Objective: To evaluate clinical outcomes and factors associated with mortality, focusing on secondary infections, in critically ill patients with COVID-19 in three Brazilian hospitals during the first pandemic wave. Methods: This was a retrospective observational study involving adult patients with COVID-19 admitted to one of the participating ICUs between March and August of 2020. We analyzed clinical features, comorbidities, source of SARS-CoV-2 infection, laboratory data, microbiology data, complications, and causes of death. We assessed factors associated with in-hospital mortality using logistic regression models. Results: We included 645 patients with a mean age of 61.4 years. Of those, 387 (60.0%) were male, 12.9% (83/643) had undergone solid organ transplant, and almost 10% (59/641) had nosocomial COVID-19 infection. During ICU stay, 359/644 patients (55.7%) required invasive mechanical ventilation, 225 (34.9%) needed renal replacement therapy, 337 (52.2%) received vasopressors, and 216 (33.5%) had hospital-acquired infections (HAIs), mainly caused by multidrug-resistant gram-negative bacteria. HAIs were independently associated with a higher risk of death. The major causes of death were refractory shock and multiple organ dysfunction syndrome but not ARDS, as previously reported in the literature. Conclusions: In this study, most of our cohort required invasive mechanical ventilation and almost one third had HAIs, which were independently associated with a higher risk of death. Other factors related to death were Charlson Comorbidity Index, SOFA score at admission, and clinical complications during ICU stay. Nosocomial COVID-19 infection was not associated with death. The main immediate causes of death were refractory shock and multiple organ dysfunction syndrome.

Keywords: COVID-19/mortality; Sepsis; Multiple organ failure.

Objective: Because SARS-CoV-2 infection can severely affect the lungs and persistent functional changes can occur after severe disease, we aimed to determine lung function parameters of COVID-19 patients at 45 days after hospital discharge and compare changes according to the severity of the disease. Methods: This was a prospective descriptive analytical multicenter study. The participants were allocated into three groups: ward admission (WA) group; ICU admission not on mechanical ventilation (ICU/MV-) group; and ICU admission on MV (ICU/MV+) group. Lung volumes, DLco, MIP, MEP, and six-minute walk distance (6MWD) were measured 45 days after discharge. Results: The sample comprised 242 patients (mean age = 59.4 ± 14.8 years; 52.1% of males), and 232 (96%) had altered lung function. In the total cohort, restrictive disorder was observed in 96%, as well as reductions in DLco (in 21.2% of the patients), FEV1/FVC (in 39.7%), and PEmax (in 95.8%), with no differences between the groups. Comparing the groups, the ICU/MV+ group had reduced DLco in 50% of the patients (p < 0.001) and a lower mean 6MWD % of the predicted value (p = 0.013). Oxygen desaturation in the six-minute walk test was observed in 32.3% of the cohort and was less frequent in the IE group. Conclusions: This is the first South American study involving severe COVID-19 survivors whose lung function was assessed 45 days after hospital discharge. Changes were frequent, especially in those on MV, which highlights the importance of lung function evaluation after severe COVID-19.

Keywords: COVID-19; Respiratory function tests; Pulmonary diffusing capacity; Virus disease; SARS-CoV-2.

Objective: There is still limited information on the clinical characteristics and outcomes of cystic fibrosis (CF) patients with COVID-19 in Brazil. The objective of this study was to describe the cumulative incidence of COVID-19 in CF patients, as well as their clinical characteristics and outcomes. Methods: This was a prospective cohort study involving unvaccinated adult CF patients and conducted during the first year of the SARS-CoV-2 pandemic in the city of Porto Alegre, in southern Brazil. The clinical course of the disease was rated on the WHO Ordinal Scale for Clinical Improvement. The primary outcome was the number of incident cases of COVID-19. Results: Between April 30, 2020 and April 29, 2021, 98 CF patients were included in the study. Seventeen patients were diagnosed with COVID-19. For the CF patients, the annual cumulative incidence of COVID-19 was 17.3%, similar to that for the general population, adjusted for age (18.5%). The most common symptoms at diagnosis of COVID-19 were cough (in 59%), dyspnea (in 53%), fatigue (in 53%), and fever (in 47%). Only 6 (35%) of the patients required hospitalization, and 3 (17.6%) required oxygen support. Only 1 patient required mechanical ventilation, having subsequently died. Conclusions: During the first year of the SARS-CoV-2 pandemic in southern Brazil, the cumulative incidence rate of COVID-19 was similar between CF patients and the general population. More than 50% of the CF patients with SARS-CoV-2 infection had a mild clinical presentation, without the need for hospital admission, and almost the entire sample recovered completely from the infection, the exception being 1 patient who had advanced lung disease and who died.

Keywords: Cystic fibrosis; COVID-19; SARS-CoV-2.

Objective: To identify factors associated with prolonged weaning and mortality in critically ill COVID-19 patients admitted to ICUs and under invasive mechanical ventilation. Methods: Between March of 2020 and July of 2021, we retrospectively recorded clinical and ventilatory characteristics of critically ill COVID-19 patients from the day of intubation to the outcome. We classified the patients regarding the weaning period in accordance with established criteria. A logistic regression analysis was performed to identify variables associated with prolonged weaning and mortality. Results: The study involved 303 patients, 100 of whom (33.0%) had a prolonged weaning period. Most of the patients were male (69.6%), 136 (44.8%) had more than 50% of pulmonary involvement on chest CT, and 93 (30.6%) had severe ARDS. Within the prolonged weaning group, 62% died within 60 days. Multivariate analysis revealed that lung involvement greater than 50% on CT and delay from intubation to the first separation attempt from mechanical ventilation were significantly associated with prolonged weaning, whereas age and prolonged weaning were significantly associated with mortality. Conclusions: Prolonged weaning can be used as a milestone in predicting mortality in critically ill COVID-19 patients. Lung involvement greater than 50% on CT and delay from intubation to the first separation attempt from mechanical ventilation were identified as significant predictors of prolonged weaning. These results might provide valuable information for healthcare professionals when making clinical decisions regarding the management of critically ill COVID-19 patients who are on mechanical ventilation.

Keywords: COVID-19; Pneumonia, viral; Respiratory distress syndrome; Respiration, artificial; Ventilator weaning; Cohort studies; Hospital mortality; Patient outcome assessment.

Objective: The present study aimed to assess the functional status of children diagnosed with COVID-19 at the time of hospitalization and the associations with clinical features. Methods: This prospective cohort study was carried out with children diagnosed with COVID-19 admitted to a tertiary hospital. The patients' functioning was assessed using the pediatric Functional Status Scale (FSS). Results: A total of 62 children with a median age of 3 years old were included in the study, and 70% had some comorbidity prior to the diagnosis of COVID-19. The median length of stay was nine days, during which period five patients died. The FSS assessment of the sample showed that approximately 55% had some functional alteration. The group of patients with the highest FSS scores presented a lengthier hospital stay (p = 0.016), required more oxygen therapy (p < 0.001), mechanical ventilation (p = 0.001), and intensive care unit admissions (p = 0.019), and had more cardiac (p = 0.007), neurological (p = 0.003), and respiratory (p = 0.013) comorbidities. In the multivariate analysis, there was an association between the dependent variable length of stay and the total FSS score (b = 0.349, p = 0.004) and the presence of comorbidities (b = 0.357, p = 0.004). Conclusions: We observed that more than half of the children hospitalized due to COVID-19 had some level of functional change. Greater alterations in functional status were associated with the presence of previous comorbidities, a greater need for ventilatory support, and longer hospital stays.

Keywords: COVID-19, coronavirus, pediatrics, physical functional performance, functional status.

Objective: To identify factors that lead to a positive oxygenation response and predictive factors of mortality after prone positioning. Methods: This was a retrospective, multicenter, cohort study involving seven hospitals in Brazil. Inclusion criteria were being > 18 years of age with a suspected or confirmed diagnosis of COVID-19, being on invasive mechanical ventilation, having a PaO2/FIO2 ratio < 150 mmHg, and being submitted to prone positioning. After the first prone positioning session, a 20 mmHg improvement in the PaO2/FIO2 ratio was defined as a positive response. Results: The study involved 574 patients, 412 (72%) of whom responded positively to the first prone positioning session. Multiple logistic regression showed that responders had lower Simplified Acute Physiology Score III (SAPS III)/SOFA scores and lower D-dimer levels (p = 0.01; p = 0.04; and p = 0.04, respectively). It was suggested that initial SAPS III and initial PaO2/FIO2 were predictors of oxygenation response. The mortality rate was 69.3%. Increased risk of mortality was associated with age (OR = 1.04 [95 CI: 1.01-1.06]), time to first prone positioning session (OR = 1.18 [95 CI: 1.06-1.31]), number of sessions (OR = 1.31 [95% CI: 1.00-1.72]), proportion of pulmonary impairment (OR = 1.55 [95% CI: 1.02-2.35]), and immunosuppression (OR = 3.83 [95% CI: 1.35-10.86]). Conclusions: Our results show that most patients in our sample had a positive oxygenation response after the first prone positioning session. However, the mortality rate was high, probably due to the health status and the number of comorbidities of the patients, as well as the severity of their disease. Our results also suggest that SAPS III and the initial PaO2/FIO2 predict the oxygenation response; in addition, age, time to first prone positioning, number of sessions, pulmonary impairment, and immunosuppression can predict mortality.

Keywords: Respiratory distress syndrome; Coronavirus infections; Pulmonary medicine; COVID-19; Prone position; SARS-CoV-2.

Objective: To assess the influence of the COVID-19 pandemic on hospital admissions (HA), intra-hospital deaths (HD), and intra-hospital lethality rates (HL) related to respiratory diseases (RD) other than COVID-19 in Brazil. Methods: This observational time-series study was conducted through comparative analyses of the HA, HD, and HL related to non-COVID-19 RD registered between March and December 2020 by the Brazilian Unified Public Health System on the DataSUS Tabnet platform, using as reference the values recorded in the same period of 2019 and those projected by linear regression methods for 2020, considering the period from 2015 to 2019. The adopted statistical significance level was 5% (p < 0.05). Results: Compared to 2019, in 2020, there was a 42% decrease in HA and a 7.4% decrease in total HD related to non-COVID-19 RD, followed by a 60% increase in HL associated with this group of diseases. The HA and HL registered in 2020 differed significantly from the projected trend for that year by linear regression (p < 0.05). Of note, a significant reduction in hospitalizations due to asthma (-46%), chronic obstructive pulmonary disease (-45%), bronchiectasis (-54%), pneumonia (-46%), and acute bronchitis (-73%) was observed. Conclusions: During the first 8 months of the pandemic, there was a decline in HA and an increase in HL related to non-COVID-19 RD in Brazil, which can hypothetically reflect logistical challenges and delays in the management of this group of diseases.

Keywords: Pulmonary disease, COVID-19, non-COVID-19, Hospitalization, Mortality.

Objective: The present study aimed to describe the clinical forms and the time taken to diagnose new tuberculosis cases and to statistically analyze the isolated and combined forms of the disease in children and adolescents treated at a university hospital in Rio de Janeiro during the first year of the COVID-19 pandemic in Brazil. Methods: This was a cross-sectional study that used retrospective data on children (0-9 years old) and adolescents (10-18 years old) with pulmonary (PTB), extrapulmonary (EPTB), and combined tuberculosis (PTB + EPTB) followed up at the outpatient clinic from January 2019 to March 2021. Categorical data were analyzed by descriptive statistics and expressed as frequency and proportions. Categorical variables were compared using the Chi-square test, and numerical variables using Student's T-test. Results: A total of 51 cases were included, 63% (32/51) of which comprised patients in the year of the pandemic (group A), while 37% (19/51) were patients attended in previous years (group B). In group A, 19% (6/32) of the patients presented PTB, 59% (16/32) had EPTB, and 31% (10/32) had PTB+EPTB. In group B, 42% (8/19) of the patients presented PTB, 42% (8/19) had EPTB, and 16% (3/19) had PTB+EPTB. Conclusion: Our study revealed more tuberculosis cases in the first year of the pandemic than in the same period of the previous year, with greater variation of sites affected by the disease, including rarer and more severe forms.

Keywords: pandemic, children, adolescents, tuberculosis, coronavirus.

Objective: To determine whether the severity of non-neurological critically ill patients correlates with clinical predictors of bronchial aspiration. Methods: We evaluated adults undergoing prolonged orotracheal intubation (> 48 h) and bedside swallowing assessment within the first 48 h after extubation. We collected data regarding the risk of bronchial aspiration performed by a speech-language pathologist, whereas data regarding the functional level of swallowing were collected with the American Speech-Language-Hearing Association National Outcome Measurement System (ASHA NOMS) scale and those regarding health status were collected with the Sequential Organ Failure Assessment (SOFA). Results: The study sample comprised 150 patients. For statistical analyses, the patients were grouped by ASHA NOMS score: ASHA1 (levels 1 and 2), ASHA2 (levels 3 to 5); and ASHA3 (levels 6 and 7). In comparison with the other patients, those in the ASHA3 group were significantly younger, remained intubated for fewer days, and less severe overall clinical health status (SOFA score). The clinical predictors of bronchial aspiration that best characterized the groups were abnormal cervical auscultation findings and cough after swallowing. None of the patients in the ASHA 3 group presented with either of those signs. Conclusions: Critically ill patients 55 years of age or older who undergo prolonged orotracheal intubation (≥ 6 days), have a SOFA score ≥ 5, have a Glasgow Coma Scale score ≤ 14, and present with abnormal cervical auscultation findings or cough after swallowing should be prioritized for a full speech pathology assessment.

Keywords: Deglutition; Deglutition disorders; Intubation, intratracheal; Pneumonia, aspiration; Intensive care units.

The evaluation of critically ill patients using lung ultrasound, even if performed by nonspecialists, has recently garnered greater interest. Because lung ultrasound is based on the fact that every acute illness reduces lung aeration, it can provide information that complements the physical examination and clinical impression, the main advantage being that it is a bedside tool. The objective of this review was to evaluate the clinical applications of lung ultrasound by searching the PubMed and the Brazilian Virtual Library of Health databases. We used the following search terms (in Portuguese and English): ultrasound; lung; and critical care. In addition to the most relevant articles, we also reviewed specialized textbooks. The data show that lung ultrasound is useful in the differential diagnosis of pulmonary infiltrates, having good accuracy in identifying consolidations and interstitial syndrome. In addition, lung ultrasound has been widely used in the evaluation and treatment of pleural effusions, as well as in the identification of pneumothorax. This technique can also be useful in the immediate evaluation of patients with dyspnea or acute respiratory failure. Other described applications include monitoring treatment response and increasing the safety of invasive procedures. Although specific criteria regarding training and certification are still lacking, lung ultrasound is a fast, inexpensive, and widely available tool. This technique should progressively come to be more widely incorporated into the care of critically ill patients.

Keywords: Ultrasonography; Lung; Critical care; Intensive care units.

Objective: To identify which noninvasive ventilation (NIV) masks are most commonly used and the problems related to the adaptation to such masks in critically ill patients admitted to a hospital in the city of São Paulo, Brazil. Methods: An observational study involving patients ≥ 18 years of age admitted to intensive care units and submitted to NIV. The reason for NIV use, type of mask, NIV regimen, adaptation to the mask, and reasons for non-adaptation to the mask were investigated. Results: We evaluated 245 patients, with a median age of 82 years. Acute respiratory failure was the most common reason for NIV use (in 71.3%). Total face masks were the most commonly used (in 74.7%), followed by full face masks and near-total face masks (in 24.5% and 0.8%, respectively). Intermittent NIV was used in 82.4% of the patients. Adequate adaptation to the mask was found in 76% of the patients. Masks had to be replaced by another type of mask in 24% of the patients. Adequate adaptation to total face masks and full face masks was found in 75.5% and 80.0% of the patients, respectively. Non-adaptation occurred in the 2 patients using near-total facial masks. The most common reason for non-adaptation was the shape of the face, in 30.5% of the patients. Conclusions: In our sample, acute respiratory failure was the most common reason for NIV use, and total face masks were the most commonly used. The most common reason for non-adaptation to the mask was the shape of the face, which was resolved by changing the type of mask employed.

Keywords: Intermittent positive-pressure ventilation; Masks; Respiratory insufficiency.

Objectives: To evaluate the incidence of venous thromboembolism (VTE) in hospitalized patients with COVID-19 who underwent diagnostic tests for suspected VTE, and to correlate the IMPROVE-DD score with the incidence of VTE in this cohort. Methods: This retrospective study included consecutive patients with COVID-19 and suspected VTE, admitted between March 2020 and September 2021 at a private hospital in Salvador (BA), Brazil, who underwent lower or upper limb venous Doppler ultrasound or chest angiotomography. Descriptive analyses and comparisons using the chi-square test were performed to identify factors potentially associated with the risk of VTE. Results: A total of 517 patients were included, with an in-hospital VTE incidence of 18.6% (96 events). Risk factors significantly associated with VTE included obesity, ICU admission, central venous catheter use, longer hospital stays, greater lung tomographic involvement/severity, the need for mechanical ventilation, D-dimer levels at least twice the upper limit of normal (2xULN), and the IMPROVE-DD score. The mean IMPROVE-DD score among patients with VTE was 4.7 (±3) versus 3.3 (±2.4) in those without VTE (p < 0.0001). D-dimer 2xULN was sensitive in identifying 94% of the 96 patients with VTE (p < 0.0001). The in-hospital mortality rate was 14.1%, with higher rates observed in patients with VTE (24%) compared to those without VTE (11.9%) (p = 0.003). Conclusions: The incidence of VTE in hospitalized COVID-19 patients was high and correlated with increased mortality. The IMPROVE-DD score effectively identified patients at risk for in-hospital VTE, suggesting it could help to identify a high-risk subgroup that may benefit from extended thromboprophylaxis.

Keywords: Venous thromboembolism, COVID-19, IMPROVE-DD.

Objective: To evaluate the association between the risk of death from COPD and air temperature events in ten major Brazilian microregions. Methods: This was a time series analysis of daily COPD deaths and daily mean air temperatures between 1996 and 2017. Using distributed nonlinear lag models, we estimated the cumulative relative risks of COPD mortality for four temperature percentiles (representing moderate and extreme cold and heat events) in relation to a minimum mortality temperature, with a lag of 21 days, in each microregion. Results: Significant associations were found between extreme air temperature events and the risk of death from COPD in the southern and southeastern microregions in Brazil. There was an association of extreme cold and an increased mortality risk in the following microregions: 36% (95% CI, 1.12-1.65), in Porto Alegre; 27% (95% CI, 1.03-1.58), in Curitiba; and 34% (95% CI, 1.19-1.52), in São Paulo; whereas moderate cold was associated with an increased risk of 20% (95% CI, 1.01-1.41), 33% (95% CI, 1.09-1.62), and 24% (95% CI, 1.12-1.38) in the same microregions, respectively. There was an increased COPD mortality risk in the São Paulo and Rio de Janeiro microregions: 17% (95% CI, 1.05-1.31) and 12% (95% CI, 1,02-1,23), respectively, due to moderate heat, and 23% (95% CI, 1,09-1,38) and 32% (95% CI, 1,15-1,50) due to extreme heat. Conclusions: Non-optimal air temperature events were associated with an increased risk of death from COPD in tropical and subtropical areas of Brazil.

Keywords: Pulmonary disease, chronic obstructive/mortality; Temperature; Climate.