ABSTRACT
INTRODUCTION: Guidelines advocate caution against the use of non-invasive ventilatory (NIV) support in the management of de novo hypoxemic respiratory failure, especially acute respiratory distress syndrome (ARDS). However, NIV support was used extensively during the COVID-19 pandemic. We hypothesized that the use of NIV, especially bi-level positive airway support (BiPAP), is associated with adverse outcomes in COVID-19 induced ARDS, as it may delay intubation and expose patients to harmful effects of ventilation induced lung injury. METHOD(S): This is a retrospective, single-center study of adult patients admitted to a tertiary medical center's ICUs with COVID-19 induced respiratory failure between March- September 2020 who required BiPAP support. We excluded patients who were using BiPAP at home prior to admission or required BiPAP after extubation. NIV failure is defined as the need for intubation after a trial of BiPAP. RESULT(S): A total of 35 patients (out of 129) fulfilled the criteria for inclusion in the study. The mean (standard deviation, SD) age was 63.5 (13.8) years, and the majority were Caucasian men (60%). The mean (SD) BMI was 35.4 (9.6) kg/m2, and the mean (SD) APACHE II score was 16 (6.4). 18 out of 35 patients (51%) had NIV failure. Patients who failed BiPAP support had increased ICU and hospital mortality compared to those who did not require intubation after BiPAP therapy (66.6% vs. 11.7% and 72.2% vs. 17.6%, respectively;P< 0.001). ICU and hospital lengths of stay were also higher for the patients with NIV failure (17 vs. 3.4 days and 23.5 vs. 13.1 days, respectively;P< 0.001). CONCLUSION(S): NIV failure was associated with adverse clinical outcomes in the management of COVID-19 induced ARDS.
ABSTRACT
Objective: To describe the prevalence, associated risk factors, and outcomes of serious neurologic manifestations (encephalopathy, stroke, seizure, and meningo-encephalitis) among patients hospitalized with coronavirus disease 2019 (COVID-19). Background: Though case series abound, limited prospective multi-center data exists describing neurologic manifestations of COVID-19 Design/Methods: Prospective observational study of hospitalized adults in 179 hospitals in 24 countries with laboratory-confirmed SARS-CoV-2 infection within the SCCM Discovery Viral Infection and Respiratory Illness University Study (VIRUS) COVID-19 Registry Results: Of 16,225 patients enrolled in the registry with discharge status available, 2,092 (12.9%) developed serious neurologic manifestations including 1,656 (10.2%) with encephalopathy at admission, 331 (2.0%) with stroke, 243 (1.5%) with seizure, and 73 (0.5%) with meningitis/encephalitis at admission or during hospitalization. Patients with serious neurologic manifestations were older with median (IQR) age 72 (61.0-81.0) vs. 61 (48.0-72.0) years and had higher prevalence of chronic medical conditions, including vascular risk factors. Systemic viral symptoms (fever, dyspnea, and cough) were less commonly reported in patients with severe neurologic manifestations as were milder neurologic symptoms including anosmia, dysgeusia, and headache. Adjusting for sex and time since the onset of the pandemic, serious neurologic manifestations were associated with more severe disease (OR 1.82, p<0.001) as defined by the WHO ordinal disease severity scale. Patients with neurologic manifestations were more likely to be admitted to the ICU (OR 1.45, p<0.001) and ICU interventions (ECMO: OR 1.78, p=0.009 and RRT: OR 1.99, p<0.001). Hospital and 28-day mortality for patients with neurologic manifestations was higher (OR 1.51 and 1.58, p<0.001), and patients had fewer ICU-free, hospital-free, and ventilator-free days (OR -0.84, -1.34, and -0.84, p<0.001). Conclusions: Encephalopathy at admission is common in COVID-19 infection and is associated with worse outcomes. While serious neurologic manifestations including stroke, seizure, and meningitis/encephalitis were less common, all were associated with increased ICU support utilization, more severe disease, and worse outcomes.