238: COVID-19 L-Phenotype Treatment Approach

Abstract

INTRODUCTION: Although initially compared to ARDS, COVID-19 pneumonitis presents with unique features, suggesting tailored approaches may be required Gattinoni et al recently described two distinct phenotypes of COVID-19, L-type and H-type, with low or high elastance, V/Q ratio, lung weight, and recruitability, respectively METHODS: 76 F with lymphoma presented with worsening cough and fever and tested positive for COVID-19 She was saturating 93% on room air with no increased work of breathing (SpO2/FiO2 442), suggesting L-phenotype CT chest showed multifocal groundglass opacities On day 3, she developed worsening hypoxemia (SpO2/FiO2 158 3) Despite a significant drop in SpO2/FiO2 ratio, she denied subjective dyspnea and had no increased work of breathing, continuing to demonstrate L-phenotype The patient requested to avoid invasive mechanical ventilation and a timed trial of HFNC was agreed upon She received therapies as per institutional protocol, which included remdesivir, convalescent plasma, steroids, aspirin once daily, enoxaparin 40 mg twice daily, and three doses of tocilizumab Despite receiving all this, she continued to worsen, requiring 100% FiO2 HFNC A 7-day course of anakinra was started The patient continued to remain an L-phenotype with no increased work of breathing Following the first dose of anakinra, FiO2 requirements decreased significantly from 100 to 70%, and over the course of 2 weeks, she weaned to 2L NC, making a complete clinical recovery and was discharged to a long-term acute care facility for further rehabilitation RESULTS: The difference in pulmonary presentation and treatment of COVID-19 remains undetermined Our patient had severe hypoxemia with no increased work of breathing, consistent with L-phenotype Due to a high provider to patient ratio at our institution, we were able to provide a prolonged time limited trial of HFNC and avoid invasive mechanical ventilation We found the patient's respiratory status dramatically improved following anakinra The treatment of select COVID-19 patients with HFNC and anakinra may avoid invasive mechanical ventilation, preventing ventilator complications and conserving resources