Management in the ICU

Patients hospitalised due to infection with SARS-CoV-2 frequently require admission to the ICU for organ support. Most of these admissions are due to acute respiratory failure, often fulfilling the criteria for ARDS. This chapter will review current evidence-based management of this patient population. We discuss how oxygenation can be supported via noninvasive and invasive methods, and describe how invasive ventilation should be set to provide lung protection. We discuss how there is no place for routine antiviral, antibiotic and therapeutic anticoagulation in ICU patients with COVID-19-related ARDS, but there is a place for steroids and immunomodulation via anti-IL-6. Finally, we provide an overview of the complications and long-term consequences of critical illness caused by COVID-19.Copyright © ERS 2021.

The relationship between symptoms and functional physiological outcomes in survivors of severe COVID-19 pneumonia

P136 Table 1Results of correlation analysis Correlation analysis 4MGS 1STSreps SpO2% desaturation Results r p-value r p-value r p-value Pre-COVID mMRC dyspnoea score 0(0–1) -0.267** <0.001 -0.285** <0.001 -0.108 0.094 Post-COVID mMRC dyspnoea score 1(0–2) -0.442** <0.001 -0.457** <0.001 -0.143* 0.025 NRS breathlessness 3(0–5) -0.287** <0.001 -0.406** <0.001 -0.490 0.445 NRS fatigue 3(0–5) -0.315** <0.001 -0.379** <0.001 -0.190* 0.003 NRS cough 0(0–2) -0.660 0.292 -0.153* 0.017 0.083 0.194 NRS pain 1(0–4) -0.278** <0.001 -0.346** <0.001 -0.188* 0.003 NRS sleep difficulty 2(0–5) -0.246** <0.001 -0.386** <0.001 -0.122 0.057 Data are presented as median (interquartile range) or frequency (proportion%;95% confidence interval). SpO2% desaturation = SpO2% desaturation from baseline during 1 minute sit to stand test;1STSreps = repetitions per minute during 1 minute sit to stand test;4MGS = 4 metre gait speed;mMRC = modified Medical Research Council;NRS = 0 – 10 numerical rating scale;r = Spearman correlation coefficient. *indicates statistical significance at 0.05 level. **indicates statistical significance at 0.001 level.ConclusionRespiratory symptoms were not strong predictors of 4-metre gait speed and 1-minute sit-to-stand test performance. These data highlight the importance of face-to-face testing to objectively assess functional limitation in patients recovering from severe COVID pneumonia.

Clinical, functional and psychological characteristics of survivors of severe COVID-19 pneumonia: a comparison of outcomes from the first and second waves

P135 Table 1Patient demographics, self-reported scores and functional test results by wave 1st wave 2nd wave p-value Demographics n=167 n=141 Age 59±13 58±12 0.564 Female 60 (35.93;28.94–43.40) 62 (43.97;35.97–52.22) 0.15 BMI (kg/m2) 30.5 (26.6–35.2) 32.1 (28.5–37.9) 0.009 ** BAME 115 (69.7;62.39–76.32) 72 (59.5;50.62–67.94) 0.073 Number of comorbidities 2 (1–3) 2 (1–3) 0.144 Patients Receiving Drugs Dexamethasone 11 (6.63;3.57–11.17) 138 (97.87;94.43–99.40) <0.001 *** Remdesivir 18 (10.84;6.79–16.24) 81 (57.45;49.20–65.39) <0.001 *** Other Immunomodulator 2 (1.20;0.25–3.81) 31 (21.99;15.76–29.35) <0.001 *** Questionnaire Scores n=164 n=132 NRS Breathlessness 2 (0–5) 3 (0–5) 0.153 ≥4 56 (34.78;27.75–42.36) 52 (37.14;29.47–45.34) 0.67 NRS Cough 0 (0–2) 0 (0–3) 0.439 ≥4 17 (10.56;6.52–16.00) 18 (13.64;8.59–20.26) 0.419 NRS Fatigue 3 (0–5) 3 (0–5) 0.867 ≥4 65 (40.63;33.24–48.35) 48 (36.92;28.99–45.43) 0.52 NRS Pain 0 (0–5) 1 (0–3) 0.682 ≥4 44 (27.50;21.03–34.78) 30 (23.08;16.48–30.86) 0.39 NRS Sleep disturbance 2 (0–5) 2 (0–5) 0.558 ≥4 52 (32.50;25.61–40.02) 49 (37.40;29.47–45.89) 0.382 Pre-COVID-19 mMRC 1 (0–2) 1 (1–2) 0.478 Post-COVID-19 mMRC 0 (0–1) 0 (0–1) 0.329 Post-COVID-19 mMRC ≥2 66 (40.99;33.61–48.70) 49 (38.58;30.45–47.23) 0.678 PCFS 2 (0–3) 1 (0–2) 0.055 PCFS ≥2 80 (50.00;42.31–57.69) 51 (42.15;33.62–51.05) 0.191 PHQ-9 ≥10 32 (20.38;14.66–27.19) 29 (23.02;16.33–30.92) 0.592 GAD-7 ≥10 34 (21.38;15.56–28.24) 16 (12.80;7.81- 19.49) 0.059 TSQ ≥6 43 (27.56;21.01–34.94) 27 (22.31;15.60–30.33) 0.319 Functional Tests n=160 n=139 4MGS <0.8 (ms-1) 67 (42.41;34.89–50.19) 47 (35.07;27.38–43.40) 0.201 1STS repetitions 18 (12–23) 17 (12–21) 0.460 <2.5 percentile 96 (60.00;52.29–67.36) 108 (77.70;70.25–84.00) 0.011 * Desaturation ≥4% 52 (34.67;27.40–4 .52) 42 (32.31;24.73–40.67) 0.677 Parametric data are presented as mean ± standard deviation, non-parametric data are presented as median (interquartile range) or frequency (proportion;95% confidence interval). Statistical significance indicated by * (p<0.05), ** (p<0.01), *** (p<0.001). BMI = Body mass index, BAME = Black, Asian or minority ethnic, NRS = Numerical rating scale (0–10), mMRC = modified Medical Research Council for dyspnoea (0–4), PCFS = Post-COVID-19 functional status scale (0–4), PHQ-9 = Patient health questionnaire 9 (0–27), GAD-7 = General Anxiety Disorder-7 scale (0–21), TSQ = Trauma screening questionnaire (0–10), 4MGS = 4-metre gait speed, 1STS = 1-minute sit-to-stand.ConclusionDespite shorter admission duration, and less frequent IMV, the burden of symptoms and functional limitation experienced post-hospitalisation for severe COVID-19 pneumonia was at least as severe during Wave 2 as in Wave 1. Identification of contributing factors and impact on post-COVID rehabilitation outcomes requires further study.

Mortality in patients requiring home mechanical ventilation during the COVID-19 pandemic: experiences of a regional specialist ventilation unit

P101 Figure 1(A) Monthly mortality of patients under Lane Fox Respiratory Service follow-up, dotted lines represent upper and lower bounds of 95% confidence intervals (B) Proportion of home mechanical ventilation (HMV) users in each disease category who died between 1st March and 30th ApriI by year[Figure omitted. See PDF]ConclusionsDeaths amongst HMV users at our regional ventilation centre were highest in the first two months following the onset of the COVID-19 pandemic. A subsequent fall in mortality may relate to effective shielding advice following national lockdown and departmental guidance offered. The majority of deaths were in patients with obesity-related respiratory failure. These data support previous observations that obesity is a major risk factor for adverse outcomes in patients with COVID-19.

Parasternal electromyography as a measure of respiratory muscle function in patients Recovering from severe covid-19 pneumonia

Introduction Conventional lung function testing involves forced expiratory manoeuvres which risk aerosolisation of respiratory droplets and nosocomial transmission of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2/COVID-19). Between-patient decontamination procedures render routine testing impractical. Parasternal electromyography (EMGpara) is an effort-independent method of assessing inspiratory muscle activity that tracks clinical trajectory in COPD, cystic fibrosis and pulmonary fibrosis. We evaluated EMGpara as a method of monitoring respiratory muscle function during recovery from COVID-19 pneumonia in Post-COVID clinic. Methods Prospective single-centre observational cohort study (05/Q0703/82). All patients hospitalised with severe COVID-19 pneumonia (oxygen requirement-40% or critical care admission) were invited to clinic 6-8 weeks post-discharge. EMGpara was recorded in consecutive patients attending 12 clinic sessions using transcutaneous second intercostal space electromyography. Measurements were made over 2 minutes of tidal breathing followed by maximal inspiratory manoeuvres (inspiration to total lung capacity and maximal sniff manoeuvres) and the values for root mean square (RMS) EMGpara per breath, EMGpara%max (RMS EMGpara as a proportion of volitional maximum), Neural Respiratory Drive Index (NRDI) and sex-specific standardised residuals (z-scores) recorded. After each measurement, equipment was decontaminated using alcohol-based wipes and surface electrodes were disposed of. Symptom questionnaires and radiographic assessment of lung oedema (RALE) scores were recorded. Results Between 4th June and 2nd July 2020, EMGpara was measured in 25 patients. All approached patients consented to participate, no adverse events occurred. Mean±SD age 57.1 ±15.6 years, 64% male, BMI 29.4±5.6 kg/m2, 29% current/ex-smokers. mMRC was at pre-COVID baseline in 56%, 32% reported persistent burdensome breathlessness. Respiratory rate 15±3 breaths/minute, oxygen saturation 98±2.0%, heart rate 87±12 bpm. EMGpara measures are presented in table 1. Zscores of all EMGpara indices were raised. NRDI was associated with admission, worst inpatient and follow-up RALE scores (R=0.41 (p=0.04), R=0.40 (p=0.046) and R=0.49 (p=0.01), respectively), not mMRC (R=0.24, p=0.24 Conclusions Inspiratory muscle activation was high, which may reflect underlying interstitial pathology, critical illness myopathy, deconditioning or anxiety relating to clinic attendance. Parasternal electromyography is a well-tolerated technique that avoids aerosolisation of respiratory droplets and utilises equipment that is easily decontaminated between patients. This makes it a practical and informative measure of lung function during the COVID-19 pandemic.

Clinical, radiological, functional and psychological characteristics of severe covid-19 pneumonia survivors: A prospective observational cohort study

Introduction The 'Long COVID' syndrome, where symptoms persist beyond the acute illness with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2/COVID-19), is anecdotally described. However, a comprehensive report of clinical, radiological, functional and psychological recovery from COVID-19 is currently lacking. We present a detailed radiological, patient-reported and physiological characterisation of patients attending face-to-face assessment following hospitalisation with COVID-19 pneumonia. Methods Prospective single-centre observational cohort study at an inner-city South London teaching hospital. All patients admitted with severe COVID-19 pneumonia (admission duration-48 hours, oxygen requirement-40% or critical care admission) were invited to attend Post-COVID Clinic 6-8 weeks following hospital discharge. Primary outcome: Radiological resolution of COVID-19 pneumonitis. Secondary outcomes: Demographics and anthropometrics, inpatient clinical course, patient-reported and physiological outcomes at follow-up (symptoms, functional disability, mental health screening, 4-metre gait speed (4MGS), 1-minute sit-to-stand (STS) test). Results 119 consecutive patients attended clinic between 3rd June and 2nd July 2020, at median (IQR) 61 (51-67) days post discharge. Baseline characteristics are presented in table 1. Despite apparent radiographic resolution of lung infiltrates in the majority (RALE score <5 in 87% of patients), patients commonly reported persistent fatigue (78/115 (67.8%;95%CI 60.0-76.5)), sleep disturbance (65/115 (56.5;47.3-66.1)) and breathlessness (37/115 (32.2;25.2-40.0)). mMRC breathlessness score was above pre-COVID baseline in 55/115 (46.2;37.8-54.6). Burdensome cough was less common (8/115 (7.0;3.5-10.4)). 56 thoracic computed tomography scans were performed, of which 75% demonstrated COVID-related interstitial lung disease and/or airways disease. Significant depression (PHQ-9-9) or anxiety (GAD-7-9) were present in 20/111 (18.0;11.7-23.4) and 25/113 (22.1;15.0-29.8), respectively. The Trauma Screening Questionnaire was positive (-6) in 28/113 (24.8;18.1-31.9). Post-COVID functional scale was-2 in 47/115 (40.9;33.0-47.8). 4MGS was <0.8 m/s in 44/115 (38.3;29.6-46.1), 39/109 (34.5;26.5-41.6) desaturated by-4% during STS, 25/32 (78.1;62.5-93.1) who desaturated also had abnormal CT findings. Conclusions Persistent symptoms, functional limitation and adverse mental health outcomes are common 8 weeks after severe COVID-19 pneumonia. Follow-up chest radiograph is a poor marker of recovery. Physiological testing to identify oxygen desaturation is useful for triaging patients for further investigation. Face-to-face or virtual clinical assessments are recommended to facilitate early recognition and management of post-COVID sequelae in this vulnerable cohort.

S55 Clinical, radiological, functional and psychological characteristics of severe COVID-19 pneumonia survivors: a prospective observational cohort study

S55 Table 1Baseline characteristicsAge (years) 58.7 ± 14.4 Sex Female 45 (37.8;29.4–46.2) Male 74 (62.2;53.8–70.6) Ethnicity BAME (Yes/No) 83 (69.7;61.3–78.2) White 36 (30.3;22.6–37.8) Black 52 (43.7;36.1–51.3) Asian 18 (15.1;10.1–20.2) Mixed race 5 (4.2;1.7–6.7) Other 8 (6.7;3.4–10.9) Index of multiple deprivation score (n=115) 26.6 ± 9.7 Body Mass Index (kg/m2) (n=118) 30.0 (25.9–35.2) Charlson comorbidity index 2 (1–4) Admission PaO2:FiO2 168.8 (105.9–272.3) Critical care admission 41 (34.5;26.9–42.9) COVID-19 complications None during admission 49 (41.2;33.6–48.7) Venous thromboembolism 27 (22.7;16.8–29.4) Pulmonary embolism 23 (19.3;12.6–26.1) Deep vein thrombosis 6 (5.0;2.5–7.6) Acute kidney injury 41 (34.5;25.2–43.7) Deranged liver function 17 (14.3;9.2–20.2) Delirium 18 (15.1;10.1–20.2) Data presented as mean ± SD, median (IQR) or frequency (%;95% confidence interval). Abbreviations: BAME = Black, Asian or Minority Ethnic, PaO2:FiO2 = ratio of arterial partial pressure of oxygen to fraction of inspired oxygen.Results119 consecutive patients attended clinic between 3rd June and 2nd July 2020, at median (IQR) 61 (51–67) days post discharge. Baseline characteristics are presented in table 1. Despite apparent radiographic resolution of lung infiltrates in the majority (RALE score <5 in 87% of patients), patients commonly reported persistent fatigue (78/115 (67.8%;95%CI 60.0–76.5)), sleep disturbance (65/115 (56.5;47.3–66.1)) and breathlessness (37/115 (32.2;25.2–40.0)). mMRC breathlessness score was above pre-COVID baseline in 55/115 (46.2;37.8–54.6). Burdensome cough was less common (8/115 (7.0;3.5–10.4)). 56 thoracic computed tomography scans were performed, of which 75% demonstrated COVID-related interstitial lung disease and/or airways disease. Significant depression (PHQ-9 ≥9) or anxiety (GAD-7 ≥9) were present in 20/111 (18.0;11.7–23.4) and 25/113 (22.1;15.0–29.8), respectively. The Trauma Screening Questionnaire was positive (≥6) in 28/113 (24.8;18.1–31.9). Post-COVID functional scale was ≥2 in 47/115 (40.9;33.0–47.8). 4MGS was <0.8 m/s in 44/115 (38.3;29.6–46.1), 39/109 (34.5;26.5–41.6) desaturated by ≥4% during STS, 25/32 (78.1;62.5–93.1) who desaturated also had abnormal CT findings.ConclusionsPersistent symptoms, functional limitation and adverse mental health outcomes are common 8 weeks after severe COVID-19 pneumonia. Follow-up chest radiograph is a poor marker of recovery. Physiological testing to identify oxygen desaturation is useful for triaging patients for further investigation. Face-to-face or virtual clinical assessments are recommended to facilitate early recognition and management of post-COVID sequelae in this vulnerable cohort.

P240 Parasternal electromyography as a measure of respiratory muscle function in patients recovering from severe COVID-19 pneumonia

P240 Table 1Measures of parasternal electromyography Measured value Z-score EMGpara (µV) 5.80 (3.91–12.26) 1.27 (0.73–2.10) EMGpara%max (%) 15.45 (11.41–23.27) 2.93 (1.91–4.34) NRDI (%.bpm) 224 (164–306) 2.68 (1.79–3.90) Data are presented as median (interquartile range). Abbreviations: z-score = standardised residual, EMGpara = mean root mean square parasternal electromyography per breath, µV = microvolts, EMGpara%max = EMGpara as a proportion of volitional maximum, NRDI = Neural Respiratory Drive Index.ConclusionsInspiratory muscle activation was high, which may reflect underlying interstitial pathology, critical illness myopathy, deconditioning or anxiety relating to clinic attendance. Parasternal electromyography is a well-tolerated technique that avoids aerosolisation of respiratory droplets and utilises equipment that is easily decontaminated between patients. This makes it a practical and informative measure of lung function during the COVID-19 pandemic.