Phenotypes of post covid interstitial lung disease, clinical, radiological, and pathological correlations

Introduction: The clinical-radiologic-pathologic features of post-COVID interstitial lung disease (ILD) remain to be explored. Method(s): In a prospective multicenter Italian study (PCOILS), subsequent patients seen at 4-18 months after the acute infection underwent transbronchial lung cryobiopsy and BAL if they showed a significant ILD (progressive and/or symptomatic and/or with pulmonary function impairment). Result(s): 19 patients enrolled;characteristics are summarized in Fig.2. We identified 3 post-COVID phenotypes: 1) prominent vascular changes;2) post-COVID fibrosis;3) persistent COVID. Fig. 1. Phenotype 1 was detected only in 2 cases with similar characteristics as showed in Fig. 1 Phenotype 2 was detected in 7 patients all with HRCT NSIP/OP features. Histology showed fibrotic or mixed NSIP, fibrotic OP, fibrotic DAD and bronchiolar damage. Phenotype 3 was detected only in the case reported in Fig.1.The remaining 9 patients were reclassified as known ILDs and treated according to current guidelines. Conclusion(s): We identified 3 phenotypes of postcovid damage with heterogeneous pictures and leading to differenttreatment choices.

Role of BAL in COVID-19 patients: a prospective multicentre study

The present study is part of DRAGON, a prospective multicentre European project aimed at improving the diagnosis of COVID-19. The primary aim of this study is to evaluate BAL role in detecting coexisting infections. Secondary aims are BAL impact on the management of COVID patients, characteristics of BAL cellularity in COVID patients, and safety of BAL in COVID patients and for healthcare providers. The study was carried out in 2021. It involved hospitalized patients in non-ICU wards at Careggi University Hospital in Florence, at CHU of Liege and at Morgagni Hospital Bologna University/Forli. All patients underwent BAL for microbiological and cytological analysis. Coinfections were detected in 35 out of 115 patients. In 34% of cases we demonstrated the presence of lymphocytic alveolitis;in 49% of cases a neutrophilic alveolitis and in 7% of cases we observed the presence of a mixed lymphocytic/neutrophilic alveolitis. All patients tested positive for Sars-Cov-2 PCR nasal swabs on admission. BAL was positive for Sars-Cov-2 in all cases, 7 PCR nasal swab performed at the time of the BAL were negative. No major adverse events were demonstrated in the 24 hours after BAL in enrolled patients. There were no cases of infection among health care workers involved in bronchoscopic procedures. Coinfections in COVID-19 patients are common. BAL is a safe tool to identify the presence of coinfections and help clinicians manage these patients correctly. BAL cellularity in covid patients shows a predominance of neutrophils, particularly in cases of co-infection. Our data suggests an earlier negativisation of nasopharyngeal swab compared to BAL.

The second wave of COVID-19 in Italy: a cohort study in a Respiratory Semi-Intensive Care Unit

Introduction. To face the second outbreak of COVID-19, our Respiratory Ward at Morgag-ni-Pierantoni General Hospital (Forlì FC, Italy) underwent a reorganization and a Respiratory Semi-Intensive Care Unit (RSICU) of 16 beds was created. Material and methods. In this monocentric, retrospective, cohort study we report our expe-rience in treating patients with moderate to severe acute respiratory failure due to COVID-19 infection. Results. 108 patients were admitted to our RSICU between the beginning of October and 31st December 2020 and included in this study, with a median PaO2/FiO2 of 133.5 mmHg [IQR 85.8-170.8]. CPAP therapy was the most used support system (64.8%) and was associated with the lowest mortality (14.3%). NIV was provided to 29 patients (26.8%), with higher mortality (41.3%, n = 12) and intubation rates (n = 6) compared to the continuous positive airway pressure (CPAP) cohort. Only 10 (9.5%) patients out of 108 underwent intubation, 6 (60%) of whom died. Coronary hearth diseases (CHD) and hypertension were higher among non-survivor, while there was no significant difference for IL-6 and D-dimer levels and CT Severity Score. Discussion. The use of non-invasive ventilation was correlated with need of intubation only in few patients with moderate to severe COVID-19 related acute hypoxemic respiratory failure (AHRF). CPAP therapy showed the best outcomes, with a mortality rate of 14.3% (n = 10). The histopathologic, CT and pathophysiological features of the L-phenotype sug-gest that in these COVID-19 patients, intubation and high PEEP might not be necessary for alveolar recruitment. Thus, a non-invasive approach can be appropriate, and this is consistent with our data. Pre-existing comorbidities might also affect the outcome of COVID-19. Conclusions. Our findings indicate that non-invasive ventilation, particularly CPAP therapy is feasible and can be effective in treating in deteriorating COVID-19 patients, reducing the need for ICUs transferal.

A multidisciplinary multicenter study evaluating risk factors, prevalence and characteristics of post-COVID-19 interstitial lung syndrome pcoils

Backgrounds: Available data indicate that a large minority of patients with COVID-19 develop ARDS, and pulmonary fibrosis is a recognized sequela of ARDS. However, the long-term pulmonary consequences of COVID-19 remain speculative. The aim of this study is to evaluate risk factors, prevalence and characteristics of POST-COVID-19 interstitial lung changes, with the unique opportunity to evaluate radiologic and pathologic correlations using HRCT and transbronchial lung cryobiopsy specimens.Methods: Here we present the preliminary data on HRCT features of POST-COVID-19 ILD. Data were collected at the time of the first interim analysis (28/11/2020) of the PCOILS trial: a prospective, multicenter national study involving 12 Italian centers (Fig 1). We collected data of consecutively hospitalized patients at baseline and then at 6 (+/-1) months after hospital discharge. HRCT changes at 6 months involving more than 5% of the total lung volume were considered significant. Patients with significant HRCT changes will undergo BAL and/or cryobiopsy and a subsequent follow-up with HRCT and lung function evaluation at 12(+/-1) and 18 (+/-1) months.Results: At the time of the present interim analysis, 524 patients from 9 centers were enrolled (enrollment is still ongoing and will end on January 31st, 2021). Median age was 67 years (range 18-87), 330 were males (62.9%). HRCT changes were detected in 333 participants (63.5%), and in 219 (41.7%) were considered significant. 118 cases (22.5%) showed fibrotic changes including the following HRCT patterns: 7 (1.3%) probable UIP, 45 (8.5%) NSIP (with or without OP), 38 (7.2%) indeterminate, 28 (5.3%) fibrotic consolidations. Among the remaining 101 (19.2%) non fibrotic cases the radiologists described: 11 (2%) NSIP-OP, 15 (2.8%) indeterminate, 67 (12.7%) pure ground glass, 8 (1.5%) consolidations all suspected for lung cancer. Conclusions: This preliminary analysis confirms that after COVID-19 infection a large minority of patients develops interstitial lung changes mostly with NSIP-OP, indeterminate features or ground glass. The hypothesis that post-COVID-19 interstitial changes and interstitial lung diseases may share common risk factors, pathogenetic mechanisms and disease behaviour warrants further evaluations. .

Pathophysiology of light phenotype SARS-CoV-2 interstitial pneumonia: from histopathological features to clinical presentations.

Little is known about the light phenotype of SARS-CoV-2 pneumonia, which behaves in an unusual way, unlike other known respiratory diseases. We believe that the histopathological features of early COVID-19 could be considered the pathophysiological hallmark of this disease. Lung cryobiopsies show almost pristine alveoli, enlarged/hyperplasic alveolar capillaries along with dilatation of the post capillary pulmonary venules. Hypoxemia could therefore be explained by a reduction of the normal V/Q ratio, due to blood overflow around well ventilated alveoli. This could clarify typical manifestations of type L COVID-19, such as happy hypoxemia, response to awake prone positioning, response to PEEP/CPAP and platypnea orthodeoxia.

Pragmatic approach to the diagnosis of covid-19 pneumonia SARS-CoV-2 (COVID-19). from the epidemic phase to the two and three one

Pneumonia represents the main cause of hospitalization and mortality secondary to SARS-CoV-2 (Severe Acute Respiratory Syndrome Corona-virus 2) infection. The etiological diagnosis of COVID-19 pneumonia requires confirmation of the presence of viral genetic material detected with RT-PCR (Reverse Transcriptase-Polymerase Chain Reaction) test, usually obtained using nasopharyngeal or oropharyngeal swab;how-ever, several evidences demonstrate that a significant proportion of swabs, in particular at the first determination, results negative even in the presence of COVID-19 pneumonia. These patients may be erroneously hospitalized in a non-COVID-19 area and therefore contribute to the nosocomial transmission of the virus. For this reason the Italian Thoracic Society (ITS) promoted the production of a document that recommends a pragmatic approach to the COVID-19 pneumonia diagnosis with negative RT-PCR using a decisional clinical-radiological algorithm as a proxy to the commonly adopted gold standard, represented by RT-PCR, aimed at isolating patient and promoting investigations for a correct clinical-therapeutic classification. Difficulties in the first COVID-19 epidemic phase allowed us to know better characteristics and virus dangerousness. What we have learned has to be usefully implemented in clinical practice in order to contain the infection in the second and third phases to prevent a possible second wave of the infection during the autumnal period.