Clinico-radiological recovery following severe COVID-19 pneumonia

Background The recovery course following COVID-19 pneumonia remains poorly understood. Analysis of routine clinical and imaging follow up of patients admitted with COVID-19 pneumonia undertaken in accordance with British Thoracic Society (BTS) guidance offers an opportunity to improve our understanding of the recovery course following acute infection. Methods All patients requiring Intensive or Respiratory High Dependency Unit care with COVID-19 pneumonia who survived to discharge were offered telephone review and interval chest radiograph (CXR) at 6 and 12 weeks respectively in accordance with BTS guidance. Patients were contacted in chronological order by discharge date. The data presented here covers discharges between 25/03-03/05/20 inclusive. All chest radiographs were reported by a consultant radiologist. Results A total of N=73 patients were identified (74% male, mean age 57.6 years, range 22-84). N=41 (56.1%) had been admitted to ITU, with the remainder admitted to HDU. Following discharge, N=6 (8.2%) were re-admitted within 30 days (median time to first re-admission 19.1 days). N=2 (3.5%) patients were diagnosed with pulmonary emboli following the index admission. 1 patient died within 30 days of discharge (unrelated to COVID infection). Follow up calls occurred with N=57 patients, at median 9.6 weeks post discharge (range 6-12 weeks). Patient reported persistence of symptoms at time of review is summarised in table 1. Interval CXR was available in N=49 patients. Of these, N=34 (71.7%) were clear, N=10 (19.5%) showed linear atelectasis, and N=5 (8.7%) showed persistent consolidation (all improved compared to admission CXR). Discussion These data describe the clinico-radiological course following admission with severe COVID-19 pneumonia. Limitations of this analysis include limitation to patients receiving HDU/ITU level care and the retrospective categorisation of symptom persistence. Prospective studies serially assessing full symptomatology are required. Nevertheless, these data highlight persistent symptoms at 6-12 weeks;particularly exertional dyspnoea and fatigue. 91% of patients were free from cough at this time;investigating for possible alternative causes should therefore be considered in patients experiencing chronic cough. These data are valuable in planning long-term support for patients following COVID-19 pneumonia, and support the BTS recommendations for early proactive follow up of this cohort.

Gloucestershire nhs foundation trust Experience-covid-19 associated mortality in Mechanical ventilation vs non mechanical Ventilation

Background COVID-19 is associated with significant mortality and morbidity in high risk groups requiring ventilatory support as per the Intensive Care National Audit & Research Centre (ICNARC).1 Mechanical (IMV) and non-mechanical ventilation modalities [Continuous positive airway pressure (CPAP)/High Flow Nasal Oxygen (HFNO)] support acute respiratory failure in COVID-19 but the mortality data comparing these modalities is limited. Gloucestershire NHS Foundation Trust admitted a total of 860 COVID-19 patients, 130 requiring ventilatory support between February-July 2020;the highest number in the South-West. Respiratory High dependency (HDU) and Intensive care units (ITU) were reconfigured in anticipation of clinical demand with HDU expanded to 31 beds compared to a normal capacity of 10 and ITU expanded to 36 beds, compared to a usual capacity of 12. Patients requiring CPAP only were managed on HDU unless deemed at high risk of deterioration to require IMV. Method We conducted a prospective observational study to assess comparative mortality in all COVID-19 patients admitted to HDU/ITU with acute respiratory failure and treated with IMV versus CPAP/HFNO or both. Parameters assessed included age, gender, clinical frailty score (CFS), co-morbidities, smoking and resuscitation status. Comparative mortality was assessed statistically by calculating relative risk ratio and p-value using Welch's t-test. Results 130 patients were treated with CPAP/HFNO, IMV or both. Overall mortality was 33% (n=43). Resuscitation status and treatment escalation plans were reviewed for all patients on admission. 1.5% patients (n=2) had a pre-existing DNAR and CPR was not deemed appropriate for 23% patients (n=30). 62% patients (n=58) required IMV out of 72% patients (n=93) deemed suitable for it. Comparative mortality between all 3 subgroups is summarised in table 1. Discussion Overall mortality was higher among COVID-19 patients requiring IMV reflecting disease severity. Male gender, previous smoking history, airways disease, hypertension, diabetes, CKD and immunosuppression were associated with higher mortality in patients requiring IMV. Interestingly CFS of >3 was associated with increased mortality in the CPAP cohort compared to CFS of <3 in the IMV cohort. This is likely to reflect selection bias of patients deemed appropriate for IMV.

The Yellow Lanyard Team-Gloucestershire Foundation Nhs Trust Covid-19 Initiative

Background Anticipating the COVID-19 pandemic burden, Gloucestershire NHS Foundation trusts Associate Chief Nurse Craig Bradley proposed the yellow lanyard initiative to utilise specialist respiratory nurses to educate, train and support trust wide health care staff in managing these patients;albeit outside their clinical speciality. The yellow lanyards allowed early identification of this frontline specialist respiratory nursing team integral to ensuring adequate clinical standards were maintained whilst delivering a 24/7 holistic care to the ever increasing COVID-19 patient admissions (figure 1a & 1b). What we did The yellow lanyard team consisted of 40 nurses working on two sites across the Trust [(Gloucester Royal (GRH) and Cheltenham General Hospitals (CGH)]. Our role particularly focused on non-ventilatory training (Continuous positive airway pressures) a leadership strategy employed by the Trust to manage COVID-19 patients with high FiO2 requirement in a respiratory high dependency unit (HDU) setting. The respiratory HDU was expanded to 31 beds compared to a normal capacity of 10 and all patients requiring non-ventilatory support only were managed on it unless deemed at high risk. We also liaised with our lung physiology department daily for equipment calibration and programming enabling us to manage the quick turnover of patients admitted. Additionally we offered training opportunities to all staff including NEWS monitoring, documentation, adequate use of personal protective equipment, oxygen management, initiating Hi-Flow nasal oxygen, and escalation of patients to intensive care alongside delivery of conventional respiratory care. Outcome Our strategies upskilled healthcare worker to manage the ever increasing case load of COVID-19 patients using enhanced decision making, critical thinking and improved communication skills preparing them to work in the ever changing environment. The yellow lanyard team was an asset during the pandemic available 24/7 and successfully managed patients to recover from their illness (figure 1c). Future plans The trust aims to expand the respiratory HDU currently being used for patients receiving aerosol generating procedures and utilise the skill set of our trained staff with the prospect of offering immediate support for patients in case of a second wave of COVID-19.

South west experience of continuous positive airway pressure non-invasive ventilation for covid-19

Introduction Continuous positive airway pressure non-invasive ventilation (CPAP) was recommended by NHS England for patients with COVID-19 and hypoxaemic respiratory failure either as a ceiling of treatment, trial to avoid intubation or as a bridge to intubation.1 However, In the absence of clinical trials, its role in the treatment of COVID-19 is poorly understood. We collected observational data on outcomes of patients with COVID-19 requiring CPAP. Methods Data was collected by members of the PRISM trainee research network. Patient demographics, comorbidities, Rockwood clinical frailty scale (CFS) and outcomes (death or discharge) were collected for patients requiring CPAP for hypoxaemic respiratory failure with confirmed or clinically suspected COVID-19 across 6 sites in the South West over 11 weeks from March-June 2020. Results Data was collected for 164 patients. Ages of patients ranged from 30-88 years (mean 62.13), 110 (61.1%) male. Most patients received CPAP on a respiratory ward (79.3%). A treatment escalation plan was recorded for 153 (85%) of patients on admission to hospital. Of 100 patients eligible for escalation to intensive care (ICU), 50 required intubation and invasive mechanical ventilation (IMV) despite CPAP therapy. CFS scores ranged from 1 to 7 (mean 2.5). Average CFS score those eligible for IMV was 1.75, compared to 3.67 for those who were deemed ineligible for IMV. Mortality data are shown in table 1. Average length of stay for survivors was 15.6 days (1-63). The average number of days from admission to death was 8.6 (0-48). Conclusion In our cohort of patients who received CPAP as a ceiling of treatment mortality was high, especially compared to patients eligible for invasive mechanical ventilation. We highlight the need for early treatment escalation decisions, informed discussions with patients and relatives and involvement of palliative care where appropriate. These data are potentially limited by variation in practice between sites, and further robust evidence is needed to establish patient selection and timing of CPAP.

S96 South West experience of continuous positive airway pressure non-invasive ventilation for COVID-19

S96 Table 1Mortality of different patient groups. *p<0.01 comparing mortality of those who received CPAP as a ceiling of care vs those eligible for IMV. Number (n) Mortality (%) All patients 164 68 (41.5%) Patient who received CPAP as ceiling of treatment 64 47 (73.4%) Patients eligible for IMV 100 21 (21%)* Patients who required intubation and IMV 50 19 (38%) Patients eligible for intubation but in whom this was not required 50 2 (4%) CFS score 1–4 (non-frail) 151 59 (39.1%) CFS 5–7 (frail). NB No patient had CFS score above 7 13 9 (69.2%) ConclusionIn our cohort of patients who received CPAP as a ceiling of treatment mortality was high, especially compared to patients eligible for invasive mechanical ventilation. We highlight the need for early treatment escalation decisions, informed discussions with patients and relatives and involvement of palliative care where appropriate. These data are potentially limited by variation in practice between sites, and further robust evidence is needed to establish patient selection and timing of CPAP.ReferenceNHS England and NHS Improvement Guidance for the role and use of non-invasive respiratory support in adult patients with COVID19 (confirmed or suspected), 6 April 2020, Version 3.

P3 The yellow lanyard team – gloucestershire foundation NHS trust COVID-19 initiative

P3 Figure 1The yellow lanyards - Gloucestershire Foundation NHS Trust COVID-19 initiative[Figure omitted. See PDF]Future plansThe trust aims to expand the respiratory HDU currently being used for patients receiving aerosol generating procedures and utilise the skill set of our trained staff with the prospect of offering immediate support for patients in case of a second wave of COVID-19.

P55 Gloucestershire NHS foundation trust experience – COVID-19 associated mortality in mechanical ventilation vs non mechanical ventilation

P55 Table 1*Mortality associated with ventilatory modalities, demographic characteristics and co-morbiditiesCPAP onlyIMV onlyCPAP and IMVHFNO% of entire cohortTotal Patients (n =130)55% (n=71)26% (n=34)18.5% (n=24)0.8% (n=1)Mean Age and Standard Deviation (SD)61.7 (SD 11.5)58.8 (SD 13.2)56 (SD 12.8)n/a (age = 56) Recovered70% (n=50)62% (n=21)62.5% (n=15)100% (n=1)67% (n=87)Mortality30% (n=21)38% (n=13)37.5% (n=9)0% (n=0)33% (n=43)Relative Risk vs CPAP1.31.395% Confidence Interval[0.740, 2.259][0.676, 2.378]P-value0.180.24Test appliedWelch’s t-testWelch’s t-testGenderMale68% (n=48) *29% (n=14)80% (n=27) *38% (n=13)70% (n=17) *47% (n=8)100% (n=1) *Nil72% (n= 93) *27% (n=35)Female32% (n=23) *22%(n=5)20% (n=7) *43% (n=3)30% (n=7) *0% (n=0)0% (n=0) *Nil28% (n=37) *6% (n=8)Clinical Frailty Score (CFS)Score < 358% (n=41) *10% (n=4)100% (n=34) *38% (n=13)96% (n=23) *9% (n=2)100% (n=1) *Nil76% (n=99) *15% (n=19)Score >342% (n=30) *60% (n=18)0% (n=0) *Nil4% (n=1) *100% (n=1)0% (n=0) *Nil24% (n=31) *15% (n=19)Smoking StatusNon smoker48% (n=34) *15% (n=5)29% (n=10) *20% (n=2)54% (n=13) *23% (n=3)100% (n=1) *Nil45% (n=58) *8% (n=10)Ex-smoker35% (n=25) *44% (n=11)35% (n=12) *67% (n=8)29% (n=7) *71%(n=5)0% (n=0) *Nil34% (n=44) *19% (n=24)Current3% (n=2) *100%(n=2)9% (n=3) *33% (n=1)0%(n=0) *Nil0% (n=0) *Nil4% (n=5) *2% (n=3)Unknown14% (n=10) *30% (n=3)26% (n=9) *22%(n=2)16% (n=4) *25%(n=1)0% (n=0) *Nil18% (n=23) *5% (n=6)ComorbiditiesAsthma/Chronic Obstructive Pulmonary Disease (COPD)16% (n=11) *45.5% (n=5)18% (n=6) *68% (n=2)30% (n=7) *14% (n=1)0%(n=0) *Nil19% (n=24) *6% (n=8)Obstructive Sleep Apnoea (OSA)14% (n=10) *40% (n=4)3% (n=1) *Nil4%(n=1) *100% (n=1)0% (n=0) *Nil9% (n=12) *4% (n=5)Obesity21% (n=15) *33% (n=5)12% (n=4) *Nil21% (n=5) *Nil100% (n=1) *Nil19% (n=25) *4% (n=5)Diabetes30% (n=21) *33% (n=7)6% (n=2) *50% (n=1)12.5% (n=3) *66% (n=2)100% (n=1) *Nil21% (n=27) *8% (n=10)Hypertension52% (n=37) *38% (n=14)18% (n=6) *67%(n=4)33% (n=8) *63% (n=5)0%(n=0) *Nil40% (n=51) *18% (n=23)Ischaemic heart disease (IHD)13% (n=9) *33% (n=3)3% (n=1) *Nil4% (n=1) *Nil100% (n=1) *Nil9%(n=12) *2% (n=3)Chronic Kidney disease (CKD)10% (n=7) *57% (n=4)3% (n=1) *100% (n=1)4% (n=1) *100% (n=1)0 (n=0) *Nil7% (n=9) *5% (n=6)Immunosuppression8.5% (n=6) *50% (n=3)12% (n=4) *75% (n=3)4% (n=1) *Nil0%(n=0) *Nil9% (n=11) *5% (n=6)DiscussionOverall mortality was higher among COVID-19 patients requiring IMV reflecting disease severity. Male gender, previous smoking history, airways disease, hypertension, diabetes, CKD and immunosuppression were associated with higher mortality in patients requiring IMV. Interestingly CFS of >3 was associated with increased mortality in the CPAP cohort compared to CFS of <3 in the IMV cohort. This is likely to reflect selection bias of patients deemed appropriate for IMV.ReferenceICNARC Reports.[https://www.icnarc.org/Our-Audit/Audits/Cmp/Reports.August 2020]