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\begin{document}

\title{A case report of successful survival after tracheal intubation and IMV
in elderly patient of COVID-19 with hypertension}



\author[1]{ruijing XIAO}%
\author[2]{Chaogui Zhang}%
\author[3]{Fengling Luo}%
\author[3]{Yingcheng Zheng}%
\author[4]{Li Liu}%
\author[2]{Hua Yang}%
\author[3]{Wanhong Liu}%
\affil[1]{Affiliation not available}%
\affil[2]{University Hospital of Hubei University for Nationalities}%
\affil[3]{Wuhan University}%
\affil[4]{The University of Hong Kong,}%


\vspace{-1em}



  
  \date{June 08, 2024}


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\selectlanguage{english}
\begin{abstract}
Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory
syndrome coronavirus (SARS-CoV)-2 infection has become a pandemic cause
of viral pneumonia. Elderly patients with chronic comorbidities are
susceptible to SARS-CoV-2, and are more likely to have complications
that can lead to severe or even fatal consequences. It is important to
seek the appropriate effective treatment for these susceptible persons.
Here we report a case of elderly COVID-19 patient with hypertension,
which was a member of the familial cluster COVID-19 in Enshi City, Hubei
Province, China. He successfully survived after removal of tracheal
intubation and inhalation of the invasive mechanical ventilation (IMV).
This report aims to provide an inspiration for the prevention and
treatment of critical COVID-19 cases.%
\end{abstract}%



\sloppy


\textbf{Introduction}

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory
syndrome coronavirus (SARS-CoV)-2 infection has become a pandemic cause
of viral pneumonia (Lescure FX et al, 2020; Wang C et al, 2020), leading
to over 2 million cases with more than 146 thousands death up to April
18\textsuperscript{th}, 2020. Studies have shown that pediatric patients
present mostly mild and moderate cases (Qiu H et al, 2020). In contrast,
Elderly patients with comorbidities are susceptible to SARS-CoV-2, and
are more likely to have complications that can lead to severe or even
fatal consequences (Chen N et al, 2020). SARS-CoV-2 is highly
contagious, especially in the case of family cluster transmission (Chan
JF et al, 2020). Early and effective isolation of diagnosed COVID-19
patients will reduce the chance of infection for other family members.

Here, we report a case of family cluster COVID-19 with high-risk
characteristics: older age, history of hypertension, which successfully
survived after removal of tracheal intubation and invasive mechanical
ventilation (IMV) in Enshi City, Hubei Province, China. Due to the
current poor prognosis of tracheal intubation and IMV in patients with
COVID-19, the successful survival of this case has given great
encouragement and confidence to clinicians and similar patients. We
actively discussed the relevant content of this case with a view to
inspiring the prevention and treatment of critical COVID-19 cases.

\textbf{Case presentation}

The patient was a 60-year-old COVID-19 male with hypertension who had
undergone long-term contact with a confirmed COVID-19 patient (his
father, who had passed away on Feb 10, 2020). He was admitted to the
hospital in Enshi City as a moderate COVID-19 case on Feb 12, 2020 after
initial diagnoses: productive coughing, positive SARS-CoV-2 nucleic acid
test, and CT results (infectious lesions of the right and left lower
lobe, ground glass changes) (Figure 1A). Blood test displayed an
increased neutrophil percentage (73.5\%) and a decreased lymphocyte
percentage (15.6\%) (Table1). In view of continuous fever, Computed
Tomography (CT) was reviewed on the 8th day (Feb 16, 2020). The image
presented multifocal ground glass opacities with consolidation of
significantly larger range and higher density compared to previous
observations. In addition, there were several fibrous calcifications in
the lungs (Figure 1B).

On the 12th day of admission, the patient developed dyspnea and a
non-invasive mechanical ventilation (NIV) was used to assist breathing.
On the 13th day, the patient's condition further deteriorated
(SaO\textsubscript{2} 49\selectlanguage{ngerman}·2\%) (Table1). Tracheal intubation and invasive
mechanical ventilation (IMV) were performed immediately,
SaO\textsubscript{2} subsequently rose to 100\%. After intubation, the
patient developed a second-degree atrioventricular block of the heart
and an increase in blood pressure (190/100 mmHg), which returned to
normal after symptomatic treatment of atropine and sodium nitroprusside.
Meanwhile, he continued to be treated for anti-infection, antiviral,
nutritional support, stomach protection and correction of electrolyte
disorders. On the 5th day after intubation (Feb 28, 2020), the patient's
liver function became worse (ALT 239.0 U/L, AST 168 U/L and \selectlanguage{greek}γ-\selectlanguage{english}GT 108
U/L) (Table 1). With the enhancement of liver protection treatment,
patients' liver function did not deteriorate further.

On the 20th day, the patient was conscious. Tracheal intubation was
removed and NIV was used to assist breathing (SaO2 100\%). After the
removal of intubation, CT re-examination showed ground glass opacities
with consolidation in the lungs, the range was larger and the density of
some lesions was higher than before (Figure 1C). On the 35th day the
patient satisfied discharge criteria and was maintained in isolation.
The last lung CT image showed that the lesion was absorbed compared to
previous observations (Figure 1D). During the isolation period,
treatments such as oxygen inhalation, liver protection, phlegm
elimination, and anti-infection were continued. On Mar 22, 2020, patient
SARS-CoV-2 IgG antibody tested positive.

\textbf{Discussion}

We report a critical COVID-19 case in Enshi City who successfully
survived after tracheal intubation and IMV treatment. A 60-year-old
patient, a history of hypertension, persistent recurrent fever after
admission, the results of blood tests and CT results all indicated that
he could progress to critical status (Shi H et al, 2020; Zhang G et al,
2020). Due to deterioration, NIV treatment was performed on Feb 23,
2020, but the breathing condition was not improved. The next day (Feb
24, 2020), tracheal intubation and IMV were performed. Subsequently, the
breathing condition was greatly improved, after which the
SaO\textsubscript{2} remained at 99-100\%.We believed that early and
timely assisted breathing interventions have played a better role in
curbing the disease progression of this patient.

Hypertension and diabetes are reported to be the most common
comorbidities of COVID-19, followed by cardiovascular disease (Huang C
et al, 2020; Wang D et al, 2020). Wang FS et al. reported (Zhang Cet al,
2020) that 2-11\% of patients with COVID-19 have liver comorbidities,
while 14-53\% of patients with abnormal levels of ALT and AST, and the
critical COVID-19 patients seem to have a higher rate of liver
dysfunction. In this case, the patient had abnormal heart conditions,
increased blood pressure, and hepatic dysfunction after intubation.
However, they can be gradually improved via active and effective
symptomatic treatment.

In general, for elderly patients with comorbidities, in the case of
critical symptoms such as dyspnea and extreme decline of
SaO\textsubscript{2}, the active control of the progress of
comorbidities, and early and timely assisted respiratory interventions
may prevent the disease from progressing to adverse outcomes. In
addition, for patients of COVID-19 with impaired liver function,
stricter surveillance and targeted treatment are needed. The successful
recovery of this patient has given great encouragement and confidence to
clinicians. However, multiple factors contribute to COVID-19 pathology
and its composite endpoint. More related research and reports are needed
in the future.

\textbf{Ethical Statement}

All studies were approved by and performed according to the guidelines
of the ethics committee at University Hospital of Hubei University for
Nationalities and Wuhan University (China).

\textbf{Data Availability Statement}

All data, models, and code generated or used during the study appear in
the submitted article.

\textbf{Acknowledgment}

We thank these parents involved in the study. This work was supported by
grants from the Central Universities of China and the Translational
Medical Research Fund of Wuhan University School of Medicine.

\textbf{Conflict of interest}

No conflicts of interest were declared.

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\textbf{Tables}

\textbf{Table 1. Analysis of Clinical Characteristics and Laboratory
Findings of this patient.}

\textbf{Figure Legends}

\textbf{Figure1. Chest computed tomographic images of this patient of
COVID-19 from outpatient department to discharge criteria were met.} A.
CT image before admission: right lung and left lung lower lobe
infectious lesions, multifocal ground glass changes. B. CT image on the
8th day after admission (2020.02.19 before tracheal intubation):
multiple infectious lesions in the lungs, showing multifocal ground
glass opacities with consolidation, the range is significantly larger
than before, the density is higher than before, a few fibrous
calcifications in the lungs. C. CT image on the 26th day after admission
(2020.03.08 after removal of tracheal intubation): Multiple infectious
lesions in the lungs show ground glass changes, the range is larger than
the previous results and the density of some lesions is higher than
before. D. CT image on the 36th day after admission (the second day of
isolated observation on 2020.03.18): the absorption of bilateral ground
glass opacity compared with the previous image.\selectlanguage{english}
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