ABSTRACT
Aim and objective: To correlate a chest CT score in COVID-19 pneumonia with clinical severity and inflammatory biomarkers and overall patient's outcome. Materials and methods: In this retrospective single-center analysis, we collected data of 200 patients admitted to Fortis hospital during the peaks of the two waves of the COVID-19 pandemic. Data for 1st wave were collected between July and September 2020 (100 patients) and 2nd wave from March to April 2021 (100 patients). We collected clinical and laboratory data for analysis, derived from the electronic medical record system for the above durations. Only symptomatic patients within 10 days of onset of symptoms who had CT imaging done at admission were included in the study. A team of experienced radiologists analysed the images to determine the CT severity score based on the extent of lobar involvement. Each lung lobe was visually scored from 0-5, 0-no involvement, 1: <5% involvement, 2: 5-25% involvement;3: 26-50% involvement;4: 51-75% involvement;5: >75% involvement. The total CT score was the sum of individual lobar scores ranging from 0 (no involvement) to 25 (maximum involvement). The results of the chest HRCT images were collected and evaluated using the picture archiving and communication systems (PACS). Patient's chest CT score, P/F ratio, O2 requirement, and need for ventilatory support and mortality were compared. Descriptive statistics of patients demographics, clinical, and laboratory results were reported as numbers and relative frequencies. Frequencies of CT scores were calculated and compared with other clinical variables. The Pearson correlation coefficient test was used for correlations, considering p < 0.05 statistically significant. Results: Our study highlights the clinical implication of initial CT findings as a prognostic indicator in patients with COVID-19. In terms of demographic distribution median age was 57.5 and 58 years, respectively, and both the waves had a median male predominance of 65%. Wave 1 had more patients with lower CT scores and higher P/F ratio, whereas wave 2 had a significant lower P/F ratio for the same CT scores as compared to wave 1, especially at higher CT scores. CT score of >18/25 is associated with increased probability of ventilatory requirement and hence increased mortality in both the waves which was found to be statistically significant with p = 0.005. Also, higher CT scores were found to be positively correlated with lymphopenia, increased serum CRP, d-dimer, and ferritin levels. Conclusion: Chest CT imaging has played an important role in monitoring disease progression and predicting prognosis during the COVID-19 pandemic. They can be pivotal in assisting clinicians in diagnosing the severity, predicting the outcomes and most of all, in the management plan for the concerned patient. In our analysis of one of the largest single-centre studies conducted during the two waves of the COVID-19 pandemic in India, CT severity score was directly proportional with inflammatory lab markers, length of hospital stays, and oxygen requirement in patients with COVID-19 infection. CT Chest score of >18/25 on admission is associated with poor prognosis and increased mortality.
ABSTRACT
Aim and background: Infection due to SARS-CoV-2 may lead to an atypical ARDS, requiring in the most severe cases VV ECMO. The management of persistent severe hypoxemia under VV ECMO requires a multistep clinical approach including prone positioning which could improve oxygenation. Objective: To assess the synergistic effect of prone ventilation and VV-ECMO in addition to lung-protective ventilation to improve patient outcomes in severe ARDS. Materials and methods: Fortis hospital has been an established ECMO center prior to the COVID-19 pandemic but has now become a primary referral center for ECMO retrieval of critically ill patients. In the past 10 months, we had 19 ECMO patients. All patients who underwent ECMO insertion had CT imaging done on the day of ECMO insertion. Patients with inhomogeneous lung opacities on imaging were postulated to potentially benefit from proning on ECMO. We would like to present a case series of 3 patients (2 retrievals and 1 in-house) subjected to prone ventilation immediately after initiation of VV ECMO in view of ARDS with refractory hypoxia, high driving pressures, and Murray score of >3. Femoro-jugular configuration of VV ECMO was used with adequate anticoagulation. All patients were subjected to proning and supining with a dedicated team of 8-10 members including a senior intensivist and airway expert at the head end and perfusionist taking care of the ECMO circuit along with 6 support staff on side of the patient and 1-2 staff for placing/removing the head support, chest, and pelvic bolsters. All patients received immunomodulation with methylprednisolone for the persistent maladaptive hyperinflammatory states. Ventilatory parameters on conventional lung-protective ventilation were compared to parameters on ECMO at the initiation of proning and after completion of prone sessions. Any complications associated with proning were noted. Results: We describe 3 patients with severe COVID-19 bronchopneumonia with refractory hypoxemia who received prone ventilation on VV ECMO. The median age of patients was 40 years with 1 male and 2 female patients. The median time from symptom onset to mechanical ventilation was 7 days and from mechanical ventilation to VV ECMO initiation was 1.5 days. The median duration on VV-ECMO was 5 days with a duration of prone sessions lasting 18 hours. The mean driving pressure has reduced by 17.6% with an improvement in compliance by 26.3%. The paO2 and P/F ratio improved by 63.2% and 260%, respectively, on ECMO support and these changes were sustained post-ECMO decannulation. None of the patients had any major complications associated with proning. The median duration of hospital stay was 30 days. Days to discharge were prolonged due to sepsis from secondary infection. All 3 patients survived to hospital discharge with minimal to no oxygen requirement, mobilized to an adequate functional capacity to perform activities of daily living. Conclusion: ECMO is often used in patients with severe ARDS and refractory hypoxemia to improve oxygenation and survival. Prone positioning concurrently with ECMO in selected patients can further aid in optimizing alveolar recruitment and reducing ventilator-induced lung injury, which ultimately may be associated with a reduction in-hospital mortality.