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1.
J Med Internet Res ; 24(2): e28890, 2022 02 15.
Article in English | MEDLINE | ID: covidwho-1686308

ABSTRACT

BACKGROUND: Commercially available wearable (ambulatory) pulse oximeters have been recommended as a method for managing patients at risk of physiological deterioration, such as active patients with COVID-19 disease receiving care in hospital isolation rooms; however, their reliability in usual hospital settings is not known. OBJECTIVE: We report the performance of wearable pulse oximeters in a simulated clinical setting when challenged by motion and low levels of arterial blood oxygen saturation (SaO2). METHODS: The performance of 1 wrist-worn (Wavelet) and 3 finger-worn (CheckMe O2+, AP-20, and WristOx2 3150) wearable, wireless transmission-mode pulse oximeters was evaluated. For this, 7 motion tasks were performed: at rest, sit-to-stand, tapping, rubbing, drinking, turning pages, and using a tablet. Hypoxia exposure followed, in which inspired gases were adjusted to achieve decreasing SaO2 levels at 100%, 95%, 90%, 87%, 85%, 83%, and 80%. Peripheral oxygen saturation (SpO2) estimates were compared with simultaneous SaO2 samples to calculate the root-mean-square error (RMSE). The area under the receiver operating characteristic curve was used to analyze the detection of hypoxemia (ie, SaO2<90%). RESULTS: SpO2 estimates matching 215 SaO2 samples in both study phases, from 33 participants, were analyzed. Tapping, rubbing, turning pages, and using a tablet degraded SpO2 estimation (RMSE>4% for at least 1 device). All finger-worn pulse oximeters detected hypoxemia, with an overall sensitivity of ≥0.87 and specificity of ≥0.80, comparable to that of the Philips MX450 pulse oximeter. CONCLUSIONS: The SpO2 accuracy of wearable finger-worn pulse oximeters was within that required by the International Organization for Standardization guidelines. Performance was degraded by motion, but all pulse oximeters could detect hypoxemia. Our findings support the use of wearable, wireless transmission-mode pulse oximeters to detect the onset of clinical deterioration in hospital settings. TRIAL REGISTRATION: ISRCTN Registry 61535692; http://www.isrctn.com/ISRCTN61535692. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1136/bmjopen-2019-034404.


Subject(s)
COVID-19 , Wearable Electronic Devices , Humans , Hypoxia/diagnosis , Oximetry , Reproducibility of Results , SARS-CoV-2
2.
Lancet ; 397(10285): 1637-1645, 2021 May 01.
Article in English | MEDLINE | ID: covidwho-1655260

ABSTRACT

BACKGROUND: In this study, we aimed to evaluate the effects of tocilizumab in adult patients admitted to hospital with COVID-19 with both hypoxia and systemic inflammation. METHODS: This randomised, controlled, open-label, platform trial (Randomised Evaluation of COVID-19 Therapy [RECOVERY]), is assessing several possible treatments in patients hospitalised with COVID-19 in the UK. Those trial participants with hypoxia (oxygen saturation <92% on air or requiring oxygen therapy) and evidence of systemic inflammation (C-reactive protein ≥75 mg/L) were eligible for random assignment in a 1:1 ratio to usual standard of care alone versus usual standard of care plus tocilizumab at a dose of 400 mg-800 mg (depending on weight) given intravenously. A second dose could be given 12-24 h later if the patient's condition had not improved. The primary outcome was 28-day mortality, assessed in the intention-to-treat population. The trial is registered with ISRCTN (50189673) and ClinicalTrials.gov (NCT04381936). FINDINGS: Between April 23, 2020, and Jan 24, 2021, 4116 adults of 21 550 patients enrolled into the RECOVERY trial were included in the assessment of tocilizumab, including 3385 (82%) patients receiving systemic corticosteroids. Overall, 621 (31%) of the 2022 patients allocated tocilizumab and 729 (35%) of the 2094 patients allocated to usual care died within 28 days (rate ratio 0·85; 95% CI 0·76-0·94; p=0·0028). Consistent results were seen in all prespecified subgroups of patients, including those receiving systemic corticosteroids. Patients allocated to tocilizumab were more likely to be discharged from hospital within 28 days (57% vs 50%; rate ratio 1·22; 1·12-1·33; p<0·0001). Among those not receiving invasive mechanical ventilation at baseline, patients allocated tocilizumab were less likely to reach the composite endpoint of invasive mechanical ventilation or death (35% vs 42%; risk ratio 0·84; 95% CI 0·77-0·92; p<0·0001). INTERPRETATION: In hospitalised COVID-19 patients with hypoxia and systemic inflammation, tocilizumab improved survival and other clinical outcomes. These benefits were seen regardless of the amount of respiratory support and were additional to the benefits of systemic corticosteroids. FUNDING: UK Research and Innovation (Medical Research Council) and National Institute of Health Research.


Subject(s)
Antibodies, Monoclonal, Humanized/administration & dosage , COVID-19/drug therapy , COVID-19/therapy , Hypoxia/therapy , Adolescent , Adult , Aged , Aged, 80 and over , Antibodies, Monoclonal, Humanized/adverse effects , COVID-19/complications , COVID-19/diagnosis , COVID-19/mortality , Female , Hospital Mortality , Hospitalization , Humans , Hypoxia/diagnosis , Hypoxia/virology , Male , Middle Aged , Respiration, Artificial/statistics & numerical data , SARS-CoV-2/isolation & purification , Severity of Illness Index , Treatment Outcome , Young Adult
3.
Open Heart ; 8(2)2021 12.
Article in English | MEDLINE | ID: covidwho-1582998

ABSTRACT

OBJECTIVE: Soluble ST2 (sST2) reflects inflammation, endothelial dysfunction and myocardial fibrosis, is produced in the lungs and is an established biomarker in heart failure. We sought to determine the role of sST2 in COVID-19 by assessing pathophysiological correlates and its association to in-hospital outcomes. METHODS: We enrolled 123 consecutive, hospitalised patients with COVID-19 in the prospective, observational COVID-19 MECH study. Biobank samples were collected at baseline, day 3 and day 9. The key exposure variable was sST2, and the outcome was ICU treatment with mechanical ventilation or in-hospital death. RESULTS: Concentrations of sST2 at baseline was median 48 (IQR 37-67) ng/mL, and 74% had elevated concentrations (>37.9 ng/mL). Higher baseline sST2 concentrations were associated with older age, male sex, white race, smoking, diabetes, hypertension and chronic kidney disease. Baseline sST2 also associated with the presence of SARS-CoV-2 viraemia, lower oxygen saturation, higher respiratory rate and increasing concentrations of biomarkers reflecting inflammation, thrombosis and cardiovascular disease. During the hospitalisation, 8 (7%) patients died and 27 (22%) survivors received intensive care unit (ICU) treatment. Baseline sST2 concentrations demonstrated a graded association with disease severity (median, IQR): medical ward 43 (36-59) ng/mL; ICU 67 (39-104) ng/mL and non-survivors 107 (72-116) ng/mL (p<0.001 for all comparisons). These associations persisted at day 3 and day 9 . CONCLUSIONS: sST2 concentrations associate with SARS-CoV-2 viraemia, hypoxaemia and concentrations of inflammatory and cardiovascular biomarkers. There was a robust association between baseline sST2 and disease severity that was independent of, and superior to, established risk factors. sST2 reflects key pathophysiology and may be a promising biomarker in COVID-19. TRIAL REGISTRATION NUMBER: NCT04314232.


Subject(s)
COVID-19 , Hypoxia , Interleukin-1 Receptor-Like 1 Protein/analysis , SARS-CoV-2/isolation & purification , Viremia , Aged , Biomarkers/analysis , COVID-19/blood , COVID-19/mortality , COVID-19/physiopathology , Comorbidity , Correlation of Data , Female , Hospital Mortality , Humans , Hypoxia/diagnosis , Hypoxia/etiology , Intensive Care Units/statistics & numerical data , Male , Middle Aged , Norway/epidemiology , Prognosis , Risk Factors , Severity of Illness Index , Smoking/epidemiology , Viremia/diagnosis , Viremia/etiology
4.
Am J Respir Crit Care Med ; 205(4): 431-439, 2022 02 15.
Article in English | MEDLINE | ID: covidwho-1551111

ABSTRACT

Rationale: The "Berlin definition" of acute respiratory distress syndrome (ARDS) does not allow inclusion of patients receiving high-flow nasal oxygen (HFNO). However, several articles have proposed that criteria for defining ARDS should be broadened to allow inclusion of patients receiving HFNO. Objectives: To compare the proportion of patients fulfilling ARDS criteria during HFNO and soon after intubation, and 28-day mortality between patients treated exclusively with HFNO and patients transitioned from HFNO to invasive mechanical ventilation (IMV). Methods: From previously published studies, we analyzed patients with coronavirus disease (COVID-19) who had PaO2/FiO2 of ⩽300 while treated with ⩾40 L/min HFNO, or noninvasive ventilation (NIV) with positive end-expiratory pressure of ⩾5 cm H2O (comparator). In patients transitioned from HFNO/NIV to invasive mechanical ventilation (IMV), we compared ARDS severity during HFNO/NIV and soon after IMV. We compared 28-day mortality in patients treated exclusively with HFNO/NIV versus patients transitioned to IMV. Measurements and Main Results: We analyzed 184 and 131 patients receiving HFNO or NIV, respectively. A total of 112 HFNO and 69 NIV patients transitioned to IMV. Of those, 104 (92.9%) patients on HFNO and 66 (95.7%) on NIV continued to have PaO2/FiO2 ⩽300 under IMV. Twenty-eight-day mortality in patients who remained on HFNO was 4.2% (3/72), whereas in patients transitioned from HFNO to IMV, it was 28.6% (32/112) (P < 0.001). Twenty-eight-day mortality in patients who remained on NIV was 1.6% (1/62), whereas in patients who transitioned from NIV to IMV, it was 44.9% (31/69) (P < 0.001). Overall mortality was 19.0% (35/184) and 24.4% (32/131) for HFNO and NIV, respectively (P = 0.2479). Conclusions: Broadening the ARDS definition to include patients on HFNO with PaO2/FiO2 ⩽300 may identify patients at earlier stages of disease but with lower mortality.


Subject(s)
COVID-19/therapy , Hypoxia/therapy , Oxygen Inhalation Therapy/methods , Respiratory Distress Syndrome/therapy , Aged , COVID-19/mortality , COVID-19/physiopathology , Female , Humans , Hypoxia/diagnosis , Hypoxia/mortality , Hypoxia/virology , Italy/epidemiology , Male , Middle Aged , Oxygen Inhalation Therapy/mortality , Patient Acuity , Respiration, Artificial/methods , Respiration, Artificial/mortality , Respiratory Distress Syndrome/diagnosis , Respiratory Distress Syndrome/mortality , Respiratory Distress Syndrome/virology , Treatment Outcome
5.
Prim Health Care Res Dev ; 22: e56, 2021 10 18.
Article in English | MEDLINE | ID: covidwho-1475228

ABSTRACT

AIM: To validate the Roth score as a triage tool for detecting hypoxaemia. BACKGROUNDS: The virtual assessment of patients has become increasingly important during the corona virus disease (COVID-19) pandemic, but has limitations as to the evaluation of deteriorating respiratory function. This study presents data on the validity of the Roth score as a triage tool for detecting hypoxaemia remotely in potential COVID-19 patients in general practice. METHODS: This cross-sectional validation study was conducted in Dutch general practice. Patients aged ≥18 with suspected or confirmed COVID-19 were asked to rapidly count from 1 to 30 in a single breath. The Roth score involves the highest number counted during exhalation (counting number) and the time taken to reach the maximal count (counting time).Outcome measures were (1) the correlation between both Roth score measurements and simultaneous pulse oximetry (SpO2) on room air and (2) discrimination (c-statistic), sensitivity, specificity and predictive values of the Roth score for detecting hypoxaemia (SpO2 < 95%). FINDINGS: A total of 33 physicians enrolled 105 patients (52.4% female, mean age of 52.6 ± 20.4 years). A positive correlation was found between counting number and SpO2 (rs = 0.44, P < 0.001), whereas only a weak correlation was found between counting time and SpO2 (rs = 0.15, P = 0.14). Discrimination for hypoxaemia was higher for counting number [c-statistic 0.91 (95% CI: 0.85-0.96)] than for counting time [c-statistic 0.77 (95% CI: 0.62-0.93)]. Optimal diagnostic performance was found at a counting number of 20, with a sensitivity of 93.3% (95% CI: 68.1-99.8) and a specificity of 77.8% (95% CI: 67.8-85.9). A counting time of 7 s showed the best sensitivity of 85.7% (95% CI: 57.2-98.2) and specificity of 81.1% (95% CI: 71.5-88.6). CONCLUSIONS: A Roth score, with an optimal counting number cut-off value of 20, maybe of added value for signalling hypoxaemia in general practice. Further external validation is warranted before recommending integration in telephone triage.


Subject(s)
COVID-19 , Triage , Adult , Aged , Cross-Sectional Studies , Family Practice , Female , Humans , Hypoxia/diagnosis , Male , Middle Aged , SARS-CoV-2
6.
J Infect Dev Ctries ; 15(3): 353-359, 2021 Mar 31.
Article in English | MEDLINE | ID: covidwho-1444370

ABSTRACT

INTRODUCTION: The early identification of factors that predict the length of hospital stay (HS) in patients affected by coronavirus desease (COVID-19) might assist therapeutic decisions and patient flow management. METHODOLOGY: We collected, at the time of admission, routine clinical, laboratory, and imaging parameters of hypoxia, lung damage, inflammation, and organ dysfunction in a consecutive series of 50 COVID-19 patients admitted to the Respiratory Disease and Infectious Disease Units of the University Hospital of Sassari (North-Sardinia, Italy) and alive on discharge. RESULTS: Prolonged HS (PHS, >21 days) patients had significantly lower PaO2/FiO2 ratio and lymphocytes, and significantly higher Chest CT severity score, C-reactive protein (CRP) and lactic dehydrogenase (LDH) when compared to non-PHS patients. In univariate logistic regression, Chest CT severity score (OR = 1.1891, p = 0.007), intensity of care (OR = 2.1350, p = 0.022), PaO2/FiO2 ratio (OR = 0.9802, p = 0.007), CRP (OR = 1.0952, p = 0.042) and platelet to lymphocyte ratio (OR = 1.0039, p = 0.036) were significantly associated with PHS. However, in multivariate logistic regression, only the PaO2/FiO2 ratio remained significantly correlated with PHS (OR = 0.9164; 95% CI 0.8479-0.9904, p = 0.0275). In ROC curve analysis, using a threshold of 248, the PaO2/FiO2 ratio predicted PHS with sensitivity and specificity of 60% and 91%, respectively (AUC = 0.780, 95% CI 0.637-0.886 p = 0.002). CONCLUSIONS: The PaO2/FiO2 ratio on admission is independently associated with PHS in COVID-19 patients. Larger prospective studies are needed to confirm this finding.


Subject(s)
COVID-19/diagnosis , COVID-19/physiopathology , Hypoxia/diagnosis , Length of Stay/statistics & numerical data , Aged , Aged, 80 and over , COVID-19/epidemiology , Female , Humans , Hypoxia/virology , Italy/epidemiology , Male , Middle Aged , Prospective Studies , Retrospective Studies
7.
Chest ; 161(4): 971-978, 2022 Apr.
Article in English | MEDLINE | ID: covidwho-1439285

ABSTRACT

BACKGROUND: Pulse oximeters may produce less accurate results in non-White patients. RESEARCH QUESTION: Do pulse oximeters detect arterial hypoxemia less effectively in Black, Hispanic, and/or Asian patients than in White patients in respiratory failure and about to undergo extracorporeal membrane oxygenation (ECMO)? STUDY DESIGN AND METHODS: Data on adult patients with respiratory failure readings 6 h before ECMO were provided by the Extracorporeal Life Support Organization registry. Data was collected from 324 centers between January 2019 and July 2020. Our primary analysis was of rates of occult hypoxemia-low arterial oxygen saturation (Sao2 ≤ 88%) on arterial blood gas measurement despite a pulse oximetry reading in the range of 92% to 96%. RESULTS: The rate of pre-ECMO occult hypoxemia, that is, arterial oxygen saturation (Sao2) ≤ 88%, was 10.2% (95% CI, 6.2%-15.3%) for 186 White patients with peripheral oxygen saturation (Spo2) of 92% to 96%; 21.5% (95% CI, 11.3%-35.3%) for 51 Black patients (P = .031 vs White); 8.6% (95% CI, 3.2%-17.7%) for 70 Hispanic patients (P = .693 vs White); and 9.2% (95% CI, 3.5%-19.0%) for 65 Asian patients (P = .820 vs White). Black patients with respiratory failure had a statistically significantly higher risk of occult hypoxemia with an OR of 2.57 (95% CI, 1.12-5.92) compared with White patients (P = .026). The risk of occult hypoxemia for Hispanic and Asian patients was equivalent to that of White patients. In a secondary analysis of patients with Sao2 ≤ 88% despite Spo2 > 96%, Black patients had more than three times the risk compared with White patients (OR, 3.52; 95% CI, 1.12-11.10; P = .032). INTERPRETATION: Compared with White patients, the prevalence of occult hypoxemia was higher in Black patients than in White patients about to undergo ECMO for respiratory failure, but it was comparable in Hispanic and Asian patients compared with White patients.


Subject(s)
Extracorporeal Membrane Oxygenation , Racism , Respiratory Insufficiency , Adult , Humans , Hypoxia/diagnosis , Hypoxia/etiology , Oximetry/methods , Oxygen , Respiratory Insufficiency/diagnosis , Respiratory Insufficiency/therapy , Retrospective Studies
8.
BMJ Open ; 11(9): e050995, 2021 09 07.
Article in English | MEDLINE | ID: covidwho-1398696

ABSTRACT

OBJECTIVES: To characterise adoption and explore specific clinical and patient factors that might influence pulse oximetry and oxygen use in low-income and middle-income countries (LMICs) over time; to highlight useful considerations for entities working on programmes to improve access to pulse oximetry and oxygen. DESIGN: A multihospital retrospective cohort study. SETTINGS: All admissions (n=132 737) to paediatric wards of 18 purposely selected public hospitals in Kenya that joined a Clinical Information Network (CIN) between March 2014 and December 2020. OUTCOMES: Pulse oximetry use and oxygen prescription on admission; we performed growth-curve modelling to investigate the association of patient factors with study outcomes over time while adjusting for hospital factors. RESULTS: Overall, pulse oximetry was used in 48.8% (64 722/132 737) of all admission cases. Use rose on average with each month of participation in the CIN (OR: 1.11, 95% CI 1.05 to 1.18) but patterns of adoption were highly variable across hospitals suggesting important factors at hospital level influence use of pulse oximetry. Of those with pulse oximetry measurement, 7% (4510/64 722) had hypoxaemia (SpO2 <90%). Across the same period, 8.6% (11 428/132 737) had oxygen prescribed but in 87%, pulse oximetry was either not done or the hypoxaemia threshold (SpO2 <90%) was not met. Lower chest-wall indrawing and other respiratory symptoms were associated with pulse oximetry use at admission and were also associated with oxygen prescription in the absence of pulse oximetry or hypoxaemia. CONCLUSION: The adoption of pulse oximetry recommended in international guidelines for assessing children with severe illness has been slow and erratic, reflecting system and organisational weaknesses. Most oxygen orders at admission seem driven by clinical and situational factors other than the presence of hypoxaemia. Programmes aiming to implement pulse oximetry and oxygen systems will likely need a long-term vision to promote adoption, guideline development and adherence and continuously examine impact.


Subject(s)
Oximetry , Oxygen , Child , Humans , Hypoxia/diagnosis , Kenya , Prospective Studies , Retrospective Studies
9.
Trials ; 22(1): 534, 2021 Aug 12.
Article in English | MEDLINE | ID: covidwho-1352669

ABSTRACT

BACKGROUND: Recent studies point to a lower number and reduced severity of cases in higher altitude cities with decreased oxygen concentration. Specific literature has shown several benefits of physical training, so, in this sense, physical training with hypoxic stimulus appears as an alternative that supports the conventional treatments of the COVID-19 patient's recovery. Thus, this study's primary aim is to analyze the effects of moderate-intensity intermittent hypoxic training on health outcomes in COVID-19 recovered patients. METHODS: A clinical trial controlled double-blind study was designed. Participants (30-69 years old) will be recruited among those with moderate to severe COVID-19 symptoms, approximately 30 days after recovery. They will be included in groups according to the training (T) and recovery (R) association with hypoxia (H) or normoxia (N): (a) TH:RH, (b) TN:RH, (c) TN:RN, and last (d) the control group. The 8-week exercise bike intervention will be carried out with a gradual load increase according to the established periods, three times a week in sets of 5 min, 90 to 100% of the anaerobic threshold (AT), and a 2.5-min break. Blood will be collected for genotyping. First, after 4 weeks (partial), after 8 weeks, and later, 4 weeks after the end of the physical training intervention, participants will perform assessments. The primary outcome is the maximum oxygen consumption (VO2peak). The secondary outcomes include lung function, inflammatory mediators, hematological, autonomic parameters, AT, body composition analysis, quality of life, mental health, anthropometric measurements, and physical fitness. The statistical analysis will be executed using the linear regression model with mixed effects at a 5% significance level. DISCUSSION: This study is designed to provide evidence to support the clinical benefits of moderate-intensity intermittent hypoxic training as a part of the treatment of patients recovered from COVID-19. It may also provide evidence on the efficacy and safety of intermittent hypoxic training in different health conditions. Lastly, this study presents an innovative strategy enabling up to 16 participants in the same training session. TRIAL REGISTRATION: ClinicalTrials.gov RBR-5d7hkv. Registered after the start of inclusion on 3 November 2020 with the Brazilian Clinical Trials Registry.


Subject(s)
COVID-19 , Adult , Aged , Humans , Hypoxia/diagnosis , Hypoxia/therapy , Middle Aged , Quality of Life , Randomized Controlled Trials as Topic , SARS-CoV-2 , Treatment Outcome
10.
Emerg Med J ; 38(10): 794-797, 2021 Oct.
Article in English | MEDLINE | ID: covidwho-1346074

ABSTRACT

BACKGROUND: Exercise-induced hypoxia (EIH) has been assessed at ED triage as part of an assessment of COVID-19; however, evidence supporting this practice is incomplete. We assessed the use of a 1-minute sit-to-stand exercise test among ED patients admitted for suspected COVID-19. METHODS: A case note review of all ED patients assessed for suspected COVID-19 between March and May 2020 at Monklands University Hospital was conducted. Demographic characteristics, clinical parameters, baseline blood tests and radiographic findings, hospital length of stay, intensive care and maximum oxygen requirement were obtained for those admitted. Using logistic regression, the association between EIH at admission triage and COVID-19 diagnosis was explored adjusting for confounding clinical parameters. RESULTS: Of 127 ED patients admitted for possible COVID-19, 37 were ultimately diagnosed with COVID-19. 36.4% of patients with COVID-19 and EIH had a normal admission chest radiograph. In multivariate analysis, EIH was an independent predictor of COVID-19 (adjusted OR 3.73 (95% CI (1.25 to 11.15)), as were lymphocyte count, self-reported exertional dyspnoea, C-reactive peptide and radiographic changes. CONCLUSIONS: This observational study demonstrates an association between EIH and a COVID-19 diagnosis. Over one-third of patients with COVID-19 and EIH exhibited no radiographic changes. EIH may represent an additional tool to help predict a COVID-19 diagnosis at initial presentation and may assist in triaging need for admission.


Subject(s)
COVID-19 , Hypoxia/diagnosis , Patient Admission , SARS-CoV-2 , Triage , Emergency Service, Hospital , Female , Humans , Male , Medical Records , Middle Aged , Retrospective Studies , State Medicine , United Kingdom
11.
Age Ageing ; 50(6): 1886-1887, 2021 11 10.
Article in English | MEDLINE | ID: covidwho-1316793

ABSTRACT

An 89-year-old woman was admitted to hospital with a fall, general malaise and low oxygen saturations. She tested positive for SARS-CoV-2 and commenced on standard therapy for COVID-19 pneumonia. She improved initially but reported ongoing dyspnoea exacerbated by position. Following investigations to rule out other causes, she was given a diagnosis of platypnoea-orthodeoxia syndrome (POS). She was treated with gradual verticalization therapy with supplemental oxygen and subsequently discharged to an intermediate care bed (ICB).


Subject(s)
COVID-19 , Foramen Ovale, Patent , Hypotension, Orthostatic , Aged, 80 and over , Dyspnea/diagnosis , Dyspnea/etiology , Dyspnea/therapy , Female , Hospitals , Humans , Hypoxia/diagnosis , Hypoxia/etiology , Hypoxia/therapy , SARS-CoV-2
12.
Auton Neurosci ; 235: 102855, 2021 11.
Article in English | MEDLINE | ID: covidwho-1312929

ABSTRACT

BACKGROUND: An intriguing feature recently unveiled in some COVID-19 patients is the "silent hypoxemia" phenomenon, which refers to the discrepancy of subjective well-being sensation while suffering hypoxia, manifested as the absence of dyspnea. OBJECTIVE: To describe the clinical characteristics and predictors of silent hypoxemia in hospitalized COVID-19 patients. METHODS: We conducted a prospective cohort study including consecutive hospitalized adult (≥ 18 years) patients with confirmed COVID-19 presenting to the emergency department with oxygen saturation (SpO2) ≤ 80% on room air from March 15 to June 30, 2020. We analyzed the characteristics, disease severity, and in-hospital outcomes of patients presenting with dyspnea and those without dyspnea (silent hypoxemia). RESULTS: We studied 470 cases (64.4% men; median age 55 years, interquartile range 46-64). There were 447 (95.1%) patients with dyspnea and 23 (4.9%) with silent hypoxemia. The demographic and clinical characteristics, comorbidities, laboratory and imaging findings, disease severity, and outcomes were similar between groups. Higher breathing and heart rates correlated significantly with lower SpO2 in patients with dyspnea but not in those with silent hypoxemia. Independent predictors of silent hypoxemia were the presence of new-onset headache (OR 2.919, 95% CI 1.101-7.742; P = 0.031) and presenting to the emergency department within the first eight days after symptoms onset (OR 3.183, 95% CI 1.024-9.89; P = 0.045). CONCLUSIONS: Patients with silent hypoxemia sought medical attention earlier and had new-onset headache more often. They were also likely to display lower hemodynamic compensatory responses to hypoxemia, which may underestimate the disease severity.


Subject(s)
COVID-19/complications , Hypoxia/diagnosis , COVID-19/epidemiology , Dyspnea/complications , Dyspnea/diagnosis , Dyspnea/epidemiology , Female , Hospitalization , Humans , Hypoxia/complications , Hypoxia/epidemiology , Inpatients , Male , Middle Aged , Prospective Studies
13.
Chest ; 160(1): 74-84, 2021 07.
Article in English | MEDLINE | ID: covidwho-1258346

ABSTRACT

BACKGROUND: Severity of illness in COVID-19 is consistently lower in women. A focus on sex as a biological factor may suggest a potential therapeutic intervention for this disease. We assessed whether adding progesterone to standard of care (SOC) would improve clinical outcomes of hospitalized men with moderate to severe COVID-19. RESEARCH QUESTION: Does short-term subcutaneous administration of progesterone safely improve clinical outcome in hypoxemic men hospitalized with COVID-19? STUDY DESIGN AND METHODS: We conducted a pilot, randomized, open-label, controlled trial of subcutaneous progesterone in men hospitalized with confirmed moderate to severe COVID-19. Patients were randomly assigned to receive SOC plus progesterone (100 mg subcutaneously twice daily for up to 5 days) or SOC alone. In addition to assessment of safety, the primary outcome was change in clinical status on day 7. Length of hospital stay and number of days on supplemental oxygen were key secondary outcomes. RESULTS: Forty-two patients were enrolled from April 2020 to August 2020; 22 were randomized to the control group and 20 to the progesterone group. Two patients from the progesterone group withdrew from the study before receiving progesterone. There was a 1.5-point overall improvement in median clinical status score on a seven-point ordinal scale from baseline to day 7 in patients in the progesterone group as compared with control subjects (95% CI, 0.0-2.0; P = .024). There were no serious adverse events attributable to progesterone. Patients treated with progesterone required three fewer days of supplemental oxygen (median, 4.5 vs 7.5 days) and were hospitalized for 2.5 fewer days (median, 7.0 vs 9.5 days) as compared with control subjects. INTERPRETATION: Progesterone at a dose of 100 mg, twice daily by subcutaneous injection in addition to SOC, may represent a safe and effective approach for treatment in hypoxemic men with moderate to severe COVID-19. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT04365127; URL: www.clinicaltrials.gov.


Subject(s)
COVID-19 , Progesterone/administration & dosage , SARS-CoV-2/isolation & purification , COVID-19/physiopathology , COVID-19/therapy , Clinical Protocols/standards , Drug Monitoring , Humans , Hypoxia/diagnosis , Hypoxia/etiology , Injections, Subcutaneous , Male , Middle Aged , Oxygen Inhalation Therapy/methods , Pilot Projects , Progestins/administration & dosage , Severity of Illness Index , Treatment Outcome
14.
Physiol Meas ; 42(6)2021 06 29.
Article in English | MEDLINE | ID: covidwho-1246679

ABSTRACT

Respiratory rate (RR) is routinely used to monitor patients with infectious, cardiac and respiratory diseases and is a component of early warning scores used to predict patient deterioration. However, it is often measured visually with considerable bias and inaccuracy.Objectives. Firstly, to compare distribution and accuracy of electronically measured RR (EMRR) and visually measured RR (VMRR). Secondly, to determine whether, and how far in advance, continuous electronic RR monitoring can predict oncoming hypoxic and pyrexic episodes in infectious respiratory disease.Approach.A retrospective cohort study analysing the difference between EMRR and VMRR was conducted using patient data from a large tertiary hospital. Cox proportional hazards models were used to determine whether continuous, EMRR measurements could predict oncoming hypoxic (SpO2 < 92%) and pyrexic (temperature >38 °C) episodes.Main results.Data were gathered from 34 COVID-19 patients, from which a total of 3445 observations of VMRR (independent of Hawthorne effect), peripheral oxygen saturation and temperature and 729 117 observations of EMRR were collected. VMRR had peaks in distribution at 18 and 20 breaths per minute. 70.9% of patients would have had a change of treatment during their admission based on the UK's National Early Warning System if EMRR was used in place of VMRR. An elevated EMRR was predictive of hypoxic (hazard ratio: 1.8 (1.05-3.07)) and pyrexic (hazard ratio: 9.7 (3.8-25)) episodes over the following 12 h.Significance.Continuous EMRR values are systematically different to VMRR values, and results suggest it is a better indicator of true RR as it has lower kurtosis, higher variance, a lack of peaks at expected values (18 and 20) and it measures a physiological component of breathing directly (abdominal movement). Results suggest EMRR is a strong marker of oncoming hypoxia and is highly predictive of oncoming pyrexic events in the following 12 h. In many diseases, this could provide an early window to escalate care prior to deterioration, potentially preventing morbidity and mortality.


Subject(s)
COVID-19 , Fever/diagnosis , Hypoxia/diagnosis , Monitoring, Physiologic , Respiratory Rate , COVID-19/diagnosis , Fever/virology , Humans , Hypoxia/virology , Retrospective Studies
15.
Am J Emerg Med ; 44: 116-120, 2021 06.
Article in English | MEDLINE | ID: covidwho-1245820

ABSTRACT

OBJECTIVE: We assessed the performance of the ratio of peripheral arterial oxygen saturation to the inspired fraction of oxygen (SpO2/FiO2) to predict the ratio of partial pressure arterial oxygen to the fraction of inspired oxygen (PaO2/FiO2) among patients admitted to our emergency department (ED) during the SARS-CoV-2 outbreak. METHODS: We retrospectively studied patients admitted to an academic-level ED in France who were undergoing a joint measurement of SpO2 and arterial blood gas. We compared SpO2 with SaO2 and evaluated performance of the SpO2/FiO2 ratio for the prediction of 300 and 400 mmHg PaO2/FiO2 cut-off values in COVID-19 positive and negative subgroups using receiver-operating characteristic (ROC) curves. RESULTS: During the study period from February to April 2020, a total of 430 arterial samples were analyzed and collected from 395 patients. The area under the ROC curves of the SpO2/FiO2 ratio was 0.918 (CI 95% 0.885-0.950) and 0.901 (CI 95% 0.872-0.930) for PaO2/FiO2 thresholds of 300 and 400 mmHg, respectively. The positive predictive value (PPV) of an SpO2/FiO2 threshold of 350 for PaO2/FiO2 inferior to 300 mmHg was 0.88 (CI95% 0.84-0.91), whereas the negative predictive value (NPV) of the SpO2/FiO2 threshold of 470 for PaO2/FiO2 inferior to 400 mmHg was 0.89 (CI95% 0.75-0.96). No significant differences were found between the subgroups. CONCLUSIONS: The SpO2/FiO2 ratio may be a reliable tool for hypoxemia screening among patients admitted to the ED, particularly during the SARS-CoV-2 outbreak.


Subject(s)
COVID-19/epidemiology , Hypoxia/blood , Hypoxia/diagnosis , Oxygen/blood , Adult , Aged , Blood Gas Analysis/methods , Emergency Service, Hospital/statistics & numerical data , Female , France/epidemiology , Humans , Male , Middle Aged , Predictive Value of Tests , ROC Curve , Retrospective Studies
16.
Semergen ; 48(1): 70-77, 2022.
Article in Spanish | MEDLINE | ID: covidwho-1216372

ABSTRACT

COVID-19 behaves like a heterogeneous disease. Some patients may develop dyspnea-free hypoxemia during its evolution (silent hypoxemia). Pulse oximetry plays a crucial role in detecting hypoxemia in these patients, especially when they remain at home. Patients with SpO2 levels ≤ 92% or desaturations ≥ 3% after exercise test require hospital admission. Progressive saturation declines reaching SpO2 levels < 96% require strict clinical assessment (radiological study, blood test) for which it will be sent to a health center.


Subject(s)
COVID-19 , Dyspnea , Humans , Hypoxia/diagnosis , Hypoxia/etiology , Oximetry , SARS-CoV-2
17.
Mol Biol Rep ; 48(4): 3863-3869, 2021 Apr.
Article in English | MEDLINE | ID: covidwho-1198481

ABSTRACT

The novel coronavirus disease 2019 (COVID-19) has become a severe health issue, especially to the patients who develop silent hypoxia condition after SARS-CoV-2 infection. Due to the lack of dyspnoea and extremely low oxygen saturation level, these patients are at exceptionally higher risk. Although the prevalence of silent hypoxia in COVID-19 patients has been evident in several cases, the underlying pathomechanism behind this condition is still unclear. Silent hypoxia in SARS-CoV-2 infected patients can be diagnosed with the help of a pulse oximeter, blood gas levels, and a 6-min walking test. While the clinicians and researchers figure out the exact reason for this phenomenon, the patients must be under strict day-to-day monitoring. In this article, we aim to provide comprehensive insights into the underlying symptoms, mechanism, and possible factors behind the occurrence of silent hypoxia among COVID-19 patients.


Subject(s)
COVID-19/diagnosis , COVID-19/pathology , Angiotensin-Converting Enzyme 2/metabolism , Blood Gas Analysis , COVID-19/immunology , COVID-19/metabolism , Humans , Hypoxia/diagnosis , Hypoxia/metabolism , Hypoxia/pathology , Hypoxia/virology , Hypoxia-Inducible Factor 1/metabolism , Oximetry , Practice Guidelines as Topic
18.
J Emerg Nurs ; 47(2): 279-287.e1, 2021 Mar.
Article in English | MEDLINE | ID: covidwho-1195353

ABSTRACT

INTRODUCTION: In March and April 2020 of the coronavirus disease 2019 pandemic, site clinical practice guidelines were implemented for prone positioning of patients with suspected coronavirus disease 2019 in hypoxic respiratory distress who are awake, alert, and spontaneously breathing. The purpose of this pandemic disaster practice improvement project was to measure changes in pulse oximetry associated with prone positioning of patients with coronavirus disease 2019 infection in adult acute respiratory distress or adult respiratory distress syndrome, who are awake, alert, spontaneously breathing, and nonintubated. METHODS: A retrospective chart review of patients who were coronavirus disease 2019 positive in the emergency department from March 30, 2020 to April 30, 2020 was conducted for patients with a room air pulse oximetry <90% and a preprone position pulse oximetry ≤94% who tolerated prone positioning for at least 30 minutes. The primary outcome was the change in pulse oximetry associated with prone positioning, measured on room air, with supplemental oxygen, and approximately 30 minutes after initiating prone positioning. Median and mean differences were compared with the Wilcoxon signed-rank test and paired t-test. RESULTS: Of the 440 patients with coronavirus disease 2019, 31 met inclusion criteria. Median pulse oximetry increased as 83% (interquartile range, 75%-86%) on room air, 90% (interquartile range, 89%-93%) with supplemental oxygen, and 96% (interquartile range, 94%-98%) with prone positioning (z = -4.48, P < .001). A total of 45% (n = 14) were intubated during their hospital stay, and 26% (n = 8) of the included patients died. DISCUSSION: In patients with coronavirus disease 2019 who are awake, alert, and spontaneously breathing, an initially low pulse oximetry reading improved with prone positioning. Future studies are needed to determine the association of prone positioning with subsequent endotracheal intubation and mortality.


Subject(s)
COVID-19/complications , COVID-19/therapy , Patient Positioning/methods , Respiratory Distress Syndrome/complications , Respiratory Distress Syndrome/therapy , Female , Humans , Hypoxia/complications , Hypoxia/diagnosis , Hypoxia/therapy , Intubation, Intratracheal , Male , Medical Records , Middle Aged , New Jersey , Oximetry , Prone Position , Respiratory Distress Syndrome/diagnosis , Retrospective Studies , SARS-CoV-2
19.
BMC Pulm Med ; 21(1): 126, 2021 Apr 19.
Article in English | MEDLINE | ID: covidwho-1191325

ABSTRACT

BACKGROUND: Platypnea-orthodeoxia syndrome (POS) is a rare condition characterized by dyspnoea (platypnea) and arterial desaturation in the upright position resolved in the supine position (orthodeoxia). Intracardiac shunt, pulmonary ventilation-perfusion mismatch and others intrapulmonary abnormalities are involved. CASE PRESENTATION: We report a case of POS associated with two pathophysiological issues: one, cardiac POS caused by a patent foramen ovale (PFO) and second, pulmonary POS due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) interstitial pneumonia. POS has resolved after recovery of coronavirus disease 2019 (COVID-19) pneumonia. CONCLUSIONS: Right-to-left interatrial shunt and intrapulmonary shunt caused by SARS-CoV-2 pneumonia contributed to refractory hypoxemia and POS. Therefore, in case of COVID-19 patient with unexplained POS, the existence of PFO must be investigated.


Subject(s)
COVID-19 , Dyspnea , Foramen Ovale, Patent , Hypoxia , Lung/diagnostic imaging , Pneumonia, Viral , COVID-19/diagnosis , COVID-19/physiopathology , Dyspnea/diagnosis , Dyspnea/etiology , Dyspnea/physiopathology , Echocardiography/methods , Foramen Ovale, Patent/complications , Foramen Ovale, Patent/diagnosis , Foramen Ovale, Patent/physiopathology , Hemodynamics , Humans , Hypoxia/diagnosis , Hypoxia/etiology , Hypoxia/physiopathology , Lung Diseases, Interstitial/complications , Lung Diseases, Interstitial/physiopathology , Lung Diseases, Interstitial/virology , Male , Middle Aged , Oxygen/analysis , Pneumonia, Viral/complications , Pneumonia, Viral/diagnosis , Pneumonia, Viral/physiopathology , Posture/physiology , SARS-CoV-2/isolation & purification , Syndrome , Treatment Outcome
20.
BMJ Open ; 11(3): e046282, 2021 03 08.
Article in English | MEDLINE | ID: covidwho-1189880

ABSTRACT

OBJECTIVES: The majority of patients with mild-to-moderate COVID-19 can be managed using virtual care. Dyspnoea is challenging to assess remotely, and the accuracy of subjective dyspnoea measures in capturing hypoxaemia have not been formally evaluated for COVID-19. We explored the accuracy of subjective dyspnoea in diagnosing hypoxaemia in COVID-19 patients. METHODS: This is a retrospective cohort study of consecutive outpatients with COVID-19 who met criteria for home oxygen saturation monitoring at a university-affiliated acute care hospital in Toronto, Canada from 3 April 2020 to 13 September 2020. Dyspnoea measures were treated as diagnostic tests, and we determined their sensitivity (SN), specificity (SP), negative/positive predictive value (NPV/PPV) and positive/negative likelihood ratios (+LR/-LR) for detecting hypoxaemia. In the primary analysis, hypoxaemia was defined by oxygen saturation <95%; the diagnostic accuracy of subjective dyspnoea was also assessed across a range of oxygen saturation cutoffs from 92% to 97%. RESULTS: During the study period, 89/501 (17.8%) of patients met criteria for home oxygen saturation monitoring, and of these 17/89 (19.1%) were diagnosed with hypoxaemia. The presence/absence of dyspnoea had limited accuracy for diagnosing hypoxaemia, with SN 47% (95% CI 24% to 72%), SP 80% (95% CI 68% to 88%), NPV 86% (95% CI 75% to 93%), PPV 36% (95% CI 18% to 59%), +LR 2.4 (95% CI 1.2 to 4.7) and -LR 0.7 (95% CI 0.4 to 1.1). The SN of dyspnoea was 50% (95% CI 19% to 81%) when a cut-off of <92% was used to define hypoxaemia. A modified Medical Research Council dyspnoea score >1 (SP 98%, 95% CI 88% to 100%), Roth maximal count <12 (SP 100%, 95% CI 75% to 100%) and Roth counting time <8 s (SP 93%, 95% CI 66% to 100%) had high SP that could be used to rule in hypoxaemia, but displayed low SN (≤50%). CONCLUSIONS: Subjective dyspnoea measures have inadequate accuracy for ruling out hypoxaemia in high-risk patients with COVID-19. Safe home management of patients with COVID-19 should incorporate home oxygenation saturation monitoring.


Subject(s)
COVID-19 , Canada , Dyspnea/diagnosis , Humans , Hypoxia/diagnosis , Outpatients , Retrospective Studies , SARS-CoV-2 , Sensitivity and Specificity
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