"There is no one who helps you with it." Experiences of people with long COVID regarding medical care, therapeutic measures, and barriers in the German healthcare system: results of a qualitative study with four focus groups (preprint)

Background Many people experience long-term symptoms such as fatigue, cognitive problems, or shortness of breath after an acute infection with COVID-19. This emerging syndrome, known as long COVID, is new and complex in many aspects. This study aims to collect the experiences of people with long COVID with ambulatory healthcare structures. Methods Four focus groups were conducted with a total of 23 adults with long COVID in June and July 2022. These discussions were audio-recorded, subsequently transcribed, and analyzed using the qualitative content analysis of Mayring and Kuckartz. Results Fourteen out of 19 participants who had a primary care encounter regarding their long COVID symptoms did not perceive it as helpful. Many respondents reported that their general practitioners did not take their long COVID symptoms seriously and did not refer them to specialists or made therapeutic recommendations. However, some participants reported that they were prescribed non-pharmaceutical therapies (e.g., group meetings supported by psychotherapists, occupational therapy, etc.) that improved their condition. 14 of 23 respondentsperceived care barriers such as providers' lack of awareness of long COVID, poor access to specialists, a lack of specialized care (e.g., long COVID clinics), or high bureaucratic hurdles for specific healthcare services. To improve medical care, participants suggested campaigns to raise awareness of long COVID among healthcare providers and the general population, increase research and government investments regarding the development of treatment structures for long COVID, expanding existing therapeutic services, and establishing one-stop shops for integrated specialist healthcare for people with long COVID. Conclusions Several implications for healthcare professionals and policymakers can be derived from this study: (1) general practitioners should take the symptoms of long COVID seriously, assume a care coordinating role, make referrals, and establish contact with long COVID clinics; (2) care planners should focus on developing interprofessional evidence-based care and treatment approaches for long COVID; (3) existing care structures such as long COVID outpatient clinics should be expanded. Trial registration: The study is registered in the German register for clinical trials (DRKS00026007).

Continuous positive airway pressure as a useful tool in coronavirus disease 2019-related acute hypoxemic respiratory failure: experience from three UK hospitals

Background Many coronavirus disease 2019 (COVID-19) patients suffering acute hypoxemic respiratory failure (AHRF), fail to respond to conventional oxygen therapy (COT). Subsequently, some centers escalate to continuous positive airway pressure (CPAP), while others resort directly to invasive mechanical ventilation (IMV). We conducted a study to compare the use of CPAP versus COT alone in COVID-19-related AHRF. Patients and methods It is a retrospective cohort study of laboratory-confirmed COVID-19 patients suffering AHRF and deemed eligible for IMV escalation at three university hospitals (United Kingdom) during a 3-month period. The primary endpoint was the need for intubation and the secondary endpoint was 60-day mortality. Results In total, 174 patients were included. In total, 84 patients received CPAP (group 1) and 90 received only COT (group 2). Both groups had comparable demographic criteria and disease severity. There was nonsignificant reduction in the need for IMV when using CPAP compared with COT alone (50 vs. 76.6%, P=0.866). Sixty-day mortality was significantly higher in group 2 (25 vs. 37.8%, P=0.02). COT as stand-alone therapy for COVID-19 patients (group 2) was associated with a significant increased relative risk of death (relative risk 2.14, 95% confidence interval 1.39–3.29) corresponding to a number needed to treat of 3.74 (95% confidence interval 2.47–7.73). Among patients who progressed to IMV, there was no difference in the risk of mortality between the two groups. Conclusion Introducing CPAP rather than escalating FiO2 or endotracheal intubation in COVID-19 cases refractory to COT is safe and associated with improved mortality. Clinical trials are needed to guide the optimum timing and selection of patients most likely to benefit.

CPAP as a useful tool in COVID-19 related Acute Hypoxemic Respiratory Failure: Experience from 3 UK Hospitals (preprint)

Introduction: Severe acute hypoxemic respiratory failure (AHRF) in COVID-19 pneumonia is associated with a high mortality rate, resulting in mounting pressures on intensive care units worldwide. Different oxygenation management protocols are used in different centres. Most centres switch patients who fail to oxygenate adequately using conventional oxygen therapy (COT) methods to non-invasive positive pressure ventilation (NIPPV), usually continuous positive airway pressure (CPAP). Other centres resort to invasive mechanical ventilation (IMV) directly, without a trial of NIPPV. In this trial, we aim to compare the efficacy of different approaches in managing COVID-related AHRF, and ascertain if CPAP therapy reduces the need for IMV. Methods: We carried out a retrospective cohort study on patients with laboratory-confirmed COVID-19 at three university hospitals in Essex, United Kingdom. We included all patients with significant AHRF (defined as needing oxygen therapy FiO2 more than 0.4 to maintain an oxygen saturation of 92%) who were deemed eligible for IMV escalation during a 3-month period (1st March to 31st May 2020).Results: Out of 174 patients who met the criteria, 84 patients received CPAP (Group 1). Half needed intubation (n=42). 90 patients did not have a CPAP trial (Group 2). 76.6% needed intubation (n=69). No difference was found between the two groups in demographic criteria or disease severity. Our results show a significant difference in 60-day mortality between group 1 and 2 (25% versus 37.8%, p=0.02). COT as standalone therapy for COVID-19 patients (group 2) was associated with a trend of more increased risk of intubation and an increased relative risk of death (RR 2.14, 95% CI 1.39 to 3.29). This corresponds to a number needed to treat (NNT) of 3.74 (95% CI 2.47 to 7.73). Patients in group 1 who failed CPAP trial and required intubation did not have an increased risk of mortality when compared to group 2 patients who required intubation.Conclusion: Our results support introducing CPAP rather than escalating FiO2 in cases refractory to COT. Our study suggests CPAP can be safely used to treat patients with AHRF. Clinical trials are needed to guide recommendations for optimum timing and selection of patients most likely to benefit.

Clinical characteristics and Outcomes of 500 patients with COVID Pneumonia : Results from a Single center(Southend University Hospital) (preprint)

Objectives To characterise the clinical features of hospitalised COVID 19 patients in a single centre during the first epidemic wave and explore potential predictive variables associated with outcomes such as mortality and the need for mechanical ventilation, using baseline clinical parameters. Methodology We conducted a retrospective review of electronic records for demographic, clinical and laboratory data, imaging and outcomes for 500 hospitalised patients between February 20th and May 7th 2020 from Southend University Hospital, Essex, UK. Multivariate logistic regression models were used to identify risk factors relevant to outcome. Results The mean age of the cohort admitted to hospital with Covid-19, was 69.4 and 290 (58%) were over 70. The majority were Caucasians, 437 (87%) with less than 2 co-morbidities 280(56%). Most common were hypertension 186(37 %), Cardiovascular disease 178(36 %) and Diabetes 128 (26 %), represented in a larger proportion on the mortality group. Mean CFS was 4 with Non Survivors had significantly higher CFS 5 vs 3 in survivors, p<0.001. In addition, Mean CRP was significantly higher 150 vs 90, p<0.001 in Non Survivors. We observed the baseline predictors for mortality were age, CFS and CRP. Conclusions In this single centre study, older and frailer patients with more comorbidities and a higher baseline CRP and creatinine were risk factors for worse outcomes. Integrated frailty and age based risk stratification are essential, in addition to monitoring SFR (Sp02/Fi02) and inflammatory markers throughout the disease course to allow for early intervention to improve patient outcomes.

Predictors of CPAP outcome in hospitalised COVID-19 patients (preprint)

Introduction: Throughout March - April 2020, many patients with COVID-19 presented to Southend University Hospital with Acute Hypoxaemic Respiratory Failure (AHRF). Patients were managed in a Specialist Respiratory High Dependency Unit. We present our experience on the usage of continuous positive airway pressure (CPAP) therapy and possible indicators of its success in this patient group. Methods: Data from patients (n=89) requiring mechanical ventilation during the months of March to April 2020, were retrospectively collected and analysed. 37 patients received IMV (Invasive Mechanical Ventilation) without a CPAP trial beforehand. 52 patients underwent a CPAP trial, of which 21 patients successfully avoided intubation and ITU admission. Results: The 52 patients, prior to receiving CPAP had significant respiratory failure as evidenced by a low PaO2: FiO2 (PFR) (mean +/- SD 123 +/- 60 mmHg) and mean SpO2:FiO2 (SFR) (mean +/- SD: 140+/- 50). The main indicators of CPAP success were: higher SFR before and after CPAP, lower respiratory rate (RR) , lower Neutrophil to Lymphocyte ratio (NLR) and higher PFR prior to CPAP. Discussion: CPAP proved successful in 40% of COVID-19 patients presenting with AHRF. SFR, PFR, RR and NLR are predictors of such success. SFR can be used for effective real time monitoring of patients before and after CPAP to identify likelihood of success. Based on our results, we have suggested a modified CPAP management protocol in COVID-19. These findings can guide future studies and will allow improved triage of patients to either CPAP or IMV, in the event of a future COVID peak.