Clinical Presentation and Phenotypes in COVID-19

Since the beginning of the COVID-19 pandemic, researchers have focused on the different clinical presentations of the disease. The existence of a broad spectrum of respiratory compromise has been initially interpreted as the manifestation of different clinical phenotypes, with peculiar pathophysiological aspects translating into different requirements of respiratory support. Extensive research now converges on interpreting these phenotypes as different stages rather than distinct manifestations of the same pathology. While not all patients will evolve from an early COVID-19 pneumonia to an established COVID-19 related acute respiratory distress syndrome (ARDS), the correct identification of the disease phase will translate into different therapeutic approaches. This chapter discusses the classification of COVID-19 phenotypes based on imaging and respiratory mechanics parameters, also in relation with the differences and similarities with the ARDS from causes other than COVID-19. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Invasive Mechanical Ventilation in COVID-19

Patients with severe COVID-19 pneumonia present with severe hypoxemic respiratory failure, typically meet the clinical criteria for acute respiratory distress syndrome (ARDS) and often require invasive mechanical ventilation. While peculiar pathophysiological aspects deserve discussion to better tailor the mechanical ventilation settings in these patients, most recommendations on the ventilatory management of these patients are derived from studies in patients with ARDS from causes other than COVID-19. Protective ventilation is recommended in most COVID-19 patients, tidal volume should be kept around 6 mL per kg of predicted body weight, positive end-expiratory pressure (PEEP) should be titrated individually considering that in many patients with COVID-19 improvement of oxygenation at higher PEEP is often accompanied by worsening of respiratory system compliance. Therefore, attention should be paid in limiting plateau and driving pressures to avoid excessive strain potentially resulting in ventilator-induced lung injury. Prone positioning has been used extensively in COVID-19 patients, but its impact on mortality is uncertain. Inhaled nitric oxide, extracorporeal CO2 removal (ECCO2R), and extracorporeal membrane oxygenation (ECMO) should be considered in selected patients as rescue measures. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Indications for Intubation in COVID-19

Intubation and invasive mechanical ventilation are often unavoidable in most severe cases of COVID-19 pneumonia;however, deciding the optimum timing and best practices of intubation is challenging. The decision to proceed with intubation should be based on an integrated patient evaluation and not limited to the assessment of the severity of hypoxemia alone. Intubation is a maneuver exposing the operator to a high risk of contamination, therefore adequate personal protection equipment is mandatory. Benefits of intubation over noninvasive respiratory support include reduction or suppression of the respiratory drive, reduction of the basal metabolism and allowance of maintaining protective mechanical ventilation. On the other hand, risks are related to the need for sedation, the presence of an artificial airway and exposure to mechanical ventilation, which may result in overlapping ventilator-associated bacterial pneumonia and ventilator-induced lung injury. Balancing between risks and benefits of intubation in this context is challenging and the optimum timing of intubation remains largely an open question. This chapter discusses the clinical, technical, and safety aspects that deserve to be considered when considering intubation in patients with severe COVID-19-related acute respiratory failure. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Theme 12 - Clinical Management and Support

Power wheelchair prescription, utilization, satisfaction, and cost for patients with amyotrophic lateral sclerosis: preliminary data for evidence-based guidelines. Stage at which riluzole treatment prolongs survival in patients with amyotrophic lateral sclerosis: a retrospective analysis of data from a dose-ranging study. Support needs and interventions for family caregivers of patients with amyotrophic lateral sclerosis (ALS): a narrative review with report of telemedicine experiences at the time of COVID-19 pandemic. [Extracted from the article]

What is the role of primary care in COVID-19 programs focused on people experiencing homelessness?

Background: The pandemic has had a disproportionate impact on people who are living in socially disadvantaged situations. People experiencing homelessness are less able to isolate and follow public health messaging to reduce the risk of infection. In addition, due to the higher prevalence of chronic disease, they have a poorer prognosis with infection with higher rates of mortality and hospitalisation. In the early pandemic, many countries implemented programs that were exclusively focused on the care of people experiencing homelessness. Aim/Objectives: Our aim was to describe programs that have been implemented to reduce COVID-19 transmission and severity of illness in homeless populations and to understand the involvement of primary care. Method(s): We performed a rapid review of the international literature documenting COVID-19 related programs for people experiencing homelessness. We searched PubMed, Embase, and CINAHL plus Google using search term combinations of homeless persons and COVID-19. All articles were screened by two independent reviewers and one person extracted the items of interest. Finding(s): After screening 615 studies we included 42 studies and most were from the USA (n = 26). Programs commonly focused on isolation centres for people experiencing homelessness who tested positive for COVID-19 (n = 15). Sixteen studies included an evaluation of program effectiveness and two investigated the perspective of program participants. Universal screening was more effective than symptomatic screening in reducing COVID-19 transmission in homeless shelter settings. Comprehensive healthcare, including mental health and addiction support, was essential for people to be able to tolerate isolation, but care continuity post-isolation was problematic with limited primary care involvement. Implications: Few COVID-19 programs for people experiencing homelessness involve the primary care sector. As continuity of care post-program was a common problem, primary care may have a role in cross-sector collaboration.

Nasal Pressure Swings as the Measure of Inspiratory Effort in Spontaneously Breathing Patients with De Novo Acute Respiratory Failure

Background. Excessive inspiratory effort could translate into self-inflicted lung injury, thus worsening clinical outcomes of spontaneously breathing patients with acute respiratory failure (ARF). Although esophageal manometry is a reliable method to estimate the magnitude of inspiratory effort, procedural issues significantly limit its use in daily clinical practice. The aim of this study is to describe the correlation between esophageal pressure swings (ΔPes) and nasal (ΔPnos) as a potential measure of inspiratory effort in spontaneously breathing patients with de novo ARF. Methods. From January 1st, 2021 to September 1st, 2021, 61 consecutive patients with ARF (83.6% related to COVID-19) admitted to the Respiratory Intensive Care Unit (RICU) of the University Hospital of Modena (Italy) and candidate to escalation of non-invasive respiratory support (NRS) were enrolled. Clinical features and tidal changes in esophageal and nasal pressure were recorded on admission and 24 hours after starting NRS. Correlation between ΔPes and ΔPnos served as primary outcome. The effect of ΔPnos measurements on respiratory rate and ΔPes was also assessed. Results. ΔPes and ΔPnos were strongly correlated at admission (R2=0.88, p<0.001) and 24 hours apart (R2=0.94, p<0.001). The nasal plug insertion and the mouth closure required for ΔPnos measurement did not result in significant change of respiratory rate and ΔPes. The correlation between measures at 24 hours remained significant even after splitting the study population according to the type of NRS (high-flow nasal cannulas [R2=0.79, p<0.001] or noninvasive ventilation [R2=0.95, p<0.001]). Conclusions. In a cohort of patients with ARF, nasal pressure swings did not alter respiratory mechanics in the short term and were highly correlated with esophageal pressure swings during spontaneous tidal breathing. ΔPnos might warrant further investigation as a measure of inspiratory effort in patients with ARF.

CLINICAL CHARACTERISTICS, MANAGEMENT AND OUTCOMES OF CRITICALLY ILL COVID-19 PATIENTS UNDERGOING CRRT: COMPARISON BETWEEN THE FIRST TWO PANDEMIC WAVES

BACKGROUND AND AIMS: Acute kidney injury (AKI) is a common complication of coronavirus disease-19 (COVID-19), which, particularly in critically ill patients requiring continuous renal replacement therapy (CRRT), is associated with an elevated mortality risk [1, 2]. However, knowledge about COVID-19 pathogenesis and management is evolving, and clinical practice is changing rapidly. Here, we evaluated if this process had an impact on the management and outcome of AKI patients. METHODS: We performed a retrospective observational study on critically ill adult COVID-19 patients who received CRRT in the intensive care unit (ICU) during the first two pandemic waves before the availability of COVID-19 vaccines: the first one from March to August 2020 (first) and the second one (second) from September to December 2020. RESULTS: Overall, we considered 63 patients, aged 65 (60-69) years, 76.2% males. The main comorbidities were diabetes (DM), cardiovascular disease (CVD) and chronic kidney disease (CKD). Among them, 28 (44%) were in the first group and 35 (66%) in the second group. There were no significant differences in general characteristics, such as in comorbidities, except for a higher prevalence of CVD in the first group (Fig. 1). Lab examinations at ICU admission, including serum creatinine level (sCr), were not different between the two groups. While all patients required respiratory support, non-invasive ventilation was more prevalent in the second wave. Notably, during this period, decapneization combined with CRRT was introduced. Regarding drugs, we found that in the second group, hydroxychloroquine was abandoned, tocilizumab use was reduced and heparin administration significantly increased. The AKI time course was similar between the patients of the two waves (Fig. 2). There were no significant differences in CRRT techniques. However, in the second, the use of additional CRRT-devices, in particular adsorption-based filters, significantly increased. In most cases, citrate anticoagulation was used in both groups. Looking at the outcomes, we found no significant difference between the two waves. Indeed, 17 (60.2%) and 22 (62.8%) patients died in the ICU in the first and second groups, respectively. The length of ICU hospitalization, days on CRRT, invasive ventilation and DM were significantly related to overall mortality;time of ICU hospitalization was the only remaining significant at multivariate Cox regression. Overall, 21 (33%) patients survived hospitalization. At the 6 months after the discharge, 3 of them died, 3 were on HD and 15 were dialysis-free, even if 6 of them presented CKD. CONCLUSION: Our data confirm the high complexity and mortality of COVID-19 patients undergoing CRRT. Comparing the first two pandemic waves, we found that the patients also presented similar characteristics in terms of renal function and AKI time course. Regarding treatments, we observed some significant modifications in the management of ventilation, drug administration and dialysis membranes, mainly because of the results of ongoing clinical trials. However, these changes did not impact patients' outcomes. These data support the view that only game-change strategies, such as vaccination or infection-specific drugs, may impact the presentation and outcome of COVID-19 patients undergoing CRRT. Finally, patients surviving this condition deserve special attention in the follow-up. (Table Presented).

How has the COVID-19 pandemic influenced patient-centred care? Analysis of a qualitative collective case study by high-performing practice teams

Background and objective The COVID-19 pandemic has significantly affected primary healthcare systems throughout the world. The aim of this article is to present the analysis of the perspectives and experiences of patientcentred care (PCC) during the pandemic by high-functioning general practice teams in Australia. Methods A qualitative descriptive approach and collective case study method was employed. Participants, who undertook a semi-structured interview, were representatives of high-functioning general practice teams. Reflective thematic analysis was applied to all interview data (meta-synthesis) using a constant comparison approach. Results Five clinic representatives were interviewed. Six themes developed, highlighting that despite the pandemic creating new challenges to delivering PCC, general practice teams maintained a focus on PCC. General practice teams adapted to deliver PCC through strategies not used prior to the pandemic. Discussion This study identified new approaches to PCC that can guide other general practices and progress the health system towards policy-based PCC objectives.

Time course of chest computed tomography findings and biomarkers in COVID-19 pneumonia patients

RATIONALE: Chest computed tomography (CT) has a potential role in the diagnosis, detection of complications, and prognosis of coronavirus disease 2019 (COVID-19). The value of chest CT can be further amplified when associated to physiological variables. Some studies have done efforts to correlate chest CT findings with overall oxygenation and respiratory mechanics, which although they are easily obtained may not be specifically related to COVID-19. Very few studies have tried to correlate chest CT findings with specific biomarkers related to COVID-19. For this purpose, temporal changes of chest CT were evaluated and then correlated with laboratory data in multicenter randomized clinical trial. METHODS: Adult patients who presented chest CT scan features compatible with viral pneumonia were admitted in the hospital and followed during 7 days (NCT: 04561219). CT scans and laboratory data [D-dimer, ferritin, and lactate dehydrogenase (LDH)] in blood were obtained at the moment of admission (Baseline) and on day 7 (Final). Qualitative and quantitative chest CT scan parameters were evaluated in ventral, middle and dorsal regions of interest (ROI) and classified as: hyper-, normal-, poor-, and non-aerated. RESULTS: In this study involving 45 COVID-19 patients no statistically significant differences in the overall Hounsfield Units (HU) ranges and percent of whole lung mass were found overtime. Normally aerated lung tissue reduced from Baseline to Final (p=0.004), mainly associated with a decrease in ventral (p=0.001) and middle (p=0.026) ROIs. At dorsal ROI, a reduction in CT lung mass in poorly aerated areas was observed from Baseline to Final. Poorly aerated and non-aerated lung areas were well correlated only with D-dimer blood levels (r=0.55, p<0.001;and r=0.52, p=0.001, respectively). CONCLUSION: In patients with COVID-19 pneumonia, changes in poor-and non-aerated were associated to changes in D-dimer blood levels, which may be a specific biomarker to be follow in facilities without CT as a way to infer radiologic changes.