Evaluation of PEEP and prone positioning in early COVID-19 ARDS

High PEEP/low FiO2 ventilation is associated with lower mortality in COVID-19

RATIONALE

The positive end-expiratory pressure (PEEP) strategy in patients with coronavirus 2019 (COVID-19) acute respiratory distress syndrome (ARDS) remains debated. Most studies originate from the initial waves of the pandemic. Here we aimed to assess the impact of high PEEP/low FiO2 ventilation on outcomes during the second wave in the Netherlands.

METHODS

Retrospective observational study of invasively ventilated COVID-19 patients during the second wave. Patients were categorized based on whether they received high PEEP or low PEEP ventilation according to the ARDS Network tables. The primary outcome was ICU mortality, and secondary outcomes included hospital and 90-day mortality, duration of ventilation and length of stay, and the occurrence of kidney injury. Propensity matching was performed to correct for factors with a known relationship to ICU mortality.

RESULTS

This analysis included 790 COVID-ARDS patients. At ICU discharge, 32 (22.5%) out of 142 high PEEP patients and 254 (39.2%) out of 848 low PEEP patients had died (HR 0.66 [0.46-0.96]; P = 0.03). High PEEP was linked to improved secondary outcomes. Matched analysis did not change findings.

CONCLUSIONS

High PEEP ventilation was associated with improved ICU survival in patients with COVID-ARDS.

Differences of respiratory mechanics in mechanical ventilation of acute respiratory distress syndrome between patients with COVID-19 and Influenza A

BACKGROUND

Whether COVID-19-induced acute respiratory distress syndrome (ARDS) should be approached differently in terms of mechanical ventilation therapy compared to other virus-induced ARDS is debatable. Therefore, we aimed to ascertain whether the respiratory mechanical characteristics of COVID-19-induced ARDS differ from those of influenza A induced ARDS, in order to establish a rationale for mechanical ventilation therapy in COVID-19-induced ARDS.

METHODS

This was a retrospective cohort study comparing patients with COVID-19-induced ARDS and influenza A induced ARDS. We included intensive care unit (ICU) patients with COVID-19 or Influenza A aged ≥ 19, who were diagnosed with ARDS according to the Berlin definition between January 2015 and July 2021. Ventilation parameters for respiratory mechanics were collected at specific times on days one, three, and seven after intubation.

RESULTS

The median age of the 87 participants was 71.0 (62.0-78.0) years old, and 63.2% were male. The ratio of partial pressure of oxygen in arterial blood to the fractional of inspiratory oxygen concentration in COVID-19-induced ARDS was lower than that in influenza A induced ARDS during the initial stages of mechanical ventilation (influenza A induced ARDS 216.1 vs. COVID-19-induced ARDS 167.9, p = 0.009, day 1). The positive end expiratory pressure remained consistently higher in the COVID-19 group throughout the follow-up period (7.0 vs. 10.0, p < 0.001, day 1). COVID-19 and influenza A initially showed different directions for peak inspiratory pressure and dynamic compliance; however, after day 3, both groups exhibited similar directions. Dynamic driving pressure exhibited opposite trends between the two groups during mechanical ventilation.

CONCLUSIONS

Respiratory mechanics show clear differences between COVID-19-induced ARDS and influenza A induced ARDS. Based on these findings, we can consider future treatment strategies for COVID-19-induced ARDS.

Epidemiological profile and risk factors associated with death in patients receiving invasive mechanical ventilation in an adult intensive care unit from Brazil: a retrospective study

Introduction

Understanding the epidemiological profile and risk factors associated with invasive mechanical ventilation (IMV) is essential to manage the patients better and to improve health services. Therefore, our objective was to describe the epidemiological profile of adult patients in intensive care that required IMV in-hospital treatment. Also, to evaluate the risks associated with death and the influence of positive end-expiratory pressure (PEEP) and arterial oxygen pressure (PaO2) at admission in the clinical outcome.

Methods

We conducted an epidemiological study analyzing medical records of inpatients who received IMV from January 2016 to December 2019 prior to the Coronavirus Disease (COVID)-19 pandemic in Brazil. We considered the following characteristics in the statistical analysis: demographic data, diagnostic hypothesis, hospitalization data, and PEEP and PaO2 during IMV. We associated the patients' features with the risk of death using a multivariate binary logistic regression analysis. We adopted an alpha error of 0.05.

Results

We analyzed 1,443 medical records; out of those, 570 (39.5%) recorded the patients' deaths. The binary logistic regression was significant in predicting the patients' risk of death [X2(9) = 288.335; p < 0.001]. Among predictors, the most significant in relation to death risk were: age [elderly ≥65 years old; OR = 2.226 (95%CI = 1.728-2.867)]; male sex (OR = 0.754; 95%CI = 0.593-0.959); sepsis diagnosis (OR = 1.961; 95%CI = 1.481-2.595); need for elective surgery (OR = 0.469; 95%CI = 0.362-0.608); the presence of cerebrovascular accident (OR = 2.304; 95%CI = 1.502-3.534); time of hospital care (OR = 0.946; 95%CI = 0.935-0.956); hypoxemia at admission (OR = 1.635; 95%CI = 1.024-2.611), and PEEP >8 cmH2O at admission (OR = 2.153; 95%CI = 1.426-3.250).

Conclusion

The death rate of the studied intensive care unit was equivalent to that of other similar units. Regarding risk predictors, several demographic and clinical characteristics were associated with enhanced mortality in intensive care unit patients under mechanical ventilation, such as diabetes mellitus, systemic arterial hypertension, and older age. The PEEP >8 cmH2O at admission was also associated with increased mortality since this value is a marker of initially severe hypoxia.

A Framework for Developing a Multidisciplinary Approach to Prone Positioning in Acute Respiratory Distress Syndrome

Prone position ventilation (PPV) is one of the few interventions with a proven mortality benefit in the management of acute respiratory distress syndrome (ARDS), yet it is underutilized as demonstrated by multiple large observational studies. Significant barriers to its consistent application have been identified and studied. But the complex interplay of a multidisciplinary team makes its consistent application challenging. We present a framework of multidisciplinary collaboration that identifies the appropriate patients for this intervention and discuss our institutional experience applying a multidisciplinary team to implement prone position (PP) leading up to and through the current COVID-19 pandemic. We also highlight the role of such multidisciplinary teams in the effective implementation of prone positioning in ARDS throughout a large health care system. We emphasize the importance of proper selection of patients and provide guidance on how a protocolized approach can be utilized for proper patient selection.

Time From Infiltrate on Chest Radiograph to Venovenous Extracorporeal Membrane Oxygenation in COVID-19 Affects Mortality

Venovenous extracorporeal membrane oxygenation (VV ECMO) has been used to treat severe coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome; however, patient selection criteria have evolved throughout the pandemic. In this study, we sought to determine the association of patient mortality with time from positive COVID-19 test and infiltrate on chest radiograph (x-ray) to VV ECMO cannulation. We hypothesized that an increasing duration between a positive COVID-19 test or infiltrates on chest x-ray and cannulation would be associated with increased mortality. This is a single-center retrospective chart review of COVID-19 VV ECMO patients from March 1, 2020 to July 28, 2021. Unadjusted and adjusted multivariate analyses were performed to assess for mortality differences. A total of 93 patients were included in our study. Increased time, in days, from infiltrate on chest x-ray to cannulation was associated with increased mortality in both unadjusted (5-9, P = 0.002) and adjusted regression analyses (odds ratio [OR]: 1.49, 95% CI: 1.22-1.81, P < 0.01). Time from positive test to cannulation was not found to be significant between survivors and nonsurvivors (7.5-11, P = 0.06). Time from infiltrate on chest x-ray to cannulation for VV ECMO should be considered when assessing patient candidacy. Further larger cohort and prospective studies are required.

Respiratory system mechanics, gas exchange, and outcomes in mechanically ventilated patients with COVID-19-related acute respiratory distress syndrome: a systematic review and meta-analysis

The association of respiratory mechanics, particularly respiratory system static compliance (C_RS), with severity of hypoxaemia in patients with COVID-19-related acute respiratory distress syndrome (ARDS) has been widely debated, with some studies reporting distinct ARDS phenotypes based on C_RS. Ascertaining whether such phenotypes exist is important, because they might indicate the need for ventilation strategies that differ from those used in patients with ARDS due to other causes. In a systematic review and meta-analysis of studies published between Dec 1, 2019, and March 14, 2022, we evaluated respiratory system mechanics, ventilator parameters, gas exchange parameters, and clinical outcomes in patients with COVID-19-related ARDS. Among 11 356 patients in 37 studies, mean reported C_RS, measured close to the time of endotracheal intubation, was 35·8 mL/cm H₂O (95% CI 33·9-37·8; I²=96·9%, τ²=32·6). Pooled mean C_RS was normally distributed. Increasing ARDS severity (assessed by PaO₂/FiO₂ ratio as mild, moderate, or severe) was associated with decreasing C_RS. We found no evidence for distinct C_RS-based clinical phenotypes in patients with COVID-19-related ARDS, and we therefore conclude that no change in conventional lung-protective ventilation strategies is warranted. Future studies should explore the personalisation of mechanical ventilation strategies according to factors including respiratory system mechanics and haemodynamic status in patients with ARDS.

Physiological response to prone positioning in intubated adults with COVID-19 acute respiratory distress syndrome: a retrospective study

Background

COVID-19 related acute respiratory distress syndrome (ARDS) has specific characteristics compared to ARDS in other populations. Proning is recommended by analogy with other forms of ARDS, but few data are available regarding its physiological effects in this population. This study aimed to assess the effects of proning on oxygenation parameters (PaO2/FiO2 and alveolo-arterial gradient (Aa-gradient)), blood gas analysis, ventilatory ratio (VR), respiratory system compliance (CRS) and estimated dead space fraction (VD/VT HB). We also looked for variables associated with treatment failure.

Methods

Retrospective monocentric study of intubated COVID-19 ARDS patients managed with an early intubation, low to moderate positive end-expiratory pressure and early proning strategy hospitalized from March 6 to April 30 2020. Blood gas analysis, PaO2/FiO2, Aa-gradient, VR, CRS and VD/VT HB were compared before and at the end of each proning session with paired t-tests or Wilcoxon tests (p < 0.05 considered as significant). Proportions were assessed using Fischer exact test or Chi square test.

Results

Forty-two patients were included for a total of 191 proning sessions, median duration of 16 (5–36) hours. Considering all sessions, PaO2/FiO2 increased (180 [148–210] vs 107 [90–129] mmHg, p < 0.001) and Aa-gradient decreased (127 [92–176] vs 275 [211–334] mmHg, p < 0.001) with proning. CRS (36.2 [30.0–41.8] vs 32.2 [27.5–40.9] ml/cmH2O, p = 0.003), VR (2.4 [2.0–2.9] vs 2.3 [1.9–2.8], p = 0.028) and VD/VT HB (0.72 [0.67–0.76] vs 0.71 [0.65–0.76], p = 0.022) slightly increased. Considering the first proning session, PaO2/FiO2 increased (186 [165–215] vs 104 [94–126] mmHg, p < 0.001) and Aa-gradient decreased (121 [89–160] vs 276 [238–321] mmHg, p < 0.001), while CRS, VR and VD/VT HB were unchanged. Similar variations were observed during the subsequent proning sessions. Among the patients who experienced treatment failure (defined as ICU death or need for extracorporeal membrane oxygenation), fewer expressed a positive response in terms of oxygenation (defined as increase of more than 20% in PaO2/FiO2) to the first proning (67 vs 97%, p = 0.020).

Conclusion

Proning in COVID-19 ARDS intubated patients led to an increase in PaO2/FiO2 and a decrease in Aa-gradient if we consider all the sessions together, the first one or the 4 subsequent sessions independently. When considering all sessions, CRS increased and VR and VD/VT HB only slightly increased.

Recent Advances in Marine Microalgae Production: Highlighting Human Health Products from Microalgae in View of the Coronavirus Pandemic (COVID-19)

Blue biotechnology can greatly help solve some of the most serious social problems due to its wide biodiversity, which includes marine environments. Microalgae are important resources for human needs as an alternative to terrestrial plants because of their rich biodiversity, rapid growth, and product contributions in many fields. The production scheme for microalgae biomass mainly consists of two processes: (I) the Build-Up process and (II) the Pull-Down process. The Build-Up process consists of (1) the super strain concept and (2) cultivation aspects. The Pull-Down process includes (1) harvesting and (2) drying algal biomass. In some cases, such as the manufacture of algal products, the (3) extraction of bioactive compounds is included. Microalgae have a wide range of commercial applications, such as in aquaculture, biofertilizer, bioenergy, pharmaceuticals, and functional foods, which have several industrial and academic applications around the world. The efficiency and success of biomedical products derived from microalgal biomass or its metabolites mainly depend on the technologies used in the cultivation, harvesting, drying, and extraction of microalgae bioactive molecules. The current review focuses on recent advanced technologies that enhance microalgae biomass within microalgae production schemes. Moreover, the current work highlights marine drugs and human health products derived from microalgae that can improve human immunity and reduce viral activities, especially COVID-19.

Clinical update on COVID-19 for the emergency clinician: Airway and resuscitation

INTRODUCTION

Coronavirus disease of 2019 (COVID-19) has resulted in millions of cases worldwide. As the pandemic has progressed, the understanding of this disease has evolved.

OBJECTIVE

This narrative review provides emergency clinicians with a focused update of the resuscitation and airway management of COVID-19.

DISCUSSION

Patients with COVID-19 and septic shock should be resuscitated with buffered/balanced crystalloids. If hypotension is present despite intravenous fluids, vasopressors including norepinephrine should be initiated. Stress dose steroids are recommended for patients with severe or refractory septic shock. Airway management is the mainstay of initial resuscitation in patients with COVID-19. Patients with COVID-19 and ARDS should be managed similarly to those ARDS patients without COVID-19. Clinicians should not delay intubation if indicated. In patients who are more clinically stable, physicians can consider a step-wise approach as patients' oxygenation needs escalate. High-flow nasal cannula (HFNC) and non-invasive positive pressure ventilation (NIPPV) are recommended over elective intubation. Prone positioning, even in awake patients, has been shown to lower intubation rates and improve oxygenation. Strategies consistent with ARDSnet can be implemented in this patient population, with a goal tidal volume of 4-8 mL/kg of predicted body weight and targeted plateau pressures <30 cm H₂O. Limited data support the use of neuromuscular blocking agents (NBMA), recruitment maneuvers, inhaled pulmonary vasodilators, and extracorporeal membrane oxygenation (ECMO).

CONCLUSION

This review presents a concise update of the resuscitation strategies and airway management techniques in patients with COVID-19 for emergency medicine clinicians.

Prone positioning for mechanically ventilated patients with coronavirus disease 2019: the experience of an Irish regional hospital intensive care unit

Background

The benefits of prone positioning in acute respiratory distress syndrome (ARDS) have been known for many years. While some controversy exists regarding whether coronavirus disease 2019 (COVID-19) pneumonia should be treated with the same therapeutic strategies as for non-COVID ARDS, the Surviving Sepsis Campaign still provide a weak recommendation to utilise prone positioning in this setting.

Aims

The aims of this study are to ascertain if prone positioning improves oxygenation significantly in mechanically ventilated patients with severe COVID-19 ARDS and to describe the feasibility of frequent prone positioning in an Irish regional hospital intensive care unit (ICU) with limited prior experience.

Methods

In this retrospective, observational cohort study, we investigate if the PaO₂/FiO₂ ratio and ventilatory ratio improve during and following prone positioning, and whether this improvement correlates with patient baseline characteristics or survival.

Results

Between March 2020 and 2021, 12 patients underwent prone positioning while mechanically ventilated for severe COVID ARDS. Sixty-six percent were male, mean age 60.9 (± 10.5), mean BMI 33.5 (± 6.74) and median APACHE II score on admission to ICU was 10.5 (7.25–16.3). Further, 83% were proned within 24 h of being intubated due to refractory hypoxaemia. PaO₂/FiO₂ ratio improved from 11.6 kPa (9.80–13.8) to 15.80 kPa (13.1–19.6) while prone, p < 0.0001.

Conclusions

We found prone positioning to be a safe method of significantly improving oxygenation in mechanically ventilated patients with severe COVID-19 ARDS. We did not find a relationship between patient baseline characteristics nor illness severity and degree of PaO₂/FiO₂ ratio improvement, nor did we find a relationship between degree of PaO₂/FiO₂ ratio improvement and survival.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11845-022-03085-9.

Prone ventilation in intubated COVID-19 patients: a systematic review and meta-analysis

Background

The efficacy and safety profiles of prone ventilation among intubated Coronavirus Disease 2019 (COVID-19) patients remain unclear. The primary objective was to examine the effect of prone ventilation on the ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO₂/FiO₂) in intubated COVID-19 patients.

Methods

Databases of MEDLINE, EMBASE and CENTRAL were systematically searched from inception until March 2021. Case reports and case series were excluded.

Results

Eleven studies (n = 606 patients) were eligible. Prone ventilation significantly improved PaO₂/FiO₂ ratio (studies: 8, n = 579, mean difference 46.75, 95% CI 33.35‒60.15, p < 0.00001; evidence: very low) and peripheral oxygen saturation (SpO₂) (studies: 3, n = 432, mean difference 1.67, 95% CI 1.08‒2.26, p < 0.00001; evidence: ow), but not the arterial partial pressure of carbon dioxide (PaCO₂) (studies: 5, n = 396, mean difference 2.45, 95% CI 2.39‒7.30, p = 0.32; evidence: very low), mortality rate (studies: 1, n = 215, Odds Ratio 0.66, 95% CI 0.32‒1.33, p = 0.24; evidence: very low), or number of patients discharged alive (studies: 1, n = 43, Odds Ratio 1.49, 95% CI 0.72‒3.08, p = 0.28; evidence: very low).

Conclusion

Prone ventilation improved PaO₂/FiO₂ ratio and SpO₂ in intubated COVID-19 patients. Given the substantial heterogeneity and low level of evidence, more randomized- controlled trials are warranted to improve the certainty of evidence, and to examine the adverse events of prone ventilation.

Changes in laboratory value improvement and mortality rates over the course of the pandemic: an international retrospective cohort study of hospitalised patients infected with SARS-CoV-2

OBJECTIVE

To assess changes in international mortality rates and laboratory recovery rates during hospitalisation for patients hospitalised with SARS-CoV-2 between the first wave (1 March to 30 June 2020) and the second wave (1 July 2020 to 31 January 2021) of the COVID-19 pandemic.

DESIGN, SETTING AND PARTICIPANTS

This is a retrospective cohort study of 83 178 hospitalised patients admitted between 7 days before or 14 days after PCR-confirmed SARS-CoV-2 infection within the Consortium for Clinical Characterization of COVID-19 by Electronic Health Record, an international multihealthcare system collaborative of 288 hospitals in the USA and Europe. The laboratory recovery rates and mortality rates over time were compared between the two waves of the pandemic.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was all-cause mortality rate within 28 days after hospitalisation stratified by predicted low, medium and high mortality risk at baseline. The secondary outcome was the average rate of change in laboratory values during the first week of hospitalisation.

RESULTS

Baseline Charlson Comorbidity Index and laboratory values at admission were not significantly different between the first and second waves. The improvement in laboratory values over time was faster in the second wave compared with the first. The average C reactive protein rate of change was -4.72 mg/dL vs -4.14 mg/dL per day (p=0.05). The mortality rates within each risk category significantly decreased over time, with the most substantial decrease in the high-risk group (42.3% in March-April 2020 vs 30.8% in November 2020 to January 2021, p<0.001) and a moderate decrease in the intermediate-risk group (21.5% in March-April 2020 vs 14.3% in November 2020 to January 2021, p<0.001).

CONCLUSIONS

Admission profiles of patients hospitalised with SARS-CoV-2 infection did not differ greatly between the first and second waves of the pandemic, but there were notable differences in laboratory improvement rates during hospitalisation. Mortality risks among patients with similar risk profiles decreased over the course of the pandemic. The improvement in laboratory values and mortality risk was consistent across multiple countries.

Effectiveness of prone position in acute respiratory distress syndrome and moderating factors of obesity class and treatment durations for COVID-19 patients: A Meta-Analysis

Objectives

To examine the effectiveness of prone positioning on COVID-19 patients with acute respiratory distress syndrome with moderating factors in both traditional prone positioning (invasive mechanical ventilation) and awake self-prone positioning patients (non-invasive ventilation).

Research methodology

A comprehensive search was conducted in CINAHL, Cochrane library, Embase, Medline-OVID, NCBI SARS-CoV-2 Resources, ProQuest, Scopus, and Web of Science without language restrictions. All studies with prospective and experimental designs evaluating the effect of prone position patients with COVID-19 related to acute respiratory distress syndrome were included. Pooled standardised mean differences were calculated after prone position for primary (PaO₂/FiO₂) and secondary outcomes (SpO₂ and PaO₂)

Results

A total of 15 articles were eligible and included in the final analysis. Prone position had a statistically significant effect in improving PaO₂/FiO₂ with standardised mean difference of 1.10 (95%CI 0.60–1.59), SpO₂ with standardised mean difference of 3.39 (95% CI 1.30–5.48), and PaO₂ with standardised mean difference of 0.77 (95% CI 0.19–1.35). Patients with higher body mass index and longer duration/day are associated with larger standardised mean difference effect sizes for prone positioning.

Conclusions

Our findings demonstrate that prone position significantly improved oxygen saturation in COVID-19 patients with acute respiratory distress syndrome in both traditional prone positioning and awake self-prone positioning patients. Prone position should be recommended for patients with higher body mass index and longer durations to obtain the maximum effect.

Advanced respiratory monitoring in mechanically ventilated patients with coronavirus disease 2019-associated acute respiratory distress syndrome

PURPOSE OF REVIEW

To summarize the current knowledge about the application of advanced monitoring techniques in coronavirus disease 2019 (COVID-19).

RECENT FINDINGS

Due to the heterogeneity between patients, management of COVID-19 requires daily monitoring of and/or aeration and inspiratory effort. Electrical impedance tomography can be used to optimize positive end-expiratory pressure, monitor the response to changes in treatment or body position and assess pulmonary perfusion and ventilation/perfusion matching. Lung ultrasound is more readily available and can be used to measure and monitor recruitment, provide an indication of diaphragm function and pulmonary perfusion disturbances. Esophageal pressure measurements enable the calculation of the transpulmonary pressure and inspiratory effort in order to prevent excessive stress on the lung. While esophageal pressure measurements are the golden standard in determining inspiratory effort, alternatives like P0.1, negative pressure swing during a single airway occlusion and change in central venous pressure are more readily available and capable of diagnosing extreme inspiratory efforts.

SUMMARY

Although there is little data on the effectiveness of advanced monitoring techniques in COVID-19, regular monitoring should be a central part of the management of COVID-19-related acute respiratory distress syndrome (C-ARDS).

Prone position in COVID 19-associated acute respiratory failure

PURPOSE OF REVIEW

Prone position has been widely used in the COVID-19 pandemic, with an extension of its use in patients with spontaneous breathing ('awake prone'). We herein propose a review of the current literature on prone position in mechanical ventilation and while spontaneous breathing in patients with COVID-19 pneumonia or COVID-19 ARDS.

RECENT FINDINGS

A literature search retrieved 70 studies separating whether patient was intubated (24 studies) or nonintubated (46 studies). The outcomes analyzed were intubation rate, mortality and respiratory response to prone. In nonintubated patient receiving prone position, the main finding was mortality reduction in ICU and outside ICU setting.

SUMMARY

The final results of the several randomized control trials completed or ongoing are needed to confirm the trend of these results. In intubated patients, observational studies showed that responders to prone in terms of oxygenation had a better survival than nonresponders.

Long Runs and Higher Incidence of Bleeding Complications in COVID-19 Patients Requiring Venovenous Extracorporeal Membrane Oxygenation: A Case Series from the United Arab Emirates

Although the pathophysiology of pulmonary disease caused by coronavirus disease-2019 (COVID-19) is not yet fully understood, successful extracorporeal membrane oxygenation (ECMO) use has been reported for COVID-19-related severe acute respiratory distress syndrome (ARDS). We report a case series of 12 patients who received long venovenous ECMO (VV ECMO) runs for refractory hypoxia (median PF ratio of 71.8, interquartile range (IQR) 53.5–78.5) from COVID-19-related ARDS. A majority (75%) of the patients were males with a median age of 44 (IQR 37–53.5). Overall, six (50%) patients survived to hospital discharge with five of them (83.3%) noted to be cerebral performance category 1 or 2 at the time of discharge. Survivors consistently showed an improvement in sequential organ failure assessment scores within 72 hours of ECMO initiation. The median ECMO duration was 28 days (IQR 13.5–50). Despite using standard anticoagulation strategy, six (50%) of our patients had one or more major bleeding episodes, which proved to be directly fatal in four (25%) patients. Although the overall outcomes of our cohort were acceptable, our patients had much longer ECMO runs (mean 38 days in survivors) and with much higher, often fatal bleeding complications. We compare our data with other published COVID-19 VV ECMO series.

Massive macroglossia, a rare side effect of COVID-19: clinical, histologic, and genomic findings in COVID-19-positive versus COVID-19-negative patients

Purpose

The primary purpose of this study is to identify if there is an underlying genetic predisposition for COVID-related macroglossia and if this susceptibility is higher among individuals of African heritage. Secondary objectives include determining if genetic testing of COVID-infected patients who are intubated and prone could identify patients with higher susceptibility to the development of macroglossia.

Methods

A retrospective chart review was completed for each patient, and prospectively, genetic and histopathologic analyses were completed. Whole-exome sequencing was completed on two patients; immunohistochemistry was completed on the COVID-positive tissue samples.

Results

Histopathology of the COVID-positive patient revealed significant peri-lymphocytic infiltrate, which was absent in the COVID-negative patient. Immunohistochemistry confirmed the presence of immune cells. Results from the whole-exome sequencing were inconclusive.

Conclusion

The findings of this study are consistent with others that have observed a lymphocytic infiltrate in the organs of patients infected with SARS-CoV-2. On histology, IHC highlighted a CD45 + predominance, indicating that a robust immune response is present in the tissues. The pathobiology of this phenomenon and its role in the development and/or persistence of massive macroglossia requires further study.

Understanding the Intensive Care Unit Experience of Patients and Relatives at the End-of-Life During the Coronavirus Disease 2019 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has had a significant impact on patients and relatives’ experiences of end-of-life care, as well as changing the provision of these services in intensive care units (ICUs) across the world. Established methods for assisting relatives through the grieving process have required modification due to the unique features and circumstances surrounding deaths from this disease. This mixed-methods study from the United Kingdom (UK) aims to review data from patients who died in a large ICU (the unit had a capacity for more than 100 ventilated patients), over the course of approximately 1 year. The inpatient noting of these patients was reviewed specifically for details of visiting practices, chaplaincy support, and patient positioning (prone vs supine) prior to death. Using this data, recommendations are made to improve end-of-life care services. To allow relatives the opportunity to attend the ICU, there is a need for early recognition of patients approaching the end of life. Clear explanations of the need for prone positioning and increased access to chaplaincy services were also identified.

Changing trends in mortality among solid organ transplant recipients hospitalized for COVID-19 during the course of the pandemic

Mortality among patients hospitalized for COVID-19 has declined over the course of the pandemic. Mortality trends specifically in solid organ transplant recipients (SOTR) are unknown. Using data from a multicenter registry of SOTR hospitalized for COVID-19, we compared 28-day mortality between early 2020 (March 1, 2020-June 19, 2020) and late 2020 (June 20, 2020-December 31, 2020). Multivariable logistic regression was used to assess comorbidity-adjusted mortality. Time period of diagnosis was available for 1435/1616 (88.8%) SOTR and 971/1435 (67.7%) were hospitalized: 571/753 (75.8%) in early 2020 and 402/682 (58.9%) in late 2020 (p < .001). Crude 28-day mortality decreased between the early and late periods (112/571 [19.6%] vs. 55/402 [13.7%]) and remained lower in the late period even after adjusting for baseline comorbidities (aOR 0.67, 95% CI 0.46-0.98, p = .016). Between the early and late periods, the use of corticosteroids (≥6 mg dexamethasone/day) and remdesivir increased (62/571 [10.9%] vs. 243/402 [61.5%], p < .001 and 50/571 [8.8%] vs. 213/402 [52.2%], p < .001, respectively), and the use of hydroxychloroquine and IL-6/IL-6 receptor inhibitor decreased (329/571 [60.0%] vs. 4/492 [1.0%], p < .001 and 73/571 [12.8%] vs. 5/402 [1.2%], p < .001, respectively). Mortality among SOTR hospitalized for COVID-19 declined between early and late 2020, consistent with trends reported in the general population. The mechanism(s) underlying improved survival require further study.

Management of Coronavirus Disease 2019 (COVID-19) Pneumonia

Coronavirus disease 2019 (COVID-19), caused by the SARS-CoV-2 virus, may result in multi-system pathology associated with the failure of multiple organ systems. The disease primarily manifests as a mild respiratory illness, however a minority of patients may progress to severe disease, with pneumonia, respiratory failure, and hyperinflammatory syndromes increasing mortality. This article explores the pathophysiology of SARS-CoV-2 infection and presents the management of severe COVID-19 pneumonia. Along with acute illness, the chapter looks at post-COVID sequelae, considers recovery from illness, and offers consideration for the disease into the future.

An Evidence-Based Protocol for Manual Prone Positioning of Patients With ARDS

BACKGROUND

Manual prone positioning has been shown to reduce mortality among patients with moderate to severe acute respiratory distress syndrome, but it is associated with a high incidence of pressure injuries and unplanned extubations. This study investigated the feasibility of safely implementing a manual prone positioning protocol that uses a dedicated device.

REVIEW OF EVIDENCE

A search of CINAHL and Medline identified multiple randomized controlled trials and meta-analyses that demonstrated both the reduction of mortality when prone positioning is used for more than 12 hours per day in patients with acute respiratory distress syndrome and the most common complications of this treatment.

IMPLEMENTATION

An existing safe patient-handling device was modified to enable staff to safely perform manual prone positioning with few complications for patients receiving mechanical ventilation. All staff received training on the protocol and use of the device before implementation.

EVALUATION

This study included 36 consecutive patients who were admitted to the medical intensive care unit at a large academic medical center because of hypoxemic respiratory failure/acute respiratory distress syndrome and received mechanical ventilation and prone positioning. Data were collected on clinical presentation, interventions, and complications.

SUSTAINABILITY

Using the robust protocol and the low-cost device, staff can safely perform a low-volume, high-risk maneuver. This method provides cost savings compared with other prone positioning methods.

CONCLUSIONS

Implementing a prone positioning protocol with a dedicated device is feasible, with fewer complications and lower costs than anticipated.

Ultrasound-guided central venous access for patients in the Intensive Care Unit in prone position: report of three cases

The prone position is extensively used to improve oxygenation in patients with severe acute respiratory distress syndrome caused by SARS-CoV-2 pneumonia. Occasionally, these patients exhibit cardiac and respiratory functions so severely compromised they cannot tolerate lying in the supine position, not even for the time required to insert a central venous catheter. The authors describe three cases of successful ultrasound-guided internal jugular vein cannulation in prone position. The alternative approach here described enables greater safety and well-being for the patient, reduces the number of episodes of decompensation, and risk of tracheal extubation and loss of in-situ vascular lines.

COVID-19 ARDS: Points to Be Considered in Mechanical Ventilation and Weaning

The COVID-19 disease can cause hypoxemic respiratory failure due to ARDS, requiring invasive mechanical ventilation. Although early studies reported that COVID-19-associated ARDS has distinctive features from ARDS of other causes, recent observational studies have demonstrated that ARDS related to COVID-19 shares common clinical characteristics and respiratory system mechanics with ARDS of other origins. Therefore, mechanical ventilation in these patients should be based on strategies aiming to mitigate ventilator-induced lung injury. Assisted mechanical ventilation should be applied early in the course of mechanical ventilation by considering evaluation and minimizing factors associated with patient-inflicted lung injury. Extracorporeal membrane oxygenation should be considered in selected patients with refractory hypoxia not responding to conventional ventilation strategies. This review highlights the current and evolving practice in managing mechanically ventilated patients with ARDS related to COVID-19.

Understanding an evolving pandemic: An analysis of the clinical time delay distributions of COVID-19 in the United Kingdom

Understanding and monitoring the epidemiological time delay dynamics of SARS-CoV-2 infection provides insights that are key to discerning changes in the phenotype of the virus, the demographics impacted, the efficacy of treatment, and the ability of the health service to manage large volumes of patients. This paper analyses how the pandemic has evolved in the United Kingdom through the temporal changes to the epidemiological time delay distributions for clinical outcomes. Using the most complete clinical data presently available, we have analysed, through a doubly interval censored Bayesian modelling approach, the time from infection to a clinical outcome. Across the pandemic, for the periods that were defined as epidemiologically distinct, the modelled mean ranges from 8.0 to 9.7 days for infection to hospitalisation, 10.3 to 15.0 days for hospitalisation to death, and 17.4 to 24.7 days for infection to death. The time delay from infection to hospitalisation has increased since the first wave of the pandemic. A marked decrease was observed in the time from hospitalisation to death and infection to death at times of high incidence when hospitals and ICUs were under the most pressure. There is a clear relationship between age groups that is indicative of the youngest and oldest demographics having the shortest time delay distributions before a clinical outcome. A statistically significant difference was found between genders for the time delay from infection to hospitalisation, which was not found for hospitalisation to death. The results by age group indicate that younger demographics that require clinical intervention for SARS-CoV-2 infection are more likely to require earlier hospitalisation that leads to a shorter time to death, which is suggestive of the largely more vulnerable nature of these individuals that succumb to infection. The distinction found between genders for exposure to hospitalisation is revealing of gender healthcare seeking behaviours.

Ten things you need to know about intensive care unit management of mechanically ventilated patients with COVID-19

Introduction: The ongoing pandemic caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has posed important challenges for clinicians and health-care systems worldwide.Areas covered: The aim of this manuscript is to provide brief guidance for intensive care unit management of mechanically ventilated patients with COVID-19 based on the literature and our direct experience with this population. PubMed, EBSCO, and the Cochrane Library were searched up until 15th of January 2021 for relevant literature.Expert opinion: Initially, the respiratory management of COVID-19 relied on the general therapeutic principles for acute respiratory distress syndrome; however, recent findings have suggested that the pathophysiology of hypoxemia in patients with COVID-19 presents specific features and changes over time. Several therapies, including antiviral and anti-inflammatory agents, have been proposed recently. The optimal intensive care unit management of patients with COVID-19 remains unclear; therefore, ongoing and future clinical trials are warranted to clarify the optimal strategies to adopt in this cohort of patients.

Effect of prone positioning on oxygenation and static respiratory system compliance in COVID-19 ARDS vs. non-COVID ARDS

Background

Prone positioning is recommended for patients with moderate-to-severe acute respiratory distress syndrome (ARDS) receiving mechanical ventilation. While the debate continues as to whether COVID-19 ARDS is clinically different from non-COVID ARDS, there is little data on whether the physiological effects of prone positioning differ between the two conditions. We aimed to compare the physiological effect of prone positioning between patients with COVID-19 ARDS and those with non-COVID ARDS.

Methods

We retrospectively compared 23 patients with COVID-19 ARDS and 145 patients with non-COVID ARDS treated using prone positioning while on mechanical ventilation. Changes in PaO₂/FiO₂ ratio and static respiratory system compliance (Crs) after the first session of prone positioning were compared between the two groups: first, using all patients with non-COVID ARDS, and second, using subgroups of patients with non-COVID ARDS matched 1:1 with patients with COVID-19 ARDS for baseline PaO₂/FiO₂ ratio and static Crs. We also evaluated whether the response to the first prone positioning session was associated with the clinical outcome.

Results

When compared with the entire group of patients with non-COVID ARDS, patients with COVID-19 ARDS showed more pronounced improvement in PaO₂/FiO₂ ratio [adjusted difference 39.3 (95% CI 5.2–73.5) mmHg] and static Crs [adjusted difference 3.4 (95% CI 1.1–5.6) mL/cmH₂O]. However, these between-group differences were not significant when the matched samples (either PaO₂/FiO₂-matched or compliance-matched) were analyzed. Patients who successfully discontinued mechanical ventilation showed more remarkable improvement in PaO₂/FiO₂ ratio [median 112 (IQR 85–144) vs. 35 (IQR 6–52) mmHg, P = 0.003] and static compliance [median 5.7 (IQR 3.3–7.7) vs. − 1.0 (IQR − 3.7–3.0) mL/cmH₂O, P = 0.006] after prone positioning compared with patients who did not. The association between oxygenation and Crs responses to prone positioning and clinical outcome was also evident in the adjusted competing risk regression.

Conclusions

In patients with COVID-19 ARDS, prone positioning was as effective in improving respiratory physiology as in patients with non-COVID ARDS. Thus, it should be actively considered as a therapeutic option. The physiological response to the first session of prone positioning was predictive of the clinical outcome of patients with COVID-19 ARDS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-021-01819-4.

Effect of prone position on respiratory parameters, intubation and death rate in COVID-19 patients: systematic review and meta-analysis

Prone position (PP) is known to improve oxygenation and reduce mortality in COVID-19 patients. This systematic review and meta-analysis aimed to determine the effects of PP on respiratory parameters and outcomes. PubMed, EMBASE, ProQuest, SCOPUS, Web of Sciences, Cochrane library, and Google Scholar were searched up to 1st January 2021. Twenty-eight studies were included. The Cochran's Q-test and I2 statistic were assessed heterogeneity, the random-effects model was estimated the pooled mean difference (PMD), and a meta-regression method has utilized the factors affecting heterogeneity between studies. PMD with 95% confidence interval (CI) of PaO2/FIO2 Ratio in before-after design, quasi-experimental design and in overall was 55.74, 56.38, and 56.20 mmHg. These values for Spo2 (Sao2) were 3.38, 17.03, and 7.58. PP in COVID-19 patients lead to significantly decrease of the Paco2 (PMD: - 8.69; 95% CI - 14.69 to - 2.69 mmHg) but significantly increase the PaO2 (PMD: 37.74; 95% CI 7.16-68.33 mmHg). PP has no significant effect on the respiratory rate. Based on meta-regression, the study design has a significant effect on the heterogeneity of Spo2 (Sao2) (Coefficient: 12.80; p < 0.001). No significant associations were observed for other respiratory parameters with sample size and study design. The pooled estimate for death rate and intubation rates were 19.03 (8.19-32.61) and 30.68 (21.39-40.75). The prone positioning was associated with improved oxygenation parameters and reduced mortality and intubation rate in COVID-19 related respiratory failure.

Understanding the principles of non-invasive positive pressure ventilation

Non-invasive positive pressure ventilation (NPPV) provides respiratory support to patients without the need for invasive intubation. Although it has been used for several years in critical care, NPPV has come to prominence as a management option for certain patients with respiratory complications of coronavirus disease 2019 (COVID-19). This has led to increased care provision by nurses with little or no experience and expertise in critical care and NPPV. This article provides an overview of the principles of NPPV and its use in type 1 and type 2 respiratory failure. It explains the pathophysiology of several conditions that often lead to respiratory failure and how NPPV can mitigate respiratory failure and improve gas exchange. An individualised assessment of the patient's suitability for NPPV and an evaluation of the effectiveness of the therapy are crucial to ensure its safe and effective use. Nurses also have an important role in providing explanations and support to patients.

Efficiency of Prolonged Prone Positioning for Mechanically Ventilated Patients Infected with COVID-19

Hypoxemia of the acute respiratory distress syndrome can be reduced by turning patients prone. Prone positioning (PP) is labor intensive, risks unplanned tracheal extubation, and can result in facial tissue injury. We retrospectively examined prolonged, repeated, and early versus later PP for 20 patients with COVID-19 respiratory failure. Blood gases and ventilator settings were collected before PP, at 1, 7, 12, 24, 32, and 39 h after PP, and 7 h after completion of PP. Analysis of variance was used for comparisons with baseline values at supine positions before turning prone. PP for >39 h maintained PaO₂/FiO₂ (P/F) ratios when turned supine; the P/F decrease at 7 h was not significant from the initial values when turned supine. Patients turned prone a second time, when again turned supine at 7 h, had significant decreased P/F. When PP started for an initial P/F ≤ 150 versus P/F > 150, the P/F increased throughout the PP and upon return to supine. Our results show that a single turn prone for >39 h is efficacious and saves the burden of multiple prone turns, and there is no significant advantage to initiating PP when P/F > 150 compared to P/F ≤ 150.

Practice of adjunctive treatments in critically ill COVID-19 patients-rational for the multicenter observational PRoAcT-COVID study in The Netherlands

Background

Patients with coronavirus disease 2019 (COVID-19) may need hospitalization for supplemental oxygen, and some need intensive care unit (ICU) admission for escalation of care. Practice of adjunctive and supportive treatments remain uncertain and may vary widely between countries, within countries between hospitals, and possibly even within ICUs. We aim to investigate practice of adjunctive and supportive treatments, and their associations with outcome, in critically ill COVID-19 patients.

Methods

The ‘PRactice of Adjunctive Treatments in Intensive Care Unit Patients with Coronavirus Disease 2019’ (PRoAcT-COVID) study is a national, observational study to be undertaken in a large set of ICUs in The Netherlands. The PRoAcT-COVID includes consecutive ICU patients, admitted because of COVID-19 to one of the participating ICUs during a 3-month period. Daily follow-up lasts 28 days. The primary endpoint is a combination of adjunctive treatments, including types of oxygen support, ventilation, rescue therapies for hypoxemia refractory to supplementary oxygen or during invasive ventilation, other adjunctive and supportive treatments, and experimental therapies. We will also collect tracheostomy rate, duration of invasive ventilation and ventilator-free days and alive at day 28 (VFD-28), ICU and hospital length of stay, and the mortality rates in the ICU, hospital and at day 90.

Discussion

The PRoAcT-COVID study is an observational study combining high density treatment data with relevant clinical outcomes. Information on treatment practices, and their associations with outcomes in COVID-19 patients in highly and urgently needed. The results of the PRoAcT-COVID study will be rapidly available, and circulated through online presentations, such as webinars and electronic conferences, and publications in peer-reviewed journals—findings will also be presented at a dedicated website. At request, and after agreement of the PRoAcT-COVID steering committee, source data will be made available through local, regional and national anonymized datasets.

Trial registration

The PRoAcT-COVID study is registered at clinicaltrials.gov (study identifier NCT04719182).

Clinical and virological characteristics of hospitalised COVID-19 patients in a German tertiary care centre during the first wave of the SARS-CoV-2 pandemic: a prospective observational study

Purpose

Adequate patient allocation is pivotal for optimal resource management in strained healthcare systems, and requires detailed knowledge of clinical and virological disease trajectories. The purpose of this work was to identify risk factors associated with need for invasive mechanical ventilation (IMV), to analyse viral kinetics in patients with and without IMV and to provide a comprehensive description of clinical course.

Methods

A cohort of 168 hospitalised adult COVID-19 patients enrolled in a prospective observational study at a large European tertiary care centre was analysed.

Results

Forty-four per cent (71/161) of patients required invasive mechanical ventilation (IMV). Shorter duration of symptoms before admission (aOR 1.22 per day less, 95% CI 1.10–1.37, p < 0.01) and history of hypertension (aOR 5.55, 95% CI 2.00–16.82, p < 0.01) were associated with need for IMV. Patients on IMV had higher maximal concentrations, slower decline rates, and longer shedding of SARS-CoV-2 than non-IMV patients (33 days, IQR 26–46.75, vs 18 days, IQR 16–46.75, respectively, p < 0.01). Median duration of hospitalisation was 9 days (IQR 6–15.5) for non-IMV and 49.5 days (IQR 36.8–82.5) for IMV patients.

Conclusions

Our results indicate a short duration of symptoms before admission as a risk factor for severe disease that merits further investigation and different viral load kinetics in severely affected patients. Median duration of hospitalisation of IMV patients was longer than described for acute respiratory distress syndrome unrelated to COVID-19.

Supplementary Information

The online version contains supplementary material available at 10.1007/s15010-021-01594-w.

Mortality Among US Patients Hospitalized With SARS-CoV-2 Infection in 2020

IMPORTANCE

Mortality is an important measure of the severity of a pandemic. This study aimed to understand how mortality by age of hospitalized patients who were tested for SARS-CoV-2 has changed over time.

OBJECTIVE

To evaluate trends in in-hospital mortality among patients who tested positive for SARS-CoV-2.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included patients who were hospitalized for at least 1 day at 1 of 209 US acute care hospitals of variable size, in urban and rural areas, between March 1 and November 21, 2020. Eligible patients had a SARS-CoV-2 polymerase chain reaction (PCR) or antigen test within 7 days of admission or during hospitalization, and a record of discharge or in-hospital death.

EXPOSURE

SARS-CoV-2 positivity.

MAIN OUTCOMES AND MEASURES

SARS-CoV-2 infection was defined as a positive SARS-CoV-2 PCR or antigen test within 7 days before admission or during hospitalization. Mortality was extracted from electronically available data.

RESULTS

Among 503 409 admitted patients, 42 604 (8.5%) had SARS-CoV-2-positive tests. Of those with SARS-CoV-2-positive tests, 21 592 (50.7%) were male patients. Hospital admissions among patients with SARS-CoV-2-positive tests were highest in the group aged 65 years or older (19 929 [46.8%]), followed by those aged 50 to 64 years (11 602 [27.2%]) and 18 to 49 years (10 619 [24.9%]). Hospital admissions among patients 18 to 49 years of age increased from 1099 of 5319 (20.7%) in April to 1266 of 4184 (30.3%) in June and 2156 of 7280 (29.6%) in July, briefly exceeding those in the group 50 to 64 years of age (June: 1194 of 4184 [28.5%]; 2039 of 7280 [28.0%]). Patients with SARS-CoV-2-positive tests had higher in-hospital mortality than patients with SARS-CoV-2-negative tests (4705 [11.0%] vs 11 707 of 460 805 [2.5%]; P < .001). In-hospital mortality rates increased with increasing age for both patients with SARS-CoV-2-negative tests and SARS-CoV-2-positive tests. In patients with SARS-CoV-2-negative tests, mortality increased from 45 of 11 255 (0.4%) in those younger than 18 years to 4812 of 107 394 (4.5%) in those older than 75 years. In patients with SARS-CoV-2-positive tests, mortality increased from 1 of 454 (0.2%) of those younger than 18 years to 2149 of 10 287 (20.9%) in those older than 75 years. In-hospital mortality rates among patients with SARS-CoV-2-negative tests were similar for male and female patients (6273 of 209 086 [3.0%] vs 5538 of 251 719 [2.2%]) but higher mortality was observed among male patients with SARS-CoV-2-positive tests (2700 of 21 592 [12.5%]) compared with female patients with SARS-CoV-2-positive tests (2016 of 21 012 [9.60%]). Overall, in-hospital mortality increased from March to April (63 of 597 [10.6%] to 1047 of 5319 [19.7%]), then decreased significantly to November (499 of 5350 [9.3%]; P = .04), with significant decreases in the oldest age groups (50-64 years: 197 of 1542 [12.8%] to 73 of 1341 [5.4%]; P = .02; 65-75 years: 269 of 1182 [22.8%] to 137 of 1332 [10.3%]; P = .006; >75 years: 535 of 1479 [36.2%] to 262 of 1505 [17.4%]; P = .03).

CONCLUSIONS AND RELEVANCE

This nationally representative study supported the findings of smaller, regional studies and found that in-hospital mortality declined across all age groups during the period evaluated. Reductions were unlikely because of a higher proportion of younger patients with lower in-hospital mortality in the later period.

Prone positioning for severe ARDS in a postpartum COVID-19 patient following caesarean section

A 31-year-old pregnant woman presented with symptomatic COVID-19, which was complicated by progressive hypoxaemia requiring intensive care and emergent delivery by caesarean section. Afterward, she was successfully supported with mechanical ventilation and prone positioning and ultimately recovered. We review literature regarding complications of COVID-19 affecting pregnancy and evidence-based treatment strategies.

Photosynthetically Controlled Spirulina, but Not Solar Spirulina, Inhibits TNF-α Secretion: Potential Implications for COVID-19-Related Cytokine Storm Therapy

An array of infections, including the novel coronavirus (SARS-CoV-2), trigger macrophage activation syndrome (MAS) and subsequently hypercytokinemia, commonly referred to as a cytokine storm (CS). It is postulated that CS is mainly responsible for critical COVID-19 cases, including acute respiratory distress syndrome (ARDS). Recognizing the therapeutic potential of Spirulina blue-green algae (Arthrospira platensis), in this in vitro stimulation study, LPS-activated macrophages and monocytes were treated with aqueous extracts of Spirulina, cultivated in either natural or controlled light conditions. We report that an extract of photosynthetically controlled Spirulina (LED Spirulina), at a concentration of 0.1 µg/mL, decreases macrophage and monocyte-induced TNF-α secretion levels by over 70% and 40%, respectively. We propose prompt in vivo studies in animal models and human subjects to determine the putative effectiveness of a natural, algae-based treatment for viral CS and ARDS, and explore the potential of a novel anti-TNF-α therapy.

Leptospirosis in Intensive Care Unit

Tropical infections constitute 20 – 30% of intensive care unit (ICU) admissions in developing countries. Leptospirosis is a spectrum with mild form presenting as an acute febrile illness with jaundice, complicating in few as acute kidney injury (AKI), acute respiratory distress syndrome (ARDS), disseminated intravascular coagulation (DIC), and multi-organ dysfunction syndrome (MODS). The poor prognostic markers are hemorrhagic ARDS, acute renal failure, DIC, severe metabolic acidosis, older age, chronic alcohol abuse, high SOFA score, and septic shock. The confirmatory diagnosis relies on antibody testing, such as microscopic agglutination test (MAT) and IgM ELISA, while the reverse transcription-polymerase chain reaction test being reserved for clinically suspected antibody negative cases. The spectrum of multi-organ involvement necessitates a complete hematological, biochemical workup, including electrocardiogram (ECG), chest X-ray, and two-dimensional echocardiography. Specific antimicrobial therapy consists of the following—benzylpenicillin, ceftriaxone, cefotaxime, and doxycycline. The reported mortality ranges from 6% to as high as 44%. Various ICU scores like SPiRO, THAI LEPTO score, and Faine's criteria have been useful in risk stratification. Optimizing intensive care treatment with appropriate antibiotics, lung protection ventilation strategies, strict fluid management, and if need be timely initiation of renal replacement therapy (RRT) helps in reducing mortality.

How to cite this article: Karnik ND, Patankar AS. Leptospirosis in Intensive Care Unit. Indian J Crit Care Med 2021;25(Suppl 2): S134–S137.

Effects of Prone Ventilation on Oxygenation, Inflammation, and Lung Infiltrates in COVID-19 Related Acute Respiratory Distress Syndrome: A Retrospective Cohort Study

Patients receiving mechanical ventilation for coronavirus disease 2019 (COVID-19) related, moderate-to-severe acute respiratory distress syndrome (CARDS) have mortality rates between 76-98%. The objective of this retrospective cohort study was to identify differences in prone ventilation effects on oxygenation, pulmonary infiltrates (as observed on chest X-ray (CXR)), and systemic inflammation in CARDS patients by survivorship and to identify baseline characteristics associated with survival after prone ventilation. The study cohort included 23 patients with moderate-to-severe CARDS who received prone ventilation for ≥16 h/day and was segmented by living status: living (n = 6) and deceased (n = 17). Immediately after prone ventilation, PaO2/FiO2 improved by 108% (p < 0.03) for the living and 150% (p < 3 × 10-4) for the deceased. However, the 48 h change in lung infiltrate severity in gravity-dependent lung zones was significantly better for the living than for the deceased (p < 0.02). In CXRs of the lower lungs before prone ventilation, we observed 5 patients with confluent infiltrates bilaterally, 12 patients with ground-glass opacities (GGOs) bilaterally, and 6 patients with mixed infiltrate patterns; 80% of patients with confluent infiltrates were alive vs. 8% of patients with GGOs. In conclusion, our small study indicates that CXRs may offer clinical utility in selecting patients with moderate-to-severe CARDS who will benefit from prone ventilation. Additionally, our study suggests that lung infiltrate severity may be a better indicator of patient disposition after prone ventilation than PaO2/FiO2.

The Use of a Kinetic Therapy Rotational Bed in Pediatric Acute Respiratory Distress Syndrome: A Case Series

Patients with acute respiratory distress syndrome (ARDS) commonly have dependent atelectasis and heterogeneous lung disease. Due to the heterogenous lung volumes seen, the application of positive end expiratory pressure (PEEP) can have both beneficial and deleterious effects. Alternating supine and prone positioning may be beneficial in ARDS by providing more homogenous distribution of PEEP and decreasing intrapulmonary shunt. In pediatrics, the pediatric acute lung injury and consensus conference (PALICC) recommended to consider it in severe pediatric ARDS (PARDS). Manually prone positioning patients can be burdensome in larger patients. In adults, the use of rotational beds has eased care of these patients. There is little published data about rotational bed therapy in children. Therefore, we sought to describe the use of a rotational bed in children with PARDS. We performed a retrospective case series of children who utilized a rotational bed as an adjunctive therapy for their PARDS. Patient data were collected and analyzed. Descriptive statistical analyses were performed and reported. Oxygenation indices (OI) pre- and post-prone positioning were analyzed. Twelve patients with PARDS were treated with a rotational bed with minimal adverse events. There were no complications noted. Three patients had malfunctioning of their arterial line while on the rotational bed. Oxygenation indices improved over time in 11 of the 12 patients included in the study while on the rotational bed. Rotational beds can be safely utilized in pediatric patients. In larger children with PARDS, where it may be more difficult to perform a manual prone position, use of a rotational bed can be considered a safe alternative.