ABSTRACT
INTRODUCTION: During the COVID-19 pandemic, the burden on the healthcare system makes it critical to examine readmission patterns. In this study, we evaluated the readmission rates and risk factors associated with COVID-19 from the large SCCM Discovery VIRUS: COVID-19 Registry. METHOD(S): This was a retrospective, cohort study including hospitalized adult patients from 181 hospitals in 24 countries within the VIRUS: COVID-19 Registry. Demographic, clinical, and outcome data were extracted and divided into two groups: Patients with readmission with COVID-19 in 30 days from discharge and those who were not. A univariate analysis is done using chi-square and t-test as appropriate. Multivariable logistic regression was used to measure risk factor associations with 30-day readmission. RESULT(S): Among 20,283 patients, 1,195 (5.9%) were readmitted within 30 days from discharge. The median (IQR) age of readmitted patients was 66 (55-78) years and 45.2% were female, 60.2% were white, and 78.9% non-Hispanic. Higher odds of readmission were observed in patients aged >60 vs 18-40 years (OR 2.76;95% CI, 2.23-3.41), moderate COVID-19 disease (WHO Ordinal scale 4-5) vs Severe COVID-19 (WHO Ordinal scale 6-9) (OR 1.23;95% CI, 1.10-1.39), no ICU admission at index hospitalization (OR 1.70;95% CI, 1.32-1.80), and Hospital length of stay <=14 vs >14 days (OR 1.53;95% CI, 1.32-1.80) vs those not readmitted (p= < 0.001). Comorbidities including coronary artery disease (OR 2.14;95% CI 1.84-2.48), hypertension (OR 1.58;95% CI 1.40-1.78), congestive Heart Failure (OR 2.54;95% CI 2.16-2.98), chronic pulmonary disease (OR 2.26;95% CI 1.94-2.63), diabetes (OR 1.32;95% CI 1.17-1.49) or chronic kidney disease (CKD) (OR 2.41;95% CI 1.2.09-2.78) were associated with higher odds of readmission. In multivariate logistic regression adjusted for age group, hospital length of stay <=14 days and, highest WHO COVID-19 ordinal scale and index ICU admission coronary artery disease, congestive heart failure, chronic pulmonary disease, chronic kidney disease, hospital length of stay <=14 days and age >60 years remained independent risk factors for readmission within 30 days. CONCLUSION(S): Among hospitalized patients with COVID-19, those readmitted had a higher burden of comorbidities compared to those non-readmitted.
ABSTRACT
TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Mechanical ventilation for Covid-19 – acute respiratory distress syndrome (ARDS) is challenging due to poor lung compliance and high airway pressures for a prolonged period. Under these circumstances, physicians have limited means to control air leaks when they occur. We discuss a case of severe Covid-19 ARDS complicated by early air-leak which was attributed to idiopathic tracheomegaly, and the associated challenges in the patients' care. CASE PRESENTATION: 60-year-old African American man with polymyositis and diabetes mellitus was intubated with a size 8.0 endotracheal tube (ET) for hypoxemic respiratory failure due to Covid-19 infection. Lung protective ventilation was utilized. He was extubated on day three, but he required re-intubation the following day for worsening mental status and hypoxemia. A significant cuff leak (> 400 ml) on a PEEP of 5 cm H2O was noted. Ppeak and Pplat were 42cm H20 and 39 cm H2O respectively. Arterial blood gas: pH 7.129, PCO2 79.6, PaO2 72. The air leak only resolved when cuff pressures exceeded 70 cm H2O. A chest x-ray confirmed adequate ET tube positioning. Tube exchange with another size 8.0 tube was performed, but the balloon was found to be intact. The ET tube was upsized to size 9.0, yet cuff-pressures as high as 70-80 cm H2O were needed to maintain a leak of < 200ml. Considering focal tracheomalacia, the ET tube was bronchoscopically repositioned at different lengths of the airway, without effect. Extended tracheostomy was technically unfeasible due to the severity of the respiratory failure. A computed tomography (CT) of the neck was pursued for airway injury following re-intubation. Image review suggested tracheomegaly with a tracheal diameter of 29 mm (average 21-25 mm in men);Left and Right mainstem measured 18.11 mm and 21mm respectively. (Figure 1). Size 9.0 ET tube failed to prevent air-leak and lung de-recruitment. In the absence of alternative adult airway products, and with the reassurance obtained from the CT neck, the cuff pressure was deliberately kept at 80 mm Hg to maintain adequate ventilation. DISCUSSION: Risk factors for tracheomalacia include prolonged ventilation, high cuff pressure(>35cm H2O) and airway pressures, steroid use, connective tissue diseases, and systemic shock. Our patient had a history of polymyositis but no other risk factors for early tracheomalacia. This case highlights the challenge of overcoming a life-threatening air leak that was likely exacerbated by elevated airway pressures in a patient with idiopathic tracheomegaly. The cuff leak improved after one week with the recovery of lung compliance. After 45 days in the medical intensive care unit, the patient was discharged to an LTACH with a size 8.0 Shiley tube. CONCLUSIONS: Developing alternative endotracheal airway products should be considered to account for these rare patients. REFERENCE #1: Everson DM. Tracheobronchomegaly causing endotracheal tube cuff leak. Trends in Anaesthesia and Critical Care. 2019;25:46-7. DISCLOSURES: No relevant relationships by Enambir Josan, source=Web Response No relevant relationships by Faiza Khalid, source=Web Response No relevant relationships by Ismini Kourouni, source=Web Response No relevant relationships by Yasir Tarabichi, source=Web Response
ABSTRACT
Study Objectives: Racial disparities between White and minority (non-White) asthmatics in the United States have long been documented before the COVID-19 pandemic. During the COVID-19 pandemic, minorities were also found to disproportionately bear the burden of COVID-19-related severe outcomes. The pandemic hastened the adoption of several health care system and societal changes, including expansion of telemedicine via video or phone visits, mask usage, social distancing, and remote work and schooling. These could be seen as protective to asthmatics via decreased exposure to respiratory pathogens, and increased provider access. However, it is unclear how the pandemic affected racial disparities for asthmatics. In this study, we employ the Epic Corporation’s Aggregate Data Program (ADP) to examine how the pandemic affected emergency department (ED) utilization between White and minority asthmatics. Methods: Epic’s ADP General Asthma Data Set collects national level data across all Epic customers and reports asthma prevalence, cumulative incidence of asthma exacerbation ED visits, and proportion of ED visits that comprise asthma exacerbations. This de-identified aggregate data is broken down by race, ethnicity, age groups, sex, and location (ie, state). We examined data from January 1, 2017 to February 1, 2021. We defined the start of the pandemic as March 11, 2020, when the World Health Organization officially declared a pandemic. We determined the monthly incidence of asthma ED visits for non-White and White asthmatics separately, and then calculated the risk ratio by dividing incidence for minority asthmatics by incidence for White asthmatics. This risk ratio served as our measure for racial disparity. We compared the pre-pandemic and pandemic risk ratio with an unpaired t-test. We then performed an interrupted time series (ITS) analysis to compare the trends of pre-pandemic and pandemic risk ratio. Results: Our data included 15.4e6 asthma ED visits, with 59.0% of visits comprised by minority asthmatics. The number of asthma ED visits per month on average were 3.1e5 +/- 1.2e5. Pandemic risk ratio was statistically significantly lower than pre-pandemic risk ratio (pre-pandemic mean 2.61, pandemic mean 2.54, 95% CI [0.024, 0.128], p < 0.01). ITS analysis demonstrated pre-pandemic risk ratio trend of 0.006/month, (95% CI 0.003, 0.009, p < 0.01). During the pandemic, the change in the risk ratio trend was -0.027/month, (95% CI -0.043, -0.012, p < 0.01). Pre-pandemic and pandemic trends in risk ratio are demonstrated in the figure. Conclusion: Our study demonstrates that during the pandemic, known racial disparities in asthmatic ED utilization (ie, risk ratio between minority and White asthmatics) did not worsen. In fact, the pandemic reversed a marginally positive trend pre-pandemic, although this trend appeared to begin normalizing. It is possible that any one of the changes during the pandemic caused this shift in trend, but the limitations of our dataset prevent further investigation. More research is needed to investigate the factors underlying this trend change to learn how we may address racial disparities going forward. [Formula presented]