Oxygen Saturation in Hospitalized COVID-19 Patients and Its Relation to Colchicine Treatment: A Retrospective Cohort Study with an Updated Systematic Review.

Background: Colchicine has been proposed as a cytokine storm-blocking agent for COVID-19 due to its efficacy as an anti-inflammatory drug. The findings of the studies were contentious on the role of colchicine in preventing deterioration in COVID-19 patients. We aimed to evaluate the efficacy of colchicine in COVID-19-hospitalized patients. Design: A retrospective observational cohort study was carried out at three major isolation hospitals in Alexandria (Egypt), covering multiple centers. In addition, a systematic review was conducted by searching six different databases for published studies on the utilization of colchicine in patients with COVID-19 until March 2023. The primary outcome measure was to determine whether colchicine could decrease the number of days that the patient needed supplemental oxygen. The secondary outcomes were to evaluate whether colchicine could reduce the number of hospitalization days and mortality rate in these patients. Results: Out of 515 hospitalized COVID-19 patients, 411 were included in the survival analysis. After adjusting for the patients' characteristics, patients not receiving colchicine had a shorter length of stay (median: 7.0 vs. 6.0 days) and fewer days of supplemental oxygen treatment (median: 6.0 vs. 5.0 days), p < 0.05, but there was no significant difference in mortality rate. In a subgroup analysis based on oxygen equipment at admission, patients admitted on nasal cannula/face masks who did not receive colchicine had a shorter duration on oxygen supply than those who did [Hazard Ratio (HR) = 0.76 (CI 0.59-0.97)]. Using cox-regression analysis, clarithromycin compared to azithromycin in colchicine-treated patients was associated with a higher risk of longer duration on oxygen supply [HR = 1.77 (CI 1.04-2.99)]. Furthermore, we summarized 36 published colchicine studies, including 114,878 COVID-19 patients. Conclusions: COVID-19-hospitalized patients who were given colchicine had poorer outcomes in terms of the duration of supplemental oxygen use and the length of their hospital stay. Therefore, based on these findings, the use of colchicine is not recommended for COVID-19-hospitalized adults.

Factors associated with oxygen requirement and persistent symptoms 1 year after severe COVID-19 infection.

OBJECTIVE: We aimed to describe the prevalence and factors associated with the need for supplemental oxygen and persistent symptoms 1 year after severe SARS-CoV-2 infection. METHODS: In this historical cohort and nested case-control study, we included adults with severe COVID-19 (requiring admission to the intensive care unit or invasive mechanical ventilation). We evaluated factors associated with a need for supplemental oxygen and persistent symptoms 1 year after severe infection. RESULTS: We included 135 patients (median age 62 years, 30% women). At 1-year follow-up, the main symptoms were dyspnea (32%), myalgia (9%), cough (7%), anxiety (4%), and depression (5%); 12.59% of patients had prolonged requirement for supplemental oxygen. Factors associated with a persistent requirement for supplemental oxygen were female sex (odds ratio 3.15, 95% confidence interval 1.11-8.90) and Charlson Comorbidity Index > 4 (odds ratio 1.60, 95% confidence interval 1.20-2.12). CONCLUSIONS: We found that a high prevalence of supplemental oxygen requirement 1 year after severe COVID infection was associated with female sex and a baseline high rate of comorbidities. It is unknown whether this prevalence was related to other factors, such as the altitude at which patients lived. More than half of patients had prolonged post-COVID syndrome.

Hypoxic, anemic and cardiac hypoxemia: When does tissue hypoxia begin? / Hypoxische, anämische und kardial bedingte Hypoxämie: Wann beginnt die Hypoxie im Gewebe?

In case of hypoxemia, the oxygen content is often still in the lower normal range, so that there is no hypoxia in the tissue. If the hypoxia-threshold is reached in the tissue in hypoxic, anemic and also cardiac-related hypoxemia, identical counterregulations occur in the cell metabolism, regardless of the cause of hypoxemia. In clinical practice, this pathophysiologic fact is sometimes ignored, although depending on the cause of hypoxemia, assessment and therapy vary widely. While restrictive and generally accepted rules are specified in the transfusion guidelines for anemic hypoxemia, in the case of hypoxic hypoxia, the indication for invasive ventilation is made very early. The clinical assessment and indication are limited to the parameters oxygen saturation, oxygen partial pressure and oxygenation index. During the corona pandemic, misinterpretations of pathophysiology have become evident and may have led to unnecessary intubations. However, there is no evidence for the treatment of hypoxic hypoxia with ventilation. This review addresses the pathophysiology of the different types of hypoxia focusing on the problems associated with intubation and ventilation in the intensive care unit.

Positive end-expiratory pressure induced changes in airway driving pressure in mechanically ventilated COVID-19 Acute Respiratory Distress Syndrome patients.

BACKGROUND: The profile of changes in airway driving pressure (dPaw) induced by positive-end expiratory pressure (PEEP) might aid for individualized protective ventilation. Our aim was to describe the dPaw versus PEEP curves behavior in ARDS from COVID-19 patients. METHODS: Patients admitted in three hospitals were ventilated with fraction of inspired oxygen (FiO2) and PEEP initially adjusted by oxygenation-based table. Thereafter, PEEP was reduced from 20 until 6 cmH2O while dPaw was stepwise recorded and the lowest PEEP that minimized dPaw (PEEPmin_dPaw) was assessed. Each dPaw vs PEEP curve was classified as J-shaped, inverted-J-shaped, or U-shaped according to the difference between the minimum dPaw and the dPaw at the lowest and highest PEEP. In one hospital, hyperdistention and collapse at each PEEP were assessed by electrical impedance tomography (EIT). RESULTS: 184 patients (41 including EIT) were studied. 126 patients (68%) exhibited a J-shaped dPaw vs PEEP profile (PEEPmin_dPaw of 7.5 ± 1.9 cmH2O). 40 patients (22%) presented a U (PEEPmin_dPaw of 12.2 ± 2.6 cmH2O) and 18 (10%) an inverted-J profile (PEEPmin_dPaw of 14,6 ± 2.3 cmH2O). Patients with inverted-J profiles had significant higher body mass index (BMI) and lower baseline partial pressure of arterial oxygen/FiO2 ratio. PEEPmin_dPaw was associated with lower fractions of both alveolar collapse and hyperinflation. CONCLUSIONS: A PEEP adjustment procedure based on PEEP-induced changes in dPaw is feasible and may aid in individualized PEEP for protective ventilation. The PEEP required to minimize driving pressure was influenced by BMI and was low in the majority of patients.

Oxygen Consumption with High-Flow Nasal Oxygen versus Mechanical Ventilation- An International Multicenter Observational Study in COVID-19 Patients (PROXY-COVID).

The COVID-19 pandemic led to local oxygen shortages worldwide. To gain a better understanding of oxygen consumption with different respiratory supportive therapies, we conducted an international multicenter observational study to determine the precise amount of oxygen consumption with high-flow nasal oxygen (HFNO) and with mechanical ventilation. A retrospective observational study was conducted in three intensive care units (ICUs) in the Netherlands and Spain. Patients were classified as HFNO patients or ventilated patients, according to the mode of oxygen supplementation with which a patient started. The primary endpoint was actual oxygen consumption; secondary endpoints were hourly and total oxygen consumption during the first two full calendar days. Of 275 patients, 147 started with HFNO and 128 with mechanical ventilation. Actual oxygen use was 4.9-fold higher in patients who started with HFNO than in patients who started with ventilation (median 14.2 [8.4-18.4] versus 2.9 [1.8-4.1] L/minute; mean difference = 11.3 [95% CI 11.0-11.6] L/minute; P < 0.01). Hourly and total oxygen consumption were 4.8-fold (P < 0.01) and 4.8-fold (P < 0.01) higher. Actual oxygen consumption, hourly oxygen consumption, and total oxygen consumption are substantially higher in patients that start with HFNO compared with patients that start with mechanical ventilation. This information may help hospitals and ICUs predicting oxygen needs during high-demand periods and could guide decisions regarding the source of distribution of medical oxygen.

Home oxygen therapy from the emergency department for COVID-19 an observational study.

STUDY OBJECTIVE: During the COVID-19 pandemic, prescribing supplemental oxygen was a common reason for hospitalization of patients. We evaluated outcomes of COVID-19 patients discharged from the Emergency Department (ED) with home oxygen as part of a program to decrease hospital admissions. METHODS: We retrospectively observed COVID-19 patients with an ED visit resulting in direct discharge or observation from April 2020 to January 2022 at 14 hospitals in a single healthcare system. The cohort included those discharged with new oxygen supplementation, a pulse oximeter, and return instructions. Our primary outcome was subsequent hospitalization or death outside the hospital within 30 days of ED or observation discharge. RESULTS: Among 28,960 patients visiting the ED for COVID-19, providers admitted 11,508 (39.7%) to the hospital, placed 907 (3.1%) in observation status, and discharged 16,545 (57.1%) to home. A total of 614 COVID-19 patients (535 discharge to home and 97 observation unit) went home on new oxygen therapy. We observed the primary outcome in 151 (24.6%, CI 21.3-28.1%) patients. There were 148 (24.1%) patients subsequently hospitalized and 3 (0.5%) patients who died outside the hospital. The subsequent hospitalized mortality rate was 29.7% with 44 of the 148 patients admitted to the hospital dying. Mortality all cause at 30 days in the entire cohort was 7.7%. CONCLUSIONS: Most patients discharged to home with new oxygen for COVID-19 safely avoid later hospitalization and few patients die within 30 days. This suggests the feasibility of the approach and offers support for ongoing research and implementation efforts.

Associations between onychomycosis and COVID-19 clinical outcomes: a retrospective cohort study from a US metropolitan center.

Little is known about the relationship of COVID-19 outcomes with onychomycosis. We investigated the relationship of onychomycosis with COVID-19 outcomes. A retrospective cohort study was performed on SARS-CoV-2 positive adult outpatients or inpatients who had onychomycosis and other skin diseases. Overall, 430 adults were identified with SARS-CoV-2 and a skin disease, including 98 with diagnosed onychomycosis. In bivariable logistic regression models, onychomycosis was associated with increased hospitalization {odds ratio(OR) [95% confidence interval (CI)]: 3.56 [2.18-5.80]}, initial inpatient vs. outpatient visits (OR [95% CI]: 2.24 [1.35-3.74]), use of oxygen therapy (OR [95% CI]: 2.77 [1.60-4.79]), severe-critical vs. asymptomatic-mild severity (OR [95% CI]: 2.28 [1.32-3.94]), and death (OR [95% CI]: 7.48 [1.83-30.47]) from COVID-19, but not prolonged hospitalization (OR [95% CI]: 1.03 [0.47-2.25]). In multivariable models adjusting for socio-demographics, comorbidities, and immunosuppressant medication use, the associations with onychomycosis remained significant for hospitalization, inpatient visits, oxygen therapy, severe-critical COVID-19. Onychomycosis was a significant independent risk factor for COVID-19 severity, hospitalization, and receiving supplemental oxygen therapy.

Oxygen as a drug and scarce commodity: Do we use it rationally?

BACKGROUND:  Medical grade oxygen is classified as a drug and needs to be prescribed by a qualified healthcare professional. Oxygen therapy is prescribed to people who cannot maintain normal blood oxygen saturation while breathing atmospheric air. The coronavirus disease 2019 (COVID-19) pandemic highlighted the importance of the rational use of this scarce commodity. This study investigated oxygen therapy practices in adult ward patients. METHODS:  A cross-sectional study design with an analytical component was used in the adults wards at a National District Hospital and the Pelonomi Academic Hospital in Bloemfontein. Data were collected from patient files, interviews and oxygen measurements of adult patients that received oxygen. RESULTS:  One hundred and fifteen patients were included in the study, of whom 47.0% received oxygen without an oxygen prescription. Around 62.3% of the patients with prescriptions did not receive oxygen as prescribed. The prescriptions and oxygen administration for COVID-19 patients were better than for non-COVID-19 patients. A quarter of the patients possibly received oxygen therapy unnecessarily. CONCLUSION:  Poor oxygen therapy practices were identified, including prescription errors, oxygen administration errors and oxygen wastage. A protocol should be developed and implemented for the prescription and administration of oxygen therapy. Training should occur to prevent oxygen wastage.Contribution: This study highlighted poor oxygen practices and prescriptions, as well as oxygen wastage in the absence of local oxygen therapy guidelines.

Respiratory recovery trajectories after severe-to-critical COVID-19: a 1-year prospective multicentre study.

BACKGROUND: Survivors of severe-to-critical coronavirus disease 2019 (COVID-19) may have functional impairment, radiological sequelae and persistent symptoms requiring prolonged follow-up. This pragmatic study aimed to describe their clinical follow-up and determine their respiratory recovery trajectories, and the factors that could influence them and their health-related quality of life. METHODS: Adults hospitalised for severe-to-critical COVID-19 were evaluated at 3 months and up to 12 months post-hospital discharge in this prospective, multicentre, cohort study. RESULTS: Among 485 enrolled participants, 293 (60%) were reassessed at 6 months and 163 (35%) at 12 months; 89 (51%) and 47 (27%) of the 173 participants initially managed with standard oxygen were reassessed at 6 and 12 months, respectively. At 3 months, 34%, 70% and 56% of the participants had a restrictive lung defect, impaired diffusing capacity of the lung for carbon monoxide (D LCO) and significant radiological sequelae, respectively. During extended follow-up, both D LCO and forced vital capacity percentage predicted increased by means of +4 points at 6 months and +6 points at 12 months. Sex, body mass index, chronic respiratory disease, immunosuppression, pneumonia extent or corticosteroid use during acute COVID-19 and prolonged invasive mechanical ventilation (IMV) were associated with D LCO at 3 months, but not its trajectory thereafter. Among 475 (98%) patients with at least one chest computed tomography scan during follow-up, 196 (41%) had significant sequelae on their last images. CONCLUSIONS: Although pulmonary function and radiological abnormalities improved up to 1 year post-acute COVID-19, high percentages of severe-to-critical disease survivors, including a notable proportion of those managed with standard oxygen, had significant lung sequelae and residual symptoms justifying prolonged follow-up.

High flow nasal oxygen and awake prone positioning - Two allies against COVID-19: A systematic review.

INTRODUCTION: Severe acute respiratory distress syndrome coronavirus disease-2 (SARS-CoV-2) can lead to acute hypoxemic respiratory failure (AHRF) with possible multisystemic involvement. Ventilation/perfusion mismatch and shunt increase are critical determinants of hypoxemia. Understanding hypoxemia and the mechanisms involved in its genesis is essential to determine the optimal therapeutic strategy. High flow nasal oxygen (HFNO) and awake prone positioning (APP) in patients with COVID-19 AHRF showed promising benefits. The aim of this systematic review was to depict current situation around the combined use of HFNO and APP in patients with COVID-19 AHRF. Particularly, to investigate and report the pathophysiological rationale for adopting this strategy and to evaluate the (1) criteria for initiation, (2) timing, monitoring and discontinuation, and to assess the (3) impact of HFNO/ APP on outcome. METHODS: We performed a systematic search collecting the articles present in PubMed, Scopus, EMBASE, and Cochrane databases with the following keywords: COVID-19 pneumonia, high flow nasal oxygen, awake prone position ventilation. RESULTS: Thirteen studies displayed inclusion criteria and were included, accounting for 1242 patients who received HFNO/ APP. The combination of HFNO/ APP has an encouraging pathophysiological rationale for implementing this technique. The recognition of patients who can benefit from HFNO/ APP is difficult and there are no validated protocols to start, monitoring, and discontinue HFNO/ APP therapy. The most used method to monitor the efficacy and failure of this combined technique are oxygenation indexes, but discontinuation techniques are inconsistently and poorly described limiting possible generatability. Finally, this technique provided no clear benefits on outcome. CONCLUSIONS: Our systematic search provided positive feedbacks for improving the utilization of this combination technique, although we still need further investigation about methods to guide timing, management, and discontinuation, and to assess the intervention effect on outcome.

Peritoneal Oxygenation as a Novel Technique for Extrapulmonary Ventilation; A Review and Discussion of the Literature.

The COVID-19 crisis has highlighted the difficulties that might occur when attempting to oxygenate patients who have suffered a severe pulmonary insult, including in the development of acute respiratory distress syndrome (ARDS). Traditional mechanical ventilation (MV) is effective; however, in severe cases of hypoxia, the use of rescue therapy, such as extracorporeal membrane oxygenation (ECMO), may be required but is also associated with significant complexity and complications. In this review, we describe peritoneal oxygenation; a method of oxygenation that exploits the peritoneum's gas exchange properties in a fashion that is similar to peritoneal dialysis and has shown considerable promise in animal models. We have conducted a review of the available literature and techniques, including intraperitoneal perfluorocarbons, intraperitoneal jet ventilation, a continuous low-pressure oxygen system (PEROX) and the use of phospholipid-coated oxygen microbubbles (OMBs) through peritoneal microbubble oxygenation (PMO). We conclude that peritoneal oxygenation is a promising technique that warrants further investigation and might be used in clinical settings in the future.

Presenting characteristics, length of stay and oxygen use among COVID-19 cases at a single tertiary hospital in Auckland, New Zealand, using retrospective medical recorded data.

AIMS: The purpose of our current study was to analyse demographic and presenting characteristics of COVID-19 patients, including assigning clinical severity scores, and analyse with respect to oxygen utilisation and hospital course. METHODS: This was a retrospective observational study of COVID-positive patients presenting to the Emergency Department at Middlemore Hospital in Auckland, New Zealand. Data were collected between 1 August 2021 and 1 November 2021. They were followed through 20 December 2021. Data were obtained from both the EMR system and paper charts for all eligible patients during the study period. RESULTS: There were 171 patients included, with 187 patient presentations. Oxygen data were collected on 123 admitted patients and showed that 47% of admission time was spent off oxygen. Of the total presentations, the median length of stay (LOS) was 4 days. The severity of presenting illness was associated with disposition and predictive of LOS. CONCLUSIONS: Approximately half of the admitted patient's hospital time involved no oxygen use, which suggests that we may be able to further risk stratify in order to decrease the number and duration of hospital admissions going forward. As expected, clinical severity scores were associated with oxygen utilisation, disposition and LOS.

Hyperbaric oxygen for COVID-19 patients with severe hypoxia prior to vaccine availability.

Introduction: Few treatments have demonstrated mortality benefits among hospitalized hypoxic COVID-19 patients. We evaluated the use of hyperbaric oxygen (HBO2) therapy as a therapeutic intervention among hospitalized patients with a high oxygen requirement prior to vaccine approval. Methods: We extracted data on patients with COVID-19 hypoxia who required oxygen supplementation ranging from a 6L nasal cannula up to a high-flow nasal cannula at 100% FiO2 at 60L/minute with a 100% non-rebreather mask at 15 L/minute and were eligible for off-label HBO2 therapy from October 2020 to February 2021. We followed the Monitored Emergency use of Unregistered and Investigational Interventions or (MEURI) in conjunction with the consistent re-evaluation of the protocol using the Plan-Do-Study-Act (PDSA) tool [1]. We compared patient characteristics and used Fisher's exact test and a survival analysis to assess the primary endpoint of inpatient death. Results: HBO2 therapy was offered to 36 patients, of which 24 received treatment and 12 did not receive treatment. Patients who did not receive treatment were significantly older (p ≺ 0.01) and had worse baseline hypoxia (p = 0.06). Three of the 24 (13%) patients who received treatment died compared to six of 12 (50%) patients who did not receive treatment (RR ratio: 0.25, p = 0.04, 95% CI: 0.08 to 0.83). In the survival analysis, there was a statistically significant reduction in inpatient mortality in the treatment group (HR: 0.19, p = 0.02, 95% CI: 0.05-0.74). However, after adjusting for age and baseline hypoxia, there was no difference in inpatient mortality (hazard ratio: 0.48, p = 0.42, 95% CI: 0.08-2.86). Conclusion: The survival benefit of HBO2 therapy observed in our unadjusted analysis suggests that there may be therapeutic benefits of HBO2 in treating COVID-19 hypoxia as an adjunct to standard care.

Oxygen-Saturation Targets for Critically Ill Adults Receiving Mechanical Ventilation.

BACKGROUND: Invasive mechanical ventilation in critically ill adults involves adjusting the fraction of inspired oxygen to maintain arterial oxygen saturation. The oxygen-saturation target that will optimize clinical outcomes in this patient population remains unknown. METHODS: In a pragmatic, cluster-randomized, cluster-crossover trial conducted in the emergency department and medical intensive care unit at an academic center, we assigned adults who were receiving mechanical ventilation to a lower target for oxygen saturation as measured by pulse oximetry (Spo₂) (90%; goal range, 88 to 92%), an intermediate target (94%; goal range, 92 to 96%), or a higher target (98%; goal range, 96 to 100%). The primary outcome was the number of days alive and free of mechanical ventilation (ventilator-free days) through day 28. The secondary outcome was death by day 28, with data censored at hospital discharge. RESULTS: A total of 2541 patients were included in the primary analysis. The median number of ventilator-free days was 20 (interquartile range, 0 to 25) in the lower-target group, 21 (interquartile range, 0 to 25) in the intermediate-target group, and 21 (interquartile range, 0 to 26) in the higher-target group (P = 0.81). In-hospital death by day 28 occurred in 281 of the 808 patients (34.8%) in the lower-target group, 292 of the 859 patients (34.0%) in the intermediate-target group, and 290 of the 874 patients (33.2%) in the higher-target group. The incidences of cardiac arrest, arrhythmia, myocardial infarction, stroke, and pneumothorax were similar in the three groups. CONCLUSIONS: Among critically ill adults receiving invasive mechanical ventilation, the number of ventilator-free days did not differ among groups in which a lower, intermediate, or higher Spo₂ target was used. (Supported by the National Heart, Lung, and Blood Institute and others; PILOT ClinicalTrials.gov number, NCT03537937.).

A pilot phase Ib/II study of whole-lung low dose radiation therapy (LDRT) for the treatment of severe COVID-19 pneumonia: First experience from Africa.

BACKGROUND: Low dose radiation therapy (LDRT) has been used for non-malignant conditions since early 1900s based on the ability of single fractions between 50-150 cGy to inhibit cellular proliferation. Given scarcity of resources, poor access to vaccines and medical therapies within low and middle income countries, there is an urgent need to identify other cost-effective alternatives in management of COVID-19 pneumonia. We conducted a pilot phase Ib/II investigator-initiated clinical trial to assess the safety, feasibility, and toxicity of LDRT in patients with severe COVID-19 pneumonia at the Aga Khan University Hospital in Nairobi, Kenya. Additionally, we also assessed clinical benefit in terms of improvement in oxygenation at day 3 following LDRT and the ability to avoid mechanical ventilation at day 7 post LDRT. METHODS: Patients with both polymerase chain reaction (PCR) and high-resolution computer tomogram (HRCT) confirmed severe COVID-19 pneumonia, not improving on conventional therapy including Dexamethasone and with increasing oxygen requirement were enrolled in the study. Patients on mechanical ventilation were excluded. Eligible patients received a single 100cGy fraction to the whole lung. In the absence of any dose limiting toxicity the study proposed to treat a total of 10 patients. The primary endpoints were to assess the safety/feasibility, and toxicity within the first 24 hours post LDRT. The secondary endpoints were to assess efficacy of LDRT at Day 3, 7, 14 and 28 post LDRT. RESULTS: Ten patients were treated with LDRT. All (100%) of patients were able to complete LDRT without treatment related SAE within the first 24 hours post treatment. None of the patients treated with LDRT experienced any acute toxicity as defined by change in clinical and respiratory status at 24hr following LDRT. Majority (90%) of patients avoided mechanical ventilation within 7 days of LDRT. Four patients (40%) demonstrated at least 25% improvement in oxygen requirements within 3 days. Six patients (60%) were discharged and remained off oxygen, whereas four progressed and died (1 due to sepsis and 3 in cytokine storm). Median time to discharge (n = 6) was 16.5 days and median time to death (n = 4) was 11.0 days. Patients who ultimately died showed elevated inflammatory markers including Ferritin, CRP and D-dimers as compared to those who were discharged alive. CONCLUSION: LDRT was feasible, safe and shows promise in the management of severe COVID-19 pneumonia including in patients progressing on conventional systemic treatment. Additional phase II trials are warranted to identify patients most likely to benefit from LDRT.

Integrated therapeutic plasma exchange and traditional Chinese medicine treatment in a patient with severe COVID-19: A case report.

This report presents the case of a 59-year-old man with severe COVID-19 that gradually progressed to cytokine release syndrome and then acute respiratory distress syndrome; he was successfully treated via integration of therapeutic plasma exchange and traditional Chinese medicine. The patient initially presented with a sore throat, severe muscle aches, productive cough and fever. On the worsening of symptoms, remdesivir was administered. However, as the symptoms continued to worsen and a cytokine release syndrome was suspected, oxygen was provided through a high-flow nasal cannula (50 L/min) and therapeutic plasma exchange was performed to prevent worsening of the acute respiratory distress syndrome. On the same day, a course of traditional Chinese medicine was introduced in consultation with the infectious house staff. The patient's symptoms gradually improved; the levels of C-reactive protein and D-dimers reduced, and the patient was weaned to a simple oxygen mask and eventually to room air. This is the first reported case of the integration of these treatments. Together, they prevented the patient from requiring intubation, played a role in cytokine management, and also improved the clinical symptoms, including productive purulent sputum, cough, frequent stool passage and intermittent fever, with no adverse effects. As a result, the patient was discharged within two weeks of the integration of these treatments. Therefore, the integration of therapeutic plasma exchange and traditional Chinese medicine is an effective therapy for patients with severe COVID-19.

Bronchiolitis.

Viral bronchiolitis is the most common cause of admission to hospital for infants in high-income countries. Respiratory syncytial virus accounts for 60-80% of bronchiolitis presentations. Bronchiolitis is diagnosed clinically without the need for viral testing. Management recommendations, based predominantly on high-quality evidence, advise clinicians to support hydration and oxygenation only. Evidence suggests no benefit with use of glucocorticoids or bronchodilators, with further evidence required to support use of hypertonic saline in bronchiolitis. Evidence is scarce in the intensive care unit. Evidence suggests use of high-flow therapy in bronchiolitis is limited to rescue therapy after failure of standard subnasal oxygen only in infants who are hypoxic and does not decrease rates of intensive care unit admission or intubation. Despite systematic reviews and international clinical practice guidelines promoting supportive rather than interventional therapy, universal de-implementation of interventional care in bronchiolitis has not occurred and remains a major challenge.

Clinical Impact of Empirical Antibiotic Therapy in Patients With Coronavirus Disease 2019 Requiring Oxygen Therapy.

Despite the low prevalence of secondary bacterial infection in coronavirus disease 2019 (COVID-19) patients, most of them were administered antibiotic therapy empirically. However, the prognostic impact of empirical antibiotic therapy has not been evaluated. We conducted retrospective propensity score-matched case-control study of 233 COVID-19 patients with moderate to severe illnesses who required oxygen therapy and evaluated whether empirical antibiotic therapy could improve clinical outcomes. Empirical antibiotic therapy did not improve clinical outcomes including length of stay, days with oxygen requirement, the proportion of patients with increased oxygen demand, the proportion of patients who required mechanical ventilation, and overall mortality. This finding implies that routine administration of antibiotics for the treatment of COVID-19 is not essential and should be restricted.

Role and limitations of high-flow nasal oxygen therapy in COVID-19 patients: An observational study.

Background: The management of acute respiratory failure in COVID-19 patients and the role and limitations of high-flow nasal oxygen therapy (HFNOT) remain unclear. Aim: This study aimed to investigate the effect of HFNOT, identify the characteristics of patients who will benefit from therapy, and determine monitoring strategies to decide on endotracheal intubation for patients with COVID-19. Patients and Methods: We conducted a prospective observational study of COVID-19 patients who were admitted to the intensive care unit (ICU) and required HFNOT for at least 2 days between 20 March 2020 and 20 June 2020. The exclusion criteria were a severe respiratory failure, reduced levels of consciousness, combination with other noninvasive ventilation strategies, and exhaustion. The patients were followed up until ICU discharge. The primary outcome was the proportion of patients with COVID-19 who were successfully weaned from HFNOT, whereas failure comprised intubation or death on HFNOT. Results: Thirty-five subjects (24 males, mean-age: 61.62, standard deviation: 14.9 yr.) were included in the study. A total of 20/35 (57.1%) subjects survived to discharge. C-reactive-protein (CRP) and interleukin-6 (IL-6) levels were significantly increased in the treatment failure group (CRP; effect size (r):0.35, P: 0.037, IL-6; r: 0.37, P: 0.03). Although there was a difference between repeated measures of partial-pressure-of-oxygen/fraction-of-inspired-oxygen (PaO2/FiO2:P/F) rates (partial-eta-squared (ηp2):0.79, P < 0.001), no difference was found between carbon dioxide levels (ηp2:0.29, p: 0.44). There was also no difference between ROX (ratio-of-oxygen-saturation/FiO2 to respiratory-rate) rates (Kendall's W: 0.33 P = 0.310). Conclusion: In COVID-19 patients with mild-to-moderate dyspnea and hypoxemia who are nonresponsive to conventional-oxygen-therapies, the initial approach may involve the use of HFNOT. In this study, patient monitoring could be performed with ROX and P/F ratios, and the effectiveness of the treatment could be decided by looking at these rates in the second hour. Prolongation of the period and awake prone positioning did not improve the outcome.