COVID-19 ARDS is characterized by higher extravascular lung water than non-COVID-19 ARDS: the PiCCOVID study

Rui Shi, Christopher Lai, Jean-Louis Teboul, Martin Dres, Francesca Moretto, Nello De Vita, Tài Pham, Vincent Bonny, Julien Mayaux, Rosanna Vaschetto, Alexandra Beurton, Xavier Monnet, Rui Shi, Christopher Lai, Jean-Louis Teboul, Martin Dres, Francesca Moretto, Nello De Vita, Tài Pham, Vincent Bonny, Julien Mayaux, Rosanna Vaschetto, Alexandra Beurton, Xavier Monnet

Abstract

Background: In acute respiratory distress syndrome (ARDS), extravascular lung water index (EVLWi) and pulmonary vascular permeability index (PVPI) measured by transpulmonary thermodilution reflect the degree of lung injury. Whether EVLWi and PVPI are different between non-COVID-19 ARDS and the ARDS due to COVID-19 has never been reported. We aimed at comparing EVLWi, PVPI, respiratory mechanics and hemodynamics in patients with COVID-19 ARDS vs. ARDS of other origin.

Methods: Between March and October 2020, in an observational study conducted in intensive care units from three university hospitals, 60 patients with COVID-19-related ARDS monitored by transpulmonary thermodilution were compared to the 60 consecutive non-COVID-19 ARDS admitted immediately before the COVID-19 outbreak between December 2018 and February 2020.

Results: Driving pressure was similar between patients with COVID-19 and non-COVID-19 ARDS, at baseline as well as during the study period. Compared to patients without COVID-19, those with COVID-19 exhibited higher EVLWi, both at the baseline (17 (14-21) vs. 15 (11-19) mL/kg, respectively, p = 0.03) and at the time of its maximal value (24 (18-27) vs. 21 (15-24) mL/kg, respectively, p = 0.01). Similar results were observed for PVPI. In COVID-19 patients, the worst ratio between arterial oxygen partial pressure over oxygen inspired fraction was lower (81 (70-109) vs. 100 (80-124) mmHg, respectively, p = 0.02) and prone positioning and extracorporeal membrane oxygenation (ECMO) were more frequently used than in patients without COVID-19. COVID-19 patients had lower maximal lactate level and maximal norepinephrine dose than patients without COVID-19. Day-60 mortality was similar between groups (57% vs. 65%, respectively, p = 0.45). The maximal value of EVLWi and PVPI remained independently associated with outcome in the whole cohort.

Conclusion: Compared to ARDS patients without COVID-19, patients with COVID-19 had similar lung mechanics, but higher EVLWi and PVPI values from the beginning of the disease. This was associated with worse oxygenation and with more requirement of prone positioning and ECMO. This is compatible with the specific lung inflammation and severe diffuse alveolar damage related to COVID-19. By contrast, patients with COVID-19 had fewer hemodynamic derangement. Eventually, mortality was similar between groups.

Trial registration number and date of registration: ClinicalTrials.gov (NCT04337983). Registered 30 March 2020-Retrospectively registered, https://ichgcp.net/clinical-trials-registry/NCT04337983 .

Keywords: Hemodynamic monitoring; Mechanical ventilation; SARS-CoV-2; Transpulmonary thermodilution.

Conflict of interest statement

Drs. Jean-Louis Teboul and Xavier Monnet are members of the Medical Advisory Board of Pulsion medical systems. Dr. Martin DRES received personal fees from Lungpacer (Honorarium, travel expenses). The other authors have no conflict of interest to declare.

Figures

Fig. 1
Fig. 1
Distribution of levels of extravascular lung water index along with time in COVID-19 and non-COVID-19 acute respiratory distress syndrome
Fig. 2
Fig. 2
Levels of maximum value of extravascular lung water index in COVID-19 and non-COVID-19 acute respiratory distress syndrome

References

    1. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020;382:1708–1720. doi: 10.1056/NEJMoa2002032.
    1. Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med. 2020;8:475–481. doi: 10.1016/S2213-2600(20)30079-5.
    1. Cummings MJ, Baldwin MR, Abrams D, Jacobson SD, Meyer BJ, Balough EM, et al. Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study. Lancet. 2020;395:1763–1770. doi: 10.1016/S0140-6736(20)31189-2.
    1. Grasselli G, Pesenti A, Cecconi M. Critical care utilization for the COVID-19 outbreak in Lombardy, Italy: early experience and forecast during an emergency response. JAMA. 2020;323:1545–1546. doi: 10.1001/jama.2020.4031.
    1. Gattinoni L, Coppola S, Cressoni M, Busana M, Rossi S, Chiumello D. COVID-19 does not lead to a "Typical" acute respiratory distress syndrome. Am J Respir Crit Care Med. 2020;201:1299–1300. doi: 10.1164/rccm.202003-0817LE.
    1. Gattinoni L, Chiumello D, Caironi P, Busana M, Romitti F, Brazzi L, et al. COVID-19 pneumonia: different respiratory treatments for different phenotypes? Intensive Care Med. 2020;46:1099–1102. doi: 10.1007/s00134-020-06033-2.
    1. Rello J, Storti E, Belliato M, Serrano R. Clinical phenotypes of SARS-CoV-2: implications for clinicians and researchers. Eur Respir J. 2020;55:2001028. doi: 10.1183/13993003.01028-2020.
    1. Azoulay E, Zafrani L, Mirouse A, Lengliné E, Darmon M, Chevret S. Clinical phenotypes of critically ill COVID-19 patients. Intensive Care Med. 2020;46:1651–1652. doi: 10.1007/s00134-020-06120-4.
    1. Grasselli G, Tonetti T, Protti A, Langer T, Girardis M, Bellani G, et al. Pathophysiology of COVID-19-associated acute respiratory distress syndrome: a multicentre prospective observational study. Lancet Respir Med. 2020;8:1201–1208. doi: 10.1016/S2213-2600(20)30370-2.
    1. Haudebourg AF, Perier F, Tuffet S, de Prost N, Razazi K, Mekontso Dessap A, et al. Respiratory mechanics of COVID-19- versus non-COVID-19-associated acute respiratory distress syndrome. Am J Respir Crit Care Med. 2020;202:287–290. doi: 10.1164/rccm.202004-1226LE.
    1. Grieco DL, Bongiovanni F, Chen L, Menga LS, Cutuli SL, Pintaudi G, et al. Respiratory physiology of COVID-19-induced respiratory failure compared to ARDS of other etiologies. Crit Care. 2020;24:529. doi: 10.1186/s13054-020-03253-2.
    1. Tang X, Du RH, Wang R, Cao TZ, Guan LL, Yang CQ, et al. Comparison of hospitalized patients with ARDS caused by COVID-19 and H1N1. Chest. 2020;158:195–205. doi: 10.1016/j.chest.2020.03.032.
    1. Chiumello D, Busana M, Coppola S, Romitti F, Formenti P, Bonifazi M, et al. Physiological and quantitative CT-scan characterization of COVID-19 and typical ARDS: a matched cohort study. Intensive Care Med. 2020;46:2187–2196. doi: 10.1007/s00134-020-06281-2.
    1. Ferrando C, Suarez-Sipmann F, Mellado-Artigas R, Hernández M, Gea A, Arruti E, et al. Clinical features, ventilatory management, and outcome of ARDS caused by COVID-19 are similar to other causes of ARDS. Intensive Care Med. 2020;46:2200–2211. doi: 10.1007/s00134-020-06192-2.
    1. Monnet X, Teboul JL. Transpulmonary thermodilution: advantages and limits. Crit Care. 2017;21:147. doi: 10.1186/s13054-017-1739-5.
    1. Jozwiak M, Teboul JL, Monnet X. Extravascular lung water in critical care: recent advances and clinical applications. Ann Intensive Care. 2015;5:38. doi: 10.1186/s13613-015-0081-9.
    1. Tagami T, Sawabe M, Kushimoto S, Marik PE, Mieno MN, Kawaguchi T, et al. Quantitative diagnosis of diffuse alveolar damage using extravascular lung water. Crit Care Med. 2013;41:2144–2150. doi: 10.1097/CCM.0b013e31828a4643.
    1. Monnet X, Anguel N, Osman D, Hamzaoui O, Richard C, Teboul JL. Assessing pulmonary permeability by transpulmonary thermodilution allows differentiation of hydrostatic pulmonary edema from ALI/ARDS. Intensive Care Med. 2007;33:448–453. doi: 10.1007/s00134-006-0498-6.
    1. Groeneveld AB, Verheij J. Extravascular lung water to blood volume ratios as measures of permeability in sepsis-induced ALI/ARDS. Intensive Care Med. 2006;32:1315–1321. doi: 10.1007/s00134-006-0212-8.
    1. Jozwiak M, Silva S, Persichini R, Anguel N, Osman D, Richard C, et al. Extravascular lung water is an independent prognostic factor in patients with acute respiratory distress syndrome. Crit Care Med. 2013;41:472–480. doi: 10.1097/CCM.0b013e31826ab377.
    1. Robba C, Battaglini D, Ball L, Patroniti N, Loconte M, Brunetti I, et al. Distinct phenotypes require distinct respiratory management strategies in severe COVID-19. Respir Physiol Neurobiol. 2020;279:103455. doi: 10.1016/j.resp.2020.103455.
    1. Marini JJ, Gattinoni L. Management of COVID-19 respiratory distress. JAMA. 2020;323:2329–2330. doi: 10.1001/jama.2020.6825.
    1. Merad M, Martin JC. Pathological inflammation in patients with COVID-19: a key role for monocytes and macrophages. Nat Rev Immunol. 2020;20:355–362. doi: 10.1038/s41577-020-0331-4.
    1. Del Valle DM, Kim-Schulze S, Huang HH, Beckmann ND, Nirenberg S, Wang B, et al. An inflammatory cytokine signature predicts COVID-19 severity and survival. Nat Med. 2020;26:1636–1643. doi: 10.1038/s41591-020-1051-9.
    1. Mehta P, McAuley DF, Brown M, Sanchez E, Tattersall RS, Manson JJ. COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet. 2020;395:1033–1034. doi: 10.1016/S0140-6736(20)30628-0.
    1. Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, Fan E, et al. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012;307:2526–2533.
    1. Beurton A, Teboul JL, Monnet X. Transpulmonary thermodilution techniques in the haemodynamically unstable patient. Curr Opin Crit Care. 2019;25:273–279. doi: 10.1097/MCC.0000000000000608.
    1. Monnet X, Persichini R, Ktari M, Jozwiak M, Richard C, Teboul JL. Precision of the transpulmonary thermodilution measurements. Crit Care. 2011;15:R204. doi: 10.1186/cc10421.
    1. Michard F, Alaya S, Zarka V, Bahloul M, Richard C, Teboul JL. Global end-diastolic volume as an indicator of cardiac preload in patients with septic shock. Chest. 2003;124:1900–1908. doi: 10.1378/chest.124.5.1900.
    1. Hofer CK, Furrer L, Matter-Ensner S, Maloigne M, Klaghofer R, Genoni M, et al. Volumetric preload measurement by thermodilution: a comparison with transoesophageal echocardiography. Br J Anaesth. 2005;94:748–755. doi: 10.1093/bja/aei123.
    1. Fan E, Del Sorbo L, Goligher EC, Hodgson CL, Munshi L, Walkey AJ, et al. An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: mechanical ventilation in adult patients with acute respiratory distress syndrome. Am J Respir Crit Care Med. 2017;195:1253–1263. doi: 10.1164/rccm.201703-0548ST.
    1. Papazian L, Forel JM, Gacouin A, Penot-Ragon C, Perrin G, Loundou A, et al. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med. 2010;363:1107–1116. doi: 10.1056/NEJMoa1005372.
    1. Guérin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368:2159–2168. doi: 10.1056/NEJMoa1214103.
    1. Combes A, Hajage D, Capellier G, Demoule A, Lavoué S, Guervilly C, et al. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. N Engl J Med. 2018;378:1965–1975. doi: 10.1056/NEJMoa1800385.
    1. Beloncle FM, Pavlovsky B, Desprez C, Fage N, Olivier PY, Asfar P, et al. Recruitability and effect of PEEP in SARS-Cov-2-associated acute respiratory distress syndrome. Ann Intensive Care. 2020;10:55. doi: 10.1186/s13613-020-00675-7.
    1. Diehl JL, Peron N, Chocron R, Debuc B, Guerot E, Hauw-Berlemont C, et al. Respiratory mechanics and gas exchanges in the early course of COVID-19 ARDS: a hypothesis-generating study. Ann Intensive Care. 2020;10:95. doi: 10.1186/s13613-020-00716-1.
    1. Barisione E, Grillo F, Ball L, Bianchi R, Grosso M, Morbini P, et al. Fibrotic progression and radiologic correlation in matched lung samples from COVID-19 post-mortems. Virchows Arch. 2021;478:471–485. doi: 10.1007/s00428-020-02934-1.
    1. Carsana L, Sonzogni A, Nasr A, Rossi RS, Pellegrinelli A, Zerbi P, et al. Pulmonary post-mortem findings in a series of COVID-19 cases from northern Italy: a two-centre descriptive study. Lancet Infect Dis. 2020;20:1135–1140. doi: 10.1016/S1473-3099(20)30434-5.
    1. Thille AW, Esteban A, Fernández-Segoviano P, Rodriguez JM, Aramburu JA, Peñuelas O, et al. Comparison of the Berlin definition for acute respiratory distress syndrome with autopsy. Am J Respir Crit Care Med. 2013;187:761–767. doi: 10.1164/rccm.201211-1981OC.
    1. Kuzkov VV, Kirov MY, Sovershaev MA, Kuklin VN, Suborov EV, Waerhaug K, et al. Extravascular lung water determined with single transpulmonary thermodilution correlates with the severity of sepsis-induced acute lung injury. Crit Care Med. 2006;34:1647–1653. doi: 10.1097/01.CCM.0000218817.24208.2E.
    1. Phillips CR, Chesnutt MS, Smith SM. Extravascular lung water in sepsis-associated acute respiratory distress syndrome: indexing with predicted body weight improves correlation with severity of illness and survival. Crit Care Med. 2008;36:69–73. doi: 10.1097/.
    1. Davey-Quinn A, Gedney JA, Whiteley SM, Bellamy MC. Extravascular lung water and acute respiratory distress syndrome–oxygenation and outcome. Anaesth Intensive Care. 1999;27:357–362. doi: 10.1177/0310057X9902700404.
    1. Tagami T, Nakamura T, Kushimoto S, Tosa R, Watanabe A, Kaneko T, et al. Early-phase changes of extravascular lung water index as a prognostic indicator in acute respiratory distress syndrome patients. Ann Intensive Care. 2014;4:27. doi: 10.1186/s13613-014-0027-7.
    1. Lala A, Johnson KW, Januzzi JL, Russak AJ, Paranjpe I, Richter F, et al. Prevalence and impact of myocardial injury in patients hospitalized with COVID-19 infection. J Am Coll Cardiol. 2020;76:533–546. doi: 10.1016/j.jacc.2020.06.007.
    1. Chapman AR, Adamson PD, Shah ASV, Anand A, Strachan FE, Ferry AV, et al. High-sensitivity cardiac troponin and the universal definition of myocardial infarction. Circulation. 2020;141:161–171. doi: 10.1161/CIRCULATIONAHA.119.042960.
    1. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395:1054–1062. doi: 10.1016/S0140-6736(20)30566-3.
    1. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA. 2020;323:1061–1069. doi: 10.1001/jama.2020.1585.
    1. Gopinathannair R, Merchant FM, Lakkireddy DR, Etheridge SP, Feigofsky S, Han JK, et al. COVID-19 and cardiac arrhythmias: a global perspective on arrhythmia characteristics and management strategies. J Interv Card Electrophysiol. 2020;59:329–336. doi: 10.1007/s10840-020-00789-9.
    1. Inciardi RM, Adamo M, Lupi L, Cani DS, Di Pasquale M, Tomasoni D, et al. Characteristics and outcomes of patients hospitalized for COVID-19 and cardiac disease in Northern Italy. Eur Heart J. 2020;41:1821–1829. doi: 10.1093/eurheartj/ehaa388.
    1. Oppenheimer L, Elings VB, Lewis FR. Thermal-dye lung water measurements: effects of edema and embolization. J Surg Res. 1979;26:504–512. doi: 10.1016/0022-4804(79)90041-6.
    1. Beckett RC, Gray BA. Effect of atelectasis and embolization on extravascular thermal volume of the lung. J Appl Physiol Respir Environ Exerc Physiol. 1982;53:1614–1619.
    1. Schreiber T, Hüter L, Schwarzkopf K, Schubert H, Preussler N, Bloos F, et al. Lung perfusion affects preload assessment and lung water calculation with the transpulmonary double indicator method. Intensive Care Med. 2001;27:1814–1818. doi: 10.1007/s00134-001-1122-4.
    1. Helms J, Tacquard C, Severac F, Leonard-Lorant I, Ohana M, Delabranche X, et al. High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study. Intensive Care Med. 2020;46:1089–1098. doi: 10.1007/s00134-020-06062-x.
    1. Jiménez D, García-Sanchez A, Rali P, Muriel A, Bikdeli B, Ruiz-Artacho P, et al. Incidence of VTE and bleeding among hospitalized patients with coronavirus disease 2019: a systematic review and meta-analysis. Chest. 2021;159:1182–1196. doi: 10.1016/j.chest.2020.11.005.
    1. Sakr Y, Giovini M, Leone M, Pizzilli G, Kortgen A, Bauer M, et al. Pulmonary embolism in patients with coronavirus disease-2019 (COVID-19) pneumonia: a narrative review. Ann Intensive Care. 2020;10:124. doi: 10.1186/s13613-020-00741-0.
    1. Chen W, Pan JY. Anatomical and pathological observation and analysis of SARS and COVID-19: microthrombosis is the main cause of death. Biol Proc Online. 2021;23:4. doi: 10.1186/s12575-021-00142-y.
    1. Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, et al. Surviving sepsis campaign: guidelines on the management of critically Ill adults with coronavirus disease 2019 (COVID-19) Crit Care Med. 2020;48:e440–e469. doi: 10.1097/CCM.0000000000004363.

Source: PubMed

Sponzoři a spolupracovníci

Zdravotní podmínky

Drogové intervence

3
Předplatit