Predictors of intubation in COVID-19 patients undergoing awake proning in the emergency department

BackgroundAwake prone positioning (PP) has been used to avoid intubations in hypoxic COVID-19 patients, but there is limited evidence regarding its efficacy. Moreover, clinicians have little information to identify patients at high risk of intubation despite awake PP. We sought to assess the intubation rate among patients treated with awake PP in our Emergency Department (ED) and identify predictors of need for intubation.MethodsWe conducted a multicenter retrospective cohort study of adult patients admitted for known or suspected COVID-19 who were treated with awake PP in the ED. We excluded patients intubated in the ED. Our primary outcome was prevalence of intubation during initial hospitalization. Other outcomes were intubation within 48 h of admission and mortality. We performed classification and regression tree analysis to identify the variables most likely to predict the need for intubation.ResultsWe included 97 patients; 44% required intubation and 21% were intubated within 48 h of admission. Respiratory oxygenation (ROX) index and P/F (partial pressure of oxygen / fraction of inspired oxygen) ratio measured 24 h after admission were the variables most likely to predict need for intubation (area under the receiver operating characteristic curve = 0.82).ConclusionsAmong COVID-19 patients treated with awake PP in the ED prior to admission, ROX index and P/F ratio, particularly 24 h after admission, may be useful tools in identifying patients at high risk of intubation.     

Manual proning of a morbidly obese COVID-19 patient: A case report

Continuously rising numbers of obese critical care patients pose many challenges to the healthcare workers, especially during the COVID-19 pandemic. Among them, proning may be one of the most labour-intensive tasks. Prone positioning is performed manually in hospitals where mechanical lifting aids are unavailable; however, the exact method of manual proning is not explicitly described in the literature.Here, we present a case of a morbidly obese patient with COVID-19 pneumonitis in the intensive care unit with a step-by-step guide of the manual proning technique. Our approach is simple and feasible, as only readily available tools, such as bed sheets and friction-reducing sheets, are used.     

Silent hypoxia: A harbinger of clinical deterioration in patients with COVID-19

Patients infected with the SARS-CoV-2 virus can present with a wide variety of symptoms including being entirely asymptomatic. Despite having no or minimal symptoms, some patients may have markedly reduced pulse oximetry readings. This has been referred to as “silent” or “apathetic” hypoxia (Ottestad et al., 2020 [1]). We present a case of a 72-year-old male with COVID-19 syndrome who presented to the emergency department with minimal symptoms but low peripheral oxygen saturation readings. The patient deteriorated over the following days and eventually died as a result of overwhelming multi-organ system failure. This case highlights the utility of peripheral oxygen measurements in the evaluation of patients with SARS-CoV-2 infection. Self-monitoring of pulse oximetry by patients discharged from the emergency department is a potential way to identify patients needing to return for further evaluation.     

Role of proning and positive end-expiratory pressure in COVID-19

The novel coronavirus, which was declared a pandemic by the World Health Organization in early 2020 has brought with itself major morbidity and mortality. It has increased hospital occupancy, heralded economic turmoil, and the rapid transmission and community spread have added to the burden of the virus. Most of the patients are admitted to the intensive care unit (ICU) for acute hypoxic respiratory failure often secondary to acute respiratory distress syndrome (ARDS). Based on the limited data available, there have been different opinions about the respiratory mechanics of the ARDS caused by coronavirus disease 2019 (COVID-19). Our article provides an insight into COVID-19 pathophysiology and how it differs from typical ARDS. Based on these differences, our article explains the different approach to ventilation in COVID-19 ARDS compared to typical ARDS. We critically analyze the role of positive end-expiratory pressure (PEEP) and proning in the ICU patients. Through the limited data and clinical experience are available, we believe that early proning in COVID-19 patients improves oxygenation and optimal PEEP should be titrated based on individual lung compliance.     

Mortality in patients with COVID-19 requiring extracorporeal membrane oxygenation: A meta-analysis

BACKGROUNDCoronavirus disease 2019 (COVID-19) has become a worldwide pandemic and significant public health issue. The effectiveness of extracorporeal membrane oxygenation (ECMO) in treating COVID-19 patients has been called into question.AIMTo conduct a meta-analysis on the mortality of COVID-19 patients who require ECMO.METHODSThis analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes 2020 (PRISMA) and has been registered at the International Prospective Register of Systematic Reviews (number CRD42020227414). A quality assessment for all the included articles was performed by the Newcastle-Ottawa Scale (NOS). Studies with tenor more COVID-19 patients undergoing ECMO were included. The random-effects model was used to obtain the pooled incidence of mortality in COVID-19 patients receiving ECMO. The source of heterogeneity was investigated using subgroup and sensitivity analyses.RESULTSWe identified 18 articles with 1494 COVID-19 patients who were receiving ECMO. The score of the quality assessment ranged from 5 to 8 on the NOS. The majority of patients received veno-venous ECMO (93.7%). Overall mortality was estimated to be 0.31 [95% confidence interval (CI): 0.24-0.39; I² = 84.8%] based on random-effect pooled estimates. There were significant differences in mortality between location groups (33.0% vs 55.0% vs 37.0% vs 18.0%, P < 0.001), setting groups (28.0% vs 34.0%, P < 0.001), sample size (37.0% vs 31.0%, P < 0.001), and NOS groups (39.0% vs 19.0%, P < 0.001). However, both subgroup analyses based on location, setting, and sample size, and sensitivity analysis failed to identify the source of heterogeneity. The funnel plot indicated no evident asymmetry, and the Egger''s (P = 0.95) and Begg''s (P = 0.14) tests also revealed no significant publication bias.CONCLUSIONWith more resource assessment and risk-benefit analysis, our data reveal that ECMO might be a feasible and effective treatment for COVID-19 patients.     

Effect of antiplatelet treatments on patients with COVID-19 infection: A systematic review and meta-analysis

Despite the rationale that early anti-platelet would lower the risk of major organ dysfunction, the effectiveness of this approach remains controversial. Therefore, we perform a systematic review and meta-analysis to investigate the effect of antiplatelet treatments on patients with COVID-19 infection. An electronic search was carried out in Pubmed, Embase, Cochrane library, Web of Science, MEDLINE, Wanfang and China National Knowledge Infrastructure (CNKI). Meta-analysis and statistical analyses were completed with using the RevMan 5.3 and Stata 12.0. A total of 9 articles representing data from 5970 participants were included in this study. The meta-analysis showed antiplatelet agents were not associated with higher risk of severe COVID-19 disease (OR = 0.98, 95%CI: 0.64 to 1.50, P = 0.94; I 2 = 65%), while an adjusted analysis indicated that antiplatelet agents was not associated with an increased risk of mortality (OR = 0.65, 95%CI: 0.40 to 1.06, P = 0.498; I 2 = 0%). The results of this study reveal that while there is no significant benefit on mortality demonstrated with the use of antiplatelet agents, the upper bound of the confidence interval suggests that there is unlikely to be a compelling risk of harm associated with this practice. The benefit and risk of the use of antiplatelet agents should be fully considered especially in the presence of thrombocytopenia status in patients with COVID-19.     

Benefits of ozone on mortality in patients with COVID-19: A systematic review and meta-analysis

BackgroundThe Coronavirus disease-2019 (COVID-19) pandemic continues, and the death toll continues to surge. Ozone therapy has long been used in the treatment of a variety of infectious diseases, probably through its antioxidant properties and the supply of oxygen to hypoxic tissues. This systematic review and meta-analysis aimed to determine the efficacy of ozone on mortality in patients with COVID-19.MethodsA systematic search was made of PubMed, Embase, Cochrane Library, and clinicaltrials.gov, without language restrictions. Prospective controlled trials on treatment of COVID-19 with ozone, compared with placebo or blank, were reviewed. Studies were pooled to risk ratios (RRs) and weighted mean differences (WMDs), with 95% confidence intervals (CIs).ResultsEight trials (enrolling 371 participants) met the inclusion criteria. Ozone therapy showed significant effects on mortality (RR 0.38, 95% CI 0.17–0.85; P = 0.02), length of hospital stay (WMD −1.63 days, 95% CI −3.05 to −0.22 days; P = 0.02), and polymerase chain reaction (PCR) positivity (RR 0.07, 95% CI 0.01–0.34; P = 0.001).ConclusionsOzone therapy significantly reduced mortality, PCR positivity, and length of stay in hospitalized patients with COVID-19. Ozone therapy should be considered for COVID-19 patients.     

Predictors of silent hypoxia in hospitalized patients with COVID-19 in Japan

IntroductionSilent hypoxia (SH) is common in patients with coronavirus disease (COVID-19) in Japan and other countries. Early identification of SH is important as more treatment options for COVID-19 have become available. This study aimed to identify predictors of SH using a nationwide COVID-19 registry of hospitalized patients.MethodsAdult patients who were admitted to hospital with COVID-19 between January 2020 and June 2021 and who were hypoxic on admission (SpO₂: 70–93%), not transferred from another facility, and who did not have disturbance of consciousness, confusion, or dementia, were included. SH was defined as hypoxia in the absence of shortness of breath/dyspnea upon admission. Predictors of SH were identified using univariable and multivariable logistic regression.ResultsThe study included 1904 patients, of whom 990 (52%) satisfied the criteria for SH. Compared to patients without SH, patients with SH were older, more likely to be female, and had a slightly higher SpO₂ on admission. Compared to patients without SH, patients with SH had a lower prevalence of chronic lung disease (CLD) other than chronic obstructive pulmonary disease (COPD), asthma, and obesity. Multivariable analysis revealed that the independent predictors of SH were older age, a shorter interval from symptom onset to admission, higher SpO₂, and an absence of CLD or COPD.ConclusionsThe absence of underlying lung disease and older age were important predictors of SH. The results of this study, which is the largest such study reported to date in Japan, may help clarify the mechanism of SH.     

Neutrophil-to-lymphocyte ratio on admission to predict the severity and mortality of COVID-19 patients: A meta-analysis

BackgroundThe neutrophil-to-lymphocyte ratio (NLR), an inflammatory marker, was suggested to be predictive of severity and mortality in COVID-19 patients. Here, we investigated whether NLR levels on admission could predict the severity and mortality of COVID-19 patients.MethodsA literature search was conducted on 23 July 2020 to retrieve all published articles, including grey literature and preprints, investigating the association between on-admission NLR values and severity or mortality in COVID-19 patients. A meta-analysis was performed to determine the overall standardized mean difference (SMD) in NLR values and the pooled risk ratio (RR) for severity and mortality with the 95% Confidence Interval (95%CI).ResultsA total of 38 articles, including 5699 patients with severity outcomes and 6033 patients with mortality outcomes, were included. The meta-analysis showed that severe and non-survivors of COVID-19 had higher on-admission NLR levels than non-severe and survivors (SMD 0.88; 95%CI 0.72–1.04; I² = 75.52% and 1.87; 95%CI 1.25–2.49; I² = 97.81%, respectively). Regardless of the different NLR cut-off values, the pooled mortality RR in patients with elevated vs. normal NLR levels was 2.74 (95%CI 0.98–7.66).ConclusionHigh NLR levels on admission were associated with severe COVID-19 and mortality. Further studies need to focus on determining the optimal cut-off value for NLR before clinical use.     

Clinical and radiological findings of silent hypoxia among COVID-19 patients

The aim of this study was to describe the clinical and radiological findings of COVID-19 patients with “silent hypoxia,” who had no dyspnea on admission even though their oximetry saturation was less than 94%. This retrospective cohort study included all COVID-19 patients (n = 270) at a large tertiary care hospital between January 31 and August 31, 2020. Clinical and radiological characteristics of patients who met our criteria of “silent hypoxia”, which included those who reported no dyspnea even though oximetry saturation was <94%, were extracted. Eight patients (3.0%) met the criteria for “silent hypoxia.” The median age was 61 years (interquartile range [IQR]: 48.8–72.3), and five (62.5%) were men. All patients had consolidation on CT and showed a moderate to high COVID-19 CT severity score (median: 13.5, IQR: 10.8–15.3). The median FIO2 of the maximum oxygen required was 55 (IQR: 28–70)%. Two patients (25.0%) were intubated, and one patient (12.5%) underwent extracorporeal membrane oxygenation. Some COVID-19 patients with “silent hypoxia” may develop severe disease. Close and accurate monitoring of patients using arterial blood gas and pulse oximetry is necessary, regardless of their symptoms.     

Incidence of adverse reactions to COVID-19 vaccination:A meta-analysis of randomized controlled trials

Objective:To systematically evaluate the incidence of adverse reactions to coronavirus disease 2019(COVID-19)vaccination.Methods:We systematically searched PubMed,Embase,The Cochrane Library,Web of Science,CNKI,WanFang Data,and VIP Database from the inception of each database to August 31,2021.Randomized controlled clinical trials(RCTs)on the safety of different types of COVID-19 vaccines were retrieved and analyzed.A random or fixed-effects model was used with an odds ratio as the effect size.The quality of each reference was evaluated.The incidence of the adverse reactions of the placebo group and the vaccination group was compared.Heterogeneity and publication bias were taken care of by meta-regression and sub-group analyses.Results:A total of 13 articles were included,with 81287 subjects.Compared with the placebo group,the vaccination group showed a higher combined risk ratio(RR)of total adverse reactions(RR=1.67,95%CI:1.46-1.91,P<0.01),local adverse reactions(RR=2.86,95%CI:2.11-3.87,P<0.01),systemic adverse reactions(RR=1.25,95%CI:0.92-1.72,P=0.16),pain(RR=2.55,95%CI:1.75-3.70,P<0.01),swelling(RR=4.16,95%CI:1.71-10.17,P=0.002),fever(RR=2.34,95%CI:1.84-2.97,P<0.01),fatigue(RR=1.36,95%CI:1.32-1.41,P<0.01)and headache(RR=1.22,95%CI:1.18-1.26,P<0.01).The subgroup analysis showed the incidence of adverse reactions of the vaccination group after injection of the three COVID-19 vaccines(inactivated viral vaccines,mRNA vaccines and adenovirus vector vaccines)was higher than that of the placebo group,and the difference between the placebo group and the vaccination group in the mRNA vaccine subgroup and the adenovirus vector vaccine subgroup was statistically significant(P<0.01).The incidence of adverse reactions after injection of COVID-19 vaccine in subgroups of different ages was significantly higher than that in the placebo group(P<0.01).Conclusions:COVID-19 vaccines have a good safety,among which adenovirus vector vaccine has the highest incidence of adverse reactions.Both adolescents and adults vaccinated with novel coronavirus vaccine have a certain proportion of adverse reactions,but the symptoms are mild and can be relieved by themselves.Our meta-analysis can help boost global awareness of vaccine safety,promote mass vaccination,help build regional and global immune barriers and effectively curb the recurrency of COVID-19.     

SARS-CoV-2抗体用于COVID-19诊断的Meta分析

目的 采用Meta分析探讨严重急性呼吸综合征冠状病毒2(SARS-CoV-2)抗体对新型冠状病毒肺炎(COVID-19)的诊断价值.方法 检索PubMed、Embase、Cochrane Library、中国知网、万方和维普数据库,收集相关文献.计算合并敏感性、合并特异性、诊断比值比(DOR),分析文献的异质性,采用综...     

Unusual cause of hypoxia due to incomplete removal of the closed suction catheter system during COVID-19 ventilation

Journal of Clinical Monitoring and Computing -