Experience of a Novel Specialised Cardio-Pulmonary Approach in the Management of Severely Ill Patients with COVID-19 in Intensive Care Settings

Abstract

Introduction:During the Corona-virus pandemic, our intensive care units and staff were overwhelmed by both patient numbers and the complexities of their clinical presentation. We believed that a specialist dedicated team would assist our medical and nursing colleagues and help identify and treat the various cardio-pulmonary pathologies contributing to the critical illness of our patients. To support our colleagues and to assist with diagnosis and treatment, we developed a specialist team. We named this team the Acute Respiratory Disease Support (ARDS) team. The purpose of our team was to provide specialist input for severely unwell patients with COVID-19 early in their disease and to assess for conditions that may respond to specific therapies including advanced pulmonary vasodilator therapy and steroids. Methods:The Acute Respiratory Disease Support team reviewed 44 consecutive patients referred from the intensive care units from mid-April to end of May 2020 on a daily basis and coordinated therapies for pulmonary hypertension, pulmonary thrombosis and evolving fibrosis. A follow-up post hospital discharge clinic was set up. Results:The mortality for this group was significantly lower (34%) than the total group admitted to critical care as a whole (51%) and for those not reviewed by the team (55%;p=0.012). Mortality among Asian and African-Caribbean patients was higher than Caucasians (p=0.035). Twenty-three patients (52%) were diagnosed with pulmonary thrombosis. Pulmonary hypertension was present in 84% of the patients. Thirty-two patients received sildenafil therapy and this was associated with improvement in right heart function in all survivors. Short time on mechanical ventilation was associated with a poorer outcome (p=0.0003). Ten patients with evolving pulmonary fibrosis and no evidence of sepsis received high dose steroid therapy in the form of intravenous pulsed methylprednisolone early in their disease. Repeat thoracic computerised tomographic (CT) scans were performed which showed excellent effect (Figure 1). Conclusion:Our experience has reinforced the concept that there are many contributing factors to impaired cardio-pulmonary function in COVID-19 patients and that many of these may be co-contributory to the patient's clinical presentation. It suggests that a coordinated specialised cardio-pulmonary team approach contributes significantly to successful management and outcome of severely unwell patients with COVID-19 and offers an important platform for continuity of patient care, education and staff well-being.