Severe SARS-CoV-2 Pneumonia and Pneumomediastinum/Pneumothorax: A Prospective Observational Study in an Intermediate Respiratory Care Unit.

INTRODUCTION: The occurrence of pneumomediastinum (PM) and/or pneumothorax (PTX) in patients with severe pneumonia due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was evaluated. METHODS: This was a prospective observational study conducted in patients admitted to the intermediate respiratory care unit (IRCU) of a COVID-19 monographic hospital in Madrid (Spain) between December 14, 2020 and September 28, 2021. All patients had a diagnosis of severe SARS-CoV-2 pneumonia and required noninvasive respiratory support (NIRS): high-flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), and bilevel positive airway pressure (BiPAP). The incidences of PM and/or PTX, overall and by NIRS, and their impact on the probabilities of invasive mechanical ventilation (IMV) and death were studied. RESULTS: A total of 1306 patients were included. 4.3% (56/1306) developed PM/PTX, 3.8% (50/1306) PM, 1.6% (21/1306) PTX, and 1.1% (15/1306) PM + PTX. 16.1% (9/56) of patients with PM/PTX had HFNC alone, while 83.9% (47/56) had HFNC + CPAP/BiPAP. In comparison, 41.7% (521/1250) of patients without PM and PTX had HFNC alone (odds ratio [OR] 0.27; 95% confidence interval [95% CI] 0.13-0.55; p < .001), while 58.3% (729/1250) had HFNC + CPAP/BiPAP (OR 3.73; 95% CI 1.81-7.68; p < .001). The probability of needing IMV among patients with PM/PTX was 67.9% (36/53) (OR 7.46; 95% CI 4.12-13.50; p < .001), while it was 22.1% (262/1185) among patients without PM and PTX. Mortality among patients with PM/PTX was 33.9% (19/56) (OR 4.39; 95% CI 2.45-7.85; p < .001), while it was 10.5% (131/1250) among patients without PM and PTX. CONCLUSIONS: In patients admitted to the IRCU for severe SARS-CoV-2 pneumonia requiring NIRS, incidences of PM/PTX, PM, PTX, and PM + PTX were observed to be 4.3%, 3.8%, 1.6%, and 1.1%, respectively. Most patients with PM/PTX had HFNC + CPAP/BiPAP as the NIRS device, much more frequently than patients without PM and PTX. The probabilities of IMV and death among patients with PM/PTX were 64.3% and 33.9%, respectively, higher than those observed in patients without PM and PTX, which were 21.0% and 10.5%, respectively.

Effect of the Early Combination of Continuous Positive Airway Pressure and High-Flow Nasal Cannula on Mortality and Intubation Rates in Patients With COVID-19 and Acute Respiratory Distress Syndrome. The DUOCOVID Study.

INTRODUCTION: Non invasive respiratory support (NIRS) is useful for treating acute respiratory distress syndrome (ARDS) secondary to COVID-19, mainly in mild-moderate stages. Although continuous positive airway pressure (CPAP) seems superior to other NIRS, prolonged periods of use and poor adaptation may contribute to its failure. The combination of CPAP sessions and high-flow nasal cannula (HFNC) breaks could improve comfort and keep respiratory mechanics stable without reducing the benefits of positive airway pressure (PAP). Our study aimed to determine if HFNC+CPAP initiates early lower mortality and endotracheal intubation (ETI) rates. METHODS: Subjects were admitted to the intermediate respiratory care unit (IRCU) of a COVID-19 monographic hospital between January and September 2021. They were divided according to Early HFNC+CPAP (first 24h, EHC group) and Delayed HFNC+CPAP (after 24h, DHC group). Laboratory data, NIRS parameters, and the ETI and 30-day mortality rates were collected. A multivariate analysis was performed to identify the risk factors associated with these variables. RESULTS: The median age of the 760 included patients was 57 (IQR 47-66), who were mostly male (66.1%). The median Charlson Comorbidity Index was 2 (IQR 1-3) and 46.8% were obese. The median PaO2/FiO2 upon IRCU admission was 95 (IQR 76-126). The ETI rate in the EHC group was 34.5%, with 41.8% for the DHC group (p=0.045), while 30-day mortality was 8.2% and 15.5%, respectively (p=0.002). CONCLUSIONS: Particularly in the first 24h after IRCU admission, the HFNC+CPAP combination was associated with a reduction in the 30-day mortality and ETI rates in patients with ARDS secondary to COVID-19.

Clinical Findings and Outcomes From Subjects With COVID-19 Pneumonia in an Intermediate Respiratory Care Unit.

BACKGROUND: Many patients with COVID-19 require respiratory support and close monitoring. Intermediate respiratory care units (IRCU) may be valuable to optimally and adequately implement noninvasive respiratory support (NRS) to decrease clinical failure. We aimed at describing intubation and mortality in a novel facility entirely dedicated to COVID-19 and to establish their outcomes. METHODS: This was a retrospective, observational study performed at one hospital in Spain. We included consecutive subjects age > 18 y, admitted to IRCU with COVID-19 pneumonia, and requiring NRS between December 2020-September 2021. Data collected included mode and usage of NRS, laboratory findings, endotracheal intubation, and mortality at day 30. A multivariable Cox model was used to assess risk factors associated with clinical failure and mortality. RESULTS: A total of 1,306 subjects were included; 64.6% were male with mean age of 54.7 y. During the IRCU stay, 345 subjects clinically failed NRS (85.5% intubated; 14.5% died). Cox model showed a higher clinical failure in IRCU upon onset of symptoms and hospitalization was < 10 d (hazard ratio [HR] 1.59 [95% CI 1.24-2.03], P < .001) and PaO2 /FIO2 < 100 mm Hg (HR 1.59 [95% CI 1.27-1.98], P < .001). These variables were not associated with increased 30-d mortality. CONCLUSIONS: The IRCU was a valuable option to manage subjects with COVID-19 requiring NRS, thus reducing ICU overload. Male sex, gas exchange, and blood chemistry at admission were associated with worse prognosis, whereas older age, gas exchange, and blood chemistry were associated with 30-d mortality. These findings may provide a basis for better understanding outcomes and to improve management of noninvasively ventilated patients with COVID-19.

El neumomediastino como complicación de la neumonía por SARS-CoV-2 / Pneumomediastinum as a complication of SARS-CoV-2 pneumonia

La incidencia de neumomediastino en los pacientes hospitalizados con diagnóstico de neumonía por coronavirus 2 delsíndrome respiratorio agudo grave (SARS-CoV-2) no es para nada desdeñable, muy superior en comparación con la pobla-ción general. La fisiopatología del neumomediastino en la neumonía por SARS-CoV-2 viene explicada por el aumento delgradiente de presión alveolo-intersticio (accesos de tos seca, trabajo respiratorio, barotrauma por soporte ventilatorio) sobreunos pulmones especialmente «frágiles» debido al daño alveolo-intersticial difuso de origen infeccioso-inflamatorio, todo locual aumenta significativamente el riesgo de rotura de la pared alveolar. Cuanta mayor gravedad revista la neumonía porSARS-CoV-2, más probable será la aparición de neumomediastino. El desarrollo de neumomediastino en pacientes conneumonía por SARS-CoV-2 se asocia a unas frecuencias mayores de exitus letalis, ingreso en unidad de cuidados intensi-vos (UCI) y traqueostomía y a unos tiempos mayores de estancia hospitalaria y en UCI. En la mayoría de los casos, elneumomediastino producido en el seno de la neumonía por SARS-CoV-2 es un proceso benigno y autolimitado que seresuelve con tratamiento conservador.(AU)

The incidence of pneumomediastinum in hospitalised patients diagnosed with SARS-CoV-2 pneumonia is by no means ne-gligible, much higher compared to the general population. The pathophysiology of pneumomediastinum in severe acute res-piratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia is explained by the increase in alveolar-interstitial pressure gradient(dry coughing spells, respiratory work, barotrauma from ventilatory support) in the context of particularly “fragile” lungs due todiffuse alveolar-interstitial damage from infectious-inflammatory origin, all of which significantly increases the risk of alveolarwall rupture. The more severe the SARS-CoV-2 pneumonia, the more likely it is that pneumomediastinum will occur. The deve-lopment of pneumomediastinum in patients with SARS-CoV-2 pneumonia is associated with higher frequencies of death,intensive care unit (ICU) admission and tracheostomy and longer hospital and ICU lengths of stay. In most cases, pneumo-mediastinum in SARS-CoV-2 pneumonia is a benign and self-limiting process that resolves with conservative treatment.(AU)

Clinical characteristics and respiratory care in hospitalized vaccinated SARS-CoV-2 patients.

Background: The main objective of the present study was to analyze both clinical characteristics and evolution during hospitalization of a cohort of patients admitted for COVID-19 pneumonia who were not vaccinated, or with a complete or incomplete vaccination schedule. Methods: This COVID-19 specialized single-center cohort study of 1888 COVID-19 patients hospitalized at the "Enfermera Isabel Zendal" Emergencies Hospital (HEEIZ), Madrid (Spain) was performed between July 1 and September 30, 2021. It compared the results of 1327 hospitalized unvaccinated patients to 209 hospitalized fully vaccinated and 352 hospitalized partially vaccinated patients. The four different COVID-19 vaccines authorized in Spain during the time-period studied were: BNT162b2 (Pfizer); ChAdOx1 nCoV-19 (AstraZeneca), mRNA-1273 (Moderna); Ad26.COV2.S (Janssen). Findings: Hospitalized patients' median age was 41 years (IQR 33-50) for the unvaccinated and 61 years (IQR 53-67) for the fully vaccinated ones. The main comorbidities were obesity, hypertension and diabetes mellitus. 20% of unvaccinated patients (266) required noninvasive respiratory care, as did 14% (51) of partially and 14% (30) of fully vaccinated; 6% (78) of the unvaccinated patients also needed invasive respiratory care, as did 5% (16) of partially and 11 (5%) fully vaccinated. Interpretation: Fully vaccinated patients were 84% (95% CI: 82-86%) less likely to be admitted to hospital, and protection rose for those aged <50 years. Once hospitalized, vaccinated patients displayed more protection against requiring respiratory care than unvaccinated ones, despite being older and having more comorbidities. No differences appeared for the four studied COVID-19 vaccines and complying with vaccination recommendations proved relevant. Funding: The research was funded by the "Plan Propio de Investigación" Program of the Castilla-La Mancha University /European Regional Development Fund (2021-GRIN-31,039).

[Intermediate Respiratory Care Units: Questions and Answers]. / Unidades de Cuidados Respiratorios Intermedios: preguntas y respuestas.

The intermediate respiratory care units (UCRI) are areas of monitoring and specialized care of patients with acute or chronic-exacerbated respiratory failure, whose severity does not require admission to an intensive care unit, but which due to their complexity cannot be treated in conventional hospitalization. Although the COVID-19 pandemic has proven its usefulness in the management of critical respiratory patients, the historical trajectory of the UCRI comes from many years ago, in which its cost-effectiveness has been demonstrated by far. This document presents a series of questions and answers on the history of the UCRI, in addition to the criteria for admission, infrastructure, human and technical resources, and the types of existing Units. Within the UCRI year 2021-2022 designated by the Spanish Society of Pneumology and Thoracic Surgery, any scientific dissemination linked to the in-depth knowledge of these units is timely, where multidisciplinarity and the work of professionals related to the care of critical respiratory patients converge.

Moderate obstructive sleep apnea and cardiovascular outcomes in older adults: a propensity score-matched multicenter study (CPAGE-MODE study).

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) has been associated with cardiovascular events (CVEs), although recent randomized controlled trials have not demonstrated that long-term continuous positive airway pressure (CPAP) prevents CVEs. Our objective was to determine the effect of CPAP on older adults with moderate OSA regarding CVE reduction. METHODS: An observational and multicenter study of a cohort of older adults (> 70 years of age) diagnosed with moderate OSA (apnea-hypopnea index 15.0-29.9 events/h) was conducted. Two groups were formed: (1) CPAP treatment and (2) standard of care. The primary endpoint was CVE occurrence after OSA diagnosis. Association with CPAP treatment was assessed by propensity score matching and inverse weighting probability. Secondary endpoints were incidence of CVE separately and time to first CVE. RESULTS: A total of 614 patients were included. After matching, 236 older adults (111 men, mean age 75.9 ± 4.7 years) with a follow-up of 47 months (interquartile range: 29.6-64.0 months) were considered for primary and secondary endpoint evaluations. Forty-one patients presented at least 1 CVE (17.4%): 20 were in the standard-of-care group (16.9%) and 21 were in the CPAP group (17.8%), with a relative risk of 1.05 (95% confidence interval [CI], 0.60-1.83; P = .43) for CPAP treatment. Inverse probability weighting of the initial 614 patients determined an adjusted relative risk of 1.24 (95% CI, 0.79-1.96; P = .35) for CPAP treatment. No statistical differences were found in secondary endpoint analyses. CONCLUSIONS: CPAP should not be prescribed to reduce CVE probability in older adults with moderate OSA. CITATION: López-Padilla D, Terán-Tinedo J, Cerezo-Lajas A, et al. Moderate obstructive sleep apnea and cardiovascular outcomes in older adults: a propensity score-matched multicenter study (CPAGE-MODE study). J Clin Sleep Med. 2022;18(2):553-561.

Diferencias de género en las publicaciones originales de Archivos de Bronconeumología en el periodo 2001-2018 / Gender Differences in Original Archivos de Bronconeumología Publications, 2001-2018

INTRODUCCIÓN: La desigualdad de género existe en las publicaciones científicas. El objetivo del estudio fue determinar la evolución histórica de las diferencias de género y factores asociados a las posiciones de las autorías de los trabajos originales de Archivos de Bronconeumología (AB). MÉTODOS: Estudio bibliométrico de AB en el periodo 2001-2018. Se analizó el género de las autorías en cuatro escenarios: primera firma, última firma, autorías intermedias y mentorizadas. Se realizaron comparaciones por especialidad firmante, financiación recibida, carácter multicéntirico y área temática, entre otras. Se crearon modelos multivariantes ajustados por el porcentaje de médicas colegiadas en el sistema sanitario español para predecir el género femenino de la primera, intermedia y última firma. RESULTADOS: Se analizaron 828 publicaciones, donde las mujeres figuraron como primeras autoras en 286 (34,5%) y como últimas en 169 (20,4%). Se observó un incremento gradual de mujeres como primeras autoras (p = 0,0001), pero no como últimas firmantes (p = 0,570). En general, la media de autoras mujeres aumentó con el tiempo (1,6 ± 1,4 en 2001-2005 a 3,3 ± 2,3 en 2016-2018, p = 0,0001), sin apreciarse diferencias en las medias de hombres. Los modelos multivariantes ajustados reflejaron una relación bidireccional positiva entre la primera autoría y las intermedias, y una asociación negativa entre que el primer autor haya sido español con una última autoría femenina (OR 0,57; IC95% 0,36-0,88, p = 0,012). CONCLUSIONES: Se encontraron diferencias de género en varios aspectos de las autorías de AB, resumidas en una mayor participación de las mujeres como primeras firmantes e intermedias, pero no como últimas autoras

INTRODUCTION: Gender inequality exists in scientific publications. The aim of this study was to determine changing patterns in gender differences and factors associated with the positioning of authors' names in original articles published in Archivos de Bronconeumología (AB). METHODS: We performed a bibliometric study of articles published in AB between 2001 and 2018. Author gender was analysed in four scenarios: first author, last author, middle authors, and mentee authors. Comparisons were made by authors' specialties, funding received, multicentre studies, specialist areas, and others. Multivariate models adjusted for the percentage of registered physicians in the Spanish health system were created to predict the female gender of the first, middle, and last author. RESULTS: A total of 828 publications were analysed in which women appeared as first authors in 286 (34.5%) and last authors in 169 (20.4%). A gradual increase in women as first authors was observed (P = .0001), but not as last authors (P = .570). Overall, the average number of female authors increased over time (from 1.6 ± 1.4 in 2001-2005 to 3.3 ± 2.3 in 2016-2018, P = .0001), with no differences in male averages. The adjusted multivariate models reflected a positive bi-directional relationship between the first author and the middle authors, and a negative association between the first author being Spanish and the last author being female (OR 0.57; 95% CI 0.36-0.88, P = .012). CONCLUSIONS: Gender differences were found in various aspects of authorship in AB, summarized by a greater participation of women as first and intermediate authors, but not as last authors

Errare humanum est, ¡pero afortunado error / Errare Humanum Est, Though a Lucky Mistake, Indeed

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Gender Differences in Original Archivos de Bronconeumología Publications, 2001-2018. / Diferencias de género en las publicaciones originales de Archivos de Bronconeumología en el periodo 2001-2018.

INTRODUCTION: Gender inequality exists in scientific publications. The aim of this study was to determine changing patterns in gender differences and factors associated with the positioning of authors' names in original articles published in Archivos de Bronconeumología (AB). METHODS: We performed a bibliometric study of articles published in AB between 2001 and 2018. Author gender was analysed in four scenarios: first author, last author, middle authors, and mentee authors. Comparisons were made by authors' specialties, funding received, multicentre studies, specialist areas, and others. Multivariate models adjusted for the percentage of registered physicians in the Spanish health system were created to predict the female gender of the first, middle, and last author. RESULTS: A total of 828 publications were analysed in which women appeared as first authors in 286 (34.5%) and last authors in 169 (20.4%). A gradual increase in women as first authors was observed (P = .0001), but not as last authors (P = .570). Overall, the average number of female authors increased over time (from 1.6 ± 1.4 in 2001-2005 to 3.3 ± 2.3 in 2016-2018, P = .0001), with no differences in male averages. The adjusted multivariate models reflected a positive bi-directional relationship between the first author and the middle authors, and a negative association between the first author being Spanish and the last author being female (OR 0.57; 95% CI 0.36-0.88, P = .012). CONCLUSIONS: Gender differences were found in various aspects of authorship in AB, summarized by a greater participation of women as first and intermediate authors, but not as last authors.

[All Roads Lead to Rome: Results of Non-Invasive Respiratory Therapies Applied in a Tertiary-Care Hospital Without an Intermediate Care Unit During the COVID-19 Pandemic]. / Todos los caminos llevan a Roma: resultados de las terapias respiratorias no invasivas aplicadas en un centro terciario sin Unidad de Cuidados Intermedios durante la pandemia de COVID-19.

Introduction: Non-invasive respiratory therapies (NRT) were widely used in the first wave of the COVID-19 pandemic in different settings, depending on availability. The objective of our study was to present 90-day survival and associated factors in patients treated with NRT in a tertiary hospital without an Intermediate Respiratory Care Unit. The secondary objective was to compare the outcomes of the different therapies. Methods: Observational study of patients treated with NRT outside of an intensive care or intermediate respiratory care unit setting, diagnosed with COVID-19 and acute respiratory distress syndrome by radiological criteria and SpO2/FiO2 ratio. A multivariate logistic regression model was developed to determine independently associated variables, and the outcomes of high flow nasal cannula and continuous positive airway pressure were compared. Results: In total, 107 patients were treated and 85 (79.4%) survived at 90 days. Before starting NRT, the mean SpO2/FiO2 ratio was 119.8 ± 59.4. A higher SOFA score was significantly associated with mortality (OR 2,09; 95% CI 1.34-3.27), while self-pronation was a protective factor (OR 0.23; 95% CI 0.06-0.91). High flow nasal cannula was used in 63 subjects (58.9%), and continuous positive airway pressure in 41 (38.3%), with no differences between them. Conclusion: Approximately 4 out of 5 patients treated with NRT survived to 90 days, and no significant differences were found between high flow nasal cannula and continuous positive airway pressure.