Current issues and trends in Respiratory therapy
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Assignment2Article.pdf
Clinical Characteristics, Respiratory Mechanics, and Outcomes in Critically Ill Individuals With COVID-19 Infection in an Underserved
Urban Population
Siddique Chaudhary, Sadia Benzaquen, Jessica G Woo, Jack Rubinstein, Atul Matta, Jeri Albano, Robert De Joy III, Kevin Bryan Lo, and Gabriel Patarroyo-Aponte
BACKGROUND: The COVID-19 outbreak in the United States has disproportionately affected
Black individuals, but little is known about the factors that underlie this observation. Herein, we
describe these associations with mortality in a largely minority underserved population.
METHODS: This single-center retrospective observational study included all adult subjects with
laboratory-confirmed SARS-Cov-2 treated in our ICU between March 15 and May 10, 2020.
RESULTS: 128 critically ill adult subjects were included in the study (median age 68 y [interquar-
tile range 61–76], 45% female, and 64% Black); 124 (97%) required intubation. Eighty (63%) sub-
jects died during their in-patient stay, which did not differ by race/ethnicity. Compared with other
racial/ethnic groups, Blacks had a greater proportion of women (52% vs 30%, P 5 .02) and sub- jects with hypertension (91% vs 78%, P 5 .035). Asthma (P 5 .03) was associated with lower in- patient death, primarily among Black subjects (P 5 .02). Among Black subjects, increased age (odds ratio 1.06 [95% CI 1.05–1.22] per year), positive fluid balance (odds ratio 1.06 [95% CI 1.01–
1.11] per 100 mL), and treatment with tocilizumab (odds ratio 25.0 [95% CI 3.5–180]) were inde-
pendently associated with in-patient death, while higher platelets (odds ratio 0.65 [95% CI 0.47–
0.89] per 50 3 103/mL) and treatment with intermediate dose anticoagulants (odds ratio 0.08 [95% CI 0.02–0.43]) were protective. Among other race/ethnic groups, higher total bilirubin (odds ratio
1.75 [95% CI 0.94–3.25] per 0.2 mg/dL) and higher maximum lactate (odds ratio 1.43 [95% CI
0.96–2.13] per mmol/L) were marginally associated with increased death, while tocilizumab treat-
ment was marginally protective (odds ratio 0.24 [95% CI 0.05–1.25]). During first 72 h of ventila-
tion, those who died had less increase in PaO2=FIO2 (P 5 .046) and less reduction in PEEP (P 5 .01) and FIO2 requirement (P 5 .002); these patterns did not differ by race/ethnicity. CONCLUSIONS: Black and other race/ethnicity subjects had similar mortality rates due to COVID-19 but dif-
fered in factors that were associated with increased risk of death. In both groups, subjects who
died were older, had a positive fluid balance, and less improvement in PaO2=FIO2, PEEP, and FIO2 requirement on ventilation. Key words: COVID-19; coronavirus; outcomes. [Respir Care 2021;66(6):897–908. © 2021 Daedalus Enterprises]
Introduction
In December 2019, Wuhan Province in China reported
an alarming number of cases presenting with respiratory ill-
ness that was caused by a novel coronavirus subsequently
named SARS-CoV-2.1,2 The clinical manifestation of infec-
tion by this virus is known as coronavirus disease 2019
(COVID-19), and as of this writing has resulted in > 28 million cases in the United States and > 500,000 deaths, with Black individuals representing a significant portion of
the observed morbidity and mortality (55 deaths per
100,000).3,4
Significantly increased risk of death has been reported in
the elderly, in those with prior comorbid conditions,5,6 and
in patients requiring management in the ICU and mechani-
cal ventilation.3 Despite concentrated efforts in obtaining
novel therapeutic possibilities for these patients, the vast
majority of trials have failed to conclusively demonstrate
improved outcomes secondary to pharmaceutical interven-
tions, though clinical variables and ventilatory support have
RESPIRATORY CARE � JUNE 2021 VOL 66 NO 6 897
been shown to have prognostic and possibly therapeutic
value.5,6
COVID-19 has disproportionately affected the Black
community in the United States.4 As of July 10, 2020, de-
mographic data collected by the Centers for Disease
Control and Prevention (CDC) from > 250 hospitals in the COVID-19-associated Hospitalization Surveillance
Network for the week ending in June 27, 2020, 32.5%
of the hospitalized subjects were Black.3 Furthermore,
data from the CDC indicate that 23% of reported deaths
in the United States are Black, compared with 17%
Black in the general population (weighted population
distribution taking into account where deaths occurred),
and the rate is more than twice that of whites (55 deaths
per 100,000 versus 23 deaths per 100,000).4 Whether
there are racial/ethnic differences in risk factors for
death or response to treatment for COVID-19, however,
is not well understood.
In this study we report on the clinical characteristics
of a largely underserved, racially/ethnically diverse
population in a large urban center on the East Coast of
the United States and present key clinical and ventila-
tory characteristics associated with improved outcomes
in our population.
Methods
This is a single-center retrospective case series of all
ICU subjects admitted to the hospital who were diag-
nosed with COVID-19. The study was carried out at a
700-bed, tertiary care, academic medical center with a
28-bed medical ICU and a surge capacity of 60 ICU
beds during the COVID-19 pandemic. Subjects from
both medical and surgical ICUs were included. The
hospital primarily serves the neighboring communities
with a culturally and ethnically diverse population of
59% Black, 23% Hispanic, 12% white, and 4% Asian.
Almost half of the adults (45.1%) had a family income
of # $26,200, and 68% had a family income of # $50,800. More than 80% of discharges are covered by
Medicare/Medicaid. We studied all adult subjects with
a confirmed SARS-CoV-2 polymerase chain reaction
test who were treated in the ICU between March 15 and
May 10, 2020. During this surge period, we only admit-
ted patients to the ICU if they required intubation,
while the patients on high-flow nasal cannula or CPAP
were managed on the step-down unit by our pulmonol-
ogists. Patients with incomplete data in terms of the
main clinical outcomes and demographics were
excluded from the study. The study was approved by
the hospital institutional review board, who deemed it
to be low risk and waived the requirement for informed
consent. Data were collected from the electronic medi-
cal records using International Classification of
Disease 9–10 codes. Subjects who presented with char-
acteristic symptoms were tested for COVID-19. A total
of 673 subjects were admitted to our hospital with con-
firmed COVID infection; of these subjects, 128 were
managed in the ICU during this time. We collected de-
mographic data, presenting comorbidities, laboratory
values and novel therapies used for COVID-19, and
mortality and hospital discharge data from the medical
record. Respiratory and hemodynamic values were col-
lected at baseline and at 24, 48, and 72 h.
Drs Chaudhury, Benzaquen, Matta, and Patarroyo-Aponte are affiliated
with the Division of Pulmonary and Critical Care and Sleep Medicine,
Einstein Medical Center, Philadelphia, Pennsylvania. Drs Benzaquen
and Patarroyo-Aponte are affiliated with the Department of Medicine,
Einstein Medical Center, Philadelphia, Pennsylvania. Drs Benzaquen,
Albano, De Joy, Lo, and Patarroyo-Aponte are affiliated with the Sidney
Kimmel College, Thomas Jefferson University, Philadelphia, Pennsylvania.
Dr Woo is affiliated with the Department of Pediatrics, University of
Cincinnati College of Medicine, Cincinnati, Ohio. Dr Woo is affiliated
with the Division of Biostatistics and Epidemiology, Cincinnati
Children’s Hospital Medical Center, Cincinnati, Ohio. Dr Rubinstein is
affiliated with the Department of Internal Medicine, University of
Cincinnati College of Medicine, Cincinnati, Ohio.
The authors have disclosed no conflicts of interest.
Correspondence: Siddique Chaudhary MD, Einstein Medical Center,
Philadelphia, 5501 Old York Road Philadelphia PA 19141. E-mail:
DOI: 10.4187/respcare.08319
QUICK LOOK
Current knowledge
COVID-19 is a highly inflammatory viral disease and
since the start of the pandemic data has shown that the
outcomes in Black and underserved populations is
poor. There have been clinical and epidemiological
research in China, European countries and USA that
have described this clinical entity but little is known of
its effect on the Black population.
What This Paper contributed to Our Knowledge
In our cohort of predominantly Black subjects, we
found out that the mortality was high in patients who
are on mechanical ventilation, elderly patients with
comorbid conditions, and a positive fluid balance 48
h post intubation. We did not find any differences in
outcomes by race, although there was a slightly
higher mortality in Black individuals.
SEE THE RELATED EDITORIAL ON PAGE 1041
COVID-19 IN AN UNDERSERVED AREA
898 RESPIRATORY CARE � JUNE 2021 VOL 66 NO 6
Statistical Analysis
Clinical and demographic data were evaluated relative
to the primary end point, in-patient death, overall, and
by race/ethnicity (Black versus white/Hispanic/other).
Unadjusted medians with interquartile ranges (IQR) were
obtained with non-parametric Kruskal-Wallis tests, while
number (percent) were obtained using chi-square or Fisher
exact tests, as appropriate. Multivariable logistic regression
was conducted to determine independent associations of
clinical, demographic, and treatment variables with in-
patient death, testing any variable with unadjusted P # .20 and with data available for at least 80% of subjects; elimi-
nation of variables was conducted sequentially by eliminat-
ing the least significant terms or most unstable odds ratio
estimates.
Longitudinal changes in respiratory parameters during
the first 72 h of ventilation were tested using mixed model-
ing, accounting for correlated measurements within person.
All models of respiratory parameters were adjusted for age,
race, sex, body mass index, and total days on the ventilator,
with the main discriminating variables being time (0, 24,
48, or 72 h after intubation) and in-patient death versus
survival. Linear trends were tested using time as a continu-
ous variable. Interactions of in-patient death or Black race
with time were also used to test for differences in change in
respiration parameters over time by race and outcome. For
all analyses, significant values are reported if P < .05 or if inclusion of a term in the model improved model fit, using
reductions in –2 log-likelihood values $ 4 as evidence of a better fitting model.
Results
One hundred twenty-eight subjects with laboratory-con-
firmed COVID-19 were admitted to the ICU. Intubation was
deemed necessary in 124 (97%) subjects. Demographic and
clinical characteristics are summarized in Table 1. Median
age was 68 y (IQR 61–75.5], and 57 (45%) were female.
Blacks represented 64% of the population and had a likeli-
hood of survival of 35% in comparison to 41% of the remain-
ing population; this difference was not statistically significant
(P ¼ .57). Overall, 83 (63%) subjects died while admitted. Subjects who died in the hospital were a median of 6 y older
than those who did not (median age 64 vs 70, P ¼ .02); this was statistically significant only in Black subjects (P ¼ .006). Nearly all subjects had bilateral infiltrates upon admis-
sion (96%; Table 1). Cardiovascular comorbidities were
extremely common (88%), particularly hypertension (87%),
followed by diabetes (57%) and respiratory comorbidities
(32%). Two or more comorbidities were seen in 78% of sub-
jects. Despite a high proportion of subjects with history of
hypertension, diabetes, and coronary artery disease, only
38% of subjects were being treated with renin angiotensin
aldosterone system inhibition (angiotensin-converting
enzyme inhibitors and angiotensin receptor blockers) prior to
admission. Of the comorbidities, only respiratory, particu-
larly asthma, were negatively associated with in-patient
death; respiratory comorbidities were present in 44% of sub-
jects discharged alive versus 25% of in-patients who died
(P ¼ .033), and asthma was present in 15% of subjects dis- charged alive versus 3% of in-patients who died (P ¼ .03). Asthma was associated to a greater extent in Blacks who
were discharged alive (21% vs 4%, P ¼ .02), whereas over- all respiratory comorbidities were more prevalent in other
race/ethnicity groups discharged alive (42% vs 15%,
P ¼ .049). Medication use did not differ by in-patient death.
Laboratory parameters associated with in-patient death
included higher procalcitonin (P ¼ .01), higher creatinine (P ¼.004), lower fibrinogen (P ¼.003), lower platelets (P ¼ .03), and longer partial thromboplastin time (P ¼ .009), along with marginally higher alkaline phospha-
tase (P ¼ .051) (Table 2). These differed somewhat by race/ethnicity. Among Black subjects, only lower fibrino-
gen was significantly associated with in-patient death
(P ¼ .02), with higher procalcitonin (P ¼ .08), lower pla- telets (P ¼ .057), and lower lactate dehydrogenase (P ¼ .09) marginally associated. More admission laboratory
values were associated with in-patient death among
white/Hispanic/other subjects: higher lactate (P ¼ .02), higher creatinine (P ¼ .003), higher direct bilirubin (P ¼ .005), higher total bilirubin (P ¼ .006), higher lactate dehy- drogenase (P ¼ .005), higher procalcitonin (P ¼ .02), and higher partial thromboplastin time (P ¼ .033). Considering maximum values recorded during the hospitalization, in-
patient death was associated with higher lactate (P < .001, significant in both race/ethnic groups), higher ferritin
(P ¼.02, significant in Black subjects only), higher procalci- tonin (P ¼ .001, significant in both race/ethnic groups), lower fibrinogen (P ¼ .009, significant in Black subjects only), and higher creatinine (P ¼ .02 for maximum within the first week, significant in white/Hispanic/other group
only). Maximum C-reactive protein was also marginally
higher for those with in-patient death (P ¼ .07, in Black sub- jects only).
Table 3 presents the treatments and clinical outcomes
and associations with in-patient death. Several medica-
tions were administered to these subjects, with the most
common being anticoagulants (98%), tocilizumab (71%),
and hydroxychloroquine (66%). Of all medications noted,
only steroids were associated with better outcomes (44%
among all patients discharged alive vs 26% in those with
in-patient death, P ¼ .041), but this association was not significant in either race/ethnic group. Conversely, treat-
ment with remdesivir was associated with improved out-
comes in white/Hispanic/other subjects (P ¼ .01) but not Black subjects (P > .99).
COVID-19 IN AN UNDERSERVED AREA
RESPIRATORY CARE � JUNE 2021 VOL 66 NO 6 899
T a b le
1 .
A ss o c ia ti o n s o f A d m is si o n C h a ra c te ri st ic s o f IC U S u b je c ts W it h C O V ID
-1 9 W it h O u tc o m e s b y R a c e /E th n ic it y
O v e ra ll
A ll S u b je c ts
B la c k
W h it e /H is p a n ic /O th e r
D is c h a rg e d A li v e
In -H
o sp it a l D e a th
P D is c h a rg e d A li v e
In -H
o sp it a l D e a th
P D is c h a rg e d A li v e
In -H
o sp it a l D e a th
P
S u b je c ts
1 2 8
4 8 (3 8 )
8 0 (6 3 )
2 9 (3 5 )
5 3 (6 5 )
1 9 (4 1 )
2 7 (5 9 )
A g e , y
6 8 (6 1 – 7 5 .5 )
6 4 (5 8 – 7 3 .5 )
7 0 (6 3 – 7 7 .5 )
.0 2
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7 (3 7 )
7 (2 6 )
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7 (9 )
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(2 4 .5 – 3 5 .5 )
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B il a te ra l in fi lt ra te s
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7 4 (9 5 )
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R e sp ir a to ry
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8 (1 7 )
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> .9 9
A tr ia l fi b ri ll a ti o n
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5 (1 0 )
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a rt e ry
d is e a se
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> .9 9
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4 6 (5 7 )
> .9 9
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9 (4 7 )
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> .9 9
D ia b e te s
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6 (8 )
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4 (2 1 )
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M e d ic a ti o n s a t a d m is si o n
A n ti p la te le ts
6 0 (4 7 )
2 1 (4 4 )
3 9 (4 9 )
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1 4 (4 8 )
2 8 (5 3 )
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7 (3 7 )
1 1 (4 1 )
> .9 9
N S A ID
s 8 (6 )
3 (6 )
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3 (1 0 )
6 (9 )
> .9 9
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A C E i/ A R B
4 9 (3 8 )
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2 7 (3 4 )
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1 3 (4 5 )
2 1 (4 0 )
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9 (4 7 )
6 (2 2 )
.1 1
(C o n ti n u e d )
COVID-19 IN AN UNDERSERVED AREA
900 RESPIRATORY CARE � JUNE 2021 VOL 66 NO 6
Figure 1 presents longitudinal respiratory parameters for
subjects during the first 72 h of ventilation, adjusting for
age, sex, race, body mass index, and total days on the venti-
lator. PaO2=FIO2 generally increased over time (P < .001) but increased earlier and to a greater degree in those dis-
charged alive (P ¼ .046). Similarly, FIO2 requirements (P < .001) decreased significantly over time but decreased earlier and more in those discharged alive
(P ¼ .002). PEEP decreased only in surviving subjects (P ¼.03), while plateau pressure decreased significantly for all subjects (P ¼ .008) but did not differ by outcome. Mean arterial pressure and compliance did not change
materially during ventilation, as shown in Figure 2.
None of the respiratory or ventilation parameters dif-
fered by race/ethnicity (data not shown). As shown in
Table 3, positive fluid balance in the first 48 h of intu-
bation was also significantly associated with greater
mortality (P ¼ .007) but was significant only in Black subjects (P ¼ .01). The full respiratory parameters at admission and at intu-
bation are presented in Table 4. At admission, oxygen inter-
face was predominantly either nasal cannula (54%) or non-
rebreathing mask (36%), with marginal difference by in-
patient death (P ¼ .054). Those subjects with in-hospital death presented with higher oxygen requirements at admis-
sion and prior to intubation. On intubation, the median
PaO2=FIO2 was 63 (IQR 50–105), PEEP was 10 cm H2O (IQR 7–10), plateau pressure was 25 cm H2O (IQR 22–30),
and compliance was 26 mL/cm H2O (IQR 21–33) (Table 4).
None of these values were significantly different between
survivors and in-patient deaths. Early intubation (defined as
within the first 2 d of hospitalization), prone positioning, air-
way pressure release ventilation, and vasodilator therapy
were not associated with in-patient death. Extubation was
successful in 35 subjects (29%), of whom 31 (89%) were
subsequently discharged alive (P < .001). Because of differences in patient profiles by
race/ethnicity group, logistic regression models were
developed separately by race, testing variables with
unadjusted P # .20 (Fig. 3). Among Black subjects, higher age (odds ratio [OR] 1.13 [95% CI 1.05–1.22]
per additional year of age, P ¼ .002), positive fluid bal- ance (OR 1.06 [95% CI 1.02–1.11] per 100 mL, P ¼ .008), and tocilizumab treatment (OR 25 [95% CI 3.5–
180]) were independently associated with risk of in-
patient death, while a higher platelet count (OR 0.65
[95% CI 0.47–0.89] per 50,000/mL, P ¼ .008), and in- termediate dose anticoagulation (OR 0.08 [95% CI
0.02–0.43]) were associated with improved outcomes.
Among white/Hispanic/other subjects, marginally asso-
ciated risk factors included higher total bilirubin at
admission (OR 1.75 [95% CI 0.93–3.25], P ¼ .08) and higher maximum lactate (OR 1.43 [95% CI 0.96–2.13],
P ¼ .08), while tocilizumab treatment was marginallyTa b le
1 . C o n ti n u e d
O v e ra ll
A ll S u b je c ts
B la c k
W h it e /H is p a n ic /O th e r
D is c h a rg e d A li v e
In -H
o sp it a l D e a th
P D is c h a rg e d A li v e
In -H
o sp it a l D e a th
P D is c h a rg e d A li v e
In -H
o sp it a l D e a th
P
N o v e l a n ti c o a g u la n ts
1 3 (1 0 )
5 (1 0 )
8 (1 0 )
.9 4
1 (3 )
4 (8 )
.6 5
4 (2 1 )
4 (1 5 )
.7 0
H e p a ri n
7 (5 )
3 (6 )
4 (5 )
.7 6
3 (1 0 )
3 (6 )
.6 6
0 (0 )
1 (4 )
> .9 9
S ta ti n s
7 4 (5 8 )
3 0 (6 3 )
4 4 (5 5 )
.4 1
1 7 (5 9 )
3 1 (5 8 )
> .9 9
1 3 (6 8 )
1 3 (4 8 )
.2 3
P re d n is o n e
8 (6 )
3 (6 )
5 (6 )
> .9 9
2 (7 )
4 (8 )
> .9 9
1 (5 )
1 (4 )
> .9 9
M e d ic a ti o n s, n o .
.4 2
.2 2
.4 2
0 1 9 (1 5 )
5 (1 0 )
1 4 (1 8 )
3 (1 0 )
6 (1 1 )
2 (1 1 )
8 (2 9 )
1 3 9 (3 0 )
1 5 (3 1 )
2 4 (3 0 )
1 0 (3 4 )
1 7 (3 2 )
5 (2 6 )
7 (2 6 )
2 3 9 (3 0 )
1 7 (3 5 )
2 2 (2 8 )
9 (3 1 )
1 3 (2 5 )
8 (4 2 )
9 (3 3 )
3 2 2 (1 7 )
6 (1 3 )
1 6 (2 0 )
3 (1 0 )
1 5 (2 8 )
3 (1 6 )
1 (4 )
4 9 (7 )
5 (1 0 )
4 (5 )
4 (1 4 )
2 (4 )
1 (5 )
2 (7 )
D a ta a re
p re se n te d a s n (%
) o r m e d ia n (i n te rq u a rt il e ra n g e ).
B M I ¼
b o d y m a ss
in d e x
N A ¼
n o t a v a il a b le
E S R D ¼
e n d -s ta g e re n a l d is e a se
H IV
¼ h u m a n im
m u n o d e fi c ie n c y v ir u s
N S A ID
¼ n o n st e ro id a l a n ti -i n fl a m m a to ry
d ru g
A C E i/ A R B ¼
a n g io te n si n -c o n v e rt in g e n z y m e in h ib it o rs a n d a n g io te n si n re c e p to r b lo c k e rs
COVID-19 IN AN UNDERSERVED AREA
RESPIRATORY CARE � JUNE 2021 VOL 66 NO 6 901
T a b le
2 .
L a b o ra to ry
P a ra m e te rs o f IC U S u b je c ts W it h C O V ID
-1 9 a n d A ss o c ia ti o n s W it h In -P a ti e n t D e a th
b y R a c e /E th n ic it y
O v e ra ll
A ll S u b je c ts
B la c k
W h it e /H is p a n ic /O th e r
D is c h a rg e d A li v e
In -H
o sp it a l D e a th
P D is c h a rg e d A li v e
In -H
o sp it a l D e a th
P D is c h a rg e d A li v e
In -H
o sp it a l D e a th
P
A d m is si o n la b o ra to ry
p a ra m e te rs
A lk a li n e p h o sp h a ta se , IU
/L 8 2 (6 7 – 1 1 5 )
7 8 (6 5 – 9 2 )
8 5 (7 2 – 1 3 1 )
.0 5 1
7 8 (6 1 – 9 7 )
8 2 .5
(7 2 .5 – 1 1 4 )
.1 3
7 8 (6 5 – 9 2 )
9 6 .5
(7 2 – 1 5 7 )
.1 4
A la n in e a m in o tr a n sf e ra se ,
IU /L
2 7 (1 8 – 4 9 )
2 6 .5
(1 8 – 4 2 )
3 1 .5
(1 8 – 5 2 )
.4 9
2 6 (1 8 – 4 2 )
2 5 .5
(1 6 – 4 8 .5 )
.8 5
3 0 (1 3 – 4 2 )
4 2 (2 0 – 5 9 )
.1 1
A sp a rt a te a m in o tr a n sf e ra se , IU
/L 4 5 .5
(2 9 .5 – 7 4 )
4 3 (3 2 – 5 4 )
4 6 (2 9 – 8 1 )
.2 4
3 7 (3 2 – 7 1 )
4 6 (2 8 .5 – 7 7 .5 )
.7 1
4 9 (2 7 – 5 4 )
5 3 (3 1 – 8 8 )
.1 4
W h it e b lo o d c e ll c o u n t,
1 0 3 /m L
8 ,3 8 0
(6 ,1 5 5 – 1 2 ,9 4 5 )
8 ,9 9 5
(6 ,5 6 0 – 1 3 ,1 4 5 )
8 ,1 7 0
(5 ,8 7 5 – 1 2 ,6 1 5 )
.5 1
1 0 ,1 2 0
(7 ,0 1 0 – 1 3 ,0 6 0 )
7 ,8 8 0
(5 ,7 2 0 – 1 2 ,4 0 0 )
.3 0
8 ,5 7 0
(5 ,2 2 0 – 1 3 ,2 3 0 )
8 ,9 3 0
(6 ,1 9 0 – 1 2 ,8 3 0 )
.8 8
N e u tr o p h il , %
8 0 .1
(7 0 .8 – 8 4 .9 )
7 8 .8
(7 0 .6 – 8 5 .2 )
8 0 .5
(7 0 .8 – 8 4 .9 )
.6 0
7 5 .5
(6 2 .9 – 8 4 .5 )
8 0 .6
(6 9 .0 – 8 5 .0 )
.2 3
8 1 .8
(7 3 ,7 – 8 6 .8 )
8 0 .5
(7 8 .0 – 8 4 .4 )
.4 8
L y m p h o c y te , %
9 .8
(6 .5 – 1 5 .9 )
8 .6 5 (6 .5 – 1 6 .1 )
1 0 .1
(6 .3 – 1 5 .9 )
.6 5
8 .5
(7 .0 – 1 6 .7 )
1 0 .8
(7 .4 – 1 6 .1 )
.6 0
8 .8
(6 .1 – 1 5 .1 )
9 .3
(5 .3 – 1 2 .6 )
.9 6
B a n d s, %
0 (0 – 2 .6 )
0 (0 – 1 )
0 (0 – 6 )
.3 5
0 (0 – 3 .1 )
0 (0 – 3 .1 )
.8 8
0 (0 – 0 )
0 (0 – 1 2 .5 )
.0 7
T ro p o n in , n g /m
L 0 .0 4 (0 .0 2 – 0 .1 2 )
0 .0 4 (0 .0 1 – 0 .1 2 )
0 .0 4 (0 .0 2 – 0 .1 5 )
.2 1
0 .0 4 (0 .0 1 – 0 .1 4 )
0 .0 4 (0 .0 2 – 0 .1 2 )
.7 3
0 .0 4 (0 .0 1 – 0 .0 7 )
0 .0 5 (0 .0 3 – 0 .2 8 )
.1 5
L a c ta te , m m o l/ L
1 .8 0 (1 .2 9 – 3 .0 0 )
1 .8 0 (1 .2 0 – 2 .4 0 )
1 .8 2 (1 .3 3 – 3 .2 8 )
.1 4
1 .8 7 (1 .4 1 – 2 .5 0 )
1 .8
(1 .2 – 3 .2 )
.9 0
1 .3 2 (1 .1 0 – 2 .2 4 )
2 .2
(1 .5 – 4 .6 )
.0 2
S e ru m
so d iu m , m m o l/ L
1 3 8 (1 3 6 – 1 4 3 )
1 3 8 (1 3 6 – 1 4 0 )
1 3 8 (1 3 5 – 1 4 5 )
.3 2
1 3 8 (1 3 6 – 1 3 9 )
1 3 8 (1 3 6 – 1 4 3 )
.5 0
1 3 8 (1 3 6 – 1 4 0 )
1 4 0 (1 3 2 – 1 4 9 )
.4 3
C re a ti n in e , m g /d L
1 .4 5 (1 .0 – 2 .4 5 )
1 .1
(0 .8 – 1 .7 5 )
1 .6
(1 .1 – 2 .7 5 )
.0 0 4
1 .2
(0 .9 – 2 .2 )
1 .5
(1 .0 – 2 .5 )
.1 8
1 .1
(0 .7 – 1 .7 )
2 .0
(1 .4 – 2 .8 )
.0 0 3
B il ir u b in , d ir e c t, m g /d L
0 .3
(0 .2 – 0 .5 )
0 .3
(0 .2 ,0 .5 )
0 .3
(0 .2 – 0 .5 )
.2 2
0 .3
(0 .2 – 0 .5 )
0 .3
(0 .2 – 0 .4 )
.6 1
0 .2
(0 .2 – 0 .4 )
0 .4 5 (0 .3 – 0 .6 )
.0 0 5
B il ir u b in , to ta l, m g /d L
0 .5
(0 .4 – 0 .8 )
0 .5
(0 .3 – 0 .8 )
0 .5
(0 .4 – 0 .8 )
.3 6
0 .5
(0 .3 – 0 .9 )
0 .5
(0 .3 – 0 .6 5 )
.4 3
0 .4
(0 .3 – 0 .7 )
0 .7 5 (0 .5 – 1 .1 )
.0 0 6
F e rr it in , n g /m
L 9 8 8 (4 9 1 – 2 ,1 8 1 )
7 9 8 (4 3 0 – 1 ,7 4 4 )
1 ,0 3 4 (5 0 0 – 2 ,7 6 7 )
.1 5
6 9 3 (4 2 9 – 1 ,7 6 5 )
1 ,0 0 5 (4 8 1 – 1 ,9 4 4 )
.4 9
9 4 1 (4 6 4 – 1 ,7 2 3 ) 1 ,4 4 2 (7 9 8 – 3 ,4 5 0 )
.1 1
D -d im
e r, n g /m
L 2 ,7 0 0 (1 ,4 0 0 – 5 ,8 6 0 ) 2 ,5 5 0 (1 ,1 6 0 – 4 ,4 6 0 ) 2 ,8 0 5 (1 ,4 1 5 – 5 ,9 4 5 )
.3 3
2 ,8 2 5 (1 ,6 3 0 – 4 ,2 2 5 ) 2 ,6 5 0 (1 ,3 0 0 – 6 ,0 3 0 ) .9 6
1 ,6 7 0 (6 3 0 – 5 ,9 5 0 ) 3 ,2 1 0 (2 ,1 4 0 – 5 ,5 2 0 ) .1 4
C -r e a c ti v e p ro te in , m g /L
1 7 8 (1 0 0 – 2 6 2 )
1 6 1 (9 0 – 2 4 8 )
1 8 4 (1 1 3 – 2 7 2 )
.3 2
1 4 4 (9 4 – 2 3 9 )
1 9 2 (1 0 9 – 2 7 7 )
.2 3
1 6 2 (8 4 – 2 4 8 )
1 7 7 (1 2 0 – 2 2 3 )
.9 5
L a c ta te d e h y d ro g e n a se , IU
/L 4 9 9 (3 8 1 – 6 5 3 )
4 6 4 (3 6 1 – 6 8 6 )
5 0 6 (4 0 4 – 6 4 2 )
.6 5
5 9 2 (4 2 8 – 7 5 2 )
5 0 0 (3 8 6 – 6 4 8 )
.0 9
3 6 4 (2 7 2 – 5 0 2 )
5 1 4 (4 3 9 – 6 0 1 )
.0 0 5
P ro c a lc it o n in , n g /m
L 0 .5 5 (0 .2 0 – 2 .1 4 )
0 .3 7 (0 .1 1 – 0 .9 9 )
0 .9 0 (0 .2 2 – 5 .8 7 )
.0 1
0 .3 1 (0 .1 1 – 0 .8 2 )
0 .6 1 (0 .1 8 – 2 .4 8 )
.0 8
0 .4 6 (0 .2 5 – 0 .9 9 )
1 .9 3 (0 .5 1 – 1 1 .2 )
.0 2
P ro th ro m b in
ti m e , s
1 5 .1
(1 3 .9 – 1 6 .7 )
1 5 .1
(1 3 .9 – 1 6 .0 )
1 5 .1
(1 3 .9 – 1 6 .9 )
.5 1
1 5 .1
(1 4 .3 – 1 5 .5 )
1 4 .7
(1 3 .8 – 1 6 .4 )
.7 9
1 4 .9
(1 3 .5 – 1 8 .5 )
1 5 .8
(1 4 .6 – 1 8 .2 )
.1 5
P a rt ia l th ro m b o p la st in
ti m e , s
3 6 .6
(3 1 .5 – 4 6 .3 )
3 3 .5
(3 0 .0 – 4 1 .4 )
3 7 .8
(3 3 .6 – 4 8 .5 )
.0 0 9
3 4 .0
(2 9 .7 – 4 0 .7 )
3 6 .7
(3 3 .1 – 4 8 .1 )
.1 2
3 3 .5
(3 0 .1 – 4 3 .0 )
4 2 .5
(3 7 .1 – 6 0 .4 )
.0 3 3
In te rn a ti o n a l n o rm
a li z e d ra ti o
1 .2
(1 .0 – 1 .3 )
1 .2
(1 .0
1 .2 )
1 .2
(1 .0 – 1 .3 )
.8 6
1 .2
(1 .1 – 1 .2 )
1 .1
(1 .0 – 1 .3 )
.5 7
1 .2
(1 .0 – 1 .5 )
1 .2
(1 .1 – 1 .5 )
.2 8
P la te le ts , 1 0 3 /m L
1 9 6 (1 5 1 – 2 7 1 )
2 2 9 (1 6 5 – 2 6 6 )
1 8 0 (1 4 1 – 2 7 8 )
.0 3 3
2 2 5 (1 6 8 – 2 9 9 )
1 8 0 (1 4 0 – 2 7 5 )
.0 5 7
2 3 1 (1 5 5 – 2 6 3 )
1 8 0 (1 4 7 – 2 8 0 )
.2 6
F ib ri n o g e n , m g /d L
5 7 0 (4 9 0 – 6 7 5 )
6 3 6 (5 6 8 – 7 7 4 )
5 4 4 (4 6 5 – 6 3 5 )
.0 0 3
6 3 8 (5 7 0 – 7 6 8 )
5 5 5 (4 9 0 – 6 4 5 )
.0 2
6 2 7 (5 6 6 – 7 9 3 )
5 0 3 (3 8 6 – 5 8 3 )
.0 6 6
M a x im
u m
la b o ra to ry
p a ra m e te rs
L a c ta te , m m o l/ L
2 .8
(1 .8 – 5 .9 )
2 .0 0 (1 .4 5 – 3 .0 0 )
3 .8 2 (2 .1 8 – 7 .7 2 )
< .0 0 1
2 .3
(1 .6 – 3 .1 )
3 .2
(2 .0 – 6 .9 )
.0 1
1 .9
(1 .4 – 2 .6 )
5 .1
(2 .9 – 1 0 .1 )
.0 0 2
F e rr it in , n g /m
L 2 ,3 4 0 (8 2 4 – 4 ,7 8 5 )
1 ,6 4 7 (6 7 0 – 3 ,2 3 7 )
2 ,7 0 7 (1 ,0 5 1 – 8 ,7 0 4 )
.0 2
1 ,5 0 3 (6 5 5 – 3 ,0 8 4 )
2 ,6 5 0 (1 ,0 2 2 – 9 ,2 1 9 ) .0 3 8 2 ,3 4 0 (8 2 4 – 3 ,2 3 7 ) 2 ,9 2 2 (1 ,0 6 8 – 5 ,3 9 2 ) .2 1
D -d im
e r, n g /m
L *
7 ,6 9 0
(3 ,5 5 0 – 2 3 ,0 0 0 )
5 ,5 7 5
(2 ,8 1 5 – 1 9 ,3 0 0 )
9 ,4 3 0
(3 ,9 4 0 – 2 5 ,0 0 0 )
.2 0
6 ,5 6 0
(3 ,9 7 0 – 2 5 ,0 0 0 )
1 1 ,6 8 0
(3 ,3 7 0 – 2 5 ,0 0 0 )
.7 6
4 ,5 2 0
(1 ,8 7 0 – 1 3 ,3 8 0 )
7 ,5 2 0
(4 ,0 5 0 – 1 4 ,1 5 0 )
.1 3
C -r e a c ti v e p ro te in , m g /L
2 2 3 (1 6 1 – 3 0 4 )
1 9 3 (1 5 1 – 2 7 4 )
2 3 8 (1 6 8 – 3 2 7 )
.0 7
1 8 9 (1 4 4 – 2 7 0 )
2 5 3 (1 0 – 3 3 2 )
.0 6 2
2 1 3 (1 6 1 – 2 8 5 )
2 1 1 (1 6 1 – 2 7 9 )
.7 9
L a c ta te d e h y d ro g e n a se , IU
/L 7 0 2 (5 3 7 – 1 ,0 2 7 )
6 5 5 (5 0 2 – 9 1 5 )
7 2 6 (5 4 9 – 1 ,0 4 8 )
.1 7
7 0 5 (5 5 8 – 9 6 2 )
7 8 0 (5 6 3 – 1 ,1 6 5 )
.5 8
6 1 6 (3 7 5 – 7 4 8 )
6 4 9 (5 4 6 – 8 6 1 )
.1 4
P ro c a lc it o n in , n g /m
L 1 .2 1 (0 .3 0 – 1 0 .0 8 )
0 .4 9 (0 .1 5 – 2 .0 2 )
2 .0 4 (0 .4 7 – 1 1 .4 )
.0 0 1
0 .4 2 (0 .1 2 – 2 .4 6 )
1 .4
(0 .4 – 1 0 .4 )
.0 1
0 .6 2 (0 .2 5 – 2 .0 2 )
4 .4 8 (1 .2 4 – 1 5 .8 3 )
.0 2
F ib ri n o g e n , m g /d L
6 4 2 (5 3 6 – 7 3 0 )
6 8 1 (6 3 8 – 7 8 4 )
6 0 3 (5 1 0 – 7 0 0 )
.0 0 9
6 9 7 (6 3 8 – 7 8 4 )
6 0 9 (5 2 7 – 7 0 9 )
.0 3 3
6 7 9 (5 3 6 – 7 9 3 )
6 0 2 (4 6 8 – 6 6 8 )
.0 9
C re a ti n in e , m g /d L
2 .5
(1 .4 – 4 .6 )
1 .7
(1 .2 – 4 .2 )
2 .8
(1 .9 – 4 .9 )
.0 2
1 .8
(1 .1 – 4 .0 )
2 .8
(1 .5 – 4 .3 )
.2 0
1 .4
(1 .2 – 4 .3 )
2 .8
(2 .2 – 5 .4 )
.0 2
D a ta a re
p re se n te d a s n (%
) o r m e d ia n (i n te rq u a rt il e ra n g e ).
* D -d im
e r v a lu e s $
2 5 ,0 0 0 n g /m
L a re
re p o rt e d a s 2 5 ,0 0 0 n g /m
L , th e m a x im
u m
m e a su ra b le v a lu e .
COVID-19 IN AN UNDERSERVED AREA
902 RESPIRATORY CARE � JUNE 2021 VOL 66 NO 6
T a b le
3 .
A ss o c ia ti o n o f T re a tm
e n t a n d C li n ic a l O u tc o m e W it h In -P a ti e n t D e a th
b y R a c e /E th n ic it y
O v e ra ll
A ll S u b je c ts
B la c k
W h it e /H is p a n ic /O th e r
D is c h a rg e d A li v e
In -H
o sp it a l D e a th
P D is c h a rg e d A li v e
In -H
o sp it a l D e a th
P D is c h a rg e d A li v e
In -H
o sp it a l D e a th
P
M u rr a y sc o re
2 .8
(2 .3 – 3 .3 )
2 .8
(2 .5 – 3 .3 )
2 .8
(2 .3 – 3 .3 )
.7 3
2 .5
(2 .3 – 3 .1 )
2 .8
(2 .3 – 3 .0 )
.5 1
3 .0
(2 .8 – 3 .3 )
2 .8
(2 .0 – 3 .3 )
.3 0
F lu id
b a la n c e in
fi rs t 4 8 h o f
in tu b a ti o n , m L *
2 ,5 0 9 (8 3 5 – 3 ,6 9 8 ) 1 ,7 7 3 (– 3 0 to
3 ,0 2 0 ) 2 ,6 7 6 (1 ,4 8 1 – 4 ,2 5 5 )
.0 0 7 1 ,7 2 2 (2 3 5 – 2 ,8 6 2 ) 2 ,6 6 4 (1 ,6 4 1 – 4 ,0 4 0 )
.0 1
1 ,7 7 3 (– 4 7 to
3 ,1 2 9 ) 2 ,9 1 9 (7 0 3 – 5 ,8 1 3 )
.1 8
P o si ti v e fl u id
b a la n c e
9 6 (8 5 )
3 3 (7 3 )
6 3 (9 3 )
.0 0 7
2 1 (7 5 )
4 4 (9 6 )
.0 2
1 2 (7 1 )
1 9 (8 6 )
.2 6
M e d ic a ti o n s
H y d ro x y c h lo ro q u in e
8 4 (6 6 )
3 0 (6 3 )
5 4 (6 8 )
.5 6
2 1 (7 2 )
3 7 (7 0 )
> .9 9
9 (4 7 )
1 7 (6 3 )
.3 7
S te ro id s
4 2 (3 3 )
2 1 (4 4 )
2 1 (2 6 )
.0 4 1
1 4 (4 8 )
1 6 (3 0 )
.1 5
7 (3 7 )
5 (1 9 )
.1 9
T o c il iz u m a b
9 1 (7 1 )
3 4 (7 1 )
5 7 (7 1 )
.9 6
1 9 (6 6 )
4 4 (8 3 )
.1 0
1 5 (7 9 )
1 3 (4 8 )
.0 6 4
P a ra ly ti c s
5 0 (4 0 )
1 9 (4 0 )
3 1 (4 0 )
> .9 9
1 2 (4 3 )
2 3 (4 5 )
> .9 9
7 (3 7 )
7 (2 8 )
.7 4
A n ti c o a g u la ti o n
1 2 6 (9 8 )
4 8 (1 0 0 )
7 8 (9 8 )
.5 3
2 9 (1 0 0 )
5 3 (1 0 0 )
> .9 9
1 9 (1 0 0 )
2 5 (9 3 )
.5 0
F u ll d o se
8 4 (6 6 )
3 2 (6 7 )
5 2 (6 5 )
.8 5
1 7 (5 9 )
3 7 (7 0 )
.3 4
1 5 (7 9 )
1 5 (5 6 )
.1 3
In te rm
e d ia te d o se
2 7 (2 1 )
1 4 (2 9 )
1 3 (1 6 )
.0 8
1 1 (3 8 )
9 (1 7 )
.0 5 8
3 (1 6 )
4 (1 5 )
> .9 9
P ro p h y la c ti c d o se
7 0 (5 5 )
2 6 (5 4 )
4 4 (5 5 )
.9 3
1 7 (5 9 )
3 4 (6 4 )
.6 4
9 (4 7 )
1 0 (3 7 )
.5 5
R e m d e si v ir
1 7 (1 3 )
9 (1 9 )
8 (6 )
.1 8
3 (1 0 )
7 (1 3 )
> .9 9
6 (3 2 )
1 (4 )
.0 1
C o n v a le sc e n t p la sm
a 3 (2 )
3 (6 )
0 (0 )
.0 5 1
2 (7 )
0 (0 )
.1 2
1 (5 )
0 (0 )
.4 1
C li n ic a l tr e a tm
e n ts
P ro n e p o si ti o n in g
4 4 (3 5 )
1 9 (4 0 )
2 5 (3 2 )
.3 7
1 3 (4 6 )
1 9 (3 7 )
.4 8
6 (3 2 )
6 (2 3 )
.7 3
A ir w a y p re ss u re
re le a se
v e n ti la ti o n
5 (4 )
2 (4 )
3 (4 )
> .9 9
1 (4 )
3 (6 )
> .9 9
1 (5 )
0 (0 )
.4 2
T ra c h e o st o m y
7 (6 )
6 (1 3 )
1 (1 )
.0 1
4 (1 4 )
1 (2 )
.0 5 1
2 (1 1 )
0 (0 )
.1 7
E C M O
6 (5 )
5 (1 1 )
1 (1 )
.0 2 8
3 (1 1 )
1 (2 )
.1 2
2 (1 1 )
0 (0 )
.1 7
V a so d il a to r th e ra p y
9 (7 )
5 (1 1 )
4 (5 )
.2 9
4 (1 5 )
3 (6 )
.2 2
1 (5 )
1 (4 )
> .9 9
C li n ic a l o u tc o m e s
H o sp it a l le n g th
o f st a y , d
1 3 (7 – 1 8 )
1 6 (1 3 – 2 2 )
1 1 (6 – 1 6 )
< .0 0 1
1 6 (1 0 – 2 2 )
1 3 (8 – 1 8 )
.1 4
1 6 .5
(1 5 – 2 2 )
7 (4 – 1 2 )
< .0 0 1
IC U le n g th
o f st a y , d
7 (4 – 1 4 )
7 (5 – 1 5 )
7 (4 – 1 3 .5 )
.4 7
6 .5
(3 – 1 5 )
1 0 (5 – 1 5 )
.4 0
9 .5
(6 – 1 8 )
5 (2 – 1 0 )
.0 2
D a y s o n v e n ti la to r*
7 (4 – 1 4 )
7 (4 – 1 5 .5 )
7 (4 – 1 3 )
.6 5
7 (4 – 1 5 )
1 0 (5 – 1 0 )
.5 1
9 (3 – 1 8 )
5 .5
(2 – 9 )
.0 9
D a y s p ri o r to
in tu b a ti o n *
2 (0 – 4 )
2 (0 – 4 )
1 .8
(0 – 4 )
.9 8
3 (0 – 4 )
2 (0 .5 – 4 )
.6 7
1 .5
(0 .2 5 – 4 )
0 .7 5 (0 – 3 )
.3 4
W it h d ra w a l o f c a re
4 9 (3 8 )
1 (2 )
4 8 (6 0 )
< .0 0 1
1 (3 )
2 9 (5 5 )
< .0 0 1
0 (0 )
1 9 (7 0 )
< .0 0 1
P a ll ia ti v e c a re
7 7 (6 0 )
1 8 (3 8 )
5 9 (7 4 )
< .0 0 1
1 1 (3 8 )
3 7 (7 0 )
.0 0 9
7 (3 7 )
2 2 (8 1 )
.0 0 5
N e e d fo r C R R T /H D
3 5 (2 7 )
1 0 (2 1 )
2 5 (3 1 )
.2 0
6 (2 1 )
1 8 (3 4 )
.3 1
4 (2 1 )
7 (2 6 )
> .9 9
S u c c e ss fu l e x tu b a ti o n *
3 5 (2 9 )
3 1 (7 0 )
4 (5 )
< .0 0 1
1 7 (6 8 )
4 (5 )
< .0 0 1
1 4 (7 4 )
0 (0 )
< .0 0 1
R e in tu b a ti o n
6 /3 5 (1 7 )
3 /3 1 (1 0 )
3 /4
(7 5 )
.0 1
2 /1 7 (1 2 )
3 /4
(7 5 )
.0 3
1 /1 4 (7 )
0 (0 )
> .9 9
D a ta a re
p re se n te d a s n (%
) o r m e d ia n (i n te rq u a rt il e ra n g e ).
* D a ta fo r fl u id
b a la n c e a n d in tu b a ti o n /v e n ti la ti o n p re se n te d fo r th e 1 2 4 su b je c ts re q u ir in g in tu b a ti o n .
E C M O ¼
e x tr a c o rp o re a l m e m b ra n e o x y g e n a ti o n
C R R T ¼
c o n ti n u o u s re n a l re p la c e m e n t th e ra p y
H D ¼
h e m o d ia ly si s
COVID-19 IN AN UNDERSERVED AREA
RESPIRATORY CARE � JUNE 2021 VOL 66 NO 6 903
protective (OR 0.24 [95% CI 0.05–1.25], P ¼ .09). In sen- sitivity analyses removing subjects with an ICU length of
stay # 2 d, who may not have had an opportunity to receive certain medications or therapies, the model for
Blacks remained essentially unchanged, while among
white/Hispanic/other race subjects, only higher total bili-
rubin at admission remained a significant risk factor (OR
1.74 [95% CI 1.04–2.91], P ¼ .036).
220
200
180
160
140
120
100
80
P aO
2/F IO
2 (m
m H
g)
Time post intubation (h)Time post intubation (h)
Time post intubation (h)
0 24 48 72
0 24 48 72
Time post intubation (h) 0 24 48 72
0 24 48 72
11
10
9
8
7
Survived Died
P E
E P
(c m
H 2O
)
27
26
25
24
23
22
21
P pl
at (c
m H
2O )
1.0
0.90
0.80
0.70
0.60
0.50
0.40
F I O
2
A B
C D
Fig. 1. Longitudinal ventilation parameters associated with in-patient death. Least squares means 6 SD presented from mixed models adjusted for race, sex, age, body mass index, and total time on ventilator. (A) PaO2 =FIO2 ; (B) PEEP; (C) plateau pressure (Pplat); and (D) FIO2 requirement
(%).
Time post intubation (h)Time post intubation (h)
36
34
32
30
28
26
24
Survived Died
M ea
n ar
te ria
l p re
ss ur
e
C om
pl ia
nc e
90
88
86
84
82
80
78
76
74
72 0 24 48 720 24 48 72
Fig. 2. Longitudinal ventilation parameters not associated with in-patient death. Least squares means 6 SD presented from mixed models adjusted for race, sex, age, body mass index, and total time on ventilator. (A) Compliance; (B) mean arterial pressure.
COVID-19 IN AN UNDERSERVED AREA
904 RESPIRATORY CARE � JUNE 2021 VOL 66 NO 6
T a b le
4 .
R e sp ir a to ry
P a ra m e te rs
a t A d m is si o n a n d P ri o r to
In tu b a ti o n b y In -P a ti e n t D e a th
a n d R a c e /E th n ic it y
O v e ra ll
A ll S u b je c ts
B la c k
W h it e /H is p a n ic /O th e r
D is c h a rg e d A li v e
In -H
o sp it a l D e a th
P D is c h a rg e d A li v e
In -H
o sp it a l D e a th
P D is c h a rg e d A li v e
In -H
o sp it a l D e a th
P
A t a d m is si o n /p ri o r to
in tu b a ti o n
O x y g e n m o d e a t a d m is si o n
.0 5 4
.0 3 0
.2 1
R o o m
a ir
5 (5 )
1 (2 )
4 (6 )
0 (0 )
2 (4 )
1 (5 )
2 (9 )
N a sa l c a n n u la
6 3 (5 4 )
2 5 (5 4 )
3 8 (5 4 )
1 6 (5 9 )
3 3 (6 9 )
9 (4 7 )
5 (2 2 )
N o n -r e b re a th e r m a sk
4 2 (3 6 )
1 4 (3 0 )
2 8 (3 9 )
5 (1 9 )
1 2 (2 5 )
9 (4 7 )
1 6 (7 0 )
O th e r
7 (6 )
6 (1 3 )
1 (1 )
6 (2 2 )
1 (2 )
0 (0 )
0 (0 )
P a O 2 = F IO
2 a t a d m is si o n
1 0 9 (6 4 – 1 7 4 )
1 3 4 (7 9 – 1 8 3 )
1 0 5 (6 4 – 1 6 6 )
.5 3
1 3 7 (5 4 – 1 8 3 )
1 1 7 (7 4 – 1 8 7 )
.8 0
1 3 4 (8 8 – 1 6 9 )
7 6 (5 6 – 1 0 4 )
.0 3 9
P a O 2 = F IO
2 m in im
u m
p ri o r to
in tu b a ti o n
6 2 (4 8 – 1 0 0 )
6 1 (4 9 – 1 1 0 )
6 2 (4 8 – 8 9 )
.5 8
5 5 (4 8 – 1 1 0 )
6 2 (4 8 – 8 9 )
.9 3
7 9 (5 0 – 1 3 3 )
6 4 (4 9 – 1 0 0 )
.5 0
N e e d fo r in tu b a ti o n
1 2 4 (9 7 )
4 7 (9 8 )
7 7 (9 6 )
> .9 9
2 8 (9 7 )
5 1 (9 6 )
> .9 9
1 9 (1 0 0 )
2 6 (9 6 )
> .9 9
D a y s o f m id -f lo w p ri o r to
in tu b a ti o n
1 .0
(0 .2 – 2 .5 )
1 .3
(0 .5 – 3 .0 )
0 .5
(0 – 1 .0 )
.1 3
2 .0
(0 .5 – 4 .0 )
0 .5
(0 .1 – 2 .5 )
.0 8
0 .5
(0 .2 5 – 2 .0 )
0 .5
(0 – 2 .0 )
.6 2
E a rl y in tu b a ti o n
5 9 (4 9 )
2 1 (4 7 )
3 8 (5 0 )
.8 5
1 1 (4 2 )
2 2 (4 4 )
> .9 9
1 0 (5 3 )
1 6 (6 2 )
.7 6
A t o r ju st b e fo re
st a rt o f in tu b a ti o n *
O x y g e n m o d e
.0 6 1
.1 4
.2 1
N a sa l c a n n u la
1 9 (1 6 )
6 (1 4 )
1 3 (1 8 )
3 (1 2 )
9 (1 8 )
3 (1 6 )
4 (1 7 )
N o n -r e b re a th e r m a sk
7 1 (6 1 )
2 3 (5 2 )
4 8 (6 7 )
1 1 (4 4 )
2 9 (5 9 )
1 2 (6 3 )
1 9 (8 3 )
H ig h -f lo w n a sa l c a n n u la
9 (8 )
4 (9 )
5 (7 )
3 (1 2 )
5 (1 0 )
1 (5 )
0 (0 )
C P A P
7 (6 )
3 (7 )
4 (6 )
2 (8 )
4 (8 )
1 (5 )
0 (0 )
O th e r
1 0 (9 )
8 (1 8 )
2 (3 )
6 (2 4 )
2 (4 )
2 (1 1 )
0 (0 )
P a O 2 = F IO
2 6 3 (5 0 – 1 0 5 )
7 9 (5 0 – 1 2 6 )
6 3 (4 9 – 9 1 )
.1 4
6 2 (5 0 – 1 1 6 )
6 2 (4 8 – 8 3 )
.3 8
8 5 (5 2 – 1 6 1 )
6 7 (5 1 – 1 0 5 )
.3 0
T id a l v o lu m e , m L
4 4 5 (4 0 0 – 4 7 5 )
4 5 0 (3 8 0 – 4 8 0 )
4 2 0 (4 0 0 – 4 7 3 )
.8 9
4 5 0 (3 7 0 – 5 0 0 )
4 0 0 (4 0 0 – 4 5 0 )
.7 2
4 5 0 (4 0 0 – 4 6 0 )
4 5 0 (4 0 0 – 5 0 0 )
.3 3
P E E P , c m
H 2 O
1 0 (7 – 1 0 )
1 0 (8 – 1 2 )
8 (5 – 1 0 )
.2 4
1 0 (8 – 1 0 )
1 0 (8 – 1 0 )
.9 5
1 0 (5 – 1 4 )
8 (5 – 1 0 )
.0 5 5
C o m p li a n c e , m L /c m
H 2 O
2 6 (2 1 – 3 3 )
2 7 (1 9 – 3 4 )
2 6 (2 2 – 3 3 )
.6 1
2 8 (2 0 – 3 5 )
2 6 (2 3 – 3 1 )
.5 5
2 5 (1 8 – 3 2 )
3 0 (2 2 – 3 8 )
.1 1
P la te a u p re ss u re , c m
H 2 O
2 5 (2 2 – 3 0 )
2 5 (2 2 – 3 1 )
2 5 (2 2 – 3 0 )
.8 6
2 5 (2 1 – 3 2 )
2 6 (2 3 – 3 0 )
.6 4
2 7 (2 3 – 2 9 )
2 4 (2 0 – 3 2 )
.3 8
M e a n a rt e ri a l p re ss u re , m m
H g
7 9 (7 0 – 9 2 )
8 2 (7 2 – 9 6 )
7 9 (6 8 – 9 2 )
.2 4
8 2 (7 4 – 9 4 )
7 8 (7 0 – 9 1 )
.2 8
8 2 (7 1 – 1 0 4 )
8 0 (6 6 – 9 4 )
.5 1
P a O 2 = F IO
2 , %
1 0 0 (1 0 0 – 1 0 0 )
1 0 0 (1 0 0 – 1 0 0 )
1 0 0 (9 7 – 1 0 0 )
.0 8
1 0 0 (1 0 0 – 1 0 0 )
1 0 0 (8 0 – 1 0 0 )
.2 1
1 0 0 (1 0 0 – 1 0 0 )
1 0 0 (1 0 0 – 1 0 0 )
.2 4
D a ta a re
p re se n te d a s n (%
) o r m e d ia n (i n te rq u a rt il e ra n g e ).
* D a ta fo r in tu b a ti o n p a ra m e te rs p re se n te d fo r th e 1 2 4 su b je c ts re q u ir in g in tu b a ti o n .
COVID-19 IN AN UNDERSERVED AREA
RESPIRATORY CARE � JUNE 2021 VOL 66 NO 6 905
Discussion
In this retrospective case series of critically ill subjects, we
evaluated racial/ethnic differences in mortality and risk fac-
tors for in-patient death in a diverse, urban ICU. While we
observed no statistically significant difference in risk for mor-
tality between Black and white/Hispanic/other subjects, our
results revealed different patterns of risk for the 2 race/ethnic
groups. Notably, Blacks at greater risk were older and had a
positive fluid balance during ventilation, while higher plate-
lets and administration of intermediate dose anticoagulants
were protective. Increased risk among white/Hispanic/other
race/ethnicity subjects was associated with higher bilirubin at
admission and higher maximum lactate.
Similar to other studies, we had a high proportion of elderly
subjects admitted to our ICU with a median age at presenta-
tion of 68 y (IQR 61–75.5).5 In this study, however, age was
significantly related to death only among Black subjects, who
were marginally younger, overall, compared with subjects in
the white/Hispanic/other race/ethnic group. Laboratory and
clinical findings associated with increased risk of death also
differed by race/ethnicity. Among Black subjects, the pres-
ence of a higher fluid balance during ventilation and lower
platelets at admission were independently associated with risk
of death. By contrast, among the other race/ethnic groups,
higher bilirubin and higher lactate excursions during hospitali-
zation were identified as marginal risks. Finally, we noted that
tocilizumab treatment may have opposite effects in Black and
white/Hispanic/other subjects. While this finding needs to be
confirmed in other populations as this was a small sample
size, it suggests that clinical management may need to con-
sider race when administering tocilizumab.
Interestingly, we found that, in contrast to some prior studies
(but not all), most comorbidities were not associated with worse
outcomes except for asthma, which was paradoxically associ-
ated with increased likelihood of survival, especially in Black
subjects.5,6 Other studies have shown decreased COVID-19 dis-
ease severity in individuals with asthma; while the underlying
pathophysiology behind this observation is still unclear, some
are proposing that the use of inhaled corticosteroids or decreased
expression of angiotensin-converting enzyme receptors on epi-
thelial cells may provide partial explanation.7
There has been significant controversy regarding prior
use of angiotensin-converting enzyme inhibitors and angio-
tensin receptor blockers as a risk factor for poor outcomes
in COVID-19, though most studies have not shown
increased risk.8 Our results confirm that prior treatment
with these drugs was not associated with worse outcomes,
although a lower percentage of subjects was taking these
drugs than expected based on their comorbidities.
We noted that higher procalcitonin and lower fibrinogen
levels were associated with worse outcomes as expected,
since high procalcitonin levels are associated with worsening
disease and bacterial co-infection. A recent meta-analysis
showed that an elevated procalcitonin level is associated
with � 5-fold increased risk of severe COVID-19 (OR 4.76 [95% CI 2.74–8.29]).9 Furthermore, higher baseline creati-
nine and increased partial thromboplastin time (but not pro-
thrombin time/international normalized ratio) were also
associated with higher likelihood of death. Our results were
similar to those reported by Cheng et al,10 who reported that
baseline kidney disease and acute kidney injury were inde-
pendent risk factors for in-hospital death.
The disease course for COVID-19 has been described
by Siddiqui et al11 in 3 stages. Stage I is the early infection
phase, which includes the constitutional symptoms, and it
is believed that the viral replication occurs in this phase.
Stage II is when most subjects present to the hospital with
worsening respiratory symptoms, high fevers, increase
ventilation/perfusion, abnormalities on chest radiography
or computed tomography, and markedly elevated inflam-
matory markers such as C-reactive protein, ferritin, and D-
dimer. This progresses into stage III, with worsening
inflammatory markers and a cytokine storm similar to
hemophagocytic lymphohistiocytosis and CAR-T cell
cytokine release syndrome. Subjects often end up with
multi-organ failure. Most of our subjects likely presented
in stage II or III of the disease with markedly elevated
inflammatory markers. The inflammatory markers in our
subjects were also significantly higher, with median serum
ferritin on admission of 988 (IQR 491–2,181), C-reactive
protein of 178 (IQR 100–262), and D-dimer of 2,700 (IQR
1,400–5,860). Studies in New York and China have both
Black
Age (pe
r ye ar)
Pla tele
ts ( per
50 ,00
0/µ L)
Flu id b
ala nce
(pe r 10
0 m L)
Ant ico
agu lati
on inte
rme dia
te d ose
Toc ilizu
ma b
Bili rub
in a t ad
mis sio
n (p er 0
.2 m g/d
L)
Ma xim
al l act
ate (pe
r m mo
l/L)
Toc ilizu
ma b
A dj
us te
d O
R fo
r i n-
pa tie
nt d
ea th
0
1
2
3
4 22
23
24
25
26
27
White/Hispanic/Other
Fig. 3. Odds ratios (95% CI) of factors associated with in-patient death, by race/ethnicity, presented from race/ethnicity-specific
adjusted logistic regression models. The upper limit of the 95% CI for tocilizumab treatment in Black subjects is 180 (not shown). OR ¼ odds ratio.
COVID-19 IN AN UNDERSERVED AREA
906 RESPIRATORY CARE � JUNE 2021 VOL 66 NO 6
shown markedly elevated ferritin, C-reactive protein, eryth-
rocyte sedimentation rate, and D-dimer levels.5,6,12
It has been reported that early intubation in subjects
with COVID-19 may be associated with improved out-
comes. We noted no difference between early and late
intubation in our results, although an analysis of the respi-
ratory system mechanics showed results consistent with
the traditional management of ARDS. On intubation, the
median PaO2=FIO2 was 63 (IQR 50–105), PEEP was 10 cm H2O (IQR 7–10), plateau pressure was 25 cm H2O (IQR
22–30), and compliance was 26 mL/cm H2O (IQR 21–
33). None of these values were significantly different
between survivors and in-patient deaths. However, sub-
jects who survived were found to require lower PEEP and
FIO2 early after intubation.
These compliance data are lower than what was reported
by Gattinoni et al13 in their initial experience in Italy.
Gattinoni et al13 described 2 phenotypes: phenotype L, with
low elastance, low ventilation/perfusion ratio, and low lung
recruitability; and phenotype H, with a high elastance, high
right-to-left shunt, and high lung recruitability. They recom-
mended that the subjects with phenotype L be managed with
a high tidal volume and low PEEP strategy, which is con-
trary to the ARDSNet protocol. The respiratory mechanics
data for subjects with COVID-19 in Boston also support the
low compliance ventilation strategy, which remained low
over a period of 3 d.14 The compliance in previous large
cohort of studies was also lower, and analysis of our subjects
shows similar results.15,16 In our study on intubation, the me-
dian PaO2=FIO2 was 63 (IQR 50–105) and median compli- ance was 26 mL/cm H2O (IQR 21–33), and compliance
remained low over the 72 h following intubation.
Interestingly, even though prone positioning has been
reported to improve outcomes and was performed on 35%
of subjects (of whom 40% survived) in our cohort, it was
not associated with increased likelihood of survival.17
Although prone positioning did point toward better survival
(ie, 40% vs 32%, P ¼ .37) our sample size was under-pow- ered for it to be statistically significant.
Lastly, data regarding the use of repurposed drugs for
the treatment of COVID-19 have been conflicting. Our
center attempted several of these therapies in line with
the available information at the time. Our post hoc anal-
ysis of these interventions demonstrated that only ste-
roid therapy was associated with improved outcomes.
The surviving sepsis guidelines recommend the short-
term use of steroids for intubated subjects with COVID-
19 and ARDS.18 Wu et al19 reported reduced risk of
death in COVID-19–associated ARDS for subjects who
received steroids (hazard ratio 0.38 [95% CI 0.20–
0.72], P ¼ .03). There was also a trend toward improved outcomes in the group with intermediate-dose anticoa-
gulation, which may merit further attention in light of
increased rates of thrombosis associated with COVID-
19. Treatment with systemic anticoagulation seemed to
have better survival outcomes in a large observational
study of subjects with COVID-19 in New York, and a
subgroup analysis of mechanically ventilated critically
ill subjects indicated similar benefits.20 However, treat-
ment should be based on a risk/benefit analysis due to
risk of bleeding associated with anticoagulation.
Some limitations of this study should be considered
when interpreting results. This was a retrospective study
in a single center, potentially limiting generalizability.
As a descriptive study, it can only show an association
with a finding and does not prove cause and effect, and
other known and unknown confounders can skew results.
Furthermore, given the rapidly changing pace of knowl-
edge regarding treatment of this disease, medical treat-
ments given were layered on each other and introduced at
different times, making assessment of the association of
in-patient death with any single treatment imprecise.
Small sample sizes and missing data for some analyses
also reduced the power to detect differences.
Conclusions
Despite similar in-patient mortality from COVID-19,
Black subjects and subjects of white/Hispanic/other race or
ethnicity appear to have different risk factors and responses
to treatments in relation to in-patient death. Increased age,
positive fluid balance during ventilation, and low platelet
count at admission were independent risk factors for Black
subjects, while elevated total bilirubin and elevated maxi-
mum lactate are risk factors for other race/ethnic groups.
To our knowledge, this is the only paper describing clinical
characteristics, respiratory mechanics, and outcomes by
race/ethnicity in a predominantly Black population.
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Thisarticle is approved forContinuingRespiratoryCareEducation credit. For information and to obtain your CRCE
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