Letter to the Editor
The unfriendly side of “happy hypoxaemia”: Sudden cardiac death
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Banwari, B.A. Panka" "autores" => array:4 [ 0 => array:5 [ "preGrado" => "MD" "nombre" => "C.M.C." "apellidos" => "Serbanescu-Kele Apor de Zalán" "email" => array:1 [ 0 => "cserbanescu@viecuri.nl" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0001" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0002" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0001" ] ] ] 1 => array:4 [ "preGrado" => "MD" "nombre" => "R.P." "apellidos" => "Banwarie" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0001" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0003" ] ] ] 2 => array:4 [ "preGrado" => "MD" "nombre" => "K.D." "apellidos" => "Banwari" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0001" ] ] ] 3 => array:4 [ "preGrado" => "MD" "nombre" => "B.A." "apellidos" => "Panka" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0001" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0003" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Department of Internal Medicine and Intensive Care, s Lands Hospitaal, Paramaribo, Suriname" "etiqueta" => "a" "identificador" => "aff0001" ] 1 => array:3 [ "entidad" => "Department of Intensive Care, VieCuri Medical Center, Venlo, 5900 BX Venlo, the Netherlands" "etiqueta" => "b" "identificador" => "aff0002" ] 2 => array:3 [ "entidad" => "Department of Intensive Care, Academic Hospital Paramaribo, Paramaribo, Suriname" "etiqueta" => "c" "identificador" => "aff0003" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0001" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0001" "etiqueta" => "Fig. 1 (A)" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3978 "Ancho" => 1667 "Tamanyo" => 450864 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "alt0001" "detalle" => "Fig. 1 (A)" "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spara001" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray taken in a patient with severe COVID-19. showing extensive bilateral opacities, with a slight predominance for the peripheral and basal lung fields. (B) Arterial blood sample, drawn from a patient with COVID-19 receiving non-invasive ventilation (EPAP 12; Pressure Support 4; FiO<span class="elsevierStyleInf">2</span> 100%). Blood gas analysis revealed a P<span class="elsevierStyleInf">a</span>O<span class="elsevierStyleInf">2</span> of 28mmHg (P/F ratio 28mmHg). Despite oxygen saturations below 40%, the patient denied dyspnoea and did not have elevated work of breathing.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="para0001" class="elsevierStylePara elsevierViewall">A 31 year-old female patient was admitted to our dedicated COVID-19 Intensive Care Unit with hypoxaemic respiratory insufficiency due to COVID-19 pneumonitis. Her past medical history was unremarkable, except for extreme obesity (BMI 70·3). She was not taking any medications, and was not under any regular medical care. Her chest X-ray at admission showed bilateral interstitial pulmonary consolidations (<a class="elsevierStyleCrossRef" href="#fig0001">Fig. 1</a>A). At admission, our patient was tachypneic, with a respiratory rate of 30-40/min, with SpO<span class="elsevierStyleInf">2</span> 85% to 90% while on a non-rebreather mask. We started our patient on dexamethasone, tocilizumab and enoxaparin in a therapeutic dose. Oxygenation improved markedly upon initiation of non-invasive ventilation (NIV) through a mask interface (IPAP 12 cmH<span class="elsevierStyleInf">2</span>O, EPAP 10 cmH<span class="elsevierStyleInf">2</span>O, FiO<span class="elsevierStyleInf">2</span> started at 100% and titrated to SpO<span class="elsevierStyleInf">2</span>). Initially, while on NIV, she maintained SpO<span class="elsevierStyleInf">2</span> > 90%, with FiO<span class="elsevierStyleInf">2</span> of 60-80%, whereas saturations would drop within minutes while on a non-rebreather mask (15L / min), during attempted breaks from NIV. We did not offer high-flow nasal cannula (HFNC) oxygen therapy, partially because of its excessively high oxygen consumption, which presented logistical barriers in our resource-limited setting during a pandemic. Furthermore, we expected “true” positive pressure ventilation to have more beneficial effects on obesity-related, position-dependent atelectasis, and on a potentially present obstructive sleep apnea. Over the first week of admission, she developed progressive hypoxaemia, while denying dyspnoea. Our patient repeatedly refused intubation and invasive ventilation, citing a lack of symptoms, and a fear for a worse outcome with mechanical ventilation. On day three, the patient desaturated to S<span class="elsevierStyleInf">p</span>O<span class="elsevierStyleInf">2</span> of about 50% (despite FiO<span class="elsevierStyleInf">2</span>100%), while denying dyspnoea, and without exhibiting tachypnea. Following prone positioning, saturations recovered to above 90%. Intermittent awake proning was, from that moment on, continued three times daily. On day seven, S<span class="elsevierStyleInf">p</span>O<span class="elsevierStyleInf">2</span> again dropped to 30-55%, from then on never exceeding 60%, and at times reaching levels as low as 21%, with no further response to prone positioning. Changes in ventilatory settings (EPAP as low as 6 and up to 14cmH<span class="elsevierStyleInf">2</span>O; as CPAP, or with pressure support of up to 6 cmH<span class="elsevierStyleInf">2</span>O; FiO<span class="elsevierStyleInf">2</span> from here on never below 100%) yielded no improvement in respiratory parameters. An arterial line was placed in the left brachial artery, to allow for regular blood sampling. Arterial blood was extremely dark (<a class="elsevierStyleCrossRef" href="#fig0001">Fig. 1</a>B), with a P<span class="elsevierStyleInf">a</span>O<span class="elsevierStyleInf">2</span> of 28mmHg. Accidental venous sampling was excluded with an adequate arterial blood pressure waveform. There was no methemoglobinaemia. Meanwhile, our patient was able to speak coherent, full sentences, and denied having any sensation of dyspnoea, although she was at times tachypneic. She remained firm in her view, and persistently refused endotracheal intubation. After enduring extreme hypoxaemia for about two days in a seemingly stable condition, she suddenly developed ventricular fibrillation, rapidly followed by asystole and death. Resuscitative efforts were not successful.</p><elsevierMultimedia ident="fig0001"></elsevierMultimedia><p id="para0002" class="elsevierStylePara elsevierViewall">Silent, or “happy” hypoxaemia is a well-known phenomenon in COVID-19.<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a> Several theories have been proposed for its existence, most revolving around intrapulmonary shunting as the primary driver of hypoxaemia, with relative preservation of lung compliance in the early stages of the disease,<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a> and resultant normocarbia or even hypocarbia,<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a> although a neural factor has also been proposed.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a> In our case, we think a certain level of hypoxaemia at baseline associated with previously undiagnosed, but potentially present obesity hypoventilation syndrome may have contributed to our patient's tolerance of extremely low arterial oxygen levels.</p><p id="para0003" class="elsevierStylePara elsevierViewall">The optimal timing of intubation in severe COVID-19 remains controversial. Early on in the pandemic, prominent authors urged clinicians to intubate early, in order to prevent patient self-induced lung injury (P-SILI), which was hypothesised to result from excessive respiratory effort.<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> Furthermore, non-invasive respiratory support was feared to lead to droplet formation, putting health-care workers at risk.<a class="elsevierStyleCrossRef" href="#bib0007"><span class="elsevierStyleSup">7</span></a> Conversely, it has been argued that early, potentially unnecessary intubation may increase mortality by exposing patients to the risks of sedation and invasive ventilation.<a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a> As the pandemic progressed, many clinicians adopted a “wait-and-see” strategy, where patients are initially managed with non-invasive ventilatory support (including NIV and HFNC), and are intubated only upon failure of such therapies.<a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a> More recent studies yield conflicting results, and although non-invasive respiratory support appears safe, and has been shown to reduce the need for invasive ventilation, the optimum timing of intubation in COVID-19 is as of yet still unknown.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a> It may be reasonable to use a step-up approach, starting HFNC in patients who fail conventional oxygen therapy, failure of which could be followed by a trial of CPAP, and eventually, if indicated, intubation.<a class="elsevierStyleCrossRef" href="#bib0011"><span class="elsevierStyleSup">11</span></a></p><p id="para0004" class="elsevierStylePara elsevierViewall">To aid in deciding whom to intubate, authors have proposed using the ROX index,<a class="elsevierStyleCrossRef" href="#bib0012"><span class="elsevierStyleSup">12</span></a> which, in several retrospective series, has been reported to predict failure of non-invasive respiratory support in COVID-19.<a class="elsevierStyleCrossRef" href="#bib0012"><span class="elsevierStyleSup">12</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0013"><span class="elsevierStyleSup">13</span></a> While most studies were performed in cohorts treated with HFNC, the ROX index has been reported to correlate with outcomes after CPAP as well.<a class="elsevierStyleCrossRef" href="#bib0014"><span class="elsevierStyleSup">14</span></a> It should be noted that different studies report different cut-offs (such as <3.85<a class="elsevierStyleCrossRef" href="#bib0012"><span class="elsevierStyleSup">12</span></a> and <5.99<a class="elsevierStyleCrossRef" href="#bib0013"><span class="elsevierStyleSup">13</span></a>). Our patient had ROX-indexes as low as 1.12, clearly indicating a high risk of treatment failure.</p><p id="para0005" class="elsevierStylePara elsevierViewall">The phenomenon of seemingly well-tolerated hypoxaemia in COVID-19 has led to further controversy, as it seems counter-intuitive to intubate a patient who, despite having low oxygen saturations, is feeling well. This discrepancy between subjective and objective findings has led some authors to argue that such patients should not be intubated, as long as they remain asymptomatic, and do not exhibit increased work of breathing.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">15</span></a> Even though we are inclined to agree with this concept in general, as long as hypoxaemia is mild to moderate, we believe our case demonstrates the dangers when such an approach is taken to the extreme. There is a point where hypoxaemia can lead to rapid cardiovascular decompensation,<a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a> where “happy” hypoxaemia can show its unfriendly side: sudden cardiac death.</p><span id="sec0002" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0003">Funding</span><p id="para0006" class="elsevierStylePara elsevierViewall">The authors declare that no external funding was received for the conduct of this study and/or the preparation of this manuscript.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0002" "titulo" => "Funding" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-02-03" "fechaAceptado" => "2022-05-28" "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0001" "etiqueta" => "Fig. 1 (A)" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3978 "Ancho" => 1667 "Tamanyo" => 450864 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "alt0001" "detalle" => "Fig. 1 (A)" "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spara001" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray taken in a patient with severe COVID-19. showing extensive bilateral opacities, with a slight predominance for the peripheral and basal lung fields. (B) Arterial blood sample, drawn from a patient with COVID-19 receiving non-invasive ventilation (EPAP 12; Pressure Support 4; FiO<span class="elsevierStyleInf">2</span> 100%). Blood gas analysis revealed a P<span class="elsevierStyleInf">a</span>O<span class="elsevierStyleInf">2</span> of 28mmHg (P/F ratio 28mmHg). Despite oxygen saturations below 40%, the patient denied dyspnoea and did not have elevated work of breathing.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "cebibsec1" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0001" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Why COVID-19 silent hypoxemia is baffling to physicians" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "MJ Tobin" 1 => "F Laghi" 2 => "A. Jubran" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/rccm.202006-2157CP" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2020" "volumen" => "202" "paginaInicial" => "356" "paginaFinal" => "360" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32539537" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0002" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Basing respiratory management of COVID-19 on physiological principles" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "MJ. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 12 | 3 | 15 |
| 2024 October | 43 | 30 | 73 |
| 2024 September | 70 | 33 | 103 |
| 2024 August | 118 | 50 | 168 |
| 2024 July | 88 | 30 | 118 |
| 2024 June | 57 | 34 | 91 |
| 2024 May | 67 | 34 | 101 |
| 2024 April | 59 | 37 | 96 |
| 2024 March | 55 | 28 | 83 |
| 2024 February | 66 | 32 | 98 |
| 2024 January | 97 | 60 | 157 |
| 2023 December | 76 | 29 | 105 |
| 2023 November | 85 | 67 | 152 |
| 2023 October | 93 | 54 | 147 |
| 2023 September | 61 | 39 | 100 |
| 2023 August | 77 | 31 | 108 |
| 2023 July | 62 | 37 | 99 |
| 2023 June | 94 | 25 | 119 |
| 2023 May | 85 | 43 | 128 |
| 2023 April | 59 | 24 | 83 |
| 2023 March | 99 | 38 | 137 |
| 2023 February | 70 | 28 | 98 |
| 2023 January | 65 | 27 | 92 |
| 2022 December | 116 | 46 | 162 |
| 2022 November | 170 | 67 | 237 |
| 2022 October | 63 | 49 | 112 |
| 2022 September | 34 | 38 | 72 |
| 2022 August | 44 | 45 | 89 |
| 2022 July | 40 | 29 | 69 |
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