ABSTRACT
Introduction: Lung cavitation is a rare radiological finding of COVID- 19 pneumonia associated with unfavorable outcome. Its pathogenesis is unclear and it is characterized by diffuse alveolar damage, intra-alveolar hemorrhage and necrosis of parenchymal cells. Method(s): We retrospectively reviewed the radiological findings of COVID-19 patients admitted to our ICU during the pandemic in order to identify the development of lung cavitary lesions. Result(s): From 11/2020 until 10/2022 1000 patients were admitted to our COVID-19 ICU (92% on invasive mechanical ventilation). According to our data there were three cases of lung cavity formation. The first case was a 78 years male with history of hypertension. Chest CT (Day26) showed a 11.6 cm cavity in the right middle lobe (Fig. 1). The second case was a 52 year old female with history of diabetes mellitus, obesity, hypertension and rheumatoid arthritis. Follow up chest CT (D29) revealed progressive development of multiple bilateral cavitary lesions. The third case was a 61 year old male with no medical history, who developed (D17) multiple cavitary lesions in both lower lobes, concomitant with left-sided pulmonary embolism. The presence of other well defined etiologies of cavitary lesions such as mycobacterial and fungal infections as well as neoplasmatic or autoimmune diseases had been widely excluded. However, since pulmonary cavitation is a late complication of severe COVID disease, we cannot overlook the fact that all patients suffered from superinfections by XDR Acinetobacter baumanii and/or Klebsiella pneumonia, as most of our patients with prolonged length of stay. Moreover, two of the three patients developed pneumothorax. All patients finally died. Conclusion(s): Although bacterial co-infection does not allow absolute association between cavitary formation and coronavirus disease, it seems that destructive triggers, such as bacteria or mechanical ventilation, may aggravate COVID underlying lung lesions leading to cavitation.
ABSTRACT
Introduction: APACHE II severity scoring system has been successfully used for mortality risk assessment in the ICU, however its validity in the subgroup of COVID-19 patients has been questionable. We aimed to examine the predictive value of APACHE II score in a cohort of critically ill COVID-19 patients. Method(s): We performed a retrospective analysis of prospectively collected data in a cohort of COVID-19 patients admitted to our 50-bed ICU between October 2020 and April 2022. Using a ROC analysis we assessed the performance of APACHE II score and identified the optimal cut-off value for mortality prediction. Result(s): Our cohort included 783 patients (66% male) with positive PCR forSARS-Cov-2 and respiratory failure. Mean age was 66 years. Invasive mechanical ventilation was used in 92%of patients and 89.3% had at least one comorbidity. The mean APACHE II score of the whole cohort was 20.3 (+/- 8.5). ICU mortality was 44.7%. Death rate was similar between sexes but significantly higher in those who were older and those suffering from COPD, chronic renal or heart failure, atrial fibrillation or any kind of malignancy. Non-survivors had a significantly higher APACHE II score compared to survivors (25.2 +/- 7.9 vs 16.3 +/- 6.7, p < 0.001). ROC analysis showed an AUC 0.81 (95% CI 0.78-0.84, p < 0.001). At a cut-off value of 19.5 APACHE II score could predict death with a sensitivity of 77.1% (95% CI 72.4-81.4%), a specificity of 70.7% (95% CI 66.1-74.9%), PPV 68% (95% CI 63.2-72.6%) and NPV 79.3% (95% CI 74.9-83.2%). Conclusion(s): APACHE II score is an effective tool for mortality prediction in critically ill COVID-19 patients. A cut-off value of 19.5 can be used for risk stratification in this patient population.
ABSTRACT
Introduction: Ventilation in prone-position (PP) improves survival in moderate-to-severe ARDS. However, optimal duration of the intervention to gain maximum benefit is unknown. We sought to examine the efficacy and safety of a prolonged PP protocol in COVID-19-associated ARDS. Method(s): This was a prospective observational study. We included consecutive intubated and mechanically ventilated patients with ARDS and positive PCR for SARS-CoV-2 who underwent at least one session of PP from March 2021 to August 2021. PP was undertaken if P/F < 150 with FiO2 > 0.6 and PEEP > 10cmH2O. Oxygenation parameters and respiratory mechanics were recorded before PP, at the end of PP session and 4 h after supine repositioning. Patients with PP longer than 24 h (prolonged group) were compared to patients who were proned for less than 24 h (control group). The duration of PP was at the discretion of the treating intensivist. Result(s): We recorded 56 patients (62.7% male). Five patients were excluded because PP was terminated in less than 4 h. Mean age of the 51 studied patients was 61.4 years. Patients in the prolonged group had significantly higher BMI than controls. Baseline oxygenation and respiratory mechanics were similar between groups. PP duration was 39.8 versus 20.5 h (p < 0.001). Increase of P/F was higher in the prolonged PP group during proning (103.8 +/- 70.8 vs 66 +/- 53.9, p < 0.05) and after supination (76.3 +/- 64.6 vs 48.6 +/- 34.9, p = 0.058). No change in respiratory mechanics was observed in either group. 28-day survival was 75% in the prolonged PP group and 69.5% in the control group (p = 0.665). Duration of mechanical ventilation, number of PP cycles and rate of complications were similar between groups. Conclusion(s): In patients with ARDS due to COVID-19 prolonged PP resulted in better oxygenation, but had no impact on outcome. However, it is both feasible and safe and can be an alternative in conditions of increased work load as was the case during the recent pandemic.