COVID-19 Acute Respiratory Distress Syndrome: treatment with Helmet CPAP in respiratory intermediate care unit by pulmonologists in the three Italian pandemic waves (preprint)

Background: COVID-19 Acute Respiratory Distress Syndrome (CARDS) is the major complication of COVID-19. The SARS-CoV-2 outbreaks rapidly saturating ICU beds, forcing the application of non-invasive respiratory support (NIRS) in respiratory intermediate care unit (RICU).Methods: 515 patients were enrolled in our observational prospective study based on CARDS developed in RICU during the three Italian pandemic waves (150, 180 and 185 patients respectively). All selected patients (aged 18-80) were treated with Helmet-Continuous Positive Airway Pressure (H-CPAP). The primary aim of the study is to compare the patients’ clinical characteristics and outcomes (H-CPAP success/failure and survival/death) during the three different pandemic waves. The secondary aim is to evaluate and detect the main predictors of the H-CPAP success and survival/death in patients selected by having CARDS criteria.Results: The worst ratio of arterial partial pressure of oxygen (PaO2) and fraction of inspired oxygen (FiO2) PaO2/FiO2 during H-CPAP stratified the subjects in mild (82-15.9%), moderate (202-39.2%) and severe (231-44.9%) CARDS. H-CPAP success has increased during the three waves (62%, 69% and 77% respectively) and the mortality rate has decreased (28%, 21% and 13%). H-CPAP success/failure and survival/death were related to the ratio PaO2/FiO2 (worst score) in H-CPAP and steroids administration. D-dimer at admission, FiO2 in H-CPAP, and level of PEEP were also associated with H-CPAP success.Conclusions: Our study suggests good clinical outcomes with H-CPAP in CARDS in RICU. CARDS has a biphasic trend confirmed in all the three waves, with a worsening patients’ trend from admission to subsequent days of hospitalization. A widespread use of steroids in our center could play a role in achieving good clinical outcomes. The proper management during hospitalization by pulmonologist in RICU may affect these patients’ trend. We observed a significant improvement of prognosis in the three different waves: patients are found to be progressively slightly less severe.

Six-month pulmonary impairment after severe COVID-19: a prospective, multicenter follow-up study (preprint)

Background and objective. Long-term pulmonary sequelae following SARS-CoV-2 pneumonia are not yet confirmed, however preliminary observations suggests a possible relevant clinical, functional and radiological impairment. The aim of this study was to identify and characterise pulmonary sequelae caused by SARS-CoV-2 pneumonia at 6-month follow-up. Methods. In this multicenter, prospective, observational cohort study, patients hospitalised for SARS-CoV-2 pneumonia and without prior diagnosis of structural lung diseases were stratified by maximum ventilatory support (oxygen only, continuous positive airway pressure (CPAP) and invasive mechanical ventilation (IMV)) and followed up at 6 months from discharge. Pulmonary function tests and diffusion capacity for carbon monoxide (DLCO), 6 minutes walking test, chest X-ray, physical exam and modified Medical Research Council (mMRC) dyspnoea score were collected. Results. Between March and June 2020, 312 patients were enrolled (83, 27% women; median [IQR] age 61.1 [53.4,69.3] years). The parameters that showed the highest rate of impairment were DLCO and chest-X-ray, in 46% and 25% of patients, respectively. However, only a minority of patients reported dyspnoea (31%), defined as mMRC [≥] 1, or showed a restrictive ventilatory defects (9%). In the logistic regression model, having asthma as comorbidity was associated with DLCO impairment at follow-up, while prophylactic heparin administration during hospitalisation appeared as a protective factor. Need for invasive ventilatory support during hospitalisation was associated with chest imaging abnormalities. Conclusion. DLCO and radiological assessment appear to be the most sensitive tools to monitor patients with COVID-19 during follow-up. Future studies with longer follow-up are warranted to better understand pulmonary sequelae.

Six-month Pulmonary Impairment After Severe COVID-19: a Prospective, Multicenter Follow-up Study (preprint)

Background: Long-term pulmonary sequelae following SARS-CoV-2 pneumonia are not yet confirmed, however preliminary observations suggests a possible relevant clinical, functional and radiological impairment. The aim of this study was to identify and characterise pulmonary sequelae caused by SARS-CoV-2 pneumonia at 6-month follow-up. Methods: . In this multicenter, prospective, observational cohort study, patients hospitalised for SARS-CoV-2 pneumonia and without prior diagnosis of structural lung diseases were stratified by maximum ventilatory support (“oxygen only”, “continuous positive airway pressure (CPAP)” and “invasive mechanical ventilation (IMV)”) and followed up at 6 months from discharge. Pulmonary function tests and diffusion capacity for carbon monoxide (DLCO), 6 minutes walking test, chest X-ray, physical exam and modified Medical Research Council (mMRC) dyspnoea score were collected. Results: . Between March and June 2020, 312 patients were enrolled (83, 27% women; median [IQR] age 61.1 [53.4,69.3] years). The parameters that showed the highest rate of impairment were DLCO and chest-X-ray, in 46% and 25% of patients, respectively. However, only a minority of patients reported dyspnoea (31%), defined as mMRC ≥ 1, or showed a restrictive ventilatory defects (9%). In the logistic regression model, having asthma as comorbidity was associated with DLCO impairment at follow-up, while prophylactic heparin administration during hospitalisation appeared as a protective factor. Need for invasive ventilatory support during hospitalisation was associated with chest imaging abnormalities. Conclusions: . DLCO and radiological assessment appear to be the most sensitive tools to monitor patients with COVID-19 during follow-up. Future studies with longer follow-up are warranted to better understand pulmonary sequelae. ClinicalTrials.gov Identifier: NCT04435327

Acute pulmonary embolism in patients presenting pulmonary deterioration after admission to internal medicine wards for non-critical COVID-19. (preprint)

INTRODUCTION. Emerging evidence associates COVID-19 to an increased risk of acute pulmonary embolism (APE). The present study aimed to assess the prevalence of APE in patients admitted to internal medicine department wards for non-critical COVID-19 who presented clinical deterioration, and to investigate the association of clinical and biochemical variables with a confirmed diagnosis of APE in these subjects. METHODS. All consecutive patients admitted to the internal medicine department of a general hospital with a diagnosis of non-critical COVID-19, who performed a Computer Tomography Pulmonary Angiography(CTPA) for respiratory deterioration in April 2020, were included in this retrospective cohort study. RESULTS. Study populations: 41 subjects, median(IRQ) age: 71.7(63-76) years, CPTA confirmed APE=8(19.51%,CI95%:8.82%-34.87%). Among patients with and without APE, no significant differences were found with regards symptoms, comorbidities, treatment, Wells score and outcomes. The optimal cut-off value of D-dimer for predicting APE was 2454 ng/mL, sensitivity(CI95%):63(24-91), specificity:73(54-87), Positive Predictive Value:36(13-65), Negative Predictive Value: 89(71-98) and AUC:0.62(0.38-0.85). The standard and age-adjusted D-dimer cut-offs, and the Wells score > 2 did not associate with confirmed APE, albeit a cut-off value of D-dimer=2454 ng/mL showed an RR:3.21;CI95%:0.92-13.97;p=0.073.CONCLUSION. Among patients presenting pulmonary deterioration after admission to internal medicine wards for non-critical COVID-19, the prevalence of APE was high. The traditional diagnostic tools to identify high APE pre-test probability patients does not seem to be clinically useful. These results support the use of a low threshold of suspicion for performing CTPA to exclude or confirm APE as the most appropriate diagnostic approach in this clinical setting.

Spontaneous Pneumothorax as Unusual Presenting Symptom of Covid-19 Pneumonia: Surgical Management and Pathological Findings (preprint)

Spontaneous pneumothorax has been reported as a possibile complication of novel coronavirus associated pneumonia (COVID-19). We report two cases of COVID-19 patients who developed spontaeous and recurrent pneumothorax as a presenting symptom, treated with surgical procedure. Intraoperative findings of COVID-19 pneumonia were parenchymal atelectasis and vascular congestion. Lung tissue was very frail and prone to bleeding. Histological examination showed interstitial infiltration of lymphocytes and plasma cells, as seen in non specific interstitial pneumonia, together with myo-intimal thicknening of vessels with blood extravasation and microthrombi. Lung surgery for pneumothorax in COVID-19 patients can be safely and effectively performed when necessary.