Current conception about the pathogenesis and intensive care of severe COVID-19 (review)

The aim of the research. The aim of this work was to summarize the scientific literature data on the pathogenesis and intensive care of the severe course of coronavirus infection. Materials and methods. Databases such as PubMed, Google Scholar, Scopus and Web Of Science 2020-2021 were used for literary searches. Results. An intense inflammatory response against the SARS-CoV-2 virus in COVID-19 patients causes a cytokine storm and hypercoagulability with the development of acute respiratory distress syndrome (ARDS) and multiple organ failure. Approximately 17 % to 35 % of hospitalized patients with COVID-19 are treated in the intensive care unit, most often due to hypoxemic respiratory failure and the development of ARDS, and between 29 % and 91 % of patients in intensive care units require invasive ventilation. In addition to acute respiratory failure, hospitalized patients may have acute renal failure (9 %), liver dysfunction (19 %), coagulation disorders (10 %–25 %), and septic shock (6 %). More than 75 % of hospitalized patients require additional oxygen therapy. Respiratory support could vary from the need for oxygen supplementation through a nasal catheter to invasive ventilation or extracorporeal membrane oxygenation in patients with the most severe ARDS. The uncontrolled inflammation and coagulation seen in COVID-19 patients is similar to multifactorial ARDS, where a plethora of evidence has demonstrated the ability of long-term corticosteroid therapy (CST) to reduce inflammation-coagulation-fibroproliferation and accelerate recovery. With regard to the assessment of the benefits of therapeutic anticoagulation in patients with elevated D-dimer, the question has not yet been finally resolved, and research devoted to this is still ongoing. Conclusions. The approaches to respiratory, anticoagulant, anti-inflammatory therapy in critically ill patients with COVID-19 require further research to determine the optimal treatment tactics

Factors Related to Survival in Intensive Care Unit Patients with Covid-19: A study from a Single Center in Brazil.

Introduction: The aim of this study is to the present an original research which describes the outcome in 268 ICU consecutive patients in a single center, as well analyzing the effects of viral infection on preexisting medical conditions such as hypertension, diabetes, obesity, chronic obstructive pulmonary disease, and how these factors affected survival and hospital stay.Material and methods: We retrospectively analyzed patients included in this study who were admitted to ICU between March 18th 2020 until August 30th 2020. All patients were analyzed under the same protocol at Hospital Alemão Oswaldo Cruz, São Paulo, Brazil. Several factors were considered, such as: age, gender, symptoms before hospitalization, comorbidities, vasopressors use, radiological findings and use of high flow nasal catheter. The results were presented using the hazard ratio and its respective 95% confidence intervals. For statistical inferences, p <0.05 was adopted for all analysis.Results: The median age was 72 years, 64,2 years (53-74) for patients who were discharged, and 79.9 years (71.4-88.4) for those deceased (p<0.001). The most common comorbidities associated were: systemic arterial hypertension, diabetes, thyroid disease, cardiovascular and kidney disease. The univariate analysis showed the following factors as predictors of survival: myalgia (p=0.001), cerebrovascular disease (p=0.002), COPD (p=0.003), dementia (p=0.000), the need for mechanical ventilation (p=0.000), dialysis (0.000), vasopressors use (0.000), SAPS3 (0.000), lymphopenia (p=0.004), elevated D-dimer (P=0.011), time in ICU before tracheostomy (p=0.002), and performing a tracheostomy (p=0.000). The independent predictors of mortality were: advanced age (p=0.003); the non-use of vasopressor in the ICU was protective factor (p=0.001); tracheostomy performed in ICU was a mortality predictor (p=0.002).Discussion: COVID-19 affects more older adults and there is also a high fatality rate in this subset of patients. Acute respiratory distress syndrome (ARDS) is the primary cause of death in and around < 5% of patients were reported as experiencing bacterial/fungal coinfection at admission. Our findings support the observations of earlier studies, which found a high percentage of hospitalized patients of advanced age with preexisting conditions, hypertension being the most common.Conclusion: In our analysis, age, the need for vasopressors medications patients who underwent tracheostomy and underlying comorbidities, such as systemic coronary disease, heart failure, neoplasia, COPD, were found to be significantly associated with COVID-19 severity.

Measurement of the interbronchial angle in acute viral bronchiolitis

Acute viral bronchiolitis (AVB) is the most common infection of the lower airways in children under 2 years of age. Attempts to determine the severity of the disease based on clinical and radiological manifestations are a major challenge. Measurements of the anatomy of the trachea, main bronchi and bronchioles are not limited to pure anthropometry, but are also useful for better knowledge and applicability in pulmonary physiology, thoracic surgery, anesthesiology and in the care of critically ill patients. This is a cross-sectional, retrospective study, which included all patients admitted to a tertiary hospital in the city of Porto Alegre, over a period of one year, with a diagnosis of AVB. The interbronchial angle (ITB) of these patients was measured and clinical and epidemiological characteristics were analyzed. A total of 425 patients were included, diagnosed with BVA by respiratory syncytial virus (RSV) confirmed by immunofluorescence. Most of these patients were male (59.5%) and the median age was 130 days, 91.11% of them required oxygen therapy through a nasal catheter, 3.3% used non-invasive ventilation (NIV) and 4% mechanical ventilation (MV) . Among the studied patients, we obtained only one death (0.2%). Those who required MV or NIV and support in an intensive care unit were considered serious. The mean ITB was lower for these patients than for less severe ones. It is concluded that the ABI has a correlation with the prognosis of patients with AVB and, after further studies, can be used as a severity score.

Respiratory Therapeutic Strategies in Children and Adolescents with COVID-19: a Critical Review

Abstract:: Evidence on the treatment strategies for the child population with critical conditions due to COVID-19 is scarce and lacks consensus. Thus, this study aimed to critically review non-pharmacological respiratory strategies for this population. Original studies were searched in six databases considering predefined inclusion criteria. Other studies and recommendations were also included after a manual search. Oxygen therapy, invasive (IMV) and non-invasive (NIV) ventilation were the most frequent addressed interventions. In general, the original studies cited these strategies, but detailed information on parameters used was not provided. The recommendations provided more detailed data, mainly based on experiences with other acute respiratory syndromes in childhood. In the context of oxygen therapy, the nasal catheter was the most recommended strategy for hypoxemia, followed by the high-flow nasal cannula (HFNC). However, the risks of contamination due to the dispersion of aerosols in the case of the HFNC were pointed out. Lung protective IMV with the use of bacteriological or viral filters was recommended in most documents, and there was great variation about PEEP titration. Alveolar recruitment maneuvers were mentioned in a few recommendations. NIV was not consensual between studies, and when selected, several precautions must be taken to avoid contamination. Airway suctioning with closed-circuit was recommended to reduce aerosol spread. Information on prone positioning and physiotherapy was even more scarce. In conclusion, oxygen therapy seems to be essential in the treatment of hypoxemia. If necessary, IMV should not be delayed, and protective strategies are encouraged for adequate pulmonary ventilation. Information about techniques that are adjuvant to ventilatory support is superficial and require further investigation.

Cardiac Rhabdomyoma: A Surrogate Diagnosis of Tuberous Sclerosis Complex in a Newborn Baby: Case Report from Tikur Anbessa University Hospital

BACKGROUND: Neonatal tuberous sclerosis complex is an autosomal dominant inherited disease characterized by high rate of neurological, cardiac and skin manifestations. CASEPRESENTATION: We reported a 4 days old female neonate with respiratory distress, tachypnea, tachycardia and hypomelanotic macular lesions. Her chest X-ray and echocardiographic studies revealed cardiomegaly and multiple echogenic masses in the left and right ventricles, suggestive of cardiac rhabdomyoma. Furthermore, non-contrast brain magnetic resonance imaging revealed sub-ependymal nodules and cortical tubers. Therefore, a clinical diagnosis of neonatal tuberous sclerosis complex with heart failure was made. Then, the patient was initiated on diuretic treatment with oxygen by nasal catheter with subsequent improvement. Seizure was not occurred yet in the last three and half years of follow-up. Currently, the patient is thriving well with no symptoms.CONCLUSION: Detection of prenatal or early neonatal age, cardiac rhabdomyoma is a useful clue to the diagnosis of tuberous sclerosis complex in neonates. Proper clinical evaluation of patients at the time of first contact prevents missing of findings such as skin macules and chest X-ray findings, which helped us to diagnose tuberous sclerosis complex in the present case.

Serum Mycoplasma Pneumoniae IgG in COVID-19: A Protective Factor

A correlation between prior exposure to Mycoplasma pneumoniae (IgG positive) and better clinical response to COVID-19 was elusive. In the present study, a retrospective review of 133 COVID-19 infected patients treated at Wuhan Union Hospital from Feb 1 to Mar 20 was carried out. Our data showed that COVID-19 infected patients with mycoplasma lgG positivity had a higher lymphocyte count and percentage (p = 0.026, p = 0.017), monocyte count and percentage (p = 0.028, p = 0.006) and eosinophil count and percentage (p = 0.039, p = 0.007), and a lower neutrophil count and percentage (p = 0.044, p = 0.006) than COVID-19 infected patients without mycoplasma lgG. Furthermore, requirement and use of a nasal catheter or oxygen mask was significantly lower in COVID-19 infected patients with mycoplasma lgG positivity (p = 0.029). Our findings indicate that mycoplasma IgG positivity is a potential protective factor for COVID-19.

Serum Mycoplasma pneumoniae IgG in COVID-19: A Protective Factor

BackgroundA correlation between prior exposure to Mycoplasma pneumoniae (IgG positive) and better clinical response to COVID-19 was elusive.MethodsA retrospective review of all COVID-19 infected patients treated at Wuhan Union Hospital from Feb 1 to Mar 20 was carried out. Continuous variables were described as mean, median, and interquartile range (IQR), while categorical variables were compared by X2 test or Fisher’s exact test between COVID-19 infected patients with mycoplasma lgG (-) and mycoplasma lgG (+).ResultsStatistically significant differences were shown in terms of laboratory test results. COVID-19 infected patients with mycoplasma lgG positivity had a higher lymphocyte count and percentage (p=0.026, p=0.017), monocyte count and percentage (p=0.028, p=0.006) and eosinophil count and percentage (p=0.039, p=0.007), and a lower neutrophil count and percentage (p=0.044, p=0.006) than COVID-19 infected patients without mycoplasma lgG. Other routine blood tests, including coagulation tests, blood biochemistry and infection-related biomarkers did not significantly differ except for thrombin time (p=0.001) and lactate dehydrogenase (p=0.008). Furthermore, requirement and use of a nasal catheter or oxygen mask was significantly lower in COVID-19 infected patients with mycoplasma lgG positivity (p=0.029).ConclusionsOur findings indicate that mycoplasma IgG positivity is a potential protective factor for SARS-CoV-2 infection.

Oxygen therapy via high flow nasal cannula in severe respiratory failure caused by Sars-Cov-2 infection: a real-life observational study

The worldwide spread of coronavirus disease 2019 (COVID-19), caused by the new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was declared a pandemic by the World Health Organization (WHO) in March 2020. According to clinical studies carried out in China and Italy, most patients experience mild or moderate symptoms; about a fifth of subjects develop a severe and critical disease, and may suffer from interstitial pneumonia, possibly associated with acute respiratory distress syndrome (ARDS) and death. In patients who develop respiratory failure, timely conventional oxygen therapy through nasal catheter plays a crucial role, but it can be used only in mild forms. Continuous positive airway pressure (CPAP) support or non-invasive mechanical ventilation (NIV) are uncomfortable, and require significant man–machine cooperation. Herein we describe our experience of five patients with COVID-19, who were treated with high-flow nasal cannula (HFNC) after failure of CPAP or NIV, and discuss the role of HFNC in COVID-19 patients. Our findings suggest that HFNC can be used successfully in selected patients with COVID-19-related ARDS. The reviews of this paper are available via the supplemental material section.