tetano
Editor, Senior Moderator
Am J Respir Crit Care Med
. 2020 Jul 15.
doi: 10.1164/rccm.202004-1412OC. Online ahead of print.
Pulmonary Angiopathy in Severe COVID-19: Physiologic, Imaging and Hematologic Observations
Brijesh V Patel[SUP] 1 2 [/SUP], Deepa J Arachchillage[SUP] 3 4 5 [/SUP], Carole A Ridge[SUP] 6 [/SUP], Paolo Bianchi[SUP] 7 [/SUP], James F Doyle[SUP] 7 [/SUP], Benjamin Garfield[SUP] 7 [/SUP], Stephane Ledot[SUP] 7 [/SUP], Cliff Morgan[SUP] 7 [/SUP], Maurizio Passariello[SUP] 7 [/SUP], Susanna Price[SUP] 7 [/SUP], Suveer Singh[SUP] 8 7 1 [/SUP], Louit Thakuria[SUP] 7 [/SUP], Sarah Trenfield[SUP] 7 [/SUP], Richard Trimlett[SUP] 9 [/SUP], Christine Weaver[SUP] 7 [/SUP], S John Wort[SUP] 10 [/SUP], Tina Xu[SUP] 7 [/SUP], Simon P G Padley[SUP] 11 [/SUP], Anand Devaraj[SUP] 11 [/SUP], Sujal R Desai[SUP] 11 [/SUP], & The Severe Acute Respiratory Failure Service, The Departments of Anaesthesia & Critical Care and The Interstitial Lung Disease Unit, Royal Brompton Hospital
Affiliations
Abstract
Rationale: Clinical and epidemiologic data in coronavirus disease 2019 (Covid-19) have accrued rapidly since the outbreak but few address the underlying pathophysiology.
Objectives: To ascertain the physiologic, hematologic and imaging basis of lung injury in severe Covid-19 pneumonia.
Methods: Clinical, physiologic and laboratory data were collated. Radiologic (computed tomography pulmonary angiography [CTPA, n=39] and dual-energy CT [DECT, n=20]) studies were evaluated: observers quantified CT patterns (including the extent of abnormal lung and the presence/extent of dilated peripheral vessels) and perfusion defects on DECT. Coagulation status was assessed using thromboelastography (TEG).
Measurements and results: In 39 consecutive patients (M:F 32:7; mean age, 53?10 years [range 29-79 years]; black and ethnic minority, n=25 [64%]), there was a significant vascular perfusion abnormality and increased physiologic dead-space (dynamic compliance, 33.7?14.7 mls/cmH[SUB]2[/SUB]O; Murray Lung Injury Score, 3.14?0.53; mean ventilatory ratios, 2.6?0.8) with evidence of hypercoagulability and fibrinolytic 'shutdown'. The mean CT extent (?SD) of normally-aerated lung, ground-glass opacification and dense parenchymal opacification were 23.5?16.7%, 36.3?24.7% and 42.7?27.1%, respectively. Dilated peripheral vessels were present in 21/33 (63.6%) patients with at least two assessable lobes (including 10/21 [47.6%] with no evidence of acute pulmonary emboli). Perfusion defects on DECT (assessable in 18/20 [90%]), were present in all patients (wedge-shaped, n=3; mottled, n= 9; mixed pattern, n=6).
Conclusions: Physiologic, hematologic and imaging data show not only the presence of a hypercoagulable phenotype in severe Covid-19 pneumonia but also markedly impaired pulmonary perfusion likely caused by pulmonary angiopathy and thrombosis. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords: Acute Respiratory Distress Syndrome; Mechanical Ventilation; Novel Coronavirus Disease 2019; Pulmonary perfusion; Thoracic Imaging.
. 2020 Jul 15.
doi: 10.1164/rccm.202004-1412OC. Online ahead of print.
Pulmonary Angiopathy in Severe COVID-19: Physiologic, Imaging and Hematologic Observations
Brijesh V Patel[SUP] 1 2 [/SUP], Deepa J Arachchillage[SUP] 3 4 5 [/SUP], Carole A Ridge[SUP] 6 [/SUP], Paolo Bianchi[SUP] 7 [/SUP], James F Doyle[SUP] 7 [/SUP], Benjamin Garfield[SUP] 7 [/SUP], Stephane Ledot[SUP] 7 [/SUP], Cliff Morgan[SUP] 7 [/SUP], Maurizio Passariello[SUP] 7 [/SUP], Susanna Price[SUP] 7 [/SUP], Suveer Singh[SUP] 8 7 1 [/SUP], Louit Thakuria[SUP] 7 [/SUP], Sarah Trenfield[SUP] 7 [/SUP], Richard Trimlett[SUP] 9 [/SUP], Christine Weaver[SUP] 7 [/SUP], S John Wort[SUP] 10 [/SUP], Tina Xu[SUP] 7 [/SUP], Simon P G Padley[SUP] 11 [/SUP], Anand Devaraj[SUP] 11 [/SUP], Sujal R Desai[SUP] 11 [/SUP], & The Severe Acute Respiratory Failure Service, The Departments of Anaesthesia & Critical Care and The Interstitial Lung Disease Unit, Royal Brompton Hospital
Affiliations
- PMID: 32667207
- DOI: 10.1164/rccm.202004-1412OC
Abstract
Rationale: Clinical and epidemiologic data in coronavirus disease 2019 (Covid-19) have accrued rapidly since the outbreak but few address the underlying pathophysiology.
Objectives: To ascertain the physiologic, hematologic and imaging basis of lung injury in severe Covid-19 pneumonia.
Methods: Clinical, physiologic and laboratory data were collated. Radiologic (computed tomography pulmonary angiography [CTPA, n=39] and dual-energy CT [DECT, n=20]) studies were evaluated: observers quantified CT patterns (including the extent of abnormal lung and the presence/extent of dilated peripheral vessels) and perfusion defects on DECT. Coagulation status was assessed using thromboelastography (TEG).
Measurements and results: In 39 consecutive patients (M:F 32:7; mean age, 53?10 years [range 29-79 years]; black and ethnic minority, n=25 [64%]), there was a significant vascular perfusion abnormality and increased physiologic dead-space (dynamic compliance, 33.7?14.7 mls/cmH[SUB]2[/SUB]O; Murray Lung Injury Score, 3.14?0.53; mean ventilatory ratios, 2.6?0.8) with evidence of hypercoagulability and fibrinolytic 'shutdown'. The mean CT extent (?SD) of normally-aerated lung, ground-glass opacification and dense parenchymal opacification were 23.5?16.7%, 36.3?24.7% and 42.7?27.1%, respectively. Dilated peripheral vessels were present in 21/33 (63.6%) patients with at least two assessable lobes (including 10/21 [47.6%] with no evidence of acute pulmonary emboli). Perfusion defects on DECT (assessable in 18/20 [90%]), were present in all patients (wedge-shaped, n=3; mottled, n= 9; mixed pattern, n=6).
Conclusions: Physiologic, hematologic and imaging data show not only the presence of a hypercoagulable phenotype in severe Covid-19 pneumonia but also markedly impaired pulmonary perfusion likely caused by pulmonary angiopathy and thrombosis. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords: Acute Respiratory Distress Syndrome; Mechanical Ventilation; Novel Coronavirus Disease 2019; Pulmonary perfusion; Thoracic Imaging.