RESUMO
BACKGROUND: A subset of patients with severe COVID-19 develop a hyperinflammatory syndrome, which might contribute to morbidity and mortality. This study explores a specific phenotype of COVID-19-associated hyperinflammation (COV-HI), and its associations with escalation of respiratory support and survival. METHODS: In this retrospective cohort study, we enrolled consecutive inpatients (aged ≥18 years) admitted to University College London Hospitals and Newcastle upon Tyne Hospitals in the UK with PCR-confirmed COVID-19 during the first wave of community-acquired infection. Demographic data, laboratory tests, and clinical status were recorded from the day of admission until death or discharge, with a minimum follow-up time of 28 days. We defined COV-HI as a C-reactive protein concentration greater than 150 mg/L or doubling within 24 h from greater than 50 mg/L, or a ferritin concentration greater than 1500 µg/L. Respiratory support was categorised as oxygen only, non-invasive ventilation, and intubation. Initial and repeated measures of hyperinflammation were evaluated in relation to the next-day risk of death or need for escalation of respiratory support (as a combined endpoint), using a multi-level logistic regression model. FINDINGS: We included 269 patients admitted to one of the study hospitals between March 1 and March 31, 2020, among whom 178 (66%) were eligible for escalation of respiratory support and 91 (34%) patients were not eligible. Of the whole cohort, 90 (33%) patients met the COV-HI criteria at admission. Despite having a younger median age and lower median Charlson Comorbidity Index scores, a higher proportion of patients with COV-HI on admission died during follow-up (36 [40%] of 90 patients) compared with the patients without COV-HI on admission (46 [26%] of 179). Among the 178 patients who were eligible for full respiratory support, 65 (37%) met the definition for COV-HI at admission, and 67 (74%) of the 90 patients whose respiratory care was escalated met the criteria by the day of escalation. Meeting the COV-HI criteria was significantly associated with the risk of next-day escalation of respiratory support or death (hazard ratio 2·24 [95% CI 1·62-2·87]) after adjustment for age, sex, and comorbidity. INTERPRETATION: Associations between elevated inflammatory markers, escalation of respiratory support, and survival in people with COVID-19 indicate the existence of a high-risk inflammatory phenotype. COV-HI might be useful to stratify patient groups in trial design. FUNDING: None.
RESUMO
BACKGROUND: Physiotherapy in intensive care units (ICU) has traditionally focussed on the respiratory management of mechanically ventilated patients. Gradually, focus has shifted to include rehabilitation in adult ICUs, though evidence of a similar shift in the paediatric ICU (PICU) is limited. OBJECTIVES: Review the evidence to determine the role of physiotherapists in the management of mechanically ventilated patients in PICU. DATA SOURCES: A search was conducted of: PEDro, CINAHL, Medline, PubMed and the Cochrane Library. ELIGIBILITY CRITERIA: Studies involving PICU patients who received physiotherapy while invasively ventilated were included in this review. Those involving neonatal or adult ICU patients, or patients on non-invasive or long-term ventilation, were not included in the study. STUDY APPRAISAL: All articles were critically appraised by two reviewers and results were analysed descriptively. RESULTS: Six studies on chest physiotherapy (CPT) met the selection criteria. Results support the use of the expiratory flow increase technique and CPT, especially manual hyperinflation and vibrations, for secretion clearance. Evidence does not support the routine use of either CPT or suction alone. No studies investigating rehabilitation in PICU met selection criteria. LIMITATIONS: A lack of high level evidence was available to inform this review. CONCLUSION: Evidence indicates that CPT is still the focus of physiotherapy intervention in PICU for mechanically ventilated patients, and supports its use for secretion clearance in this setting. PROSPERO register for systematic reviews (registration no. CRD42014009582).