Clinical Presentation and Phenotypes in COVID-19

Since the beginning of the COVID-19 pandemic, researchers have focused on the different clinical presentations of the disease. The existence of a broad spectrum of respiratory compromise has been initially interpreted as the manifestation of different clinical phenotypes, with peculiar pathophysiological aspects translating into different requirements of respiratory support. Extensive research now converges on interpreting these phenotypes as different stages rather than distinct manifestations of the same pathology. While not all patients will evolve from an early COVID-19 pneumonia to an established COVID-19 related acute respiratory distress syndrome (ARDS), the correct identification of the disease phase will translate into different therapeutic approaches. This chapter discusses the classification of COVID-19 phenotypes based on imaging and respiratory mechanics parameters, also in relation with the differences and similarities with the ARDS from causes other than COVID-19. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Indications for Intubation in COVID-19

Intubation and invasive mechanical ventilation are often unavoidable in most severe cases of COVID-19 pneumonia;however, deciding the optimum timing and best practices of intubation is challenging. The decision to proceed with intubation should be based on an integrated patient evaluation and not limited to the assessment of the severity of hypoxemia alone. Intubation is a maneuver exposing the operator to a high risk of contamination, therefore adequate personal protection equipment is mandatory. Benefits of intubation over noninvasive respiratory support include reduction or suppression of the respiratory drive, reduction of the basal metabolism and allowance of maintaining protective mechanical ventilation. On the other hand, risks are related to the need for sedation, the presence of an artificial airway and exposure to mechanical ventilation, which may result in overlapping ventilator-associated bacterial pneumonia and ventilator-induced lung injury. Balancing between risks and benefits of intubation in this context is challenging and the optimum timing of intubation remains largely an open question. This chapter discusses the clinical, technical, and safety aspects that deserve to be considered when considering intubation in patients with severe COVID-19-related acute respiratory failure. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Mid and Long-term Neurological and Neuropsychiatric Manifestations of PostCOVID-19 Syndrome: A Meta-analysis

Objective: To determine the prevalence of neurological and neuropsychiatric symptoms reported 12 weeks (3 months) or more after acute COVID-19 onset in adults. Background: Neurological and neuropsychiatric symptoms that persist or develop three months after the onset of COVID-19 pose a significant threat to the global healthcare system. These symptoms are yet to be synthesized and quantified via meta-analysis. Design/Methods: A systematic search of PubMed, EMBASE, Web of Science, Google Scholar and Scopus was conducted for studies published between January 1 , 2020 and August 1 , 2021. Studies were included if the length of follow-up satisfied the National Institute for Healthcare Excellence definition of post-COVID-19 syndrome. Additional criteria included reporting of neurological or neuropsychiatric symptoms in individuals with COVID-19. The primary outcome was the prevalence of neurological and neuropsychiatric symptoms reported ≥3 months post onset of COVID-19. Results: Of 1,458 articles, 19 studies, encompassing a total of 11,324 patients, were analysed. Overall prevalence for neurological post-COVID-19 symptoms were: fatigue (37%, 95% CI: 24%- 50%), brain fog (32%, 9%-55%), memory issues (27%, 18%-36%), attention disorder (22%, 10%- 34%), myalgia (18%, 4%-32%), anosmia (12%, 7%-17%), dysgeusia (11%, 4%-17%) and headache (10%, 1%-21%). Neuropsychiatric conditions included sleep disturbances (31%, 18%-43%), anxiety (23%, 13%-33%) and depression (12%, 7%-21%). Neuropsychiatric symptoms substantially increased in prevalence between mid- and long-term follow-up. Compared to non-hospitalised patients, patients hospitalised for acute COVID-19 had reduced risk of anosmia, anxiety, depression, dysgeusia, fatigue, headache, myalgia, and sleep disturbance at three (or more) months post-infection. Conversely, hospital admission was associated with higher frequency of memory issues (OR: 1.9, 95% CI: 1.4-2.3). Conclusions: Fatigue, brain fog and sleep disturbances appear to be key features of post-COVID19 syndrome. Psychiatric manifestations (sleep disturbances, anxiety, and depression) increase significantly in prevalence over time. Randomised controlled trials are necessary to develop intervention strategy to reduce disease burden.

Long covid syndrome: Why efforts like aftercor are needed

Introduction: The AFTERCOR study was developed by the COVID-19 Critical Care Consortium (>7000 intensive care unit [ICU] and >400 extracorporeal membrane oxygenation [ECMO] patients currently) to enhance understanding of occurrence and progression of long-term dysfunction post-COVID-19. Design: Prospective longitudinal (24 months) study of ICU survivors of COVID-19 to describe recovery of the following aspects: a) health-related quality of life b) dynamics of organ dysfunction and recovery and c) pulmonary function. Countries involved Italy, Spain, Ireland, Austria, South Africa, Australia, USA, Argentina, Brazil, Colombia. Protocol specifics available at https://www.aftercorstudy.com. Inclusion Criteria: 1) COVID-19 infection requiring ICU admission;2) informed consent;3) age ≥18 years. Exclusion Criteria: 1) pregnancy;2) pre-COVID paralysis;3) history of pulmonary resection;4) prior lung transplant;5) inability to perform 6-min walk test or participate in interview. Methods: Goal enrollment is 1000 patients. Follow-up visits are at 3, 6, 12, 18 and 24-month post-ICU discharge. Assessments include: 1) Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36);2) Montreal Cognitive Assessment;3) any subsequent admission 4) St. George's Respiratory Questionnaire;5) Pulmonary function testing;6) chest radiography;7) 6-minute-walk test;8) Patient Health Questionnaire 9 (PHQ-9) and 9) full blood count and biochemistry. CT chest at 6 months and repeat ECHO at 3, 12 and 24 months if performed during COVID-19 hospitalization. If results are normal, subsequent testing will not be performed. Summary: The AFTERCOR study represents a comprehensive evaluation for long-term effects from COVID-19. Interested centers are sought and invited to participate.