Non-invasive ventilation in >= 70 year old COVID-19 patients in a level two unit: retrospective cohort analysis, comparison with COVIP substudy and defense of a multifaceted work of breathing control driven strategy

Introduction: The debate about optimal management of patients with COVID-19 ARDS remains, including medical treatment, ventilatory strategies, awake proning and others. COVIP is a multicentric observational study with over 3000 patients under NIV. A substudy by Polok and al. evaluated patients (PTS) >= 70 years old. At our intermediate care unit (IU) we used a strategy of high dose corticosteroid started when the work of breathing (WOB) increased, prolonged awake prone positioning (> 12 h) and high CPAP ventilatory strategy. We describe our cohort of >= 70 years old NIV PTS and compare it to COVIP substudy results. Method(s): Descriptive retrospective study. Data were collected from electronic medical records of 95 COVID-19 PTS aged 70 years old or above under NIV at the IU between September/20 and March/21. Categorical data are presented as frequency (percentage) and were compared using chi2-test. Continuous variables were compared using Mann-Whitney U test. Cohort results were compared with those from Polok et al. COVIP substudy (COVIPss). Result(s): 95 of PTS were submitted to NIV. Median age was 76 years and 49.5% were male, versus 75.7 and 71.4% in COVIPss. Median admission SOFA score was 4 and CFS was 3 with 14% considered frail (CFS > 5). In COVIPss median SOFA was 5 and 17% of PTS were frail. The preferred mode was CPAP with median maximum pressure of 13. Mean PaO2/fiO2 ratio after start of NIV was 125, 30% < 100. NIV failure occurred in 46.3% versus 74,7% in COVIPss. Our intra-unit mortality was 31.6%. 14 PTS (14.7%) were submitted to invasive mechanical ventilation and 57% of those died. In COVIPss mortality at 30d was 52.9% in NIV and 47.7 in IMV groups. Conclusion(s): We argue that NIV is a valid option for COVID ARDS management if supported by a multifaceted strategy such as ours, using prone and CPAP for WOB control. We agree with COVIPss authors as NIV trial should be short and intubation promptly if WOB not controlled. Comparison with COVIP substudy NIV failure and mortality results, support our belief.

Potential Predictors for Disease Severity in Hospitalised COVID-19 Patients

Background and Objectives Several studies have shown that SARS-CoV-2 can induce a cytokine release storm which is a major cause of disease severity and death. Therefore, cytokine levels in the serum may predict disease severity and survival in patients with COVID-19. Methods We included 88 COVID-19 patients who were hospitalised at the Division of Pulmonology of the Vienna General Hospital between January and May 2021 in this observational trial. Blood samples for serum peptide measurements were drawn at the time closest to hospitalisation, at day 5, 9 and 13( +/- 1). We correlated the type of ventilation (nasal oxygen therapy, high flow nasal canula, non-invasive ventilation or mechanical ventilation), occurrence of consolidations on chest X-ray or if available HRCT and the level of care (general ward, IMCU or ICU) with serum peptide values. We assessed the concentration of cytokines (IL-1a, IL-1b, IL-1RA, IL-6, L-7, L-10, IFN- gamma and TNF-alpha), chemokines (CCL-3, CCL-4 and CCL-7) and growth factors (G-CSF, GM-CSF and VEGF). Results Patients were 68 years of age (median) and stayed in hospital between 5-171 days. The peak inspiratory pressure in patients receiving non-invasive ventilation or mechanical ventilation was significantly associated with IL-1RA, G-CSF and IFN-gamma and the fraction of inspired oxygen in patients receiving highflow nasal canula oxygen therapy was significantly associated with IL-6, IL-7, IFN-gamma, and CCL-7. Results are shown in Table 1. No investigated cytokine correlated with the type of ventilation, occurrence of consolidations on imaging and in-hospital mortality. Conclusions In conclusion, concentrations of IL-1RA, G-CSF, IL-6, IL-7, IFN-gamma, and CCL-7 were associated with more severe disease progression in hospitalised COVID-19 patients.

Repeated COVID-19 infection in recipients of post-living donor liver transplantation: Two real-life cases

COVID-19 is an emerging pandemic. The course and management of the disease in the liver transplant setting may be difficult due to a long-standing immunosuppressive state. In Egypt, the only available option is living donor liver transplantation (LDLT). In our centre, we have transplanted 440 livers since 2008. In this study, we report a single-centre experience with COVID-19 infection in long-term liver transplant recipients. A total of 25 recipients (5.7 %) had COVID-19 infections since March 2020. Among these recipients, two developed COVID-19 infections twice, approximately three and two months apart, respectively.Copyright © 2021 The Author(s)

Factors associated with non-invasive positive pressure ventilation failure in a COVID-19 Intermediate Care Unit

Aim: To evaluate the efficacy of NIPPV (CPAP, HELMET-CPAP or NIV) in COVID-19 patients treated in the dedicated COVID-19 Intermediate Care unit of Coimbra Hospital and University Centre (CHUC), Portugal, and to assess factors associated with NIPPV failure. Method(s): Patients admitted to the Intermediate Care Unit of CHUC, from December 1st 2020 to February 28th 2021, treated with NIPPV due to confirmed COVID-19 were included. The primary outcome was NIPPV failure (orotracheal intubation (OTI) or death during hospital stay). Factors associated with NIPPV failure were included in an univariate binary logistic regression analysis and those with a significance level of p<0.001 were selected to enter a multivariate regression model. Result(s): 163 patients were included, 64.4% were males (n=105) and the median age was 66 years (IQR 56-75). Overall, 97 patients (59.5%) were successfully treated with NIPPV, while failure was observed in 66 (40.5%), of which 26 (39.4%) were intubated and 40 (60.6%) died during hospital stay. Highest CRP during hospital stay (OR 1.164;95%CI 1.036-1.308) and morphine use (OR 24.771;95%CI 1.809-339.241) were identified as independent predictors in the multivariate logistic model. Adherence to prone positioning (OR 0.109;95%CI 0.017-0.700) and a higher value of the lowest platelet count during hospital stay (OR 0.977;95%CI 0.960-0.994) were associated with a favourable outcome. Conclusion(s): Highest CRP and morphine use were independent predictors of OTI or death. Adherence to prone positioning and a higher value of the lowest platelet count during hospital stay were associated with a favourable outcome.

Treatment of COVID-19 ARDS with a tabletop NIV device in a Respiratory Intermediate Care Unit

Background: Non-invasive ventilation (NIV) has been tried in COVID-19 ARDS (CARDS), and its role is being increasingly recognised. If proven, it could be a game-changer in resource limited settings. We report our experience with administration of respiratory support using a tabletop NIV device in a respiratory intermediate care unit (RIMCU). Methodology: We retrospectively studied a cohort of hospitalised COVID-19 patients, who received protocolised management with positive airway pressure using a tabletop NIV device in the RIMCU as a step-up rescue therapy for deterioration despite low flow oxygen support. Treatment was commenced with continuous positive airway pressure (CPAP) mode up to a pressure of 10 cm H2O and if required inspiratory pressures were added with the bilevel positive airway pressure (BPAP) mode. Success was defined as weaning from NIV and stepping down to the ward. Failure was defined as escalation to the intensive care unit (ICU) or need for intubation or death. Result(s): In all, 246 patients were treated in the RIMCU during the study period. Of these, 168 received respiratory support via tabletop NIV device as a step-up rescue therapy. Their mean age was 54 years, and 83% were males. Diabetes Mellitus (78%) and hypertension (44%) were the commonest comorbidities. Treatment was successful with tabletop NIV in 77%;of this, 41% was on CPAP alone and 36% after receiving increased inspiratory pressures on BPAP mode. Conclusion(s): Respiratory support using a tabletop NIV device is an effective, and economical treatment for CARDS. Further studies are required to assess the appropriate time of initiation for maximal benefit and judicious resource utilisation.

Clinical Characteristics and Outcomes of Patients with Acute Respiratory Failure Due to SARS-CoV-2 Interstitial Pneumonia Treated with CPAP in a Medical Intermediate Care Setting: A Retrospective Observational Study on Comparison of Four Waves.

BACKGROUND: In COVID-19 patients non-invasive-positive-pressure-ventilation (NIPPV) has held a challenging role to reduce mortality and the need for invasive mechanical ventilation (IMV). The aim of this study was to compare the characteristics of patients admitted to a Medical Intermediate Care Unit for acute respiratory failure due to SARS-CoV-2 pneumonia throughout four pandemic waves. METHODS: The clinical data of 300 COVID-19 patients treated with continuous positive airway pressure (CPAP) were retrospectively analysed, from March-2020 to April-2022. RESULTS: Non-survivors were older and more comorbid, whereas patients transferred to ICU were younger and had fewer pathologies. Patients were older (from 65 (29-91) years in I wave to 77 (32-94) in IV, p < 0.001) and with more comorbidities (from Charlson's Comorbidity Index = 3 (0-12) in I to 6 (1-12) in IV, p < 0.001). No statistical difference was found for in-hospital mortality (33.0%, 35.8%, 29.6% and 45.9% in I, II, III and IV, p = 0.216), although ICU-transfers rate decreased from 22.0% to 1.4%. CONCLUSIONS: COVID-19 patients have become progressively older and with more comorbidities even in critical care area; from risk class analyses by age and comorbidity burden, in-hospital mortality rates remain high and are thus consistent over four waves while ICU-transfers have significantly reduced. Epidemiological changes need to be considered to improve the appropriateness of care.

Clinical Findings and Outcomes From Subjects With COVID-19 Pneumonia in an Intermediate Respiratory Care Unit.

BACKGROUND: Many patients with COVID-19 require respiratory support and close monitoring. Intermediate respiratory care units (IRCU) may be valuable to optimally and adequately implement noninvasive respiratory support (NRS) to decrease clinical failure. We aimed at describing intubation and mortality in a novel facility entirely dedicated to COVID-19 and to establish their outcomes. METHODS: This was a retrospective, observational study performed at one hospital in Spain. We included consecutive subjects age > 18 y, admitted to IRCU with COVID-19 pneumonia, and requiring NRS between December 2020-September 2021. Data collected included mode and usage of NRS, laboratory findings, endotracheal intubation, and mortality at day 30. A multivariable Cox model was used to assess risk factors associated with clinical failure and mortality. RESULTS: A total of 1,306 subjects were included; 64.6% were male with mean age of 54.7 y. During the IRCU stay, 345 subjects clinically failed NRS (85.5% intubated; 14.5% died). Cox model showed a higher clinical failure in IRCU upon onset of symptoms and hospitalization was < 10 d (hazard ratio [HR] 1.59 [95% CI 1.24-2.03], P < .001) and PaO2 /FIO2 < 100 mm Hg (HR 1.59 [95% CI 1.27-1.98], P < .001). These variables were not associated with increased 30-d mortality. CONCLUSIONS: The IRCU was a valuable option to manage subjects with COVID-19 requiring NRS, thus reducing ICU overload. Male sex, gas exchange, and blood chemistry at admission were associated with worse prognosis, whereas older age, gas exchange, and blood chemistry were associated with 30-d mortality. These findings may provide a basis for better understanding outcomes and to improve management of noninvasively ventilated patients with COVID-19.

Learning from the COVID-19 pandemic: IMCU as a more efficient model of pediatric critical care organization.

BACKGROUND: A significant proportion of children with SARs-CoV-2-related illnesses have been admitted to the Pediatric intensive care unit (ICU), although often for closer monitoring or concerns related to comorbidities or young age. This may have resulted in inappropriate ICU admissions, waste of resources, ICU overcrowding, and stress for young patients and caregivers. The Pediatric Intermediate Care Unit (IMCU) may represent an appropriate setting for the care of children whose monitoring and treatment needs are beyond the resources of a general pediatric ward, but who do not qualify for critical care. However, research on pediatric IMCUs and data on their performance is very limited. METHODS: We conducted a single-center retrospective study including all patients aged 0-18 with acute COVID-19 or multisystem inflammatory syndrome in children (MIS-C), admitted to a newly established stand-alone 12-bed pediatric IMCU at Gaslini Hospital, Genoa, Italy, between 1 March 2020 and 31 January 2022. Each IMCU room has a multiparameter monitor connected to a control station and can be equipped as an ICU room in case of need for escalation of care, up to ECMO support. IMCU and ICU are adjacent and located on the same floor, allowing a timely escalation from intermediate to critical care in the IMCU, with staff changes without the need for patient transfer. RESULTS: Among 550 patients hospitalized for acute COVID-19 or MIS-C, 106 (19.2%, 80 with acute COVID-19, and 26 MIS-C) were admitted to IMCU. Three of them (2.8%) required escalation to critical care due to the worsening of their conditions. Forty-seven patients (44%) were discharged home from the IMCU, while the remaining 57 (55%) were transferred to low-intensity care units after clinical improvement. CONCLUSIONS: In our study, the need for pediatric ICU admission was low for both acute COVID-19 patients (0.8%) and MIS-C patients (3.1%) compared to the literature data. The IMCU represented an adequate setting for children with COVID-19-related illness who need a higher level of care, but lack strict indications for ICU admission, thus preventing ICU overcrowding and wasting of economic and logistical resources. Further studies are needed to better assess the impact of an IMCU on hospital costs, ICU activity, and long-term psychological sequelae on children and their families.

Creation and Evaluation of a Mixed Service Intermediate Care Unit with Obligate Critical Care Consultation to Improve ICU Capacity

Rationale: Significant capacity constraints brought on by the COVID-19 pandemic have underscored the need for novel staffing models that offload ICUs while still providing appropriate standard of care for high acuity patients. Intermediate Care Units (IMCs) provide one such outlet that have not been extensively examined, particularly during the COVID-19 era. Here we describe a quality improvement project focused on the creation of a mixed IMC with critical care support at our institution during the COVID-19 pandemic. Methods: With the support of institutional leadership, an interprofessional working group spanning critical care, surgery, hospital medicine, nursing, and respiratory therapy was convened to establish the staffing model, determine inclusion/exclusion criteria, and track IMC progress. The initial model entailed a medical-surgical service unit staffed by intermediate care-trained nurses, primary teams comprised of hospitalists or surgical teams, and an intensivist who rounded daily. All medical patients received an automatic critical care support consult;all surgical patients had the option of this consult. The maximum census was three. A retrospective chart review was conducted at the end of the initial phase to evaluate process, outcome, and balancing measures. Data were reported using simple descriptive statistics. Results: From August 9th to October 15th 2021, 36 patients - 21 medical and 15 surgical - were admitted to the IMC. The average age was 62.4, 17 (47.2%) were female, and 11 (30.5%) were admitted for COVID-19. The most frequent indications were hypoxemia (15, 71.4%) for medical patients and post-operative monitoring (12, 80%) for surgical patients. The average length of stay was 2.5 days. Most patients stepped down from an ICU or PACU rather than stepping up from a general ward or emergency department. A total of 577 ICU bed-hours were made available by admitting patients to the IMC who would have otherwise occupied an ICU bed. Seven medical patients (33.3%) required transfer back to an ICU and one medical patient (4.8%) transitioned to hospice. The remaining 13 (61.1%) medical and 14 (93.3%) surgical patients were discharged to a general ward. One patient was intubated within 48 hours of triage to the IMC, and zero patients expired while admitted to the IMC.Conclusions: Creation of an IMC provided a means to care for high acuity patients while creating ICU capacity. Subsequent phases will expand on inclusion criteria and maximum census while assessing the effect of critical care support consults on patient safety and hospitalist and intensivist workloads.

A DESCRIPTIVE, RETROSPECTIVE ANALYSIS OF HIGHDOSE INTRAVENOUS VITAMIN C ADMINISTRATION IN CRITICALLY ILL COVID-19 PATIENTS

Background and importance Proinflammatory cytokines seem to have an influence on the course and severity of a COVID- 19 infection. The use of high-dose vitamin C (HDVC) represents a possible adjunctive therapy approach for the treatment of critically ill COVID-19 patients owing to its immune-modulating, anti-inflammatory and antioxidant properties. Aim and objectives To determine the impact of adjunctive HDVC therapy on inflammatory markers such as interleukin-6 (IL-6). Material and methods Setting: A descriptive, retrospective analysis with critically ill COVID-19 patients admitted to the intermediate care unit (IMCU) and intensive care unit (ICU) in a public hospital. Adult ICU-hospitalised patients with COVID-19 were included with those who were to receive, besides the standard of care, either: 1. HDVC (treatment group with 7.5 g/day VC up to 10 days) 2. Low-dose VC (LDVC with 1g/day VC up to 10 days) 3. No additional VC (control group). All data were obtained from the patients' medical records from November to December 2020 and from March to May 2021. Results Data were collected from 83 critically ill patients with confirmed COVID-19 infection. 40 patients were administered HDVC, 24 patients received LDVC and 19 patients did not receive any VC. The mean age of the patients in the treatment group was 57.3 years, in the LDVC group 62.1 years and in the control group 55.8 years. The average IMCU and ICU length of stay was 17.4 days for patients in the HDVC-group, 21.4 days in the LDVC-group and 21.5 days in the control group. 68% from the HDVC group survived and were discharged from hospital. In the LDVC group 58% survived and in the control group 42%. Lower levels of IL-6 in the HDVC-group as compared with the LDVC-group and control group were detected. Conclusion and relevance Our findings have demonstrated that the use of HDVC can lead to a clinical benefit due to decreased levels of IL-6. Additional investigations should be encouraged in order to further characterise adjunctive HDVC treatment in COVID-19 infection. Unlike some previous studies, our results have shown no detrimental effects of HDVC on glomerular filtration rate and serum creatinine levels.

Development of a Medium Care Unit Using an Inexperienced Respiratory Staff: Lessons Learned during the COVID-19 Pandemic.

The different waves of the COVID-19 pandemic caused dramatic issues regarding the organization of care. In this context innovative solutions have to be developed in a timely manner to adapt to the organization of the care. The establishment of middle care (MC) units is a bright example of such an adaptation. A multidisciplinary MC team, including expert and non-expert respiratory health care personnel, was developed and trained to work in a COVID-19 MC unit. Important educational resources were set up to ensure rapid and effective training of the MC team, limiting the admission or delaying transfers to ICU and ensuring optimal management of palliative care. We conducted a retrospective analysis of patient data in the MC unit during the second COVID-19 wave in Belgium. The aim of this study was to demonstrate the feasibility of quickly developing an effective respiratory MC unit mixing respiratory expert and non-expert members from outside ICUs. The establishment of an MC unit during a pandemic is feasible and needed. MC units possibly relieve the pressure exerted on ICUs. A highly trained multidisciplinary team is key to ensuring the success of an MC unit during such kind of a pandemic.

Increased levels of factor VIII on admission, predict intensive care unit transferal and mortality in hospitalized COVID-19 patients

Background: Despite the necessity, there is no reliable biomarker to predict disease severity and prognosis of patients with COVID-19. Factor VIII is a procoagulant factor that is stored in endothelial cells and is released during inflammation. COVID-19 is clearly an inflammatory and thromboembolic disease, especially in its severe forms. That is why we hypothesized that FVIII could be a potential prognostic marker in this disease. Method A prospective observational cohort study was performed from 1 September 2020 to 31 August 2021. This study cohort included 91 consecutive patients admitted to the Military University Hospital of Oran (Algeria), with COVID-19 confirmed by the PCR. All these patients underwent FVIIIc assay at the admission. The primary end-point was transferal from respiratory intermediate care unit (RICU) to intensive care unit (ICU) and in-hospital mortality. Objectives To assess the prognostic value of FVIIIc, in the prediction of the transferal to ICU during the first days of hospitalization as well as in the prediction of mortality in patients with COVID-19. Results: Ninety-one patients with a confirmed COVID-19 were enrolled in this study, with a mean age of 58.5 years [CI: 55-62];67 men (73.6%) and 24 women (26.4%) with a sex ratio of 2.79. Thirty-six patients (39.6%) were admitted with moderate acute respiratory distress syndrome (ARDS), 47 (51.6%) with severe and eight (8.8%) with critical ARDS. Among these patients, 20 (22.0%) were transferred to the ICU. Eighteen (19.8%) died, of whom 3 (16.7%) died in the RICU and 15 (83.3%) died in the ICU. FVIIIc levels in patients transferred to ICU were significantly higher, compared to those who were not: 408% [CI: 334-483] vs. 261% [CI: 234-289] respectively ( p = 0.001). Same for those who died in which we found a significant increase in FVIIIc levels, compared to survivors: 409% [CI: 335-483] vs. 265% [237-294] respectively ( p = 0.001). By using the ROC curves, we established the predictive threshold values. The value of 371% for FVIIIc, predicted the risk of transfer to ICU with a sensitivity (Se) of 65% and a specificity (Sp) of 83.1%. Beyond this threshold value, patients were more likely to see their condition worsen and to be transferred to the ICU with an odds ratio of 8.29 [CI: 2.76-24.85]. While for the prediction of mortality, we had two cutoff values: 341% (Se = 72.2%;Sp = 78.1%;PPV = 44.9%;NPV = 91.9%) and 520% (Se = 27.8%;Sp = 98.6%;PPV = 83.4%;NPV = 84.7%). Using these two threshold values, we created three prognostic groups: group 1 (FVIIIc < 341%), group 2 (341% ≤ FVIIIc < 520%) and group 3 (FVIIIc ≥ 520%). Using Kaplan-Meier model, we found that these three groups had a highly different survival probability. The best survival probability for the group 1 (88.2% after 15 days of hospitalization). This probability decreased in the group 2, only 51% with a Hazard ratio (HR) of 5.11 [CI: 1.58-16.47], meaning that these patients had a higher risk of dying compared to those of the group 1. The worst survival probability was recorded in the group 3, only 15.6% with a HR = 11.22 [CI: 1.96-64.36]. Conclusion Factor VIII can predict the need for transfer from the RICU to the ICU and also mortality in patients with COVID-19. This biomarker could be a valuable one for better clinical stratification by early and meaningful profiles in patients admitted to the RICU who are at risk of transferal to the ICU..

Treatment of COVID-19 Acute Respiratory Distress Syndrome With a Tabletop Noninvasive Ventilation Device in a Respiratory Intermediate Care Unit.

Objective: To study the outcomes of noninvasive ventilation (NIV) administered through a tabletop device for coronavirus disease 2019 acute respiratory distress syndrome in the respiratory intermediate care unit (RIMCU) at a tertiary care hospital in India. Patients and Methods: We retrospectively studied a cohort of hospitalized patients deteriorating despite low-flow oxygen support who received protocolized management with positive airway pressure using a tabletop NIV device in the RIMCU as a step-up rescue therapy from July 30, 2020 to November 14, 2020. Treatment was commenced on the continuous positive airway pressure mode up to a pressure of 10 cm of H2O, and if required, inspiratory pressures were added using the bilevel positive air pressure mode. Success was defined as weaning from NIV and stepping down to the ward, and failure was defined as escalation to the intensive care unit, the need for intubation, or death. Results: In total, 246 patients were treated in the RIMCU during the study period. Of these, 168 received respiratory support via a tabletop NIV device as a step-up rescue therapy. Their mean age was 54 years, and 83% were men. Diabetes mellitus (78%) and hypertension (44%) were the commonest comorbidities. Treatment was successful with tabletop NIV in 77% (129/168) of the patients; of them, 41% (69/168) received treatment with continuous positive airway pressure alone and 36% (60/168) received additional increased inspiratory pressure via the bilevel positive air pressure mode. Conclusion: Respiratory support using the tabletop NIV device was an effective and economical treatment for coronavirus disease 2019 acute respiratory distress syndrome. Further studies are required to assess the appropriate time of initiation for maximal benefits and judicious utilization of resources.

Non-invasive ventilation in COVID-19 patients, the experience of a level 2 unit

Introduction: COVID-19 has a broad spectrum of severity and, although the majority of those infected are asymptomatic or have mild disease, many need hospitalization and organ support for respiratory failure. The approach to this dysfunction varied across the pandemic, influenced by retrospective data and centre experience. After initial unfavorable data, NIV resumed prominence during the 2nd wave, having been the modality of choice in our intermediate care unit (IU). We describe our NIV cohort and the results of our ventilatory strategy. Methods: Descriptive retrospective study. Data were collected from electronic medical records of 202 COVID-19 patients (PTS) under NIV at the IU between September/20 and March/21. Categorical data are presented as frequency (percentage) and were compared using χ2 -test. Continuous variables were compared using Mann-Whitney U test. Statistical significance was set at p < 0.05. Results: 202 of 469 PTS were submitted to NIV. Mean age was 66 years and 62.8% were male. Most common comorbidities were hypertension, dyslipidemia, obesity and diabetes. Mean admission SOFA score was 3.6. Most PTS underwent corticosteroid therapy, 86.7% in > 1 mg/ kg dosage equivalent. Remdesivir was used in 50%. In 88.6% NIV was the initial modality of ventilatory support, 11.4% after HFNC failure (23). The preferred mode was CPAP with mean maximum pressure of 13 (6-16), titrated to normalization of the work of breathing (WOB). Mean PaO2/FiO2 ratio at start of NIV was 122, < 100 in 43% of PTS. NIV failure occurred in 35.6%, intra-unit mortality was 25.6%. 35 PTS were submitted to invasive mechanical ventilation (IMV), 41% died. Advanced age, intolerance to awake prone and delirium were associated with higher mortality. Conclusions: NIV is a valid option for the management of respiratory failure secondary to COVID-19 ARDS, reducing the need for IMV. Elevated CPAP values, titrated to WOB control, complemented with prolonged periods of awake prone are essential for success.

Impact of remdesivir in COVID-19 patients under non-invasive ventilation in an intermediate care unit

Introduction: COVID-19 has generated enormous difficulties globally due to the high number of critically ill patients and uncertainty of the best therapeutic approach, even after 18 months of pandemic and multiple clinical trials. The antiviral remdesivir (RDV) has shown to reduce time to clinical recovery and, in a subgroup with low flow O2 at time of drug initiation, to reduce mortality by 70% (ACTT-1). Subsequent openlabel RCT, Solidarity and Discovery, didn't confirm these findings. In our unit, a strict protocol was used, including a 5-day cycle of 20 mg dexamethasone and start of HFNC/CPAP when increased work of breathing became noticeable, along with prolonged periods of awake prone position. The use of RDV was a point of significant variability, allowing us to compare outcomes. We describe our unit's experience and RDV impact on patients under non-invasive ventilation (NIV). Methods: Descriptive retrospective study. Data were collected from 202 COVID-19 patients under NIV at our intermediate care unit between September/ 2020 and March/2021, through medical records in the electronic clinical file. Categorical data are presented as frequency (percentage) and were compared using χ2 -test. Continuous variables were compared using Mann-Whitney U test. Statistical significance was set at p < 0.05. Results: Each group consisted of 101 patients, with the group not submitted to RDV being slightly older (mean age 70.5 vs 63 years), more frail (mean CFS 3.5 vs 2.8) and with higher mean SOFA at admission (4.0 vs 3.2). The RDV group had a lower mortality rate (20.8 vs 52.5%;p < 0.001), less NIV failure (20.8 vs 50.5%;p < 0.001), shorter duration of ventilation in survivors (7.0 vs 8.5 days;p = 0.036) and less need for intensive care admission (14.9 vs 23.8%), with favorable impact on mortality (26.6 vs 50%) in this subgroup. Conclusions: In our cohort of patients under NIV, RDV use was associated with lower mortality, less need for IMV and shorter duration of ventilation.

Cough and Dyspnea in 2021: A Case of Asthma, COVID-19, or.?

Background: COVID-19 has changed the perspective through which medical staff look at dyspnea and hypoxemia cases. Epidemiological links are frequently missing, and clinical and imagological findings are often unspecific, overlapping substantially with other respiratory infections. Case summary: We report the case of an 11-year-old girl with a known history of asthma who had recently moved from Guinea-Bissau with her mother. Although the mother reported being Ag HBs positive, no serologic studies had ever been performed on the child. The patient was admitted to the Emergency Room after 4 days of cough and the feeling of thoracic oppression, without fever. No contact with suspected or confirmed individuals infected with SARS-CoV-2 or other respiratory viruses was reported. She presented with peripheral oxygen saturation of 90%, costal retractions and a prolonged expiratory phase. After an unsuccessful course of bronchodilators and prednisolone, she was admitted to the Pediatric Intermediate Care Unit because of a sustained need for oxygen therapy. Polymerase chain reaction analysis for SARS CoV-2 came back negative. A chest radiograph displayed a bilateral reticular infiltrate, and therapy with azithromycin was started. Due to a deterioration of the dyspnea, a chest tomography was eventually performed, revealing an exuberant and bilateral ground glass-like densification suggestive of alveolar injury. Echocardiogram and e electrocardiogram were both normal. After a positive serologic result for HIV, the patient was transferred to a Level III hospital, and Pneumocystis jirovecii was identified in bronchoalveolar lavage. T cell count was 12/mm3. Highly active antiretroviral therapy and cotrimoxazole were started, prompting clinical and analytical recovery. Discussion: Pneumocystis jirovecii can cause fatal pneumonia in immunocompromised children. Even though an asthma exacerbation and atypical bacterial or viral infections, namely COVID-19, present as more usual causes of dyspnea, a low suspicion index is warranted in children coming from HIV-endemic countries, particularly those who are unresponsive to conventional bronchodilator and antibiotic therapy.

Atrial fibrillation is associated with poor clinical trajectory of COVID-19

Background: Atrial fibrillation (AF) has been described as a common cardiovascular manifestation in patients suffering from coronavirus disease 2019 (COVID-19) and is discussed to be a potential risk factor for a poor clinical course. AF is also already known to be associated with increased risk for all cause death. Purpose: In the present study we sought to investigate the impact of AF on the clinical trajectory of patients suffering from COVID-19. Methods:We included all patients hospitalized due to COVID-19 in 2020 in our Hospital. A poor clinical trajectory was defined as transfer to intensive care unit (ICU), intermediate care unit (IMC) or death from any cause. Initial ECGs were analyzed in consensus by two experienced readers. First, we compared patients with poor clinical trajectory vs. good clinical course. Secondly, the study population was categorized into two groups with or without AF on admission. A subgroup analysis was performed to differentiate between new onset AF and patients with known history of AF. To compensate for confounders (age, BMI, known cardiomyopathy (CMP), known coronary artery disease (CAD), chronic airway disease, renal insufficiency, diabetes, arterial hypertension and sex), a full clinically validated multiple logistic regression model with poor clinical trajectory as dependent target variable was performed. Results: From our enrolled 666 patients in 2020 (58% male, average age: 66 (IQR:58-80)) 223 patients (33.5%) experienced a poor clinical course. 179 (27%) patients were transferred to IMC/ICU and 86 (13%) patients died. All in all, patients with poor clinical trajectory were more frequently male (70% vs. 52%;P<0.001), older (71±14 vs. 64±20;P<0.001) and had significantly more co-morbidities such as CAD, CMP, hypertension and diabetes in comparison to patients with a good clinical course. 96 (14.4%) had AF on admission. Among these 37.5% had new-onset AF, which showed similar baseline characteristics as patients without AF. Indeed, patients with COVID-19 and new onset AF were more likely to die (25% vs 12%;P=0.038), or be in need for ICU/IMC (25% vs. 62%;P<0.001) and therefore experienced a poor clinical trajectory more frequently (75% vs. 31%;P<0.001) with a confounder adjusted OR of 5.89. In the subgroup analysis of all patients with AF on admission. Patients with new onset of AF had significantly more underlying CMP, Diabetes and chronic airways disease. While mortality was not higher in patients with new onset of AF, IMC/ICU transfers (62% vs 24%;P<0.001) and as a result poor clinical trajectory (75% vs 40%;P=0.001) was significantly increased in comparison to patients with known AF. Conclusion: In patients suffering from COVID-19, new onset of AF on admission was associated with a poor clinical course and higher in-hospital mortality.

Clinical Outcomes of Severe COVID-19 Patients Admitted to an Intermediate Respiratory Care Unit.

Introduction: Many severe COVID-19 patients require respiratory support and monitoring. An intermediate respiratory care unit (IMCU) may be a valuable element for optimizing patient care and limited health-care resources management. We aim to assess the clinical outcomes of severe COVID-19 patients admitted to an IMCU. Methods: Observational, retrospective study including patients admitted to the IMCU due to COVID-19 pneumonia during the months of March and April 2020. Patients were stratified based on their requirement of transfer to the intensive care unit (ICU) and on survival status at the end of follow-up. A multivariable Cox proportional hazards method was used to assess risk factors associated with mortality. Results: A total of 253 patients were included. Of them, 68% were male and median age was 65 years (IQR 18 years). Ninety-two patients (36.4%) required ICU transfer. Patients transferred to the ICU had a higher mortality rate (44.6 vs. 24.2%; p < 0.001). Multivariable proportional hazards model showed that age ≥65 years (HR 4.14; 95%CI 2.31-7.42; p < 0.001); chronic respiratory conditions (HR 2.34; 95%CI 1.38-3.99; p = 0.002) and chronic kidney disease (HR 2.96; 95%CI 1.61-5.43; p < 0.001) were independently associated with mortality. High-dose systemic corticosteroids followed by progressive dose tapering showed a lower risk of death (HR 0.15; 95%CI 0.06-0.40; p < 0.001). Conclusions: IMCU may be a useful tool for the multidisciplinary management of severe COVID-19 patients requiring respiratory support and non-invasive monitoring, therefore reducing ICU burden. Older age and chronic respiratory or renal conditions are associated with worse clinical outcomes, while treatment with systemic corticosteroids may have a protective effect on mortality.

Risk factors for transfer from Respiratory Intermediate Care Unit to Intensive Care Unit in COVID-19.

BACKGROUND: Patients hospitalized for COVID-19-related pneumonia often need several degrees of ventilatory support, which are performed between Respiratory Intermediate Care Units (RICUs) and Intensive Care Units (ICUs), and which depend on the severity of acute respiratory distress syndrome. There is no firm consensus on transfer predictors from the RICU to the ICU. METHODS: In this retrospective observational single center study, we evaluated 96 COVID-19 patients referred to the RICU for acute respiratory failure (ARF) according to their transferal to the ICU or their stay at the RICU. We compared demographic data, baseline laboratory profile, and final clinical outcomes to identify early risk factors for transfer. RESULTS: The best predictors for transfer to the ICU were elevated C-reactive protein and lymphopenia. The mortality rate was lower in the RICU than in the ICU, where transferred patients who died were mostly younger men and with less comorbidities than those in the RICU. CONCLUSIONS: Few inflammatory markers can predict the need for transfer from the RICU to the ICU. Due to the ongoing COVID-19 pandemic, we urge better clinical stratification by early and meaningful profiles in patients admitted to the RICU who are at risk of transferal to the ICU.

Role of Intermediate Care Unit Admission and Noninvasive Respiratory Support during the COVID-19 Pandemic: A Retrospective Cohort Study.

BACKGROUND: The COVID-19 pandemic has led to shortage of intensive care unit (ICU) capacity. We developed a triage strategy including noninvasive respiratory support and admission to the intermediate care unit (IMCU). ICU admission was restricted to patients requiring invasive ventilation. OBJECTIVES: The aim of this study is to describe the characteristics and outcomes of patients admitted to the IMCU. METHOD: Retrospective cohort including consecutive patients admitted between March 28 and April 27, 2020. The primary outcome was the proportion of patients with severe hypoxemic respiratory failure avoiding ICU admission. Secondary outcomes included the rate of emergency intubation, 28-day mortality, and predictors of ICU admission. RESULTS: One hundred fifty-seven patients with COVID-19-associated pneumonia were admitted to the IMCU. Among the 85 patients admitted for worsening respiratory failure, 52/85 (61%) avoided ICU admission. In multivariate analysis, PaO2/FiO2 (OR 0.98; 95% CI: 0.96-0.99) and BMI (OR 0.88; 95% CI: 0.78-0.98) were significantly associated with ICU admission. No death or emergency intubation occurred in the IMCU. CONCLUSIONS: IMCU admission including standardized triage criteria, self-proning, and noninvasive respiratory support prevents ICU admission for a large proportion of patients with COVID-19 hypoxemic respiratory failure. In the context of the COVID-19 pandemic, IMCUs may play an important role in preserving ICU capacity by avoiding ICU admission for patients with worsening respiratory failure and allowing early discharge of ICU patients.