Physiological and quantitative CT-scan characterization of COVID-19 and typical ARDS: a matched cohort study

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Abstract

Purpose

To investigate whether COVID-19-ARDS differs from all-cause ARDS.

Methods

Thirty-two consecutive, mechanically ventilated COVID-19-ARDS patients were compared to two historical ARDS sub-populations 1:1 matched for PaO ₂/FiO ₂ or for compliance of the respiratory system. Gas exchange, hemodynamics and respiratory mechanics were recorded at 5 and 15 cmH ₂O PEEP. CT scan variables were measured at 5 cmH ₂O PEEP.

Results

Anthropometric characteristics were similar in COVID-19-ARDS, PaO ₂/FiO ₂-matched-ARDS and Compliance-matched-ARDS. The PaO ₂/FiO ₂-matched-ARDS and COVID-19-ARDS populations (both with PaO ₂/FiO ₂ 106 ± 59 mmHg) had different respiratory system compliances (Crs) (39 ± 11 vs 49.9 ± 15.4 ml/cmH ₂O, p = 0.03). The Compliance-matched-ARDS and COVID-19-ARDS had similar Crs (50.1 ± 15.7 and 49.9 ± 15.4 ml/cmH ₂O, respectively) but significantly lower PaO ₂/FiO ₂ for the same Crs (160 ± 62 vs 106.5 ± 59.6 mmHg, p < 0.001). The three populations had similar lung weights but COVID-19-ARDS had significantly higher lung gas volume (PaO ₂/FiO ₂-matched-ARDS 930 ± 644 ml, COVID-19-ARDS 1670 ± 791 ml and Compliance-matched-ARDS 1301 ± 627 ml, p < 0.05). The venous admixture was significantly related to the non-aerated tissue in PaO ₂/FiO ₂-matched-ARDS and Compliance-matched-ARDS ( p < 0.001) but unrelated in COVID-19-ARDS ( p = 0.75), suggesting that hypoxemia was not only due to the extent of non-aerated tissue. Increasing PEEP from 5 to 15 cmH ₂O improved oxygenation in all groups. However, while lung mechanics and dead space improved in PaO ₂/FiO ₂-matched-ARDS, suggesting recruitment as primary mechanism, they remained unmodified or worsened in COVID-19-ARDS and Compliance-matched-ARDS, suggesting lower recruitment potential and/or blood flow redistribution.

Conclusions

COVID-19-ARDS is a subset of ARDS characterized overall by higher compliance and lung gas volume for a given PaO ₂/FiO ₂, at least when considered within the timeframe of our study.

Electronic supplementary material

The online version of this article (10.1007/s00134-020-06281-2) contains supplementary material, which is available to authorized users.

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Most cited references 36

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Pulmonary Vascular Endothelialitis, Thrombosis, and Angiogenesis in Covid-19

Maximilian Ackermann, Stijn Verleden, Mark Kuehnel … (2020)

Progressive respiratory failure is the primary cause of death in the coronavirus disease 2019 (Covid-19) pandemic. Despite widespread interest in the pathophysiology of the disease, relatively little is known about the associated morphologic and molecular changes in the peripheral lung of patients who die from Covid-19.

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Acute respiratory distress syndrome: the Berlin Definition.

V Ranieri, Gordon D Rubenfeld, B Taylor Thompson … (2013)

The acute respiratory distress syndrome (ARDS) was defined in 1994 by the American-European Consensus Conference (AECC); since then, issues regarding the reliability and validity of this definition have emerged. Using a consensus process, a panel of experts convened in 2011 (an initiative of the European Society of Intensive Care Medicine endorsed by the American Thoracic Society and the Society of Critical Care Medicine) developed the Berlin Definition, focusing on feasibility, reliability, validity, and objective evaluation of its performance. A draft definition proposed 3 mutually exclusive categories of ARDS based on degree of hypoxemia: mild (200 mm Hg < PaO2/FIO2 ≤ 300 mm Hg), moderate (100 mm Hg < PaO2/FIO2 ≤ 200 mm Hg), and severe (PaO2/FIO2 ≤ 100 mm Hg) and 4 ancillary variables for severe ARDS: radiographic severity, respiratory system compliance (≤40 mL/cm H2O), positive end-expiratory pressure (≥10 cm H2O), and corrected expired volume per minute (≥10 L/min). The draft Berlin Definition was empirically evaluated using patient-level meta-analysis of 4188 patients with ARDS from 4 multicenter clinical data sets and 269 patients with ARDS from 3 single-center data sets containing physiologic information. The 4 ancillary variables did not contribute to the predictive validity of severe ARDS for mortality and were removed from the definition. Using the Berlin Definition, stages of mild, moderate, and severe ARDS were associated with increased mortality (27%; 95% CI, 24%-30%; 32%; 95% CI, 29%-34%; and 45%; 95% CI, 42%-48%, respectively; P < .001) and increased median duration of mechanical ventilation in survivors (5 days; interquartile [IQR], 2-11; 7 days; IQR, 4-14; and 9 days; IQR, 5-17, respectively; P < .001). Compared with the AECC definition, the final Berlin Definition had better predictive validity for mortality, with an area under the receiver operating curve of 0.577 (95% CI, 0.561-0.593) vs 0.536 (95% CI, 0.520-0.553; P < .001). This updated and revised Berlin Definition for ARDS addresses a number of the limitations of the AECC definition. The approach of combining consensus discussions with empirical evaluation may serve as a model to create more accurate, evidence-based, critical illness syndrome definitions and to better inform clinical care, research, and health services planning.

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Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: a descriptive study

Heshui Shi, Xiaoyu Han, Nanchuan Jiang … (2020)

Summary Background A cluster of patients with coronavirus disease 2019 (COVID-19) pneumonia caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were successively reported in Wuhan, China. We aimed to describe the CT findings across different timepoints throughout the disease course. Methods Patients with COVID-19 pneumonia (confirmed by next-generation sequencing or RT-PCR) who were admitted to one of two hospitals in Wuhan and who underwent serial chest CT scans were retrospectively enrolled. Patients were grouped on the basis of the interval between symptom onset and the first CT scan: group 1 (subclinical patients; scans done before symptom onset), group 2 (scans done ≤1 week after symptom onset), group 3 (>1 week to 2 weeks), and group 4 (>2 weeks to 3 weeks). Imaging features and their distribution were analysed and compared across the four groups. Findings 81 patients admitted to hospital between Dec 20, 2019, and Jan 23, 2020, were retrospectively enrolled. The cohort included 42 (52%) men and 39 (48%) women, and the mean age was 49·5 years (SD 11·0). The mean number of involved lung segments was 10·5 (SD 6·4) overall, 2·8 (3·3) in group 1, 11·1 (5·4) in group 2, 13·0 (5·7) in group 3, and 12·1 (5·9) in group 4. The predominant pattern of abnormality observed was bilateral (64 [79%] patients), peripheral (44 [54%]), ill-defined (66 [81%]), and ground-glass opacification (53 [65%]), mainly involving the right lower lobes (225 [27%] of 849 affected segments). In group 1 (n=15), the predominant pattern was unilateral (nine [60%]) and multifocal (eight [53%]) ground-glass opacities (14 [93%]). Lesions quickly evolved to bilateral (19 [90%]), diffuse (11 [52%]) ground-glass opacity predominance (17 [81%]) in group 2 (n=21). Thereafter, the prevalence of ground-glass opacities continued to decrease (17 [57%] of 30 patients in group 3, and five [33%] of 15 in group 4), and consolidation and mixed patterns became more frequent (12 [40%] in group 3, eight [53%] in group 4). Interpretation COVID-19 pneumonia manifests with chest CT imaging abnormalities, even in asymptomatic patients, with rapid evolution from focal unilateral to diffuse bilateral ground-glass opacities that progressed to or co-existed with consolidations within 1–3 weeks. Combining assessment of imaging features with clinical and laboratory findings could facilitate early diagnosis of COVID-19 pneumonia. Funding None.

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Author and article information

Contributors

Luciano Gattinoni:

ORCID: http://orcid.org/0000-0001-5380-2494

gattinoniluciano@gmail.com

Journal

Journal ID (nlm-ta): Intensive Care Med

Journal ID (iso-abbrev): Intensive Care Med

Title: Intensive Care Medicine

Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )

ISSN (Print): 0342-4642

ISSN (Electronic): 1432-1238

Publication date (Electronic): 21 October 2020

Publication date PMC-release: 21 October 2020

Pages: 1-10

Affiliations

[1 ]GRID grid.4708.b, ISNI 0000 0004 1757 2822, Department of Anesthesiology and Intensive Care, ASST Santi e Paolo Hospital, , University of Milan, ; Milan, Italy

[2 ]GRID grid.7450.6, ISNI 0000 0001 2364 4210, Department of Anesthesiology, Intensive Care and Emergency Medicine, , Medical University of Göttingen, ; Robert-Koch Straße 40, Göttingen, Germany

[3 ]GRID grid.415025.7, ISNI 0000 0004 1756 8604, Department of Radiology, , San Gerardo Hospital, ; Monza, Italy

[4 ]GRID grid.420545.2, Department of Adult Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, , Health Centre for Human and Applied Physiological Sciences, ; London, UK

[5 ]GRID grid.17635.36, ISNI 0000000419368657, Department of Pulmonary and Critical Care Medicine, , University of Minnesota and Regions Hospital, ; St. Paul, Minnesota USA

Author information

Luciano Gattinoni http://orcid.org/0000-0001-5380-2494

Article

Publisher ID: 6281

DOI: 10.1007/s00134-020-06281-2

PMC ID: 7577365

PubMed ID: 33089348

SO-VID: 353a7a29-f46c-4066-98c8-a43278c3d032

License:

Open AccessThis article is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, which permits any non-commercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc/4.0/.

History

Date received : 7 September 2020

Date accepted : 5 October 2020

Funding

Funded by: Georg-August-Universität Göttingen (1018)

Open Access :

Open Access funding enabled and organized by Projekt DEAL.

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Physiological and quantitative CT-scan characterization of COVID-19 and typical ARDS: a matched cohort study

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Abstract

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Electronic supplementary material

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Novel Coronavirus Disease COVID-19

Most cited references 36

Pulmonary Vascular Endothelialitis, Thrombosis, and Angiogenesis in Covid-19

Acute respiratory distress syndrome: the Berlin Definition.

Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: a descriptive study

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Cited by 116

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