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Considering the commonality of the pathogenetic links of the critical forms of COVID-19 and influenza AH1N1pdm09 (cytokine over-release syndrome), the question arises: will the predictors of an unfavorable outcome in patients on mechanical ventilation and, accordingly, the universal tactics of respiratory support in these diseases be identical? Objective. In a comparative aspect, to characterize patients with influenza AH1N1pdm09 and COVID-19 who were on mechanical ventilation, to identify additional clinical and laboratory risk factors for death, to determine the degree of influence of respiratory support (RP) tactics on an unfavorable outcome in the studied category of patients. Patients and methods. Patients treated on the basis of resuscitation and intensive care departments of the State Budgetary Healthcare Institution "SKIB" in Krasnodar and the State Budgetary Healthcare Institution "IB No 2" in Sochi were studied: group 1 - 31 people with influenza AH1N1pdm09 (21 people died - subgroup 1A;10 people survived - subgroup 1B) and group 2 - 50 people with COVID-19 (29 patients died - subgroup 2A;21 people survived - subgroup 2B). All patients developed hypoxemic ARF. All patients received step-by-step tactics of respiratory support, starting with oxygen therapy and ending with the use of "traditional" mechanical ventilation. Continuous variables were compared in subgroups of deceased and surviving patients for both nosologies at the stages: hospital admission;registration of hypoxemia and the use of various methods of respiratory therapy;development of multiple organ dysfunctions. With regard to the criteria for which a statistically significant difference was found (p < 0.05), we calculated a simple correlation, the relative risk of an event (RR [CI 25-75%]), the cut-off point, which corresponded to the best combination of sensitivity and specificity. Results. Risk factors for death of patients with influenza AH1N1pdm09 on mechanical ventilation: admission to the hospital later than the 8th day of illness;the fact of transfer from another hospital;leukocytosis >=10.0 x 109/l, granulocytosis >=5.5 x 109/l and LDH level >=700.0 U/l at admission;transfer of patients to mechanical ventilation on the 9th day of illness and later;SOFA score >=8;the need for pressor amines and replacement of kidney function. Predictors of poor outcome in ventilated COVID-19 patients: platelet count <=210 x 109/L on admission;the duration of oxygen therapy for more than 4.5 days;the use of HPNO and NIV as the 2nd step of RP for more than 2 days;transfer of patients to mechanical ventilation on the 14th day of illness and later;oxygenation index <=80;the need for pressors;SOFA score >=8. Conclusion. When comparing the identified predictors of death for patients with influenza and COVID-19 who needed mechanical ventilation, there are both some commonality and differences due to the peculiarities of the course of the disease. A step-by-step approach to the application of respiratory support methods is effective both in the case of patients with influenza AH1N1pdm09 and patients with COVID-19, provided that the respiratory support method used is consistent with the current state of the patient and his respiratory system, timely identification of markers of ineffectiveness of the respiratory support stage being carried out and determining the optimal moment escalation of respiratory therapy.Copyright © 2022, Dynasty Publishing House. All rights reserved.
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Considering the commonality of the pathogenetic links of the critical forms of COVID-19 and influenza AH1N1pdm09 (cytokine over-release syndrome), the question arises: will the predictors of an unfavorable outcome in patients on mechanical ventilation and, accordingly, the universal tactics of respiratory support in these diseases be identical? Objective. In a comparative aspect, to characterize patients with influenza AH1N1pdm09 and COVID-19 who were on mechanical ventilation, to identify additional clinical and laboratory risk factors for death, to determine the degree of influence of respiratory support (RP) tactics on an unfavorable outcome in the studied category of patients. Patients and methods. Patients treated on the basis of resuscitation and intensive care departments of the State Budgetary Healthcare Institution "SKIB" in Krasnodar and the State Budgetary Healthcare Institution "IB No 2" in Sochi were studied: group 1 - 31 people with influenza AH1N1pdm09 (21 people died - subgroup 1A;10 people survived - subgroup 1B) and group 2 - 50 people with COVID-19 (29 patients died - subgroup 2A;21 people survived - subgroup 2B). All patients developed hypoxemic ARF. All patients received step-by-step tactics of respiratory support, starting with oxygen therapy and ending with the use of "traditional" mechanical ventilation. Continuous variables were compared in subgroups of deceased and surviving patients for both nosologies at the stages: hospital admission;registration of hypoxemia and the use of various methods of respiratory therapy;development of multiple organ dysfunctions. With regard to the criteria for which a statistically significant difference was found (p < 0.05), we calculated a simple correlation, the relative risk of an event (RR [CI 25-75%]), the cut-off point, which corresponded to the best combination of sensitivity and specificity. Results. Risk factors for death of patients with influenza AH1N1pdm09 on mechanical ventilation: admission to the hospital later than the 8th day of illness;the fact of transfer from another hospital;leukocytosis >=10.0 x 109/l, granulocytosis >=5.5 x 109/l and LDH level >=700.0 U/l at admission;transfer of patients to mechanical ventilation on the 9th day of illness and later;SOFA score >=8;the need for pressor amines and replacement of kidney function. Predictors of poor outcome in ventilated COVID-19 patients: platelet count <=210 x 109/L on admission;the duration of oxygen therapy for more than 4.5 days;the use of HPNO and NIV as the 2nd step of RP for more than 2 days;transfer of patients to mechanical ventilation on the 14th day of illness and later;oxygenation index <=80;the need for pressors;SOFA score >=8. Conclusion. When comparing the identified predictors of death for patients with influenza and COVID-19 who needed mechanical ventilation, there are both some commonality and differences due to the peculiarities of the course of the disease. A step-by-step approach to the application of respiratory support methods is effective both in the case of patients with influenza AH1N1pdm09 and patients with COVID-19, provided that the respiratory support method used is consistent with the current state of the patient and his respiratory system, timely identification of markers of ineffectiveness of the respiratory support stage being carried out and determining the optimal moment escalation of respiratory therapy.Copyright © 2022, Dynasty Publishing House. All rights reserved.
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Introduction: In the pandemic, porlonged weaning(PW) of mechanical ventilation (wMV) of COVID patients in the intermediate respiratory care unit IRCU was performed. It was necessary to use predictive indexes for(wMV), which do not generate aerosolization of viral particles. Objetive: To develop a oredictive indexes for wMV and tracheostomy decannulation (TCHd) for COVID-19 pneumonia in IRCU. Method(s): The sample consists of 76 serial cases to the IRCU, in 2020 and 2021. Indexes were developed with an oxygenation variable (PaO2/FiO2) or (SatO2/FiO2), respiratory rate (RR) and corrected (C) in based alveolar ventilation (PCO2), the following indexes were developed as predictors of wMV;ventilation-oxygenation index IVOX= (PaFi/RR), IVOX corrected for PCO2 is IVOX-C=(IVOX x Oco2) and with SaFi the SIVOX-C= [(SaFi/RR) x PCO2]. The StatPlus 7.3 program forWindows was used of the Mann-Whitney U (M-WU) comparing their mean values, using binary logistic regression (BLR) and area under curve AUC ROC to compare their predictability. Result(s): Mean age 58,9 +/-14,4;male 53,7% and the stay in the IRCU was 16,7+/- 11 days, mortality of 28,3%(22);received MV (71,0%) 54. wMV was(70,4%)38 and TCHd was (67,3)35. The mean differrences in disconnected and non-diconnected from MV analyzed by M-WU are significante. An BLR model was built to analyze the predictive behavior ofIVOX, IVOX-C and SIVOX-C for wMV. It was observed that the three indexes are predictive, but IVOX-C and SIVOX-C have the highest predictive weight. In turn the AUC ROC was significance. Conclusion(s): The construction of a predictive indexes of wMV and TCHd in this sample the patients who reached the objective.
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Introduction: Awake prone positioning (APP) may reduce ventilation-perfusion mismatch in the context of acute respiratory distress syndrome. The Intensive Care Society recommends its use in COVID-19 to improve oxygenation and reduce risk of progression to invasive mechanical ventilation. This audit project measured the use of APP on an Acute Respiratory Care Unit (ARCU). Method(s): Observations and patient outcomes were recorded for non-intubated patients where a clinical decision had been made to prone. The activPALTM accelerometer was used as an objective measure of APP (prone or lateral-lie positioning). Analysis was performed using STATA v16. Result(s): Between September 2020 and February 2021, 19 individuals with a median age of 68 years were included. 74% were male. In the first 48 hours, 747 person-hours of data were recorded, with 358 person-hours spent in APP. Eight individuals spent at least 50% of their first 48 hours in APP. Lateral lie was better tolerated than full prone positioning, with a median (interquartile range, IQR) of 11.6 (8.0, 20.2) hours spent in lateral lie and median (IQR) of 1.6 (0.5, 8.3) hours spent fully proned in the first 48 hours. Median (interquartile range, IQR) improvement from baseline in respiratory rate/oxygenation (ROX) index at 48 hours was +1.65 (0.90, 1.89). Median (IQR) ROX index at 12 hours for individuals not in APP was 4.80 (3.04, 8.51) and 10.41 (9.09, 11.42) for individuals who were fully proned. Nine individuals were admitted to intensive care, 13 survived to discharge. Conclusion(s): Accelerometry is an objective method to measure time spent in APP and showed that lateral lie was preferred to full prone position in this cohort. Trends suggest possible improvement in ROX, although numbers were small.
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Targeted therapeutics for SARS-CoV-2 virus caused COVID-19 are in urgent need. Chansu has been reported to have broad-spectrum antiviral effects and widely used in Southeast Asian countries. This study aims to assess the efficacy of Chansu injection in treating patients with severe COVID-19. A randomized preliminary clinical trial was conducted and eligible patients were allocated to receive general treatment plus Chansu injection or only general treatment as control for 7 days. The primary outcomes of the oxygenation index PaO2/FiO2 and ROX, secondary outcomes of white blood cell count, respiratory support step-down time (RSST), safety indicators, etc were monitored. After 7 days of treatment, the oxygenation index was improved in 95.2% patients in the treatment group compared with 68.4% in the control group. The PaO2/FiO2 and ROX indices in the treatment group (mean, 226.27+/-67.35 and 14.01+/-3.99 respectively) were significantly higher than the control group (mean, 143.23+/-51.29 and 9.64+/-5.54 respectively). The RSST was 1 day shorter in the treatment group. Multivariate regression analysis suggested that Chansu injection contributed the most to the outcome of PaO2/FiO2. No obvious adverse effects were observed. The preliminary data showed that Chansu injection had apparent efficacy in improving the respiratory function of patients with severe COVID-19.Copyright © 2021 The Authors
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SESSION TITLE: Outcomes Across COVID-19 SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: The ROX index (Respiratory rate - OXygenation), obtained by the calculation of SpO2/FiO2/respiratory rate (RR), is a tool previously found to predict intubation in patients with acute hypoxic respiratory failure (AHRF). There is variation in the time intervals described from HFNC to ROX index assessment as well as the cutoff value. This study investigates the role of the ROX index from 12 to 72 hours after HFNC initiation to predict intubation or death while on HFNC in patients with COVID-19 AHRF. METHODS: Adult patients (18 years or older) with confirmed nasopharyngeal PCR SARS-CoV-2 infection who received HFNC therapy between March 1 and July 15, 2020, at Monmouth Medical Center were included. 52 patients were available for analysis. Patients were divided into two groups: those able to be weaned to traditional nasal cannula (group one) and those who were intubated or died while on HFNC (group two). RESULTS: Of the 52 patients evaluated, 28 (54%) required intubation or died while on HFNC (Group two). Group two mortality was 53.85% and overall mortality was 42.31%. A Kaplan-Meier analysis comparing patients whose ROX remained above 4.67 (Group A) with those with ROX <= 4.67 (Group B) within the first 12 hours showed that patients in Group B had a significantly shorter time to the event than those in Group A. CONCLUSIONS: Generally, higher ROX index values are associated with a lower risk of intubation on HFNC in AHRF. In this patient sample, any ROX index less than 4.67 at 12 hours or less than 4.04 at 24 hours was associated with an increased risk of eventual intubation or death while on HFNC. Thus, a low or decreasing ROX index may prompt more frequent reassessment and, if accompanied by other evidence of deterioration, may trigger an escalation of care. CLINICAL IMPLICATIONS: This study shows that the ROX index can stratify patients into low or higher risk for deterioration on HFNC among patients with COVID-19 AHRF. This could help optimize the use of critical care services, minimize PPE use, and promote safety for patients and healthcare workers. Future studies may include prospective analysis of the ROX index and exploration of modalities for monitoring patients receiving non-invasive ventilation. DISCLOSURES: No relevant relationships by Reem alhashemi no disclosure on file for Alvin Buemio;No relevant relationships by Kenneth Granet No relevant relationships by Ikwinder Preet Kaur No relevant relationships by Violet Kramer No relevant relationships by Mohsin Mughal No relevant relationships by Chandler Patton
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SESSION TITLE: ECMO and ARDS in COVID-19 Infections SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/17/2022 12:15 pm - 1:15 pm PURPOSE: COVID-related acute respiratory distress syndrome (ARDS) is associated with significant morbidity and mortality. PaO2/Fio2 (PFR) is a prognostic and severity marker for ARDS. Other markers have been posited for ARDS. PEEP Index (PIx) [PEEP/PFR] or [(PEEP*Fio2)/PaO2] could serve as a new discriminatory marker to assess rescue therapies such as proning or ECMO referral. METHODS: Retrospective cohort study of all intubated COVID-19 patients with ARDS hospitalized at our institution between February 5th – May 11th, 2020. ARDS were calculated within first 24 hours of worst PaO2/FIO2 and their associated PEEP with bilateral infiltrates on Chest X-ray manually confirmed within 24hours of intubation fulfilling 2012 Berlin criteria. Outcomes of interest were all-cause in-hospital mortality, need for pronation and paralysis use. Binomial logistic regression with ROC curve were performed for univariate association for outcomes of interest. Cox proportional hazard regression modeling was performed and adjusted for potential confounders. PFR was transformed into a denominator of itself to reflect a direct proportional relationship. RESULTS: Data was analyzed from 113 hospitalized COVID-19 patients with identified ARDS. Mean age was 56.4 (STD 14.4);24% (27/113) were female. Median BMI was 30.3 [IQR 48.5,65.5]. Mean Tidal Volume (Vt) was 430 (STD 54). 64% (72/113) were compliant with low Vt (=<6mL/kg based on IBW). Median PFR 125 [IQR 99,192]. Mortality was 66% (74/113). 44% (50/113) were proned. 62% (70/113) required paralysis. PEEP Index outperformed PFR for discrimination for proning use: AUC 0.73 [95%CI 0.63,0.82], p< 0.005;vs AUC 0.674 [95%CI 0.58,0.77], p= 0.02. PEEP Index performed mildy better than PFR for discrimination of requiring paralytic use in ARDS with AUC 0.68 [95% 0.57,0.78], p< 0.05;vs AUC 0.62 [95%CI 0.51,0.73], p<0.05. APACHE2 score showed poor discrimination for both proning and paralytic use (AUC= 0.46 [95%CI 0.35,0.56];p=0.43 and respectively, AUC=0.45 [95%CI 0.34,0.56];p=0.36). After adjusting for confounders, PEEP Index nor PFR didn’t for predict for mortality (p>0.05);however, our sample was not powered. CONCLUSIONS: PEEP Index (PIx) is a novel tool that can serve as a better discriminatory function to evaluate patients with ARDS in the ICU who will require proning in comparison to traditional used PFR. CLINICAL IMPLICATIONS: PEEP Index (PIx) can serve as an easy alternative calculation to Oxygenation Index (OI) [(FiO2 x PAW) / PaO2] to identify patients that would benefit from early proning and other rescue therapies. Further studies are required to compare and validate PIx and OI prospectively as well as benefit cut-off points between proning and ECMO. DISCLOSURES: No relevant relationships by Perminder Gulani No relevant relationships by Manuel Hache Marliere no disclosure on file for Adarsh Katamreddy;No relevant relationships by Hyomin Lim No relevant relationships by Marzio Napolitano No relevant relationships by Leonidas Palaiodimos No relevant relationships by Anika Sasidharan Nair No relevant relationships by Jee Young You
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Introduction: Hypoxic respiratory failure, a hallmark of severe COVID-19, often requires oxygen therapy.1 Mechanical ventilation carries a high mortality.2 We evaluate trends in oxygen indices (PaO2/FiO2 ratio, CaO2, O2ER) in COVID-19 patients throughout an intensive care admission and correlation with clinical outcomes. Objectives: To establish the trends in oxygen indices in mechanically ventilated adult COVID-19 patients throughout an intensive care admission. Methods: We performed a retrospective observational cohort study in a UK university hospital (ethics through REACT COVID-193), including all adult COVID-19 patients requiring mechanical ventilation between 01/03/20 and 31/ 03/21. We collected baseline characteristics, clinical outcomes and oxygen parameters. Results: 184 patients met inclusion criteria, providing 34592 blood gas data points over 30-days. The median age was 59.5 (IQR 51, 67), and median BMI 30 (IQR 25.8, 35.5). The majority were men (62.5%) of white ethnicity (70.1%). Median mechanical ventilation duration was 15-days (IQR 8, 25) and 133 patients (72.3%) survived 30-days. Oxygen indices are presented in Table 1. Non-survivors exhibited lower oxygen extraction;there was an averaged mean difference in O2ER of -0.06 (95% CI -0.09, -0.03) across days one to seven and -0.09 (95% CI -0.10, -0.07) across days one to 30. While both survivors and non-survivors had sub-physiological CaO2 (which trended down throughout their ICU admission), non-survivors tended to exhibit higher values;there is an averaged mean difference of 0.23 (95% CI 0.13, 0.34) across day one to day seven and 0.28 (95% CI 0.21, 0.35) across days one to 30. Conclusions: As a novel cause of respiratory failure, COVID-19 offers a unique opportunity to study a homogenous cohort. In mechanically ventilated adult COVID-19 patients, oxygen indices are abnormal. Despite having similar CaO2 values, oxygen extraction differs significantly between survivors and non-survivors, suggesting COVID-19 causes impaired oxygen utilisation. Urgent further evaluation is warranted.
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Introduction: Massive bleeding on extracorporeal membrane oxygenation (ECMO) is associated with multiple coagulation defects, including depletion of coagulation factors and development of acquired von Willebrand syndrome (AVWS). The use of recombinant factors, in particular recombinant activated factor VII (rFVIIa, Novoseven), to treat severe refractory hemorrhage in ECMO has been described. However, the use of multiple recombinant factors has been avoided in large part due to concern for circuit complications and thrombosis. Here, we describe the safe and effective administration of rFVIIa and recombinant von Willebrand factor complex (vWF/ FVIII, Humate-P) via post-oxygenator pigtail catheter on VA-ECMO for the treatment of massive pulmonary hemorrhage. Case Description: A 21-month-old (13.4 kg) girl with a recent history of COVID-19 infection presented to an outside hospital with parainfluenza bronchiolitis resulting in acute refractory hypoxemic respiratory failure (oxygenation index 58), refractory septic shock, and myocardial dysfunction. She was cannulated to VA-ECMO and subsequently diagnosed with necrotizing pneumonia from Pseudomonas and herpes simplex infections. Her course was complicated by a large left-sided pneumatocele and bronchopleural fistula requiring multiple chest tubes. She also had right mainstem bronchus obstruction from necrotic airway debris and complete right lung atelectasis. She was noted to have prolonged episodes of mucosal and cutaneous bleeding (oropharynx, chest tube insertion sites, peripheral IV insertion sites) associated with absent high molecular weight von Willebrand multimers consistent with AVWS. Tranexamic acid infusion was initiated and bivalirudin anticoagulation was discontinued. VA-ECMO flows were escalated to 140-160 ml/kg/min to maintain circuit integrity and meet high patient metabolic demand in the absence of anticoagulation. On ECMO day 26, she underwent bronchoscopy to clear necrotic debris from her airway to assist with lung recruitment. The procedure was notable for mucosal bleeding requiring topical epinephrine and rFVIIa. Post-procedure, she developed acute hemorrhage from her right mainstem bronchus, resulting in significant hemothorax (estimated 950 ml) with mediastinal shift, increased venous pressures, desaturation and decreased ECMO blood flow rate, necessitating massive transfusion of 2,050 ml (150 ml/kg) of packed red blood cells, platelets, plasma and cryoprecipitate. An airway blocker was placed in the mid-trachea to control bleeding. In addition to transfusion of appropriate blood products and continuation of tranexamic acid infusion, she was given both rFVIIa (100mcg/kg) and vWF-FVIII (70 units vWF/kg loading dose on the day of hemorrhage, followed by 40 units vWF/kg every 12 hours for 3 additional doses). Both products were administered over 10 minutes through a post-oxygenator pigtail to allow the product to circulate throughout the patient prior to entering the ECMO circuit. The circuit was closely monitored during administration and no changes to circuit integrity were noted in the subsequent hours while hemostasis was achieved. The ECMO circuit remained without thrombosis for 9 days after the bleeding event. Discussion: Balancing anticoagulation and hemostasis is a central challenge in maintaining ECMO support, especially given the prevalence of acquired coagulopathies such as AVWS. For our patient, AVWS contributed to mucosal bleeding necessitating cessation of anticoagulation and utilization of a high ECMO blood flow strategy to minimize circuit clot burden. This was further complicated by absent native lung function and minimal myocardial function, resulting in complete dependence on ECMO. An acute massive pulmonary hemorrhage was treated with multiple recombinant factors (rFVIIa and vWF/FVIII), that are often avoided on ECMO. To minimize clotting risk to the circuit and to maximize transit of these factors to our patient, we added a post-oxygenator pigtail for administration. While this approach was the result of extreme circumstances, th use of a post-oxygenator pigtail for administration of recombinant factors may represent a viable strategy for refractory hemorrhage while on ECMO.
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Pulmonary complications are the most common clinical manifestations of coronavirus disease (COVID-19). From recent clinical observation, two phenotypes have emerged: a low elastance or L-type and a high elastance or H-type. Clinical presentation, pathophysiology, pulmonary mechanics, radiological and ultrasound findings of these two phenotypes are different. Consequently, the therapeutic approach also varies between the two. We propose a management algorithm that combines the respiratory rate and oxygenation index with bedside lung ultrasound examination and monitoring that could help determine earlier the requirement for intubation and other surveillance of COVID-19 patients with respiratory failure.
RéSUMé: Les complications pulmonaires du coronavirus (COVID-19) constituent ses manifestations cliniques les plus fréquentes. De récentes observations cliniques ont fait émerger deux phénotypes : le phénotype à élastance faible ou type L (low), et le phénotype à élastance élevée, ou type H (high). La présentation clinique, la physiopathologie, les mécanismes pulmonaires, ainsi que les observations radiologiques et échographiques de ces deux différents phénotypes sont différents. L'approche thérapeutique variera par conséquent selon le phénotype des patients atteints de COVID-19 souffrant d'insuffisance respiratoire.
Subject(s)
Coronavirus Infections/complications , Lung/diagnostic imaging , Pneumonia, Viral/complications , Respiratory Insufficiency/diagnostic imaging , Ultrasonography , Acute Disease , Algorithms , COVID-19 , Coronavirus Infections/diagnostic imaging , Humans , Lung/physiopathology , Lung/virology , Oxygen/metabolism , Pandemics , Phenotype , Pneumonia, Viral/diagnostic imaging , Point-of-Care Systems , Respiratory Insufficiency/virology , Respiratory Rate/physiologyABSTRACT
Introduction: One of the important COVID-19 management considerations was to prevent delayed intubation. There is a lack of objective criteria to decide the time of intubation. Previously, respiratory parameters were the only tools used to determine the success of high flow nasal cannula (HFNC) therapy, but several studies have reported on the role of respiratory rate oxygenation (ROX) index which combined respiratory rate (RR) and oxygen saturation/fraction of inspired oxygen (SpO2/FiO2) in predicting intubation after receiving high flow nasal cannula (HFNC). The primary objective of this study was to evaluate the validity of the ROX index in predicting intubation in COVID-19 pneumonia receiving HFNC. Methods: This study is a systematic review that used online databases (PubMed, Science Direct, Google Scholar, and CENTRAL) in obtaining eligible journals. The sources of data were from published observational studies and preprints. The outcomes of this study were ROX index validity, intubation predictors, and factors associated with the ROX index. Results: Seven journals were yielded during the search. ROX index was significantly lower in the HFNC failure group at any time interval with high sensitivity and specificity in predicting intubation (p ≤ 0.001). ROX index can be used to predict intubation starting at 4 hours after HFNC initiation and calculated repeatedly. Conclusion: ROX index was a good parameter in predicting intubation in COVID-19 pneumonia patients who receive HFNC. The higher value of the ROX index was associated with a higher chance of HFNC success and a lower risk of mortality.
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INTRODUCTION: Pulmonary arteriovenous malformations (PAVM) are typically associated with hereditary hemorrhagic telangiectasia. Isolated PAVM are uncommon and usually present between the 4th-6th decades of life;they are rarely seen in children and infrequently necessitate ICU admission. DESCRIPTION: A healthy 3-year-old boy presented to his pediatrician with a 3 day history of fever and rhinorrhea. He was hypoxic (SpO2=85%), so was placed on oxygen and transferred to an outside ED where he was found to have (non-COVID) coronavirus. He was admitted for supportive care but clinically deteriorated over the next 24 hours requiring intubation, ventilatory support with 100% FiO2, and inhaled nitric oxide. Despite these interventions he remained hypoxic. Echocardiogram demonstrated a structurally normal heart. Computed tomography angiogram showed multiple large peripheral PAVM in the left lower and upper lobes and no differentiation between arterial and venous phases indicating pulmonary shunting. He was transferred to our quaternary ICU for intervention. He underwent embolization of ~70% of his PAVM (limited due to contrast load). He initially improved, but 2 days post-intervention he declined with worsening hypoxia likely secondary to pulmonary vascular remodeling following intervention and residual shunt burden within the left lung. Given his instability, as well as an oxygenation index of 34, he was cannulated for venoarterial extracorporeal membrane oxygenation (ECMO). Following cannulation, his remaining PAVM were embolized. ECMO support was subsequently weaned and he was decannulated after 4 days. His ventilator support was weaned, and he was transferred back to the referring hospital on minimal settings. He was extubated the next day and quickly weaned to room air. He was discharged after 2.5 weeks and was doing well (SpO2=95%) at his pediatrician follow-up. DISCUSSION: This is the first case of a previously healthy child requiring cannulation for ECMO due to PAVM. This case is unique among patients with PAVM due to the early presentation, likely related to an acute respiratory illness disturbing previously well-compensated ventilation-perfusion mismatch. As highlighted in this case, ECMO can be used to support patients who require interventions for PAVM and during the transition to a new physiologic state.
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Objectives: Traditional Chinese medicine has been reported to be effective in the treatment of epidemic diseases. Here, we aimed to investigate the effects of combined therapy of Chinese and western medicine on coronavirus disease 2019 (COVID-19). Methods: A total of 60 patients diagnosed with COVID-19 were enrolled. Both the ordinary and severely affected patients were randomly divided into Groups A-C each with 10 cases each. The patients in Group A-C received Western medicine, Western medicine + traditional Chinese medicine, and Western medicine + traditional Chinese medicine + high dose of vitamin C, respectively. The time of disease recovery, symptoms disappearance, chest CT improvement, and tongue amelioration was recorded. Leukocyte, neutrophil and lymphocyte were monitored, as well as C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), procalitonin (PCT), inflammatory factors, partial pressure of oxygen and carbon dioxide (PaCO2) and oxygenation index (PaO2). Urinary tract stones, liver function, and other side-effects such as gastrointestinal dysfunction were also investigated. Results: Traditional Chinese medicine enhanced the effect of Western medicine, including the reduction of CRP, ESR, PCT, and inflammatory factors, and the increase of leukocyte, neutrophil, and lymphocyte counts, and the improvement of respiratory rate, PaO2, PaCO2, and oxygenation index. Traditional Chinese medicine combined with high-dose Vitamin C therapy more effectively shortened the time of disease recovery, symptom disappearance, chest CT improvement, and tongue amelioration. Conclusions: a combined therapy of Western medicine, traditional Chinese medicine, and high dose of Vitamin C results in a most effective outcome in the treatment of COVID-19.
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Background: In the treatment of severe and severe cases, New Coronavirus pneumonia diagnosis and treatment plan (Trial Seventh Edition) suggested that if the patients did not improve or deteriorate within a short time (1-2 h) after the use of high flow nasal catheter oxygen therapy or non-invasive ventilation, tracheal intubation and invasive mechanical ventilation should be carried out in time. No objective reference indexes have been proposed in the opinions, and the commonly used oxygenation index is insufficient in the clinical application of such patients, so it is particularly important to explore more valuable reference indexes. Objective: To compare the difference of dispersion index and oxygenation index in the prognosis assessment of patients diagnosed with Novel Coronavirus Pneumonia (COVID-19) who have acute respiratory distress syndrome (ARDS) when they are treated with mechanical ventilation. Methods: A retrospective single center study was conducted in 39 patients with ARDS of Novel Coronavirus Pneumonia admitted to ICU with mechanical ventilation of Wuhan Tianyou Hospital from January 25, 2020 to March 14, 2020. Two of them were lost due to death within 24 hours, patients were divided into survival group (n=11) and death group (n=26) according to their 28-day status. Ventilator parameters and corresponding blood gas values were recorded to study the correlation between dispersion index and oxygenation index and 28 days' prognosis of patients. Results: The worst oxygenation index, the dispersion index, and the worst dispersion index when entering ICU in the survival group were higher than those in the death group (P<0.05). The sensitivity of the oxygenation index to predict death when entering the ICU was 100.0%, the specificity of the oxygenation index was 46.2%, the area under the ROC curve (AUC) was 0.654, and the difference between AUC and the reference value was not statistically significant (P=0.144);The sensitivity of the oxygenation index to predict death was 3.8%, the specificity was 100.0%, and the AUC was 0.862 when the oxygenation index was the lowest, comparing with the reference value, the difference was statistically significant (P<0.05);The sensitivity of the dispersion index to predict death was 7.7%, the specificity was 100.0%, and the AUC was 0.734 when entering the ICU, comparing with the reference value, the difference was statistically significant (P<0.05);The sensitivity of the dispersion index to predict death was 100.0%, the specificity was 80.8%, and the AUC was 0.902 when the dispersion index was the lowest, comparing with the reference value, the difference was statistically significant (P<0.05). Conclusion: Dispersion index is a more sensitive and reliable prognostic indicator for ARDS in Novel Coronavirus Pneumonia patients than oxygenation index. The dispersion index is a more sensitive and reliable prognostic evaluation index than the oxygenation index in Novel Coronavirus Pneumonia patients with ARDS. Copyright © 2021 by the Chinese General Practice.
ABSTRACT
Background: Respiratory failure due to coronavirus disease of 2019 (COVID-19) often presents with worsening gas exchange over a period of days. Once patients require mechanical ventilation (MV), the temporal change in gas exchange and its relation to clinical outcome is poorly described. We investigated whether gas exchange over the first 5 days of MV is associated with mortality and ventilator-free days at 28 days in COVID-19. Methods: In a cohort of 294 COVID-19 patients, we used data during the first 5 days of MV to calculate 4 daily respiratory scores: PaO2/FiO2 (P/F), oxygenation index (OI), ventilatory ratio (VR), and Murray lung injury score. The association between these scores at early (days 1-3) and late (days 4-5) time points with mortality was evaluated using logistic regression, adjusted for demographics. Correlation with ventilator-free days was assessed (Spearman rank-order coefficients). Results: Overall mortality was 47.6%. Nonsurvivors were older (P < .0001), more male (P = .029), with more preexisting cardiopulmonary disease compared to survivors. Mean PaO2 and PaCO2 were similar during this timeframe. However, by days 4 to 5 values for all airway pressures and FiO2 had diverged, trending lower in survivors and higher in nonsurvivors. The most substantial between-group difference was the temporal change in OI, improving 15% in survivors and worsening 11% in nonsurvivors (P < .05). The adjusted mortality OR was significant for age (1.819, P = .001), OI at days 4 to 5 (2.26, P = .002), and OI percent change (1.90, P = .02). The number of ventilator-free days correlated significantly with late VR (-0.166, P < .05), early and late OI (-0.216, P < .01; -0.278, P < .01, respectively) and early and late P/F (0.158, P < .05; 0.283, P < .01, respectively). Conclusion: Nonsurvivors of COVID-19 needed increasing intensity of MV to sustain gas exchange over the first 5 days, unlike survivors. Temporal change OI, reflecting both PaO2 and the intensity of MV, is a potential marker of outcome in respiratory failure due to COVID-19.