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1.
PLoS One ; 16(2): e0246318, 2021.
Article in English | MEDLINE | ID: covidwho-1079358

ABSTRACT

BACKGROUND: Insight into COVID-19 intensive care unit (ICU) patient characteristics, rates and risks of invasive mechanical ventilation (IMV) and associated outcomes as well as any regional discrepancies is critical in this pandemic for individual case management and overall resource planning. METHODS AND FINDINGS: Electronic searches were performed for reports through May 1 2020 and reports on COVID-19 ICU admissions and outcomes were included using predefined search terms. Relevant data was subsequently extracted and pooled using fixed or random effects meta-analysis depending on heterogeneity. Study quality was assessed by the NIH tool and heterogeneity was assessed by I2 and Q tests. Baseline patient characteristics, ICU and IMV outcomes were pooled and meta-analyzed. Pooled odds ratios (pOR) were calculated for clinical features against ICU, IMV mortality. Subgroup analysis was carried out based on patient regions. A total of twenty-eight studies comprising 12,437 COVID-19 ICU admissions from seven countries were meta-analyzed. Pooled ICU admission rate was 21% [95% CI 0.12-0.34] and 69% of cases needed IMV [95% CI 0.61-0.75]. ICU and IMV mortality were 28.3% [95% CI 0.25-0.32], 43% [95% CI 0.29-0.58] and ICU, IMV duration was 7.78 [95% CI 6.99-8.63] and 10.12 [95% CI 7.08-13.16] days respectively. Besides confirming the significance of comorbidities and clinical findings of COVID-19 previously reported, we found the major correlates with ICU mortality were IMV [pOR 16.46, 95% CI 4.37-61.96], acute kidney injury (AKI) [pOR 12.47, 95% CI 1.52-102.7], and acute respiratory distress syndrome (ARDS) [pOR 6.52, 95% CI 2.66-16.01]. Subgroup analyses confirm significant regional discrepancies in outcomes. CONCLUSIONS: This is a comprehensive systematic review and meta-analysis of COVID-19 ICU and IMV cases and associated outcomes. The significant association of AKI, ARDS and IMV with mortality has implications for ICU resource planning for AKI and ARDS as well as suggesting the need for further research into optimal ventilation strategies for COVID-19 patients in the ICU setting. Regional differences in outcome implies a need to develop region specific protocols for ventilatory support as well as overall treatment.


Subject(s)
/therapy , Respiration, Artificial , /epidemiology , Critical Care/methods , Humans , Intensive Care Units , Respiration, Artificial/methods , Risk Assessment , Treatment Outcome
2.
Trials ; 22(1): 92, 2021 Jan 26.
Article in English | MEDLINE | ID: covidwho-1067263

ABSTRACT

OBJECTIVES: To evaluate the efficacy of early treatment with prednisone to decrease the progression of COVID-19 pneumonia. TRIAL DESIGN: This is a pragmatic, non-blinded, randomized, two arms, parallel trial. PARTICIPANTS: Patients between 18 and 90 years, with COVID-19 pneumonia, confirmed by RT PCR. The setting for the trial is the Hospital Santiago Oriente which is a secondary level hospital with an emergency room, intensive care, and all basic specialties of medicine. INCLUSION CRITERIA: 18 years or more COVID-19 confirmed by RT-PCR Oxygen requirements up to 35% by venturi mask or 5 liters per minute by nasal cannula (approximately FiO2 40%) Consent form signed Exclusion Criteria: Previous steroid use for more than 48 hours. Pregnancy Chronic respiratory failure Requirements of mechanical ventilation (invasive or no invasive) Chronic liver damage Child Pugh B or C Chronic kidney disease stage IV or V. Immunosuppressed Participation in another trial. INTERVENTION AND COMPARATOR: Experimental arm Prednisone 40 mg days 1 to 4. Then Prednisone 20 mg days 5 to 8. Usual care defined by the attending physician. Control arm No intervention. Usual care defined by the attending physician. MAIN OUTCOMES: Primary outcome Composite Primary End-point: Admission to ICU, Need for Invasive Mechanical Ventilation or All-cause Death by Day 28 Secondary outcomes (followed until day 28). Time to respiratory deterioration Incidence of patients requiring mechanical ventilation: Number of days on mechanical ventilation Special emphasis will be placed on observing the following serious adverse events Deterioration of the glycemic profile that requires the use of insulin Delirium Incidence of hospital infections (pneumonia, urinary tract infection, device associated infections) Cumulative incidence of grade 3 and 4 adverse events (AE). Interruption or temporary suspension of treatment for any reason RANDOMISATION: Randomisation in permuted block. Computer generated random numbers in an allocation rate of 1:1. Stata 14.0 was used. Allocated by the principal investigator (direct communication). BLINDING (MASKING): Patients not blinded. Caregivers not blinded. Participants not blinded. Statistician will not know the allocation. NUMBERS TO BE RANDOMISED (SAMPLE SIZE): 92 patients in each arm. 184 total number of patients. TRIAL STATUS: Protocol version 2.0., approved October 2, 2020. Trial ongoing. Recruitment start: June 23, 2020. Anticipate finish recruiting: November 30, 2020. The protocol has been submitted before the last patient and last visit. The delay in sending to publication is responsibility of the authors. TRIAL REGISTRATION: Early Use of Corticosteroids in Non-critical Patients With COVID-19 Pneumonia (PREDCOVID). Registration number NCT04451174 . Date of trial registration: June 26, 2020. FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.


Subject(s)
/therapy , Critical Care , RNA, Viral/analysis , Randomized Controlled Trials as Topic/methods , Respiration, Artificial/methods , /genetics , /epidemiology , Hospitalization/trends , Humans , Treatment Outcome
3.
J Laryngol Otol ; 135(1): 86-87, 2021 Jan.
Article in English | MEDLINE | ID: covidwho-1065742

ABSTRACT

BACKGROUND: Since the start of the coronavirus disease 2019 pandemic, transnasal humidified rapid-insufflation ventilatory exchange ('THRIVE') has been classified as a high-risk aerosol-generating procedure and is strongly discouraged, despite a lack of conclusive evidence on its safety. METHODS: This study aimed to investigate the safety of transnasal humidified rapid-insufflation ventilatory exchange usage and its impact on staff members. A prospective study was conducted on all transnasal humidified rapid-insufflation ventilatory exchange cases performed in our unit between March and July 2020. RESULTS: During the study period, 18 patients with a variety of airway pathologies were successfully managed with transnasal humidified rapid-insufflation ventilatory exchange. For each case, 7-10 staff members were present. Appropriate personal protective equipment protocols were strictly implemented and adhered to. None of the staff involved reported symptoms or tested positive for coronavirus disease 2019, up to at least a month following their exposure to transnasal humidified rapid-insufflation ventilatory exchange. CONCLUSION: With strictly correct personal protective equipment use, transnasal humidified rapid-insufflation ventilatory exchange can be safely employed for carefully selected patients in the current pandemic, without jeopardising the health and safety of the ENT and anaesthetic workforce.


Subject(s)
/therapy , Insufflation , Respiration, Artificial , Humans , Humidifiers , Insufflation/methods , Nose , Prospective Studies , Respiration, Artificial/methods , Time Factors
4.
Physiol Rep ; 9(3): e14715, 2021 02.
Article in English | MEDLINE | ID: covidwho-1059985

ABSTRACT

INTRODUCTION: Current knowledge on the use of extracorporeal membrane oxygenation (ECMO) in COVID-19 remains limited to small series and registry data. In the present retrospective monocentric study, we report on our experience, our basic principles, and our results in establishing and managing ECMO in critically ill COVID-19 patients. METHODS: A cohort study was conducted in patients with severe acute respiratory distress syndrome (ARDS) related to COVID-19 pneumonia admitted to the ICU of the Geneva University Hospitals and supported by VV-ECMO from March 14 to May 31. The VV-ECMO implementation criteria were defined according to an institutional algorithm validated by the local crisis unit and the Swiss Society of Intensive Care Medicine. RESULTS: Out of 137 ARDS patients admitted to our ICU, 10 patients (age 57 ± 4 years, BMI 31.5 ± 5 kg/m2 , and SAPS II score 56 ± 3) were put on VV-ECMO. The mean duration of mechanical ventilation before ECMO and mean time under ECMO were 7 ± 3 days and 19 ± 11 days, respectively. The ICU and hospital length of stay were 26 ± 11 and 35 ± 10 days, respectively. The survival rate for patients on ECMO was 40%. The comparative analysis between survivors and non-survivors highlighted that survivors had a significantly shorter mechanical ventilation duration before ECMO (4 ± 2 days vs. 9 ± 2 days, p = 0.01). All the patients who had more than 150 h of mechanical ventilation before the application of ECMO ultimately died. CONCLUSION: The present results suggest that VV-ECMO can be safely utilized in appropriately selected COVID-19 patients with refractory hypoxemia. The main information for clinicians is that late VV-ECMO therapy (i.e., beyond the seventh day of mechanical ventilation) seems futile.


Subject(s)
/therapy , Extracorporeal Membrane Oxygenation/methods , /pathology , Extracorporeal Membrane Oxygenation/adverse effects , Female , Humans , Male , Middle Aged , Respiration, Artificial/methods , Survival Analysis , Time Factors
5.
BMC Pulm Med ; 21(1): 46, 2021 Jan 29.
Article in English | MEDLINE | ID: covidwho-1054817

ABSTRACT

BACKGROUND: Sickle-cell anaemia is a widespread genetic disease prevalent worldwide among African and African-American populations. The pathogenesis is most often revealed by pulmonary conditions, including acute thoracic syndrome, which is affecting the life expectancy of these populations. The global spread of CoV2-SARS infection with a respiratory tropism, endothelial damages and procoagulant status endangers the SCD population. However, with only a few case reports, consequences of the Covid-19 pandemic on SCD population remain poorly known. CASE PRESENTATION: We report a case of a 33-year-old man with a history of homozygous SS homozygous sickle cell anemia who consulted on March 24, 2020 for febrile dyspnea 11 days after the onset of symptoms. A nasopharyngeal swab was positive for SARS-CoV-2. His respiratory status worsened rapidly in the emergency room and then in ICU leading to severe ARDS requiring intubation, curarization, and venovenous ECMO. Hematologically, severe hemolysis associated with major thrombocytopenia without documented spinal cord injury was noted. Several transfusion exchanges are performed. The evolution was finally slowly favorable and led to discharge from the intensive care unit and then from the hospital. CONCLUSIONS: This case recalls the importance of an increased prevention policy against COVID-19among the SCD population. In addition, from a therapeutic point of view, it advocates (1) a high preventive anticoagulation from the outset according to the level of D-dimers (2) the use of venovenous ECMO in this particular case, whereas this technique has had rather disappointing results in acute chest syndromes. (3) Unexpectedly, our patient did not develop pulmonary arterial hypertension (PAH) and acute cor pulmonale (ACP), whereas this is a common feature of ARDS during SCD. These last two observations suggest a different pathophysiology of pulmonary disorders in SCD patients in the case of SARS COv2. It could be associated with marked hypoxemia secondary to pulmonary vascular vasodilation.


Subject(s)
Anemia, Sickle Cell/epidemiology , Extracorporeal Membrane Oxygenation/methods , Respiration, Artificial/methods , /etiology , Adult , Anemia, Sickle Cell/therapy , /therapy , Humans , Male , Pandemics , Radiography, Thoracic , /therapy
6.
BMC Pulm Med ; 21(1): 38, 2021 Jan 22.
Article in English | MEDLINE | ID: covidwho-1044906

ABSTRACT

BACKGROUND: Clinical management of COVID-19 requires close monitoring of lung function. While computed tomography (CT) offers ideal way to identify the phenotypes, it cannot monitor the patient response to therapeutic interventions. We present a case of ventilation management for a COVID-19 patient where electrical impedance tomography (EIT) was used to personalize care. CASE PRESENTATION: The patient developed acute respiratory distress syndrome, required invasive mechanical ventilation, and was subsequently weaned. EIT was used multiple times: to titrate the positive end-expiratory pressure, understand the influence of body position, and guide the support levels during weaning and after extubation. We show how EIT provides bedside monitoring of the patient´s response to various therapeutic interventions and helps guide treatments. CONCLUSION: EIT provides unique information that may help the ventilation management in the pandemic of COVID-19.


Subject(s)
/diagnostic imaging , Electric Impedance , Lung/diagnostic imaging , Patient Positioning/methods , Respiration, Artificial/methods , Tomography/methods , /physiopathology , Humans , Male , Middle Aged , Positive-Pressure Respiration/methods , /therapy , Ventilator Weaning/methods
7.
RMD Open ; 7(1)2021 01.
Article in English | MEDLINE | ID: covidwho-1042303

ABSTRACT

INTRODUCTION: Whether patients with inflammatory rheumatic and musculoskeletal diseases (RMD) are at higher risk to develop severe courses of COVID-19 has not been fully elucidated. Aim of this analysis was to describe patients with RMD according to their COVID-19 severity and to identify risk factors for hospitalisation. METHODS: Patients with RMD with PCR confirmed SARS-CoV-2 infection reported to the German COVID-19 registry from 30 March to 1 November 2020 were evaluated. Multivariable logistic regression was used to estimate ORs for hospitalisation due to COVID-19. RESULTS: Data from 468 patients with RMD with SARS-CoV-2 infection were reported. Most frequent diagnosis was rheumatoid arthritis, RA (48%). 29% of the patients were hospitalised, 5.5% needed ventilation. 19 patients died. Multivariable analysis showed that age >65 years (OR 2.24; 95% CI 1.12 to 4.47), but even more>75 years (OR 3.94; 95% CI 1.86 to 8.32), cardiovascular disease (CVD; OR 3.36; 95% CI 1.5 to 7.55), interstitial lung disease/chronic obstructive pulmonary disease (ILD/COPD) (OR 2.79; 95% CI 1.2 to 6.49), chronic kidney disease (OR 2.96; 95% CI 1.16 to 7.5), moderate/high RMD disease activity (OR 1.96; 95% CI 1.02 to 3.76) and treatment with glucocorticoids (GCs) in dosages >5 mg/day (OR 3.67; 95% CI 1.49 to 9.05) were associated with higher odds of hospitalisation. Spondyloarthritis patients showed a smaller risk of hospitalisation compared with RA (OR 0.46; 95% CI 0.23 to 0.91). CONCLUSION: Age was a major risk factor for hospitalisation as well as comorbidities such as CVD, ILD/COPD, chronic kidney disease and current or prior treatment with GCs. Moderate to high RMD disease activity was also an independent risk factor for hospitalisation, underlining the importance of continuing adequate RMD treatment during the pandemic.


Subject(s)
/diagnosis , Glucocorticoids/adverse effects , Musculoskeletal Diseases/complications , Rheumatic Diseases/complications , /genetics , Adult , Age Factors , Aged , Aged, 80 and over , Arthritis, Rheumatoid/complications , Arthritis, Rheumatoid/drug therapy , /therapy , Case-Control Studies , Comorbidity , Female , Germany/epidemiology , Glucocorticoids/therapeutic use , Hospitalization/statistics & numerical data , Humans , Male , Middle Aged , Musculoskeletal Diseases/drug therapy , Registries , Respiration, Artificial/methods , Retrospective Studies , Rheumatic Diseases/drug therapy , Risk Factors
8.
PLoS One ; 16(1): e0245578, 2021.
Article in English | MEDLINE | ID: covidwho-1034959

ABSTRACT

COVID-19 pandemic sets the healthcare system to a shortage of ventilators. We aimed at assessing tidal volume (VT) delivery and air recirculation during expiration when one ventilator is divided into 2 test-lungs. The study was performed in a research laboratory in a medical ICU of a University hospital. An ICU (V500) and a lower-level ventilator (Elisée 350) were attached to two test-lungs (QuickLung) through a dedicated flow-splitter. A 50 mL/cmH2O Compliance (C) and 5 cmH2O/L/s Resistance (R) were set in both A and B test-lungs (A C50R5 / B C50R5, step1), A C50-R20 / B C20-R20 (step 2), A C20-R20 / B C10-R20 (step 3), and A C50-R20 / B C20-R5 (step 4). Each ventilator was set in volume and pressure control mode to deliver 800mL VT. We assessed VT from a pneumotachograph placed immediately before each lung, pendelluft air, and expiratory resistance (circuit and valve). Values are median (1st-3rd quartiles) and compared between ventilators by non-parametric tests. Between Elisée 350 and V500 in volume control VT in A/B test- lungs were 381/387 vs. 412/433 mL in step 1, 501/270 vs. 492/370 mL in step 2, 509/237 vs. 496/332 mL in step 3, and 496/281 vs. 480/329 mL in step 4. In pressure control the corresponding values were 373/336 vs. 430/414 mL, 416/185 vs. 322/234 mL, 193/108 vs. 176/ 92 mL and 422/201 vs. 481/329mL, respectively (P<0.001 between ventilators at each step for each volume). Pendelluft air volume ranged between 0.7 to 37.8 ml and negatively correlated with expiratory resistance in steps 2 and 3. The lower-level ventilator performed closely to the ICU ventilator. In the clinical setting, these findings suggest that, due to dependence of VT to C, pressure control should be preferred to maintain adequate VT at least in one patient when C and/or R changes abruptly and monitoring of VT should be done carefully. Increasing expiratory resistance should reduce pendelluft volume.


Subject(s)
/therapy , Respiration, Artificial/methods , Ventilators, Mechanical/adverse effects , Female , Humans , Lung Compliance , Lung Volume Measurements , Male , Maximal Respiratory Pressures , Respiration, Artificial/adverse effects , Respiration, Artificial/instrumentation , Ventilators, Mechanical/standards
10.
Isr Med Assoc J ; 22(12): 733-735, 2020 Dec.
Article in English | MEDLINE | ID: covidwho-1001293

ABSTRACT

BACKGROUND: Patients diagnosed with coronavirus disease-19 (COVID-19) who deteriorate to respiratory failure and require mechanical ventilation may later need to be weaned from the ventilator and undergo a rehabilitation process. The rate of weaning COVID-19 patients from mechanical ventilation is unknown. OBJECTIVES: To present our experience with ventilator weaning of COVID-19 patients in a dedicated facility. METHODS: A retrospective cohort study was conducted of 18 patients hospitalized in a COVID-19 dedicated ventilator weaning unit. RESULTS: Eighteen patients were hospitalized in the dedicated unit between 6 April and 19 May 2020. Of these, 88% (16/18) were weaned and underwent decannulation, while two patients deteriorated and were re-admitted to the intensive care unit. The average number of days spent in our department was 12. There was no statistically significant correlation between patient characteristics and time to weaning from ventilation or with the time to decannulation. CONCLUSIONS: Despite the high mortality of COVID-19 patients who require mechanical ventilation, most of the patients in our cohort were weaned in a relatively short period of time. Further large-scale studies are necessary to assess the cost effectiveness of dedicated COVID-19 departments for ventilator weaning.


Subject(s)
/therapy , Intensive Care Units , Pandemics , Respiration, Artificial/methods , Ventilator Weaning/methods , Adult , Aged , Female , Follow-Up Studies , Humans , Israel/epidemiology , Length of Stay/trends , Male , Middle Aged , Prognosis , Retrospective Studies , Young Adult
11.
PLoS One ; 15(12): e0244963, 2020.
Article in English | MEDLINE | ID: covidwho-999852

ABSTRACT

The COVID-19 pandemic disrupted the world in 2020 by spreading at unprecedented rates and causing tens of thousands of fatalities within a few months. The number of deaths dramatically increased in regions where the number of patients in need of hospital care exceeded the availability of care. Many COVID-19 patients experience Acute Respiratory Distress Syndrome (ARDS), a condition that can be treated with mechanical ventilation. In response to the need for mechanical ventilators, designed and tested an emergency ventilator (EV) that can control a patient's peak inspiratory pressure (PIP) and breathing rate, while keeping a positive end expiratory pressure (PEEP). This article describes the rapid design, prototyping, and testing of the EV. The development process was enabled by rapid design iterations using additive manufacturing (AM). In the initial design phase, iterations between design, AM, and testing enabled a working prototype within one week. The designs of the 16 different components of the ventilator were locked by additively manufacturing and testing a total of 283 parts having parametrically varied dimensions. In the second stage, AM was used to produce 75 functional prototypes to support engineering evaluation and animal testing. The devices were tested over more than two million cycles. We also developed an electronic monitoring system and with automatic alarm to provide for safe operation, along with training materials and user guides. The final designs are available online under a free license. The designs have been transferred to more than 70 organizations in 15 countries. This project demonstrates the potential for ultra-fast product design, engineering, and testing of medical devices needed for COVID-19 emergency response.


Subject(s)
/therapy , Equipment Design/methods , Respiration, Artificial/instrumentation , Ventilators, Mechanical/adverse effects , Animals , Humans , Respiration, Artificial/methods , Respiratory Mechanics/physiology , Respiratory Rate/physiology , Swine
12.
Eur Rev Med Pharmacol Sci ; 24(23): 12558-12574, 2020 12.
Article in English | MEDLINE | ID: covidwho-995016

ABSTRACT

The Coronavirus Disease 2019 (COVID-19) is a viral infection caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), which emerged in East Asia and spread around the world from December 2019. The most severe stage of COVID-19 pathology is characterized by respiratory distress requiring intubation. In specific cases, tracheostomy is indicated to ensure the safety of the procedure. The aim of our study was to analyze the scientific literature identifying the indications for tracheostomy and safety precautions to reduce contamination. We analyzed the literature from February 2003 to April 2020, including papers on pandemics of other coronaviruses, such As Severe Acute Respiratory Syndrome Coronavirus 1 and Middle East Respiratory Syndrome Coronavirus, to obtain a variety of relevant information. We focused on indications for tracheostomy in patients affected by COVID-19 or related viruses and the measures adopted to perform a safe procedure. We included 35 papers, of which 24 (68.57%) discussed guidelines for tracheostomy indications. All 35 studies discussed the procedures for performing tracheostomy safely. Data obtained indicated that the authors generally agreed on safety measures but expressed different opinions about indications. Therefore, we provided guidelines addressing safety recommendations. After the pandemic has been resolved, we plan to conduct an international retrospective study to identify the criteria for tracheostomy indications.


Subject(s)
/therapy , Respiratory Insufficiency/therapy , Tracheostomy/methods , Airway Management/methods , /transmission , Coronavirus Infections , Eye Protective Devices , Humans , Infectious Disease Transmission, Patient-to-Professional/prevention & control , Patient Isolators , Personal Protective Equipment , Respiration, Artificial/methods , Respiratory Protective Devices , Severe Acute Respiratory Syndrome , Time Factors
13.
J Cardiopulm Rehabil Prev ; 40(4): 205-208, 2020 07.
Article in English | MEDLINE | ID: covidwho-981439

ABSTRACT

DETAILS OF THE CLINICAL CASE: A 51-yr-old man underwent a respiratory rehabilitation program (RRP), after being tracheostomized and ventilated due to acute respiratory distress syndrome (ARDS) from coronavirus disease-2019 (COVID-19) infection. Respiratory care, early mobilization, and neuromuscular electrical stimulation were started in the ad hoc isolation ward of our rehabilitation center. At baseline, muscle function was consistent with intensive care unit-acquired weakness and the patient still needed mechanical ventilation (MV) and oxygen support. During the first week of RRP in isolation, the patient was successfully weaned from MV, the tracheal cannula was removed, and the walking capacity was recovered. At the end of the RRP, continued in a standard department, respiratory muscles strength increased by 7% and muscle function improved as indicated by the quadriceps size enlargement of 13% and the change of the Medical Research Council sum score from 48/60 to 58/60. DISCUSSION: Providing RRP in patients with severe COVID-19 ARDS involves risks for operators and organizational difficulties, especially in rehabilitation centers; nevertheless, its continuity is important to prevent the development of permanent disabilities in previously healthy subjects. Limited to the experience of only one patient, we were able to carry out a safe RRP during the COVID-19 pandemic, promoting the complete functional recovery of a COVID-19 young patient. SUMMARY: Most patients who develop serious consequences of COVID-19 infection risk a reduction in their quality of life. However, by organizing and directing specialized resources, subacute rehabilitation facilities could ensure the continuity of the RRPs even during the COVID-19 pandemic.


Subject(s)
Coronavirus Infections/therapy , Pneumonia, Viral/therapy , Respiratory Therapy/methods , Ventilator Weaning/methods , Coronavirus Infections/diagnosis , Feasibility Studies , Humans , Male , Middle Aged , Pandemics , Patient Isolation , Pneumonia, Viral/diagnosis , Recovery of Function , Rehabilitation Centers , Respiration, Artificial/methods , Respiratory Function Tests , Risk Assessment , Severity of Illness Index , Tracheostomy/methods , Treatment Outcome
14.
PLoS One ; 15(12): e0243966, 2020.
Article in English | MEDLINE | ID: covidwho-977709

ABSTRACT

In this paper, we provide a retrospective cohort study with patients that have been hospitalized for general or intensive care unit admission due to COVID-19, between March 3 and July 29, 2020, in the state of Bahia, Brazil. We aim to correlate those patients' demographics, symptoms and comorbidities, with the risk of mortality from COVID-19, length of hospital stay, and time from diagnosis to definitive outcome. On the basis of a dataset provided by the Health Secretary of the State of Bahia, we selected 3,896 hospitalized patients from a total of 154,868 COVID-19 patients that included non-hospitalized patients and patients with invalid registration in the dataset. Then, we statistically analyzed whether there was a significant correlation between the patient record data and the COVID-19 pandemic, and our main findings reinforced by the use of a multivariable logistic regression were that older age (Odds Ratio [OR] = 1.03, 95% Confidence Interval [CI] = 1.03-1.04, p-value (p) <0.001), an initial symptom of shortness of breath (OR = 1.88, 95% CI = 1.60-2.20, p < 0.001), and the presence of comorbidities, mainly chronic kidney disease (OR = 2.41, 95% CI = 1.67-3.48, p < 0.001) are related to an increased risk of mortality from COVID-19. On the other hand, sore throat (OR = 0.74, 95% CI = 0.58-0.95, p = 0.02) and length of hospital stay (OR = 0.96, 95% CI = 0.58-0.95, p < 0.001) are more related to a reduced risk of mortality from COVID-19. Moreover, a multivariable linear regression conducted with statistically significant variables (p < 0.05) showed that age (OR = 0.97, 95% CI = 0.95-0.98, p < 0.001) and time from diagnosis to definitive outcome (OR = 1.67, 95% CI = 1.64-1.71, p < 0.001) are associated with the length of hospital stay.


Subject(s)
/epidemiology , Coronavirus Infections/epidemiology , Pandemics , Pneumonia, Viral/epidemiology , Adult , Aged , Brazil/epidemiology , /therapy , Comorbidity , Coronavirus Infections/complications , Coronavirus Infections/therapy , Coronavirus Infections/virology , Female , Hospitalization , Humans , Intensive Care Units , Male , Middle Aged , Pneumonia, Viral/complications , Pneumonia, Viral/therapy , Pneumonia, Viral/virology , Respiration, Artificial/methods , Risk Factors , /pathogenicity
15.
PLoS One ; 15(11): e0242123, 2020.
Article in English | MEDLINE | ID: covidwho-941704

ABSTRACT

BACKGROUND: With large numbers of COVID-19 patients requiring mechanical ventilation and ventilators possibly being in short supply, in extremis two patients may have to share one ventilator. Careful matching of patient ventilation requirements is necessary. However, good matching is difficult to achieve as lung characteristics can have a wide range and may vary over time. Adding flow restriction to the flow path between ventilator and patient gives the opportunity to control the airway pressure and hence flow and volume individually for each patient. This study aimed to create and validate a simple model for calculating required flow restriction. METHODS AND FINDINGS: We created a simple linear resistance-compliance model, termed the BathRC model, of the ventilator tubing system and lung allowing direct calculation of the relationships between pressures, volumes, and required flow restriction. Experimental measurements were made for parameter determination and validation using a clinical ventilator connected to two test lungs. For validation, differing amounts of restriction were introduced into the ventilator circuit. The BathRC model was able to predict tidal lung volumes with a mean error of 4% (min:1.2%, max:9.3%). CONCLUSION: We present a simple model validated model that can be used to estimate required flow restriction for dual patient ventilation. The BathRC model is freely available; this tool is provided to demonstrate that flow restriction can be readily estimated. Models and data are available at DOI 10.15125/BATH-00816.


Subject(s)
Coronavirus Infections/therapy , Pneumonia, Viral/therapy , Respiration, Artificial/methods , Ventilators, Mechanical , Betacoronavirus , Equipment Design , Humans , Linear Models , Pandemics , Pressure , Respiration, Artificial/instrumentation , Tidal Volume
16.
BMC Pulm Med ; 20(1): 301, 2020 Nov 16.
Article in English | MEDLINE | ID: covidwho-925848

ABSTRACT

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) rapidly reached pandemic proportions. Given that the main target of SARS-CoV-2 are lungs leading to severe pneumonia with hyperactivation of the inflammatory cascade, we conducted a prospective study to assess alveolar inflammatory status in patients with moderate to severe COVID-19. METHODS: Diagnostic bronchoalveolar lavage (BAL) was performed in 33 adult patients with SARS-CoV-2 infection by real-time PCR on nasopharyngeal swab admitted to the Intensive care unit (ICU) (n = 28) and to the Intermediate Medicine Ward (IMW) (n = 5). We analyze the differential cell count, ultrastructure of cells and Interleukin (IL)6, 8 and 10 levels. RESULTS: ICU patients showed a marked increase in neutrophils (1.24 × 105 ml- 1, 0.85-2.07), lower lymphocyte (0.97 × 105 ml- 1, 0.024-0.34) and macrophages fractions (0.43 × 105 ml- 1, 0.34-1.62) compared to IMW patients (0.095 × 105 ml- 1, 0.05-0.73; 0.47 × 105 ml- 1, 0.28-1.01 and 2.14 × 105 ml- 1, 1.17-3.01, respectively) (p < 0.01). Study of ICU patients BAL by electron transmission microscopy showed viral particles inside mononuclear cells confirmed by immunostaining with anti-viral capsid and spike antibodies. IL6 and IL8 were significantly higher in ICU patients than in IMW (IL6 p < 0.01, IL8 p < 0.0001), and also in patients who did not survive (IL6 p < 0.05, IL8 p = 0.05 vs. survivors). IL10 did not show a significant variation between groups. Dividing patients by treatment received, lower BAL concentrations of IL6 were found in patients treated with steroids as compared to those treated with tocilizumab (p < 0.1) or antivirals (p < 0.05). CONCLUSIONS: Alveolitis, associated with COVID-19, is mainly sustained by innate effectors which showed features of extensive activation. The burden of pro-inflammatory cytokines IL6 and IL8 in the broncho-alveolar environment is associated with clinical outcome.


Subject(s)
Bronchoalveolar Lavage Fluid/immunology , Coronavirus Infections/immunology , Inflammation/immunology , Interleukin-6/immunology , Interleukin-8/immunology , Leukocytes/immunology , Lung/immunology , Macrophages, Alveolar/immunology , Pneumonia, Viral/immunology , Adenosine Monophosphate/analogs & derivatives , Adenosine Monophosphate/therapeutic use , Adrenal Cortex Hormones/therapeutic use , Aged , Alanine/analogs & derivatives , Alanine/therapeutic use , Antibodies, Monoclonal, Humanized/therapeutic use , Antiviral Agents/therapeutic use , Betacoronavirus , Bronchoalveolar Lavage , Bronchoalveolar Lavage Fluid/cytology , Bronchoalveolar Lavage Fluid/virology , Coronavirus Infections/drug therapy , Coronavirus Infections/therapy , Drug Combinations , Female , Humans , Hydroxychloroquine/therapeutic use , Intensive Care Units , Interleukin-10/immunology , Italy , Leukocytes, Mononuclear/virology , Lopinavir/therapeutic use , Lung/cytology , Lung/virology , Lymphocytes/immunology , Male , Microscopy, Electron, Transmission , Middle Aged , Neutrophils/immunology , Pandemics , Pneumonia, Viral/therapy , Prognosis , Prospective Studies , Respiration, Artificial/methods , Ritonavir/therapeutic use , Spike Glycoprotein, Coronavirus/metabolism , Survival Rate , Virion/metabolism , Virion/ultrastructure
17.
Trials ; 21(1): 919, 2020 Nov 11.
Article in English | MEDLINE | ID: covidwho-917940

ABSTRACT

OBJECTIVES: Assessing the effect of surfactant on clinical outcome in patients with COVID-19 under mechanical ventilation TRIAL DESIGN: Single centre, two arm, parallel group (1:1 allocation ratio), randomised superiority trial with blinded care and outcome assessment. PARTICIPANTS: Inclusion criteria: Adult COVID-19 patients admitted to the ICU in Modarres hospital, Tehran, Iran (age range of 18 to 99 years) with moderate to severe ARDS (based on definition of P/F ratio) requiring auxiliary respiratory devices (either intubation or face mask). EXCLUSION CRITERIA: ● Existence of a major underlying pulmonary disease in addition to COVID-19 ● Underlying congenital heart disease ● Patients needing extracorporeal membrane oxygenation (ECMO) ● ARDS primarily due to any other reason rather than COVID-19 ● The primary source of pulmonary involvement was bacterial pneumonia or any other etiology except for COVID-10 induced lung involvement ● Those who refused to continue the study (either the patient or their family) ● any patient had any sign of healing before entering the study leading to discharge from ICU in less than 12 hours INTERVENTION AND COMPARATOR: In the intervention group, the dose of the drug is a vial containing 4 ml, equivalent to 100 mg, which is prescribed for an adult weighing about 70 kg each time, and if the patient's weight is much lower or higher, it will be adjusted accordingly. Surfactant is prescribed inside the trachea in two doses, starting on the day of intubation with a second dose 6 hours later. The control group will receive the same volume of normal saline, based on weight, administered into the trachea with the same time schedule. MAIN OUTCOMES: 30 days mortality; patient mortality during stay in ICU up to 30 days; ICU length of stay up to 30 days; Time under mechanical ventilation up to 30 days. RANDOMISATION: After the participant enters the study, i.e. after the qualification of the patients in the trial is confirmed and their informed written consent is taken, we will use a simple randomisation method using a table of random numbers. In order to hide the random allocation process, a central randomisation approach will be used and the random sequence will be at the disposal of one of the researchers, excluding the principal investigator. BLINDING (MASKING): Participants, healthcare providers and the principal investigator assessing the outcomes will all be blinded to the group assignment. NUMBERS TO BE RANDOMISED (SAMPLE SIZE): A total of 60 participants will be randomised in a 1:1 allocation ratio (30 patients allocated to the intervention group and 30 patients allocated to the control group). TRIAL STATUS: The protocol is Version 1.0, May 31, 2020. Recruitment began July 30, 2020, and is anticipated to be completed by October 30, 2020. TRIAL REGISTRATION: IRCT registration number: IRCT20091201002804N12 Registration date: 1st June 2020, 1399/03/12 FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.


Subject(s)
Coronavirus Infections/therapy , Pneumonia, Viral/therapy , Pulmonary Surfactants , Respiration, Artificial/methods , Adult , Betacoronavirus , Dose-Response Relationship, Drug , Double-Blind Method , Drug Dosage Calculations , Drug Monitoring/methods , Female , Humans , Male , Mortality , Pandemics , Pulmonary Surfactants/administration & dosage , Pulmonary Surfactants/adverse effects , Randomized Controlled Trials as Topic , Surface-Active Agents/administration & dosage , Surface-Active Agents/adverse effects , Treatment Outcome
18.
Medicina (Kaunas) ; 56(11)2020 Oct 29.
Article in English | MEDLINE | ID: covidwho-902594

ABSTRACT

Coronavirus disease (COVID-19) started in Wuhan (China) at the end of 2019, and then increased rapidly. In patients with severe acute respiratory distress syndrome (ARDS) caused by COVID-19, venovenous extracorporeal membrane oxygenation (VV-ECMO) is considered a rescue therapy that provides adequate gas exchange. The way in which mechanical ventilation is applied during VV-ECMO is not clear, however it is associated with prognosis. Currently, the mortality rate of COVID-19 patients that receive VV-ECMO stands at approximately 50%. Here, we report three patients that successfully recovered from COVID-19-induced ARDS after VV-ECMO and implementation of an ultra-protective ventilation. This ventilation strategy involved maintaining a peak inspiratory pressure of ≤20 cmH2O and a positive end-expiratory pressure (PEEP) of ≤ 10 cmH2O, which are lower values than have been previously reported. Thus, we suggest that this ultra-protective ventilation be considered during VV-ECMO as it minimizes the ventilator-induced lung injury.


Subject(s)
Coronavirus Infections/therapy , Extracorporeal Membrane Oxygenation/methods , Glucocorticoids/therapeutic use , Pneumonia, Viral/therapy , Respiration, Artificial/methods , Ventilator-Induced Lung Injury/prevention & control , Aged , Anti-Bacterial Agents/therapeutic use , Antiviral Agents/therapeutic use , Betacoronavirus , Coronavirus Infections/drug therapy , Female , Humans , Immunization, Passive , Male , Middle Aged , Pandemics
19.
PLoS One ; 15(11): e0241544, 2020.
Article in English | MEDLINE | ID: covidwho-902055

ABSTRACT

INTRODUCTION: COVID-19 has spread globally to now be considered a pandemic by the World Health Organisation. Initially patients appeared to have a respiratory limited disease but there are now increasing reports of multiple organ involvement including renal disease in association with COVID-19. We studied the development and outcomes of acute kidney injury (AKI) in patients with COVID-19, in a large multicultural city hospital trust in the UK, to better understand the role renal disease has in the disease process. METHODS: This was a retrospective review using electronic records and laboratory data of adult patients admitted to the four Manchester University Foundation Trust Hospitals between March 10 and April 30 2020 with a diagnosis of COVID-19. Records were reviewed for baseline characteristics, medications, comorbidities, social deprivation index, observations, biochemistry and outcomes including mortality, admission to critical care, mechanical ventilation and the need for renal replacement therapy. RESULTS: There were 1032 patients included in the study of whom 210 (20.3%) had AKI in association with the diagnosis of COVID-19. The overall mortality with AKI was considerably higher at 52.4% compared to 26.3% without AKI (p-value <0.001). More patients with AKI required escalation to critical care (34.8% vs 11.2%, p-value <0.001). Following admission to critical care those with AKI were more likely to die (54.8% vs 25.0%, p-value <0.001) and more likely to require mechanical ventilation (86.3% vs 66.3%, p-value 0.006). DISCUSSION: We have shown that the development of AKI is associated with dramatically worse outcomes for patients, in both mortality and the requirement for critical care. Patients with COVID-19 presenting with, or at risk of AKI should be closely monitored and appropriately managed to prevent any decline in renal function, given the significant risk of deterioration and death.


Subject(s)
Acute Kidney Injury/epidemiology , Acute Kidney Injury/etiology , Coronavirus Infections/complications , Coronavirus Infections/epidemiology , Pandemics , Pneumonia, Viral/complications , Pneumonia, Viral/epidemiology , Acute Kidney Injury/mortality , Acute Kidney Injury/virology , Aged , Aged, 80 and over , Coronavirus Infections/mortality , Coronavirus Infections/virology , Female , Hospital Mortality , Hospitalization , Hospitals, Urban , Humans , Length of Stay , Male , Middle Aged , Pneumonia, Viral/mortality , Pneumonia, Viral/virology , Respiration, Artificial/methods , Retrospective Studies , United Kingdom/epidemiology
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