A Prospective Cohort Study (OUTSTRIP-COVID) on Functional and Spirometry Outcomes in COVID-19 ICU Survivors at 3 Months.

Purpose: COVID-19 pandemic resulted in a significant number of critical care admissions secondary to severe pneumonia and acute respiratory distress syndrome. We evaluated the short-, medium- and long-term outcomes of lung function and quality of life in this prospective cohort study and reported the outcomes at 7 weeks and 3 months from discharge from intensive care unit. Methods: A prospective cohort study of ICU survivors with COVID-19 was conducted from August 2020 to May 2021 to evaluate baseline demographic and clinical variables as well as determine lung function, exercise capacity, and health-related quality of life (HRQOL) using spirometry and 6-minute walk test (6MWT) conducted in accordance with American Thoracic Society standards, and SF-36 (Rand), respectively. SF-36 is a generic 36 question standardized health survey. Descriptive and inferential statistics (alpha = 0.05) were used to analyse the data. Results: At baseline, 100 participants were enrolled in the study of whom 76 followed up at 3 months. Majority of the patients were male (83%), Asians (84%) and less than 60 years of age (91%). HRQOL showed significant improvement in all domains of SF-36, except in emotional wellbeing. Spirometry variables also showed significant improvement in all variables over time with greatest improvement in percentage predicted Forced expiratory volume 1 (79% vs 88% p < 0.001). 6MWT showed significant improvement in variables of walk distance, dyspnea, and fatigue with greatest improvement in change in oxygen saturation (3% vs 1.44% p < 0.001). Intubation status did not impact the changes in SF-36, spirometry or 6MWT variables. Conclusion: Our findings suggest that ICU survivors of COVID-19 have significant improvement in their lung function, exercise capacity and HRQOL within 3 months of ICU discharge regardless of intubation status.

Clinical outcomes of intravenous immunoglobulin therapy in COVID-19 related acute respiratory distress syndrome: a retrospective cohort study.

BACKGROUND: Intravenous immunoglobulin (IVIG) has been used as an immunomodulatory therapy to counteract severe systemic inflammation in coronavirus disease 2019 (COVID-19). But its use in COVID-19 related acute respiratory distress syndrome (ARDS) is not well established. METHODS: We conducted a retrospective analysis of electronic health records of COVID-19 patients admitted to intensive care units (ICUs) at Hazm Mebaireek General Hospital, Qatar, between March 7, 2020 and September 9, 2020. Patients receiving invasive mechanical ventilation for moderate-to-severe ARDS were divided into two groups based on whether they received IVIG therapy or not. The primary outcome was all-cause ICU mortality. Secondary outcomes studied were ventilator-free days and ICU-free days at day-28, and incidence of acute kidney injury (AKI). Propensity score matching was used to adjust for confounders, and the primary outcome was compared using competing-risks survival analysis. RESULTS: Among 590 patients included in the study, 400 received routine care, and 190 received IVIG therapy in addition to routine care. One hundred eighteen pairs were created after propensity score matching with no statistically significant differences between the groups. Overall ICU mortality in the study population was 27.1%, and in the matched cohort, it was 25.8%. Mortality was higher among IVIG-treated patients (36.4% vs. 15.3%; sHR 3.5; 95% CI 1.98-6.19; P < 0.001). Ventilator-free days and ICU-free days at day-28 were lower (P < 0.001 for both), and incidence of AKI was significantly higher (85.6% vs. 67.8%; P = 0.001) in the IVIG group. CONCLUSION: IVIG therapy in mechanically ventilated patients with COVID-19 related moderate-to-severe ARDS was associated with higher ICU mortality. A randomized clinical trial is needed to confirm this observation further.

Hypercapnic respiratory failure during pregnancy due to polymyositis-related respiratory muscle weakness: a case report.

BACKGROUND: Polymyositis is a rare medical disorder complicating pregnancy. Ventilatory muscle weakness leading to respiratory failure is an uncommon manifestation of this autoimmune disease. We report a case of life-threatening hypercapnic respiratory failure due to polymyositis-related respiratory muscle weakness in a pregnant woman. CASE PRESENTATION: A 31-year-old, African woman in her second trimester of pregnancy presented to the emergency department with fever, shortness of breath and muscle weakness. Initial investigations excluded pulmonary infection, thromboembolism, and cardiac dysfunction as the underlying cause of her symptoms. She developed deterioration in her level of consciousness due to carbon dioxide narcosis requiring invasive mechanical ventilation. Further workup revealed markedly elevated serum creatine kinase, abnormal electromyography and edema of her thigh muscles on magnetic resonance imaging. Diagnosis of polymyositis was confirmed by muscle biopsy. After receiving pulse steroid, intravenous immunoglobulins, and maintenance immunosuppressive therapy, our patient's respiratory muscle function improved and she was weaned off mechanical ventilation. Despite good maternal recovery from critical illness, the fetus developed intrauterine growth retardation and distress necessitating emergency cesarian section. CONCLUSIONS: New-onset polymyositis during pregnancy presenting with respiratory failure is rare. Early diagnosis and prompt initiation of therapy is necessary to improve fetal and maternal outcomes.

Somatic survival and organ donation among brain-dead patients in the state of Qatar.

BACKGROUND: The Qatari law, as in many other countries, uses brain death as the main criteria for organ donation and cessation of medical support. By contrast, most of the public in Qatar do not agree with the limitation or withdrawal of medical care until the time of cardiac death. The current study aims to examine the duration of somatic survival after brain death, organ donation rate in brain-dead patients as well as review the underlying etiologies and level of support provided in the state of Qatar. METHODS: This is a retrospective study of all patients diagnosed with brain death over a 10-year period conducted at the largest tertiary center in Qatar (Hamad General Hospital). RESULTS: Among the 53 patients who were diagnosed with brain death during the study period, the median and mean somatic survivals of brain-dead patients in the current study were 3 and 4.5 days respectively. The most common etiology was intracranial hemorrhage (45.3 %) followed by ischemic stroke (17 %). Ischemic stroke patients had a median survival of 11 days. Organ donation was accepted by only two families (6.6 %) of the 30 brain dead patients deemed suitable for organ donation. CONCLUSION: The average somatic survival of brain-dead patients is less than one week irrespective of supportive measures provided. Organ donation rate was extremely low among brain-dead patients in Qatar. Improved public education may lead to significant improvement in resource utilization as well as organ transplant donors and should be a major target area of future health care policies.

Epidemiology and Outcome of Ventilator-Associated Pneumonia in a Heterogeneous ICU Population in Qatar.

Objective. The purpose of this study is to collect data on epidemiology, microbiology, and outcome of VAP in our ICUs for reevaluation of the therapeutic strategies. Methods. This retrospective study involved all adult patients, 15 years of age or older, diagnosed with VAP in multidisciplinary ICUs at Hamad General Hospital between January 2010 and December 2012. Results. A total of 106 patients were enrolled. The mean incidence of VAP was 5.0 per 1000 ventilator-days. It was predominant among younger age group (<60 years), male patients (80.2%), and trauma ICU admissions (49.0%). The most common comorbidity was hypertension (34%) and polytrauma (36.8%) was the most frequent admission diagnosis. 30-day mortality was 23.6% and it was significantly higher in ≥60 years age group, female gender, patients with diabetes mellitus, hypertension, chronic respiratory disease, ≥1 comorbidity, and poor functional status, smokers, medical and surgical ICU admissions, and patients with previous stay in medical/surgical wards, inappropriate empirical therapy, and admission diagnosis of respiratory failure. Gram-negative bacilli were the most frequent respiratory specimen isolates, Pseudomonas spp. being the most common. Majority of our Acinetobacter isolates were multidrug resistant. Conclusion. The incidence of VAP in our ICUs was low. Higher mortality rates were observed in certain subgroup of patients. Resistance to commonly used antimicrobials is likely to require reevaluation of the therapeutic strategies at our institution.

Extra corporeal membrane oxygenation to facilitate lung protective ventilation and prevent ventilator-induced lung injury in severe Pneumocystis pneumonia with pneumomediastinum: a case report and short literature review.

BACKGROUND: Pulmonary infections caused by Pneumocystis jirovecii in immunocompromised host can be associated with cysts, pneumatoceles and air leaks that can progress to pneumomediastinum and pneumothoraxes. In such cases, it can be challenging to maintain adequate gas exchange by conventional mechanical ventilation and at the same time prevent further ventilator-induced lung injury. We report a young HIV positive male with poorly compliant lungs and pneumomediastinum secondary to severe Pneumocystis infection, rescued with veno-venous extra corporeal membrane oxygenation (V-V ECMO). CASE PRESENTATION: A 26 year old male with no significant past medical history was admitted with fever, cough and shortness of breath. He initially required non-invasive ventilation for respiratory failure. However, his respiratory function progressively deteriorated due to increasing pulmonary infiltrates and development of pneumomediastinum, eventually requiring endotracheal intubation and invasive ventilation. Despite attempts at optimizing gas exchange by ventilatory maneuvers, patients' pulmonary parameters worsened necessitating rescue ECMO therapy. The introduction of V-V ECMO facilitated the use of ultra-protective lung ventilation and prevented progression of pneumomediastinum, maintaining optimal gas exchange. It allowed time for the antibiotics to show effect and pulmonary parenchyma to heal. Further diagnostic workup revealed Pneumocystis jirovecii as the causative organism for pneumonia and serology confirmed Human Immunodeficiency Virus infection. Patient was successfully treated with appropriate antimicrobials and de-cannulated after six days of ECMO support. CONCLUSION: ECMO was an effective salvage therapy in HIV positive patient with an otherwise fatal respiratory failure due to Pneumocystis pneumonia and air leak syndrome.