Rate Of Invasive Mechanical Ventilation Research Articles

S1461 Investigating the Obesity Paradox in Hospitalized Patients With Chronic Obstructive Lung Disease Exacerbation in the United States

Introduction: Obesity is a public health concern that is common among individuals with chronic obstructive pulmonary disease (COPD) and is associated with increased dyspnea and poor quality of life. Despite these negative associations, however, evidence suggests that obese patients with COPD have lower mortality than underweight COPD patients. This “obesity paradox” has been studied in long-term outcomes of COPD, but studies evaluating the effect of obesity on in-hospital outcomes of COPD exacerbation are few. Herein we evaluate the obesity paradox in hospitalized patients with COPD exacerbation using the National Inpatient Sample (NIS) database. Methods: A cohort study was conducted using NIS data from 2016 to 2019. Adult hospitalizations with an admitting diagnosis of COPD exacerbation and a documented body mass index (BMI) were included in the study. Patients were stratified by BMI as underweight, normal weight, overweight, class 1 obesity, class 2 obesity, and class 3 obesity. The primary outcome was in-hospital mortality. Secondary outcomes were invasive mechanical ventilation (IMV), non-invasive ventilation (NIV), and hospital length of stay (LOS). Multivariate analysis was used to adjust for outcomes. Covariates were selected using a univariate screen and literature review. Results: A total of 1,474,985 COPD exacerbation admissions were identified. In-hospital mortality was 6.1% in underweight, 5.8% in normal weight, 3.4% in overweight, and 1.9%, 1.7%, and 2.1% in class 1, class 2 and class 3 obesity groups, respectively (Table). Obesity class 1 and 2 had the lowest rates of IMV. Compared to normal weight patients, obese patients had greater rates of NIV, with class 3 obesity having the highest rate. LOS was lower in obese patients. After adjusting for potential confounders, both overweight and obesity were independently associated with higher rates of NIV and lower rates of IMV and mortality (Figure). Conclusion: This study demonstrates lower rates of mortality and IMV in obese patients admitted with COPD exacerbation. These findings support the existence of the obesity paradox in hospitalized patients with COPD exacerbation. However, several factors may confound the relation between obesity, COPD, and mortality, thus further prospective studies are needed to shed light on this complex phenomenon and its implications on healthcare.Figure 1.: Adjusted odds ratios for mortality, invasive mechanical ventilation, and non-invasive ventilation across the different ranges of BMI in reference to normal weight (BMI 20-24.9). Table 1. - In-hospital outcomes in COPD exacerbation hospitalizations across multiple BMI ranges Outcome Underweight Normal weight Overweight Obesity class1 Obesity class 2 Obesity class 3 Mortality 6.1% (5.9% - 6.3%) 5.8% (5.4% - 6.1%) 3.4% (3.2% - 3.7%) 1.9% (1.8% - 2.0%) 1.7% (1.6% - 1.9%) 2.1% (2.1% - 2.2%) Invasive ventilation 9.9% (9.7% - 10.2%) 10.7% (10.3% - 11.2%) 9.5% (9.1% - 10.0%) 7.5% (7.1% - 7.6%) 7.4% (7.1% - 7.6%) 9.8% (9.6% - 10.0%) Non-invasive ventilation 15.4% (15.0% - 15.8%) 14.8% (14.2% - 15.4%) 16.0% (15.3% - 16.6%) 16.2% (15.7% - 16.8%) 16.9% (16.4% - 17.4%) 20.8% (20.3% - 21.3%) > 5 days length of stay 44.7% (44.3% - 45.2%) 48.7% (47.9% - 49.6%) 42.5% (41.7% - 43.4%) 35.8% (35.3% - 36.7%) 35.1% (34.6% - 35.6%) 38.9% (38.6% - 39.3%) Parenthetical ranges represent 95% confidence intervals.

Adding colchicine to tocilizumab in hospitalized patients with severe COVID-19 pneumonia: An open-label randomized controlled trial.

Introduction:Colchicine acts upstream in the cytokines cascade by inhibiting the nod-like receptor protein 3 (NLRP3) inflammasome while interleukin 6 (IL-6) receptor antagonists, such as tocilizumab, block the end result of the cytokines cascade. Hence, adding colchicine to tocilizumab with the aim of blocking the early and end products of the cytokines cascade, might reduce the risk of developing cytokine storm.Methods and analysis:We aim to conduct an open-label randomized controlled trial to evaluate the efficacy and safety of adding colchicine to tocilizumab among patients with severe COVID-19 pneumonia to reduce the rate of invasive mechanical ventilation and mortality. We will include patients with severe COVID-19 pneumonia who received tocilizumab according to our local guidelines. Enrolled patients will be then randomized in 1:1 to colchicine versus no colchicine. Patients will be followed up for 30 days. The primary outcome is the rate of invasive mechanical ventilation and will be determined using Cox proportional hazard model.Discussion:Given colchicine’s ease of use, low cost, good safety profile, and having different anti-inflammatory mechanism of action than other IL-6 blockade, colchicine might serve as a potential anti-inflammatory agent among patients with severe COVID-19 pneumonia. This study will provide valuable insights on the use of colchicine in severe COVID-19 when added to IL-6 antagonists.Ethics and dissemination:The Medical Research Center and Institutional Review Board at Hamad Medical Corporation in Qatar approved the study protocol (MRC-01-21-299). Results of the analysis will be submitted for publication in a peer-reviewed journal.

Terapia de electroestimulación diafragmática transcutánea temprana en pacientes críticos con ventilación mecánica invasiva: su repercusión en el destete

IntroductionThere is a rapid diaphragmatic atrophy in the first 6h of invasive mechanical ventilation (IMV). Ultrasound is useful in the assessment of diaphragmatic function. Rehabilitation is a fundamental part in the recovery of the critically ill patient. ObjectiveTo determine the usefulness of early transcutaneous diaphragmatic electrostimulation therapy in critically ill patients with IMV for successful weaning from IMV. Material and methodProspective, analytical case-control study in 46 patients with IMV: 23 cases (group A, intervention group, with application of transcutaneous diaphragmatic electrostimulation therapy at 6h from admission to ICU) and 23 controls (group B); from August 1, 2021 to December 30, 2021, in the IMSS ICU, UMAE HE No. 1, CMN del Bajío, León Guanajuato. Ultrasound measurement of diaphragmatic thickness, shortening fraction, and diaphragmatic excursion of all patients were taken into consideration. From the statistical analysis, χ2 test, Spearman correlation and analysis of variance were performed. ResultsGroup A presented 16.66% extubation failure, group B had 66% failure (P=.051). A moderate correlation was obtained (r=0.419; P=.047) with total days of IMV and diaphragmatic thickness assessed at extubation. ConclusionsInitiation of early transcutaneous diaphragmatic electrostimulation therapy rehabilitation at 6h from ICU admission results in better outcomes after extubation with a lower failure rate and fewer days of IMV.

RT-PCR Ct values combined with age predicts invasive mechanical ventilation and mortality in hospitalized COVID-19 patients in a MERS-CoV-endemic country

BackgroundSeveral risk factors have been used to predict severity of coronavirus disease 2019 (COVID-19), real-time reverse transcriptase polymerase chain reaction (RT-PCR) cycle threshold (Ct) values have not been included. MethodsA retrospective analysis of laboratory-confirmed COVID-19 patients who were hospitalized between March 2 and September 1, 2020, in an academic hospital in Riyadh that serves as a Middle East respiratory syndrome coronavirus (MERS-CoV) referral center was conducted. Nasopharyngeal (NP) and endotracheal (ET) samples were tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by RT-PCR, and viral load (VL) was determined based on the Ct values of E genes. The Ct values were distributed into four groups, with group Ct1 (≤19) indicating the highest VL and Ct4 (≥31) indicating the lowest VL. Univariate logistic regression was used to analyze age, gender, and comorbidities in relation to Ct groups for a primary endpoint of either invasive mechanical ventilation (IMV) or mortality. Significant variables were further analyzed by multivariate logistic regression. ResultsThe analysis included 728 patients hospitalized with COVID-19 (38% female; median age = 53 years; 41.3% diabetic; 39.4% hypertensive). Overall, 13.6% of these patients required IMV, and the in-hospital mortality rate was 15.5%. The IMV rate was higher in the Ct1 and Ct2 groups (15.2% and 15.5%, respectively) than in the Ct4 group (6.4%; p = 0.01). The mortality rate was also higher in the Ct1 and Ct2 groups (19.4% and 18.9%, respectively) than in the Ct4 group (8.9%; p = 0.02). The univariate analysis showed that lower Ct values and increasing age were associated with an increased risk of IMV (OR: 1.03; 95% CI: 1.01, 1.04; P < 0.0001) and mortality (OR: 1.04; 95% CI: 1.03, 1.06; P < 0.0001). The multivariate analysis showed that Ct1 was associated with the highest risk of mortality (OR: 2.29; 95% CI: 1.16, 5.52; P = 0.016), while Ct2 was associated with the highest risk of IMV (OR: 3.1; 95% CI: 1.47, 6.53; P = 0.003). ConclusionThe SARS-CoV-2 RT-PCR Ct values of hospitalized COVID-19 patients can be used as predictors of IMV and mortality, and this effect increases when combined with age. Clinicians could use these predictors to triage older patients for risk stratification and allocate IMV.

Clinical characteristics, risk factors, and rate of severity of a nationwide COVID-19 Saudi cohort

ObjectiveTo evaluate COVID19 patients’ clinical characteristics, risk factors, and COVID-19 severity at baseline and over one month following hospitalization. Design, setting, and participantsThis prospective cohort study of 598 Saudi COVID19 patients recruited from 4 major medical institutions nationwide between June 01, 2020, and February 28, 2021. Patients were stratified into different demographic characteristics and COVID-19 severity scale. ResultsOf the 598 hospitalized adult COVID19 patients (mean [range] age, 57 [46 to 65] years; 59% male), 300 (50.16%) had severe clinical COVID-19. Comorbidity was high among hospitalized patients (73.5 %), with diabetes mellitus (n=; 46%) and hypertension (n=; 41%) being the most common prevalent. In a multivariate logistic regression model, patient demographics and clinical factors such as age (odds ratio [OR], 1.014 per year; 95% CI, 1.003–1.025), male sex (OR, 1.63; 95% CI, 1.02–2.62), diabetes mellitus (OR, 1.63; 95% CI, 1.06–2.49), obesity (OR, 1.93; 95% CI, 1.26–2.94), oxygen saturation<92% (OR, 4.83; 95% CI, 2.96–7.86), and high neutrophil to lymphocyte ratio (OR, 3.74 per unit; 95% CI, 1.96–7.14) were independently associated with higher COVID-19 severity. Moreover, more than 60% of male patients and middle-aged patients (40–60 years) were associated with the use of COVID-19 medications, including favipiravir and dexamethasone, during their hospital stay. Additionally, the rate of invasive mechanical ventilation was the highest in female patients (61.5%) and in middle-aged patients (46.2%). However, the death rate was slightly higher in males (56%) than in female patients and in elderly patients (52%). In Cox proportional analysis, age associated with increased risk of 60-days mortality (Hazard ratio; HR, 1.05 per year; 95% CI, 1.018–1.098). Additionally, the Riyadh region associated with more COVID-19 cases required invasive respiratory support (57.7%) and Jeddah was associated with more deceased COVID-19 cases (44%). ConclusionsThe data shows that comorbidity is associated with hospitalization among COVID-19 patients, which indicates the level of severity. Infection during the winter season (November), male gender, elderly, and those with pre-existing diabetes mellitus or obesity were associated with higher COVID-19 clinical severity.

Blood Urea Nitrogen as a Prognostic Marker in Severe Acute Pancreatitis.

Objectives To explore independent risk factors with good and early predictive power for SAP severity and prognosis. Methods Patients with SAP were enrolled at Central South University Xiangya Hospital between April 2017 and May 2021 and used as the training cohort. From June 2021 to February 2022, all patients with SAP were defined as external patients for validation. Patients were grouped by survival status at a 30-day posthospital admission and then compared in terms of basic information and laboratory tests to screen the independent risk factors. Results A total of 249 patients with SAP were enrolled in the training cohort. The all-cause mortality rate at a 30-day postadmission was 25.8% (51/198). Blood urea nitrogen (BUN) levels were significantly higher in the mortality group (20.45 [interquartile range (IQR), 19.7] mmol/L) than in the survival group (6.685 [IQR, 6.3] mmol/L; P < 0.001). After propensity score matching (PSM), the BUN level was still higher in the mortality group than in the survival group (18.415 [IQR, 19.555] mmol/L vs. 10.63 [IQR, 6.03] mmol/L; P = 0.005). The area under the curve (AUC) of the receiver operating characteristic curve (ROC) of BUN was 0.820 (95% confidence interval, 0.721–0.870; P < 0.001). The optimal BUN level cut-off for predicting a 30-day all-cause mortality was 10.745 mmol/L. Moreover, patients with SAP were grouped according to BUN levels and stratified according to optimal cut-off value. Patients with high BNU levels were associated with significantly higher rates of invasive mechanical ventilation (before PSM: 61.8% vs. 20.6%, P < 0.001; after PSM: 71.1% vs. 32%, P = 0.048) and a 30-day all-cause mortality (before PSM: 44.9% vs. 6.9%, P < 0.001; after PSM: 60% vs. 34.5%, P = 0.032) than those with low BNU levels before or after PSM. The effectiveness of BUN as a prognostic marker was further validated using ROC curves for the external validation set (n = 49). The AUC of BUN was 0.803 (95% CI, 0.655–0.950; P = 0.011). It showed a good ability to predict a 30-day all-cause mortality in patients with SAP. We also observed similar results regarding disease severity, including the Acute Physiology and Chronic Health Evaluation II score (before PSM: 16 [IQR, 8] vs. 8 [IQR, 6], P < 0.001; after PSM: 18 [IQR, 10] vs. 12 [IQR, 7], P < 0.001), SOFA score (before PSM: 7 [IQR, 5] vs. 3 [IQR, 3], P < 0.001; after PSM: 8 [IQR, 5] vs. 5 [IQR, 3.5], P < 0.001), and mMarshall score (before PSM: 4 [IQR, 3] vs. 3 [IQR, 1], P < 0.001; after PSM: 5 [IQR, 2.5] vs. 3 [IQR, 1], P < 0.001). There was significant increase in intensive care unit occupancy in the high BUN level group before PSM (93.3% vs. 73.1%, P < 0.001), but not after PSM (97.8% vs. 86.2%, P = 0.074). Conclusions Our results showed that BUN levels within 24 h after hospital admission were independent risk factors for a 30-day all-cause death in patients with SAP.

Letter to the Editor: "Use of inhaled epoprostenol with high flow nasal oxygen in non-intubated patients with severe COVID-19".

PurposeAcute lung injury associated with COVID-19 contributes significantly to its morbidity and mortality. Though invasive mechanical ventilation is sometimes necessary, the use of high flow nasal oxygen may avoid the need for mechanical ventilation in some patients. For patients approaching the limits of high flow nasal oxygen support, addition of inhaled pulmonary vasodilators is becoming more common but little is known about its effects. This is the first descriptive study of a cohort of patients receiving inhaled epoprostenol with high flow nasal oxygen for COVID-19.Materials and methodsWe collected clinical data from the first fifty patients to receive inhaled epoprostenol while on high flow nasal oxygen at our institution. We compared the characteristics of patients who did and did not respond to epoprostenol addition.ResultsThe 18 patients that did not stabilize or improve following initiation of inhaled epoprostenol had similar rates of invasive mechanical ventilation as those who improved or stabilized (50% vs 56%). Rates of mortality were not significantly different between the two groups (17% and 31%).ConclusionsIn patients with COVID-19 induced hypoxemic respiratory failure, the use of inhaled epoprostenol with high flow nasal oxygen is feasible, but physiologic signs of response were not related to clinical outcomes.

Flu-IV score: a predictive tool for assessing the risk of invasive mechanical ventilation in patients with influenza-related pneumonia

BackgroundThe need for invasive mechanical ventilation (IMV) is linked to significant morbidity and mortality in patients with influenza-related pneumonia (Flu-p). We aimed to develop an assessment tool to predict IMV among Flu-p patients within 14 days of admission.MethodsIn total, 1107 Flu-p patients from five teaching hospitals were retrospectively enrolled from January 2012 to December 2019, including 895 patients in the derivation cohort and 212 patients in the validation cohort. The predictive model was established based on independent risk factors for IMV in the Flu-p patients from the derivation cohort.ResultsOverall, 10.6% (117/1107) of patients underwent IMV within 14 days of admission. Multivariate regression analyses revealed that the following factors were associated with IMV: early neuraminidase inhibitor use (− 3 points), lymphocytes < 0.8 × 109/L (1 point), multi-lobar infiltrates (1 point), systemic corticosteroid use (1 point), age ≥ 65 years old (1 points), PaO2/FiO2 < 300 mmHg (2 points), respiratory rate ≥ 30 breaths/min (3 points), and arterial PH < 7.35 (4 points). A total score of five points was used to identify patients at risk of IMV. This model had a sensitivity of 85.5%, a specificity of 88.8%, and exhibited better predictive performance than the ROX index (AUROC = 0.909 vs. 0.594, p = 0.004), modified ROX index (AUROC = 0.909 vs. 0.633, p = 0.012), and HACOR scale (AUROC = 0.909 vs. 0.622, p < 0.001) using the validation cohort.ConclusionsFlu-IV score is a valuable prediction rule for 14-day IMV rates in Flu-p patients. However, it should be validated in a prospective study before implementation.

Noninvasive high-frequency oscillatory ventilation versus bi-level positive pressure ventilation in premature infants with respiratory failure: A retrospective study.

Objectives:Noninvasive high-frequency oscillatory ventilation (nHFOV) is a novel respiratory support mode for premature infants. This retrospective study aimed to compare the effect of nHFOV and bi-level nasal continuous positive airway pressure (BiPAP) in premature infants with neonatal respiratory failure (NRF) as initial noninvasive ventilation (NIV) support mode.Methods:We retrospectively analyzed medical records of preterm infants admitted to the tertiary neonatal intensive care units (NICUs) of Fujian Maternal and Child Health Hospital from January 2019 to December 2020. Preterm infants with the gestational age of 25-34 weeks, diagnosed with NRF, used nHFOV or BiPAP as the initial respiratory support mode were analyzed. The rates of invasive mechanical ventilation (IMV) within the first seven days after birth and adverse outcomes were compared between the two groups.Results:Two hundred fifty-five preterm infants were analyzed (128 in nHFOV group,127 in BiPAP group). There was no significant difference in baseline characteristics between the two groups. Compared with the BiPAP group, the nHFOV group had significantly lower need for IMV within the first seven days after birth (18/128 vs. 33/127, p = 0.01) and PCO2 at 12 and 24 hours post-treatment (46.34±5.24mmHg vs. 51.18±4.83mmHg, P<0.01; 40.72±4.02mmHg vs. 42.50±3.86mmHg, P<0.01). The incidence of BPD, ROP, air leak syndromes, IVH≥ grade 3, PVL, NEC≥II stage, abdominal distension, and nasal trauma were similar between the two groups.Conclusion:nHFOV significantly reduced the need for IMV and improved the elimination of CO2 compared with BiPAP in preterm infants with NRF without increasing the incidence of adverse effects.

THE FIRST AND SECOND WAVES OF THE COVID-19 PANDEMIC IN A COMMUNITY HOSPITAL ICU

TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: Several countries have seen a two-wave pattern of the COVID-19 pandemic. However, clinical characteristics and outcomes between waves vary across regions. A study in England suggested a substantial improvement in survival amongst people admitted to critical care with COVID-19, with markedly higher survival rates in people admitted in the first wave compared with those admitted in the second wave, while a study in Africa, the second wave appeared to be much more aggressive. Therefore, regional-specific analyses are needed. METHODS: We retrospectively reviewed a de-identified dataset of patients with COVID-19 admitted to our community hospital ICU, from March 1, 2020, to February 28, 2021. Only molecularly confirmed COVID-19 cases defined by a positive result on an RT-PCR assay or NAAT of a specimen collected on a nasopharyngeal swab were included. We then identified patients from the first wave as those admitted during the initial peak of admissions observed at our hospital between March 1, 2020, and September 3, 2020. The second wave was defined as those admitted during the second peak of admissions observed between October 1, 2020, and February 28, 2021. Descriptive statistics were performed to summarize data. RESULTS: Between March 1, 2020, and February 28, 2021, a total of 190 patients were admitted to our community-hospital ICU. Of those, 132 (69.5%) were identified as patients from the first wave, and 58 (30.5%) were identified as patients from the second wave. The median age was not significantly different among patients from the first and second wave (69 years [IQR 59 – 78 years] vs. 69 years [IQR 61 – 77.25 years;p=.841]. Sex distribution was also not significantly different between the two waves (85/132 males [64.4%] vs. 40/58 males [69%];p=.541). A significantly higher rate of patients was admitted from long-term care facilities during the first wave compared to the second wave (77/132 [58.3%] vs. 7/58 [12.1%];p<.001). The distribution of comorbidities was similar between groups, except for neurocognitive disorders, which were mostly observed in the first wave (46/132 [34.8% vs. 7/58 [12.1%];p=.001). While the rates of invasive mechanical ventilation were similar between groups (75/132 [56.8%] vs. 36-58 [62.1%];p=.499, significant higher rates of patients received humidified high-flow nasal cannula (19/132 [14.4%] vs. 29/58 [50%];p<.001) and noninvasive ventilation (9/132 [6.8%] vs. 23/58 [39.7%];p<.001) during the second wave. Following the release of some pivotal clinical trials, more patients during the second wave received corticosteroids (87/132 [65.9%] vs. 56/58 [96.6%];p<.001) and remdesivir (19/132 [14.4%] vs. 48/58 [82.8%];p<.001). However, the in-hospital case-fatality rate was not significantly different between groups (68/132 [51.5%] vs. 32/58 [55.2%];p=.642). CONCLUSIONS: While epidemiological characteristics of patients with COVID-19 admitted to our ICU between the two waves were grossly similar, a significantly higher rate of patients was admitted from long-term care facilities during the first wave, and non-invasive ventilation and targeted therapies were used more during the second wave. The in-hospital case-fatality rate was not significantly different. CLINICAL IMPLICATIONS: In our community hospital in the Chicago North Shore area, the ICU case-fatality rate was not significantly different between two different waves of the COVID-19 pandemic. DISCLOSURES: No relevant relationships by Chul Won Chung, source=Web Response No relevant relationships by Goar Egoryan, source=Web Response No relevant relationships by Harvey Friedman, source=Web Response No relevant relationships by Emre Ozcekirdek, source=Web Response No relevant relationships by Ece Ozen, source=Web Response No relevant relationships by Bidhya Poudel, source=Web Response No relevant relationships by Guillermo Rodriguez-Nava, source=Web Response No relevant relationships by Daniela Trelles Garcia, source=Web Response No relevant relationships by Valer a Trelles Garcia, source=Web Response No relevant relationships by Maria Yanez-Bello, source=Web Response No relevant relationships by Qishuo Zhang, source=Web Response

Association between probiotics and bronchopulmonary dysplasia in preterm infants

Bronchopulmonary dysplasia is a chronic pulmonary disease with a high incidence in premature infants, and there is still no effective treatment. The purpose of our study was to analyze the association between the use of probiotics and BPD in premature infants. We retrospectively collected clinical data of infants with gestational age < 32 weeks admitted to the NICU of The First Hospital of Jilin University from January 1, 2019 to March 31, 2020. Demographic and clinicopathological data of the inclusion population were collected. The outcome was the incidence of BPD or death. The χ2 tests was used to compare the categorical variables. The t test and non-parametric Wilcoxon rank-sum test were used to compare the continuous data. Univariate and multivariate logistic regression were used to analyze the association between probiotics and BPD. A total of 318 newborns met the inclusion criteria, of which 94 received probiotics and 224 received no probiotics. There were 16 deaths and 115 newborns with BPD in the included population. The results of univariate analysis showed differences in the maternal diabetes, the proportion of systemic antibiotics given to mother within 24 h before birth, the receiving rate of invasive mechanical ventilation, the prevalence of BPD/death, PDA, RDS and Ivh between newborns with and without probiotics (p < 0.05); The results of unadjusted univariate logistic regression model showed that probiotic (OR 0.034, 95% CI 0.012–0.096) was the factor affecting BPD in preterm infants (p < 0.05). Multivariate logistic regression result (OR 0.037, 95% CI 0.013–0.105) was consistent with univariate analysis (P < 0.001). Probiotics are associated with a reduced risk of BPD in preterm infants < 32 weeks of age. More prospective studies with large samples are still needed.

Role of SpO2/FiO2 Ratio and ROX Index in Predicting Early Invasive Mechanical Ventilation in COVID-19. A Pragmatic, Retrospective, Multi-Center Study.

The ability of COVID-19 to compromise the respiratory system has generated a substantial proportion of critically ill patients in need of invasive mechanical ventilation (IMV). The objective of this paper was to analyze the prognostic ability of the pulse oximetry saturation/fraction of inspired oxygen ratio (SpO2/FiO2) and the ratio of SpO2/FiO2 to the respiratory rate–ROX index–as predictors of IMV in an emergency department in confirmed COVID-19 patients. A multicenter, retrospective cohort study was carried out in four provinces of Spain between March and November 2020. The discriminative power of the predictive variable was assessed through a prediction model trained using a derivation sub-cohort and evaluated by the area under the curve (AUC) of the receiver operating characteristic (ROC) on the validation sub-cohort. A total of 2040 patients were included in the study. The IMV rate was 10.1%, with an in-hospital mortality rate of 35.3%. The performance of the SpO2/FiO2 ratio was better than the ROX index–AUC = 0.801 (95% CI 0.746–0.855) and AUC = 0.725 (95% CI 0.652–0.798), respectively. In fact, a direct comparison between AUCs resulted in significant differences (p = 0.001). SpO2 to FiO2 ratio is a simple and promising non-invasive tool for predicting risk of IMV in patients infected with COVID-19, and it is realizable in emergency departments.

Clinical efficacy and safety of Janus kinase inhibitors for COVID-19: A systematic review and meta-analysis of randomized controlled trials

ObjectivesThis systematic review and meta-analysis of randomized controlled trials (RCTs) aimed to investigate the clinical efficacy and safety of Janus kinase (JAK) inhibitors for COVID-19 patients. MethodsPubMed, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched from inception to July 12, 2021. RCTs comparing the clinical efficacy and safety of JAK inhibitors with a placebo or standard care in treating COVID-19 patients were included. The primary outcome was all-cause mortality rate at day 28. ResultsThree RCTs were included in this meta-analysis. The all-cause mortality rate at day 28 was lower among the patients receiving JAK inhibitors than among the controls (4.1% [28/647] versus 7.0% [48/684], OR, 0.57; 95% CI, 0.36–0.92, I2 = 0). The clinical recovery rate was higher among the patients receiving JAK inhibitors than among the controls (85.1% (579/680) versus 80.0% [547/684], OR, 1.45; 95% CI, 1.09–1.93, I2 = 0). Additionally, the use of JAK inhibitors was associated with a shorter time to recovery than among the controls (MD, −2.84; 95% CI, −5.56 to −0.12; I2 = 50%). The rate of invasive mechanical ventilation (MV) was lower in the patients who used JAK inhibitors than among the controls. Finally, no significant difference was observed between the patients who used JAK inhibitors and the controls in the risk of any adverse events (OR, 0.92; 95% CI, 0.64–1.34; I2 = 33%) and serious adverse events (OR, 0.80; 95% CI, 0.45–1.44; I2 = 46%). ConclusionsJAK inhibitors can lead to a better clinical outcome of hospitalized COVID-19 patients, and they are a safe agent in the treatment of COVID-19.

In-hospital mortality associated factors in elderly patients with invasive mechanical ventilation in the emergency department

AimsTo identify factors associated with in-hospital mortality, to estimate the intubation rate and to describe in-hospital mortality in patients over 65 years old with invasive mechanical ventilation (IMV) in the emergency department (ED). MethodsRetrospective cohort study of patients over 65 years old, who were intubated in an ED of a high complexity hospital between 2016 and 2018. Demographic data, comorbidities, and severity scores on admission were described. Bivariate and multivariate analyses were performed with logistic regression according to mortality and possible confounders. ResultsA total of 285 patients with a mean age of 80 years required IMV in the emergency department, for a median of 3 days, and with a mean APACHE II score of 20 points of severity. The IMV rate was .48% (95% CI .43–.54), and 55.44% (158) died. Mortality-associated factors after age and sex adjustment were stroke (OR 2.13; 95% CI 1.21–3.76), chronic kidney failure, (OR 4.,38; 95% CI 1.91–10.04), Charlson index (OR 1.19; 95% CI 1.02−1.38), APACHE II score (OR 1.07; 95% CI 1.02−1.12), and SOFA score (OR 1.14; 95% CI 1.03−1.27). DiscussionOur IMV rate was lower than that stated by Johnson et al. in the United States in 2018 (.59%). In-hospital mortality in our study exceeded that predicted by the APACHE II score (40%) and SOFA (33%). However it was consistent with that reported by Lieberman et al. in Israel and Esteban et al. in the United States. ConclusionsAlthough the IMV rate was low in the ED, more than half the patients died during hospitalization. Pre-existing cerebrovascular and renal diseases and high results in the comorbidities index and severity scores on admission were independent factors associated with in-hospital mortality.

Clinical characteristics and outcomes of COVID-19 patients with prediabetes

Background and aimsWe aimed to examine the clinical characteristics and outcomes of coronavirus disease 2019 (COVID-19) patients with prediabetes. MethodsThis was a retrospective cohort study of 102 COVID-19 patients admitted to a tertiary care hospital in India between May and October 2020. ResultsMost patients had a poor clinical profile on admission. They had high rates of invasive mechanical ventilation (48%), intensive care unit admission (48%), complications (72.6%), and mortality (32.4%). ConclusionPeople with prediabetes are at high risk for poor outcomes from COVID-19.

Heliox for Pediatric Critical Asthma: A Multicenter, Retrospective, Registry-Based Descriptive Study.

In cases of critical asthma (CA), heliox may be applied as an adjunctive rescue therapy to avoid invasive mechanical ventilation (MV), improve deposition of aerosolized medications, and enhance laminar airflow through obstructed airways. Using the Pediatric Health Information System (PHIS) registry, we evaluate heliox prescribing and explored for differences in MV rates and hospital length of stay (LOS) among children with and without heliox exposure. We performed a retrospective cohort study using PHIS data from 42 pediatric intensive care units among children 5-17 years of age admitted for CA from 2010 through 2019. Primary outcomes were heliox prescribing rates and trends. Secondary outcomes were invasive MV rates and LOS assessed in a subgroup of children receiving ≥ 1 adjunctive intervention(s). Of the 19,780 studied, heliox was prescribed in 12.5% and linearly declined from 16.1% in 2010 to 5.6% in 2019. The overall MV rate was 12.8% and was lower in subjects receiving heliox alone (4.9%) compared to heliox plus alternative adjunctive therapies [31.2%] or children receiving non-heliox adjunctive therapies [22.1%], P < .01). Accounting for MV, no difference in LOS was observed. In exploratory adjusted models, MV free hospitalization was associated with heliox-only exposure (OR: 0.33, 95% CI: 0.17-0.63, P < .01) and exposure to multiple adjunctive therapies was associated with MV (OR: 2.48, 95% CI: 1.56-3.94, P < .01). In this multicenter retrospective study from 42 children's hospitals, heliox prescribing for CA declined over the last decade. Subjects receiving multiple adjunctive therapies more commonly required invasive MV perhaps indicating a greater severity of illness. At this time, prospective trials needed to identify the role of heliox for pediatric CA.

Factores asociados a mortalidad intrahospitalaria en pacientes adultos mayores con asistencia ventilatoria mecánica invasiva en el servicio de urgencias

AimsTo identify factors associated with in-hospital mortality, to estimate the intubation rate and to describe in-hospital mortality in patients over 65 years old with invasive mechanical ventilation (IMV) in the emergency department (ED). MethodsRetrospective cohort study of patients over 65 years old, who were intubated in an ED of a high complexity hospital between 2016 and 2018. Demographic data, comorbidities, and severity scores on admission were described. Bivariate and multivariate analyses were performed with logistic regression according to mortality and possible confounders. ResultsA total of 285 patients with a mean age of 80 years required IMV in the emergency department, for a median of 3 days, and with a mean APACHE II score of 20 points of severity. The IMV rate was .48% (95% CI .43-.54), and 55.44% (158) died. Mortality-associated factors after age and sex adjustment were stroke (OR 2.13; 95%CI 1.21-3.76), chronic kidney failure, (OR 4.,38; 95%CI 1.91-10.04), Charlson index (OR 1.19; 95%CI 1.02-1.38), APACHE II score (OR 1.07; 95%CI 1.02-1.12), and SOFA score (OR 1.14; 95%CI 1.03-1.27). DiscussionOur IMV rate was lower than that stated by Johnson et al. in the United States in 2018 (.59%). In-hospital mortality in our study exceeded that predicted by the APACHE II score (40%) and SOFA (33%). However it was consistent with that reported by Lieberman et al. in Israel and Esteban et al. in the United States. ConclusionsAlthough the IMV rate was low in the ED, more than half the patients died during hospitalization. Pre-existing cerebrovascular and renal diseases and high results in the comorbidities index and severity scores on admission were independent factors associated with in-hospital mortality.

Acute healthcare resource utilization by age: A cohort study

BackgroundGranular data related to the likelihood of individuals of different ages accessing acute and critical care services over time is lacking.MethodsWe used population-based, administrative data from Ontario to identify residents of specific ages (20, 30, 40, etc. to 100) on January 1st every year from 1995–2019. We assessed rates of emergency department (ED) visits (2003–19), hospitalizations, intensive care unit (ICU) admissions (2003–19), and mechanical ventilation.FindingsOverall the 25-year study period, ED were the most common acute healthcare encounter with 100-year-olds having the lowest rate (138.7/1,000) and 90-year-olds the highest (378.5/1,000). Rates of hospitalization ranged from 24.2/1,000 for those age 20 up to 224.9/1,000 for those age 90. Rates of ICU admission and mechanical ventilation were lowest for those age 20 (1.0 and 0.4/1,000), more than tripled by age 50 (3.3 and 1.7/1,000) and peaked at age 80 (20.3 and 10.1/1,000). Over time rates of ED visits increased (164.3 /1,000 in 2003 vs 199.1 /1,000 in 2019) as did rates of invasive mechanical ventilation (2.0/1,000 in 1995 vs 2.9/1,000 in 2019), whereas rates of ICU admission remained stable (4.8/1,000 in 2003 vs 4.9/1,000 in 2019) and hospitalization declined (66.8/1,000 in 1995 vs 51.5/1,000 in 2019). Age stratified analysis demonstrated that rates of ED presentation increased for those age 70 and younger while hospitalization decreased for all age groups; ICU admission and mechanical ventilation rates changed variably by age, with increasing rates demonstrated primarily among people under the age of 50.InterpretationRates of hospitalizations have decreased over time across all age groups, whereas rates of ED presentation, ICU admissions, and mechanical ventilation have increased, primarily driven by younger adults. These findings suggest that although the delivery of healthcare may be moving away from inpatient medicine, there is a growing population of young adults requiring significant healthcare resources.

551 Outcomes of Sickle Cell Crisis in Relation to Pediatric Obstructive Sleep Apnea in the United States: A US Population cohort study

Abstract Introduction This study aimed to quantify the impact of obstructive sleep apnea (OSA) on the mortality, morbidity, and resources utilization among children admitted with Sickle cell crisis (SCC) Methods This is a retrospective analysis using the 2016 and 2017 National Inpatient Sample Database. The Inclusion Criteria was a principal Diagnosis of SSC and age &amp;lt;18 years. OSA, as a Secondary Diagnosis, was identified using the appropriate ICD-10 CM codes. The Primary Outcomes were Inpatient Mortality, and secondary outcomes were: In-Hospital Length of Stay(LOS), Total hospitalization Cost, Blood transfusion (BT) requirement, and a requirement for Invasive mechanical ventilation (IMV). We used Multivariate Linear/ logistic regression to adjust for confounders including age and sex. Results Out of 36,484 children with SSC included in the study, 1450 children had OSA (SCC+OSA). SSC-OSA and SSC+OSA groups did not differ in gender, household income, and hospital characteristics, but did so in age (11.3 vs 12.4; p &amp;lt;0.001). OSA was most common in the age group of 13–18 (54%) and lowest in 0–4 (2.4%). Compared to SSC-OSA, the SCC+OSA cohort had significantly higher odds of mortality (adjusted OR= 11.9, [95% Confidence Interval: 1.02- 138.8],p=0.04). Additionally, SSC+OSA cohort was associated with increased odds of IMV (aOR=5.24 [CI: 1.84 – 14.8], p=0.002), longer LOS (adjusted mean difference (aMD)=0.67 [CI-0.32 – 1.02], p=&amp;lt;0.001), and higher hospitalization Cost (aMD=2818.76 [CI-1680- 4157], p=&amp;lt;0.001). No difference in BT (aOR=0.94 [CI: 0.68 – 1.29], p=0.71) was noted. Conclusion This study demonstrates that the presence of OSA is associated with detrimental outcomes in SSC with higher in-hospital mortality, higher morbidity (Invasive mechanical ventilation rate), and higher resource utilization (LOS, total hospitalization cost). More attention to the screening, early diagnosis, and appropriate treatment of OSA is imperative to improve health outcomes in children with sickle cell disease. Support (if any):

Empiric use of anticoagulation in hospitalized patients with COVID-19: a propensity score-matched study of risks and benefits

BackgroundHospitalized patients with COVID-19 demonstrate a higher risk of developing thromboembolism. Anticoagulation (AC) has been proposed for high-risk patients, even without confirmed thromboembolism. However, benefits and risks of AC are not well assessed due to insufficient clinical data. We performed a retrospective analysis of outcomes from AC in a large population of COVID-19 patients.MethodsWe retrospectively reviewed 1189 patients hospitalized for COVID-19 between March 5 and May 15, 2020, with primary outcomes of mortality, invasive mechanical ventilation, and major bleeding. Patients who received therapeutic AC for known indications were excluded. Propensity score matching of baseline characteristics and admission parameters was performed to minimize bias between cohorts.ResultsThe analysis cohort included 973 patients. Forty-four patients who received therapeutic AC for confirmed thromboembolic events and atrial fibrillation were excluded. After propensity score matching, 133 patients received empiric therapeutic AC while 215 received low dose prophylactic AC. Overall, there was no difference in the rate of invasive mechanical ventilation (73.7% versus 65.6%, p = 0.133) or mortality (60.2% versus 60.9%, p = 0.885). However, among patients requiring invasive mechanical ventilation, empiric therapeutic AC was an independent predictor of lower mortality (hazard ratio [HR] 0.476, 95% confidence interval [CI] 0.345–0.657, p < 0.001) with longer median survival (14 days vs 8 days, p < 0.001), but these associations were not observed in the overall cohort (p = 0.063). Additionally, no significant difference in mortality was found between patients receiving empiric therapeutic AC versus prophylactic AC in various subgroups with different D-dimer level cutoffs. Patients who received therapeutic AC showed a higher incidence of major bleeding (13.8% vs 3.9%, p < 0.001). Furthermore, patients with a HAS-BLED score of ≥2 had a higher risk of mortality (HR 1.482, 95% CI 1.110–1.980, p = 0.008), while those with a score of ≥3 had a higher risk of major bleeding (Odds ratio: 1.883, CI: 1.114–3.729, p = 0.016).ConclusionEmpiric use of therapeutic AC conferred survival benefit to patients requiring invasive mechanical ventilation, but did not show benefit in non-critically ill patients hospitalized for COVID-19. Careful bleeding risk estimation should be pursued before considering escalation of AC intensity.