Human Ecology, Chang Gung University of Science and Technology, Taoyuan, Taiwan
| | - Wei-Lun Liu
- Department of Emergency and Critical Care Medicine, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City, Taiwan
- Data Science Center, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
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13
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Brandi N, Ciccarese F, Rimondi MR, Balacchi C, Modolon C, Sportoletti C, Renzulli M, Coppola F, Golfieri R. An Imaging Overview of COVID-19 ARDS in ICU Patients and Its Complications: A Pictorial Review. Diagnostics (Basel) 2022; 12:846. [PMID: 35453894 PMCID: PMC9032937 DOI: 10.3390/diagnostics12040846] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 03/23/2022] [Accepted: 03/28/2022] [Indexed: 01/08/2023] Open
Abstract
A significant proportion of patients with COVID-19 pneumonia could develop acute respiratory distress syndrome (ARDS), thus requiring mechanical ventilation, and resulting in a high rate of intensive care unit (ICU) admission. Several complications can arise during an ICU stay, from both COVID-19 infection and the respiratory supporting system, including barotraumas (pneumothorax and pneumomediastinum), superimposed pneumonia, coagulation disorders (pulmonary embolism, venous thromboembolism, hemorrhages and acute ischemic stroke), abdominal involvement (acute mesenteric ischemia, pancreatitis and acute kidney injury) and sarcopenia. Imaging plays a pivotal role in the detection and monitoring of ICU complications and is expanding even to prognosis prediction. The present pictorial review describes the clinicopathological and radiological findings of COVID-19 ARDS in ICU patients and discusses the imaging features of complications related to invasive ventilation support, as well as those of COVID-19 itself in this particularly fragile population. Radiologists need to be familiar with COVID-19's possible extra-pulmonary complications and, through reliable and constant monitoring, guide therapeutic decisions. Moreover, as more research is pursued and the pathophysiology of COVID-19 is increasingly understood, the role of imaging must evolve accordingly, expanding from the diagnosis and subsequent management of patients to prognosis prediction.
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Affiliation(s)
- Nicolò Brandi
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (F.C.); (C.B.); (M.R.); (F.C.); (R.G.)
| | - Federica Ciccarese
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (F.C.); (C.B.); (M.R.); (F.C.); (R.G.)
| | - Maria Rita Rimondi
- Cardio-Thoracic Radiology Unit, University Hospital S.Orsola-Malpighi, 40138 Bologna, Italy; (M.R.R.); (C.M.); (C.S.)
| | - Caterina Balacchi
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (F.C.); (C.B.); (M.R.); (F.C.); (R.G.)
| | - Cecilia Modolon
- Cardio-Thoracic Radiology Unit, University Hospital S.Orsola-Malpighi, 40138 Bologna, Italy; (M.R.R.); (C.M.); (C.S.)
| | - Camilla Sportoletti
- Cardio-Thoracic Radiology Unit, University Hospital S.Orsola-Malpighi, 40138 Bologna, Italy; (M.R.R.); (C.M.); (C.S.)
| | - Matteo Renzulli
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (F.C.); (C.B.); (M.R.); (F.C.); (R.G.)
| | - Francesca Coppola
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (F.C.); (C.B.); (M.R.); (F.C.); (R.G.)
- Italian Society of Medical and Interventional Radiology, SIRM Foundation, Via della Signora 2, 20122 Milano, Italy
| | - Rita Golfieri
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (F.C.); (C.B.); (M.R.); (F.C.); (R.G.)
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Küçük M, Ergan B, Yakar MN, Ergün B, Akdoğan Y, Cantürk A, Gezer NS, Kalkan F, Yaka E, Cömert B, Gökmen NA. The Predictive Values of Respiratory Rate Oxygenation Index and Chest Computed Tomography Severity Score for High-Flow Nasal Oxygen Failure in Critically Ill Patients with Coronavirus Disease-2019. Balkan Med J 2022; 39:140-147. [PMID: 35330565 PMCID: PMC8941223 DOI: 10.4274/balkanmedj.galenos.2021.2021-7-32] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 12/12/2021] [Indexed: 12/01/2022] Open
Abstract
Background The prediction of high-flow nasal oxygen (HFNO) failure in patients with coronavirus disease-2019 (COVID-19) having acute respiratory failure (ARF) may prevent delayed intubation and decrease mortality. Aims To define the related risk factors to HFNO failure and hospital mortality. Study Design Retrospective cohort study. Methods To this study, 85 critically ill patients (≥18 years) with COVID-19 related acute kidney injury who were treated with HFNO were enrolled. Treatment success was defined as the de-escalation of the oxygenation support to the conventional oxygen therapies. HFNO therapy failure was determined as the need for invasive mechanical ventilation or death. The patients were divided into HFNO-failure (HFNO-F) and HFNO-success (HFNO-S) groups. Electronic medical records and laboratory data were screened for all patients. Respiratory rate oxygenation (ROX) index on the first hour and chest computed tomography (CT) severity score were calculated. Factors related to HFNO therapy failure and mortality were defined. Results This study assessed 85 patients (median age 67 years, 69.4% male) who were divided into two groups as HFNO success (n = 33) and HFNO failure (n = 52). The respiratory rate oxygenation (ROX) was measured at 1 hour and the computed tomography (CT) score indicated HFNO failure and intubation, with an area under the receiver operating characteristic of 0.695 for the ROX index and 0.628 for the CT score. A ROX index of <3.81 and a CT score of >15 in the first hour of therapy were the predictors of HFNO failure and intubation. Age, Acute Physiology and Chronic Health Evaluation II score, arterial blood gas findings "(i.e., partial pressure of oxygen [PaO2], PaO2 [fraction of inspired oxygen]/SO2 [oxygen saturation] ratio)", and D-dimer levels were also associated with HFNO failure; however, based on logistic regression analysis, a calculated ROX on the first hour of therapy of <3.81 (odds ratio [OR] = 4.78, 95% confidence interval [CI] = 1.75-13.02, P = 0.001) and a chest CT score of >15 (OR = 2.83, 95% CI = 1.01-7.88, P = <0.001) were the only independent risk factors. In logistic regression analysis, a ROX calculated on the first hour of therapy of <3.81 (OR = 4.78, [95% CI = 1.75-13.02], P = 0.001) and a chest CT score of >15 (OR 2.83, 95% CI = 1.01-7.88, P = <0.001) were the independent risk factors for the HFNO failure. The intensive care unit and hospital mortality rates were 80.2% and 82.7%, respectively, in the HFNO failure group. Conclusion The early prediction of HFNO therapy failure is essential considering the high mortality rate in patients with HFNO therapy failure. Using the ROX index and the chest CT severity score combined with the other clinical parameters may reduce mortality. Additionally, multi-centre observational studies are needed to define the predictive value of ROX and chest CT score not only for COVID-19 but also other causes of ARF.
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Affiliation(s)
- Murat Küçük
- Department of Internal Medicine, Division of Intensive Care, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Begüm Ergan
- Department of Pulmonary and Critical Care, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Mehmet Nuri Yakar
- Department of Anaesthesiology and Reanimation, Division of Intensive Care and Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Bişar Ergün
- Department of Internal Medicine, Division of Intensive Care, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Yunus Akdoğan
- Department of Statistics, Faculty of Science, Selçuk University, Konya, Turkey
| | - Ali Cantürk
- Department of Radiology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Naciye Sinem Gezer
- Department of Radiology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Fahreddin Kalkan
- Department of Actuarial Sciences, Faculty of Science, Selçuk University, Konya, Turkey
| | - Erdem Yaka
- Department of Neurology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Bilgin Cömert
- Department of Internal Medicine, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Necati Ali Gökmen
- Department of Anaesthesiology and Reanimation, Division of Intensive Care and Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
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15
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Comparison of Early and Late Intubation in COVID-19 and Its Effect on Mortality. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19053075. [PMID: 35270767 PMCID: PMC8910588 DOI: 10.3390/ijerph19053075] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/16/2022] [Accepted: 03/03/2022] [Indexed: 01/08/2023]
Abstract
Background: Best practices for management of COVID-19 patients with acute respiratory failure continue to evolve. Initial debate existed over whether patients should be intubated in the emergency department or trialed on noninvasive methods prior to intubation outside the emergency department. Objectives: To determine whether emergency department intubations in COVID-19 affect mortality. Methods: We conducted a retrospective observational chart review of patients who had a confirmed positive COVID-19 test and required endotracheal intubation during their hospital course between 1 March 2020 and 1 June 2020. Patients were divided into two groups based on location of intubation: early intubation in the emergency department or late intubation performed outside the emergency department. Clinical and demographic information was collected including comorbid medical conditions, qSOFA score, and patient mortality. Results: Of the 131 COVID-19-positive patients requiring intubation, 30 (22.9%) patients were intubated in the emergency department. No statistically significant difference existed in age, gender, ethnicity, or smoking status between the two groups at baseline. Patients in the early intubation cohort had a greater number of existing comorbidities (2.5, p = 0.06) and a higher median qSOFA score (3, p ≤ 0.001). Patients managed with early intubation had a statistically significant higher mortality rate (19/30, 63.3%) compared to the late intubation group (42/101, 41.6%). Conclusion: COVID-19 patients intubated in the emergency department had a higher qSOFA score and a greater number of pre-existing comorbidities. All-cause mortality in COVID-19 was greater in patients intubated in the emergency department compared to patients intubated outside the emergency department.
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16
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Defining Failure of Noninvasive Ventilation for Acute Respiratory Distress Syndrome: Have We Succeeded? Ann Am Thorac Soc 2022; 19:167-169. [PMID: 35103563 PMCID: PMC8867363 DOI: 10.1513/annalsats.202109-1059ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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17
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Olanipekun T, Abe T, Sobukonla T, Tamizharasu J, Gamo L, Kuete NT, Bakinde N, Westney G, Snyder RH. Association between race and risk of ICU mortality in mechanically ventilated COVID-19 patients at a safety net hospital. J Natl Med Assoc 2022; 114:18-25. [PMID: 34615602 PMCID: PMC8443330 DOI: 10.1016/j.jnma.2021.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 08/09/2021] [Accepted: 09/11/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE To determine racial differences in intensive care unit (ICU) mortality outcomes among mechanically ventilated patients with severe coronavirus disease 2019 (COVID-19) infection in a safety net hospital. METHODS We retrospectively analyzed a cohort of patients ≥ 18 years old with confirmed severe acute respiratory syndrome-CoV-2 disease associated respiratory failure who were treated with invasive mechanical ventilation and admitted to the ICU from May 1, 2020 - July 30 -2020 at Grady Memorial Hospital, Atlanta, Georgia - a safety net hospital. We evaluated the association between mortality and demographics, co-morbidities, inpatient laboratory, and radiological parameters. RESULTS Among 181 critically ill mechanically ventilated African American patients treated at a safety net hospital, the mortality rate was 33%. On stratified analysis by race (Table 2), mortality rates were significantly higher in African Americans (39%) and Hispanics (26.3%), compared to Whites (18.9%). On multivariate regression, African Americans were 3 times more likely to die in the ICU compared to Whites (OR 3.1 95% CI 1.6 -5.5). Likewise, the likelihood of mortality was higher in Hispanics compared to Whites (OR 1.3 95% CI 1.0 -3.9). CONCLUSIONS Our study demonstrated a high ICU mortality rate in a cohort of mechanically ventilated patients with severe COVID-19 infection treated at a safety net hospital. African Americans and Hispanics had significantly higher risks of ICU mortality compared to Whites. These study findings further elucidate the disproportionately higher burden of COVID-19 infection in African Americans and Hispanics.
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Affiliation(s)
- Titilope Olanipekun
- Department of Hospital Medicine, Covenant Health System, Knoxville, TN, United States.
| | - Temidayo Abe
- Department of Internal Medicine, Morehouse School of Medicine, Atlanta, GA, United States
| | - Timothy Sobukonla
- Department of Internal Medicine, Morehouse School of Medicine, Atlanta, GA, United States
| | - Jothika Tamizharasu
- Department of Internal Medicine, Morehouse School of Medicine, Atlanta, GA, United States
| | - Linda Gamo
- Department of Internal Medicine, Morehouse School of Medicine, Atlanta, GA, United States
| | - Nelson T Kuete
- Department of Internal Medicine, Morehouse School of Medicine, Atlanta, GA, United States
| | - Nicolas Bakinde
- Department of Internal Medicine, Morehouse School of Medicine, Atlanta, GA, United States
| | - Gloria Westney
- Department of Internal Medicine, Morehouse School of Medicine, Atlanta, GA, United States; Division of Pulmonary and Critical Care Medicine, Morehouse School of Medicine, Atlanta, GA, United States
| | - Richard H Snyder
- Department of Internal Medicine, Morehouse School of Medicine, Atlanta, GA, United States; Division of Pulmonary and Critical Care Medicine, Morehouse School of Medicine, Atlanta, GA, United States
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Ahmad Q, Green A, Chandel A, Lantry J, Desai M, Simou J, Osborn E, Singh R, Puri N, Moran P, Dalton H, Speir A, King C. Impact of Noninvasive Respiratory Support in Patients With COVID-19 Requiring V-V ECMO. ASAIO J 2022; 68:171-177. [PMID: 35089261 PMCID: PMC8796828 DOI: 10.1097/mat.0000000000001626] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The impact of the duration of noninvasive respiratory support (RS) including high-flow nasal cannula and noninvasive ventilation before the initiation of extracorporeal membrane oxygenation (ECMO) is unknown. We reviewed data of patients with coronavirus disease 2019 (COVID-19) treated with V-V ECMO at two high-volume tertiary care centers. Survival analysis was used to compare the effect of duration of RS on liberation from ECMO. A total of 78 patients required ECMO and the median duration of RS and invasive mechanical ventilation (IMV) before ECMO was 2 days (interquartile range [IQR]: 0, 6) and 2.5 days (IQR: 1, 5), respectively. The median duration of ECMO support was 24 days (IQR: 11, 73) and 59.0% (N = 46) remained alive at the time of censure. Patients that received RS for ≥3 days were significantly less likely to be liberated from ECMO (HR: 0.46; 95% CI: 0.26-0.83), IMV (HR: 0.42; 95% CI: 0.20-0.89) or be discharged from the hospital (HR: 0.52; 95% CI: 0.27-0.99) compared to patients that received RS for <3 days. There was no difference in hospital mortality between the groups (HR: 1.12; 95% CI: 0.56-2.26). These relationships persisted after adjustment for age, gender, and duration of IMV. Prolonged duration of RS before ECMO may result in lung injury and worse subsequent outcomes.
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Affiliation(s)
- Qamar Ahmad
- From the *Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, Virginia
| | - Adam Green
- Division of Critical Care Medicine, Cooper University Healthcare, Camden, New Jersey
| | - Abhimanyu Chandel
- Division of Pulmonary and Critical Care Medicine, Walter Reed National Medical Center, Bethesda, Maryland
| | - James Lantry
- Department of Pulmonary and Critical Care Medicine, INOVA Health System, Falls Church, Virginia
| | - Mehul Desai
- Department of Pulmonary and Critical Care Medicine, INOVA Health System, Falls Church, Virginia
| | - Jikerkhoun Simou
- Department of Pulmonary and Critical Care Medicine, INOVA Health System, Falls Church, Virginia
| | - Erik Osborn
- Department of Pulmonary and Critical Care Medicine, INOVA Health System, Falls Church, Virginia
| | - Ramesh Singh
- Cardiothoracic Surgery, INOVA Health System, Falls Church, Virginia
| | - Nitin Puri
- Division of Critical Care Medicine, Cooper University Healthcare, Camden, New Jersey
| | - Patrick Moran
- Cardiothoracic Surgery, INOVA Health System, Falls Church, Virginia
- Innovative ECMO Solutions
| | - Heidi Dalton
- Department of Pulmonary and Critical Care Medicine, INOVA Health System, Falls Church, Virginia
| | - Alan Speir
- Cardiothoracic Surgery, INOVA Health System, Falls Church, Virginia
| | - Christopher King
- Department of Pulmonary and Critical Care Medicine, INOVA Health System, Falls Church, Virginia
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19
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Mu SC, Chien YH, Lai PZ, Chao KY. Helmet Ventilation for Pediatric Patients During the COVID-19 Pandemic: A Narrative Review. Front Pediatr 2022; 10:839476. [PMID: 35186812 PMCID: PMC8847782 DOI: 10.3389/fped.2022.839476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 01/11/2022] [Indexed: 12/15/2022] Open
Abstract
The air dispersion of exhaled droplets from patients is currently considered a major route of coronavirus disease 2019 (COVID-19) transmission, the use of non-invasive ventilation (NIV) should be more cautiously employed during the COVID-19 pandemic. Recently, helmet ventilation has been identified as the optimal treatment for acute hypoxia respiratory failure caused by COVID-19 due to its ability to deliver NIV respiratory support with high tolerability, low air leakage, and improved seal integrity. In the present review, we provide an evidence-based overview of the use of helmet ventilation in children with respiratory failure.
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Affiliation(s)
- Shu-Chi Mu
- Department of Pediatrics, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan.,School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Yu-Hsuan Chien
- Department of Pediatrics, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan.,Department of Pediatrics, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Pin-Zhen Lai
- Department of Respiratory Therapy, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Ke-Yun Chao
- Department of Respiratory Therapy, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City, Taiwan.,School of Physical Therapy, Graduate Institute of Rehabilitation Sciences, Chang Gung University, Taoyuan, Taiwan
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20
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Dhala A, Gotur D, Hsu SHL, Uppalapati A, Hernandez M, Alegria J, Masud F. A Year of Critical Care: The Changing Face of the ICU During COVID-19. Methodist Debakey Cardiovasc J 2021; 17:31-42. [PMID: 35855452 PMCID: PMC9244858 DOI: 10.14797/mdcvj.1041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 09/17/2021] [Indexed: 11/10/2022] Open
Abstract
During the SARS-CoV-2 pandemic, admissions to hospital intensive care units (ICUs) surged, exerting unprecedented stress on ICU resources and operations. The novelty of the highly infectious coronavirus disease 2019 (COVID-19) required significant changes to the way critically ill patients were managed. Houston Methodist’s incident command center team navigated this health crisis by ramping up its bed capacity, streamlining treatment algorithms, and optimizing ICU staffing while ensuring adequate supplies of personal protective equipment (PPE), ventilators, and other ICU essentials. A tele–critical-care program and its infrastructure were deployed to meet the demands of the pandemic. Community hospitals played a vital role in creating a collaborative ecosystem for the treatment and referral of critically ill patients. Overall, the healthcare industry’s response to COVID-19 forced ICUs to become more efficient and dynamic, with improved patient safety and better resource utilization. This article provides an experiential account of Houston Methodist’s response to the pandemic and discusses the resulting impact on the function of ICUs.
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Affiliation(s)
- Atiya Dhala
- Houston Methodist Hospital, Houston, Texas, US
| | - Deepa Gotur
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, US
| | - Steven Huan-Ling Hsu
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, US
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21
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Inkrott JC, White JR. Oxygen Economics: The Use of Heated High-Flow Nasal Oxygen in Air Medical Transport of the Adult Patient. Air Med J 2021; 40:380-384. [PMID: 34794774 PMCID: PMC8266262 DOI: 10.1016/j.amj.2021.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/03/2021] [Accepted: 06/05/2021] [Indexed: 11/22/2022]
Abstract
The use of oxygen via a heated high-flow nasal cannula (HHFNC) in transport of the adult patient experiencing hypoxemic respiratory failure is an emerging and successful adjunct. Although early intubation was thought to be the safest intervention early in the coronavirus disease 2019 pandemic, what we have learned over the past year was that it would serve the patient best to avoid intubation. We discuss an individual case study of a coronavirus disease 2019–infected patient who required subsequent interfacility air transport to our quaternary care facility. This patient presented to the receiving air medical team on HHFNC. Before January 2021, the capability of this program to transport these patients on HHFNC was not possible because our current ventilation platforms had to be upgraded to include the high-flow option and because of the relative infancy of the HHFNC platforms available for adult air transport. The previously noted approach to not intubate these patients, or to certainly use caution when making the decision to intubate, was not the common theme until late in 2020. Presented in this case discussion will be pertinent positive and negatives as they relate to transporting the patient on HHFNC to include the all-important issue of oxygen supply and demand. The authors would emphasize that the named products in this case are simply products used by the receiving air medical program and do not in any way support an endorsement of these products over any other platforms used to provide positive patient interventions and outcomes.
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Affiliation(s)
- Jon C Inkrott
- Department of Flight Medicine and Emergency Medical Services, AdventHealth Orlando, Flight 1, Orlando, FL.
| | - Jason R White
- Department of Flight Medicine and Emergency Medical Services, AdventHealth Orlando, Flight 1, Orlando, FL
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22
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Nitesh J, Kashyap R, Surani SR. What we learned in the past year in managing our COVID-19 patients in intensive care units? World J Crit Care Med 2021; 10:81-101. [PMID: 34316444 PMCID: PMC8291007 DOI: 10.5492/wjccm.v10.i4.81] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/07/2021] [Accepted: 05/17/2021] [Indexed: 02/06/2023] Open
Abstract
Coronavirus disease 2019 is a pandemic, was first recognized at Wuhan province, China in December 2019. The disease spread quickly across the globe, spreading stealthily from human to human through both symptomatic and asymptomatic individuals. A multisystem disease which appears to primarily spread via bio aerosols, it has exhibited a wide clinical spectrum involving multiple organ systems with the respiratory system pathology being the prime cause of morbidity and mortality. Initially unleashing a huge destructive trail at Wuhan China, Lombardy Italy and New York City, it has now spread to all parts of the globe and has actively thrived and mutated into new forms. Health care systems and Governments responded initially with panic, with containment measures giving way to mitigation strategies. The global medical and scientific community has come together and responded to this huge challenge. Professional medical societies quickly laid out "expert" guidelines which were conservative in their approach. Many drugs were re formulated and tested quickly with the help of national and international collaborative groups, helping carve out effective treatment strategies and help build a good scientific foundation for evidence-based medicine. Out of the darkness of chaos, we now have an orderly approach to manage this disease both from a public health preventive and therapeutic standpoint. With preventive measures such as masking and social distancing to the development of highly effective and potent vaccines, the public health success of such measures has been tempered by behavioral responses and resource mobilization. From a therapy standpoint, we now have drugs that were promising but now proven ineffective, and those that are effective when given early during viral pathogenesis or later when immune dysregulation has established, and the goal is to help reign in the destructive cascade. It has been a fascinating journey for mankind and our work here recapitulates the evolution of various aspects of critical care and other inpatient practices which continue to evolve.
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Affiliation(s)
- Jain Nitesh
- Department of Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Rahul Kashyap
- Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, United States
| | - Salim R Surani
- Department of Medicine, Texas A&M University, Corpus Christi, TX 78404, United States
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23
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Early Intubation and Increased Coronavirus Disease 2019 Mortality: A Propensity Score-Matched Retrospective Cohort Study. Crit Care Explor 2021; 3:e0452. [PMID: 34151281 PMCID: PMC8208412 DOI: 10.1097/cce.0000000000000452] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Supplemental Digital Content is available in the text. Objectives: There has been controversy about the timing and indications for intubation and mechanical ventilation in novel coronavirus disease 2019. This study assessed the effect of early intubation and mechanical ventilation on all-cause, inhospital mortality for coronavirus disease 2019 patients. Design: Multicenter retrospective cohort study. Setting: Eleven municipal hospitals in New York City from March 1, 2020, to December 1, 2020. Patients: Adult patients who tested positive for coronavirus disease 2019 in the emergency department were subsequently admitted. Patients with do-not-intubate orders at admission were excluded. Interventions: Intubation within 48 hours of triage and intubation at any point during hospital stay. Measurements and Main Results: Data from 7,597 coronavirus disease 2019 patients were included; of these, 1,628 (21%) were intubated overall and 807 (11%) were intubated within 48 hours of triage. After controlling for available confounders, intubation rates for coronavirus disease 2019 patients varied significantly across hospitals and decreased steadily as the pandemic progressed. After nearest neighbor propensity score matching, intubation within 48 hours of triage was associated with higher all-cause mortality (hazard ratio, 1.30 [1.15–1.48]; p < 0.0001), as was intubation at any time point (hazard ratio, 1.62 [1.45–1.80]; p < 0.0001). Among intubated patients, intubation within 48 hours of triage was not significantly associated with differences in mortality (hazard ratio, 1.09 [0.94–1.26]; p = 0.26). These results remained robust to multiple sensitivity analyses. CONCLUSIONS: Intubation within 48 hours of triage, as well as at any time point in the hospital course, was associated with increased mortality in coronavirus disease 2019 patients in this observational study.
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24
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Chandel A, Patolia S, Brown AW, Collins AC, Sahjwani D, Khangoora V, Cameron PC, Desai M, Kasarabada A, Kilcullen JK, Nathan SD, King CS. High-Flow Nasal Cannula Therapy in COVID-19: Using the ROX Index to Predict Success. Respir Care 2021; 66:909-919. [PMID: 33328179 DOI: 10.4187/respcare.08631] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Optimal timing of mechanical ventilation in COVID-19 is uncertain. We sought to evaluate outcomes of delayed intubation and examine the ROX index (ie, [[Formula: see text]]/breathing frequency) to predict weaning from high-flow nasal cannula (HFNC) in patients with COVID-19. METHODS We performed a multicenter, retrospective, observational cohort study of subjects with respiratory failure due to COVID-19 and managed with HFNC. The ROX index was applied to predict HFNC success. Subjects that failed HFNC were divided into early HFNC failure (≤ 48 h of HFNC therapy prior to mechanical ventilation) and late failure (> 48 h). Standard statistical comparisons and regression analyses were used to compare overall hospital mortality and secondary end points, including time-specific mortality, need for extracorporeal membrane oxygenation, and ICU length of stay between early and late failure groups. RESULTS 272 subjects with COVID-19 were managed with HFNC. One hundred sixty-four (60.3%) were successfully weaned from HFNC, and 111 (67.7%) of those weaned were managed solely in non-ICU settings. ROX index >3.0 at 2, 6, and 12 hours after initiation of HFNC was 85.3% sensitive for identifying subsequent HFNC success. One hundred eight subjects were intubated for failure of HFNC (61 early failures and 47 late failures). Mortality after HFNC failure was high (45.4%). There was no statistical difference in hospital mortality (39.3% vs 53.2%, P = .18) or any of the secondary end points between early and late HFNC failure groups. This remained true even when adjusted for covariates. CONCLUSIONS In this retrospective review, HFNC was a viable strategy and mechanical ventilation was unecessary in the majority of subjects. In the minority that progressed to mechanical ventilation, duration of HFNC did not differentiate subjects with worse clinical outcomes. The ROX index was sensitive for the identification of subjects successfully weaned from HFNC. Prospective studies in COVID-19 are warranted to confirm these findings and to optimize patient selection for use of HFNC in this disease.
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Affiliation(s)
- Abhimanyu Chandel
- Department of Pulmonary and Critical Care, Walter Reed National Military Medical Center, Bethesda, Maryland.
| | - Saloni Patolia
- Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - A Whitney Brown
- Department of Advanced Lung Disease and Transplant, Inova Fairfax Hospital, Falls Church, Virginia
| | - A Claire Collins
- Advanced Lung Disease Research, Inova Fairfax Hospital, Falls Church, Virginia
| | - Dhwani Sahjwani
- Department of Pediatrics, Inova Fairfax Hospital, Falls Church, Virginia
| | - Vikramjit Khangoora
- Department of Advanced Lung Disease and Transplant, Inova Fairfax Hospital, Falls Church, Virginia
| | - Paula C Cameron
- Respiratory Therapy, Inova Fairfax Hospital, Falls Church, Virginia
| | - Mehul Desai
- Medical Critical Care Service, Inova Fairfax Hospital, Falls Church, Virginia
| | | | - Jack K Kilcullen
- Respiratory Therapy, Inova Fairfax Hospital, Falls Church, Virginia
| | - Steven D Nathan
- Department of Advanced Lung Disease and Transplant, Inova Fairfax Hospital, Falls Church, Virginia
| | - Christopher S King
- Department of Advanced Lung Disease and Transplant, Inova Fairfax Hospital, Falls Church, Virginia
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25
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Oxygenation Strategies in Critically Ill Patients With COVID-19. Dimens Crit Care Nurs 2021; 40:75-82. [PMID: 33961375 DOI: 10.1097/dcc.0000000000000463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Severe acute respiratory syndrome coronavirus 2 is the virus that causes coronavirus disease 2019 (COVID-19). COVID-19 is a disease characterized by a range of clinical syndromes including variable degrees of respiratory symptoms from mild respiratory illness and severe interstitial pneumonia to acute respiratory distress syndrome, septic shock, coagulopathies, and multiorgan dysfunction. This virus carries the potential to manifest in a wide range of pulmonary findings and hypoxemias, from mild respiratory symptoms to more severe syndromes, such as acute respiratory distress syndrome. The rapid accumulation of evidence and persistent gaps in knowledge related to the virus presents a host of challenges for clinicians. This creates a complex environment for clinical decision-making. OBJECTIVE To examine oxygenation strategies in critically ill patients with hypoxia who are hospitalized with COVID-19. DISCUSSION These proposed strategies may help to improve the respiratory status and oxygenation of those affected by COVID-19. However, additional high-quality research is needed to provide further evidence for improved respiratory management strategies. Areas of future research should focus on improving understanding of the inflammatory and clotting processes associated with the virus, particularly in the lungs. High-level evidence and randomized controlled trials should target the most effective strategies for improving oxygenation, time requiring mechanical ventilation, and survival for hospitalized patients with COVID-19 presenting with hypoxemia.
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26
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Braude D, Lauria M, O'Donnell M, Shelly J, Berve M, Torres M, Olvera D, Jarboe S, Mazon A, Dixon D. Safety of air medical transport of patients with COVID-19 by personnel using routine personal protective equipment. J Am Coll Emerg Physicians Open 2021; 2:e12389. [PMID: 33728418 PMCID: PMC7934067 DOI: 10.1002/emp2.12389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 12/27/2020] [Accepted: 01/22/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Air medical transport of patients with known or suspected coronavirus disease 2019 (COVID-19) likely represents a high-risk exposure to crew members as aircraft cabins are quite small resulting in close personal contact. The actual risk to medical crew members is not known. METHODS We conducted an institutional review board-exempt, retrospective study of air medical transport of patients with known or suspected COVID-19 by 8 programs in the Four Corners Region to determine the number of symptomatic COVID-19 among air medical crew members compared to total exposure time. All programs used similar routine personal protective equipment (PPE), including N-95 masks and eye protection. Total exposure time was considered from time of first patient contact until handoff at a receiving hospital. RESULTS There were 616 air transports: 62% by fixed-wing and 38% by rotor-wing aircraft between March 15 and September 6, 2020. Among transported patients, 407 (66%) were confirmed COVID+ and 209 (34%) were under investigation. Patient contact time ranged from 38 to 432 minutes with an average of 140 minutes. The total exposure time for medical crew was 2924 hours; exposure time to confirmed COVID+ patients was 2008 hours. Only 30% of patients were intubated, and the remainder had no oxygen (8%), low-flow nasal cannula (42%), mask (11%), high-flow nasal cannula (4.5%), and continuous positive airway pressure or bilevel positive airway pressure (3.5%). Two flight crew members out of 108 developed COVID that was presumed related to work. CONCLUSIONS Air medical transport of patients with known or suspected COVID-19 using routine PPE is considered effective for protecting medical crew members, even when patients are not intubated. This has implications for health care personnel in any setting that involves care of patients with COVID-19 in similarly confined spaces.
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Affiliation(s)
- Darren Braude
- Lifeguard Air Emergency ServicesDepartment of Emergency MedicineUniversity of New MexicoAlbuquerqueNew MexicoUSA
| | - Michael Lauria
- Lifeguard Air Emergency ServicesDepartment of Emergency MedicineUniversity of New MexicoAlbuquerqueNew MexicoUSA
| | | | | | | | | | | | | | | | - Douglas Dixon
- Lifeguard Air Emergency ServicesDepartment of Emergency MedicineUniversity of New MexicoAlbuquerqueNew MexicoUSA
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27
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Shulman JG, Ford T, Cervantes-Arslanian AM. Neurologic Emergencies during the Coronavirus Disease 2019 Pandemic. Neurol Clin 2021; 39:671-687. [PMID: 33896538 PMCID: PMC7995638 DOI: 10.1016/j.ncl.2021.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Julie G Shulman
- Department of Neurology, Boston University School of Medicine, 72 East Concord Street, Suite C3, Boston, MA 02118, USA.
| | - Thomas Ford
- Department of Neurology, Boston University School of Medicine, 72 East Concord Street, Suite C3, Boston, MA 02118, USA
| | - Anna M Cervantes-Arslanian
- Department of Neurology, Boston University School of Medicine, 72 East Concord Street, Suite C3, Boston, MA 02118, USA; Department of Neurosurgery, Boston University School of Medicine, 725 Albany St, Suite 7C, Boston, MA 02118, USA; Department of Medicine (Infectious Diseases), Boston University School of Medicine, 801 Massachusetts Avenue, Crosstown, 2nd floor, Boston MA 02118, USA
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28
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Mellado-Artigas R, Ferreyro BL, Angriman F, Hernández-Sanz M, Arruti E, Torres A, Villar J, Brochard L, Ferrando C. High-flow nasal oxygen in patients with COVID-19-associated acute respiratory failure. Crit Care 2021; 25:58. [PMID: 33573680 PMCID: PMC7876530 DOI: 10.1186/s13054-021-03469-w] [Citation(s) in RCA: 113] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 01/13/2021] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Whether the use of high-flow nasal oxygen in adult patients with COVID-19 associated acute respiratory failure improves clinically relevant outcomes remains unclear. We thus sought to assess the effect of high-flow nasal oxygen on ventilator-free days, compared to early initiation of invasive mechanical ventilation, on adult patients with COVID-19. METHODS We conducted a multicentre cohort study using a prospectively collected database of patients with COVID-19 associated acute respiratory failure admitted to 36 Spanish and Andorran intensive care units (ICUs). Main exposure was the use of high-flow nasal oxygen (conservative group), while early invasive mechanical ventilation (within the first day of ICU admission; early intubation group) served as the comparator. The primary outcome was ventilator-free days at 28 days. ICU length of stay and all-cause in-hospital mortality served as secondary outcomes. We used propensity score matching to adjust for measured confounding. RESULTS Out of 468 eligible patients, a total of 122 matched patients were included in the present analysis (61 for each group). When compared to early intubation, the use of high-flow nasal oxygen was associated with an increase in ventilator-free days (mean difference: 8.0 days; 95% confidence interval (CI): 4.4 to 11.7 days) and a reduction in ICU length of stay (mean difference: - 8.2 days; 95% CI - 12.7 to - 3.6 days). No difference was observed in all-cause in-hospital mortality between groups (odds ratio: 0.64; 95% CI: 0.25 to 1.64). CONCLUSIONS The use of high-flow nasal oxygen upon ICU admission in adult patients with COVID-19 related acute hypoxemic respiratory failure may lead to an increase in ventilator-free days and a reduction in ICU length of stay, when compared to early initiation of invasive mechanical ventilation. Future studies should confirm our findings.
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Affiliation(s)
- Ricard Mellado-Artigas
- Department of Anesthesiology and Critical Care, Institut D'investigació August Pi I Sunyer, Hospital Clínic, Villarroel 170, 08025, Barcelona, Spain.
| | - Bruno L Ferreyro
- Department of Medicine, Sinai Health System and University Health Network, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Federico Angriman
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - María Hernández-Sanz
- Department of Anesthesiology and Critical Care, Hospital de Cruces, Vizcaya, Spain
| | | | - Antoni Torres
- Department of Respirology, Hospital Clínic, Institut D'investigació August Pi i Sunyer, Barcelona, Spain
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- CIBERESUCICOVID, Instituto de Salud Carlos III, Madrid, Spain
| | - Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Multidisciplinary Organ Dysfunction Evaluation Research Network, Research Unit, Hospital Universitario Dr. Negrin, Las Palmas de Gran Canaria, Spain
- Keenan Research Centre for Biomedical Science at the Li Kan Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Keenan Research Centre for Biomedical Science at the Li Kan Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Carlos Ferrando
- Department of Anesthesiology and Critical Care, Institut D'investigació August Pi I Sunyer, Hospital Clínic, Villarroel 170, 08025, Barcelona, Spain
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
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29
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Emergency Department Management of Severe Hypoxemic Respiratory Failure in Adults With COVID-19. J Emerg Med 2020; 60:729-742. [PMID: 33526308 PMCID: PMC7836534 DOI: 10.1016/j.jemermed.2020.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 11/14/2020] [Accepted: 12/13/2020] [Indexed: 01/19/2023]
Abstract
Background While emergency physicians are familiar with the management of hypoxemic respiratory failure, management of mechanical ventilation and advanced therapies for oxygenation in the emergency department have become essential during the coronavirus disease 2019 (COVID-19) pandemic. Objective We review the current evidence on hypoxemia in COVID-19 and place it in the context of known evidence-based management of hypoxemic respiratory failure in the emergency department. Discussion COVID-19 causes mortality primarily through the development of acute respiratory distress syndrome (ARDS), with hypoxemia arising from shunt, a mismatch of ventilation and perfusion. Management of patients developing ARDS should focus on mitigating derecruitment and avoiding volutrauma or barotrauma. Conclusions High flow nasal cannula and noninvasive positive pressure ventilation have a more limited role in COVID-19 because of the risk of aerosolization and minimal benefit in severe cases, but can be considered. Stable patients who can tolerate repositioning should be placed in a prone position while awake. Once intubated, patients should be managed with ventilation strategies appropriate for ARDS, including targeting lung-protective volumes and low pressures. Increasing positive end-expiratory pressure can be beneficial. Inhaled pulmonary vasodilators do not decrease mortality but may be given to improve refractory hypoxemia. Prone positioning of intubated patients is associated with a mortality reduction in ARDS and can be considered for patients with persistent hypoxemia. Neuromuscular blockade should also be administered in patients who remain dyssynchronous with the ventilator despite adequate sedation. Finally, patients with refractory severe hypoxemic respiratory failure in COVID-19 should be considered for venovenous extracorporeal membrane oxygenation.
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30
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Timing of Intubation and Its Implications on Outcomes in Critically Ill Patients With Coronavirus Disease 2019 Infection. Crit Care Explor 2020; 2:e0262. [PMID: 33134950 PMCID: PMC7587415 DOI: 10.1097/cce.0000000000000262] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Supplemental Digital Content is available in the text. In critically ill patients with coronavirus disease 2019, there has been considerable debate about when to intubate patients with acute respiratory failure. Early expert recommendations supported early intubation. However, as we learned more about this disease, the risks versus benefits of early intubation are less clear. We report our findings from an observational study aimed to compare the difference in outcomes of critically ill patients with coronavirus disease 2019 who were intubated early versus later in the disease course. Early need for intubation was defined as intubation either at admission or within 2 days of having a documented Fio2 greater than or equal to 0.5. In the final sample of 111 patients, 76 (68%) required early intubation. The mean age among those who received early intubation was significantly higher (69.79 ± 12.15 vs 65.03 ± 8.37 years; p = 0.038). Also, the patients who required early intubation had significantly higher Sequential Organ Failure Assessment scores at admission (6.51 vs 3.48; p ≤ 0.0001). The outcomes were equivocal among both groups. In conclusion, we suggest that the timing of intubation has no impact on clinical outcomes among patients with coronavirus disease 2019 pneumonia.
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31
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Singer AJ, Fries BC. COVID-19: challenges and opportunities. Clin Exp Emerg Med 2020; 7:141-143. [PMID: 32683854 PMCID: PMC7550809 DOI: 10.15441/ceem.20.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 06/03/2020] [Accepted: 06/03/2020] [Indexed: 11/23/2022] Open
Affiliation(s)
- Adam J Singer
- Departments of Emergency Medicine and Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Bettina C Fries
- Departments of Emergency Medicine and Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
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