Tension #pneumomediastinum in patients with #COVID19 (Thorax, summary)

[Source: Thorax, full page: (LINK). Summary, edited.]

Tension pneumomediastinum in patients with COVID-19

Alessio Campisi 1, Venerino Poletti 2,3, Angelo Paolo Ciarrocchi 1, Maurizio Salvi 4, Franco Stella 1

Author affiliations: 1 Thoracic Surgery Unit, Department of Thoracic Diseases, G.B. Morgagni-L. Pierantoni Hospital, University of Bologna, Forlì, Italy; 2 Pulmonary Operative Unit, Department of Thoracic Diseases, Morgagni-Pierantoni Hospital, AUSL of Romagna, Forli’, Italy; 3 Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark; 4 Thoracic Surgery Unit, Department of Thoracic Diseases, G.B. Morgagni-L. Pierantoni Hospital, AUSL della Romagna Rimini, Forlì, Italy;

Correspondence to Dr Alessio Campisi, Thoracic Surgery Unit, Department of Thoracic Diseases, G.B. Morgagni-L. Pierantoni Hospital, University of Bologna, Forlì, Emilia-Romagna, Italy; alessio.campisi@studio.unibo.it

DOI: http://dx.doi.org/10.1136/thoraxjnl-2020-215012


A 65-year-old obese male, with no other comorbidities, was admitted to our intensive care unit for acute respiratory failure due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The patient was mechanically ventilated (intermittent positive pressure ventilation autoflow mode with tidal volume of 6 mL/kg, positive end expiratory pressure (PEEP) 12 cmH2O, respiratory rate 20 breaths/min and fractional inspired oxygen (FiO2) to the lowest level to maintain arterial pO2 in a range of 55–60 mm Hg) for 7 days before his condition abruptly worsened. He became haemodynamically unstable with changes in the cardiac electrical activity and hypotension unresponsive to catecholamines. An initial plain chest X-ray revealed widespread subcutaneous emphysema.


Keywords: SARS-CoV-2; COVID-19; ARDS; Intensive Care.


Development of a work of #breathing #scale and monitoring need of #intubation in #COVID19 pneumonia (Crit Care, summary)

[Source: Critical Care, full page: (LINK). Summary, edited.]

Development of a work of breathing scale and monitoring need of intubation in COVID-19 pneumonia

Mylene Apigo, Jeffrey Schechtman, Nyembezi Dhliwayo, Mohammed Al Tameemi & Raúl J. Gazmuri

Critical Care volume 24, Article number: 477 (2020)


COVID-19 pneumonia presents in most patients with scattered areas of lung involvement within healthy lungs displaying hypoxemia and tachypnea but with relatively minor reductions in lung compliance [1, 2]. Noninvasive ventilation and high-flow nasal cannula (HFNC) are reasonable initial interventions reserving endotracheal intubation for worsening disease severity evidenced by increased work of breathing (WOB), risking respiratory muscle fatigue leading to hypoventilation, hypoxemia, and cardiac arrest and large transpulmonary pressure swings risking patient self-inflicted lung injury (SILI) [3, 4].


Keywords: SARS-CoV-2; COVID-19; Intensive Care.


#Cardiac #injury associated with #severe disease or #ICU admission and #death in hospitalized patients with #COVID19: a meta-analysis and systematic review (Crit Care, abstract)

[Source: Critical Care, full page: (LINK). Abstract, edited.]

Cardiac injury associated with severe disease or ICU admission and death in hospitalized patients with COVID-19: a meta-analysis and systematic review

Xinye Li, Xiandu Pan, Yanda Li, Na An, Yanfen Xing, Fan Yang, Li Tian, Jiahao Sun, Yonghong Gao, Hongcai Shang & Yanwei Xing

Critical Care volume 24, Article number: 468 (2020)




Cardiac injury is now a common complication of coronavirus disease (COVID-19), but it remains unclear whether cardiac injury-related biomarkers can be independent predictors of mortality and severe disease development or intensive care unit (ICU) admission.


Two investigators searched the PubMed, EMBASE, Cochrane Library, MEDLINE, Chinese National Knowledge Infrastructure (CNKI), Wanfang, MedRxiv, and ChinaXiv databases for articles published through March 30, 2020. Retrospective studies assessing the relationship between the prognosis of COVID-19 patients and levels of troponin I (TnI) and other cardiac injury biomarkers (creatine kinase [CK], CK myocardial band [CK-MB], lactate dehydrogenase [LDH], and interleukin-6 [IL-6]) were included. The data were extracted independently by two investigators.


The analysis included 23 studies with 4631 total individuals. The proportions of severe disease, ICU admission, or death among patients with non-elevated TnI (or troponin T [TnT]), and those with elevated TnI (or TnT) were 12.0% and 64.5%, 11.8% and 56.0%, and 8.2% and. 59.3%, respectively. Patients with elevated TnI levels had significantly higher risks of severe disease, ICU admission, and death (RR 5.57, 95% CI 3.04 to 10.22, P < 0.001; RR 6.20, 95% CI 2.52 to 15.29, P < 0.001; RR 5.64, 95% CI 2.69 to 11.83, P < 0.001). Patients with an elevated CK level were at significantly increased risk of severe disease or ICU admission (RR 1.98, 95% CI 1.50 to 2.61, P < 0.001). Patients with elevated CK-MB levels were at a higher risk of developing severe disease or requiring ICU admission (RR 3.24, 95% CI 1.66 to 6.34, P = 0.001). Patients with newly occurring arrhythmias were at higher risk of developing severe disease or requiring ICU admission (RR 13.09, 95% CI 7.00 to 24.47, P < 0.001). An elevated IL-6 level was associated with a higher risk of developing severe disease, requiring ICU admission, or death.


COVID-19 patients with elevated TnI levels are at significantly higher risk of severe disease, ICU admission, and death. Elevated CK, CK-MB, LDH, and IL-6 levels and emerging arrhythmia are associated with the development of severe disease and need for ICU admission, and the mortality is significantly higher in patients with elevated LDH and IL-6 levels.

Keywords: SARS-CoV-2; COVID-19; Intensive Care; Cardiology.


#Age, #sex, and #comorbidities predict #ICU admission or #mortality in cases with #SARS-CoV2 infection: a population-based cohort study (Crit Care, summary)

[Source: Critical Care, full page: (LINK). Summary, edited.]

Age, sex, and comorbidities predict ICU admission or mortality in cases with SARS-CoV2 infection: a population-based cohort study

Filipe S. Cardoso, Ana L. Papoila, Rita Sá Machado & Pedro Fidalgo

Critical Care volume 24, Article number: 465 (2020)


Dear Editor, Previous studies have identified risk factors for severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) severe outcomes preferentially among hospitalized patients; therefore, they may have understated the denominator of such estimations [1, 2]. We aimed to determine pre-hospital risk factors and estimate individual probabilities of SARS-CoV2 severe outcomes among a nationwide cohort of cases of SARS-CoV2 infection, including those with and without hospitalization.


Keywords: SARS-CoV-2; COVID-19; Intensive Care; Portugal.


#Epidemiology of invasive #pulmonary #aspergillosis among #COVID19 intubated patients: a prospective study (Clin Infect Dis., abstract)

[Source: Clinical Infectious Diseases, full page: (LINK). Abstract, edited.]

Epidemiology of invasive pulmonary aspergillosis among COVID-19 intubated patients: a prospective study

Michele Bartoletti, Renato Pascale, Monica Cricca, Matteo Rinaldi, Angelo Maccaro, Linda Bussini, Giacomo Fornaro, Tommaso Tonetti, Giacinto Pizzilli, Eugenia Francalanci, Lorenzo Giuntoli, Arianna Rubin, Alessandra Moroni, Simone Ambretti, Filippo Trapani, Oana Vatamanu, Vito Marco Ranieri, Andrea Castelli, Massimo Baiocchi, Russell Lewis, Maddalena Giannella, Pierluigi Viale, PREDICO study group

Clinical Infectious Diseases, ciaa1065, https://doi.org/10.1093/cid/ciaa1065

Published: 28 July 2020




In this study we evaluated the incidence of invasive pulmonary aspergillosis among intubated patients with critical coronavirus disease 2019 (COVID-19) and evaluated different case definitions of invasive aspergillosis.


Prospective, multicentre study on adult patients with microbiologically confirmed COVID-19 receiving mechanical ventilation. All included participants underwent screening protocol for invasive pulmonary aspergillosis with bronchoalveolar lavage galactomannan and cultures performed on admission at 7 days and in case of clinical deterioration. Cases were classified as coronavirus associated pulmonary aspergillosis (CAPA) according to previous consensus definitions. The new definition was compared with putative invasive pulmonary aspergillosis (PIPA).


A total of 108 patients were enrolled. Probable CAPA was diagnosed in 30 (27.7%) of patients after a median of 4 (2-8) days from intensive care unit (ICU) admission. Kaplan-Meier curves showed a significant higher 30-day mortality rate from ICU admission among patients with either CAPA (44% vs 19%, p= 0.002) or PIPA (74% vs 26%, p<0.001) when compared with patients not fulfilling criteria for aspergillosis. The association between CAPA [OR 3.53 (95%CI 1.29-9.67), P=0.014] or PIPA [OR 11.60 (95%CI 3.24-41.29) p<0.001] with 30-day mortality from ICU admission was confirmed even after adjustment for confounders with a logistic regression model. Among patients with CAPA receiving voriconazole treatment (13 patients, 43%) A trend toward lower mortality (46% vs 59% p=0.30) and reduction of galactomannan index in consecutive samples was observed.


We found a high incidence of CAPA among critically ill COVID-19 patients and that its occurrence seems to change the natural history of disease

SARS-CoV-2, COVID-19, severe respiratory failure, aspergillosis, voriconazole

Issue Section: Major Article

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This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Keywords: SARS-CoV-2; COVID-19; Aspergillosis.


Provision of #ECPR during #COVID19: #evidence, #equity, and #ethical dilemmas (Crit Care, abstract)

[Source: Critical Care, full page: (LINK). Abstract, edited.]

Provision of ECPR during COVID-19: evidence, equity, and ethical dilemmas

Elliott Worku, Denzil Gill, Daniel Brodie, Roberto Lorusso, Alain Combes & Kiran Shekar

Critical Care volume 24, Article number: 462 (2020)



The use of extracorporeal cardiopulmonary resuscitation (ECPR) to restore circulation during cardiac arrest is a time-critical, resource-intensive intervention of unproven efficacy. The current COVID-19 pandemic has brought additional complexity and significant barriers to the ongoing provision and implementation of ECPR services. The logistics of patient selection, expedient cannulation, healthcare worker safety, and post-resuscitation care must be weighed against the ethical considerations of providing an intervention of contentious benefit at a time when critical care resources are being overwhelmed by pandemic demand.

Keywords: SARS-CoV-2; COVID-19; Intensive Care; Bioethics.


#Incidence and #mortality of #pulmonary #embolism in #COVID19: a systematic review and meta-analysis (Crit Care, summary)

[Source: Critical Care, full page: (LINK). Summary, edited.]

Incidence and mortality of pulmonary embolism in COVID-19: a systematic review and meta-analysis

Shu-Chen Liao, Shih-Chieh Shao, Yih-Ting Chen, Yung-Chang Chen & Ming-Jui Hung

Critical Care volume 24, Article number: 464 (2020)


Coronavirus disease 2019 (COVID-19) remains an increasing global pandemic, with significant morbidity and mortality. Severe complications of COVID-19 associated with coagulation changes, mainly characterized by increased D-dimer and fibrinogen levels with higher thrombosis risk, in particular pulmonary embolism (PE), have been reported recently [1]. However, the epidemiology of PE among COVID-19 patients is currently only based on small case series and retrospective studies. This systematic review and meta-analysis addresses this gap in knowledge, facilitating first-line healthcare providers’ understanding of PE incidence and mortality in COVID-19.


Keywords: SARS-CoV-2; COVID-19; Pulmonary embolism; Intensive Care.


High-flow #nasal #cannula #oxygen #therapy to treat patients with hypoxemic acute #respiratory #failure consequent to #SARS-CoV-2 infection (Thorax, abstract)

[Source: Thorax, full page: (LINK). Abstract, edited.]

High-flow nasal cannula oxygen therapy to treat patients with hypoxemic acute respiratory failure consequent to SARS-CoV-2 infection

Andrea Vianello1, Giovanna Arcaro2, Beatrice Molena2, Cristian Turato3, Andi Sukthi2, Gabriella Guarnieri2, Francesca Lugato2, Gianenrico Senna4, Paolo Navalesi5

Author affiliations: 1 Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy; 2 Department of Cardiac, Thoracic and Vascular Sciences, University-City Hospital of Padova, Padova, Italy; 3 Department of Molecular Medicine, University of Pavia, Pavia, Italy; 4 Department of Medicine, University of Verona, Verona, Italy; 5 Department of Medicine DIMED, University of Padova, Padova, Italy

Correspondence to Professor Andrea Vianello, -, Padova 35128,  Italy; andrea.vianello@aopd.veneto.it



This observational study aims to assess the outcome and safety of O2-therapy by high-flow nasal cannula (HFNC) in 28 consecutive patients with severe hypoxemic acute respiratory failure (hARF) consequent to SARS-CoV-2 infection, unresponsive to conventional O2-therapy. Nineteen patients had a positive response. Nine patients required escalation of treatment to non-invasive ventilation (five subsequently intubated). None of the staff had a positive swab testing during the study period and the following 14 days. Severity of hypoxemia and C reactive protein level were correlated with HFNC failure. These data suggest HFNC to be a safe treatment for less severe patients with SARS-CoV-2 hARF and efficacy will need to be assessed as part of a clinical trial.

This article is made freely available for use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

DOI: http://dx.doi.org/10.1136/thoraxjnl-2020-214993

Keywords: SARS-CoV-2; COVID-19; Intensive Care.


#Lung #ultrasound #score to monitor #COVID19 pneumonia #progression in patients with #ARDS (PLOS One, abstract)

[Source: PLOS One, full page: (LINK). Abstract, edited.]


Lung ultrasound score to monitor COVID-19 pneumonia progression in patients with ARDS

Auguste Dargent , Emeric Chatelain, Louis Kreitmann,  Jean-Pierre Quenot, Martin Cour, Laurent Argaud, the COVID-LUS study group

Published: July 21, 2020 | DOI: https://doi.org/10.1371/journal.pone.0236312



COVID-19 pneumonia typically begins with subpleural ground glass opacities with progressive extension on computerized tomography studies. Lung ultrasound is well suited to this interstitial, subpleural involvement, and it is now broadly used in intensive care units (ICUs). The extension and severity of lung infiltrates can be described numerically with a reproducible and validated lung ultrasound score (LUSS). We hypothesized that LUSS might be useful as a tool to non-invasively monitor the evolution of COVID-19 pneumonia at the bedside. LUSS monitoring was rapidly implemented in the management of our COVID-19 patients with RT-PCR-documented COVID-19. The LUSS was evaluated repeatedly at the bedside. We present a graphic description of the course of LUSS during COVID-19 in 10 consecutive patients admitted in our intensive care unit with moderate to severe ARDS between March 15 and 30th. LUSS appeared to be closely related to the disease progression. In successfully extubated patients, LUSS decreased and was lower than at the time of intubation. LUSS increased inexorably in a patient who died from refractory hypoxemia. LUSS helped with the diagnosis of ventilator-associated pneumonia (VAP), showing an increased score and the presence of new lung consolidations in all 5 patients with VAPs. There was also a good agreement between CT-scans and LUSS as for the presence of lung consolidations. In conclusion, our early experience suggests that LUSS monitoring accurately reflect disease progression and indicates potential usefulness for the management of COVID-19 patients with ARDS. It might help with early VAP diagnosis, mechanical ventilation weaning management, and potentially reduce the need for X-ray and CT exams. LUSS evaluation is easy to use and readily available in ICUs throughout the world, and might be a safe, cheap and simple tool to optimize critically ill COVID-19 patients care during the pandemic.


Citation: Dargent A, Chatelain E, Kreitmann L, Quenot J-P, Cour M, Argaud L, et al. (2020) Lung ultrasound score to monitor COVID-19 pneumonia progression in patients with ARDS. PLoS ONE 15(7): e0236312. https://doi.org/10.1371/journal.pone.0236312

Editor: Muhammad Adrish, BronxCare Health System, Affiliated with Icahn School of Medicine at Mount Sinai, NY, USA, UNITED STATES

Received: May 17, 2020; Accepted: July 4, 2020; Published: July 21, 2020

Copyright: © 2020 Dargent et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Keywords: SARS-CoV-2; COVID-19; Radiology; Intensive Care; ARDS.


#Pharmacokinetics of #lopinavir / #ritonavir #oral #solution to treat #COVID19 in mechanically ventilated #ICU patients (J Antimicrob Chemother., abstract)

[Source: Journal of Antimicrobial Chemotherapy, full page: (LINK). Abstract, edited.]

Pharmacokinetics of lopinavir/ritonavir oral solution to treat COVID-19 in mechanically ventilated ICU patients

Minh Patrick Lê, Pierre Jaquet, Juliette Patrier, Paul-Henri Wicky, Quentin Le Hingrat, Marc Veyrier, Juliette Kauv, Romain Sonneville, Benoit Visseaux, Cédric Laouénan, Lila Bouadma, Diane Descamps, Etienne de Montmollin, Gilles Peytavin, Jean-François Timsit

Journal of Antimicrobial Chemotherapy, dkaa261, https://doi.org/10.1093/jac/dkaa261

Published: 20 July 2020




The combination lopinavir/ritonavir is recommended to treat HIV-infected patients at the dose regimen of 400/100 mg q12h, oral route. The usual lopinavir trough plasma concentrations are 3000–8000 ng/mL. A trend towards a 28 day mortality reduction was observed in COVID-19-infected patients treated with lopinavir/ritonavir.


To assess the plasma concentrations of lopinavir and ritonavir in patients with severe COVID-19 infection and receiving lopinavir/ritonavir.

Patients and methods

Mechanically ventilated patients with COVID-19 infection included in the French COVID-19 cohort and treated with lopinavir/ritonavir were included. Lopinavir/ritonavir combination was administered using the usual adult HIV dose regimen (400/100 mg q12h, oral solution through a nasogastric tube). A half-dose reduction to 400/100 mg q24h was proposed if lopinavir Ctrough was >8000 ng/mL, the upper limit considered as toxic and reported in HIV-infected patients. Lopinavir and ritonavir pharmacokinetic parameters were determined after an intensive pharmacokinetic analysis. Biological markers of inflammation and liver/kidney function were monitored.


Plasma concentrations of lopinavir and ritonavir were first assessed in eight patients treated with lopinavir/ritonavir. Median (IQR) lopinavir Ctrough reached 27 908 ng/mL (15 928–32 627). After the dose reduction to 400/100 mg q24h, lopinavir/ritonavir pharmacokinetic parameters were assessed in nine patients. Lopinavir Ctrough decreased to 22 974 ng/mL (21 394–32 735).


In mechanically ventilated patients with severe COVID-19 infections, the oral administration of lopinavir/ritonavir elicited plasma exposure of lopinavir more than 6-fold the upper usual expected range. However, it remains difficult to safely recommend its dose reduction without compromising the benefit of the antiviral strategy, and careful pharmacokinetic and toxicity monitoring are needed.


Keywords: SARS-CoV-2; COVID-19; Intensive Care; ICU; Antivirals; Lopinavir/Ritonavir.