Pulmonary Edema in COVID-19 Treated with Furosemide and Negative Fluid Balance (NEGBAL): A Different and Promising Approach

Jose L Francisco Santos, Patricio Zanardi, Veronica Alo, Marcelo Rodriguez, Federico Magdaleno, Virginia De Langhe, Vanina Dos Santos, Giuliana Murialdo, Andrea Villoldo, Micaela Coria, Diego Quiros, Claudio Milicchio, Eduardo Garcia Saiz, Jose L Francisco Santos, Patricio Zanardi, Veronica Alo, Marcelo Rodriguez, Federico Magdaleno, Virginia De Langhe, Vanina Dos Santos, Giuliana Murialdo, Andrea Villoldo, Micaela Coria, Diego Quiros, Claudio Milicchio, Eduardo Garcia Saiz

Abstract

In COVID-19, pulmonary edema has been attributed to "cytokine storm". However, it is known that SARS-CoV2 promotes angiotensin-converting enzyme 2 deficit, increases angiotensin II, and this triggers volume overload. Our report is based on COVID-19 patients with tomographic evidence of pulmonary edema and volume overload to whom established a standard treatment with diuretic (furosemide) guided by objectives: Negative Fluid Balance (NEGBAL approach). Retrospective observational study. We reviewed data from medical records: demographic, clinical, laboratory, blood gas, and chest tomography (CT) before and while undergoing NEGBAL, from 20 critically ill patients. Once the NEGBAL strategy was started, no patient required mechanical ventilation. All cases reverted to respiratory failure with NEGBAL, but subsequently two patients died from sepsis and acute myocardial infarction (AMI). The regressive analysis between PaO2/FiO2BAL and NEGBAL demonstrated correlation (p < 0.032). The results comparing the Pao2Fio2 between admission to NEGBAL to NEGBAL day 4, were statistically significant (p < 0.001). We noted between admission to NEGBAL and day 4 improvement in CT score (p < 0.001), decrease in the superior vena cava diameter (p < 0.001) and the decrease of cardiac axis (p < 0.001). Though our study has several limitations, we believe the promising results encourage further investigation of this different pathophysiological approach.

Keywords: COVID-19; NEGBAL; diuretic; edema; furosemide; volume overload.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
PAFI evolution during NEGBAL approach. (A) Scatter plot and regression line for PAFIBAL onto NEGBAL. (B) Boxplot for the PaO2/FiO2 ratio on the day of admission, day 4, day 8, and on day of discharge.
Figure 2
Figure 2
CT score evolution pre- and post-NEGBAL of CT, HTO, Ø SVC, and Ø CARD. (A) Box plot for CT score previous to NEGBAL, CT score adm. NEGBAL, CT day 4, and CT day 8. (B) Box plot for previous HTO, HTO adm. NEGBAL, and HTO day 4. (C) Box plot for Ø SVC previous NEGBAL, Ø SVC adm. NEGBAL, and Ø SVC day 4. (D) Box plot for Ø CARD previous NEGBAL, Ø CARD adm. NEGBAL, and Ø CARD day 4.

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