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Aşar S, Rahim F, Rahimi P, Acicbe Ö, Tontu F, Çukurova Z. Novel Oxygenation and Saturation Indices for Mortality Prediction in COVID-19 ARDS Patients: The Impact of Driving Pressure and Mechanical Power. J Intensive Care Med 2024; 39:595-608. [PMID: 38179691 PMCID: PMC11092301 DOI: 10.1177/08850666231223498] [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] [Indexed: 01/06/2024]
Abstract
Background: The oxygenation index (OI) and oxygen saturation index (OSI) are proven mortality predictors in pediatric and adult patients, traditionally using mean airway pressure (Pmean). We introduce novel indices, replacing Pmean with DP (ΔPinsp), MPdyn, and MPtot, assessing their potential for predicting COVID-19 acute respiratory distress syndrome (ARDS) mortality, comparing them to traditional indices. Methods: We studied 361 adult COVID-19 ARDS patients for 7 days, collecting ΔPinsp, MPdyn, and MPtot, OI-ΔPinsp, OI-MPdyn, OI-MPtot, OSI-ΔPinsp, OSI-MPdyn, and OSI-MPtot. We compared these in surviving and non-surviving patients over the first 7 intensive care unit (ICU) days using Mann-Whitney U test. Logistic regression receiver operating characteristic (ROC) analysis assessed AUC and CI values for ICU mortality on day three. We determined cut-off values using Youden's method and conducted multivariate Cox regression on parameter limits. Results: All indices showed significant differences between surviving and non-surviving patients on the third day of ICU care. The AUC values of OI-ΔPinsp were significantly higher than those of P/F and OI-Pmean (P values .0002 and <.0001, respectively). Similarly, AUC and CI values of OSI-ΔPinsp and OSI-MPdyn were significantly higher than those of SpO2/FiO2 and OSI-Pmean values (OSI-ΔPinsp: P < .0001, OSI-MPdyn: P values .047 and .028, respectively). OI-ΔPinsp, OSI-ΔPinsp, OI-MPdyn, OSI-MPdyn, OI-MPtot, and OSI-MPtot had AUC values of 0.72, 0.71, 0.69, 0.68, 0.66, and 0.64, respectively, with cut-off values associated with hazard ratios and P values of 7.06 (HR = 1.84, P = .002), 8.04 (HR = 2.00, P ≤ .0001), 7.12 (HR = 1.68, P = .001), 5.76 (HR = 1.70, P ≤ .0001), 10.43 (HR = 1.52, P = .006), and 10.68 (HR = 1.66, P = .001), respectively. Conclusions: Critical values of all indices were associated to higher ICU mortality rates and extended mechanical ventilation durations. The OI-ΔPinsp, OSI-ΔPinsp, and OSI-MPdyn indices displayed the strongest predictive capabilities for ICU mortality. These novel indices offer valuable insights for intensivists in the clinical management and decision-making process for ARDS patients.
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Affiliation(s)
- Sinan Aşar
- Department of Anesthesiology and Reanimation, Bakırköy Dr SadiKonuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Fatih Rahim
- Department of Industrial Engineering, Koç University, Istanbul, Turkey
| | - Payam Rahimi
- Department of Anesthesiology and Reanimation, Bakırköy Dr SadiKonuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Özlem Acicbe
- Department of Anesthesiology and Reanimation, Şişli HamidiyeEtfal Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Furkan Tontu
- Department of Anesthesiology and Reanimation, Ağrı Training and Research Hospital, Ağrı, Turkey
| | - Zafer Çukurova
- Department of Anesthesiology and Reanimation, Bakırköy Dr SadiKonuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
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2
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Jouffroy R, Fabre T, Gilbert B, Travers S, Bloch-Laine E, Ecollan P, Boularan J, Bounes V, Vivien B, Gueye P. Association between prehospital ROX index with 30-day mortality among septic shock. Eur J Med Res 2024; 29:304. [PMID: 38822441 PMCID: PMC11141059 DOI: 10.1186/s40001-024-01902-8] [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: 03/18/2024] [Accepted: 05/24/2024] [Indexed: 06/03/2024] Open
Abstract
PURPOSE Respiratory dysfunction is one of the most frequent symptoms observed during sepsis reflecting hypoxemia and/or acidosis that may be assessed by the ROX index (ratio of oxygen saturation by pulse oximetry/fraction of inspired oxygen to respiratory rate). This study aimed to describe the relationship between the prehospital ROX index and 30-day mortality rate among septic shock patients cared for in the prehospital setting by a mobile intensive care unit (MICU). METHODS From May 2016 to December 2021, 530 septic shock patients cared for by a prehospital MICU were retrospectively analysed. Initial ROX index value was calculated at the first contact with MICU. A Cox regression analysis after propensity score matching was performed to assess the relationship between 30-day mortality rate and a ROX index ≤ 10. RESULTS Pulmonary, digestive and urinary sepsis were suspected among 43%, 25% and 17% patients, respectively. The 30-day overall mortality reached 31%. Cox regression analysis showed a significant association between 30-day mortality and a ROX index ≤ 10: adjusted hazard ratio of 1.54 [1.08-2.31], p < 0.05. CONCLUSIONS During the prehospital stage of septic shock patients cared for by a MICU, ROX index is significantly associated with 30-day mortality. A prehospital ROX ≤ 10 value is associated with a 1.5-fold 30-day mortality rate increase. Prospective studies are needed to confirm the ability of prehospital ROX to predict sepsis outcome since the prehospital setting.
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Affiliation(s)
- Romain Jouffroy
- Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique - Hôpitaux de Paris, 9 avenue Charles De Gaulle, 92100, Boulogne-Billancourt, France.
- U1018 INSERM, Centre de Recherche en Epidémiologie et Santé des Populations, Paris Saclay University, Gif-sur-Yvette, France.
- EA 7329, Institut de Recherche Médicale et d'Épidémiologie du Sport, Institut National du Sport, de l'Expertise et de la Performance, Paris, France.
| | - Tristan Fabre
- SAMU 972, Centre Hospitalier Universitaire de Martinique, Fort-de-France Martinique, France
- EA 7525, University of the Antilles, French West Indies, France
| | - Basile Gilbert
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | | | - Emmanuel Bloch-Laine
- Emergency Department, Cochin Hospital, Paris, France
- Emergency Department, SMUR, Hôtel Dieu Hospital, Paris, France
| | - Patrick Ecollan
- Intensive Care Unit, SMUR, Pitie Salpêtriere Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | | | - Vincent Bounes
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | - Benoît Vivien
- SAMU de Paris, Service d'Anesthésie Réanimation, Hôpital Universitaire Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Papa Gueye
- SAMU 972, Centre Hospitalier Universitaire de Martinique, Fort-de-France Martinique, France
- EA 7525, University of the Antilles, French West Indies, France
- UR5_3 PC2E Pathologie Cardiaque, Toxicité Environnementale et Envenimations, Université des Antilles, Pointe-à-Pitre, France
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3
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Pannu S, Exline MC, Bednash JS, Englert JA, Diaz P, Bartlett A, Brock G, Wu Q, Davis IC, Crouser ED. SCARLET (Supplemental Citicoline Administration to Reduce Lung injury Efficacy Trial): study protocol for a single-site, double-blinded, placebo-controlled, and randomized Phase 1/2 trial of i.v. citicoline (CDP-choline) in hospitalized SARS CoV-2-infected patients with hypoxemic acute respiratory failure. Trials 2024; 25:328. [PMID: 38760804 PMCID: PMC11102211 DOI: 10.1186/s13063-024-08155-0] [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] [Received: 03/26/2024] [Accepted: 05/07/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND The SARS CoV-2 pandemic has resulted in more than 1.1 million deaths in the USA alone. Therapeutic options for critically ill patients with COVID-19 are limited. Prior studies showed that post-infection treatment of influenza A virus-infected mice with the liponucleotide CDP-choline, which is an essential precursor for de novo phosphatidylcholine synthesis, improved gas exchange and reduced pulmonary inflammation without altering viral replication. In unpublished studies, we found that treatment of SARS CoV-2-infected K18-hACE2-transgenic mice with CDP-choline prevented development of hypoxemia. We hypothesize that administration of citicoline (the pharmaceutical form of CDP-choline) will be safe in hospitalized SARS CoV-2-infected patients with hypoxemic acute respiratory failure (HARF) and that we will obtain preliminary evidence of clinical benefit to support a larger Phase 3 trial using one or more citicoline doses. METHODS We will conduct a single-site, double-blinded, placebo-controlled, and randomized Phase 1/2 dose-ranging and safety study of Somazina® citicoline solution for injection in consented adults of any sex, gender, age, or ethnicity hospitalized for SARS CoV-2-associated HARF. The trial is named "SCARLET" (Supplemental Citicoline Administration to Reduce Lung injury Efficacy Trial). We hypothesize that SCARLET will show that i.v. citicoline is safe at one or more of three doses (0.5, 2.5, or 5 mg/kg, every 12 h for 5 days) in hospitalized SARS CoV-2-infected patients with HARF (20 per dose) and provide preliminary evidence that i.v. citicoline improves pulmonary outcomes in this population. The primary efficacy outcome will be the SpO2:FiO2 ratio on study day 3. Exploratory outcomes include Sequential Organ Failure Assessment (SOFA) scores, dead space ventilation index, and lung compliance. Citicoline effects on a panel of COVID-relevant lung and blood biomarkers will also be determined. DISCUSSION Citicoline has many characteristics that would be advantageous to any candidate COVID-19 therapeutic, including safety, low-cost, favorable chemical characteristics, and potentially pathogen-agnostic efficacy. Successful demonstration that citicoline is beneficial in severely ill patients with SARS CoV-2-induced HARF could transform management of severely ill COVID patients. TRIAL REGISTRATION The trial was registered at www. CLINICALTRIALS gov on 5/31/2023 (NCT05881135). TRIAL STATUS Currently enrolling.
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Affiliation(s)
- Sonal Pannu
- Division of Pulmonary, Critical Care and Sleep Medicine of the Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Matthew C Exline
- Division of Pulmonary, Critical Care and Sleep Medicine of the Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Joseph S Bednash
- Division of Pulmonary, Critical Care and Sleep Medicine of the Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Joshua A Englert
- Division of Pulmonary, Critical Care and Sleep Medicine of the Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Philip Diaz
- Division of Pulmonary, Critical Care and Sleep Medicine of the Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Amy Bartlett
- Center for Clinical and Translational Sciences, The Ohio State University, Columbus, OH, USA
| | - Guy Brock
- Department of Biomedical Informatics, The Ohio State University, Columbus, OH, USA
| | - Qing Wu
- Department of Biomedical Informatics, The Ohio State University, Columbus, OH, USA
| | - Ian C Davis
- Department of Veterinary Biosciences, The Ohio State University, Columbus, OH, USA.
| | - Elliott D Crouser
- Division of Pulmonary, Critical Care and Sleep Medicine of the Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
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Estenssoro E, González I, Plotnikow GA. Post-pandemic acute respiratory distress syndrome: A New Global Definition with extension to lower-resource regions. Med Intensiva 2024; 48:272-281. [PMID: 38644108 DOI: 10.1016/j.medine.2024.01.011] [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: 01/24/2024] [Accepted: 01/27/2024] [Indexed: 04/23/2024]
Abstract
Acute respiratory distress syndrome (ARDS), first described in 1967, is characterized by acute respiratory failure causing profound hypoxemia, decreased pulmonary compliance, and bilateral CXR infiltrates. After several descriptions, the Berlin definition was adopted in 2012, which established three categories of severity according to hypoxemia (mild, moderate and severe), specified temporal aspects for diagnosis, and incorporated the use of non-invasive ventilation. The COVID-19 pandemic led to changes in ARDS management, focusing on continuous monitoring of oxygenation and on utilization of high-flow oxygen therapy and lung ultrasound. In 2021, a New Global Definition based on the Berlin definition of ARDS was proposed, which included a category for non-intubated patients, considered the use of SpO2, and established no particular requirement for oxygenation support in regions with limited resources. Although debates persist, the continuous evolution seeks to adapt to clinical and epidemiological needs, and to the search of personalized treatments.
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Affiliation(s)
- Elisa Estenssoro
- Escuela de Gobierno en Salud, Ministerio de Salud, Buenos Aires, Argentina; Facultad de Ciencias Médicas, Universidad Nacional de La Plata, Buenos Aires, Argentina.
| | - Iván González
- Servicio de Rehabilitación, Área de Kinesiología Crítica, Hospital Británico de Buenos Aires, CABA, Argentina
| | - Gustavo A Plotnikow
- Servicio de Rehabilitación, Área de Kinesiología Crítica, Hospital Británico de Buenos Aires, CABA, Argentina; Facultad de Medicina y Ciencias de la Salud, Universidad Abierta Interamericana, Argentina
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Matsubara S, Sudo K, Kushimoto K, Yoshii R, Inoue K, Kinoshita M, Kooguchi K, Shikata S, Inaba T, Sawa T. Prediction of acute lung injury assessed by chest computed tomography, oxygen saturation/fraction of inspired oxygen ratio, and serum lactate dehydrogenase in patients with COVID-19. J Infect Chemother 2024; 30:406-416. [PMID: 37984540 DOI: 10.1016/j.jiac.2023.11.013] [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: 08/19/2023] [Revised: 10/10/2023] [Accepted: 11/12/2023] [Indexed: 11/22/2023]
Abstract
INTRODUCTION In treating acute hypoxemic respiratory failure (AHRF) caused by coronavirus disease 2019 (COVID-19), clinicians choose respiratory therapies such as low-flow nasal cannula oxygenation, high-flow nasal cannula oxygenation, or mechanical ventilation after assessment of the patient's condition. Chest computed tomography (CT) imaging contributes significantly to diagnosing COVID-19 pneumonia. However, the costs and potential harm to patients from radiation exposure need to be considered. This study was performed to predict the quantitative extent of COVID-19 acute lung injury using clinical indicators such as an oxygenation index and blood test results. METHODS We analyzed data from 192 patients with COVID-19 AHRF. Multiple logistic regression was used to determine correlations between the lung infiltration volume (LIV) and other pathophysiological or biochemical laboratory parameters. RESULTS Among 13 clinical parameters, we identified the oxygen saturation/fraction of inspired oxygen ratio (SF ratio) and serum lactate dehydrogenase (LD) concentration as factors associated with the LIV. In the binary classification of an LIV of ≥20 % or not and with the borderline LD = 2.2 × [SF ratio]-182.4, the accuracy, precision, diagnostic odds ratio, and area under the summary receiver operating characteristic curve were 0.828, 0.818, 23.400, and 0.870, respectively. CONCLUSIONS These data suggest that acute lung injury due to COVID-19 pneumonia can be estimated using the SF ratio and LD concentration without a CT scan. These findings may provide significant clinical benefit by allowing clinicians to predict acute lung injury levels using simple, minimally invasive assessment of oxygenation capacity and biochemical blood tests.
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Affiliation(s)
- Shin Matsubara
- Department of General Medicine & Community Healthcare, Kyoto Prefectural University of Medicine, Kajiicho 465, Kawaramachi-Hirokoji, Kamigyo, Kyoto, 602-8566, Japan.
| | - Kazuki Sudo
- Department of Anesthesiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kajiicho 465, Kawaramachi-Hirokoji, Kamigyo, Kyoto, 602-8566, Japan.
| | - Kohsuke Kushimoto
- Department of Anesthesiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kajiicho 465, Kawaramachi-Hirokoji, Kamigyo, Kyoto, 602-8566, Japan.
| | - Ryogo Yoshii
- Division of Intensive Care, The Hospital of Kyoto Prefectural University, Kajiicho 465, Kawaramachi-Hirokoji, Kamigyo, Kyoto, 602-8566, Japan.
| | - Keita Inoue
- Division of Intensive Care, The Hospital of Kyoto Prefectural University, Kajiicho 465, Kawaramachi-Hirokoji, Kamigyo, Kyoto, 602-8566, Japan.
| | - Mao Kinoshita
- Department of Anesthesiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kajiicho 465, Kawaramachi-Hirokoji, Kamigyo, Kyoto, 602-8566, Japan.
| | - Kunihiko Kooguchi
- Division of Intensive Care, The Hospital of Kyoto Prefectural University, Kajiicho 465, Kawaramachi-Hirokoji, Kamigyo, Kyoto, 602-8566, Japan.
| | - Satoru Shikata
- Department of General Medicine & Community Healthcare, Kyoto Prefectural University of Medicine, Kajiicho 465, Kawaramachi-Hirokoji, Kamigyo, Kyoto, 602-8566, Japan.
| | - Tohru Inaba
- Division of Clinical Laboratory, Kyoto Prefectural University of Medicine Hospital, Kajiicho 465, Kawaramachi-Hirokoji, Kamigyo, Kyoto, 602-8566, Japan.
| | - Teiji Sawa
- Department of Anesthesiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kajiicho 465, Kawaramachi-Hirokoji, Kamigyo, Kyoto, 602-8566, Japan; The Hospital of Kyoto Prefectural University of Medicine, Kajiicho 465, Kawaramachi-Hirokoji, Kamigyo, Kyoto, 602-8566, Japan.
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Liu K, Ma XY, Xiao H, Gu WJ, Lyu J, Yin HY. Association between the ROX index and mortality in patients with acute hypoxemic respiratory failure: a retrospective cohort study. Respir Res 2024; 25:143. [PMID: 38553757 PMCID: PMC10981314 DOI: 10.1186/s12931-024-02771-9] [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] [Received: 11/12/2023] [Accepted: 03/13/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND Although ROX index is frequently used to assess the efficacy of high-flow nasal cannula treatment in acute hypoxemic respiratory failure (AHRF) patients, the relationship between the ROX index and the mortality remains unclear. Therefore, a retrospective cohort study was conducted to evaluate the ability of the ROX index to predict mortality risk in patients with AHRF. METHOD Patients diagnosed with AHRF were extracted from the MIMIC-IV database and divided into four groups based on the ROX index quartiles. The primary outcome was 28-day mortality, while in-hospital mortality and follow-up mortality were secondary outcomes. To investigate the association between ROX index and mortality in AHRF patients, restricted cubic spline curve and COX proportional risk regression were utilized. RESULT A non-linear association (L-shaped) has been observed between the ROX index and mortality rate. When the ROX index is below 8.28, there is a notable decline in the 28-day mortality risk of patients as the ROX index increases (HR per SD, 0.858 [95%CI 0.794-0.928] P < 0.001). When the ROX index is above 8.28, no significant association was found between the ROX index and 28-day mortality. In contrast to the Q1 group, the mortality rates in the Q2, Q3, and Q4 groups had a substantial reduction (Q1 vs. Q2: HR, 0.749 [0.590-0.950] P = 0.017; Q3: HR, 0.711 [0.558-0.906] P = 0.006; Q4: HR, 0.641 [0.495-0.830] P < 0.001). CONCLUSION The ROX index serves as a valuable predictor of mortality risk in adult patients with AHRF, and that a lower ROX index is substantially associated with an increase in mortality.
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Affiliation(s)
- Kai Liu
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, 613 Huangpu Avenue West, Guangzhou, 510630, China
| | - Xin-Yi Ma
- The First Clinical Medical College, Southern Medical University, Guangzhou, China
| | - Hua Xiao
- Department of Nephrology, Shenzhen People's Hospital (The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of Southern University of Science and Technology), Shenzhen, China
| | - Wan-Jie Gu
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, 613 Huangpu Avenue West, Guangzhou, 510630, China
| | - Jun Lyu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China.
| | - Hai-Yan Yin
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, 613 Huangpu Avenue West, Guangzhou, 510630, China.
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Pozzi T, Fratti I, Tomarchio E, Bruno G, Catozzi G, Monte A, Chiumello D, Coppola S. Early time-course of respiratory mechanics, mechanical power and gas exchange in ARDS patients. J Crit Care 2024; 79:154444. [PMID: 37862955 DOI: 10.1016/j.jcrc.2023.154444] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 09/04/2023] [Accepted: 09/30/2023] [Indexed: 10/22/2023]
Abstract
PURPOSE To describe the clinical course of ARDS during the first three days of mechanical ventilation, to compare ventilatory setting, respiratory mechanics and gas exchange variables collected during the first three days of mechanical ventilation between patients who survived and died during intensive care unit (ICU) stay and to investigate the variables associated with mortality at ICU admission and throughout the first three days of mechanical ventilation. MATERIALS AND METHODS Prospective observational study. Mechanically ventilated ARDS patients were studied at ICU admission and for the following three days. Univariate logistic regression models were performed for PaO2/FiO2 ratio, driving pressure and alveolar dead space fraction and for mechanical power and mechanical power ratio. RESULTS Mechanical power ratio was higher in non survivors at ICU admission and over time; PaO2/FiO2 ratio was higher in survivors with a similar behavior over time in the two groups while alveolar dead space fraction was similar at ICU admission and over time between groups. Mechanical power ratio was the only physiological variable which remained consistently associated with ICU mortality throughout the study. CONCLUSIONS The alteration in oxygenation, dead space, and mechanical power ratio should be assessed not at intensive care admission, but during the first days of mechanical ventilation to better predict outcome.
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Affiliation(s)
- Tommaso Pozzi
- Department of Health Sciences, University of Milan, Italy
| | | | | | - Giovanni Bruno
- Department of Health Sciences, University of Milan, Italy
| | - Giulia Catozzi
- Department of Health Sciences, University of Milan, Italy
| | | | - Davide Chiumello
- Department of Health Sciences, University of Milan, Italy; Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital Milan, Italy; Coordinated Research Center on Respiratory Failure, University of Milan, Italy.
| | - Silvia Coppola
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital Milan, Italy
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Alipanah-Lechner N, Cavalcanti AB, Diaz J, Ferguson ND, Myatra SN, Calfee CS. From Berlin to Global: The Need for Syndromic Definitions of Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2024; 209:21-23. [PMID: 37816094 PMCID: PMC10870889 DOI: 10.1164/rccm.202308-1441vp] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/09/2023] [Indexed: 10/12/2023] Open
Affiliation(s)
- Narges Alipanah-Lechner
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, and
| | | | - Janet Diaz
- World Health Organization, Geneva, Switzerland
| | - Niall D. Ferguson
- Division of Respirology and Critical Care, Department of Medicine, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Medicine and
- Department of Physiology, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; and
| | - Sheila N. Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Carolyn S. Calfee
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, and
- Department of Anesthesia, University of California, San Francisco, San Francisco, California
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Hasin Y, Helviz Y, Einav S. Multiorgan failure in patients after out of hospital resuscitation: a retrospective single center study. Intern Emerg Med 2024; 19:159-173. [PMID: 37589938 DOI: 10.1007/s11739-023-03389-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 07/27/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Information on extracerebral system dysfunction is important for assessing the needs of critically ill patients after cardiac arrest. AIMS To describe the prevalence of organ dysfunction and patient severity after out of hospital cardiac arrest (OHCA) using scores commonly used in intensive care and the association between these and mortality. METHODS Retrospective analysis of observational data collected in real time in a tertiary medical center where care withdrawal is mostly illegal. Adult patients after nontraumatic OHCA with ROSC who survived for more than two hours were included. Primary outcome-prevalence of organ failure, based on common definitions for organ dysfunction, in the 1 days of hospitalization. Secondary outcomes-rates of survival to hospital discharge and survival with a good neurological outcome (CPC 1 or 2), and associations between organ dysfunction SOFA and APACHE-II scores and outcomes. Associations were assessed using fisher's exact test for categorical variables and Mann-Whitney and T test for continuous variables. Multivariable models were also constructed for all measurements showing associations in previous tests. For severity scores compatibility, we used receiver-operating curve (ROC). RESULTS Overall 369 patients (median age 75 years, 65% male) were included. Most arrests (64%) were witnessed, bystander CPR was provided in 15%. Median call to arrival time was 4 min. The presenting rhythm was asystole in 48% and VT/VF in 22%. Cardiovascular causes of arrest predominated (48%, n = 178). The median length of hospitalization was 5 days. Overall 28% of the patients (n = 98) survived to hospital discharge, mostly with a good neurological status (18.7%, n = 57). The rates of organ dysfunction were: hemodynamic instability 65% (n = 247), respiratory dysfunction 94% (n = 296), kidney dysfunction 70% (n = 259), hepatic dysfunction 14% (n = 50). The median SOFA score on day 1 was 9 and the median APACHE II score was 34. Modeling was limited by missing data. Neurological dysfunction (i.e. GCS and seizures) and kidney injury were consistently correlated with the outcomes in the multivariable models. Severity of critical illness assessed by above scoring systems correlated with mortality (all ROC curves had an AUC ranging between 0.728 and 0.849). CONCLUSIONS Multiorgan failure is common after ROSC (1-4). Therefore, the management of patients after ROSC may require advanced multidisciplinary care. Scores describing the severity of critical illness should be routinely reported in resuscitation research. Our unique setting where withdrawal of care is illegal, allows assessment of extremely ill patients and may assist in defining margins for futility.
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Affiliation(s)
- Yaacov Hasin
- Department of Internal Medicine A, Hadassah Hebrew University Medical Center, Kalman Yaakov Man St, Ein Kerem, 91120, Jerusalem, Israel.
| | - Yigal Helviz
- Intensive Care Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Sharon Einav
- Intensive Care Unit, Shaare Zedek Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
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Matthay MA, Arabi Y, Arroliga AC, Bernard G, Bersten AD, Brochard LJ, Calfee CS, Combes A, Daniel BM, Ferguson ND, Gong MN, Gotts JE, Herridge MS, Laffey JG, Liu KD, Machado FR, Martin TR, McAuley DF, Mercat A, Moss M, Mularski RA, Pesenti A, Qiu H, Ramakrishnan N, Ranieri VM, Riviello ED, Rubin E, Slutsky AS, Thompson BT, Twagirumugabe T, Ware LB, Wick KD. A New Global Definition of Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2024; 209:37-47. [PMID: 37487152 PMCID: PMC10870872 DOI: 10.1164/rccm.202303-0558ws] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/24/2023] [Indexed: 07/26/2023] Open
Abstract
Background: Since publication of the 2012 Berlin definition of acute respiratory distress syndrome (ARDS), several developments have supported the need for an expansion of the definition, including the use of high-flow nasal oxygen, the expansion of the use of pulse oximetry in place of arterial blood gases, the use of ultrasound for chest imaging, and the need for applicability in resource-limited settings. Methods: A consensus conference of 32 critical care ARDS experts was convened, had six virtual meetings (June 2021 to March 2022), and subsequently obtained input from members of several critical care societies. The goal was to develop a definition that would 1) identify patients with the currently accepted conceptual framework for ARDS, 2) facilitate rapid ARDS diagnosis for clinical care and research, 3) be applicable in resource-limited settings, 4) be useful for testing specific therapies, and 5) be practical for communication to patients and caregivers. Results: The committee made four main recommendations: 1) include high-flow nasal oxygen with a minimum flow rate of ⩾30 L/min; 2) use PaO2:FiO2 ⩽ 300 mm Hg or oxygen saturation as measured by pulse oximetry SpO2:FiO2 ⩽ 315 (if oxygen saturation as measured by pulse oximetry is ⩽97%) to identify hypoxemia; 3) retain bilateral opacities for imaging criteria but add ultrasound as an imaging modality, especially in resource-limited areas; and 4) in resource-limited settings, do not require positive end-expiratory pressure, oxygen flow rate, or specific respiratory support devices. Conclusions: We propose a new global definition of ARDS that builds on the Berlin definition. The recommendations also identify areas for future research, including the need for prospective assessments of the feasibility, reliability, and prognostic validity of the proposed global definition.
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Affiliation(s)
- Michael A. Matthay
- Department of Medicine
- Department of Anesthesia
- Cardiovascular Research Institute, and
| | - Yaseen Arabi
- King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | | | - Gordon Bernard
- Division of Allergy, Pulmonary, and Critical Care Medicine, Center for Lung Research, and
| | | | - Laurent J. Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Carolyn S. Calfee
- Department of Medicine
- Department of Anesthesia
- Cardiovascular Research Institute, and
| | - Alain Combes
- Médecine Intensive – Réanimation, Sorbonne Université, APHP Hôpital Pitié-Salpêtrière, Paris, France
| | - Brian M. Daniel
- Respiratory Therapy, University of California, San Francisco, San Francisco, California
| | - Niall D. Ferguson
- Interdepartmental Division of Critical Care Medicine and
- Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Michelle N. Gong
- Department of Medicine, Montefiore Medical Center, Bronx, New York
| | - Jeffrey E. Gotts
- Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | | | - John G. Laffey
- Anesthesia, University Hospital Galway, University of Galway, Galway, Ireland
| | | | - Flavia R. Machado
- Intensive Care Department, Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Thomas R. Martin
- Department of Medicine, University of Washington, Seattle, Washington
| | - Danny F. McAuley
- Centre for Experimental Medicine, Queen’s University Belfast, Belfast, United Kingdom
| | - Alain Mercat
- Medical ICU, Angers University Hospital, Angers, France
| | - Marc Moss
- Department of Medicine, University of Colorado Denver, Aurora, Colorado
| | | | - Antonio Pesenti
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Haibo Qiu
- Critical Care Medicine, Zhongda Hospital, Nanjing, China
| | | | - V. Marco Ranieri
- Emergency and Intensive Care Medicine, Alma Mater Studorium University of Bologna, Bologna, Italy
| | - Elisabeth D. Riviello
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Arthur S. Slutsky
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - B. Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Theogene Twagirumugabe
- Department of Anesthesia, Critical Care, and Emergency Medicine, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda; and
| | - Lorraine B. Ware
- Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Katherine D. Wick
- Department of Medicine, University of California, Davis, Davis, California
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11
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Wu SH, Kor CT, Chi SH, Li CY. Categorizing Acute Respiratory Distress Syndrome with Different Severities by Oxygen Saturation Index. Diagnostics (Basel) 2023; 14:37. [PMID: 38201346 PMCID: PMC10795683 DOI: 10.3390/diagnostics14010037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/20/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024] Open
Abstract
The oxygen saturation index (OSI), defined by FIO2/SpO2 multiplied by the mean airway pressure, has been reported to exceed the Berlin definition in predicting the mortality of acute respiratory distress syndrome (ARDS). The OSI has served as an alternative to the Berlin definition in categorizing pediatric ARDS. However, the use of the OSI for the stratification of adult ARDS has not been reported. A total of 379 invasively ventilated adult ARDS patients were retrospectively studied. The ARDS patients were classified into three groups by their incidence rate of mortality: mild (OSI < 14.69), moderate (14.69 < OSI < 23.08) and severe (OSI > 23.08). OSI-based categorization was highly correlated with the Berlin definition by a Kendall's tau of 0.578 (p < 0.001). The Kaplan-Meier curves of the three OSI-based groups were significantly different (p < 0.001). By the Berlin definition, the hazard ratio for 28-day mortality was 0.58 (0.33-1.05) and 0.95 (0.55-1.67) for the moderate and severe groups, respectively (compared to the mild group). In contrast, the corresponding hazard ratio was 1.01 (0.69-1.47) and 2.39 (1.71-3.35) for the moderate and severe groups defined by the OSI. By multivariate analysis, OSI-based severe ARDS was independently associated with 28-D or 90-D mortality. In conclusion, we report the first OSI-based stratification for adult ARDS and find that it serves well as an alternative to the Berlin definition.
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Affiliation(s)
- Shin-Hwar Wu
- Division of Critical Care Internal Medicine, Department of Emergency Medicine and Critical Care, Changhua Christian Hospital, Changhua 50006, Taiwan
| | - Chew-Teng Kor
- Big Data Center, Changhua Christian Hospital, Changhua 50006, Taiwan;
- Graduate Institute of Statistics and Information Science, National Changhua University of Education, Changhua 50006, Taiwan
| | - Shu-Hua Chi
- Section of Respiratory Therapy, Department of Emergency Medicine and Critical Care, Changhua Christian Hospital, Changhua 50006, Taiwan; (S.-H.C.); (C.-Y.L.)
| | - Chun-Yu Li
- Section of Respiratory Therapy, Department of Emergency Medicine and Critical Care, Changhua Christian Hospital, Changhua 50006, Taiwan; (S.-H.C.); (C.-Y.L.)
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12
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Fox TH, Mazalewski WR, Tran HS, Lindsey T, Krishnan A, Kantrow SP, Happel KI, Janz DR, deBoisblanc BP, Lammi MR. Discordance Between Invasive and NonInvasive Oxygen Saturation in Critically Ill COVID-19 Patients. J Intensive Care Med 2023; 38:1151-1157. [PMID: 37415515 PMCID: PMC10331117 DOI: 10.1177/08850666231186947] [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] [Indexed: 07/08/2023]
Abstract
OBJECTIVES To investigate discordance in oxy-hemoglobin saturation measured both by pulse oximetry (SpO2) and arterial blood gas (ABG, SaO2) among critically ill coronavirus disease 2019 (COVID-19(+)) patients compared to COVID-19(-) patients. METHODS Paired SpO2 and SaO2 readings were collected retrospectively from consecutive adult admissions to four critical care units in the United States between March and May 2020. The primary outcome was the rate of discordance (|SaO2-SpO2|>4%) in COVID-19(+) versus COVID-19(-) patients. The odds each cohort could have been incorrectly categorized as having a PaO2/FiO2 above or below 150 by their SpO2: Fractional inhaled oxygen ratio (pulse oximetry-derived oxyhemoglobin saturation:fraction of inspired oxygen ratio [SF]) was examined. A multivariate regression analysis assessed confounding by clinical differences between cohorts including pH, body temperature, renal replacement therapy at time of blood draw, and self-identified race. RESULTS There were 263 patients (173 COVID-19(+)) included. The rate of saturation discordance between SaO2 and SpO2 in COVID-19(+) patients was higher than in COVID-19(-) patients (27.9% vs 16.7%, odds ratio [OR] 1.94, 95% confidence interval [CI]: 1.11 to 2.27). The average difference between SaO2 and SpO2 for COVID-19(+) patients was -1.24% (limits of agreement, -13.6 to 11.1) versus -0.11 [-10.3 to 10.1] for COVID-19(-) patients. COVID-19(+) patients had higher odds (OR: 2.61, 95% CI: 1.14-5.98) of having an SF that misclassified that patient as having a PaO2:FiO2 ratio above or below 150. There was not an association between discordance and the confounders of pH, body temperature, or renal replacement therapy at time of blood draw. After controlling for self-identified race, the association between COVID-19 status and discordance was lost. CONCLUSIONS Pulse oximetry was discordant with ABG more often in critically ill COVID-19(+) than COVID-19(-) patients. However, these findings appear to be driven by racial differences between cohorts.
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Affiliation(s)
- Thomas H. Fox
- Section of Internal/Emergency Medicine, LSU School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - William R. Mazalewski
- Section of Pulmonary/Critical Care and Allergy/Immunology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Hai S. Tran
- Section of Pulmonary/Critical Care and Allergy/Immunology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Travis Lindsey
- Department of Psychiatry, LSU School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Amita Krishnan
- Section of Pulmonary/Critical Care and Allergy/Immunology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Stephen P. Kantrow
- Section of Internal/Emergency Medicine, LSU School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Kyle I. Happel
- Section of Internal/Emergency Medicine, LSU School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - David R. Janz
- Section of Pulmonary/Critical Care and Allergy/Immunology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
- University Medical Center, New Orleans, LA, USA
| | - Bennett P. deBoisblanc
- Section of Pulmonary/Critical Care and Allergy/Immunology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Matthew R. Lammi
- Section of Pulmonary/Critical Care and Allergy/Immunology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
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13
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Windradi C, Asmarawati TP, Rosyid AN, Marfiani E, Mahdi BA, Martani OS, Giarena G, Agustin ED, Rosandy MG. Hemodynamic, Oxygenation and Lymphocyte Parameters Predict COVID-19 Mortality. PATHOPHYSIOLOGY 2023; 30:314-326. [PMID: 37606387 PMCID: PMC10443272 DOI: 10.3390/pathophysiology30030025] [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: 05/05/2023] [Revised: 07/17/2023] [Accepted: 07/22/2023] [Indexed: 08/23/2023] Open
Abstract
The mortality of COVID-19 patients has left the world devastated. Many scoring systems have been developed to predict the mortality of COVID-19 patients, but several scoring components cannot be carried out in limited health facilities. Herein, the authors attempted to create a new and easy scoring system involving mean arterial pressure (MAP), PF Ratio, or SF ratio-respiration rate (SF Ratio-R), and lymphocyte absolute, which were abbreviated as MPL or MSLR functioning, as a predictive scoring system for mortality within 30 days for COVID-19 patients. Of 132 patients with COVID-19 hospitalized between March and November 2021, we followed up on 96 patients. We present bivariate and multivariate analyses as well as the area under the curve (AUC) and Kaplan-Meier charts. From 96 patients, we obtained an MPL score of 3 points: MAP < 75 mmHg, PF Ratio < 200, and lymphocyte absolute < 1500/µL, whereas the MSLR score was 6 points: MAP < 75 mmHg, SF Ratio < 200, lymphocyte absolute < 1500/µL, and respiration rate 24/min. The MPL cut-off point is 2, while the MSLR is 4. MPL and MSLR have the same sensitivity (79.1%) and specificity (75.5%). The AUC value of MPL vs. MSLR was 0.802 vs. 0.807. The MPL ≥ 2 and MSLR ≥ 4 revealed similar predictions for survival within 30 days (p < 0.05). Conclusion: MPL and MSLR scores are potential predictors of mortality in COVID-19 patients within 30 days in a resource-limited country.
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Affiliation(s)
- Choirina Windradi
- Department of Internal Medicine, Faculty of Medicine, Airlangga University, Surabaya 60286, East Java, Indonesia; (C.W.); (A.N.R.); (E.M.); (O.S.M.)
| | - Tri Pudy Asmarawati
- Department of Internal Medicine, Faculty of Medicine, Airlangga University, Surabaya 60286, East Java, Indonesia; (C.W.); (A.N.R.); (E.M.); (O.S.M.)
- Universitas Airlangga Hospital, Airlangga University, Surabaya 60115, East Java, Indonesia
| | - Alfian Nur Rosyid
- Department of Internal Medicine, Faculty of Medicine, Airlangga University, Surabaya 60286, East Java, Indonesia; (C.W.); (A.N.R.); (E.M.); (O.S.M.)
- Universitas Airlangga Hospital, Airlangga University, Surabaya 60115, East Java, Indonesia
- Department of Pulmonary and Respiratory Medicine, Faculty of Medicine, Airlangga University, Surabaya 60286, East Java, Indonesia
| | - Erika Marfiani
- Department of Internal Medicine, Faculty of Medicine, Airlangga University, Surabaya 60286, East Java, Indonesia; (C.W.); (A.N.R.); (E.M.); (O.S.M.)
- Universitas Airlangga Hospital, Airlangga University, Surabaya 60115, East Java, Indonesia
| | - Bagus Aulia Mahdi
- Department of Internal Medicine, Faculty of Medicine, Airlangga University, Surabaya 60286, East Java, Indonesia; (C.W.); (A.N.R.); (E.M.); (O.S.M.)
| | - Okla Sekar Martani
- Department of Internal Medicine, Faculty of Medicine, Airlangga University, Surabaya 60286, East Java, Indonesia; (C.W.); (A.N.R.); (E.M.); (O.S.M.)
| | - Giarena Giarena
- Department of Internal Medicine, Faculty of Medicine, Airlangga University, Surabaya 60286, East Java, Indonesia; (C.W.); (A.N.R.); (E.M.); (O.S.M.)
| | - Esthiningrum Dewi Agustin
- Department of Internal Medicine, Faculty of Medicine, Airlangga University, Surabaya 60286, East Java, Indonesia; (C.W.); (A.N.R.); (E.M.); (O.S.M.)
| | - Milanitalia Gadys Rosandy
- Department of Internal Medicine, Faculty of Medicine, Brawijaya University, Malang 65145, East Java, Indonesia;
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14
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Affiliation(s)
- Dean R Hess
- Managing Editor, Respiratory Care Respiratory Care Department Massachusetts General Hospital Boston, MassachusettsNortheastern University Boston, Massachusetts
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15
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Higgs EF, Flood BA, Pyzer AR, Rouhani SJ, Trujillo JA, Gajewski TF. Insights from a Rapidly Implemented COVID-19 Biobank Using Electronic Consent and Informatics Tools. Biopreserv Biobank 2023; 21:166-175. [PMID: 35771982 PMCID: PMC10125396 DOI: 10.1089/bio.2021.0169] [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: 01/08/2023] Open
Abstract
Biobanking during the COVID-19 pandemic presented unique challenges regarding patient enrollment, sample collection, and experimental analysis. This report details the ways in which we rapidly overcame those challenges to create a robust database of clinical information and patient samples while maintaining clinician and researcher safety. We developed a pipeline using REDCap (Research Electronic Data Capture) to coordinate electronic informed consent, sample collection, immunological assay execution, and data analysis for biobanking samples from patients with COVID-19. We then integrated immunological assay data with clinical data extracted from the electronic health record to link study parameters with clinical readouts. Of the 193 inpatients who participated in this study, 138 consented electronically and 56 provided paper consent. We collected and banked blood samples to measure circulating cytokines and chemokines, peripheral immune cell composition and activation status, anti-COVID-19 antibodies, and germline gene polymorphisms. In addition, we collected DNA and RNA from nasopharyngeal swabs to assess viral titer and microbiome composition by 16S sequencing. The rapid spread and contagious nature of COVID-19 required special considerations and innovative solutions to biobank samples quickly while protecting researchers and clinicians. Overall, this workflow and computational pipeline allowed for comprehensive immune profiling of 193 inpatients infected with COVID-19, as well as 89 outpatients, 157 patients receiving curbside COVID-19 testing, and 86 healthy controls. We describe a novel electronic framework for biobanking and analyzing patient samples during COVID-19, and present insights and strategies that can be applied more broadly to other biobank studies.
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Affiliation(s)
- Emily F. Higgs
- Department of Pathology, The University of Chicago, Chicago, Illinois, USA
| | - Blake A. Flood
- Department of Pathology, The University of Chicago, Chicago, Illinois, USA
| | - Athalia R. Pyzer
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Sherin J. Rouhani
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Jonathan A. Trujillo
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Thomas F. Gajewski
- Department of Pathology, The University of Chicago, Chicago, Illinois, USA
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, Illinois, USA
- The Ben May Department for Cancer Research, The University of Chicago, Chicago, Illinois, USA
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16
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Unger K, Martin LG. Noncardiogenic pulmonary edema in small animals. J Vet Emerg Crit Care (San Antonio) 2023; 33:156-172. [PMID: 36815753 DOI: 10.1111/vec.13278] [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: 11/13/2020] [Revised: 04/16/2021] [Accepted: 04/16/2021] [Indexed: 02/24/2023]
Abstract
OBJECTIVE To review various types of noncardiogenic pulmonary edema (NCPE) in cats and dogs. ETIOLOGY NCPE is an abnormal fluid accumulation in the lung interstitium or alveoli that is not caused by cardiogenic causes or fluid overload. It can be due to changes in vascular permeability, hydrostatic pressure in the pulmonary vasculature, or a combination thereof. Possible causes include inflammatory states within the lung or in remote tissues (acute respiratory distress syndrome [ARDS]), airway obstruction (post-obstructive pulmonary edema), neurologic disease such as head trauma or seizures (neurogenic pulmonary edema), electrocution, after re-expansion of a collapsed lung or after drowning. DIAGNOSIS Diagnosis of NCPE is generally based on history, physical examination, and diagnostic imaging. Radiographic findings suggestive of NCPE are interstitial to alveolar pulmonary opacities in the absence of signs of left-sided congestive heart failure or fluid overload such as cardiomegaly or congested pulmonary veins. Computed tomography and edema fluid analysis may aid in the diagnosis, while some forms of NCPE require additional findings to reach a diagnosis. THERAPY The goal of therapy for all types of NCPE is to preserve tissue oxygenation and reduce the work of breathing. This may be achieved by removing the inciting cause (eg, airway obstruction) and cage rest in mild cases and supplemental oxygen in moderate cases and may require mechanical ventilation in severe cases. PROGNOSIS Prognosis is generally good for most causes of veterinary NCPE except for ARDS, although data are scarce for some etiologies of NCPE.
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Affiliation(s)
- Karin Unger
- Department of Veterinary Clinical Sciences, Washington State University, Pullman, Washington, USA
| | - Linda G Martin
- Department of Veterinary Clinical Sciences, Washington State University, Pullman, Washington, USA
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17
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Mastruzzo C, Commodari E, Grasso U, La Rosa VL, Balsamo D, Circo C, Oliveri R. Early Stage Combination Treatment with Methylprednisolone Pulse and Remdesivir for Severe COVID-19 Pneumonia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1081. [PMID: 36673839 PMCID: PMC9859517 DOI: 10.3390/ijerph20021081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND This study evaluated the clinical outcomes of patients with severe COVID-19 pneumonia treated with remdesivir plus standard corticosteroid treatment (SCT) or with remdesivir plus high-dose corticosteroid pulse therapy (HDCPT). METHODS One hundred and two patients with severe COVID-19 pneumonia and respiratory failure were included. The patients were divided into two cohorts. The first comprised patients who received remdesivir and SCT, consisting of 6 mg dexamethasone daily for up to 10 days or until hospital discharge. The second included patients who received remdesivir and HDCPT, composed of 250 mg iv of methylprednisolone for three days, followed by a slow reduction in the dose of steroids. The severity of hypoxemia was assessed using the SaO2/FiO2 peripheral oxygen saturation index. RESULTS 55 received remdesivir plus HDCPT, and 47 received remdesivir plus SCT. Mortality at 30 days was significantly lower among patients who received remdesivir plus HDCPT (4/55) than among those who did not (15/47). In patients who received remdesivir plus HDCPT, 7.3% required invasive mechanical ventilation and admission to the ICU and 36.4% non-invasive ventilation versus 29.8% and 61.7%, respectively, among those treated with remdesivir plus SCT. Remdesivir plus HDCPT induced a significantly faster improvement in the SaO2/FiO2 index. CONCLUSION Early combination treatment with remdesivir plus HDCPT reduced in-hospital mortality and the need for admission to the ICU. Furthermore, it improved the SaO2/FiO2 index faster in patients with severe COVID-19 pneumonia.
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Affiliation(s)
- Claudio Mastruzzo
- Unit of Respiratory Diseases, Department of Medicine, Garibaldi Hospital, 95124 Catania, Italy
| | - Elena Commodari
- Department of Educational Sciences, University of Catania, 95124 Catania, Italy
| | - Umberto Grasso
- Unit of Internal Medicine, Department of Medicine, Garibaldi Hospital, 95124 Catania, Italy
| | | | - Daniela Balsamo
- Unit of Internal Medicine, Department of Medicine, Garibaldi Hospital, 95124 Catania, Italy
| | - Cristina Circo
- Unit of Respiratory Diseases, Department of Medicine, Garibaldi Hospital, 95124 Catania, Italy
| | - Rosario Oliveri
- Unit of Respiratory Diseases, Department of Medicine, Garibaldi Hospital, 95124 Catania, Italy
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18
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Wick KD, Matthay MA, Ware LB. Pulse oximetry for the diagnosis and management of acute respiratory distress syndrome. THE LANCET. RESPIRATORY MEDICINE 2022; 10:1086-1098. [PMID: 36049490 PMCID: PMC9423770 DOI: 10.1016/s2213-2600(22)00058-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 01/30/2022] [Accepted: 02/10/2022] [Indexed: 02/07/2023]
Abstract
The diagnosis of acute respiratory distress syndrome (ARDS) traditionally requires calculation of the ratio of partial pressure of arterial oxygen to fraction of inspired oxygen (PaO2/FiO2) using arterial blood, which can be costly and is not possible in many resource-limited settings. By contrast, pulse oximetry is continuously available, accurate, inexpensive, and non-invasive. Pulse oximetry-based indices, such as the ratio of pulse-oximetric oxygen saturation to FiO2 (SpO2/FiO2), have been validated in clinical studies for the diagnosis and risk stratification of patients with ARDS. Limitations of the SpO2/FiO2 ratio include reduced accuracy in poor perfusion states or above oxygen saturations of 97%, and the potential for reduced accuracy in patients with darker skin pigmentation. Application of pulse oximetry to the diagnosis and management of ARDS, including formal adoption of the SpO2/FiO2 ratio as an alternative to PaO2/FiO2 to meet the diagnostic criterion for hypoxaemia in ARDS, could facilitate increased and earlier recognition of ARDS worldwide to advance both clinical practice and research.
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Affiliation(s)
- Katherine D Wick
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California, San Francisco, CA, USA
| | - Michael A Matthay
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California, San Francisco, CA, USA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine and Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN, USA.
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19
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Muniraman HK, Kibe R, Namjoshi A, Song AY, Lakshmanan A, Ramanathan R, Biniwale M. Evaluation of Correlation and Agreement between SpO2/FiO2 ratio and PaO2/FiO2 ratio in Neonates. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1756716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Abstract
Objectives This article evaluates correlation and agreement between oxygen saturation (SpO2)/fraction of inspired oxygen (FiO2) (SF) ratio and partial pressure of oxygen (PaO2)/FiO2 (PF) ratio. It also derives and validates predictive PF ratio from noninvasive SF ratio measurements for clinically relevant PF ratios and derives SF ratio equivalent of PF ratio cutoffs used to define acute lung injury (ALI, PF < 300) and acute respiratory distress syndrome (ARDS, PF < 200).
Methods Retrospective cohort study including neonates with respiratory failure over a 6-year study period. Correlation and agreement between PF ratio with SF ratio was analyzed by Pearson's correlation coefficient and Bland–Altman analysis. Generalized estimating equation was used to derive PF ratio from measured PF ratio and derive corresponding SF ratio for PF ratio cutoffs for ALI and ARDS.
Results A total of 1,019 paired measurements from 196 neonates with mean 28 (± 4.7) weeks' gestational age and 925 (± 1111) g birth weight were analyzed. Strong correlation was noted between SF ratio and PF ratio (r = 0.90). Derived PF ratios from regression (1/PF = –0.0004304 + 2.0897987/SF) showed strong accuracy measures for PF ratio cutoffs < 200 (area under the curve [AUC]: 0.85) and < 100 (AUC: 0.92) with good agreement. Equivalent SF ratio to define ALI was < 450, moderate ARDS was < 355, and severe ARDS was < 220 with strong accuracy measures (AUC > 0.81, 0.84, and 0.93, respectively).
Conclusion SF ratio correlated strongly with PF ratio with good agreement between derived PF ratio from noninvasive SpO2 source and measure PF ratio. Derived PF ratio may be useful to reliably assess severity of respiratory failure in neonates. Further studies are needed to validate SF ratio with clinical illness severity and outcomes.
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Affiliation(s)
- Hemananda K. Muniraman
- Division of Neonatology, Department of Child Health, Phoenix Children's Hospital, University of Arizona, Phoenix, Arizona, United States
- Department of Pediatrics, Creighton University School of Medicine, Phoenix, Arizona, United States
| | - Rutuja Kibe
- Division of Neonatology, Department of Pediatrics, LAC+ USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, California, United States
| | - Abhijeet Namjoshi
- Division of Neonatology, Department of Child Health, Phoenix Children's Hospital, University of Arizona, Phoenix, Arizona, United States
| | - Ashley Y. Song
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States
| | - Ashwini Lakshmanan
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
- Fetal and Neonatal Institute, Division of Neonatology, Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, United States
| | - Rangasamy Ramanathan
- Division of Neonatology, Department of Pediatrics, LAC+ USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, California, United States
| | - Manoj Biniwale
- Division of Neonatology, Department of Pediatrics, LAC+ USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, California, United States
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20
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Ortiz G, Bastidas A, Garay-Fernández M, Lara A, Benavides M, Rocha E, Buitrago A, Díaz G, Ordóñez J, Reyes LF. Correlation and validity of imputed PaO2/FiO2 and SpO2/FiO2 in patients with invasive mechanical ventilation at 2600m above sea level. Med Intensiva 2022; 46:501-507. [PMID: 36057441 DOI: 10.1016/j.medine.2021.05.010] [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: 02/06/2021] [Accepted: 05/04/2021] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To establish the correlation and validity between PaO2/FiO2 obtained on arterial gases versus noninvasive methods (linear, nonlinear, logarithmic imputation of PaO2/FiO2 and SpO2/FiO2) in patients under mechanical ventilation living at high altitude. DESIGN Ambispective descriptive multicenter cohort study. SETTING Two intensive care units (ICU) from Colombia at 2600m a.s.l. PATIENTS OR PARTICIPANTS Consecutive critically ill patients older than 18 years with at least 24h of mechanical ventilation were included from June 2016 to June 2019. INTERVENTIONS None. VARIABLES Variables analyzed were demographic, physiological messures, laboratory findings, oxygenation index and clinical condition. Nonlinear, linear and logarithmic imputation formulas were used to calculate PaO2 from SpO2, and at the same time the SpO2/FiO2 by severe hypoxemia diagnosis. The intraclass correlation coefficient, area under the ROC curve, sensitivity, specificity, positive predictive value, negative predictive value, positive and negative likelihood ratio were calculated. RESULTS The correlation between PaO2/FiO2 obtained from arterial gases, PaO2/FiO2 derived from one of the proposed methods (linear, non-linear, and logarithmic formula), and SpO2/FiO2 measured by the intraclass correlation coefficient was high (greater than 0.77, p<0.001). The different imputation methods and SpO2/FiO2 have a similar diagnostic performance in patients with severe hypoxemia (PaO2/FiO2 <150). PaO2/FiO2 linear imputation AUC ROC 0,84 (IC 0.81-0.87, p<0.001), PaO2/FiO2 logarithmic imputation AUC ROC 0.84 (IC 0.80-0.87, p<0.001), PaO2/FiO2 non-linear imputation AUC ROC 0.82 (IC 0.79-0.85, p<0.001), SpO2/FiO2 oximetry AUC ROC 0.84 (IC 0.81-0.87, p<0.001). CONCLUSIONS At high altitude, the SaO2/FiO2 ratio and the imputed PaO2/FiO2 ratio have similar diagnostic performance in patients with severe hypoxemia ventilated by various pathological conditions.
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Affiliation(s)
- G Ortiz
- Pulmonary Medicine, Universidad El Bosque, Intensive Care Unit, Hospital Santa Clara Bogotá, Colombia
| | - A Bastidas
- School of Medicine, Universidad de la Sabana, Clínica Universidad de La Sabana, Chía, Colombia.
| | - M Garay-Fernández
- Pulmonary Medicine Universidad El Bosque, Intensive Care Unit, Hospital Santa Clara Bogotá, Colombia
| | - A Lara
- Pulmonary Medicine Universidad El Bosque, Intensive Care Unit, Hospital Santa Clara Bogotá, Colombia
| | - M Benavides
- Pulmonary Medicine Universidad El Bosque, Intensive Care Unit, Hospital Santa Clara Bogotá, Colombia
| | - E Rocha
- Intensive Care Unit, Hospital Santa Clara Bogotá, Colombia
| | - A Buitrago
- Pulmonary Medicine Universidad El Bosque, Intensive Care Unit, Hospital Santa Clara Bogotá, Colombia
| | - G Díaz
- Pulmonary Medicine Universidad El Bosque, Intensive Care Unit, Hospital Santa Clara Bogotá, Colombia
| | - J Ordóñez
- Pulmonary Medicine Universidad El Bosque, Intensive Care Unit, Hospital Santa Clara Bogotá, Colombia
| | - L F Reyes
- School of Medicine, Universidad de la Sabana, Clínica Universidad de La Sabana, Chía, Colombia
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21
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Yuan X, Pan C, Xie J, Qiu H, Liu L. An expanded definition of acute respiratory distress syndrome: Challenging the status quo. JOURNAL OF INTENSIVE MEDICINE 2022; 3:62-64. [PMID: 36785583 PMCID: PMC9848386 DOI: 10.1016/j.jointm.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/16/2022] [Accepted: 06/24/2022] [Indexed: 10/16/2022]
Abstract
Although the Berlin definition of acute respiratory distress syndrome (ARDS), 2012 has been widely used in clinical practice, issues have occasionally been raised regarding various criteria since it was proposed. High-flow nasal oxygen (HFNO) is widely used for effective respiratory support in acute respiratory failure. As patients who do not require ventilation but meet the Berlin criteria have similar characteristics to those with ARDS, the definition of ARDS may be broadened to include patients receiving HFNO. As the PaO2/FiO2 under-recognizes the diagnosis of ARDS, a SpO2/FiO2 value of ≤315 may be considered instead of a PaO2/FiO2 value of ≤300 for diagnosing the condition in resource-constrained settings. In this context, patients with severe COVID-19 always meet other criteria for ARDS except for 7-day acute onset. Therefore, the timeframe for the onset of ARDS may be extended to up to 14 days. An expanded definition of ARDS may allow early identification of patients with less severe diseases and facilitate testing and application of new therapies in patients with a high risk of poor outcomes. Here, we discuss the major controversies regarding the extension of the ARDS definition with a view to improving clinical implementation and patient outcomes.
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22
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Tasaka S, Ohshimo S, Takeuchi M, Yasuda H, Ichikado K, Tsushima K, Egi M, Hashimoto S, Shime N, Saito O, Matsumoto S, Nango E, Okada Y, Hayashi K, Sakuraya M, Nakajima M, Okamori S, Miura S, Fukuda T, Ishihara T, Kamo T, Yatabe T, Norisue Y, Aoki Y, Iizuka Y, Kondo Y, Narita C, Kawakami D, Okano H, Takeshita J, Anan K, Okazaki SR, Taito S, Hayashi T, Mayumi T, Terayama T, Kubota Y, Abe Y, Iwasaki Y, Kishihara Y, Kataoka J, Nishimura T, Yonekura H, Ando K, Yoshida T, Masuyama T, Sanui M. ARDS Clinical Practice Guideline 2021. J Intensive Care 2022; 10:32. [PMID: 35799288 PMCID: PMC9263056 DOI: 10.1186/s40560-022-00615-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 05/10/2022] [Indexed: 12/16/2022] Open
Abstract
Background The joint committee of the Japanese Society of Intensive Care Medicine/Japanese Respiratory Society/Japanese Society of Respiratory Care Medicine on ARDS Clinical Practice Guideline has created and released the ARDS Clinical Practice Guideline 2021. Methods The 2016 edition of the Clinical Practice Guideline covered clinical questions (CQs) that targeted only adults, but the present guideline includes 15 CQs for children in addition to 46 CQs for adults. As with the previous edition, we used a systematic review method with the Grading of Recommendations Assessment Development and Evaluation (GRADE) system as well as a degree of recommendation determination method. We also conducted systematic reviews that used meta-analyses of diagnostic accuracy and network meta-analyses as a new method. Results Recommendations for adult patients with ARDS are described: we suggest against using serum C-reactive protein and procalcitonin levels to identify bacterial pneumonia as the underlying disease (GRADE 2D); we recommend limiting tidal volume to 4–8 mL/kg for mechanical ventilation (GRADE 1D); we recommend against managements targeting an excessively low SpO2 (PaO2) (GRADE 2D); we suggest against using transpulmonary pressure as a routine basis in positive end-expiratory pressure settings (GRADE 2B); we suggest implementing extracorporeal membrane oxygenation for those with severe ARDS (GRADE 2B); we suggest against using high-dose steroids (GRADE 2C); and we recommend using low-dose steroids (GRADE 1B). The recommendations for pediatric patients with ARDS are as follows: we suggest against using non-invasive respiratory support (non-invasive positive pressure ventilation/high-flow nasal cannula oxygen therapy) (GRADE 2D), we suggest placing pediatric patients with moderate ARDS in the prone position (GRADE 2D), we suggest against routinely implementing NO inhalation therapy (GRADE 2C), and we suggest against implementing daily sedation interruption for pediatric patients with respiratory failure (GRADE 2D). Conclusions This article is a translated summary of the full version of the ARDS Clinical Practice Guideline 2021 published in Japanese (URL: https://www.jsicm.org/publication/guideline.html). The original text, which was written for Japanese healthcare professionals, may include different perspectives from healthcare professionals of other countries. Supplementary Information The online version contains supplementary material available at 10.1186/s40560-022-00615-6.
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Affiliation(s)
- Sadatomo Tasaka
- Department of Respiratory Medicine, Hirosaki University Graduate School of Medicine, 5 Zaifucho, Hirosaki, Aomori, 036-8562, Japan.
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kazuya Ichikado
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Kenji Tsushima
- International University of Health and Welfare, Tokyo, Japan
| | - Moritoki Egi
- Department of Anesthesiology, Kobe University Hospital, Hyogo, Japan
| | - Satoru Hashimoto
- Department of Anesthesiology and Intensive Care Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Osamu Saito
- Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Shotaro Matsumoto
- Division of Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Eishu Nango
- Department of Family Medicine, Seibo International Catholic Hospital, Tokyo, Japan
| | - Yohei Okada
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kenichiro Hayashi
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
| | - Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Mikio Nakajima
- Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Satoshi Okamori
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shinya Miura
- Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
| | - Tatsuma Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Tadashi Ishihara
- Department of Emergency and Critical Care Medicine, Urayasu Hospital, Juntendo University, Chiba, Japan
| | - Tetsuro Kamo
- Department of Critical Care Medicine, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Tomoaki Yatabe
- Department of Anesthesiology, Nishichita General Hospital, Tokai, Japan
| | | | - Yoshitaka Aoki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Yusuke Iizuka
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Chihiro Narita
- Department of Emergency Medicine, Shizuoka General Hospital, Shizuoka, Japan
| | - Daisuke Kawakami
- Department of Anesthesia and Critical Care, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Hiromu Okano
- Department of Critical Care and Emergency Medicine, National Hospital Organization Yokohama Medical Center, Kanagawa, Japan
| | - Jun Takeshita
- Department of Anesthesiology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Keisuke Anan
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kyoto, Japan
| | | | - Shunsuke Taito
- Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, Hiroshima, Japan
| | - Takuya Hayashi
- Pediatric Emergency and Critical Care Center, Saitama Children's Medical Center, Saitama, Japan
| | - Takuya Mayumi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Takero Terayama
- Department of Psychiatry, School of Medicine, National Defense Medical College, Saitama, Japan
| | - Yoshifumi Kubota
- Kameda Medical Center Department of Infectious Diseases, Chiba, Japan
| | - Yoshinobu Abe
- Division of Emergency and Disaster Medicine Tohoku Medical and Pharmaceutical University, Miyagi, Japan
| | - Yudai Iwasaki
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Yuki Kishihara
- Department of Emergency Medicine, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Jun Kataoka
- Department of Critical Care Medicine, Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Tetsuro Nishimura
- Department of Traumatology and Critical Care Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiroshi Yonekura
- Department of Anesthesiology and Pain Medicine, Fujita Health University Bantane Hospital, Aichi, Japan
| | - Koichi Ando
- Division of Respiratory Medicine and Allergology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Takuo Yoshida
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, Tokyo, Japan
| | - Tomoyuki Masuyama
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
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23
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Tasaka S, Ohshimo S, Takeuchi M, Yasuda H, Ichikado K, Tsushima K, Egi M, Hashimoto S, Shime N, Saito O, Matsumoto S, Nango E, Okada Y, Hayashi K, Sakuraya M, Nakajima M, Okamori S, Miura S, Fukuda T, Ishihara T, Kamo T, Yatabe T, Norisue Y, Aoki Y, Iizuka Y, Kondo Y, Narita C, Kawakami D, Okano H, Takeshita J, Anan K, Okazaki SR, Taito S, Hayashi T, Mayumi T, Terayama T, Kubota Y, Abe Y, Iwasaki Y, Kishihara Y, Kataoka J, Nishimura T, Yonekura H, Ando K, Yoshida T, Masuyama T, Sanui M. ARDS clinical practice guideline 2021. Respir Investig 2022; 60:446-495. [PMID: 35753956 DOI: 10.1016/j.resinv.2022.05.003] [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: 04/19/2022] [Revised: 05/07/2022] [Accepted: 05/13/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND The joint committee of the Japanese Society of Intensive Care Medicine/Japanese Respiratory Society/Japanese Society of Respiratory Care Medicine on ARDS Clinical Practice Guideline has created and released the ARDS Clinical Practice Guideline 2021. METHODS The 2016 edition of the Clinical Practice Guideline covered clinical questions (CQs) that targeted only adults, but the present guideline includes 15 CQs for children in addition to 46 CQs for adults. As with the previous edition, we used a systematic review method with the Grading of Recommendations Assessment Development and Evaluation (GRADE) system as well as a degree of recommendation determination method. We also conducted systematic reviews that used meta-analyses of diagnostic accuracy and network meta-analyses as a new method. RESULTS Recommendations for adult patients with ARDS are described: we suggest against using serum C-reactive protein and procalcitonin levels to identify bacterial pneumonia as the underlying disease (GRADE 2D); we recommend limiting tidal volume to 4-8 mL/kg for mechanical ventilation (GRADE 1D); we recommend against managements targeting an excessively low SpO2 (PaO2) (GRADE 2D); we suggest against using transpulmonary pressure as a routine basis in positive end-expiratory pressure settings (GRADE 2B); we suggest implementing extracorporeal membrane oxygenation for those with severe ARDS (GRADE 2B); we suggest against using high-dose steroids (GRADE 2C); and we recommend using low-dose steroids (GRADE 1B). The recommendations for pediatric patients with ARDS are as follows: we suggest against using non-invasive respiratory support (non-invasive positive pressure ventilation/high-flow nasal cannula oxygen therapy) (GRADE 2D); we suggest placing pediatric patients with moderate ARDS in the prone position (GRADE 2D); we suggest against routinely implementing NO inhalation therapy (GRADE 2C); and we suggest against implementing daily sedation interruption for pediatric patients with respiratory failure (GRADE 2D). CONCLUSIONS This article is a translated summary of the full version of the ARDS Clinical Practice Guideline 2021 published in Japanese (URL: https://www.jrs.or.jp/publication/jrs_guidelines/). The original text, which was written for Japanese healthcare professionals, may include different perspectives from healthcare professionals of other countries.
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Affiliation(s)
- Sadatomo Tasaka
- Department of Respiratory Medicine, Hirosaki University Graduate School of Medicine, Aomori, Japan.
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Saitama, Japan
| | - Kazuya Ichikado
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Kenji Tsushima
- International University of Health and Welfare, Tokyo, Japan
| | - Moritoki Egi
- Department of Anesthesiology, Kobe University Hospital, Hyogo, Japan
| | - Satoru Hashimoto
- Department of Anesthesiology and Intensive Care Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Osamu Saito
- Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Shotaro Matsumoto
- Division of Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Eishu Nango
- Department of Family Medicine, Seibo International Catholic Hospital, Tokyo, Japan
| | - Yohei Okada
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kenichiro Hayashi
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
| | - Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Mikio Nakajima
- Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Satoshi Okamori
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shinya Miura
- Paediatric Intensive Care Unit, The Royal Children's Hospital Melbourne, Melbourne, Australia
| | - Tatsuma Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Tadashi Ishihara
- Department of Emergency and Critical Care Medicine, Juntendo University, Urayasu Hospital, Chiba, Japan
| | - Tetsuro Kamo
- Department of Critical Care Medicine, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Tomoaki Yatabe
- Department of Anesthesiology, Nishichita General Hospital, Aichi, Japan
| | | | - Yoshitaka Aoki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Yusuke Iizuka
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University, Urayasu Hospital, Chiba, Japan
| | - Chihiro Narita
- Department of Emergency Medicine, Shizuoka General Hospital, Shizuoka, Japan
| | - Daisuke Kawakami
- Department of Anesthesia and Critical Care, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Hiromu Okano
- Department of Critical Care and Emergency Medicine, National Hospital Organization Yokohama Medical Center, Kanagawa, Japan
| | - Jun Takeshita
- Department of Anesthesiology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Keisuke Anan
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | | | - Shunsuke Taito
- Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, Hiroshima, Japan
| | - Takuya Hayashi
- Pediatric Emergency and Critical Care Center, Saitama Children's Medical Center, Saitama, Japan
| | - Takuya Mayumi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Takero Terayama
- Department of Psychiatry, School of Medicine, National Defense Medical College, Saitama, Japan
| | - Yoshifumi Kubota
- Department of Infectious Diseases, Kameda Medical Center, Chiba, Japan
| | - Yoshinobu Abe
- Division of Emergency and Disaster Medicine, Tohoku Medical and Pharmaceutical University, Miyagi, Japan
| | - Yudai Iwasaki
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Yuki Kishihara
- Department of Emergency Medicine, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Jun Kataoka
- Department of Critical Care Medicine, Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Tetsuro Nishimura
- Department of Traumatology and Critical Care Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiroshi Yonekura
- Department of Anesthesiology and Pain Medicine, Fujita Health University Bantane Hospital, Aichi, Japan
| | - Koichi Ando
- Division of Respiratory Medicine and Allergology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Takuo Yoshida
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, Tokyo, Japan
| | - Tomoyuki Masuyama
- Department of Emergency and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Saitama, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
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Schwartz BC, Jayaraman D, Yang SS, Wong EG, Lipes J, Dial S. High-flow nasal oxygen as first-line therapy for COVID-19-associated hypoxemic respiratory failure: a single-centre historical cohort study. Can J Anaesth 2022; 69:582-590. [PMID: 35211876 PMCID: PMC8870079 DOI: 10.1007/s12630-022-02218-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 11/11/2021] [Accepted: 11/11/2021] [Indexed: 12/15/2022] Open
Abstract
PURPOSE The optimal noninvasive modality for oxygenation support in COVID-19-associated hypoxemic respiratory failure and its association with healthcare worker infection remain uncertain. We report here our experience using high-flow nasal oxygen (HFNO) as the primary support mode for patients with COVID-19 in our institution. METHODS We conducted a single-centre historical cohort study of all COVID-19 patients treated with HFNO for at least two hours in our university-affiliated and intensivist-staffed intensive care unit (Jewish General Hospital, Montreal, QC, Canada) between 27 August 2020 and 30 April 2021. We report their clinical characteristics and outcomes. Healthcare workers in our unit cared for these patients in single negative pressure rooms wearing KN95 or fit-tested N95 masks; they underwent mandatory symptomatic screening for COVID-19 infection, as well as a period of asymptomatic screening. RESULTS One hundred and forty-two patients were analysed, with a median [interquartile range (IQR)] age of 66 [59-73] yr; 71% were male. Patients had a median [IQR] Sequential Organ Failure Assessment Score of 3 [2-3], median [IQR] oxygen saturation by pulse oximetry/fraction of inspired oxygen ratio of 120 [94-164], and a median [IQR] 4C score (a COVID-19-specific mortality score) of 12 [10-14]. Endotracheal intubation occurred in 48/142 (34%) patients, and overall hospital mortality was 16%. Barotrauma occurred in 21/142 (15%) patients. Among 27 symptomatic and 139 asymptomatic screening tests, there were no cases of HFNO-related COVID-19 transmission to healthcare workers. CONCLUSION Our experience indicates that HFNO is an effective first-line therapy for hypoxemic respiratory failure in COVID-19 patients, and can be safely used without significant discernable infection risk to healthcare workers.
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Affiliation(s)
- Blair Carl Schwartz
- Division of Critical Care, Jewish General Hospital, McGill University, Pavilion H-364.1, 3755 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1E2, Canada.
| | - Dev Jayaraman
- Division of Critical Care, Jewish General Hospital, McGill University, Pavilion H-364.1, 3755 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1E2, Canada
| | - Stephen Su Yang
- Division of Critical Care, Jewish General Hospital, McGill University, Pavilion H-364.1, 3755 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1E2, Canada
| | - Evan G Wong
- Division of Critical Care, Jewish General Hospital, McGill University, Pavilion H-364.1, 3755 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1E2, Canada
| | - Jed Lipes
- Division of Critical Care, Jewish General Hospital, McGill University, Pavilion H-364.1, 3755 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1E2, Canada
| | - Sandra Dial
- Division of Critical Care, Jewish General Hospital, McGill University, Pavilion H-364.1, 3755 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1E2, Canada
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Numata K, Kobayashi D, Hosoda T, Saito Y, Minoura A, Yamazaki S, Fujitani S. Efficacy of awake prone positioning for severe illness coronavirus disease 2019 patients: a propensity
score‐adjusted
cohort study. Acute Med Surg 2022; 9:e734. [PMID: 35169487 PMCID: PMC8840898 DOI: 10.1002/ams2.734] [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: 09/25/2021] [Revised: 01/14/2022] [Accepted: 01/26/2022] [Indexed: 12/12/2022] Open
Abstract
Aim Awake prone positioning (PP) in patients with coronavirus disease 2019 (COVID‐19) can improve oxygenation. However, evidence showing that it can prevent intubation is lacking. This study investigated the efficacy of awake PP in patients with COVID‐19 who received remdesivir, dexamethasone, and anticoagulant therapy. Methods This was a two‐center cohort study. Patients admitted to the severe COVID‐19 patient unit were included. The primary outcome was the intubation rate and secondary outcome was length of stay in the severe COVID‐19 unit. After propensity score adjustment, we undertook multivariable regression to calculate the estimates of outcomes between patients who received awake PP and those who did not. Results Overall, 108 patients were included (54 [50.0%] patients each who did and did not undergo awake PP), of whom 25 (23.2%) were intubated (with awake PP, 5 [9.3%] vs. without awake PP, 20 [37.0%]; P < 0.01). The median length of stay in the severe COVID‐19 unit did not significantly differ (with awake PP, 5 days vs. without awake PP, 5.5 days; P = 0.68). After propensity score adjustment, those who received awake PP had a lower intubation rate than those who did not (odds ratio, 0.22; 95% confidence interval, 0.06–0.85; P = 0.03). Length of stay in the severe COVID‐19 patient unit did not differ significantly (adjusted percentage difference, −24.4%; 95% confidence interval, −56.3% to 30.8%; P = 0.32). Conclusion Awake PP could be correlated with intubation rate in patients with COVID‐19 who are receiving remdesivir, dexamethasone, and anticoagulant therapy.
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Affiliation(s)
- Kenji Numata
- Department of Emergency and Critical Care Medicine St Marianna University School of Medicine Kawasaki Japan
| | - Daiki Kobayashi
- Division of General Internal Medicine St Luke’s International Hospital Tokyo Japan
| | - Tomohiro Hosoda
- Department of Infectious Diseases Kawasaki Municipal Hospital Kawasaki Japan
| | - Yutaka Saito
- Department of Emergency Medicine Kawasaki Municipal Hospital Kawasaki Japan
| | - Ayu Minoura
- Department of Emergency and Critical Care Medicine St Marianna University School of Medicine Kawasaki Japan
| | - Satsuki Yamazaki
- Department of Emergency and Critical Care Medicine St Marianna University School of Medicine Kawasaki Japan
| | - Shigeki Fujitani
- Department of Emergency and Critical Care Medicine St Marianna University School of Medicine Kawasaki Japan
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Cagle LA, Hopper K, Epstein SE. Indications and outcome associated with positive-pressure ventilation in dogs and cats: 127 cases. J Vet Emerg Crit Care (San Antonio) 2022; 32:365-375. [PMID: 35043547 DOI: 10.1111/vec.13176] [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: 08/11/2020] [Revised: 12/31/2020] [Accepted: 01/14/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine the indications and outcomes of positive-pressure ventilation (PPV) and identify factors associated with successful weaning. DESIGN Retrospective study from October 2009 to September 2013. SETTING University teaching hospital. ANIMALS One hundred and eleven dogs and 16 cats. MEASUREMENTS AND MAIN RESULTS Medical records were retrospectively reviewed; signalment, indication for PPV, patient characteristics, blood gas, and ventilator variables during PPV, duration of PPV, and outcome were recorded. Dogs were most commonly ventilated for pneumonia (36/111; 32%) and cats for multiple pulmonary diseases (8/16; 50%). The median duration of PPV for all animals was 25.7 h (range, 0.1-957 h). Long-term PPV (≥24 h) was performed in 53% of cases. No differences were noted in successful weaning rates between cases ventilated for pulmonary etiologies (23/99; 23%) versus nonpulmonary etiologies (9/28; 32%). Overall, 32 of 127 (25%; 30 dogs, 2 cats) animals were successfully weaned from PPV and 28 of 127 (22%; 26 dogs, 2 cats) survived to hospital discharge. Long-term ventilation had a higher likelihood of successful weaning (26/67 [39%] vs 6/60 [10%], P = 0.0002) and higher rates of survival to discharge (23/67 [34%] vs 5/60 [8%], P = 0.0005) than short-term ventilation. Animals with higher Pao2 /Fio2 and Spo2 /Fio2 and lower APPLE and SOFA scores on day 1 of PPV were more likely to be weaned (P < 0.03). CONCLUSIONS The outcome of PPV appears to be most heavily determined by the underlying disease process and no clear improvement in outcome could be demonstrated in this study, despite advances in veterinary critical care and ventilator management strategies since previous studies. Dogs and cats receiving PPV for more than 24 h in this study had a higher likelihood of a positive outcome. Several indices of oxygenation and illness severity at the onset of PPV were predictive of outcome and maybe useful when considering prognosis of these cases.
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Affiliation(s)
- Laura A Cagle
- William R. Pritchard Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
| | - Kate Hopper
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
| | - Steven E Epstein
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
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Dong GY, Jin FF, Huang Q, Wu CB, Zhu JH, Wang TB. Exploratory COVID-19 death risk score based on basic laboratory tests and physiological clinical measurements. World J Emerg Med 2022; 13:453-458. [PMID: 36636572 PMCID: PMC9807385 DOI: 10.5847/wjem.j.1920-8642.2022.103] [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: 03/09/2022] [Accepted: 06/10/2022] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND In the event of a sudden shortage of medical resources, a rapid, simple, and accurate prediction model is essential for the 30-day mortality rate of patients with COVID-19. METHODS This retrospective study compared the characteristics of the survivals and non-survivals of 278 patients with COVID-19. Logistic regression analysis was performed to obtain the "COVID-19 death risk score" (CDRS) model. Using the area under the receiver operating characteristic (AUROC) curve and Hosmer-Lemeshow goodness-of-fit test, discrimination and calibration were assessed. Internal validation was conducted using a regular bootstrap method. RESULTS A total of 63 (22.66%) of 278 included patients died. The logistic regression analysis revealed that high-sensitivity C-reactive protein (hsCRP; odds ratio [OR]=1.018), D-dimer (OR=1.101), and respiratory rate (RR; OR=1.185) were independently associated with 30-day mortality. CDRS was calculated as follows: CDRS=-10.245+(0.022×hsCRP)+(0.172×D-dimer)+(0.203×RR). CDRS had the same predictive effect as the sequential organ failure assessment (SOFA) and "confusion, uremia, respiratory rate, blood pressure, and age over 65 years" (CURB-65) scores, with AUROCs of 0.984 for CDRS, 0.975 for SOFA, and 0.971 for CURB-65, respectively. And CDRS showed good calibration. The AUROC through internal validations was 0.980 (95% confidence interval [CI]: 0.965-0.995). Regarding the clinical value, the decision curve analysis of CDRS showed a net value similar to that of CURB-65 in this cohort. CONCLUSION CDRS is a novel, efficient and accurate prediction model for the early identification of COVID-19 patients with poor outcomes. Although it is not as advanced as the other models, CDRS had a similar performance to that of SOFA and CURB-65.
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Affiliation(s)
- Gui-ying Dong
- Emergency Department, Peking University People’s Hospital, Beijing 100044, China
| | - Fei-fei Jin
- Trauma Center, Peking University People’s Hospital, Key Laboratory of Trauma and Neural Regeneration (Peking University), Ministry of Education, Beijing100044, China
| | - Qi Huang
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing100044, China
| | - Chun-bo Wu
- Emergency Department, Peking University People’s Hospital, Beijing 100044, China
| | - Ji-hong Zhu
- Emergency Department, Peking University People’s Hospital, Beijing 100044, China,Corresponding Authors: Ji-hong Zhu, ;
| | - Tian-bing Wang
- Trauma Center, Peking University People’s Hospital, Key Laboratory of Trauma and Neural Regeneration (Peking University), Ministry of Education, Beijing100044, China,
Tian-bing Wang,
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Babu S, Abhilash KP, Kandasamy S, Gowri M. Association between SpO 2/FiO 2 Ratio and PaO 2/FiO 2 Ratio in Different Modes of Oxygen Supplementation. Indian J Crit Care Med 2021; 25:1001-1005. [PMID: 34963717 PMCID: PMC8664040 DOI: 10.5005/jp-journals-10071-23977] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Acute hypoxemic respiratory failure (AHRF) is a major factor for increased mortality in the intensive care unit (ICU). We hypothesized that the noninvasive index SpO2/FiO2 (SF) ratio can be used as a surrogate to invasive index PaO2/FiO2 (PF) as SF ratio correlates with PF ratio in all modes of oxygen supplementation. Patients and methods Patients with acute respiratory failure admitted to the intensive care unit were enrolled in this retrospective cross-sectional study. Fraction of inspired oxygen (FiO2), method of oxygen supplementation, and partial pressure of arterial oxygen (PaO2) were noted from the ABG reports in the medical records. The corresponding SpO2 was noted from the nurse's chart. The calculated SF and PF ratios were recorded, and correlation between the same was noted in different methods of oxygen administration. Results A total of 300-sample data were collected. Pearson's correlation was used to quantify the relationship between the variables. The study showed a positive correlation, r = 0.66 (p <0.001), between PF ratio and SF ratio. SF threshold values were 285 and 323 for corresponding PF values of 200 and 300 with a sensitivity and specificity in the range of 70 to 80%. In addition, SF and PF could also be used interchangeably irrespective of the mode of oxygen supplementation, as the median values of PF ratio (p = 0.06) and SF ratio (p = 0.88) were not statistically significant. Conclusion In patients with AHRF, the noninvasive SF ratio can be used as a surrogate to invasive index PF in all modes of oxygen supplementation. How to cite this article Babu S, Abhilash KPP, Kandasamy S, Gowri M. Association between SpO2/FiO2 Ratio and PaO2/FiO2 Ratio in Different Modes of Oxygen Supplementation. Indian J Crit Care Med 2021;25(9):1001–1005.
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Affiliation(s)
- Sheetal Babu
- Surgical Intensive Care Unit, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Subramani Kandasamy
- Division of Critical Care and Surgical ICU, Christian Medical College, Vellore, Tamil Nadu, India
| | - Mahasampath Gowri
- Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India
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Zheng H, Zhu J, Xie W, Zhong J. Reinforcement learning assisted oxygen therapy for COVID-19 patients under intensive care. BMC Med Inform Decis Mak 2021; 21:350. [PMID: 34920724 PMCID: PMC8678583 DOI: 10.1186/s12911-021-01712-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 11/12/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Patients with severe Coronavirus disease 19 (COVID-19) typically require supplemental oxygen as an essential treatment. We developed a machine learning algorithm, based on deep Reinforcement Learning (RL), for continuous management of oxygen flow rate for critically ill patients under intensive care, which can identify the optimal personalized oxygen flow rate with strong potentials to reduce mortality rate relative to the current clinical practice. METHODS We modeled the oxygen flow trajectory of COVID-19 patients and their health outcomes as a Markov decision process. Based on individual patient characteristics and health status, an optimal oxygen control policy is learned by using deep deterministic policy gradient (DDPG) and real-time recommends the oxygen flow rate to reduce the mortality rate. We assessed the performance of proposed methods through cross validation by using a retrospective cohort of 1372 critically ill patients with COVID-19 from New York University Langone Health ambulatory care with electronic health records from April 2020 to January 2021. RESULTS The mean mortality rate under the RL algorithm is lower than the standard of care by 2.57% (95% CI: 2.08-3.06) reduction (P < 0.001) from 7.94% under the standard of care to 5.37% under our proposed algorithm. The averaged recommended oxygen flow rate is 1.28 L/min (95% CI: 1.14-1.42) lower than the rate delivered to patients. Thus, the RL algorithm could potentially lead to better intensive care treatment that can reduce the mortality rate, while saving the oxygen scarce resources. It can reduce the oxygen shortage issue and improve public health during the COVID-19 pandemic. CONCLUSIONS A personalized reinforcement learning oxygen flow control algorithm for COVID-19 patients under intensive care showed a substantial reduction in 7-day mortality rate as compared to the standard of care. In the overall cross validation cohort independent of the training data, mortality was lowest in patients for whom intensivists' actual flow rate matched the RL decisions.
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Affiliation(s)
- Hua Zheng
- Department of Mechanical and Industrial Engineering, Northeastern University, 360 Huntington Avenue, 334 SN, Boston, MA, 02115, USA
| | - Jiahao Zhu
- Department of Mechanical and Industrial Engineering, Northeastern University, 360 Huntington Avenue, 334 SN, Boston, MA, 02115, USA
| | - Wei Xie
- Department of Mechanical and Industrial Engineering, Northeastern University, 360 Huntington Avenue, 334 SN, Boston, MA, 02115, USA.
| | - Judy Zhong
- Division of Biostatistics, Department of Population Health, New York University School of Medicine, NYU Langone Health, 180 Madison Avenue, 4th Floor, Room 452, New York, NY, 10016, USA.
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Roozeman JP, Mazzinari G, Serpa Neto A, Hollmann MW, Paulus F, Schultz MJ, Pisani L. Prognostication using SpO 2/FiO 2 in invasively ventilated ICU patients with ARDS due to COVID-19 - Insights from the PRoVENT-COVID study. J Crit Care 2021; 68:31-37. [PMID: 34872014 PMCID: PMC8641962 DOI: 10.1016/j.jcrc.2021.11.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/02/2021] [Accepted: 11/13/2021] [Indexed: 12/19/2022]
Abstract
Background The SpO2/FiO2 is a useful oxygenation parameter with prognostic capacity in patients with ARDS. We investigated the prognostic capacity of SpO2/FiO2 for mortality in patients with ARDS due to COVID–19. Methods This was a post-hoc analysis of a national multicenter cohort study in invasively ventilated patients with ARDS due to COVID–19. The primary endpoint was 28–day mortality. Results In 869 invasively ventilated patients, 28–day mortality was 30.1%. The SpO2/FiO2 on day 1 had no prognostic value. The SpO2/FiO2 on day 2 and day 3 had prognostic capacity for death, with the best cut-offs being 179 and 199, respectively. Both SpO2/FiO2 on day 2 (OR, 0.66 [95%–CI 0.46–0.96]) and on day 3 (OR, 0.70 [95%–CI 0.51–0.96]) were associated with 28–day mortality in a model corrected for age, pH, lactate levels and kidney dysfunction (AUROC 0.78 [0.76–0.79]). The measured PaO2/FiO2 and the PaO2/FiO2 calculated from SpO2/FiO2 were strongly correlated (Spearman's r = 0.79). Conclusions In this cohort of patients with ARDS due to COVID–19, the SpO2/FiO2 on day 2 and day 3 are independently associated with and have prognostic capacity for 28–day mortality. The SpO2/FiO2 is a useful metric for risk stratification in invasively ventilated COVID–19 patients.
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Affiliation(s)
- Jan-Paul Roozeman
- Department of Intensive Care, Amsterdam UMC, Location 'AMC', Amsterdam, the Netherlands; Department of Anesthesiology, Amsterdam UMC, Location 'AMC', Amsterdam, the Netherlands.
| | - Guido Mazzinari
- Department of Anesthesiology, Hospital Universitario la Fe, Valencia, Spain; Perioperative Medicine Research Group, Instituto de Investigación Sanitaria Valencia, Spain
| | - Ary Serpa Neto
- Department of Intensive Care, Amsterdam UMC, Location 'AMC', Amsterdam, the Netherlands; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam UMC, Location 'AMC', Amsterdam, the Netherlands
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam UMC, Location 'AMC', Amsterdam, the Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC, Location 'AMC', Amsterdam, the Netherlands; Department of Anesthesiology, Amsterdam UMC, Location 'AMC', Amsterdam, the Netherlands; Mahidol-Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Luigi Pisani
- Department of Intensive Care, Amsterdam UMC, Location 'AMC', Amsterdam, the Netherlands; Anesthesia and Intensive Care Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy; Department of Anesthesiology and Intensive Care Medicine, Miulli Regional Hospital, Acquaviva delle Fonti, Italy
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Li J, Scott JB, Fink JB, Reed B, Roca O, Dhand R. Optimizing high-flow nasal cannula flow settings in adult hypoxemic patients based on peak inspiratory flow during tidal breathing. Ann Intensive Care 2021; 11:164. [PMID: 34837553 PMCID: PMC8626729 DOI: 10.1186/s13613-021-00949-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 11/03/2021] [Indexed: 12/26/2022] Open
Abstract
Background Optimal flow settings during high-flow nasal cannula (HFNC) therapy are unknown. We investigated the optimal flow settings during HFNC therapy based on breathing pattern and tidal inspiratory flows in patients with acute hypoxemic respiratory failure (AHRF). Methods We conducted a prospective clinical study in adult hypoxemic patients treated by HFNC with a fraction of inspired oxygen (FIO2) ≥ 0.4. Patient’s peak tidal inspiratory flow (PTIF) was measured and HFNC flows were set to match individual PTIF and then increased by 10 L/min every 5–10 min up to 60 L/min. FIO2 was titrated to maintain pulse oximetry (SpO2) of 90–97%. SpO2/FIO2, respiratory rate (RR), ROX index [(SpO2/FIO2)/RR], and patient comfort were recorded after 5–10 min on each setting. We also conducted an in vitro study to explore the relationship between the HFNC flows and the tracheal FIO2, peak inspiratory and expiratory pressures. Results Forty-nine patients aged 58.0 (SD 14.1) years were enrolled. At enrollment, HFNC flow was set at 45 (38, 50) L/min, with an FIO2 at 0.62 (0.16) to obtain an SpO2/FIO2 of 160 (40). Mean PTIF was 34 (9) L/min. An increase in HFNC flows up to two times of the individual patient’s PTIF, incrementally improved oxygenation but the ROX index plateaued with HFNC flows of 1.34–1.67 times the individual PTIF. In the in vitro study, when the HFNC flow was set higher than PTIF, tracheal peak inspiratory and expiratory pressures increased as HFNC flow increased but the FIO2 did not change. Conclusion Mean PTIF values in most patients with AHRF were between 30 and 40 L/min. We observed improvement in oxygenation with HFNC flows set above patient PTIF. Thus, a pragmatic approach to set optimal flows in patients with AHRF would be to initiate HFNC flow at 40 L/min and titrate the flow based on improvement in ROX index and patient tolerance. Trial registration: ClinicalTrials.gov (NCT03738345). Registered on November 13th, 2018. https://clinicaltrials.gov/ct2/show/NCT03738345?term=NCT03738345&draw=2&rank=1 Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00949-8.
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Affiliation(s)
- Jie Li
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University, 600 S Paulina St, Suite 765, Chicago, IL, 60612, USA.
| | - J Brady Scott
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University, 600 S Paulina St, Suite 765, Chicago, IL, 60612, USA
| | - James B Fink
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University, 600 S Paulina St, Suite 765, Chicago, IL, 60612, USA.,Aerogen Pharma Corp, San Mateo, CA, USA
| | - Brooke Reed
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University, 600 S Paulina St, Suite 765, Chicago, IL, 60612, USA
| | - Oriol Roca
- Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Ciber Enfermedades Respiratorias (Ciberes), Instituto de Salud Carlos III, Madrid, Spain
| | - Rajiv Dhand
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
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Daniel MF, Mario GD, Edgar B, Mario V, Alejandra H, Nicolas G, Pablo V, Victor N, Albert V, Diego G, Antonio VS, Ramon MJ. Use of High-Flow Nasal Cannula in Patients With Pneumonia and Hypoxemic Respiratory Failure at Altitudes Above 2600 m: What Is the Best Predictor of Success? J Intensive Care Med 2021; 37:1199-1205. [PMID: 34812065 DOI: 10.1177/08850666211057503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Introduction: The use of high-flow nasal cannulas (HFNC) in patients with hypoxemic ventilatory failure reduces the need for mechanical ventilation and does not increase mortality when intubation is promptly applied. The aim of the study is to describe the behavior of HFNC in patients who live at high altitudes, and the performance of predictors of success/failure of this strategy. Methods: Prospective multicenter cohort study, with patients aged over 18 years recruited for 12 months in 2020 to 21. All had a diagnosis of hypoxemic respiratory failure secondary to pneumonia, were admitted to intensive care units, and were receiving initial management with a high-flow nasal cannula. The variables assessed included need for intubation, mortality in ICU, and the validation of SaO2, respiratory rate (RR) and ROX index (IROX) as predictors of HFNC success / failure. Results: One hundred and six patients were recruited, with a mean age of 59 years and a success rate of 74.5%. Patients with treatment failure were more likely to be obese (BMI 27.2 vs 25.5; OR: 1.03; 95% CI: .95-1.1) and had higher severity scores at admission (APACHE II 12 vs 20; OR 1.15; 95% CI: 1.06-1.24). Respiratory rates after 12 (AUC .81 CI: .70-.92) and 18 h (AUC .85 CI: .72-0.90) of HFNC use were the best predictors of failure, performing better than those that included oxygenation. ICU mortality was higher in the failure group (6% vs 29%; OR 8.8; 95% CI:1.75-44.7). Conclusions: High-flow oxygen cannula therapy in patients with hypoxemic respiratory failure living at altitudes above 2600 m is associated with low rates of therapy failure and a reduced need for mechanical ventilation in the ICU. The geographical conditions and secondary physiological changes influence the performance of the traditionally validated predictors of therapy success. Respiratory rate <30 proved to be the best indicator of early success of the device at 12 h of use.
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Affiliation(s)
- Molano Franco Daniel
- San José Hospital, 42709Fundación Universitaria De Ciencias de la Salud (FUCS), CIMCA research group, Bogotá, Colombia
| | - Gómez Duque Mario
- San José Hospital, 42709Fundación Universitaria De Ciencias de la Salud (FUCS), CIMCA research group, Bogotá, Colombia
| | - Beltrán Edgar
- San José Hospital, 42709Fundación Universitaria De Ciencias de la Salud (FUCS), CIMCA research group, Bogotá, Colombia
| | - Villabon Mario
- San José Hospital, 42709Fundación Universitaria De Ciencias de la Salud (FUCS), CIMCA research group, Bogotá, Colombia
| | - Hurtado Alejandra
- San José Hospital, 42709Fundación Universitaria De Ciencias de la Salud (FUCS), CIMCA research group, Bogotá, Colombia
| | - Gómez Nicolas
- San José Hospital, 42709Fundación Universitaria De Ciencias de la Salud (FUCS), CIMCA research group, Bogotá, Colombia
| | - Vásquez Pablo
- Critical Care Pediatric Unit, Ethics Committee, Hospital San José, Bogotá, Colombia
| | - Nieto Victor
- 28009Universidad el Bosque, GRIBOS research group, Bogotá, Colombia
| | - Valencia Albert
- 28009Universidad el Bosque, GRIBOS research group, Bogotá, Colombia
| | - Garzón Diego
- 503424Clínica Reina Sofia, Fundación Universitaria Unisanitas, Bogotá, Colombia
| | - Viruez-Soto Antonio
- Hospital el Alto and Hospital Agramont, GRIMIA research group, El Alto, La Paz, Bolivia
| | - Masclans Joan Ramon
- Department of Experimental and Health Sciences (DCEXS) of the Pompeu Fabra University (UPF), Barcelona, Spain
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Salvatore V, Gianstefani A, Farina G, Carletti I, Carpentieri N, Tinuper AL, Trabalza F, Grignaschi A, Giostra F. CovHos, a New Score to Predict the Need of Hospitalization for Coronavirus Disease 2019 (COVID-19) Patients at the Emergency Department. Cureus 2021; 13:e18717. [PMID: 34790472 PMCID: PMC8588726 DOI: 10.7759/cureus.18717] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2021] [Indexed: 01/10/2023] Open
Abstract
Introduction and aim: As first receivers of suspected coronavirus disease 2019 (COVID-19) patients, clinicians of the Emergency Department (ED) have to rapidly perform the first clinical assessment evaluating the intensity of care needed. So far, clear management guidelines still lack. We identified variables associated with hospitalization in order to give a quick tool to assist clinicians in stratifying cases based on the severity at their arrival at the ED and in predicting the need for hospital care. Methods: This is a monocentric observational prospective study enrolling COVID-19 patients. A score for hospitalization prediction (CovHos Score) was created using variables associated with hospitalization at multivariate analysis and then validated on an internal subsequent cohort. Results: A total of 667 patients were included; 465 (69.7%) were hospitalized and 108 (16.2%) died at 30-days follow-up. In a multivariate analysis, male sex, age>65, alveolar-to-arterial oxygen gradient percentage increase compared to that expected for age, neutrophils/lymphocytes ratio and C-reactive protein levels were significantly associated with a higher rate of hospital admission. A CovHos score cut-off of 12 points predicted hospitalization with 85% sensitivity and 82.4 % specificity (area under a receiver operating characteristic curve [AUROC] = 0.909, 95% CI 0.884 - 0.935). Similar results were obtained in the validation court. A cut-off of 22 has 79% sensitivity and 77% specificity in predicting mortality (AUROC = 0.824; 95% CI 0.782-0.866); sensitivity and specificity were respectively 71.4% and 71.3% in the validation group. Conclusions: Although medical judgment still remains crucial, the CovHos score is an effective tool to assist emergency clinicians in predicting the need for hospitalization or to optimize allocation in a shortage of hospital resources.
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Affiliation(s)
- Veronica Salvatore
- Emergency Department, Medicina d'Urgenza e Pronto Soccorso, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, ITA
| | - Alice Gianstefani
- Emergency Department, Medicina d'Urgenza e Pronto Soccorso, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, ITA
| | - Gabriele Farina
- Emergency Department, Medicina d'Urgenza e Pronto Soccorso, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, ITA
| | - Ilaria Carletti
- Emergency Department, Medicina d'Urgenza e Pronto Soccorso, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, ITA
| | - Nicoletta Carpentieri
- Emergency Department, Medicina d'Urgenza e Pronto Soccorso, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, ITA
| | - Anna Laura Tinuper
- Emergency Department, Medicina d'Urgenza e Pronto Soccorso, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, ITA
| | - Francesca Trabalza
- Emergency Department, Medicina d'Urgenza e Pronto Soccorso, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, ITA
| | - Alice Grignaschi
- Emergency Department, Medicina d'Urgenza e Pronto Soccorso, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, ITA
| | - Fabrizio Giostra
- Emergency Department, Medicina d'Urgenza e Pronto Soccorso, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, ITA
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Mortality Prediction Using SaO 2/FiO 2 Ratio Based on eICU Database Analysis. Crit Care Res Pract 2021; 2021:6672603. [PMID: 34790417 PMCID: PMC8592728 DOI: 10.1155/2021/6672603] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 12/24/2020] [Accepted: 09/25/2021] [Indexed: 12/02/2022] Open
Abstract
Purpose PaO2 to FiO2 ratio (P/F) is used to assess the degree of hypoxemia adjusted for oxygen requirements. The Berlin definition of Acute Respiratory Distress Syndrome (ARDS) includes P/F as a diagnostic criterion. P/F is invasive and cost-prohibitive for resource-limited settings. SaO2/FiO2 (S/F) ratio has the advantages of being easy to calculate, noninvasive, continuous, cost-effective, and reliable, as well as lower infection exposure potential for staff, and avoids iatrogenic anemia. Previous work suggests that the SaO2/FiO2 ratio (S/F) correlates with P/F and can be used as a surrogate in ARDS. Quantitative correlation between S/F and P/F has been verified, but the data for the relative predictive ability for ICU mortality remains in question. We hypothesize that S/F is noninferior to P/F as a predictive feature for ICU mortality. Using a machine-learning approach, we hope to demonstrate the relative mortality predictive capacities of S/F and P/F. Methods We extracted data from the eICU Collaborative Research Database. The features age, gender, SaO2, PaO2, FIO2, admission diagnosis, Apache IV, mechanical ventilation (MV), and ICU mortality were extracted. Mortality was the dependent variable for our prediction models. Exploratory data analysis was performed in Python. Missing data was imputed with Sklearn Iterative Imputer. Random assignment of all the encounters, 80% to the training (n = 26690) and 20% to testing (n = 6741), was stratified by positive and negative classes to ensure a balanced distribution. We scaled the data using the Sklearn Standard Scaler. Categorical values were encoded using Target Encoding. We used a gradient boosting decision tree algorithm variant called XGBoost as our model. Model hyperparameters were tuned using the Sklearn RandomizedSearchCV with tenfold cross-validation. We used AUC as our metric for model performance. Feature importance was assessed using SHAP, ELI5 (permutation importance), and a built-in XGBoost feature importance method. We constructed partial dependence plots to illustrate the relationship between mortality probability and S/F values. Results The XGBoost hyperparameter optimized model had an AUC score of .85 on the test set. The hyperparameters selected to train the final models were as follows: colsample_bytree of 0.8, gamma of 1, max_depth of 3, subsample of 1, min_child_weight of 10, and scale_pos_weight of 3. The SHAP, ELI5, and XGBoost feature importance analysis demonstrates that the S/F ratio ranks as the strongest predictor for mortality amongst the physiologic variables. The partial dependence plots illustrate that mortality rises significantly above S/F values of 200. Conclusion S/F was a stronger predictor of mortality than P/F based upon feature importance evaluation of our data. Our study is hypothesis-generating and a prospective evaluation is warranted. Take-Home Points. S/F ratio is a noninvasive continuous method of measuring hypoxemia as compared to P/F ratio. Our study shows that the S/F ratio is a better predictor of mortality than the more widely used P/F ratio to monitor and manage hypoxemia.
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Impact of Air Transport on SpO 2/FiO 2 among Critical COVID-19 Patients during the First Pandemic Wave in France. J Clin Med 2021; 10:jcm10225223. [PMID: 34830505 PMCID: PMC8624612 DOI: 10.3390/jcm10225223] [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: 10/16/2021] [Revised: 11/02/2021] [Accepted: 11/05/2021] [Indexed: 01/08/2023] Open
Abstract
During the first wave of the COVID-19 pandemic, some French regions were more affected than others. To relieve those areas most affected, the French government organized transfers of critical patients, notably by plane or helicopter. Our objective was to investigate the impact of such transfers on the pulse oximetric saturation (SpO2)-to-inspired fraction of oxygen (FiO2) ratio among transferred critical patients with COVID-19. We conducted a retrospective study on medical and paramedical records. The primary endpoint was the change in SpO2/FiO2 during transfers. Thirty-eight patients were transferred between 28 March and 5 April 2020, with a mean age of 62.4 years and a mean body mass index of 29.8 kg/m2. The population was 69.7% male, and the leading medical history was hypertension (42.1%), diabetes (34.2%), and dyslipidemia (18.4%). Of 28 patients with full data, we found a decrease of 28.9 points in SpO2/FiO2 (95% confidence interval, 5.8 to 52.1, p = 0.01) between the starting and the arrival intensive care units (SpO2/FiO2, 187.3 ± 61.3 and 158.4 ± 62.8 mmHg, respectively). Air medical transfers organized to relieve intensive care unit teams under surging conditions during the first COVID wave were associated with significant decreases in arterial oxygenation.
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Mesquida J, Caballer A, Cortese L, Vila C, Karadeniz U, Pagliazzi M, Zanoletti M, Pacheco AP, Castro P, García-de-Acilu M, Mesquita RC, Busch DR, Durduran T. Peripheral microcirculatory alterations are associated with the severity of acute respiratory distress syndrome in COVID-19 patients admitted to intermediate respiratory and intensive care units. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:381. [PMID: 34749792 PMCID: PMC8575160 DOI: 10.1186/s13054-021-03803-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 10/25/2021] [Indexed: 12/12/2022]
Abstract
Background COVID-19 is primarily a respiratory disease; however, there is also evidence that it causes endothelial damage in the microvasculature of several organs. The aim of the present study is to characterize in vivo the microvascular reactivity in peripheral skeletal muscle of severe COVID-19 patients. Methods This is a prospective observational study carried out in Spain, Mexico and Brazil. Healthy subjects and severe COVID-19 patients admitted to the intermediate respiratory (IRCU) and intensive care units (ICU) due to hypoxemia were studied. Local tissue/blood oxygen saturation (StO2) and local hemoglobin concentration (THC) were non-invasively measured on the forearm by near-infrared spectroscopy (NIRS). A vascular occlusion test (VOT), a three-minute induced ischemia, was performed in order to obtain dynamic StO2 parameters: deoxygenation rate (DeO2), reoxygenation rate (ReO2), and hyperemic response (HAUC). In COVID-19 patients, the severity of ARDS was evaluated by the ratio between peripheral arterial oxygen saturation (SpO2) and the fraction of inspired oxygen (FiO2) (SF ratio). Results Healthy controls (32) and COVID-19 patients (73) were studied. Baseline StO2 and THC did not differ between the two groups. Dynamic VOT-derived parameters were significantly impaired in COVID-19 patients showing lower metabolic rate (DeO2) and diminished endothelial reactivity. At enrollment, most COVID-19 patients were receiving invasive mechanical ventilation (MV) (53%) or high-flow nasal cannula support (32%). Patients on MV were also receiving sedative agents (100%) and vasopressors (29%). Baseline StO2 and DeO2 negatively correlated with SF ratio, while ReO2 showed a positive correlation with SF ratio. There were significant differences in baseline StO2 and ReO2 among the different ARDS groups according to SF ratio, but not among different respiratory support therapies. Conclusion Patients with severe COVID-19 show systemic microcirculatory alterations suggestive of endothelial dysfunction, and these alterations are associated with the severity of ARDS. Further evaluation is needed to determine whether these observations have prognostic implications. These results represent interim findings of the ongoing HEMOCOVID-19 trial. Trial registration ClinicalTrials.gov NCT04689477. Retrospectively registered 30 December 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03803-2.
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Affiliation(s)
- Jaume Mesquida
- Àrea de Crítics, Parc Taulí Hospital Universitari, Parc Taulí, 1, 08208, Sabadell, Spain.
| | - A Caballer
- Àrea de Crítics, Parc Taulí Hospital Universitari, Parc Taulí, 1, 08208, Sabadell, Spain
| | - L Cortese
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Castelldefels, Barcelona, Spain
| | - C Vila
- Servei de Medicina Intensiva, Parc Salut Mar Hospital, Barcelona, Spain
| | - U Karadeniz
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Castelldefels, Barcelona, Spain
| | - M Pagliazzi
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Castelldefels, Barcelona, Spain
| | - M Zanoletti
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Castelldefels, Barcelona, Spain
| | | | - P Castro
- Medical Intensive Care Unit, Hospital Clínic de Barcelona, IDIBAPS, Barcelona, Spain
| | - M García-de-Acilu
- Intensive Care Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - R C Mesquita
- Institute of Physics, University of Campinas, Campinas, Brazil
| | - D R Busch
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - T Durduran
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Castelldefels, Barcelona, Spain.,Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
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Bowring MG, Wang Z, Xu Y, Betz J, Muschelli J, Garibaldi BT, Zeger SL. Outcome-Stratified Analysis of Biomarker Trajectories for Patients Infected With Severe Acute Respiratory Syndrome Coronavirus 2. Am J Epidemiol 2021; 190:2094-2106. [PMID: 33984860 PMCID: PMC8241476 DOI: 10.1093/aje/kwab138] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 04/12/2021] [Accepted: 05/04/2021] [Indexed: 12/23/2022] Open
Abstract
Longitudinal trajectories of vital signs and biomarkers during admission remain
poorly characterized for COVID-19 patients despite their potential to provide
critical insights about disease progression. We studied 1884 patients with
SARS-CoV2 infection from 3/4/2020-6/25/2020 within one Maryland hospital system
and used a retrospective longitudinal framework with linear mixed-effects models
to investigate relevant biomarker trajectories leading up to three critical
outcomes: mechanical ventilation, discharge, and death. Trajectories of four
vital signs (respiratory rate, SpO2/FiO2, pulse, and
temperature) and four lab values (C-reactive protein (CRP), absolute lymphocyte
count (ALC), estimated glomerular filtration rate (eGFR), and D-dimer) clearly
distinguished the trajectories of COVID-19 patients. Prior to any ventilation,
log-CRP, log-ALC, respiratory rate, and SpO2/FiO2
trajectories diverge approximately 8-10 days before discharge or death.
Following ventilation, log-CRP, log-ALC, respiratory rate,
SpO2/FiO2, and eGFR trajectories again diverge 10-20
days prior to death or discharge. Trajectories improved until discharge and
remained unchanged or worsened until death. Our approach characterizes the
distribution of biomarker trajectories leading up to competing outcomes of
discharge versus death. Moving forward, this model can contribute to quantifying
the joint probability of future biomarkers and outcomes provided clinical data
up to a given moment.
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Affiliation(s)
| | - Zitong Wang
- Department of Biostatistics Johns Hopkins University
Bloomberg School of Public Health, Baltimore Maryland
| | - Yizhen Xu
- Department of Biostatistics Johns Hopkins University
Bloomberg School of Public Health, Baltimore Maryland
| | - Joshua Betz
- Department of Biostatistics Johns Hopkins University
Bloomberg School of Public Health, Baltimore Maryland
| | - John Muschelli
- Department of Biostatistics Johns Hopkins University
Bloomberg School of Public Health, Baltimore Maryland
| | - Brian T Garibaldi
- Division of Pulmonary and Critical Care, Johns Hopkins
University School of Medicine, Baltimore Maryland
| | - Scott L Zeger
- Department of Biostatistics Johns Hopkins University
Bloomberg School of Public Health, Baltimore Maryland
- Correspondence to Dr. Scott Zeger, MD PhD Department of
Biostatistics, 615 N. Wolfe Street, Room E3650 Johns Hopkins University
Bloomberg School of Public Health Baltimore MD 21205 Phone: 410-502-9054
(e-mail: )
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Chalmers SJ, Odeyemi YE, Lal A, Li H, Frank RD, Gajic O, Yadav H. F IO2 Trajectory as a Pragmatic Intermediate Marker in Acute Hypoxic Respiratory Failure. Respir Care 2021; 66:1521-1530. [PMID: 34404689 PMCID: PMC9993558 DOI: 10.4187/respcare.09053] [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: 11/05/2022]
Abstract
BACKGROUND Several markers of oxygenation are used as prognostic markers in acute hypoxemic respiratory failure. Real-world use is limited by the need for invasive measurements and unreliable availability in the electronic health record. A pragmatic, reliable, and accurate marker of acute hypoxemic respiratory failure is needed to facilitate epidemiologic studies, clinical trials, and shared decision-making with patients. [Formula: see text] is easily obtained at the bedside and from the electronic health record. The [Formula: see text] trajectory may be a valuable marker of recovery in patients with acute hypoxemic respiratory failure. METHODS This was a historical cohort study of adult subjects admitted to an ICU with acute hypoxemic respiratory failure secondary to community-acquired pneumonia and/or ARDS. RESULTS Our study included 2,670 subjects. [Formula: see text] and [Formula: see text] were consistently more available than was [Formula: see text] in the electronic health record: ([Formula: see text] vs [Formula: see text] vs [Formula: see text] : 100 vs 100 vs 72.8% on day 1, and 100 vs 99 vs 21% on day 5). A worsening [Formula: see text] trajectory was associated with reduced ventilator-free days. From days 2 to 5, every increase in [Formula: see text] by 10% from the previous day was associated with fewer ventilator-free days (on day 2: adjusted mean -1.25 [95% CI -1.45 to -1.05] d, P < .001). The [Formula: see text] trajectory also provided prognostic information. On days 3 - 5, an increase in [Formula: see text] from the previous day was associated with increased ventilator-free days (on day 3: adjusted mean 2.09 (95% CI 1.44-2.74) d; P < .001). [Formula: see text] models did not add predictive information compared with models with [Formula: see text] alone (on day 2: adjusted [Formula: see text] vs [Formula: see text] R2 0.122 vs 0.119; and on day 3: 0.153 vs 0.163). CONCLUSIONS [Formula: see text] and [Formula: see text] are pragmatic and readily available intermediate prognostic markers in acute hypoxic respiratory failure. The [Formula: see text] trajectory in the first 5 d of ICU admission provided important prognostic information (ventilator-free days). Although the [Formula: see text] trajectory was also associated with ventilator-free days, it did not provide more information than the [Formula: see text] trajectory alone.
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Affiliation(s)
- Sarah J Chalmers
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic-Rochester, Rochester, Minnesota.
| | - Yewande E Odeyemi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic-Rochester, Rochester, Minnesota
| | - Amos Lal
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic-Rochester, Rochester, Minnesota
| | - Heyi Li
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic-Rochester, Rochester, Minnesota
| | - Ryan D Frank
- Division of Biomedical Statistics and Informatics, Mayo Clinic-Rochester, Rochester, Minnesota
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic-Rochester, Rochester, Minnesota
| | - Hemang Yadav
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic-Rochester, Rochester, Minnesota
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Nightingale R, Lewis J, Monsell KR, Jones L, Smith C, Kundu S, Bond H, Burhan H, Fletcher T, Blanchard T, Beadsworth M, Hampshire P, Gautam M, Todd S, Jones G, Aston S. CPAP delivered outside critical care during the second wave of COVID-19: outcomes from a UK respiratory surge unit. BMJ Open Respir Res 2021; 8:8/1/e000907. [PMID: 34521649 PMCID: PMC8441225 DOI: 10.1136/bmjresp-2021-000907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 08/07/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND NHS England recommends non-invasive continuous positive airway pressure (CPAP) as a possible treatment for type 1 respiratory failure associated with COVID-19 pneumonitis, either to avoid intubation or as a ceiling of care. However, data assessing this strategy are sparse, especially for the use of CPAP as a ceiling of care, and particularly when delivered outside of a traditional critical care environment. We describe a cohort of patients from Liverpool, UK, who received CPAP on a dedicated respiratory surge unit at the start of the second wave of the COVID-19 pandemic in UK. METHODS Retrospective cohort analysis of consecutive patients receiving CPAP for the treatment of respiratory failure secondary to COVID-19 on the respiratory surge unit at the Royal Liverpool Hospital, Liverpool, UK from 21 September until 30 November 2020. RESULTS 88 patients were included in the analysis. 56/88 (64%) were deemed suitable for escalation to invasive mechanical ventilation (IMV) and received CPAP as a trial; 32/88 (36%) received CPAP as a ceiling of care. Median age was 63 years (IQR: 56-74) and 58/88 (66%) were men. Median SpO2/FiO2 immediately prior to CPAP initiation was 95 (92-152). Among patients for escalation to IMV, the median time on CPAP was 6 days (IQR 4-7) and survival at day 30 was 84% (47/56) with 14/56 (25%) escalated to IMV. Of those patients for whom CPAP was ceiling of care, the median duration of CPAP was 9 days (IQR 7-11) and 18/32 (56%) survived to day 30. Pulmonary barotrauma occurred in 9% of the cohort. There were no associations found on multivariant analysis that were associated with all-cause 30-day mortality. CONCLUSIONS With adequate planning and resource redistribution, CPAP may be delivered effectively outside of a traditional critical care setting for the treatment of respiratory failure due to COVID-19. Clinicians delivering CPAP to patients with COVID-19 pneumonitis should be alert to the dangers of pulmonary barotrauma. Among patients who are for escalation of care, the use of CPAP may avoid the need for IMV in some patients. Our data support the NHS England recommendation to consider CPAP as a ceiling of care.
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Affiliation(s)
- Rebecca Nightingale
- Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK .,Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Joseph Lewis
- Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.,Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.,Institute of Infection, Veterinary and Ecological Sciences, Univeristy of Liverpool, Liverpool, UK
| | - Katelyn Rhiannon Monsell
- Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Lewis Jones
- Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Christopher Smith
- Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Shantanu Kundu
- School of Medicine, Univeristy of Liverpool, Liverpool, UK
| | - Helena Bond
- Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Hassan Burhan
- Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.,Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Tom Fletcher
- Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.,Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Thomas Blanchard
- Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.,Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.,Institute of Infection, Veterinary and Ecological Sciences, Univeristy of Liverpool, Liverpool, UK
| | - Michael Beadsworth
- Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.,Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Peter Hampshire
- Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Manish Gautam
- Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Stacy Todd
- Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Gareth Jones
- Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Stephen Aston
- Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.,Institute of Infection, Veterinary and Ecological Sciences, Univeristy of Liverpool, Liverpool, UK
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Ende VJ, Singh G, Babatsikos I, Hou W, Li H, Thode HC, Singer AJ, Duong TQ, Richman PS. Survival of COVID-19 Patients With Respiratory Failure is Related to Temporal Changes in Gas Exchange and Mechanical Ventilation. J Intensive Care Med 2021; 36:1209-1216. [PMID: 34397301 PMCID: PMC8442134 DOI: 10.1177/08850666211033836] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background: Respiratory failure due to coronavirus disease of 2019 (COVID-19) often presents with worsening gas exchange over a period of days. Once patients require mechanical ventilation (MV), the temporal change in gas exchange and its relation to clinical outcome is poorly described. We investigated whether gas exchange over the first 5 days of MV is associated with mortality and ventilator-free days at 28 days in COVID-19. Methods: In a cohort of 294 COVID-19 patients, we used data during the first 5 days of MV to calculate 4 daily respiratory scores: PaO2/FiO2 (P/F), oxygenation index (OI), ventilatory ratio (VR), and Murray lung injury score. The association between these scores at early (days 1-3) and late (days 4-5) time points with mortality was evaluated using logistic regression, adjusted for demographics. Correlation with ventilator-free days was assessed (Spearman rank-order coefficients). Results: Overall mortality was 47.6%. Nonsurvivors were older (P < .0001), more male (P = .029), with more preexisting cardiopulmonary disease compared to survivors. Mean PaO2 and PaCO2 were similar during this timeframe. However, by days 4 to 5 values for all airway pressures and FiO2 had diverged, trending lower in survivors and higher in nonsurvivors. The most substantial between-group difference was the temporal change in OI, improving 15% in survivors and worsening 11% in nonsurvivors (P < .05). The adjusted mortality OR was significant for age (1.819, P = .001), OI at days 4 to 5 (2.26, P = .002), and OI percent change (1.90, P = .02). The number of ventilator-free days correlated significantly with late VR (-0.166, P < .05), early and late OI (-0.216, P < .01; -0.278, P < .01, respectively) and early and late P/F (0.158, P < .05; 0.283, P < .01, respectively). Conclusion: Nonsurvivors of COVID-19 needed increasing intensity of MV to sustain gas exchange over the first 5 days, unlike survivors. Temporal change OI, reflecting both PaO2 and the intensity of MV, is a potential marker of outcome in respiratory failure due to COVID-19.
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Affiliation(s)
- Victoria J Ende
- 12300Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Gurinder Singh
- 12300Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Ioannis Babatsikos
- 12300Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Wei Hou
- 12300Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Haifang Li
- 12300Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Henry C Thode
- 12300Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Adam J Singer
- 12300Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Tim Q Duong
- 205134Jack D Weiler Hospital of the Albert Einstein College of Medicine Emergency Room, Bronx, NY, USA
| | - Paul S Richman
- 12300Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
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Shimizu M, Hashimoto S. Peripheral oxygen saturation to inspiratory oxygen fraction ratio-based identification of critically ill coronavirus disease patients for early therapeutic interventions. J Anesth 2021; 35:827-836. [PMID: 34392404 PMCID: PMC8364630 DOI: 10.1007/s00540-021-02986-w] [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: 01/04/2021] [Accepted: 08/09/2021] [Indexed: 01/08/2023]
Abstract
Background Early identification of critically ill coronavirus disease (COVID-19) patients in clinical settings is crucial in reducing the mortality rate. Therefore, this study aimed to determine whether the saturation of peripheral oxygen (SpO2) to fraction of inspiratory oxygen (FiO2) ratio (SF ratio) at admission is useful for the early identification of severe COVID-19. Methods This single-center, retrospective, observational study conducted at the University Hospital, Kyoto, Japan, included 26 patients diagnosed with COVID-19 between January 24 and May 6, 2020. COVID-19 severity was classified into two groups based on the SF ratio: ≤ 235 (moderate to severe disease: low group) and > 235 (normal to mild disease: high group). The characteristics, laboratory data, and outcomes of the patients were examined retrospectively and compared between the groups. Results Of the 26 patients [median age 51.5 years, interquartile range 35.8–67.0], 6 were in the low group (23%) and 20 in the high group (77%). The low group had a higher respiratory rate than the high group (p < 0.05). Blood tests immediately after admission showed that the low group had significantly lower albumin (p < 0.01), and higher lactate dehydrogenase (p < 0.01), C-reactive protein (p < 0.01), and D-dimer (p < 0.01) levels than the high group. Moreover, all patients received antiviral agents; four received continuous renal replacement therapy and invasive positive pressure ventilation, one received extracorporeal membrane oxygenation, and two died in the low group. Conclusion SF ratio measurement at admission could assist clinicians in the early identification of severe COVID-19, which in turn can lead to early therapeutic interventions.
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Affiliation(s)
- Masaru Shimizu
- Department of Anesthesiology, University Hospital, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kamigyo Ward, Kyoto, 602-8566, Japan.
| | - Satoru Hashimoto
- Department of Intensive Care, University Hospital, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kamigyo Ward, Kyoto, 602-8566, Japan
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Andrade Filho PHD, Brasil ESDA, Costa LG, M Sousa DE, Pereira TS, Silva JM. Prediction of Extubation Failure in COVID-19. Respir Care 2021; 66:1323-1329. [PMID: 34006593 PMCID: PMC9994376 DOI: 10.4187/respcare.08564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND [Formula: see text] may be a reliable noninvasive alternative to the [Formula: see text] index. Furthermore, the ROX index (ie, the ratio of [Formula: see text] to breathing frequency) has been validated to predict high-flow nasal cannula failure in subjects under spontaneous breathing. However, these indices have not been tested in subjects with COVID-19 receiving invasive mechanical ventilation. This study aims to verify the correlation between both the ROX index and [Formula: see text] with [Formula: see text] and the ratio of [Formula: see text] to breathing frequency, and to determine the accuracy of the indices that use [Formula: see text] for the prediction of extubation failure in subjects with COVID-19. METHODS A prospective cohort study was conducted from May 15, 2020, to June 15, 2020, with subjects with COVID-19 on invasive mechanical ventilation. Indices using [Formula: see text] in the formula were compared to those using [Formula: see text]. Additionally, the performance of the indices in predicting extubation failure was evaluated. RESULTS This study included 69 subjects age 64.8 ± 14.6 y. There were no differences between the median values of the indices, including between the ROX index and [Formula: see text] to breathing frequency (P = .40) or between [Formula: see text] and [Formula: see text] (P = .83). When comparing the ROX index with the [Formula: see text] index to breathing frequency, they were found to be strongly correlated (R2 = 0.75 [95% CI 0.6763-0.8152], P < .001). The comparison of [Formula: see text] with [Formula: see text] revealed R2 = 0.70 (95% CI 0.563-0.749, P < .001). The area under the receiver operating characteristic curve for the ROX index to determine extubation failure was 0.74 (P = .01), whereas for [Formula: see text] it was 0.78 (P < .001). CONCLUSIONS The indices presented a good correlation in subjects with COVID-19 on invasive mechanical ventilation, and both the ROX index and [Formula: see text] can discriminate extubation failure in this population.
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Affiliation(s)
- Pedro H de Andrade Filho
- Anesthesiology Department, São Paulo- Hospital do Servidor Publico Estadual, São Paulo, Brazil
- Postgraduate Program in Anesthesiology, Surgical Sciences, and Perioperative Medicine, Faculdade de Medicina da Universidade de São Paulo-FMUSP, São Paulo, Brazil
| | | | - Ladyer G Costa
- Anesthesiology Department, São Paulo- Hospital do Servidor Publico Estadual, São Paulo, Brazil
| | - Daniel Escóssia M Sousa
- Anesthesiology Department, São Paulo- Hospital do Servidor Publico Estadual, São Paulo, Brazil
| | - Talison S Pereira
- Anesthesiology Department, São Paulo- Hospital do Servidor Publico Estadual, São Paulo, Brazil
- Postgraduate Program in Anesthesiology, Surgical Sciences, and Perioperative Medicine, Faculdade de Medicina da Universidade de São Paulo-FMUSP, São Paulo, Brazil
| | - João Manoel Silva
- Anesthesiology Department, São Paulo- Hospital do Servidor Publico Estadual, São Paulo, Brazil.
- Postgraduate Program in Anesthesiology, Surgical Sciences, and Perioperative Medicine, Faculdade de Medicina da Universidade de São Paulo-FMUSP, São Paulo, Brazil
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Pavlov I, He H, McNicholas B, Perez Y, Tavernier E, Trump MW, Jackson JA, Zhang W, Rubin DS, Spiegel T, Hung A, Estrada MÁI, Roca O, Vines DL, Cosgrave D, Mirza S, Laffey JG, Rice TW, Ehrmann S, Li J. Awake Prone Positioning in Non-Intubated Patients With Acute Hypoxemic Respiratory Failure Due to COVID-19. Respir Care 2021; 67:102-114. [PMID: 34234032 DOI: 10.4187/respcare.09191] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Awake prone positioning (APP) has been advocated to improve oxygenation and prevent intubation of patients with acute hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19). This paper aims to synthesize the available evidence on the efficacy of APP. METHODS We performed a systematic review of proportional outcomes from observational studies to compare intubation rate in patients treated with APP or with standard care. RESULTS A total of 46 published and 4 unpublished observational studies that included 2,994 subjects were included, of which 921 were managed with APP and 870 were managed with usual care. APP was associated with significant improvement of oxygenation parameters in 381 cases of 19 studies that reported this outcome. Among the 41 studies assessing intubation rates (870 subjects treated with APP and 852 subjects treated with usual care), the intubation rate was 27% (95% CI 19-37%) as compared to 30% (95% CI 20-42%) (P = .71), even when duration of application, use of adjunctive respiratory assist device (high-flow nasal cannula or noninvasive ventilation), and severity of oxygenation deficit were taken into account. There appeared to be a trend toward improved mortality when APP was compared with usual care (11% vs 22%), which was not statistically significant. CONCLUSIONS APP was associated with improvement of oxygenation but did not reduce the intubation rate in subjects with acute respiratory failure due to COVID-19. This finding is limited by the high heterogeneity and the observational nature of included studies. Randomized controlled clinical studies are needed to definitively assess whether APP could improve key outcome such as intubation rate and mortality in these patients.
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Affiliation(s)
- Ivan Pavlov
- Department of Emergency Medicine, Hôpital de Verdun, Montréal, Québec, Canada
| | - Hangyong He
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Bairbre McNicholas
- Anaesthesia and Intensive Care Medicine, School of Medicine, National University of Ireland Galway and Department of Anaesthesia, University Hospital Galway, Saolta Hospital Group, Galway, Ireland
| | - Yonatan Perez
- Médecine Intensive Réanimation, CIC INSERM 1415, CRICS-TriggerSEP research network, CHRU Tours, Tours, France and INSERM, Centre d'étude des pathologies respiratoires, U1100, Université de Tours, Tours, France
| | - Elsa Tavernier
- INSERM 1246-SPHERE, Universities of Tours and Nantes, Tours, France; Clinical Investigation Center, INSERM 1415, CHRU Tours, Tours, France
| | - Matthew W Trump
- Department Pulmonary and Critical Care Medicine, The Iowa Clinic, West Des Moines, Iowa
| | - Julie A Jackson
- Department of Respiratory Therapy, UnityPoint Health, Des Moines, Iowa
| | - Wei Zhang
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital, Second Military Medical University, Shanghai, China
| | - Daniel S Rubin
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
| | - Thomas Spiegel
- Section of Emergency Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Anthony Hung
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Miguel Ángel Ibarra Estrada
- Intensive Care Unit, Hospital Civil Fray Antonio Alcalde, Universidad de Guadalajara. Guadalajara, Jalisco, Mexico
| | - Oriol Roca
- Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Barcelona, Spain; Ciber Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - David L Vines
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, Illinois
| | - David Cosgrave
- Anaesthesia and Intensive Care Medicine, School of Medicine, National University of Ireland Galway and Department of Anaesthesia, University Hospital Galway, Saolta Hospital Group, Galway, Ireland
| | - Sara Mirza
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, National University of Ireland Galway and Department of Anaesthesia, University Hospital Galway, Saolta Hospital Group, Galway, Ireland
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Stephan Ehrmann
- Médecine Intensive Réanimation, CIC INSERM 1415, CRICS-TriggerSEP research network, CHRU Tours, Tours, France and INSERM, Centre d'étude des pathologies respiratoires, U1100, Université de Tours, Tours, France.
| | - Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, Illinois.
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SpO 2/FiO 2 as a predictor of high flow nasal cannula outcomes in children with acute hypoxemic respiratory failure. Sci Rep 2021; 11:13439. [PMID: 34188123 PMCID: PMC8242081 DOI: 10.1038/s41598-021-92893-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 06/14/2021] [Indexed: 11/16/2022] Open
Abstract
The high-flow nasal cannula (HFNC) is a useful treatment modality for acute hypoxemic respiratory failure (AHRF) in children. We compared the ability of the oxygen saturation to fraction of inspired oxygen ratio (S/F) and arterial oxygen partial pressure to fraction of inspired oxygen ratio (P/F) to predict HFNC outcomes in children with AHRF. This study included children treated with HFNC due to AHRF from April 2013 to March 2019 at the Severance Children’s Hospital. HFNC failure was defined as the need for mechanical ventilation. Trends of S/F and P/F during HFNC were analyzed. To predict HFNC outcomes, a nomogram was constructed based on predictive factors. A total of 139 patients with arterial blood gas data were included in the S/F and P/F analyses. S/F < 230 at initiation showed high prediction accuracy for HFNC failure (area under the receiver operating characteristic curve: 0.751). Univariate analyses identified S/F < 230 at HFNC initiation and < 200 at 2 h (odds ratio [OR] 12.83, 95% CI 5.06–35.84), and hemato-oncologic disease (OR 3.79, 95% CI 1.12–12.78) as significant predictive factors of HFNC failure. The constructed nomogram had a highly predictive performance, with a concordance index of 0.765 and 0.831 for the exploratory and validation groups, respectively. S/F may be used as a predictor of HFNC outcomes. Our nomogram with S/F for HFNC failure within 2 h may prevent delayed intubation in children with AHRF.
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Ortiz G, Bastidas A, Garay-Fernández M, Lara A, Benavides M, Rocha E, Buitrago A, Díaz G, Ordóñez J, Reyes LF. Correlation and validity of imputed PaO2/FiO2 and SpO2/FiO2 in patients with invasive mechanical ventilation at 2600m above sea level. Med Intensiva 2021; 46:S0210-5691(21)00100-5. [PMID: 34167826 DOI: 10.1016/j.medin.2021.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 04/09/2021] [Accepted: 05/04/2021] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To establish the correlation and validity between PaO2/FiO2 obtained on arterial gases versus noninvasive methods (linear, nonlinear, logarithmic imputation of PaO2/FiO2 and SpO2/FiO2) in patients under mechanical ventilation living at high altitude. DESIGN Ambispective descriptive multicenter cohort study. SETTING Two intensive care units (ICU) from Colombia at 2600m a.s.l. PATIENTS OR PARTICIPANTS Consecutive critically ill patients older than 18 years with at least 24h of mechanical ventilation were included from June 2016 to June 2019. INTERVENTIONS None. VARIABLES Variables analyzed were demographic, physiological messures, laboratory findings, oxygenation index and clinical condition. Nonlinear, linear and logarithmic imputation formulas were used to calculate PaO2 from SpO2, and at the same time the SpO2/FiO2 by severe hypoxemia diagnosis. The intraclass correlation coefficient, area under the ROC curve, sensitivity, specificity, positive predictive value, negative predictive value, positive and negative likelihood ratio were calculated. RESULTS The correlation between PaO2/FiO2 obtained from arterial gases, PaO2/FiO2 derived from one of the proposed methods (linear, non-linear, and logarithmic formula), and SpO2/FiO2 measured by the intraclass correlation coefficient was high (greater than 0.77, p<0.001). The different imputation methods and SpO2/FiO2 have a similar diagnostic performance in patients with severe hypoxemia (PaO2/FiO2 <150). PaO2/FiO2 linear imputation AUC ROC 0,84 (IC 0.81-0.87, p<0.001), PaO2/FiO2 logarithmic imputation AUC ROC 0.84 (IC 0.80-0.87, p<0.001), PaO2/FiO2 non-linear imputation AUC ROC 0.82 (IC 0.79-0.85, p<0.001), SpO2/FiO2 oximetry AUC ROC 0.84 (IC 0.81-0.87, p<0.001). CONCLUSIONS At high altitude, the SaO2/FiO2 ratio and the imputed PaO2/FiO2 ratio have similar diagnostic performance in patients with severe hypoxemia ventilated by various pathological conditions.
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Affiliation(s)
- G Ortiz
- Pulmonary Medicine, Universidad El Bosque, Intensive Care Unit, Hospital Santa Clara Bogotá, Colombia
| | - A Bastidas
- School of Medicine, Universidad de la Sabana, Clínica Universidad de La Sabana, Chía, Colombia.
| | - M Garay-Fernández
- Pulmonary Medicine Universidad El Bosque, Intensive Care Unit, Hospital Santa Clara Bogotá, Colombia
| | - A Lara
- Pulmonary Medicine Universidad El Bosque, Intensive Care Unit, Hospital Santa Clara Bogotá, Colombia
| | - M Benavides
- Pulmonary Medicine Universidad El Bosque, Intensive Care Unit, Hospital Santa Clara Bogotá, Colombia
| | - E Rocha
- Intensive Care Unit, Hospital Santa Clara Bogotá, Colombia
| | - A Buitrago
- Pulmonary Medicine Universidad El Bosque, Intensive Care Unit, Hospital Santa Clara Bogotá, Colombia
| | - G Díaz
- Pulmonary Medicine Universidad El Bosque, Intensive Care Unit, Hospital Santa Clara Bogotá, Colombia
| | - J Ordóñez
- Pulmonary Medicine Universidad El Bosque, Intensive Care Unit, Hospital Santa Clara Bogotá, Colombia
| | - L F Reyes
- School of Medicine, Universidad de la Sabana, Clínica Universidad de La Sabana, Chía, Colombia
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Koyauchi T, Yasui H, Enomoto N, Hasegawa H, Hozumi H, Suzuki Y, Karayama M, Furuhashi K, Fujisawa T, Nakamura Y, Inui N, Yokomura K, Suda T. Pulse oximetric saturation to fraction of inspired oxygen (SpO 2/FIO 2) ratio 24 hours after high-flow nasal cannula (HFNC) initiation is a good predictor of HFNC therapy in patients with acute exacerbation of interstitial lung disease. Ther Adv Respir Dis 2021; 14:1753466620906327. [PMID: 32046604 PMCID: PMC7016313 DOI: 10.1177/1753466620906327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND High-flow nasal cannula (HFNC) oxygen therapy provides effective respiratory management in patients with hypoxemic respiratory failure. However, the efficacy and tolerability of HFNC for patients with acute exacerbation of interstitial lung disease (AE-ILD) have not been established. This study was performed to assess the efficacy and tolerability of HFNC for patients with AE-ILD and identify the early predictors of the outcome of HFNC treatment. METHODS We retrospectively reviewed the records of patients with AE-ILD who underwent HFNC. Overall survival, the success rate of HFNC treatment, adverse events, temporary interruption of treatment, discontinuation of treatment at the patient's request, and predictors of the outcome of HFNC treatment were evaluated. RESULTS A total of 66 patients were analyzed. Of these, 26 patients (39.4%) showed improved oxygenation and were successfully withdrawn from HFNC. The 30-day survival rate was 48.5%. No discontinuations at the patient's request were observed, and no serious adverse events occurred. The pulse oximetric saturation to fraction of inspired oxygen (SpO2/FIO2) ratio 24 h after initiating HFNC showed high prediction accuracy (area under the receiver operating characteristic curve, 0.802) for successful HFNC treatment. In the multivariate logistic regression analysis, an SpO2/FIO2 ratio of at least 170.9 at 24 h after initiation was significantly associated with successful HFNC treatment (odds ratio, 51.3; 95% confidence interval, 6.13-430; p < 0.001). CONCLUSIONS HFNC was well tolerated in patients with AE-ILD, suggesting that HFNC is a reasonable respiratory management for these patients. The SpO2/FIO2 ratio 24 h after initiating HFNC was a good predictor of successful HFNC treatment. The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- Takafumi Koyauchi
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan.,Department of Respiratory Medicine, Respiratory Disease Center, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Hideki Yasui
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi Ward, Hamamatsu, Shizuoka 431-3192, Japan; Department of Emergency and Disaster Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Noriyuki Enomoto
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Hirotsugu Hasegawa
- Department of Respiratory Medicine, Respiratory Disease Center, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Hironao Hozumi
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Yuzo Suzuki
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Masato Karayama
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Kazuki Furuhashi
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Tomoyuki Fujisawa
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Yutaro Nakamura
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Naoki Inui
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Koshi Yokomura
- Department of Respiratory Medicine, Respiratory Disease Center, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Takafumi Suda
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
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Postintubation Decline in Oxygen Saturation Index Predicts Mortality in COVID-19: A Retrospective Pilot Study. Crit Care Res Pract 2021; 2021:6682944. [PMID: 34136282 PMCID: PMC8162249 DOI: 10.1155/2021/6682944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 05/11/2021] [Indexed: 01/25/2023] Open
Abstract
Background Acute respiratory failure from COVID-19 pneumonia is a major cause of death after SARS-CoV-2 infection. We investigated whether PaO2/FiO2, oxygenation index (OI), SpO2/FiO2, and oxygen saturation index (OSI), commonly used to assess the severity of acute respiratory distress syndrome (ARDS), can predict mortality in mechanically ventilated COVID-19 patients. Methods In this single-centered retrospective pilot study, we enrolled 68 critically ill mechanically ventilated adult patients with confirmed COVID-19. Physiological variables were recorded on the day of intubation (day 0) and postintubation days 3 and 7. The association between physiological parameters, PaO2/FiO2, OI, SpO2/FiO2, and OSI with mortality was assessed using multiple variable logistic regression analysis. Receiver operating characteristic analysis was conducted to evaluate the performance of the predictive models. Results The ARDS severity indices were not statistically different on the day of intubation, suggesting similar baseline conditions in nonsurviving and surviving patients. However, these indices were significantly worse in the nonsurviving as compared to surviving patients on postintubation days 3 and 7. On intubation day 3, PaO2/FiO2 was 101.0 (61.4) in nonsurviving patients vs. 140.2 (109.6) in surviving patients, p=0.004, and on day 7 106.3 (94.2) vs. 178.0 (69.3), p < 0.001. OI was 135.0 (129.7) in nonsurviving vs. 84.8 (86.1) in surviving patients (p=0.003) on day 3 and 150.0 (118.4) vs. 61.5 (46.7) (p < 0.001) on day 7. OSI was 12.0 (11.7) vs. 8.0 (10.0) (p=0.006) on day 3 and 14.7 (13.2) vs. 6.5 (5.4) (p < 0.001) on day 7. Similarly, SpO2/FiO2 was 130 (90) vs. 210 (90) (p=0.003) on day 3 and 130 (90) vs. 230 (50) (p < 0.001) on day 7, while OSI was 12.0 (11.7) vs. 8.0 (10.0) (p=0.006) on day 3 and 14.7 (13.2) vs. 6.5 (5.4) (p < 0.001) on day 7 in the nonsurviving and surviving patients, respectively. All measures were independently associated with hospital mortality, with significantly greater odds ratios observed on day 7. The area under the receiver operating characteristic curve (AUC) for mortality prediction was greatest on intubation day 7 (AUC = 0.775, 0.808, and 0.828 for PaO2/FiO2, OI, SpO2/FiO2, and OSI, respectively). Conclusions Decline in oxygenation indices after intubation is predictive of mortality in COVID-19 patients. This time window is critical to the outcome of these patients and a possible target for future interventions. Future large-scale studies to confirm the prognostic value of the indices in COVID-19 patients are warranted.
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Zheng H, Zhu J, Xie W, Zhong J. Reinforcement Learning Assisted Oxygen Therapy for COVID-19 Patients Under Intensive Care. ARXIV 2021:arXiv:2105.08923v2. [PMID: 34031644 PMCID: PMC8142656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Revised: 11/07/2021] [Indexed: 11/10/2022]
Abstract
Background Patients with severe Coronavirus disease 19 (COVID-19) typically require supplemental oxygen as an essential treatment. We developed a machine learning algorithm, based on deep Reinforcement Learning (RL), for continuous management of oxygen flow rate for critically ill patients under intensive care, which can identify the optimal personalized oxygen flow rate with strong potentials to reduce mortality rate relative to the current clinical practice. Methods We modeled the oxygen flow trajectory of COVID-19 patients and their health outcomes as a Markov decision process. Based on individual patient characteristics and health status, an optimal oxygen control policy is learned by using deep deterministic policy gradient (DDPG) and real-time recommends the oxygen flow rate to reduce the mortality rate. We assessed the performance of proposed methods through cross validation by using a retrospective cohort of 1,372 critically ill patients with COVID-19 from New York University Langone Health ambulatory care with electronic health records from April 2020 to January 2021. Results The mean mortality rate under the RL algorithm is lower than the standard of care by 2.57% (95% CI: 2.08-3.06) reduction (P<0.001) from 7.94% under the standard of care to 5.37 % under our proposed algorithm. The averaged recommended oxygen flow rate is 1.28 L/min (95% CI: 1.14-1.42) lower than the rate delivered to patients. Thus, the RL algorithm could potentially lead to better intensive care treatment that can reduce the mortality rate, while saving the oxygen scarce resources. It can reduce the oxygen shortage issue and improve public health during the COVID-19 pandemic. Conclusions A personalized reinforcement learning oxygen flow control algorithm for COVID-19 patients under intensive care showed a substantial reduction in 7-day mortality rate as compared to the standard of care. In the overall cross validation cohort independent of the training data, mortality was lowest in patients for whom intensivists' actual flow rate matched the RL decisions.
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Affiliation(s)
- Hua Zheng
- Department of Mechanical and Industrial Engineering, Northeastern University, 360 Huntington Avenue, Boston, MA 02115
| | - Jiahao Zhu
- Department of Mechanical and Industrial Engineering, Northeastern University, 360 Huntington Avenue, Boston, MA 02115
| | - Wei Xie
- Department of Mechanical and Industrial Engineering, Northeastern University, 360 Huntington Avenue, Boston, MA 02115
| | - Judy Zhong
- Division of Biostatistics, Department of Population Health, New York University School of Medicine, 180 Madison Avenue, New York, NY 10016
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Busana M, Gasperetti A, Giosa L, Forleo GB, Schiavone M, Mitacchione G, Bonino C, Villa P, Galli M, Tondo C, Saguner A, Steiger P, Curnis A, Dello Russo A, Pugliese F, Mancone M, Marini JJ, Gattinoni L. Prevalence and outcome of silent hypoxemia in COVID-19. Minerva Anestesiol 2021; 87:325-333. [PMID: 33694360 DOI: 10.23736/s0375-9393.21.15245-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND In the early stages of COVID-19 pneumonia, hypoxemia has been described in absence of dyspnea ("silent" or "happy" hypoxemia). Our aim was to report its prevalence and outcome in a series of hypoxemic patients upon Emergency Department admission. METHODS In this retrospective observational cohort study we enrolled a study population consisting of 213 COVID-19 patients with PaO<inf>2</inf>/FiO<inf>2</inf> ratio <300 mmHg at hospital admission. Two groups (silent and dyspneic hypoxemia) were defined. Symptoms, blood gas analysis, chest X-ray (CXR) severity, need for intensive care and outcome were recorded. RESULTS Silent hypoxemic patients (68-31.9%) compared to the dyspneic hypoxemic patients (145-68.1%) showed greater frequency of extra respiratory symptoms (myalgia, diarrhea and nausea) and lower plasmatic LDH. PaO<inf>2</inf>/FiO<inf>2</inf> ratio was 225±68 mmHg and 192±78 mmHg in silent and dyspneic hypoxemia respectively (P=0.002). Eighteen percent of the patients with PaO<inf>2</inf>/FiO<inf>2</inf> from 50 to 150 mmHg presented silent hypoxemia. Silent and dyspneic hypoxemic patients had similar PaCO<inf>2</inf> (34.2±6.8 mmHg vs. 33.5±5.7 mmHg, P=0.47) but different respiratory rates (24.6±5.9 bpm vs. 28.6±11.3 bpm respectively, P=0.002). Even when CXR was severely abnormal, 25% of the population was silent hypoxemic. Twenty-six point five percent and 38.6% of silent and dyspneic patients were admitted to the ICU respectively (P=0.082). Mortality rate was 17.6% and 29.7% (log-rank P=0.083) in silent and dyspneic patients. CONCLUSIONS Silent hypoxemia is remarkably present in COVID-19. The presence of dyspnea is associated with a more severe clinical condition.
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Affiliation(s)
- Mattia Busana
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Medical University of Göttingen, Göttingen, Germany -
| | | | - Lorenzo Giosa
- Department of Surgical Sciences, Città della Salute e della Scienza, Turin, Italy
| | | | | | | | | | | | | | | | | | | | - Antonio Curnis
- Spedali Civili Hospital, University of Brescia, Brescia, Italy
| | - Antonio Dello Russo
- Clinic of Cardiology and Arithmology, Department of Biomedical Sciences and Public Health, Umberto I-Lancisi-Salesi University Hospital, Marche Polytechnic University, Ancona, Italy
| | - Francesco Pugliese
- Department of General Surgery, Paride Stefanini Surgical Specialties, Sapienza University, Rome, Italy
| | - Massimo Mancone
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University, Rome, Italy
| | - John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota and Regions Hospital, Minneapolis, MN, USA
| | - Luciano Gattinoni
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Medical University of Göttingen, Göttingen, Germany
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Home Management of Patients with Moderate or Severe Respiratory Failure Secondary to COVID-19, Using Remote Monitoring and Oxygen with or without HFNC. Pathogens 2021; 10:pathogens10040413. [PMID: 33915796 PMCID: PMC8065650 DOI: 10.3390/pathogens10040413] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/20/2021] [Accepted: 03/29/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Home treatment of patients affected by COVID-19 is still a matter of daily debate. During the clinical evolution of the disease, there are high risks of lung failure, which requires oxygen therapy. Here, we report our clinical experience with at-home treatment using high-flow nasal cannula in non-hospitalised patients with confirmed COVID-19. PATIENTS AND METHODS In this study, 18 patients with moderate-to-severe respiratory failure secondary to COVID-19 were monitored at home daily for temperature and SpO2 measurements. Other parameters such as saturation of peripheral oxygen (SpO2), SpO2/FiO2 (fraction of inspired oxygen), temperature, and lung performance were monitored periodically. Depending on oxygen requirements, the patients also received either standard oxygen via a face mask or, if higher FiO2 required, high-flow nasal cannula (HFNC). RESULTS All 18 patients had favourable outcomes and recovered from COVID-19. No death was recorded in this group. CONCLUSION Our clinical experience proves that high-flow nasal cannula oxygen therapy may be considered for at-home treatment of COVID-19 patients with moderate lung failure. This could be useful for further treatment during the pandemic and may also be considered in future epidemics.
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