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SESSION TITLE: Encounters with Mechanical Ventilation SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/17/2022 12:15 pm - 1:15 pm PURPOSE: Baseline radiographic edema on chest X-ray (CXR) in patients with COVID-19 presenting to the emergency department has been associated with need for hospital and intensive care unit (ICU) admission as well need for mechanical ventilation and 30-day mortality. Whether this is true for radiographic edema quantified after initiation of mechanical ventilation is unclear. We sought to evaluate this question using a well-validated scoring system (the Radiographic Assessment of Lung Edema [RALE] score) using data over 6 months from a large, multi-hospital healthcare system including all adult (age >= 18) patients. METHODS: We collected CXRs performed in patients after endotracheal intubation for COVID-19 associated hypoxemic respiratory failure between March and September 2020. We quantified severity of radiographic edema using the RALE score. Two independent reviewers quantified radiographic edema using the RALE scoring system. We examined the association of radiographic edema with time from hospital admission to intubation and 30-day mortality. RESULTS: 65 patients were identified (median age 68, 40% female). Inter-rate agreement for RALE score was excellent (ICC = 0.84, 95% CI 0.82 - 0.87, p < 0.0001). Mortality at 30 days was 54% (n = 35). There was no association between time to ICU admission from ED presentation (r = -0.14, p = 0.27). RALE scores were not different in survivors and non-survivors (8 [4-17] and 7 [5-15], p = 0.92 respectively). When adjusted for age and history of diabetes, there was no difference in 30-day mortality between the lowest and highest RALE quartiles (HR 0.67 [0.24 - 1.85], p = 0.44). CONCLUSIONS: In unvaccinated patients with COVID-19 hypoxemic respiratory failure requiring mechanical ventilation there is no association between baseline (time of intubation) radiographic edema as captured by CXR and 30-day mortality. Larger observational studies accounting for vaccination status, oxygenation strategies and medical therapy are needed. CLINICAL IMPLICATIONS: In small sample of unvaccinated patients requiring mechanical ventilation for COVID-19-associated hypoxemic respiratory failure, baseline radiographic edema on CXR does not provide prognostic value. DISCLOSURES: No relevant relationships by Samantha Gillenwater No relevant relationships by Christine Girard No relevant relationships by Anas Hadeh No relevant relationships by Andrew Kim No relevant relationships by Daniel Kotok No relevant relationships by Allen Lavina No relevant relationships by Jose Rivera No relevant relationships by Shruti Shettigar
ABSTRACT
Introduction: Naso-(NGT) and oro-gastric tubes play an integral role in the nutritional support of patients who are not able to meet dietary needs through independent oral consumption. Although uncommon, serious pulmonary complications may arise from this mostly blindly performed procedure (0.2-2%). We report a case of an elderly female who developed a right-sided tension pneumothorax (PTX). necessitating tube thoracostomy following NGT misplacement. Case: Our patient is a 79-year-old elderly female woman with no known past medical history who was admitted for altered mentation and hypoxemia due to COVID-19. Although her initial course was complicated by progressive respiratory failure requiring ICU admission and initiation of high-flow nasal cannula, she was quickly weaned to nasal cannula and transferred to a regular floor. Due to poor mentation and inconsistent food intake, enteral access was attempted using a weighted-tip 10 FR NGT. The patient had mild cough and discomfort during the procedure. There was no resistance during insertion. After advancement to 55 CM the patient ceased coughing and the procedure was completed. Chest X-ray (CXR) obtained as part of routine post-procedural evaluation revealed an intra-pleural NGT abutting the R hemi-diaphragm (Figure) and small PTX. Follow-up CXR revealed enlarging PTX with mediastinal shift to the left for which emergent thoracostomy utilizing a 14FR pig-tail catheter was performed. There was complete resolution of the pneumothorax with removal of the chest tube three days later. The patient was discharged home shortly after. Discussion: NGT placement is commonly performed by healthcare providers of varying degrees of expertise and experience. Risk factors associated with complications include multiple attempts, insertion at night, presence of artificial airway and altered mentation, among others. In case of trans-pulmonary placement, withdrawal of intra-pleural NGTs is associated with high risk of pneumothorax and requires close observation. To decrease the likelihood of malposition, a two-step radiograph, gradual progression technique can be deployed if fluoroscopic placement is not available. This should be strongly considered in patients at high risk for adverse events. Conclusions: Blind insertion of NGT using traditional techniques may be of limited safety and put patients at risk of complications. This is particularly true in those who are critically ill, frail or experiencing altered mentation. Institutional protocols to identify patients at high risk on whom blind placement should not be attempted are warranted. Post-withdrawal CXR to rule-out the presence of tension physiology is highly recommended.
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Background: Symptoms of COVID-19 are often indistinguishable from other upper and/or viral lower respiratory tract infections, with some studies suggesting higher risk for severe disease and worse outcomes in certain symptom groups compared to others. We sought to evaluate the association of specific symptom/symptom groups and their duration with severity of radiographic edema - a clinical feature that has been independently associated with poor outcomes in patients with COVID-19. Methods: We collected CXRs, demographic and clinical data from patients with a naso- and/or oropharyngeal swab positive for SARS-CoV-2 PCR visiting the ED for COVID-19-related symptoms between March and September 2020 in a large, multi-hospital healthcare system. Two independent reviewers quantified radiographic edema using the Radiographic Assessment of Lung Edema (RALE) scoring system. We collected symptom duration based on the following groups: overall (total), dyspnea, cough, constitutional (fever, chills, malaise, myalgia), nausea and/or vomiting, and diarrhea. We assessed for correlation between radiographic edema and symptom duration as continuous variables using Pearson's R and based on symptom duration quartiles using one-way analysis of variance (ANOVA). Results: 433 symptomatic patients with available CXRs were identified (median age 54, 52% female). Inter-rate agreement for RALE score was excellent (interclass correlation coefficient = 0.89, 95% CI 0.87 - 0.92, p < 0.0001). Radiographic edema associations were as following (% of patients with symptom[s], Pearson's R and respective p-value;ANOVA p-value): total duration (r = 0.19, p < 0.001;p < 0.001), constitutional (84%, r = 0.23, p < 0.00;p < 0.001), dyspnea (55%, r = 0.14, p = 0.03;p = 0.1), cough (72%, r = 0.25, p < 0.001;p < 0.001), diarrhea (22%, r = 0.02, p = 0.83;p = 0.71) and nausea and/or vomiting (17%, r = 0.04, p = 0.71;p = 0.63). Conclusions: In a multi-center study of patients presenting to the ED with symptomatic COVID-19, severity of radiographic edema was associated with overall duration of symptoms, constitutional symptoms and cough but not with duration of dyspnea, diarrhea or nausea and/or vomiting.
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Rationale: Diverse presentations of SARS-CoV-2 infection exist, with some studies differentiating as many as five phenotypes. Each of the phenotypes describes varying symptoms, inflammatory markers, and lung physiology - many of which require testing to diagnose. The two most common phenotypes, L-type and H-type, advance along a spectrum indicating an evolving illness. Recently, this physiology has been explained as a shift from an acute viral illness to progressive inflammatory response. The objective of this study is to identify differences in the SAMI Score between death and non-death cohorts, from data collected in a large, multi-center healthcare system for adult (age >18) patients. Methods: All patients enrolled in this retrospective study were identified by a positive nasal or oropharyngeal swab for SARS-CoV-2 PCR in the ED between March and September 2020. Symptomatic data was collected based on ED admission histories and prior medical records. The SAMI score was calculated based on duration of days from symptom onset to hospital admission (SA score), time to ICU admission (AM score), and time to intubation (MI score). Patient cohorts were separated by mortality. Results: Out of 510 patients, 227 patients met inclusion criteria for enrollment. In the death cohort (43 patients, mean age 75, 53% female), the mean SA score and AM score were 5.6d and 1.9d, respectively. The average MI score was 2.3d and the SAMI score was 11.6d among those intubated. In the non-death cohort (184 patients, mean age 60, 49% female), the mean SA score was 6.3d while the AM score was 1.3d. The average MI score and SAMI score were 0.4d and 6.0d, respectively. Overall, the mean MI score between the two groups (2.3d death group, 0.4d non-death group) was statistically significant, p = 0.045. Similarly, the mean SAMI score between the two groups (11.6d vs. 6.0d respectively) was also statistically significant, p = 0.026. There was no significant difference between the average SA score (p = 0.63) or AM score (p = 0.37). Conclusion: Patients who required rapid intubation after symptom onset (short SAMI score) are associated with less mortality than those requiring a prolonged time to intubation (long SAMI score). Physiologically, rapid intubation and a short MI score suggest a recoverable acute disease state. Conversely, prolonged time to intubation may be indicative of a progressive irreversible process. This research allows for further sub-group analysis to determine if inflammatory markers are higher in the group with longer SAMI scores.
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Rationale: The neutrophil-to-lymphocyte ratio (NLR) as a predictor of outcomes has been studied in different disease states such as sepsis, ARDS and pancreatitis. In COVID-19 patients, NLR has been shown to be an independent risk factor associated with disease severity with a few studies suggesting an association between NLR and outcomes. Using data from a large multi-hospital healthcare system over a 6-month period, we sought to independently evaluate the NLR's ability to predict need for hospitalization, ICU admission, need for mechanical ventilation, 30-day mortality, and its association with hypoxemia. Methods: We collected demographic, historic and clinical data from patients with a naso-and/or oropharyngeal swab positive for SARS-CoV-2 PCR visiting the ED for COVID-19-related complaints between March-September 2020. Fraction of inspired oxygen (FiO2) was calculated using 1 liter per minute (lpm) supplemental O2 to 3% FiO2 conversion and capped at 15 lpm O2. We examined the association of NLR with hypoxemia, need for hospitalization, ICU admission, need for mechanical ventilation within 7 days of ED visit and 30-day mortality after adjustment for history of hypertension, diabetes, severity of hypoxemia and age. Results: From 510 patients analyzed, 357 had a complete blood count (CBC) drawn (median age 57, 51% female). Median NLR was 2.09 with IQR of 3.69-5.88. NLR negatively correlated with degree of hypoxemia as quantified by SpO2-FiO2 (SF) ratio (Rho =-0.33, p < 0.001). Patients requiring hospital admission had higher NLR compared to those who did not (median 2.59 IQR [4.45-7.6] vs 1.57 [2.75-4.36], p < 0.001). In patients admitted to the hospital, NLR was higher in those requiring ICU admission compared to those who did not [2.99 [6.21-10.8] vs 2.37 [4.05-6.05], p < 0.01]. In those with NLR above the median there was a trend towards higher need for intubation within 7 days, although this did not achieve statistical significance (OR 2.28, 95% CI 0.94-5.53, p = 0.07). 30-day mortality was higher in those with NLR above the median compared to those below the median (OR 2.84, 95% CI 1.29-6.28, p < 0.01). Conclusions: In patients presenting to the ED with COVID-19, an increased NLR is associated with need for hospitalization, ICU admission and worse 30-day mortality while being inversely correlated with degree of hypoxemia. The cost-effectiveness and wide-spread availability of CBC testing makes NLR an easily implementable prognostication tool in COVID-19 patients.
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Background: Severity of radiographic abnormalities on chest X-rays (CXR) obtained in the emergency department (ED) in patients diagnosed with COVID-19 has been shown to be associated with outcomes, but studies are limited by different scoring systems, sample size, patient age and study duration. We sought to evaluate this question using a well-validated scoring system (the Radiographic Assessment of Lung Edema [RALE] score) using data over 6 months from a large, multi-hospital healthcare system including all adult (age >= 18) patients. Methods: We collected CXRs, demographic, historic and clinical data from patients with a nasoand/ or oropharyngeal swab positive for SARS-CoV-2 PCR visiting the ED for COVID-19-related complaints between March and September 2020. Two independent reviewers quantified radiographic edema using the RALE scoring system. Fraction of inspired oxygen (FiO2) was calculated using 1 liter per minute (lpm) supplemental O2 to 3% FiO2 conversion and capped at 15 lpm O2. We examined the association of radiographic edema with hypoxemia, need for hospital admission, ICU admission, need for mechanical ventilation within 7 days of admission and 30-day mortality. Results: 453 patients met criteria for inclusion (median age 54, 51% female). Inter-rate agreement for RALE score was excellent (interclass correlation coefficient = 0.89, 95% CI 0.87-0.92, p < 0.0001). 99 patients had a normal (RALE = 0) CXR on ED visit. Median RALE score was 3. RALE scores negatively correlated with degree of hypoxemia as quantified by SpO2-FiO2 (SF) ratio (r =-0.34, p < 0.001). Patients admitted to the hospital had higher RALE scores than those who were discharged home (median 2 IQR [0, 6] vs 3 [10, 17], p < 0.001). Among 199 patients admitted to the hospital, RALE scores were higher in those requiring admission to the ICU compared to those who did not (7 [14,20], 2 [8,16], p = 0.007). Patients in the 3rd and 4th RALE quartiles were more likely to require mechanical ventilation and had higher 30-day mortality compared to those with RALE scores below the median, even after adjustment for age, SF ratio and history of diabetes (p < 0.02 for all). Conclusions: The RALE score is highly reproducible and easily implementable in adult patients presenting to the ED with COVID-19. Its association with physiologic parameters and outcomes makes it a readily available tool for prognostication and early ICU triage, particularly in patients with severe radiographic edema as quantified by the RALE score.