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Salvatore V, Trabalza F, Casadei L, Giostra F. CovHos score for predicting severe respiratory failure in COVID-19 patients presenting at the emergency department. Intern Emerg Med 2022; 17:1795-1801. [PMID: 35750874 PMCID: PMC9243846 DOI: 10.1007/s11739-022-03006-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 05/14/2022] [Indexed: 11/05/2022]
Abstract
Hospitalization of COVID-19 patients in low-intensity wards may put patients at risk in case of clinical deterioration. We tested CovHos score in predicting severe respiratory failure (SFR) at emergency department (ED) admission. This is a monocentric observational prospective study enrolling adult COVID-19 patients admitted to the ED of IRCCS AOU di Bologna Policlinico S.Orsola in October 2020, both discharged and hospitalized. Patients were then dichotomized based on days from symptoms onset. Main outcome was the occurrence of SRF. Receiver operating characteristic (ROC) analysis was used to identify cut-off and corresponding accuracy. A CovHos cut-off of 22 yielded a sensitivity of 84.7% and specificity of 75.3% in predicting SRF (AUROC 0.856; CI 95% 0.813-0.898). In patients with symptoms onset up to 8 days, a CovHos cut-off of 22 was able to predict SRF with a sensitivity of 91.7% and a specificity of 78.6% (AUROC 0.901; CI 95% 0.861-0.941). Negative predictive value (NPV) was 97.1%. A CovHos score lower than 22, in patients with COVID-19 symptoms onset dated 8 or less days prior to the ED admittance, had a NPV of 97.1% for the development of SRF, meaning that almost none of those patients will evolve into SRF and could be therefore suitable for a lower intensity of care.
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Affiliation(s)
- Veronica Salvatore
- Medicina d'Urgenza E Pronto Soccorso, Emergency Department, IRCCS AOU di Bologna Policlinico di S.Orsola, Via Albertoni 15, 40138, Bologna, Italy.
| | - Francesca Trabalza
- Medicina d'Urgenza E Pronto Soccorso, Emergency Department, IRCCS AOU di Bologna Policlinico di S.Orsola, Via Albertoni 15, 40138, Bologna, Italy
| | - Lorenzo Casadei
- Medicina d'Urgenza E Pronto Soccorso, Emergency Department, IRCCS AOU di Bologna Policlinico di S.Orsola, Via Albertoni 15, 40138, Bologna, Italy
| | - Fabrizio Giostra
- Medicina d'Urgenza E Pronto Soccorso, Emergency Department, IRCCS AOU di Bologna Policlinico di S.Orsola, Via Albertoni 15, 40138, Bologna, Italy
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2
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Renieris G, Karakike E, Gkavogianni T, Droggiti DE, Stylianakis E, Andriopoulou T, Spanou VM, Kafousopoulos D, Netea MG, Eugen-Olsen J, Simard J, Giamarellos-Bourboulis EJ. IL-1 Mediates Tissue-Specific Inflammation and Severe Respiratory Failure in COVID-19. J Innate Immun 2022; 14:643-656. [PMID: 35545011 PMCID: PMC9801253 DOI: 10.1159/000524560] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 03/21/2022] [Indexed: 01/02/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) in COVID-19 has been associated with catastrophic inflammation. We present measurements in humans and a new animal model implicating a role in danger-associated molecular patterns. Calprotectin (S100A8/A9) and high-mobility group box 1 (HMGB1) were measured in patients without/with ARDS, and admission calprotectin was associated with soluble urokinase plasminogen activator receptor (suPAR). An animal model was developed by intravenous injection of plasma from healthy or patients with COVID-19 ARDS into C57/BL6 mice once daily for 3 consecutive days. Mice were treated with one anti-S100A8/A9 antibody, the IL-1 receptor antagonist anakinra or vehicle, and Flo1-2a anti-murine anti-IL-1α monoclonal antibody or the specific antihuman IL-1α antibody XB2001 or isotype controls. Cytokines and myeloperoxidase (MPO) were measured in tissues. Calprotectin, but not HMGB1, was elevated in ARDS. Higher suPAR indicated higher calprotectin. Animal challenge with COVID-19 plasma led to inflammatory reactions in murine lung and intestines as evidenced by increased levels of TNFα, IL-6, IFNγ, and MPO. Lung inflammation was attenuated with anti-S100A8/A9 pre-treatment. Anakinra treatment restored these levels. Similar decrease was found in mice treated with Flo1-2a but not with XB2001. Circulating alarmins, specifically calprotectin, of critically ill COVID-19 patients induces tissue-specific inflammatory responses through an IL-1-mediated mechanism. This could be attenuated through inhibition of IL-1 receptor or of IL-1α.
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Affiliation(s)
- Georgios Renieris
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Eleni Karakike
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Theologia Gkavogianni
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Dionysia-Eirini Droggiti
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Emmanouil Stylianakis
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Theano Andriopoulou
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Victoria-Marina Spanou
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Dionyssios Kafousopoulos
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Mihai G. Netea
- Immunology and Metabolism, Life & Medical Sciences Institute, University of Bonn, Bonn, Germany,Department of Internal Medicine and Center for Infectious Diseases, Radboud University, Nijmegen, The Netherlands
| | - Jesper Eugen-Olsen
- Department of Clinical Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | | | - Evangelos J. Giamarellos-Bourboulis
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece,*Evangelos J. Giamarellos-Bourboulis,
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3
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Whebell S, Zhang J, Lewis R, Berry M, Ledot S, Retter A, Camporota L. Survival benefit of extracorporeal membrane oxygenation in severe COVID-19: a multi-centre-matched cohort study. Intensive Care Med 2022; 48:467-478. [PMID: 35238946 PMCID: PMC8892395 DOI: 10.1007/s00134-022-06645-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/07/2022] [Indexed: 01/19/2023]
Abstract
Purpose Extracorporeal membrane oxygenation (ECMO) has become an established therapy for severe respiratory failure in coronavirus disease 2019 (COVID-19). The added benefit of receiving ECMO in COVID-19 remains uncertain. The aim of this study is to analyse the impact of receiving ECMO at specialist centres on hospital mortality. Methods A multi-centre retrospective study was conducted in COVID-19 patients from 111 hospitals, referred to two specialist ECMO centres in the United Kingdom (UK) (March 2020 to February 2021). Detailed covariate data were contemporaneously curated from electronic referral systems. We analysed added benefit of ECMO treatment in specialist centres using propensity score matching techniques. Results 1363 patients, 243 receiving ECMO, were analysed. The best matching technique generated 209 matches, with a marginal odds ratio (OR) for mortality of 0.44 (95% CI 0.29–0.68, p < 0.001) and absolute mortality reduction of 18.2% (44% vs 25.8%, p < 0.001) for treatment with ECMO in a specialist centre. Conclusion We found ECMO provided at specialist centres conferred significant survival benefit. Where resources and specialism allow, ECMO should be widely offered. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-022-06645-w.
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Affiliation(s)
- Stephen Whebell
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK.
- Department of Adult Critical Care, St Thomas' Hospital, London, SE1 7EH, UK.
| | - Joe Zhang
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
- Institute of Global Health Innovation, Imperial College London, London, UK
| | - Rebecca Lewis
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Michael Berry
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Stephane Ledot
- Department of Adult Intensive Care, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Andrew Retter
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Division of Asthma, Allergy and Lung Biology, King's College London, London, UK
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4
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Willemse BWM, van der Crabben SN, Kerstjens-Frederikse WS, Timens W, van Montfrans JM, Lindemans CA, Boelens JJ, Hennus MP, van Haaften G. New insights in phenotype and treatment of lung disease immuno-deficiency and chromosome breakage syndrome (LICS). Orphanet J Rare Dis 2021; 16:137. [PMID: 33741030 PMCID: PMC7980653 DOI: 10.1186/s13023-021-01770-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 03/09/2021] [Indexed: 11/10/2022] Open
Abstract
We report five patients with lung disease immuno-deficiency and chromosome breakage syndrome (LICS) but without recurrent infections and severe immunodeficiency. One patient had extended survival to 6.5 years. Hematopoietic stem-cell transplantation failed to cure another patient. Our findings suggest that the immunological abnormalities can be limited and do not fully explain the LICS phenotype.
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Affiliation(s)
- Brigitte W M Willemse
- Department of Pediatric Pulmonology and Pediatric Allergology, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
| | - Saskia N van der Crabben
- Department of Metabolic Diseases, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Clinical Genetics, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Wim Timens
- Department of Pathology and Medical Biology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Joris M van Montfrans
- Department of Pediatric Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Caroline A Lindemans
- Department of Pediatric Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Pediatric Blood and Bone Marrow Transplantation, Princess Maxima Center and UMC Utrecht, Utrecht, The Netherlands
| | - Jaap Jan Boelens
- Department of Pediatric Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands.,Stem Cell Transplantation and Cellular Therapies Program, Department Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marije P Hennus
- Pediatric Intensive Care, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gijs van Haaften
- Department of Genetics (Center for Molecular Medicine, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
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5
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Shaefi S, Brenner SK, Gupta S, O'Gara BP, Krajewski ML, Charytan DM, Chaudhry S, Mirza SH, Peev V, Anderson M, Bansal A, Hayek SS, Srivastava A, Mathews KS, Johns TS, Leonberg-Yoo A, Green A, Arunthamakun J, Wille KM, Shaukat T, Singh H, Admon AJ, Semler MW, Hernán MA, Mueller AL, Wang W, Leaf DE; STOP-COVID Investigators. Extracorporeal membrane oxygenation in patients with severe respiratory failure from COVID-19. Intensive Care Med 2021; 47:208-21. [PMID: 33528595 DOI: 10.1007/s00134-020-06331-9] [Citation(s) in RCA: 122] [Impact Index Per Article: 40.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 12/04/2020] [Indexed: 01/19/2023]
Abstract
PURPOSE Limited data are available on venovenous extracorporeal membrane oxygenation (ECMO) in patients with severe hypoxemic respiratory failure from coronavirus disease 2019 (COVID-19). METHODS We examined the clinical features and outcomes of 190 patients treated with ECMO within 14 days of ICU admission, using data from a multicenter cohort study of 5122 critically ill adults with COVID-19 admitted to 68 hospitals across the United States. To estimate the effect of ECMO on mortality, we emulated a target trial of ECMO receipt versus no ECMO receipt within 7 days of ICU admission among mechanically ventilated patients with severe hypoxemia (PaO2/FiO2 < 100). Patients were followed until hospital discharge, death, or a minimum of 60 days. We adjusted for confounding using a multivariable Cox model. RESULTS Among the 190 patients treated with ECMO, the median age was 49 years (IQR 41-58), 137 (72.1%) were men, and the median PaO2/FiO2 prior to ECMO initiation was 72 (IQR 61-90). At 60 days, 63 patients (33.2%) had died, 94 (49.5%) were discharged, and 33 (17.4%) remained hospitalized. Among the 1297 patients eligible for the target trial emulation, 45 of the 130 (34.6%) who received ECMO died, and 553 of the 1167 (47.4%) who did not receive ECMO died. In the primary analysis, patients who received ECMO had lower mortality than those who did not (HR 0.55; 95% CI 0.41-0.74). Results were similar in a secondary analysis limited to patients with PaO2/FiO2 < 80 (HR 0.55; 95% CI 0.40-0.77). CONCLUSION In select patients with severe respiratory failure from COVID-19, ECMO may reduce mortality.
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Bartoletti M, Giannella M, Scudeller L, Tedeschi S, Rinaldi M, Bussini L, Fornaro G, Pascale R, Pancaldi L, Pasquini Z, Trapani F, Badia L, Campoli C, Tadolini M, Attard L, Puoti M, Merli M, Mussini C, Menozzi M, Meschiari M, Codeluppi M, Barchiesi F, Cristini F, Saracino A, Licci A, Rapuano S, Tonetti T, Gaibani P, Ranieri VM, Viale P. Development and validation of a prediction model for severe respiratory failure in hospitalized patients with SARS-CoV-2 infection: a multicentre cohort study (PREDI-CO study). Clin Microbiol Infect 2020; 26:1545-1553. [PMID: 32781244 PMCID: PMC7414420 DOI: 10.1016/j.cmi.2020.08.003] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 07/21/2020] [Accepted: 08/02/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVES We aimed to develop and validate a risk score to predict severe respiratory failure (SRF) among patients hospitalized with coronavirus disease-2019 (COVID-19). METHODS We performed a multicentre cohort study among hospitalized (>24 hours) patients diagnosed with COVID-19 from 22 February to 3 April 2020, at 11 Italian hospitals. Patients were divided into derivation and validation cohorts according to random sorting of hospitals. SRF was assessed from admission to hospital discharge and was defined as: Spo2 <93% with 100% Fio2, respiratory rate >30 breaths/min or respiratory distress. Multivariable logistic regression models were built to identify predictors of SRF, β-coefficients were used to develop a risk score. Trial Registration NCT04316949. RESULTS We analysed 1113 patients (644 derivation, 469 validation cohort). Mean (±SD) age was 65.7 (±15) years, 704 (63.3%) were male. SRF occurred in 189/644 (29%) and 187/469 (40%) patients in the derivation and validation cohorts, respectively. At multivariate analysis, risk factors for SRF in the derivation cohort assessed at hospitalization were age ≥70 years (OR 2.74; 95% CI 1.66-4.50), obesity (OR 4.62; 95% CI 2.78-7.70), body temperature ≥38°C (OR 1.73; 95% CI 1.30-2.29), respiratory rate ≥22 breaths/min (OR 3.75; 95% CI 2.01-7.01), lymphocytes ≤900 cells/mm3 (OR 2.69; 95% CI 1.60-4.51), creatinine ≥1 mg/dL (OR 2.38; 95% CI 1.59-3.56), C-reactive protein ≥10 mg/dL (OR 5.91; 95% CI 4.88-7.17) and lactate dehydrogenase ≥350 IU/L (OR 2.39; 95% CI 1.11-5.11). Assigning points to each variable, an individual risk score (PREDI-CO score) was obtained. Area under the receiver-operator curve was 0.89 (0.86-0.92). At a score of >3, sensitivity, specificity, and positive and negative predictive values were 71.6% (65%-79%), 89.1% (86%-92%), 74% (67%-80%) and 89% (85%-91%), respectively. PREDI-CO score showed similar prognostic ability in the validation cohort: area under the receiver-operator curve 0.85 (0.81-0.88). At a score of >3, sensitivity, specificity, and positive and negative predictive values were 80% (73%-85%), 76% (70%-81%), 69% (60%-74%) and 85% (80%-89%), respectively. CONCLUSION PREDI-CO score can be useful to allocate resources and prioritize treatments during the COVID-19 pandemic.
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Affiliation(s)
- Michele Bartoletti
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola, Bologna, Italy.
| | - Maddalena Giannella
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola, Bologna, Italy.
| | - Luigia Scudeller
- Clinical Trials Team, Scientific Direction, IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Italy
| | - Sara Tedeschi
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant’Orsola, Bologna, Italy
| | - Matteo Rinaldi
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant’Orsola, Bologna, Italy
| | - Linda Bussini
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant’Orsola, Bologna, Italy
| | - Giacomo Fornaro
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant’Orsola, Bologna, Italy
| | - Renato Pascale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant’Orsola, Bologna, Italy
| | - Livia Pancaldi
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant’Orsola, Bologna, Italy
| | - Zeno Pasquini
- Infectious Diseases Unit, Azienda Ospedaliera Ospedali Riuniti Marche Nord, Pesaro, Italy,Clinica Malattie Infettive, Dipartimento di Scienze Biomediche e Sanità Pubblica, Università Politecnica Delle Marche, Azienda Ospedaliera Universitaria, Ospedali Riuniti Umberto I-Lancisi-Salesi, Ancona, Italy
| | - Filippo Trapani
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant’Orsola, Bologna, Italy
| | - Lorenzo Badia
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant’Orsola, Bologna, Italy
| | - Caterina Campoli
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant’Orsola, Bologna, Italy
| | - Marina Tadolini
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant’Orsola, Bologna, Italy
| | - Luciano Attard
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant’Orsola, Bologna, Italy
| | - Massimo Puoti
- Division of Infectious Diseases, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Marco Merli
- Division of Infectious Diseases, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Cristina Mussini
- Infectious Diseases Unit, Policlinico di Modena, Università Degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Marianna Menozzi
- Infectious Diseases Unit, Policlinico di Modena, Università Degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Marianna Meschiari
- Infectious Diseases Unit, Policlinico di Modena, Università Degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Mauro Codeluppi
- Infectious Diseases Unit, “Guglielmo da Saliceto” Hospital, Piacenza, Italy
| | - Francesco Barchiesi
- Infectious Diseases Unit, Azienda Ospedaliera Ospedali Riuniti Marche Nord, Pesaro, Italy,Clinica Malattie Infettive, Dipartimento di Scienze Biomediche e Sanità Pubblica, Università Politecnica Delle Marche, Azienda Ospedaliera Universitaria, Ospedali Riuniti Umberto I-Lancisi-Salesi, Ancona, Italy
| | | | - Annalisa Saracino
- Infectious Disease Unit - Department of Biomedical Sciences and Human Oncology, University of Bari, Policlinico di Bari, Italy
| | - Alberto Licci
- Infectious Disease Unit, Augusto Murri Hospital Fermo, Italy
| | - Silvia Rapuano
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy
| | - Tommaso Tonetti
- Intensive Care Unit, Department of Medical and Surgical Sciences, Policlinico Sant’Orsola, Bologna, Italy
| | - Paolo Gaibani
- Centro di Riferimento Regionale per le Emergenze Microbiologiche (CRREM), Clinical Microbiology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Policlinico Sant’Orsola, Bologna, Italy
| | - Vito M. Ranieri
- Intensive Care Unit, Department of Medical and Surgical Sciences, Policlinico Sant’Orsola, Bologna, Italy
| | - Pierluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant’Orsola, Bologna, Italy
| | - PREDICO study group†RaumerLuigi14GuerraLuca14TumiettoFabio14CascavillaAlessandra14ZampariniEleonora14VerucchiGabriella14ColadonatoSimona14RubinArianna14IannirubertoStefano14FrancalanciEugenia14VolpatoFrancesca14VirgiliGiulio14RossiNicolò14Del TurcoElena Rosselli14GuardigniViola14FasuloGiovanni14DentaleNicola14FulgaroCiro14LegnaniGiorgio14CampaciEmanuele14BassoCristina14ZuppiroliAlberto14PassinoAmalia Sanna14TesiniGiulia14AngelelliLucia14BadeanuAdriana14RossiAgostino14SantangeloGiulia14DautiFlovia14KoprivikaVidak14RoncagliNicholas14TzimasIoannis14LiuzziGuido Maria14BaxhakuIrid14PasinelliLetizia14NeriMattia14ZanaboniTommaso14Dell'OmoFrancesco14VatamanuOana14GoriAlice14ZavattaIdina14AntoniniStefano14PironiChiara14PicciniElena14EspositoLuca14ZuccottiAlessandro14UrbinatiGiacomo14PratelliAgnese14SartiAlberto14SempriniMichela14EvangelistiEnrico14D'OnofrioMara14SasdelliGiuseppe14PizzilliGiacinto15PierucciElisabetta15RossiniGiada16VocaleCaterina16MarconiLorenzo17LeoniMaria Cristina18FrontiElisa18GuaraldiGiovanni19BavaroDavide20LaghettiPaola20University of Bologna, Bologna, ItalyDepartment of Medical and Surgical Sciences, Policlinico Sant’Orsola, Bologna, ItalyCentro di Riferimento Regionale per le Emergenze Microbiologiche (CRREM), Clinical Microbiology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Policlinico Sant’Orsola, Bologna, ItalyInfectious Diseases Unit, Rimini-Forlì-Cesena Hospitals, Rimini, ItalyIInfectious Diseases Unit, “Guglielmo da Saliceto” Hospital, Piacenza, ItalyIInfectious Diseases Unit, Policlinico di Modena, Università Degli Studi di Modena e Reggio Emilia, Modena, ItalyILucia Diella Infectious Disease Unit - Department of Biomedical Sciences and Human Oncology, University of Bari, Policlinico di Bari, Italy
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7
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Kodama T, Kouzaki Y, Kawano S, Obinata H, Taniguchi H, Sasaki H, Ota S, Kawana A, Tamura K. Serial serum SARS-CoV-2 RNA results in two COVID-19 cases with severe respiratory failure. J Infect Chemother 2020; 26:1220-1223. [PMID: 32792249 PMCID: PMC7366999 DOI: 10.1016/j.jiac.2020.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 07/06/2020] [Accepted: 07/13/2020] [Indexed: 01/30/2023]
Abstract
Coronavirus disease 2019 (COVID-19) is spreading worldwide and poses an imminent threat to public health. We encountered 2 cases of COVID-19 with progression resulting in severe respiratory failure and improvement without any specific treatment. To examine the course of infection, we performed reverse-transcription (RT) polymerase chain reaction assay with serum specimens, and serum SARS-CoV-2 RNA was detected in both cases when body temperature increased and respiratory status deteriorated. We, then examined, retrospectively and prospectively, the clinical course during hospitalization by performing serial examinations of serum SARS-CoV-2 RNA status. The findings from our cases suggest that not only is detection of viremia useful as a predictive marker of severity, but also serial serum SARS-CoV-2 RNA results can be helpful for predicting the clinical course.
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Affiliation(s)
- Tatsuya Kodama
- Division of Pulmonary Medicine, Department of Internal Medicine, Self-Defense Forces Central Hospital, 1-2-24 Ikejiri, Setagaya, Tokyo 154-8532, Japan.
| | - Yuji Kouzaki
- Division of Infectious Diseases and Pulmonary Medicine, Department of Internal Medicine, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513, Japan
| | - Shuichi Kawano
- Division of Pulmonary Medicine, Department of Internal Medicine, Self-Defense Forces Central Hospital, 1-2-24 Ikejiri, Setagaya, Tokyo 154-8532, Japan
| | - Hirofumi Obinata
- Department of Anesthesiology, Self-Defense Forces Central Hospital, 1-2-24 Ikejiri, Setagaya, Tokyo 154-8532, Japan
| | - Hiroaki Taniguchi
- Department of Emergency, Japan Self Defense Force Sapporo Hospital, 17 Makomanai, Minami, Sapporo 005-8543, Japan
| | - Hisashi Sasaki
- Division of Pulmonary Medicine, Department of Internal Medicine, Self-Defense Forces Central Hospital, 1-2-24 Ikejiri, Setagaya, Tokyo 154-8532, Japan
| | - Shinichiro Ota
- Department of Internal Medicine, Japan Self Defense Forces Hospital, 1776-1 Tauraminatomachi, Yokosuka, Kanagawa 237-0071, Japan
| | - Akihiko Kawana
- Division of Infectious Diseases and Pulmonary Medicine, Department of Internal Medicine, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513, Japan
| | - Kaku Tamura
- Division of Infectious Disease, Department of Internal Medicine, Self-Defense Forces Central Hospital, 1-2-24 Ikejiri, Setagaya, Tokyo 154-8532, Japan
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Carter KT, Kutcher ME, Shake JG, Panos AL, Cochran RP, Creswell LL, Copeland H. Heparin-Sparing Anticoagulation Strategies Are Viable Options for Patients on Veno-Venous ECMO. J Surg Res 2019; 243:399-409. [PMID: 31277018 DOI: 10.1016/j.jss.2019.05.050] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 05/14/2019] [Accepted: 05/30/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO), a rescue therapy for pulmonary failure, has traditionally been limited by anticoagulation requirements. Recent practice has challenged the absolute need for anticoagulation, expanding the role of ECMO to patients with higher bleeding risk. We hypothesize that mortality, bleeding, thrombotic events, and transfusions do not differ between heparin-sparing and full therapeutic anticoagulation strategies in veno-venous (VV) ECMO management. MATERIALS AND METHODS Adult VV ECMO patients between October 2011 and May 2018 at a single center were reviewed. A heparin-sparing strategy was implemented in October 2014; we compared outcomes in an as-treated fashion. The primary end point was survival. Secondary end points included bleeding, thrombotic complications, and transfusion requirements. RESULTS Forty VV ECMO patients were included: 17 (147 circuit-days) before and 23 (214 circuit-days) after implementation of a heparin-sparing protocol. Patients treated with heparin-sparing anticoagulation had a lower body mass index (28.5 ± 7.1 versus 38.1 ± 12.4, P = 0.01), more often required inotropic support before ECMO (82 versus 50%, P = 0.05), and had a lower mean activated clotting time (167 ± 15 versus 189 ± 15 s, P < 0.01). There were no significant differences in survival to decannulation (59 versus 83%, P = 0.16) or discharge (50 versus 72%, P = 0.20), bleeding (32 versus 33%, P = 1.0), thromboembolic events (18 versus 39%, P = 0.17), or transfusion requirements (median 1.1 versus 0.9 unit per circuit-day, P = 0.48). CONCLUSIONS Survival, bleeding, thrombotic complications, and transfusion requirements did not differ between heparin-sparing and full therapeutic heparin strategies for management of VV ECMO. VV ECMO can be a safe option in patients with traditional contraindications to anticoagulation.
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Affiliation(s)
- Kristen T Carter
- Department of Surgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - Matthew E Kutcher
- Division of Trauma, Critical Care, and Acute Care Surgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - Jay G Shake
- Division of Cardiothoracic Surgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - Anthony L Panos
- Division of Cardiothoracic Surgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - Richard P Cochran
- Division of Cardiothoracic Surgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - Lawrence L Creswell
- Division of Cardiothoracic Surgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - Hannah Copeland
- Division of Cardiothoracic Surgery, University of Mississippi Medical Center, Jackson, Mississippi.
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McCann C, Adams K, Schizas A, George M, Barrett NA, Wyncoll DLA, Camporota L. Outcomes of emergency laparotomy in patients on extracorporeal membrane oxygenation for severe respiratory failure: A retrospective, observational cohort study. J Crit Care 2019; 53:253-257. [PMID: 31301640 DOI: 10.1016/j.jcrc.2019.06.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 04/21/2019] [Accepted: 06/20/2019] [Indexed: 11/17/2022]
Abstract
PURPOSE There is a paucity of literature to support undertaking emergency laparotomy when indicated in patients supported on ECMO. Our study aims to identify the prevalence, outcomes and complications of this high risk surgery at a large ECMO centre. MATERIALS AND METHODS A single centre, retrospective, observational cohort study of 355 patients admitted to a university teaching hospital Severe Respiratory Failure service between December 2011 and January 2017. RESULTS The prevalence of emergency laparotomy in patients on ECMO was 3.7%. These patients had significantly higher SOFA and APACHE II scores compared to similar patients not requiring laparotomy. There was no difference in the duration of ECMO or intensive care unit (ICU) stay post decannulation between the two groups. 31% of laparotomy patients survived to hospital discharge. Major haemorrhage was uncommon, however emergency change of ECMO oxygenator was commonly required. CONCLUSION Survival to hospital discharge is possible following emergency laparotomy on ECMO, however the mortality is higher than for those patients not requiring laparotomy, this likely reflects the severity of underlying organ failure rather than the surgery itself. Our service's collocation with a general surgical service has made this development in care possible. ECMO service planning should consider general surgical provision.
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Affiliation(s)
- C McCann
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
| | - K Adams
- Department of Colorectal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
| | - A Schizas
- Department of Colorectal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
| | - M George
- Department of Colorectal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
| | - N A Barrett
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Centre for Human & Applied Physiological Sciences, King's College London, London, United Kingdom.
| | - D L A Wyncoll
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
| | - L Camporota
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Centre for Human & Applied Physiological Sciences, King's College London, London, United Kingdom.
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Vogel DJ, Murray J, Czapran AZ, Camporota L, Ioannou N, Meadows CIS, Sherren PB, Daly K, Gooby N, Barrett N. Veno-arterio-venous ECMO for septic cardiomyopathy: a single-centre experience. Perfusion 2018; 33:57-64. [PMID: 29788842 DOI: 10.1177/0267659118766833] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION The role of extracorporeal support for patients with septic shock remains unclear. METHODS We conducted a retrospective analysis of our single-centre experience with veno-arterio-venous extracorporeal membrane oxygenation (VAV ECMO) in adult patients with severe respiratory failure and septic cardiomyopathy. Clinical data was extracted from electronic medical records including a dedicated ECMO referral and follow-up database. RESULTS Twelve patients were commenced on VAV ECMO for septic cardiomyopathy for a median of four days (IQR 3.0 to 5.3) between 01/2014 and 12/2017. Five patients (41.7%) had a cardiac arrest prior to initiation of ECMO support. At baseline, median left ventricular ejection fraction was 16.25% (IQR 13.13 to 17.5) and median PaO2/FiO2 ratio was 9 kPa (IQR 6.5 to 12.0) [67.50 mmHg (IQR 48.75 to 90.00)]. The survival rate to hospital discharge for VAV ECMO was 75% in this cohort. None of the surviving patients died within the follow-up period (median six month). CONCLUSION VAV ECMO is a feasible rescue strategy for a small proportion of patients with combined respiratory and cardiac failure secondary to septic shock with septic cardiomyopathy. We provide a detailed report of our experience with this technique. Further research is required comparing the different extracorporeal strategies directly to conventional resuscitation and against each other.
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Affiliation(s)
- Dominik J Vogel
- 1 Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, UK
| | - Josie Murray
- 1 Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, UK
| | - Adam Z Czapran
- 1 Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, UK
| | - Luigi Camporota
- 1 Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, UK
| | - Nicholas Ioannou
- 1 Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, UK
| | - Chris I S Meadows
- 1 Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, UK
| | - Peter B Sherren
- 1 Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, UK
| | - Kathleen Daly
- 1 Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, UK
| | - Nigel Gooby
- 2 Department of Clinical Perfusion, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, UK
| | - Nicholas Barrett
- 1 Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, UK
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Horvath CM, Brutsche MH, Schoch OD, Schillig B, Baty F, vonOw D, Rüdiger JJ. NIV by an interdisciplinary respiratory care team in severe respiratory failure in the emergency department limited to day time hours. Intern Emerg Med 2017; 12:1215-1223. [PMID: 27722910 DOI: 10.1007/s11739-016-1546-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 09/19/2016] [Indexed: 10/20/2022]
Abstract
Non-invasive ventilatory support is frequently used in patients with severe respiratory failure (SRF), but is often limited to intensive care units (ICU). We hypothesized that an instantaneous short course of NIV (up to 2 h), limited to regular working hours as an additional therapy on the emergency department (ED) would be feasible and could improve patient´s dyspnoea measured by respiratory rate and Borg visual dyspnea scale. NIV was set up by an interdisciplinary respiratory care team. Outside these predefined hours NIV was performed in the ICU. This is an observational cohort study over 1 year in the ED in a non-university hospital. Fifty-one % of medical emergencies arrived during regular working hours (5475 of 10,718 patients). In total, 63 patients were treated with instantaneous NIV. Door to NIV in the ED was 56 (31-97) min, door to ICU outside regular working hours was 84 (57-166) min. Within 1 h of NIV, the respiratory rate decreased from 30/min (25-35) to 19/min (14-24, p < 0.001), the Borg dyspnoea scale improved from 7 (5-8) to 2 (0-3, p < 0.001). In hypercapnic patients, the blood-pH increased from 7.29 (7.24-7.33) to 7.35 (7.29-7.40) and the pCO2 dropped from 8.82 (8.13-10.15) to 7.45 (6.60-8.75) kPa. In patients with SRF of varying origin, instantaneous NIV in the ED during regular working hours was feasible in a non-university hospital setting, and rapidly and significantly alleviated dyspnoea and reduced respiratory rate. This approach proved to be useful as a bridge to the ICU as well as an efficient palliative dyspnoea treatment.
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Affiliation(s)
- Christian Michael Horvath
- Pneumology and Sleep Medicine, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland.
| | - Martin Hugo Brutsche
- Pneumology and Sleep Medicine, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
| | - Otto Dagobert Schoch
- Pneumology and Sleep Medicine, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
| | - Bernarde Schillig
- Pneumology and Sleep Medicine, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
| | - Florent Baty
- Pneumology and Sleep Medicine, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
| | - Dieter vonOw
- Emergency Department, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
| | - Jochen Julius Rüdiger
- Pneumology and Sleep Medicine, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
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Guo X, Sun Y, Miao J, Cui M, Wang J, Han S. No inhalation in combination with high frequency ventilation treatment in the treatment of neonatal severe respiratory failure. Pak J Med Sci 2016; 32:1218-1223. [PMID: 27882025 PMCID: PMC5103137 DOI: 10.12669/pjms.325.10682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To discuss over NO inhalation (iNO) in combination with high frequency ventilation treatment in relieving clinical symptoms and respiratory state of patients with neonatal severe respiratory failure. Methods: Ninety newborns with severe respiratory failure who received treatment in our hospital were selected for this study. They were divided into research group and control group according to visiting time. Patients in the control group were given conventional treatment in combination with high-frequency oscillatory ventilation, while patients in the research group were given iNO for treatment additionally besides the treatment the same as the control group. Changes of respiratory function indexes and arterial blood gas indexes of patients in the two groups were compared. Mechanical ventilation time, time of oxygen therapy and the length of hospital stay were recorded. Besides, postoperative outcome and the incidence of complications were analyzed. Results: After treatment, the level of PaO2 of both groups significantly improved, and respiratory function indexes such as partial pressure of carbon dioxide in artery (PaCO2), oxygenation index (OI), fraction of inspiration O2 (FiO2) and mean arterial pressure (MAP) decreased (P<0.05); the improvement of various indexes of the research group was more obvious than that of the control group (P<0.05). Mechanical ventilation time, oxygen therapy time and the length of hospital stay of the research group was much shorter than those of the control group. The incidence of complications in the two groups had no statistically significant difference (P>0.05), but the clinical outcome of the research group was better than that of the control group. Conclusion: NO inhalation in combination with high frequency ventilation for treating neonatal severe respiratory failure is effective in improving blood gas index and respiratory function, enhance cure rate, and reduce the incidence of complications and mortality; hence it is safe and effective and worth clinical promotion.
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Affiliation(s)
- Xiaohui Guo
- Xiaohui Guo, Department of Pediatrics, Binzhou People's Hospital, Shandong 256610, China
| | - Yanfeng Sun
- Yanfeng Sun, Department of Oncology, Binzhou People's Hospital, Shandong 256610, China
| | - Jing Miao
- Jing Miao, Department of Pediatrics, Binzhou People's Hospital, Shandong 256610, China
| | - Min Cui
- Min Cui, Department of Pediatrics, Binzhou People's Hospital, Shandong 256610, China
| | - Jiangbo Wang
- Jiangbo Wang, Department of Pediatrics, Binzhou People's Hospital, Shandong 256610, China
| | - Shuzhen Han
- Shuzhen Han, Department of Pediatrics, Binzhou People's Hospital, Shandong 256610, China
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Piroddi IMG, Ferraioli G, Barlascini C, Castagneto C, Nicolini A. Severe respiratory failure as a presenting feature of an interstitial lung disease associated with anti-synthetase syndrome (ASS). Respir Investig 2016; 54:284-8. [PMID: 27424829 DOI: 10.1016/j.resinv.2016.01.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 01/12/2016] [Accepted: 01/25/2016] [Indexed: 12/23/2022]
Abstract
Anti-synthetase syndrome (ASS) is defined as a heterogeneous connective tissue disorder characterized by the association of an interstitial lung disease (ILD) with or without inflammatory myositis with the presence of anti-aminoacyl-tRNA-synthetase antibodies. ILD is one of the major extra-muscular manifestations of polymyositis and dermatomyositis. We report a case of a patient with dyspnea, cough, and intermittent fever as well as ILD associated ASS in the absence of muscular involvement. This patient was admitted to the emergency department with severe respiratory failure requiring non-invasive ventilation. Our patient's case demonstrates that the diagnosis of ASS may not be obvious. However, its diagnosis leads to appropriate and potentially life-saving treatment.
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Affiliation(s)
| | | | | | | | - Antonello Nicolini
- Respiratory Diseases Unit ASL4 Chiavarese, Via Terzi 43, 16039 Sestri Levante, Italy.
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14
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Nicolini A, Piroddi IMG, Barlascini C, Senarega R. Predictors of non-invasive ventilation failure in severe respiratory failure due to community acquired pneumonia. Tanaffos 2014; 13:20-8. [PMID: 25852758 PMCID: PMC4386012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 11/05/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Non-invasive ventilation (NIV) has been used for acute respiratory failure to avoid endotracheal intubation and intensive care admission. Few studies have assessed the usefulness of NIV in patients with severe community acquired pneumonia (CAP). The use of NIV in severe CAP is controversial because there is a greater variability in success compared to other pulmonary conditions. MATERIALS AND METHODS We retrospectively followed 130 patients with CAP and severe acute respiratory failure (PaO2/FiO2 < 250) admitted to a Respiratory Monitoring Unit (RMU) and underwent NIV. We assessed predictors of NIV failure and hospital mortality using univariate and multivariate analyses. RESULTS NIV failed in 26 patients (20.0%). Higher chest X-ray score at admission, higher heart rate after 1 hour of NIV, and a higher alveolar-arteriolar gradient (A-aDO2) after 24 hours of NIV each independently predicted NIV failure. Higher chest X ray score, higher LDH at admission, higher heart rate after 24 hours of NIV and higher A-aDO2 after 24 hours of NIV were directly related to hospital mortality. CONCLUSION NIV treatment had high rate of success. Successful treatment is related to less lung involvement and to early good response to NIV and continuous improvement in clinical response.
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