Respiratory Intensive Care Unit Research Articles

Impact of respiratory viral infections on mortality and critical illness among hospitalized patients with chronic obstructive pulmonary disease.

Seasonal respiratory viral infections are associated with exacerbations and morbidity among patients with COPD. The real-world clinical outcomes associated with seasonal viral infections are less well established among hospitalized patients. To estimate the association between seasonal respiratory viral infections, 30-day mortality, and intensive care unit (ICU) admission among hospitalized COPD patients. We conducted an analysis of a national prospective multicenter cohort of COPD patients hospitalized with acute respiratory illness during winter seasons (2011-2015) in Canada. Nasopharyngeal swabs were performed on all patients at the onset of hospital admission for diagnosis of viral infection. Primary outcomes were 30-day mortality and ICU admissions. Secondary outcomes included invasive/non-invasive ventilation use. Among 3931 hospitalized patients with COPD, 28.5% (1122/3931) were diagnosed with seasonal respiratory viral infection. Viral infection was associated with increased admission to ICU (OR 1.5, 95% CI 1.2-1.9) and need for mechanical ventilation (OR 1.9, 95% CI 1.4-2.5), but was not associated with mortality (OR 1.1, 95% CI 0.8-1.4). Patients with respiratory syncytial virus (RSV) were equally likely to require ICU admission (OR 1.09, 95% CI 0.67-1.78), and more likely to need non-invasive ventilation (OR 3.1; 95% CI 1.8-5.1) compared to patients with influenza. Our results suggest COPD patients requiring hospitalization for respiratory symptoms should routinely receive viral testing at admission, especially for RSV and influenza, to inform prognosis, clinical management, and infection control practices during winter seasons. Patients with COPD will be an important target population for newly developed RSV therapeutics. ClinicalTrials.gov ID: NCT01517191.

Respiratory Intensive Care Unit management and efficacy during the COVID-19 outbreak in Naples, Italy.

The World Health Organization declared the Coronavirus Diseases 2019 (COVID-19) outbreak a global pandemic on March 11, 2020. COVID-19 had an impact on over 500 million people worldwide. According to the American Thoracic Society criteria, the respiratory spectrum of this disease ranges from mild illness to severe pneumonia, with the latter occurring in a not insignificant 15% of patients. A rapid increase in the incidence of COVID-19 pneumonia cases has been observed all over the world, resulting in a saturation of the Intensive Care Unit's capacity (ICUs). Because of this impressive outbreak, the ICU beds and invasive mechanical ventilators reached their capacity. Non-invasive supportive care has become an important option for keeping respiratory conditions under control. As a result, proper healthcare resource management was required to ensure adequate patient care. Respiratory Intensive Care Units (RICUs) have become a useful resource for managing complex patients due to a shortage of ICU capacity. This highlighted the importance of RICUs, where patients with moderate to severe respiratory failure can be treated with non-invasive respiratory support rather than being admitted to the ICU. The clinical outcomes and baseline characteristics of patients admitted to the RICU of Cotugno Hospital, a tertiary referral center in Naples (Italy), from January 2021 to October 2021 are described in this report.

Presence of Antibodies to Severe Acute Respiratory Syndrome Coronavirus-2 on Admission Is Associated With Decreased Mortality in COVID-19 Critical Illness.

OBJECTIVES:To determine whether the early serologic response in COVID-19 critical illness is associated with hospital mortality. To evaluate if time-to-seroconversion differs by receipt of dexamethasone therapy.DESIGN:Patients were prospectively enrolled within 24 hours of ICU admission from two University of Washington Hospitals. Plasma was collected on enrollment and on days 3, 7, 10, and 14.SETTING:ICUs between March 2020 and April 2021.PATIENTS:Consecutive adults with COVID-19 admitted to an ICU.MEASUREMENTS AND MAIN RESULTS:We measured longitudinal total antispike protein antibody levels (anti-S abs) and total antinucleocapsid antibody levels (anti-N ab) using a U.S. Food and Drug Administration-authorized Roche instrument. We evaluated whether detectable anti-S abs on ICU admission were associated with host factors, initial disease severity, and hospital mortality. We evaluated whether dexamethasone therapy was associated with time-to-seroconversion. Among 93 unvaccinated participants, 47 (51%) had detectable anti-S abs on ICU admission. There was no difference in Acute Physiology and Chronic Health Evaluation II score or time between first positive severe acute respiratory syndrome coronavirus-2 PCR and ICU admission in those with detectable versus undetectable anti-S abs. Adjusting for age, body mass index, and sex, patients with detectable anti-S abs had a lower risk of inhospital death (hazard ratio, 0.40; 95% CI, 0.17–0.94; p = 0.04). Among 21 patients with undetectable anti-S abs on ICU admission and serial measurements available, time-to-seroconversion was not significantly affected by receipt of dexamethasone therapy.CONCLUSIONS:In COVID-19 critical illness, a significant proportion of patients do not have detectable antibodies at ICU admission, and this is independent of severity of illness. Detectable anti-S abs were associated with lower risk of inhospital death. Despite concern that corticosteroids may impair an appropriate antiviral serologic response, early antibody kinetics were not significantly affected by administration of dexamethasone; however, CIs were wide and require further study.

Accuracy of Transthoracic Ultrasound in the Diagnosis of Different Pleural and Pulmonary Diseases: Zagazig University Experience

Recently, there is an increase application of chest ultrasound to evaluate and monitor pleuropulmonary diseases. Computed tomography (CT) is the gold standard for most different lung pathologies with limitations. This study aims to assess the effectiveness of Chest Ultrasound compared to Computed Tomography in diagnosis of different pleuropulmonary disorders and to define the rules of chest ultrasound in pulmonary medicine. This study was conducted upon randomly selected 110 patients with different pleuropulmonary disorders who were admitted to the respiratory ward and ICU, Zagazig University Hospitals, from April 2018 to April 2020. All patients with abnormal chest X. ray opacities were evaluated for complete history taking, full clinical examination, laboratory investigations, then Chest US was performed on the first day of admission then CT was done as a gold standard for the final diagnosis then results of both Chest US and CT were compared. Compared to CT, Chest US had sensitivity (95.8%) for free pleural effusion diagnosis, specificity (90.3%), and (92.7%) accuracy; for pneumonia, (90.9%), (96.1%), and (94.5%) respectively, while pneumothorax had (81.8%), (98%), and (96.3%) accuracy, respectively; for pulmonary edema, (89.5%), (97.8%), and (96.4%) accuracy, respectively. The US plays a valuable role in the diagnosis of different pleuropulmonary diseases and can be used as the first routine radiological modality in both ward & ICU.

Clinical and epidemiological aspects of SARS-CoV-2 infection among pregnant and postpartum women in Mozambique: a prospective cohort study

BackgroundAlthough there is a significant increase of evidence regarding the prevalence and impact of COVID-19 on maternal and perinatal outcomes, data on the effects of the pandemic on the obstetric population in sub-Saharan African countries are still scarce. Therefore, the study aims were to assess the prevalence and impact of COVID-19 on maternal and neonatal outcomes in the obstetric population at Central Hospital of Maputo (HCM), Mozambique.MethodsProspective cohort study conducted at teaching and referral maternity, HCM, from 20 October 2020 to 22 July 2021. We collected maternal and perinatal outcomes up to 6 weeks postpartum of eligible women (pregnant and postpartum women—up to the 14th day postpartum) screened for COVID-19 (individual test for symptomatic participants and pool testing for asymptomatic). The primary outcome was maternal death, Severe Acute Respiratory Syndrome (SARS) and Intensive Care Unit (ICU) admission. We estimated the COVID-19 prevalence and the unadjusted RR (95% CI) for maternal and perinatal outcomes. We used the chi-square or Fisher's exact test to compare categorical variables (two-sided p-value < 0.05 for statistical significance).ResultsWe included 239 participants. The overall prevalence of COVID-19 was 9.2% (22/239) and in the symptomatic group was 32.4% (11/34). About 50% of the participants with COVID-19 were symptomatic. Moreover, the most frequent symptoms were dyspnoea (33.3%), cough (28.6%), anosmia (23.8%), and fever (19%). Not having a partner, being pregnant, and alcohol consumption were vulnerability factors for SARS-CoV-2 infection. The risk of adverse maternal and neonatal outcomes (abortion, foetal death, preterm birth, Apgar, and NICU admission) was not significantly increased with COVID-19. Moreover, we did not observe a significant difference in the primary outcomes (SARS, ICU admission and maternal death) between COVID-19 positive and COVID-19 negative groups.ConclusionThe prevalence of COVID-19 in the obstetric population is higher than in the general population, and fifty percent of pregnant and postpartum women with COVID-19 infection are asymptomatic. Not having a partner and alcohol consumption were factors of greatest vulnerability to SARS-COV-2 infection. Moreover, being pregnant versus postpartum was associated with increased vulnerability to COVID-19. Data suggest that pregnant women with COVID-19 may have a higher frequency of COVID-19 infection, reinforcing the need for universal testing, adequate follow-up for this population, and increasing COVID-19 therapy facilities in Mozambique. Moreover, provide counselling during Antenatal care for COVID-19 preventive measures. However, more prospective and robust studies are needed to assess these findings.

Associations Between Weight and Lower Respiratory Tract Disease Outcomes in Hospitalized Children.

To identify associations between weight status and clinical outcomes in children with lower respiratory tract infection (LRTI) or asthma requiring hospitalization. We performed a retrospective cohort study of 2 to 17 year old children hospitalized for LRTI and/or asthma from 2009 to 2019 using electronic health record data from the PEDSnet clinical research network. Children <2 years, those with medical complexity, and those without a calculable BMI were excluded. Children were classified as having underweight, normal weight, overweight, or class 1, 2, or 3 obesity based on Body Mass Index percentile for age and sex. Primary outcomes were need for positive pressure respiratory support and ICU admission. Subgroup analyses were performed for children with a primary diagnosis of asthma. Outcomes were modeled with mixed-effects multivariable logistic regression incorporating age, sex, and payer as fixed effects. We identified 65 132 hospitalizations; 6.7% with underweight, 57.8% normal weight, 14.6% overweight, 13.2% class 1 obesity, 5.0% class 2 obesity, and 2.8% class 3 obesity. Overweight and obesity were associated with positive pressure respiratory support (class 3 obesity versus normal weight odds ratio [OR] 1.62 [1.38-1.89]) and ICU admission (class 3 obesity versus normal weight OR 1.26 [1.12-1.42]), with significant associations for all categories of overweight and obesity. Underweight was also associated with positive pressure respiratory support (OR 1.39 [1.24-1.56]) and ICU admission (1.40 [1.30-1.52]). Both underweight and overweight or obesity are associated with increased severity of LRTI or asthma in hospitalized children.

Comparison of Efficacy of Oral Nifedipine Versus Vaginal Micronized Progesterone in Management of Preterm Labor

Objective: Preterm delivery causes the deaths of approximately 1 million children annually. The World Health Organization (WHO) estimates a prevalence of 5--18% of births occur prematurely worldwide; exceptionally rare studies are published comparing nifedipine with progesterone for use in the maintenance of tocolysis. This study compares oral nifedipine to veginal micronized progesterone in preterm labor-prone women Methods: This randomized clinical study was carried out at gynecology department from 02-march 2021 to 01-March-2022. A total of 126 women with pre-term labor ware included. In group A, women took nifedipine 20mg sublingually 3 times every 30 minutes then maintained with nifedipine SR 20mg every 12 hours until 37 weeks of gestational amenorrhea or cervical dilatation &gt;4cm (for 48 hours). In group B, women were asked to take vaginal micronized progesterone tablets of 200mg vaginally once a day or until 37 weeks of gestation amenorrhea or cervical dilatation at &gt;4cm (for 48 hours). We compared premature birth, mode of delivery, side effects, neonate’s respiratory distress, ventilator time, ICU stay, and death rate between the groups. Results: Patients in both groups had similar demographics in terms of age and parity of patients. Pregnancy was delayed with a mean of 19.61±6.66 days in nifedipine group, at the same time the pregnancy was delayed for 33.06±8.66 days in progesterone group (p-value &lt; 0.001). The average birth weight was 2.99 ± 0.29 Kg in nifedipine and 3.20 ± 0.17 Kg in progesterone group (p &lt; 0.001). Conclusion: According to the findings of the present study, Progesterone did not affect overall mortality. Progesterone looks like a promising medicine in this aspect, Keywords: preterm, nifedipine, progesterone, tocolysis

Applications of Ultrasonography in Respiratory Intensive Care

Emerging evidence suggests that ultrasonography of lung is a fast, inexpensive, widely available bed-side diagnostic tool which is useful for quick and early diagnosis of respiratory diseases. It is useful in the differential diagnosis of pulmonary infiltrates and has good accuracy in identifying consolidation and alveolar-interstitial syndrome. This technique can also be useful in the immediate evaluation of patients with dyspnoea or acute respiratory failure in the respiratory intensive care unit and helps in monitoring treatment response. Ultrasonography of lung has also been found to be useful in the diagnosis of pulmonary embolism, traumatic lung contusion and lung consolidation as well. There is a need for developing specific guidelines for establishing the standards of training and education regarding lung ultrasonography in India.

Impact of establishing a respiratory high dependency unit for SCAP patients on the therapeutic effect, prognosis, and expenditure: a retrospective case–control study

To explore the effects of establishing a high dependency unit (HDU) on the prognosis, outcome, and expenditure of patients with severe community-acquired pneumonia (SCAP). 108 SCAP patients were recruited from the respiratory intensive care unit (RICU) of the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China. Of these, 87 qualified the study-selection criteria and were divided into HDU group (treated in HDU after discharge from RICU prior to transfer to normal unit) (n = 40) and normal group (not treated in the HDU) (n = 47). In the 87 patients, 40 were divided into HDU group, which meant they transferring to HDU when got stable while another 47 were divided into normal group which meant they staying longer in RICU and transferring to normal unit when got stable. Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores, duration of mechanical ventilation, hospital infection, intensive care unit syndrome, length of stay, and expenditure were compared between the two groups. The primary outcome was discharging from hospital while the secondary outcome was length of stay. There was no significant difference with respect to noninvasive ventilation time, oxygenation index, or APACHE II and SOFA scores at admission or discharge from RICU (P > 0.05). The mean invasive ventilation time (176 ± 160 h) of the HDU group was not significantly different from that in the normal group (206 ± 179 h). The period of sequential noninvasive ventilation in the HDU group (135 ± 82 h) was significantly shorter than that in the normal group (274 ± 182 h, P < 0.05). The HDU group had a shorter length of stay in hospital and RICU, and incurred lesser expenditure than patients in the normal group (P < 0.05). Patients in HDU group had almost the same therapeutic effect with shorter length of stay in hospital and RICU, and lesser expenditure.

Weak cough is associated with increased mortality in COPD patients with scheduled extubation: a two-year follow-up study

BackgroundCough strength is associated with short-term outcome in patients with scheduled extubation who successfully complete a spontaneous breathing trial (SBT). However, the long-term outcome is unclear.MethodsThis was a prospective observational study performed in a respiratory ICU of a teaching hospital. COPD patients who successfully completed a SBT were candidates. We enrolled the case who assessed the cough strength by cough peak flow (CPF) or semiquantitative cough strength score (SCSS, ranging from 0 = weak to 5 = strong). Patients were followed up to two years by phone every 3 months.ResultsA total of 215 patients were enrolled in current study. Among them, CPF and SCSS were measured in 214 and 208 cases, respectively. Strong cough was associated with a 16% decrease in the risk of two-year mortality (adjusted hazard ratio [HR] 0.84, 95%CI: 0.78–0.91) per 10 L/min increment of CPF. When it was tested by SCSS, decrease in the risk of two-year mortality per unit increment was 27% (adjusted HR 0.73, 95%CI: 0.62–0.86). Similar results were confirmed in the discharged patients. In all patients, the two-year mortality was 75%, 53%, and 38% in patients with CPF < 60, 60–90, and > 90 L/min; and 85%, 70%, and 40% in patients with SCSS of 0–1, 2–3, and 4–5, respectively. Similar trend was found among the discharged patients whether it was assessed by CPF or SCSS.ConclusionsIn COPD patients, weak cough is associated with increased two-year mortality after a scheduled extubation. It provides objective information to caregivers to improve decision-making process during hospitalization and after discharge.

Early use of corticosteroids and sarilumab in SARS-Cov-2 pneumonia.

The cytokine storm underlying the inflammatory phase of COVID19 has been suggested since the beginning of the pandemic as a target for treatment of the disease. The identification of the presence of elevated IL6 levels in patients with severe SARS-CoV-2 infection led to the hypothesis that the use of already marketed drugs whose mechanism of action is the inhibition of IL6 could result in clinical benefit for these patients. We hypothesised that the use of glucocorticoid-associated sarilumab in early stages of the proinflammatory phase of COVID19 could prevent progression to respiratory distress syndrome and death. Hospitalised patients with SARS-CoV2 pneumonia, treated with nasal cannula and with analytical parameters of inflammation, were randomised (1:1 ratio) to receive sarilumab + standard therapy (sarilumab group) or standard therapy (control group). In all cases, standard therapy included glucocorticoid treatment for at least 3 days at a dose equivalent to methylprednisolone mg/kg/day. The primary endpoint was the percentage of patients who progressed to severe respiratory failure (defined as a BRESCIA-COVID score ≥3), intensive care unit (ICU) admission or death at any time up to day 15. A total of 201 patients were included, of whom 99 were randomised to the sarilumab group and 102 to the control group. The percentage of patients who progressed to severe respiratory failure (BRESCIA≥3), ICU admission or death at any time up to day 15 was 16.6% in the sarilumab group and 15.69% in the control group (RR 1.03; 95% CI, 0.48 to 2.20). No differences in the safety profile between the two groups were detected. Mortality at day 28 was 2.02% in the sarilumab group vs. 1.96% in the control group (RR 1.03; 95% CI 0.14 - 7.46). In conclusion, an early intervention with sarilumab and glucocorticoids did not demonstrate clinical benefit in our study population compared to standard therapy.

Simulation-based Assessment to Measure Proficiency in Mechanical Ventilation among Residents.

BackgroundMechanical ventilation (MV) skills are essential for clinicians caring for critically ill patients, yet few training programs use structured curricula and appropriate assessments. Objective structured clinical exams (OSCEs) have been used to assess clinical competency in many areas, but there are no OSCE models focused on MV.ObjectiveTo develop and validate a simulation-based assessment (SBA) with an OSCE structure to assess baseline MV competence among residents and identify knowledge gaps.MethodsWe developed an SBA using a lung simulator and a mechanical ventilator, and an OSCE structure, with six clinical scenarios in MV. We included internal medicine residents at the beginning of their rotation in the respiratory intensive care unit (ICU) of a university-affiliated hospital. A subset of residents was also evaluated with a validated multiple-choice exam (MCE) at the beginning and at the end of the ICU rotation. Scores on both assessments were normalized to range from 0 to 10. We used Cronbach’s α coefficient to assess reliability and Spearman correlation to estimate the correlation between the SBA and the MCE.ResultsWe included 80 residents, of whom 42 also completed the MCE examinations. The final version of the SBA had 32 items, and the Cronbach’s α coefficient was 0.72 (95% confidence interval [CI], 0.64–0.81). The average SBA score was 6.2 ± 1.3, and performance was variable across items, with 80% correctly adjusting initial ventilatory settings and only 12% correctly identifying asynchrony. The MCE had 24 questions, and the average score was 7.6 ± 2.4 at the beginning of the rotation and 8.2 ± 2.3 at the end of the rotation (increase of 0.6 points; 95% CI, 0.30–0.90; P < 0.001). There was moderate correlation between the SBA and the MCE (rho = 0.41; P = 0.002).ConclusionWe developed and validated an objective structured assessment on MV using a pulmonary simulator and a mechanical ventilator addressing the main competencies in MV. The performance of residents in the SBA at the beginning of an ICU rotation was lower than the performance in MCE, highlighting the need for greater emphasis on practical skills in MV during residency.

Delirium incidence and risk factors in patients undergoing non-invasive ventilation for acute respiratory failure: a multicenter observational trial.

Noninvasive ventilation (NIV) still has high failure rate when used for de novo acute respiratory failure (ARF). Delirium may impact the outcome, however data regarding its incidence, timing of occurrence and clinical predictors in this subset of patients are scarce. Consecutive patients with de novo ARF subjected to NIV were recruited in 10 Italian Respiratory Intensive Care Units (RICUs) and Intensive Care Units (ICUs). Demographics and clinical features, including tolerance to interface and NIV setting were recorded on admission and during stay, whereas delirium onset and type was assessed by the Confusion Assessment Method for ICU (CAM-ICU)-7 scale and Richmond Agitation Sedation Scale (RASS) twice/per day up to a week. The association between clinical variables and the occurrence of delirium and its influence on NIV failure and other clinical outcomes were analyzed. Thirty-two out of 90 enrolled patients (36%) developed delirium over seven days upon admission; median time to onset was 48 hours (24-60). Older age (OR=2.7 [1.9-9], P=0.01), the presence of cancer OR=3.7 [2-5.4], P=0.002), sepsis (OR=1.7 [1.1-3.4], P=0.01), SOFA Score (OR=1.8 [1.1-3.1], P=0.01), low tolerance to interface (OR=3.2 [2.1-5], P=0.002), use of helmet (OR=1.9 [1.2-4.3] P=0.04), and higher PRE-DELIRIC (OR=3.5 [1.3-15], P=0.03) and BORG (OR=1.7 [1.1-4.6], P=0.02] scores were significantly associated with delirium. Delirium had high risk for NIV failure (HR=3.5 95% CI: [1.4-8.6], P=0.0002) and it significantly associated with longer RICU/ICU stay and higher mortality. Delirium onset in acute hypoxic patients undergoing NIV is frequent and negatively affects the outcome. Multiple related clinical factors should be addressed early on admission to prevent the delirium-related risk of NIV failure in these patients.

Factors influencing the choice of endotracheal intubation and mechanical ventilation in patients with acute respiratory distress syndrome caused by viral pneumonia

To investigate the influencing factors of endotracheal intubation and mechanical ventilation (ETI-MV) in patients with acute respiratory distress syndrome (ARDS) caused by viral pneumonia, and to provide evidence for individualized use of ETI-MV. Patients with ARDS due to viral pneumonia admitted to the respiratory intensive care unit (RICU) of the First Affiliated Hospital of Xinjiang Medical University were retrospectively analyzed from November 2017 to March 2022. The gender, age, concomitant diseases, clinical symptoms and signs, complications, lab results, ARDS severity, infectious virus type, acute physiology and chronic health evaluation II (APACHE II), respiratory support methods and prognosis-related variables were collected. Univariate analysis was performed on each factor, and the variables with statistical significance in the univariate analysis were subjected multivariate logistic regression analysis. The receiver operating characteristic curve (ROC curve) was drawn to evaluate the predictive value of each index for the implementation of ETI-MV. A total of 117 patients were enrolled in the study, including 61 patients in the ETI-MV group, and 3 patients (4.9%), 39 patients (63.9%) and 19 patients (31.1%) with mild, moderate and severe ARDS, respectively. There were 56 patients in non-ETI-MV group, and the mild, moderate and severe ARDS cases were 16 cases (28.6%), 38 cases (67.8%) and 2 cases (3.6%), respectively. There was significant difference between the two groups (P < 0.05). Univariate analysis showed that during 24 hours admitted to RICU, the levels of interleukin-6 [IL-6 (ng/L): 104.0±90.0 vs. 62.4±76.0], oxygenation index [PaO2/FiO2 (mmHg, 1 mmHg ≈ 0.133 kPa): 123.9±30.9 vs. 173.6±28.5], the proportion of cases with pulmonary infiltrating opacity distribution range ≥ 3/4 lung fields [85.3% (52/61) vs. 21.5% (12/56)], APACHE II score ≥ 16.5 [67.2% (41/61) vs. 42.9% (24/56)], the rate of nosocomial invasive aspergillus infection [14.8% (9/61) vs. 3.6% (2/56)], the percentage of nosocomial bacterial infection [16.4% (10/61) vs. 3.6% (2/56)], and the lowest CD4+ T lymphocyte count in the course of the disease [cells/mm3: 192.2±35.8 vs. 215.0±58.3] had significant differences between ETI-MV and non-ETI-MV group (all P < 0.05). Multivariate Logistic regression analysis showed that during 24 hours admitted to RICU the distribution range of pulmonary infiltrating opacity ≥ 3/4 the lung fields [odds ratio (OR) = 12.527, 95% confidence interval (95%CI) = 3.279-47.859, P < 0.001], APACHE II score ≥ 16.5 (OR = 30.604, 95%CI = 4.318-216.932, P = 0.001), PaO2/FiO2 (OR = 0.948, 95%CI = 0.925-0.972, P < 0.001), CD4+ T lymphocytes cell count (OR = 0.975, 95%CI = 0.955-0.995, P = 0.015), and nosocomial bacterial infection (OR = 38.338, 95%CI = 1.638-897.158, P = 0.023) were independent risk factors for ETI-MV. The area under the ROC curve (AUC) of ROC showed that PaO2/FiO2 had the greatest predictive value for ETI-MV, with AUC of 0.903, sensitivity of 91.1% and specificity of 95.1% in case of cutoff value of 151 mmHg. The AUC of pulmonary infiltrating opacity distribution range was 0.809, the sensitivity of 85.2%, specificity of 78.6% when the cutoff value was ≥ 3/4 lung field. APACHE II scores had the lowest predictive value for selecting ETI-MV, with AUC of 0.704, sensitivity of 83.6% and specificity of 57.1% under the cutoff value was 16.5. For patients with ARDS caused by viral pneumonia, PaO2/FiO2 is still the classic reference for selecting ETI-MV, however, the distribution range of pulmonary infiltrating opacity and the systemic severity of the disease during 24 hours admitted to the RICU may provide supplemental helpful information to determine whether the patients choose ETI-MV, especially for moderate ARDS.

Outcomes of hepatocellular carcinoma in obese patients: Insights from a nationwide database.

e16178 Background: Obesity is associated with hepatocellular carcinoma (HCC), affecting mortality and post-surgical outcomes. Growing epidemiological obesity trends parallel the constant rise of HCC incidence. Therefore, we sought to examine outcomes of HCC in obese patients. Methods: We investigated the National Inpatient Sample and National Readmission Database 2018-2019 using International Classification of Diseases-10 codes for adult patients with HCC. Analyses were performed using STATA (v 14.2), considering 2 sided P&lt; 0.05 as statistically significant. Proportions were compared using Fisher exact test and continuous variables using Student’s t-test. Confounding variables were adjusted using multivariate logistic and linear regression analyses. Results: Obese patients with HCC had lower odds of inpatient mortality and higher odds of hospice discharge ( P&lt; 0.05). Obesity was associated with a higher length of stay (LOS) by 0.90 days and hospital cost by 5,453 USD ( P&lt; 0.01). We found higher odds of acute renal failure (Adjusted odds ratio (aOR) 1.37, P&lt; 0.01) and a higher prevalence of HCV, smoking, and alcohol use in obese patients. There were no differences in lobectomy, partial hepatectomy, or transarterial radioembolization; however, higher odds of liver transplant were observed (aOR 1.82, P&lt; 0.01). A higher proportion of obese HCC patients had lymph nodes metastasis (6.43% vs. 6.08%, P:0.64). Rates of respiratory problems, ICU admission, cardiac arrest, HIV, DVT, myocardial infarction, and stroke were not different between the two groups ( P&gt; 0.05). Conclusions: Obese patients with HCC appear to have an advanced stage at presentation leading to lower rates of lobectomy, partial hepatectomy, and TARE and higher rates of liver transplant and hospice utilization. Future studies need to address the barriers leading to delays in diagnosis.[Table: see text]

Does acute cholangitis impact outcomes of cholangiocarcinoma? Insights from a nationwide database.

e16138 Background: Cholangiocarcinoma is a malignancy associated with poor survival and outcomes. Structural abnormalities causing bile duct obstruction frequently lead to superimposed acute cholangitis (AC). We evaluated the impact of AC on hospitalized patients with cholangiocarcinoma. Methods: We investigated National Inpatient Sample 2019, employing International Classification of Diseases-10 (ICD-10) codes to include adult patients with cholangiocarcinoma. Analyses were performed using STATA (v 14.2), considering 2 sided P&lt; 0.05 as statistically significant. Proportions were compared using Fisher exact test and continuous variables using Student’s t-test. Confounding variables were adjusted using multivariate logistic and linear regression analyses and included: gender, race, Charlson Comorbidity Index (CCI) score, median household income for patients’ zip codes, hospital location/region/ bedside, and insurance status. Results: A total of 36,900 patients were included in the analysis. Of those 15.26% (5,630) had AC on presentation (Table). Concomitant AC was associated with a higher adjusted length of stay (LOS) by 1.78 days and hospitalization cost by 3,028 USD in cholangiocarcinoma patients ( P&lt; 0.01). There were higher adjusted odds of acute renal failure (Adjusted odds ratio (aOR) 1.31, P&lt; 0.01) and lower odds of aspiration pneumonia while hospitalized in AC patients (aOR 0.37, P&lt; 0.01). ERCP represented the primary technique of biliary drainage. No disparities were seen between the two groups undergoing ERCP or cholecystostomy tube, which resulted in comparable mortality trends ( P&gt; 0.05). Rates of acute respiratory failure, mechanical ventilation, ICU admission, cardiac arrest, and sepsis were not different between the two groups ( P&gt; 0.05). Conclusions: Unbiased and comparable biliary drainage via either ERCP or cholecystostomy resulted in observing no mortality differences between the two groups. However, superimposed AC in cholangiocarcinoma patients results in higher LOS driven by acute renal failure.[Table: see text]

Prevalence and outcome of sepsis in respiratory intensive care unit

BackgroundSepsis is a life-threatening organ dysfunction caused by a dysregulated host response to an infection.ObjectiveTo assess the prevalence and outcome of sepsis in RICUPatients and methodsThe study was conducted upon 403 patients admitted at RICU of the Abbassia Chest Hospital, Cairo, Egypt; 100 of them had sepsis either on admission or acquired in the RICU during the period from May 2019 to November 2019. Severity of illness was assessed by Acute Physiology and Chronic Health Evaluation II (APACHE II score), which was recorded within 24 h from patient admission. Quick sepsis-related organ failure assessment (qSOFA) score was recorded in emergency room, and sepsis-related organ failure assessment (SOFA) score was recorded on ICU admission and on the 3rd and 7th day of ICU stay. Type of infection (community or hospital acquired), infection site, and pathogenic organisms, all were recorded. Assessment was done also regarding mechanical ventilation, length of RICU stay, the presence of comorbidities, survived patients, and dead ones, as regards causes of death and risk factors.ResultsThe study included 100 cases with sepsis out of 403 admitted cases in the same duration with frequency 24%. Among sepsis patients, 72% were males and 28%were females, with mean age 51.62 ± 18.62 years. The main diagnosis was pneumonia (62%), and the main comorbidity was diabetes mellitus (23%). There was significant increase in age among non-survivors when compared with survivors. There was significant increase in number of mechanically ventilated patients and a highly significant incidence of complications and need for vasoactive drugs among non-survivors when compared with survivors. There was a highly significant higher APACHE II score on the 1st day of admission among non-survivor patients. The SOFA score was significantly higher on the 1st day of admission and significantly higher on the 3rd and 7th day of admission among non-survivor patients when compared to survived patients.ConclusionThe current study showed that sepsis affects nearly one quarter of cases admitted at RICU, and it is usually associated with higher mortality rate in those patients.Trial registrationClinicalTrials.gov NCT05240157. Registered February 15, 2022. Retrospectively registered.

Smartphone-Guided Self-prone Positioning vs Usual Care in Nonintubated Hospital Ward Patients With COVID-19: A Pragmatic Randomized Clinical Trial

BackgroundSafe, effective, and easily implementable treatments that reduce the progression of respiratory failure in COVID-19 are urgently needed. Despite the increased adoption of prone positioning during the pandemic, the effectiveness of this technique on progression of respiratory failure among nonintubated patients is unclear.Research QuestionWhat is the effectiveness of smartphone-guided self-prone positioning recommendations and instructions compared with usual care in reducing progression of respiratory failure among nonintubated patients with COVID-19?Study Design and MethodsAwake Prone Position for Early Hypoxemia in COVID-19 (APPEX-19) is a multicenter randomized clinical trial that randomized nonintubated adults with COVID-19 on < 6 L/min of supplemental oxygen to receive a smartphone-guided self-prone positioning intervention or usual care. The primary outcome was the composite of respiratory deterioration (an increase in supplemental oxygen requirement) or ICU transfer. Using a Bayesian statistical approach, the posterior probability of superiority within each treatment arm (superiority threshold 95%) was calculated.ResultsThe trial was stopped early for slow enrollment. A total of 293 participants were included in the modified intention-to-treat analysis (159 self-prone positioning intervention and 134 usual care). Among participants who self-reported body positioning (n = 139 [70 intervention, 69 usual care]), 71.4% in the intervention arm and 59.4% in the usual care arm attempted prone positioning. Thirty-one participants (posterior mean, 24.7%; 95% credible interval, 18.6-31.4) receiving usual care and 32 participants (posterior mean, 22.1%; 95% credible interval, 16.6-28.1) receiving the self-prone positioning intervention experienced the primary outcome; the posterior probability of superiority for the self-prone positioning intervention was 72.1%, less than the 95% threshold for superiority. Adverse events occurred in 26.9% of participants in the usual care arm and in 11.9% of participants in the intervention arm.InterpretationAmong nonintubated patients with COVID-19, smartphone-guided self-prone positioning recommendations and instructions did not promote strong adherence to prone positioning.Clinical Trial RegistrationClinicalTrials.gov; No.: NCT04344587; URL: www.clinicaltrials.gov.

Comparison of the cardiovascular system, clinical condition, and laboratory results in COVID-19 patients with and without vitamin D insufficiency

BackgroundSerum vitamin D levels may have a protective role against severe coronavirus disease 2019 (COVID-19). Studies have shown that deficiency in vitamin D may be a significant risk factor for poor outcomes. This study aims to compare the outcome and clinical condition of patients diagnosed with COVID-19 infection considering serum vitamin D levels.MethodsIn this cross-sectional study, 202 COVID-19 patients without known cardiovascular disease (reduced ejection fraction, uncontrolled arrhythmia, pericardial effusion, cardiac block, valvular disease, or hypertension) were included. Patients were divided into three groups of insufficient (< 30 ng/mL), normal (30 to 50 ng/mL), and high (> 50 ng/mL) serum vitamin D levels. Clinical outcome was defined as severe if invasive respiratory intervention and ICU admission was required.ResultsThe patients were divided into three groups based on their vitamin D level: 127 cases in the insufficient vitamin D group, 53 cases in the normal vitamin D group, and 22 cases in the high vitamin D group. The mean age of the population study was 56 years. Thirty-four patients had severe clinical outcomes. The distribution of this group was as follows: 21 patients in the insufficient vitamin D group (16.5%), eight patients in the normal vitamin D group (15.1%), and five patients in the high vitamin D group (22.7%); P = 0.74. No significant differences were found between the groups in terms of mortality rate (P = 0.46). Moreover, the mean of leukocytes (mean ± SD = 6873.5 ± 4236.2), ESR (mean ± SD = 38.42 ± 26.7), and CPK-MB (mean ± SD = 63 ± 140.7) were higher in the insufficient vitamin D group, but it was not statistically significant (P > 0.05).ConclusionThe finding of the present study showed that vitamin D could not make a significant difference in cardiovascular systems, laboratory results, and severity of the disease in COVID-19 patients.

Six-month sequelae of post-vaccination SARS-CoV-2 infection: A retrospective cohort study of 10,024 breakthrough infections

Vaccination has proven effective against infection with SARS-CoV-2, as well as death and hospitalisation following COVID-19 illness. However, little is known about the effect of vaccination on other acute and post-acute outcomes of COVID-19. Data were obtained from the TriNetX electronic health records network (over 81 million patients mostly in the USA). Using a retrospective cohort study and time-to-event analysis, we compared the incidences of COVID-19 outcomes between individuals who received a COVID-19 vaccine (approved for use in the USA) at least 2 weeks before SARS-CoV-2 infection and propensity score-matched individuals unvaccinated for COVID-19 but who had received an influenza vaccine. Outcomes were ICD-10 codes representing documented COVID-19 sequelae in the 6 months after a confirmed SARS-CoV-2 infection (recorded between January 1 and August 31, 2021, i.e. before the emergence of the Omicron variant). Associations with the number of vaccine doses (1 vs. 2) and age (<60 vs. ≥ 60 years-old) were assessed. Among 10,024 vaccinated individuals with SARS-CoV-2 infection, 9479 were matched to unvaccinated controls. Receiving at least one COVID-19 vaccine dose was associated with a significantly lower risk of respiratory failure, ICU admission, intubation/ventilation, hypoxaemia, oxygen requirement, hypercoagulopathy/venous thromboembolism, seizures, psychotic disorder, and hair loss (each as composite endpoints with death to account for competing risks; HR 0.70–0.83, Bonferroni-corrected p < 0.05), but not other outcomes, including long-COVID features, renal disease, mood, anxiety, and sleep disorders. Receiving 2 vaccine doses was associated with lower risks for most outcomes. Associations between prior vaccination and outcomes of SARS-CoV-2 infection were marked in those <60 years-old, whereas no robust associations were observed in those ≥60 years-old. In summary, COVID-19 vaccination is associated with lower risk of several, but not all, COVID-19 sequelae in those with breakthrough SARS-CoV-2 infection. The findings may inform service planning, contribute to forecasting public health impacts of vaccination programmes, and highlight the need to identify additional interventions for COVID-19 sequelae.