Post extubation swallowing in critical patients with and without COVID-19 during the pandemic / Deglución post extubación de pacientes críticos con y sin diagnóstico de COVID-19 durante la pandemia

Estudios previos han caracterizado la disfagia en pacientes críticos hospitalizados que requieren intubación y ventilación mecánica invasiva. A raíz de la pandemia COVID-19 es necesario conocer las características deglutorias de pacientes diagnosticados con la enfermedad para su manejo. El objetivo de este estudio es analizar las características deglutorias de pacientes críticos extubados con y sin diagnóstico de COVID-19. Se llevó a cabo un estudio de cohorte retrospectivo con una muestra a conveniencia de 43 sujetos mayores de 15 años, ingresados al Hospital San Juan de Dios (Santiago, Chile) entre el 01 de junio y el 31 de agosto de 2020, intubados con o sin diagnóstico de COVID-19. Del total de sujetos, 22 padecieron de COVID-19 quienes estuvieron significativamente más días intubados que aquellos sin la patología (p=0,002). Inmediatamente posterior a la extubación orotraqueal, más del 90% de la muestra presentó disfagia. No hubo diferencia significativa en el nivel FILS ni asociación significativa en el grado de severidad de la disfagia entre sujetos con y sin COVID-19. Tampoco hubo diferencia significativa en el nivel FILS entre los grupos a los 10 días post-extubación. El nivel FILS a los 10 días aumentó significativamente en aquellos sujetos con COVID-19 (p=0,016) y sin COVID-19 (p=0,004). En la muestra, el nivel FILS y grado de severidad de la disfagia de los pacientes con y sin COVID-19 no mostraron diferencias estadísticas, siendo alto el porcentaje de disfagia en ambos grupos, lo que se podría asociar a la intubación orotraqueal y al tubo orotraqueal. Es necesaria la incorporación del fonoaudiólogo dentro de los equipos de Unidades de Pacientes Críticos para el manejo de los pacientes con COVID-19 y disfagia. Además, se recomienda continuar con más estudios en el área.

Previous research have described the deglutition disorders in critical hospitalised patients who required intubation and mechanical ventilation. In the pandemic context, it is mandatory to study both level and grade of dysphagia in patients suffering from COVID-19. The aim of this study is to analyse the deglutition features of extubated critical patients with and without COVID-19. A retrospective cohort study was performed, considering a convenience sample of 43 patients from 15 years old hospitalised at 'Hospital San Juan de Dios' between June 1st and August 31th 2020, who were intubated, with and without the diagnosis of COVID-19. 22of out 43 patients were diagnosed with COVID-19 who were intubated for significantly more days in comparison with those without COVID-19 (p=.002). After the intratracheal extubation, 90% of the sample was diagnosed with dysphagia. There was no significant difference in the FILS score nor significant association in dysphagia severity between patients with and without COVID-19. After 10 days post extubation, there was no significant difference in the FILS score between both groups. The FILS score increased significantly in the COVID-19 (p=.016) and non-COVID-19 (p=.004) patients after 10 days post extubation. Post extubation, there are no statistical differences in the FILS score and dysphagia severity in critical ill patients with and without COVID-19, with a high percentage of dysphagia in both groups which could be associated with intratracheal intubation and endotracheal tubes. The incorporation of speech and language therapists in Critical Care Units is mandatory. Furthermore, it is recommended to perform extra research in the area.

Prevention of COVID-19 aerosol exposure during orotracheal intubation / Prevenção da exposição ao aerossol COVID-19 durante a intubação orotraqueal / Prevención de la exposición a aerosoles de COVID-19 durante la intubación orotraqueal

Background and objectives: during orotracheal intubation (OTI), it occurs the exposure to COVID-19 aerosols and consequent contamination of the professionals involved, observing the need to apply preventive measures. The objective is to know, in the scientific literature, which are the main preventive measures for health professionals to aerosols generated during OTI of patients suspected or confirmed for COVID-19. Contents: this is an integrative review, with search in the LILACS, SciELO, BDENF, MEDLINE, PubMed and Cochrane Wiley databases. Primary articles, with full text in Portuguese, Spanish and English, which contemplated the research objective, were selected. Of the 335 articles found, 22 were selected according to the inclusion criteria. In 18 (82%) of articles, they highlighted the use of barrier methods when performing the intubation procedure, such as acrylic box and plastic tarpaulin. In other studies (3; 14%), it was observed the need to include qualified intubation teams in hospital institutions to reduce the contamination of professionals, in addition to the application of checklists that guide the procedure. A single article brought the use of an orthopedic protective cover adapted to protect the intubator. Conclusion: the measures are defended to reduce exposure to aerosols and allow the safety of health professionals. The use of an intubation box must be used with caution, weighing the risks and benefits against the possibility of aerosolization during its use in orotracheal intubation.(AU)

Justificativa e objetivos: durante a intubação orotraqueal (IOT), ocorre a exposição a aerossóis de COVID-19 e consequente contaminação dos profissionais envolvidos, observando a necessidade de aplicação de medidas preventivas. O objetivo é conhecer, na literatura científica, quais são as principais medidas preventivas dos profissionais de saúde aos aerossóis gerados durante a IOT de pacientes suspeitos ou confirmados para COVID-19. Conteúdo: trata-se de uma revisão integrativa, com busca nas bases de dados LILACS, SciELO, BDENF, MEDLINE, PubMed e Cochrane Wiley. Foram selecionados artigos primários, com texto completo em português, espanhol e inglês, que contemplassem o objetivo da pesquisa. Dos 335 artigos encontrados, 22 foram selecionados de acordo com os critérios de inclusão. Em 18 (82%) dos artigos, destacaram o uso de métodos de barreira na realização do procedimento de intubação, como caixa de acrílico e lona plástica. Em outros estudos (3; 14%), observou-se a necessidade de incluir equipes de intubação qualificadas nas instituições hospitalares para reduzir a contaminação dos profissionais, além da aplicação de checklists que orientam o procedimento. Um único artigo trouxe o uso de uma capa protetora ortopédica adaptada para proteger o intubador. Conclusão: defendem-se as medidas para reduzir a exposição aos aerossóis e permitir a segurança dos profissionais de saúde. O uso da caixa de intubação deve ser feito com cautela, ponderando os riscos e benefícios em relação à possibilidade de aerossolização durante seu uso na intubação orotraqueal.(AU)

Justificación y objetivos: durante la intubación orotraqueal (OTI), ocurre la exposición a los aerosoles de COVID-19 y la consecuente contaminación de los profesionales involucrados, observándose la necesidad de aplicar medidas preventivas. El objetivo es conocer, en la literatura científica, cuáles son las principales medidas preventivas de los profesionales de la salud ante los aerosoles generados durante las IOT de pacientes sospechosos o confirmados de COVID-19. Contenido: se trata de una revisión integradora, con búsqueda en las bases de datos LILACS, SciELO, BDENF, MEDLINE, PubMed y Cochrane Wiley. Fueron seleccionados artículos primarios, con texto completo en portugués, español e inglés, que contemplaran el objetivo de la investigación. De los 335 artículos encontrados, 22 fueron seleccionados según los criterios de inclusión. En 18 (82%) de los artículos, destacaron el uso de métodos de barrera al realizar el procedimiento de intubación, como caja de acrílico y lona plástica. En otros estudios (3; 14%), se observó la necesidad de incluir equipos de intubación calificados en las instituciones hospitalarias para reducir la contaminación de los profesionales, además de la aplicación de listas de verificación que orientan el procedimiento. Un solo artículo trajo el uso de una cubierta protectora ortopédica adaptada para proteger al intubador. Conclusión: se defienden las medidas para reducir la exposición a los aerosoles y permitir la seguridad de los profesionales de la salud. El uso de una caja de intubación debe hacerse con precaución, sopesando los riesgos y beneficios frente a la posibilidad de aerosolización durante su uso en la intubación orotraqueal.(AU)

Noninvasive respiratory support outside the intensive care unit for acute respiratory failure related to coronavirus-19 disease: a systematic review and meta-analysis.

BACKGROUND: Noninvasive respiratory support (NIRS) has been diffusely employed outside the intensive care unit (ICU) to face the high request of ventilatory support due to the massive influx of patients with acute respiratory failure (ARF) caused by coronavirus-19 disease (COVID-19). We sought to summarize the evidence on clinically relevant outcomes in COVID-19 patients supported by NIV outside the ICU. METHODS: We searched PUBMED®, EMBASE®, and the Cochrane Controlled Clinical trials register, along with medRxiv and bioRxiv repositories for pre-prints, for observational studies and randomized controlled trials, from inception to the end of February 2021. Two authors independently selected the investigations according to the following criteria: (1) observational study or randomized clinical trials enrolling ≥ 50 hospitalized patients undergoing NIRS outside the ICU, (2) laboratory-confirmed COVID-19, and (3) at least the intra-hospital mortality reported. Preferred Reporting Items for Systematic reviews and Meta-analysis guidelines were followed. Data extraction was independently performed by two authors to assess: investigation features, demographics and clinical characteristics, treatments employed, NIRS regulations, and clinical outcomes. Methodological index for nonrandomized studies tool was applied to determine the quality of the enrolled studies. The primary outcome was to assess the overall intra-hospital mortality of patients under NIRS outside the ICU. The secondary outcomes included the proportions intra-hospital mortalities of patients who underwent invasive mechanical ventilation following NIRS failure and of those with 'do-not-intubate' (DNI) orders. RESULTS: Seventeen investigations (14 peer-reviewed and 3 pre-prints) were included with a low risk of bias and a high heterogeneity, for a total of 3377 patients. The overall intra-hospital mortality of patients receiving NIRS outside the ICU was 36% [30-41%]. 26% [21-30%] of the patients failed NIRS and required intubation, with an intra-hospital mortality rising to 45% [36-54%]. 23% [15-32%] of the patients received DNI orders with an intra-hospital mortality of 72% [65-78%]. Oxygenation on admission was the main source of between-study heterogeneity. CONCLUSIONS: During COVID-19 outbreak, delivering NIRS outside the ICU revealed as a feasible strategy to cope with the massive demand of ventilatory assistance. REGISTRATION: PROSPERO, https://www.crd.york.ac.uk/prospero/ , CRD42020224788, December 11, 2020.

COVID-19-associated aspergillosis in a Brazilian referral centre: Diagnosis, risk factors and outcomes.

BACKGROUND: COVID-19 patients on mechanical ventilation are at risk to develop invasive aspergillosis. To provide additional data regarding this intriguing entity, we conducted a retrospective study describing risk factors, radiology and prognosis of this emerging entity in a Brazilian referral centre. METHODS: This retrospective study included intubated (≥18 years) patients with COVID-19 admitted from April 2020 until July 2021 that had bronchoscopy to investigate pulmonary co-infections. COVID-19-associated aspergillosis (CAPA) was defined according to the 2020 European Confederation of Medical Mycology/International Society of Human and Animal Mycosis consensus criteria. The performance of tracheal aspirate (TA) cultures to diagnose CAPA were described, as well as the radiological findings, risk factors and outcomes. RESULTS: Fourteen patients (14/87, 16%) had probable CAPA (0.9 cases per 100 ICU admissions). The sensitivity, specificity, positive predictive value and negative predictive value of TA for the diagnosis of CAPA were 85.7%, 73.1%, 46.2% and 95% respectively. Most of the radiological findings of CAPA were classified as typical of invasive pulmonary aspergillosis (64.3%). The overall mortality rate of probable CAPA was 71.4%. Age was the only independent risk factor for CAPA [p = .03; odds ratio (OR) 1.072]. CAPA patients under renal replacement therapy (RRT) may have a higher risk for a fatal outcome (p = .053, hazard ratio 8.047). CONCLUSIONS: CAPA was a prevalent co-infection in our cohort of patients under mechanical ventilation. Older patients had a higher risk to develop CAPA, and a poor prognosis may be associated with RRT.

Plasma microparticles of intubated COVID-19 patients cause endothelial cell death, neutrophil adhesion and netosis, in a phosphatidylserine-dependent manner.

COVID-19 has compelled scientists to better describe its pathophysiology to find new therapeutic approaches. While risk factors, such as older age, obesity, and diabetes mellitus, suggest a central role of endothelial cells (ECs), autopsies have revealed clots in the pulmonary microvasculature that are rich in neutrophils and DNA traps produced by these cells, called neutrophil extracellular traps (NETs.) Submicron extracellular vesicles, called microparticles (MPs), are described in several diseases as being involved in pro-inflammatory pathways. Therefore, in this study, we analyzed three patient groups: one for which intubation was not necessary, an intubated group, and one group after extubation. In the most severe group, the intubated group, platelet-derived MPs and endothelial cell (EC)-derived MPs exhibited increased concentration and size, when compared to uninfected controls. MPs of intubated COVID-19 patients triggered EC death and overexpression of two adhesion molecules: P-selectin and vascular cell adhesion molecule-1 (VCAM-1). Strikingly, neutrophil adhesion and NET production were increased following incubation with these ECs. Importantly, we also found that preincubation of these COVID-19 MPs with the phosphatidylserine capping endogenous protein, annexin A5, abolished cytotoxicity, P-selectin and VCAM-1 induction, all like increases in neutrophil adhesion and NET release. Taken together, our results reveal that MPs play a key role in COVID-19 pathophysiology and point to a potential therapeutic: annexin A5.

Face mask versus nasal prong or nasopharyngeal tube for neonatal resuscitation in the delivery room: a systematic review and meta-analysis.

IMPORTANCE: The current neonatal resuscitation guidelines recommend positive pressure ventilation via face mask or nasal prongs at birth. Using a nasal interface may have the potential to improve outcomes for newborn infants. OBJECTIVE: To determine whether nasal prong/nasopharyngeal tube versus face mask during positive pressure ventilation of infants born <37 weeks' gestation in the delivery room reduces in-hospital mortality and morbidity. DATA SOURCES: MEDLINE (through PubMed), Google Scholar and EMBASE, Clinical Trials.gov and the Cochrane Central Register of Controlled Trials through August 2019. STUDY SELECTION: Randomised controlled trials comparing nasal prong/nasopharyngeal tube versus face mask during positive pressure ventilation of infants born <37 weeks' gestation in the delivery room. DATA ANALYSIS: Risk of bias was assessed using the Covidence Collaboration Tool, results were pooled into a meta-analysis using a random effects model. MAIN OUTCOME: In-hospital mortality. RESULTS: Five RCTs enrolling 873 infants were combined into a meta-analysis. There was no statistical difference in in-hospital mortality (risk ratio (RR 0.98, 95% CI 0.63 to 1.52, p=0.92, I2=11%), rate of chest compressions in the delivery room (RR 0.37, 95% CI 0.10 to 1.33, p=0.13, I2=28%), rate of intraventricular haemorrhage (RR 1.54, 95% CI 0.88 to 2.70, p=0.13, I2=0%) or delivery room intubations in infants ventilated with a nasal prong/tube (RR 0.63, 95% CI 0.39,1.02, p=0.06, I2=52%). CONCLUSION: In infants born <37 weeks' gestation, in-hospital mortality and morbidity were similar following positive pressure ventilation during initial stabilisation with a nasal prong/tube or a face mask.

Bacterial and fungal growth in sputum cultures from 165 COVID-19 pneumonia patients requiring intubation: evidence for antimicrobial resistance development and analysis of risk factors.

BACKGROUND: Coronavirus SARS-CoV-2 causes COVID-19 illness which can progress to severe pneumonia. Empiric antibacterials are often employed though frequency of bacterial coinfection superinfection is debated and concerns raised about selection of bacterial antimicrobial resistance. We evaluated sputum bacterial and fungal growth from 165 intubated COVID-19 pneumonia patients. Objectives were to determine frequency of culture positivity, risk factors for and outcomes of positive cultures, and timing of antimicrobial resistance development. METHODS: Retrospective reviews were conducted of COVID-19 pneumonia patients requiring intubation admitted to a 1058-bed four community hospital system on the east coast United States, March 1 to May 1, 2020. Length of stay (LOS) was expressed as mean (standard deviation); 95% confidence interval (95% CI) was computed for overall mortality rate using the exact binomial method, and overall mortality was compared across each level of a potential risk factor using a Chi-Square Test of Independence. All tests were two-sided, and significance level was set to 0.05. RESULTS: Average patient age was 68.7 years and LOS 19.9 days. Eighty-three patients (50.3% of total) originated from home, 10 from group homes (6.1% of total), and 72 from nursing facilities (43.6% of total). Mortality was 62.4%, highest for nursing home residents (80.6%). Findings from 253 sputum cultures overall did not suggest acute bacterial or fungal infection in 73 (45%) of 165 individuals sampled within 24 h of intubation. Cultures ≥ 1 week following intubation did grow potential pathogens in 72 (64.9%) of 111 cases with 70.8% consistent with late pneumonia and 29.2% suggesting colonization. Twelve (10.8% of total) of these late post-intubation cultures revealed worsened antimicrobial resistance predominantly in Pseudomonas, Enterobacter, or Staphylococcus aureus. CONCLUSIONS: In severe COVID-19 pneumonia, a radiographic ground glass interstitial pattern and lack of purulent sputum prior to/around the time of intubation correlated with no culture growth or recovery of normal oral flora ± yeast. Discontinuation of empiric antibacterials should be considered in these patients aided by other clinical findings, history of prior antimicrobials, laboratory testing, and overall clinical course. Continuing longterm hospitalisation and antibiotics are associated with sputum cultures reflective of hospital-acquired microbes and increasing antimicrobial resistance. TRIAL REGISTRATION: Not applicable as this was a retrospective chart review study without interventional arm.

Effect of mortality from COVID-19 on inpatient outcomes.

When hospitals first encountered coronavirus disease 2019 (COVID-19), there was a dearth of therapeutic options and nearly 1 in 3 patients died from the disease. By the summer of 2020, as deaths from the disease declined nationally, multiple single-center studies began to report declining mortality of patients with COVID-19. To evaluate the effect of COVID-19 on hospital-based mortality, we searched the Vizient Clinical Data Base for outcomes data from approximately 600 participating hospitals, including 130 academic medical centers, from January 2017 through December 2020. More than 32 million hospital admissions were included in the analysis. After an initial spike, mortality from COVID-19 declined in all regions of the country to under 10% by June 2020 and remained constant for the remainder of the year. Despite this, inpatient, all-cause mortality has increased since the beginning of the pandemic, even those without respiratory failure. Inpatient mortality has particularly increased in elderly patients and in those requiring intubation for respiratory failure. Since June 2020, COVID-19 kills one in every 10 patients admitted to the hospital with this diagnosis. The addition of this new disease has raised overall hospital mortality especially those who require intubation for respiratory failure.

Safety and efficacy of Favipiravir in moderate to severe SARS-CoV-2 pneumonia.

BACKGROUND: We examined the safety and efficacy of a treatment protocol containing Favipiravir for the treatment of SARS-CoV-2. METHODS: We did a multicenter randomized open-labeled clinical trial on moderate to severe cases infections of SARS-CoV-2. Patients with typical ground glass appearance on chest computerized tomography scan (CT scan) and oxygen saturation (SpO2) of less than 93% were enrolled. They were randomly allocated into Favipiravir (1.6 gr loading, 1.8 gr daily) and Lopinavir/Ritonavir (800/200 mg daily) treatment regimens in addition to standard care. In-hospital mortality, ICU admission, intubation, time to clinical recovery, changes in daily SpO2 after 5 min discontinuation of supplemental oxygen, and length of hospital stay were quantified and compared in the two groups. RESULTS: 380 patients were randomly allocated into Favipiravir (193) and Lopinavir/Ritonavir (187) groups in 13 centers. The number of deaths, intubations, and ICU admissions were not significantly different (26, 27, 31 and 21, 17, 25 respectively). Mean hospital stay was also not different (7.9 days [SD = 6] in the Favipiravir and 8.1 [SD = 6.5] days in Lopinavir/Ritonavir groups) (p = 0.61). Time to clinical recovery in the Favipiravir group was similar to Lopinavir/Ritonavir group (HR = 0.94, 95% CI 0.75 - 1.17) and likewise the changes in the daily SpO2 after discontinuation of supplemental oxygen (p = 0.46) CONCLUSION: Adding Favipiravir to the treatment protocol did not reduce the number of ICU admissions or intubations or In-hospital mortality compared to Lopinavir/Ritonavir regimen. It also did not shorten time to clinical recovery and length of hospital stay.

Video-based reflection on neonatal interventions during COVID-19 using eye-tracking glasses: an observational study.

OBJECTIVE: The aim of this study was to determine the experience with, and the feasibility of, point-of-view video recordings using eye-tracking glasses for training and reviewing neonatal interventions during the COVID-19 pandemic. DESIGN: Observational prospective single-centre study. SETTING: Neonatal intensive care unit at the Leiden University Medical Center. PARTICIPANTS: All local neonatal healthcare providers. INTERVENTION: There were two groups of participants: proceduralists, who wore eye-tracking glasses during procedures, and observers who later watched the procedures as part of a video-based reflection. MAIN OUTCOME MEASURES: The primary outcome was the feasibility of, and the proceduralists and observers' experience with, the point-of-view eye-tracking videos as an additional tool for bedside teaching and video-based reflection. RESULTS: We conducted 12 point-of-view recordings on 10 different patients (median gestational age of 30.9±3.5 weeks and weight of 1764 g) undergoing neonatal intubation (n=5), minimally invasive surfactant therapy (n=5) and umbilical line insertion (n=2). We conducted nine video-based observations with a total of 88 observers. The use of point-of-view recordings was perceived as feasible. Observers further reported the point-of-view recordings to be an educational benefit for them and a potentially instructional tool during COVID-19. CONCLUSION: We proved the practicability of eye-tracking glasses for point-of-view recordings of neonatal procedures and videos for observation, educational sessions and logistics considerations, especially with the COVID-19 pandemic distancing measures reducing bedside teaching opportunities.

Static compliance and driving pressure are associated with ICU mortality in intubated COVID-19 ARDS.

BACKGROUND: Pathophysiological features of coronavirus disease 2019-associated acute respiratory distress syndrome (COVID-19 ARDS) were indicated to be somewhat different from those described in nonCOVID-19 ARDS, because of relatively preserved compliance of the respiratory system despite marked hypoxemia. We aim ascertaining whether respiratory system static compliance (Crs), driving pressure (DP), and tidal volume normalized for ideal body weight (VT/kg IBW) at the 1st day of controlled mechanical ventilation are associated with intensive care unit (ICU) mortality in COVID-19 ARDS. METHODS: Observational multicenter cohort study. All consecutive COVID-19 adult patients admitted to 25 ICUs belonging to the COVID-19 VENETO ICU network (February 28th-April 28th, 2020), who received controlled mechanical ventilation, were screened. Only patients fulfilling ARDS criteria and with complete records of Crs, DP and VT/kg IBW within the 1st day of controlled mechanical ventilation were included. Crs, DP and VT/kg IBW were collected in sedated, paralyzed and supine patients. RESULTS: A total of 704 COVID-19 patients were screened and 241 enrolled. Seventy-one patients (29%) died in ICU. The logistic regression analysis showed that: (1) Crs was not linearly associated with ICU mortality (p value for nonlinearity = 0.01), with a greater risk of death for values < 48 ml/cmH2O; (2) the association between DP and ICU mortality was linear (p value for nonlinearity = 0.68), and increasing DP from 10 to 14 cmH2O caused significant higher odds of in-ICU death (OR 1.45, 95% CI 1.06-1.99); (3) VT/kg IBW was not associated with a significant increase of the risk of death (OR 0.92, 95% CI 0.55-1.52). Multivariable analysis confirmed these findings. CONCLUSIONS: Crs < 48 ml/cmH2O was associated with ICU mortality, while DP was linearly associated with mortality. DP should be kept as low as possible, even in the case of relatively preserved Crs, irrespective of VT/kg IBW, to reduce the risk of death.

Association between Hyperglycemia at Hospital Presentation and Hospital Outcomes in COVID-19 Patients with and without Type 2 Diabetes: A Retrospective Cohort Study of Hospitalized Inner-City COVID-19 Patients.

This study aimed to determine the relationships among hyperglycemia (HG), the presence of type 2 diabetes (T2D), and the outcomes of COVID-19. Demographic data, blood glucose levels (BG) measured on admission, and hospital outcomes of COVID-19 patients hospitalized at Boston University Medical Center from 1 March to 4 August 2020 were extracted from the hospital database. HG was defined as BG > 200 mg/dL. Patients with type 1 diabetes or BG < 70 mg/dL were excluded. A total of 458 patients with T2D and 976 patients without T2D were included in the study. The mean ± SD age was 56 ± 17 years and 642 (45%) were female. HG occurred in 193 (42%) and 42 (4%) of patients with and without T2D, respectively. Overall, the in-hospital mortality rate was 9%. Among patients without T2D, HG was statistically significantly associated with mortality, ICU admission, intubation, acute kidney injury, and severe sepsis/septic shock, after adjusting for potential confounders (p < 0.05). However, only ICU admission and acute kidney injury were associated with HG among patients with T2D (p < 0.05). Among the 235 patients with HG, the presence of T2D was associated with decreased odds of mortality, ICU admission, intubation, and severe sepsis/septic shock, after adjusting for potential confounders, including BG (p < 0.05). In conclusion, HG in the subset of patients without T2D could be a strong indicator of high inflammatory burden, leading to a higher risk of severe COVID-19.

Viral load dynamics in intubated patients with COVID-19 admitted to the intensive care unit.

BACKGROUND: Prolonged viral RNA detection in respiratory samples from patients with COVID-19 has been described, but the clinical relevance remains unclear. We studied the dynamics of SARS-CoV-2 on a group and individual level in intubated ICU patients. METHODS: In a cohort of 86 patients, we analysed SARS-CoV-2 RT-PCR results on nasopharyngeal and sputum samples (obtained as part of clinical care twice a week) according to time after intubation. Subsequently, we performed survival analyses. RESULTS: 870 samples were tested by RT-PCR. Overall viral load was highest in the first week (median nasopharynx 3.5, IQR 1.5-4.3; median sputum 4.3, IQR 3.3-5.6) and decreased over time. In 20% of patients a relapsing pattern was observed. Nasopharyngeal and sputum PCR status on day 14 was not significantly associated with survival up to day 60 in this small cohort. CONCLUSION: In general SARS-CoV-2 RNA levels in respiratory samples in patients with severe COVID-19 decrease after the first week after intubation, but individual SARS-CoV-2 RNA levels can show a relapsing pattern. Larger studies are needed to address the association of clearance of SARS-CoV-2 RNA from respiratory samples with survival, because we observed a trend towards better survival in patients with early clearance from sputum.

COVID-IRS: A novel predictive score for risk of invasive mechanical ventilation in patients with COVID-19.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a systemic disease that can rapidly progress into acute respiratory failure and death. Timely identification of these patients is crucial for a proper administration of health-care resources. OBJECTIVE: To develop a predictive score that estimates the risk of invasive mechanical ventilation (IMV) among patients with COVID-19. STUDY DESIGN: Retrospective cohort study of 401 COVID-19 patients diagnosed from March 12, to August 10, 2020. The score development cohort comprised 211 patients (52.62% of total sample) whereas the validation cohort included 190 patients (47.38% of total sample). We divided participants according to the need of invasive mechanical ventilation (IMV) and looked for potential predictive variables. RESULTS: We developed two predictive scores, one based on Interleukin-6 (IL-6) and the other one on the Neutrophil/Lymphocyte ratio (NLR), using the following variables: respiratory rate, SpO2/FiO2 ratio and lactic dehydrogenase (LDH). The area under the curve (AUC) in the development cohort was 0.877 (0.823-0.931) using the NLR based score and 0.891 (0.843-0.939) using the IL-6 based score. When compared with other similar scores developed for the prediction of adverse outcomes in COVID-19, the COVID-IRS scores proved to be superior in the prediction of IMV. CONCLUSION: The COVID-IRS scores accurately predict the need for mechanical ventilation in COVID-19 patients using readily available variables taken upon admission. More studies testing the applicability of COVID-IRS in other centers and populations, as well as its performance as a triage tool for COVID-19 patients are needed.

Prone position in intubated, mechanically ventilated patients with COVID-19: a multi-centric study of more than 1000 patients.

BACKGROUND: Limited data are available on the use of prone position in intubated, invasively ventilated patients with Coronavirus disease-19 (COVID-19). Aim of this study is to investigate the use and effect of prone position in this population during the first 2020 pandemic wave. METHODS: Retrospective, multicentre, national cohort study conducted between February 24 and June 14, 2020, in 24 Italian Intensive Care Units (ICU) on adult patients needing invasive mechanical ventilation for respiratory failure caused by COVID-19. Clinical data were collected on the day of ICU admission. Information regarding the use of prone position was collected daily. Follow-up for patient outcomes was performed on July 15, 2020. The respiratory effects of the first prone position were studied in a subset of 78 patients. Patients were classified as Oxygen Responders if the PaO2/FiO2 ratio increased ≥ 20 mmHg during prone position and as Carbon Dioxide Responders if the ventilatory ratio was reduced during prone position. RESULTS: Of 1057 included patients, mild, moderate and severe ARDS was present in 15, 50 and 35% of patients, respectively, and had a resulting mortality of 25, 33 and 41%. Prone position was applied in 61% of the patients. Patients placed prone had a more severe disease and died significantly more (45% vs. 33%, p < 0.001). Overall, prone position induced a significant increase in PaO2/FiO2 ratio, while no change in respiratory system compliance or ventilatory ratio was observed. Seventy-eight % of the subset of 78 patients were Oxygen Responders. Non-Responders had a more severe respiratory failure and died more often in the ICU (65% vs. 38%, p = 0.047). Forty-seven % of patients were defined as Carbon Dioxide Responders. These patients were older and had more comorbidities; however, no difference in terms of ICU mortality was observed (51% vs. 37%, p = 0.189 for Carbon Dioxide Responders and Non-Responders, respectively). CONCLUSIONS: During the COVID-19 pandemic, prone position has been widely adopted to treat mechanically ventilated patients with respiratory failure. The majority of patients improved their oxygenation during prone position, most likely due to a better ventilation perfusion matching. TRIAL REGISTRATION: clinicaltrials.gov number: NCT04388670.

Progression and Resolution of COVID-19 Pneumonia on Chest Radiograph.

OBJECTIVE: To evaluate the temporal changes on serial chest radiographs (CXRs)of hospitalised COVID-19 positive patients till their outcome(discharge/death); to determine the severity of CXR score and its correlation with clinical outcome (hospital stay, chest intubation and mortality). STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Shifa International Hospital (SIH), Islamabad from March to June 2020. METHODOLOGY: After IRB approval, 112 patients were consecutively enrolled, having laboratory-confirmed SARS-CoV-2 and hospitalised in SIH. Patients' demographics and clinical data were retrieved from Radiology Information System (RIS). Chest radiographs (CXR) were retrieved from picture archive and communication system (PACS). CXR severity scoring was determined by three radiologists, and results were analysed. RESULTS: Lung opacities (98.2%), involvement of both lungs (96.4%), both peripheral and central region involvement (62.5%) and upper/mid/lower zone distribution (61.6%) were the most frequent findings. Males affected more than females with a mean age of 58.9 ± 13.1 years. Zonal involvement, density and extent of opacities peaked on 10-13th day of illness. In the last CXR, opacities showed decrease in extent as well as density, reduction in zonal involvement, and few having mixed interstitial thickening/fibrosis. One hundred and five out of 112 (93.8%) patients had residual radiographic abnormalities on discharge. CONCLUSION: Serial chest radiography can be used to monitor disease progression and temporal changes after initial HRCT. Patients who have CXR severity score of 4 or more at the time of admission, is a red flag for prolonged hospital stay and possible intubation. Severity of CXR findings peaked at 10-13 days. It is recommended to repeat CXRs every 3-4th day during hospital stay. Majority of the patients has residual radiographic abnormality on discharge. Key Words: COVID-19, Radiography, Thoracic, Pandemic, Chest X-ray.