1
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Lloyd-Jones G, Alcock R, Oudkerk M. COVID-19 lung disease is a pulmonary vasculopathy. Clin Radiol 2024; 79:e975-e978. [PMID: 38714395 DOI: 10.1016/j.crad.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 04/03/2024] [Indexed: 05/09/2024]
Affiliation(s)
- G Lloyd-Jones
- Department of Clinical Radiology, Salisbury NHS Foundation Trust, Salisbury, United Kingdom.
| | - R Alcock
- Department of Clinical Radiology, Salisbury NHS Foundation Trust, Salisbury, United Kingdom.
| | - M Oudkerk
- University of Groningen, Groningen, The Netherlands; Institute for Diagnostic Accuracy, Groningen, The Netherlands.
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2
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Moore J, Remy J, Altschul E, Chusid J, Flohr T, Raoof S, Remy-Jardin M. Thoracic Applications of Spectral CT Scan. Chest 2024; 165:417-430. [PMID: 37619663 DOI: 10.1016/j.chest.2023.07.4225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 07/29/2023] [Accepted: 07/31/2023] [Indexed: 08/26/2023] Open
Abstract
TOPIC IMPORTANCE Thoracic imaging with CT scan has become an essential component in the evaluation of respiratory and thoracic diseases. Providers have historically used conventional single-energy CT; however, prevalence of dual-energy CT (DECT) is increasing, and as such, it is important for thoracic physicians to recognize the utility and limitations of this technology. REVIEW FINDINGS The technical aspects of DECT are presented, and practical approaches to using DECT are provided. Imaging at multiple energy spectra allows for postprocessing of the data and the possibility of creating multiple distinct image reconstructions based on the clinical question being asked. The data regarding utility of DECT in pulmonary vascular disorders, ventilatory defects, and thoracic oncology are presented. A pictorial essay is provided to give examples of the strengths associated with DECT. SUMMARY DECT has been most heavily studied in chronic thromboembolic pulmonary hypertension; however, it is increasingly being used across a wide spectrum of thoracic diseases. DECT combines morphologic and functional assessments in a single imaging acquisition, providing clinicians with a powerful diagnostic tool. Its role in the evaluation and treatment of thoracic diseases will likely continue to expand in the coming years as clinicians become more experienced with the technology.
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Affiliation(s)
- Jonathan Moore
- Department of Pulmonary and Critical Care Medicine, Lenox Hill Hospital, Northwell Health Physician Partners, New York, NY
| | - Jacques Remy
- Univ Lille, Department of Thoracic Imaging, Lille, France
| | - Erica Altschul
- Department of Pulmonary and Critical Care Medicine, Lenox Hill Hospital, Northwell Health Physician Partners, New York, NY
| | - Jesse Chusid
- Feinstein Institutes for Medical Research, and Imaging Services, Department of Radiology, Northwell Health, Manhasset, NY
| | - Thomas Flohr
- Department of Computed Tomography Research & Development, Siemens Healthineers, Forchheim, Germany
| | - Suhail Raoof
- Department of Pulmonary and Critical Care Medicine, Lenox Hill Hospital, Northwell Health Physician Partners, New York, NY.
| | - Martine Remy-Jardin
- Univ Lille, Department of Thoracic Imaging, Lille, France; Univ Lille, CHU Lille, Evaluation des technologies de santé et des pratiques médicales, Lille, France
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3
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Bogot NR, Steiner R, Helviz Y, Weiss C, Cherniavsky K, Pichkhadze O, Ball L, Frank Y, Levin P, Pelosi P, Benjaminov O, Einav S. Distribution of Aeration and Pulmonary Blood Volume in Healthy, ARDS and COVID-19 Lungs: A Dual-Energy Computed Tomography Retrospective Cohort Study. Acad Radiol 2023; 30:2548-2556. [PMID: 36966073 PMCID: PMC10035816 DOI: 10.1016/j.acra.2023.01.016] [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: 08/21/2022] [Revised: 01/12/2023] [Accepted: 01/13/2023] [Indexed: 01/20/2023]
Abstract
RATIONALE AND OBJECTIVES Few reports have studied lung aeration and perfusion in normal lungs, COVID-19, and ARDS from other causes (NC-ARDS) using dual-energy computed tomography pulmonary angiograms (DE-CTPA). To describe lung aeration and blood-volume distribution using DE-CTPAs of patients with NC-ARDS, COVID-19, and controls with a normal DE-CTPA ("healthy lungs"). We hypothesized that each of these conditions has unique ranges of aeration and pulmonary blood volumes. MATERIALS AND METHODS This retrospective, single-center study of DE-CTPAs included patients with COVID-19, NC-ARDS (Berlin criteria), and controls. Patients with macroscopic pulmonary embolisms were excluded. The outcomes studied were the (1) lung blood-volume in areas with different aeration levels (normal, ground glass opacities [GGO], consolidated lung) and (2) aeration/blood-volume ratios. RESULTS Included were 20 patients with COVID-19 (10 milds, 10 moderate-severe), six with NC-ARDS, and 12 healthy-controls. Lung aeration was lowest in patients with severe COVID-19 24% (IQR13%-31%) followed by those with NC-ARDS 40%(IQR21%-46%). Blood-volume in GGO was lowest in patients with COVID-19 [moderate-severe:-28.6 (IQR-33.1-23.2); mild: -30.1 (IQR-33.3-23.4)] and highest in normally aerated areas in NC-ARDS -37.4 (IQR-52.5-30.2-) and moderate-severe COVID-19 -33.5(IQR-44.2-28.5). The median aeration/blood-volume ratio was lowest in severe COVID-19 but some values overlapped with those observed among patients with NC-ARDS. CONCLUSION Severe COVID-19 disease is associated with low total aerated lung volume and blood-volume in areas with GGO and overall aeration/blood volume ratios, and with high blood volume in normal lung areas. In this hypothesis-generating study, these findings were most pronounced in severe COVID disease. Larger studies are needed to confirm these preliminary findings.
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Affiliation(s)
| | | | - Yigal Helviz
- The Intensive Care Unit, Jerusalem, Israel; The Shaare Zedek Medical Center, Hebrew University Faculty of Medicine, Samuel Byte 12, Jerusalem, Israel
| | - Chedva Weiss
- The Intensive Care Unit, Jerusalem, Israel; Department of pediatrics, Hadassah Medical Center Jerusalem, Jerusalem, Israel
| | | | | | - Lorenzo Ball
- The Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy; Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Yigal Frank
- Department of Radiology(,) Jerusalem, Israel
| | - Philip Levin
- The Intensive Care Unit, Jerusalem, Israel; The Shaare Zedek Medical Center, Hebrew University Faculty of Medicine, Samuel Byte 12, Jerusalem, Israel
| | - Paolo Pelosi
- The Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy; Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | | | - Sharon Einav
- The Intensive Care Unit, Jerusalem, Israel; The Shaare Zedek Medical Center, Hebrew University Faculty of Medicine, Samuel Byte 12, Jerusalem, Israel.
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4
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Foti G, Longo C, Faccioli N, Guerriero M, Stefanini F, Buonfrate D. Quantitative Assessment of Lung Volumes and Enhancement in Patients with COVID-19: Role of Dual-Energy CT. Diagnostics (Basel) 2023; 13:diagnostics13061201. [PMID: 36980509 PMCID: PMC10047841 DOI: 10.3390/diagnostics13061201] [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: 01/30/2023] [Revised: 02/24/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
Dual-energy computed tomography (DECT) has been used for detecting pulmonary embolism, but the role of lung perfusion DECT as a predictor of prognosis of coronavirus disease 2019 (COVID-19) has not been defined yet. The aim of our study was to explore whether the enhancement pattern in COVID-19+ patients relates to the disease outcome. A secondary aim was to compare the lung volumes in two subgroups of patients. In this observational study, we considered all consecutive COVID-19+ patients who presented to the emergency room between January 2021 and December 2021 with respiratory symptoms (with mild to absent lung consolidation) and were studied by chest contrast-enhanced DECT to be eligible. Two experienced radiologists post-processed the images using the "lung-analysis" software (SyngoVia). Absolute and relative enhancement lung volumes were assessed. Patients were stratified in two subgroups depending on clinical outcome at 30 days: (i) good outcome (i.e., discharge, absence of clinical or imaging signs of disease); (ii) bad outcome (i.e., hospitalization, death). Patient sub-groups were compared using chi-square test or Fisher test for qualitative parameters, chi-square test or Spearman's Rho test for quantitative parameters, Students' t-test for parametric variables and Wilcoxon test for non-parametric variables. We enrolled 78 patients (45M), of whom, 16.7% had good outcomes. We did not observe any significant differences between the two groups, both in terms of the total enhancement evaluation (p = 0.679) and of the relative enhancement (p = 0.918). In contrast, the average lung volume of good outcome patients (mean value of 4262 mL) was significantly larger than that of bad outcome patients (mean value of 3577.8 mL), p = 0.0116. All COVID-19+ patients, with either good or bad outcomes, presented similar enhancement parameters and relative enhancements, underlining no differences in lung perfusion. Conversely, a significant drop in lung volume was identified in the bad outcome subgroup eligible compared to the good outcome subgroup.
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Affiliation(s)
- Giovanni Foti
- Radiology Department, IRCCS Sacro Cuore Don Calabria Hospital, 37024 Negrar di Valpolicella, Italy
| | - Chiara Longo
- Radiology Department, IRCCS Sacro Cuore Don Calabria Hospital, 37024 Negrar di Valpolicella, Italy
| | - Niccolò Faccioli
- Radiology Department, Verona University Hospital, 37129 Verona, Italy
| | - Massimo Guerriero
- Clinical Research Unit, IRCCS Sacro Cuore Don Calabria Hospital, 37024 Negrar di Valpolicella, Italy
| | - Flavio Stefanini
- Department of Emergency Medicine, IRCCS Sacro Cuore Don Calabria Hospital, 37024 Negrar di Valpolicella, Italy
| | - Dora Buonfrate
- Department of Infectious Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, 37024 Negrar di Valpolicella, Italy
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5
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van Beek EJ. Radiologic Findings after COVID-19 and the Correlation with Lung Function. Radiology 2023; 307:e230221. [PMID: 36786706 PMCID: PMC9969413 DOI: 10.1148/radiol.230221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Affiliation(s)
- Edwin J.R. van Beek
- The University of Edinburgh Centre for Cardiovascular Science, Edinburgh Imaging, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, Edinburgh, United Kingdom
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6
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Dintakurti SH, Kamath S, Mahon C, Singh S, Rawal B, Padley SP, Devaraj A, Price LC, Desai SR, Semple T, Ridge CA. Pulmonary hypertension: the hallmark of acute COVID-19 microvascular angiopathy? ERJ Open Res 2023; 9:00389-2022. [PMID: 36751674 PMCID: PMC9790091 DOI: 10.1183/23120541.00389-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 11/08/2022] [Indexed: 12/24/2022] Open
Abstract
In situ pulmonary arterial thrombosis in COVID-19 is not visible on CTPA. However, the presence of CT-measured right heart and pulmonary artery dilatation in COVID-19 is likely attributable to this process and may be a possible surrogate for its detection. https://bit.ly/3g7z5TV.
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Affiliation(s)
| | - Sanjana Kamath
- Department of Imaging, Royal Brompton Hospital, London, UK
| | - Ciara Mahon
- Department of Imaging, Royal Brompton Hospital, London, UK
| | - Suveer Singh
- Department of Adult Intensive Care, Royal Brompton Hospital, London, UK
| | - Bhavin Rawal
- Department of Imaging, Royal Brompton Hospital, London, UK
| | | | - Anand Devaraj
- Department of Imaging, Royal Brompton Hospital, London, UK
| | - Laura C. Price
- Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK
| | - Sujal R. Desai
- Department of Imaging, Royal Brompton Hospital, London, UK
| | - Tom Semple
- Department of Imaging, Royal Brompton Hospital, London, UK
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7
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Aydın S, Karavaş E, Ünver E, Şenbil DC, Kantarcı M. Long-term lung perfusion changes related to COVID-19: a dual energy computed tomography study. Diagn Interv Radiol 2023; 29:103-108. [PMID: 36960546 PMCID: PMC10679602 DOI: 10.5152/dir.2022.211090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 03/16/2022] [Indexed: 01/15/2023]
Abstract
PURPOSE Although the findings of acute new coronavirus disease (COVID-19) infection on dual-energy computed tomography (DECT) have recently been defined, the long-term changes in lung perfusion associated with COVID-19 pneumonia have not yet been clarified. We aimed to examine the longterm course of lung perfusion in COVID-19 pneumonia cases using DECT and to compare changes in lung perfusion to clinical and laboratory findings. METHODS On initial and follow-up DECT scans, the presence and extent of perfusion deficit (PD) and parenchymal changes were assessed. The associations between PD presence and laboratory parameters, initial DECT severity score, and symptoms were evaluated. RESULTS The study population included 18 females and 26 males with an average age of 61.32 ± 11.3 years. Follow-up DECT examinations were performed after the mean of 83.12 ± 7.1 (80-94 days) days. PDs were detected on the follow-up DECT scans of 16 (36.3%) patients. These 16 patients also had ground-glass parenchymal lesions on the follow-up DECT scans. Patients with persistent lung PDs had significantly higher mean initial D-dimer, fibrinogen, and C-reactive protein values than patients without PDs. Patients with persistent PDs also had significantly higher rates of persistent symptoms. CONCLUSION Ground-glass opacities and lung PDs associated with COVID-19 pneumonia can persist for up to 80-90 days. Dual-energy computed tomography can be used to reveal long-term parenchymal and perfusion changes. Persistent PDs are commonly seen together with persistent COVID-19 symptoms.
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Affiliation(s)
- Sonay Aydın
- Department of Radiology, Erzincan University Faculty of Medicine, Erzincan, Turkey
| | - Erdal Karavaş
- Department of Radiology, Erzincan University Faculty of Medicine, Erzincan, Turkey
| | - Edhem Ünver
- Department of Chest Disease, Erzincan University Faculty of Medicine, Erzincan, Turkey
| | - Düzgün Can Şenbil
- Department of Radiology, Erzincan University Faculty of Medicine, Erzincan, Turkey
| | - Mecit Kantarcı
- Department of Radiology, Atatürk University Faculty of Medicine, Erzurum, Turkey
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8
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Michishita T, Saji R, Miyazaki H, Mishima S, Shimada K, Minami S, Okano H, Suzuki N, Otsuka T, Abe T, Takeuchi I, Furuya R. Utility of dual-energy computed tomography in the association of COVID-19 pneumonia severity. Acute Med Surg 2022; 9:e811. [PMID: 36570597 PMCID: PMC9767859 DOI: 10.1002/ams2.811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 12/05/2022] [Indexed: 12/27/2022] Open
Abstract
Aim Coronavirus disease 2019 pneumonia differs from ordinary pneumonia in that it is associated with lesions that reduce pulmonary perfusion. Dual-energy computed tomography is well suited to elucidate the etiology of coronavirus disease 2019 pneumonia, because it highlights changes in organ blood flow. In this study, we investigated whether dual-energy computed tomography could be used to determine the severity of coronavirus disease 2019 pneumonia. Methods Patients who were diagnosed with coronavirus disease 2019 pneumonia, admitted to our hospital, and underwent dual-energy computed tomography were included in this study. Dual-energy computed tomography findings, plane computed tomography findings, disease severity, laboratory data, and clinical features were compared between two groups: a critical group (18 patients) and a non-critical group (30 patients). Results The dual-energy computed tomography results indicated that the percentage of flow loss was significantly higher in the critical group compared with the non-critical group (P < 0.001). Additionally, our data demonstrated that thrombotic risk was associated with differences in clinical characteristics (P = 0.018). Receiver operating characteristic analysis revealed that the percentage of flow loss, evaluated using dual-energy computed tomography, could predict severity in the critical group with 100% sensitivity and 77% specificity. However, there were no significant differences in the receiver operating characteristic values for dual-energy computed tomography and plane computed tomography. Conclusion Dual-energy computed tomography can be used to associate the severity of coronavirus disease 2019 pneumonia with high accuracy. Further studies are needed to draw definitive conclusions.
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Affiliation(s)
- Takahiro Michishita
- Department of Critical Care and Emergency MedicineNational Hospital Organization Yokohama Medical CenterYokohamaJapan,Department of Emergency MedicineYokohama City University Graduate School of MedicineYokohamaJapan
| | - Ryo Saji
- Department of Emergency MedicineYokohama City University Graduate School of MedicineYokohamaJapan,Department of Emergency MedicineYokohama City UniversityYokohamaJapan
| | - Hiroshi Miyazaki
- Department of Critical Care and Emergency MedicineNational Hospital Organization Yokohama Medical CenterYokohamaJapan
| | - Sena Mishima
- Department of Critical Care and Emergency MedicineNational Hospital Organization Yokohama Medical CenterYokohamaJapan,Department of Emergency MedicineYokohama City University Graduate School of MedicineYokohamaJapan
| | - Kosuke Shimada
- Department of Critical Care and Emergency MedicineNational Hospital Organization Yokohama Medical CenterYokohamaJapan,Department of Emergency MedicineYokohama City University Graduate School of MedicineYokohamaJapan
| | - Sakura Minami
- Department of Critical Care and Emergency MedicineNational Hospital Organization Yokohama Medical CenterYokohamaJapan,Department of Emergency MedicineYokohama City University Graduate School of MedicineYokohamaJapan
| | - Hiromu Okano
- Department of Critical Care and Emergency MedicineNational Hospital Organization Yokohama Medical CenterYokohamaJapan
| | - Naoya Suzuki
- Department of Critical Care and Emergency MedicineNational Hospital Organization Yokohama Medical CenterYokohamaJapan,Department of Emergency MedicineYokohama City University Graduate School of MedicineYokohamaJapan
| | - Tsuyoshi Otsuka
- Department of Critical Care and Emergency MedicineNational Hospital Organization Yokohama Medical CenterYokohamaJapan,Department of Emergency MedicineYokohama City University Graduate School of MedicineYokohamaJapan
| | - Takeru Abe
- Department of Emergency MedicineYokohama City University Graduate School of MedicineYokohamaJapan
| | - Ichiro Takeuchi
- Department of Emergency MedicineYokohama City University Graduate School of MedicineYokohamaJapan
| | - Ryosuke Furuya
- Department of Critical Care and Emergency MedicineNational Hospital Organization Yokohama Medical CenterYokohamaJapan,Department of Emergency MedicineYokohama City University Graduate School of MedicineYokohamaJapan
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9
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Yu JZ, Granberg T, Shams R, Petersson S, Sköld M, Nyrén S, Lundberg J. Lung perfusion disturbances in nonhospitalized post-COVID with dyspnea-A magnetic resonance imaging feasibility study. J Intern Med 2022; 292:941-956. [PMID: 35946904 PMCID: PMC9539011 DOI: 10.1111/joim.13558] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Dyspnea is common after COVID-19. Though the underlying mechanisms are largely unknown, lung perfusion abnormalities could contribute to lingering dyspnea. OBJECTIVES To detect pulmonary perfusion disturbances in nonhospitalized individuals with the post-COVID condition and persistent dyspnea 4-13 months after the disease onset. METHODS Individuals with dyspnea and matched healthy controls were recruited for dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI), a 6-min walk test, and an assessment of dyspnea. The DCE-MRI was quantified using two parametric values: mean time to peak (TTP) and TTP ratio, reflecting the total lung perfusion resistance and the fraction of lung with delayed perfusion, respectively. RESULTS Twenty-eight persons with persistent dyspnea (mean age 46.5 ± 8.0 years, 75% women) and 22 controls (mean age 44.1 ± 10.8 years, 73% women) were included. There was no systematic sex difference in dyspnea. The post-COVID group had no focal perfusion deficits but had higher mean pulmonary TTP (0.43 ± 0.04 vs. 0.41 ± 0.03, p = 0.011) and TTP ratio (0.096 ± 0.052 vs. 0.068 ± 0.027, p = 0.032). Post-COVID males had the highest mean TTP of 0.47 ± 0.02 and TTP ratio of 0.160 ± 0.039 compared to male controls and post-COVID females (p = 0.001 and p < 0.001, respectively). Correlations between dyspnea and perfusion parameters were demonstrated in males (r = 0.83, p < 0.001 for mean TTP; r = 0.76, p = 0.003 for TTP ratio), but not in females. CONCLUSIONS DCE-MRI demonstrated late contrast bolus arrival in males with post-COVID dyspnea, suggestive of primary vascular lesions or secondary effects of hypoxic vasoconstriction. Since this effect was not regularly observed in female patients, our findings suggest sex differences in the mechanisms underlying post-COVID dyspnea, which warrants further investigation in dedicated trials.
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Affiliation(s)
- Jimmy Z. Yu
- Department of Radiology SolnaKarolinska University HospitalStockholmSweden
- Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
| | - Tobias Granberg
- Department of NeuroradiologyKarolinska University HospitalStockholmSweden
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
| | - Roya Shams
- Department of NeuroradiologyKarolinska University HospitalStockholmSweden
| | - Sven Petersson
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
- Department of Medical Radiation Physics and Nuclear MedicineKarolinska University HospitalStockholmSweden
| | - Magnus Sköld
- Department of Respiratory Medicine and AllergyKarolinska University HospitalStockholmSweden
- Department of Medicine SolnaKarolinska InstitutetStockholmSweden
| | - Sven Nyrén
- Department of Radiology SolnaKarolinska University HospitalStockholmSweden
- Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
| | - Johan Lundberg
- Department of NeuroradiologyKarolinska University HospitalStockholmSweden
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
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10
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Villalba JA, Hilburn CF, Garlin MA, Elliott GA, Li Y, Kunitoki K, Poli S, Alba GA, Madrigal E, Taso M, Price MC, Aviles AJ, Araujo-Medina M, Bonanno L, Boyraz B, Champion SN, Harris CK, Helland TL, Hutchison B, Jobbagy S, Marshall MS, Shepherd DJ, Barth JL, Hung YP, Ly A, Hariri LP, Turbett SE, Pierce VM, Branda JA, Rosenberg ES, Mendez-Pena J, Chebib I, Rosales IA, Smith RN, Miller MA, Rosas IO, Hardin CC, Baden LR, Medoff BD, Colvin RB, Little BP, Stone JR, Mino-Kenudson M, Shih AR. Vasculopathy and Increased Vascular Congestion in Fatal COVID-19 and Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2022; 206:857-873. [PMID: 35671465 PMCID: PMC9799276 DOI: 10.1164/rccm.202109-2150oc] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Rationale: The leading cause of death in coronavirus disease 2019 (COVID-19) is severe pneumonia, with many patients developing acute respiratory distress syndrome (ARDS) and diffuse alveolar damage (DAD). Whether DAD in fatal COVID-19 is distinct from other causes of DAD remains unknown. Objective: To compare lung parenchymal and vascular alterations between patients with fatal COVID-19 pneumonia and other DAD-causing etiologies using a multidimensional approach. Methods: This autopsy cohort consisted of consecutive patients with COVID-19 pneumonia (n = 20) and with respiratory failure and histologic DAD (n = 21; non-COVID-19 viral and nonviral etiologies). Premortem chest computed tomography (CT) scans were evaluated for vascular changes. Postmortem lung tissues were compared using histopathological and computational analyses. Machine-learning-derived morphometric analysis of the microvasculature was performed, with a random forest classifier quantifying vascular congestion (CVasc) in different microscopic compartments. Respiratory mechanics and gas-exchange parameters were evaluated longitudinally in patients with ARDS. Measurements and Main Results: In premortem CT, patients with COVID-19 showed more dilated vasculature when all lung segments were evaluated (P = 0.001) compared with controls with DAD. Histopathology revealed vasculopathic changes, including hemangiomatosis-like changes (P = 0.043), thromboemboli (P = 0.0038), pulmonary infarcts (P = 0.047), and perivascular inflammation (P < 0.001). Generalized estimating equations revealed significant regional differences in the lung microarchitecture among all DAD-causing entities. COVID-19 showed a larger overall CVasc range (P = 0.002). Alveolar-septal congestion was associated with a significantly shorter time to death from symptom onset (P = 0.03), length of hospital stay (P = 0.02), and increased ventilatory ratio [an estimate for pulmonary dead space fraction (Vd); p = 0.043] in all cases of ARDS. Conclusions: Severe COVID-19 pneumonia is characterized by significant vasculopathy and aberrant alveolar-septal congestion. Our findings also highlight the role that vascular alterations may play in Vd and clinical outcomes in ARDS in general.
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Affiliation(s)
- Julian A. Villalba
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Caroline F. Hilburn
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Michelle A. Garlin
- Center for Systems Biology, Massachusetts General Hospital, Boston, Massachusetts;,Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York
| | | | - Yijia Li
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Keiko Kunitoki
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts;,Department of Psychiatry
| | - Sergio Poli
- Department of Medicine, Mount Sinai Medical Center, Miami Beach, Florida
| | - George A. Alba
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Department of Medicine
| | - Emilio Madrigal
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Manuel Taso
- Division of MRI Research, Department of Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Melissa C. Price
- Division of Thoracic Imaging and Intervention, Department of Radiology
| | | | | | - Liana Bonanno
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Baris Boyraz
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Samantha N. Champion
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts;,C. S. Kubik Laboratory for Neuropathology, Department of Pathology, Massachusetts General Hospital Charlestown HealthCare Center, Charlestown, Massachusetts;,Miami-Dade County Medical Examiner Department, Miami, Florida
| | - Cynthia K. Harris
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Timothy L. Helland
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Bailey Hutchison
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Soma Jobbagy
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Michael S. Marshall
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Daniel J. Shepherd
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | | | - Yin P. Hung
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Amy Ly
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Lida P. Hariri
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts;,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Department of Medicine
| | - Sarah E. Turbett
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts;,Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Virginia M. Pierce
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts;,Pediatric Infectious Disease Unit, MassGeneral Hospital for Children, Boston, Massachusetts
| | - John A. Branda
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Eric S. Rosenberg
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts;,Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Ivan Chebib
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Ivy A. Rosales
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts;,Immunopathology Research Laboratory, and
| | - Rex N. Smith
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts;,Immunopathology Research Laboratory, and
| | - Miles A. Miller
- Center for Systems Biology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ivan O. Rosas
- Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Charles C. Hardin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Department of Medicine
| | - Lindsey R. Baden
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Benjamin D. Medoff
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Department of Medicine
| | - Robert B. Colvin
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts;,Immunopathology Research Laboratory, and
| | - Brent P. Little
- Division of Thoracic Imaging and Intervention, Department of Radiology,,Division of Cardiothoracic Imaging, Department of Radiology, Mayo Clinic Florida, Jacksonville, Florida
| | - James R. Stone
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Mari Mino-Kenudson
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Angela R. Shih
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
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11
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Ball L, Scaramuzzo G, Herrmann J, Cereda M. Lung aeration, ventilation, and perfusion imaging. Curr Opin Crit Care 2022; 28:302-307. [PMID: 35653251 PMCID: PMC9178949 DOI: 10.1097/mcc.0000000000000942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Lung imaging is a cornerstone of the management of patients admitted to the intensive care unit (ICU), providing anatomical and functional information on the respiratory system function. The aim of this review is to provide an overview of mechanisms and applications of conventional and emerging lung imaging techniques in critically ill patients. RECENT FINDINGS Chest radiographs provide information on lung structure and have several limitations in the ICU setting; however, scoring systems can be used to stratify patient severity and predict clinical outcomes. Computed tomography (CT) is the gold standard for assessment of lung aeration but requires moving the patients to the CT facility. Dual-energy CT has been recently applied to simultaneous study of lung aeration and perfusion in patients with respiratory failure. Lung ultrasound has an established role in the routine bedside assessment of ICU patients, but has poor spatial resolution and largely relies on the analysis of artifacts. Electrical impedance tomography is an emerging technique capable of depicting ventilation and perfusion at the bedside and at the regional level. SUMMARY Clinicians should be confident with the technical aspects, indications, and limitations of each lung imaging technique to improve patient care.
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Affiliation(s)
- Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
- Anesthesia and Intensive Care, Ospedale Policlinico San Martino, IRCCS per l’Oncologia e le Neuroscienze, Genoa, Italy
| | - Gaetano Scaramuzzo
- Department of Translational medicine, University of Ferrara, Ferrara, Italy
- Anesthesia and intensive care, Arcispedale Sant’Anna, Ferrara, Italy
| | - Jake Herrmann
- Roy J. Carver Department of Biomedical Engineering, University of Iowa, Iowa City, United States of America
| | - Maurizio Cereda
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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12
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Review of Thoracic Imaging Manifestations of COVID-19 and Other Pathologic Coronaviruses. Radiol Clin North Am 2022; 60:359-369. [PMID: 35534124 PMCID: PMC8747969 DOI: 10.1016/j.rcl.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an easily transmissible coronavirus that emerged in late 2019 and has caused a global pandemic characterized by acute respiratory disease named coronavirus disease 2019 (COVID-19). Diagnostic imaging can be helpful as a complementary tool in supporting the diagnosis of COVID-19 and identifying alternative pathology. This article presents an overview of acute and postacute imaging findings in COVID-19.
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13
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Camporota L, Cronin JN, Busana M, Gattinoni L, Formenti F. Pathophysiology of coronavirus-19 disease acute lung injury. Curr Opin Crit Care 2022; 28:9-16. [PMID: 34907979 PMCID: PMC8711311 DOI: 10.1097/mcc.0000000000000911] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW More than 230 million people have tested positive for severe acute respiratory syndrome-coronavirus-2 infection globally by September 2021. The infection affects primarily the function of the respiratory system, where ∼20% of infected individuals develop coronavirus-19 disease (COVID-19) pneumonia. This review provides an update on the pathophysiology of the COVID-19 acute lung injury. RECENT FINDINGS In patients with COVID-19 pneumonia admitted to the intensive care unit, the PaO2/FiO2 ratio is typically <26.7 kPa (200 mmHg), whereas lung volume appears relatively unchanged. This hypoxaemia is likely determined by a heterogeneous mismatch of pulmonary ventilation and perfusion, mainly associated with immunothrombosis, endothelialitis and neovascularisation. During the disease, lung weight, elastance and dead space can increase, affecting respiratory drive, effort and dyspnoea. In some severe cases, COVID-19 pneumonia may lead to irreversible pulmonary fibrosis. SUMMARY This review summarises the fundamental pathophysiological features of COVID-19 in the context of the respiratory system. It provides an overview of the key clinical manifestations of COVID-19 pneumonia, including gas exchange impairment, altered pulmonary mechanics and implications of abnormal chemical and mechanical stimuli. It also critically discusses the clinical implications for mechanical ventilation therapy.
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Affiliation(s)
- Luigi Camporota
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London
- Intensive Care Unit, Guy's and St Thomas' NHS Foundation Trust
| | - John N Cronin
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London
- Department of Anaesthetics, Royal Brompton and Harefield, part of Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Mattia Busana
- Department of Anesthesiology, University Medical Center of Göttingen, Göttingen, Germany
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center of Göttingen, Göttingen, Germany
| | - Federico Formenti
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London
- Nuffield Division of Anaesthetics, University of Oxford, Oxford, UK
- Department of Biomechanics, University of Nebraska Omaha, Omaha, Nebraska, USA
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14
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Stammes MA, Lee JH, Meijer L, Naninck T, Doyle-Meyers LA, White AG, Borish HJ, Hartman AL, Alvarez X, Ganatra S, Kaushal D, Bohm RP, le Grand R, Scanga CA, Langermans JAM, Bontrop RE, Finch CL, Flynn JL, Calcagno C, Crozier I, Kuhn JH. Medical imaging of pulmonary disease in SARS-CoV-2-exposed non-human primates. Trends Mol Med 2022; 28:123-142. [PMID: 34955425 PMCID: PMC8648672 DOI: 10.1016/j.molmed.2021.12.001] [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] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 12/01/2021] [Accepted: 12/01/2021] [Indexed: 12/11/2022]
Abstract
Chest X-ray (CXR), computed tomography (CT), and positron emission tomography-computed tomography (PET-CT) are noninvasive imaging techniques widely used in human and veterinary pulmonary research and medicine. These techniques have recently been applied in studies of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-exposed non-human primates (NHPs) to complement virological assessments with meaningful translational readouts of lung disease. Our review of the literature indicates that medical imaging of SARS-CoV-2-exposed NHPs enables high-resolution qualitative and quantitative characterization of disease otherwise clinically invisible and potentially provides user-independent and unbiased evaluation of medical countermeasures (MCMs). However, we also found high variability in image acquisition and analysis protocols among studies. These findings uncover an urgent need to improve standardization and ensure direct comparability across studies.
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Affiliation(s)
- Marieke A Stammes
- Biomedical Primate Research Centre (BPRC), 2288 GJ, Rijswijk, The Netherlands.
| | - Ji Hyun Lee
- Integrated Research Facility at Fort Detrick (IRF-Frederick), Division of Clinical Research (DCR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Fort Detrick, Frederick, MD 21702, USA
| | - Lisette Meijer
- Biomedical Primate Research Centre (BPRC), 2288 GJ, Rijswijk, The Netherlands
| | - Thibaut Naninck
- Center for Immunology of Viral, Auto-immune, Hematological and Bacterial diseases (IMVA-HB/IDMIT), Université Paris-Saclay, Inserm, CEA, 92260 Fontenay-aux-Roses, France
| | - Lara A Doyle-Meyers
- Tulane National Primate Research Center, Covington, LA 70433, USA; Department of Medicine, Tulane University School of Medicine, New Orleans, LA 70112, USA
| | - Alexander G White
- Department of Microbiology and Molecular Genetics, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - H Jacob Borish
- Department of Microbiology and Molecular Genetics, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Amy L Hartman
- Center for Vaccine Research, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA; Department of Infectious Diseases and Microbiology, School of Public Health, University of Pittsburgh, Pitt Public Health, Pittsburgh, PA 15261, USA
| | - Xavier Alvarez
- Texas Biomedical Research Institute, San Antonio, TX 78227, USA
| | | | - Deepak Kaushal
- Texas Biomedical Research Institute, San Antonio, TX 78227, USA
| | - Rudolf P Bohm
- Tulane National Primate Research Center, Covington, LA 70433, USA; Department of Medicine, Tulane University School of Medicine, New Orleans, LA 70112, USA
| | - Roger le Grand
- Center for Immunology of Viral, Auto-immune, Hematological and Bacterial diseases (IMVA-HB/IDMIT), Université Paris-Saclay, Inserm, CEA, 92260 Fontenay-aux-Roses, France
| | - Charles A Scanga
- Department of Microbiology and Molecular Genetics, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA; Center for Vaccine Research, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Jan A M Langermans
- Biomedical Primate Research Centre (BPRC), 2288 GJ, Rijswijk, The Netherlands; Department Population Health Sciences, Division of Animals in Science and Society, Faculty of Veterinary Medicine, Utrecht University, 3584 CL, Utrecht, The Netherlands
| | - Ronald E Bontrop
- Biomedical Primate Research Centre (BPRC), 2288 GJ, Rijswijk, The Netherlands; Department of Biology, Theoretical Biology and Bioinformatics, Utrecht University, 3584 CH, Utrecht, The Netherlands
| | - Courtney L Finch
- Integrated Research Facility at Fort Detrick (IRF-Frederick), Division of Clinical Research (DCR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Fort Detrick, Frederick, MD 21702, USA
| | - JoAnne L Flynn
- Department of Microbiology and Molecular Genetics, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA; Center for Vaccine Research, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Claudia Calcagno
- Integrated Research Facility at Fort Detrick (IRF-Frederick), Division of Clinical Research (DCR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Fort Detrick, Frederick, MD 21702, USA
| | - Ian Crozier
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD 21701, USA
| | - Jens H Kuhn
- Integrated Research Facility at Fort Detrick (IRF-Frederick), Division of Clinical Research (DCR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Fort Detrick, Frederick, MD 21702, USA
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15
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Petit M, Jullien E, Vieillard-Baron A. Right Ventricular Function in Acute Respiratory Distress Syndrome: Impact on Outcome, Respiratory Strategy and Use of Veno-Venous Extracorporeal Membrane Oxygenation. Front Physiol 2022; 12:797252. [PMID: 35095561 PMCID: PMC8795709 DOI: 10.3389/fphys.2021.797252] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/21/2021] [Indexed: 12/16/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is characterized by protein-rich alveolar edema, reduced lung compliance and severe hypoxemia. Despite some evidence of improvements in mortality over recent decades, ARDS remains a major public health problem with 30% 28-day mortality in recent cohorts. Pulmonary vascular dysfunction is one of the pivot points of the pathophysiology of ARDS, resulting in a certain degree of pulmonary hypertension, higher levels of which are associated with morbidity and mortality. Pulmonary hypertension develops as a result of endothelial dysfunction, pulmonary vascular occlusion, increased vascular tone, extrinsic vessel occlusion, and vascular remodeling. This increase in right ventricular (RV) afterload causes uncoupling between the pulmonary circulation and RV function. Without any contractile reserve, the right ventricle has no adaptive reserve mechanism other than dilatation, which is responsible for left ventricular compression, leading to circulatory failure and worsening of oxygen delivery. This state, also called severe acute cor pulmonale (ACP), is responsible for excess mortality. Strategies designed to protect the pulmonary circulation and the right ventricle in ARDS should be the cornerstones of the care and support of patients with the severest disease, in order to improve prognosis, pending stronger evidence. Acute cor pulmonale is associated with higher driving pressure (≥18 cmH2O), hypercapnia (PaCO2 ≥ 48 mmHg), and hypoxemia (PaO2/FiO2 < 150 mmHg). RV protection should focus on these three preventable factors identified in the last decade. Prone positioning, the setting of positive end-expiratory pressure, and inhaled nitric oxide (INO) can also unload the right ventricle, restore better coupling between the right ventricle and the pulmonary circulation, and correct circulatory failure. When all these strategies are insufficient, extracorporeal membrane oxygenation (ECMO), which improves decarboxylation and oxygenation and enables ultra-protective ventilation by decreasing driving pressure, should be discussed in seeking better control of RV afterload. This review reports the pathophysiology of pulmonary hypertension in ARDS, describes right heart function, and proposes an RV protective approach, ranging from ventilatory settings and prone positioning to INO and selection of patients potentially eligible for veno-venous extracorporeal membrane oxygenation (VV ECMO).
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Affiliation(s)
- Matthieu Petit
- Medical Intensive Care Unit, University Hospital Ambroise Paré, APHP, Boulogne-Billancourt, France
- UFR des Sciences de la Santé Simone Veil, Université Paris-Saclay, Montigny-le-Bretonneux, France
| | - Edouard Jullien
- Medical Intensive Care Unit, University Hospital Ambroise Paré, APHP, Boulogne-Billancourt, France
- UFR des Sciences de la Santé Simone Veil, Université Paris-Saclay, Montigny-le-Bretonneux, France
| | - Antoine Vieillard-Baron
- Medical Intensive Care Unit, University Hospital Ambroise Paré, APHP, Boulogne-Billancourt, France
- UFR des Sciences de la Santé Simone Veil, Université Paris-Saclay, Montigny-le-Bretonneux, France
- *Correspondence: Antoine Vieillard-Baron,
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16
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Potential long-term effects of SARS-CoV-2 infection on the pulmonary vasculature: a global perspective. Nat Rev Cardiol 2021; 19:314-331. [PMID: 34873286 PMCID: PMC8647069 DOI: 10.1038/s41569-021-00640-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/25/2021] [Indexed: 12/13/2022]
Abstract
The lungs are the primary target of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, with severe hypoxia being the cause of death in the most critical cases. Coronavirus disease 2019 (COVID-19) is extremely heterogeneous in terms of severity, clinical phenotype and, importantly, global distribution. Although the majority of affected patients recover from the acute infection, many continue to suffer from late sequelae affecting various organs, including the lungs. The role of the pulmonary vascular system during the acute and chronic stages of COVID-19 has not been adequately studied. A thorough understanding of the origins and dynamic behaviour of the SARS-CoV-2 virus and the potential causes of heterogeneity in COVID-19 is essential for anticipating and treating the disease, in both the acute and the chronic stages, including the development of chronic pulmonary hypertension. Both COVID-19 and chronic pulmonary hypertension have assumed global dimensions, with potential complex interactions. In this Review, we present an update on the origins and behaviour of the SARS-CoV-2 virus and discuss the potential causes of the heterogeneity of COVID-19. In addition, we summarize the pathobiology of COVID-19, with an emphasis on the role of the pulmonary vasculature, both in the acute stage and in terms of the potential for developing chronic pulmonary hypertension. We hope that the information presented in this Review will help in the development of strategies for the prevention and treatment of the continuing COVID-19 pandemic. In this Review, the authors discuss the potential causes of the heterogeneity of COVID-19 and summarize the pathobiology of the disease, with an emphasis on the role of the pulmonary vasculature in the acute stage and the potential for developing chronic pulmonary hypertension. A thorough understanding of the dynamic behaviour of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is essential to understanding its heterogeneous effects on the pulmonary vasculature in patients with coronavirus disease 2019 (COVID-19). The severity and clinical phenotype of COVID-19 are influenced by host factors, including socioeconomic factors and genetics. Silent hypoxia is a major and independent cause of lung damage in COVID-19; the use of modern imaging techniques is proving to be very valuable in identifying silent hypoxia. The pulmonary vascular system has a major role in the pathobiology of COVID-19. Both COVID-19 and chronic pulmonary hypertension are global diseases with a complex interaction.
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17
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Li K, Li Y, Qi Z, Garrett JW, Grist TM, Chen GH. Quantitative lung perfusion blood volume using dual energy CT-based effective atomic number (Z eff ) imaging. Med Phys 2021; 48:6658-6672. [PMID: 34520066 PMCID: PMC8595877 DOI: 10.1002/mp.15227] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 08/31/2021] [Accepted: 09/06/2021] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Iodine material images (aka iodine basis images) generated from dual energy computed tomography (DECT) have been used to assess potential perfusion defects in the pulmonary parenchyma. However, iodine material images do not provide the needed absolute quantification of the pulmonary blood pool, as materials with effective atomic numbers (Zeff ) different from those of basis materials may also contribute to iodine material images, thus confounding the quantification of perfusion defects. PURPOSE (i) To demonstrate the limitations of iodine material images in pulmonary perfusion defect quantification and (ii) to develop and validate a new quantitative biomarker using effective atomic numbers derived from DECT images. METHODS The quantitative relationship between the perfusion blood volume (PBV) in pulmonary parenchyma and the effective atomic number (Zeff ) spatial distribution was studied to show that the desired quantitative PBV maps are determined by the spatial maps of Zeff as PB V Z eff ( x ) = a Z eff β ( x ) + b , where a, b, and β are three constants. Namely, quantitative PB V Z eff is determined by Zeff images instead of the iodine basis images. Perfusion maps were generated for four human subjects to demonstrate the differences between conventional iodine material image-based PBV (PBViodine ) derived from two-material decompositions and the proposed PB V Z eff method. RESULTS Among patients with pulmonary emboli, the proposed PB V Z eff maps clearly show the perfusion defects while the PBViodine maps do not. Additionally, when there are no perfusion defects present in the derived PBV maps, no pulmonary emboli were diagnosed by an experienced thoracic radiologist. CONCLUSION Effective atomic number-based quantitative PBV maps provide the needed sensitive and specific biomarker to quantify pulmonary perfusion defects.
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Affiliation(s)
- Ke Li
- Department of Medical Physics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Yinsheng Li
- Department of Medical Physics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Zhihua Qi
- Department of Radiology, Henry Ford Health System, Detroit, Michigan, USA
| | - John W. Garrett
- Department of Medical Physics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Thomas M. Grist
- Department of Medical Physics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Guang-Hong Chen
- Department of Medical Physics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
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18
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Trunz LM, Lee P, Lange SM, Pomeranz CL, Needleman L, Ford RW, Karambelkar A, Sundaram B. Imaging approach to COVID-19 associated pulmonary embolism. Int J Clin Pract 2021; 75:e14340. [PMID: 33966326 PMCID: PMC8237008 DOI: 10.1111/ijcp.14340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 05/04/2021] [Indexed: 12/21/2022] Open
Abstract
The novel coronavirus disease-2019 (COVID-19) illness and deaths, caused by the severe acute respiratory syndrome coronavirus-2, continue to increase. Multiple reports highlight the thromboembolic complications, such as pulmonary embolism (PE), in COVID-19. Imaging plays an essential role in the diagnosis and management of COVID-19 patients with PE. There continues to be a rapid evolution of knowledge related to COVID-19 associated PE. This review summarises the current understanding of prevalence, pathophysiology, role of diagnostic imaging modalities, and management, including catheter-directed therapy for COVID-19 associated PE. It also describes infection control considerations for the radiology department while providing care for patients with COVID-19 associated PE.
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Affiliation(s)
- Lukas M. Trunz
- Department of RadiologyThomas Jefferson UniversityPhiladelphiaPAUSA
| | - Patrick Lee
- Department of RadiologyThomas Jefferson UniversityPhiladelphiaPAUSA
| | - Steven M. Lange
- Department of RadiologyThomas Jefferson UniversityPhiladelphiaPAUSA
| | | | | | - Robert W. Ford
- Department of RadiologyThomas Jefferson UniversityPhiladelphiaPAUSA
| | - Ajit Karambelkar
- Department of RadiologyThomas Jefferson UniversityPhiladelphiaPAUSA
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19
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Cronin JN, Camporota L, Formenti F. Mechanical ventilation in COVID-19: A physiological perspective. Exp Physiol 2021; 107:683-693. [PMID: 34541721 PMCID: PMC8667647 DOI: 10.1113/ep089400] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/24/2021] [Indexed: 12/13/2022]
Abstract
New Findings What is the topic of this review? This review presents the fundamental concepts of respiratory physiology and pathophysiology, with particular reference to lung mechanics and the pulmonary phenotype associated with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection and subsequent coronavirus disease 2019 (COVID‐19) pneumonia. What advances does it highlight? The review provides a critical summary of the main physiological aspects to be considered for safe and effective mechanical ventilation in patients with severe COVID‐19 in the intensive care unit.
Abstract Severe respiratory failure from coronavirus disease 2019 (COVID‐19) pneumonia not responding to non‐invasive respiratory support requires mechanical ventilation. Although ventilation can be a life‐saving therapy, it can cause further lung injury if airway pressure and flow and their timing are not tailored to the respiratory system mechanics of the individual patient. The pathophysiology of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection can lead to a pattern of lung injury in patients with severe COVID‐19 pneumonia typically associated with two distinct phenotypes, along a temporal and pathophysiological continuum, characterized by different levels of elastance, ventilation‐to‐perfusion ratio, right‐to‐left shunt, lung weight and recruitability. Understanding the underlying pathophysiology, duration of symptoms, radiological characteristics and lung mechanics at the individual patient level is crucial for the appropriate choice of mechanical ventilation settings to optimize gas exchange and prevent further lung injury. By critical analysis of the literature, we propose fundamental physiological and mechanical criteria for the selection of ventilation settings for COVID‐19 patients in intensive care units. In particular, the choice of tidal volume should be based on obtaining a driving pressure < 14 cmH2O, ensuring the avoidance of hypoventilation in patients with preserved compliance and of excessive strain in patients with smaller lung volumes and lower lung compliance. The level of positive end‐expiratory pressure (PEEP) should be informed by the measurement of the potential for lung recruitability, where patients with greater recruitability potential may benefit from higher PEEP levels. Prone positioning is often beneficial and should be considered early. The rationale for the proposed mechanical ventilation settings criteria is presented and discussed.
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Affiliation(s)
- John N Cronin
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK.,Department of Anaesthetics, Royal Brompton and Harefield, part of Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Luigi Camporota
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK.,Intensive Care Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Federico Formenti
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK.,Nuffield Division of Anaesthetics, University of Oxford, Oxford, UK.,Department of Biomechanics, University of Nebraska Omaha, Omaha, Nebraska, USA
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20
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Battaglini D, Robba C, Ball L, Silva PL, Cruz FF, Pelosi P, Rocco PRM. Noninvasive respiratory support and patient self-inflicted lung injury in COVID-19: a narrative review. Br J Anaesth 2021; 127:353-364. [PMID: 34217468 PMCID: PMC8173496 DOI: 10.1016/j.bja.2021.05.024] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/17/2021] [Accepted: 05/16/2021] [Indexed: 12/20/2022] Open
Abstract
COVID-19 pneumonia is associated with hypoxaemic respiratory failure, ranging from mild to severe. Because of the worldwide shortage of ICU beds, a relatively high number of patients with respiratory failure are receiving prolonged noninvasive respiratory support, even when their clinical status would have required invasive mechanical ventilation. There are few experimental and clinical data reporting that vigorous breathing effort during spontaneous ventilation can worsen lung injury and cause a phenomenon that has been termed patient self-inflicted lung injury (P-SILI). The aim of this narrative review is to provide an overview of P-SILI pathophysiology and the role of noninvasive respiratory support in COVID-19 pneumonia. Respiratory mechanics, vascular compromise, viscoelastic properties, lung inhomogeneity, work of breathing, and oesophageal pressure swings are discussed. The concept of P-SILI has been widely investigated in recent years, but controversies persist regarding its mechanisms. To minimise the risk of P-SILI, intensivists should better understand its underlying pathophysiology to optimise the type of noninvasive respiratory support provided to patients with COVID-19 pneumonia, and decide on the optimal timing of intubation for these patients.
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Affiliation(s)
- Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy; Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Lorenzo Ball
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Pedro L Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; COVID-19 Virus Network, Ministry of Science, Technology, and Innovation, Brasilia, Brazil
| | - Fernanda F Cruz
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; COVID-19 Virus Network, Ministry of Science, Technology, and Innovation, Brasilia, Brazil
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; COVID-19 Virus Network, Ministry of Science, Technology, and Innovation, Brasilia, Brazil.
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21
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Nagpal P, Motahari A, Gerard SE, Guo J, Reinhardt JM, Comellas AP, Hoffman EA, Kaczka DW. Case Studies in Physiology: Temporal variations of the lung parenchyma and vasculature in asymptomatic COVID-19 pneumonia: a multispectral CT assessment. J Appl Physiol (1985) 2021; 131:454-463. [PMID: 34166081 PMCID: PMC8384565 DOI: 10.1152/japplphysiol.00147.2021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/27/2021] [Accepted: 06/18/2021] [Indexed: 12/20/2022] Open
Abstract
This study reports systematic longitudinal pathophysiology of lung parenchymal and vascular effects of asymptomatic COVID-19 pneumonia in a young, healthy never-smoking male. Inspiratory and expiratory noncontrast along with contrast dual-energy computed tomography (DECT) scans of the chest were performed at baseline on the day of acute COVID-19 diagnosis (day 0), and across a 90-day period. Despite normal vital signs and pulmonary function tests on the day of diagnosis, the CT scans and corresponding quantification metrics detected abnormalities in parenchymal expansion based on image registration, ground-glass (GGO) texture (inflammation) as well as DECT-derived pulmonary blood volume (PBV). Follow-up scans on day 30 showed improvement in the lung parenchymal mechanics as well as reduced GGO and improved PBV distribution. Improvements in lung PBV continued until day 90. However, the heterogeneity of parenchymal mechanics and texture-derived GGO increased on days 60 and 90. We highlight that even asymptomatic COVID-19 infection with unremarkable vital signs and pulmonary function tests can have measurable effects on lung parenchymal mechanics and vascular pathophysiology, which may follow apparently different clinical courses. For this asymptomatic subject, post COVID-19 regional mechanics demonstrated persistent increased heterogeneity concomitant with return of elevated GGOs, despite early improvements in vascular derangement.NEW & NOTEWORTHY We characterized the temporal changes of lung parenchyma and microvascular pathophysiology from COVID-19 infection in an asymptomatic young, healthy nonsmoking male using dual-energy CT. Lung parenchymal mechanics and microvascular disease followed different clinical courses. Heterogeneous perfused blood volume became more uniform on follow-up visits up to 90 days. However, post COVID-19 mechanical heterogeneity of the lung parenchyma increased after apparent improvements in vascular abnormalities, even with normal spirometric indices.
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Affiliation(s)
- Prashant Nagpal
- Department of Radiology, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Amin Motahari
- Department of Radiology, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Sarah E Gerard
- Department of Radiology, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Junfeng Guo
- Department of Radiology, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Roy J. Carver Department of Biomedical Engineering, University of Iowa College of Engineering, Iowa City, Iowa
| | - Joseph M Reinhardt
- Roy J. Carver Department of Biomedical Engineering, University of Iowa College of Engineering, Iowa City, Iowa
| | - Alejandro P Comellas
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Eric A Hoffman
- Department of Radiology, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Roy J. Carver Department of Biomedical Engineering, University of Iowa College of Engineering, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - David W Kaczka
- Department of Radiology, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Roy J. Carver Department of Biomedical Engineering, University of Iowa College of Engineering, Iowa City, Iowa
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa
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22
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Price LC, Ridge C, Wells AU. Pulmonary vascular involvement in COVID-19 pneumonitis: Is this the first and final insult? Respirology 2021; 26:832-834. [PMID: 34322959 PMCID: PMC8446977 DOI: 10.1111/resp.14123] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 07/19/2021] [Indexed: 01/04/2023]
Abstract
See relatedarticle See relatedarticle
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Affiliation(s)
- Laura Claire Price
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK.,National Lung and Heart Institute, Imperial College London, London, UK
| | - Carole Ridge
- National Lung and Heart Institute, Imperial College London, London, UK.,Department of Radiology, Royal Brompton Hospital, London, UK
| | - Athol U Wells
- National Lung and Heart Institute, Imperial College London, London, UK.,Interstitial Lung Disease Service, Royal Brompton Hospital, London, UK
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23
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Parry AH, Wani AH. Novel pulmonary vascular imaging signs in COVID-19: pathophysiology, significance and management. BJR Open 2021; 2:20210001. [PMID: 34381939 PMCID: PMC8320153 DOI: 10.1259/bjro.20210001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 11/06/2022] Open
Abstract
A growing body of evidence points to the frequent involvement of pulmonary
microvessels in COVID-19 which was recognized first on CT, and subsequently
demonstrated by clinical and pathological studies. Microvasculopathy occurring
chiefly from endothelial and pericyte damage with resultant disruption of
immune, thrombotic and renin–angiotensin–aldosterone balance leads
to a constellation of clinical and biochemical derangements. Exploration of
potential therapies directed at normalizing the vascular health can prove a
major boon in the treatment of COVID-19.
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Affiliation(s)
- Arshed Hussain Parry
- Department of Radiodiagnosis, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu & Kashmir, India
| | - Abdul Haseeb Wani
- Department of Radiodiagnosis, Government Medical College, Srinagar, Jammu & Kashmir, India
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24
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Poschenrieder F, Meiler S, Lubnow M, Zeman F, Rennert J, Scharf G, Schaible J, Stroszczynski C, Pfeifer M, Hamer OW. Severe COVID-19 pneumonia: Perfusion analysis in correlation with pulmonary embolism and vessel enlargement using dual-energy CT data. PLoS One 2021; 16:e0252478. [PMID: 34101734 PMCID: PMC8186798 DOI: 10.1371/journal.pone.0252478] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 05/16/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Gas exchange in COVID-19 pneumonia is impaired and vessel obstruction has been suspected to cause ventilation-perfusion mismatch. Dual-energy CT (DECT) can depict pulmonary perfusion by regional assessment of iodine uptake. OBJECTIVE The purpose of this study was the analysis of pulmonary perfusion using dual-energy CT in a cohort of 27 consecutive patients with severe COVID-19 pneumonia. METHOD We retrospectively analyzed pulmonary perfusion with DECT in 27 consecutive patients (mean age 57 years, range 21-73; 19 men and 8 women) with severe COVID-19 pneumonia. Iodine uptake (IU) in regions-of-interest placed into normally aerated lung, ground-glass opacifications (GGO) and consolidations was measured using a dedicated postprocessing software. Vessel enlargement (VE) within opacifications and presence of pulmonary embolism (PE) was assessed by subjective analysis. Linear mixed models were used for statistical analyses. RESULTS Compared to normally aerated lung 106/151 (70.2%) opacifications without upstream PE demonstrated an increased IU, 9/151 (6.0%) an equal IU and 36/151 (23.8%) a decreased IU. The estimated mean iodine uptake (EMIU) in opacifications without upstream PE (GGO 1.77 mg/mL; 95%-CI: 1.52-2.02; p = 0.011, consolidations 1.82 mg/mL; 95%-CI: 1.56-2.08, p = 0.006) was significantly higher compared to normal lung (1.22 mg/mL; 95%-CI: 0.95-1.49). In case of upstream PE, EMIU of opacifications (combined GGO and consolidations) was significantly decreased compared to normal lung (0.52 mg/mL; 95%-CI: -0.07-1.12; p = 0.043). The presence of VE in opacifications correlated significantly with iodine uptake (p<0.001). CONCLUSIONS DECT revealed the opacifications in a subset of patients with severe COVID-19 pneumonia to be perfused non-uniformly with some being hypo- and others being hyperperfused. Mean iodine uptake in opacifications (both ground-glass and consolidation) was higher compared to normally aerated lung except for areas with upstream pulmonary embolism. Vessel enlargement correlated with iodine uptake: In summary, in a cohort of 27 consecutive patients with severe COVID-19 pneumonia, dual-energy CT demonstrated a wide range of iodine uptake in pulmonary ground-glass opacifications and consolidations as a surrogate marker for hypo- and hyperperfusion compared to normally aerated lung. Applying DECT to determine which pathophysiology is predominant might help to tailor therapy to the individual patient´s needs.
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Affiliation(s)
| | - Stefanie Meiler
- Department of Radiology, Regensburg University Medical Center, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, Regensburg University Medical Center, Regensburg, Germany
| | - Florian Zeman
- Center for Clinical Studies, Regensburg University Medical Center, Regensburg, Germany
| | - Janine Rennert
- Department of Radiology, Regensburg University Medical Center, Regensburg, Germany
| | - Gregor Scharf
- Department of Radiology, Regensburg University Medical Center, Regensburg, Germany
| | - Jan Schaible
- Department of Radiology, Regensburg University Medical Center, Regensburg, Germany
| | | | - Michael Pfeifer
- Department of Internal Medicine II, Regensburg University Medical Center, Regensburg, Germany
- Department of Pneumology, Donaustauf Hospital, Donaustauf, Germany
| | - Okka W. Hamer
- Department of Radiology, Regensburg University Medical Center, Regensburg, Germany
- Department of Radiology, Donaustauf Hospital, Donaustauf, Germany
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25
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Remy-Jardin M, Duthoit L, Perez T, Felloni P, Faivre JB, Fry S, Bautin N, Chenivesse C, Remy J, Duhamel A. Assessment of pulmonary arterial circulation 3 months after hospitalization for SARS-CoV-2 pneumonia: Dual-energy CT (DECT) angiographic study in 55 patients. EClinicalMedicine 2021; 34:100778. [PMID: 33817609 PMCID: PMC8008988 DOI: 10.1016/j.eclinm.2021.100778] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND During COVID-19, the main manifestations of the disease are not only pneumonia but also coagulation disorders. The purpose of this study was to evaluate pulmonary vascular abnormalities 3 months after hospitalization for SARS-CoV-2 pneumonia in patients with persistent respiratory symptoms. METHODS Among the 320 patients who participated in a systematic follow-up 3 months after hospitalization, 76 patients had residual symptoms justifying a specialized follow-up in the department of pulmonology. Among them, dual-energy CT angiography (DECTA) was obtained in 55 patients. FINDINGS The 55 patients had partial (n = 40; 72.7%) or complete (n = 15; 27.3%) resolution of COVID-19 lung infiltration. DECTA was normal in 52 patients (52/55; 94.6%) and showed endoluminal filling defects in 3 patients (3/55; 5.4%) at the level of one (n = 1) and two (n = 1) segmental arteries of a single lobe and within central and peripheral arteries (n = 1). DECT lung perfusion was rated as non-interpretable (n = 2;3.6%), normal (n = 17; 30.9%) and abnormal (n = 36; 65.5%), the latter group comprising 32 patients with residual COVID-19 opacities (32/36; 89%) and 4 patients with normal lung parenchyma (4/36; 11%). Perfusion abnormalities consisted of (a) patchy defects (30/36; 83%), (b) PE-type defects (6/36; 16.6%) with (n = 1) or without proximal thrombosis (n = 5); and (c) focal areas of hypoperfusion (2/36; 5.5%). Increased perfusion was seen in 15 patients, always matching GGOs, bands and/or vascular tree-in- bud patterns. INTERPRETATION DECT depicted proximal arterial thrombosis in 5.4% of patients and perfusion abnormalities suggestive of widespread microangiopathy in 65.5% of patients. Lung microcirculation was abnormal in 4 patients with normal lung parenchyma.
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Affiliation(s)
- Martine Remy-Jardin
- Univ.Lille, CHU Lille, Department of Thoracic Imaging, ULR 2694 METRICS Evaluation des technologies de santé et des pratiques médicales, F-59000 LILLE, France
- Hospital Calmette, University Hospital Center of Lille, Blvd Jules Leclercq F-59000 LILLE, France
| | - Louise Duthoit
- Hospital Calmette, University Hospital Center of Lille, Blvd Jules Leclercq F-59000 LILLE, France
- Univ.Lille, CHU Lille, Department of Pulmonology, Hospital Calmette, University Hospital Center of Lille, Blvd Jules Leclercq, F-59000 LILLE, France
| | - Thierry Perez
- Hospital Calmette, University Hospital Center of Lille, Blvd Jules Leclercq F-59000 LILLE, France
- Department of Pulmonary Function Testing, Hospital Calmette, University Hospital Center of Lille, Blvd Jules Leclercq, F-59000 LILLE, France
| | - Paul Felloni
- Univ.Lille, CHU Lille, Department of Thoracic Imaging, ULR 2694 METRICS Evaluation des technologies de santé et des pratiques médicales, F-59000 LILLE, France
- Hospital Calmette, University Hospital Center of Lille, Blvd Jules Leclercq F-59000 LILLE, France
| | - Jean-Baptiste Faivre
- Univ.Lille, CHU Lille, Department of Thoracic Imaging, ULR 2694 METRICS Evaluation des technologies de santé et des pratiques médicales, F-59000 LILLE, France
- Hospital Calmette, University Hospital Center of Lille, Blvd Jules Leclercq F-59000 LILLE, France
| | - Stéphanie Fry
- Hospital Calmette, University Hospital Center of Lille, Blvd Jules Leclercq F-59000 LILLE, France
- Univ.Lille, CHU Lille, Department of Pulmonology, Hospital Calmette, University Hospital Center of Lille, Blvd Jules Leclercq, F-59000 LILLE, France
| | - Nathalie Bautin
- Hospital Calmette, University Hospital Center of Lille, Blvd Jules Leclercq F-59000 LILLE, France
- Univ.Lille, CHU Lille, Department of Pulmonology, Hospital Calmette, University Hospital Center of Lille, Blvd Jules Leclercq, F-59000 LILLE, France
| | - Cécile Chenivesse
- Hospital Calmette, University Hospital Center of Lille, Blvd Jules Leclercq F-59000 LILLE, France
- Univ.Lille, CHU Lille, Department of Pulmonology, Hospital Calmette, University Hospital Center of Lille, Blvd Jules Leclercq, F-59000 LILLE, France
| | - Jacques Remy
- Univ.Lille, CHU Lille, Department of Thoracic Imaging, ULR 2694 METRICS Evaluation des technologies de santé et des pratiques médicales, F-59000 LILLE, France
- Hospital Calmette, University Hospital Center of Lille, Blvd Jules Leclercq F-59000 LILLE, France
| | - Alain Duhamel
- Univ.Lille, CHU Lille, Department of Biostatistics, ULR 2694 METRICS Evaluation des technologies de santé et des pratiques médicales, F-59000 LILLE, France
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26
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Arru CD, Digumarthy SR, Hansen JV, Lyhne MD, Singh R, Rosovsky R, Nielsen-Kudsk JE, Kabrhel C, Saba L, Kalra MK. Qualitative and quantitative DECT pulmonary angiography in COVID-19 pneumonia and pulmonary embolism. Clin Radiol 2021; 76:392.e1-392.e9. [PMID: 33714541 PMCID: PMC7906503 DOI: 10.1016/j.crad.2021.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 02/17/2021] [Indexed: 12/23/2022]
Abstract
AIM To assess differences in qualitative and quantitative parameters of pulmonary perfusion from dual-energy computed tomography (CT) pulmonary angiography (DECT-PA) in patients with COVID-19 pneumonia with and without pulmonary embolism (PE). MATERIALS AND METHODS This retrospective institutional review board-approved study included 74 patients (mean age 61±18 years, male:female 34:40) with COVID-19 pneumonia in two countries (one with 68 patients, and the other with six patients) who underwent DECT-PA on either dual-source (DS) or single-source (SS) multidetector CT machines. Images from DS-DECT-PA were processed to obtain virtual mono-energetic 40 keV (Mono40), material decomposition iodine (MDI) images and quantitative perfusion statistics (QPS). Two thoracic radiologists determined CT severity scores based on type and extent of pulmonary opacities, assessed presence of PE, and pulmonary parenchymal perfusion on MDI images. The QPS were calculated from the CT Lung Isolation prototype (Siemens). The correlated clinical outcomes included duration of hospital stay, intubation, SpO2 and death. The significance of association was determined by receiver operating characteristics and analysis of variance. RESULTS One-fifth (20.2%, 15/74 patients) had pulmonary arterial filling defects; most filling defects were occlusive (28/44) located in the segmental and sub-segmental arteries. The parenchymal opacities were more extensive and denser (CT severity score 24±4) in patients with arterial filling defects than without filling defects (20±8; p=0.028). Ground-glass opacities demonstrated increased iodine distribution; mixed and consolidative opacities had reduced iodine on DS-DECT-PA but increased or heterogeneous iodine content on SS-DECT-PA. QPS were significantly lower in patients with low SpO2 (p=0.003), intubation (p=0.006), and pulmonary arterial filling defects (p=0.007). CONCLUSION DECT-PA QPS correlated with clinical outcomes in COVID-19 patients.
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Affiliation(s)
- C D Arru
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA; Azienda Ospedaliera Universitaria, SS 554 km 4,500, Monserrato, 09042, Cagliari, Italy
| | - S R Digumarthy
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA.
| | - J V Hansen
- Department of Cardiology, Department of Clinical Medicine, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - M D Lyhne
- Department of Cardiology, Department of Clinical Medicine, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - R Singh
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA
| | - R Rosovsky
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA
| | - J E Nielsen-Kudsk
- Department of Cardiology, Department of Clinical Medicine, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - C Kabrhel
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA
| | - L Saba
- Azienda Ospedaliera Universitaria, SS 554 km 4,500, Monserrato, 09042, Cagliari, Italy
| | - M K Kalra
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA
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27
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Garfield B, McFadyen C, Briar C, Bleakley C, Vlachou A, Baldwin M, Lees N, Price S, Ledot S, McCabe C, Wort SJ, Patel BV, Price LC. Potential for personalised application of inhaled nitric oxide in COVID-19 pneumonia. Br J Anaesth 2021; 126:e72-e75. [PMID: 33288208 PMCID: PMC7666572 DOI: 10.1016/j.bja.2020.11.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/06/2020] [Accepted: 11/06/2020] [Indexed: 11/28/2022] Open
Affiliation(s)
- Benjamin Garfield
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Charlotte Briar
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK
| | | | | | - Melissa Baldwin
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - Nick Lees
- Adult Intensive Care Unit, Harefield Hospital, Harefield, UK
| | - Susanna Price
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Stephane Ledot
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - Colm McCabe
- National Heart and Lung Institute, Imperial College London, London, UK; National Pulmonary Hypertension Service, Royal Brompton Hospital, UK
| | - S John Wort
- National Heart and Lung Institute, Imperial College London, London, UK; National Pulmonary Hypertension Service, Royal Brompton Hospital, UK
| | - Brijesh V Patel
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK; Anaesthetics, Pain Medicine and Intensive Care, Surgery and Cancer, Imperial College London, UK
| | - Laura C Price
- National Heart and Lung Institute, Imperial College London, London, UK; National Pulmonary Hypertension Service, Royal Brompton Hospital, UK.
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28
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Price LC, Garfield B, Bleakley C, Keeling AG, Mcfadyen C, McCabe C, Ridge CA, Wort SJ, Price S, Arachchillage DJ. Rescue therapy with thrombolysis in patients with severe COVID-19-associated acute respiratory distress syndrome. Pulm Circ 2020; 10:2045894020973906. [PMID: 33403100 PMCID: PMC7745572 DOI: 10.1177/2045894020973906] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 10/24/2020] [Indexed: 12/14/2022] Open
Abstract
Acute respiratory distress syndrome in patients with Coronavirus disease 19 is associated with an unusually high incidence of pulmonary embolism and microthrombotic disease, with evidence for reduced fibrinolysis. We describe seven patients requiring invasive ventilation for COVID-19-associated acute respiratory distress syndrome with pulmonary thromboembolic disease, pulmonary hypertension ± severe right ventricular dysfunction on echocardiography, who were treated with alteplase as fibrinolytic therapy. All patients were non-smokers, six (86%) were male and median age was 56.7 (50-64) years. They had failed approaches including therapeutic anticoagulation, prone ventilation (n = 4), inhaled nitric oxide (n = 5) and nebulised epoprostenol (n = 2). The median duration of mechanical ventilation prior to thrombolysis was seven (5-11) days. Systemic alteplase was administered to six patients (50 mg or 90 mg bolus over 120 min) at 16 (10-22) days after symptom onset. All received therapeutic heparin pre- and post-thrombolysis, without intracranial haemorrhage or other major bleeding. Alteplase improved PaO2/FiO2 ratio (from 97.0 (86.3-118.6) to 135.6 (100.7-171.4), p = 0.03) and ventilatory ratio (from 2.76 (2.09-3.49) to 2.36 (1.82-3.05), p = 0.011) at 24 h. Echocardiographic parameters at two (1-3) days (n = 6) showed right ventricular systolic pressure (RVSP) was 63 (50.3-75) then 57 (49-66) mmHg post-thrombolysis (p = 0.26), tricuspid annular planar systolic excursion (TAPSE) was unchanged (from 18.3 (11.9-24.5) to 20.5 (15.4-24.2) mm, p = 0.56) and right ventricular fractional area change (from 15.4 (11.1-35.6) to 31.2 (16.4-33.1)%, p = 0.09). At seven (1-13) days after thrombolysis, using dual energy computed tomography imaging (n = 3), average relative peripheral lung enhancement increased from 12.6 to 21.6% (p = 0.06). In conclusion, thrombolysis improved PaO2/FiO2 ratio and ventilatory ratio at 24 h as rescue therapy in patients with right ventricular dysfunction due to COVID-19-associated ARDS despite maximum therapy, as part of a multimodal approach, and warrants further study.
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Affiliation(s)
- Laura C. Price
- National Pulmonary Hypertension Service, Royal Brompton & Harefield NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Benjamin Garfield
- National Pulmonary Hypertension Service, Royal Brompton & Harefield NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Intensive Care Medicine, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Caroline Bleakley
- Department of Intensive Care Medicine, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | | | - Charles Mcfadyen
- Department of Intensive Care Medicine, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Colm McCabe
- National Pulmonary Hypertension Service, Royal Brompton & Harefield NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Carole A. Ridge
- Department of Radiology, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Stephen J. Wort
- National Pulmonary Hypertension Service, Royal Brompton & Harefield NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Susanna Price
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Intensive Care Medicine, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Deepa J. Arachchillage
- Department of Haematology, Royal Brompton & Harefield NHS Foundation Trust, London, UK
- Department of Immunology and Inflammation, Imperial College London, London, UK
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
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