Browsing by Author "Van Zyl-Smit, Richard"

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    Early sequelae of post COVID-19 lung disease in patients who were mechanically ventilated for severe COVID-19 pneumonia
    (2023) Singh, Nevadna; Van Zyl-Smit, Richard
    Introduction: COVID-19 resulted in an unprecedented worldwide spike in hospital and ICU admissions; predominantly for adult respiratory distress syndrome (ARDS). Survival rates for patients requiring mechanical ventilation in Cape Town during the waves driven by the ancestral strain and beta variant were approximately 30% during the first 3 waves of the pandemic. However, post-ICU admission sequelae and recovery trajectory in sub-Saharan Africa remain unknown. Methods: We systematically evaluated a cohort of COVID-19 ICU survivors at three months following hospital discharge. A retrospective single-centre study enrolled all COVID-19 pneumonia patients who were admitted to ICU for mechanical ventilation and followed up at the post-COVID-19 Lung Disease Clinic between 1 July 2020 and 30 December 2021. Results: A total of 26 patients were evaluated at 3 months after discharge from hospital following mechanical ventilation: 53% were male and 81% had at least one co-morbidity. Diabetes and hypertension were present in 42% and 54% of patients respectively. Persistent dyspnoea (89%) and fatigue (54%) were the most common post-COVID-19 symptoms. Median FEV1 and FVC were 73% (IQR 65-83) and 71% (IQR 61-77) of predicted values respectively, whilst median DLCO was 59% (IQR 41- 70) of predicted values. Abnormalities were confirmed in all patients (24/26) who underwent high resolution computer tomography (HRCT) of the chest, with ground glass opacities (46%) and interstitial thickening (58%) being most common. No significant risk factors for post-COVID-19 impairment were identified. Conclusion: At 3 months after hospitalization, patients who received mechanical ventilation for COVID-19 pneumonia frequently reported ongoing symptoms. Lung function was moderately impaired with a disproportionate reduction in DLCO, and radiographic abnormalities were common. Long term follow up is required to determine the natural history post severe-COVID-19 lung disease.
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    Outcomes of patients with COVID-19 Acute Respiratory Distress Syndrome requiring Invasive Mechanical Ventilation admitted to an Intensive Care Unit in South Africa
    (2022) Arnold-Day, Christel; Piercy, Jenna; Van Zyl-Smit, Richard
    Background Up to 30% of patients with COVID-19 pneumonia may require ICU admission or mechanical ventilation [Guan et al., 2020; Huang et al., 2020]. Data from low- and middle-income countries for COVID-19 ARDS are limited. Groote Schuur Hospital in Cape Town, South Africa expanded its ICU service to support patients with COVID-19 ARDS requiring invasive mechanical ventilation (IMV). We report on patients' characteristics and outcomes from two pandemic waves. Methods All patients with COVID-19 ARDS admitted to the ICU for IMV were included in this prospective cohort study. Data were collected from 5th April 2020 to 5th April 2021. Ethical approval was granted (HREC: 362/2020), consent was waived for deceased patients and deferred for survivors. Results Over the 12-month study period 461 patients were admitted to the designated COVID-19 ICU. Of these, 380 patients met study criteria and 377 had confirmed hospital discharge outcomes. The median age of patients was 51 years (range 17-71), 50.5% were female and the median BMI was 32kg/m2 (IQR 28-38). The median P/F ratio was 97 (IQR 71.5-127.5) after IMV was initiated. Comorbidities included diabetes (47.6%), hypertension (46.3%) and HIV infection (10%). Of the patients admitted, 30.8% survived to hospital discharge with a median ICU length of stay of 19.5 days (IQR 9- 36). Predictors of mortality after adjusting for confounders were: male (OR:1.79), increasing age (OR:1.04) and SOFA score (OR:1.29). Conclusion In a resource limited environment, escalation of ICU IMV support achieved a 30.8% hospital survival in patients with COVID-19 ARDS. The ability to predict survival remains difficult given this complex disease.
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    The characteristics of intersitial lung disease patients attending Groote Schuur Hospital Respiratory clinic
    (2023) Soin, Gurveen; Van Zyl-Smit, Richard
    Rationale: Interstitial lung diseases (ILDs) encompass a myriad of clinical conditions posing diagnostic challenges in low-income settings. The incidence of Idiopathic pulmonary fibrosis (IPF) is unknown on the African continent. Groote Schuur Hospital (GSH) provides a tertiary referral and follow-up service for patients with suspected ILDs. We set out to determine the burden of IPF and progressive pulmonary fibrosis (PPF) in an African setting. Methods: All patients attending the GSH respiratory clinic with known or suspected ILD were identified over six months. Demographics, spirometry, high-resolution CT findings, histology, and final diagnosis and treatments were captured. IPF incidence was estimated using published population and medical insurance numbers, hospital referral area/pattern, and new IPF diagnoses over a full year period. The presence of PPF was determined by worsening clinical features and lung function in accordance with ATS/ERS guidelines. Results: A total of 103 patients (28 new and 75 follow-ups) were seen over six months. The follow-up patients were predominantly female (81%), diagnosed with systemic sarcoidosis (57%) & connective tissue disease-ILD (CT-ILD) 26%. Hypersensitivity pneumonitis accounted for 5% of follow-up patients, and only 2 IPF patients were in follow-up. CTD-ILD was the most common diagnosis in new patients: 43% and 29% had sarcoidosis. Five new patients were diagnosed with IPF during the 6-month study review and a total of 11 over 1 year. 31% of the CTD-ILD patients had systemic sclerosis SSC; 70% diffuse, and 30% limited. A further 25% had rheumatoid arthritis, and 13% had SLE. Six patients were confirmed to have hypersensitivity pneumonia. Thirteen patients met the criteria for PPF, and a further five patients had rates of decline over four months that, if projected to 12 months, would fulfil the PPF criteria. All 18 patients had an FVC decline of >100mls: mean(range) rate of decline 9.2% (5–22%). Conclusions: Specialised resources and diagnostic modalities to identify and manage ILD patients are required in low resourced settings. The burden of IPF is low but requires confirmation and is likely an underestimate. The potential need for anti-fibrotic treatment is impacted upon by the definition of FVC decline over 12 months.
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    The relationship between clinical trial participation and inhaler technique errors in asthma and COPD patients
    (2020) Perumal, Rubeshan; Van Zyl-Smit, Richard
    Background Incorrect inhaler use is associated with poorer health outcomes, reduced quality of life, and higher healthcare utilisation in patients with asthma and COPD. Method We performed an observational study of pressurized metered-dose inhaler technique in patients with asthma or COPD. Patients were assessed using a six-point inhaler checklist to identify common critical inhaler technique errors. An inadequate inhaler technique was defined as the presence of one or more critical errors. A multivariate logistic regression model was used to determine the odds of an inadequate inhaler technique. Results During the 14-month study period, 357 patients were enrolled. At least one critical error was executed by 66.7% of participants, and 24.9% made four or more critical errors. The most common errors were: failure to exhale completely prior to pMDI activation and inhalation (49.6%), failure to perform a slow, deep inhalation following device activation (48.7%), and failure to perform a breathhold at the end of inspiration (47.3%). The risk of a critical error was higher in COPD patients (aOR 2.25, 95%CI 1.13 – 4.47). Prior training reduced error risk specifically when trained by a doctor (aOR 0.08, 95% CI 0.1 – 0.57) or a pharmacist (aOR 0.02, 95% CI 0.01 – 0.26) compared to those with no training. Previous clinical trial participation significantly reduced error risk and rate:< 3 trials (aOR 0.35, 95% CI 0.19 – 0.66) and ≥3 trials (aOR 0.17, 95% CI 0.07 – 0.42). The rate of critical errors was not significantly associated with age, sex, or prior pMDI experience. Conclusion This study found a high rate of critical inhaler technique errors in a mixed population of asthma and COPD patients; however, prior training and in particular, multiple previous clinical trial participation significantly reduced the risk of errors.