Effects of intubation timing in patients with COVID-19 throughout the four waves of the pandemic: a matched analysis

Association between high-flow nasal cannula use and mortality in patients with sepsis-induced acute lung injury: a retrospective propensity score-matched cohort study

BACKGROUND

High-flow nasal cannula (HFNC) has emerged as a promising noninvasive method for delivering oxygen to critically ill patients, particularly those with sepsis and acute lung injury. However, uncertainties persist regarding its therapeutic benefits in this specific patient population.

METHODS

This retrospective study utilized a propensity score-matched cohort from the Medical Information Mart in Intensive Care-IV (MIMIC-IV) database to explore the correlation between HFNC utilization and mortality in patients with sepsis-induced acute lung injury. The primary outcome was 28-day all-cause mortality.

RESULTS

In the propensity score-matched cohort, the 28-day all-cause mortality rate was 18.63% (95 out of 510) in the HFNC use group, compared to 31.18% (159 out of 510) in the non-HFNC group. The use of HFNC was associated with a lower 28-day all-cause mortality rate (hazard ratio [HR] = 0.53; 95% confidence interval [CI] = 0.41-0.69; P < 0.001). HFNC use was also associated with lower ICU mortality (odds ratio [OR] = 0.52; 95% CI = 0.38-0.71; P < 0.001) and lower in-hospital mortality (OR = 0.51; 95% CI = 0.38-0.68; P < 0.001). Additionally, HFNC use was found to be associated with a statistically significant increase in both the ICU and overall hospitalization length.

CONCLUSIONS

These findings indicate that HFNC may be beneficial for reducing mortality rates among sepsis-induced acute lung injury patients; however, it is also associated with longer hospital stays.

New Guidelines for Severe Community-acquired Pneumonia

In 2023, the new European guidelines on severe community-acquired pneumonia, providing clinical practice recommendations for the management of this life-threatening infection, characterized by a high burden of mortality, morbidity, and costs for the society. This review article aims to summarize the principal evidence related to eight different questions covered in the guidelines, by also highlighting the future perspectives for research activity.

Intubation Decision Based on Illness Severity and Mortality in COVID-19: An International Study

OBJECTIVES

To evaluate the impact of intubation timing, guided by severity criteria, on mortality in critically ill COVID-19 patients, amidst existing uncertainties regarding optimal intubation practices.

DESIGN

Prospective, multicenter, observational study conducted from February 1, 2020, to November 1, 2022.

SETTING

Ten academic institutions in the United States and Europe.

PATIENTS

Adults (≥ 18 yr old) confirmed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and hospitalized specifically for COVID-19, requiring intubation postadmission. Exclusion criteria included patients hospitalized for non-COVID-19 reasons despite a positive SARS-CoV-2 test.

INTERVENTIONS

Early invasive mechanical ventilation (EIMV) was defined as intubation in patients with less severe organ dysfunction (Sequential Organ Failure Assessment [SOFA] < 7 or Pao2/Fio2 ratio > 250), whereas late invasive mechanical ventilation (LIMV) was defined as intubation in patients with SOFA greater than or equal to 7 and Pao2/Fio2 ratio less than or equal to 250.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was mortality within 30 days of hospital admission. Among 4464 patients, 854 (19.1%) required mechanical ventilation (mean age 60 yr, 61.7% male, 19.3% Black). Of those, 621 (72.7%) were categorized in the EIMV group and 233 (27.3%) in the LIMV group. Death within 30 days after admission occurred in 278 patients (42.2%) in the EIMV and 88 patients (46.6%) in the LIMV group (p = 0.28). An inverse probability-of-treatment weighting analysis revealed a statistically significant association with mortality, with patients in the EIMV group being 32% less likely to die either within 30 days of admission (adjusted hazard ratio [HR] 0.68; 95% CI, 0.52-0.90; p = 0.008) or within 30 days after intubation irrespective of its timing from admission (adjusted HR 0.70; 95% CI, 0.51-0.90; p = 0.006).

CONCLUSIONS

In severe COVID-19 cases, an early intubation strategy, guided by specific severity criteria, is associated with a reduced risk of death. These findings underscore the importance of timely intervention based on objective severity assessments.

COVID-19 among undocumented migrants admitted to French intensive care units during the 2020-2021 period: a retrospective nationwide study

BACKGROUND

Before the Coronavirus Disease 2019 (COVID-19) pandemic in France, undocumented migrants had a higher risk than general population for being admitted to the intensive care unit (ICU) because of acute respiratory failure or severe infection. Specific data concerning the impact of COVID-19 on undocumented migrants in France are lacking. We aimed to analyze the mortality and respiratory severity of COVID-19 in this specific population. We retrospectively included all undocumented adult migrants admitted in French ICUs from March 2020 through April 2021 using the French nationwide hospital information system (Programme de Médicalisation des Systèmes d'Information). We focused on admissions related to COVID-19. Undocumented migrants were compared to the general population, first in crude analysis, then after matching on age, severity and main comorbidities. The primary outcome was the ICU mortality from COVID-19. Secondary objectives were the incidence of acute respiratory distress syndrome (ARDS), the need for mechanical ventilation (MV), the duration of MV, ICU and hospital stay.

RESULTS

During the study period, the rate of ICU admission among patients hospitalized for COVID-19 was higher for undocumented migrants than for general population (463/1627 (28.5%) vs. 81 813/344 001 (23.8%); p < 0.001). Although ICU mortality was comparable after matching (14.3% for general population vs. 13.3% for undocumented migrants; p = 0.50), the incidence of ARDS was higher among undocumented migrants (odds ratio, confidence interval (OR (CI)) 1.25 (1.06-1.48); p = 0.01). Undocumented migrants needed more frequently invasive MV (OR (CI) 1.2 (1.01-1.42); p = 0.04 than general population. There were no differences between groups concerning duration of MV, ICU and hospital length of stay.

CONCLUSION

During the first waves of COVID-19 in France, undocumented migrants had a mortality similar to the general population but a higher risk for ICU admission and for developing an ARDS. These results highlight the need for reinforcing prevention and improving primary healthcare access for people in irregular situation.

Development and validation of a prediction model for mechanical ventilation based on comorbidities in hospitalized patients with COVID-19

Background

Timely recognition of respiratory failure and the need for mechanical ventilation is crucial in managing patients with coronavirus disease 2019 (COVID-19) and reducing hospital mortality rate. A risk stratification tool could assist to avoid clinical deterioration of patients with COVID-19 and optimize allocation of scarce resources. Therefore, we aimed to develop a prediction model for early identification of patients with COVID-19 who may require mechanical ventilation.

Methods

We included patients with COVID-19 hospitalized in United States. Demographic and clinical data were extracted from the records of the Healthcare Cost and Utilization Project State Inpatient Database in 2020. Model construction involved the use of the least absolute shrinkage and selection operator and multivariable logistic regression. The model's performance was evaluated based on discrimination, calibration, and clinical utility.

Results

The training set comprised 73,957 patients (5,971 requiring mechanical ventilation), whereas the validation set included 10,428 (887 requiring mechanical ventilation). The prediction model incorporating age, sex, and 11 other comorbidities (deficiency anemias, congestive heart failure, coagulopathy, dementia, diabetes with chronic complications, complicated hypertension, neurological disorders unaffecting movement, obesity, pulmonary circulation disease, severe renal failure, and weight loss) demonstrated moderate discrimination (area under the curve, 0.715; 95% confidence interval, 0.709-0.722), good calibration (Brier score = 0.070, slope = 1, intercept = 0) and a clinical net benefit with a threshold probability ranged from 2 to 34% in the training set. Similar model's performances were observed in the validation set.

Conclusion

A robust prognostic model utilizing readily available predictors at hospital admission was developed for the early identification of patients with COVID-19 who may require mechanical ventilation. Application of this model could support clinical decision-making to optimize patient management and resource allocation.

The Dark Side of Nosocomial Infections in Critically Ill COVID-19 Patients

Coronavirus disease 2019 (COVID-19) is a potentially serious acute respiratory infection caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Since the World Health Organization (WHO) declared COVID-19 a global pandemic, the virus has spread to more than 200 countries with more than 500 million cases and more than 6 million deaths reported globally. It has long been known that viral respiratory tract infections predispose patients to bacterial infections and that these co-infections often have an unfavourable clinical outcome. Moreover, nosocomial infections, also known as healthcare-associated infections (HAIs), are those infections that are absent at the time of admission and acquired after hospitalization. However, the impact of coinfections or secondary infections on the progression of COVID-19 disease and its lethal outcome is still debated. The aim of this review was to assess the literature on the incidence of bacterial co-infections and superinfections in patients with COVID-19. The review also highlights the importance of the rational use of antibiotics in patients with COVID-19 and the need to implement antimicrobial stewardship principles to prevent the transmission of drug-resistant organisms in healthcare settings. Finally, alternative antimicrobial agents to counter the emergence of multidrug-resistant bacteria causing healthcare-associated infections in COVID-19 patients will also be discussed.

Modeling mortality risk in patients with severe COVID-19 from Mexico

Background

Severe acute respiratory syndrome caused by a coronavirus (SARS-CoV-2) is responsible for the COVID-19 disease pandemic that began in Wuhan, China, in December 2019. Since then, nearly seven million deaths have occurred worldwide due to COVID-19. Mexicans are especially vulnerable to the COVID-19 pandemic as Mexico has nearly the worst observed case-fatality ratio (4.5%). As Mexican Latinos represent a vulnerable population, this study aimed to determine significant predictors of mortality in Mexicans with COVID-19 who were admitted to a large acute care hospital.

Methods

In this observational, cross-sectional study, 247 adult patients participated. These patients were consecutively admitted to a third-level referral center in Yucatan, Mexico, from March 1st, 2020, to August 31st, 2020, with COVID-19-related symptoms. Lasso logistic and binary logistic regression were used to identify clinical predictors of death.

Results

After a hospital stay of about eight days, 146 (60%) patients were discharged; however, 40% died by the twelfth day (on average) after hospital admission. Out of 22 possible predictors, five crucial predictors of death were found, ranked by the most to least important: (1) needing to be placed on a mechanical ventilator, (2) reduced platelet concentration at admission, (3) increased derived neutrophil to lymphocyte ratio, (4) increased age, and (5) reduced pulse oximetry saturation at admission. The model revealed that these five variables shared ~83% variance in outcome.

Conclusion

Of the 247 Mexican Latinos patients admitted with COVID-19, 40% died 12  days after admission. The patients' need for mechanical ventilation (due to severe illness) was the most important predictor of mortality, as it increased the odds of death by nearly 200-fold.

Treatment options for patients with severe COVID-19

The coronavirus disease 2019 (COVID-19) pandemic has affected the world for over 3 years. Treatment options have improved substantially during this period, including antiviral drugs, antibody drugs, immune-based agents, and vaccination. While these improvements have reduced mortality rates in patients with COVID-19, some patients still develop severe illness. In this review, we aimed to provide an overview of treatments for patients with severe COVID-19 from study reports and clinical experience. We discussed the treatments from two perspectives: respiratory care and drug treatments. In the respiratory care section, we discussed the usefulness of high-flow nasal cannula therapy and non-invasive ventilation as an alternative to invasive ventilation. In the drug treatments section, we focused on three classes for severe COVID-19 treatment: antiviral drugs, immune-based agents, and anticoagulation therapy. We did not discuss antibody drugs and vaccination, as they are not used for severe COVID-19 treatment.

Timing of intubation and ICU mortality in COVID-19 patients: a retrospective analysis of 4198 critically ill patients during the first and second waves

BACKGROUND

The optimal time to intubate patients with SARS-CoV-2 pneumonia has not been adequately determined. While the use of non-invasive respiratory support before invasive mechanical ventilation might cause patient-self-induced lung injury and worsen the prognosis, non-invasive ventilation (NIV) is frequently used to avoid intubation of patients with acute respiratory failure (ARF). We hypothesized that delayed intubation is associated with a high risk of mortality in COVID-19 patients.

METHODS

This is a secondary analysis of prospectively collected data from adult patients with ARF due to COVID-19 admitted to 73 intensive care units (ICUs) between February 2020 and March 2021. Intubation was classified according to the timing of intubation. To assess the relationship between early versus late intubation and mortality, we excluded patients with ICU length of stay (LOS) < 7 days to avoid the immortal time bias and we did a propensity score and a cox regression analysis.

RESULTS

We included 4,198 patients [median age, 63 (54‒71) years; 71% male; median SOFA (Sequential Organ Failure Assessment) score, 4 (3‒7); median APACHE (Acute Physiology and Chronic Health Evaluation) score, 13 (10‒18)], and median PaO₂/FiO₂ (arterial oxygen pressure/ inspired oxygen fraction), 131 (100‒190)]; intubation was considered very early in 2024 (48%) patients, early in 928 (22%), and late in 441 (10%). ICU mortality was 30% and median ICU stay was 14 (7‒28) days. Mortality was higher in the "late group" than in the "early group" (37 vs. 32%, p < 0.05). The implementation of an early intubation approach was found to be an independent protective risk factor for mortality (HR 0.6; 95%CI 0.5‒0.7).

CONCLUSIONS

Early intubation within the first 24 h of ICU admission in patients with COVID-19 pneumonia was found to be an independent protective risk factor of mortality.

TRIAL REGISTRATION

The study was registered at Clinical-Trials.gov (NCT04948242) (01/07/2021).

Management of COVID-19 Infection in Pregnancy

Although the majority of pregnant patients who contract severe acute respiratory syndrome coronavirus 2 will have a mild course of illness, pregnant patients with coronavirus disease-2019 are more likely than their nonpregnant counterparts to develop a severe illness with an increased risk of poor maternal and fetal outcomes. Although the extent of research in this specific patient population remains limited, there are tenets of care with which physicians and other providers must be familiar to increase the chances of better outcomes for the two patients in their care.