[Prognostic factors in an individualised approach to non-pharmacological therapy of COVID-19: from oxygen and mechanical ventilation to extracorporeal membrane oxygenation]. / Prognostische Faktoren bei einem schrittweisen Ansatz zur nicht-pharmakologischen Therapie von Sauerstoff und mechanischer Beatmung bis hin zur extrakorporalen Membranoxygenierung bei COVID-19.

BACKGROUND: Our centre followed a stepwise approach in the nonpharmacological treatment of respiratory failure in COVID-19 in accordance with German national guidelines, escalating non-invasive measures before invasive mechanical ventilation (IMV) or extracorporeal membrane oxygenation (ECMO). The aim of this study was to analyse this individualized approach to non-pharmacologic therapy in terms of patient characteristics and clinical features that may help predict more severe disease, particularly the need for intensive care. METHOD: This retrospective single-centre study of COVID-19 inpatients between March 2020 and December 2021 analysed anthropometric data, non-pharmacological maximum therapy and survival status via a manual medical file review. RESULTS: Of 1052 COVID-19-related admissions, 835 patients were included in the analysis cohort (54% male, median 58 years); 34% (n=284) received no therapy, 40% (n=337) conventional oxygen therapy (COT), 3% (n=22) high flow nasal cannula (NHFC), 9% (n=73) continuous positive airway pressure (CPAP), 7% (n=56) non-invasive ventilation (NIV), 4% (n=34) intermittent mandatory ventilation (IMV), and 3% (n=29) extracorporeal membrane oxygenation (ECMO). Of 551 patients treated with at least COT, 12.3% required intubation. A total of 183 patients required ICU treatment, and 106 (13%) died. 25 (74%) IMV patients and 23 (79%) ECMO patients died. Arterial hypertension, diabetes and dyslipidemia was more prevalent in non-survivors. Binary logistic analysis revealed the following risk factors for increased mortality: an oxygen supplementation of ≥2 L/min at baseline (OR 6.96 [4.01-12.08]), age (OR 1.09 [1.05-1.14]), and male sex (OR 2.23 [0.79-6.31]). CONCLUSION: The physician's immediate clinical decision to provide oxygen therapy, along with other recognized risk factors, plays an important role in predicting the severity of the disease course and thus aiding in the management of COVID-19.

Analysis of an Individualised Stepwise Approach to Non-Pharmacological Therapy in COVID-19.

BACKGROUND: Early intubation versus use of conventional or high-flow nasal cannula oxygen therapy (COT/HFNC), continuous positive airway pressure (CPAP), and non-invasive ventilation (NIV) has been debated throughout the COVID-19 pandemic. Our centre followed a stepwise approach, in concordance with German national guidelines, escalating non-invasive modalities prior to invasive mechanical ventilation (IMV) or extracorporeal membrane oxygenation (ECMO), rather than early or late intubation. OBJECTIVES: The aims of the study were to investigate the real-life usage of these modalities and analyse patient characteristics and survival. METHOD: A retrospective monocentric observation was conducted of all consecutive COVID-19 hospital admissions between March 2020 and December 2021 at a university-affiliated pulmonary centre in Germany. Anthropometric data, therapy, and survival status were descriptively analysed. RESULTS: From 1,052 COVID-19-related admissions, 835 patients were included (54% male, median 58 years). Maximum therapy was as follows: 34% (n = 284) no therapy, 40% (n = 337) COT, 3% (n = 22) HFNC, 9% (n = 73) CPAP, 7% (n = 56) NIV, 4% (n = 34) IMV, and 3% (n = 29) ECMO. Of 551 patients treated with at least COT, 12.3% required intubation. Overall, 183 patients required intensive unit care, and 106 (13%) died. Of the 68 patients who received IMV/ECMO, 48 died (74%). The strategy for non-pharmacological therapy was individual but remained consistent throughout the studied period. CONCLUSIONS: This study provides valuable insight into COVID-19 care in Germany and shows how the majority of patients could be treated with the maximum treatment required according to disease severity following the national algorithm. Escalation of therapy modality is interlinked with disease severity and thus associated with mortality.

Successful weaning and decannulation after interventional bronchoscopic recanalization of tracheal stenosis.

PURPOSE: Early posttracheostomy tracheal stenosis (PTTS) may cause weaning and decannulation failure. Although bronchoscopic recanalization offers an effective treatment, it is not known how successfully patients can be weaned and decannulated after recanalization. The aims of this study were to determine the incidence of PTTS in a modern weaning center and to elucidate the benefit of interventional recanalization in terms of weaning and decannulation success. MATERIALS AND METHODS: A total of 722 patients admitted within a 24-month period were examined. Patients' baseline characteristics, incidence of weaning and decannulation failure, incidence of PTTS, and rate of postinterventional weaning and decannulation success were determined. RESULTS: Of 722 patients, 450 were deemed suitable for weaning from invasive ventilation. Two hundred eighty-eight patients showed initial weaning and decannulation failure, and 14 of these 288 patients (4.9%) were found to have a PTTS. Recanalization was performed in all cases without procedure-associated complications. Ten (71%) of 14 patients could be successfully weaned and decannulated. Seven of these 10 patients were discharged, 3 patients died during the hospital stay, and 4 (29%) of 14 patients could not be weaned. CONCLUSIONS: Posttracheostomy tracheal stenosis remains a relevant cause of weaning and decannulation failure. Bronchoscopic recanalization is safe and facilitates weaning and successful decannulation in about half of the cases.

An emboligenic pulmonary abscess leading to ischemic stroke and secondary brain abscess.

BACKGROUND: Ischemic stroke by septic embolism occurs primarily in the context of infective endocarditis or in patients with a right-to-left shunt and formation of a secondary cerebral abscess is a rare event. Erosion of pulmonary veins by a pulmonary abscess can lead to transcardiac septic embolism but to our knowledge no case of septic embolic ischemic stroke from a pulmonary abscess with secondary transformation into a brain abscess has been reported to date. CASE PRESENTATION: We report the case of a patient with a pulmonary abscess causing a septic embolic cerebral infarction which then transformed into a cerebral abscess. After antibiotic therapy and drainage of the abscess the patient could be rehabilitated and presented an impressive improvement of symptoms. CONCLUSION: Septic embolism should be considered as cause of ischemic stroke in patients with pulmonary abscess and can be followed by formation of a secondary cerebral abscess. Early antibiotic treatment and repeated cranial CT-scans for detection of a secondary abscess should be performed.