COVID-19 Phenotype L & H

Daily thoughts & numbers on the COVID-19 pandemic from a M.D. working in the front lines at the Emergency Department in a hospital in Stockholm, Sweden. 

What if I told you that perhaps all COVID-19 pneumonia is not best treated as severe ARDS?

Gattinoni et al suggested yesterday, 2020-04-14, in an editorial to Intensive Care Medicine, that there’s a disparity in symptoms and treatment-response in patients with COVID-19, therefore categorizing them in two different phenotypes of COVID-19 pneumonia that can help explain the different ways in which it presents. They describe how type L is different from severe ARDS (those with type H) , and that there is different optimal treatments for each: *

Yet, COVID-19 pneumonia [2], despite falling in most of the circumstances under the Berlin definition of ARDS [3], is a specific disease, whose distinctive features are severe hypoxemia often associated with near normal respiratory system compliance (more than 50% of the 150 patients measured by the authors and further confirmed by several colleagues in Northern Italy). This remarkable combination is almost never seen in severe ARDS. These severely hypoxemic patients despite sharing a single etiology (SARS-CoV-2) may present quite differently from one another: normally breathing (“silent” hypoxemia) or remarkably dyspneic; quite responsive to nitric oxide or not; deeply hypocapnic or normo/hypercapnic; and either responsive to prone position or not. Therefore, the same disease actually presents itself with impressive non-uniformity. (…) Type L, characterized by Low elastance (i.e., high compliance), Low ventilation-to-perfusion ratio, Low lung weight and Low recruitability and Type H, characterized by High elastance, High right-to-left shunt, High lung weight and High recruitability. *

The best way to differentiate between type L and type H patients is, according to the authors, by CT scan where type L patients have only ground-glass opacities primarily located subpleurally and along the lung fissures while typ H patients CT scans shows a ‘remarkable increase in lung weight (> 1.5 kg), on the order of magnitude of severe ARDS.’

They also suggest that the relationship between type L & H is dynamic and can change over time, as a patient presenting with type L at admission kan transition into type H over a couple of days:

Image: from Gattinoni et al, “COVID-19 pneumonia: different respiratory treatments for different phenotypes?” editorial published in Intensive Care Medicine, 2020-04-14. *

Nota bene: Gattinoni et al generally advise against non-invasive options (regardless of type) as they argue that they are associated with high failure rates and delayed intubation!

COVID-19 Numbers Sweden 2020-04-15 *

• 1 203 deaths nationally
  • 702 of them in Stockholm
• 11 927 confirmed cases nationally
  DEATHS [SWE]
  
  New confirmed deaths daily in Sweden. 
  (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
  ICU [SWE]
  
  New Covid-19 patients Being Treated at the ICU in Sweden. 
  (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
  NEW CONFIRMED CASES [SWE]  
  
  New confirmed cases daily in Sweden.
  (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
  TOTAL CONFIRMED CASES [SWE]  
  
  New confirmed cases accumulated over time in Sweden. 
  (Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
  
• Intensive care Sweden: *
  • 970 COVID-19 confirmed patients treated in the ICU in total so far
  • 10,5 days from symptoms to ICU
  • 25,4 % women
    
    Total number of recorded of COVID-19 patients needing ICU care each week. From Week 10 it seems to more than triple each week for the first 4 weeks. From week ten: 5 →  24  → 129 → 425 → 760 → 1105 (1213 this week up until now, however since it’s only wednesday this weeks numbers are yet incomplete)

COVID-19 Numbers Globally (updated today 2020-04-15 at 14:00 CET) *

• 123 126 confirmed deaths
• 1 918 126 confirmed cases
• 5 389 new deaths

That’s it until tomorrow, keep calm and stay safe!