COVID-19 Related Acute Respiratory Distress Syndrome Research Articles

How Is Life After Severe COVID-19?: Functional Cardiopulmonary Outcome and Quality of Life

BACKGROUND AND AIMData on long-term outcomes of COVID19-related acute respiratory distress syndrome (ARDS) are scarce and repose mostly on patients reported outcomes. This study aimed to study cardiopulmonary functions combined with psychosocial sequels in a cohort of severe COVID-19 patients requiring intensive care unit (ICU) management and intubation, with a follow-up of 12 months. DESIGN AND METHODSWe studied a longitudinal cohort of 39 mechanically ventilated COVID-19 patients from the early pandemic phase. Pulmonary function tests (PFT), cardiopulmonary exercise testing (CPET), and subjective health perception data 6 and 12 months after ICU admission were collected. RESULTSTwelve months after COVID-19, 19.3% of the participants showed at least moderate alteration in PFT, and 35.7% a pathologically reduced effort capacity by CPET. A considerable impact on daily activities was reported, with only 41.7% being able to entirely resume work and 71% reporting a relevant health impairment due to residual respiratory symptoms. The health perception scores did not correlate significantly with the measured cardiopulmonary performance or lung function. CONCLUSIONSA persistent objective limitation in physical activity was observed in this population of unvaccinated patients from the early pandemic phase, studied for 12 months after COVID19-related ARDS. Patients also reported a profound impact on functional autonomy, daily activities, professional life, and health perception. Despite being primarily attributed to residual respiratory symptoms, the observed health impairment is probably multifactorial, with physical and psychological factors playing a role.The prolonged course of the symptoms and the underlying complexity should be considered in future programs for the care of post-COVID patients.

Anticoagulation with argatroban using hemoclot™ targets is safe and effective in CARDS patients receiving venovenous extracorporeal membrane oxygenation: An exploratory bi-centric cohort study

Direct thrombin inhibitors, including argatroban, are increasingly used for anticoagulation during venovenous extracorporeal membrane oxygenation (VV ECMO). In many centers activated partial thromboplastin time (aPTT) is used for monitoring, but it can be affected by several confounders. The aim of this study was to evaluate the safety and efficacy of anticoagulation with argatroban titrated according to diluted thrombin time targets (hemoclot™ assay) compared to anti-Xa guided anticoagulation with unfractionated heparin (UFH). MethodsThis cohort study included adults at two tertiary care centers who required VV ECMO for severe COVID-19-related acute respiratory distress syndrome (CARDS). Patients received center-dependent argatroban or UFH for anticoagulation during ECMO. Argatroban was guided following a hemoclot™ target range of 0.4–0.6 μg/ml. UFH was guided by anti-factor Xa (antiXa) levels (0.2–0.3 IU/ml). The primary outcome was safety of argatroban compared to UFH, assessed by time to first clinically relevant bleeding event or death during ECMO. Secondary outcomes included efficacy (time to thromboembolism) and feasibility (proportion of anticoagulation targets within range). ResultsFrom 2019 to 2021 57 patients were included in the study with 27 patients (47 %) receiving argatroban and 30 patients (53 %) receiving UFH. The time to the first clinically relevant bleeding or death during ECMO was similar between groups (HR (argatroban vs. UFH): 1.012, 95 % CI 0.44–2.35, p = 0.978). Argatroban was associated with a decreased risk for thromboembolism compared to UFH (HR 0.494 (95 % CI 0.26–0.95; p = 0.034)). The overall proportion of anticoagulation within target ranges was not different between groups (46 % (23–54 %) vs. 46 % (37 %–57 %), p = 0.45). ConclusionAnticoagulation with argatroban according to hemoclot™ targets (0.4–0.6 μg/ml) compared to antiXa guided UFH (0.2–0.3 IU/ml) is safe and may prolong thromboembolism-free time in patients with severe ARDS requiring VV ECMO.

Inhaled nitric oxide in patients with acute respiratory distress syndrome caused by COVID-19: treatment modalities, clinical response, and outcomes

BackgroundInhaled nitric oxide (iNO) has been widely used in patients with COVID-19-related acute respiratory distress syndrome (C-ARDS), though its physiological effects and outcome are debated in this setting. The objective of this cohort study was to describe the modalities of iNO use, clinical response, and outcomes in a large cohort of C-ARDS patients.MethodsMulticentre, retrospective cohort study conducted in France.ResultsFrom end February to December 2020, 300 patients (22.3% female) were included, 84.5% were overweight and 69.0% had at least one comorbidity. At ICU admission, their median (IQR) age, SAPS II, and SOFA score were 66 (57–72) years, 37 (29–48), and 5 (3–8), respectively. Patients were all ventilated according to a protective ventilation strategy, and 68% were prone positioned before iNO initiation. At iNO initiation, 2%, 37%, and 61% of patients had mild, moderate, and severe ARDS, respectively. The median duration of iNO treatment was 2.8 (1.1–5.5) days with a median dosage of 10 (7–13) ppm at initiation. Responders (PaO2/FiO2 ratio improving by 20% or more) represented 45.7% of patients at 6 h from iNO initiation. The severity of ARDS was the only predictive factor associated with iNO response. Among all evaluable patients, the crude mortality was not significantly different between responders at 6 h and their counterparts. Of the 62 patients with refractory ARDS (who fulfilled extracorporeal membrane oxygenation criteria before iNO initiation), 32 (51.6%) no longer fulfilled these criteria after 6 h of iNO. The latter showed significantly lower mortality than the other half (who remained ECMO eligible), including after confounder adjustment (adjusted OR: 0.23, 95% CI 0.06, 0.89, p = 0.03).ConclusionsOur study reports the benefits of iNO in improving arterial oxygenation in C-ARDS patients. This improvement seems more relevant in the most severe cases. In patients with ECMO criteria, an iNO-driven improvement in gas exchange was associated with better survival. These results must be confirmed in well-designed prospective studies.

Machine learning-based COVID-19 acute respiratory distress syndrome phenotyping and clinical outcomes: A systematic review

COVID-19-related acute respiratory distress syndrome (CARDS) has been suggested to differ from the typical ARDS. While distinct phenotypes of ARDS have been identified through latent class analysis (LCA), it is unclear whether such phenotypes exist for CARDS and how they affect clinical outcomes. To address this question, we conducted a systematic review of the current evidence.We searched several, including PubMed, EBSCO Host, and Web of Science, from inception to July 1, 2022. Our exposure and outcome of interest were different CARDS phenotypes identified and their associated outcomes, such as 28-day, 90-day, 180-day mortality, ventilator-free days, and other relevant outcomes.We identified four studies comprising a total of 1776 CARDS patients.Of the four studies, three used LCA to identify subphenotypes (SPs) of CARDS. One study based on longitudinal data identified two SPs, with SP2 associated with worse ventilation and mechanical parameters than SP1. The other two studies based on baseline data also identified two SPs, with SP2 and SP1 were associated with hyperinflammatory and hypoinflammatory CARDS, respectively. The fourth study identified three SPs primarily stratified by comorbidities using multifactorial analysis.All studies identified a subphenotype associated with poorer outcomes, including mortality, ventilator-free days, multiple-organ injury, and pulmonary embolism. Two studies reported differential responses to corticosteroids among the SPs, with improved mortality in the hyperinflammatory and worse in the hypoinflammatory SPs.Overall, our review highlights the importance of phenotyping in understanding CARDS and its impact on disease management and prognostication. However, a consensus approach to phenotyping is necessary to ensure consistency and comparability across studies. We recommend that randomized clinical trials stratified by phenotype should only be initiated after such consensus is reached. Short titleCOVID-19 ARDS subphenotypes and outcomes.

Effectiveness of exercise training on the dyspnoea of individuals with long COVID: A randomised controlled multicentre trial.

COVID-19-related acute respiratory distress syndrome (CARDS) is a severe evolution of the Sars-Cov-2 infection and necessitates intensive care. COVID-19 may subsequently be associated with long COVID, whose symptoms can include persistent respiratory symptoms up to 1 year later. Rehabilitation is currently recommended by most guidelines for people with this condition. To evaluate the effects of exercise training rehabilitation (ETR) on dyspnoea and health-related quality of life measures in people with continuing respiratory discomfort following CARDS. In this multicentre, two-arm, parallel, open, assessor-blinded, randomised controlled trial, we enroled adults previously admitted with CARDS to 3 French intensive care units who had been discharged at least 3 months earlier and who presented with an mMRC dyspnoea scale score > 1. Participants received either ETR or standard physiotherapy (SP) for 90 days. The primary outcome was dyspnoea, as measured by the Multidimensional Dyspnoea Profile (MDP), at day 0 (inclusion) and after 90 days of physiotherapy. Secondary outcomes were the mMRC and 12-item Short-Form Survey scores. Between August 7, 2020, and January 26, 2022, 487 participants with CARDS were screened for inclusion, of whom 60 were randomly assigned to receive either ETR (n=27) or SP (n=33). Mean MDP following ETR was 42% lower than after SP (26.15vs. 44.76); a difference of -18.61 (95% CI -27.78 to -9.44; p<10-4). People who were still suffering from breathlessness three months after being discharged from hospital with CARDS had significantly improved dyspnoea scores when treated with ETR therapy for 90 days unlike those who only received SP. Study registered 29/09/2020 on Clinicaltrials.gov (NCT04569266).

HYPERTENSION AND RISK FACTOR TO MORTALITY IN CORONAVIRUS DISEASE (COVID-19)

Objective: the aim of this study is to assess whether hypertension was considered a risk factor for mortality in in adult patients with COVID-19 hospitalized for acute respiratory distress syndrome (ARDS). Design and method: Retrospective study with analysis of electronic medical records of adult patients admitted for mild and moderate COVID-19 and related acute respiratory distress syndrome in a single quaternary private hospital in Rio de Janeiro, Brazil. Consecutive patients aged 18 years and older with COVID-19 confirmed by a positive reverse transcription polymerase chain reaction (RT-PCR) testing. ll data were collected in spreadsheets in Microsoft Excel version 365 (Microsoft Corp., Redmon – WA – USA) and the statistical analysis was performed using SAS Guide 4.3 (SAS Institute Inc., Cary – NV – USA). Results: Two hundred and two patients were were consecutively admitted for mild or moderate COVID-19 related ARDS and were included in this study. The mean age of the studied population was 69.1 ± 14.8 years. Of these, 130 patients (64.4%) were male. The mean BMI was 29.9 ± 6 kg/m2. Hypertension was present in 134 patients, corresponding to 67% of the studied population. 35.8% of patients had diabetes and 10.45% dyslipidemia. Among hypertensive patients, 58 (74%) died, with a relative risk of 1.45 (CI 0.96-2.2) Conclusions: The studies presented systemic arterial hypertension as the most common chronic disease in subjects diagnosed with covid-19. Hypertension is one of the main risk factors for adverse outcomes in subjects with covid-19. The results found in this study suggest that hypertension is associated with an increased risk of developing the severe form of covid-19, and increased mortality. Future studies should include the analysis of individual variables that may influence the outcome of systemic arterial hypertension subjects infected by SARS-CoV-2, such as genetic factors, race/ethnicity, occupation, lifestyle habits, in addition to the evaluation of educational level and diagnosis of the socioeconomic and environmental situation.

Failing categorization of severe COVID-19 ARDS into ventilatory subphenotypes studied via the clinical-histopathologic relationship

BackgroundCategorization of severe COVID-19 related acute respiratory distress syndrome (CARDS) into subphenotypes does not consider the trajectories of respiratory mechanoelastic features and histopathologic patterns. This study aimed to assess the correlation between mechanoelastic ventilatory features and lung histopathologic findings in critically ill patients who died because of CARDS. MethodsMechanically ventilated patients with severe CARDS who had daily ventilatory data were considered. The histopathologic assessment was performed through full autopsy of deceased patients. Patients were categorized into two groups according to the median worst respiratory system compliance during ICU stay (CrsICU). ResultsEighty-seven patients admitted to ICU had daily ventilatory data. Fifty-one (58.6%) died in ICU, 41 (80.4%) underwent full autopsy and were considered for the clinical-histopathological correlation analysis. Respiratory system compliance at ICU admission and its trajectory were not different in survivors and non-survivors. Median CrsICU in the deceased patients was 22.9 ml/cmH2O. An inverse correlation was found between the CrsICU and late-proliferative diffuse alveolar damage (DAD) (r = −0.381, p = 0.026). Late proliferative DAD was more extensive (p = 0.042), and the probability of stay in ICU was higher (p = 0.004) in the “low” compared to the “high” CrsICU group. Cluster analysis further endorsed these findings. ConclusionsIn critically ill mechanically ventilated patients, worsening of the respiratory system compliance correlated pathologically with the transition from early damage to late fibroproliferative patterns in non-survivors of CARDS. Categorization of CARDS into ventilatory subphenotypes by mechanoelastic properties at ICU admission does not account for the complexity of the histopathologic features.

Abstracts from The Aerosol Society Drug Delivery to the Lungs 33.

Abstracts from The Aerosol Society Drug Delivery to the Lungs 33.

Brief Overview of the Use of Extracorporeal Membrane Oxygenation (ECMO) in COVID-19 Patients with Severe Acute Respiratory Distress Syndrome (ARDS)

Background A serious complication of coronavirus disease 2019 (COVID-19) is acute respiratory distress syndrome (ARDS). Hypoxemia refractory to traditional management, including invasive positive pressure ventilation, is not uncommon with COVID-19. It can lead to circulatory failure necessitating the use of mechanical circulatory support devices, specifically extracorporeal membrane oxygenation (ECMO). Aim This paper provides a brief update on the use and indications of ECMO for adult patients with COVID-19 around the world. Methods We conducted a rapid umbrella review on the use of ECMO in treating COVID-19-related ARDS (CARDS), as well as current indications and contraindications for the initiation of ECMO. We reviewed the use of venovenous (V-V) ECMO and veno-arterial (V-A) ECMO in CARDS. Findings V-V ECMO is the primary ECMO mode employed in the majority of the patients who required ECMO support for CARDS. Although the duration of V-V ECMO in COVID-19 was longer than the V-V ECMO in non-COVID-19 patients with ARDS, the mortality rate appears similar. Meta-analyses reviewed reported an in-hospital mortality rate ranging from 37% to 49% for COVID-19 patients who required V-V ECMO. Conclusion The survival benefit of ECMO in COVID-19 patients with severe cardiopulmonary failure is not clearly established, but V-V ECMO may be considered in adults with COVID-19 and severe cardiopulmonary compromise when resources are available. V-A ECMO may be considered in COVID-19 patients with severe cardiac failure, but limited data are available on survival benefits.

Are There Distinct Cardiovascular Subclasses in Acute Respiratory Distress Syndrome? Maybe.

Are There Distinct Cardiovascular Subclasses in Acute Respiratory Distress Syndrome? Maybe.

Echocardiographic detection of transpulmonary bubble transit during coronavirus-2019 disease (COVID-19)

BackgroundTranspulmonary bubble transit (TPBT) detected with contrast echocardiography is reported as a sign of intrapulmonary arteriovenous shunt. However, its pathological meaning is not clear during coronavirus-2019 disease (COVID-19) related acute respiratory distress syndrome (ARDS). Our aim was to determine the prevalence and clinical significance of TPBT detection during COVID-19 related ARDS. MethodsWe carried out a prospective observational study performed in a high complexity intensive care unit from Argentina. Patients with COVID-19 related ARDS underwent transthoracic echocardiography with saline contrast. Moderate-to-large TPBT was defined as right-to-left passage of at least twelve bubbles to left chambers after at least three cardiac cycles and complete opacification of the right atrium. ResultsWe analyzed the results of 28 patients (24 men and 4 women). Seventy-five percent of the patients received invasive mechanical ventilation. Moderate-to-large TPBT was detected in 1 patient (3.5%). Among the 27 patients without significant TPBT, 23 had no TPBT and 4 had a minor TPBT. TPBT was not associated with invasive mechanical ventilation requirement (p=0.5737) nor in-hospital mortality (p=1). ConclusionsTPBT was not associated with severe hypoxemia or invasive mechanical ventilation requirement, although more studies are needed to further clarify its contributing role in COVID-19 hypoxemia.

Artificial intelligence assessment of the potential of tocilizumab along with corticosteroids therapy for the management of COVID-19 evoked acute respiratory distress syndrome.

Acute respiratory distress syndrome (ARDS), associated with high mortality rate, affects up to 67% of hospitalized COVID-19 patients. Early evidence indicated that the pathogenesis of COVID-19 evoked ARDS is, at least partially, mediated by hyperinflammatory cytokine storm in which interleukin 6 (IL-6) plays an essential role. The corticosteroid dexamethasone is an effective treatment for severe COVID-19 related ARDS. However, trials of other immunomodulatory therapies, including anti-IL6 agents such as tocilizumab and sarilumab, have shown limited evidence of benefit as monotherapy. But recently published large trials have reported added benefit of tocilizumab in combination with dexamethasone in severe COVID-19 related ARDS. In silico tools can be useful to shed light on the mechanisms evoked by SARS-CoV-2 infection and of the potential therapeutic approaches. Therapeutic performance mapping system (TPMS), based on systems biology and artificial intelligence, integrate available biological, pharmacological and medical knowledge to create mathematical models of the disease. This technology was used to identify the pharmacological mechanism of dexamethasone, with or without tocilizumab, in the management of COVID-19 evoked ARDS. The results showed that while dexamethasone would be addressing a wider range of pathological processes with low intensity, tocilizumab might provide a more direct and intense effect upon the cytokine storm. Based on this in silico study, we conclude that the use of tocilizumab alongside dexamethasone is predicted to induce a synergistic effect in dampening inflammation and subsequent pathological processes, supporting the beneficial effect of the combined therapy in critically ill patients. Future research will allow identifying the ideal subpopulation of patients that would benefit better from this combined treatment.

Comparing lung mechanics of patients with COVID related respiratory distress syndrome versus non-COVID acute respiratory distress syndrome: a retrospective observational study

Background Most patients admitted to the intensive care unit with coronavirus disease (COVID-19) develop severe respiratory failure. Understanding lung mechanics helps to guide protective mechanical ventilation, improve oxygenation, and reduce the ventilator induce lung injury. This study aims to describe lung mechanics characteristics of patients with COVID -19 related acute respiratory distress syndrome (CARDS) and to compare them with non-COVID-19 associated ARDS. Methods We performed a retrospective observational study of lung mechanics: plateau pressure (Pplat), Driving pressure (DP), Mechanical power (MPw), Elastic (dynamic) power (EdPw), Total ventilatory power (TPw), and oxygenation parameters (ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2), the ratio of arterial oxygen partial pressure to fractional inspired oxygen multiplied by PEEP [PaO2/(FiO2 x PEEP)], arterial and venous carbon dioxide partial pressure (PaCO2, PvCO2), and Ventilation dead space (VD) were measured and compared between the two groups after initiation of mechanical ventilation. Results 30 CARDS and 10 ARDS patients fulfilled the study requirements. We observed a significant higher MPw in the CARDS group (29.17 ± 8.29 J/min vs 15.78 ± 4.45 J/min, P 0.007), similarly observed with EdPw (256.7 ± 84.06 mJ/min vs 138.1 ± 39.15 mJ/min, P 0.01) and TPw (289.1 ± 84.51 mJ/min vs 161.5 ± 45.51, P 0.007). Inside the CARDS group, we found 2 subgroups, a low shunt subgroup and a higher shunt (Qs/Qt (%): 6.61 ± 2.46 for vs 40.3 ± 20.6, P 0.0009), however, between these two subgroups we didn’t find statistical differences on lung mechanic parameters but only in oxygenation parameters (PaO2/FiO2 and PaO2/FiO2*PEEP). When comparing these two subgroups with ARDS patients, we found more similarity between the low shunt CARDS and the ARDS patients on MP (R2 0.99, P 0.001), EdPw (R2 0.89, P 0.05) and TPw (R2 0.99, P 0.0009). Conclusions: Our study suggests important differences between CARDS and ARDS regarding mechanical parameters that could lead to more complicated management of CARDS patients and a higher prevalence of VILI. However due to the study limitations, a bigger study is necessary to corroborate our findings. Keywords: COVID-19, CARDS, ARDS, lung mechanics, VILI.

Worse survival in patients with right ventricular dysfunction and COVID-19–associated acute respiratory distress requiring extracorporeal membrane oxygenation: A multicenter study from the ORACLE Group

ObjectiveWe sought to determine the impact of right ventricular dysfunction on the outcomes of mechanically ventilated patients with COVID-19 requiring veno-venous extracorporeal membrane oxygenation. MethodsSix academic centers conducted a retrospective analysis of mechanically ventilated patients with COVID-19 stratified by support with veno-venous extracorporeal membrane oxygenation during the first wave of the pandemic (March to August 2020). Echocardiograms performed for clinical indications were reviewed for right and left ventricular function. Baseline characteristics, hospitalization characteristics, and survival were compared. ResultsThe cohort included 424 mechanically ventilated patients with COVID-19, 126 of whom were cannulated for veno-venous extracorporeal membrane oxygenation. Right ventricular dysfunction was observed in 38.1% of patients who received extracorporeal membrane oxygenation and 27.4% of patients who did not receive extracorporeal membrane oxygenation with an echocardiogram. Biventricular dysfunction was observed in 5.5% of patients who received extracorporeal membrane oxygenation. Baseline patient characteristics were similar in both the extracorporeal membrane oxygenation and non–extracorporeal membrane oxygenation cohorts stratified by the presence of right ventricular dysfunction. In the extracorporeal membrane oxygenation cohort, right ventricular dysfunction was associated with increased inotrope use (66.7% vs 24.4%, P < .001), bleeding complications (77.1% vs 53.8%, P = .015), and worse survival independent of left ventricular dysfunction (39.6% vs 64.1%, P = .012). There was no significant difference in days ventilated before extracorporeal membrane oxygenation, length of hospital stay, hours on extracorporeal membrane oxygenation, duration of mechanical ventilation, vasopressor use, inhaled pulmonary vasodilator use, infectious complications, clotting complications, or stroke. The cohort without extracorporeal membrane oxygenation cohort demonstrated no statistically significant differences in in-hospital outcomes. ConclusionsThe presence of right ventricular dysfunction in patients with COVID-19–related acute respiratory distress syndrome supported with veno-venous extracorporeal membrane oxygenation was associated with increased in-hospital mortality. Additional studies are required to determine if mitigating right ventricular dysfunction in patients requiring veno-venous extracorporeal membrane oxygenation improves mortality.

Feasibility and outcomes with subclavian vein access for crescent jugular dual lumen catheter for venovenous extracorporeal membrane oxygenation in COVID-19 related acute respiratory distress syndrome.

Femoral-femoral Veno-Venous ExtraCorporeal Life Support (V-V ECLS) has been associated with higher infections rates, vascular site bleeding complications, and restricted patient mobility. Jugular or bicaval dual lumen V-V ECLS conceptually overcomes some of these adverse factors, but experience has shown that jugular vein cannulation still limits mobility and has increased bleeding complications. Technique and outcomes of subclavian vein single-cannulation with Crescent jugular dual-lumen V-V ECLS is described. five patients with COVID-19 related acute respiratory distress syndrome (ARDS) underwent right subclavian vein V-V ECLS placement with the Crescent 32 French jugular dual-lumen V-V ECLS catheter. A standardized percutaneous technique was developed that allowed efficient insertion without need for any specialized imaging (i.e. transesophageal echocardiogram) and outcomes assessed. Mean age of the five patients was 41.2years, all obese with an average basal mass index of 45.2kg/m2 and mean days to decannulation of 24.2days. Outcomes discovered included; improved patient mobility allowing physical rehabilitation, no vascular access site related complications requiring surgery or endovascular intervention, and none had evidence of superior vena cava syndrome. One patient had subclavian/axillary vein thrombosis with resolution after 3months of direct-acting oral anticoagulants, and one patient had blood cultures positive at day 37, nearing decannulation. Subclavian vein access for crescent jugular dual lumen V-V ECLS catheter appears to be safe and feasible with added benefits of decreased bleeding and increased mobility over jugular or femoral-femoral access site for long term V-V ECLS support in COVID-19 related ARDS patients.

Prolonged Noninvasive Respiratory Support Before Intubation Is Associated With Increased Duration of Extracorporeal Membrane Oxygenation.

Prolonged Noninvasive Respiratory Support Before Intubation Is Associated With Increased Duration of Extracorporeal Membrane Oxygenation.

Association Between Vaccination Status and Mortality Among Intubated Patients With COVID-19–Related Acute Respiratory Distress Syndrome

Although vaccination substantially reduces the risk of severe COVID-19, it is yet unknown whether vaccinated patients who develop COVID-19 and require invasive mechanical ventilation have lower mortality than controls. To examine the association between COVID-19 vaccination status and mortality among critically ill patients who require invasive mechanical ventilation owing to acute respiratory distress syndrome (ARDS) related to COVID-19. This multicenter cohort study was performed between June 7, 2021, and February 1, 2022, among 265 consecutive adult patients with COVID-19 in academic intensive care units who underwent invasive mechanical ventilation owing to ARDS. Patients in the full vaccination group had completed the primary COVID-19 vaccination series more than 14 days but less than 5 months prior to intubation. This time threshold was chosen because guidelines from the US Centers for Disease Control and Prevention recommend a booster dose beyond that time. The remaining patients (ie, those who were unvaccinated, partially vaccinated, or fully vaccinated <14 days or >5 months before intubation) comprised the control group. The primary outcome was time from intubation to all-cause intensive care unit mortality. A Cox proportional hazards regression model including vaccination status, age, comorbid conditions, and baseline Sequential Organ Failure Assessment score on the day of intubation was used. A total of 265 intubated patients (170 men [64.2%]; median age, 66.0 years [IQR, 58.0-76.0 years]; 26 [9.8%] in the full vaccination group) were included in the study. A total of 20 patients (76.9%) in the full vaccination group received the BNT162b2 vaccine, and the remaining 6 (23.1%) received the ChAdOx1 nCoV-19 vaccine. Patients in the full vaccination group were older (median age, 72.5 years [IQR, 62.8-80.0 years] vs 66.0 years [IQR, 57.0-75.0 years]) and more likely to have comorbid conditions (24 of 26 [92.3%] vs 160 of 239 [66.9%]), including malignant neoplasm (6 of 26 [23.1%] vs 18 of 239 [7.5%]), than those in the control group. Full vaccination status was significantly associated with lower mortality compared with controls (16 of 26 patients [61.5%] died in the full vaccination group vs 163 of 239 [68.2%] in the control group; hazard ratio, 0.55 [95% CI, 0.32-0.94]; P = .03). In this cohort study, full vaccination status was associated with lower mortality compared with controls, which suggests that vaccination might be beneficial even among patients who were intubated owing to COVID-19-related ARDS. These results may inform discussions with families about prognosis.

METABOLOMIC PROFILING AND PROGNOSTICATION IN COVID-19-RELATED ARDS

METABOLOMIC PROFILING AND PROGNOSTICATION IN COVID-19-RELATED ARDS

VACCINE-INDUCED ANTIBODY DEPENDENT ENHANCEMENT IN COVID-19

VACCINE-INDUCED ANTIBODY DEPENDENT ENHANCEMENT IN COVID-19

Extracorporeal membrane oxygenation circuits in parallel for refractory hypoxemia in patients with COVID-19

ObjectivesRefractory hypoxemia can occur in patients with acute respiratory distress syndrome from COVID-19 despite support with venovenous (VV) extracorporeal membrane oxygenation (ECMO). Parallel ECMO circuits can be used to increase physiologic support. We report our clinical experience using ECMO circuits in parallel for select patients with persistent severe hypoxemia despite the use of a single ECMO circuit. MethodsWe performed a retrospective cohort study of all patients with COVID–19-related acute respiratory distress syndrome who received VV-ECMO with an additional circuit in parallel at Vanderbilt University Medical Center between March 1, 2020, and March 1, 2022. We report demographic characteristics and clinical characteristics including ECMO settings, mechanical ventilator settings, use of adjunctive therapies, and arterial blood gas results after initial cannulation, before and after receipt of a second ECMO circuit in parallel, and before removal of the circuit in parallel, and outcomes. ResultsOf 84 patients with COVID-19 who received VV-ECMO during the study period, 22 patients (26.2%) received a circuit in parallel. The median duration of ECMO was 40.0 days (interquartile range, 31.6-53.1 days), of which 19.0 days (interquartile range, 13.0-33.0 days) were spent with a circuit in parallel. Of the 22 patients who received a circuit in parallel, 16 (72.7%) survived to hospital discharge and 6 (27.3%) died before discharge. ConclusionsIn select patients, the additional use of an ECMO circuit in parallel can increase ECMO blood flow and improve oxygenation while allowing for lung-protective mechanical ventilation and excellent outcomes.