Faculty Bibliography

INTRODUCTION/BACKGROUND:Legionella pneumophila is an important cause of pneumonia, however there is scant literature assessing the therapeutic benefit of corticosteroids in treatment. We sought to investigate the association between corticosteroid use and in-hospital mortality for patients hospitalized with Legionella pneumonia. METHODS:Data was collected retrospectively 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. Exclusion criteria included age <18, concurrent immunosuppression, and HIV diagnosis. We assessed the relationship between corticosteroid use and in-hospital mortality. Statistical analyses were performed in RStudio. RESULTS:The study included 160 patients, among which 32 (20%) received steroids. Overall mortality was 7.5% (12.5% among steroid recipients, 6.2% among controls). 25% of patients were admitted to the ICU (37.5% among steroid recipients, 21.9% among controls). Adjusted analysis showed steroid recipients did not have significantly different mortality (aOR = 2.56, p = 0.436). Steroid use was not significantly associated with longer LOS (p = 0.22). Steroid use was significantly associated with hyperglycemia (aOR = 2.91, p = 0.018) and GI bleed (OR = 9.0, p = 0.014). CONCLUSIONS:We found that in patients hospitalized with Legionella pneumonia, corticosteroid administration was not significantly associated with longer hospitalization or mortality. All findings held true when adjusting for known predictors of pneumonia severity. Corticosteroid use was associated with increased rates of hyperglycemia and GIB requiring blood transfusion. The results of this study are consistent with guidelines recommending against routine use of corticosteroids in CAP.

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.

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

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.

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

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.

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.

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.

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.