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1.
EuropePMC; 2020.
Preprint in English | EuropePMC | ID: ppcovidwho-311563

ABSTRACT

Background: Identifying preventive strategies in Covid-19 patients will help to improve resource-allocation and reduce mortality. In this Journal, we recently demonstrated in a post-mortem cohort that SARS-CoV-2 renal tropism was associated with kidney injury, disease severity and mortality. We also proposed an algorithm to predict the risk of adverse outcomes in Covid-19 patients harnessing urinalysis and protein/coagulation parameters on admission for signs of kidney injury. Here, we aimed to validate this hypothesis in a multicenter cohort.Methods: Patients hospitalized for Covid-19 at four tertiary centers were screened for an available urinalysis, serum albumin (SA) and antithrombin-III activity (AT-III) obtained prospectively within 48h upon admission. The respective presumed risk for an unfavorable course was categorized as “low”, “intermediate” or “high”, depending on a normal urinalysis, an abnormal urinalysis with SA ≥2 g/dl and AT-III ≥70%, or an abnormal urinalysis with at least one SA or AT-III abnormality. Time to ICU or death within ten days served as primary, in-hospital mortality and required organ support served as secondary endpoints.Findings: Among a total of N=223 screened patients, N=145 were eligible for enrollment, falling into the low (N=43), intermediate (N=84), and high risk (N=18) categories. The risk for ICU transfer or death was 100% in the high risk group and significantly elevated in the composite of high and intermediate risk as compared to the low risk group (63·7% vs. 27·9%;HR 2·6;95%-CI 1·4 to 4·9;P=0·0020). Having an abnormal urinalysis was associated with mortality, need for mechanical ventilation, extra-corporeal membrane oxygenation (ECMO) or renal replacement therapy (RRT).Interpretation: Our data confirm that Covid-19-associated urine abnormalities on admission predict disease aggravation. This supports the conceptual relevance of Covid-19-associated kidney injury. By engaging a simple urine dipstick our algorithm allows for early preventive measures and appropriate patient stratification. Trial Registration: (ClinicalTrials.gov number NCT04347824)Funding Statement: This work was supported by the DFG (GR 1852/6-1 to OG;CRC1192 to JET, EH and TBH), (HU 1016/8-2, HU 1016/11-1, HU 1016/ 12-1 to TBH) and (GR 1852/6-1 to OG);by the BMBF (STOP-FSGS-01GM1518C and NephrESA-031L0191E to TBH), by the Else-Kröner Fresenius Foundation (Else Kröner-Promotionskolleg –iPRIME to TBH), and by the H2020-IMI2 consortium BEAt-DKD (115974 to TBH). In addition, the UMG Göttingen applied for Government funding (Covid-19 program) by The German Federal Ministry of Education and Research and the application currently is under consideration.Declaration of Interests: All authors report no conflict of interest in relation to this observational cohort-study. Ethics Approval Statement: According to the German Medicines Act, the study was approved by the leading institutional review board (IRB) of the UMG Göttingen (41/4/20), and all others.

2.
EuropePMC; 2020.
Preprint in English | EuropePMC | ID: ppcovidwho-311562

ABSTRACT

Purpose: Identifying preventive strategies in Covid-19 patients helps to improve ICU-resource-allocation and reduce mortality. We recently demonstrated in a post-mortem cohort that SARS-CoV-2 renal tropism was associated with kidney injury, disease severity and mortality. We also proposed an algorithm to predict the need for ICU-resources and the risk of adverse outcomes in Covid-19 patients harnessing urinalysis and protein/coagulation parameters on admission for signs of kidney injury. Here, we aimed to validate this hypothesis in a multicenter cohort. Methods: : Patients hospitalized for Covid-19 at four tertiary centers were screened for an available urinalysis, serum albumin (SA) and antithrombin-III activity (AT-III) obtained prospectively within 48h upon admission. The respective presumed risk for an unfavorable course was categorized as “low”, “intermediate” or “high”, depending on a normal urinalysis, an abnormal urinalysis with SA ≥2 g/dl and AT-III ≥70%, or an abnormal urinalysis with at least one SA or AT-III abnormality. Time to ICU or death within ten days served as primary, in-hospital mortality and required organ support served as secondary endpoints. Results: : Among a total of N=223 screened patients, N=145 were eligible for enrollment, falling into the low (N=43), intermediate (N=84), and high risk (N=18) categories. The risk for ICU transfer or death was 100% in the high risk group and significantly elevated in the composite of high and intermediate risk as compared to the low risk group (63.7% vs. 27.9%;HR 2.6;95%-CI 1.4 to 4.9;P=0.0020). Having an abnormal urinalysis was associated with mortality, need for mechanical ventilation, extra-corporeal membrane oxygenation (ECMO) or renal replacement therapy (RRT). Conclusion: Our data confirm that Covid-19-associated urine abnormalities on admission predict disease aggravation and need for ICU. By engaging a simple urine dipstick on hospital admission our algorithm allows for early preventive measures and appropriate patient stratification. (ClinicalTrials.gov number NCT04347824)

3.
PLoS One ; 17(1): e0262315, 2022.
Article in English | MEDLINE | ID: covidwho-1622359

ABSTRACT

BACKGROUND: The role of non-invasive ventilation (NIV) in severe COVID-19 remains a matter of debate. Therefore, the utilization and outcome of NIV in COVID-19 in an unbiased cohort was determined. AIM: The aim was to provide a detailed account of hospitalized COVID-19 patients requiring non-invasive ventilation during their hospital stay. Furthermore, differences of patients treated with NIV between the first and second wave are explored. METHODS: Confirmed COVID-19 cases of claims data of the Local Health Care Funds with non-invasive and/or invasive mechanical ventilation (MV) in the spring and autumn pandemic period in 2020 were comparable analysed. RESULTS: Nationwide cohort of 17.023 cases (median/IQR age 71/61-80 years, 64% male) 7235 (42.5%) patients primarily received IMV without NIV, 4469 (26.3%) patients received NIV without subsequent intubation, and 3472 (20.4%) patients had NIV failure (NIV-F), defined by subsequent endotracheal intubation. The proportion of patients who received invasive MV decreased from 75% to 37% during the second period. Accordingly, the proportion of patients with NIV exclusively increased from 9% to 30%, and those failing NIV increased from 9% to 23%. Median length of hospital stay decreased from 26 to 21 days, and duration of MV decreased from 11.9 to 7.3 days. The NIV failure rate decreased from 49% to 43%. Overall mortality increased from 51% versus 54%. Mortality was 44% with NIV-only, 54% with IMV and 66% with NIV-F with mortality rates steadily increasing from 62% in early NIV-F (day 1) to 72% in late NIV-F (>4 days). CONCLUSIONS: Utilization of NIV rapidly increased during the autumn period, which was associated with a reduced duration of MV, but not with overall mortality. High NIV-F rates are associated with increased mortality, particularly in late NIV-F.


Subject(s)
COVID-19/therapy , Noninvasive Ventilation , Respiration, Artificial , Adult , Aged , Aged, 80 and over , COVID-19/epidemiology , COVID-19/mortality , Female , Hospital Mortality , Humans , Intubation, Intratracheal/statistics & numerical data , Length of Stay , Male , Middle Aged , Noninvasive Ventilation/statistics & numerical data , Respiration, Artificial/statistics & numerical data , Treatment Outcome , Young Adult
4.
2021.
Preprint in English | Other preprints | ID: ppcovidwho-295101

ABSTRACT

Rationale The role of non-invasive ventilation (NIV) in severe COVID-19 remains a matter of debate. Objectives To determine the utilization and outcome of NIV in COVID-19 in an unbiased cohort. Methods Observational study of confirmed COVID-19 cases of claims data of the Local Health Care Funds comparing patients with non-invasive and invasive mechanical ventilation (IMV) between spring versus autumn period 2020. Measurements and Main Results Nationwide cohort of 7490 cases (median/IQR age 70/60–79 years, 66% male) 3851 (51%) patients primarily received IMV without NIV, 1614 (22%) patients received NIV without subsequent intubation, and 1247 (17%) patients had NIV failure (NIV-F), defined by subsequent endotracheal intubation. The proportion of patients who received invasive MV decreased from 74% to 39% during the second period. Accordingly, the proportion of patients with NIV exclusively increased from 10% to 28%, and those failing NIV increased from 9% to 21%. Median length of hospital stay decreased from 26 to 22 days, and duration of MV decreased from 11.6 to 7.6 days. The NIV failure rate decreased from 49% to 42%. Overall mortality remained unchanged (51% versus 53%). Mortality was 39% with NIV-only, 52% with IMV and 66% with NIV-F with mortality rates steadily increasing from 58% in early NIV-F (day 1) to 75% in late NIV-F (>4 days). Conclusion Utilization of NIV rapidly increased during the autumn period, which was associated with a reduced duration of MV, but not with overall mortality. High NIV-F rates are associated with increased mortality, particularly in late NIV-F. Funding Institutional support and physical resources were provided by the University Witten/Herdecke and Kliniken der Stadt Köln and the Federal Association of the Local Health Care Funds. At a Glance Commentary Scientific Knowledge on the Subject Current management of ventilatory support in COVID-19 patients with respiratory failure is heterogeneous. Despite increasing use of non-invasive ventilation (NIV), defining intubation criteria still remains a matter of uncertainty and discussion, especially with regard to the balance between the NIV benefits and the risk of NIV failure. In addition, robust data concerning the influence of the duration and failure of NIV on intubation and mortality rates are still missing, although the time span between initiation of NIV and subsequent intubation in case of respiratory failure progression is suggested to influence patient outcome. What This Study Adds to the Field This is the first large observational study describing differences of ventilatory strategies between the spring and autumn period of the SARS-CoV-2 pandemic in Germany and provides the in-hospital mortality rate of 7,490 patients who received mechanical ventilation. The increased utilization of NIV from 10% (first period) to 29% (second period) was associated with overall reduced durations of mechanical ventilation and length of hospital stay, but overall mortality remained comparably high and reached 51%, 53% respectively. Patients succeeding with NIV had lower mortality rates than those getting intubated without preceding NIV attempts, but those failing NIV had higher mortality rates, respectively, and this became even more predominant in late NIV failure. The present observational study shows the increasing role of NIV in the concert of ICU medicine related to COVID-19, but also clearly addresses its risks in addition to its benefits, both impacting on mortality.

6.
Microorganisms ; 9(12)2021 Nov 28.
Article in English | MEDLINE | ID: covidwho-1542674

ABSTRACT

BACKGROUND: Pulmonary rehabilitation (PR) following severe and very severe COVID-19 infection is known to be effective, according to typical assessments. However, not all patients benefit from PR to the same extent. This analysis aimed to identify the impact of different factors on PR outcomes in post-COVID-19 patients. METHODS: This prospective observational study included 184 post-COVID-19 patients. The achievement of the predicted reference walking distance (6 min walking distance (6-MWD)) served as a parameter with which to identify responders and non-responders to PR. Several parameters (e.g., Functional Independent Measurement (FIM); pulmonary function testing (Forced Vital Capacity, FVC); 6MWD) were assessed in order to estimate their impact on PR success. Logistic regression models and classification and regression trees were used for multivariate analysis. RESULTS: A total of 94 patients (51%) reached their reference 6MWD by the end of PR. FVC (0.95 (0.93-0.97)), 6MWD at admission (0.99 (0.99-1.00)), and FIM motoric (0.96 (0.93-0.99)) correlated with the risk not reaching the reference distance. The most important variable was the 6MWD at admission. Classification and regression tree identified 6MWD ≥ 130 m at admission and FVC predicted of >83% as the strongest predictor for reaching predicted 6-MWD. CONCLUSION: Post-COVID-19 patients with lower 6MWD, lower motoric FIM scores and lower FVC at admission have a high risk of not reaching their target values of physical performance despite intensive rehabilitation. As well as identifying them, it is of utmost importance to develop optimal PR concepts for these patients.

9.
J Clin Med ; 10(14)2021 Jul 09.
Article in English | MEDLINE | ID: covidwho-1308366

ABSTRACT

In COVID-19, guidelines recommend a urinalysis on hospital admission as SARS-CoV-2 renal tropism, post-mortem, was associated with disease severity and mortality. Following the hypothesis from our pilot study, we now validate an algorithm harnessing urinalysis to predict the outcome and the need for ICU resources on admission to hospital. Patients were screened for urinalysis, serum albumin (SA) and antithrombin III activity (AT-III) obtained prospectively on admission. The risk for an unfavorable course was categorized as (1) "low", (2) "intermediate" or (3) "high", depending on (1) normal urinalysis, (2) abnormal urinalysis with SA ≥ 2 g/dL and AT-III ≥ 70%, or (3) abnormal urinalysis with SA or AT-III abnormality. Time to ICU admission or death served as the primary endpoint. Among 223 screened patients, 145 were eligible for enrollment, 43 falling into the low, 84 intermediate, and 18 into high-risk categories. An abnormal urinalysis significantly elevated the risk for ICU admission or death (63.7% vs. 27.9%; HR 2.6; 95%-CI 1.4 to 4.9; p = 0.0020) and was 100% in the high-risk group. Having an abnormal urinalysis was associated with mortality, a need for mechanical ventilation, extra-corporeal membrane oxygenation or renal replacement therapy. In conclusion, our data confirm that COVID-19-associated urine abnormalities on admission predict disease aggravation and the need for ICU (ClinicalTrials.gov number NCT04347824).

10.
Pneumo News ; 13(3): 39-46, 2021.
Article in German | MEDLINE | ID: covidwho-1270557
11.
Pneumo News ; 13(3): 6-9, 2021.
Article in German | MEDLINE | ID: covidwho-1270556
12.
Pneumologie ; 75(6): 424-431, 2021 Jun.
Article in German | MEDLINE | ID: covidwho-1223124

ABSTRACT

Non-invasive strategies such as HFOT (high-flow oxygen therapy), CPAP (continuous positive airway pressure) and NIV (non-invasive ventilation) are increasingly being used during the COVID-19 pandemics in order to treat acute hypoxemic respiratory failure related to COVID-19, and this is aimed at avoiding intubation. This review article summarizes the current evidence by also emphasizing its heterogeneity. Importantly, current evidence suggests that these non-invasive strategies can be successfully used even in case of severe respiratory failure and are, thus, indeed capable of avoiding intubation, and consequently, tube-related complications. In contrast, it also remains to be emphasized that prolonged spontaneous breathing supported by non-invasive treatment strategies is also prone to complications. In particular, late NIV failure is associated with substantially deteriorated outcome, which is suggested to be meaningful in view of NIV failure rates still being high in Germany. Finally, the current article also refers to a parallel article that addresses the discussion being held in the public media in Germany concerning this topic. Here, its textual questionability, but also its negative consequences for both the research community and the general society are elaborated. In this context, the importance of national and regularly updated guidelines is emphasized.


Subject(s)
COVID-19 , Noninvasive Ventilation , Respiratory Insufficiency , Germany , Humans , Respiratory Insufficiency/therapy , SARS-CoV-2
13.
ERJ Open Res ; 7(2)2021 Apr.
Article in English | MEDLINE | ID: covidwho-1186553

ABSTRACT

This correspondence argues that the conclusion given in the article "Conservative management of COVID-19-associated hypoxaemia" is not supported by the data https://bit.ly/3qAn7la.

14.
Int J Environ Res Public Health ; 18(5)2021 03 07.
Article in English | MEDLINE | ID: covidwho-1134147

ABSTRACT

BACKGROUND: Severe COVID-19 infection often leads to impairments requiring pulmonary rehabilitation (PR) following the acute phase. Little is known about the efficacy of PR in these patients. We therefore compared post-COVID-19 patients (PG) referred to PR patients with other lung diseases (LG). METHODS: 99 PG were admitted to PR. In a prospective design, the results of PG were collected and compared to the results of LG of 2019 (n = 419) according to Functional Independence Measurement (FIM), Cumulative Illness Rating Scale (CIRS), 6-min walk test (6-MWT), duration of PR, and Feeling Thermometer (FT). RESULTS: According to age, sex, and CIRS, both groups showed no significant differences. The improvements in the 6-MWT in the pre to post comparison were on average 180 (±101) meters for PG and 102 (±89) meters for LG (p < 0.001). FT showed a significant enhancement for PG of 21 (±14) points and for LG of 17 (±16) points (p < 0.039), while FIM significantly increased by 11 (±10) points in PG and 7 (±8) points in LG (p < 0.001). CONCLUSIONS: Comprehensive PR in PG is very effective according to the results in FIM, 6-MWT and FT. Therefore, we recommend PR following severe post-COVID-19 infections.


Subject(s)
COVID-19 , Lung Diseases , Humans , Prospective Studies , SARS-CoV-2 , Treatment Outcome , Walk Test
15.
Medicine (Baltimore) ; 100(1): e24256, 2021 Jan 08.
Article in English | MEDLINE | ID: covidwho-1024164

ABSTRACT

ABSTRACT: Brochoalvelolar lavages (BALs) from patients suffering from hospitalized infections with SARS-CoV-2, other corona viruses (human coronavirus (HCoV)-229E, HCoV-OC43, HCoV-NL63, and HCoV-HKU1), Influenza virus type A and B, Haemophilus influenzae and Pneumocystis jirovecii were compared cytopathologically.The aim of the study was to evaluate if the cellular profile detectable in BAL may be specific for the respective pathogens and could lead to diagnosis of COVID-19 even in the absence of PCR results.Differential cytology and flow cytometry datasets of 62 patients were observed and compared.We observed a significant association between individual cell pattern changes and the causing pathogen, but no general cell distribution pattern.The cytology pattern of the BAL fluid in COVID-19 is not specific enough to use it as a sole diagnostic criterion, although it may support clinical decision making.


Subject(s)
Bronchoalveolar Lavage Fluid/virology , COVID-19/diagnosis , Coronavirus/isolation & purification , Haemophilus influenzae/isolation & purification , Orthomyxoviridae/isolation & purification , Pneumonia, Viral/virology , SARS-CoV-2/isolation & purification , Adult , Aged , Aged, 80 and over , Bronchoalveolar Lavage , Bronchoalveolar Lavage Fluid/microbiology , Female , Flow Cytometry , Humans , Male , Middle Aged , Pneumocystis carinii/isolation & purification
16.
Dtsch Arztebl Int ; 117(31-32): 528-533, 2020 08 03.
Article in English | MEDLINE | ID: covidwho-750754

ABSTRACT

BACKGROUND: The reported high mortality of COVID-19 patients in intensive care has given rise to a debate over whether patients with this disease are being intubated too soon and might instead benefit from more non-invasive ventilation. METHODS: This review is based on articles published up to 12 June 2020 that were retrieved by a selective literature search on the topic of invasive and non-invasive ventilation for respiratory failure in COVID-19. Guideline recommendations and study data on patients with respiratory failure in settings other than COVID-19 are also considered, as are the current figures of the intensive care registry of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin). RESULTS: The high mortality figures among patients receiving invasive ventilation that have been reported in studies from abroad cannot be uncritically applied to the current situation in Germany. Study data on ventilation specifically in COVID-19 patients would be needed to do justice to the special pathophysiology of this disease, but such data are lacking. Being intubated too early is evidently associated with risks for the patient, but being intubated too late is as well. A particularly im - portant consideration is the potential harm associated with prolonged spontaneous breathing, with or without non-invasive assistance, as any increase in respiratory work can seriously worsen respiratory failure. On the other hand, it is clearly unacceptable to intubate patients too early merely out of concern that the medical staff might become infected with COVID-19 if they were ventilated non-invasively. CONCLUSION: Nasal high flow, non-invasive ventilation, and invasive ventilation with intubation should be carried out in a stepwise treatment strategy, under appropriate intensive-care monitoring and with the observance of all relevant anti-infectious precautions. Germany is better prepared that other countries to provide COVID-19 patients with appropriate respiratory care, in view of the high per capita density of intensive-care beds and the availability of a nationwide, interdisciplinary intensive care registry for the guidance and coordination of intensive care in patients who need it.


Subject(s)
Coronavirus Infections/therapy , Pneumonia, Viral/therapy , Respiration, Artificial/methods , Respiratory Insufficiency/therapy , COVID-19 , Coronavirus Infections/epidemiology , Germany/epidemiology , Humans , Noninvasive Ventilation , Pandemics , Pneumonia, Viral/epidemiology
17.
Respiration ; 99(6): 521-542, 2020.
Article in English | MEDLINE | ID: covidwho-610252

ABSTRACT

Against the background of the pandemic caused by infection with the SARS-CoV-2 virus, the German Respiratory Society has appointed experts to develop therapy strategies for COVID-19 patients with acute respiratory failure (ARF). Here we present key position statements including observations about the pathophysiology of (ARF). In terms of the pathophysiology of pulmonary infection with SARS-CoV-2, COVID-19 can be divided into 3 phases. Pulmonary damage in advanced COVID-19 often differs from the known changes in acute respiratory distress syndrome (ARDS). Two types (type L and type H) are differentiated, corresponding to early- and late-stage lung damage. This differentiation should be taken into consideration in the respiratory support of ARF. The assessment of the extent of ARF should be based on arterial or capillary blood gas analysis under room air conditions, and it needs to include the calculation of oxygen supply (measured from the variables of oxygen saturation, hemoglobin level, the corrected values of Hüfner's factor, and cardiac output). Aerosols can cause transmission of infectious, virus-laden particles. Open systems or vented systems can increase the release of respirable particles. Procedures in which the invasive ventilation system must be opened and endotracheal intubation carried out are associated with an increased risk of infection. Personal protective equipment (PPE) should have top priority because fear of contagion should not be a primary reason for intubation. Based on the current knowledge, inhalation therapy, nasal high-flow therapy (NHF), continuous positive airway pressure (CPAP), or noninvasive ventilation (NIV) can be performed without an increased risk of infection to staff if PPE is provided. A significant proportion of patients with ARF present with relevant hypoxemia, which often cannot be fully corrected, even with a high inspired oxygen fraction (FiO2) under NHF. In this situation, the oxygen therapy can be escalated to CPAP or NIV when the criteria for endotracheal intubation are not met. In ARF, NIV should be carried out in an intensive care unit or a comparable setting by experienced staff. Under CPAP/NIV, a patient can deteriorate rapidly. For this reason, continuous monitoring and readiness for intubation are to be ensured at all times. If the ARF progresses under CPAP/NIV, intubation should be implemented without delay in patients who do not have a "do not intubate" order.


Subject(s)
Betacoronavirus , Coronavirus Infections/complications , Pneumonia, Viral/complications , Respiration Disorders/therapy , Respiration, Artificial , Acute Disease , COVID-19 , Disease Progression , Germany , Humans , Hypoxia/etiology , Pandemics , Patient Acuity , Pneumonia, Viral/etiology , Pneumonia, Viral/therapy , Respiration Disorders/etiology , Respiratory Distress Syndrome/etiology , Respiratory Distress Syndrome/therapy , Respiratory Insufficiency/etiology , Respiratory Insufficiency/physiopathology , Respiratory Insufficiency/therapy , SARS-CoV-2
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