Background Uncertainty about the optimal respiratory support strategies in critically ill COVID-19 patients is widespread. While the risks and benefits of noninvasive techniques versus early invasive mechanical ventilation (IMV) are intensely debated, actual evidence is lacking. We sought to assess the risks and benefits of different respiratory support strategies, employed in intensive care units during the first months of the COVID-19 pandemic on intubation and intensive care unit (ICU) mortality rates. Methods Subanalysis of a prospective, multinational registry of critically ill COVID-19 patients. Patients were subclassified into standard oxygen therapy ≥10 L/min (SOT), high-flow oxygen therapy (HFNC), noninvasive positive-pressure ventilation (NIV), and early IMV, according to the respiratory support strategy employed at the day of admission to ICU. Propensity score matching was performed to ensure comparability between groups. Results Initially, 1421 patients were assessed for possible study inclusion. Of these, 351 patients (85 SOT, 87 HFNC, 87 NIV, and 92 IMV) remained eligible for full analysis after propensity score matching. 55% of patients initially receiving noninvasive respiratory support required IMV. The intubation rate was lower in patients initially ventilated with HFNC and NIV compared to those who received SOT (SOT: 64%, HFNC: 52%, NIV: 49%, p = 0.025). Compared to the other respiratory support strategies, NIV was associated with a higher overall ICU mortality (SOT: 18%, HFNC: 20%, NIV: 37%, IMV: 25%, p = 0.016). Conclusion In this cohort of critically ill patients with COVID-19, a trial of HFNC appeared to be the most balanced initial respiratory support strategy, given the reduced intubation rate and comparable ICU mortality rate. Nonetheless, considering the uncertainty and stress associated with the COVID-19 pandemic, SOT and early IMV represented safe initial respiratory support strategies. The presented findings, in agreement with classic ARDS literature, suggest that NIV should be avoided whenever possible due to the elevated ICU mortality risk.

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Benign airway stenosis (BAS) is one of the most severe complications of endotracheal intubation. The aim of this pilot study was to compare the frequencies of four polymorphisms of the transforming growth factor (TGF) beta1 gene in patients with BAS due to endotracheal intubation (n = 36) and a control group of intensive care patients who had also undergone endotracheal intubation but did not present BAS (n = 30). One of the studied polymorphisms, the -509 C/T, demonstrated a differential genotype distribution between the affected and the control population: the ratio of heterozygous mutants was significantly (P = 0.0116) higher among the control patients. These data suggest a protective function of the frequent heterozygous C/T genotype against BAS; alternatively, the C/C genotype might be a susceptibility factor for BAS (OR 4.5; 95% CI 1.5123-13.3902). Our findings suggest that, besides other iatrogenic factors, a genetic predisposition might contribute to the pathogenesis of BAS.

Diabetes mellitus increases smooth muscle tone and causes tissue remodelling affecting elastin and collagen. Since lung is dominated by these elements, diabetes is expected to modify the airway function and respiratory tissue mechanics. Therefore, we characterized the respiratory function in patients with diabetes with and without associated obesity. Mechanically ventilated patients with normal body shapes were divided into the control non-diabetic (n=73) and diabetic (n=31) groups. The other two groups included obese patients without diabetes (n=43) or with diabetes (n=30). The mechanical properties of the respiratory system were determined by forced oscillation technique. Airway resistance (Raw), tissue damping (G), and tissue elastance (H) were assessed by forced oscillation. Capnography was applied to determine phase 3 slopes and dead space indices. The intrapulmonary shunt fraction (Qs/Qt) and the lung oxygenation index (PaO2/FiO2) were estimated from arterial and central venous blood samples. Compared with the corresponding control groups, diabetes alone increased the Raw (7.6 ± 6 cmH2O.s/l vs. 3.1 ± 1.9 cmH2O.s/l), G (11.7 ± 5.5 cmH2O/l vs. 6.5 ± 2.8 cmH2O/l), and H (31.5 ± 11.8 cmH2O/l vs. 24.2 ± 7.2 cmH2O/l, (p < 0.001 for all). Diabetes increased the capnographic phase 3 slope, whereas PaO2/FiO2 or Qs/Qt were not affected. Obesity alone caused similar detrimental changes in respiratory mechanics and alveolar heterogeneity, but these alterations also compromised gas exchange. We conclude that diabetes-induced intrinsic mechanical abnormalities are counterbalanced by hypoxic pulmonary vasoconstriction, which maintained intrapulmonary shunt fraction and oxygenation ability of the lungs.

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Background It remains elusive how the characteristics, the course of disease, the clinical management and the outcomes of critically ill COVID-19 patients admitted to intensive care units (ICU) worldwide have changed over the course of the pandemic. Methods Prospective, observational registry constituted by 90 ICUs across 22 countries worldwide including patients with a laboratory-confirmed, critical presentation of COVID-19 requiring advanced organ support. Hierarchical, generalized linear mixed-effect models accounting for hospital and country variability were employed to analyse the continuous evolution of the studied variables over the pandemic. Results Four thousand forty-one patients were included from March 2020 to September 2021. Over this period, the age of the admitted patients (62 [95% CI 60–63] years vs 64 [62–66] years, p < 0.001) and the severity of organ dysfunction at ICU admission decreased (Sequential Organ Failure Assessment 8.2 [7.6–9.0] vs 5.8 [5.3–6.4], p < 0.001) and increased, while more female patients (26 [23–29]% vs 41 [35–48]%, p < 0.001) were admitted. The time span between symptom onset and hospitalization as well as ICU admission became longer later in the pandemic (6.7 [6.2–7.2| days vs 9.7 [8.9–10.5] days, p < 0.001). The PaO2/FiO2 at admission was lower (132 [123–141] mmHg vs 101 [91–113] mmHg, p < 0.001) but showed faster improvements over the initial 5 days of ICU stay in late 2021 compared to early 2020 (34 [20–48] mmHg vs 70 [41–100] mmHg, p = 0.05). The number of patients treated with steroids and tocilizumab increased, while the use of therapeutic anticoagulation presented an inverse U-shaped behaviour over the course of the pandemic. The proportion of patients treated with high-flow oxygen (5 [4–7]% vs 20 [14–29], p < 0.001) and non-invasive mechanical ventilation (14 [11–18]% vs 24 [17–33]%, p < 0.001) throughout the pandemic increased concomitant to a decrease in invasive mechanical ventilation (82 [76–86]% vs 74 [64–82]%, p < 0.001). The ICU mortality (23 [19–26]% vs 17 [12–25]%, p < 0.001) and length of stay (14 [13–16] days vs 11 [10–13] days, p < 0.001) decreased over 19 months of the pandemic. Conclusion Characteristics and disease course of critically ill COVID-19 patients have continuously evolved, concomitant to the clinical management, throughout the pandemic leading to a younger, less severely ill ICU population with distinctly different clinical, pulmonary and inflammatory presentations than at the onset of the pandemic.

2019 decemberében új koronavírus okozta járvány ütötte fel a fejét a kínai Wuhanban. Az azonosított kórokozó egy új koronavírus, melyet "severe acute respiratory syndrome coronavirus 2"-nek, azaz SARS-CoV-2-nek neveztek el, az általa kiváltott légzési tünetegyüttes pedig a "coronavirus disease 2019", azaz COVID-19 nevet kapta. Az Egészségügyi Világszervezet (WHO) a járványt 2020 márciusában pandémiává minősítette. Áttekintettük a jelenleg elérhető nemzetközi irodalmat a COVID-19-járvány vonatkozásában. Írásunkban az új koronavírus diagnosztikájára és prognosztikájára vonatkozó releváns információkat összegezzük. Részletezzük a klinikai gyanú felvetéséhez szükséges anamnesztikus tényezőket és kezdeti vizsgálati eredményeket, a mikrobiológiai mintavétel módját, a molekuláris diagnosztikai tesztre -az arany standardnak minősülő 'real-time' reverztranszkriptáz polimeráz-láncreakcióra (RT-PCR) -vonatkozó alapvető információkat, különös tekintettel a diagnosztikus tesztelést érintő, jelenleg érvényben lévő népegészségügyi szabályozásra. Hangsúlyt fektetünk továbbá a nagy rizikójú betegek paramétereire és felismerésük módjára. A COVID-19-pandémia Magyarországon is jelentős járványügyi és egészségügyi következményekkel járhat. A járvány lassítására irányuló epidemiológiai intézkedéseken túl a már fertőzött személyek időbeli felismerése és megfelelő kórházi ellátása mortalitási szempontból is kulcskérdés. A kritikus állapotú betegek esélyeit csak magas minőségű, körültekintő intenzív terápiás ellátással lehet javítani, s hogy a legjobbat tudjuk nyújtani, hasznos, ha felhasználjuk a már endémiás országokban dolgozó orvoskollégák tapasztalatait. Orv Hetil. 2020; 160(17): 667-671. and bedside estimation of the prognosis in COVID-19 patients]. Orv Hetil. 2020; 161(17): 667-671. (Beérkezett: 2020. március 27.; elfogadva: 2020. március 30.) Rövidítések APTI = aktivált parciális tromboplasztinidő; BAL = bronchoalveolaris lavage; CMV = cytomegalovirus; COVID-19 = (coronavirus disease 2019) koronavírus-betegség 2019; CT = (computed tomography) számítógépes tomográfia; EBV = Epstein-Barr-vírus; H 1 N 1 = a hemagglutinin 1-es és a neuraminidáz 1-es típusát tartalmazó vírus; HSV = herpes simplex virus; LDH = laktátdehidrogenáz; MERS = (Middle East respiratory syndrome) közel-keleti légzési szindróma; pH = pondus hidrogenii; pCO 2 = (partial pressure of carbon dioxide) a széndioxid parciális nyomása; PCR = (polymerase chain reaction) polimeráz-láncreakció; RNS = ribonukleinsav; RS-vírus = respiratory syncytial virus; RT-PCR = (real-time reverse transcriptase polymerase chain reaction) valós idejű reverztranszkriptáz PCR; SARS-CoV = (severe acute respiratory syndrome coronavirus) heveny akut légzési szindrómát okozó koronavírus; SARS-CoV-2 = (severe acute respiratory syndrome coronavirus 2) SARS-koronavírus-2; SOFA = (sequential organ failure assessment) a szervi elégtelenség súlyossági pontrendszere; WHO = (World Health Organization) Egészségügyi Világszervezet

Premature ventricular contractions (PVC-s) induce baroreflex mediated arterial pressure and heart rate fluctuations. PVC-related RR interval fluctuations detected on Holter ECG recordings could be characterized by the heart rate turbulence (HRT) parameters, including early post-extrasystolic acceleration, described by turbulence onset, and late deceleration, described by turbulence slope (TS). We have determined the increasing and decreasing spontaneous baroreflex sequence sensitivity (up- and down-BRS) parameters in supine and in upright position in 12 patients with VVI pacemaker while in sinus rhythm. Five-five premature ventricular pacemaker extrastmuli were also applied in both body positions and HRT parameters were calculated. Up- and down-BRS values showed a very close relationship with TS both in the supine (R = 0.94, P < 0.001 and R = 0.92, P < 0.001, respectively), and upright position (R = 0.96, P < 0.001, and R = 0.94, P < 0.001, respectively). The BRS indices decreased significantly upon tilting, which was paralleled by a significant decrease in TS (from 21.6 to 13.9 ms/cycle, P = 0.02). Our findings confirm the close association between TS and spontaneous BRS indices. The relationship is further supported by the similar postural behavior of these parameters. Our results suggest that the confounding effect of posture should be considered when analyzing Holter recordings.