Predictors of prolonged ventilator weaning and mortality in critically ill patients with COVID-19

OBJECTIVE

To identify factors associated with prolonged weaning and mortality in critically ill COVID-19 patients admitted to ICUs and under invasive mechanical ventilation.

METHODS

Between March of 2020 and July of 2021, we retrospectively recorded clinical and ventilatory characteristics of critically ill COVID-19 patients from the day of intubation to the outcome. We classified the patients regarding the weaning period in accordance with established criteria. A logistic regression analysis was performed to identify variables associated with prolonged weaning and mortality.

RESULTS

The study involved 303 patients, 100 of whom (33.0%) had a prolonged weaning period. Most of the patients were male (69.6%), 136 (44.8%) had more than 50% of pulmonary involvement on chest CT, and 93 (30.6%) had severe ARDS. Within the prolonged weaning group, 62% died within 60 days. Multivariate analysis revealed that lung involvement greater than 50% on CT and delay from intubation to the first separation attempt from mechanical ventilation were significantly associated with prolonged weaning, whereas age and prolonged weaning were significantly associated with mortality.

CONCLUSIONS

Prolonged weaning can be used as a milestone in predicting mortality in critically ill COVID-19 patients. Lung involvement greater than 50% on CT and delay from intubation to the first separation attempt from mechanical ventilation were identified as significant predictors of prolonged weaning. These results might provide valuable information for healthcare professionals when making clinical decisions regarding the management of critically ill COVID-19 patients who are on mechanical ventilation.

The American College of Nuclear Medicine Guidance on Operating Procedures for a Nuclear Medicine Facility During COVID-19 Pandemic

ABSTRACT

The novel coronavirus 2 pandemic is causing widespread disruption in everyday life necessitating urgent and radical adaptations in operating procedures at nuclear medicine facilities. The potential for causing severe illness, COVID-19, calls for strict observance of preventive measures aimed to mitigate the spread of the virus. The threat of COVID-19 is particularly serious as there is no vaccine and no specific antiviral therapy. Further complications are introduced by shortages of personal protective equipment for healthcare workers who have direct contact with patients and effective testing to identify infected patients, raising the need for delaying some testing and therapies. Certain vulnerable segments of the general population have been identified (advanced age and certain comorbidities), which should heighten further their preventive efforts. Therefore, this guidance is intended to be operationalized depending on a facility's specific needs and local disease prevalence.

Intermittent High-Frequency Percussive Ventilation Therapy in 3 Patients with Severe COVID-19 Pneumonia

BACKGROUND High-frequency percussive ventilation (HFPV) is a method that combines mechanical ventilation with high-frequency oscillatory ventilation. This report describes 3 cases of patients with severe COVID-19 pneumonia who received intermittent adjunctive treatment with HFPV at a single center without requiring admission to the Intensive Care Unit (ICU). CASE REPORT Case 1 was a 60-year-old woman admitted to the hospital 14 days after the onset of SARS-CoV-2 infection symptoms, and cases 2 and 3 were men aged 65 and 72 years who were admitted to the hospital 10 days after the onset of SARS-CoV-2 infection symptoms. All 3 patients presented with clinical deterioration accompanied by worsening lung lesions on computed tomography (CT) scans after 21 days from the onset of symptoms. SARS-CoV-2 infection was confirmed in all patients by real-time reverse transcription-polymerase chain reaction (RT-PCR) assay from nasal swabs. All 3 patients had impending respiratory failure when non-invasive intermittent HFPV therapy was initiated. After therapy, the patients had significant clinical improvement and visibly decreased lung lesions on followup CT scans performed 4-6 days later. CONCLUSIONS The 3 cases described in this report showed that the use of intermittent adjunctive treatment with HFPV in patients with severe pneumonia due to infection with SARS-CoV-2 improved lung function and may have prevented clinical deterioration. However, recommendations on the use of intermittent HFPV as an adjunctive treatment in COVID-19 pneumonia requires large-scale controlled clinical studies. In the pandemic context, with a shortage of ICU beds, avoiding ICU admission by using adjunctive therapies on the ward is a useful option.

Lung Lesion Burden found on Chest CT as a Prognostic Marker in Hospitalized Patients with High Clinical Suspicion of COVID-19 Pneumonia: a Brazilian experience

OBJECTIVE

To investigate the relationship between lung lesion burden (LLB) found on chest computed tomography (CT) and 30-day mortality in hospitalized patients with high clinical suspicion of coronavirus disease 2019 (COVID-19), accounting for tomographic dynamic changes.

METHODS

Patients hospitalized with high clinical suspicion of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in a dedicated and reference hospital for COVID-19, having undergone at least one RT-PCR test, regardless of the result, and with one CT compatible with COVID-19, were retrospectively studied. Clinical and laboratory data upon admission were assessed, and LLB found on CT was semi-quantitatively evaluated through visual analysis. The primary outcome was 30-day mortality after admission. Secondary outcomes, including the intensive care unit (ICU) admission, mechanical ventilation used, and length of stay (LOS), were assessed.

RESULTS

A total of 457 patients with a mean age of 57±15 years were included. Among these, 58% presented with positive RT-PCR result for COVID-19. The median time from symptom onset to RT-PCR was 8 days [interquartile range 6-11 days]. An initial LLB of ≥50% using CT was found in 201 patients (44%), which was associated with an increased crude at 30-day mortality (31% vs. 15% in patients with LLB of <50%, p<0.001). An LLB of ≥50% was also associated with an increase in the ICU admission, the need for mechanical ventilation, and a prolonged LOS after adjusting for baseline covariates and accounting for the CT findings as a time-varying covariate; hence, patients with an LLB of ≥50% remained at a higher risk at 30-day mortality (adjusted hazard ratio 2.17, 95% confidence interval 1.47-3.18, p<0.001).

CONCLUSION

Even after accounting for dynamic CT changes in patients with both clinical and imaging findings consistent with COVID-19, an LLB of ≥50% might be associated with a higher risk of mortality.

CT imaging features of different clinical types of COVID-19 calculated by AI system: a Chinese multicenter study

Background

The study is designed to explore the chest CT features of different clinical types of coronavirus disease 2019 (COVID-19) pneumonia based on a Chinese multicenter dataset using an artificial intelligence (AI) system.

Methods

A total of 164 patients confirmed COVID-19 were retrospectively enrolled from 6 hospitals. All patients were divided into the mild type (136 cases) and the severe type (28 cases) according to their clinical manifestations. The total CT severity score and quantitative CT features were calculated by AI pneumonia detection and evaluation system with correction by radiologists. The clinical and CT imaging features of different types were analyzed.

Results

It was observed that patients in the severe type group were older than the mild type group. Round lesions, Fan-shaped lesions, crazy-paving pattern, fibrosis, “white lung”, pleural thickening, pleural indentation, mediastinal lymphadenectasis were more common in the CT images of severe patients than in the mild ones. A higher total lung severity score and scores of each lobe were observed in the severe group, with higher scores in bilateral lower lobes of both groups. Further analysis showed that the volume and number of pneumonia lesions and consolidation lesions in overall lung were higher in the severe group, and showed a wider distribution in the lower lobes of bilateral lung in both groups.

Conclusions

Chest CT of patients with severe COVID-19 pneumonia showed more consolidative and progressive lesions. With the assistance of AI, CT could evaluate the clinical severity of COVID-19 pneumonia more precisely and help the early diagnosis and surveillance of the patients.

Role for Anti-Cytokine Therapies in Severe Coronavirus Disease 2019

The causative agent for coronavirus disease 2019, severe acute respiratory syndrome coronavirus 2, appears exceptional in its virulence and immunopathology. In some patients, the resulting hyperinflammation resembles a cytokine release syndrome. Our knowledge of the immunopathogenesis of coronavirus disease 2019 is evolving and anti-cytokine therapies are under active investigation. This narrative review summarizes existing knowledge of the immune response to coronavirus infection and highlights the current and potential future roles of therapeutic strategies to combat the hyperinflammatory response of patients with coronavirus disease 2019.

DATA SOURCES

Relevant and up-to-date literature, media reports, and author experiences were included from Medline, national newspapers, and public clinical trial databases.

STUDY SELECTION

The authors selected studies for inclusion by consensus.

DATA EXTRACTION

The authors reviewed each study and selected approrpriate data for inclusion through consensus.

DATA SYNTHESIS

Hyperinflammation, reminiscent of cytokine release syndromes such as macrophage activation syndrome and hemophagocytic lymphohistiocytosis, appears to drive outcomes among adults with severe coronavirus disease 2019. Cytokines, particularly interleukin-1 and interleukin-6, appear to contribute importantly to such systemic hyperinflammation. Ongoing clinical trials will determine the efficacy and safety of anti-cytokine therapies in coronavirus disease 2019. In the interim, anti-cytokine therapies may provide a treatment option for adults with severe coronavirus disease 2019 unresponsive to standard critical care management, including ventilation.

CONCLUSIONS

This review provides an overview of the current understanding of the immunopathogenesis of coronavirus disease 2019 in adults and proposes treatment considerations for anti-cytokine therapy use in adults with severe disease.

Clinical and Demographic Characteristics of Cluster Cases and Sporadic Cases of Coronavirus Disease 2019 (COVID-19) in 141 Patients in the Main District of Chongqing, China, Between January and February 2020

BACKGROUND In December 2019, an outbreak of coronavirus disease 2019 (COVID-19), due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), occurred in Wuhan, China. Patients with COVID-19 were also identified in Chongqing. This study aimed to investigate the clinical and demographic characteristics of cluster cases and sporadic cases of COVID-19 in 141 patients in the main district of Chongqing during one month, between January and February 2020. MATERIAL AND METHODS A retrospective study included 141 patients with a diagnosis of COVID-19. The diagnosis was confirmed using real-time reverse transcription-polymerase chain reaction (RT-PCR) for SARS-CoV-2. The patients were divided into cluster cases (n=90) and sporadic cases (n=51). Demographic and clinical characteristics were compared between the two study groups and included the presence of comorbidities, the presenting symptoms, chest computed tomography (CT) imaging findings, and laboratory findings. RESULTS The mean age of the 141 patients diagnosed with COVID-19 was 47.3 years, and the most common presenting symptom was a persistent cough (48.9%). The 90 cluster cases (63.8%) were older than the sporadic cases, and cross-infection from family gathering occurred in 82.2%, and cough was more common than fever, and there was an increased prevalence of asymptomatic, mild, and moderate cases. Cluster cases showed fewer typical manifestations of COVID-19 on chest CT. However, the laboratory findings between the cluster and sporadic cases showed no significant differences. CONCLUSIONS There were demographic and clinical differences between cluster cases and sporadic cases of COVID-19 in the main district of Chongqing during the month between January to February 2020.

Where to buy face masks? Survey of applications using Taiwan's open data in the time of coronavirus disease 2019

BACKGROUND

The coronavirus disease 2019 (COVID-19) had spread rapidly since late December 2019. Personal protective equipment was essential to prevent transmission. Owing to shortage of face masks, Taiwan government began to implement quasi rationing on February 6, 2020, by allowing each resident to purchase two masks in seven days. Taiwan National Health Insurance Administration offered online data with real-time updates on face mask availability in all contracted pharmacies and selected local health centers. Based on the open data, numerous software applications quickly emerged to assist the public in finding sales locations efficiently.

METHODS

Up until March 15, 2020, the Public Digital Innovation Space of Taiwan government had recorded 134 software applications of face mask availability, and 24 software applications were excluded due to defect, duplicate, and unavailability. These applications were analyzed according to platform, developer type, and display mode.

RESULTS

Of the 110 valid software applications, 67 (60.9%) applications were deployed on websites, followed by 21 (19.1%) on social networking sites, 19 (17.3%) as mobile applications, and 3 (2.7%) in other modes. Nearly two thirds (n = 70) of applications were developed by individuals, one third (n = 37) by commercial companies, only two applications by central and local governments, and one by a nongovernmental organization. With respect to the display mode, 47 (42.7%) applications adopted map-view only, 41 (37.3%) adopted table-view only, and 19 (17.3%) adopted both modes. Of the remaining three applications, two offered voice user interfaces and one used augmented reality.

CONCLUSION

Taiwan's open data strategy facilitated rapid development of software applications for information dissemination to the public during the COVID-19 crisis. The transparency of real-time data could help alleviate the panic of the public. The collaborative contributions from the grassroots in disasters were priceless treasures.

To breastfeed or not to breastfeed? Lack of evidence on the presence of SARS-CoV-2 in breastmilk of pregnant women with COVID-19

A rapid systematic review was carried out to evaluate the current evidence related to the presence of SARS-CoV-2 in breast milk from pregnant women with COVID-19. Eight studies analyzing the presence of SARS-CoV-2 RNA in the breast milk of 24 pregnant women with COVID-19 during the third trimester of pregnancy were found. All patients had fever and/or symptoms of acute respiratory illness and chest computed tomography images indicative of COVID-19 pneumonia. Most pregnant women had cesarean delivery (91.7%) and two neonates had low birthweight (< 2 500 g). Biological samples collected immediately after birth from upper respiratory tract (throat or nasopharyngeal) of neonates and placental tissues showed negative results for the presence SARS-CoV-2 by RT-PCR test. No breast milk samples were positive for SARS-CoV-2 and, to date, there is no evidence on the presence of SARS-CoV-2 in breast milk of pregnant women with COVID-19. However, data are still limited and breastfeeding of women with COVID-19 remains a controversial issue. There are no restrictions on the use of milk from a human breast milk bank.

Comparing South Korea and Italy's healthcare systems and initiatives to combat COVID-19

Italy and South Korea have two distinctly different healthcare systems, causing them to respond to public health crises such as the COVID-19 pandemic in markedly different ways. Differences exist in medical education for both countries, allowing South Korean medical graduates to have a more holistic education in comparison to their Italian counterparts, who specialize in medical education earlier on. Additionally, there are fewer South Korean physicians per 1000 people in South Korea compared to Italian physicians per 1000 people in Italy. However, both countries have a national healthcare system with universal healthcare coverage. Despite this underlying similarity, the two countries addressed COVID-19 in nearly opposite manners. South Korea employed technology and the holistic education of its physician community, despite having a smaller proportion of physicians in society, to its advantage by implementing efficacious drive-through centers that test suspected individuals rapidly and with little to no contact with healthcare staff, decreasing the possibility of transmission of COVID-19. Conversely, Italy is presently considered the epicenter of the outbreak in Europe and has recorded the highest death toll of any country outside of mainland China. This is partially due to the reactionary nature of Italy’s public health measures compared to South Korea’s proactive response. The different healthcare responses of South Korea and Italy can inform decisions made by public health bodies in other countries, especially in countries across the Americas, which can selectively adopt policies that have worked in curtailing the spread of COVID-19 and learn from mistakes made by both countries.

Recommendations for a safety dental care management during SARS-CoV-2 pandemic

As the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is transmitted mainly through droplets, sneezes and aerosols, there is a high risk of transmission during dental procedures. This report describes measures that can be adopted by oral healthcare personnel to minimize the risk of cross-contamination in clinical practice during the current SARS-CoV-2 pandemic.

Clinical trials on drug repositioning for COVID-19 treatment

The World Health Organization (WHO) was informed on December 2019 about a coronavirus pneumonia outbreak in Wuhan, Hubei province (China). Subsequently, on March 12, 2020, 125,048 cases and 4,614 deaths were reported. Coronavirus is an enveloped RNA virus, from the genus Betacoronavirus, that is distributed in birds, humans, and other mammals. WHO has named the novel coronavirus disease as COVID-19. More than 80 clinical trials have been launched to test coronavirus treatment, including some drug repurposing or repositioning for COVID-19. Hence, we performed a search in March 2020 of the clinicaltrials.gov database. The eligibility criteria for the retrieved studies were: contain a clinicaltrials.gov base identifier number; describe the number of participants and the period for the study; describe the participants' clinical conditions; and utilize interventions with medicines already studied or approved for any other disease in patients infected with the novel coronavirus SARS-CoV-2 (2019-nCoV). It is essential to emphasize that this article only captured trials listed in the clinicaltrials.gov database. We identified 24 clinical trials, involving more than 20 medicines, such as human immunoglobulin, interferons, chloroquine, hydroxychloroquine, arbidol, remdesivir, favipiravir, lopinavir, ritonavir, oseltamivir, methylprednisolone, bevacizumab, and traditional Chinese medicines (TCM). Although drug repurposing has some limitations, repositioning clinical trials may represent an attractive strategy because they facilitate the discovery of new classes of medicines; they have lower costs and take less time to reach the market; and there are existing pharmaceutical supply chains for formulation and distribution.

Oxygen therapy for lower respiratory tract infections in children between 3 months and 15 years of age

BACKGROUND

Treatment for lower respiratory tract infections (LRTIs) includes administering complementary oxygen. The effectiveness of oxygen therapy and of different delivery methods remains uncertain.

OBJECTIVES

To determine the effectiveness and safety of oxygen therapy and oxygen delivery methods in the treatment of LRTIs and to define the indications for oxygen therapy in children with LRTIs.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE, EMBASE and LILACS from March 2008 to October 2014.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or non-RCTs comparing oxygen versus no oxygen therapy or different methods of oxygen delivery in children with LRTI aged from three months to 15 years. To determine the indications for oxygen therapy, we included observational studies or diagnostic test accuracy studies.

DATA COLLECTION AND ANALYSIS

Three review authors independently scanned the search results to identify studies for inclusion. Two authors independently performed the methodological assessment and the third author resolved any disagreements. We calculated risk ratios (RRs) and their 95% confidence intervals (CIs) for dichotomous outcomes and adverse events (AEs). We performed fixed-effect meta-analyses for the estimation of pooled effects whenever there was no heterogeneity between included RCTs. We summarised the results reported in the included observational studies for the clinical indicators of hypoxaemia.

MAIN RESULTS

In this review update, we included four studies (479 participants) assessing the efficacy of non-invasive delivery methods for the treatment of LRTI in children and 14 observational studies assessing the clinical sign indicators of hypoxaemia in children with LRTIs.Three RCTs (399 participants) compared the effectiveness of nasal prongs or nasal cannula with nasopharyngeal catheter; one non-RCT (80 participants) compared head box, face mask, nasopharyngeal catheter and nasal cannula. The nasopharyngeal catheter was the control group. Treatment failure was defined as number of children failing to achieve adequate arterial oxygen saturation. All included studies had a high risk of bias because of allocation methods and lack of blinded outcome assessment.For nasal prongs versus nasopharyngeal catheter, the pooled effect estimate for RCTs showed a worrying trend towards no difference between the groups (two RCTs; 239 participants; RR 0.93, 95% CI 0.36 to 2.38). Similar results were shown in the one non-RCT (RR 1.0, 95% CI 0.44 to 2.27). The overall quality of this evidence is very low. Nasal obstruction due to severe mucus production was different between treatment groups (three RCTs, 338 participants; RR 0.20, 95% CI 0.09 to 0.44; I(2) statistic = 0%). The quality of this evidence is low.The use of a face mask showed a statistically significant lower risk of failure to achieve arterial oxygen > 60 mmHg than the nasopharyngeal catheter (one non-RCT; 80 participants; odds ratio (OR) 0.20, 95% CI 0.05 to 0.88).The use of a head box showed a non-statistically significant trend towards a reduced risk of treatment failure compared to the nasopharyngeal catheter (one non-RCT; OR 0.40, 95% CI 0.13 to 1.12). The quality of this evidence is very low.To determine the presence of hypoxaemia in children presenting with LRTI, we assessed the sensitivity and specificity of nine clinical signs reported by the included observational studies and used this information to calculate likelihood ratios. The results showed that there is no single clinical sign or symptom that accurately identifies hypoxaemia.

AUTHORS' CONCLUSIONS

It appears that oxygen therapy given early in the course of pneumonia via nasal prongs at a flow rate of 1 to 2 L/min does not prevent children with severe pneumonia from developing hypoxaemia. However, the applicability of this evidence is limited as it comes from a small pilot trial.Nasal prongs and nasopharyngeal catheter are similar in effectiveness when used for children with LRTI. Nasal prongs are associated with fewer nasal obstruction problems. The use of a face mask and head box has been poorly studied and it is not superior to a nasopharyngeal catheter in terms of effectiveness or safety in children with LRTI.Studies assessing the effectiveness of oxygen therapy and oxygen delivery methods in children with different baseline risks are needed.There is no single clinical sign or symptom that accurately identifies hypoxaemia in children with LRTI. The summary of results presented here can help clinicians to identify children with more severe conditions.This review is limited by the small number of trials assessing oxygen therapy and oxygen delivery methods as part of LRTI treatment. There is insufficient evidence to determine which non-invasive delivery methods should be used in children with LRTI and low levels of oxygen in their blood.