Identifying organ dysfunction trajectory-based subphenotypes in critically ill patients with COVID-19 (preprint)

Rationale. COVID-19-associated respiratory failure offers the unprecedented opportunity to evaluate the differential host response to a uniform pathogenic insult. Prior studies of Acute Respiratory Distress Syndrome (ARDS) have identified subphenotypes with differential outcomes. Understanding whether there are distinct subphenotypes of severe COVID-19 may offer insight into its pathophysiology. Objectives. To identify and characterize distinct subphenotypes of COVID-19 critical illness defined by the post-intubation trajectory of Sequential Organ Failure Assessment (SOFA) score. Methods. Intubated COVID-19 patients at two hospitals in New York city were leveraged as development and validation cohorts. Patients were grouped into mild, intermediate, and severe strata by their baseline post-intubation SOFA. Hierarchical agglomerative clustering was performed within each stratum to detect subphenotypes based on similarities amongst SOFA score trajectories evaluated by Dynamic Time Warping. Statistical tests defined trajectory subphenotype predictive markers. Measurements and Main Results. Distinct worsening and recovering subphenotypes were identified within each stratum, which had distinct 7-day post-intubation SOFA progression trends. Patients in the worsening suphenotypes had a higher mortality than those in the recovering subphenotypes within each stratum (mild stratum, 29.7% vs. 10.3%, p=0.033; intermediate stratum, 29.3% vs. 8.0%, p=0.002; severe stratum, 53.7% vs. 22.2%, p<0.001). Worsening and recovering subphenotypes were replicated in the validation cohort. Routine laboratory tests, vital signs, and respiratory variables rather than demographics and comorbidities were predictive of the worsening and recovering subphenotypes. Conclusions. There are clear worsening and recovering subphenotypes of COVID-19 respiratory failure after intubation, which are more predictive of outcomes than baseline severity of illness. Organ dysfunction trajectory may be well suited as a surrogate for research in COVID-19 respiratory failure.

Symptoms at disease onset predict prognosis in COVID-19 disease (preprint)

Background: The main clinical manifestations of coronavirus disease 2019 (COVID-19) onset are respiratory symptoms, including cough, sputum and dyspnea. However, a significant proportion of patients initially manifested extra-respiratory symptoms, such as fever, myalgia and diarrhea. Here we compared the different characteristics and outcomes between the patients with respiratory symptoms and extra-respiratory symptoms at illness onset.Methods: The patients admitted to the respiratory departments from eight hospitals out of Wuhan with nucleic acid-positive of severe acute respiratory syndrome coronavirus (SARS-CoV-2) were recruited. Epidemiological information, clinical manifestations, laboratory findings, and radiological characteristics, treatment regimens and outcomes data were recorded and analyzed.Results: The median age of the recruited 541 subjects was 43 years (IQR, 33-55). Of the 541 subjects, 404 (74.5%) subjects had initial symptom that were respiratory, while 137 (25.5%) subjects had extra-respiratory symptoms. Respiratory COVID-19 subjects had more secondary bacterial infections (p<0.001), needed the intensive care unit more (p=0.005), non-invasive ventilation more (p=0.004), developed ARDS more (p=0.001) and needed longer to recover (p=0.003) compared to predominately extra-respiratory COVID-19 subjects. The multivariate model showed that age (OR = 1.04, p = 0.01) dyspnea (OR = 4.91, p < 0.001) and secondary bacterial infection (OR = 19.8, p < 0.001) were independently associated with development of ARDS among COVID-19 patients.Conclusion: we identify COVID-19 subjects with dyspnea at disease onset have worse prognosis. We also demonstrate age and secondary bacterial infections to be independently associated with ARDS development in subjects with COVID-19.