Clinical Outcomes of Routine Awake Prone Positioning in COVID-19 Patients: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

Before coronavirus disease 2019 (COVID-19) emerged, proning had been demonstrated to improve oxygenation in those with acute hypoxic respiratory failure and be performed in non-intensive care settings. This benefit was further exemplified by the COVID-19 pandemic, leading to awake prone positioning (APP). We assessed the efficacy of routine APP versus standard care in preventing death and invasive mechanical ventilation (IMV) in non-intubated hypoxic COVID-19 patients. PubMed, Cochrane Library, Scopus, and medRxiv databases were used from January 1st, 2020, to January 15th, 2022, to identify randomized controlled trials (RCTs). Routine APP group were encouraged to be self-prone, whereas the standard care group received care according to local clinical practice and allowed APP crossover as rescue therapy. We included eight COVID-19 RCTs assessing 809 APP vs. 822 standard care patients. APP group had less IMV requirement (26.5% vs. 30.9%; OR - odds ratio 0.77; P=0.03) than the standard care group, with subgroup analysis showing greater benefit (32.5% vs. 39.1%; OR 0.75; P=0.02) for those mainly requiring oxygen support of non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC). The time to IMV initiation was similar (mean 8.3 vs. 10.0 days; P=0.66) for patients requiring NIMV and HFNC. Patients mainly receiving supplemental oxygen and non-rebreather masks had improved oxygenation parameters, although not statistically significant. Other outcomes involving all-cause hospital mortality, hospital and ICU (intensive care unit) length of stay, and adverse events were comparable. APP appeared to be an important modality for reducing IMV requirements, especially in those requiring NIMV and HFNC.

Clinical Outcomes of Early Versus Late Tracheostomy in Coronavirus Disease 2019 Patients: A Systematic Review and Meta-Analysis.

BACKGROUND: A significant proportion of Coronavirus Disease 2019 (COVID-19) patients require admission to the intensive care unit (ICU) and invasive mechanical ventilation (IMV). Tracheostomy is increasingly performed when a prolonged course of IMV is anticipated. OBJECTIVES: To determine clinical and resource utilization benefits of early versus late tracheostomy among COVID-19 patients. METHODS: Pubmed, Cochrane Library, Scopus, and Embase were used to identify relevant studies comparing outcomes of COVID-19 patients undergoing early and late tracheostomy from January 1, 2020, to December 1, 2021. RESULTS: Twelve studies were selected, and 2222 critically ill COVID-19 patients hospitalized between January to December 2020 were included. Among the included patients, 34.5% and 65.5% underwent early and late tracheostomy, respectively. Among the included studies, 58.3% and 41.7% defined early tracheostomy using cutoffs of 14 and 10 days, respectively. All-cause in-hospital mortality was not different between the early and late tracheostomy groups (32.9% vs. 33.1%; OR = 1.00; P = 0.98). Sensitivity analysis demonstrated a similar mortality rate in studies using a cutoff of 10 days (34.6% vs. 35.5%; OR = 0.97; P = 0.89) or 14 days (31.2% vs. 27.7%; OR = 1.05; P = 0.78). The early tracheostomy group had shorter ICU length of stay (LOS) (mean: 23.18 vs. 30.51 days; P < 0.001) and IMV duration (mean: 20.49 vs. 28.94 days; P < 0.001) than the late tracheostomy group. The time from tracheostomy to decannulation was longer (mean: 23.36 vs. 16.24 days; P = 0.02) in the early tracheostomy group than in the late tracheostomy group, but the time from tracheostomy to IMV weaning was similar in both groups. Other clinical characteristics, including age, were similar in both groups. CONCLUSIONS: Early tracheostomy reduced the ICU LOS and IMV duration among COVID-19 patients compared with late tracheostomy, but the mortality rate was similar in both groups. The findings have important implications for the treatment of COVID-19 patients, especially in a resource-limited setting.

Comparison of clinical characteristics and outcomes of COVID-19 patients undergoing early versus late intubation from initial hospital admission: A systematic review and meta-analysis.

BACKGROUND: The true impact of intubation and mechanical ventilation in coronavirus disease 2019 (COVID-19) patients remains controversial. METHODS: We searched Pubmed, Cochrane Library, Embase, and Web of Science databases from inception to October 30th, 2021 for studies containing comparative data of COVID-19 patients undergoing early versus late intubation from initial hospital admission. Early intubation was defined as intubation within 48 h of hospital admission. The primary outcomes assessed were all-cause in-hospital mortality, renal replacement therapy (RRT), and invasive mechanical ventilation (IMV) duration. RESULTS: Four cohort studies with 498 COVID-19 patients were included between February to August 2020, in which 28.6% had early intubation, and 36.0% underwent late intubation. Although the pooled hospital mortality rate was 32.1%, no significant difference in mortality rate was observed (odds ratio [OR] 0.81; 95% confidence interval 0.32-2.00; P = 0.64) among those undergoing early and late intubation. IMV duration (mean 9.62 vs. 11.77 days; P = 0.25) and RRT requirement (18.3% vs. 14.6%; OR 1.19; P = 0.59) were similar regardless of intubation timing. While age, sex, diabetes, and body mass index were comparable, patients undergoing early intubation had higher sequential organ failure assessment (SOFA) scores (mean 7.00 vs. 5.17; P < 0.001). CONCLUSIONS: The timing of intubation from initial hospital admission did not significantly alter clinical outcomes during the early phase of the COVID-19 pandemic. Higher SOFA scores could explain early intubation. With the advancements in COVID-19 therapies, more research is required to determine optimal intubation time beyond the first wave of the pandemic.

Successful use of endobronchial valve for persistent air leak in a patient with COVID-19 and bullous emphysema.

Patients with SARS-CoV-2 pneumonia can suffer from pneumothorax and persistent air leak (PAL). The pneumothorax occurs with or without pre-existing lung disease. PAL refers to air leak lasting more than 5-7 days and arises due to bronchopleural or alveolopleural fistula. The management of PAL can be challenging as a standard management guideline is lacking. Here we present the case of a 42-year-old smoker with COVID-19 who presented to the hospital with fever, cough, acute left-sided chest pain and shortness of breath. He suffered from a large left-sided pneumothorax requiring immediate chest tube drainage. Unfortunately, the air leak persisted for 13 days before one-way endobronchial valve (EBV) was used with complete resolution of the air leak. We also review the literature regarding other cases of EBV utilisation for PAL in patients with COVID-19.

Clinical Characteristics Between Survivors and Nonsurvivors of COVID-19 Patients Requiring Extracorporeal Membrane Oxygenation (ECMO) Support: A Systematic Review and Meta-Analysis.

Background: The use of extracorporeal membrane oxygenation (ECMO) in coronavirus disease 2019 (COVID-19) for refractory respiratory failure, severe cardiac dysfunction, and bridge to lung transplantation has been steadily increasing during the ongoing global pandemic. Objective: Our meta-analysis aims to compare the clinical characteristics between COVID-19 survivors and nonsurvivors requiring ECMO support. Methods: A systematic search of Pubmed, Cochrane, Embase, Scopus, and Web of Science databases was performed between December first, 2019, to June first, 2021. Studies with comparative data of COVID-19 ECMO patients were selected, in which clinical characteristics and complications were assessed. Results: Sixteen cohort studies involving 706 COVID-19 patients requiring ECMO support with pooled mortality rate of 40% were included. Younger age (mean 51 years vs 55 years; P < .001), fewer comorbidities (23% vs 31%; odds ratio [OR] 0.55; P = .02), and less renal replacement therapy (RRT) (21% vs 39%; OR 0.41; P = .007) and vasopressor (76% vs 92%; OR 0.35; P = .008) requirement were demonstrated in COVID-19 survivors requiring ECMO support than nonsurvivors. Survivors also had higher pre-ECMO pH (mean 7.33 vs 7.26; P < .001) than nonsurvivors. No difference was observed in gender, body mass index, duration of mechanical ventilation (MV) before ECMO support initiation, total ECMO support duration, and pre-ECMO parameters of PaO2/FiO2 ratio, tidal volume (mL/kg), positive end-expiratory pressure, and plateau pressure. The rate of bleeding complications was lower in survivors (32% vs 59%; OR 0.36; P = .001) than nonsurvivors, but no difference was observed in thromboembolism and secondary infections. Conclusions: We found advanced age, multiple comorbidities, lower pre-ECMO pH, greater RRT, and vasopressor requirements, and bleeding are predictors of death in COVID-19 patients requiring ECMO support. The duration of MV before ECMO support initiation and total ECMO support duration was similar among survivors and nonsurvivors. Our study results have important clinical implications when considering ECMO support in critically ill COVID-19 patients.

Comparing the clinical characteristics and outcomes of COVID-19-associate pulmonary aspergillosis (CAPA): a systematic review and meta-analysis.

PURPOSE: Invasive pulmonary aspergillosis has been increasingly recognized in COVID-19 patients, termed COVID-19-associate pulmonary aspergillosis (CAPA). Our meta-analysis aims to assess the clinical characteristics and outcomes of patients diagnosed with CAPA compared to those without CAPA. METHODS: We searched the Pubmed, Cochrane Library, SCOPUS, and Web of Science databases for studies published between January 1, 2020 and August 1, 2021, containing comparative data of patients diagnosed with CAPA and those without CAPA. RESULTS: Eight cohort studies involving 729 critically ill COVID-19 patients with comparative data were included. CAPA patients were older (mean age 66.58 vs. 59.25 years; P = 0.007) and had underlying chronic obstructive pulmonary disease (COPD) (13.7 vs. 6.1%; OR 2.75; P = 0.05). No differences in gender, body mass index (BMI), and comorbidities of diabetes and cancer were observed. CAPA patients were more likely to receive long-term corticosteroid treatment (15.0 vs. 5.3%; OR 3.53; P = 0.03). CAPA patients had greater severity of illness based on sequential organ failure assessment (SOFA) score with a higher all-cause in-hospital mortality rate (42.6 vs. 26.5%; OR 3.39; P < 0.001) and earlier ICU admission from illness onset (mean 11.00 vs. 12.00 days; P = 0.003). ICU length of stay (LOS), invasive mechanical ventilation (IMV) duration, the requirement of inotropic support and renal replacement therapy were comparable between the two groups. CONCLUSIONS: CAPA patients are typically older with underlying COPD and received long-term corticosteroid treatment. Furthermore, CAPA is associated with higher SOFA scores, mortality, and earlier onset of ICU admission from illness onset.

A systematic review and meta-analysis comparing the clinical characteristics and outcomes of COVID-19 and influenza patients on ECMO.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a valuable rescue therapy to treat refractory hypoxemia caused by influenza. The present meta-analysis aimed to compare the clinical characteristics and outcomes of ECMO between COVID-19 and influenza. METHODS: We searched the PubMed, Cochrane Library, SCOPUS, and Web of Science databases from inception to May 1, 2021. The included studies compared the clinical characteristics and outcomes of ECMO between adults with COVID-19 and those with influenza. RESULTS: The study included four retrospective cohorts involving a total of 129 patients with COVID-19 and 140 with influenza who were treated using ECMO. Clinical characteristics were similar between the COVID-19 and influenza groups, including body mass index (BMI), diabetes mellitus, hypertension, and immunocompromised status. A higher proportion of patients with COVID-19 on ECMO were male (75.9% vs. 62.9%; P = 0.04). There was no difference between the groups in terms of illness severity based on sequential organ failure assessment (SOFA) score or serum pH. Patients with COVID-19 had a longer mean duration of mechanical ventilation before ECMO (6.63 vs. 3.38 days; P < 0.01). The pooled mortality rate was 43.8%. The mean ECMO duration (14.13 vs. 12.55 days; P = 0.25) and mortality rate (42.6% vs. 45.0%; P = 0.99) were comparable between the groups. CONCLUSION: Clinical characteristics, ECMO duration, and mortality were comparable between patients with COVID-19 and those with influenza who required ECMO to treat refractory hypoxemia. The duration of mechanical ventilation before ECMO did not influence outcomes. Patients with COVID-19 benefit from ECMO salvage therapy similarly to those with influenza.