J Bras Pneumol. 2022;48(5):e20220361 https://dx.doi.org/10.36416/1806-3756/e20220361 EDITORIAL The COVID-19 challenge. What have we learned? Adrian Ceccato1,2,3a, Carlos M Luna4a, Antonio Artigas1,2,5a Since COVID-19 (the disease caused by SARS-CoV-2) Interestingly, the presence of complications, including broke out in December of 2019 in China and became liver failure, arrhythmias, hand/foot ischemia, hemorrhage, a pandemic in March of 2020, health care systems of and health care-associated infections, were independently every country have had the challenge of dealing with the related to lower survival rates. Health care-associated disease. Specific conditions in Latin-American countries, infections have been reported to be high in COVID-19 such as previous shortcomings in the health care system, patients, as well as the mortality associated with these financial problems, the complexity in the geography infections.(7,8) It is not well known why the occurrence of and infrastructure of the region, and the emergence of secondary infections increased; however, immune tolerance new variants (gamma and lambda), hindered the fight in critically ill/septic patients, the use of corticosteroids, against the pandemic. and the overwhelmed health care system during the Data collected and studies performed during the pandemic could be related. According to the study,(6) pandemic were important to investigate the performance only 46.8% of the patients received corticosteroids. Early of health care systems, evaluating their strengths and in the pandemic, in March of 2020, an observational limitations. study showed that methylprednisolone was associated with lower mortality(9) in patients with ARDS; however, Ranzani et al.(1) analyzed a large cohort of COVID-19- corticosteroids were not recommended because of concerns related hospitalized patients during the first months of raised by the experience with other viral diseases, such the pandemic in Brazil and found that mortality was high as influenza or Middle East respiratory syndrome. Quickly, and that the differences among regions were notable. several studies evaluated the efficacy/effectiveness of The overall in-hospital mortality was 38%, whereas corticosteroids in patients with COVID-19, the study mortality in the ICU was 59%. Although mortality rates designated RECOVERY(10) being the first to be published were comparable with those in other countries, younger and showed a reduced risk of death only in those patients patients were included in this cohort. who required supplementary oxygen. Corticosteroids are Data from other countries are available. In Mexico, cheap and widely available, even though they are not the mortality rate reported in August of 2020 in patients exempt from risk. Corticosteroids have been associated receiving invasive mechanical ventilation was extremely with an increased risk of secondary infections, mainly high (73.7%).(2) Nevertheless, other reports coming hospital-acquired pneumonia.(11) More studies are from Latin-American countries showed mortality rates warranted to clarify which phenotypes could benefit from comparable with those from high-income countries. Reyes the use of corticosteroids and which ones should avoid the et al.(3) observed in an international cohort including use of these medications because the risks would exceed patients from eight Latin-American countries an in-hospital the benefits. However, several drugs were prescribed in mortality rate of 35%. the early phase of the pandemic without a piece of clear Many countries had to open new beds with access to evidence showing benefits. Data were extrapolated from ventilators in high-dependency care units or increase the in vitro studies or from the experience gathered with number of beds in the ICU. Controversies about increased the first SARS. Ramos et al.(6) reported that more than mortality have been observed in these units or during 40% of the patients were exposed to drugs with low periods of high demands,(4,5) highlighting the importance levels of evidence (or even none) that supported their of qualified personnel and appropriate resources. use. Moreover, oseltamivir, an antiviral recommended In this issue of the Jornal Brasileiro de Pneumologia, for influenza, was associated with an increased risk of Ramos et al.(6) reported data obtained from three ICUs in death in this population. São Paulo, Brazil, during the first pandemic wave. Of the In summary, the COVID-19 pandemic has provided 645 patients included, about 10% acquired the disease several lessons. First, infectious diseases are a constant in the hospital. Approximately 55% required invasive threat, and governments should invest in research to be mechanical ventilation, 35% needed renal replacement prepared to fight them. Second, although the health care therapy, and 52.2% received vasopressor therapy. The system has shown the capacity to increase the number in-hospital mortality was high, reaching 42.4%, mainly in of beds for critically ill patients, the lack of availability of those patients who required organ support. Unlike other trained personnel to give support to severely/critically ill cohorts, septic shock and multiple organ dysfunction patients is an unresolved problem. Third, the prescription were the most common causes of death.(6) of off-label drugs might have increased the risk of harm 1. Critical Care Center, Parc Taulí Hospital Universitari, Institut d’Investigació i Innovació Parc Taulí I3PT, Sabadell, Spain. 2. CIBER of Respiratory Diseases (CIBERES), Institute of Health Carlos III, Madrid, Spain. 3. Intensive Care Unit, Hospital Universitari Sagrat Cor, Grupo Quironsalud, Barcelona, Spain. 4. Facultad de Medicina, Hospital de Clínicas, Universidad de Buenos Aires, Buenos Aires, Argentina. 5. Bioscience and Medicine Faculty, Universitat Autònoma de Barcelona, Bellaterra, Spain. © 2022 Sociedade Brasileira de Pneumologia e Tisiologia ISSN 1806-3756 1/2 The COVID-19 challenge. What have we learned? without a clear benefit, and therefore physicians from these experiences, aiming to improve our clinical should act following recommendations based on practice and be ready for future epidemics. evidence. Fourth, COVID-19 survivors can experience severe pulmonary sequelae and other morbidities. ACKNOWLEDGEMENTS Finally, we have to highlight the quick response of the research community to the pandemic, based on basic, AC acknowledges receiving financial support from observational, and interventional collaborative studies. Instituto de Salud Carlos III (ISCIII; Sara Borrell Appling new technologies and knowledge allowed the 2021: CD21/00087). development of new vaccines in a short time, changing the course of the pandemic. CONFLICT OF INTEREST It is unclear whether the COVID-19 pandemic is about to end; however, we must continue learning None declared. REFERENCES 1. 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