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TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: Many studies have been published so far describing barotrauma and volutrauma in patients with COVID-19 (SARS-COV-2) infection on non-invasive and invasive positive pressure ventilation (PPV). The pathophysiology is thought to be multifactorial with underlying lung damage, severe Acute Respiratory Distress Syndrome (ARDS), bullae formation similar to one noted in SARS(Severe Acute Respiratory Syndrome) 2004, free oxygen radical generation by over oxygenation along with atelectrauma. Steroids are routinely used now as a part of treatment regimen which might delay lung healing and hence increase the chances of lung injury. METHODS: Two databases MEDLINE and EMBASE were searched by two independent authors to find eligible studies. Out of the 704 articles reviewed, 83 individual cases met our study criteria. We included case reports and case series which described patients aged 18 years or above and were confirmed to be COVID-19 positive at the time of the event who suffered from pneumothorax (PTX) with or without evidence of other air leak syndrome (subcutaneous emphysema, pneumomediastinum or pneumopericardium) and who did not receive any form of PPV at any point of the illness. A systematic review and descriptive analysis was done. RESULTS: The mean age of the sample was 54.7 years and majority (81.9%) were males. Significant comorbidities reported include smoking (15%), underlying lung condition (7.2%) and diabetes mellitus(12%). The duration since onset of COVID symptoms to diagnosis of PTX varied largely from day 0 to day 64 with a median of 16.4(IQR=15). 45.7% of the cases were found to have PTX at admission and 10.8% were diagnosed and readmitted with PTX after recent hospitalization with COVID. 34.9% patients were noted to have evidence of other air leak syndrome and 25% had evidence of bulla on chest imaging. Majority (63.7%) of these patients were on room air since diagnosis, 17.5% on nasal cannula (NC), 10% on high flow NC and remaining 7% on non-rebreather mask. 50%(32/64) of these patients were treated with steroids for unspecified duration. 72.5% of these patients required management with a chest tube, the rest were conservatively managed. 13.2% suffered from recurrent PTX. 42% patients were admitted to intensive care unit later on, and 16.2% required mechanical ventilation. 68% of these patients unfortunately died. CONCLUSIONS: This review focuses on patients with COVID-19 who only received low pressure oxygen delivery devices or even on room air but unfortunately suffered from PTX. Obesity is known to have an association to outcomes in these patients, however majority of the cases did not report that data. Most patients with PTX notably did not have significant underlying lung condition and eventually required procedural intervention and escalation of care during the course of their illness and were associated with high rates of mortality. CLINICAL IMPLICATIONS: The current literature describes PTX in COVID-19 patients commonly as barotrauma or volutrauma secondary to PPV. Physicians should have high suspicion for PTX regardless of the mode of oxygen support in COVID-19 patients. This review calls for further studies to look closer into association of air leak syndrome in COVID- 19 patients with steroid use and bullae formation in lungs making them prone to such lung injury. DISCLOSURES: No relevant relationships by Jeeyune Bahk, source=Web Response No relevant relationships by Joseph Ghassibi, source=Web Response No relevant relationships by Christian Lo Cascio, source=Web Response No relevant relationships by Archana Pattupara, source=Web Response No relevant relationships by DISHANT SHAH, source=Web Response
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SESSION TITLE: Pulmonary Vascular Disease Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: To investigates the association between the use of anticoagulation and mortality among hospitalized patients with COVID-19 in order to provide clinical insights. METHODS: An electronic search was conducted in Pubmed, Scopus, and Medrxiv (preprint articles), using the search strategy included all MeSH terms and free keywords found for “coronavirus 2019” OR “COVID-19” OR “2019-nCoV” or “SARS-CoV-2”, AND “anticoagulation” OR “heparin” OR “enoxaparin” OR “apixaban” OR “rivaroxaban” between 2019 and present time without language restriction. The title, abstract, and full text of all documents captured with these search criteria were scrutinized, and those reporting the rate of anticoagulation in COVID-19 patients were included in this meta-analysis. The reference list of these identified studies was also analyzed (forward and backward citation tracking) for detection gother potential eligible articles. A meta-analysis was performed with Comprehensive Meta-Analysis software (version 3.3.070) in accordance with the PRISMA guidelines. RESULTS: Overall, 286 documents could be initially identified based on our search criteria and from the reference list, 283 of which were excluded after title, abstract, or full text reading, since they were reviewed articles, commentaries, or other editorial materials, or they did not provide the information on mortality associated with the use of anticoagulation. Therefore, 3 studies could finally be included in our meta-analysis, totalling 5297 patients, 2969 of which received anticoagulation. In summary, the odds ratio of mortality was 0.85 [random effect;95% confidence interval (CI) 0.41-0.99, p<0.05], indicating that on an average, patients receiving anticoagulation had a 15% less likelihood of dying compared to those without anticoagulation. The variation in effect size was assessed by Q-value (8.36, df=2), I² (76.1%), and T² (0.11). Based on the Q-value, we rejected the null hypothesis that the true effect size is identified in all studies. Based on the I², 76.1% of the variance in observed effects reflects variance in true effects rather than sampling error. Publication bias, a concern where studies included in the analysis could be a non-random subset of all studies, were assessed by the Begg’s (p=0.60) and Egger’s test (p=0.07), which demonstrated no significant publication bias. CONCLUSIONS: In conclusion, the results of this preliminary meta-analysis suggested that anticoagulation to be associated with a reduction in mortality in patients with COVID-19. Our study is not without limitations. Given the novelty of the COVID-19 pandemic, many clinical trial studies were not available at the time of analysis and we had to rely on observational studies, which were less reliable, to evaluate the risk of death. CLINICAL IMPLICATIONS: The use of anticoagulation was associated with a reduction in mortality in patients with COVID-19 DISCLOSURES: No relevant relationships by Yasmin Herrera, source=Web Response No relevant relationships by Kam Sing Ho, source=Web Response no disclosure on file for Bharat Narasimhan;No relevant relationships by Archana Pattupara, source=Web Response No relevant relationships by Joseph Poon, source=Web Response No relevant relationships by Justin Poon, source=Web Response
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SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: The rapid and unprecedented spread of severe acute respiratory syndrome coronavirus disease 2019 (COVID-19) has significantly limited our understanding of this disease. As the pandemic continues to evolve, cardio-pulmonary symptoms predominate, however new atypical manifestation of COVID are increasingly recognized. CASE PRESENTATION: A previously healthy 70-year-old man presents with a witnessed episode of new-onset seizures. Per family accounts, the episode lasted three minutes with tonic-clonic movements of all extremities, followed by a period of confusion. He had endorsed worsening fatigue and headaches with a declining appetite over the preceding two weeks. There was no history of cough, respiratory symptoms, sick contacts or prior similar episodes. Travel history was significant for a trip to California two weeks prior. He denied any medication, health supplement or illicit substance use. Past medical, surgical and family histories were unremarkable. On examination, the patient was obtunded and afebrile (37.3°C). He appeared visibly dyspneic, with an SpO2 of 85% on room air and RR of 34 /minute, but remained hemodynamically stable. Lung auscultation revealed scattered bilateral crackles while the neurological exam was non-focal. Clinically the patient appeared euvolemic. Computed tomography of the brain was unrevealing with no additional explanation for his prolonged altered mentation. Chest-radiography revealed bilateral air-space opacities. Labs indicated mild leukocytopenia (3.2 x109/L) with lymphopenia (0.6 x109/L) and a profound hyponatremia of 104 mEq/L. Renal and liver parameters were normal. Workup of his hyponatremia revealed a serum and urine osmolality of 230 mOsm/kg and 693 mOsm/Kg respectively with a urine sodium of 58 mmol/L. TSH and Cortisol levels were normal. Inflammatory markers were significantly elevated as summarized in Table 1. Influenza PCR, respiratory viral PCR panel, legionella urine antigen and blood cultures were all negative;however, the COVID-19 PCR assay was subsequently found to be positive. Based on the patient’s clinical and biochemical data, he was diagnosed with severe symptomatic hyponatremia secondary to SIADH in the setting of COVID-19 pneumonia. DISCUSSION: SIADH in the setting of pneumonia has been extensively studied and reported. A number of potential mechanisms have been postulated including extensive cytokine release, hypoxemia, nausea and stress. Additionally, inflammation (IL-6 in particular) itself has been reported to directly impair osmoregulation leading to hyponatremia. We hypothesize that milder forms of hypercytokinemia and hyper-inflammation could result in a number of less dramatic atypical presentations including SIADH. CONCLUSIONS: A high index of suspicion and awareness of this association is essential to mitigate SIADH related complications as cases of COVID-19 continue to rise. Reference #1: Edmonds, Z. V. (2012). Hyponatremia in pneumonia. Journal of Hospital Medicine, 7(S4). doi: 10.1002/jhm.1933 Reference #2: Swart RM, Swart RM, Hoorn EJ, Betjes MG, Zietse R. Hyponatremia and Inflammation: The Emerging Role of Interleukin-6 in Osmoregulation. NEP. 2011;118(2):p45–51. DISCLOSURES: No relevant relationships by Yasmin Herrera, source=Web Response No relevant relationships by Kam Sing Ho, source=Web Response no disclosure on file for Bharat Narasimhan;No relevant relationships by Archana Pattupara, source=Web Response No relevant relationships by Joseph Poon, source=Web Response no disclosure on file for James Salonia;
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SESSION TITLE: Chest Infections Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: The pathophysiology of respiratory distress in hospitalized patients with COVID-19 is not yet fully understood. Spontaneous pulmonary barotrauma (PBT) is a pulmonary complication typically seen in intubated patients. However, in the related viral epidemic of SARS in 2002, 6.6% to 15% of patients on non-invasive ventilation (NIV) were described to have developed PBT, with severe alveolar destruction as the suggested mechanism. Within the COVID-19 pandemic, isolated case studies have described bulla and PBT, and a systematic review of imaging has suggested PBT to be a sign of disease progression. METHODS: In this single center retrospective case series, two patients with confirmed COVID-19 infection who developed PBT on NIV were identified in a New York City hospital from March 2020 to April 2020 and were included in this study. RESULTS: Both the patients were non-smokers with no pre-existing lung disease. The first patient was a 58-year-old woman with a history of pemphigus vulgaris, and the second patient was a 69-year-old man with a history of hypertension and type 2 diabetes mellitus. Both patients received treatment with hydroxychloroquine, azithromycin, therapeutic anticoagulation, high dose steroids, and were enrolled in the hospital’s remdesivir trial. Both patients required oxygen therapy which included escalation from nasal cannula to continuous positive airway pressure (CPAP), and both were encouraged to self-prone. The first patient was found to have a large left pneumothorax (PTX), pneumomediastinum (PM), and extensive subcutaneous emphysema (SE) on day 18 of hospitalization while on CPAP of 12 cm H2O, requiring surgical chest tube placement. The second patient developed a small left apical PTX, PM, and SE on day eight of hospitalization while on CPAP of 14 cm H2O, which was conservatively managed. Both patients eventually required intubation for worsening hypoxemia and later succumbed to their illness. CONCLUSIONS: In this study we identified two patients who developed PBT without being subjected to invasive ventilation or very high levels of PEEP. Both patients had poor outcomes, suggesting that COVID-19 may be associated with alveolar destruction, especially in the setting of steroid use. Glucocorticoid use may interfere with lung healing which could further increase the risk of alveolar rupture. CLINICAL IMPLICATIONS: This study encourages clinicians to have low threshold to suspect PBT in COVID-19 patients even while on NIV. Prospective studies are needed further to determine the utility of steroid use, given this potential risk for PBT and the clinical significance of our observations in COVID-19 patients. DISCLOSURES: No relevant relationships by Kirtipal Bhatia, source=Web Response No relevant relationships by Joseph Ghassibi, source=Web Response No relevant relationships by Julia Goldberg, source=Web Response No relevant relationships by Yasmin Herrera, source=Web Response No relevant relationships by Kam Sing Ho, source=Web Response No relevant relationships by Vivek Modi, source=Web Response No relevant relationships by Archana Pattupara, source=Web Response
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SESSION TITLE: Chest Infections Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: To study the impact of hydroxychloroquine on mortality and to determine the incidence of associated adverse effects among patients with COVID-19. METHODS: We performed a systemic search in PubMed, Scopus, Embase, and Google Scholar, and medRxiv (pre-print) using all available MeSH terms for COVID-19 and hydroxychloroquine. Two independent authors assessed the quality of studies, extracted data from included studies, and analyzed them using CMA version 3.3.070. RESULTS: In summary, the risk ratio of mortality was 0.95 [random effect;95% confidence interval (CI) 0.52-1.72, p=0.85], indicating that on an average, patients receiving hydroxychloroquine had a 5% less likelihood of dying compared to those without hydroxychloroquine. However, this impact on mortality was not statistically significant given that the confidence interval was between 0.52-1.72 (p=0.85). The variation in effect size was assessed by Q-value (16.9, df=4), I² (76.4%), and T² (0.56). Based on the I², 76.4% of the variance in observed effects reflects variance in true effects rather than sampling error. Publication bias, a concern where studies included in the analysis could be a non-random subset of all studies, were assessed by the Begg’s (p=0.5) and Egger’s test (p=0.95), which demonstrated no significant publication bias. Among patients who received hydroxychloroquine, 79.2% of patient tested negative for SARS-CoV-2 on nasopharyngeal PCR by day 5 (endpoint: viral clearance, random effect;95% C.I 56.6-91.4), and 67.5% of patients from randomized clinical trials tested negative for SARS-CoV-2 by day 6 (random effect;95% C.I 44.1-80.9). The Q-value was 41.2 (df=3), I² was 92.7%, and T² was 1.33 from the observational studies. Given that the confidence interval was overlapping between the hydroxychloroquine and the control group, we could not conclude there was a considerable difference in viral clearance to hydroxychloroquine. Finally, the use of hydroxychloroquine was not without risks. We report an overall adverse event rate of 8.2% (random effect;95% CI 3.1-20.0) and diarrhea was the most common event. CONCLUSIONS: Hydroxychloroquine has not shown significant clinical benefits for the treatment of COVID-19 and larger clinical trials are needed. CLINICAL IMPLICATIONS: Despite promising results from in vitro studies, hydroxychloroquine has not shown comparable clinical benefits among COVID-19 patients. To date, many of these findings are derived from observational studies and data from ongoing larger clinical trials will be invaluable in determining the ultimate utility of hydroxychloroquine as adjunctive therapy versus COVID-19. DISCLOSURES: No relevant relationships by Yasmin Herrera, source=Web Response No relevant relationships by Kam Sing Ho, source=Web Response No relevant relationships by Archana Pattupara, source=Web Response No relevant relationships by Justin Poon, source=Web Response No relevant relationships by Joseph Poon, source=Web Response No relevant relationships by David Steiger, source=Web Response
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SESSION TITLE: Chest Infections Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: To understand the characteristics, comorbid conditions, and clinical outcome of patients hospitalized with coronavirus disease 2019 (COVID-19) in the US. METHODS: This analysis included data from 7 acute care hospitals in the Mount Sinai Health System, which serves approximately 3.5 million patients in the New York metropolitan area. We included all consecutively hospitalized adults between March 1st to May 10th, 2020, who had a positive polymerase-chain-reaction testing (RT-PCR) for SARS-CoV-2 infection by nasopharyngeal or oropharyngeal swab and who had a completed hospital course (discharged alive or died) at time of analysis, May 15th, 2020. Initial testing for SARS-CoV-2 was conducted by the New York State Department of Health until March 15, 2020, when internal testing was available at the Mount Sinai laboratory. Patients who died or who were transferred to another facility within 24 hours after hospital admission were excluded from the analysis. The study used de-identified data from the Mount Sinai Data Warehouse (MSDW) ‒ “COVID-19 Project”. The Mount Sinai COVID-19 Clinical Research Protocol Review Committee approved this study and the institutional review board of Icahn School of Medicine at Mount Sinai exempted the research project from approval as it is a retrospective review of already collected, de-identified data. RESULTS: A total of 4,903 consecutive admissions with RT-PCR confirmed COVID-19 were admitted to seven Mount Sinai Hospitals between March 1st to May 10th, 2020. Among these 4313 patients 1270 died during their hospitalization while 3043 were successfully discharged as demonstrated in Figure 1. The mean age of the study population was 65.08 ± 16.8, with a male predominance (56.6%) as outlined in Table 1. Hypertension, diabetes, chronic kidney disease, smokers, a history of chronic obstructive pulmonary disease, and a history of smoking were significantly more common among non-survivors (all p<0.05). Inflammatory biomarkers were examined in patients on admission (Table 1). Survivors were more likely to have a lower mean level of CRP, D-dimer, procalcitonin. CONCLUSIONS: In this case series, we described our early clinical experience with COVID-19. We illustrated the characteristics, comorbid conditions, and clinical outcome of sequentially hospitalized patients with confirmed COVID-19 in New York City. CLINICAL IMPLICATIONS: In this case series that included 4313 patients hospitalized with COVID-19 in New York City, 56% were male and 45% were Hispanics. The most common comorbidities were hypertension (35%) and diabetes (23%), and 56% had a Charlson Comorbidity Index of 3 or greater. While 72% of hospitalized patients had moderate disease and 13% required intubation. Overall, 70.5% (n=3043) of Covid-19 patients were discharged and 29.4% (n=1270) died at the time of analysis. DISCLOSURES: No relevant relationships by Yasmin Herrera, source=Web Response No relevant relationships by Kam Sing Ho, source=Web Response No relevant relationships by Archana Pattupara, source=Web Response No relevant relationships by Joseph Poon, source=Web Response No relevant relationships by Justin Poon, source=Web Response No relevant relationships by David Steiger, source=Web Response