RESUMEN
Background: Obesity is now well recognised as a risk factor for severe COVID-19, but the true prevalence of obesity in hospitalised adults with COVID-19 remains unclear because formal body mass indices (BMIs) are not routinely measured on admission. Objectives: To describe the true prevalence of obesity measured by the BMI, and associated comorbidities, in patients hospitalised with severe COVID-19, including people with HIV (PWH). Methods: We conducted a point-prevalence study of measured BMI in consecutive patients with severe COVID-19 admitted to the medical COVID-19 wards in a tertiary academic hospital in Cape Town, South Africa (SA). Patients were enrolled over a 2-week period during the peak of the first COVID-19 wave in SA. Results: We were able to measure the BMI in 122 of the 146 patients admitted during the study period. The prevalence of HIV was 20% (n=24/122). Most of the participants were overweight or obese (n=104; 85%), and 84 (68.9%) met criteria for obesity. The mean (standard deviation) BMI was 33 (7.5), and 34.5 (9.1) in PWH. Of PWH, 83% (n=20/24) were overweight or obese and 75% (n=18) met criteria for obesity. Multimorbidity was present in 22 (92%) of PWH. Conclusion: We found that most patients, including PWH, met criteria for being overweight or obese. The high prevalence of obesity in PWH and severe COVID-19 reinforces the need for targeted management of non-communicable diseases, including obesity, in PWH. Study synopsis: What the study adds. We found that the true prevalence of obesity, including in people with HIV (PWH), measured with the formal body mass index in hospitalised patients with severe COVID-19 was much higher than reported previously.Multimorbidity was present in over half of all patients, and in 92% of PWH. Implications of the findings. Urgent public health measures are required to tackle the rise in obesity, including in low- and middle-income countries.HIV care must integrate management of non-communicable diseases, including obesity.The pathogenic mechanism of the link between obesity and severe COVID-19 needs further research.
RESUMEN
The recent pandemic has seen unprecedented demand for respiratory support of patients with COVID-19 pneumonia, stretching services and clinicians. Yet despite the global numbers of patients treated, guidance is not clear on the correct choice of modality or the timing of escalation of therapy for an individual patient. This narrative review assesses the available literature on the best use of different modalities of respiratory support for an individual patient, and discusses benefits and risks of each, coupled with practical advice to improve outcomes. On current data, in an ideal context, it appears that as disease severity worsens, conventional oxygen therapy is not sufficient alone. In more severe disease, i.e. PaO2/FiO2 ratios below approximately 200, helmet-CPAP (continuous positive airway pressure) (although not widely available) may be superior to high-flow nasal cannula (HFNC) therapy or facemask non-invasive ventilation (NIV)/CPAP, and that facemask NIV/CPAP may be superior to HFNC, but with noted important complications, including risk of pneumothoraces. In an ideal context, invasive mechanical ventilation should not be delayed where indicated and available. Vitally, the choice of respiratory support should not be prescriptive but contextualised to each setting, as supply and demand of resources vary markedly between institutions. Over time, institutions should develop clear policies to guide clinicians before demand exceeds supply, and should frequently review best practice as evidence matures.
