Vital signs and work of breathing assessment in the emergency department as predictor for acute failure in COVID-19

Coronavirus disease 2019 (COVID-19) with acute respiratory failure (ARF) has a high mortality rate. This study aimed to investigate the vital signs and work of breathing parameters in COVID-19 pneumonia patients to predict ARF. We predicted the risk of acute respiratory distress syndrome (ARDS) in COVID-19 patients within 72 hours of admission to the emergency department (ED) and determined cut-off values. We performed an observational prospective cohort study at the tertiary referral Persahabatan Hospital in Jakarta, Indonesia, from July to December 2020. The vital signs were as follows: of respiratory rate (RR), heart rate (HR), pulse oxygen saturation (SpO2), mean arterial pressure (MAP), and axillary body temperature. The work of breathing, which was indicated by nasal flaring and the contraction of the sternocleidomastoid and abdominal muscles, was assessed one hour after a triage examination. The ARF was monitored within 72 hours. The cut-off values of vital signs were determined using the Youden index. In total, 71 (13.65%) of the 520 patients had ARF within 72 hours of admission. The mean values of RR, HR, MAP and SpO2 in the ARF group were 26 breaths/minute, and 102 pulses/minute, at 100 and 92%, respectively. All ARF patients had nasal flaring, 86.4% had a contraction of the sternocleidomastoid, and 67.6% had a contraction of the abdominal muscle. The cut-off values for predicting ARF were as follows: RR >23 breaths/minute (sensitivity 83.1%; specificity 86%), SpO2 <93% (sensitivity 80.5%; specificity 75.2%), HR = 92 pulses/minute (sensitivity 71.8%; sensitivity 75.2%), and MAP = 93.5 (specificity 64.8%; sensitivity 60.4%). Our results indicate that vital signs and work of breathing within the first hour in the emergency department can predict ARF in COVID-19 pneumonia patients within 72 hours.