Chest X-ray for predicting mortality and the need for ventilatory support in COVID-19 patients presenting to the emergency department.

OBJECTIVES: To evaluate the inter-rater agreement of chest X-ray (CXR) findings in coronavirus disease 2019 (COVID-19) and to determine the value of initial CXR along with demographic, clinical, and laboratory data at emergency department (ED) presentation for predicting mortality and the need for ventilatory support. METHODS: A total of 340 COVID-19 patients who underwent CXR in the ED setting (March 1-13, 2020) were retrospectively included. Two reviewers independently assessed CXR abnormalities, including ground-glass opacities (GGOs) and consolidation. Two scoring systems (Brixia score and percentage of lung involvement) were applied. Inter-rater agreement was assessed by weighted Cohen's kappa (κ) or intraclass correlation coefficient (ICC). Predictors of death and respiratory support were identified by logistic or Poisson regression. RESULTS: GGO admixed with consolidation (n = 235, 69%) was the most common CXR finding. The inter-rater agreement was almost perfect for type of parenchymal opacity (κ = 0.90), Brixia score (ICC = 0.91), and percentage of lung involvement (ICC = 0.95). The Brixia score (OR: 1.19; 95% CI: 1.06, 1.34; p = 0.003), age (OR: 1.16; 95% CI: 1.11, 1.22; p < 0.001), PaO2/FiO2 ratio (OR: 0.99; 95% CI: 0.98, 1; p = 0.002), and cardiovascular diseases (OR: 3.21; 95% CI: 1.28, 8.39; p = 0.014) predicted death. Percentage of lung involvement (OR: 1.02; 95% CI: 1.01, 1.03; p = 0.001) and PaO2/FiO2 ratio (OR: 0.99; 95% CI: 0.99, 1.00; p < 0.001) were significant predictors of the need for ventilatory support. CONCLUSIONS: CXR is a reproducible tool for assessing COVID-19 and integrates with patient history, PaO2/FiO2 ratio, and SpO2 values to early predict mortality and the need for ventilatory support. KEY POINTS: • Chest X-ray is a reproducible tool for assessing COVID-19 pneumonia. • The Brixia score and percentage of lung involvement on chest X-ray integrate with patient history, PaO2/FIO2 ratio, and SpO2 values to early predict mortality and the need for ventilatory support in COVID-19 patients presenting to the emergency department.

Severity of respiratory failure and outcome of patients needing a ventilatory support in the Emergency Department during Italian novel coronavirus SARS-CoV2 outbreak: Preliminary data on the role of Helmet CPAP and Non-Invasive Positive Pressure Ventilation.

BACKGROUND: Novel Coronavirus SARS-CoV-2 pandemic is spreading around the world. At the end of February, the outburst of the pandemic has hit hard on northern Italian's hospitals. As of today, no data have been published regarding the severity of respiratory failure of patients presenting to the Emergency Departments. Moreover, the outcome the patients forced to undergo Continuous Positive Airway Pressure (CPAP) or Non-Invasive Positive Pressure Ventilation (NIPPV) due to lack of Intensive Care resources is unknown. "Papa Giovanni XXIII" hospital (HPG23) of Bergamo is one of the largest hospitals in the Country, with an Emergency Department (ED) managing over 100,000 patients per year. METHODS: This is a retrospective observational study based on chart review of patients presenting to the Emergency Department of HPG23 from 29/02/2020 to 10/03/2020 with a clinical condition highly suspicious for COVID-19 infection. Registration of admission rates, severity of respiratory failure (ARDS classification), need of respiratory support, SARS-CoV-2 PCR test and outcome of patients treated with a ventilatory support were registered on 10th of May 2020. FINDINGS: From 29/02 to 10/03 611 patients with a suspected diagnosis of COVID-19 infection were evaluated in our ED; 320 (52%) met the criteria for hospital admission and 99 (31%) needed to be immediately started on ventilatory support (81% CPAP, 7% NIPPV, 12% Invasive Mechanical Ventilation). Eighty-five (86%) of the 99 patients needing a ventilatory support eventually had SARS-CoV-2 infection confirmed by PCR test on nasal-pharyngeal swab. Their median PO2/FiO2 ratio was 128 (IQR 85-168), with 23 patients (29.5%) classified as severe ARDS. Mortality rate as of 10th of May was 76.5%, ranging from 44.4% within patients <60 years old to 85% within those older than 60 years (p = 0.001). NIPPV/CPAP failure occurred in 91.5% of patients. INTERPRETATION: The population of patients suspected for COVID-19 infection presenting at our ED showed a very high rate of severe respiratory failure, with urgent need of a large amount of intensive care resources. Mortality rates of critically ill patients with confirmed COVID-19 (76.5%) are similar to previously reported studies with similar population. CPAP/NIPPV could be a valid strategy to treat severely hypoxic patients that cannot be intubated in the ED due to lack of intensive care resources. FUNDING: No funds were received for this research project.

Novel 2019 coronavirus SARS-CoV-2 (COVID-19): An updated overview for emergency clinicians

The novel coronavirus, COVID-19, has quickly become a worldwide threat to health, travel, and commerce. This overview analyzes the best information from the early research, including epidemiologic and demographic features from SARS-CoV-1 and MERS-CoV viruses; lessons learned from the experience of an emergency physician in Northern Italy, where the outbreak has devastated the healthcare system; evidence on transmission and prevention through safe use of PPE; evidence and advice on SARS-CoV-2 testing and co-infection; management options; airway management options; steps for rapid sequence intubation in the ED and managing disaster ventilation; and information on managing pediatric and pregnant patients.

Calculated Decisions: Brescia-COVID Respiratory Severity Scale (BCRSS)/Algorithm

The Brescia-COVID respiratory severity scale/algorithm is a stepwise management approach to COVID-19 patients based on clinical severity. The BCRSS was rapidly developed in Brescia, Italy, during that nation's COVID-19 crisis. The scale has not been validated or tested in other populations. The BCRSS uses patient examination features along with the need for escalating levels of respiratory support (NIV, intubation, proning) to suggest treatment recommendations. The scale simplifies the clinical summary of a patient's status, and allows clinicians to compare patients to one another and to track the trend of a patient's level of respiratory severity over time.