Prognostic value of respiratory parameters for COVID-19 patients in the emergency department: results from the EC-COVID study.

While several studies have evaluated the prognostic weight of respiratory parameters in patients with COVID-19, few have focused on patients' clinical conditions at the first emergency department (ED) assessment. We analyzed a large cohort of ED patients recruited within the EC-COVID study over the year 2020, and assessed the association between key bedside respiratory parameters measured in room air (pO2, pCO2, pH, and respiratory rate [RR]) and hospital mortality, after adjusting for key confounding factors. Analyses were based on a multivariable logistic Generalized Additive Model (GAM). After excluding patients who did not perform a blood gas analysis (BGA) test in room air or with incomplete BGA results, a total of 2458 patients were considered in the analyses. Most patients were hospitalized on ED discharge (72.0%); hospital mortality was 14.3%. Strong, negative associations with hospital mortality emerged for pO2, pCO2 and pH (p-values: < 0.001, < 0.001 and 0.014), while a significant, positive association was observed for RR (p-value < 0.001). Associations were quantified with nonlinear functions, learned from the data. No cross-parameter interaction was significant (all p-values were larger than 0.10), suggesting a progressive, independent effect on the outcome as the value of each parameter departed from normality. Our results collide with the hypothesized existence of patterns of breathing parameters with specific prognostic weight in the early stages of the disease.

SIMEU position paper on non-invasive respiratory support in COVID-19 pneumonia.

The rapid worldwide spread of the Coronavirus disease (COVID-19) crisis has put health systems under pressure to a level never experienced before, putting intensive care units in a position to fail to meet an exponentially growing demand. The main clinical feature of the disease is a progressive arterial hypoxemia which rapidly leads to ARDS which makes the use of intensive care and mechanical ventilation almost inevitable. The difficulty of health systems to guarantee a corresponding supply of resources in intensive care, together with the uncertain results reported in the literature with respect to patients who undergo early conventional ventilation, make the search for alternative methods of oxygenation and ventilation and potentially preventive of the need for tracheal intubation, such as non-invasive respiratory support techniques particularly valuable. In this context, the Emergency Department, located between the area outside the hospital and hospital ward and ICU, assumes the role of a crucial junction, due to the possibility of applying these techniques at a sufficiently early stage and being able to rapidly evaluate their effectiveness. This position paper describes the indications for the use of non-invasive respiratory support techniques in respiratory failure secondary to COVID-19-related pneumonia, formulated by the Non-invasive Ventilation Faculty of the Italian Society of Emergency Medicine (SIMEU) on the base of what is available in the literature and on the authors' direct experience. Rationale, literature, tips & tricks, resources, risks and expected results, and patient interaction will be discussed for each one of the escalating non-invasive respiratory techniques: standard oxygen, HFNCO, CPAP, NIPPV, and awake self-repositioning. The final chapter describes our suggested approach to the failing patient.

Using vital signs measurements to identify patients with COVID-19 who require early continuous positive airway pressure.

BACKGROUND: The coronavirus disease 2019 (COVID-19) can result in severe pneumonia, leading to acute respiratory distress syndrome, which are treated using continuous positive airway pressure (CPAP). Patients must be evaluated quickly to commence early CPAP if required. AIM: To identify patients with COVID-19 in the emergency department (ED) who require early CPAP, using vital signs measurements during triage. METHOD: This was a retrospective, observational, single-centre cohort study of patients with COVID-19 admitted to the ED of a university hospital in Lombardy, Italy, between 21 February 2020 and 30 April 2020. These patients were divided into two groups: those who required CPAP and those did not require CPAP. Recordings of their vital signs were retrieved from triage medical records. The vital signs values recorded in the two groups on their arrival at the ED were compared. RESULTS: Of 601 patients, 120 (20%) required CPAP. It was identified that the typical characteristics of patients requiring early CPAP were: male (P=.013) with a median age of 68 years (P=.000), oxygen saturation of 92% (P=.000), temperature ≥38°C (P=.008), respiratory rate of 26 breaths per minute (P=.000) and had received pre-hospital oxygen therapy before arriving at the ED (P=.000). The CPAP group was divided into two subgroups: patients who had received pre-hospital oxygen therapy and those who had not. The median respiratory rate values between the two subgroups presented a statistically significant difference (P=.004). CONCLUSION: This study identified the characteristics of a typical patient with COVID-19 who requires early CPAP. Based on the results, the authors have devised a triage flow chart that uses selected vital signs measurements (oxygen saturation, respiratory rate and receipt of pre-hospital oxygen therapy) to identify patients requiring early CPAP. This flow chart should be trialled in a prospective study before it is used to inform clinical decision-making.

Diagnostic performance of chest radiography in high COVID-19 prevalence setting: experience from a European reference hospital.

PURPOSE: The study's aim is to analyse the diagnostic performance of chest radiography (CXR) in patients with suspected coronavirus disease 19 (COVID-19). METHODS: We retrospectively considered 826 consecutive patients with suspected COVID-19 presenting to our emergency department (ED) from February 21 to March 31, 2020, in a high disease prevalence setting. We enrolled patients who underwent CXR and rhino-oropharyngeal swab for real-time reverse transcription-polymerase chain reaction (rRT-PCR). CXRs were evaluated by an expert radiologist; a second independent analysis was performed by two residents in consensus. All readers, blinded to rRT-PCR results, classified CXRs positive/negative depending on presence/absence of typical findings of COVID-19, using rRT-PCR as reference standard. RESULTS: We finally analysed 680 patients (median age 58); 547 (80%) tested positive for COVID-19. The diagnostic performance of CXR, interpreted by the expert reader, was as follows: sensitivity (79.0%; 95% CI: 75.3-82.3), specificity (81.2%; 95% CI: 73.5-87.5), PPV (94.5%;95% CI: 92.0-96.4), NPV (48.4%; 95% CI: 41.7-55.2), and accuracy (79.3%; 95% CI: 76.0-82.2). For the residents: sensitivity (75.1%; 95% CI: 71.2-78.7), specificity (57.9%; 95% CI: 49.9-66.4), PPV (88.0%; 95% CI: 84.7-90.8), NPV (36.2%; 95% CI: 29.7-43.0), and accuracy (71.6%; 95% CI: 68.1-75.0). We found a significant difference between the reporting sensitivity (p = 0.013) and specificity (p < 0.0001) of expert radiologist vs residents. CXR sensitivity was higher in patients with symptom onset > 5 days before ED presentation compared to ≤ 5 days (84.4% vs 70.7%). CONCLUSIONS: CXR showed a sensitivity of 79% and a specificity of 81% in diagnosing viral pneumonia in symptomatic patients with clinical suspicion of COVID-19. Further studies in lower prevalence settings are needed.

Correlation between continuous Positive end-expiratory pressure (PEEP) values and occurrence of Pneumothorax and Pneumomediastinum in SARS-CoV2 patients during non-invasive ventilation with Helmet.

BACKGROUND: Acute Hypoxemic Respiratory Failure is a common complication of SARS-CoV2 related pneumonia, for which non-invasive ventilation (NIV) with Helmet Continuous Positive Airway Pressure (CPAP) is widely used. The frequency of pneumothorax in SARS-CoV2 was reported in 0.95% of hospitalized patients in 6% of mechanically ventilated patients, and in 1% of a post-mortem case series. OBJECTIVES: Aim of our retrospective study was to investigate the incidence of pneumothorax and pneumomediastinum (PNX/PNM) in SARS-CoV2 pneumonia patients treated with Helmet CPAP. Moreover, we examined the correlation between PNX/PNM and Positive end-expiratory pressure (PEEP) values. METHODS: We collected data from patients admitted to "Luigi Sacco" University Hospital of Milan from 2 February to 5 May 2020 with SARS-CoV2 pneumonia requiring CPAP. Patients, who need NIV with bi-level pressure or endotracheal intubation (ETI) for any reason except those who needed ETI after PNX/PNM, were excluded. Population was divided in two groups according to PEEP level used (≤10 cmH2O and >10 cmH20). RESULTS: 154 patients were enrolled. In the overall population, 42 patients (27%) were treated with High-PEEP (>10 cmH2O), and 112 with Low-PEEP (≤10 cmH2O). During hospitalization 3 PNX and 2 PNM occurred (3.2%). Out of these five patients, 2 needed invasive ventilation after PNX and died. All the PNX/PNM occurred in the High-PEEP group (5/37 vs 0/112, p<0,001). CONCLUSION: The incidence of PNX appears to be lower in SARS-CoV2 than SARS and MERS. Considering the association of PNX/PNM with high PEEP we suggest using the lower PEEP as possible to prevent these complications.

A proposal of a "ready to use" COVID-19 control strategy in an Oncology ward: Utopia or reality?

The Coronavirus Disease-2019 (COVID-19) pandemic is spreading in Italy and Lombardy is one of the most affected region. Cancer patients are higher risk of complication from COVID-19 complications; therefore they should be protected from contagion while still ensuring access to cancer care. The aim of this article is to suggest a strategy to reorganize hospital spaces and Healthcare Professionals (HCPs) staff in order to avoid COVID-19 nosocomial infection in an Oncology ward. SARS-CoV-2 is primarily transmitted through respiratory droplets and by contact. We speculated that precautions against droplet and contact transmission should be the proper way to preserve ward from COVID-19. The essence of our protocol involves: triage outside of the ward, identification of risk zones, traffic control, surveillance of all the involved subjects. Whoever attends the ward must follow the general risk prevention and mitigation measures. The application of this practical strategy can contribute to breaking the cycle of community-hospital-community transmission.

Impending Central Retinal Vein Occlusion in a Patient with Coronavirus Disease 2019 (COVID-19).

PURPOSE: To report a case of impending central retinal vein occlusion (iCRVO) in a COVID-19 patient. CASE REPORT: A 54 years old woman with COVID-19 related pneumonia presented to our emergency department complaining of scotomas and decreased vision in her right eye. Funduscopic examination and multimodal imaging revealed rare retinal hemorrhages, retinal whitening, and fern-like hypo-autofluorescent appearance typical of iCRVO. She had no risk factors other than a transient hyper-coagulability status likely related to the ongoing infection. Systemic treatment with steroids normalized her inflammatory and coagulation status and the occlusion completely resolved. CONCLUSIONS: Retinal circulation should be considered as a potential site for thromboembolic complications from COVID-19.

30-day mortality in patients hospitalized with COVID-19 during the first wave of the Italian epidemic: A prospective cohort study.

Italy was the first European country hit by the COVID-19 pandemic and has the highest number of recorded COVID-19 deaths in Europe. This prospective cohort study of the correlates of the risk of death in COVID-19 patients was conducted at the Infectious Diseases and Intensive Care units of Luigi Sacco Hospital, Milan, Italy. The clinical characteristics of all the COVID-19 patients hospitalised in the early days of the epidemic (21 February -19 March 2020) were recorded upon admission, and the time-dependent probability of death was evaluated using the Kaplan-Meier method (censored as of 20 April 2020). Cox proportional hazard models were used to assess the factors independently associated with the risk of death. Forty-eight (20.6 %) of the 233 patients followed up for a median of 40 days (interquartile range 33-47) died during the follow-up. Most were males (69.1 %) and their median age was 61 years (IQR 50-72). The time-dependent probability of death was 19.7 % (95 % CI 14.6-24.9 %) 30 days after hospital admission. Age (adjusted hazard ratio [aHR] 2.08, 95 % CI 1.48-2.92 per ten years more) and obesity (aHR 3.04, 95 % CI 1.42-6.49) were independently associated with an increased risk of death, which was also associated with critical disease (aHR 8.26, 95 % CI 1.41-48.29), C-reactive protein levels (aHR 1.17, 95 % CI 1.02-1.35 per 50 mg/L more) and creatinine kinase levels above 185 U/L (aHR 2.58, 95 % CI 1.37-4.87) upon admission. Case-fatality rate of patients hospitalized with COVID-19 in the early days of the Italian epidemic was about 20 %. Our study adds evidence to the notion that older age, obesity and more advanced illness are factors associated to an increased risk of death among patients hospitalized with COVID-19.

Treatment with ferric carboxymaltose in stable patients with severe iron deficiency anemia in the emergency department.

The AABB Choosing Wisely Campaign recommends "don't transfuse for iron deficiency without hemodynamic instability". However, the management of iron deficiency anemia (IDA) in the emergency department (ED) is heterogeneous and patients are often over-transfused. Intravenous iron is effective in correcting anemia and new formulations, including ferric carboxymaltose (FCM), allow the administration of high doses with low immunogenicity. The aim of this retrospective study was to analyze the management of hemodynamically stable patients aged 18-55 years with severe IDA (hemoglobin < 8 g/dL), who presented to the ED from January 2014 to July 2018. Patients who received FCM (FCM1) and those who did not receive FCM (FCM0) were compared. Efficacy and safety of FCM at follow-up were evaluated. Seventy-one subjects fulfilled the inclusion criteria (FCM0 n = 48; FCM1 n = 23). The mean Hb at admission was 6.6 g/dL. 40% in the FCM0 and 13% in FCM1 were transfused (p = 0.02). 21% of FCM0 patients were admitted to the ward, while all FCM1 were discharged (p = 0.02). Within 2 weeks, the Hb increase was 2.8 ± 1 g/dL in the FCM1 group. Sixteen FCM1 patients were evaluated at 52 ± 28 days (median 42, range 27-122): the average Hb increase was 5.3 ± 1.4 g/dL. In summary, we showed that FCM administration in the ED in hemodynamically stable patients was associated with fewer transfusions and hospital admissions compared to the FCM0 group; moreover, it succeeded in safely, effectively and rapidly increasing Hb levels after discharge from the ED. Further studies are needed to develop recommendations for IDA in the ED and to identify transfusion thresholds for non-hospitalized patients.

Prevalence, risk factors and outcomes of patients coming from the community with sepsis due to multidrug resistant bacteria.

BACKGROUND: Although previous studies showed an increasing prevalence of infections due to multi-drug resistant (MDR) bacteria in the community, specific data on sepsis are lacking. We aimed to assess prevalence, risk factors and outcomes of patients with sepsis due to MDR bacteria. METHODS: An observational, retrospective study was conducted on consecutive adult patients coming from the community and admitted to the Policlinico Hospital, Milan, Italy, with a diagnosis of sepsis between January 2011 and December 2015. Primary study outcome was in-hospital mortality. RESULTS: Among 518 patients, at least one MDR bacteria was isolated in 88 (17%). ESBL+ Enterobacteriaceae were the most prevalent MDR bacteria (9.7%) followed by MRSA (3.9%). Independent risk factors for sepsis due to MDR bacteria were septic shock (OR: 2.2; p = 0.002) and hospitalization in the previous 90 days (OR: 2.3; p = 0.003). Independent risk factors for sepsis due to ESBL+ bacteria were hospitalization in the previous 90 days (OR: 2.1; p = 0.02) and stroke (OR: 2.1; p = 0.04). A significantly higher mortality was detected among patients with vs. without MDR bacteria (40.2% vs. 23.1% respectively, p = 0.001). Independent risk factors for mortality among patients with sepsis were coagulation dysfunction (OR: 3.2; p = 0.03), septic shock (OR: 3.2; p = 0.003), and isolation of a MDR bacteria (OR: 4.6; p < 0.001). CONCLUSION: In light of the prevalence and impact of MDR bacteria causing sepsis in patients coming from the community, physicians should consider ESBL coverage when starting an empiric antibiotic therapy in patients with specific risk factors, especially in the presence of septic shock.

Non-invasive positive pressure ventilation in pneumonia outside Intensive Care Unit: An Italian multicenter observational study.

BACKGROUND AND OBJECTIVE: Non-Invasive Ventilation (NIV) represents a standard of care to treat some acute respiratory failure (ARF). Data on its use in pneumonia are lacking, especially in a setting outside the Intensive Care Unit (ICU). The aims of this study were to evaluate the use of NIV in ARF due to pneumonia outside the ICU, and to identify risk factors for in-hospital mortality. METHODS: Prospective, observational study performed in 19 centers in Italy. Patients with ARF due to pneumonia treated outside the ICU with either continuous positive airway pressure (CPAP) or noninvasive positive pressure ventilation (NPPV) were enrolled over a period of at least 3 consecutive months in 2013. Independent factors related to in-hospital mortality were evaluated. RESULTS: Among the 347 patients enrolled, CPAP was applied as first treatment in 176 (50.7%) patients,NPPV in 171 (49.3%). The NPPV compared with CPAP group showed a significant higher PaCO2 (55 [47-78] vs 37 [32-43] mmHg, p < 0.001), a lower arterial pH (7.30 [7.21-7.37] vs 7.43 [7.35-7.47], p < 0.001), higher HCO3- (28 [24-33] vs 24 [21-27] mmol/L, p < 0.001). De-novo ARF was more prevalent in CPAP group than in NPPV group (86/176 vs 31/171 patients,p < 0.001). In-hospital mortality was 23% (83/347). Do Not Intubate (DNI) order and Charlson Comorbidity Index (CCI) ≥3 were independent risk factors for in-hospital mortality. CONCLUSIONS: Outside ICU setting, CPAP was used mainly for hypoxemic non-hypercapnic ARF, NPPV for hypercapnic ARF. In-hospital mortality was mainly associated to patients' basal status (DNI status, CCI) rather than the baseline degree of ARF.

A real life evaluation of non invasive ventilation in acute cardiogenic pulmonary edema: a multicenter, perspective, observational study for the ACPE SIMEU study group.

BACKGROUND: During the past three decades conflicting evidences have been published on the use of non-invasive ventilation (NIV) in patients with acute cardiogenic pulmonary edema (ACPE). The aim of this study is to describe the management of acute respiratory failure (ARF) due to ACPE in twelve Italian emergency departments (EDs). We evaluated prevalence, characteristics and outcomes of ACPE patients treated with oxygen therapy, continuous positive airway pressure (CPAP) or Bi-level positive airway pressure (BiPAP) on admission to the EDs. METHODS: In this multicenter, prospective, observational study, consecutive adult patients with ACPE were enrolled in 12 EDs in Italy from May 2009 to December 2013. Three study groups were identified according to the initial respiratory treatment: patients receiving oxygen therapy, those treated with CPAP and those treated with BiPAP. Treatment failure was evaluated as study outcome. RESULTS: We enrolled 1293 patients with acute cardiogenic pulmonary edema. 273 (21%) began with oxygen, 788 (61%) with CPAP and 232 (18%) with BiPAP. One out of four patient who began with oxygen was subsequently switched to NIV and initial treatment with oxygen therapy had an odds ratio for treatment failure of 3.65 (95% CI: 2.55-5.23, p < 0.001). CONCLUSIONS: NIV seems to be the first choice for treatment of ARF due to ACPE, showing high clinical effectiveness and representing a rescue option for patients not improving with conventional oxygen therapy.

Non-invasive mechanical ventilation in patients with diffuse interstitial lung diseases.

BACKGROUND: To evaluate noninvasive ventilation (NIV) in diffuse interstitial lung diseases (DILD) patients with acute respiratory failure (ARF) according to baseline radiological patterns and the etiology of ARF. METHODS: In a multicenter, observational, retrospective study, consecutive DILD patients undergoing NIV because of an episode of ARF were evaluated in six Italian high dependency units. Three groups of patients were identified based on the etiology of ARF: those with pneumonia (Group A), those with acute exacerbation of fibrosis, (Group B) and those with other triggers (Group C). Clinical failure was defined as any among in-hospital mortality, endotracheal intubation and extra-corporeal membrane oxygenation use. RESULTS: Among the 60 patients enrolled (63% males; median age: 71 years), pneumonia (42%) and acute exacerbation of fibrosis (39%) were the two most frequent causes of ARF. A significant increase of PaO2/FiO2 ratio during NIV treatment was detected in Group A (p = 0.010), but not in Group B. No significant difference in PaO2/FiO2 ratio, PaCO2 and pH values during NIV treatment was detected in patients with a radiological pattern of usual interstitial pneumonia (UIP) and non-specific interstitial pneumonia (NSIP). 22 patients (37%) suffered for a clinical failure. No significant differences in the study outcome were detected in Group A vs. Group B, as well as among patients with a radiological pattern of UIP vs. NSIP CONCLUSIONS: NIV treatment should be individualized in DILD patients with ARF according to the etiology, but not the baseline radiological pattern, in order to improve oxygenation.