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1.
Critical Care ; 26(SUPPL 1), 2022.
Article in English | EMBASE | ID: covidwho-1793858

ABSTRACT

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.

2.
Critical Care ; 26(SUPPL 1), 2022.
Article in English | EMBASE | ID: covidwho-1793857

ABSTRACT

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.

3.
Cogent Medicine ; 8, 2021.
Article in English | EMBASE | ID: covidwho-1617062

ABSTRACT

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.

4.
European Heart Journal ; 42(SUPPL 1):465, 2021.
Article in English | EMBASE | ID: covidwho-1554635

ABSTRACT

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.

5.
Front Med (Lausanne) ; 8: 711027, 2021.
Article in English | MEDLINE | ID: covidwho-1317231

ABSTRACT

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.

6.
Respir Investig ; 59(5): 602-607, 2021 Sep.
Article in English | MEDLINE | ID: covidwho-1270631

ABSTRACT

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.


Subject(s)
COVID-19 , Respiratory Insufficiency , Humans , Intensive Care Units , Male , Pandemics , Respiratory Insufficiency/epidemiology , Respiratory Insufficiency/etiology , Respiratory Insufficiency/therapy , Retrospective Studies , Risk Factors , SARS-CoV-2
7.
Respiration ; 100(8): 786-793, 2021.
Article in English | MEDLINE | ID: covidwho-1238620

ABSTRACT

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.


Subject(s)
COVID-19/therapy , Noninvasive Ventilation , Respiratory Care Units/statistics & numerical data , Respiratory Insufficiency/therapy , Aged , COVID-19/complications , COVID-19/mortality , Female , Health Personnel/statistics & numerical data , Humans , Male , Middle Aged , Respiratory Insufficiency/virology , Retrospective Studies , Sick Leave/statistics & numerical data , Switzerland/epidemiology
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