Preface for the special series on “Management of COVID-19 in ICU: What’s New A Year Later?”

In 2020, the coronavirus pandemic brought about dramatic changes to our daily lives. Millions of people were infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the pathogenic agent of coronavirus disease 2019 (COVID-19). Some patients required hospital admission, and the most severe cases required admission to the intensive care unit (ICU). Hospitals needed to reorganize their wards, and at the peak of pandemic many ICUs experienced bed shortages (1). In this preface, we would like to comment on the three articles published in Journal of Public Health and Emergency discussing the management of COVID-19 patients in the ICU.

In the first manuscript, Dr. Divella investigates the mechanisms underlying acute and chronic pain in COVID-19, and stresses how systemic inflammation and cytokine storm were critical players in its pathophysiology, especially in patients with moderate to severe symptoms (2). Dr. Divella also emphasizes that pain was reported across the entire disease spectrum, with headache, myalgia, and arthralgia being the most frequent symptoms in the acute phase of COVID-19. At the height of the pandemic, the number of people in the population suffering from chronic pain also increased due to the pandemic’s impact on healthcare systems, which had to postpone or cancel all elective surgical procedures, including pain management services and surgical procedures such as total joint arthroplasty. Other forms of non-COVID-19-related chronic pain also increased during the pandemic due to the impact of COVID-19 on the healthcare systems, which had to postpone or cancel all elective surgical procedures, including pain management services and surgical procedures such as total joint arthroplasty. Pain suffered in the ICU also had negative impacts on patient quality of life, as was recently demonstrated by our group (3). Moreover, the pandemic demonstrated that a significant number of patients contracting COVID-19 went on to exhibit long-term effects, known as post-COVID conditions (PCC) or long-COVID. The symptoms, which cannot be explained by other causes, (usually) start within three months of infection and generally last for months (4). At the present time, with the bulk of the pandemic behind us, evidence shows that being fully vaccinated reduces the risk of developing long-COVID (5).

The second manuscript addresses the use of prone positioning as a critical rescue maneuver in the fight against COVID-19. As described by Dr. Lassola, prone position proved to be essential for improving oxygenation and reducing mortality in COVID-19 acute respiratory distress syndrome (C-ARDS). It improves resting lung volume in the dorso-caudal regions by reducing the superimposed pressure of the heart and the abdomen (6). The prone position also improves ventilation/perfusion mismatch, with perfusion remaining preferentially distributed in the dorsal lung regions with more homogeneous aeration of the alveolar units. A PaO₂/FiO₂ value below 150 mmHg, measured with a positive end-expiratory pressure (PEEP) level of at least 5 mmH₂O, represents a reasonable criterion for prone positioning in C-ARDS, with the goal of minimizing ventilation damage in the early phase. In cases of severe hypoxemia, this maneuver is unanimously considered a life-saving therapy, especially when performed by expert and standardized teams. Indeed, the most recent trials revealed a positive relationship between longer durations of pronation and favorable outcomes (PROSEVA study) (7). Other promising results suggest that the prone position can even be used in patients suffering from acute hypoxemic respiratory failure due to COVID-19 and in those receiving non-invasive respiratory support, such as high-flow nasal cannula and helmet non-invasive ventilation (NIV), for at least eight hours a day (8).

Finally, the third article addresses the use of ultrasound in COVID-19. Maringelli et al. explored the role of lung, heart, vascular, and diaphragm ultrasound in COVID-19 patients with cardiovascular instability and assessed the associated complications (9). The benefits offered by ultrasound during the pandemic were enormous, with lung ultrasound quickly identifying COVID-19 interstitial pneumonia at home. It was also a valuable tool for monitoring patient complications in the ICU. Although lung ultrasound cannot replace the computed tomography (CT) scan, its use was fundamental during the height of the pandemic. For instance, Dr. Roberto Cosentini, head of the Emergency Department at the main hospital in Bergamo, Italy (the Province of Bergamo was one of the most stricken by the epidemic), mentioned that they were receiving up to 60–80 COVID-19 admissions per day, most of which were concentrated in afternoon (10). It was, therefore, impossible to obtain a CT scan for each patient. By consequence, ultrasound became the most used diagnostic tool for COVID-19. Cardiac ultrasound was used in COVID-19 patients to look at the direct involvement of cardiac function, myocardial depression and pericardial effusion, or in patients with prolonged ventilation to demonstrate ventilator-induced diaphragm dysfunction after prolonged mechanical ventilation and weaning failure (11-14). Furthermore, due to the thrombotic tendency of COVID-19 patients, vascular ultrasound was used to exclude deep venous thrombosis.

We would like to conclude this editorial by honoring one of the authors of this last article, who sadly passed away last September. Prof. Nicola Brienza was an esteemed colleague and great friend. He will be deeply missed. Critical care medicine has lost one of its true leaders.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Public Health and Emergency for the series “Management of COVID-19 in ICU: What’s New a Year Later?”. The article did not undergo external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-2023-01/coif). The series “Management of COVID-19 in ICU: What’s New a Year Later?” was commissioned by the editorial office without any funding or sponsorship. LV served as an unpaid Guest Editor of the series and serves as an unpaid editorial board member of the Journal of Public Health and Emergency from December 2021 to November 2023. CD served as an unpaid Guest Editor of the series. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Deana C, Rovida S, Orso D, et al. Learning from the Italian experience during COVID-19 pandemic waves: be prepared and mind some crucial aspects. Acta Biomed 2021;92:e2021097. [PubMed]
2. Divella M. COVID-19 and pain: any relation? J Public Health Emerg 2022;6:17. [Crossref]
3. Deana C, Vetrugno L, Cortegiani A, et al. Quality of Life in COVID-Related ARDS Patients One Year after Intensive Care Discharge (Odissea Study): A Multicenter Observational Study. J Clin Med 2023;12:1058. [Crossref] [PubMed]
4. Deana C, Verriello L, Pauletto G, et al. Insights into neurological dysfunction of critically ill COVID-19 patients. Trends Anaesth Crit Care 2021;36:30-8. [Crossref]
5. Byambasuren O, Stehlik P, Clark J, et al. Effect of COVID-19 vaccination on long covid: systematic review. BMJ Medicine 2023;2:e000385. [Crossref]
6. Lassola S. Pronation in acute respiratory distress syndrome (ARDS) secondary to COVID-19. J Public Health Emerg 2022;6:18. [Crossref]
7. Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013;368:2159-68. [Crossref] [PubMed]
8. Ding L, Wang L, Ma W, et al. Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study. Crit Care 2020;24:28. [Crossref] [PubMed]
9. Maringelli G, Arcamone E, Brienza N. Ultrasound in COVID-19: only lung? J Public Health Emerg 2022;6:16. [Crossref]
10. Vetrugno L, Baciarello M, Bignami E, et al. The "pandemic" increase in lung ultrasound use in response to Covid-19: can we complement computed tomography findings? A narrative review. Ultrasound J 2020;12:39. [Crossref] [PubMed]
11. Vetrugno L, Orso D, Corradi F, et al. Diaphragm ultrasound evaluation during weaning from mechanical ventilation in COVID-19 patients: a pragmatic, cross-section, multicenter study. Respir Res 2022;23:210. [Crossref] [PubMed]
12. Corradi F, Isirdi A, Malacarne P, et al. Low diaphragm muscle mass predicts adverse outcome in patients hospitalized for COVID-19 pneumonia: an exploratory pilot study. Minerva Anestesiol 2021;87:432-8. [Crossref] [PubMed]
13. Cammarota G, Rossi E, Vitali L, et al. Effect of awake prone position on diaphragmatic thickening fraction in patients assisted by noninvasive ventilation for hypoxemic acute respiratory failure related to novel coronavirus disease. Crit Care 2021;25:305. [Crossref] [PubMed]
14. Corradi F, Vetrugno L, Orso D, et al. Diaphragmatic thickening fraction as a potential predictor of response to continuous positive airway pressure ventilation in Covid-19 pneumonia: A single-center pilot study. Respir Physiol Neurobiol 2021;284:103585. [Crossref] [PubMed]

Luigi Vetrugno

Cristian Deana