ABSTRACT
Background: Coronavirus disease 2019 (COVID-19) has been frequently complicated by severe acute respiratory distress syndrome (ARDS) with prolonged invasive ventilation. While respiratory system compliance and lung recruitability have been described within the first days after ICU admission, data about their longitudinal changes are still limited. Therefore, we conducted this study to assess the evolution of respiratory system compliance and lung recruitability in patients with COVID-19-related ARDS. Method: We conducted a prospective single-center study in patients admitted for COVID-19-related ARDS during the first wave of the pandemic, from March 16, 2020 to April 10, 2020. Respiratory system compliance was calculated daily at clinical positive end-expiratory pressure (PEEP) during passive breathing. The potential for lung recruitment was assessed by measuring the volume derecruited between PEEP 15 cmH2O and 5 cmH2O, and using the calculation of the recruitment-to-inflation ratio (R/I ratio). Recruitable lung was considered when the R/I ratio was at least 0.5. The primary outcome was the evolution of respiratory mechanics over time. The secondary outcome was the evolution of lung recruitability over time. Results: Thirty-two patients were included in this study. The respiratory mechanics were assessed 222 times (7 ± 5 times per patient). Respiratory system compliance at clinical PEEP was 29.1 mL/cmH2O (interquartile range [IQR]: 24.1-33.9 mL/cmH2O) and decreased significantly over time (P <0.0001). Lung recruitability was assessed in 22 out of the 32 patients (60 assessments). The median volume derecruited between PEEP 15 cmH2O and 5 cmH2O was 246.8 mL (IQR: 180.8-352.2 mL) and the median R/I ratio was 0.56 (IQR: 0.39-0.73). Neither changed significantly over time. The proportion of patients with recruitable lung was 50.0% (6/12) within the first 3 days after intubation, 69.2% (9/13) between day 4 and day 7, and 66.7% (8/12) after day 7 (P=0.7934). Conclusions: In our cohort, respiratory system compliance was low and decreased over time. The potential for lung recruitment was high and persisted despite prolonged mechanical ventilation, suggesting that maintaining high PEEP levels in the later course of COVID-19 could be adequate.
ABSTRACT
BACKGROUND: COVID-19 may induce endovascular injury of pulmonary vessels and could be associated with increased risk of pulmonary embolism. The main objective was to compare the incidence of pulmonary embolism in patients with acute respiratory distress syndrome (ARDS) related to COVID-19 versus patients with pulmonary ARDS unrelated to COVID-19. METHODS: This is an observational controlled-cohort study performed at a single center of a university teaching hospital in France. The incidence of pulmonary embolism was prospectively assessed using computed tomography pulmonary angiography (CTPA) in patients with ARDS related to COVID-19 and compared to patients from a 3-year historical cohort of patients with pulmonary ARDS unrelated to COVID-19. In patients with ARDS related to COVID-19, CTPA was performed approximately 7 days after intubation or earlier in case of respiratory or hemodynamic worsening. RESULTS: CTPA was performed in 29 out of the 42 patients (69%) with ARDS related to COVID-19 and in 51 out of the 156 patients (33%) from the historical cohort of patients with pulmonary ARDS unrelated to COVID-19. Incidence of pulmonary embolism was 40% (17/42) in patients with ARDS related to COVID-19 and 3% (5/156) in the historical cohort (P=0.001). The proportion of patients with pulmonary embolism among all patients who had CTPA was 59% (17/29) in patients with ARDS related to COVID-19 and 10% (5/51) in the historical cohort (P=0.0001). After adjustment on the interval between ICU admission and computed tomography, COVID-19 remained independently associated with pulmonary embolism. CONCLUSIONS: Pulmonary embolism was particularly frequent in patients with ARDS related to COVID-19, thereby suggesting that CTPA should be systematically performed in these patients.
ABSTRACT
BACKGROUND: The COVID-19 pandemic led authorities to evacuate via various travel modalities critically ill ventilated patients into less crowded units. However, it is not known if interhospital transport impacts COVID-19 patient's mortality in intensive care units (ICUs). A cohort from three French University Hospitals was analysed in ICUs between 15th of March and the 15th of April 2020. Patients admitted to ICU with positive COVID-19 test and mechanically ventilated were recruited. RESULTS: Among the 133 patients included in the study, 95 (71%) were male patients and median age was 63 years old (interquartile range: 54-71). Overall ICU mortality was 11%. Mode of transport included train (48 patients), ambulance (6 patients), and plane plus helicopter (14 patients). During their ICU stay, 7 (10%) transferred patients and 8 (12%) non-transferred patients died (p = 0.71). Median SAPS II score at admission was 33 (interquartile range: 25-46) for the transferred group and 35 (27-42) for non-transferred patients (p = 0.53). SOFA score at admission was 4 (3-6) for the transferred group versus 3 (2-5) for the non-transferred group (p = 0.25). In the transferred group, median PaO2/FiO2 ratio (P/F) value in the 24 h before departure was 197 mmHg (160-250) and remained 166 mmHg (125-222) in the first 24 h post arrival (p = 0.13). During the evacuation 46 (68%) and 21 (31%) of the patients, respectively, benefited from neuromuscular blocking agents and from vasopressors. Transferred and non-transferred patients had similar rate of nosocomial infections, 37/68 (54%) versus 34/65 (52%), respectively (p = 0.80). Median length of mechanical ventilation was significantly increased in the transferred group compared to the non-transferred group, 18 days (11-24) and 14 days (8-20), respectively (p = 0.007). Finally, ICU and hospital length of stay did not differ between groups. CONCLUSIONS: In France, inter-hospital evacuation of COVID-19 ventilated ICU patients did not appear to increase mortality and therefore could be proposed to manage ICU surges in the future.