Pneumomediastinum as a complication of SARS-CoV-2 pneumonia

The incidence of pneumomediastinum in hospitalised patients diagnosed with SARS-CoV-2 pneumonia is by no means negligible, much higher compared to the general population. The pathophysiology of pneumomediastinum in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia is explained by the increase in alveolar-interstitial pressure gradient (dry coughing spells, respiratory work, barotrauma from ventilatory support) in the context of particularly "fragile" lungs due to diffuse alveolar-interstitial damage from infectious-inflammatory origin, all of which significantly increases the risk of alveolar wall rupture. The more severe the SARS-CoV-2 pneumonia, the more likely it is that pneumomediastinum will occur. The development of pneumomediastinum in patients with SARS-CoV-2 pneumonia is associated with higher frequencies of death, intensive care unit (ICU) admission and tracheostomy and longer hospital and ICU lengths of stay. In most cases, pneumomediastinum in SARS-CoV-2 pneumonia is a benign and self-limiting process that resolves with conservative treatment. © 2022 Sociedad Madrinela de Neumologia y Cirugia Toracica. All rights reserved.

Severe SARS-CoV-2 pneumonia and pneumomediastinum and/or pneumothorax: a prospective observational study in an intermediate respiratory care unit

Introduction: The occurrence of pneumomediastinum (PNMMD) or pneumothorax (PNMTX) was evaluated in patients with severe SARS-CoV-2 pneumonia. Method(s): This is a prospective observational descriptive study that was carried out on patients admitted to the IRCU of a COVID-19 monographic hospital in Madrid from 14/01/2021 to 27/09/2021. All of them had a diagnosis of severe SARS-CoV-2 pneumonia and required NIRS (HFNC, CPAP, BPAP). The incidences of PNMMD and PNMTX, total and according to NIRS, and their impact on the probability of IMV and death were studied. Result(s): (tables 1 and 2) 4.3% (56/1306) developed PNMMD or PNMTX, 3.8% (50) PNMMD, 1.6% (21) PNMTX, and 1.1% (15) PNMMD+PNMTX. 16.1% of patients with PNMMD or PNMTX had HFNC alone (vs 41.7% without PNMMD or PNMTX;p<0.001) and 83.9% CPAP (vs 57.5%;p<0.001). There was a probability of needing IMV of 64.3% among patients with PNMMD or PNMTX (vs 21.0%;p<0.001), and a mortality of 33.9% (vs 10.5%;p<0.001). Conclusion(s): In patients admitted to the IRCU for severe SARS-CoV-2 pneumonia who required NIRS, incidences of 3.8% for PNMMD and 1.6% for PNMTX were observed. LDH was a risk factor for developing PNMMD or PNMTX (median 438 vs 395;p=0.013), and PNMMD (median 438 vs 395;p=0.014). The majority of patients with PNMMD or PNMTX had CPAP as the NIRS device, much more frequently than patients without PNMTX or PNMMD. However, the pressures used in CPAP were even lower in patients with PNMMD or PNMTX (median 8 vs 10;p=0.031). The probabilities of IMV and mortality among patients with PNMMD or PNMTX were 64.3% and 33.9%, respectively, higher than in patients without PNMMD or PNMTX, 21.0% and 10.5%.

Intermediate Respiratory Care Units: Questions and Answers

The intermediate respiratory care units (UCRI) are areas of monitoring and specialized care of patients with acute or chronic-exacerbated respiratory failure, whose severity does not require admission to an intensive care unit, but which due to their complexity cannot be treated in conventional hospitalization. Although the COVID-19 pandemic has proven its usefulness in the management of critical respiratory patients, the historical trajectory of the UCRI comes from many years ago, in which its cost-effectiveness has been demonstrated by far. This document presents a series of questions and answers on the history of the UCRI, in addition to the criteria for admission, infrastructure, human and technical resources, and the types of existing Units. Within the UCRI year 2021-2022 designated by the Spanish Society of Pneumology and Thoracic Surgery, any scientific dissemination linked to the in-depth knowledge of these units is timely, where multidisciplinarity and the work of professionals related to the care of critical respiratory patients converge.Copyright © 2022

Clinical Findings and Outcomes from 1306 Patients with Covid-19 Pneumonia in an Intermediate Respiratory Care Unit: A Prospective, Observational Study

Background: An intermediate respiratory care unit (IRCU) may be a valuable tool for optimizing patient care, allowing to implement standardized algorithm management to decrease clinical failure and mortality. We aimed to describe the practice of noninvasive respiratory strategies (NRS) in a novel facility fully dedicated to COVID-19 and to establish outcomes of these patients Methods: Prospective, observational study performed at one hospital in Spain. We included consecutive patients admitted to IRCU due to COVID-19 requiring NRS between December 2020 and September 2021. Data collected included mode and usage of NRS, endotracheal intubation and mortality to day 30. A multivariable Cox proportional hazards method was used to assess risk factors associated with clinical failure and mortality Findings: 1306 patients with COVID-19 were included. Of them, 64.6% were men and mean age was 54.7 years. During IRCU stay, 345 patients presented a clinical failure, (89.6% intubated;14.5% died). Cox model showed a higher clinical failure in IRCU when time between symptoms onset and hospitalization < 10 days (HR 1.59;95% CI 1.24-2.03;p<0.001) and PaO2/FiO2 <100 (HR 1.59;95% CI 1.27-1.98;p<0.001). Conversely, these variables were not associated with an increased mortality to day 30 Interpretation: IRCU may be a useful option for the multidisciplinary management of COVID-19 patients requiring NRS;thus, reducing ICU overcharge. Men gender, gas-exchange and blood chemistry at admission are associated with worse clinical outcomes, while older age, gas-exchange and blood chemistry are associated with 30-day mortality.

Usefulness of the early combination of non-invasive respiratory therapies in patients with COVID-19

Aim: To determine the effect of the early combination of high flow nasal cannula (HFNC) plus continuous positive airway pressure (CPAP) regarding endotracheal intubation (ETI) and 30-day mortality in patients with SARS-CoV-2 pneumonia. Method(s): Observational study of patients admitted to the intermediate respiratory care unit (IRCU) who received HFNC+CPAP. Two groups were formed according to the time of starting the combined therapy: Early HFNC+CPAP (first 24 h - EHC) and Late HFNC+CPAP (after 24 h - LHC). A multivariate analysis was performed to establish the strength of the association with ETI and 30-day mortality. Result(s): 780 patients were included (502 male, mean age 56.5 +/- 12.9 years). Table 1 shows the baseline characteristics. 273 patients were subjected to ETI, 32.9% in the EHC group vs 38.9% in the LHC group (p 0.05). 30day mortality was 8.2% in the EHC vs 15.5% LHC (p 0.02). Table 2 shows the multivariate analysis. Conclusion(s): The combination of HFNC+CPAP, especially in the first 24 hours after IRCU admission, is a useful tool in the management of SARS-CoV-2 pneumonia.

Clinical characteristics and respiratory care of hospitalized patients according to vaccination status of COVID 19

Although protection of vaccines against COVID-19 has been reported, very little is known about the clinical characteristics of hospitalized vaccinated patients. Method(s): This single-center cohort study of 1888 COVID-19 patients hospitalized at the "Enfermera Isabel Zendal" Emergencies Hospital, Madrid (Spain) was performed between July and September, 2021. It compared the results of 1327 unvaccinated patients to 209 fully vaccinated and 352 partially vaccinated. Vaccines administered were: BNT162b2, ChAdOx1 nCoV-19, mRNA-1273, Ad26.COV2.S. Finding(s): Hospitalized patients' median age was 41 years (IQR 33.0-50.0) for the unvaccinated and 61.0 years (IQR 53.0-67.0) for the fully vaccinated ones. The main comorbidities were obesity, hypertension and diabetes mellitus. The fully vaccinated patients obtained higher C-reactive protein values (median 48.9 mg/l [IQR 21.7-102.9]) and significantly lower for ferritin (median 367.0 ng/ml [IQR 182.0-731.0]) and lactate dehydrogenase (median 269.0 units/l [IQR 218.5-330.5]) values. 266 unvaccinated patients required noninvasive respiratory care, as did 51 partially vaccinated and 30 fully vaccinated patients;78 of the unvaccinated patients also needed invasive respiratory care, as did 16 partially vaccinated and 11 fully vaccinated patients. The fully vaccinated patients were 84% less likely to be admitted to hospital, and protection for those aged <50 years. Interpretation(s): Once hospitalized, the vaccinated patients displayed more protection against requiring respiratory care than the unvaccinated ones, despite being older and having more comorbidities. No differences appeared for the four studied vaccine types.

Intermediate Respiratory Care Units: Questions and Answers

The intermediate respiratory care units (UCRI) are areas of monitoring and specialized care of patients with acute or chronic-exacerbated respiratory failure, whose severity does not require admission to an intensive care unit, but which due to their complexity cannot be treated in conventional hospitalization. Although the COVID-19 pandemic has proven its usefulness in the management of critical respiratory patients, the historical trajectory of the UCRI comes from many years ago, in which its cost-effectiveness has been demonstrated by far. This document presents a series of questions and answers on the history of the UCRI, in addition to the criteria for admission, infrastructure, human and technical resources, and the types of existing Units. Within the UCRI year 2021-2022 designated by the Spanish Society of Pneumology and Thoracic Surgery, any scientific dissemination linked to the in-depth knowledge of these units is timely, where multidisciplinarity and the work of professionals related to the care of critical respiratory patients converge. Copyright © 2022

All Roads Lead to Rome: Results of Non-Invasive Respiratory Therapies Applied in a Tertiary-Care Hospital Without an Intermediate Care Unit During the COVID-19 Pandemic

Introduction: Non-invasive respiratory therapies (NRT) were widely used in the first wave of the COVID-19 pandemic in different settings, depending on availability. The objective of our study was to present 90-day survival and associated factors in patients treated with NRT in a tertiary hospital without an Intermediate Respiratory Care Unit. The secondary objective was to compare the outcomes of the different therapies. Methods: Observational study of patients treated with NRT outside of an intensive care or intermediate respiratory care unit setting, diagnosed with COVID-19 and acute respiratory distress syndrome by radiological criteria and SpO2/FiO2 ratio. A multivariate logistic regression model was developed to determine independently associated variables, and the outcomes of high flow nasal cannula and continuous positive airway pressure were compared. Results: In total, 107 patients were treated and 85 (79.4%) survived at 90 days. Before starting NRT, the mean SpO2/FiO2 ratio was 119.8 ± 59.4. A higher SOFA score was significantly associated with mortality (OR 2,09;95% CI 1.34-3.27), while self-pronation was a protective factor (OR 0.23;95% CI 0.06-0.91). High flow nasal cannula was used in 63 subjects (58.9%), and continuous positive airway pressure in 41 (38.3%), with no differences between them. Conclusion: Approximately 4 out of 5 patients treated with NRT survived to 90 days, and no significant differences were found between high flow nasal cannula and continuous positive airway pressure.