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      Proning reduces ventilation heterogeneity in patients with elevated BMI: implications for COVID-19 pneumonia management?

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          Abstract

          Coronavirus disease 2019 (COVID-19) is caused by a novel zoonotic coronavirus known as severe acute respiratory syndrome coronavirus 2 and has been identified as a pandemic by the World Health Organization (WHO) [1]. Several risk factors have been identified for severe COVID-19-associated pneumonia, with obesity identified as a significant and independent risk factor for death [2].

          Abstract

          Simulations of patient-based lungs suggest that proning reduces ventilation heterogeneity in overweight and obese subjects but increases heterogeneity in non-overweight subjects. This suggests proning may be beneficial for overweight #COVID19 patients. https://bit.ly/2MfCiyk

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          Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

          Fei Zhou, Ting Yu, Ronghui Du … (2020)
          Summary Background Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described. Methods In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. Findings 191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p<0·0001), and d-dimer greater than 1 μg/mL (18·42, 2·64–128·55; p=0·0033) on admission. Median duration of viral shedding was 20·0 days (IQR 17·0–24·0) in survivors, but SARS-CoV-2 was detectable until death in non-survivors. The longest observed duration of viral shedding in survivors was 37 days. Interpretation The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future. Funding Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences; National Science Grant for Distinguished Young Scholars; National Key Research and Development Program of China; The Beijing Science and Technology Project; and Major Projects of National Science and Technology on New Drug Creation and Development.
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            Early Self‐Proning in Awake, Non‐intubated Patients in the Emergency Department: A Single ED’s Experience During the COVID‐19 Pandemic

            Nicholas D. Caputo, Reuben Strayer, Richard E. Levitan (2020)
            Abstract Objective Prolonged and unaddressed hypoxia can lead to poor patient outcomes. Proning has become a standard treatment in the management of patients with ARDS who have difficulty achieving adequate oxygen saturation. The purpose of this study was to describe the use of early proning of awake, non‐intubated patients in the emergency department (ED) during the COVID‐19 pandemic. Methods This pilot study was carried out in a single urban ED in New York City. We included patients suspected of having COVID‐19 with hypoxia on arrival. A standard pulse oximeter was used to measure SpO2. SpO2 measurements were recorded at triage and after 5 minutes of proning. Supplemental oxygenation methods included non‐rebreather mask (NRB) and nasal cannula. We also characterized post‐proning failure rates of intubation within the first 24 hours of arrival to the ED. Results Fifty patients were included. Overall, the median SpO2 at triage was 80% (IQR 69 to 85). After application of supplemental oxygen was given to patients on room air it was 84% (IQR 75 to 90). After 5 minutes of proning was added SpO2 improved to 94% (IQR 90 to 95). Comparison of the pre‐ to post‐median by the Wilcoxon Rank‐sum test yielded P = 0.001. Thirteen patients (24%) failed to improve or maintain their oxygen saturations and required endotracheal intubation within 24 hours of arrival to the ED. Conclusion Awake early self‐proning in the emergency department demonstrated improved oxygen saturation in our COVID‐19 positive patients. Further studies are needed to support causality and determine the effect of proning on disease severity and mortality.
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              Impact of obesity on respiratory function.

              Stephen Littleton (2012)
              Obesity has long been recognized as having significant effects on respiratory function. The topic has been studied for at least the last half century, and some clear patterns have emerged. Obese patients tend to have higher respiratory rates and lower tidal volumes. Total respiratory system compliance is reduced for a variety of reasons, which will be discussed. Lung volumes tend to be decreased, especially expiratory reserve volume. Spirometry, gas exchange and airway resistance all tend to be relatively well preserved when adjusted for lung volumes. Patients may be mildly hypoxaemic, possibly due to ventilation-perfusion mismatching at the base of the lungs, where microatelectasis is likely to occur. Weight loss leads to a reversal of these changes. For all of these changes, the distribution of fat, that is, upper versus lower body, may be more important than body mass index. © 2011 The Author. Respirology © 2011 Asian Pacific Society of Respirology.
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                Author and article information

                Journal
                Journal ID (nlm-ta): ERJ Open Res
                Journal ID (iso-abbrev): ERJ Open Res
                Journal ID (publisher-id): ERJOR
                Journal ID (hwp): erjor
                Title: ERJ Open Research
                Publisher: European Respiratory Society
                ISSN (Electronic): 2312-0541
                Publication date Collection: April 2020
                Publication date (Electronic): 13 July 2020
                Volume: 6
                Issue: 2
                Electronic Location Identifier: 00292-2020
                Affiliations
                [1 ]Center for Systems Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
                [2 ]Dept of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
                [3 ]National Institute for Health Research (NIHR), Leicester Biomedical Research Centre (Respiratory theme) and College of Life Sciences, University of Leicester, Leicester, UK
                Author notes
                Salman Siddiqui, NIHR Respiratory Biomedical Research Centre, Respiratory Theme and Dept of Respiratory Sciences, University of Leicester, Glenfield Hospital, Leicester LE3 9QP, UK. E-mail: ss338@ 123456le.ac.uk
                Article
                Publisher ID: 00292-2020
                DOI: 10.1183/23120541.00292-2020
                PMC ID: 7357272
                SO-VID: d43fff3b-cc51-4f43-854c-6f494b6059b3
                Copyright © Copyright ©ERS 2020
                License:

                This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial Licence 4.0.

                History
                Date received : 21 May 2020
                Date accepted : 22 May 2020
                Categories
                Subject: Original Research Letters
                Subject: 4

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