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1.
Sci Prog ; 105(2): 368504221092891, 2022.
Article in English | MEDLINE | ID: covidwho-1784977

ABSTRACT

Coronavirus disease 2019 (COVID-19) has been declared a pandemic by the World Health Organization; it has affected millions of people and caused hundreds of thousands of deaths. Patients with COVID-19 pneumonia may develop acute hypoxia respiratory failure and require noninvasive respiratory support or invasive respiratory management. Healthcare workers have a high risk of contracting COVID-19 while fitting respiratory devices. Recently, European experts have suggested that the use of helmet continuous positive airway pressure should be the first choice for acute hypoxia respiratory failure caused by COVID-19 because it reduces the spread of the virus in the ambient air. By contrast, in the United States, helmets were restricted for respiratory care before the COVID-19 pandemic until the Food and Drug Administration provided the 'Umbrella Emergency Use Authorization for Ventilators and Ventilator Accessories'. This narrative review provides an evidence-based overview of the use of helmet ventilation for patients with respiratory failure.


Subject(s)
COVID-19 , Noninvasive Ventilation , Respiratory Distress Syndrome , Respiratory Insufficiency , COVID-19/epidemiology , Head Protective Devices/adverse effects , Humans , Hypoxia/complications , Noninvasive Ventilation/adverse effects , Pandemics , Respiratory Insufficiency/epidemiology , Respiratory Insufficiency/etiology , Respiratory Insufficiency/therapy
2.
BMC Anesthesiol ; 22(1): 59, 2022 03 04.
Article in English | MEDLINE | ID: covidwho-1724413

ABSTRACT

BACKGROUND: Data on the lung respiratory mechanics and gas exchange in the time course of COVID-19-associated respiratory failure is limited. This study aimed to explore respiratory mechanics and gas exchange, the lung recruitability and risk of overdistension during the time course of mechanical ventilation. METHODS: This was a prospective observational study in critically ill mechanically ventilated patients (n = 116) with COVID-19 admitted into Intensive Care Units of Sechenov University. The primary endpoints were: «optimum¼ positive end-expiratory pressure (PEEP) level balanced between the lowest driving pressure and the highest SpO2 and number of patients with recruitable lung on Days 1 and 7 of mechanical ventilation. We measured driving pressure at different levels of PEEP (14, 12, 10 and 8 cmH2O) with preset tidal volume, and with the increase of tidal volume by 100 ml and 200 ml at preset PEEP level, and calculated static respiratory system compliance (CRS), PaO2/FiO2, alveolar dead space and ventilatory ratio on Days 1, 3, 5, 7, 10, 14 and 21. RESULTS: The «optimum¼ PEEP levels on Day 1 were 11.0 (10.0-12.8) cmH2O and 10.0 (9.0-12.0) cmH2O on Day 7. Positive response to recruitment was observed on Day 1 in 27.6% and on Day 7 in 9.2% of patients. PEEP increase from 10 to 14 cmH2O and VT increase by 100 and 200 ml led to a significant decrease in CRS from Day 1 to Day 14 (p < 0.05). Ventilatory ratio was 2.2 (1.7-2,7) in non-survivors and in 1.9 (1.6-2.6) survivors on Day 1 and decreased on Day 7 in survivors only (p < 0.01). PaO2/FiO2 was 105.5 (76.2-141.7) mmHg in non-survivors on Day 1 and 136.6 (106.7-160.8) in survivors (p = 0.002). In survivors, PaO2/FiO2 rose on Day 3 (p = 0.008) and then between Days 7 and 10 (p = 0.046). CONCLUSION: Lung recruitability was low in COVID-19 and decreased during the course of the disease, but lung overdistension occurred at «intermediate¼ PEEP and VT levels. In survivors gas exchange improvements after Day 7 mismatched CRS. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04445961 . Registered 24 June 2020-Retrospectively registered.


Subject(s)
COVID-19/epidemiology , COVID-19/therapy , Lung/physiopathology , Respiration, Artificial/statistics & numerical data , Respiratory Insufficiency/epidemiology , Aged , COVID-19/physiopathology , Critical Care/methods , Female , Humans , Male , Middle Aged , Noninvasive Ventilation/statistics & numerical data , Positive-Pressure Respiration , Prospective Studies , Respiratory Insufficiency/physiopathology , Respiratory Mechanics , Russia/epidemiology , SARS-CoV-2 , Survival Analysis , Tidal Volume , Treatment Failure
3.
Am J Emerg Med ; 53: 215-221, 2022 03.
Article in English | MEDLINE | ID: covidwho-1616338

ABSTRACT

BACKGROUND: The COVID 19 pandemic has had a crucial effect on the patterns of disease and treatment in the healthcare system. This study examines the effect of the COVID-19 pandemic on respiratory ED visits and admissions broken down by age group and respiratory diagnostic category. METHODS: Data on non-COVID related ED visits and hospitalizations from the ED were obtained in a retrospective analysis for 29 acute care hospitals, covering 98% of ED beds in Israel, and analyzed by 5 age groups: under one-year-old, 1-17, 18-44, 45-74 and 75 and over. Diagnoses were classified into three categories: Upper respiratory tract infections (URTI), pneumonia, and COPD or asthma. Data were collected for the whole of 2020, and compared for each month to the average number of cases in the three pre-COVID years (2017-2019). RESULTS: In 2020 compared to 2017-2019, there was a decrease of 34% in non-COVID ED visits due to URTI, 40% for pneumonia and a 35% decrease for COPD and asthma. Reductions occurred in most age groups, but were most marked among infants under a year, during and following lockdowns, with an 80% reduction. Patients over 75 years old displayed a marked drop in URTI visits. Pediatric asthma visits fell during lockdowns, but spiked when restrictions were lifted, accompanied by a higher proportion admitted. The percent of admissions from the ED visits remained mostly stable for pneumonia; the percent of young adults admitted with URTI decreased significantly from March to October. CONCLUSIONS: Changing patterns of ED use were probably due to a combination of a reduced rate of viral diseases, availability of additional virtual services, and avoidance of exposure to the ED environment. Improved hygiene measures during peaks of respiratory infections could be implemented in future to reduce respiratory morbidity; and continued provision of remote health services may reduce overuse of ED services for mild cases.


Subject(s)
COVID-19/prevention & control , Emergency Service, Hospital/statistics & numerical data , Patient Acceptance of Health Care/statistics & numerical data , Respiratory Insufficiency/diagnosis , Adolescent , Adult , Aged , COVID-19/transmission , Child , Child, Preschool , Emergency Service, Hospital/organization & administration , Female , Humans , Infant , Israel/epidemiology , Male , Middle Aged , Respiratory Insufficiency/epidemiology , Retrospective Studies
5.
J Med Internet Res ; 23(2): e24246, 2021 02 10.
Article in English | MEDLINE | ID: covidwho-1573886

ABSTRACT

BACKGROUND: Predicting early respiratory failure due to COVID-19 can help triage patients to higher levels of care, allocate scarce resources, and reduce morbidity and mortality by appropriately monitoring and treating the patients at greatest risk for deterioration. Given the complexity of COVID-19, machine learning approaches may support clinical decision making for patients with this disease. OBJECTIVE: Our objective is to derive a machine learning model that predicts respiratory failure within 48 hours of admission based on data from the emergency department. METHODS: Data were collected from patients with COVID-19 who were admitted to Northwell Health acute care hospitals and were discharged, died, or spent a minimum of 48 hours in the hospital between March 1 and May 11, 2020. Of 11,525 patients, 933 (8.1%) were placed on invasive mechanical ventilation within 48 hours of admission. Variables used by the models included clinical and laboratory data commonly collected in the emergency department. We trained and validated three predictive models (two based on XGBoost and one that used logistic regression) using cross-hospital validation. We compared model performance among all three models as well as an established early warning score (Modified Early Warning Score) using receiver operating characteristic curves, precision-recall curves, and other metrics. RESULTS: The XGBoost model had the highest mean accuracy (0.919; area under the curve=0.77), outperforming the other two models as well as the Modified Early Warning Score. Important predictor variables included the type of oxygen delivery used in the emergency department, patient age, Emergency Severity Index level, respiratory rate, serum lactate, and demographic characteristics. CONCLUSIONS: The XGBoost model had high predictive accuracy, outperforming other early warning scores. The clinical plausibility and predictive ability of XGBoost suggest that the model could be used to predict 48-hour respiratory failure in admitted patients with COVID-19.


Subject(s)
COVID-19/physiopathology , Hospitalization , Intubation, Intratracheal/statistics & numerical data , Machine Learning , Respiration, Artificial/statistics & numerical data , Respiratory Insufficiency/epidemiology , Aged , COVID-19/complications , Clinical Decision Rules , Early Warning Score , Emergency Service, Hospital , Female , Hospitals , Humans , Logistic Models , Male , Middle Aged , Patient Admission , ROC Curve , Respiratory Insufficiency/etiology , Retrospective Studies , SARS-CoV-2 , Triage
6.
Intern Med J ; 51(11): 1810-1815, 2021 11.
Article in English | MEDLINE | ID: covidwho-1526370

ABSTRACT

BACKGROUND: COVID-19 long-term sequelae are ill-defined since only a few studies have explored the long-term consequences of this disease so far. AIMS: To evaluate the 6-month respiratory outcome and exercise capacity of COVID-19 acute respiratory failure (ARF) patients treated with continuous positive airway pressure (CPAP) during the first wave of the ongoing COVID-19 pandemic. METHODS: A retrospective observational study included COVID-19 patients with ARF. Interventions included CPAP during hospitalisation and 6-month follow up. Frailty assessment was carried out through frailty index (FI), pO2 /FiO2 during hospitalisation and at follow up, respiratory parameters, 6-min walking test (6MWT) and the modified British Medical Research Council (mMRC) and Borg scale at follow up. RESULTS: More than half of the patients had no dyspnoea according to the mMRC scale. Lower in-hospital pO2 /FiO2 correlated with higher Borg scale levels after 6MWT (ρ 0.27; P 0.04) at the follow-up visit. FI was positively correlated with length of hospitalisation (ρ 0.3; P 0.03) and negatively with the 6MWT distance walked (ρ -0.36; P 0.004). CONCLUSIONS: Robust and frail patients with COVID-19 ARF treated with CPAP outside the intensive care unit setting had good respiratory parameters and exercise capacity at 6-month follow up, although more severe patients had slightly poorer respiratory performance compared with patients with higher PaO2 /FiO2 and lower FI.


Subject(s)
COVID-19 , Respiratory Insufficiency , Continuous Positive Airway Pressure , Exercise Tolerance , Humans , Pandemics , Respiratory Insufficiency/epidemiology , Respiratory Insufficiency/therapy , Retrospective Studies , SARS-CoV-2
7.
Int J Environ Res Public Health ; 18(22)2021 11 12.
Article in English | MEDLINE | ID: covidwho-1512349

ABSTRACT

COVID-19 survivors are associated with acute respiratory failure (ARF) and show a high prevalence of impairment in physical performance. The present studied aimed to assess whether we may cluster these individuals according to an exercise test. The presented study is a retrospective analysis of 154 survivors who were admitted to two hospitals of Istituti Clinici Scientifici Maugeri network, Italy. Clinical characteristics, walked distance, heart rate (HR), pulse oximetry (SpO2), dyspnoea, and leg fatigue (Borg scale: Borg-D and Borg-F, respectively) while performing the six-minute walking test (6MWT) were entered into unsupervised clustering analysis. Multivariate linear regression identified variables that were informative for the set of variables used for cluster definition. Cluster 1 (C1: 86.4% of participants) and Cluster 2 (C2: 13.6%) were identified. Compared to C1, the individuals in C2 were significantly older, showed significantly higher increase in fatigue and in dyspnoea, greater reduction in SpO2, and a lower HRpeak during the test. The need of walking aids, time from admission to acute care hospitals, age, body mass index, endotracheal intubation, baseline HR and baseline Borg-D, and exercise-induced SpO2 change were significantly associated with the variables that were used for cluster definition. Different characteristics and physiological parameters during the 6MWT characterise survivors of COVID-19-associated ARF. These results may help in the management of the long-term effects of the disease.


Subject(s)
COVID-19 , Respiratory Insufficiency , Exercise Test , Humans , Respiratory Insufficiency/epidemiology , Retrospective Studies , SARS-CoV-2 , Survivors , Walking
8.
Expert Rev Respir Med ; 15(12): 1505-1515, 2021 12.
Article in English | MEDLINE | ID: covidwho-1487398

ABSTRACT

INTRODUCTION: Respiratory high dependency units (RHDUs) set up in European countries in the last decade are based on being a transitional step between the intensive care units (ICUs) and the conventional hospital ward in terms of staffing, level of monitoring, and patients' severity. In the pre-COVID-19 era, its main use has been the treatment of hypercapnic acute-on-chronic respiratory failure with noninvasive respiratory support, and more recently, for hypoxemic acute respiratory failure. AREAS COVERED: We searched the following databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, limited to the terms: COVID-19 and RHDU, Respiratory Intermediate care Unit, acute respiratory distress syndrome (ARDS), noninvasive ventilation (NIV), high flow nasal cannula (HFNC), prone position, and monitoring. In this review, we summarize RHDU´s dual purpose: on the one hand, to decrease the number of admissions into ICU, and on the other hand, early discharges of patients from ICU with prolonged admissions due to the need of care or laborious weaning from invasive mechanical ventilation. Although this dual purpose of RHDUs has contributed to decrease the overload of the ICUs during the pandemic, the hundreds of patients admitted in hospitals, with approximately 20%-30% needing critical care, has exceeded the forecasts of many hospitals. EXPERT OPINION: It seems clear that a reorganization and optimization of the care of patients with severe COVID-19 is necessary, minimizing admissions to the ICU and facilitating an early discharge. During the pandemic, several hospitals have spontaneously created new RHDUs or extended preexisting RHDUs or up-graded respiratory wards in order to receive less sick patients requiring lower levels of monitoring and nurse-to-patient ratios. This article reviews under a European expert perspective this topic and proposes an adaptation and optimization of the RHDUs to meet the emergent needs caused by the pandemic emphasizing the role of the expert application of noninvasive respiratory therapies in preventing intubation and ICU access.


Subject(s)
COVID-19 , Noninvasive Ventilation , Respiratory Insufficiency , Humans , Intensive Care Units , Oxygen Inhalation Therapy , Pandemics , Respiratory Insufficiency/diagnosis , Respiratory Insufficiency/epidemiology , Respiratory Insufficiency/therapy , SARS-CoV-2
9.
Acta Anaesthesiol Scand ; 66(1): 48-55, 2022 01.
Article in English | MEDLINE | ID: covidwho-1472297

ABSTRACT

BACKGROUND: Diabetes is common among patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-induced respiratory failure. We aimed to investigate the relationship between different stages of chronic dysglycemia and development of respiratory failure in hospitalized SARS-CoV-2 positive patients. METHODS: In this retrospective observational study, we included 385 hospitalized SARS-CoV-2 positive patients at Karolinska University Hospital, Sweden with an HbA1c test obtained within 3 months before admission. Based on HbA1c level and previous diabetes history, we classified patients into the following dysglycemia categories: prediabetes, unknown diabetes, controlled diabetes, or uncontrolled diabetes. We used multivariable logistic regression analysis adjusted for age, sex, and body mass index, to assess the association between dysglycemia categories and development of SARS-CoV-2-induced respiratory failure. RESULTS: Of the 385 study patients, 88 (22.9%) had prediabetes, 68 (17.7%) had unknown diabetes, 36 (9.4%) had controlled diabetes, and 83 (21.6%) had uncontrolled diabetes. Overall, 299 (77.7%) patients were admitted with or developed SARS-CoV-2-induced respiratory failure during hospitalization. In multivariable logistic regression analysis compared with no chronic dysglycemia, prediabetes (OR 14.41, 95% CI 5.27-39.43), unknown diabetes (OR 15.86, 95% CI 4.55-55.36), and uncontrolled diabetes (OR 17.61, 95% CI 5.77-53.74) was independently associated with increased risk of SARS-CoV-2-induced respiratory failure. CONCLUSION: In our cohort of hospitalized SARS-CoV-2 positive patients with available HbA1c data, prediabetes, undiagnosed diabetes, and poorly controlled diabetes were associated with a markedly increased risk of SARS-CoV-2-associated respiratory failure.


Subject(s)
COVID-19 , Diabetes Mellitus , Respiratory Insufficiency , Diabetes Mellitus/epidemiology , Hospitalization , Humans , Respiratory Insufficiency/epidemiology , Respiratory Insufficiency/etiology , Retrospective Studies , Risk Factors , SARS-CoV-2
11.
BMC Infect Dis ; 21(1): 954, 2021 Sep 15.
Article in English | MEDLINE | ID: covidwho-1411524

ABSTRACT

BACKGROUND: In Poland, little is known about the most serious cases of influenza that need admittance to the intensive care unit (ICU), as well as the use of extracorporeal respiratory support. METHODS: This was an electronic survey comprising ICUs in two administrative regions of Poland. The aim of the study was to determine the number of influenza patients with respiratory failure admitted to the ICU in the autumn-winter season of 2018/2019. Furthermore, respiratory support, outcome and other pathogens detected in the airways were investigated. RESULTS: Influenza infection was confirmed in 76 patients. The A(H1N1)pdm09 strain was the most common. 34 patients died (44.7%). The median age was 62 years, the median sequential organ failure assessment (SOFA) score was 11 and was higher in patients who died (12 vs. 10, p = 0.017). Mechanical ventilation was used in 75 patients and high flow nasal oxygen therapy in 1 patient. Extracorporeal membrane oxygenation (ECMO) was used in 7 patients (6 survived), and extracorporeal carbon dioxide removal (ECCO2R) in 2 (1 survived). The prone position was used in 16 patients. In addition, other pathogens were detected in the airways on admittance to the ICU. CONCLUSION: A substantial number of influenza infections occurred in the autumn-winter season of 2018/2019 that required costly treatment in the intensive care units. Upon admission to the ICU, influenza patients had a high degree of organ failure as assessed by the SOFA score, and the mortality rate was 44.7%. Advanced extracorporeal respiratory techniques offer real survival opportunities to patients with severe influenza-related ARDS. The presence of coinfection should be considered in patients with influenza and respiratory failure.


Subject(s)
Influenza A Virus, H1N1 Subtype , Influenza, Human , Respiratory Distress Syndrome , Respiratory Insufficiency , Humans , Infant, Newborn , Influenza, Human/complications , Influenza, Human/epidemiology , Intensive Care Units , Poland/epidemiology , Respiration, Artificial , Respiratory Insufficiency/epidemiology , Respiratory Insufficiency/therapy
12.
Ann Surg ; 274(5): e388-e394, 2021 11 01.
Article in English | MEDLINE | ID: covidwho-1455430

ABSTRACT

OBJECTIVE: Does extracorporeal membrane oxygenation (ECMO) improve outcomes in ECMO-eligible patients with COVID-19 respiratory failure compared to maximum ventilation alone (MVA)? SUMMARY BACKGROUND DATA: ECMO is beneficial in severe cases of respiratory failure when mechanical ventilation is inadequate. Outcomes for ECMO-eligible COVID-19 patients on MVA have not been reported. Consequently, a direct comparison between COVID-19 patients on ECMO and those on MVA has not been established. METHODS: A total of 3406 COVID-19 patients treated at two major medical centers in Chicago were studied. One hundred ninety-five required maximum ventilatory support, and met ECMO eligibility criteria. Eighty ECMO patients were propensity matched to an equal number of MVA patients using detailed demographic, physiological, and comorbidity data. Primary outcome was survival and disposition at discharge. RESULTS: Seventy-one percent of patients were decannulated from ECMO. Mechanical ventilation was discontinued in 75% ECMO and 16% MVA patients. Twenty-five percent of patients in the ECMO arm expired, 21% while on ECMO, compared with 74% in the MVA cohort. Mortality was significantly lower across all age and BMI groups in the ECMO arm. Sixty-eight percent ECMO and 26% MVA patients were discharged from the hospital. Fewer ECMO patients required long-term rehabilitation. Major complications such as septic shock, ventilator associated pneumonia, inotropic requirements, acute liver and kidney injuries are less frequent among ECMO patients. CONCLUSIONS: ECMO-eligible patients with severe COVID-19 respiratory failure demonstrate a 3-fold improvement in survival with ECMO. They are also in a better physical state at discharge and have lower overall complication rates. As such, strong consideration should be given for ECMO when mechanical ventilatory support alone becomes insufficient in treating COVID-19 respiratory failure.


Subject(s)
COVID-19/therapy , Extracorporeal Membrane Oxygenation/methods , Propensity Score , Respiration, Artificial/methods , Respiratory Insufficiency/therapy , Adult , Aged , COVID-19/complications , COVID-19/epidemiology , Female , Follow-Up Studies , Humans , Male , Middle Aged , Pandemics , Patient Discharge/trends , Respiratory Insufficiency/epidemiology , Respiratory Insufficiency/etiology , Retrospective Studies , SARS-CoV-2 , Severity of Illness Index , Survival Rate/trends , United States/epidemiology , Young Adult
13.
Eur J Med Res ; 26(1): 117, 2021 Oct 02.
Article in English | MEDLINE | ID: covidwho-1448444

ABSTRACT

BACKGROUND: Interleukin-6 receptor antagonists (IL-6RAs) and steroids are emerging immunomodulatory therapies for severe and critical coronavirus disease (COVID-19). In this preliminary report, we aim to describe the epidemiology, clinical characteristics, and outcomes of adult critically ill COVID-19 patients, requiring invasive mechanical ventilation (iMV), and receiving IL-6RA and steroids therapy over the last 11 months. MATERIALS AND METHODS: International, multicenter, cohort study derived from Viral Infection and Respiratory Illness University Study registry and conducted through Discovery Network, Society of Critical Care Medicine. Data were collected between March 01, 2020, and January 10, 2021. RESULTS: Of 860 patients who met eligibility criteria, 589 received steroids, 170 IL-6RAs, and 101 combinations. Patients who received IL-6RAs were younger (median age of 57.5 years vs. 61.1 and 61.8 years in the steroids and combination groups, respectively). The median C-reactive protein level was > 75 mg/L, indicating a hyperinflammatory phenotype. The median daily steroid dose was 7.5 mg dexamethasone or equivalent (interquartile range: 6-14 mg); 80.8% and 19.2% received low-dose and high-dose steroids, respectively. Of the patients who received IL-6RAs, the majority received one dose of tocilizumab and sarilumab (dose range of 600-800 mg for tocilizumab and 200-400 mg for sarilumab). Regarding the timing of administration, we observed that steroid and IL-6RA administration on day 0 of ICU admission was only 55.6% and 39.5%, respectively. By day 28, when compared with steroid use alone, IL-6RA use was associated with an adjusted incidence rate ratio (aIRR) of 1.12 (95% confidence interval [CI] 0.88, 1.4) for ventilator-free days, while combination therapy was associated with an aIRR of 0.83 (95% CI 0.6, 1.14). IL-6RA use was associated with an adjusted odds ratio (aOR) of 0.68 (95% CI 0.44, 1.07) for the 28-day mortality rate, while combination therapy was associated with an aOR of 1.07 (95% CI 0.67, 1.70). Liver dysfunction was higher in IL-6RA group (p = 0.04), while the bacteremia rate did not differ among groups. CONCLUSIONS: Discordance was observed between the registry utilization patterns (i.e., timing of steroids and IL-6RA administration) and new evidence from the recent randomized controlled trials and guideline recommendations. These data will help us to identify areas of improvement in prescribing patterns and enhance our understanding of IL-6RA safety with different steroid regimens. Further studies are needed to evaluate the drivers of hospital-level variation and their impact on clinical outcomes. Trial registration ClinicalTrials.gov: NCT04486521. Registered on July 2020.


Subject(s)
Adrenal Cortex Hormones/therapeutic use , COVID-19/complications , Receptors, Interleukin-6/antagonists & inhibitors , Registries/statistics & numerical data , Respiration, Artificial/methods , Respiratory Insufficiency/mortality , SARS-CoV-2/isolation & purification , Adolescent , Adult , Aged , Aged, 80 and over , Critical Illness , Female , Follow-Up Studies , Humans , International Agencies , Male , Middle Aged , Prognosis , Respiratory Insufficiency/epidemiology , Respiratory Insufficiency/therapy , Respiratory Insufficiency/virology , Survival Rate , Young Adult
14.
J Allergy Clin Immunol ; 148(5): 1176-1191, 2021 11.
Article in English | MEDLINE | ID: covidwho-1401557

ABSTRACT

BACKGROUND: The risk of severe coronavirus disease 2019 (COVID-19) varies significantly among persons of similar age and is higher in males. Age-independent, sex-biased differences in susceptibility to severe COVID-19 may be ascribable to deficits in a sexually dimorphic protective attribute that we termed immunologic resilience (IR). OBJECTIVE: We sought to examine whether deficits in IR that antedate or are induced by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection independently predict COVID-19 mortality. METHODS: IR levels were quantified with 2 novel metrics: immune health grades (IHG-I [best] to IHG-IV) to gauge CD8+ and CD4+ T-cell count equilibrium, and blood gene expression signatures. IR metrics were examined in a prospective COVID-19 cohort (n = 522); primary outcome was 30-day mortality. Associations of IR metrics with outcomes in non-COVID-19 cohorts (n = 13,461) provided the framework for linking pre-COVID-19 IR status to IR during COVID-19, as well as to COVID-19 outcomes. RESULTS: IHG-I, tracking high-grade equilibrium between CD8+ and CD4+ T-cell counts, was the most common grade (73%) among healthy adults, particularly in females. SARS-CoV-2 infection was associated with underrepresentation of IHG-I (21%) versus overrepresentation (77%) of IHG-II or IHG-IV, especially in males versus females (P < .01). Presentation with IHG-I was associated with 88% lower mortality, after controlling for age and sex; reduced risk of hospitalization and respiratory failure; lower plasma IL-6 levels; rapid clearance of nasopharyngeal SARS-CoV-2 burden; and gene expression signatures correlating with survival that signify immunocompetence and controlled inflammation. In non-COVID-19 cohorts, IR-preserving metrics were associated with resistance to progressive influenza or HIV infection, as well as lower 9-year mortality in the Framingham Heart Study, especially in females. CONCLUSIONS: Preservation of immunocompetence with controlled inflammation during antigenic challenges is a hallmark of IR and associates with longevity and AIDS resistance. Independent of age, a male-biased proclivity to degrade IR before and/or during SARS-CoV-2 infection predisposes to severe COVID-19.


Subject(s)
COVID-19/immunology , HIV Infections/epidemiology , HIV-1/physiology , Respiratory Insufficiency/epidemiology , SARS-CoV-2/physiology , Sex Factors , T-Lymphocytes/immunology , Adult , Aged , COVID-19/epidemiology , COVID-19/mortality , Cohort Studies , Disease Resistance , Female , Humans , Immunocompetence , Interleukin-6/blood , Longitudinal Studies , Male , Middle Aged , Prospective Studies , Severity of Illness Index , Survival Analysis , Transcriptome/immunology , United States/epidemiology , Viral Load
15.
Eur J Clin Invest ; 51(11): e13582, 2021 Nov.
Article in English | MEDLINE | ID: covidwho-1365071

ABSTRACT

BACKGROUND: A systematic analysis of concomitant arterial hypertension in COVID-19 patients and the impact of angiotensin-converting-enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARBs) have not been studied in a large multicentre cohort yet. We conducted a subanalysis from the international HOPE Registry (https://hopeprojectmd.com, NCT04334291) comparing COVID-19 in presence and absence of arterial hypertension. MATERIALS AND METHODS: Out of 5837 COVID-19 patients, 2850 (48.8%) patients had the diagnosis arterial hypertension. 1978/2813 (70.3%) patients were already treated with ACEI or ARBs. The clinical outcome of the present subanalysis included all-cause mortality over 40 days of follow-up. RESULTS: Patients with arterial hypertension suffered significantly more from different complications including respiratory insufficiency (60.8% vs 39.5%), heart failure (9.9% vs 3.1%), acute kidney injury (25.3% vs 7.3%), pneumonia (90.6% vs 86%), sepsis (14.7% vs 7.5%), and bleeding events (3.6% vs 1.6%). The mortality rate was 29.6% in patients with concomitant arterial hypertension and 11.3% without arterial hypertension (P < .001). Invasive and non-invasive respiratory supports were significantly more required in presence of arterial hypertension as compared without it. In the multivariate cox regression analysis, while age≥65, benzodiazepine, antidepressant at admission, elevated LDH or creatinine, respiratory insufficiency and sepsis might be a positive independent predictors of mortality, antiviral drugs, interferon treatment, ACEI or ARBs at discharge or oral anticoagulation at discharge might be an independent negative predictor of the mortality. CONCLUSIONS: The mortality rate and in-hospital complications might be increased in COVID-19 patients with a concomitant history of arterial hypertension. The history of ACEI or ARBs treatments does not seem to impact the outcome of these patients.


Subject(s)
Acute Kidney Injury/epidemiology , COVID-19/epidemiology , Heart Failure/epidemiology , Hypertension/epidemiology , Pneumonia/epidemiology , Respiratory Insufficiency/epidemiology , Sepsis/epidemiology , Age Factors , Aged , Angiotensin Receptor Antagonists/therapeutic use , Angiotensin-Converting Enzyme Inhibitors/therapeutic use , Antiviral Agents/therapeutic use , COVID-19/metabolism , COVID-19/therapy , Creatinine/metabolism , Female , Germany/epidemiology , Hospital Mortality , Humans , Hypertension/drug therapy , Italy/epidemiology , L-Lactate Dehydrogenase/metabolism , Male , Middle Aged , Multivariate Analysis , Noninvasive Ventilation , Proportional Hazards Models , Registries , Respiration, Artificial , SARS-CoV-2 , Severity of Illness Index , Spain/epidemiology
16.
J Gen Intern Med ; 36(10): 3080-3087, 2021 10.
Article in English | MEDLINE | ID: covidwho-1351344

ABSTRACT

BACKGROUND: Age is a risk factor for COVID severity. Most studies performed in hospitalized patients with SARS-CoV2 infection have shown an over-representation of older patients and consequently few have properly defined COVID-19 in younger patients who require hospital admission. The aim of the present study was to analyze the clinical characteristics and risk factors for the development of respiratory failure among young (18 to 50 years) hospitalized patients with COVID-19. METHODS: This retrospective nationwide cohort study included hospitalized patients from 18 to 50 years old with confirmed COVID-19 between March 1, 2020, and July 2, 2020. All patient data were obtained from the SEMI-COVID Registry. Respiratory failure was defined as the ratio of partial pressure of arterial oxygen to fraction of inspired oxygen (PaO2/FiO2 ratio) ≤200 mmHg or the need for mechanical ventilation and/or high-flow nasal cannula or the presence of acute respiratory distress syndrome. RESULTS: During the recruitment period, 15,034 patients were included in the SEMI-COVID-19 Registry, of whom 2327 (15.4%) were younger than 50 years. Respiratory failure developed in 343 (14.7%), while mortality occurred in 2.3%. Patients with respiratory failure showed a higher incidence of major adverse cardiac events (44 (13%) vs 14 (0.8%), p<0.001), venous thrombosis (23 (6.7%) vs 14 (0.8%), p<0.001), mortality (43 (12.5%) vs 7 (0.4%), p<0.001), and longer hospital stay (15 (9-24) vs 6 (4-9), p<0.001), than the remaining patients. In multivariate analysis, variables associated with the development of respiratory failure were obesity (odds ratio (OR), 2.42; 95% confidence interval (95% CI), 1.71 to 3.43; p<0.0001), alcohol abuse (OR, 2.40; 95% CI, 1.26 to 4.58; p=0.0076), sleep apnea syndrome (SAHS) (OR, 2.22; 95% CI, 1.07 to 3.43; p=0.032), Charlson index ≥1 (OR, 1.77; 95% CI, 1.25 to 2.52; p=0.0013), fever (OR, 1.58; 95% CI, 1.13 to 2.22; p=0.0075), lymphocytes ≤1100 cells/µL (OR, 1.67; 95% CI, 1.18 to 2.37; p=0.0033), LDH >320 U/I (OR, 1.69; 95% CI, 1.18 to 2.42; p=0.0039), AST >35 mg/dL (OR, 1.74; 95% CI, 1.2 to 2.52; p=0.003), sodium <135 mmol/L (OR, 2.32; 95% CI, 1.24 to 4.33; p=0.0079), and C-reactive protein >8 mg/dL (OR, 2.42; 95% CI, 1.72 to 3.41; p<0.0001). CONCLUSIONS: Young patients with COVID-19 requiring hospital admission showed a notable incidence of respiratory failure. Obesity, SAHS, alcohol abuse, and certain laboratory parameters were independently associated with the development of this complication. Patients who suffered respiratory failure had a higher mortality and a higher incidence of major cardiac events, venous thrombosis, and hospital stay.


Subject(s)
COVID-19 , Respiratory Insufficiency , Adolescent , Adult , Cohort Studies , Hospitals , Humans , Middle Aged , RNA, Viral , Registries , Respiratory Insufficiency/epidemiology , Respiratory Insufficiency/etiology , Respiratory Insufficiency/therapy , Retrospective Studies , Risk Factors , SARS-CoV-2 , Spain/epidemiology , Young Adult
18.
Epidemiol Infect ; 149: e31, 2021 Jan 20.
Article in English | MEDLINE | ID: covidwho-1279772

ABSTRACT

This study was a retrospective multicentre cohort study of patients with coronavirus disease 2019 (COVID-19) diagnosed at 24 hospitals in Jiangsu province, China as of 15 March 2020. The primary outcome was the occurrence of acute respiratory failure during hospital stay. Of 625 patients, 56 (9%) had respiratory failure. Some selected demographic, epidemiologic, clinical and laboratory features as well as radiologic features at admission and treatment during hospitalisation were significantly different in patients with and without respiratory failure. The multivariate logistic analysis indicated that age (in years) (odds ratio [OR], 1.07; 95% confidence interval [CI]: 1.03-1.10; P = 0.0002), respiratory rate (breaths/minute) (OR, 1.23; 95% CI: 1.08-1.40; P = 0.0020), lymphocyte count (109/l) (OR, 0.18; 95% CI: 0.05-0.69; P = 0.0157) and pulmonary opacity score (per 5%) (OR, 1.38; 95% CI: 1.19-1.61; P < 0.0001) at admission were associated with the occurrence of respiratory failure. Older age, increased respiratory rate, decreased lymphocyte count and greater pulmonary opacity score at admission were independent risk factors of respiratory failure in patients with COVID-19. Patients having these risk factors need to be intensively managed during hospitalisation.


Subject(s)
COVID-19/epidemiology , Pneumonia, Viral/epidemiology , Pneumonia, Viral/virology , Respiratory Insufficiency/epidemiology , Respiratory Insufficiency/virology , Adult , China/epidemiology , Female , Humans , Male , Middle Aged , Retrospective Studies , Risk Factors , SARS-CoV-2
19.
J Clin Anesth ; 74: 110409, 2021 11.
Article in English | MEDLINE | ID: covidwho-1275446

ABSTRACT

OBJECTIVE: While studies have reported increased post-operative pulmonary complications with SARS-CoV-2 infection, many are limited by use of historical controls or focus on less severe respiratory complications. We characterized the association between pre-operative SARS-CoV-2 infection and post-operative respiratory failure (PORF). DESIGN AND SETTING: This was a single center retrospective cohort study in New York City between March 14-June 14, 2020. PATIENTS: Exclusion criteria were age < 18-years, obstetric procedures, absence of SARS-CoV-2 PCR testing, and pre-operative respiratory failure. A total of 778 patients met criteria, of which 87 had SARS-CoV-2. MEASUREMENTS: The primary outcome, PORF, included inability to extubate for ≥24 h or unplanned re-intubation within 5 days. Multiple exposures were measured including SARS-CoV-2 infection 4 weeks before or 5 days after surgery. Multivariable logistic regression was performed to adjust for pre-operative hypoxemia, oxygen use, and pneumonia as well as tachycardia, gender, Charlson Comorbidity Index (CCI), Surgical Mortality Probability Model (S-MPM) index, and peri-operative blood transfusion. MAIN RESULTS: SARS-CoV patients had higher CCI (P = 0.007) and S-MPM scores (P = 0.02). The incidence of PORF was 16% versus 7% in uninfected comparators (P = 0.001). Amongst infected individuals, 39% exhibited symptoms of COVID-19 and PORF was more common in these patients compared to asymptomatic individuals (26% vs. 9%, P = 0.04). Adjusted analysis revealed increased odds of PORF with infection (OR 2.8, 95% CI 1.2-6.2). This persisted even when adjusting for probable mediators such as pre-operative hypoxemia. Infected patients also demonstrated increased adjusted odds of 30-day mortality (OR 3.5, 95% CI 1.4-9.1). CONCLUSIONS: Detection of SARS-CoV-2 infection within 4 weeks before or 5 days after surgery is associated with increased odds of 5-day PORF and 30-day mortality. This supports delaying elective surgery, but questions remain regarding the applicability of this recommendation for asymptomatic patients needing urgent or semi-urgent procedures such as oncologic surgery.


Subject(s)
COVID-19 , Respiratory Insufficiency , Adolescent , Female , Humans , Incidence , Pregnancy , Respiratory Insufficiency/epidemiology , Respiratory Insufficiency/etiology , Retrospective Studies , SARS-CoV-2
20.
Respiration ; 100(9): 909-917, 2021.
Article in English | MEDLINE | ID: covidwho-1270908

ABSTRACT

BACKGROUND: During the first wave of the SARS-CoV-2 pandemic in Switzerland, confinement was imposed to limit transmission and protect vulnerable persons. These measures may have had a negative impact on perceived quality of care and symptoms in patients with chronic disorders. OBJECTIVES: To determine whether patients under long-term home noninvasive ventilation (LTHNIV) for chronic respiratory failure (CRF) were negatively affected by the 56-day confinement (March-April 2020). METHODS: A questionnaire-based survey exploring mood disturbances (HAD), symptom scores related to NIV (S3-NIV), and perception of health-care providers during confinement was sent to all patients under LTHNIV followed up by our center. Symptom scores and data obtained by ventilator software were compared between confinement and the 56 days prior to confinement. RESULTS: Of a total of 100 eligible patients, 66 were included (median age: 66 years [IQR: 53-74]): 35 (53%) with restrictive lung disorders, 20 (30%) with OHS or SRBD, and 11 (17%) with COPD or overlap syndrome. Prevalence of anxiety (n = 7; 11%) and depressive (n = 2; 3%) disorders was remarkably low. Symptom scores were slightly higher during confinement although this difference was not clinically relevant. Technical data regarding ventilation, including compliance, did not change. Patients complained of isolation and lack of social contact. They felt supported by their relatives and caregivers but complained of the lack of regular contact and information by health-care professionals. CONCLUSIONS: Patients under LTHNIV for CRF showed a remarkable resilience during the SARS-CoV-2 confinement period. Comments provided may be helpful for managing similar future health-care crises.


Subject(s)
COVID-19 , Communicable Disease Control , Home Care Services/standards , Noninvasive Ventilation , Respiratory Insufficiency , Aged , COVID-19/epidemiology , COVID-19/prevention & control , COVID-19/psychology , Chronic Disease , Communicable Disease Control/methods , Communicable Disease Control/statistics & numerical data , Female , Health Services Needs and Demand , Humans , Long-Term Care/methods , Male , Mood Disorders/epidemiology , Mood Disorders/physiopathology , Noninvasive Ventilation/methods , Noninvasive Ventilation/statistics & numerical data , Qualitative Research , Quality of Health Care/statistics & numerical data , Respiratory Insufficiency/epidemiology , Respiratory Insufficiency/etiology , Respiratory Insufficiency/psychology , Respiratory Insufficiency/therapy , SARS-CoV-2 , Social Support , Switzerland/epidemiology , Symptom Assessment/methods , Symptom Assessment/statistics & numerical data
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