ABSTRACT
RATIONALE AIMS AND OBJECTIVES: Patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and diabetes mellitus form a special population due to an increased risk of hyperglycemia from the use of corticosteroids. There is limited data regarding specific outcomes in diabetic patients with AECOPD. METHODS: A retrospective data analysis of adult patients admitted to North Florida Division of the Hospital Corporation of America (HCA Healthcare) with a primary or secondary diagnosis of AECOPD from January 1, 2018, to December 31, 2018. We excluded patients who needed intensive care unit (ICU) care on day 0. Outcomes assessed included length of stay, mortality, and need for ICU transfer after 48 h from admission. Characteristics included age, sex, and race, comorbidities such as diabetes mellitus, chronic kidney disease, acute kidney injury, congestive heart failure, and anemia were analyzed. Comparisons were analyzed via binary and multivariate logistic regression models. RESULTS: A total of 3788 patients admitted for AECOPD were included; amongst them, 1356 patients (~36%) had diabetes mellitus. This subset of patients had higher rates of comorbidities. A significant portion of diabetic patients (72%) received intravenous rather than oral steroids, similar to non-diabetic patients. In addition, diabetic patients were more likely to develop acute kidney injury (14.2% vs 8.0%, p < 0.004) and decompensated heart failure (9.2% vs 4.6%, p < 0.001). Diabetic patients had higher length of stay and increased need for ICU transfer. However, diabetes itself did not independently affect length of stay (CI -0.028, 0.479, p = 0.081) when adjusted to comorbidities and patient's characteristics. Moreover, diabetes was independently associated with an increased need for transfer to ICU (Odds ratio 1.9, p = 0.031). The oral route of steroid use was associated with decreased LOS (ß coefficient - 0.9, p < 0.001). CONCLUSION: Diabetes mellitus is independently associated with increased ICU transfers amongst patients hospitalized with AECOPD. The use of oral steroids rather than intravenous steroids was independently associated with decreased length of stay in diabetic and non-diabetic patients. Despite no difference in intravenous vs. oral corticosteroids demonstrated in previous COPD trials, a significant portion of diabetic patients continue to receive intravenous corticosteroids. Further investigation is required to explore these findings.
ABSTRACT
As the COVID-19 pandemic continues to manifest in our society, we still lack evidence-based treatment guidelines. Current treatment for COVID-19 pneumonia has been modeled from currently established guidelines such as that of acute respiratory distress syndrome (ARDS). COVID-19 pneumonia, also known as SARS-CoV-2, is characterized by severe hypoxia and near-normal respiratory system compliance with a time-related presentation. Dexmedetomidine is a centrally acting alpha-2 receptor agonist that promotes sedative and anxiolytic effects without the risk of respiratory depression and can provide cooperative or semi-rousable sedation. Patients who are developing ARDS secondary to COVID-19 pneumonia have been treated with self-proning intervals in combination with supplementation of oxygenation via high-flow nasal cannula (HFNC) or non-invasive positive pressure ventilation (NIPPV); however, a few patients have poor tolerance to the devices, leading to poor compliance and eventual worsening respiratory symptoms leading to intubation. In the current case report, we detail how a patient was able to successfully be self-proned with proper tolerance to HFNC and NIPPV while using dexmedetomidine, leading to discharge without the need for further oxygen supplementation at home.
ABSTRACT
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic and its high virulence along with its variable presentation have generated a significant amount of interest within the medical community. The heterogeneous nature of the symptoms of the disease caused by SARS-CoV-2, coronavirus disease 2019 (COVID-19), ranging from being asymptomatic to severe acute respiratory distress syndrome (ARDS), has created significant interest in potential therapeutics. Given the lack of randomized controlled trials, most medications are experimental, and only anecdotal evidence is available so far regarding their efficacy. One medication that emerged as an early frontrunner as a promising therapeutic was hydroxychloroquine (HCQ), a common antimalarial and lupus drug. The adverse side effects that could result from its use did not gain much attention initially. We present the cases of two COVID-19-positive patients treated with HCQ at our institution, which showed adverse effects of the medication. While HCQ may have some therapeutic effect, it should be borne in mind that patients may experience more harm than benefit from its use.
