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Inhaled pulmonary vasodilators are not associated with improved gas exchange in mechanically ventilated patients with COVID-19: A retrospective cohort study

Lubinsky, Anthony Steven; Brosnahan, Shari B; Lehr, Andrew; Elnadoury, Ola; Hagedorn, Jacklyn; Garimella, Bhaskara; Bender, Michael T; Amoroso, Nancy; Artigas, Antonio; Bos, Lieuwe D J; Kaufman, David
PURPOSE/OBJECTIVE:Measure the effect of inhaled pulmonary vasodilators on gas exchange in mechanically ventilated patients with COVID-19. METHODS:ratio, oxygenation Index (OI), and ventilatory ratio (VR) after initiation of inhaled pulmonary vasodilators. RESULTS:, OI and VR did not significantly change over a five day period starting the day prior to drug initiation in patients who received either iNO or iEPO assessed with a fixed effects model. CONCLUSION/CONCLUSIONS:Inhaled pulmonary vasodilators were not associated with significant improvement in gas exchange in mechanically ventilated patients with COVID-19.
PMCID:8847100
PMID: 35180636
ISSN: 1557-8615
CID: 5163672

Effects of corticosteroids in hospitalized patients with legionella pneumonia cohort study [Meeting Abstract]

Beaty, W; Elnadoury, O; Lubinsky, A
INTRODUCTION: Legionella pneumophila is an important cause of both community and hospital-acquired pneumonia. Despite this, little literature has assessed the therapeutic benefit of corticosteroid use and no specific guidelines exist. We sought to investigate the association between corticosteroid use and in-hospital mortality for patients hospitalized with Legionella pneumonia.
METHOD(S): Data was retrospectively collected from January 2012 to July 2019 at a 705 bed hospital in New York City. Patients were included if they received a positive Legionella test via serology, urine antigen, or culture. Exclusion criteria included prior immunosuppressive therapy, prior systemic corticosteroid use, and HIV diagnosis. We assessed the relationship between corticosteroid use and in-hospital mortality, ICU admission, and length of hospitalization. Statistical analyses were performed in RStudio.
RESULT(S): The study included 160 patients, among which 32 (20%) received corticosteroids. Overall mortality was 7.5% (12.5% among corticosteroid recipients, 6.2% among controls). 25% of patients were admitted to the ICU (37.5% among corticosteroid recipients, 21.9% among controls). Case-controlled logistic regression showed corticosteroid use was not significantly associated with mortality (aOR = 2.48 [95% CI: 0.24, 25.9], p=.45) with a trend towards increased ICU admissions (aOR = 2.21 [0.87, 5.61], p=.09). Linear regression showed corticosteroid use was not significantly associated with a change in hospitalization length (Adjusted Coefficient: 1.65 days [-1.00, 4.31], p=.22).
CONCLUSION(S): We found that in patients hospitalized with Legionella pneumonia, patients who were given corticosteroids were not significantly associated with longer hospitalization, mortality, or ICU admissions. All findings held true when adjusting for known predictors of pneumonia severity. It is possible that differences in outcomes were due to underlying variation in demographics or illness severity not captured by known confounds. Because pneumonia generally has a low mortality rate, it is difficult to adequately power studies to capture therapeutic benefit. Legionella often goes undiagnosed and the true burden may not be fully understood. Further randomized studies are necessary to elucidate specific patient populations that may benefit from therapy
EMBASE:637190318
ISSN: 1530-0293
CID: 5158312

Microbial signatures in the lower airways of mechanically ventilated COVID-19 patients associated with poor clinical outcome

Sulaiman, Imran; Chung, Matthew; Angel, Luis; Tsay, Jun-Chieh J; Wu, Benjamin G; Yeung, Stephen T; Krolikowski, Kelsey; Li, Yonghua; Duerr, Ralf; Schluger, Rosemary; Thannickal, Sara A; Koide, Akiko; Rafeq, Samaan; Barnett, Clea; Postelnicu, Radu; Wang, Chang; Banakis, Stephanie; Pérez-Pérez, Lizzette; Shen, Guomiao; Jour, George; Meyn, Peter; Carpenito, Joseph; Liu, Xiuxiu; Ji, Kun; Collazo, Destiny; Labarbiera, Anthony; Amoroso, Nancy; Brosnahan, Shari; Mukherjee, Vikramjit; Kaufman, David; Bakker, Jan; Lubinsky, Anthony; Pradhan, Deepak; Sterman, Daniel H; Weiden, Michael; Heguy, Adriana; Evans, Laura; Uyeki, Timothy M; Clemente, Jose C; de Wit, Emmie; Schmidt, Ann Marie; Shopsin, Bo; Desvignes, Ludovic; Wang, Chan; Li, Huilin; Zhang, Bin; Forst, Christian V; Koide, Shohei; Stapleford, Kenneth A; Khanna, Kamal M; Ghedin, Elodie; Segal, Leopoldo N
Respiratory failure is associated with increased mortality in COVID-19 patients. There are no validated lower airway biomarkers to predict clinical outcome. We investigated whether bacterial respiratory infections were associated with poor clinical outcome of COVID-19 in a prospective, observational cohort of 589 critically ill adults, all of whom required mechanical ventilation. For a subset of 142 patients who underwent bronchoscopy, we quantified SARS-CoV-2 viral load, analysed the lower respiratory tract microbiome using metagenomics and metatranscriptomics and profiled the host immune response. Acquisition of a hospital-acquired respiratory pathogen was not associated with fatal outcome. Poor clinical outcome was associated with lower airway enrichment with an oral commensal (Mycoplasma salivarium). Increased SARS-CoV-2 abundance, low anti-SARS-CoV-2 antibody response and a distinct host transcriptome profile of the lower airways were most predictive of mortality. Our data provide evidence that secondary respiratory infections do not drive mortality in COVID-19 and clinical management strategies should prioritize reducing viral replication and maximizing host responses to SARS-CoV-2.
PMID: 34465900
ISSN: 2058-5276
CID: 4998422

Experience of nurses caring for covid-19 patients supported by vv ecmo after educational ecmo crash course [Meeting Abstract]

Emmarco, A; Toy, B; Pavone, J; Lubinsky, A S; Goldenberg, R; Smith, D E
Introduction: During a six-week period beginning in early March 2020, thirty patients with severe COVID-19 were supported with VV-ECMO. This volume increase mandated rapidly training 116 nurses with no prior ECMO experience via a two-hour crash course. A qualitative study was conducted to evaluate the experiences of this unique nursing cohort.
Method(s): A total of 14 nurses were enrolled. Eligibility criteria included direct assignment of COVID-19 ECMO patients, attendance of the crash course, and no prior ECMO experience. Two semi-structured interviews were conducted. The first interview involved collecting demographics and asking a series of eight opened ended questions. The follow-up interview allowed each subject time for reflection and validated the initial interaction. All interviews were audio recorded and transcribed verbatim utilizing a transcription service. Thematic analysis of the interviews was completed using Colaizzi's phenomenological method.
Result(s): Of the 14 subjects, 13 completed the study in its entirety with one subject not completing the follow-up interview. Themes identified were anxiety, fear of patient harm, value of didactic education with reinforced clinical experience, team collaboration, professional growth, pride, and compassion. Newly trained nurses found patient care to be rewarding and viewed ECMO as a hopeful opportunity during the pandemic. Nurses also verbalized feeling better equipped to face future emergencies or pandemics.
Conclusion(s): Nurses faced multiple obstacles during the pandemic. ECMO added a layer of complexity, as these patients required labor-intensive, highly acute nursing care. The impact of the pandemic and its unique challenges on nursing and medical staff warrants further investigation
EMBASE:636263397
ISSN: 1538-943x
CID: 5179402

Microbial signatures in the lower airways of mechanically ventilated COVID19 patients associated with poor clinical outcome

Sulaiman, Imran; Chung, Matthew; Angel, Luis; Koralov, Sergei; Wu, Benjamin; Yeung, Stephen; Krolikowski, Kelsey; Li, Yonghua; Duerr, Ralf; Schluger, Rosemary; Thannickal, Sara; Koide, Akiko; Rafeq, Samaan; Barnett, Clea; Postelnicu, Radu; Wang, Chang; Banakis, Stephanie; Perez-Perez, Lizzette; Jour, George; Shen, Guomiao; Meyn, Peter; Carpenito, Joseph; Liu, Xiuxiu; Ji, Kun; Collazo, Destiny; Labarbiera, Anthony; Amoroso, Nancy; Brosnahan, Shari; Mukherjee, Vikramjit; Kaufman, David; Bakker, Jan; Lubinsky, Anthony; Pradhan, Deepak; Sterman, Daniel; Heguy, Adriana; Uyeki, Timothy; Clemente, Jose; de Wit, Emmie; Schmidt, Ann Marie; Shopsin, Bo; Desvignes, Ludovic; Wang, Chan; Li, Huilin; Zhang, Bin; Forst, Christian; Koide, Shohei; Stapleford, Kenneth; Khanna, Kamal; Ghedin, Elodie; Weiden, Michael; Segal, Leopoldo
Mortality among patients with COVID-19 and respiratory failure is high and there are no known lower airway biomarkers that predict clinical outcome. We investigated whether bacterial respiratory infections and viral load were associated with poor clinical outcome and host immune tone. We obtained bacterial and fungal culture data from 589 critically ill subjects with COVID-19 requiring mechanical ventilation. On a subset of the subjects that underwent bronchoscopy, we also quantified SARS-CoV-2 viral load, analyzed the microbiome of the lower airways by metagenome and metatranscriptome analyses and profiled the host immune response. We found that isolation of a hospital-acquired respiratory pathogen was not associated with fatal outcome. However, poor clinical outcome was associated with enrichment of the lower airway microbiota with an oral commensal ( Mycoplasma salivarium ), while high SARS-CoV-2 viral burden, poor anti-SARS-CoV-2 antibody response, together with a unique host transcriptome profile of the lower airways were most predictive of mortality. Collectively, these data support the hypothesis that 1) the extent of viral infectivity drives mortality in severe COVID-19, and therefore 2) clinical management strategies targeting viral replication and host responses to SARS-CoV-2 should be prioritized.
PMCID:8010736
PMID: 33791687
ISSN: n/a
CID: 4830952

Use of a Multidisciplinary Mechanical Ventilation Weaning Protocol to Improve Patient Outcomes and Empower Staff in a Medical Intensive Care Unit

Gunther, Ingrid; Pradhan, Deepak; Lubinsky, Anthony; Urquhart, Annie; Thompson, Julie A; Reynolds, Staci
BACKGROUND:Prolonged duration of mechanical ventilation is associated with higher mortality and increased patient complications; conventional physician-directed weaning methods are highly variable and permit significant time that weaning is inefficient and ineffective. OBJECTIVES/OBJECTIVE:The primary objective of this quality improvement project was to implement a registered nurse (RN)- and respiratory therapist (RT)-driven mechanical ventilation weaning protocol in a medical intensive care unit (ICU) at a tertiary care academic medical center. METHODS:This quality improvement project used a quasi-experimental design with a retrospective usual care group who underwent physician-directed (conventional) weaning (n = 51) and a prospective intervention group who underwent protocol-directed weaning (n = 54). Outcomes included duration of mechanical ventilation, ICU length of stay, reintubation rates, and RN and RT satisfaction with the weaning protocol. RESULTS:Patients in the RN- and RT-driven mechanical ventilation weaning protocol group had significantly lower duration of mechanical ventilation (74 vs 152 hours; P = .002) and ICU length of stay (6.7 vs 10.2 days; P = .031). There was no significant difference in reintubation rates between groups. Staff surveys indicate that both RN and RTs were satisfied with the process change. DISCUSSION/CONCLUSIONS:Implementation of a multidisciplinary mechanical ventilation weaning protocol is a safe and effective way to improve patient outcomes and empower ICU staff.
PMID: 33961373
ISSN: 1538-8646
CID: 4897792

Microbial signatures in the lower airways of mechanically ventilated COVID19 patients associated with poor clinical outcome

Sulaiman, Imran; Chung, Matthew; Angel, Luis; Tsay, Jun-Chieh J; Wu, Benjamin G; Yeung, Stephen T; Krolikowski, Kelsey; Li, Yonghua; Duerr, Ralf; Schluger, Rosemary; Thannickal, Sara A; Koide, Akiko; Rafeq, Samaan; Barnett, Clea; Postelnicu, Radu; Wang, Chang; Banakis, Stephanie; Perez-Perez, Lizzette; Jour, George; Shen, Guomiao; Meyn, Peter; Carpenito, Joseph; Liu, Xiuxiu; Ji, Kun; Collazo, Destiny; Labarbiera, Anthony; Amoroso, Nancy; Brosnahan, Shari; Mukherjee, Vikramjit; Kaufman, David; Bakker, Jan; Lubinsky, Anthony; Pradhan, Deepak; Sterman, Daniel H; Weiden, Michael; Hegu, Adriana; Evans, Laura; Uyeki, Timothy M; Clemente, Jose C; De Wit, Emmie; Schmidt, Ann Marie; Shopsin, Bo; Desvignes, Ludovic; Wang, Chan; Li, Huilin; Zhang, Bin; Forst, Christian V; Koide, Shohei; Stapleford, Kenneth A; Khanna, Kamal M; Ghedin, Elodie; Segal, Leopoldo N
Mortality among patients with COVID-19 and respiratory failure is high and there are no known lower airway biomarkers that predict clinical outcome. We investigated whether bacterial respiratory infections and viral load were associated with poor clinical outcome and host immune tone. We obtained bacterial and fungal culture data from 589 critically ill subjects with COVID-19 requiring mechanical ventilation. On a subset of the subjects that underwent bronchoscopy, we also quantified SARS-CoV-2 viral load, analyzed the microbiome of the lower airways by metagenome and metatranscriptome analyses and profiled the host immune response. We found that isolation of a hospital-acquired respiratory pathogen was not associated with fatal outcome. However, poor clinical outcome was associated with enrichment of the lower airway microbiota with an oral commensal ( Mycoplasma salivarium ), while high SARS-CoV-2 viral burden, poor anti-SARS-CoV-2 antibody response, together with a unique host transcriptome profile of the lower airways were most predictive of mortality. Collectively, these data support the hypothesis that 1) the extent of viral infectivity drives mortality in severe COVID-19, and therefore 2) clinical management strategies targeting viral replication and host responses to SARS-CoV-2 should be prioritized.
PMCID:7924286
PMID: 33655261
ISSN: n/a
CID: 4801472

Evaluation of the Lower Airway Microbiota in Patients with Severe SARS-CoV2 [Meeting Abstract]

Barnett, C. R.; Sulaiman, I; Tsay, J-C; Wu, B.; Krolikowski, K.; Li, Y.; Postelnicu, R.; Carpenito, J.; Rafeq, S.; Clemente, J. C.; Angel, L. F.; Mukherjee, V; Pradhan, D.; Brosnahan, S.; Lubinsky, A. S.; Yeung, S.; Jour, G.; Shen, G.; Chung, M.; Khanna, K.; Ghedin, E.; Segal, L. N.
ISI:000685468900221
ISSN: 1073-449x
CID: 5230292

Uninterrupted Continuous and Intermittent Nebulizer Therapy in a COVID-19 Patient Using Sequential Vibratory Mesh Nebulizers: A Case Report

Elnadoury, Ola; Beattie, Jason; Lubinsky, Anthony S
Interruptions in continuous nebulized pulmonary vasodilators, such as epoprostenol, can potentially result in clinical deterioration in respiratory status. Coadministration of other intermittent nebulized therapies may require opening the ventilator circuit to facilitate administration. However, in patients with SARS-CoV2 infection, it is preferred to avoid opening the circuit whenever feasible to prevent aerosolization of the virus and exposure of health care workers. In this study, we describe a unique method of administering continuous epoprostenol nebulization and intermittent nebulized antibiotics, mucolytics, and bronchodilators, using Aerogen vibrating mesh nebulizers without interruptions in epoprostenol or opening the ventilator circuit. This technique set up consisted of stacking two Aerogen nebulizer cups, each with its own controller. This approach was successful in allowing concomitant delivery of intermittent and continuous nebulized therapy without interruptions. To our knowledge, this method has not been previously described in the literature and may be helpful to bedside clinicians facing a similar clinical scenario.
PMID: 32852238
ISSN: 1941-2703
CID: 4629732

Where to start? A single center retrospective analysis of early liberation from mechanical ventilation in vv ECMO patients with acute respiratory failure [Meeting Abstract]

Gunther, I; Toy, B; Andriotis, A; Hagedorn, J; Morgenstern, T; Staccone, L; Smith, D; Lubinsky, A
Intro: The optimal strategy for weaning of respiratory support during lung recovery of patients requiring VV ECMO for acute respiratory failure is unknown. We hypothesized that earlier liberation from the ventilator in these patients may correlate with improved outcomes.
Method(s): We retrospectively reviewed all VV ECMO patients at our center from November 2015 to May 2019. Patients who were on VV ECMO as bridge to transplant or for isolated intraoperative indications were excluded. The final study population included 18 patients; 6 were liberated from mechanical ventilation prior to ECMO decannulation and 12 were decannulated from ECMO, but remained mechanically ventilated. Demographics and outcomes were compared between the two groups.
Result(s): Patients liberated from the ventilator prior to ECMO were treated for asthma, pneumonia and vasculitis (33% each) versus predominantly pneumonia (58%), had a lower rate of pre-existing lung disease (17% vs 33%), and lower APACHE II scores (median of 21 vs 24). These patients had longer duration of ECMO (220 vs 205 hours), less ventilator days (5 vs 20.5 days), higher average Richmond Agitation Scores (-1 vs -3), fewer days until they were able to get out of bed (4.5 vs 15 days), shorter ICU stays (16 vs 29 days), and were more likely to survive to hospital discharge (100% vs 67%).
Conclusion(s): Early ventilator liberation of patients on VV ECMO was associated with improved outcomes. Our study is limited by small sample size, retrospective design, and potential for confounding due to baseline differences between groups
EMBASE:631095458
ISSN: 1538-943x
CID: 4387222