If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. 25, 106 (2021). Leonard, S. et al. Study data were collected and managed using REDCap electronic data capture toolshosted at ISGlobal (Institut de Salut Global, Barcelona)23. Share this post. In the current situation with few available data from randomized control trials regarding the best choice to treat COVID-19 patients with noninvasive respiratory support, data from real-life studies like ours may be appropriate43. Failure of noninvasive ventilation for de novo acute hypoxemic respiratory failure: Role of tidal volume. 384, 693704 (2021). Hammad Zafar, Harris, P. A. et al. Fourth, it could be argued that changes in treatment strategies over the timeframe of the study may have led to differential effects of the NIRS. In the NIV group, a pressure support ventilator mode was adjusted; a high positive end-expiratory pressure (PEEP) and a low support pressure were used to set a tidal volume<9ml/kg of predicted body weight8. So far, observational COVID-19 studies have suggested that either HFNC, CPAP or NIV may improve oxygenation and reduce the need for intubation or the risk of death13,14,15,16,17,18, but the effects of different NIRS techniques have been compared in few studies16,19,20. The overall mortality rate 4 weeks after hospital admission was 24%, with age, acute kidney injury, and respiratory distress as the associated factors. Ferreyro, B. et al. B. Acquisition, analysis or interpretation of data: S.M., A.-E.C., J.S., M.P., I.A., T.M., M.L., C.L., G.S., M.B., P.P., J.M.-L., J.T., O.B., A.C., L.L., S.M., E.V., E.P., S.E., A.B., J.G.-A. Talking with patients about resuscitation preferences can be challenging. Roughly 2.5 percent of people with COVID-19 will need a mechanical ventilator. By submitting a comment you agree to abide by our Terms and Community Guidelines. Average PaO2/FiO2 during hospitalization was lower in non-survivors [167 (IQR 132.7194.1)] versus survivors [202 (IQR 181.8234.4)] p< 0.001. Finally, additional unmeasured factors might have played a significant role in survival. The patients who had died by day 28 were 117 (31.9%), 91 (65%) of those patients were treated with NIRS as ceiling of treatment and 26 (11.5%) were treated with NIRS not regarded as ceiling of treatment. Also, of note, 37.4% of our study population received convalescent plasma, and larger studies are underway to understand its role in the treatment of severe COVID-19 [14, 32]. There have been five outbreaks in Japan to date. Competing interests: The authors have declared that no competing interests exist. 56, 2002130 (2020). All patients with COVID-19 who met criteria for critical care admission from AdventHealth hospitals were transferred and managed at AdventHealth Orlando, a 1368-bed hospital with 170 ICU beds and dedicated inhouse 24/7 intensivist coverage. An observational study analyzing 670 patients found no differences in 30-day mortality or endotracheal intubation between HFNC, CPAP and NIV used outside the ICU, after adjusting for confounders16. The data used in these figures are considered preliminary, and the results may change with subsequent releases. Membership of the author group is listed in the Acknowledgments. Am. Flowchart. Care Med. ISGlobal acknowledges support from the Spanish Ministry of Science and Innovation through the Centro de Excelencia Severo Ochoa 20192023 Program (CEX2018-000806-S), and from the Generalitat de Catalunya through the CERCA Program. 57, 2004247 (2021). Table S3 shows the NIRS settings. First, the observational design could have resulted in residual confounding by selection bias. For weeks where there are less than 30 encounters in the denominator, data are suppressed. Additional adjustment for D-dimer, respiratory rate, Charlson index, or treatment with systemic corticosteroids produced very similar results (Table S10). In total, 139 of 372 patients (37%) died. The study was conducted from October 2020 to March 2022 in a province in southern Thailand. The unadjusted 30-day mortality of people with COVID-19 requiring critical care peaked in March 2020 with an HDU mortality of 28.4% and ICU mortality of 42.0%. These data are complementary and still useful later on by including some patients usually excluded from randomized studies; patients with do-not-intubate orders are an example and, obviously, they represent a challenge for the physician responsible to decide the best therapeutic strategy. Our observed mortality does not suggest a detrimental effect of such treatment. Surviving sepsis campaign: Guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19). An experience with a bubble CPAP bundle: is chronic lung disease preventable? Chest 150, 307313 (2016). Secondary outcomes were 28-day mortality, endotracheal intubation at day 28, in-hospital mortality, and duration of hospital stay. In short, the addition of intentional leaks, as in our study, led to a lower maximal pressure without a significant impact on the work of breathing and without increasing patient-ventilator asynchronies34. There are several potential explanations for our study findings. indicates that survival in our patients with COVID-19 pneumonia did not improve after receiving treatment with GCs. Nevertheless, we do not think it may have influenced our results, because analyses were adjusted for relevant treatments such as systemic corticosteroids40 and included the time period as a covariate. Sonja Andersen, To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. However, there are a few ways to differentiate between COVID-19-related dyspnea and COPD exacerbation. Your gift today will help accelerate vaccine development, gene therapies and new treatments. 1), which was approved by the research ethics committee at each participating hospital (study coordinator centre, Hospital Vall d'Hebron, Barcelona; protocol No. Postoperatively, patients with COVID-19 had higher rates of early primary graft dysfunction (70.0% vs. 20.8%) and longer stays in the ICU (18 vs. 9 days) and in the hospital (28 vs. 6 days). As noted above, a single randomized study has evaluated helmet NIV against HFNC in COVID-1919, and, in spite of the lower intubation rate in the helmet NIV group, no differences in 28-day mortality were registered. Effect of helmet noninvasive ventilation vs. high-flow nasal oxygen on days free of respiratory support in patients with COVID-19 and moderate to severe hypoxemic respiratory failure: The HENIVOT randomized clinical trial. People who had severe illness with COVID-19 might experience organ damage affecting the heart, kidneys, skin and brain. This study shows that noninvasive ventilation initiated outside the ICU for the treatment of hypoxemic acute respiratory failure secondary to COVID-19 resulted in higher mortality or intubation rate at 28days (i.e., treatment failure) than high-flow oxygen or CPAP. Advanced age, malignancy, cirrhosis, AIDS, and renal failure are associated . Noninvasive respiratory support (NIRS) techniques, including high-flow oxygen administered via nasal cannula (HFNC), continuous positive airway pressure (CPAP) and noninvasive ventilation (NIV), have been used in severe COVID-19 patients, although their use was initially controversial due to doubts about its effectiveness3,4,5,6, and the risk of aerosol-linked infection spread7. Potential benefit has been described for remdesivir in reducing the duration of hospital LOS, but it has not been shown to improve patient survival, especially in the critically ill population [11]. Since then, a RCT has shown that steroids in doses even lower than what we used (6 mg a day for up to 10 days) improve survival with an NNT of 35 (ARR 2.7%) in all patients requiring supplemental oxygen [35]. Neil Finkler Brochard, L., Slutsky, A. Abstract Introduction Atrial fibrillation (AF), the most frequent arrhythmia of older patients, associates with serious . Out of 1283, 429 (33.4%) were admitted to AHCFD hospitals, of which 131 (30.5%) were admitted to the AdventHealth Orlando COVID-19 ICU. Google Scholar. Background. Other relevant factors that in our opinion are likely to have influenced our outcomes were that our healthcare delivery system was never overwhelmed. Vianello, A. et al. CAS These patients universally required a higher level of care than our average patient admission and may explain our slightly higher ICU admission rate as compared to the literature (2227.4%) [10, 20]. Most patients were supported with mechanical ventilation. Clinical severity and laboratory values were well balanced between the groups (Table 2 and Table S2), except for respiratory rate (higher in patients treated with NIV). J. Biomed. Days between NIRS initiation and intubation (median (P25-P75) 3 (15), 3.5 (27), and 3 (35), for HFNC, CPAP, and NIV groups respectively; p=0.341) and the length of hospital stay did not differ between groups (Table 4). Mayo Clinic is on the front line leading COVID-19-focused research efforts. Excluding these patients showed no relevant changes in the associations observed (Table S9). "In severe cases, it can lead to a life threatening condition called acute respiratory distress syndrome." Healthline reported that ventilators can be lifesaving for people with severe respiratory symptoms, and that toughly 2.5% of people with COVID-19 will need a mechanical ventilator. Am. A total of 422 COVID-19 patients treated were analyzed, of these more than one tenth (11.14%) deaths, with a mortality rate of 6.35 cases per 1000 person-days. Respiratory support in patients with severe COVID-19 in the International Severe Acute Respiratory and Emerging Infection (ISARIC) COVID-19 study: a prospective, multinational,. Vitacca, M., Nava, S., Santus, P. & Harari, S. Early consensus management for non-ICU acute respiratory failure SARS-CoV-2 emergency in Italy: From ward to trenches. KEY Points. Copyright: 2021 Oliveira et al. We compared patient characteristics and demographics between pre-pandemic and pandemic periods, with data collected from January 2018 to March 2022. National Health System (NHS). Care Med. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. However, as more home devices were used in the CPAP group (81.6% vs. 38% in the NIV group; Table S3), and better outcomes were recorded in the CPAP-treated patients, our result do not support this concern. Noninvasive ventilation of patients with acute respiratory distress syndrome. The overall hospital mortality and MV-related mortality were 19.8% and 23.8% respectively. Patout, M. et al. 372, 21852196 (2015). Another potential aspect that may have contributed to reduce our MV-related mortality and overall mortality is the use of steroids. Scott Silverstry, . As a result, a considerable proportion of severe patients are being treated in hospital settings outside the ICU. Joshua Goldberg, Among 429 admissions during the study period in this large observational study in Florida, 131 were admitted to the ICU (30.5%). Given the small number of missing information and that missing were considered at random, we conducted a complete case approach. B. et al. Intubation was performed when clinically indicated based on the judgment of the responsible physician. Effect of prone position on respiratory parameters, intubation and death rate in COVID-19 patients: Systematic review and meta-analysis. | World News Membership of the author group is listed in the Acknowledgments. The high mortality rate, especially among elderly patients with some . What is the survival rate for ECMO patients? Baseline clinical characteristics of the patients admitted to ICU with COVID-19. However, little is known about the physiologic consequences of the volatile anesthetics when used for long periods in patients who are infected with Covid-19. John called his wife, who urged him to follow the doctors' recommendation. J. A total of 367 patients were finally included in the study (Fig. The decision to intubate was left to physician judgement, which may restrict the generalizability of our results to institutions with stricter criteria for mechanical ventilation. The requirement of informed consent was waived due to the retrospective nature of the study. The overall survival rate for ventilated patients was 79%, 65% for those receiving ECMO. Most of these patients admitted to ICU, will finally require invasive mechanical ventilation (MV) due to diffuse lung injury and acute respiratory distress syndrome (ARDS). Patients with haematological malignancies (HM) and SARS-CoV-2 infection present a higher risk of severe COVID-19 and mortality. 202, 10391042 (2020). Those patients requiring mechanical ventilation were supervised by board-certified critical care physicians (intensivists). In addition, some COVID-19 patients cannot be considered for invasive ventilation due to their frailty or comorbidities, and others are unwilling to undergo invasive techniques. Our study demonstrates an important improvement in mortality of patients with severe COVID-19 who required ICU admission and MV in comparison to previous observational reports and emphasizes the importance of standard of care measures in the management of COVID-19. Eur. The aim of the study was to investigate whether vaccination and monoclonal antibodies (mAbs) have modified the outcomes of HM patients with COVID-19. Care 17, R269 (2013). Research Institute, AdventHealth Orlando, Orlando, Florida, United States of America, Affiliation: J. Med. Research was performed in accordance with the Declaration of Helsinki. How Long Do You Need a Ventilator? J. To obtain (2021) ICU outcomes and survival in patients with severe COVID-19 in the largest health care system in central Florida. The 28-days Kaplan Meier curves from: (a) day starting NIRS to death or intubation; (b) day starting NIRS to intubation; and (c) day starting NIRS to death. At age 53 with Type 2 diabetes and a few extra pounds, my chance of survival was far less than 50 percent. https://doi.org/10.1038/s41598-022-10475-7, DOI: https://doi.org/10.1038/s41598-022-10475-7. A stall in treatment advances for Covid-19 has raised concern among medical experts about unvaccinated people, who still make up half the country, and their likelihood of surviving the coming wave . Singer, M. et al. But there are reports that people with COVID-19 who are put on ventilators stay on them for days or weeksmuch longer than those who require ventilation for other reasonswhich further reduces . Respir. In mechanically ventilated patients, mortality has ranged from 5097%. Our study demonstrates the possibility of better outcomes for COVID-19 associated with critical illness, including COVID-19 patients requiring mechanical ventilation. J. Respir. 100, 16081613 (2006). Respir. Slider with three articles shown per slide. The scores APACHE IVB, MEWS, and SOFA scores were computed to determine the severity of illness and data for these scoring was provided by the electronic health records. Multivariable Cox proportional-hazards regression models were used to estimate the hazard ratios (HR) for patients treated with NIV and CPAP as compared to HFNC (the reference group), adjusting for age, sex, and variables found to be significantly different between treatments at baseline (hospital, date of admission and sleep apnea). Third, a bench study has recently reported that some approaches to minimize aerosol dispersion can modify ventilator performance34. Crit. Of these patients who were discharged, 60 (45.8%) went home, 32 (24.4%) were discharged to skill nurse facilities and 2 (1.5%) were discharged to other hospitals. Support COVID-19 research at Mayo Clinic. Investigators from a rural health system (3 hospitals) in Georgia analyzed all patients (63) with COVID-19 who underwent CPR from March to August 2020. Reports of ICU mortality due to COVID-19 around the world and in the Unites States, in particular, have ranged from 2062% [7]. During March 11 to May 18, a total of 1283 COVID-19 positive patients were evaluated in the Emergency Department or ambulatory care centers of AHCFD. Repeat tests were performed after an initial negative test by obtaining a lower respiratory sample if there was a high clinical pretest probability of COVID-19. J. 2b,c, Table 4). Second, patient-ventilator asynchronies might have arisen in NIV-treated patients making more difficult their management outside the ICU setting and thereby explaining, at least partially, their worse outcomes. We are reporting that 55% of the patients who required mechanical ventilation received methylprednisolone or dexamethasone. Higher P/F rations and no difference in inflammatory parameters between deceased and survivors (Tables 2 and 3), suggest less sick patients were intubated. Intensivist were not responsible for more than 20 patients per 12 hours shift. In case of doubt, the final decision was discussed by the ethical committee at each centre. On average about 98.2% of known COVID-19 patients in the U.S. survive, but each individual's chance of dying from the virus will vary depending on their age, whether they have an underlying . To minimize the importance of vaccination, an Instagram post claimed that the COVID-19 survival rate is over 99% for most age groups, while the COVID-19 vaccine's effectiveness was 94%. Thorax 75, 9981000 (2020). Recommended approaches to minimize aerosol dispersion of SARS-CoV-2 during noninvasive ventilatory support can cause ventilator performance deterioration: A benchmark comparative study. COVID-19 patients also . College Station, TX: StataCorp LLC. volume12, Articlenumber:6527 (2022) ICU specific management and interventions including experimental therapies and hospital as well as ICU length of stay (LOS) are described in Table 3. The mortality rate among 165 COVID-19 patients placed on a ventilator at Emory was just under 30%. Curr. J. Obviously, reaching a definitive conclusion on this point will require further studies with better phenotypic characterization of patients, and considering additional factors implicated in the response to therapies such as the interface used or the monitoring of the inspiratory effort. JAMA 324, 5767 (2020). Approximately half of the study population had commercial insurance (67, 51%) followed by Medicare (40, 30.5%), Medicaid (12, 9.2%) and uninsured (12, 9.2%). Med. Patient characteristics and clinical outcomes were compared by survival status of COVID-19 positive patients. First, in the Italian study, the mean PaO2/FIO2 ratio was 152mm Hg, suggesting a less severe respiratory failure than in our patients (125mm Hg). Perkins, G. D. et al. And unlike the New York study, only a few patients were still on a ventilator when the. Higher mortality and intubation rate in COVID-19 patients treated with noninvasive ventilation compared with high-flow oxygen or CPAP, https://doi.org/10.1038/s41598-022-10475-7. Baseline demographic characteristics of the patients admitted to ICU with COVID-19. In fact, our mortality rates for mechanically ventilated COVID-19 patients were similar to APACHE IVB predicted mortality, which was based on critically ill patients admitted with respiratory failure secondary to viral and/or bacterial pneumonia. Respir. Standardized respiratory care was implemented favoring intubation and MV over non-invasive positive pressure ventilation. Second, the Italian study did not provide data on PaCO2, meaning that the improvements with NIV might have been attributable to the inclusion of some patients with hypercapnic respiratory failure, who were excluded in our study. Franco, C. et al. Data Availability: All relevant data are within the paper and its Supporting information files. To account for the potential effect modification, analyses were stratified according to hypoxemia severity (moderate-severe: PaO2/FIO2<150mm Hg; mild-moderate: PaO2/FIO2150mm Hg)4. The regional and institutional variations in ICU outcomes and overall mortality are not clearly understood yet and are not related to the use experimental therapies, given the fact that recent reports with the use remdesivir [11], hydroxychloroquine/azithromycin [12], lopinavir-ritonavir [13] and convalescent plasma [14, 15] have been inconsistent in terms of mortality reduction and improvement of ICU outcomes. The median age of the patients admitted to the ICU was 61 years (IQR 49.571.5). These results were robust to a number of stratified and sensitivity analyses. Despite these limitations, our experience and results challenge previously reported high mortality rates. broad scope, and wide readership a perfect fit for your research every time. Frat, J. P. et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). In the figure, weeks with suppressed data do not have a corresponding data point on the indicator line. Patients not requiring ICU level care were admitted to a specially dedicated isolation unit at each AHCFD hospital. In this context, the utility of tracheostomy has been questioned in this group of ill patients. Clinical course of COVID-19 patients needing supplemental oxygen outside the intensive care unit, Clinical features and predictors of severity in COVID-19 patients with critical illness in Singapore, Outcome in early vs late intubation among COVID-19 patients with acute respiratory distress syndrome: an updated systematic review and meta-analysis, Nasal intermittent positive pressure ventilation as a rescue therapy after nasal continuous positive airway pressure failure in infants with respiratory distress syndrome, Clinical relevance of timing of assessment of ICU mortality in patients with moderate-to-severe Acute Respiratory Distress Syndrome, https://amhp.org.uk/app/uploads/2020/03/Guidance-Respiratory-Support.pdf, http://creativecommons.org/licenses/by/4.0/. Inspired oxygen fraction achieved with a portable ventilator: Determinant factors. All analyses were performed using StataCorp. The truth is that 86% of adult COVID-19 patients are ages 18-64, so it's affecting many in our community. Jul 3, 2020. Epidemiological studies have shown that 6 to 10% of patients develop a more severe form of COVID-19 and will require admission to the intensive care unit (ICU) due to acute hypoxemic respiratory failure [2]. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. 195, 6777 (2017). An analysis prepared for STAT by the independent nonprofit FAIR Health found that the mortality rate of select hospitalized Covid-19 patients in the U.S. dropped from 11.4% in March to below 5%. All authors have approved the submission and provide consent to publish. During March 11 to May 18, a total of 1283 COVID-19 positive patients were evaluated in the Emergency Department or ambulatory care centers of AHCFD. 4h ago. PubMed J. Respir. Twitter. A multivariate logistic regression model was performed to investigate the associations between mortality and clinical and demographic characteristics of COVID-19 positive patients on mechanical ventilation in the ICU. Moreover, NIRS treatment groups exhibited only minor differences which were accounted for in the multivariable and sensitivity analyses thus minimizing the selection bias risk. 2a). The 30 ml/kg crystalloid resuscitation recommendation was applied for those patients presenting with evidence of septic shock and fluid resuscitation was closely monitored to minimize overhydration [18]. We accomplished strict protocol adherence for low tidal volume ventilation targeting a plateau pressure goal of less than 30 cmH2O and a driving pressure of less than 15 cmH2O. Children with acute lymphoblastic leukemia living in US-Mexico border regions had worse 5-year survival rates compared with children living in other parts of Texas, a recent study found. 44, 282290 (2016). The. Opin. However, the inclusion of patients was consecutive and the collection of variables was really comprehensive. Future research should seek to identify and predict factors associated with mortality in COVID-19 populations admitted to the ICU. However, the retrospective design of our study does not allow establishing a causative link between NIV and the worse clinical outcomes observed. High-flow nasal cannula in critically III patients with severe COVID-19. Clinicaltrials.gov identifier: NCT04668196. Arch. Am. Because the true number of infections is much larger than just the documented cases, the actual survival rate of all COVID-19 infections is even higher than 98.2%. Give now I believe the most recent estimates for the survival rate for ECMO in the United States, for all types of COVID ECMO, is a little above 50%. Differences were also found in the NIRS treatments applied according to the date of admission: HFNC was the most frequent treatment early in the period (before 23 March), while CPAP was the most frequent choice in the second and the third periods (Table 1, p=0.008). Oxygen therapy for acutely ill medical patients: A clinical practice guideline. Our study describes the clinical characteristics and outcomes of patients with severe COVID-19 admitted to ICU in the largest health care system in the state of Florida, United States. In a May 26 study in the journal Critical Care Medicine, Martin and a group of colleagues found that 35.7 percent of covid-19 patients who required ventilators died a significant percentage. Of the 1511 inpatients with CAP, COVID-19 was the leading cause, accounting for 27%. Of the 131 ICU patients, 109 (83.2%) required MV and 9 (6.9%) received ECMO. A significant interaction (P<0.001) was found between year and county-level COVID-19 mortality rate, with patients in communities with high (51-100 deaths per 1 000 000) and very high (>100 deaths per 1 000 000) monthly COVID-19 mortality rates experiencing, respectively, 28% and 42% lower survival during the surge period in 2020 as compared . NHCS results provided on COVID-19 hospital use are from UB-04 administrative claims data from March 18, 2020 through September 27, 2022 from 42 hospitals that submitted inpatient data and 43 hospitals that submitted ED data. Recently, a 60-year-old coronavirus patientwho . Our study is the first and the largest in the state Florida and probably one of the most encouraging in the United States to show lower overall mortality and MV-related mortality in patients with severe COVID-19 admitted to ICU compared to other previous cases series. Study flow diagram of patients with COVID-19 admitted to Intensive Care Unit (ICU). Hospital, Universitari Vall dHebron, Passeig Vall dHebron, 119-129, 08035, Barcelona, Spain, Sergi Marti,Jlia Sampol,Mercedes Pallero,Eduardo Vlez-Segovia&Jaume Ferrer, Universitat Autnoma de Barcelona (UAB), Barcelona, Spain, CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain, Sergi Marti,Jlia Sampol,Mercedes Pallero,Manel Lujan,Cristina Lalmolda,Juana Martinez-Llorens&Jaume Ferrer, Anne-Elie Carsin,Susana Mendez&Judith Garcia-Aymerich, Universitat Pompeu Fabra (UPF), Barcelona, Spain, Anne-Elie Carsin,Juana Martinez-Llorens&Judith Garcia-Aymerich, CIBER Epidemiologa y Salud Pblica (CIBERESP), Madrid, Spain, Respiratory Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain, Respiratory Department, Corporaci Sanitria Parc Tauli, Sabadell, Spain, Manel Lujan,Cristina Lalmolda&Elena Prina, Department of Pulmonology, Dr. Josep Trueta, University Hospital of Girona, Santa Caterina Hospital of Salt, Girona, Spain, Gladis Sabater,Marc Bonnin-Vilaplana&Saioa Eizaguirre, Girona Biomedical Research Institute (IDIBGI), Girona, Spain, Respiratory Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain, Respiratory Department, Hospital del Mar, Barcelona, Spain, Juana Martinez-Llorens&Ana Bala-Corber, Respiratory Department, Hospital General de Granollers, Granollers, Spain, Universitat Internacional de Catalunya, Barcelona, Spain, Respiratory Department, Althaia Xarxa Assistencial Universitria de Manresa, Manresa, Spain, Respiratory Department, Hospital Universitari de Bellvitge, LHospitalet de Llobregat, Llobregat, Spain, Respiratory Department, Hospital Mtua de Terrassa, Terrassa, Spain, You can also search for this author in