BARICITINIB IN HOSPITALIZED PATIENTS WITH COVID-19: META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

SESSION TITLE: Acute COVID-19 and Beyond: from Hospital to Homebound SESSION TYPE: Original Investigations PRESENTED ON: 10/18/2022 02:45 pm - 03:45 pm PURPOSE: To date, only dexamethasone, tocilizumab, and casirivimab/imdevimab have been shown to reduce mortality in COVID-19 patients. Baricitinib is a selective Janus kinase 1/2 inhibitor with known anti-inflammatory and anti-viral properties. We sought to perform a meta-analysis of RCTs assessing the role of baricitinib in hospitalized patients with COVID-19 disease. METHODS: Electronic databases such as MEDLINE, EMBASE, and Cochrane Central were searched till March 20, 2022, for randomized controlled trials evaluating the efficacy of baricitinib in hospitalized COVID-19 patients. The outcomes assessed were 28-day mortality, progression to respiratory failure needing positive pressure ventilation or death, progression to mechanical ventilation or ECMO, duration of hospitalization and time to discharge. RESULTS: Four studies (with 10,815 patients) were included in the analysis. In total, 5,477 patients received baricitinib, and 5,338 patients received standard care. Pooled analysis showed a significantly decreased risk of 28-day mortality (OR 0.85, 95% CI 0.76-0.96, p=0.006) and progression to invasive mechanical ventilation or ECMO (OR 0.80, 95% CI 0.69-0.94, p=0.005) in the baricitinib arm compared to standard therapy or placebo. In addition, there was a significant reduction in duration of hospitalization (MD -1.43, 95% CI -2.46, -0.40, p=0.007) and time to recovery (MD -0.88, 95% CI -1.34, -0.41, p=0.0002). CONCLUSIONS: Baricitinib improved the patient-centric outcomes of mortality and progression to severe disease i.e., need for invasive mechanical ventilation, in hospitalized patients with COVID-19 disease compared with standard therapy alone. CLINICAL IMPLICATIONS: Baricitinib may be used in conjunction with standard of care treatments to improve morbidity and mortality in hospitalized COVID-19 patients. DISCLOSURES: No relevant relationships by Gerardo Carino No relevant relationships by ARKADIY FINN No relevant relationships by Amos Lal No relevant relationships by VIJAIRAM SELVARAJ

PATIENT WITH RECENT COVID-19 INFECTION PRESENTING WITH ACUTE UPPER AIRWAY OBSTRUCTION

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Acute airway obstruction is a life-threatening event requiring emergent identification and management. Limited reports of acute airway compromise in patients with recent novel coronavirus infection (COVID-19) suggest this may be a rare and late complication in COVID-19 patients. CASE PRESENTATION: A 19-year-old Guatemalan male with no known past medical history, unclear vaccination status, no smoking or alcohol history presented to the emergency department with complaints of worsening sore throat, muffled voice, difficulty swallowing, bloody vomitus, and subjective fever for two hours prior to arrival. He was diagnosed with mild COVID-19 3 weeks prior. History was limited by severe respiratory distress. On physical exam, the patient was afebrile. He had muffled voice, stridor, and a normal uvula. Labs were significant for leukocytosis, and respiratory panel positive for SARS-CoV-2. X-ray of chest and neck were unremarkable. Patient was given dexamethasone and antibiotics. Given concern for airway compromise and possible epiglottitis, the patient was urgently intubated. First attempt with video laryngoscopy was unsuccessful due to extensive edema and erythema of the hypopharyngeal tissues, then re-attempted successfully with a smaller endotracheal tube. The epiglottis could not be visualized. CT neck showed diffuse inflammation with enlargement of the adenoids and tonsils;epiglottis was obscured given presence of the endotracheal tube;no abscess seen. Differential included bacterial or viral epiglottitis, idiopathic angioedema reaction, and post-COVID reaction. The patient was admitted to the ICU for management of presumed epiglottitis and continued on dexamethasone for 40 hours and empiric antibiotics. He had rapid resolution of airway edema, was successfully extubated on day 4 of admission, and discharged home on day 6 with a 10-day course of cephalexin. DISCUSSION: Most mild, symptomatic cases of COVID-19 typically resolve within 2-3 weeks. This late presentation raises concern for epiglottitis as a rare but serious complication of COVID-19. The time course additionally suggests possible post-viral superinfection of the epiglottis and upper airway from other causes. Confirmation via direct visualization or imaging was not possible in this patient but he was treated presumptively for epiglottitis given his concerning physical exam findings. In cases of acute respiratory distress, airway management should supersede diagnostic evaluation due to the risk of rapid respiratory compromise. CONCLUSIONS: There are many known etiologies of acute airway obstruction, including epiglottitis, but it is important to consider COVID-19 as another possible etiology. While direct visualization is the gold standard for confirmation, diagnosis should not precede emergent intubation in cases of severe respiratory distress. REFERENCE #1: Çaytemel B, Kılıç H, Çomoğlu Ş. Approach to otolaryngology emergency in COVID-19 pandemic. Tr-ENT. 2020;30(50):24-36. DISCLOSURES: No relevant relationships by Gerardo Carino, source=Web Response No relevant relationships by Sugi Min, source=Web Response No relevant relationships by Claudia Sorin, source=Web Response

Initiating enteral nutrition in mechanically ventilated SARS-CoV-2 ards patients

INTRODUCTION: Early enteral nutrition is beneficial in critically ill patients. Enteral nutrition may reduce muscle wasting, decrease length of ICU stay, stress ulcer development, maintain gut health, and reduce risk of bacterial pneumonia. In this study, we looked to see whether mechanically ventilated SARS-CoV-2 patients were receiving adequate tube feeds, identify barriers to feeding, and follow clinical outcomes in these patients with prolonged ICU stays due to hypoxemia. METHODS: Study Design: This study involved retrospective chart review of 33 mechanically ventilated patients at a medium sized university based hospital from February 2020 to April 2020 who had ARDS secondary to SARSCoV- 2. Main Outcomes and Measures: i) ICU length of stay ii) Time to initiation of tube feeding iii) Days Goal Caloric Intake achieved iv) Barriers to early tube feeding v) Mortality outcomes vi) Disposition RESULTS: On average, these patients were intubated for 12.1 ± 7.6 days and ICU length of stay was 15.6 ± 9.6 days. Initiation of tube feeding was 3.7 ± 2.5 days after mechanical ventilation. The main barriers to starting early enteral nutrition were vasopressor usage (93.9%), paralytics (69.6%), and proning (48.5%). For 64.34 ± 25.3% of the days intubated did the patients receive tube feeds, and only 39.7 ± 25.7% of the days intubated did patients receive one hundred percent of their goal caloric intake. Survival rate for patients aged ≥65 years was higher in patients tube fed >50% of the intubated days, compared to those who were tube fed for ≤50% of intubated days. Patients suffered severe protein calorie malnutrition and their BMI dropped by 8.2% at time of discharge. Also, patients with BMI ≥30 and age ≥65 years, had a 75% mortality rate, which was 1.7 times the overall average mortality rate of 45.5%. Of the 54.5% patients who survived the hospitalization, 12.12% were discharged home. 31.5% of the survived patients developed critical illness myopathy requiring aggressive rehabilitation therapy. CONCLUSIONS: Delayed initiation of enteral nutrition in intubated SARS-CoV-2 patients was mainly due to vasopressor and paralytic usage. Further studies are also needed to evaluate the nutritional requirements of intubated SARS-CoV-2 patients with long ICU stays as compared to non SARS-CoV-2 patients.