Respiratory Support Techniques for COVID-19-Related ARDS in a Sub-Saharan African Country: A Multicenter Observational Study.

BACKGROUND: Limited data from low-income countries report on respiratory support techniques in COVID-19-associated ARDS. RESEARCH QUESTION: Which respiratory support techniques are used in patients with COVID-19-associated ARDS in Uganda? STUDY DESIGN AND METHODS: A multicenter, prospective, observational study was conducted at 13 Ugandan hospitals during the pandemic and included adults with COVID-19-associated ARDS. Patient characteristics, clinical and laboratory data, initial and most advanced respiratory support techniques, and 28-day mortality were recorded. Standard tests, log-rank tests, and logistic regression analyses were used for statistical analyses. RESULTS: Four hundred ninety-nine patients with COVID-19-associated ARDS (mild, n = 137; moderate, n = 247; and severe, n = 115) were included (ICU admission, 38.9%). Standard oxygen therapy (SOX), high-flow nasal oxygen (HFNO), CPAP, noninvasive ventilation (NIV), and invasive mechanical ventilation (IMV) was used as the first-line (most advanced) respiratory support technique in 37.3% (35.3%), 10% (9.4%), 11.6% (4.8%), 23.4% (14.4%), and 17.6% (36.6%) of patients, respectively. The first-line respiratory support technique was escalated in 19.8% of patients. Twenty-eight-day mortality was 51.9% (mild ARDS, 13.1%; moderate ARDS, 62.3%; severe ARDS, 75.7%; P < .001) and was associated with respiratory support techniques as follows: SOX, 19.9%; HFNO, 31.9%; CPAP, 58.3%; NIV 61.1%; and IMV, 83.9% (P < .001). Proning was used in 79 patients (15.8%; 59 of 79 awake) and was associated with lower mortality (40.5% vs 54%; P = .03). The oxygen saturation to Fio2 ratio (OR, 0.99; 95% CI, 0.98-0.99; P < .001) and respiratory rate (OR, 1.07; 95% CI, 1.03-1.12; P = .002) at admission and NIV (OR, 6.31; 95% CI, 2.29-17.37; P < .001) or IMV (OR, 8.08; 95% CI, 3.52-18.57; P < .001) use were independent risk factors for death. INTERPRETATION: SOX, HFNO, CPAP, NIV, and IMV were used as respiratory support techniques in patients with COVID-19-associated ARDS in Uganda. Although these data are observational, they suggest that the use of SOX and HFNO therapy as well as awake proning are associated with a lower mortality resulting from COVID-19-associated ARDS in a resource-limited setting.

Association between CD4 T cell counts and the immune status among adult critically ill HIV-negative patients in intensive care units in Uganda.

Background: Cluster of differentiation 4 (CD4) T cells play a central role in regulation of adaptive T cell-mediated immune responses. Low CD4 T cell counts are not routinely reported as a marker of immune deficiency among HIV-negative individuals, as is the norm among their HIV positive counterparts. Despite evidence of mortality rates as high as 40% among Ugandan critically ill HIV-negative patients, the use of CD4 T cell counts as a measure of the immune status has never been explored among this population. This study assessed the immune status of adult critically ill HIV-negative patients admitted to Ugandan intensive care units (ICUs) using CD4 T cell count as a surrogate marker. Methods: A multicentre prospective cohort was conducted between 1st August 2017 and 1st March 2018 at four Ugandan ICUs. A total of 130 critically ill HIV negative patients were consecutively enrolled into the study. Data on sociodemographics, clinical characteristics, critical illness scores, CD4 T cell counts were obtained at baseline and mortality at day 28. Results: The mean age of patients was 45± 18 years (mean±SD) and majority (60.8%) were male. After a 28-day follow up, 71 [54.6%, 95% CI (45.9-63.3)] were found to have CD4 counts less than 500 cells/mm³, which were not found to be significantly associated with mortality at day 28, OR (95%) 1 (0.4-2.4), p = 0.093. CD4 cell count receiver operator characteristic curve (ROC) area was 0.5195, comparable to APACHE II ROC area 0.5426 for predicting 24-hour mortality. Conclusions: CD4 T cell counts were generally low among HIV-negative critically ill patients. Low CD4 T cells did not predict ICU mortality at day 28. CD4 T cell counts were not found to be inferior to APACHE II score in predicting 24 hour ICU mortality.