Long-term support of COVID-19 patients with veno-venous extracorporeal membrane oxygenation: Complications, predictors of mortality and long-term outcome

Objectives: Treatment of severe respiratory distress syndrome (ARDS) due to COVID-19 by veno-venous extracorporeal membrane oxygenation (VV-ECMO) had a mortality of up to 70% in Germany. Many patients with COVID-19 need VV-ECMO support longer than 28 days (long-term VV-ECMO). Evidence on mortality, complications during intensive care, functional status after discharge and mortality-predictors for patients supported with long-term VV-ECMO is lacking. Method(s): Retrospective study of 137 consecutive patients treated with VV-ECMO for ARDS due to COVID-19 at University Hospital Regensburg from March 2020 to March 2022. Result(s): 38% (n=52;87% male) of patients needed longterm VV-ECMO support. In these, SOFA score (median [IQR]) at ECMO initiation was 9 [8-11], age 58.2 [50.6- 62.5] years, PaO2/FiO2-ratio 67 [52-88] mmHg, pCO262 [52-74] mmHg, Murray-Score 3.3 [3.0-3.6] and PEEP 15 [13 - 16] cmH2O. Duration of long-term support was 45 [35-65] days. 26 (50%) patients were discharged from the ICU. Only one patient died after hospital discharge. At VVECMO initiation, baseline characteristics did not differ between deceased and survivors. Complications were frequent (acute kidney injury: 31/52, renal replacement therapy: 14/52, pulmonary embolism: 21/52, intracranial hemorrhage 8/52, major bleeding 34/52 and secondary sclerosing cholangitis: 5/52) and more frequent in the deceased. Karnofsky index (normal 100) after rehabilitation was 70 [57.5-82.5]. Twelve of the 18 patients discharged from rehabilitation had a satisfactory quality of life according to their own subjective assessment. Four patients required nursing support. Mortality-predictors within the first 30 days on VV-ECMO only observed in those who deceased later, were: Bilirubin >5mg/dl for > 7 days, pulmonary compliance <10ml/mbar for >14 days, and repeated serum concentrations of interleukin 8 >150ng/L. Conclusion(s): Long-term extracorporeal lung support in patients with COVID-19 resulted in 50 % survival and subsequently lead to a satisfactory quality of life and functionality in the majority of patients. It should preferably be performed in experienced centers because of a high incidence of complications. Several findings during the early course were associated with late mortality but need validation in large prospective studies.

Determinants of death in patients with COVID-19 pneumonia treated with venovenous extracorporeal membrane oxygenation support

Objectives: Death from SARS-CoV-2 pneumonia resulted from progressive respiratory failure in most patients. Whenever accessible, venovenous extracorporeal membrane oxygenation (VVECMO) was implemented to rescue patients with refractory hypoxemia. Reported mortality in this population reached values from 20 to 50 percent, but the direct causes of death were not so widely acknowledged. The aim of our study was to characterize mortality in patients treated with VVECMO support. Method(s): Retrospective review of a prospectively collected database in an ECMO referral centre. All patients with diagnosis of SARS-CoV-2 infection treated with VVECMO support were included. Survivors and nonsurvivors were compared using t-student and chi2 methods. A Cox regression analysis was performed to identify predictors of mortality at admission. Result(s): Ninety-three patients were included (29% female). Median age was 54+/-12 years, mean SOFA was 5.7+/-2.9 and SAPS II was 35.6+/-13.6. Hospital mortality was 24.7%. Main causes of death were septic shock in 39.1% (9 patients), irreversible lung fibrosis 30.4% (7 patients) and catastrophic hemorrhage in 4.3% (4 patients). End-of-life care measures (withdrawal or withholding) were adopted in 65.2% of non-survivals. Patients who died were older (55 vs 48 years, p<0.05), had longer disease course (19 vs 15.3 days, p<0.05), longer invasive mechanical ventilation course before cannulation (8.5 vs 5 days, p<0.05), lower static lung compliance (25.5 vs 31.8 mL/cmH2O, p<0.05) and were ventilated with lower PEEP (8 vs 10 cmH2O, p<0.05) on cannulation. On a Cox-regression model, only prone ventilation before cannulation (HR 9,7;CI 95% 1,4- 68,6;p<0.05) and SAPS II (HR 1.04;CI 95% 1,001- 1,083;p<0.05) predicted mortality. Conclusion(s): Mortality in patients with severe SARSCoV-2 pneumonia treated with VVECMO was exceedingly low in our study, when compared with other series. Only one-third died from progressive lung disease, which suggests that protocol improvement can further reduce mortality.

Dysphagia rehabilitation in post-COVID patients: Review of the literature

COVID-19 causes acute respiratory failure syndrome (SIRA), leading patients to require intubation in the intensive care unit (ICU). A common complication of this ventilatory support is dysphagia, which has a prevalence of up to 30%.This work aims to describe rehabilitation methods in patients with coronavirus infection based on levels of evidence according to the GRADE System, so a systematic review of the literature was carried out. The selected articles were divided into the following subtopics: diagnosis of dysphagia and rehabilitation in COVID patients. The gold standard for the diagnosis of dysphagia is the videofluoroscopic swallowing study (VFS). Fiberoptic Evaluation of Swallowing Assessment (FEES) has high sensitivity and specificity, although they have the disjunction of an aerosol-generating procedure (AGP);however, in a pandemic situation, the study of choice in the literature is VF. Once the diagnosis is made, it is necessary to initiate rehabilitation as soon as possible, even from hospitalization in patients who have hemodynamic stability to prevent long-term effects and promote normal swallowing even before discharge. In patients with COVID-19 infection dysphagia, the risk-benefit of assessment tools and therapy used for diagnosis should be decided to help to maintain social distancing. It becomes imperative to carry out clinical studies with high levels of evidence that allow us to generate Clinical Practice Guides for the benefit of our patients.Copyright © 2021 Sociedad Medica del Hospital General de Mexico. Published by Permanyer.

Clinical characteristics and risk factors of patients with COVID-19 developing barotrauma

Background: At our hospital, people with COVID-19 (coronavirus disease 2019) had a high rate of pulmonary barotrauma. Therefore, the current study looked at barotrauma in COVID-19 patients getting invasive and non-invasive positive pressure ventilation to assess its prevalence, clinical results, and features. Methodology: Our retrospective cohort study comprised of adult COVID-19 pneumonia patients who visited our tertiary care hospital between April 2020 and September 2021 and developed barotrauma. Result(s): Sixty-eight patients were included in this study. Subcutaneous emphysema was the most frequent type of barotrauma, reported at 67.6%;pneumomediastinum, reported at 61.8%;pneumothorax, reported at 47.1%. The most frequent device associated with barotrauma was CPAP (51.5%). Among the 68 patients, 27.9% were discharged without supplemental oxygen, while 4.4% were discharged on oxygen. 76.5% of the patients expired because of COVID pneumonia and its complications. In addition, 38.2% of the patients required invasive mechanical breathing, and 77.9% of the patients were admitted to the ICU. Conclusion(s): Barotrauma in COVID-19 can pose a serious risk factor leading to mortality. Also, using CPAP was linked to a higher risk of barotrauma.Copyright © 2021 Muslim OT et al.

ECMO for the immunocompromised pediatric patient: Our experience

Objectives: To present a series of immunosuppressed patients (oncohematological disease, congenital immunosuppression, hematopoietic stem cell (HSCT), and solid organ transplant) assisted on ECMO. Method(s): Descriptive, retrospective study (2011-2020) of a cohort of 9 immunosuppressed patients, supported on ECMO. Medical records were reviewed and demographic, clinical, and analytical variables were collected. Result(s): In our series of 9 patients, 5 were male, the median age was 8 years [RIC 3-11 years]. Considering the underlying disease, 6 were oncologic, 1 liver transplant and 2 with congenital immunodeficiency after HSCT. 4 were under active chemotherapy (median 6 days after the last cycle [RIC 5-188]). 6 were admitted due to acute respiratory failure, 3 due to hemodynamic instability (3/9), (one septic shock). The median PEEP was 12 [RIC 9-15] and FiO2 100% (81-100%). 78% (6) required vasoactive drugs (median inotropic score 35 [RIC 0-75]. 40%. 5 had severe neutropenia and/or plateletopenia in the 24 hours prior to ECMO, and alterations in acid-base balance (median pH 7. 1 [RIC 6.9-7.15]. 5 were on multiorgan failure. TPrimary ECMO transport was performed in 4 patients (44%). Cannulation was peripheral in 80% (57% cervical, 43% femoral) and central in 20%;70% VA-ECMO. Median time of assistance was 15 days [RIC 3.5-31.5] in cardiac ECMO (4), and 29 days [RIC 13.5-42] and in pulmonary ECMO (n=5). The median total time of admission was 45 days [RIC 27-59]. 9 had an infection, 2 COVID after HSCT, and 8 bleeding complications, but only one required surgical revision. Renal replacement therapy was used in 5 (median 9 days [RIC 5-34.5]). Other therapies used were polymyxin hemadsorption(2), intratracheal surfactant(2), plasma exchange(1), infusion of mesenchymal cells(1) and specific memory T lymphocytes(2). 4 patients died, 5 survived decannulation, 2 died later, with an overall survival rate to hospital discharge of 33% (3/9). Conclusion(s): Despite having a worse prognosis, ECMO can increase survival in immunosuppressed patients, in situations that are challenging and require a multidisciplinary approach.

Case Report of a Transfusion-Associated Circulatory Overload Leading to Cardiac Arrest in a COVID-19 Positive Patient

Although case reports have been made regarding adverse transfusion reactions, few have been made regarding blood transfusions leading to cardiac arrest. Today, we present a case of a COVID-19 positive Bahraini male, triple vaccinated, transfused with packed red blood cell (pRBC) after finding out he has low haemoglobin levels (64 g/dl) after routine laboratory investigations. During the blood transfusion, he developed hypertension, tachycardia and tachypnoea. The patient went into cardiac arrest within a few minutes of this presentation. Return of spontaneous circulation was achieved, and the patient was managed as transfusion-associated circulatory overload (TACO) with a good overall outcome.Copyright © 2023, Bahrain Medical Bulletin. All rights reserved.

Lung inhomogeneities in COVID-19 related acute respiratory distress syndrome

Introduction: In acute respiratory distress syndrome (ARDS) inhomogeneities in lung aeration can act as local multipliers of pressure during inspiration (stress risers), increasing the risk of lung damage even in presence of airway pressures considered safe [1]. In this study we aimed to describe lung inhomogeneities in COVID-19 related ARDS (C-ARDS) and to relate these to disease severity and lung morphology. Method(s): We enrolled patients with C-ARDS within 3 days from mechanical ventilation start, deeply sedated and paralyzed. Lung CT scan was obtained at PEEP of 5 cmH2O to measure lung weight compartments (non-, poorly-, well- and over-aerated). Lung inhomogeneities were computed as the gas/tissue ratio of each voxel compared to the neighboring voxels. We considered values > 1.61 as pathologic lung inhomogeneities, as previously described [1]. The fraction of total lung volume with pathologic inhomogeneities (extent) and the average severity of inhomogeneities contained in that fraction (intensity) was calculated. Respiratory system compliance and blood gas analysis were obtained at the same PEEP level of the CT scan. Some results have been presented in another publication [2]. Result(s): Forty patients were studied in the supine position 1 (0-1) days after ICU admission. The extent of pathologic lung inhomogeneities represented 18 +/- 4% of total lung volume. The intensity of pathologic lung inhomogeneities was on average 2.53 +/- 0.12. Extent was positively correlated with the amount of poorly aerated lung weight ( r2 = 0.51, p < 0.001) (Fig. 1) and negatively correlated with the amount of non-aerated lung weight ( r2 = 0.22, p = 0.002). No correlation was found between extent and intensity and PaO2/ FiO2, dead space fraction or respiratory system compliance. Conclusion(s): In C-ARDS lung inhomogeneities represent roughly 20% of total lung volume. In these regions local stress is increased with risk of secondary lung damage.

Ventilator management and risk of air leak syndrome for patients with COVID-19 pneumonia

Introduction: Coronavirus disease 2019 (COVID-19) pneumonia is reportedly associated with air leak syndrome (ALS), including mediastinal emphysema and pneumothorax, and has a high mortality rate. In this study, we compared values obtained every minute from the ventilator to clarify the relationship between ventilatory management and the risk of developing ALS. Method(s): This was a single-center, retrospective, observational study for a 21-months period. Patient background, ventilator data, and outcomes were collected from adult patients with COVID-19 pneumonia on ventilator-assisted respiratory management. The primary outcome was the development of ALS within 30 days of starting ventilator management. Result(s): Of the 105 patients, 14 (13%) developed ALS. The mean positive-end expiratory pressure (PEEP) difference was 0.33 cmH2O (95% confidence interval (CI) 0.31-0.33), and it was higher in the ALS than in the non-ALS group (9.18 +/- 2.20 versus 8.85 +/- 2.63, respectively). For peak pressure, the mean difference was -0.18 cmH2O (95% CI -0.20 to -0.15), (20.70 +/- 5.30 vs. 20.87 +/- 5.65) and the mean pressure difference of -0.05 cmH2O (95% CI -0.04 to -0.07) (12.80 +/- 3.13 vs. 12.85 +/- 3.55, respectively) was also higher in the non-ALS group. The difference in the single ventilation volume per ideal body weight was 0.65 ml/kg (95% CI 0.63-0.66) (7.83 +/- 3.16 vs. 7.18 +/- 2.96, respectively), and the difference in dynamic lung compliance was 8.57 mL/cmH2O (95% CI 8.43-8.70) (50.32 +/- 31.68 vs. 49.68 +/- 15.16, respectively), and both were higher in the ALS group. The percentage of times that the ventilation volume per body weight exceeded 8 was higher in the ALS group (53.7% vs. 38.6%, p < 0.001). Conclusion(s): There was no association between higher ventilator pressures and the development of ALS. The ALS group had higher dynamic lung compliance and higher tidal volumes, which may indicate a pulmonary contribution to ALS, and ventilatory management that limits tidal volume may prevent the development of ALS.

Prolonged prone position in COVID-19-associated ARDS: a prospective study

Introduction: Ventilation in prone-position (PP) improves survival in moderate-to-severe ARDS. However, optimal duration of the intervention to gain maximum benefit is unknown. We sought to examine the efficacy and safety of a prolonged PP protocol in COVID-19-associated ARDS. Method(s): This was a prospective observational study. We included consecutive intubated and mechanically ventilated patients with ARDS and positive PCR for SARS-CoV-2 who underwent at least one session of PP from March 2021 to August 2021. PP was undertaken if P/F < 150 with FiO2 > 0.6 and PEEP > 10cmH2O. Oxygenation parameters and respiratory mechanics were recorded before PP, at the end of PP session and 4 h after supine repositioning. Patients with PP longer than 24 h (prolonged group) were compared to patients who were proned for less than 24 h (control group). The duration of PP was at the discretion of the treating intensivist. Result(s): We recorded 56 patients (62.7% male). Five patients were excluded because PP was terminated in less than 4 h. Mean age of the 51 studied patients was 61.4 years. Patients in the prolonged group had significantly higher BMI than controls. Baseline oxygenation and respiratory mechanics were similar between groups. PP duration was 39.8 versus 20.5 h (p < 0.001). Increase of P/F was higher in the prolonged PP group during proning (103.8 +/- 70.8 vs 66 +/- 53.9, p < 0.05) and after supination (76.3 +/- 64.6 vs 48.6 +/- 34.9, p = 0.058). No change in respiratory mechanics was observed in either group. 28-day survival was 75% in the prolonged PP group and 69.5% in the control group (p = 0.665). Duration of mechanical ventilation, number of PP cycles and rate of complications were similar between groups. Conclusion(s): In patients with ARDS due to COVID-19 prolonged PP resulted in better oxygenation, but had no impact on outcome. However, it is both feasible and safe and can be an alternative in conditions of increased work load as was the case during the recent pandemic.

Latent class analysis of imaging and clinical respiratory parameters from patients with COVID-19-related ARDS identifies recruitment subphenotypes

Introduction: Patients with COVID-19-related acute respiratory distress syndrome (ARDS) require respiratory support with invasive mechanical ventilation and show varying responses to recruitment manoeuvres. In patients with ARDS not related to COVID-19, two pulmonary subphenotypes that differed in recruitability were identified using latent class analysis (LCA) of imaging and clinical respiratory parameters [1]. We aimed to validate these phenotypes and evaluate if similar subphenotypes are present in patients with COVID-19-related ARDS. Method(s): This is the retrospective analysis of mechanically ventilated patients with COVID-19-related ARDS who underwent CT scans at positive end-expiratory pressure of 10 cmH2O and after a recruitment manoeuvre at 20 cmH2O. LCA was applied to quantitative CT-derived parameters, clinical respiratory parameters, blood gas analysis and routine laboratory values before recruitment to identify subphenotypes. Result(s): 99 patients were included. Using 12 variables, a two-class LCA model was identified as best fitting. Subphenotype 2 (recruitable) was characterized by a lower PaO2/ FiO2, lower normally aerated lung volume and lower compliance as opposed to a higher nonaerated lung mass and higher mechanical power when compared to subphenotype 1 (non-recruitable) (Fig. 1). Patients with subphenotype 2 had more decrease in non-aerated lung mass in response to a standardized recruitment manoeuvre (p = 0.024) and were mechanically ventilated longer until successful extubation (adjusted SHR 0.46, 95% CI 0.23-0.91, p = 0.026), while no difference in survival was found (p = 0.814). Conclusion(s): A recruitable and non-recruitable subphenotype were identified in patients with COVID-19-related ARDS. The subphenotypes are similar to non-COVID-19-related ARDS and are promising for identification of recruitable patients in future practice as they can be classified with only few clinically available parameters before the recruitment manoeuvre.

A nationwide cohort study of pregnant and postpartum patients with severe COVID-19 pneumonitis in ICU in Israel

Introduction: This study included pregnant patients with severe COVID to test the hypothesis that the impact of delivery on maternal outcome depends upon illness severity at the time of delivery;we hypothesized that patients not yet requiring IPPV would improve following delivery (due to improvement in respiratory mechanics), while patients already on IPPV, or close to requiring ventilation, would deteriorate (due to maternal cardiovascular intolerance to autotransfusion). Method(s): This multicenter, prospective/retrospective cohort study evaluated Israeli ICU admissions of pregnant women with COVID-19 pneumonitis from 1-Feb-2020 to 31-Jan-2022. We assessed maternal, neonatal outcomes and longitudinal maternal clinical data. The primary outcome was maternal outcome (no-IPPV, IPPV, ECMO, death). The primary longitudinal outcome was SOFA score, the secondary longitudinal outcome was the novel PORCH score (PEEP, Oxygenation, Respiratory-support, Chest-X-ray, Haemodynamic-support). Patients were classified into: no-delivery, postpartum admission, deliverycritical and delivery-not-critical groups. Result(s): 84 patients in 13 ICUs were analysed;there were 34 nodelivery, 4 postpartum, 32 delivery-critical, 14 delivery-not-critical patients. Delivery-critical and postpartum had worse outcomes with, 26/32(81%) and 4/4(100%) requiring IPPV;12/32(38%) and 3/4(75%) requiring ECMO;1/32(3%) and 2/4(50%) dying. Deliverynot- critical and no-delivery had far better outcomes with, respectively, 6/34(18%) and 2/14(14%) requiring mechanical ventilation;no patients required ECMO or died. SpO2, S/F ratio, P/F ratio in Deliverycritical deteriorated on the day of delivery, continued to deteriorate, and took longer to recover;delivery-not-critical improved rapidly following delivery. The day of delivery was a highly significant covariate for PORCH (p < 0.0001), not SOFA (p = 0.09). Conclusion(s): Interventional delivery should be considered for maternal indications before patients deteriorate and require IPPV.

Lung ultrasound scoring system vs ROX index as a predictor for progression to the invasive mechanical ventilation in COVID-19 patients

Background: During the outbreak of the highly contagious Coronavirus disease 19 (COVID19), rapid and simple prognostic tools were needed to support clinical decisions and predict the need of invasive mechanical ventilation. the ROX index, and the lung ultrasound score (LUSS) were proposed to objectively predict patient prognosis in addition to the subjective clinical assessment Aim: This study aimed to compare lung ultrasound score with ROX index in predicting the need of invasive ventilation in COVID-19 patients requiring advanced oxygen therapy. Patients and Methods: We studied 50 patients with severe COVID-19 pneumonia in the intensive care unit in the isolated area at Kasr Al-Ainy hospital. Complete Medical history, physical examination and laboratory investigations were obtained on admission. All patients underwent bedside lung ultrasonography scan and LUSS was calculated at the 2nd and the 12th hours, also ROX index was calculated at the 2nd, 6th and 12th hours from initiating the advanced oxygen therapy. Result(s): From a total of fifty patients with COVID-19, 56.0% were males, with mean age of 65.98 + 11.68 years, and mortality rate was 68%. The optimal cut off value of the ROX index at (2, 6, 12 hour) is (2.495, 2.675, 3.06) respectively, (p <0.001) with sensitivity 90.9% and specificity 76.5% at the 12 hour. Also the optimal cut off point of LUSS is 25.50 (p <0.001) with sensitivity 93.9% and specificity 88.2% for prediction of the invasive mechanical ventilation. Conclusion and recommendations: The study concluded that LUSS is more sensitive in predicting the need of invasive mechanical ventilation than ROX index.Copyright © 2023, Codon Publications. All rights reserved.

Tidal volume measurement during non-invasive respiratory support by helmet continuous-flow CPAP is feasible and accurate in a bench model

Introduction: We investigated a novel technique designed to measure tidal volume during non-invasive helmet continuous-flow CPAP, a device for non-invasive respiratory support largely used during the recent COVID-19 pandemic to treat acutely ill hypoxic respiratory failure patients. Method(s): An active lung simulator coupled with a helmet CPAP was used to compare measured and Reference tidal volumes at PEEP 5, 10 and 15 cmH2O and different levels of distress (pMusc 10, 15 20 and 25 cmH2O;respiratory rate 15, 20, 25 breaths per minutes). Tidal volume measurement was based on helmet outflow-trace analysis. Helmet inflow was increased from 60 to 75 and 90 L/min to match patients' inspiratory flow;an additional subset of tests was conducted in condition of purposely insufficient inflow (i.e.: high respiratory distress and 60 L/min inflow). Result(s): Explored tidal volumes ranged from 250 to 910 mL. The Bland-Altman analysis showed a bias of -3.2 +/- 29.3 mL for measured tidal volumes as compared to Reference, corresponding to an average relative error of -1 +/- 4.4% (see Fig. 1). At univariate analyses, tidal volume underestimation correlated with respiratory rate (rho = .411, p = .004) but not with peak inspiratory flow, distress, or PEEP. When the helmet inflow was purposely maintained insufficient as compared to the simulated inspiratory flow, the Bland-Altman analysis showed a significant tidal volume underestimation (bias -93.3 +/- 83.9 mL), corresponding to an error of -14.8 +/- 6.3%. Conclusion(s): We showed that tidal volume measurement is feasible and accurate in a model of bench continuous-flow helmet CPAP therapy by the analysis of the outflow signal, provided that helmet inflow is maintained adequate to match patient's inspiratory efforts. Insufficient inflow resulted in tidal volume underestimation.

Long-Term Sequelae of severe COVID-19: Outpatient assessment of radiological and pulmonary function tests

Objective: Identify lung sequelae of COVID-19 through radiological and pulmonary function assessment. Design(s): Prospective, longitudinal, cohort study from March 2020 to March 2021. Setting(s): Intensive Care Units (ICU) in a tertiary hospital in Portugal. Patient(s): 254 patients with COVID-19 admitted to ICU due to respiratory illness. Intervention(s): A chest computed tomography (CT) scan and pulmonary function tests (PFT) were performed at 3 to 6 months. Main variables of interest: CT-scan;PFT;decreased diffusion capacity of carbon monoxide (DLCO). Result(s): All CT scans revealed improvement in the follow-up, with 72% of patients still showing abnormalities, 58% with ground glass opacities and 62% with evidence of fibrosis. PFT had abnormalities in 94 patients (46%): thirteen patients (7%) had an obstructive pattern, 35 (18%) had a restrictive pattern, and 58 (30%) had decreased DLCO. There was a statistically significant association between abnormalities in the follow-up CT scan and older age, more extended hospital and ICU stay, higher SAPS II and APACHE scores and invasive ventilation. Mechanical ventilation, especially with no lung protective parameters, was associated with abnormalities in PFT. Multivariate regression showed more abnormalities in lung function with more extended ICU hospitalization, chronic obstructive pulmonary disease (COPD), chronic kidney disease, invasive mechanical ventilation, and ventilation with higher plateau pressure, and more abnormalities in CT-scan with older age, more extended ICU stay, organ solid transplants and ventilation with higher positive end-expiratory pressure (PEEP). Conclusion(s): Most patients with severe COVID-19 still exhibit abnormalities in CT scans or lung function tests three to six months after discharge.Copyright © 2023

Ventilatory support in Covid-19 pneumonia.

The Covid-19 pandemic led to a major influx of patients suffering from acute hypoxemic respiratory failure, which conducted intensivists to adapt ICU structures and question respiratory support strategies. Available data suggest that pathophysiology of Covid-19 associated - acute respiratory distress syndrome (ARDS) is substantially similar to the pathophysiology of ARDS unrelated to Covid-19. Specific vascular injuries may however be more frequent during Covid-19 and some patients may present a major alteration in hypoxic pulmonary vasoconstriction. To date, ventilatory support strategies of patients with Covid-19 should be in line with guidelines for ARDS unrelated to Covid-19, including in particular a cautious evaluation of positive end-expiratory pressure effects.Copyright © SRLF 2021.

Can Pneumothorax Developing in COVID-19 Patients be a Mortality Marker?

Objectives: The purpose of this study is to investigate the effects of pneumothorax (PX), a rare complication of COVID-19, on mortality. Method(s): All patients admitted to our hospital with the diagnosis of COVID-19 were screened, and patients who developed PX were included in the study. Patient demographics data, number of days of hospitalization for comorbidities, day and duration of thorax tube insertion, and laboratory findings during hospitalization were recorded by scanning the hospital automation system and patient records. Result(s): For our study, 7485 patients hospitalized with the diagnosis of COVID-19 were screened in intensive care unit. PX was detected in 32 (0.296%) of the patients. About 59.4% of these patients included in the study were male. DM was the most common comorbid condition at 56.3%. In these patients, the mortality rate was found to be 90.6%. Conclusion(s): The data obtained indicate that PX, a COVID-19 complication, leads to a serious increase in mortality. We believe that using protective ventilation methods to avoid the development of pneumotarax will help to reduce mortality.© Copyright 2022 by The Cardiovascular Thoracic Anaesthesia and Intensive Care - Available online at www.gkdaybd.org.

Lung Ultrasound versus SpO2-guided as 'Best-PEEP' titration in SARS-CoV2 ARDS

Background: SARS-CoV2 pneumonia with respiratory failure may evolve to ARDS. The effects of high PEEP on respiratory compliance varies in different patients. Our study is based on the high accurancy and sensitivity of Lung Ultrasound (LUS) in evaluating the heterogeneous distribution of aeration loss, and use of LUS to individualize PEEP titration to produce the best lung aeration. Method(s): Retrospective trial on two cohorts of patients (15+15) with SARS-CoV2 ARDS mild-to-moderate(according to Berlin Criteria), aged 18 to 80 y.o. In Group I(GI) PEEP titration was LUS guided, in Group II(GII) titration was SpO2-guided. In GI LUS score was calculated dividing lungs in six regions per hemithorax. Patients were treated with NIV or CPAP Helmet. In GII FiO2 was initially set at 40% and increased if target oxygenation was not met. In GI PEEP was set at 5 cmH2O and guided by LUS aeration. Cases were managed by PEEP values from 7.5-15 cmH2O. Determination of optimal PaO2/FiO2 was the primary outcome. Secondary outcomes were adverse event: incidence of barotrauma/pneumothorax/pneumomediastinum, haemodynamics (MAP and HR), time spent on NIV/ CPAP, length of stay, weaning categories, and mortality at day 28. Result(s): P/F ratio was 282+/-38.6 in GI, and 243+/-43.2 in GII. We didn't detect significant statistical differences between the two groups in terms of mortality (6.2% in Gi vs 6.8% in GII) nor in time to weaning (5+/-6 in GI vs 16+/-4.5 in GII). In-stead there were fewer AE in GI vs GII. Length of stay was reduced with mean value of 4.3 days. Conclusion(s): Compared to SpO2-guided PEEP titration, LUS-based titration was associated with favorable effects on rate of adverse events and length of hospital stay.

Spontaneous pneumomediastinum, subcutaneous emphysema and pneumothorax in non-intubated patients with COVID-19 pneumonitis: a retrospective case note review of a single centre experience

Introduction: Emerging evidence suggests COVID-19 is associated with a higher incidence of pneumomediastinum (PM), subcutaneous emphysema (SCE) and pneumothorax (PTX). Aims and objectives: To determine whether the presence of concurrent SCE and PTX in addition to PM were associated with a higher risk of admission to ITU or death compared to PM alone. Method(s): Study period: September 2020 to June 2021. Patients identified through the Trust Operations Centre prospective records of all COVID-19 admissions. PACS radiology system used to further identify patients who had CT scans. Every CT scan reviewed for presence of PM, SCE and PTX. Case notes reviewed retrospectively. Statistical analyses: GraphPad Prism;group difference assessments: Kruskal-Wallis tests. Result(s): PM was confirmed on CT scans in 24 patients. Mean age was 63.29 years (SD+/-10.05). 66.7% were male. 83.3% required CPAP;12.5% venturi masks and 4.2% optiflow. In addition to PM, 11 patients had SCE, 8 had PTX and 4 pneumopericardium. There was no significant difference in admission SpO2, maximum FiO2 and maximum PEEP in PM patients who developed SCE or PTX (p=0.94 and 0.91) versus PM alone. ~40% of patients in each group developed pneumonia or sepsis. Higher percentages of SCE or PTX patients were admitted to ITU (81.7% and 87.5%) compared to PM alone (62.5%), however this was not statistically significant, nor associated with higher risk of death (p=0.10;p=0.89 respectively). Conclusion(s): PM patients with and without SCE and PTX had no significant differences in respiratory support mechanisms, PEEP, FiO2, ITU admission or risk of death.

Pneumomediastinum in COVID-19 critically ill patients

Pneumomediastinum in COVID-19 critically ill patients Introduction: Pneumomedisatinum(PM) is an uncommon potentially life-threatening complication of COVID-19 and can be an aggravating factor. This study aimed to determine the incidence and outcomes of PM in critically ill COVI19 patients. Method(s): A retrospective study carried out in a 9-bed intensive care unit from October 1st, 2020 to February 28, 2021 including patients with confirmed COVID19 related acute respiratory distress syndrome (ARDS) with confirmed PM on Chest computed tomography (CT). Were recorded patients characteristics, management and outcomes. Result(s): 7 cases of PM were reported : 5 men, 2 women, aged between 47 and 70 years-old. None of them had underlying lung disease. 4 patients were under invasive mechanical ventilation (IMV), 2 under non-invasive ventilation (NIV) and one had a spontaneous PM at the time of the event. Chest CT scan showed : pulmonary involvement, moderate (n=4/7) to severe (n=3/7), PM (n=7/7), subcutaneous emphysema (n=5/7) and pneumothorax (n=2/7). The highest positive end-expiratory pressure (PEEP) for patients receiving IMV and NIV were respectively 10cmH2O and 6cmH2O. Urgent mediastinal decompression wasn't immediately indicated, conservative therapy with reduced airway pressure was adopted. Patients with NIV were intubated after NIV failure. Despite protective ventilation with lower pressure, needle aspiration and chest drainage, all patients expired during their hospital stay. Conclusion(s): Our findings suggest that PM is secondary to inflammatory response due to COVID-19 and mostly triggered by the use of positive pressure ventilation and it is associated with poor outcome in critically ill COVID-19 patients.