Use Of Invasive Mechanical Ventilation Research Articles

Characteristics, risk factors, and outcomes of bloodstream Candida infections in the intensive care unit: a retrospective cohort study

The main objective was to assess the clinical characteristics, associated factors, and outcomes of patients admitted to the ICU for candidemia. The secondary objective was to examine the relationship of candidemia with the length of stay and mortality. The analysis was a retrospective single-center cohort study addressing the effect of invasive candidemia on outcomes. This study was performed in a medical-surgical ICU located in a tertiary private hospital in São Paulo, Brazil. Data was collected through the review of the hospital database. In total, 18,442 patients were included in our study, including 22 patients with candidemia. The median age was similar in patients with and without candidemia [67 (56-84) vs. 67 (51-80)]. Most patients were male, and the proportion of men was higher among patients with candidemia (77% vs. 55.3%). The rates of renal replacement therapy (40.9% vs. 3.3%), mechanical ventilation (63.6% vs. 29.6%), and parenteral nutrition (40.9% vs. 4.8%) were higher in patients with candidemia than in those without candidemia. The mortality rate (77.3% vs. 11.9%) and length of hospital stay [42 days (23.0-78.8) vs. 8 days (5.0-17.0)] were significantly higher in patients with candidemia. Patients with candidemia are prone to longer hospital stay and mortality. In addition, we found associations of candidemia with the use of invasive mechanical ventilation, renal replacement therapy, and parenteral nutrition.

Consideraciones radiológicas del cáncer de pulmón y Covid-19: una mirada oncológica

Patients with SARS-Cov-2 infection and lung cancer have an unfavorable prognosis, characterized by higher rates of respiratory failure, use of invasive mechanical ventilation and higher mortality rates. Due to similarities in affected organs in Covid-19 and lung cancer, the radiological accurate diagnosis has become a challenge for physicians. Radiologic findings of lung cancer, such as parenchymal consolidation, spiculation and microlobulations are not specific. Imaging findings of Covid-19 in patients with lung cancer consist of multiple patchy multifocal bilateral ground-glass opacities and consolidations, being hardly distinguishable from an underlying lung malignancy. Differential radiological diagnosis in patients with lung cancer and Covid-19 must include pneumonitis and lung toxicity caused by chemotherapy, target therapies and radiotherapy. Follow-up and simulation tomography in radiotherapy have become an unexpected ally in the early detection of Covid-19 in asymptomatic stages in lung cancer patients. Patients with lung cancer should have particular considerations due to their high risk and the adverse effects of systemic therapies and radiotherapy.

18: EPIDEMIOLOGY OF NONINVASIVE AND INVASIVE MECHANICAL VENTILATION USE FOR CHILDREN AT THE END OF LIFE

Introduction: Invasive mechanical ventilation (IMV) is an intensive intervention commonly experienced by children at the end of life. Non-invasive mechanical ventilation (NIV) is a potential alternative to IMV, and studies have shown increasing use of NIV without decreasing IMV for adults. The objective was to describe the trends, predictors, and hospital variability in use of NIV and IMV for children at the end of life. Methods: Multi-center retrospective cohort study of children 0 to 21 years who died in 1 of 37 hospitals in Pediatrics Health Information Systems (PHIS) Database between 2010 and 2019. ICD-9, ICD-10, and CTC codes were used to identify mode of ventilation (IMV, NIV, both or none). Descriptive statistics summarized socio-demographic and clinical characteristics by mode of ventilation, and hospital NIV use quartiles were calculated. The Cochran-Armitage test assessed for trends over time and multivariable random-effect logistic regression assessed for independent predictors of ventilatory support. Results: 41,091 patients (median age 0.4, IQR [0,6.7] y, 45% female, 42% white) died in the hospital. Increasing age predicted lower odds of IMV (aOR .95 per year, 95% CI .95-.96, p<.001) or both (aOR .98 per year, 95% CI .97-.99, p=.005) compared to none. Number of complex chronic conditions (CCC) (median [IQR]) was 2 [1,3] overall and for IMV, 3 [2,3] for NIV, and 3 [2,4] for both. Self-pay patients were less likely than commercially or government insured to receive IMV (aOR .69, 95% CI .56-.84, p<.001) or both (aOR .37, 95% CI .27-.5, p<.001). From 2010 to 2019, exposure to NIV increased (771 [18.8%] vs. 1075 [25.9%], p<.001) with no change in IMV (3636 [88.6%] vs. 3669 [88.5%], p=.86); increase in NIV was more often experienced as both (688 [16.8%] vs. 944 [22.8%]) than NIV (83 [2%] vs. 131 [3.2%]). For hospitals in the highest NIV use quartile, the aOR for any NIV was 6.16 (95% CI 3.98-9.52, p<.001) and any IMV was .8 (95% CI .55-1.17, p=.249) compared to the lowest NIV use quartile. Conclusions: Use of NIV has increased over time for children nearing the end of life, without a reciprocal decrease in use of IMV. Differences exist based on age, insurance status, and chronic medical complexity. Significant interhospital variability in NIV use exists, which does not correlate with use of IMV.

711: INVASIVE VERSUS NONINVASIVE MECHANICAL VENTILATION IN PEDIATRIC ASTHMA: A SINGLE-CENTER STUDY

Introduction: Asthma is a leading cause of pediatric hospitalization. Endotracheal intubation and invasive mechanical ventilation (IMV) in status asthmaticus (SA) are associated with increased complications and mortality. Recent practice trends favor non-invasive ventilation (NIV) to support respiratory failure in SA. Comparison of patients receiving IMV or NIV for SA can help predict which patients are at risk of intubation and poor outcomes. Methods: This is a single center retrospective cohort study. The study period was from 2011-2020. Inclusion criteria were status asthmaticus and age 2-20 years. Patients who received invasive support were matched 1:2 with those receiving NIV by date of intubation. Data collected included demographics, past medical history, history of prior PICU stay, IMV or NIV use, home medications, environmental risk factors, asthma and non-asthma directed medical management, length of stay (LOS), complications, morbidity and mortality. Categorical data was compared using Chi square or Fisher’s exact test as appropriate. T-tests were used to compare means. Results: 49 patients received IMV for SA over a 10-year period and 98 patients who received NIV were identified as a control. There was no difference in gender, race, history of allergies, eczema, smoke exposure, pets, home medication or prior PICU stay. Intubated patients were 2.2 years older (p=0.02) and were more likely to have previously been intubated (18.4% vs 7.1%, p=0.04). Need for IMV was associated with a longer LOS (12.3d vs 5.4d, p< 0.01) as well as several complications, including pneumothorax, neuromyopathy, hypoxic ischemic encephalopathy, CPR and death. The groups had similar rates of pneumonia, which has previously been identified as a risk factor for intubation. Five patients (10.2%) died; all received IMV. 80% (n=4) of these patients had a pre-hospital arrest. None of the patients with mortality had previously been intubated. Conclusions: In this study, use of IMV was associated with older age and prior history of IMV. However, history of prior IMV was not associated with mortality. Pre-hospital arrest was a major driver of mortality. Efforts to reduce mortality in pediatric asthma may benefit from identifying high risk children in the community setting.

2170. Association Between End-of-Treatment Procalcitonin Levels with Mortality &amp; Recurrent Ventilator-Associated Pneumonia

Abstract Background In the only randomized controlled trial utilizing procalcitonin in ventilator-associated pneumonia (VAP), 30% of patients failed to normalize procalcitonin levels by the end of treatment, a finding of uncertain clinical importance. The prognostic value of procalcitonin for VAP mortality has been examined only in studies with limited sample sizes and the relationship between end-of-treatment procalcitonin (EOT-P) and VAP recurrence—which affects up to 40% of patients with VAP—has never been examined. We aimed to determine the relationship between VAP EOT-P and recurrent pneumonia or mortality. Methods Retrospective single-center cohort study of hospitalized adult patients between 2013 – 2022 with VAP (defined as use of invasive mechanical ventilation for ≥ 2 days, positive respiratory culture and treatment for ≥ 5 days with pneumonia-specific antibiotics) who had serum procalcitonin levels obtained within 48 of antibiotic completion (AC). Exclusion criteria included death or discharge to hospice within 48 hours of AC. Patients with EOT-P &amp;lt; 0.5 were compared with those with EOT-P ≥ 0.5. The primary outcome was a composite endpoint of recurrent pneumonia (defined as clinical suspicion sufficient to warrant respiratory culture collection) and/or death within 30 days of AC. Results Of 140 included patients, 79 (56.4%) had EOT-P levels &amp;lt; 0.5, and 61 (43.6%) had levels ≥ 0.5. Patients with elevated EOT-P were more likely to have renal disease, longer duration of antibiotic treatment and longer antecedent hospital length of stay than those with non-elevated EOT-P. Demographic characteristics and comorbidities were otherwise similar between groups (Table 1). After multivariable adjustment, patients with elevated EOT-P were significantly more likely to have recurrent pneumonia or death within 30 days (Table 2 and Figure 1, OR 2.39 (95% 1.19-4.80 CI), adjusted OR 2.37 (95% CI 1.09-5.17)). Patient demographics of the study group. "EOT-P" = serum procalcitonin level drawn following completion of antibiotics. Patients with EOT-P &amp;lt;0.5 were compared with those with EOT-P ≥ 0.5. "Immunocompromised" = combination of HIV/AIDS positivity, actively taking immunosuppressive medications, metastatic or hematologic malignancy, history of stem cell transplant, or organ transplantation. Patient outcomes, followed for 30 days following antibiotic completion. The primary endpoint was a composite of death or recurrent pneumonia. The secondary endpoints are death or recurrent pneumonia examined separately. "EOT-P" = serum procalcitonin level drawn following completion of antibiotics. Patients with EOT-P &amp;lt;0.5 were compared with those with EOT-P ≥ 0.5. "VAP" = ventillator-assisted pneumonia. Percentage of patients who survived without recurrence of pneumonia, followed for 30 days following antibiotic completion. "EOT-P" = serum procalcitonin level drawn following completion of antibiotics. Patients with EOT-P &amp;lt;0.5 were compared with those with EOT-P ≥ 0.5. Conclusion Elevated EOT-P in VAP was independently associated with increased VAP recurrence or mortality within 30 days. To our knowledge, this is the largest study to date of the prognostic value of procalcitonin in a ventilator-associated pneumonia cohort. Use of end-of-treatment procalcitonin in VAP may serve as a candidate biomarker to predict VAP recurrence and death. Disclosures Owen Albin, MD, Charles River Laboratory: Advisor/Consultant|Cipla Pharmaceuticals: Advisor/Consultant|Shionogi Inc: Advisor/Consultant.

686: THERAPEUTIC THRESHOLDS OF DEXMEDETOMIDINE IN THE DEVELOPMENT OF ICU DELIRIUM

Introduction: The use of dexmedetomidine is increasing as a sedation agent in the pediatric population. The aim of this study is to determine if there is a dose-dependent relationship between dexmedetomidine and the development of ICU delirium in the pediatric cardiac intensive care unit (PCICU). We sought to describe a relationship between both the cumulative dose and the average continuous dose of dexmedetomidine with ICU delirium in patients admitted to a PCICU. Methods: This is a single-center, retrospective chart review of patients age 0-21 years admitted to the PCICU for more than 24 hours, who had delirium assessments performed using the Cornell Assessment of Pediatric Delirium (CAPD). CAPD scores were collected. Exposures prior to each CAPD score were collected in 12-hour time intervals. The primary outcome was cumulative dose exposure of dexmedetomidine in micrograms per kilogram over the course of each admission. Cumulative dosing was obtained by accounting for the amount of both the continuous infusions and intermittent bolus received over the entire admission. Average dose exposure in micrograms/kilogram/hour was also obtained over each twelve-hour time period before the next CAPD score was recorded. Descriptive statistics was used to characterize the cohort and report dosing outcomes. Results: Two-hundred and seventy-seven patients were included in the analysis, which accounted for a total of 5,031 CAPD assessments. Increased length of stay, use of invasive mechanical ventilation, and exposure to dexmedetomidine, benzodiazepines, or opiates, were independently associated with delirium. Patients with delirium received a higher cumulative dose of dexmedetomidine (0.81 microgram/kilogram vs 15.01 micrograms/kilogram, p = 0.003). Additionally, patients with delirium, on average, received a higher continuous infusion dose of dexmedetomidine (0.23 micrograms/kilogram/hour vs 0.54 micrograms/kilogram/hour, p < 0.001). Conclusions: Patients with delirium in the PCICU had a higher cumulative dose of dexmedetomidine and higher average dose of a continuous infusion of dexmedetomidine. Future initiatives and studies examining institutional protocols for sedation in this population should incorporate considerations for their impact on the development of ICU delirium.

607: IMPLEMENTING A HIGH-FLOW NASAL CANNULA HOLIDAY AND DISCHARGE CRITERIA FOR BRONCHIOLITIS PATIENTS

Introduction: Costs for bronchiolitis have risen over the years. Previous studies have shown that respiratory therapist (RT) driven high flow nasal cannula (HFNC) management protocols can decrease length of HFNC as well as pediatric intensive care unit (PICU) and hospital length of stay (LOS). The aim of this study was to determine if modifications to an existing RT-driven HFNC management protocol could further safely decrease length of HFNC and PICU and hospital LOS. Methods: This is a quality improvement project performed at a quaternary academic PICU. This study included patients less than 24 months of age admitted to the PICU with an admission diagnosis of bronchiolitis requiring HFNC. After initial implementation of a (RT)-driven HFNC protocol [Plan-Do-Study-Act (PDSA) 1] in October 2017, additional interventions included adjusting HFNC wean rate (PDSA 2) in July 2020, a HFNC holiday (PDSA 3), and standardized discharge criteria (PDSA 4) in October 2021. Duration of HFNC was used as the primary outcome measure and PICU LOS and hospital LOS were used as secondary outcome measures. Noninvasive ventilation use, invasive mechanical ventilation use and 7-day PICU and hospital readmission rates were used as balancing measures. Results: A total of 1,310 patients were included. Patients in PDSA 2, PDSA 3&4 groups were older compared to pre-intervention and PDSA 1 (median of 9 and 10 months compared to 8 months, p=0.01). HFNC duration decreased from 2.5 to 1.8 days after PDSA 1, then to 1.3 days after PDSA 2. PICU LOS decreased from 2.6 to 2.1 days after PDSA 1, 1.8 days after PDSA 2 and 1.5 days after PDSA 3&4. Hospital LOS decreased from 5.7 days to 4.5 days after PDSA 1, 3.1 days after PDSA 2 and 2.7 days after PDSA 3&4. The use of non-invasive ventilation and invasive mechanical ventilation decreased throughout the study from 23.2% in the pre-intervention group, to 6.9% at end of the project. The 7-day PICU and hospital readmission rates did not increase. The percentage of patients discharged from the PICU increased from 6.2% to 21.5%. Conclusions: Modifications to an existing RT-driven HFNC protocol and standardized discharge criteria led to an improvement in bronchiolitis patients’ outcomes without an increase in adverse events.

Does High Flow Nasal Cannula avoid intubation and improve the mortality of adult patients in acute respiratory failure in the intensive care setting, when compared to others methods as Conventional Oxygen Therapy or Non-Invasive Ventilation? A narrative review

High-flow oxygen therapy via nasal cannula (HFNC) has been used for many years to oxygenate patients in respiratory failure. However, scientific data in literature are divergent about its value to prevent invasive mechanical ventilation and mortality. The use of HFNC has increased following the COVID-19 pandemic. Our review considers the impact of HFNC on intubation rates and mortality compared with conventional oxygen therapy (COT) and noninvasive ventilation (NIV). HFNC would decrease the use of invasive mechanical ventilation compared to COT and would be equivalent to NIV. Combination of NIV and HFNC would have a benefit compared to NIV alone. Some etiologies of respiratory failure would benefit more from this technique as post-extubation critical ill patient or COVID-19 pneumonia. HFNC seems to reduce mortality in COVID-19 patients compared to NIV.

Early Prediction of High-Flow Oxygen Therapy Failure in COVID-19 Acute Hypoxemic Respiratory Failure: A Retrospective Study of Scores and Thresholds.

Background High-flow oxygen therapy (HFOT) has been widely used as an effective alternative to invasive mechanical ventilation (IMV) in some critically ill patients with COVID-19pneumonia. This study aimed to compare different tools, including the respiratory rate and oxygenation (ROX) index, to predict HFOT failure in this setting. Methodology This single-center retrospective observational study was conducted from September to December 2020 and assessed COVID-19 patients who required HFOT as the first treatment at admission; HFOT failure was defined as IMV use. Prognostic scoring tools were as follows: the Sequential Organ Failure Assessment (SOFA), Acute Physiology And Chronic Health Evaluation (APACHE) II, and Simplified Acute Physiology Score (SAPS) III scores; C-reactive protein; lung consolidation percentage on chest CT; mean partial pressure of oxygen in arterial blood (PaO2)/fraction of inspired oxygen (FiO2) ratio; and ROX index and modified ROX index, calculated using PaO2 instead of blood oxygen saturation, within the first 24 hours after admission to theintensive care unit (ICU). These scores were analyzed using a multivariate Cox proportional hazard model; optimal cutoffs were computed using the R system for statistical computing. Results The study enrolled 52 patients, 31 (60%) of whom experienced HFOT failure. The best predictors of HFOT failure measured 24 hours after HFOT initiation were as follows: PaO2/FiO2 (threshold 123.6, sensitivity 87%, specificity 81%, hazard ratio [HR] 7.76, and 95% confidence interval [CI] 2.39-17.1); ROX index (threshold 5.63, sensitivity 68%, specificity 95%, HR 6.18, and 95% CI2.54-13.4); and modified ROX index (threshold 4.94, sensitivity 81%, specificity 90%, HR 8.16, and 95% CI3.16-21.5) (P < 0.001 for all). Conclusions Early assessment of the ROX index, modified ROX index, and PaO2/FiO2ratio can adequately predict, with high accuracy, HFOT failure in COVID-19 patients. Because thresholds remain debated and are still not sufficiently validated, we advocate using them with caution for clinical decision-making in this context.

Spontaneous pneumomediastinum: a surrogate of P-SILI in critically ill COVID-19 patients

Spontaneous pneumomediastinum (SP) has been described early during the COVID-19 pandemic in large series of patients with severe pneumonia, but most patients were receiving invasive mechanical ventilation (IMV) at the time of SP diagnosis. In this retrospective multicenter observational study, we aimed at describing the prevalence and outcomes of SP during severe COVID-19 with pneumonia before any IMV, to rule out mechanisms induced by IMV in the development of pneumomediastinum.Among 549 patients, 21 patients (4%) developed a SP while receiving non-invasive respiratory support, after a median of 6 days [4–12] from ICU admission. The proportion of patients requiring IMV was similar. However, the time to tracheal intubation was longer in patients with SP (6 days [5–13] vs. 2 days [1–4]; P = 0.00002), with a higher first-line use of non-invasive ventilation (n = 11; 52% vs. n = 150; 28%; P = 0.02). The 21 patients who developed a SP had persisting signs of severe lung disease and respiratory failure with lower ROX index between ICU admission and occurrence of SP (3.94 [3.15–5.55] at admission vs. 3.25 [2.73–4.02] the day preceding SP; P = 0.1), which may underline potential indirect signals of Patient-self inflicted lung injury (P-SILI).In this series of critically ill COVID-19 patients, the prevalence of SP without IMV was not uncommon, affecting 4% of patients. They received more often vasopressors and had a longer ICU length of stay, as compared with their counterparts. One pathophysiological mechanism may potentially be carried out by P-SILI related to a prolonged respiratory failure, as underlined by a delayed use of IMV and the evolution of the ROX index between ICU admission and the day preceding SP.

Evaluation of Glycemic Control and Predictors of Severe Illness and Death in Patients with Diabetes Hospitalized With COVID-19.

To identify risk factors for severe disease and death among patients with diabetes and coronavirus disease 2019 (COVID-19) infection. This retrospective cohort study conducted at three hospitals included 733 consecutive patients with DM admitted with confirmed COVID-19 (March 1 - December 31, 2020). Multivariable logistic regression was performed to identify predictors of severe disease and death. The mean age was 67.4 ± 14.3 years, 46.9% were males and 61.5% were African American. Among all patients, 116 (15.8%) died in the hospital. A total of 317 (43.2%) patients developed severe disease, 183 (25%) were admitted to an ICU and 118 (16.1%) required invasive mechanical ventilation. Increasing BMI (OR, 1.13; 95% CI, 1.02-1.25), history of chronic lung disease (OR, 1.49; 95% CI, 1.05-2.10) and increasing time since the last HbA1c test (OR, 1.25; 95% CI, 1.05-1.49) were the preadmission factors associated with increased odds of severe disease. Preadmission use of metformin (OR, 0.67; 95% CI, 0.47-0.95) or GLP-1 agonists (OR, 0.49; 95% CI, 0.27-0.87) was associated with decreased odds of severe disease. Increasing age (OR, 1.21; 95% CI, 1.09-1.34), co-existing chronic kidney disease greater than stage 3 (OR, 3.38; 95% CI, 1.67-6.84), ICU admission (OR, 2.93; 95% CI, 1.28-6.69) and use of invasive mechanical ventilation (OR, 8.67, 95% CI, 3.88-19.39) were independently associated with greater odds of in-hospital death. Several clinical characteristics were identified to be predictive of severe disease and in-hospital death among patients with underlying diabetes hospitalized with COVID-19.

Abstract 9809: Clinical Outcomes of Transcatheter Aortic Valve Replacement vs.surgical Aortic Valve Replacement in Patients With Durable Left Ventricular Assist Device

Introduction: Patients with left ventricular assist device (LVAD) often develop aortic insufficiency (AI) requiring an intervention on the aortic valve. We sought to analyze the outcomes of patients with a history of LVAD who underwent either transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). Methods: The Nationwide Readmission Database (NRD) was used to extract relevant patient information from January 1, 2016, to December 31, 2018. The NRD is a nationally representative sample of all-payer discharges from U.S. non-federal hospitals. The primary outcome of interest was in-hospital mortality. Secondary outcomes included length of stay, inpatient outcomes, costs, and 30-day all-cause readmissions. Complex samples multivariable logistic and linear regression models were used to determine the association of procedure type with outcomes. Results: Among 148 hospitalizations with a history of LVAD, 87 underwent TAVR, and 61 underwent SAVR. The inpatient mortality in SAVR group was numerically higher compared to the TAVR cohort, however, it did not reach statistical significance. The use of invasive mechanical ventilation, cardiogenic shock, bleeding, and vascular complications were higher in the SAVR cohort compared to the TAVR cohort. The mean length of stay (in days) and costs were higher in the SAVR cohort compared to the TAVR cohort. The 30-day all-cause readmission rate was numerically higher in the SAVR group, however, it was not statistically significant (Table 1). Conclusions: TAVR in patients with LVAD is a viable treatment option for AI and potentially leads to better inpatient mortality and inpatient outcomes compared to patients who undergo SAVR.

The association between macrovascular complications and intensive care admission, invasive mechanical ventilation, and mortality in people with diabetes hospitalized for coronavirus disease-2019 (COVID-19)

BackgroundIt is not clear whether pre-existing macrovascular complications (ischemic heart disease, stroke or peripheral artery disease) are associated with health outcomes in people with diabetes mellitus hospitalized for COVID-19.MethodsWe conducted cohort studies of adults with pre-existing diabetes hospitalized for COVID-19 infection in the UK, France, and Spain during the early phase of the pandemic (between March 2020—October 2020). Logistic regression models adjusted for demographic factors and other comorbidities were used to determine associations between previous macrovascular disease and relevant clinical outcomes: mortality, intensive care unit (ICU) admission and use of invasive mechanical ventilation (IMV) during the hospitalization. Output from individual logistic regression models for each cohort was combined in a meta-analysis.ResultsComplete data were available for 4,106 (60.4%) individuals. Of these, 1,652 (40.2%) had any prior macrovascular disease of whom 28.5% of patients died. Mortality was higher for people with compared to those without previous macrovascular disease (37.7% vs 22.4%). The combined crude odds ratio (OR) for previous macrovascular disease and mortality for all four cohorts was 2.12 (95% CI 1.83–2.45 with an I2 of 60%, reduced after adjustments for age, sex, type of diabetes, hypertension, microvascular disease, ethnicity, and BMI to adjusted OR 1.53 [95% CI 1.29–1.81]) for the three cohorts. Further analysis revealed that ischemic heart disease and cerebrovascular disease were the main contributors of adverse outcomes. However, proportions of people admitted to ICU (adjOR 0.48 [95% CI 0.31–0.75], I2 60%) and the use of IMV during hospitalization (adjOR 0.52 [95% CI 0.40–0.68], I2 37%) were significantly lower for people with previous macrovascular disease.ConclusionsThis large multinational study of people with diabetes mellitus hospitalized for COVID-19 demonstrates that previous macrovascular disease is associated with higher mortality and lower proportions admitted to ICU and treated with IMV during hospitalization suggesting selective admission criteria. Our findings highlight the importance correctly assess the prognosis and intensive monitoring in this high-risk group of patients and emphasize the need to design specific public health programs aimed to prevent SARS-CoV-2 infection in this subgroup.

Impact of the Use of Oral Antiviral Agents on the Risk of Hospitalization in Community Coronavirus Disease 2019 Patients (COVID-19).

ABSTRACTBackgroundWe examined the effectiveness of molnupiravir and nirmatrelvir/ritonavir in reducing hospitalization and deaths in a real-world cohort of non-hospitalized COVID-19 patients.MethodsThis was a territory-wide retrospective cohort study in Hong Kong. Non-hospitalized COVID-19 patients who attended designated outpatient clinics between 16 February and 31 March 2022 were identified. Patients hospitalized on the day of the first clinic appointment or used both oral antivirals were excluded. The primary endpoint was hospitalization. The secondary endpoint was a composite of intensive care unit admission, invasive mechanical ventilation use, and/or death.ResultsOf 93,883 patients, 83,154 (88.6%), 5,808 (6.2%), and 4,921 (5.2%) were oral antiviral non-users, molnupiravir users, and nirmatrelvir/ritonavir users respectively. Compared to non-users, oral antiviral users were older and had more comorbidities, lower complete vaccination rate, and more hospitalizations in the previous year. Molnupiravir users were older, and had more comorbidities, lower complete vaccination rate, and more hospitalizations in the previous year than nirmatrelvir/ritonavir users. At a median follow-up of 30 days, 1,931 (2.1%) patients were hospitalized and 225 (0.2%) patients developed the secondary endpoint. After propensity score weighting, nirmatrelvir/ritonavir use (weighted hazard ratio 0.79, 95%CI 0.65-0.95, P = 0.011) but not molnupiravir use (weighted hazard ratio 1.17, 95%CI 0.99-1.39, P = 0.062) was associated with a reduced risk of hospitalization than non-users. The use of molnupiravir or nirmatrelvir/ritonavir was not associated with a lower risk of the secondary endpoint as compared to non-users.ConclusionUse of nirmatrelvir/ritonavir but not molnupiravir was associated with a reduced risk of hospitalization in real-world non-hospitalized COVID-19 patients.

Differential impact of systolic and diastolic heart failure on in-hospital treatment, outcomes, and cost of patients admitted for pneumonia

BackgroundPatients admitted with pneumonia and heart failure (HF) have increased mortality and cost compared to those without HF, but it is not known whether outcomes differ between systolic and diastolic HF. Management of concomitant pneumonia and HF is complicated because HF treatments can worsen complications of pneumonia. MethodsThis is a retrospective cohort study from the Premier Database among patients admitted with pneumonia between 2010 and 2015. Patients were categorized based on systolic, diastolic, and combined HF using ICD-9 codes. The primary outcome was in-hospital mortality. Secondary outcomes included use of HF medications, length of stay, cost, intensive care unit (ICU) admission, as well as use of invasive mechanical ventilation (IMV), vasopressors and inotropes. Multivariable logistic regression was used to describe associations of these outcomes with type of HF. ResultsOf 123,211 patients with pneumonia and HF, 41,196 (33.4%) had systolic HF, 69,982 (56.8%) diastolic HF, and 12,033 (9.8%) had combined HF. Compared to patients with diastolic HF, after multivariable adjustment systolic HF was associated with higher in-hospital mortality (OR 1.15; 95% CI:1.11–1.20), ICU admission, and use of IMV and vasoactive agents, but not with increased length of stay or cost. Among patients with systolic HF, 80% received a loop diuretic, 72% a beta blocker, 48% angiotensin converting enzyme inhibitor or angiotensin receptor blocker, and 12.5% a mineralocorticoid receptor antagonist. ConclusionSystolic HF is associated with added risk in pneumonia compared to diastolic HF. There may also be an opportunity to optimize medications in systolic HF prior to discharge.

Low quality antibody responses in critically ill patients hospitalized with pandemic influenza A(H1N1)pdm09 virus infection

Although some adults infected with influenza 2009 A(H1N1)pdm09 viruses mounted high hemagglutination inhibition (HAI) antibody response, they still suffered from severe disease, or even death. Here, we analyzed antibody profiles in patients (n = 31, 17–65 years) admitted to intensive care units (ICUs) with lung failure and invasive mechanical ventilation use due to infection with A(H1N1)pdm09 viruses during 2009–2011. We performed a comprehensive analysis of the quality and quantity of antibody responses using HAI, virus neutralization, biolayer interferometry, enzyme-linked-lectin and enzyme-linked immunosorbent assays. At time of the ICU admission, 45% (14/31) of the patients had HAI antibody titers ≥ 80 in the first serum (S1), most (13/14) exhibited narrowly-focused HAI and/or anti-HA-head binding antibodies targeting single epitopes in or around the receptor binding site. In contrast, 42% (13/31) of the patients with HAI titers ≤ 10 in S1 had non-neutralizing anti-HA-stem antibodies against A(H1N1)pdm09 viruses. Only 19% (6/31) of the patients showed HA-specific IgG1-dominant antibody responses. Three of 5 fatal patients possessed highly focused cross-type HAI antibodies targeting the (K130 + Q223)-epitopes with extremely low avidity. Our findings suggest that narrowly-focused low-quality antibody responses targeting specific HA-epitopes may have contributed to severe infection of the lower respiratory tract.

Characteristics and Risk Factors for Mortality in Critically Ill Patients with COVID-19 Receiving Invasive Mechanical Ventilation: The Experience of a Private Network in Sao Paulo, Brazil.

IntroductionThe use of invasive mechanical ventilation (IMV) in COVID-19 represents in an incremental burden to healthcare systems.Aim of the studyWe aimed to characterize patients hospitalized for COVID-19 who received IMV and identify risk factors for mortality in this population.Material and MethodsA retrospective cohort study including consecutive adult patients admitted to a private network in Brazil who received IMV from March to October, 2020. A bidirectional stepwise logistic regression analysis was used to determine the risk factors for mortality.ResultsWe included 215 patients, of which 96 died and 119 were discharged from ICU. The mean age was 62.7 ± 15.4 years and the most important comorbidities were hypertension (62.8%), obesity (50.7%) and diabetes (40%). Non-survivors had lower body mass index (BMI) (28.3 [25.5; 31.6] vs. 31.2 [28.3; 35], p<0.001, and a shorter duration from symptom onset to intubation (8.5 [6.0; 12] days vs. 10 [8.0; 12.5] days, p = 0.005). Multivariable regression analysis showed that the risk factors for mortality were age (OR: 1.07, 95% CI: 1.03 to 1.1, p < 0.001), creatinine level at the intubation date (OR: 3.28, 95% CI: 1.47 to 7.33, p = 0.004), BMI (OR: 0.91, 95% CI: 0.84 to 0.99, p = 0.033), lowest PF ratio within 48 hours post-intubation (OR: 0.988, 95% CI: 0.979 to 0.997, p = 0.011), barotrauma (OR: 5.18, 95% CI: 1.14 to 23.65, p = 0.034) and duration from symptom onset to intubation (OR: 0.76, 95% CI: 0.76 to 0.95, p = 0.006).ConclusionIn our retrospective cohort we identified the main risk factors for mortality in COVID-19 patients receiving IMV: age, creatinine at the day of intubation, BMI, lowest PF ratio 48-hours post-intubation, barotrauma and duration from symptom onset to intubation.

Changes over time in characteristics, resource use and outcomes among ICU patients with COVID-19-A nationwide, observational study in Denmark.

BackgroundCharacteristics and care of intensive care unit (ICU) patients with COVID‐19 may have changed during the pandemic, but longitudinal data assessing this are limited. We compared patients with COVID‐19 admitted to Danish ICUs in the first wave with those admitted later.MethodsAmong all Danish ICU patients with COVID‐19, we compared demographics, chronic comorbidities, use of organ support, length of stay and vital status of those admitted 10 March to 19 May 2020 (first wave) versus 20 May 2020 to 30 June 2021. We analysed risk factors for death by adjusted logistic regression analysis.ResultsAmong all hospitalised patients with COVID‐19, a lower proportion was admitted to ICU after the first wave (13% vs. 8%). Among all 1374 ICU patients with COVID‐19, 326 were admitted during the first wave. There were no major differences in patient's characteristics or mortality between the two periods, but use of invasive mechanical ventilation (81% vs. 58% of patients), renal replacement therapy (26% vs. 13%) and ECMO (8% vs. 3%) and median length of stay in ICU (13 vs. 10 days) and in hospital (20 vs. 17 days) were all significantly lower after the first wave. Risk factors for death were higher age, larger burden of comorbidities (heart failure, pulmonary disease and kidney disease) and active cancer, but not admission during or after the first wave.ConclusionsAfter the first wave of COVID‐19 in Denmark, a lower proportion of hospitalised patients with COVID‐19 were admitted to ICU. Among ICU patients, use of organ support was lower and length of stay was reduced, but mortality rates remained at a relatively high level.

A multicenter, randomized controlled, non-inferiority trial, comparing nasal continuous positive airway pressure with nasal intermittent positive pressure ventilation as primary support before minimally invasive surfactant administration for preterm infants with respiratory distress syndrome (the NIV-MISA-RDS trial): Study protocol.

BackgroundNon-invasive ventilation (NIV) treatment has been developed to minimize lung damage and to avoid invasive mechanical ventilation (IMV) in preterm infants, especially in those with a gestational age of <30 weeks. Our hypothesis is that for preterm infants <30 weeks with potential to develop respiratory distress syndrome (RDS), nasal continuous positive airway pressure (NCPAP) is non-inferior to the nasal intermittent positive pressure ventilation (NIPPV) as primary respiratory support before minimal invasive surfactant administration (MISA).Methods and designThe NIV-MISA-RDS trial is planned as an unblinded, multicenter, randomized, non-inferiority trial at 14 tertiary neonatal intensive care units (NICUs) in China. Eligible infants are preterm infants of 24–29+6 weeks of gestational age who have spontaneous breaths at birth and require primary NIV support for RDS. Infants are randomized 1:1 to treatment with either NCPAP or NIPPV once admitted into NICUs. If an infant presents progressively aggravated respiratory distress and is clinically diagnosed as having RDS, pulmonary surfactant will be supplemented by MISA in the first 2 h of life. The primary outcome is NIV treatment failure within 72 h after birth. With a specified non-inferiority margin of 10%, using a two-sided 95% CI and 80% power, the study requires 480 infants per group (in total 960 infants).DiscussionCurrent evidence shows that NIV and MISA may be the most effective strategy for minimizing IMV in preterm infants with RDS. However, there are few large randomized controlled trials to compare the effectiveness of NCPAP and NIPPV as the primary respiratory support after birth and before surfactant administration. We will conduct this trial to test the hypothesis that NCPAP is not inferior to NIPPV as the initial respiratory support in reducing the use of IMV in premature infants who have spontaneous breaths after birth and who do not require intubation in the first 2 h after birth. The study will provide clinical data for the selection of the initial non-invasive ventilation mode in preterm infants with a gestational age of <30 weeks with spontaneous breaths after birth.Clinical trial registrationhttps://register.clinicaltrials.gov, identifier: NCT05137340.

EASIX, Modified EASIX and Simplified EASIX as an Early Predictor for Intensive Care Unit Admission and Mortality in Severe COVID-19 Patients.

COVID-19 receives a lot of attention due to its threat to global public health. Research is ongoing to find universal methods to assess the baseline health status of a patient to determine prognosis and management strategies. This study aims to assess the predictive potential of the EASIX (Endothelial Activation and Stress Index) and two of its modifications (mEASIX and sEASIX) in terms of the need for admission to the ICU (intensive care unit), the use of IMV (invasive mechanical ventilation) and death due to COVID-19. The medical data of 370 severely ill patients hospitalised in the COVID-19 departments of the Regional Specialist Hospital in Wroclaw (Poland), including the ICU, were analysed retrospectively. The mortality rate in the group studied was 65.7% (243 cases). In the case of all three indices, EASIX, mEASIX and sEASIX, there was a statistically significant correlation between the need for admission to the ICU (p = 0.026, p = 0.019, p = 0.001, respectively) and the risk of death (p < 0.001). In terms of the risk of death, the high values of the assessed indices (EASIX ≥ 2.36, mEASIX ≥ 704.03, sEASIX ≥ 3.81) were characterised by low sensitivity (≤40%), high specificity (approximately 90%) and low NPV (negative predictive value) (approximately 40%) with high PPV (positive predictive value) (approximately 80%). Due to the ease of implementation and the low cost of performing basic laboratory tests, the above-mentioned indices can be used as an additional, but not universal tool for the initial assessment of the health condition of patients admitted to the hospital.