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

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.

Figure 1.

Scout view (on the left) and two slices of chest CT scan acquired in the supine (middle) and prone positions (right) in a 37 yr old massively obese woman (149 kg/158 cm) after 7 d of mechanical ventilation for a severe coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome. The images of the chest tube entering the pleural space (vertical arrows) ensure that the two slices are taken at the same level. Note the upward shift of the right hemidiaphragm (black asterisk) and the gravitational atelectasis of the left lower lobe in supine position. In prone position, the recruitment of the lung is impressive, revealing the pulmonary nodular infiltrates and fibrotic streaks (the horizontal arrows) of COVID-19 pneumonia.