Introduction
Corona virus disease emanated from Wuhan City in China and spread throughout the world. In India the pandemic started from March 2020. Lock down observed in India decreased the spread of the disease and mortality. India witnessed more than 10 million cases in different states with a mortality of 1.47%. Severe viral Pneumonia and inflammatory storm associated with intravascular thrombosis is responsible for hypoxia and respiratory failure, ARDS and death.1, 2 The disease has a short incubation period of around 5 to 12 days and is particularly severe in old people and people with comorbidities.3
In this hospital based study we studied the clinical, radiological parameters, duration of hospital stay, comorbidities, history of smoking and alcohol intake, past history of lung disease, mode of oxygenation given and special drugs administered among the 241 patients who died because of COVID19.
Materials and Methods
A total of 10,682 COVID patients were admitted in NRI Medical College General Hospital from 1st April 2020 to 31st January 2021. We have analysed the deaths of 241 patients who died of COVID 19 disease up to September 2020. After having taken consent from the patient and families and approval from the ethical committee of the hospital, we conducted this study. There was a total death toll of 419 patients till January 31st 2021. Hospital based mortality was 3.92%. We studied the history, symptomatology, HRCT chest, comorbidities, duration of hospital stay and special drugs administered along with the type of oxygen therapy among these 241 patients.
Results
Analysis of 241 deaths taken place in the hospital up to 10th September 2020 from the beginning of the pandemic in March 2020
Table 1
Gender Distribution:
|
Gender |
No. of Patients |
Total No. of Deaths No |
Percentage |
|
Male |
171 |
241 |
71% |
|
Female |
70 |
241 |
29% |
Table 2
Age Distribution
|
Age Group |
0-10 |
11-20 |
21-30 |
31-40 |
41-50 |
51-60 |
61-70 |
71-80 |
81 and above |
|
No. of Patients |
01 |
01 |
03 |
12 |
30 |
57 |
81 |
44 |
12 |
|
Percentage |
0.41% |
0.41% |
1.23% |
4.92% |
12.3% |
23.37% |
33.21% |
18.04% |
4.92% |
Table 3
Duration of Hospital stay
|
Duration of Hospital Stay |
1-5 days |
6-10 days |
11-15 days |
16-20 days |
>20 days |
|
No. of Patients |
172 |
55 |
09 |
04 |
01 |
|
Percentage |
71.36% |
22.82% |
3.73% |
1.66% |
0.41% |
A total of 10682 COVID patients were admitted and among them 419 patients died up to 31 January 2021 with a mortality rate of 3.92%.
Table 4
Comorbidities among COVID deaths
Table 5
Lung Burden involvement by HRCT scan Chest
|
Lung Burden |
No. of Patients |
Percentage |
|
10-20% |
03 |
1% |
|
20-30% |
27 |
11% |
|
30-40% |
36 |
15% |
|
40-50% |
67 |
28% |
|
50-60% |
43 |
18% |
|
60-70% |
36 |
15% |
|
>70% |
29 |
12% |
Table 6
CO-RADSscore by CT Chest
|
CO-RADS Score |
No. of Patients |
Percentage |
|
CORADS 4 |
60 |
25% |
|
CO-RADS 5 |
76 |
32% |
|
CO-RADS 6 |
105 |
43% |
Table 7
CT Severity Index
|
CT severity |
No. of patients |
Percentage |
|
0-7/25 |
02 |
0.82% |
|
8-15/25 |
42 |
17.42% |
|
15-25/25 |
96 |
39.83% |
|
20-25/25 |
101 |
41.9% |
Table 8
Comparison of No. of days of Hospital stay and SPO2 at admission
Table 9
Comparing the SPO2 at Admission and Hospital stay:
|
SPO2 at Admission |
Hospital stay 1-5 days |
6-10 days |
11-15 days |
16 – 20 days |
>20 days |
|
<80% |
66 |
12 |
3 |
1 |
0 |
|
80-85% |
54 |
14 |
2 |
1 |
0 |
|
85-90% |
42 |
16 |
1 |
1 |
1 |
|
90-95% |
9 |
8 |
1 |
1 |
0 |
|
>95% |
1 |
5 |
2 |
0 |
0 |
|
Total |
172 |
55 |
9 |
4 |
1 |
Table 10
H/O Alcohol Intake
|
Habit of Alcohol Intake |
No. of Patients |
Percentage |
Total Number of patients |
|
Yes |
83 |
34.43% |
241 |
|
No |
158 |
65.56%% |
241 |
Table 11
Smoking History
|
Smoking History |
No. of patients |
Percentage |
Total No. of Patients |
|
Yes |
101 |
41.9% |
241 |
|
No |
140 |
58.09% |
241 |
Table 12
Past History of Lung Disease
|
Lung Disease |
No. of patients |
Percentage |
|
COPD |
29 |
12% |
|
ILD |
15 |
6.2% |
|
Bronchiectasis |
14 |
5.8% |
|
Bronchial Asthma |
28 |
11.6% |
|
Tuberculosis |
5 |
2% |
|
No Lung Disease |
150 |
62.24% |
Table 13
Complaints at the time of admission
Table 14
MMRC Scale of SOB at the time of Admission
|
MMRC Grading |
No. of Patients |
Percentage |
|
Grade I |
21 |
8.71% |
|
Grade II |
45 |
18.67% |
|
Grade III |
80 |
33.19% |
|
Grade IV |
95 |
39.41% |
Table 15
Duration of Symptomsbefore Admission
|
Duration of symptoms |
No. of Patients |
Percentage |
|
1-5 days |
45 |
18.67% |
|
5-10 days |
60 |
24.89% |
|
10-15 days |
136 |
56.43% |
Discussion
We have analysed 241 deaths that took place in our tertiary care covid hospital. A total of 10691 patients were admitted and 419 deaths occurred among COVID 19 patients with a mortality rate of 3.92% among hospital admissions. 71% of the patients are males and 29% are females. 93% of patients belonged to age group of 30 and above. A third of deaths occurred in the age group of 60 to 70.71% of patients died in the first five days of admission and 94% of patients died within 10 days of admission. 77% of patients dying of COVID had associated comorbidities single or multiple. 23% of the patients did not have any comorbidities.
HRCT chest analysis of the patients who have died of COVID disease revealed 88% of patients had more than 30% of lung burden. CT severity index was was more than 15/25 in 82% of these patients. All the patients have CO-RADS 4 or more in CT scan chest. Ran Yang study revealed CT index correlated with severity of inflammation with 83% specificity and 94% sensitivity.4 Mathias Prokop etal., proposed CO-RADS score offers a five-point scale of suspicion for pulmonary involvement of COVID-19 at chest CT.5 Same view is endorsed by Lieveld, et al.,6 Egyptian study of Mona A. F. Hafez et al., reiterated same fact.7
72% of our patients died within first five days. Many of them were treated outside and were rushed to our centre with severe symptoms. Severity of symptoms hastened death among them. 99% of deaths occurred in first 10 days. 34% presented with SPO2 of less than 80% and 29% presented with SpO2 between 80 and 85%. 19% of patients had SPO2 between 85% and 90%. 82% of patients on the whole had SPO2 <90%. Xie et al., proved an association of mortality and hypoxia in COVIDd 19 patients. 8
77% of these patients have associated comorbidities single or multiple and 23% had none. Patients having higher age, of>65 years, Diabetes, Hypertension and cardiovascular disease have more severe disease and increased mortality.9 Smoking history was seen in 41.9% and history of alcohol intake was present in 34.43%.
Past history of Lung disease was present in 38% of patients and 62% had no history of lung disease. According to Leung et al., COPD patients have increased risk of severe COVID-19 pneumonia and poor outcome probably because of poor lung reserve and increased expression of ACE2 receptors in the small airways.10 Hong Huang et al., study revealed patients of ILD have worse prognosis compared to non ILD COVID-19 patients. 11
Breathlessness was present in all the patients followed by general weakness. Loss of smell and taste were found in less than 10% of patients. Hypoxemia without proportional signs of respiratory distress was found in our study also. This happy hypoxemia is due to hyperventilation secondary to leftward shift of Oxy-hemoglobin curve and alteration of hemoglobin by virus. Ventilation perfusion mismatch with increased alveolar dead space occurs in hypoxic patients.12 73% of our patients presented with grade 3 and 4 of MMRC at the time of admission. 81% patients in our study had 5 to 15 days of symptoms before coming to the hospital.
High flow nasal oxygen and mechanical ventilation were provided for less than 5% of patients with each modality. Bilevel positive airway pressure and non-rebreathing masks were provided for a majority.
Apart from anticoagulant and corticosteroid therapy Remdesivir was provided for more than 96% of patients. Tocilizumab was given for 26% and Convalescent Plasma therapy was given for less than 5% of patients. 13
Conclusions
COVID pandemic started in our tertiary care centre in the month of April 2020 and peaked in August and September 2020 both in terms of hospital admissions and mortality. After that the pandemic has shown a decline with an overall mortality of 3.92%. Patients dying of COVID-19 disease had significant CT scan changes suggestive of corona disease. Past history of lung disease was seen in only a third. Shortness of breath was the commonest symptom and majority of the patients presented with SPO2 of <90% and moderate to severe breathlessness. All modalities oxygenation were provided except ECMO. Ventilation and HFNO were provided for <5%. Remdesivir was given for a majority. Limited number of patients received Tocilizumab and Convalescent Plasma.
Article DOI
