Coronavirus Disease 2019 (COVID-19): A critical care perspective beyond China

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Article

Reference

Coronavirus Disease 2019 (COVID-19): A critical care perspective beyond China

RELLO, Jordi, et al.

Abstract No abstract available.

RELLO, Jordi, et al . Coronavirus Disease 2019 (COVID-19): A critical care perspective beyond China. Anaesthesia Critical Care & Pain Medicine , 2020, vol. 39, no. 2, p. 167-169

DOI : 10.1016/j.accpm.2020.03.001 PMID : 32142972

Available at:

http://archive-ouverte.unige.ch/unige:138501

Disclaimer: layout of this document may differ from the published version.

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Editorial

Coronavirus Disease 2019 (COVID-19): A critical care perspective beyond China

Clinical evidence helps to progress in patient-level and population-level decision-making. We need to build on prior experience and identify similarities versus differences. In this sense,thepandemicinfluenzasurgein2009canbeofhelp.Our colleaguesinWuhan,who placedtheir lives atrisk bytreating patientswithCOVID-19,recentlyreported theirexperience ina scenarioofcrisismanagementwithlimitedresources[1].Inter- pretation of these findings in comparison with first reports of pandemic influenza in European ICUs would help to better confrontthecurrentchallenge[2].Someintensivistsareextrapo- latinginfluenzaA(H1N1)pdm2009dataandapplyingittoCOVID- 19,but thereis ahuge differencebetween thecoronavirusand influenza,withrespecttotheimpactoftheir viralshedding.In influenzaA (H1N1)pdm2009, death wasnot asfrequent in the medicalandnursingstaffthaninpatients.InSARSandMERSthis wasthecase,anditappearsthathospitalstaffarealsoparticularly vulnerableinCOVID-19[3].Itislikelythatsome‘‘sick’’coronavirus patientsshedverylargeamounts ofvirus,whereasininfluenza thatisnotnecessarilythecase.Ifahealthcareworkerisexposedto alargeinitialinoculumofcoronavirus,ARDScandeveloprapidly.

Toprovideusefulinsight,Table1comparestheWuhanreport with our experience with the first ICU admissions caused by influenzaA(H1N1)pdm2009[2].Among37ventilatedpatientsin the Wuhan cohort [1], only 4 (10.8%) were alive and free of mechanicalventilation28-daysafterICUadmission.Incontrast,a first look suggests that 28-day survival rate in the European influenzacohortwasmorethandoubled.Thiscanbeduetothe delayedintubation(patientsadmittedinICUwhenalreadyunder mechanicalventilationorrequiringafractionofinspiredoxygen (FiO2)60%)associatedwiththeextremeworkingconditionsand the limited resources in Wuhan. Indeed, data from a detailed surveillancestudy fromtheChinaCDC indicates that mortality

ratesincriticallyillpatientsfromotherChineseprovinceswere lower than 50% [3]. This analysis reports that overall, 80% of confirmed cases were mild, 15% of severe cases required hospitalisation and 5% were critically ill. However, as many patients canremain asymptomaticorwithvery lowsymptom- atology and because criteria of hospital admission were not standardised, the proportion of patients requiring supportive techniquesforhypoxemiaisprobablylower.COVID-19isshowing respiratorydeterioration7-9daysafteronset,whichisdoublethe 3-5days perioddocumentedin influenzapandemic, suggesting thatitcannotberelatedtotheviralload.Thisinterpretationmay justify the high rate of use of steroids in the Wuhan report [1]. Despite some controversies, steroids, alpha-interferon and macrolides are not beneficial [4]. Prior experience with viral pneumonia, including influenzaand MERS-coronavirus, suggest that steroids can contribute to higher mortality, increase viral replication with longer periods of viral clearance and more superinfections (including invasive pulmonary aspergillosis, as alreadyreportedintheWuhancohort)[5,6].

Another difference is that most COVID-19 infected patients werediagnosedwithviralpneumonia,whereasacuteexacerba- tions of COPD or bronchospasm or myocarditis were more commonininﬂuenza.Theeffectonepidemiologyandpresentation isunknownduetoitscoexistencewithintheepidemicseasonof inﬂuenza.Becausepresentationisoverlapping,testsforSARS-CoV- 2 should be conducted in patients with severe pneumonia of unknown aetiology, concomitantly with the search for other respiratoryviruses.

Acommonaspect withtheinfluenzavirusisthetropismfor lower respiratory tract and its impacton theinterpretation of diagnostictests[7].RT-PCRtestscanbeaffectedbysamplingerrors and viral load, with prior studies in SARS demonstrating low sensitivityduringthefirstdaysafteronset.Moreover,multipleRT- PCRtestsofthroatornasopharyngealswabshavebeenreportedas false negative when compared with BAL tests. Its consequent impact on screening of potential organor tissue donors is the reason whya definitionofclinically‘‘suspectedcases’’of acute respiratorydiseasewasintroducedforrecordingcasesinHubei, andwhychestCTforCOVID-19screeningiscurrentlyconductedin China.Practicalimplicationsarethatpersonalprotective equip- ment(PPE)shouldbeusedandinfectioncontrolmeasuresshould notbeminimisedin patientswithpneumoniaandhighclinical suspicion,duetothehighriskofspreadandcontagionofthisvirus.

In intubatedpatients, a non-bronchoscopic BAL (Combicath ¹) AnaesthCritCarePainMed39(2020)167–169

ARTICLE INFO

Keywords:

Inﬂuenza SARS-COV-2 Mechanicalventilation Outbreak

Coronavirus

Intensivecaremedicine Pneumonia

https://doi.org/10.1016/j.accpm.2020.03.001

2352-5568/^C 2020Socie´te´ franc¸aised’anesthe´sieetdere´animation(Sfar).PublishedbyElsevierMassonSAS.Allrightsreserved.

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Table1

BaselinecharacteristicsofICUpatientswithconﬁrmedacuterespiratoryillness.

Study Yangetal.,2020[1] Relloetal.,2009[2]

Illness SARS-CoV-2pneumonia inﬂuenzaA(H1N1)pdm2009

Totalpatientswithconﬁrmedillness 52 32

Age,mean(SD) 59.7(13.3) 40(13.9)

Sex

Male 35(67%) 21(65.6%)

Female 17(33%) 34.4%(11)

DaysfromonsetsymptomstoICUadmission,median(IQR) 9.5(7–12.5) 3(2-6)

Daysfromonsetsymptomstodiagnosis,median(IQR) 5(3-7) 2(1-6)

APACHEIIscore,mean(SD) 16.7(1.3) 13.8(6.4)

SOFAscore,mean(SD) - 7.1(3.3)

Signsandsymptoms^a

Fever 98% 96%

Cough 77% 88%

Dyspnoea 63.5% -

Malaise 35% 30%

Myalgia 11.5% 69%

Headache 6% 45.9%

Rhinorrhoea 6% -

Vomiting 4% -

Arthralgia 2% -

Chestpain 2% -

Sorethroat - 58%

Suddenonsetsymptoms - 46%

Treatment

Antibacterialagents 49(94%) 32(100%)

beta-lactamplusﬂuoroquinolones - 20(62.5%)

beta-lactamplusmacrolides - 6(18.7%)

beta-lactampluslinezolid - 5(15.6%)

levoﬂoxacinasmonotherapy - 1(3.1%)

Steroids 30(58%) 11(34.4%)

MV 37(71%) 24(75%)

Invasive 22(42%) 16(66.6%)

Non-invasive 29(56%) 8(33.3%)

HFNC 33(63.5%) -

Immunoglobulin 28(54%) -

Antiviralagents 23(44%) 21(65.6%)

Oseltamivirstandarddose(75mgtwice/daily) 18(35%) 32(100%)

Oseltamivirhighdose(150mgtwice/daily) - 10(31.2%)

Ganiciclovir 14(27%) -

Lopinavir 7(13.5%) -

Vasoconstrictiveagents 18(35%) 20(62.5%)

Renalreplacementtherapy 9(17%) 7(21.9%)

Pronepositionventilation 6(11.5%) 8(33%)

ECMO 6(11.5%) Notimplemented

Comorbidities/Complications ARDS:35(67%) Obesity:10(31.3%)

Hyperglycaemia:18(35%) BMI30to40:6(18.7%) Acutekidneyinjury:15(29%) Asthma:5(15.6%) Liverdysfunction:15(29%) BMI>40:4(12.5%)

Cardiacinjury:12(23%) COPD:4(12.5%)

HAP:7(13.5%) Pregnancy:2(6.3%)

Gastrointestinalhaemorrhage:2(4%) Heartfailure:1(3.1%) Pneumothorax:1(2%) Arterialhypertension:1(3.1%) Bacteraemia:1(2%) Chronicrenalfailure:1(3.1%) Urinarytractinfection:1(2%) Diabetesmellitus:1(3.1%)

HIV:1(3.1%)

Neuromusculardisease:1(3.1%) Haematologicdisease:1(3.1%) Pathogensidentiﬁed

Pseudomonasaeruginosa 1(2%) 3(9.3%)

Aspergillusﬂavus 1(2%) 1(3.1%)

Aspegillus.fumigates 1(2%) -

Klebsiellapneumoniae 1(2%) -

Serratiamarcescens 1(2%) -

Invasivecandidiasis 1(2%) -

Overall28-dayMortality 32(61.5%) 16(30.8%)

LengthofMVforsurvivors,median(IQR) - 10(1-21)

SARS-CoV-2:severeacuterespiratorysyndromecoronavirus2;SD:standarddesviation;IQR:interquartilerange;ICU:intensivecareunit;APACHE:acutephysiologyand chronichealthevaluationII;SOFA:sequentialorganfailureassessment;MV:mechanicalventilation;HFNC:High-ﬂownasalcannula;ECMO:Extracorporealmembrane oxygenation;ARDS:acuterespiratorydistresssyndrome;HAP:hospital-acquiredpneumonia;BMI:bodymassindex;COPD:chronicobstructivepulmonarydisease;HIV:

positivehumanimmunodeﬁciencyvirus;IMV:invasivemechanicalventilation

aRelloetal.reportedsignsandsymptomsfromatotalof735casesofinﬂuenzaA(H1N1)vthatwereconﬁrmedinSpainin2009.

Editorial/AnaesthCritCarePainMed39(2020)167–169 168

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specimenshouldbeobtained(ratherthanaCTscan)incaseswith negativeRT-PCRupperrespiratorytractswabs.

Thin-sliceChestCTﬁndingshavebeenrecommendedinHubei, China as a major evidence for clinical diagnosis of COVID-19.

TypicalCTﬁndingsofCOVID-19includeperipherallydistributed multifocalground-glassopacitieswithpatchyconsolidationsand posteriorpartoflowerlobe involvementpredilection. SerialCT scanshavebeenusedtomonitorevolution.Extentanddensitiesof ground-glassopacitiesindicatediseaseprogression[8].Itisnot clearthat it wouldprovide betterinformationthan monitoring hypoxemia,asasurrogateofseverity.

Protectinghealth care workers and preparednessof ICUs to confrontanepidemicclustershouldbethemainpriority,basedon experienceslearntfromMERS-coronavirusand2003SARScoro- navirus[8].Recently,antiseptichandrubbingusingethanol-based disinfectantswasfoundtobelesseffectivethanhandwashingin inactivatinginﬂuenzavirusunderexperimentalconditions[9].For patients with coronavirus suspicion in the ICU, airborne plus contactprecautionsandeyeprotectionshouldbeimplemented.

During aerosol-generationprocedures,wearinga ﬁt-testedN95 mask in addition to gloves, gown and face/eye protection is recommended.Open suctioningoftherespiratory tract,manual ventilation before intubation, nebuliser treatment, and chest compressionswereidentiﬁedasriskproceduresduringtheSARS outbreak [10]. Close-circuitsuctioning mayreduce exposure to aerosolsinintubatedpatients.Thus,supportwithearlydiagnosis, implementation of effective infection control measures, and limitation of procedures associated with risk of environmental andpersonalcontamination,suchasaerosolisation,bronchosco- piesortransfersforCTscansshouldbeimplemented.

Ventilator strategies favouring aerosolisation, such as non- invasivemechanicalventilation(NIV),whichmayquitedelaybut not avoid intubation, should be limited, and hypoxemia rescue therapiessuchasnitricoxideshouldbeimplemented.Useofnon- invasive ventilation is controversial,showing limitedefficacy in MERSandis associated with veryhighlevels of aerosolspread, exposingstaffatmuchgreaterriskofinfection[11,12].However, NIVcanavoidtheneedforventilation,atleastinSARS.Thereis thereforeanargumentthatitmaybeappropriateonlyifadequate levelsofstaffprotectiveequipmentareavailable[13].Ininfluenza,a smallcohortofpatientsshowedthathigh-flownasalcannulawas associatedwithavoidanceofintubationin45%ofpatients,although thosewith shockor high severityof illnessrequired intubation [14].Thus,effortsshouldbedonenottodelayintubationinpatients withviralpneumoniaandacuterespiratoryfailure.

Insummary,itisnecessarytogobeyondChina,assomeresults and practices may not be generalisable elsewhere. A priority should be to protect healthcare workers from exposure. ICU doctors should participate in early identiﬁcation and lead the managementofthesepatients.

Disclosureofinterest

Theauthorsdeclarethattheyhavenocompetinginterest.

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JordiRelloâ,b,c,*,SofiaTejadaâ,b,CarolineUserovici^d,e, KostoulaArvaniti^f,Je´roˆmePugin^g,GrantWaterer^h

aCentrodeInvestigacio´nBiomedicaenReddeEnfermedades Respiratorias(CIBERES),InstitutoSaludCarlosIII,Madrid,Spain

bClinicalResearch/EpidemiologyinPneumoniaandSepsis(CRIPS),Vall d’HebronInstitutofResearch(VHIR),Barcelona,Spain

cAnaesthesiologyandCriticalCareDivision,CHUNıˆmes,University Montpellier-Nıˆmes,Nıˆmes,France

dDe´partementAnesthe´sieRe´animation,HoˆpitalPitie´-Salpeˆtrie`re,Paris, France

eJuniorGroupoftheFrenchSocietyofAnaesthesiaandIntensiveCare Medicine(SFAR),Paris,France

fCriticalCareDepartment,GeneralHospitalPapageorgiou,Thessaloniki, Greece

gDivisionofIntensiveCare,UniversityHospitalsofGeneva,Geneva, Switzerland

hSchoolofMedicine,UniversityofWesternAustralia,Perth,Australia

*Correspondingauthorat:Valld’HebronInstitutdeRecerca,PsVall d’Hebron119AMI-14thﬂoor,08035Barcelona,Spain E-mailaddress:[email protected](J.Rello).

Availableonline3March2020

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