Source/Disclosures
Disclosures: The study was funded by the National Institute of Allergy and Infectious Diseases, the National Center for Advancing Translational Sciences, the NIH and the Columbia University Irving Institute for Clinical and Translational Research. Cummings is a minority shareholder at iCE Neurosystems. Please see the study for all other authors’ relevant financial disclosures. Grasselli reports he has received personal fees from Biotest, Draeger, Fisher & Paykel, Maquet, Merck Sharp & Dohme and Pfizer. Zanella reports no relevant financial disclosures.
May 20, 2020
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Mortality, mechanical ventilation common among critically ill patients with COVID-19 in NYC

Source/Disclosures
Disclosures: The study was funded by the National Institute of Allergy and Infectious Diseases, the National Center for Advancing Translational Sciences, the NIH and the Columbia University Irving Institute for Clinical and Translational Research. Cummings is a minority shareholder at iCE Neurosystems. Please see the study for all other authors’ relevant financial disclosures. Grasselli reports he has received personal fees from Biotest, Draeger, Fisher & Paykel, Maquet, Merck Sharp & Dohme and Pfizer. Zanella reports no relevant financial disclosures.
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Among patients with COVID-19 treated during the height of the pandemic in New York City, critical illness was common and was significantly associated with invasive mechanical ventilation, extrapulmonary organ dysfunction and in-hospital mortality, according to a study published in The Lancet.

“In the U.S., there have been almost 1.5 million cases of confirmed COVID-19 and nearly 90,000 deaths. Although the clinical spectrum of disease has been characterized in reports from China and Italy, until now, detailed understanding of how the virus is affecting critically ill patients in the U.S. has been limited to reports from a small number of cases. Our study aimed to identify risk factors associated with death in critically ill COVID-19 patients in a U.S. hospital setting,” Natalie Yip, MD, of the division of pulmonary, allergy and critical care medicine at Columbia University Irving Center, said in a press release.

The report included information on 1,150 adults with COVID-19 admitted to two NewYork-Presbyterian Hospitals affiliated with Columbia University from March 2 to April 1 who were followed for at least 28 days. Of these patients, 257 (22%) were critically ill with acute hypoxemic respiratory failure.

High incidence of mortality, mechanical ventilation

The researchers found that as of April 28, the last day of follow-up, 39% of critically ill patients had died after a median of 9 days in the hospital, 37% remained in the hospital with a median duration of hospitalization of 33 days and 23% were discharged alive. Most critically ill patients (80%) required invasive mechanical ventilation for a median of 18 days, 66% received vasopressors and 31% received renal replacement therapy. The median time to clinical deterioration after hospital admission was 3 days.

In terms of patient demographics, the median age was 62 years, approximately two-thirds were men and 62% were Hispanic or Latino. More than 82% had at least one chronic illness, most often hypertension (63%) and diabetes (36%). Notably, 46% of patients had obesity, including 71% of the 55 critically ill patients younger than 50 years. Patients presented to the hospital at a median of 5 days after onset of symptoms, which frequently included shortness of breath, fever, cough, muscle pain and diarrhea. Black or African American and Hispanic or Latino patients, however, tended to present later in their illness than white patients.

Five percent of critically ill patients were health care workers, although it could not be determined with certainty if they became infected while working in a clinical setting, the researchers noted.

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After adjustment for multiple covariates, the risk for in-hospital mortality appeared to be higher for older patients (adjusted HR = 1.31; 95% CI, 1.09-1.57), those with chronic cardiac disease (aHR = 1.76; 95% CI, 1.08-2.86), chronic pulmonary disease (aHR = 2.94; 95% CI, 1.48-5.84), higher concentrations of interleukin-6 (aHR = 1.11 per decile increase; 95% CI, 1.02-1.2) and higher concentrations of D-dimer (aHR = 1.1; 95% CI, 1.01-1.19).

Clinical implications

These findings, such as the higher rate of mechanical ventilation, differ somewhat from other smaller case series from the United States but are consistent with findings from other countries, including Italy, according to the researchers. These data, they noted, can help hospitals across the country prepare for potential health care needs during this time.

“Our study provides in-depth understanding of how COVID-19 may be affecting critically ill patients in U.S. hospitals. Of particular interest is the finding that over time, three-quarters of critically ill patients required a ventilator and almost one-third required renal dialysis support. This has important implications for resource allocation in hospitals, where access to equipment and specialized staff needed to deliver this level of care is limited,” Max O’Donnell, MD, of the division of pulmonary, allergy and critical care medicine, department of medicine, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, said in the release.

The researchers wrote, however, that their findings may not be generalizable to all populations and locations, as their study was concentrated at only two hospitals in New York City.

In an accompanying editorial, Giacomo Grasselli, MD, and Alberto Zanella, MD, both of the department of pathophysiology and transplantation at the University of Milan, noted that the study provides valuable information during a time when much is still unknown about COVID-19.

“The study by Cummings and colleagues shows that clinicians can produce high-quality research even when facing an overwhelming clinical workload. However, despite providing important insights, this work leaves us with some unanswered questions. While waiting for the availability of a COVID-19 vaccine, further studies are required to improve and personalize patient treatment, with particular attention to the role of initial noninvasive respiratory support strategies, timing of intubation, optimal setting of mechanical ventilation, and efficacy and safety of immunomodulating agents and anticoagulation strategies,” they wrote. – by Melissa Foster

Disclosures: The study was funded by the National Institute of Allergy and Infectious Diseases, the National Center for Advancing Translational Sciences, the NIH and the Columbia University Irving Institute for Clinical and Translational Research. Cummings is a minority shareholder at iCE Neurosystems. Please see the study for all other authors’ relevant financial disclosures. Grasselli reports he has received personal fees from Biotest, Draeger, Fisher & Paykel, Maquet, Merck Sharp & Dohme and Pfizer. Zanella reports no relevant financial disclosures.