Diagnosis of pulmonary embolism in patients with acute exacerbations of chronic obstructive pulmonary disease: a cross-sectional study

Introduction: Pulmonary embolism (PE) remains a frequent complication in patients with chronic obstructive pulmonary disease (COPD). It is unclear that the extent to which the traditional risk stratifying scores for PE are accurate in this population. Methods: Cross-sectional study of adult patients with COPD and suspected PE included in an Institutional Registry of Thromboembolic Disease at a tertiary teaching hospital in the city of Buenos Aires, Argentina. We estimated the area under the receiver operating characteristic curves (AU-ROC), sensitivity and specificity of the Wells and Geneva scores using a positive computed tomography angiography as the gold standard for PE. We also estimated the sensitivity and specificity for the presence of isolated worsening of dyspnea at presentation, without other cardinal symptoms of acute exacerbation of COPD. Results: A total of 168 patients were included, of which 22% had confirmed PE. The AUC was 0.66 (95% CI 0.56-0.76) and 0.56 (95% CI 0.45-0.67) for the Wells and Geneva, respectively. Considering the most widely used cutoff points, the sensitivity and specificity were 24% and 90% for the Wells and 59% and 43% for the Geneva score, respectively. Isolated worsening of dyspnea on presentation had a sensitivity of 92% and specificity of 37%. Conclusions: Both Wells and Geneva scores exhibit poor diagnostic accuracy for the diagnosis of PE in patients with COPD. The presence of isolated worsening of dyspnea on presentation could be an easy to identify criteria for the initial triage in this population. Further validation of our findings remains warranted.Fil: Maritano Furcada, Joaquín. Hospital Italiano; ArgentinaFil: Castro, Horacio Matías. Hospital Italiano; ArgentinaFil: de Vito, Eduardo. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Universidad de Buenos Aires. Facultad de Medicina. Instituto de Investigaciones Médicas; ArgentinaFil: Grande Ratti, María Florencia. Hospital Italiano; ArgentinaFil: Posadas Martinez, Maria Lourdes. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Hospital Italiano; ArgentinaFil: Giunta, Diego Hernan. Hospital Italiano; ArgentinaFil: Vazquez, Fernando Javier. Hospital Italiano; ArgentinaFil: Ferreyro, Bruno Leonel. Hospital Italiano; Argentina. University of Toronto; Canad

High-flow nasal oxygen in patients with COVID-19-associated acute respiratory failure

Purpose: Whether the use of high-flow nasal oxygen in adult patients with COVID-19 associated acute respiratory failure improves clinically relevant outcomes remains unclear. We thus sought to assess the effect of high-flow nasal oxygen on ventilator-free days, compared to early initiation of invasive mechanical ventilation, on adult patients with COVID-19. Methods: We conducted a multicentre cohort study using a prospectively collected database of patients with COVID-19 associated acute respiratory failure admitted to 36 Spanish and Andorran intensive care units (ICUs). Main exposure was the use of high-flow nasal oxygen (conservative group), while early invasive mechanical ventilation (within the first day of ICU admission; early intubation group) served as the comparator. The primary outcome was ventilator-free days at 28 days. ICU length of stay and all-cause in-hospital mortality served as secondary outcomes. We used propensity score matching to adjust for measured confounding. Results: Out of 468 eligible patients, a total of 122 matched patients were included in the present analysis (61 for each group). When compared to early intubation, the use of high-flow nasal oxygen was associated with an increase in ventilator-free days (mean difference: 8.0 days; 95% confidence interval (CI): 4.4 to 11.7 days) and a reduction in ICU length of stay (mean difference: - 8.2 days; 95% CI - 12.7 to - 3.6 days). No difference was observed in all-cause in-hospital mortality between groups (odds ratio: 0.64; 95% CI: 0.25 to 1.64). Conclusions: The use of high-flow nasal oxygen upon ICU admission in adult patients with COVID-19 related acute hypoxemic respiratory failure may lead to an increase in ventilator-free days and a reduction in ICU length of stay, when compared to early initiation of invasive mechanical ventilation. Future studies should confirm our findings

Predictors of failure with high-flow nasal oxygen therapy in COVID-19 patients with acute respiratory failure: a multicenter observational study

Purpose: We aimed to describe the use of high-flow nasal oxygen (HFNO) in patients with COVID-19 acute respiratory failure and factors associated with a shift to invasive mechanical ventilation. Methods: This is a multicenter, observational study from a prospectively collected database of consecutive COVID-19 patients admitted to 36 Spanish and Andorran intensive care units (ICUs) who received HFNO on ICU admission during a 22-week period (March 12-August 13, 2020). Outcomes of interest were factors on the day of ICU admission associated with the need for endotracheal intubation. We used multivariable logistic regression and mixed effects models. A predictive model for endotracheal intubation in patients treated with HFNO was derived and internally validated. Results: From a total of 259 patients initially treated with HFNO, 140 patients (54%) required invasive mechanical ventilation. Baseline non-respiratory Sequential Organ Failure Assessment (SOFA) score [odds ratio (OR) 1.78; 95% confidence interval (CI) 1.41-2.35], and the ROX index calculated as the ratio of partial pressure of arterial oxygen to inspired oxygen fraction divided by respiratory rate (OR 0.53; 95% CI: 0.37-0.72), and pH (OR 0.47; 95% CI: 0.24-0.86) were associated with intubation. Hospital site explained 1% of the variability in the likelihood of intubation after initial treatment with HFNO. A predictive model including non-respiratory SOFA score and the ROX index showed excellent performance (AUC 0.88, 95% CI 0.80-0.96). Conclusions: Among adult critically ill patients with COVID-19 initially treated with HFNO, the SOFA score and the ROX index may help to identify patients with higher likelihood of intubation

Diagnosis of pulmonary embolism in patients with acute exacerbations of chronic obstructive pulmonary disease: A cross‐sectional study

Introduction: Pulmonary embolism (PE) remains a frequent complication in patients with chronic obstructive pulmonary disease (COPD). It is unclear that the extent to which the traditional risk stratifying scores for PE are accurate in this population. Methods: Cross-sectional study of adult patients with COPD and suspected PE included in an Institutional Registry of Thromboembolic Disease at a tertiary teaching hospital in the city of Buenos Aires, Argentina. We estimated the area under the receiver operating characteristic curves (AU-ROC), sensitivity and specificity of the Wells and Geneva scores using a positive computed tomography angiography as the gold standard for PE. We also estimated the sensitivity and specificity for the presence of isolated worsening of dyspnea at presentation, without other cardinal symptoms of acute exacerbation of COPD. Results: A total of 168 patients were included, of which 22% had confirmed PE. The AUC was 0.66 (95% CI 0.56-0.76) and 0.56 (95% CI 0.45-0.67) for the Wells and Geneva, respectively. Considering the most widely used cutoff points, the sensitivity and specificity were 24% and 90% for the Wells and 59% and 43% for the Geneva score, respectively. Isolated worsening of dyspnea on presentation had a sensitivity of 92% and specificity of 37%. Conclusions: Both Wells and Geneva scores exhibit poor diagnostic accuracy for the diagnosis of PE in patients with COPD. The presence of isolated worsening of dyspnea on presentation could be an easy to identify criteria for the initial triage in this population. Further validation of our findings remains warranted.Fil: Maritano Furcada, Joaquín. Hospital Italiano; ArgentinaFil: Castro, Horacio Matías. Hospital Italiano; ArgentinaFil: de Vito, Eduardo. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Universidad de Buenos Aires. Facultad de Medicina. Instituto de Investigaciones Médicas; ArgentinaFil: Grande Ratti, María Florencia. Hospital Italiano; ArgentinaFil: Posadas Martinez, Maria Lourdes. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Hospital Italiano; ArgentinaFil: Giunta, Diego Hernan. Hospital Italiano; ArgentinaFil: Vazquez, Fernando Javier. Hospital Italiano; ArgentinaFil: Ferreyro, Bruno Leonel. Hospital Italiano; Argentina. University of Toronto; Canad

Impact of exposure time in awake prone positioning on clinical outcomes of patients with COVID-19-related acute respiratory failure treated with high-flow nasal oxygen: a multicenter cohort study

Abstract Background: In patients with COVID-19-related acute respiratory failure (ARF), awake prone positioning (AW-PP) reduces the need for intubation in patients treated with high-fow nasal oxygen (HFNO). However, the efects of different exposure times on clinical outcomes remain unclear. We evaluated the efect of AW-PP on the risk of endotracheal intubation and in-hospital mortality in patients with COVID-19-related ARF treated with HFNO and analyzed the efects of diferent exposure times to AW-PP. Methods: This multicenter prospective cohort study in six ICUs of 6 centers in Argentine consecutively included patients>18 years of age with confrmed COVID-19-related ARF requiring HFNO from June 2020 to January 2021. In the primary analysis, the main exposure was awake prone positioning for at least 6 h/day, compared to non-prone positioning (NON-PP). In the sensitivity analysis, exposure was based on the number of hours receiving AW-PP. Inverse probability weighting-propensity score (IPW-PS) was used to adjust the conditional probability of treatment assignment. The primary outcome was endotracheal intubation (ETI); and the secondary outcome was hospital mortality. Results: During the study period, 580 patients were screened and 335 were included; 187 (56%) tolerated AW-PP for [median (p25-75)] 12 (9-16) h/day and 148 (44%) served as controls. The IPW-propensity analysis showed standardized diferences<0.1 in all the variables assessed. After adjusting for other confounders, the OR (95% CI) for ETI in the AW-PP group was 0.36 (0.2-0.7), with a progressive reduction in OR as the exposure to AW-PP increased. The adjuste