Implications of Obesity for the Management of Severe Coronavirus Disease 2019 Pneumonia

Malcolm Lemyze, MD; Nathan Courageux, MD; Thomas Maladobry, MD; Clothilde Arumadura, MD; Philippe Pauquet, MD; Annis Orfi, MD; Matthieu Komorowski, MD, PhD; Jihad Mallat, MD, Msc; Maxime Granier, MD

Disclosures

Crit Care Med. 2020;48(9):e761-e767. 

In This Article

Abstract and Introduction

Abstract

Objectives: To investigate patients' characteristics, management, and outcomes in the critically ill population admitted to the ICU for severe acute respiratory syndrome coronavirus disease 2019 pneumonia causing an acute respiratory distress syndrome.

Design: Retrospective case-control study.

Setting: A 34-bed ICU of a tertiary hospital.

Patients: The first 44 coronavirus disease 2019 acute respiratory distress syndrome patients were compared with a historical control group of 39 consecutive acute respiratory distress syndrome patients admitted to the ICU just before the coronavirus disease 2019 crisis.

Interventions: None.

Measurements and Main Results: Obesity was the most frequent comorbidity exhibited by coronavirus disease 2019 patients (n = 32, 73% vs n = 11, 28% in controls; p < 0.001). Despite the same severity of illness and level of hypoxemia at admission, coronavirus disease 2019 patients failed more high flow oxygen via nasal cannula challenges (n = 16, 100% vs n = 5, 45% in controls; p = 0.002), were more often intubated (n = 44, 100% vs n = 22, 56% in controls; p < 0.001) and paralyzed (n = 34, 77% vs n = 3, 14% in controls; p < 0.001), required higher level of positive end-expiratory pressure (15 vs 8 cm H2O in controls; p < 0.001), more prone positioning (n = 33, 75% vs n = 6, 27% in controls; p < 0.001), more dialysis (n = 16, 36% vs n = 3, 8% in controls; p = 0.003), more hemodynamic support by vasopressors (n = 36, 82% vs n = 22, 56% in controls; p = 0.001), and had more often a prolonged weaning from mechanical ventilation (n = 28, 64% vs n = 10, 26% in controls; p < 0.01) resulting in a more frequent resort to tracheostomy (n = 18, 40.9% vs n = 2, 9% in controls; p = 0.01). However, an intensive management requiring more staff per patient for positioning coronavirus disease 2019 subjects (6 [5–7] vs 5 [4–5] in controls; p < 0.001) yielded the same ICU survival rate in the two groups (n = 34, 77% vs n = 29, 74% in controls; p = 0.23).

Conclusions: In its most severe form, coronavirus disease 2019 pneumonia striked preferentially the vulnerable obese population, evolved toward a multiple organ failure, required prolonged mechanical ventilatory support, and resulted in a high workload for the caregivers.

Introduction

The world has recently been facing a rapidly spreading infectious epidemic, first appearing in China in December 2019, due to a new coronavirus called the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The high contagiousness of this coronavirus disease 2019 (COVID-19) caused a massive influx of patients to hospitals with severe forms of lower respiratory tract infections. Most ICUs in Europe and United States have now been overwhelmed by a surge of critically ill patients exhibiting a life-threatening form of COVID-19 induced acute respiratory distress syndrome (COVID-19 ARDS).[1] Most of the published data currently available originated from the first Chinese cluster of the epidemic. In a Chinese population of 1590 patients, Guan et al[2] showed that patients' comorbidities worsen the prognosis with a higher chance to need mechanical ventilation and to die in those having two or more comorbidities compared with healthier groups. However, only 8.2% of their population reported having two or more comorbidities, which may not mirror the critically ill population commonly seen in Europe or the United States, in particular with regards to prevalence of obesity.[3–6] Here, we report on our experience from our first 44 cases of COVID-19 critically ill patients and analyze the link between obesity and this new form of ARDS caused by the SARS-CoV-2 with its potential implications for patients' management.

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