Prolonged prone position ventilation is associated with reduced mortality in intubated COVID-19 patients.

BACKGROUND: Prone position ventilation (PPV) is resource-intensive, yet the optimal strategy for PPV in intubated patients with COVID-19 is unclear. RESEARCH QUESTION: Does a prolonged (24 or more hours) PPV strategy improve mortality in intubated COVID-19 patients compared to intermittent (∼16 hours with daily supination) PPV? STUDY DESIGN AND METHODS: Multicenter, retrospective cohort study of consecutively admitted intubated COVID-19 patients treated with PPV between March 11 - May 31, 2020. The primary outcome was 30-day all-cause mortality. Secondary outcomes included 90-day all-cause mortality and prone-related complications. Inverse probability treatment weights (IPTW) were used to control for potential treatment selection bias. RESULTS: Of the COVID-19 patients who received PPV, 157 underwent prolonged and 110 underwent intermittent PPV. Patients undergoing prolonged PPV had reduced 30-day (adjusted hazard ratio [aHR] 0.475, 95% CI 0.336-0.670, P value < 0.001) and 90-day (aHR 0.638, 95% CI 0.461-0.883, P value = 0.006) mortality compared to intermittent PPV. In patients with PaO2/FIO2 ≤ 150 at the time of pronation, prolonged PPV was associated with reduced 30-day (aHR 0.357, 95% CI 0.213-0.597, P value < 0.001) and 90-day mortality (aHR 0.562, 95% CI 0.357-0.884, P value = 0.008). Patients treated with prolonged PPV underwent fewer pronation and supination events (median 1, 95% CI 1-2 versus 3, 95% CI 1-4, P value < 0.001). PPV strategy was not associated with overall PPV-related complications though patients receiving prolonged PPV had increased rates of facial edema and lower rates of peri-proning hypotension. INTERPRETATION: Among intubated COVID-19 patients who received PPV, prolonged PPV was associated with reduced mortality. Prolonged PPV was associated with fewer pronation and supination events and a small increase in rates of facial edema. These findings suggest that prolonged PPV is a safe, effective strategy for mortality reduction in intubated COVID-19 patients.

Feeding intolerance in critically ill patients with COVID-19.

BACKGROUND & AIMS: Early reports suggest significant difficulty with enteral feeding in critically ill COVID-19 patients. This study aimed to characterize the prevalence, clinical manifestations, and outcomes of feeding intolerance in critically ill patients with COVID-19. METHODS: We examined 323 adult patients with COVID-19 admitted to the intensive care units (ICUs) of Massachusetts General Hospital between March 11 and June 28, 2020 who received enteral nutrition. Systematic chart review determined prevalence, clinical characteristics, and hospital outcomes (ICU complications, length of stay, and mortality) of feeding intolerance. RESULTS: Feeding intolerance developed in 56% of the patients and most commonly manifested as large gastric residual volumes (83.9%), abdominal distension (67.2%), and vomiting (63.9%). Length of intubation (OR 1.05, 95% CI 1.03-1.08), ≥1 GI symptom on presentation (OR 0.76, 95% CI 0.59-0.97), and severe obesity (OR 0.29, 95% CI 0.13-0.66) were independently associated with development of feeding intolerance. Compared to feed-tolerant patients, patients with incident feeding intolerance were significantly more likely to suffer cardiac, renal, hepatic, and hematologic complications during their hospitalization. Feeding intolerance was similarly associated with poor outcomes including longer ICU stay (median [IQR] 21.5 [14-30] vs. 15 [9-22] days, P < 0.001), overall hospitalization time (median [IQR] 30.5 [19-42] vs. 24 [15-35], P < 0.001) and in-hospital mortality (33.9% vs. 16.1%, P < 0.001). Feeding intolerance was independently associated with an increased risk of death (HR 3.32; 95% CI 1.97-5.6). CONCLUSIONS: Feeding intolerance is a frequently encountered complication in critically ill COVID-19 patients in a large tertiary care experience and is associated with poor outcomes.

Increased Internet Search Interest for GI Symptoms May Predict COVID-19 Cases in US Hotspots.

Google Trends is an online tool that allows measurement of search term popularity on Google, spatially and temporally. While not an epidemiological tool for determining incidence, it can estimate the popularity of a certain disease by search volume over time.1,2 It has previously correlated well with infectious disease incidence and has demonstrated utility in disease forecasting, especially with influenza data.3 We utilized Google Trends to investigate whether search interest in common gastrointestinal (GI) symptoms would correlate with coronavirus disease 2019 (COVID-19) incidence data.