Respiratory vaccination.

Vaccinations are among the most cost-effective preventive health strategies to reduce healthcare costs and prevent morbidities. Every year, many adults and elderly encounter hospitalization because of infectious respiratory diseases. Among these, viral and bacterial pneumonia, tuberculosis, diphtheria and pertussis infections are some of the diseases that can be prevented and managed with fewer complications, with adequate preventive immunization. This review tries to outline the vaccines available for the prevention of these respiratory ailments along with their schedule and dosages.

Clinical profile of ChAdOx1 nCoV-19- and BBV152-vaccinated individuals among hospitalized COVID-19 patients: a pair-matched study.

Background: COVID-19 infections among severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-vaccinated individuals are of clinical concern, especially in those requiring hospitalization. Such real-world data on ChAdOx1 nCoV-19- and BBV152-vaccinated individuals are scarce. Hence, there is an urgent need to understand their clinical profile and outcomes. Methods: A 1:1 pair-matched study was performed among vaccinated and unvaccinated COVID-19 patients admitted between March 2021 and June 2021 at a tertiary care centre in New Delhi, India. The vaccinated group (received at least one dose of ChAdOx1 nCoV-19 or BBV152) was prospectively followed till discharge or death and matched [for age (±10 years), sex, baseline disease severity and comorbidities] with a retrospective group of unvaccinated patients admitted during the study period. Paired analysis was done to look for clinical outcomes between the two groups. Results: The study included a total of 210 patients, with 105 in each of the vaccinated and unvaccinated groups. In the vaccinated group, 47 (44.8%) and 58 (55.2%) patients had received ChAdOx1 nCoV-19 and BBV152, respectively. However, 73 patients had received one dose and 32 had received two doses of the vaccine. Disease severity was mild in 36.2%, moderate in 31.4% and severe in 32.4%. Two mortalities were reported out of 19 fully vaccinated individuals. All-cause mortality in the vaccinated group was 8.6% (9/105), which was significantly lower than the matched unvaccinated group mortality of 21.9% (23/105), p = 0.007. Vaccination increased the chances of survival (OR = 3.8, 95% CI: 1.42-10.18) compared to the unvaccinated group. Conclusion: In the second wave of the pandemic predominated by delta variant of SARS CoV-2, vaccination reduced all-cause mortality among hospitalized patients, although the results are only preliminary.

Is it a challenging task to work with personal protective equipment in a COVID-19 ICU: Findings from a hospital-based cross-sectional study from north India.

Introduction: Amidst the coronavirus disease 2019 (COVID-19) pandemic, the use of personal protective equipment (PPE) is mandatory for healthcare workers to remain protected against infection. The present study was undertaken to evaluate challenges faced by the healthcare workers while using level 3 PPE. Methods: This hospital-based study was conducted among resident doctors selected by convenience sampling method using a pretested, semi-structured, self-administered questionnaire after getting informed consent from the participants to collect data on the somatic, psychological, and technical problems faced while working in PPE. Bivariate and multivariable logistic regression was done between outcome variables and other independent variables to check for the association. Results: Of the total, 252 resident doctors completed the survey, their age ranged from 22 to 36 years with 140 (55.6%) males and 112 (44.4%) females. One-twenty-nine (51.2%) residents were trained to work in ICU, 73 (29%) participants used PPE ≤10 times and the rest 179 (71%) used PPE more than 10 times. The difficulties faced were as follows: visual impairment (n = 244, 96.8%), headache (n = 226, 89.6%), breathing difficulty (n = 216, 85.7%), hearing impairment (n = 201, 79.8%), sweating (n = 242, 96%), and fear of being infected (n = 156,61.9%). Two-thirty-six (93.6%) participants felt that overall work quality reduced due to PPE. Headache, hunger, urge to micturate, anxiety, sleep disturbances, and need to change the timing of medication or diet were higher with increased duration of work with PPE. Conclusion: A longer duration of work is associated with headache, hunger, anxiety, and sleep disturbances. More research has to be done to improve the PPE to reduce problems like visual impairment, skin irritation, sweating, and breathing difficulty.

Outcomes of HFNC Use in COVID-19 Patients in Non-ICU Settings: A Single-center Experience.

How to cite this article: Aggarwal A, Arora U, Mittal A, Aggarwal A, Singh K, Ray A, et al.Outcomes of HFNC Use in COVID-19 Patients inNon-ICU Settings: A Single-center Experience. Indian J Crit Care Med 2022;26(4):528-530.

Establishing communication with relatives of admitted obstetrical patients with COVID-19 infection during COVID-19 pandemic: A quality improvement initiative.

OBJECTIVES: To establish communication with relatives of obstetrical patients with coronavirus disease 2019 (COVID-19) admitted to an isolation ward by systematic use of quality improvement tools during the COVID-19 pandemic as there were many challenges in communicating with relatives. METHODS: The study was conducted in the Department of Obstetrics and Gynecology at a tertiary-care teaching hospital based on four systematic steps of Point of Care Improvement methodology. After identifying the problem, a quality improvement team was constituted, which formed a specific aim. After root-cause analysis with fishbone tool, three Plan-Do-Study-Act (PDSA) cycles with various interventions were planned. RESULTS: The outcome was measured as percentage of relatives of obstetrical patients admitted to the hospital with COVID-19 who were counseled about vital patient-related information. The baseline percentage of counseling of relatives of COVID-19-positive obstetrical patients admitted to the hospital was 14% per day. After three PDSA cycles, the target of 66.5% was achieved. CONCLUSION: Communication with the relatives of COVID-19-positive obstetrical patients admitted to isolation wards in the hospital could be easily streamlined without any additional resources using the principles of quality improvement during the COVID-19 pandemic.

Clinicoepidemiological Features and Mortality Analysis of Deceased Patients with COVID-19 in a Tertiary Care Center.

BACKGROUND AND OBJECTIVE: A large number of studies describing the clinicoepidemiological features of coronavirus disease-2019 (COVID-19) patients are available but very few studies have documented similar features of the deceased. This study was aimed to describe the clinicoepidemiological features and the causes of mortality of COVID-19 deceased patients admitted in a dedicated COVID center in India. METHODOLOGY: This was a retrospective study done in adult deceased patients admitted in COVID ICU from April 4 to July 24, 2020. The clinical features, comorbidities, complications, and causes of mortality in these patients were analyzed. Pediatric deceased were analyzed separately. RESULTS: A total of 654 adult patients were admitted in the ICU during the study period and ICU mortality was 37.7% (247/654). Among the adult deceased, 65.9% were males with a median age of 56 years [interquartile range (IQR), 41.5-65] and 94.74% had one or more comorbidities, most common being hypertension (43.3%), diabetes mellitus (34.8%), and chronic kidney disease (20.6%). The most common presenting features in these deceased were fever (75.7%), cough (68.8%), and shortness of breath (67.6%). The mean initial sequential organ failure assessment score was 9.3 ± 4.7 and 24.2% were already intubated at the time of admission. The median duration of hospital stay was 6 days (IQR, 3-11). The most common cause of death was sepsis with multi-organ failure (55.1%) followed by severe acute respiratory distress syndrome (ARDS) (25.5%). All pediatric deceased had comorbid conditions and the most common cause of death in this group was severe ARDS. CONCLUSION: In this cohort of adult deceased, most were young males with age less than 65 years with one or more comorbidities, hypertension being the most common. Only 5% of the deceased had no comorbidities. Sepsis with multi-organ dysfunction syndrome was the most common cause of death. HOW TO CITE THIS ARTICLE: Aggarwal R, Bhatia R, Kulshrestha K, Soni KD, Viswanath R, Singh AK, et al. Clinicoepidemiological Features and Mortality Analysis of Deceased Patients with COVID-19 in a Tertiary Care Center. Indian J Crit Care Med 2021; 25(6):622-628.

COVID-19-associated subacute invasive pulmonary aspergillosis.

BACKGROUND: Though invasive pulmonary aspergillosis is a well known complication of COVID-19 pneumonia, indolent forms of aspergillosis have been rarely described. METHODS: We prospectively collected the clinico-radio-microbiological data of 10 patients of subacute invasive pulmonary aspergillosis (SAIA), who presented to our hospital with recent history of COVID-19 pneumonia along with cavitary lung disease, positive IgG (against Aspergillus) with or without positive respiratory samples for Aspergillus spp. RESULT: The mean age of presentation of SAIA was 50.7 ± 11.8 years. All the patients had recently recovered from severe COVID-19 illness with a mean duration of 29.2 ± 12 days from COVID-19 positivity. Cough was the predominant symptom seen in 8/10 (80%) patients followed by haemoptysis. 7/10 (70%) patients were known diabetic. While serum galactomannan was positive in 5/9 patients (55.5%), fungal culture was positive in 2/7 patients (28.5%) and polymerase chain reaction (PCR) for Aspergillus was positive in three patients. Eight (80%) patients presented with a single cavitary lesion; pseudoaneurysm of pulmonary artery was seen in two patients and post-COVID-19 changes were seen in all patients. All patients were treated with voriconazole, out of which four (40%) patients died during the follow-up period. CONCLUSION: SAIA should be considered in the differential diagnosis of cavitating lung lesions in patients with recent history of COVID-19 in the background of steroid use with or without pre-existing diabetes.

Risk Factors, Clinical Characteristics, and Outcome of Air Leak Syndrome in COVID-19: A Systematic Review.

INTRODUCTION: Air leak consisting of pneumothorax, pneumomediastinum, and subcutaneous emphysema has been described as one of the complications of coronavirus disease-2019 (COVID-19) infection affecting disease course and outcome. We aimed to conduct a systematic review of published literature to highlight the risk factors, types, and outcomes in COVID-19. METHOD: A systematic search of PubMed, Embase, Scopus, and Google Scholar was performed from November 1, 2019, to February 28, 2021. Seventy-one studies fulfilled the inclusion criteria and 136 adult patients were included in the final analysis. RESULTS: Majority of patients were male (75.2%) with the mean age of 58 years. Hypertension was the most common comorbidity followed by diabetes mellitus. Moreover, 12.5% of patients had a history of smoking while 11.7% had preexisting lung disease. Isolated pneumothorax (48.5%) was the most common and 17.65% had developed spontaneous pneumothorax. Mean onset time was 11.6 days and 67% of patients required an intercostal drainage tube for management. Mortality was 40%, and elderly, female gender, obese and hypertensive were at higher risk. CONCLUSION: COVID-19-related air leaks are associated with higher mortality and longer hospital stay and can occur even without positive pressure ventilation. History of smoking and preexisting lung disease has not been shown to increase the incidence of air leak. A well-designed study is required for a better understanding of COVID-19-related air leak. HOW TO CITE THIS ARTICLE: Singh A, Singh Y, Pangasa N, Khanna P, Trikha A. Risk Factors, Clinical Characteristics, and Outcome of Air Leak Syndrome in COVID-19: A Systematic Review. Indian J Crit Care Med 2021;25(12):1434-1445.

Vitamin C and COVID-19 treatment: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND AND AIMS: Vitamin C has been used as an anti-oxidant in various diseases including viral illnesses like coronavirus disease (COVID-19). METHODS: Meta-analysis of randomized controlled trials (RCT) investigating the role of vitamin C supplementation in COVID-19 was carried out. RESULTS: Total 6 RCTs including n = 572 patients were included. Vitamin C treatment didn't reduce mortality (RR 0.73, 95% CI 0.42 to 1.27; I2 = 0%; P = 0.27), ICU length of stay [SMD 0.29, 95% CI -0.05 to 0.63; I2 = 0%; P = 0.09), hospital length of stay (SMD -0.23, 95% CI -1.04 to 0.58; I2 = 92%; P = 0.57) and need for invasive mechanical ventilation (Risk Ratio 0.93, 95% CI 0.61 to 1.44; I2 = 0%; P = 0.76). Further sub-group analysis based on severity of illness (severe vs. non-severe), route of administration (IV vs. oral) and dose (high vs. low) failed to show any observable benefits. CONCLUSION: No significant benefit noted with vitamin C administration in COVID-19. Well-designed RCTs with standardized control group needed on this aspect.

Role of platelet-to-lymphocyte count ratio (PLR), as a prognostic indicator in COVID-19: A systematic review and meta-analysis.

Prognostic predictors are of paramount interest for prompt intervention and optimal utilization of the healthcare system in the ongoing context of the COVID-19 pandemic. The platelet-to-lymphocyte count ratio (PLR), has emerged as a potential tool for risk stratification of critically ill patients with sepsis. The current systematic review explores the utility of PLR as a prognostic predictor of COVID-19 patients. We screened the electronic databases until May 15, 2021 after enrolling in PROSPERO (CRD42021220269). Studies evaluating the association between PLR on admission and outcomes in terms of mortality and severity among COVID-19 patients were included. We retrieved 32 studies, with a total of 2768 and 3262 COVID-19 patients for mortality and disease severity outcomes. Deceased and critically ill patients had higher PLR levels on admission in comparison to survivors and non-severe patients (mean differences [MD] = 66.10; 95% confidence interval [CI]: 47.75-84.44; p < 0.00001 and MD = 86.74; 95% CI: 67.7-105.7; p < 0.00001, respectively). A higher level of PLR on admission in COVID-19 patients is associated with increased morbidity and mortality. However, the evidence is of low quality and further studies regarding the cut-off value of PLR are the need of the hour.

Convalescent Plasma-A Light at the End of the Tunnel: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

In the absence of a definitive therapy during this ongoing unprecedented crisis, coronavirus disease-2019 (COVID-19) pandemic, convalescent plasma transfusion (CPT) has shown some promising results. This review summarizes the existing evidence of the efficacy of CPT in COVID-19 patients based upon scientific publications to date. We have included only the randomized controlled trials (RCTs) through an extensive screening of electronic databases up to July 31, 2021. In 19 RCTs, with a total of 16,476 COVID-19 patients we found low-quality evidence of significant reduction in mortality (odds ratio (OR) = 0.80; 95% confidence interval (CI): 0.66-0.96, I2 = 40%), better clinical outcome when applied <7 days (OR = 2.13, 95% CI 1.28-3.53, I2 = 0%), and improved viral clearance (OR = 2.6, 95% CI: 1.3-5.45, I2 = 74%). Meta-regression analysis found that as a covariate, intubation on admission (p = 0.007) had a significant impact. However, there was any significant reduction neither in duration for clinical improvement (MD = -0.79, 95% CI: -2.76-1.18, I2 = 98%), nor in total period of hospital stay (MD = 0.02, 95% CI: -0.75-0.78, I2 = 81%). Early application of CPT is still relevant in reducing morbidity and mortality in critically ill patients and is too early to write it off as a potential therapeutic modality for COVID-19 patients. HOW TO CITE THIS ARTICLE: Sarkar S, Khanna P, Singh AK. Convalescent -Plasma-A Light at the End of the Tunnel: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Indian J Crit Care Med 2021;25(11):1292-1300.

Vitamin C and COVID-19 treatment: A systematic review and meta-analysis of randomized controlled trials

Background and aims Vitamin C has been used as an anti-oxidant in various diseases including viral illnesses like coronavirus disease (COVID-19) Methods Meta-analysis of randomized controlled trials (RCT) investigating the role of vitamin C supplementation in COVID-19 was carried out. Results Total 6 RCTs including n = 572 patients were included. Vitamin C treatment didn't reduce mortality (RR 0.73, 95% CI 0.42 to 1.27;I2 = 0%;P = 0.27), ICU length of stay [SMD 0.29, 95% CI -0.05 to 0.63;I2 = 0%;P = 0.09), hospital length of stay (SMD -0.23, 95% CI -1.04 to 0.58;I2 = 92%;P = 0.57) and need for invasive mechanical ventilation (Risk Ratio 0.93, 95% CI 0.61 to 1.44;I2 = 0%;P = 0.76). Further sub-group analysis based on severity of illness (severe vs. non-severe), route of administration (IV vs. oral) and dose (high vs. low) failed to show any observable benefits. Conclusion No significant benefit noted with vitamin C administration in COVID-19. Well-designed RCTs with standardized control group needed on this aspect.

The Impact of Neutrophil-Lymphocyte Count Ratio in COVID-19: A Systematic Review and Meta-Analysis.

Background: The neutrophil-lymphocyte count ratio (NLR) has emerged as a potential prognostic tool for different diseases. In the current coronavirus disease (COVID-19) pandemic, the NLR may be a useful tool for risk scarification and the optimal utilization of limited healthcare resources. However, there is no consensus regarding the optimal value of NLR, and the association with disease severity and mortality. Thus, this study aims to systematically analyze the current evidence of the utility of baseline NLR as a predictive tool for mortality, disease severity in COVID-19 patients. Methods: A compendious screening of electronic databases up to June 15, 2021, was done after enlisting the protocol in PROSPERO (CRD42020202659). Studies evaluating the utility of baseline NLR in COVID-19 are included for this review as per the PRISMA statement. Results: We retrieved a total of 13112 and 12986 COVID-19 patients for survivability and severity over 90 studies. The expired and critically sick patients had elevated baseline NLR on admission, in comparison to survivors and noncritical patients. (SMD = 3.82; 95% CI: 2.79-4.85; I2 = 100% and SMD = 1.42; 95% CI: 1.22-1.63; I2 = 95%, respectively). The summary receiver operating curve analysis for mortality (AUC = 0.87; 95% CI: 0.86-0.87; I2 = 94.7%), and severity (AUC = 0.82; 95% CI: 0.80-0.84; I2 = 79.7%) were also suggestive of its significant predictive value. Conclusions: The elevated NLR on admission in COVID-19 patients is associated with poor outcomes.

Posaconazole in the Prevention of COVID-19-associated Mucormycosis: A Concerning Contributor to the Rise in Antifungal Resistance.

How to cite this article: Kayarat B, Khanna P. Posaconazole in the Prevention of COVID-19-associated Mucormycosis: A Concerning Contributor to the Rise in Antifungal Resistance. Indian J Crit Care Med 2021;25(10):1209-1210.

Comparative evaluation of ventilator-associated pneumonia in critically ill COVID- 19 and patients infected with other corona viruses: a systematic review and meta-analysis.

The Coronavirus disease 19 (COVID-19) pandemic is associated with an unprecedented requirement for intensive care unit (ICU) admission, invasive mechanical ventilation, and thereby significantly increasing the risk of secondary nosocomial pneumonia, ventilator-associated pneumonia (VAP). Our study aims to identify the overall incidence of VAP, common organisms associated with it, and outcome in COVID-19 patients in comparison to the non-SARS-CoV-2 infected critically ill ventilated COVID-19 patients. A comprehensive screening was conducted using major electronic databases), from January 1st 2020 to May 31st 2021, as per the PRISMA statement. In our rapid review, we included a total of 34 studies (involving 8901 cases. Overall VAP was reported in 48.15 % (95% CI 42.3%-54%) mechanically ventilated COVID-19 patients and the mortality rate was 51.4% (95% CI 42.5%-60%). COVID-19 patients had increased risk of VAP and mortality in comparison to other non-SARS-CoV-2 viral pneumonia (OR=2.33; 95%CI 1.75-3.11; I2=15%, and OR=1.46; 95%CI 1.15-1.86; I2=0% respectively). Critically ill COVID-19 patients are prone to develop VAP, which worsens the outcome.

Converting an Under-Construction Healthcare Facility into a COVID-19 Screening and Emergency Response Centre During Complete Lockdown in India.

In view of the COVID-19 surge, the construction of the Burns and Plastic Surgery Block at AIIMS, New Delhi was expedited at war footing level and converted into a COVID-19 Emergency response Centre (ERC). Engineering works were completed in a speedy manner and various patient care areas were equipped as deemed necessary for providing tertiary care to COVID-19 patients. A highly spirited team comprising of Emergency Medicine Specialists, Anesthesia and Critical Care specialist, Hospital Administrators and Nursing Officers was formed. Effective segregation of patient care areas into clean, contaminated, and intermediate zones was done using physical barriers and air conditioning modifications. The screening area for patients suspected of having COVID-19 was created in addition to a 2-step process i.e., Triage 1 and Triage 2, thereafter, patients requiring admission would be referred to the emergency area. An in-house designed and fabricated sampling booth was created to bring down the use of PPEs and for better infection control. The ERC has a general ward and state of the art intensive care units. Mobilizing resources (machinery, manpower, consumables etc.) during the lockdown required commitment from top leadership, motivated teams, expeditious procurement, coordination with multiple agencies working on site, expediting statutory clearances, coordination with police services, transportation of labor etc.

Tracheostomy in Patients with Coronavirus Disease 2019: An Overview.

As the coronavirus disease 2019 (COVID-19) pandemic is gripping the entire world, many patients are mainly presenting with respiratory problems and subsequently require intubation and mechanical ventilation in severe cases. The need to perform tracheostomy may arise, and the intensivist, anaesthetist, and other surgical specialties may be asked to perform a tracheostomy in known COVID-19 or suspected patients. Surgeons should be prepared for this eventuality while performing the procedures, taking all the measures to keep themselves and their team members safe from the undue risk of infection and exposure. This is a brief review of all the evidence present, till now, for those who will be performing tracheostomy in such patients.

"Vitamin D supplementation and COVID-19 treatment: A systematic review and meta-analysis".

BACKGROUND: Vitamin-D is an immune-modulator which might be linked to disease severity by SARS-CoV-2. METHODS: Meta-analysis of RCTs and quasi-experimental studies, evaluating the role of vitamin-D supplementation in COVID patients was done. RESULTS: Total 5 studies (3 RCTs and 2 Quasi-experimental) including n = 467 patients were included. Vitamin D didn't reduce mortality (RR 0.55, 95%CI 0.22 to 1.39, p = 0.21), ICU admission rates (RR 0.20, 95% CI 0.01-4.26, p = 0.3) and need for invasive ventilation (RR 0.24, 95% CI 0.01-7.89, p = 0.42). CONCLUSION: No significant difference with vitamin-D supplementation on major health related outcomes in COVID-19. Well-designed RCTs are required addressing this topic.