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    COVID-19 Resource Center
    Interview with Italian Intensivist Dr. Simone Piva, Discussing the Brescia-COVID Respiratory Severity Score (BCRSS)

    The interview goes into detail about Dr. Piva's experience managing COVID-19 patients, as well as how the BCRSS is being used practically to simplify and communicate the respiratory status of patients.

    March 29, 2020

    As we write this, 681,706 people around the world have been infected with COVID-19, and Italy just reported its 10,000th death. We think the Brescia-COVID Respiratory Severity Score (BCRSS) may be an incredibly useful tool developed by clinicians working together in Brescia (in the Lombardy region of Italy), especially in areas facing overwhelming numbers of COVID-19 patients. This last point is key: this tool was developed in a time of crisis to create a simple, agreed-upon, step-wise approach for managing, staging, and trending COVID-19 patients’ disease progression and severity. After discussions with Dr. Simone Piva, an intensivist in Brescia, we realized there are many pearls we’ve learned - not just about the score - but how these Italian physicians are using it day-to-day to care for patients. Below, we’ve summarized an hour-long discussion with him into question/answer tidbits for our medical colleagues across the world.

    Editorial Note: Obviously in this time of crisis this score has not been validated or used outside of Italy, but we at MDCalc felt since the score uses mostly agreed-upon clinical variables, no other framework like this exists (that we know about), and the respiratory management of the patients is quite standard, this score would be worth publishing to at least create a framework for hospitals/governments/agencies to build from. (The medication recommendations are certainly more from a “Italian expert medical opinion” perspective as so little data exists in this space. It should be noted that while “consider dexamethasone” appears in the BCRSS this is particularly controversial at this time.)

    How are you applying this score?

    SP: We use this on every single patient, from the emergency room to the ICU. You assess the patient, apply the 4 testing criteria, and keep re-assessing the patient after interventions. Patients go up on the score, and they can also go down on the score as they improve. We all use this score to make it easy for us to quickly understand how sick a patient is.

    How frequently do you “re-assess” the patients?

    SP: You just use your clinical judgment; obviously a patient in the ER may rapidly be reassessed multiple times if he or she is not improving. On the medical floors the patients might be assessed several times per day, depending on severity. In the ICU, the patients are re-assessed at least every 8 hours.

    Many physicians will find including non-invasive ventilation in your pathway surprising due to concerns about aerosolizing viral particles, especially given the PPE shortages. Some guidelines in the US are recommending intubating all patients.

    SP: Yes, the aerosolization is a concern, however we are in wartime. We do not have enough ventilators for everyone. Many of these patients require PEEP. We do not have other options. We are trying everything we can; for example, we are using nitrous oxide (Heliox) for some patients, and we might give 3 patients 4 hours each of the nitrous.

    We have also gone to sporting goods stores and purchased scuba masks; we then 3D-printed an attachment from the scuba mask to a BiPAP machine, which has worked incredibly well. We tested it and found it creates a PEEP of 8cm H20, and it is actually much more comfortable for patients to wear than the standard medical BiPAP mask.

    Do you have any other criteria you use to see who is getting better or worse besides clinical judgment, vitals signs, and pulse oximetry?

    SP: We use a chest x-ray opacity score and include this as part of the BCRSS “Level” as well.

    1. First, divide each lung into 3 segments/areas on x-ray (upper/middle/lower).

    2. Rate each of these 6 segments in terms of opacity, 0-3.

    0: No Opacity

    3: Full white-out of the lung segment

    3. Add each of these scores together.

    For example, a patient might be “BCRSS Level 3-12, suggesting they are Level 3 of the BCRSS Score, but have 12 points of opacity on their chest x-ray, and this patient would likely be watched more closely for deterioration than a BCRSS Level 3-4, because their is less opacification of the latter patient’s lungs.”

    These scores make it easy to compare patients to each other, and also trend patients’ individual scores over time. In fact, in our ICU, the patient’s score is posted on the wall above them, so it is particularly easy to immediately see how severe the patient is. “Yesterday this patient was an 18, today they’re a 14.”

    This is also how we quickly round on patients to check-in before we go home. As an ICU doctor, I might go to the medical floors and be told, “We have 12 patients that are Level 2, 4 patients that are Level 3, and 2 patients that are Level 3 with increasing chest x-ray points,” so that we can plan ahead for escalating care.

    What oxygen saturation do you target for your patients?

    SP: Same as in the “Testing Criteria” - we aim for an O2 sat >90%.

    Are you ordering inflammatory markers daily on these patients?

    SP: Not daily, but there is certainly a subset of patients with a hyper-inflammatory state; in these patients we certainly consult between infectious disease and critical care on how to manage these patients.

    What are you using for your lung compliance calculation?

    SP: We have a number of different ventilators, some older, so we decided to use the static lung compliance equation to keep things standard.

    Anything else you can tell us about what you are seeing?

    SP: We are performing daily echo on our patients in the ICU. We are seeing a number of patients with echo signs of pulmonary embolism (dilated right ventricle, tricuspid regurgitation). These patients are typically in the ICU and are too unstable to get CT angiography. These patients are not necessarily ones who have been immobile in the ICU. We think this is because COVID-19 causes a massive hypercoagulable state, many patients have D-dimer levels extremely high on presentation. We have given IV tPA on 4 patients thus far, and typically their hypoxia and echo findings improve quickly after this is given.

    Update: Friday April 10, 2020

    As the United States became increasingly familiar with COVID-19, a number of additional questions came up for the Brescia-COVID group; their collated responses are below.

    We are seeing a number of patients with hypoxia and few other symptoms or respiratory distress. People have started calling them “Happy Hypoxic” or “Silent Hypoxic.” We are now realizing these patients can often improve with just supplemental oxygen and prone positioning while awake. Is this one of the reasons you created the 4 testing criteria? Since some patients may have hypoxia for example, but no other symptoms?

    Yes; this is exactly why we have the four criteria, because we were seeing the same thing, and realizing many of these patients did not require immediate intubation.

    We are also hypothesizing that the patients who do not improve with prone positioning are more likely to be in the "hyper-inflammatory" subgroup (with acute endothelial involvement), and in this subgroup, we are more likely to consider steroids.

    Your comment about PE got many people very interested. A few questions about anticoagulation for you. Are you routinely anticoagulating everyone admitted? What medication are you using? Low molecular weight heparin? Are you seeing bad outcomes from this (hemoptysis, GI bleeding, etc)?

    We are finding patients arriving from home and do typically have some degree of "immobility" because of both dyspnea/hypoxia as well as the quarantine orders; we are taking into consideration both immobility and inflammatory markers when considering anticoagulation in our patients.

    When patients have increased inflammatory markers (ferritin, d-dimer, CRP, etc) we give an increased amount of low molecular weight heparin (LMWH/lovenox); in particular, we tend to use 2 daily doses as opposed to daily dosing. Here is our internal protocol:

    <50 kg: enoxaparin 2000U SQ BID
    50-65 kg: enoxaparin 3000U SQ BID
    65-80 kg: enoxaparin 4000U SQ BID
    >80kg: enoxaparin 6000U SQ BID
    if (eGFR) < 30 ml/min/1.73s: Reduce dosage by 50%.

    We are attempting to get a small case series published of 10 patients we have given thrombolysis (TPA) and who have had good outcomes.

    We have not had any important bad outcomes -- we have had some minor hemorrhagic episodes such as rectal bleeding, hematemesis and tracheostomy bleeding, but none have required transfusion.

    Finally, several people had questions about how to discharge patients — do you have criteria you are using to decide when patients can go home who are admitted? Or which patients can go home if they are evaluated in the emergency department?

    For the ED:

    In many Italian EDs we are using a protocol with a simplified walking test (see below). Patients that are not hypoxic at rest and with ambulation are sent home even if they have abnormal imaging (CXR/US). If they have pneumonia on chest XR/US we give them a portable pulse oximeter and teach them how to do a walking test at home; we then follow them up daily by phone call and have them come back only if the walking test gets positive. We had no bad outcomes within patients discharged from the ED following this protocol.

    Walking Test:

    1. Patient walks briskly (as fast as they can without running) for 100 feet/30 meters.

    2. If the patient desaturates by 5% or more: failed test, should not be discharged.

    3. If the patient does NOT desaturate by 5% or more: passed test, safe for discharge.

    ED Discharge Criteria - Presumed COVID-19 but Normal Imaging:

    · Resting O2 Saturation ≥95% or ≥91% if known chronic pulmonary disease

    · EKG reassuring

    · Clinically patient appears well enough for discharge

    · Passes Walking Test

    Patient gets a followup phone call by healthcare team; encouraged to hydrate; take acetaminophen, possibly NSAIDs; return if walk test becomes positive or hypoxia develops (they are sent home with pulse oximetry).

    ED Discharge Criteria - Abnormal Imaging (suggestive of COVID-19)

    · Resting O2 Saturation ≥95% or ≥91% if known chronic pulmonary disease

    · EKG reassuring

    · Clinically patient appears well enough for discharge

    · Passes Walking Test

    Patient gets a followup phone call by healthcare team; encouraged to hydrate; take acetaminophen for fevers, return if walk test becomes positive or hypoxia develops (they are sent home with pulse oximetry). In addition, they are offering antibiotics (cefixime or azithromycin) as well as hydroxychloroquine (acknowledging this is off-label and carries risk) and enoxaparin 4000U SQ daily until symptoms improve and physical activity recovers.

    For discharge from the hospital/medical ward we have two options for patients who are clinically improved: Patients with an improved CXR without need for supplemental oxygen and with other signs of clinical recovery can be discharged home. We have two pathways for returning home:

    1. Isolation. They must self-isolate, while waiting for two negative swabs (planned about 14 days after the discharge).

    2. "Cure." Patients who are virologically recovered, with two consecutive negative swabs (24h apart) while in the hospital. They can be discharged and return to the community as "cured" patients.

    Thank you again to the Brescia-COVID Group for their replies; including:

    Emanuele Focà, MD, PhD

    Division of Infectious and Tropical Diseases

    Nicola Latronico, MD

    Full Professor of Anesthesia and Critical Care Medicine

    Simone Piva, MD

    Department of Anesthesia, Critical Care and Emergency

    Andrea Duca, MD

    Division of Emergency Medicine


    Thank you for everything you do.

    - The MDCalc Team


    Simone Piva, MD

    Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia

    Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy