COVID-19-RELATED ARDS PHENOTYPES AND PROGRESSION BETWEEN THEM: A CASE REPORT

Abstract

SESSION TITLE: Fellows' COVID-19 SESSION TYPE: Fellow Case Reports PRESENTED ON: October 18-21, 2020 INTRODUCTION: Since January 20th, 2020 when the first case of the novel coronavirus SARS-CoV-2 was confirmed in the United States [1], there have been several reports of the disease caused by the virus known as COVID19. In the recent literature there have been descriptions of two different phenotypes of the virus presentation among hospitalized patients and particularly those requiring mechanical ventilation. These phenotypes, known as “L type” and “H type”, report what appear to be two distinct presentations with drastically different management which a patient can transition between [2]. We present a case of a patient with confirmed COVID19 who progressed through both phenotypes during his treatment consistent with these theorized phenotypes. CASE PRESENTATION: A 40 year old male presented to the hospital with shortness of breath and cough. Medical and social history was unremarkable. Workup initially showed patchy bilateral infiltrates, negative procalcitonin, fever of 103, and sats of 93% on 4L. The patient’s respiratory status quickly degraded and he required mechanical ventilation. He tested positive for SARS-CoV-2 via PCR. Initially the patient had subpleural ground glass opacities and low peep requirements before stress index became >1. He developed dyssynchrony and required more peep causing higher pressure with worse compliance. Standard supportive care for ARDS was followed. After several days the peak and plateau pressures continued to be elevated. The patient was started on nitric oxide and flolan with paralytics. He returned to a high compliance state and was ultimately extubated and discharged. DISCUSSION: There are two phenotypes with COVID-19 ARDS. The first, L-type, has high compliance, low V/Q ratio, and low lung recruitability. It has been theorized that viral infection leads to interstitial edema with vasoplegia accounting for the severe hypoxemia. This leads to increased minute volume and a more negative intrathoracic pressure with little dyspnea. The increased negative intrathoracic pressure and high tidal volumes likely lead to edema due to inflammation and increased lung permeability. This leads to dependent atelectasis and increased work of breathing. It is unclear if this is from the virus itself versus and/or high-stress ventilation. The second, H-type, has decreased compliance and high recruitability. One of the crucial things to prevent progression from L to H type is controlling work of breathing. In community hospital settings this is hard to monitor. The patient's dyssynchrony caused a significantly negative intrathoracic pressure and resulted in a form of patient-self inflicted lung injury that caused the transition from L to H phenotype. Once this was controlled with paralytics, the patient returned to L-type and recovered. CONCLUSIONS: Control of the work of breathing in a patient with COVID-19 ARDS is critical in preventing progression between L and H phenotypes. Reference #1: 1. Holshue LH, DeBolt C, Lindquist S, et al. First Case of 2019 Novel Coronavirus in the United States. N Engl J Med. 2020; 382:929-936. Reference #2: 2. Gattinoni DC, Caironi P, Busana M, et al. COVID-19 pneumonia: different respiratory treatment for different phenotypes?. J Intens Care Med. 2020; DOI: 10.1007/s00134-020-06033-2. Reference #3: 3. Yoshida T, Grieco DL, Brochard L, Fujino Y. Patient self inflicted lung injury and positive end-expiratory pressure for safe spontaneous breathing. Curr Opin Crit Care. 2020; 26(1):59-65. DISCLOSURES: No relevant relationships by Muhammad Ahmed, source=Admin input no disclosure on file for Nisarfathima Kazimuddin; No relevant relationships by Ahmed Qadir, source=Web Response No relevant relationships by karan Singh, source=Web Response No relevant relationships by Rodney Steff, source=Web Response