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Pepe F, Fabiani G, Cogozzo C, Mazzilli V, Villanti M, Pini R, Innocenti F. HACOR score to predict NIV failure in patients with COVID-related hypoxemic respiratory failure managed in the ordinary ward and in the critical care setting. Intern Emerg Med 2024:10.1007/s11739-024-03628-1. [PMID: 38739206 DOI: 10.1007/s11739-024-03628-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/24/2024] [Indexed: 05/14/2024]
Abstract
We evaluated the prevalence of non-invasive ventilation (NIV) failure among patients with COVID-19-related pneumonia, managed in the ordinary ward and in the HDU/ICU and we tested the prognostic role of the HACOR score in those different settings. This is a retrospective study, conducted in the University-Hospital Careggi. We included all subjects with COVID-19 and ARF requiring NIV between March 2020 and May 2021, respectively managed in the ordinary ward (G1) and in the critical care setting (G2). Clinical parameters, HACOR and SOFA score were evaluated at Day 0 and after 1, 2 and 5 days of treatment. The primary outcome was NIV failure. 13% G1 patients and 40% G2 patients underwent endotracheal intubation (ETI). NIV was successful in 60% G1 AND 43% G2 patients (p < 0.001). In G1, compared to those with successful NIV, patients who underwent ETI, had a higher HACOR since the baseline evaluation (T0: 6 [5-6] vs 5 [3-6]; T1: 6 [5-6] vs 5 [3-6], all p < 0.05). An HACOR score > 5 was associated with an increased prevalence of ETI independent to an advanced age and a SOFA score > 5 both in G1 (T1: RR 4.87, 95% CI 1.462-16.275; T5: 3.630, 95% CI 0.979-13.462) and G2 (T0: 1.76, 95% CI 0.906-3.422; T1: 3.38, 95% CI 1.386-8.265). Among patients with COVID-related-ARF, NIV could be managed in the ordinary ward in a consistent proportion of patients and, among them, an HACOR score > 5 was independently associated with increased NIV failure from the earliest evaluations.
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Affiliation(s)
- Francesco Pepe
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Ginevra Fabiani
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Carolina Cogozzo
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Valerio Mazzilli
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Maurizio Villanti
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Riccardo Pini
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Francesca Innocenti
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy.
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2
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Singh MK. Hail the HACOR as a Customized Indian Weaning Score! Indian J Crit Care Med 2024; 28:198-199. [PMID: 38476997 PMCID: PMC10926033 DOI: 10.5005/jp-journals-10071-24675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024] Open
Abstract
Singh MK. Hail the HACOR as a Customized Indian Weaning Score! Indian J Crit Care Med 2024;28(3):198-199.
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Affiliation(s)
- Manoj K Singh
- Department of Pulmonary and Critical Care Medicine, Zydus Hospitals, Ahmedabad, Gujarat, India
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3
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Rodrigues de Moraes L, Robba C, Battaglini D, Pelosi P, Rocco PRM, Silva PL. New and personalized ventilatory strategies in patients with COVID-19. Front Med (Lausanne) 2023; 10:1194773. [PMID: 37332761 PMCID: PMC10273276 DOI: 10.3389/fmed.2023.1194773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/09/2023] [Indexed: 06/20/2023] Open
Abstract
Coronavirus disease (COVID-19) is caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) virus and may lead to severe respiratory failure and the need for mechanical ventilation (MV). At hospital admission, patients can present with severe hypoxemia and dyspnea requiring increasingly aggressive MV strategies according to the clinical severity: noninvasive respiratory support (NRS), MV, and the use of rescue strategies such as extracorporeal membrane oxygenation (ECMO). Among NRS strategies, new tools have been adopted for critically ill patients, with advantages and disadvantages that need to be further elucidated. Advances in the field of lung imaging have allowed better understanding of the disease, not only the pathophysiology of COVID-19 but also the consequences of ventilatory strategies. In cases of refractory hypoxemia, the use of ECMO has been advocated and knowledge on handling and how to personalize strategies have increased during the pandemic. The aims of the present review are to: (1) discuss the evidence on different devices and strategies under NRS; (2) discuss new and personalized management under MV based on the pathophysiology of COVID-19; and (3) contextualize the use of rescue strategies such as ECMO in critically ill patients with COVID-19.
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Affiliation(s)
- Lucas Rodrigues de Moraes
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Chiara Robba
- Unit of Anaesthesia and Intensive Care, San Martino Hospital (IRCCS), Genoa, Italy
| | - Denise Battaglini
- Unit of Anaesthesia and Intensive Care, San Martino Hospital (IRCCS), Genoa, Italy
| | - Paolo Pelosi
- Unit of Anaesthesia and Intensive Care, San Martino Hospital (IRCCS), Genoa, Italy
| | - Patricia R. M. Rocco
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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4
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Porosnicu TM, Sandesc D, Jipa D, Gindac C, Oancea C, Bratosin F, Fericean RM, Kodimala SC, Pilut CN, Nussbaum LA, Sirbu IO. Assessing the Outcomes of Patients with Severe SARS-CoV-2 Infection after Therapeutic Plasma Exchange by Number of TPE Sessions. J Clin Med 2023; 12:jcm12051743. [PMID: 36902537 PMCID: PMC10003394 DOI: 10.3390/jcm12051743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/19/2023] [Accepted: 02/20/2023] [Indexed: 02/24/2023] Open
Abstract
The high mortality risk in severe SARS-CoV-2 infections is tightly correlated to the extreme elevation of inflammatory markers. This acute accumulation of inflammatory proteins can be cleared using plasma exchange (TPE), commonly known as plasmapheresis, although the available data on performing TPE in COVID-19 patients is limited regarding the optimal treatment protocol. The purpose for this study was to examine the efficacy and outcomes of TPE based on different treatment methods. A thorough database search was performed to identify patients from the Intensive Care Unit (ICU) of the Clinical Hospital of Infectious Diseases and Pneumology between March 2020 and March 2022 with severe COVID-19 that underwent at least one session of TPE. A total of 65 patients satisfied the inclusion criteria and were eligible for TPE as a last resort therapy. Of these, 41 patients received 1 TPE session, 13 received 2 TPE sessions, and the remaining 11 received more than 2 TPE sessions. It was observed that IL-6, CRP, and ESR decreased significantly after all sessions were performed in all three groups, with the highest decrease of IL-6 in those who received >2 TPE sessions (from 305.5 pg/mL to 156.0 pg/mL). Interestingly, there was a significant increase in leucocyte levels after TPE, but there was no significant difference in MAP changes, SOFA score, APACHE 2 score, or the PaO2/FiO2 ratio. The ROX index was significantly higher among the patients who underwent more than two TPE sessions, with an average of 11.4, compared to 6.5 in group 1 and 7.4 in group 2, which increased significantly after TPE. Nevertheless, the mortality rate was very high (72.3%), and the Kaplan-Meier analysis identified no significant difference in survival according to the number of TPE sessions. TPE can be used as last resort salvage therapy that can be regarded as an alternative treatment method when the standard management of these patients fails. It significantly decreases the inflammatory status measured via IL-6, CRP, and WBC, as well as demonstrating an improvement of the clinical status measured via PaO2/FiO2, and duration of hospitalization. However, the survival rate does not seem to change with the number of TPE sessions. Based on the survival analysis, one session of TPE as last resort treatment in patients with severe COVID-19 proved to have the same effect as repeated TPE sessions of 2 or more.
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Affiliation(s)
- Tamara Mirela Porosnicu
- Doctoral School, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania
- Intensive Care Unit, “Victor Babes” Clinical Hospital for Infectious Diseases and Pneumology, 300041 Timisoara, Romania
| | - Dorel Sandesc
- Department of Anesthesia and Intensive Care, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania
- Intensive Care Unit, “Pius Brinzeu” Emergency Clinical Hospital, 300041 Timisoara, Romania
| | - Daniel Jipa
- Intensive Care Unit, “Pius Brinzeu” Emergency Clinical Hospital, 300041 Timisoara, Romania
| | - Ciprian Gindac
- Intensive Care Unit, “Pius Brinzeu” Emergency Clinical Hospital, 300041 Timisoara, Romania
| | - Cristian Oancea
- Center for Research and Innovation in Precision Medicine of Respiratory Disease, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania
| | - Felix Bratosin
- Department XIII, Discipline of Infectious Disease, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania
| | - Roxana Manuela Fericean
- Department XIII, Discipline of Infectious Disease, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania
| | - Shiva Charana Kodimala
- MediCiti Institute of Medical Sciences, NTR University of Health Sciences, Hyderabad 501401, India
| | - Ciprian Nicolae Pilut
- Department of Microbiology, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania
- Correspondence:
| | - Laura Alexandra Nussbaum
- Department of Neurosciences, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania
| | - Ioan Ovidiu Sirbu
- Center for Complex Network Sciences, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania
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5
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Gül F, Gonen ZB, Jones OY, Taşlı NP, Zararsız G, Ünal E, Özdarendeli A, Şahin F, Eken A, Yılmaz S, Karakukçu M, Kırbaş OK, Gökdemir NS, Bozkurt BT, Özkul Y, Oktay BD, Uygut MA, Cinel I, Çetin M. A pilot study for treatment of severe COVID-19 pneumonia by aerosolized formulation of convalescent human immune plasma exosomes (ChipEXO™). Front Immunol 2022; 13:963309. [PMID: 36439138 PMCID: PMC9682905 DOI: 10.3389/fimmu.2022.963309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 09/20/2022] [Indexed: 07/22/2023] Open
Abstract
This is a single-center prospective, open-label, single arm interventional study to test the safety and efficacy of recently described ChipEXO™ for severe COVID-19 pneumonia. The ChipEXO™ is a natural product derived from convalescent human immune plasma of patients recovered from moderate COVID-19 infection. In September 2021, 13 patients with pending respiratory failure were treated with ChipEXO™ adapted for aerosolized formulation delivered via jet nebulizer. Patients received 1-5x1010 nano vesicle/5 mL in distilled water twice daily for five days as an add-on to ongoing conventional COVID-19 treatment. The primary endpoint was patient safety and survival over a 28-day follow-up. The secondary endpoint was longitudinal assessment of clinical parameters following ChipEXO™ to evaluate treatment response and gain insights into the pharmacodynamics. ChipEXO™ was tolerated well without any allergic reaction or acute toxicity. The survival rate was 84.6% and 11 out of 13 recovered without any sequel to lungs or other organs. ChipEXO™ treatment was effective immediately as shown in arterial blood gas analyses before and two hours after exosome inhalation. During the 5 days of treatment, there was a sustainable and gradual improvement on oxygenation parameters: i.e. respiratory rate (RR) [20.8% (P < 0.05)], oxygen saturation (SpO2) [6,7% (P < 0.05)] and partial pressure of oxygen to the fraction of inspired oxygen (PaO2/FiO2) [127.9% (P < 0.05)] that correlated with steep decrease in the disease activity scores and inflammatory markers, i.e. the sequential organ failure assessment (SOFA) score (75%, p < 0.05), C-reactive protein (46% p < 0.05), ferritin (58% p = 0.53), D-dimer (28% p=0.46). In conclusion, aerosolized ChipEXO™ showed promising safety and efficacy for life-threatening COVID-19 pneumonia. Further studies on larger patient populations are required to confirm our findings and understand the pathophysiology of improvement toward a new therapeutic agent for the treatment of severe COVID-19 pneumonia.
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Affiliation(s)
- Fethi Gül
- Department of Anesthesiology and Reanimation, Division of Critical Care Medicine, School of Medicine, Marmara University, Istanbul, Türkiye
| | | | - Olcay Y. Jones
- Division of Rheumatology, Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Neslihan Pakize Taşlı
- Department of Genetics and Bioengineering, Faculty of Engineering and Architecture, Yeditepe University, İstanbul, Türkiye
| | - Gökmen Zararsız
- Department of Biostatistics, Faculty of Medicine, Erciyes University, Kayseri, Türkiye
| | - Ekrem Ünal
- Department of Pediatrics, Division of Pediatric Hematology, Faculty of Medicine, Erciyes University, Kayseri, Türkiye
| | - Aykut Özdarendeli
- Faculty of Medicine, Vaccine Research and Development Application and Research Center, Erciyes University, Kayseri, Türkiye
| | - Fikrettin Şahin
- Department of Genetics and Bioengineering, Faculty of Engineering and Architecture, Yeditepe University, İstanbul, Türkiye
| | - Ahmet Eken
- Department of Biology, Faculty of Science, Erciyes University, Kayseri, Türkiye
| | - Semih Yılmaz
- Institute of Health Sciences, Department of Medical Biochemistry, Erciyes University, Kayseri, Türkiye
| | - Musa Karakukçu
- Department of Pediatrics, Division of Pediatric Hematology, Faculty of Medicine, Erciyes University, Kayseri, Türkiye
| | - Oğuz Kaan Kırbaş
- Department of Genetics and Bioengineering, Faculty of Engineering and Architecture, Yeditepe University, İstanbul, Türkiye
| | - Nur Seda Gökdemir
- Betül-Ziya Eren Genome and Stem Cell Center (GENKOK), Kayseri, Türkiye
| | - Batuhan Turhan Bozkurt
- Department of Genetics and Bioengineering, Faculty of Engineering and Architecture, Yeditepe University, İstanbul, Türkiye
| | - Yusuf Özkul
- Faculty of Medicine, Erciyes University, Kayseri, Türkiye
| | - Burçin Doruk Oktay
- Department of Anesthesiology and Reanimation, Division of Critical Care Medicine, School of Medicine, Marmara University, İstanbul, Türkiye
| | - Muhammet Ali Uygut
- Vaccine Research and Development Application and Research Center, Erciyes University, Kayseri, Türkiye
| | - Ismail Cinel
- Department of Anesthesiology and Reanimation, Division of Critical Care Medicine, School of Medicine, Marmara University, İstanbul, Türkiye
| | - Mustafa Çetin
- Faculty of Medicine, Erciyes University, Kayseri, Türkiye
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6
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Gül F, Gonen ZB, Jones OY, Taşlı NP, Zararsız G, Ünal E, Özdarendeli A, Şahin F, Eken A, Yılmaz S, Karakukçu M, Kırbaş OK, Gökdemir NS, Bozkurt BT, Özkul Y, Oktay BD, Uygut MA, Cinel I, Çetin M. A pilot study for treatment of severe COVID-19 pneumonia by aerosolized formulation of convalescent human immune plasma exosomes (ChipEXO™). Front Immunol 2022. [DOI: https://doi.org/10.3389/fimmu.2022.963309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
This is a single-center prospective, open-label, single arm interventional study to test the safety and efficacy of recently described ChipEXO™ for severe COVID-19 pneumonia. The ChipEXO™ is a natural product derived from convalescent human immune plasma of patients recovered from moderate COVID-19 infection. In September 2021, 13 patients with pending respiratory failure were treated with ChipEXO™ adapted for aerosolized formulation delivered via jet nebulizer. Patients received 1-5x1010 nano vesicle/5 mL in distilled water twice daily for five days as an add-on to ongoing conventional COVID-19 treatment. The primary endpoint was patient safety and survival over a 28-day follow-up. The secondary endpoint was longitudinal assessment of clinical parameters following ChipEXO™ to evaluate treatment response and gain insights into the pharmacodynamics. ChipEXO™ was tolerated well without any allergic reaction or acute toxicity. The survival rate was 84.6% and 11 out of 13 recovered without any sequel to lungs or other organs. ChipEXO™ treatment was effective immediately as shown in arterial blood gas analyses before and two hours after exosome inhalation. During the 5 days of treatment, there was a sustainable and gradual improvement on oxygenation parameters: i.e. respiratory rate (RR) [20.8% (P < 0.05)], oxygen saturation (SpO2) [6,7% (P < 0.05)] and partial pressure of oxygen to the fraction of inspired oxygen (PaO2/FiO2) [127.9% (P < 0.05)] that correlated with steep decrease in the disease activity scores and inflammatory markers, i.e. the sequential organ failure assessment (SOFA) score (75%, p < 0.05), C-reactive protein (46% p < 0.05), ferritin (58% p = 0.53), D-dimer (28% p=0.46). In conclusion, aerosolized ChipEXO™ showed promising safety and efficacy for life-threatening COVID-19 pneumonia. Further studies on larger patient populations are required to confirm our findings and understand the pathophysiology of improvement toward a new therapeutic agent for the treatment of severe COVID-19 pneumonia.
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7
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Gül F, Gonen ZB, Jones OY, Taşlı NP, Zararsız G, Ünal E, Özdarendeli A, Şahin F, Eken A, Yılmaz S, Karakukçu M, Kırbaş OK, Gökdemir NS, Bozkurt BT, Özkul Y, Oktay BD, Uygut MA, Cinel I, Çetin M. A pilot study for treatment of severe COVID-19 pneumonia by aerosolized formulation of convalescent human immune plasma exosomes (ChipEXO™). Front Immunol 2022. [DOI: https:/doi.org/10.3389/fimmu.2022.963309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
This is a single-center prospective, open-label, single arm interventional study to test the safety and efficacy of recently described ChipEXO™ for severe COVID-19 pneumonia. The ChipEXO™ is a natural product derived from convalescent human immune plasma of patients recovered from moderate COVID-19 infection. In September 2021, 13 patients with pending respiratory failure were treated with ChipEXO™ adapted for aerosolized formulation delivered via jet nebulizer. Patients received 1-5x1010 nano vesicle/5 mL in distilled water twice daily for five days as an add-on to ongoing conventional COVID-19 treatment. The primary endpoint was patient safety and survival over a 28-day follow-up. The secondary endpoint was longitudinal assessment of clinical parameters following ChipEXO™ to evaluate treatment response and gain insights into the pharmacodynamics. ChipEXO™ was tolerated well without any allergic reaction or acute toxicity. The survival rate was 84.6% and 11 out of 13 recovered without any sequel to lungs or other organs. ChipEXO™ treatment was effective immediately as shown in arterial blood gas analyses before and two hours after exosome inhalation. During the 5 days of treatment, there was a sustainable and gradual improvement on oxygenation parameters: i.e. respiratory rate (RR) [20.8% (P < 0.05)], oxygen saturation (SpO2) [6,7% (P < 0.05)] and partial pressure of oxygen to the fraction of inspired oxygen (PaO2/FiO2) [127.9% (P < 0.05)] that correlated with steep decrease in the disease activity scores and inflammatory markers, i.e. the sequential organ failure assessment (SOFA) score (75%, p < 0.05), C-reactive protein (46% p < 0.05), ferritin (58% p = 0.53), D-dimer (28% p=0.46). In conclusion, aerosolized ChipEXO™ showed promising safety and efficacy for life-threatening COVID-19 pneumonia. Further studies on larger patient populations are required to confirm our findings and understand the pathophysiology of improvement toward a new therapeutic agent for the treatment of severe COVID-19 pneumonia.
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8
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Innocenti F, Lazzari C, Paolucci E, De Paris A, Lagomarsini A, Guerra F, Alleonato P, Casalini L, Buggea M, Caldi F, Zanobetti M, Pieralli F, Guazzini G, Lastraioli L, Luise F, Milia A, Sammicheli L, Maddaluni L, Lavorini F, Pini R. Role of prognostic scores in predicting in-hospital mortality and failure of non-invasive ventilation in adults with COVID-19. Intern Emerg Med 2022; 17:2367-2377. [PMID: 35918627 PMCID: PMC9345392 DOI: 10.1007/s11739-022-03058-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 07/18/2022] [Indexed: 12/04/2022]
Abstract
We tested the prognostic performance of different scores for the identification of subjects with acute respiratory failure by COVID-19, at risk of in-hospital mortality and NIV failure. We conducted a retrospective study, in the Medical High-Dependency Unit of the University-Hospital Careggi. We included all subjects with COVID-19 and ARF requiring non-invasive ventilation (NIV) between March 2020 and January 2021. Clinical parameters, the HACOR score (Heart rate, Acidosis, Consciousness, Oxygenation, Respiratory Rate) and ROX index ((SpO2/FiO2)/respiratory rate) were collected 3 (-3) and 1 day (-1) before the NIV initiation, the first day of treatment (Day0) and after 1 (+1), 2 (+2), 5 (+5), 8 (+8) and 11 (+11) of treatment. The primary outcomes were in-hospital mortality and NIV failure. We included 135 subjects, mean age 69±13 years, 69% male. Patients, who needed mechanical ventilation, showed a higher HACOR score (Day0: 6 [5-7] vs 6 [6-7], p=.057; Day+2: 6 [6-6] vs 6 [4-6], p=.013) and a lower ROX index (Day0: 4.2±2.3 vs 5.1±2.3, p=.055; Day+2: 4.4±1.2.vs 5.5±1.3, p=.001) than those with successful NIV. An HACOR score >5 was more frequent among nonsurvivors (Day0: 82% vs 58%; Day2: 82% vs 48%, all p<0.01) and it was associated with in-hospital mortality (Day0: RR 5.88, 95%CI 2.01-17.22; Day2: RR 4.33, 95%CI 1.64-11.41) independent to age and Charlson index. In conclusion, in subjects treated with NIV for ARF caused by COVID19, respiratory parameters collected after the beginning of NIV allowed to identify those at risk of an adverse outcome. An HACOR score >5 was independently associated with increased mortality rate.
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Affiliation(s)
- Francesca Innocenti
- High-Dependency Unit, Emergency Department, Careggi University-Hospital, Lg. Brambilla 3, 50134, Florence, Italy.
| | - Cristian Lazzari
- High-Dependency Unit, Emergency Department, Careggi University-Hospital, Lg. Brambilla 3, 50134, Florence, Italy
| | - Elisa Paolucci
- High-Dependency Unit, Emergency Department, Careggi University-Hospital, Lg. Brambilla 3, 50134, Florence, Italy
| | - Anna De Paris
- High-Dependency Unit, Emergency Department, Careggi University-Hospital, Lg. Brambilla 3, 50134, Florence, Italy
| | - Alessia Lagomarsini
- High-Dependency Unit, Emergency Department, Careggi University-Hospital, Lg. Brambilla 3, 50134, Florence, Italy
| | - Federica Guerra
- High-Dependency Unit, Emergency Department, Careggi University-Hospital, Lg. Brambilla 3, 50134, Florence, Italy
| | - Patrizia Alleonato
- High-Dependency Unit, Emergency Department, Careggi University-Hospital, Lg. Brambilla 3, 50134, Florence, Italy
| | - Lisa Casalini
- High-Dependency Unit, Emergency Department, Careggi University-Hospital, Lg. Brambilla 3, 50134, Florence, Italy
| | - Michele Buggea
- High-Dependency Unit, Emergency Department, Careggi University-Hospital, Lg. Brambilla 3, 50134, Florence, Italy
| | - Francesca Caldi
- High-Dependency Unit, Emergency Department, Careggi University-Hospital, Lg. Brambilla 3, 50134, Florence, Italy
| | - Maurizio Zanobetti
- High-Dependency Unit, Emergency Department, Careggi University-Hospital, Lg. Brambilla 3, 50134, Florence, Italy
| | - Filippo Pieralli
- Intermediate Care Unit, Careggi University-Hospital, Florence, Italy
| | - Giulia Guazzini
- Intermediate Care Unit, Careggi University-Hospital, Florence, Italy
| | - Lisa Lastraioli
- Intermediate Care Unit, Careggi University-Hospital, Florence, Italy
| | - Fabio Luise
- Intermediate Care Unit, Careggi University-Hospital, Florence, Italy
| | - Alessandro Milia
- Intermediate Care Unit, Careggi University-Hospital, Florence, Italy
| | - Lucia Sammicheli
- Intermediate Care Unit, Careggi University-Hospital, Florence, Italy
| | - Lucia Maddaluni
- High-Dependency Unit, Emergency Department, Careggi University-Hospital, Lg. Brambilla 3, 50134, Florence, Italy
| | - Federico Lavorini
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Riccardo Pini
- High-Dependency Unit, Emergency Department, Careggi University-Hospital, Lg. Brambilla 3, 50134, Florence, Italy
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
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9
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The optimal management of the patient with COVID‐19 pneumonia: HFNC, NIV/CPAP or mechanical ventilation? Afr J Thorac Crit Care Med 2022; 28. [DOI: 10.7196/ajtccm.2022.v28i3.241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2022] [Indexed: 11/07/2022] Open
Abstract
The recent pandemic has seen unprecedented demand for respiratory support of patients with COVID‐19 pneumonia, stretching services and clinicians. Yet despite the global numbers of patients treated, guidance is not clear on the correct choice of modality or the timing of escalation of therapy for an individual patient.This narrative review assesses the available literature on the best use of different modalities of respiratory support for an individual patient, and discusses benefits and risks of each, coupled with practical advice to improve outcomes.
On current data, in an ideal context, it appears that as disease severity worsens, conventional oxygen therapy is not sufficient alone. In more severe disease, i.e. PaO2/FiO2 ratios below approximately 200, helmet‐CPAP (continuous positive airway pressure) (although not widely available) may be superior to high‐flow nasal cannula (HFNC) therapy or facemask non‐invasive ventilation (NIV)/CPAP, and that facemask NIV/CPAP may be superior to HFNC, but with noted important complications, including risk of pneumothoraces.
In an ideal context, invasive mechanical ventilation should not be delayed where indicated and available. Vitally, the choice of respiratory support should not be prescriptive but contextualised to each setting, as supply and demand of resources vary markedly between institutions. Over time, institutions should develop clear policies to guide clinicians before demand exceeds supply, and should frequently review best practice as evidence matures.
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Pande RK, Sharma J. Heart Rate, Acidosis, Consciousness, Oxygenation, and Respiratory Rate: A Perfect Weaning Index or Just a New Kid on the Block. Indian J Crit Care Med 2022; 26:887-888. [PMID: 36042771 PMCID: PMC9363811 DOI: 10.5005/jp-journals-10071-24290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Successful weaning is when spontaneous breathing is sustained for more than 48 hours after extubation. Despite a plethora of individual and composite weaning indices being available, most indices have not found much clinical utility, and weaning continues to be largely based on clinical assessment. Heart rate, acidosis, consciousness, oxygenation, and respiratory rate (HACOR) is a new score for prediction of failure of noninvasive ventilation (NIV) in hypoxemic patients receiving NIV. The present study explores its utilization in weaning from invasive ventilation.
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Affiliation(s)
- Rajesh Kumar Pande
- Department of Critical Care, BLK-MAX Super Speciality Hospital, New Delhi, India
- Rajesh Kumar Pande, Department of Critical Care, BLK-MAX Super Speciality Hospital, New Delhi, India, Phone: +91 9810536268, e-mail:
| | - Jitin Sharma
- Department of Critical Care, BLK-MAX Super Speciality Hospital, New Delhi, India
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11
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Mannarino MR, Bianconi V, Cosentini E, Figorilli F, Natali C, Cellini G, Colangelo C, Giglioni F, Braca M, Pirro M. The HACOR Score Predicts Worse in-Hospital Prognosis in Patients Hospitalized with COVID-19. J Clin Med 2022; 11:jcm11123509. [PMID: 35743579 PMCID: PMC9225644 DOI: 10.3390/jcm11123509] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/15/2022] [Accepted: 06/16/2022] [Indexed: 02/05/2023] Open
Abstract
Non-invasive respiratory support (NIRS) is widely used in COVID-19 patients, although high rates of NIRS failure are reported. Early detection of NIRS failure and promptly defining the need for intubation are crucial for the management of patients with acute respiratory failure (ARF). We tested the ability of the HACOR score¸ a scale based on clinical and laboratory parameters, to predict adverse outcomes in hospitalized COVID-19 patients with ARF. Four hundred patients were categorized according to high (>5) or low (≤5) HACOR scores measured at baseline and 1 h after the start of NIRS treatment. The association between a high HACOR score and either in-hospital death or the need for intubation was evaluated. NIRS was employed in 161 patients. Forty patients (10%) underwent intubation and 98 (25%) patients died. A baseline HACOR score > 5 was associated with the need for intubation or in-hospital death in the whole population (HR 4.3; p < 0.001), in the subgroup of patients who underwent NIRS (HR 5.2; p < 0.001) and in no-NIRS subgroup (HR 7.9; p < 0.001). In the NIRS subgroup, along with the baseline HACOR score, also 1-h HACOR score predicted NIRS failure (HR 2.6; p = 0.039). In conclusion, the HACOR score is a significant predictor of adverse clinical outcomes in patients with COVID-19-related ARF.
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Alessandri F, Tosi A, De Lazzaro F, Andreoli C, Cicchinelli A, Carrieri C, Lai Q, Pugliese F. Use of CPAP Failure Score to Predict the Risk of Helmet-CPAP Support Failure in COVID-19 Patients: A Retrospective Study. J Clin Med 2022; 11:jcm11092593. [PMID: 35566728 PMCID: PMC9104739 DOI: 10.3390/jcm11092593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/26/2022] [Accepted: 05/02/2022] [Indexed: 02/01/2023] Open
Abstract
(1) Background: the aim of this study was to create a score to predict the incidence of CPAP failure in COVID-19 patients early. (2) Methods: in this retrospective observational study, we included all consecutive adult patients admitted between February and April 2021. The main outcome was the failure of CPAP support (intubation or death). (3) Results: two-hundred and sixty-three COVID-19 patients were managed with CPAP. The population was divided in short-CPAP (CPAP days ≤ 10; 72.6%) and long-CPAP (>10; 27.4%) groups. After balancing the entire population using a stabilized IPTW method, we applied a multivariable logistic regression analysis to identify the risk factors for CPAP failure. We used the identified covariates to create a mathematical model, the CPAP Failure Score (CPAP-FS). The multivariable logistic regression analysis identified four variables: SpO2 (OR = 0.86; p-value = 0.001), P/F ratio (OR = 0.99; p-value = 0.008), the Call Score (OR = 1.44; p-value = 0.02), and a pre-existing chronic lung disease (OR = 3.08; p-value = 0.057). The beta-coefficients obtained were used to develop the CPAP-FS, whose diagnostic ability outperformed other relevant COVID-19-related parameters (AUC = 0.87; p-value < 0.0001). We validated the CPAP-FS using a 10-fold internal cross-validation method which confirmed the observed results (AUCs 0.76−0.80; p-values < 0.0001). (4) Conclusions: the CPAP-FS can early identify COVID-19 patients who are at risk of CPAP failure.
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Affiliation(s)
- Francesco Alessandri
- Department of General Surgery and Organ Transplantation Unit, Sapienza University of Rome, Policlinico Umberto I, 00161 Rome, Italy; (Q.L.); (F.P.)
- Correspondence:
| | - Antonella Tosi
- Department of Anesthesiology, Critical Care and Pain Medicine, Sapienza University of Rome, Policlinico Umberto I, 00161 Rome, Italy; (A.T.); (F.D.L.); (A.C.); (C.C.)
| | - Francesco De Lazzaro
- Department of Anesthesiology, Critical Care and Pain Medicine, Sapienza University of Rome, Policlinico Umberto I, 00161 Rome, Italy; (A.T.); (F.D.L.); (A.C.); (C.C.)
| | - Chiara Andreoli
- Department of Radiology, Sapienza University of Rome, Policlinico Umberto I, 00161 Rome, Italy;
| | - Andrea Cicchinelli
- Department of Anesthesiology, Critical Care and Pain Medicine, Sapienza University of Rome, Policlinico Umberto I, 00161 Rome, Italy; (A.T.); (F.D.L.); (A.C.); (C.C.)
| | - Cosima Carrieri
- Department of Anesthesiology, Critical Care and Pain Medicine, Sapienza University of Rome, Policlinico Umberto I, 00161 Rome, Italy; (A.T.); (F.D.L.); (A.C.); (C.C.)
| | - Quirino Lai
- Department of General Surgery and Organ Transplantation Unit, Sapienza University of Rome, Policlinico Umberto I, 00161 Rome, Italy; (Q.L.); (F.P.)
| | - Francesco Pugliese
- Department of General Surgery and Organ Transplantation Unit, Sapienza University of Rome, Policlinico Umberto I, 00161 Rome, Italy; (Q.L.); (F.P.)
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Bai L, Ding F, Xiong W, Shu W, Jiang L, Liu Y, Duan J. Early assessment of the efficacy of noninvasive ventilation tested by HACOR score to avoid delayed intubation in patients with moderate to severe ARDS. Ther Adv Respir Dis 2022; 16:17534666221081042. [PMID: 35199609 PMCID: PMC8883367 DOI: 10.1177/17534666221081042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Use of noninvasive ventilation (NIV) in patients with moderate to severe ARDS is controversial. We aimed to use HACOR (combination of heart rate, acidosis, consciousness, oxygenation and respiratory rate) score to comprehensively assess the efficacy of NIV in ARDS patients with PaO2/FiO2 ⩽ 150 mmHg. Methods: Secondary analysis was performed using the data collected from two databases. We screened the ARDS patients who used NIV as a first-line therapy. Patients with PaO2/FiO2 ⩽ 150 mmHg were enrolled. NIV failure was defined as requirement of intubation. Results: A total of 224 moderate to severe ARDS patients who used NIV as a first-line therapy were enrolled. Of them, 125 patients (56%) experienced NIV failure and received intubation. Among the intubated patients, the survivor had shorter time from initiation of NIV to intubation than nonsurvivors (median 10 vs 22 h, p < 0.01). The median differences of HACOR score before and 1–2 h of NIV were 1 point (interquartile range: 0–3). We defined the patients with △HACOR >1 as responders (n = 102) and the rest to non-responders (n = 122). Compared to non-responders, the responders had higher HACOR score before NIV. However, the HACOR score was lower in the responders than non-responders after 1–2 h, 12 h, and 24 h of NIV. The responders also had lower NIV failure rate (36% vs 72%, p < 0.01) and lower 28-day mortality (32% vs 47%, p = 0.04) than non-responders. Conclusions: NIV failure was high among patients with moderate to severe ARDS. Delayed intubation is associated with increased mortality. The reduction of HACOR score after 1–2 h of NIV can identify the patients who respond well to NIV.
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Affiliation(s)
- Linfu Bai
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Fei Ding
- Department of Respiratory and Critical Care Medicine, The Bishan Hospital of Chongqing, Chongqing, China
| | - Weiming Xiong
- Department of Neurosurgery, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, China
| | - Weiwei Shu
- Department of Critical Care Medicine, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Lei Jiang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yuliang Liu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jun Duan
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing 400016, Sichuan, P.R. China
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Fridman SE, Di Giampietro P, Sensoli A, Beleffi M, Bucce C, Salvatore V, Giostra F, Gianstefani A. Prediction of Conventional Oxygen Therapy Failure in COVID-19 Patients With Acute Respiratory Failure by Assessing Serum Lactate Concentration, PaO2/FiO2 Ratio, and Body Temperature. Cureus 2022; 14:e21987. [PMID: 35155050 PMCID: PMC8820760 DOI: 10.7759/cureus.21987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2022] [Indexed: 12/13/2022] Open
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15
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Luján M, Sayas J, Mediano O, Egea C. Non-invasive Respiratory Support in COVID-19: A Narrative Review. Front Med (Lausanne) 2022; 8:788190. [PMID: 35059415 PMCID: PMC8763700 DOI: 10.3389/fmed.2021.788190] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/30/2021] [Indexed: 12/20/2022] Open
Abstract
Acute respiratory failure secondary to COVID-19 pneumonia may require a variety of non-pharmacological strategies in addition to oxygen therapy to avoid endotracheal intubation. The response to all these strategies, which include high nasal flow, continuous positive pressure, non-invasive ventilation, or even prone positioning in awake patients, can be highly variable depending on the predominant phenotypic involvement. Deciding when to replace conventional oxygen therapy with non-invasive respiratory support, which to choose, the role of combined methods, definitions, and attitudes toward treatment failure, and improved case improvement procedures are directly relevant clinical questions for the daily care of critically ill COVID-19 patients. The experience accumulated after more than a year of the pandemic should lead to developing recommendations that give answers to all these questions.
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Affiliation(s)
- Manel Luján
- Pneumology Service, Hospital Universitari Parc Taulí, Sabadell, Spain.,Centro de Investigacion Biomédica en Red (CIBERES), Madrid, Spain
| | - Javier Sayas
- Pneumology Service, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Olga Mediano
- Pneumology Department, Hospital Universitario de Guadalajara, Guadalajara, Spain
| | - Carlos Egea
- Centro de Investigacion Biomédica en Red (CIBERES), Madrid, Spain.,Hospital Universitario de Araba, Universidad País Vasco, Vitoria Gasteiz, Spain
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Nair A, Esquinas A. HACOR score to predict failure of non-invasive ventilation in patients with acute hypoxemic respiratory failure: When simplicity is best. Saudi J Anaesth 2022; 16:267-268. [PMID: 35431731 PMCID: PMC9009566 DOI: 10.4103/sja.sja_88_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 01/31/2022] [Accepted: 02/03/2022] [Indexed: 11/13/2022] Open
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