Clinical Course and Outcome of COVID-19 Acute Respiratory Distress Syndrome: Data From a National Repository

  1. Ali A. El-Solh
  2. Umberto G. Meduri
  3. Yolanda Lawson
  4. Michael Carter
  5. Kari A. Mergenhagen

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Abstract

Mortality attributable to coronavirus disease-19 (COVID-19) 2 infection occurs mainly through the development of viral pneumonia-induced acute respiratory distress syndrome (ARDS).

Research Question:

The objective of the study is to delineate the clinical profile, predictors of disease progression, and 30-day mortality from ARDS using the Veterans Affairs Corporate Data Warehouse.

Study Design and Methods:

Analysis of a historical cohort of 7,816 hospitalized patients with confirmed COVID-19 infection between January 1, 2020, and August 1, 2020. Main outcomes were progression to ARDS and 30-day mortality from ARDS, respectively.

Results:

The cohort was comprised predominantly of men (94.5%) with a median age of 69 years (interquartile range [IQR] 60-74 years). 2,184 (28%) were admitted to the intensive care unit and 643 (29.4%) were diagnosed with ARDS. The median Charlson Index was 3 (IQR 1-5). Independent predictors of progression to ARDS were body mass index (BMI) ≥40 kg/m 2 , diabetes, lymphocyte counts <700 × 109/L, LDH >450 U/L, ferritin >862 ng/ml, C-reactive protein >11 mg/dL, and D-dimer >1.5 ug/ml. In contrast, the use of an anticoagulant lowered the risk of developing ARDS (OR 0.66 [95% CI 0.49-0.89]. Crude 30-day mortality rate from ARDS was 41% (95% CI 38%-45%). Risk of death from ARDS was significantly higher in those who developed acute renal failure and septic shock. Use of an anticoagulant was associated with 2-fold reduction in mortality. Survival benefit was observed in patients who received corticosteroids and/or remdesivir but there was no advantage of combination therapy over either agent alone.

Conclusions:

Among those hospitalized for COVID-19, nearly 1 in 10 progressed to ARDS. Septic shock, and acute renal failure are the leading causes of death in these patients. Treatment with either remdesivir and corticosteroids reduced the risk of mortality from ARDS. All hospitalized patients with COVID-19 should be placed at a minimum on prophylactic doses of anticoagulation.

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  1. Version published to 10.1177/0885066621994476
  2. ScreenIT

    SciScore for 10.1101/2020.10.16.20214130: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board StatementIRB: The local Institutional Review Board deemed the current research as exempt based on federal regulation 45CFR46.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    Analysis was conducted in Stata MP version 15 (StataCorp).
    StataCorp
    suggested: (Stata, RRID:SCR_012763)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Among the limitations include the inherent biases of retrospective analyses involving large administrative databases, such as confounding effects and coding errors. Since the VA places less emphasis on billing, this may impact the prevalence of the condition under examination. Second, the predominance of male representation in this cohort may limit the applicability of the findings to other groups. Third, we did not collect data on do-not-resuscitate or do-not-intubate orders or the availability of palliative care for patients. These factors may have contributed to differing rates of intubation and ICU admission, and thus mortality from ARDS. Conclusions: In this large cohort of hospitalized patients with COVID-19, morbid obesity and elevated proinflammatory markers were associated with progression to ARDS while advanced age, septic shock, and acute renal failure predicted poor prognosis in those with ARDS. A higher survival rate from ARDS was observed in those who received prophylactic or therapeutic anticoagulation. Remdesivir and corticosteroids offered also a survival advantage in those being treated for ARDS. Rigorous randomized clinical trials are urgently needed to evaluate whether a combination strategy of available treatment modalities may impart further survival advantage over existing monotherapies.

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

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  3. Version published to 10.1101/2020.10.16.20214130v1 on medRxiv