ABSTRACT
INTRODUCTION: Dyspnea is common and distressing in patients with acute critical illness who require mechanical ventilation (MV), and is often a presenting symptom for COVID-19. However, little is known about the long-term persistence of dyspnea or its impact on patients recovering from mechanical ventilation. This study sought to evaluate early and persistent dyspnea, and its emotional impact, among survivors of respiratory failure due to COVID-19. METHODS: We conducted a prospective observational cohort study at Beth Israel Deaconess Medical Center. We identified ICU survivors who underwent at least 48 hours of MV for COVID-19. We contacted eligible patients via telephone at 6 months post-hospital discharge. We assessed the presence and severity of dyspnea throughout their illness (ICU, hospital floor, hospital discharge, 6 months post-discharge) using components of the Multidimensional Dyspnea Profile (MDP), a validated instrument. Additionally, we asked patients with persistent dyspnea at the time of follow up whether dyspnea triggered specific emotional responses, using the MDP. Data are means + standard deviation or number (percent). RESULTS: Forty of 43 patients contacted by telephone completed interviews and 3 declined. Twenty-three patients (58%) were male, 7 (18%) had COPD, 9 (22%) had obstructive sleep apnea, and 11 (28%) had active tobacco use. The duration of invasive MV was 14+7.1 days and hospital length of stay was 24.7+9.6 days. Six-month post-discharge data revealed 25 patients (62.5%) with any dyspnea, and 10 (25%) with moderate to severe dyspnea (10-point severity scale score > 4). Among patients with persistent dyspnea at 6 months, the majority reported fear (60%), anxiety (57.5%), or frustration (52.5%). Depression was the most common severe emotional response accompanying dyspnea (10-point severity scale score of 7-10), reported by 9 patients (22.5%). CONCLUSIONS: Six months after COVID-19-associated respiratory failure, dyspnea was persistent in the majority of patients and commonly associated with negative emotions. Fear and anxiety were most commonly reported. Prior to COVID-19, long-term dyspnea had been described in up to 40% of patients after respiratory failure, though data are limited. Thus dyspnea appears as, or more, common after COVID-19. In addition to the typical components of post-intensive care syndrome (PICS), dyspnea and the negative emotional states it evokes may impair quality-of-life for COVID-19 survivors and should be specifically assessed during post-hospital care visits.
ABSTRACT
RATIONALE: Prior to the emergence of coronavirus disease 2019 (COVID-19), critical illness survivors were known to suffer long-term impairments in physical function, mental health, and cognition. These deficits, collectively termed the post-intensive care syndrome (PICS), impact health-related quality-of-life. Survivors of COVID-19-associated respiratory failure may be at particularly high risk of PICS due to delirium and prolonged mechanical ventilation, and factors unique to the pandemic, including physical isolation from medical staff, lack of in-hospital family presence, limited post-acute care rehabilitation, and widespread economic recession. Given this context, we describe the prevalence of PICS 6 months following hospital discharge among survivors of COVID-19-associated respiratory failure. METHODS: We conducted a multicenter prospective cohort study from March to December 2020 at Beth Israel Deaconess Medical Center and the Hospital of the University of Pennsylvania. We identified ICU survivors who underwent at least 48 hours of mechanical ventilation for COVID-19. We contacted eligible patients via telephone at 6 months post-hospital discharge. Sample size was determined by thematic saturation of interviews within a concurrent qualitative assessment. We used the Society of Critical Care Medicine international consensus recommendations for PICS assessment. We assessed anxiety, depression, and post-traumatic stress disorder (PTSD) using the Hospital Anxiety and Depression Scale and Impact-of-Events Scale, respectively. We assessed physical impairment with the EQ-5D questionnaire, and cognitive impairment using the Montreal Cognitive Assessment-Blind. Data are means + standard deviation or number (percent). RESULTS: We completed telephone interviews with 50 of 173 eligible patients (53 contacted, 3 declined). Age was 57+13 years, duration of invasive mechanical ventilation was 14+8.2 days and PaO2:FiO2 ratio at intubation was 174±46. Delirium developed in 35 patients (70%). Six months post-discharge, 38 patients (76%) met criteria for PICS, with 1 or more domains impaired. Among patients with PICS, 22 (44%) were impaired in at least 2 domains, and 9 (18%) impaired in all 3 domains. PTSD was present in 17 patients (34%), anxiety in 19 (38%), and depression in 20 (40%). Twenty-four patients (48%) had impairments in activities of daily living. Nineteen patients (37%) demonstrated cognitive impairment. CONCLUSIONS Over three quarters of COVID-19-associated respiratory failure survivors demonstrated PICS 6 months after hospital discharge. Patients were commonly impaired in at least two domains. These estimates of PICS prevalence appear broadly similar to those reported in the pre-COVID-19 literature and should drive focused efforts to identify COVID-19 survivors at high risk for PICS prior to discharge.