Predictors of mortality and morbidity in critically ill COVID-19 patients: An experience from a low mortality country.

Background and Aims: Clinical characteristics and factors associated with mortality in patients admitted to the intensive care unit (ICU) in countries with low case fatality rates (CFR) are unknown. We sought to determine these in a large cohort of critically ill COVID-19 patients in Qatar and explore the early mortality predictors. Methods: We retrospectively studied the clinical characteristics and outcomes in patients admitted to the ICU at the national referral hospital for COVID-19 patients in Qatar. Logistic regression analysis was used to determine factors associated with mortality. Results: Between March 7 and July 16, 2020, a total of 1079 patients with COVID-19 were admitted to the ICU. The median (IQR) age of patients was 50 (41-59) years. Diabetes (47.3%) and hypertension (42.6%) were the most common comorbidities. In-hospital mortality was 12.6% overall and 25.9% among those requiring mechanical ventilation. Factors independently associated with mortality included older age ([OR]; 2.3 [95% CI; 1.92-2.75] for each 10-year increase in age, p < 0.001), chronic kidney disease (OR; 1.9 [95% CI; 1.02-3.54], p = 0.04), active malignancy (OR; 6.15 [95% CI; 1.79-21.12], p = 0.004), lower platelet count at ICU admission (OR; 1.41 [95% CI; 1.13-1.75] for each 100 × 103/µl decrease, p = 0.002), higher neutrophil-to-lymphocyte ratio at admission (OR; 1.01 [95% CI; 1-1.02] for each 1- point increase, p = 0.016), higher serum ferritin level at admission (OR; 1.05 [(95% CI; 1.02-1.08] for each 500 µg/L increase, p = 0.002), and higher serum bilirubin level at admission (OR; 1.19 [95% CI; 1.04-1.36] for each 10 µmol/L increase, p = 0.01). Conclusions: The mortality rate among critically ill COVID-19 patients is low in Qatar compared to other countries. Older age, chronic kidney disease, active malignancy, higher neutrophil-to-lymphocyte ratios, lower platelet counts, higher serum ferritin levels, and higher serum bilirubin levels are independent predictors of in-hospital mortality.

Tension Pneumomediastinum: A life-threatening condition in patients with COVID-19.

Tension pneumomediastinum (TPM) is a rare but potentially fatal clinical entity. TPM leads to the leakage of air into the mediastinal cavity and increased pressure in thoracic vessels, respiratory tract, and the heart. Herein, this report presents a series of five cases of coronavirus disease-2019 (COVID-19) that caused acute respiratory distress syndrome (ARDS) and TPM. All patients were male who had severe ARDS with a secondary lung infection that required invasive ventilation and had moderate positive-end expiratory pressure. All patients required vasopressors to maintain hemodynamics, and two patients needed decompression with chest drains. One patient received extracorporeal membrane oxygenation therapy. Three patients had cardiac arrest, and two patients died; thus, the mortality rate was 40%. Patients with COVID-19 pneumonia with ARDS required invasive ventilation and prone positioning. Secondary lung infection can cause TPM, and TPM may cause cardiac arrest. Management should be prompt recognition and decompression with the insertion of drains, and conservative treatment is required in stable cases. Protocols for the management of pneumomediastinum and TPM may enable early detection, earlier management, and prevention of TPM.

Spontaneous pneumomediastinum and pneumothorax in COVID-19 patients: A tertiary care experience.

INTRODUCTION: COVID-19 can occasionally complicate into spontaneous pneumothorax (SP) and/or spontaneous pneumomediastinum (SM). This study aims at exploring the occurrence of SP and or SM, risk factors, and outcomes in COVID-19 patients. MATERIALS AND METHODS: All patients with COVID-19, which complicated into SP and/or SM at Hamad Medical Corporation (the principal public healthcare provider in Qatar) from March to September 2020, were retrospectively enrolled. The clinical diagnosis was confirmed by CXR and CT. Between-group comparisons were performed by using Chi-square and t-test. Differences were considered statistically significant at P ≤ .05. RESULTS: A total of 1100 patients were admitted, and 43 patients developed SP, SP + SM, or SM. Most patients were males (42/97.9%), and the most common comorbidity was diabetes mellitus (13/30.2%). All patients had acute respiratory distress syndrome (ARDS), and most patients had low lung compliance at the time of developing SP or SM. Twenty-two of the patients developed SP (51.2%), 11 patients had both SP and SM (25.6%), and 10 patients had SM only (23.3%). There was no significant difference in the development of SP or SM and patients' gender or blood group or whether patients were on invasive or noninvasive ventilation or even the mortality (P > .05). Lung compliance was significantly (P < .05) lower in patients complicated with SP and or SM. Patients with SP required significantly higher (P < .001) chest drain insertion. CONCLUSION: Patients with severe COVID-19 pneumonia can complicate into SP and SM. These complications are more common in male diabetic patients. Patients with ARDS and having low lung compliance are at a higher risk of developing SP, SP + SM, or SM.

Comparison of the clinical outcomes of non-invasive ventilation by helmet vs facemask in patients with acute respiratory distress syndrome.

ABSTRACT: The main aim of this study is to compare the use of non-invasive ventilation (NIV) via helmet versus face mask where different interfaces and masks can apply NIV. However, some of the limitations of the NIV face mask were air leak, face mask intolerance, and requirement of high positive end expiratory pressure, which could be resolved with the use of the helmet NIV. NIV facemask will be applied as per the facial contour of the patient. NIV helmet is a transparent hood and size will be measured as per the head size. Both groups will have a standard protocol for titration of NIV.Patients aged more than 18 years old and diagnosed with acute respiratory distress syndrome as per Berlin definition will be enrolled in the study after signing the informed consent. Subjects who met the inclusion criteria will receive 1 of the 2 interventions; blood gases, oxygenation status [Po2/Fio2] will be monitored in both groups. The time of intubation will be the main comparison factor among the 2 groups. The primary and secondary outcomes will be measured by the number of patients requiring endotracheal intubation after application of helmet device, Improvement of oxygenation defined as PaO2/FiO2 ≥ 200 or increase from baseline by 100, duration of mechanical ventilation via an endotracheal tube, intensive care unit length of stay, death from any cause during hospitalization at the time of enrolment, need for proning during the hospital stay, intensive care unit mortality, and the degree to which overt adverse effects of a drug can be tolerated by a patient including feeding tolerance. TRIAL REGISTRATION NUMBER: NCT04507802. PROTOCOL VERSION: May 2020.