key: cord-0826288-e741yukj authors: Correa-Londoño, Nicolás; Mesa-Murillo, Juan Pablo; Moncayo-Viveros, Jairo Giovanny; Mejía-Sierra, Juan Miguel; Sánchez-Moreno, Ana María; Uribe-Londoño, Luisa; Agudelo-Escudero, Alejandro; Zumaqué-Valverde, Erika; Dallos-Ferrerosa, Juan Nicolás; Arango-Guerra, Pablo; Ramírez-Vélez, Andrés; Moreno-Bedoya, Sara title: TEST DE MARCHA COMO VALORACIÓN CLÍNICA PARA DESENMASCARAR HIPOXEMIA OCULTA EN COVID-19: SERIE DE CASOS date: 2021-12-23 journal: Acta Colombiana de Cuidado Intensivo DOI: 10.1016/j.acci.2021.08.003 sha: 34f6bb0aa9056c1dc9474aaace20e6a61ce8e441 doc_id: 826288 cord_uid: e741yukj La infección por SARS-CoV-2 (del inglés Severe Acute Respiratory Syndrome Coronavirus 2) es una infección respiratoria identificada inicialmente en Wuhan, China, en diciembre de 2019. Se ha encontrado que algunos de los pacientes no presentan signos de dificultad respiratoria; sin embargo, cuando se miden los niveles de saturación de oxígeno se encuentran anormalmente más bajos de lo esperado en relación con su condición clínica. Esta es la razón por la que se han recopilado una serie de casos de pacientes con diagnóstico de COVID-19 (enfermedad por Coronavirus 2019) a quienes se les realizó una prueba de marcha de 2 minutos durante la evaluación inicial en el servicio de urgencias. La caída en la saturación de oxígeno por debajo de 90% era considerada un resultado positivo. El 85% de los pacientes con una prueba de marcha positiva requirieron manejo intrahospitalario y 70% requirió suplementación de oxígeno durante la hospitalización. Esta herramienta clínica pudiera ayudar a determinar cuáles de estos pacientes podrían requerir atención hospitalaria debido a hipoxemia oculta, considerando la situación epidemiológica actual y las altas tasas de ocupación de camas. SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) infection is a respiratory infection initially identified in Wuhan, China, in December 2019. Some of the patients have been found to show no signs of respiratory distress; however, when oxygen saturation levels are measured, they are abnormally lower than expected in relation to their clinical condition. This is why we collected a series of cases from patients diagnosed with COVID-19 (Coronavirus disease 2019) who underwent a 2-minute walking test during the initial evaluation in the emergency department. A drop in oxygen saturation below 90% was considered a positive result. Eighty-five percent of patients with a positive walking test required in-hospital management and 70% required oxygen supplementation during hospitalization. This clinical tool could help determine which of these patients might require in-hospital care due to occult hypoxaemia, considering the current epidemiological situation and high bed occupancy rates. It has been interesting to observe that patients with COVID 19 with pulmonary compromise rarely manifest with a feeling of breathlessness, even with low oxygen saturations; this is what has been called "silent hypoxemia" or "happy hypoxemia." This has made it somewhat challenging to identify patients who could potentially complicate and require inpatient management and even in a highly dependent unit. It has been difficult to predict the need for admission to inpatient care due to the exponential rise of the CoVID-19 cases and the lack of tools during the first evaluation of those patients without a significant respiratory compromise. Given the socio-economic conditions of our country, the high demand and little relative availability of hospital beds, it is necessary to design a method to identify patients who have a potential risk of complications, oxygen requirements, and need for a high dependency unit and who it can be applicable from triage, attention in emergency services of any level of complexity, ambulatory programs, and outpatient monitoring for the administration of the health resource. Page 5 of 12 J o u r n a l P r e -p r o o f Previous studies have described the walking or exercise test (6 minutes walk) as an easy measure for decision-making at emergency rooms and ambulatory care (4). The following article describes a case series of patients, observed in a tertiary-level hospital in the city of Medellin, Colombia, who were admitted with a diagnosis of CoVID-19 without clinical signs of respiratory distress, neither requirement of oxygen supplementation to achieve a SatO2 more than 92%, given the reference value for the altitude of the city. Hereby, this case series presents the data of the patients that followed the walking test during medical attention exposing the plausibility of the utilization (in all areas, starting with triage up to high dependency services) for early establishing which patients could benefit from inpatient care. We obtained the data of 27 patients with CoVID-19, diagnosed by reverse transcription polymerase chain reaction (RT-PCR) through nasopharyngeal aspirate. They were admitted to the emergency department in a tertiary-level hospital in Medellin (Colombia), without oxygen requirement (Sat >92%) and with hemodynamic stability (no requirement for vasoactive support to achieve mean arterial pressure> 90 mmHg and adequate peripheral perfusion). The demographic data, rest vital signs and posttest vital signs were collected from electronical medical history. During the medical evaluation, a walking test was performed. The test consisted of asking the patient to walk around the room for 2 minutes long. A positive result was considered as a drop in the oximetry below 90% after the walking test. Most of the patients were masculine (74%), with a ratio of 2:1 man to woman and a mean age of 48 years (± 14). The main comorbidities of the patients were arterial hypertension (25.9%), followed by diabetes and COPD/asthma with 14% and 18.5%, respectively. Along with the patients that had positive walking test results, 30% had arterial hypertension, 20% diabetes mellitus, and 15% COPD/Asthma. The mean of the oxygenation index (PaO2/FiO2) was 291 mmHg ± 43. Of the patients with a positive walking test, 85% required inpatient care, 70% required oxygen supplementation, and 10% were admitted to a high dependency unit during the hospital care. The mean length of stay was six days, and most of the patients had a minimum stay of 48 hours. In the collected cases, it was observed that from the second minute of the walking test, the patients already had a drop in SatO2%, which we suppose led to the suspension of the maneuver. It is reasonable, understanding the context of low functional capacity of the CoVID19 patient, not to extend the test until 6 minutes. In this case, the goal was to adopt these recommendations and observe the behavior of the patients who had a positive walk test with confirmed SARS-CoV-2 infection. When analyzing the data, it was observed that the patients who had a positive test required hospitalization in 85% and a hospital stay greater than 48 hours. It draws attention and pathologies, and there is no study to date that validates the use of this strategy. Concerning the above, this study intends to propose a cost-effective and easy-to-use resource to all kinds of institutions in outpatient and inpatient care settings that help health care professionals make decisions related to the management of those patients, like hospitalization or oxygen supplementation. Thanks to the concluded results of the case series, the emergency department from which the data were taken included the walking test in its standard-of-care as part of its initial medical evaluation for CoVID19 patients. Given that there has been an overflow of patients with this pathology, saturating health services, this strategy could help reduce the costs and take better advantage of the health care staff. Hypoxia is an independent factor associated with higher mortality in the context of SARS-CoV-2 infection; therefore, its recognition is necessary. Multiple models and classification scales have been developed, which try to stratify and predict the possible adverse outcome There is still no study with adequate methodological rigor to determine how the walking test manages to discriminate the possibility or risk of clinical deterioration in patients with SARS-CoV-2 infection. Therefore, this study intends to consider the walking test for the creation of prognostic models and to validate it as a possible independent factor of paraclinical parameters in patients with CoVID-19. Given the infection rates by SARS-CoV-2, associated with the high occupation percentages and the increase in health resources consumption, it is necessary to create clinical tools that allow the detection of patients who require in-hospital treatment. A simple-to-perform walking test is presented, which could help to identify patients with occult hypoxemia. Studies with greater methodological rigor are required to validate its performance. Happy Hypoxemia in COVID-19-A Neural Hypothesis The neuroinvasive potential of SARS-CoV2 may play a role in the respiratory failure of COVID-19 patients Dyspneic and non-dyspneic (silent) hypoxemia in COVID-19: Possible neurological mechanism What is the efficacy and safety of rapid exercise tests for exertional desaturation in Covid-19: A rapid review protocol Estimates of the severity of coronavirus disease 2019: a model-based analysis Clinical Characteristics of Coronavirus Disease 2019 in China Simplified exercise test for the initial differential diagnosis of Pneumocystis carinii pneumonia in HIV antibody positive patients Proposed Modifications in the 6-Minute Walk Test for Potential Application in Patients With Mild COVID-19: A Step to Optimize Triage Guidelines Besides other Signs, Can a 6-min Walk Test be Applied as a Criterion for Going to the Hospital with a Diagnosis of COVID-19? Unmasking Hypoxia in COVID 19 -Six Minute Walk Test This research corresponds to an unpublished work that has not been published previously.The authors declare that the work did not receive funding from public, commercial, or nonprofit entities. The authors declare that there is no potential conflict of interest related to the execution of the research work or the publication of the article.