BACKGROUND Coronavirus patients demonstrate varying degrees of respiratory insufficiency; many will progress to respiratory failure with a severe version of acute respiratory distress syndrome refractory to traditional supportive strategies. Providers must consider alternative therapies to deter or prevent the cascade of decompensation to fulminant respiratory failure. METHODS This is a case-series of five COVID-19 positive patients who demonstrated severe hypoxemia, declining respiratory performance, and escalating oxygen requirements. Patients met the following criteria: COVID-19 positivity, worsening respiratory performance, severe hypoxemia (Pao 2 ≤ 80) despite traditional supportive measures, escalating supplemental oxygen requirements, and D-dimer greater than 1.5 μg/mL. All patients received protocol directed thrombolytic therapy with tissue plasminogen activator (tPA). RESULTS All five patients improved without deleterious effects of thrombolytic therapy. Patient one was on maximum ventilator support, paralytics, and prone positioning without improvement. During tPA administration his Pao 2/FIO2 ratio improved from 69 to 127. Ventilator support was weaned immediately on posttreatment day 1, and he was extubated on posttreatment day 12. Our second through fifth patients were not intubated at time of initiation of tPA therapy. These patients each required significant oxygen supplementation trending toward intubation. After tPA therapy, all patients demonstrated a noticeable increase in Pao 2 values overtime. Three of these patients avoided intubation due to COVID-19–associated respiratory failure. CONCLUSION Administration of thrombolytics was followed by overall improvement in patients' oxygen requirements, and in three cases, prevented progression to mechanical ventilation, without deleterious effects. Clinical trials of thrombolytic therapy would further serve to underscore the efficacy and utility of this therapy. LEVEL OF EVIDENCE Case series of therapeutic effect, Level V.

Background The coronavirus disease 2019 (COVID-19) global pandemic has impacted daily life and medical practices around the world. Hospitals are continually making observations about this unique population as it relates to laboratory data and outcomes. Plasma D-dimer levels have been shown to be promising as a prognostic factor for outcomes in COVID-19 patients. This single institution retrospective study investigates the correlation between D-dimer and patient outcomes in our inpatient COVID-19 patient population. Methods COVID-19 confirmed positive patients who were admitted between March 2020 and May 2020 at our hospital were identified. Admission and peak D-dimer values and patient outcomes, including intubation and mortality, were retrospectively analyzed. Results Ninety-seven patients met criteria for inclusion in the study Mean age was 63.2 years, median admission D-dimer 2.35ug/mL, and median peak D-dimer 2.74ug/mL. Average time to peak D-dimer was 3.2 days. Patient’s requiring intubation had higher admission D-dimers (3.79ug/mL vs. 1.62 ug/mL) Discussion Higher admission and peak D-dimer values were associated with worsening clinical outcomes, specifically with higher rates of intubation and mortality. Noting D-dimer trends early in a patients’ COVID course, regardless of patients’ clinical condition, may allow opportunities for physicians to provide early intervention to prevent these outcomes.