Background:The coronavirus disease 2019 (COVID-19) is an ongoing pandemic. Invasive mechanical ventilation (IMV) is essential for the management of COVID-19 with acute respiratory distress syndrome (ARDS). We aimed to assess the impact of compliance with a respiratory decision support system on the outcomes of patients with COVID-19-associated ARDS who required IMV. Methods:In this retrospective, single-center, case series study, patients with COVID-19-associated ARDS who required IMV at Zhongnan Hospital of Wuhan University, China, from January 8th, 2020, to March 24th, 2020, with the final follow-up date of April 20th, 2020, were included. Demographic, clinical, laboratory, imaging, and management information were collected and analyzed. Compliance with the respiratory support decision system was documented, and its relationship with 28-day mortality was evaluated. Results:The study included 46 COVID-19-associated ARDS patients who required IMV. The median age of the 46 patients was 68.5 years, and 31 were men. The partial pressure of arterial oxygen (PaO2)/fraction of inspired oxygen (FiO2) ratio at intensive care unit (ICU) admission was 104 mmHg. The median total length of IMV was 12.0 (interquartile range [IQR]: 6.0-27.3) days, and the median respiratory support decision score was 11.0 (IQR: 7.8-16.0). To 28 days after ICU admission, 18 (39.1%) patients died. Survivors had a significantly higher respiratory support decision score than non-survivors (15.0 [10.3-17.0] vs. 8.5 (6.0-10.3), P = 0.001). Using receiver operating characteristic (ROC) curve to assess the discrimination of respiratory support decision score to 28-day mortality, the area under the curve (AUC) was 0.796 (95% confidence interval [CI]: 0.657-0.934, P = 0.001) and the cut-off was 11.5 (sensitivity = 0.679, specificity = 0.889). Patients with a higher score (>11.5) were more likely to survive at 28 days after ICU admission (log-rank test, P < 0.001). Conclusions:For severe COVID-19-associated ARDS with IMV, following the respiratory support decision and assessing completion would improve the progress of ventilation. With a decision score of >11.5, the mortality at 28 days after ICU admission showed an obvious decrease.

Importance: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections outbreak in China is now a global issue. There is only a limited understanding of the clinical characteristics of patients with SARS-CoV-2 infections is available. Objective: To describe the characteristics, management strategies, and outcomes of critically ill patients with SARS-CoV-2 infection. Design, Setting, and Patients: This is aretrospective, multi-center case series of 50 critically ill patients with confirmed SARS-CoV-2 infection who were admitted at Zhongnan Hospital of Wuhan University and Wuhan Pulmonary Hospital in Wuhan, China, from January 8 to February 9, 2020. Exposures: Documented Corona Virus Disease, 2019 (COVID-19). Main Outcome Measures: Demographic, clinical, laboratory, imaging data were collected along with management strategies, complications and outcomes of enrolled individuals. Results Fifty critically ill patients with SARS-CoV-2 infections were enrolled. Their median age was 62 (range, 29-92) [IQR,49.5-69.0] years, 68% were male, and 28 (56%) patients had comorbidities, the most common being hypertension. In this cohort, 20(40%) patients survived ,16(32%) patients died, and the rest remained hospitalized. The invasive mechanical ventilator was used in 36(72%) patients with 15(30%) of them requiring prone positioning, and 17(34%) switched to ECMO. The compliance scores of lungs (Cstat)on the day of ICU admission among survivors were higher than those in non-survivors [42.0(18.0-47.0), vs. 19.5(14.0-24.2), p=0.038].The blood IL-6 levels and neutrophils counts at the first day of ICU admission were significantly higher in non-survivors compared to survivors [123.7(85.3-228.8), vs. 20.2(6.8-67.2) ng/ml, p=0.025 for IL-6, and 20.2(6.8-67.2) vs. 4.01(1.99-7.05) × 10⁹/L, p=0.02 for neutrophils counts].The heart rates, PaCO2, lung injury scale (LIS), and positive end-expiratory pressure levels were constantly higher for 10 days in non-survivors than those who survived (p<0.05). The frequency of vasopressor uses and neuromuscular blockers was higher in non-survivors from day 1 to day 10 compared to survivors (p<0.05). In the whole cohort, the most common complications were ARDS (97%), shock (44%), arrhythmia (38%), acute cardiac injury (26%), and acute kidney injury (22%). A secondary bacterial infection was noted in 17(34%) patients. Univariate analysis indicated that lower lung complianceand higher neutrophil counts at the day of ICU admission were related to higher mortality (p-0.03, and 0.04, respectively) Conclusion We demonstrated that SARS-CoV-2 infection-related critical illness predominantly affected old individuals with comorbidities and characterized by severe hypoxemic respiratory failure, often requiring prolonged mechanical ventilation and rescue therapies. Low lung compliance and persistently elevated PaCO2 indicated poor outcomes.

Abstract Background In December 2019, coronavirus disease 2019 (COVID-19) outbreak was reported from Wuhan, China. Information on the clinical course and prognosis of COVID-19 was not thoroughly described. We described the clinical courses and prognosis in COVID-19 patients. Methods Retrospective case series of COVID-19 patients from Zhongnan Hospital of Wuhan University in Wuhan and Xishui Hospital, Hubei Province, China, up to February 10, 2020. Epidemiological, demographic, and clinical data were collected. The clinical course of survivors and non-survivors were compared. Risk factors for death were analyzed. Results A total of 107 discharged patients with COVID-19 were enrolled. The clinical course of COVID-19 presented as a tri-phasic pattern. Week 1 after illness onset was characterized by fever, cough, dyspnea, lymphopenia, and radiological multi-lobar pulmonary infiltrates. In severe cases, thrombocytopenia, acute kidney injury, acute myocardial injury, and adult respiratory distress syndrome were observed. During week 2, in mild cases, fever, cough, and systemic symptoms began to resolve and platelet count rose to normal range, but lymphopenia persisted. In severe cases, leukocytosis, neutrophilia, and deteriorating multi-organ dysfunction were dominant. By week 3, mild cases had clinically resolved except for lymphopenia. However, severe cases showed persistent lymphopenia, severe acute respiratory dyspnea syndrome, refractory shock, anuric acute kidney injury, coagulopathy, thrombocytopenia, and death. Older age and male sex were independent risk factors for poor outcome of the illness. Conclusions A period of 7–13 days after illness onset is the critical stage in the COVID-19 course. Age and male gender were independent risk factors for death of COVID-19.

Objective: The information about the critically ill coronavirus disease 2019 (COVID-19) was limited and controversy. This study was to analyze the clinical feature and predictors for outcome in critically ill COVID-19. Design: This was a descriptive study from two hospitals. Setting: This study was conducted in intensive care units (ICUs) from university hospitals. Methods: Critically ill COVID-19 patients admitted in ICU from Zhongnan Hospital of Wuhan University and Wuhan Pulmonary Hospital from January 8 to February 20, 2020, were screened. Interventions: None. Measurements and Main Results: Clinical, laboratory data were collected with management strategies and outcomes. Sixty-eight critically ill patients were enrolled. Their median age was 64 (interquartile range, 54-72) years, and 67.65% were male. In this cohort, 44 (65%) patients survived for 28 days. The invasive mechanical ventilator was used in 51 (75%) patients, with 20 of them requiring prone positioning, and 17 switched to extracorporeal membrane oxygenation. The compliance scores of lungs on the day of intubation among survivors were higher than those in nonsurvivors (25.00 [13.50-39.00] vs. 17.00 [12.00-22.00], P = 0.01). The blood interlukin-6 (IL-6) levels at the ICU admission were significantly higher in nonsurvivors compared to survivors (71.27 [51.48-144.15] vs. 18.15 [7.55-68.02] ng/ml, P = 0.025). The heart rates, lung injury scale, and positive end-expiratory pressure were constantly higher for 10 days in nonsurvivors. The frequency of vasopressor uses and neuromuscular blockers was higher in nonsurvivors from day 5 to day 10 (P < 0.05). In the whole cohort, the most common complications were acute respiratory distress syndrome (95.59%), shock (48.53%), arrhythmia (33.82%), acute cardiac injury (33.82%), and acute kidney injury (27.94%). Multivariate analysis indicated that lower lung compliance at the day of intubation and higher Acute Physiology and Chronic Health Evaluation II (APACHE II) at ICU admission were related to higher mortality (P = 0.02 and 0.05, respectively). Conclusion: COVID-19-related critical illness predominantly affected old individuals and was characterized by severe hypoxemic respiratory failure, often requiring prolonged mechanical ventilation and rescue therapies. High APACHE II scores and low lung compliance indicated poor outcomes.

Abstract Background We aimed to report the clinical characteristics of imported coronavirus disease-19 (COVID-19) in Jiangsu Province. Methods We retrospectively investigated the clinical, imaging, and laboratory characteristics of confirmed cases of COVID-19 with WHO interim guidance in three Grade ⅢA hospitals of Jiangsu from Jan 22 to Feb 14, 2020. Real time RT-PCR was used to detect the new coronavirus in respiratory samples. Results Of the 80 patients infected with COVID-19, 41 patients were female, with a median age of 46.1 years. Except for 3 severe patients, the rest of the 77 patients exhibited mild or moderate symptoms. 9 patients were unconfirmed until a third-time nucleic acid test. 38 cases had a history of chronic diseases. The main clinical manifestations of the patients were fever and cough, which accounted for 63 cases (78.75%) and 51 cases (-63.75%) respectively. Only 3 patients (3.75%) showed liver dysfunction. Imaging examination showed that 55 patients (-68.75%) showed abnormal, 25 cases (31.25%) had no abnormal density shadow in the parenchyma of both lungs. Up to now, 21 cases were discharged from the hospital, and no patient died. The average length of stay for discharged patients was 8 days. Conclusions Compared with the cases in Wuhan, the cases in Jiangsu exhibited mild or moderate symptoms and no obvious gender susceptivity. The proportion of patients having liver dysfunction and abnormal CT imaging was relatively lower than that of Wuhan. Notably, infected patients may be falsely excluded based on two consecutively negative respiratory pathogenic nucleic acid test results.

The vagus nerve can sense peripheral inflammation and transmit action potentials from the periphery to the brainstem. Vagal afferent signaling is integrated in the brainstem, and efferent vagus nerves carry outbound signals that terminate in spleen and other organs. Stimulation of efferent vagus nerve leads to the release of acetylcholine in these organs. In turn, acetylcholine interacts with members of the nicotinic acetylcholine receptor (nAChR) family, particularly with the alpha7 nicotinic acetylcholine receptor (α7nAChR), which is expressed by macrophages and other cytokine-producing cells. Ultimately, the production of proinflammatory cytokines is markedly inhibited. This neuroimmune communication is termed "the inflammatory reflex". The uncontrolled inflammation as a result from sepsis can lead to multiple organ failure, and even death. Experimental data show that regulation of the inflammatory reflex appears to be a useful interventional strategy for septic response. Herein, we review recent advances in the understanding of the inflammatory reflex and discuss potential therapeutics that vagal modulation of the immune system for the treatment of severe sepsis and septic shock.

Particle number (PN) concentrations and particle size distributions (PSD) in the size range of 5.5-350 nm were continuously measured from 22 December 2010 to 20 January 2011 at an urban site in Hong Kong when northeastern monsoon prevailed. Apart from the PN peaks appeared in traffic rush hours (i.e. 08:00-09:00 and 17:00-18:00), a distinct peak of PN concentrations in the afternoon (11:00-16:00) was observed during the sampling period. Concurrent measurement data of PSD, ozone (O-3) and proxy sulfuric acid (H2SO4) concentrations revealed that the afternoon peaks observed were likely due to new particle formation (NPF) via photochemical reactions. These NPF events were frequently observed under a clean and dry weather in Hong Kong. The occurrence of NPF was closely associated with high solar radiation (SR), low relative humidity (RH) and low condensation sink (CS) in the atmosphere. Besides the NPF events, we also found four nucleation mode particle burst events, typically with increased number concentrations of nucleation mode particles (N-nuc) without growth to larger size particles. These burst events were generally accompanied by high-level primary air pollutants, i.e. sulfur dioxide (SO2), nitrogen oxide (NOx) and carbon monoxide (CO), low SR and high CS conditions. The very different characteristics of the burst events from those of the NPF events indicated that these nucleation mode particle burst events were not caused by the photochemical reactions, but by the primary emission from the local combustion source(s). (C) 2014 Elsevier Ltd. All rights reserved.

In order to investigate the formation and growth processes of nucleation mode particles, and to quantify the particle number (PN) concentration and size distributions in Hong Kong, an intensive field measurement was conducted from 25 October to 29 November in 2010 near the mountain summit of Tai Mo Shan, a suburban site approximately the geographical centre of the New Territories in Hong Kong. Based on observations of the particle size distribution, new particle formation (NPF) events were found on 12 out of 35 days with the estimated formation rate J5.5 from 0.97 to 10.2 cm−3 s−1, and the average growth rates from 1.5 to 8.4 nm h−1. The events usually began at 10:00–11:00 LT characterized by the occurrence of a nucleation mode with a peak diameter of 6–10 nm. Solar radiation, wind speed, sulfur dioxide (SO2) and ozone (O3) concentrations were on average higher, whereas temperature, relative humidity and daytime nitrogen dioxide (NO2) concentration were lower on NPF days than on non-NPF days. Back trajectory analysis suggested that in majority of the NPF event days, the air masses originated from the northwest to northeast directions. The concentrations of gaseous sulfuric acid (SA) showed good power-law relationship with formation rates, with exponents ranging from 1 to 2. The result suggests that the cluster activation theory and kinetic nucleation could potentially explain the observed NPF events in this mountainous atmosphere of Hong Kong. Meanwhile, in these NPF events, the contribution of sulfuric acid vapor to particle growth rate (GR5.5–25) ranged from 9.2 to 52.5% with an average of 26%. Measurement-based calculated oxidation rates of monoterpenes (i.e. α-pinene, β-pinene, myrcene and limonene) by O3 positively correlated with the GR5.5–25 (R = 0.80, p < 0.05). The observed associations of the estimated formation rate J5.5 and the growth rate GR5.5–25 with gaseous sulfuric acid and volatile organic compounds (VOCs) suggested the critical roles of sulfuric acid and biogenic VOCs (e.g. α-pinene and β-pinene) in these NPF events.