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COVID-19 pneumonia: pathophysiology and management

Luciano Gattinoni, Simone Gattarello, Irene Steinberg, Mattia Busana, Paola Palermo, Stefano Lazzari, Federica Romitti, Michael Quintel, Konrad Meissner, John J. Marini, Davide Chiumello, Luigi Camporota
European Respiratory Review 2021 30: 210138; DOI: 10.1183/16000617.0138-2021
Luciano Gattinoni
1Dept of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
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  • ORCID record for Luciano Gattinoni
  • For correspondence: gattinoniluciano@gmail.com
Simone Gattarello
1Dept of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
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Irene Steinberg
1Dept of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
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Mattia Busana
1Dept of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
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  • ORCID record for Mattia Busana
Paola Palermo
1Dept of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
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Stefano Lazzari
1Dept of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
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Federica Romitti
1Dept of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
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Michael Quintel
1Dept of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
2Dept of Anesthesiology, Intensive Care and Emergency Medicine Donau-Isar-Klinikum Deggendorf, Deggendorf, Germany
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Konrad Meissner
1Dept of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
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John J. Marini
3Dept of Pulmonary and Critical Care Medicine, University of Minnesota and Regions Hospital, St. Paul, MN, USA
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Davide Chiumello
4Dept of Anesthesia and Intensive Care, San Paolo Hospital, University of Milan, Milan, Italy
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Luigi Camporota
5Dept of Adult Critical Care, Guy's and St Thomas’ NHS Foundation Trust, Health Centre for Human and Applied Physiological Sciences, London, UK
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  • Article
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  • FIGURE 1
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    FIGURE 1

    A representative flow of patients with COVID-19 from the emergency department through the high-dependency unit to intensive care from an unspecified number of infected individuals. Data from Martinelli et al. [5], from 281 461 patients. Post-COVID-19 data not available. ED: emergency department; HDU: high-dependency unit; ICU: intensive care unit; PH: prehospital.

  • FIGURE 2
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    FIGURE 2

    COVID-19 representative computed tomography scans. a) Emergency department: Lung weight=1197.5 g; Gas volume=3937.6 mL; Fraction of non-aerated tissue=0.054; PaO2/FIO2 ratio=146. b) High-dependency unit: Lung weight=1088.6 g; Gas volume=1569.9 mL; Fraction of non-aerated tissue=0.168; PaO2/FIO2 ratio=210. c) Intensive care unit: Lung weight=1399.2 g; Gas volume=1257.5 mL; Fraction of non-aerated tissue=0.389; PaO2/FIO2 ratio=112. FIO2: inspiratory oxygen fraction; PaO2: arterial oxygen tension.

  • FIGURE 3
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    FIGURE 3

    Summary of COVID-19 pathophysiology time course of patients who fail to improve. Atelectasis/recruitability progressively increase during the disease course until a later phase, characterised by fibrosis development. These anatomical changes are associated with a progressive decrease of respiratory system compliance, same or higher ventilation and a decreased PaCO2. Note that oxygenation does not change remarkably during the disease course, although, the mechanisms of hypoxaemia are likely to shift from V′A/Q′ misdistribution to true shunt. ED: emergency department; HDU: high-dependency unit; ICU: intensive care unit; PaCO2: arterial carbon dioxide tension; V′A/Q′: ventilation/perfusion ratio.

Tables

  • Figures
  • TABLE 1

    Clinical presentation of COVID-19 pneumonia during the first (1 February 2020 to 31 May 2020) and second (1 June 2020 to 1 June 2021) waves

    VariablesFirst waveSecond waveWaveReferences
    Age (years)61±11.6352±18.61°[6, 7, 9, 12, 14, 16, 17, 19–22]
    2°[14, 15, 17, 19–22]
    Gender, male (%)51551°[6–9, 14–17, 19–22]
    2°[14, 15, 17, 19–22]
    Symptoms]
     Cough (%)47.240.81°[6, 8, 13, 14, 16, 19, 22]
    2°[13, 14, 19, 22]
     Fever (%)46.6551°[6, 8, 14, 16, 19, 22]
    2°[13, 14, 19, 21, 22]
     Dyspnoea (%)31.733.51°[6, 8, 13, 14, 16, 19, 22]
    2°[13, 14, 19, 22]
     Fatigue, asthenia (%)18.2271°[8, 16]
    2°[22]
     Acute kidney injury (%)10.8171°[19]
    2°[19]
     Diarrhoea (%)651°[6, 8, 14, 16, 19]
    2°[13, 14, 19, 22]
     Vomiting (%)2.751°[14, 16, 19]
    2°[14, 19]
     Neurological symptoms (%)0.60.71°[14, 16]
    2°[14]
    Gas exchange]
      PaO2 (mmHg)69.7±21.3665 (56–74)1°[8, 15]
    2°[15]
      PaCO2 (mmHg)34.1±4.732 (28–84)1°[10, 15]
    2°[15]
      PaO2/FIO2 ratio (mmHg)182±65.29249±1111°[7, 9, 10, 15]
    2°[15]
     Respiratory rate (breaths per min)23±4.828 (22–33)1°[8, 10, 15]
    2°[15]
     Saturation (%)94±2.7893 (89–97)1°[8, 15, 18]
    2°[15]

    Data expressed as mean±sd or median (interquartile range), unless otherwise stated. PaO2: arterial oxygen tension; PaCO2: arterial carbon dioxide tension; FIO2: inspiratory oxygen fraction.

    • TABLE 2

      Mechanical ventilation in COVID-19 pneumonia

      AuthorPatients enrolledEarly intubation n (%)Deceased n (%)Late intubation n (%)Deceased n (%)
      Zuccon [79]5425 (46.3)9 (36)23 (42.6)12 (52.2)
      Lee [80]4723 (48.9)13 (56.5)16 (34.0)7 (43.8)
      Karagiannidis [81]10 0211318 (13.2)696 (52.8)141 (1.4)70 (49.6)
      Grasselli [82]39882929 (73.4)1514 (51.7)151 (3.8)NA
      Matta [83]11176 (68.5)54 (71.1)35 (31.5)20 (57.1)
      Hernandez-Romieu [84]231132 (57.1)47 (35.6)42 (18.2)16 (38.1)
      Mellado-Artigas [85]12261 (50)13 (21.3)23 (18.9)6 (26.1)
      Pandya [86]7537 (49.3)20 (54.1)38 (50.7)18 (47.4)
      Roedl [87]22366 (29.6)26 (39.4)46 (20.6)20 (43.5)
      Bavishi [88]5430 (55.6)2 (6.7)24 (44.4)7 (29.2)
      COVID-ICU Group [89]42442635 (62.1)957 (36.3)741 (17.5)244 (32.9)
      Total49787332 (38.2)3351 (45.7)1280 (6.7)420 (37.2)

      The weighted means of the different studies are summarised in the final row. NA: data not available.

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      COVID-19 pneumonia: pathophysiology and management
      Luciano Gattinoni, Simone Gattarello, Irene Steinberg, Mattia Busana, Paola Palermo, Stefano Lazzari, Federica Romitti, Michael Quintel, Konrad Meissner, John J. Marini, Davide Chiumello, Luigi Camporota
      European Respiratory Review Dec 2021, 30 (162) 210138; DOI: 10.1183/16000617.0138-2021

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      COVID-19 pneumonia: pathophysiology and management
      Luciano Gattinoni, Simone Gattarello, Irene Steinberg, Mattia Busana, Paola Palermo, Stefano Lazzari, Federica Romitti, Michael Quintel, Konrad Meissner, John J. Marini, Davide Chiumello, Luigi Camporota
      European Respiratory Review Dec 2021, 30 (162) 210138; DOI: 10.1183/16000617.0138-2021
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