Patient self-proning with high-flow nasal cannula improves oxygenation in COVID-19 pneumonia

Effects of awake-prone positioning on oxygenation and physiological outcomes in non-intubated patients with COVID-19: A randomized controlled trial

BACKGROUND

Prone positioning is a well-known supportive approach for increasing oxygenation and reducing mortality in non-COVID-19 patients with moderate to severe acute respiratory distress syndrome. However, studies highlighting the effects of proning in patients with COVID-19 are limited.

AIM

To investigate the effects of awake-prone positioning (APP) on oxygenation and physiological outcomes in non-intubated patients with COVID-19.

STUDY DESIGN

A randomized controlled trial was carried out with two parallel groups at 1:1 ratio. Adult awake non-intubated patients with confirmed COVID-19, non-rebreathing face mask or continuous positive airway pressure, PaO2 /FiO2 ratio ≤150 mmHg were randomly assigned to the APP group or control group. The control group was subjected to conventional positioning interventions. Outcome measures were PaO2 /FiO2 ratio, ROX index, PaO2 , PaCO2 , SaO2 , respiratory rate, blood pressure, and shock index. These parameters were recorded immediately before positioning, 10 min after patient positioning, and 1 h after patient positioning.

RESULTS

Of 115 patients assessed for eligibility, 82 were randomized to the APP group or control group (41 patients in each group). The use of APP for non-intubated patients with COVID-19 resulted in statistically significant improvements in oxygenation parameters, that is, SpO2 , PaO2 /FiO2 , ROX index, PaO2 , and SaO2 , at the three study time points (p = .000, .007, .000, .011, and .000 respectively). The SpO2 was increased to 92.15 ± 2.735 mmHg for the APP group versus 88.17 ± 4.847 for the control group after 1 h of patients' positioning. The PaO2 /FiO2 ratio increased in the APP group before proning compared with 1 h after proning (79.95 ± 22.508 vs. 98.91 ± 34.44) respectively. APP improved the SpO2 , PaO2 /FiO2 , ROX index, PaO2 , and SaO2 values for the APP group, representing an increase of 5.85%, 23.71%, 30.79%, 22.59%, and 5.26%, respectively.

CONCLUSION

Awake proning in non-intubated patients with COVID-19 showed marked improvement in oxygenation and physiological parameters.

RELEVANCE TO CLINICAL PRACTICE

This study provides evidence for critical care nurses to implement APP in non-intubated patients with COVID-19 to improve oxygenation and physiological parameters, as it was tolerated by most of the patients without serious adverse events.

Reduction in risk of death among patients admitted with COVID-19 between first and second epidemic waves in New York City

Background

Many regions have experienced successive epidemic waves of COVID-19 since the emergence of SARS-CoV-2 with heterogeneous differences in mortality. Elucidating factors differentially associated with mortality between epidemic waves may inform clinical and public health strategies.

Methods

We examined clinical and demographic data among patients admitted with COVID-19 during the first (March-August 2020) and second (August 2020-March 2021) epidemic waves at an academic medical center in New York City.

Results

Hospitalized patients (N = 4631) had lower overall and 30-day in-hospital mortality, defined as death or discharge to hospice, during the second wave (14% and 11%) than the first (22% and 21%). The wave 2 in-hospital mortality decrease persisted after adjusting for several potential confounders. Adjusting for the volume of COVID-19 admissions, a measure of health system strain, accounted for the mortality difference between waves. Several demographic and clinical patient factors were associated with an increased risk of mortality independent of wave; SARS-CoV-2 cycle threshold, Do-Not-Intubate status, oxygen requirement, and intensive care unit admission.

Conclusions

This work suggests that increased in-hospital mortality rates observed during the first epidemic wave were partly due to strain on hospital resources. Preparations for future epidemics should prioritize evidence-based patient risks, treatment paradigms, and approaches to augment hospital capacity.

Posición prono en respiración espontánea: una lección más del COVID-19

Con la pandemia se implementaron diversas estrategias para evitar la intubación y la ventilación mecánica invasiva. La posición prona tiene claros efectos benéficos en mejorar la oxigenación por diversos mecanismos al tiempo que genera cambios hemodinámicos que pueden optimizar la función del ventrículo derecho.

La evidencia de la posición prona en pacientes con síndrome de dificultad respiratoria aguda en ventilación mecánica invasiva es contundente y obliga a considerarla en las primeras 24 h de pacientes con PaO₂/FiO₂ ≤ 150 mmHg. La posición prona en respiración espontánea puede mejorar la oxigenación en pacientes con falla respiratoria y si se implementa mediante un protocolo que incluya una adecuada selección de pacientes puede evitar la intubación de pacientes en falla respiratoria.

La presente revisión resume los antecedentes históricos, las bases fisiológicas de la posición prona en el paciente despierto, así como la evidencia que evalúa su aplicación en el paciente con COVID-19 al tiempo que resume el protocolo y la experiencia de un centro con esta estrategia como propuesta para estudios multicéntricos.

Various Aspects of Non-Invasive Ventilation in COVID-19 Patients: A Narrative Review

Non-invasive ventilation (NIV) is primarily used to treat acute respiratory failure. However, it has broad applications to manage a range of other diseases successfully. The main advantage of NIV lies in its capability to provide the same physiological effects as invasive ventilation while avoiding the placement of an artificial airway and its associated life-threatening complications.

The war on the COVID-19 pandemic is far from over. The present narrative review aimed at identifying various aspects of NIV usage, in COVID-19 and other patients, such as the onset time, mode, setting, positioning, sedation, and types of interface. A search for articles published from May 2020 to April 2021 was conducted using MEDLINE, PMC central, Scopus, Web of Science, Cochrane Library, and Embase databases. Of the initially identified 5,450 articles, 73 studies and 24 guidelines on the use of NIV were included. The search was limited to studies involving human cases and English language articles. Despite several reported benefits of NIV, the evidence on the use of NIV in COVID-19 patients does not yet fully support its routine use.

Reduction in risk of death among patients admitted with COVID-19 between first and second epidemic waves in New York City

Many regions have experienced successive epidemic waves of COVID-19 since the emergence of SARS-CoV-2 with heterogeneous differences in mortality. Elucidating factors differentially associated with mortality between epidemic waves may inform clinical and public health strategies. We examined clinical and demographic data among patients admitted with COVID-19 during the first (March-June 2020) and second (December 2020-March 2021) epidemic waves at an academic medical center in New York City. Hospitalized patients (N=4631) had lower mortality during the second wave (14%) than the first (23%). Patients in the second wave had a lower 30-day mortality (Hazard Ratio (HR) 0.52, 95% CI 0.44, 0.61) than those in the first wave. The mortality decrease persisted after adjusting for confounders except for the volume of COVID-19 admissions (HR 0.88, 95% CI 0.70, 1.11), a measure of health system strain. Several demographic and clinical patient factors were associated with an increased risk of mortality independent of wave.

Article summary

Using clinical and demographic data from COVID-19 hospitalizations at a tertiary New York City medical center, we show that a reduction in mortality during the second epidemic wave was associated with decreased strain on healthcare resources.

ASSESSMENT OF PROCEDURAL PAIN IN PATIENTS WITH COVID-19 IN THE INTENSIVE CARE UNIT

Aim

The purpose of the study was to assess the level of procedural pain in patients treated in the COVID-19 intensive care unit, in a tertiary university hospital.

Method

We performed the procedural pain assessment of COVID-19 patients in this study, and 162 (93.6 %) of 173 hospitalized patients assessed during this period. While pain was assessed before, during, and at the 20th minute after endotracheal aspiration, wound care, and position change, which are procedural patient practices, the pain was assessed before, during, and up to the fourth hour after prone positioning, high-flow oxygen therapy (HFOT), and the non-invasive mechanical ventilation (NIMV) procedure. The Numerical Pain Scale was used for conscious patients in pain assessment, while the Behavioral Pain Scale and the Richmond Agitation-Sedation Scale were used for unconscious patients.

Results

Patients who underwent endotracheal aspiration, wound care, and positioning had higher pain levels during procedure than other time points. Patients in the prone position with HFOT and NIMV applied had the highest pain scores at fourth hour after procedure; this increase was statistically significant (p = .000, p < .05).

Conclusions

The study found that COVID-19 patients in the ICU had pain due to procedural practices and that the level of pain during the procedures was higher because endotracheal aspiration, wound care, and positioning were all short-term procedures. Moreover, prone positioning was found to be associated with pressure-related tissue damage, and patients' pain levels increased with the increasing duration of HFOT and NIMV procedure.

Role of high-flow nasal oxygen therapy in COVID-19 pneumonia with Eisenmenger syndrome: A case report

Since the coronavirus disease 2019 (COVID-19) pandemic emerged in November 2019, various international guidelines and local protocols have been published to assist clinicians face the pandemic effectively. Medical and ventilatory strategies have evolved and researchers have come out with multiple studies and solutions within a short period of time. The patient's best interest is always the goal of the management. We present a case report of COVID-19 pneumonia in a patient with underlying Eisenmenger syndrome and the potential benefits of high-flow nasal oxygen therapy in this patient.

Awake prone positioning and oxygen therapy in patients with COVID-19: the APRONOX study

BACKGROUND

The awake prone positioning strategy for patients with acute respiratory distress syndrome is a safe, simple and cost-effective technique used to improve hypoxaemia. We aimed to evaluate intubation and mortality risk in patients with coronavirus disease 2019 (COVID-19) who underwent awake prone positioning during hospitalisation.

METHODS

In this retrospective, multicentre observational study conducted between 1 May 2020 and 12 June 2020 in 27 hospitals in Mexico and Ecuador, nonintubated patients with COVID-19 managed with awake prone or awake supine positioning were included to evaluate intubation and mortality risk through logistic regression models; multivariable and centre adjustment, propensity score analyses, and E-values were calculated to limit confounding.

RESULTS

827 nonintubated patients with COVID-19 in the awake prone (n=505) and awake supine (n=322) groups were included for analysis. Fewer patients in the awake prone group required endotracheal intubation (23.6% versus 40.4%) or died (19.8% versus 37.3%). Awake prone positioning was a protective factor for intubation even after multivariable adjustment (OR 0.35, 95% CI 0.24-0.52; p<0.0001, E=2.12), which prevailed after propensity score analysis (OR 0.41, 95% CI 0.27-0.62; p<0.0001, E=1.86) and mortality (adjusted OR 0.38, 95% CI 0.26-0.55; p<0.0001, E=2.03). The main variables associated with intubation among awake prone patients were increasing age, lower baseline peripheral arterial oxygen saturation/inspiratory oxygen fraction ratio (P aO2 /F IO2 ) and management with a nonrebreather mask.

CONCLUSIONS

Awake prone positioning in hospitalised nonintubated patients with COVID-19 is associated with a lower risk of intubation and mortality.

High Flow Nasal Cannula Therapy in the Emergency Department: Main Benefits in Adults, Pediatric Population and against COVID-19: A Narrative Review

This review aims to summarize the literature’s main results about high flow nasal cannula therapy (HFNC) HFNC benefits in the Emergency Department (ED) in adults and pediatrics, including new Coronavirus Disease (COVID-19). HFNC has recently been established as the usual treatment in the ED to provide oxygen support. Its use has been generalized due to its advantages over traditional oxygen therapy devices, including decreased nasopharyngeal resistance, washing out of the nasopharyngeal dead space, generation of positive pressure, increasing alveolar recruitment, easy adaptation due to the humidification of the airways, increased fraction of inspired oxygen and improved mucociliary clearance. A wide range of pathologies has been studied to evaluate the potential benefits of HFNC; some examples are heart failure, pneumonia, chronic pulmonary obstructive disease, asthma, and bronchiolitis. The regular use of this oxygen treatment is not established yet due to the literature’s controversial results. However, several authors suggest that it could be useful in several pathologies that generate acute respiratory failure. Consequently, the COVID-19 irruption has generated the question of HFNC as a safety and effective treatment. Our results suggested that HFNC seems to be a useful tool in the ED, especially in patients affected by acute hypoxemic respiratory failure, acute heart failure, pneumonia, bronchiolitis, asthma and acute respiratory distress syndrome in patients affected by COVID-19. Its benefits in hypercapnic respiratory failure are more discussed, being only observed benefits in patients with mild-moderate disease. These results are based in clinical as well as cost-effectiveness outcomes. Future studies with largest populations are required to confirm these results as well as establish a practical guideline to use this device.

Response to Awake Prone Position in Nonintubated Individuals With COVID-19

BACKGROUND

Prone positioning is used for patients with ARDS undergoing invasive mechanical ventilation; its effectiveness in nonventilated awake patients is unclear. We aimed to evaluate the effectiveness of the prone maneuver in decreasing the risk of intubation and increasing the odds of favorable events.

METHODS

We prospectively evaluated 66 subjects with COVID-19-related moderate ARDS who were admitted to the ICU; treated with high-flow nasal cannula, noninvasive ventilation, a reservoir mask, or a nasal cannula; and subjected to awake prone maneuvers from March 1, 2020-August 30, 2020. The following factors were recorded at ICU admission: age, sex, prior illness, simplified acute physiology score 3, body mass index, and changes in gas exchange after and before prone positioning. Subjects were divided into a group of responders and nonresponders according to a 20% increase in the P_aO2 /F_IO2 ratio before and after the maneuver. The need for intubation within 48 h of the start of the maneuver was also evaluated. We also analyzed the differences in mortality, ICU length of stay, hospital length of stay, and duration of mechanical ventilation. A generalized estimating equation model was applied to preprone and postprone means. To control for confounding factors, multivariate Poisson regression was applied.

RESULTS

Forty-one subjects age 54.1 y ± 12.9 were enrolled. Responders showed increased S_pO2 (P < .001), P_aO2 (P < .001), and P_aO2 /F_IO2 ratios (P < .001) with the maneuver and reduced breathing frequency. Responders had shorter lengths of stay in the ICU (P < .001) and hospital (P < .003), lower intubation rates at 48 h (P < .012), fewer days of ventilation (P < .02), and lower mortality (P < .001). Subjects who responded to the maneuver had a 54% reduction in the risk of ventilation and prolonged stay in the ICU.

CONCLUSIONS

Among the responders to prone positioning, there were fewer deaths, shorter duration of mechanical ventilation, shorter ICU length of stay, and shorter hospital length of stay.

Awake Prone Positioning in the Management of COVID-19 Pneumonia: A Systematic Review

Background: The aim was to investigate the efficacy of prone positioning (PP) in the management of coronavirus disease-2019 (COVID-19) pneumonia in various setups, with various modes of oxygen therapy and its optimal duration. Materials and methods: A systematic literature search was conducted from inception until May 15, 2021. Patients with a validated diagnosis of COVID-19 and receiving PP were included. Various factors, including intensive care unit (ICU) or non-ICU setup, mode of oxygen therapy, outcome, duration of proning, and limitations, were noted. Results: We retrieved 36 articles with a total of 1,385 patients for qualitative analysis. Out of 36 articles, there were 17 original articles, 09 case series, and 10 case reports. Out of 1,385 participants, 78.9% (n = 1,093) and 21.0% (n = 292) of patients were managed in ICU and non-ICU setup, respectively. Awake PP with high flow nasal cannula (HFNC) was found to be a promising technique; however, the result was inconclusive with helmet continuous positive airway pressure (CPAP). No study has evaluated the optimal duration of awake PP and the associated long-term outcomes. Conclusion: We encourage the use of early awake self-proning in the management of COVID19 disease. However, the evidence in terms of its use in non-ICU setup, the optimal duration of PP, and various oxygenation devices are insufficient, thereby mandating further well-designed multicentric studies to evaluate its efficacy as an adjunct in the management of COVID-19 pneumonia in context to the aforementioned factor. How to cite this article: Chilkoti GT, Mohta M, Saxena AK, Ahmad Z, Sharma CS. Awake Prone Positioning in the Management of COVID-19 Pneumonia: A Systematic Review. Indian J Crit Care Med 2021;25(8):896-905.

Effect of mortality from COVID-19 on inpatient outcomes

When hospitals first encountered coronavirus disease 2019 (COVID‐19), there was a dearth of therapeutic options and nearly 1 in 3 patients died from the disease. By the summer of 2020, as deaths from the disease declined nationally, multiple single‐center studies began to report declining mortality of patients with COVID‐19. To evaluate the effect of COVID‐19 on hospital‐based mortality, we searched the Vizient Clinical Data Base for outcomes data from approximately 600 participating hospitals, including 130 academic medical centers, from January 2017 through December 2020. More than 32 million hospital admissions were included in the analysis. After an initial spike, mortality from COVID‐19 declined in all regions of the country to under 10% by June 2020 and remained constant for the remainder of the year. Despite this, inpatient, all‐cause mortality has increased since the beginning of the pandemic, even those without respiratory failure. Inpatient mortality has particularly increased in elderly patients and in those requiring intubation for respiratory failure. Since June 2020, COVID‐19 kills one in every 10 patients admitted to the hospital with this diagnosis. The addition of this new disease has raised overall hospital mortality especially those who require intubation for respiratory failure.

Inpatient mortality from COVID‐19 fell from 22% in March to under 10% in June and remained at similar levels for the remainder of 2020.

There was an increase in all‐cause, inpatient mortality since the beginning of the pandemic, even in those without respiratory failure.

Only patient with respiratory failure who required intubated had an increase in average inpatient mortality.

Effect of early awake prone positioning application on prognosis in patients with acute respiratory failure due to COVID-19 pneumonia: a retrospective observational study

Background

We evaluated the effect of early awake prone position administration on oxygenation and intubation requirements and short-term mortality in patients with acute respiratory failure due to coronavirus disease 2019 (COVID-19) pneumonia.

Methods

This is an observational-cohort study. Patients receiving mask oxygen therapy in our intensive care units because of acute respiratory failure due to COVID-19 pneumonia were included. The Awake Prone Position (APP) group consisted of patients who were applied awake prone position, whereas non-APP group consisted of patients who were not applied awake prone position. PaCO₂, PaO₂, pH, SpO₂ values and PaO₂/FiO₂ ratios were recorded at the beginning and 24th hour. Demographic data, comorbidities, intubation requirements, ventilator-free days, length of intensive care unit stay and short-term mortality of the patients were recorded.

Results

The data of total 225 patients were examined, and 48 patients who met our study criteria were included. At the 24th hour, the median SpO₂ value of the APP group was 95%, the median PaO₂ value was 82 mmHg, whereas the SpO₂ value of the non-APP group was 90% and the PaO₂ value was 66 mmHg. (p = 0.001, p = 0.002). There was no statistically significant difference between the groups in length of intensive care unit stay and ventilator-free days, but short-term mortality and intubation requirements was lower in the APP group (p = 0.020, p = 0.001)

Conclusion

Awake prone position application in patients receiving non-rebreather mask oxygen therapy for respiratory failure due to COVID-19 pneumonia improves oxygenation and decreases the intubation requirements and mortality.

Prolonged Active Prone Positioning in Spontaneously Breathing Non-intubated Patients With COVID-19-Associated Hypoxemic Acute Respiratory Failure With PaO2/FiO2 >150

Background: The COVID-19 pandemic has led to new approaches to manage patients outside the ICU, including prone positioning in non-intubated patients.

Objectives: To report the use of prolonged active prone positioning in spontaneously breathing patients with COVID-19-associated acute respiratory failure. Spontaneously breathing vs non-invasive respiratory support for COVID19 associated acute respiratory failure.

Methods: Patients with PaO₂/FiO₂ > 150, with lung posterior consolidations as assessed by means of lung ultrasound, and chest x-ray were studied. Under continuous pulse oximetry (SpO₂) monitoring, patients maintained active prone position. A PaO₂/FiO₂ < 150 was considered as treatment failure and patients had to be switched to non-invasive respiratory support. Retrospectively, data of 16 patients undergoing who refused proning and underwent non-invasive respiratory support were used as controls. The primary outcome was the proportion of patients maintaining prolonged prone position and discharged home. Secondary outcomes included improvement in oxygenation, hospital length of stay, and 6-month survival.

Results: Three out of 16 (18.7%) patients did not tolerate the procedure. Three more patients showed a worsening in PaO₂/FiO₂ to <150 and required non-invasive support, two of whom finally needing endotracheal intubation. After 72 h, 10 out of 16 (62.5%) patients improved oxygenation [PaO₂/FiO₂: from 194.6 (42.1) to 304.7 (79.3.2) (p < 0.001)] and were discharged home. In the control group, three out of 16 failed, required invasive ventilatory support, and died within 1 month in ICU. Thirteen were successful and discharged home.

Conclusion: In non-intubated spontaneously breathing COVID-19 patients with PaO₂/FiO₂ >150, active prolonged prone positioning was feasible and tolerated with significant improvement in oxygenation.

Awake Prone Positioning in Non-Intubated Patients With Acute Hypoxemic Respiratory Failure Due to COVID-19

BACKGROUND

Awake prone positioning (APP) has been advocated to improve oxygenation and prevent intubation of patients with acute hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19). This paper aims to synthesize the available evidence on the efficacy of APP.

METHODS

We performed a systematic review of proportional outcomes from observational studies to compare intubation rate in patients treated with APP or with standard care.

RESULTS

A total of 46 published and 4 unpublished observational studies that included 2,994 subjects were included, of which 921 were managed with APP and 870 were managed with usual care. APP was associated with significant improvement of oxygenation parameters in 381 cases of 19 studies that reported this outcome. Among the 41 studies assessing intubation rates (870 subjects treated with APP and 852 subjects treated with usual care), the intubation rate was 27% (95% CI 19-37%) as compared to 30% (95% CI 20-42%) (P = .71), even when duration of application, use of adjunctive respiratory assist device (high-flow nasal cannula or noninvasive ventilation), and severity of oxygenation deficit were taken into account. There appeared to be a trend toward improved mortality when APP was compared with usual care (11% vs 22%), which was not statistically significant.

CONCLUSIONS

APP was associated with improvement of oxygenation but did not reduce the intubation rate in subjects with acute respiratory failure due to COVID-19. This finding is limited by the high heterogeneity and the observational nature of included studies. Randomized controlled clinical studies are needed to definitively assess whether APP could improve key outcome such as intubation rate and mortality in these patients.

Evaluation of thiamine as adjunctive therapy in COVID-19 critically ill patients: a two-center propensity score matched study

Background

Thiamine is a precursor of the essential coenzyme thiamine pyrophosphate required for glucose metabolism; it improves the immune system function and has shown to reduce the risk of several diseases. The role of thiamine in critically ill septic patient has been addressed in multiple studies; however, it’s role in COVID-19 patients is still unclear. The aim of this study was to evaluate the use of thiamine as an adjunctive therapy on mortality in COVID-19 critically ill patients.

Methods

This is a two-center, non-interventional, retrospective cohort study for critically ill patients admitted to intensive care units (ICUs) with a confirmed diagnosis of COVID19. All patients aged 18 years or older admitted to ICUs between March 1, 2020, and December 31, 2020, with positive PCR COVID-19 were eligible for inclusion. We investigated thiamine use as an adjunctive therapy on the clinical outcomes in critically ill COVID-19 patients after propensity score matching.

Results

A total of 738 critically ill patients with COVID-19 who had been admitted to ICUs were included in the study. Among 166 patients matched using the propensity score method, 83 had received thiamine as adjunctive therapy. There was significant association between thiamine use with in-hospital mortality (OR = 0.39; 95% CI 0.19–0.78; P value = 0.008) as well as the 30-day mortality (OR = 0.37; 95% CI 0.18–0.78; P value = 0.009). Moreover, patients who received thiamine as an adjunctive therapy were less likely to have thrombosis during ICU stay [OR (95% CI) 0.19 (0.04–0.88), P value = 0.03].

Conclusion

Thiamine use as adjunctive therapy may have potential survival benefits in critically ill patients with COVID-19. Additionally, it was associated with a lower incidence of thrombosis. Further interventional studies are required to confirm these findings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03648-9.

COVID-19 is a systemic vascular hemopathy: insight for mechanistic and clinical aspects

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is presenting as a systemic disease associated with vascular inflammation and endothelial injury. Severe forms of SARS-CoV-2 infection induce acute respiratory distress syndrome (ARDS) and there is still an ongoing debate on whether COVID-19 ARDS and its perfusion defect differs from ARDS induced by other causes. Beside pro-inflammatory cytokines (such as interleukin-1 β [IL-1β] or IL-6), several main pathological phenomena have been seen because of endothelial cell (EC) dysfunction: hypercoagulation reflected by fibrin degradation products called D-dimers, micro- and macrothrombosis and pathological angiogenesis. Direct endothelial infection by SARS-CoV-2 is not likely to occur and ACE-2 expression by EC is a matter of debate. Indeed, endothelial damage reported in severely ill patients with COVID-19 could be more likely secondary to infection of neighboring cells and/or a consequence of inflammation. Endotheliopathy could give rise to hypercoagulation by alteration in the levels of different factors such as von Willebrand factor. Other than thrombotic events, pathological angiogenesis is among the recent findings. Overexpression of different proangiogenic factors such as vascular endothelial growth factor (VEGF), basic fibroblast growth factor (FGF-2) or placental growth factors (PlGF) have been found in plasma or lung biopsies of COVID-19 patients. Finally, SARS-CoV-2 infection induces an emergency myelopoiesis associated to deregulated immunity and mobilization of endothelial progenitor cells, leading to features of acquired hematological malignancies or cardiovascular disease, which are discussed in this review. Altogether, this review will try to elucidate the pathophysiology of thrombotic complications, pathological angiogenesis and EC dysfunction, allowing better insight in new targets and antithrombotic protocols to better address vascular system dysfunction. Since treating SARS-CoV-2 infection and its potential long-term effects involves targeting the vascular compartment and/or mobilization of immature immune cells, we propose to define COVID-19 and its complications as a systemic vascular acquired hemopathy.

Awake prone positioning in patients with hypoxemic respiratory failure due to COVID-19: the PROFLO multicenter randomized clinical trial

Background

The effect of awake prone positioning on intubation rates is not established. The aim of this trial was to investigate if a protocol for awake prone positioning reduces the rate of endotracheal intubation compared with standard care among patients with moderate to severe hypoxemic respiratory failure due to COVID-19.

Methods

We conducted a multicenter randomized clinical trial. Adult patients with confirmed COVID-19, high-flow nasal oxygen or noninvasive ventilation for respiratory support and a PaO₂/FiO₂ ratio ≤ 20 kPa were randomly assigned to a protocol targeting 16 h prone positioning per day or standard care. The primary endpoint was intubation within 30 days. Secondary endpoints included duration of awake prone positioning, 30-day mortality, ventilator-free days, hospital and intensive care unit length of stay, use of noninvasive ventilation, organ support and adverse events. The trial was terminated early due to futility.

Results

Of 141 patients assessed for eligibility, 75 were randomized of whom 39 were allocated to the control group and 36 to the prone group. Within 30 days after enrollment, 13 patients (33%) were intubated in the control group versus 12 patients (33%) in the prone group (HR 1.01 (95% CI 0.46–2.21), P = 0.99). Median prone duration was 3.4 h [IQR 1.8–8.4] in the control group compared with 9.0 h per day [IQR 4.4–10.6] in the prone group (P = 0.014). Nine patients (23%) in the control group had pressure sores compared with two patients (6%) in the prone group (difference − 18% (95% CI − 2 to − 33%); P = 0.032). There were no other differences in secondary outcomes between groups.

Conclusions

The implemented protocol for awake prone positioning increased duration of prone positioning, but did not reduce the rate of intubation in patients with hypoxemic respiratory failure due to COVID-19 compared to standard care.

Trial registration

ISRCTN54917435. Registered 15 June 2020 (https://doi.org/10.1186/ISRCTN54917435).

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03602-9.

The Considerations and Controversies in Using High-Flow Nasal Oxygen with Self-Prone Positioning in SARS-CoV-2 COVID-19 Disease

Evidence exists for the use of high-flow nasal oxygen (HFNO) in the general critical care population for acute hypoxemic respiratory failure. There is discord between guidelines for hypoxemia management in COVID-19. Both noninvasive management and intubation present risk to patients and staff and potentially overwhelm hospital mechanical ventilator capacity. The use of HFNO has been particularly controversial in the UK, with oxygen infrastructure failure. We discuss our experience of managing COVID-19 with HFNO and awake self-prone positioning. We focus upon the less-usual case of an eighteen-year-old female to illustrate the type of patient where HFNO may be used when perhaps earlier intubation once was. It is important to consider the wider implications of intubation. We have used HFNO as a bridge to intubation or as definitive management. As we await clinical trial evidence, HFNO with self-prone positioning has a role in COVID-19 for certain patients. Response parameters must be set and reviewed, oxygen infrastructure considered, and potential staff droplet exposure minimised.

Ventilatory Support in Patients with COVID-19

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) caused the novel coronavirus disease 2019 (COVID-19) pandemic, which spread throughout the world. Acute hypoxemic respiratory failure is the most dangerous complication of COVID-19 pneumonia. To date, no specific therapeutic drugs or vaccines have been proven efficacious. Ventilatory support is still a significant challenge for physicians facing COVID-19. The mechanisms underlying hypoxemia in those patients are not fully understood, but a new physiopathology model has been proposed. Oxygen therapy should be delivered to patients with mild to moderate hypoxemia. More severe patients could benefit from other treatments (high-flow nasal cannula, noninvasive ventilation or intubation, and invasive ventilation). Given the rapid evolution of COVID-19, there has been a paucity of the high-quality data that typically inform clinical practice guidelines from professional societies, and a worldwide consensus is still lacking. This chapter aims to illustrate the potentials of ventilatory support as therapeutic options for adult and pediatric patients affected by COVID-19 pneumonia.

Awake Proning as an Adjunctive Therapy for Refractory Hypoxemia in Non-Intubated Patients with COVID-19 Acute Respiratory Failure: Guidance from an International Group of Healthcare Workers

Non-intubated patients with acute respiratory failure due to COVID-19 could benefit from awake proning. Awake proning is an attractive intervention in settings with limited resources, as it comes with no additional costs. However, awake proning remains poorly used probably because of unfamiliarity and uncertainties regarding potential benefits and practical application. To summarize evidence for benefit and to develop a set of pragmatic recommendations for awake proning in patients with COVID-19 pneumonia, focusing on settings where resources are limited, international healthcare professionals from high and low- and middle-income countries (LMICs) with known expertise in awake proning were invited to contribute expert advice. A growing number of observational studies describe the effects of awake proning in patients with COVID-19 pneumonia in whom hypoxemia is refractory to simple measures of supplementary oxygen. Awake proning improves oxygenation in most patients, usually within minutes, and reduces dyspnea and work of breathing. The effects are maintained for up to 1 hour after turning back to supine, and mostly disappear after 6-12 hours. In available studies, awake proning was not associated with a reduction in the rate of intubation for invasive ventilation. Awake proning comes with little complications if properly implemented and monitored. Pragmatic recommendations including indications and contraindications were formulated and adjusted for resource-limited settings. Awake proning, an adjunctive treatment for hypoxemia refractory to supplemental oxygen, seems safe in non-intubated patients with COVID-19 acute respiratory failure. We provide pragmatic recommendations including indications and contraindications for the use of awake proning in LMICs.

Planning for the Pandemic: A Community Hospital Story

When the Covid 19 pandemic affected New York State, Federal and mostly State, mandates were given to hospitals to prepare for the expected influx of patients. This is a community hospital's planning journey that includes preparing for placing patients, educating caregivers, matching the abilities of the available caregivers with the needs of the patients, securing needed equipment and supplies, and caring for the caregivers. Planning for patient placement resulted in a phased-in guide, accommodating seriously and critically ill affected patients. Education and training were initial and ongoing, rapidly changing as new information became available. Effective care delivery models that focused on team were modified depending on the needs of patients and staff competence. Securing and maintaining equipment and supplies were challenging and caring for the caregivers was a priority. Working as a team, this community hospital developed a road map that was effective in planning for the surge and allowed the hospital to maintain a safe environment for staff and patients who received quality care in difficult time.

Implementing Prone Positioning for COVID-19 Patients Outside the Intensive Care Unit

BACKGROUND

Proning intubated intensive care unit patients for the management of acute respiratory distress syndrome is an accepted standard of practice. We examined the nursing climate in 4 units and its impact on implementing a novel self-proning protocol to treat COVID-19 patients outside the intensive care unit.

LOCAL PROBLEM

Nursing units previously designated for medical/surgical populations had to adjust quickly to provide evidence-based care for COVID-19 patients attempting self-proning.

METHODS

Nurses from 4 nursing units were surveyed about the implementation process on the self-proning protocol. Their perception of unit implementation was assessed via the Implementation Climate Scale.

INTERVENTIONS

A new self-proning nursing protocol was implemented outside the intensive care unit.

RESULTS

Consistent education on the protocol, belief in the effectiveness of the intervention, and a strong unit-based climate of evidence-based practice contributed to greater implementation of the protocol.

CONCLUSIONS

Implementation of a new nursing protocol is possible with strong unit-based support, even during a pandemic.

Utilização da posição prona em ventilação espontânea em paciente com COVID-19

OBJETIVO: Descrever caso de uma paciente adulta com COVID-19, internada em unidade de terapia intensiva (UTI) e submetida à posição prona. RELATO DO CASO: paciente do sexo feminino, 44 anos, portadora de síndrome metabólica prévia, com síndrome da imunodeficiência adquirida, chegou ao pronto atendimento apresentando febre, congestão nasal, negando dispneia. Após a realização de exames clínicos e de imagem, foi transferida para a UTI, com suspeita de COVID-19. Na chegada na unidade intensiva, estava respirando espontaneamente com oxigenoterapia de baixo fluxo à 5L/min, apresentando hipoxemia (SpO2 = 88% e PaO2=76mmHg). Além das terapias médicas instituídas, foi orientada a se posicionar na PP durante um período de 15 a 30 minutos, realizado uma vez por turno. Após o primeiro posicionamento foi possível observar melhora na difusão pulmonar, pois a gasometria arterial demonstrou aumento da PaO2 para 96mmHg e de 18% na relação PaO2/FiO2, além de evolução clínica favorável. CONCLUSÕES: A indicação precoce da PP como terapia adicional no tratamento de paciente com COVID-19 pode ter contribuído para o desfecho clínico favorável, principalmente no que tange à oxigenação, evidenciada através da melhora de parâmetros de PaO2, relação PaO2/FiO2 e progressão com alta hospitalar.

Knowledge translation tools to guide care of non-intubated patients with acute respiratory illness during the COVID-19 Pandemic

Providing optimal care to patients with acute respiratory illness while preventing hospital transmission of COVID-19 is of paramount importance during the pandemic; the challenge lies in achieving both goals simultaneously. Controversy exists regarding the role of early intubation versus use of non-invasive respiratory support measures to avoid intubation. This review summarizes available evidence and provides a clinical decision algorithm with risk mitigation techniques to guide clinicians in care of the hypoxemic, non-intubated, patient during the COVID-19 pandemic. Although aerosolization of droplets may occur with aerosol-generating medical procedures (AGMP), including high flow nasal oxygen and non-invasive ventilation, the risk of using these AGMP is outweighed by the benefit in carefully selected patients, particularly if care is taken to mitigate risk of viral transmission. Non-invasive support measures should not be denied for conditions where previously proven effective and may be used even while there is suspicion of COVID-19 infection. Patients with de novo acute respiratory illness with suspected/confirmed COVID-19 may also benefit. These techniques may improve oxygenation sufficiently to allow some patients to avoid intubation; however, patients must be carefully monitored for signs of increased work of breathing. Patients showing signs of clinical deterioration or high work of breathing not alleviated by non-invasive support should proceed promptly to intubation and invasive lung protective ventilation strategy. With adherence to these principles, risk of viral spread can be minimized.

[All Roads Lead to Rome: Results of Non-Invasive Respiratory Therapies Applied in a Tertiary-Care Hospital Without an Intermediate Care Unit During the COVID-19 Pandemic]

Introduction

Non-invasive respiratory therapies (NRT) were widely used in the first wave of the COVID-19 pandemic in different settings, depending on availability. The objective of our study was to present 90-day survival and associated factors in patients treated with NRT in a tertiary hospital without an Intermediate Respiratory Care Unit. The secondary objective was to compare the outcomes of the different therapies.

Methods

Observational study of patients treated with NRT outside of an intensive care or intermediate respiratory care unit setting, diagnosed with COVID-19 and acute respiratory distress syndrome by radiological criteria and SpO2/FiO2 ratio. A multivariate logistic regression model was developed to determine independently associated variables, and the outcomes of high flow nasal cannula and continuous positive airway pressure were compared.

Results

In total, 107 patients were treated and 85 (79.4%) survived at 90 days. Before starting NRT, the mean SpO2/FiO2 ratio was 119.8 ± 59.4. A higher SOFA score was significantly associated with mortality (OR 2,09; 95% CI 1.34-3.27), while self-pronation was a protective factor (OR 0.23; 95% CI 0.06-0.91). High flow nasal cannula was used in 63 subjects (58.9%), and continuous positive airway pressure in 41 (38.3%), with no differences between them.

Conclusion

Approximately 4 out of 5 patients treated with NRT survived to 90 days, and no significant differences were found between high flow nasal cannula and continuous positive airway pressure.

Early, awake proning in emergency department patients with COVID-19

Objective

Proning has been shown to improve oxygenation and mortality in certain populations of intubated patients with acute respiratory distress syndrome. Small observational analyses of COVID-19 patients suggest awake proning may lead to clinical improvement. Data on safety and efficacy is lacking. We sought to describe the effect of proning on oxygenation in nonintubated COVID-19 patients. We also evaluated feasibility, safety, and other physiological and clinical outcomes associated with this intervention.

Methods

We conducted a prospective, observational cohort study of nonintubated patients with COVID-19 who underwent proning per an Emergency Department (ED) clinical protocol. Patients with mild to moderate respiratory distress were included. We calculated change in oxygenation by comparing the oxygen saturation to fraction of inspired oxygen ratio (SpO2:FiO2) during the five minutes prior to proning and first 30 min of proning. We also captured data on respiratory rate, duration of proning, need for intubation, intensive care unit admission, survival to discharge.

Results

Fifty-two patients were enrolled. Thirty were excluded for not meeting protocol inclusion criteria or missing baseline oxygenation data, leaving 22 for analysis. The SpO2:FiO2 ratio increased by a median of 5 (IQR: 0–15) in the post-proning period compared to the pre-proning period (median: 298 (IQR: 263–352) vs 295 (IQR: 276–350), p = 0.01). Respiratory rate did not change significantly between time periods. No immediate adverse events occurred during proning. Five patients (23%) were intubated within 48 h of admission.

Conclusion

Early, awake proning may be feasible in select COVID-19 patients and was associated with improved oxygenation.

The utility of high-flow nasal oxygen for severe COVID-19 pneumonia in a resource-constrained setting: A multi-centre prospective observational study

BACKGROUND

The utility of heated and humidified high-flow nasal oxygen (HFNO) for severe COVID-19-related hypoxaemic respiratory failure (HRF), particularly in settings with limited access to intensive care unit (ICU) resources, remains unclear, and predictors of outcome have been poorly studied.

METHODS

We included consecutive patients with COVID-19-related HRF treated with HFNO at two tertiary hospitals in Cape Town, South Africa. The primary outcome was the proportion of patients who were successfully weaned from HFNO, whilst failure comprised intubation or death on HFNO.

FINDINGS

The median (IQR) arterial oxygen partial pressure to fraction inspired oxygen ratio (P_aO2/FiO₂) was 68 (54-92) in 293 enroled patients. Of these, 137/293 (47%) of patients [P_aO2/FiO₂ 76 (63-93)] were successfully weaned from HFNO. The median duration of HFNO was 6 (3-9) in those successfully treated versus 2 (1-5) days in those who failed (p<0.001). A higher ratio of oxygen saturation/FiO2 to respiratory rate within 6 h (ROX-6 score) after HFNO commencement was associated with HFNO success (ROX-6; AHR 0.43, 0.31-0.60), as was use of steroids (AHR 0.35, 95%CI 0.19-0.64). A ROX-6 score of ≥3.7 was 80% predictive of successful weaning whilst ROX-6 ≤ 2.2 was 74% predictive of failure. In total, 139 patents (52%) survived to hospital discharge, whilst mortality amongst HFNO failures with outcomes was 129/140 (92%).

INTERPRETATION

In a resource-constrained setting, HFNO for severe COVID-19 HRF is feasible and more almost half of those who receive it can be successfully weaned without the need for mechanical ventilation.

Oxygen therapy via high flow nasal cannula in severe respiratory failure caused by Sars-Cov-2 infection: a real-life observational study

The worldwide spread of coronavirus disease 2019 (COVID-19), caused by the new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was declared a pandemic by the World Health Organization (WHO) in March 2020. According to clinical studies carried out in China and Italy, most patients experience mild or moderate symptoms; about a fifth of subjects develop a severe and critical disease, and may suffer from interstitial pneumonia, possibly associated with acute respiratory distress syndrome (ARDS) and death.

In patients who develop respiratory failure, timely conventional oxygen therapy through nasal catheter plays a crucial role, but it can be used only in mild forms. Continuous positive airway pressure (CPAP) support or non-invasive mechanical ventilation (NIV) are uncomfortable, and require significant man–machine cooperation. Herein we describe our experience of five patients with COVID-19, who were treated with high-flow nasal cannula (HFNC) after failure of CPAP or NIV, and discuss the role of HFNC in COVID-19 patients. Our findings suggest that HFNC can be used successfully in selected patients with COVID-19-related ARDS.

The reviews of this paper are available via the supplemental material section.

Rehabilitation and COVID-19: a rapid living systematic review 2020 by Cochrane Rehabilitation Field. Update as of September 30th, 2020

INTRODUCTION

The COVID-19 outbreak response requires identifying and understanding the long-term consequences of this new pathology and how to manage these. This living systematic review presents the most current and seminal information coming from the scientific literature. It is the monthly update of the second edition of the rapid living systematic review 2020 conducted by Cochrane Rehabilitation REH-COVER Action Steering Committee. The aim of this review was to update the monthly COVID-19 and rehabilitation literature research up to September 30, 2020.

EVIDENCE ACQUISITION

Methodology described in the second edition of the rapid living systematic review 2020 conducted by Cochrane Rehabilitation REH-COVER action was applied. The most important medical databases were searched, and papers related to COVID-19 and rehabilitation were retrieved and summarized descriptively.

EVIDENCE SYNTHESIS

The database search retrieved 2526 publications. Duplicates were removed, and 1150 unique records were screened for inclusion. After screening titles, abstracts and full-texts, 37 papers were included in the present review. According to OCEBM 2011 levels of evidence table, most studies (78.4%) fall within the level of evidence 4 category, while the remainder (22.6%) are categorized as level of evidence 3. Most studies described patients in acute (51.4%) or subacute (35.0%) phase, while no studies described the chronic consequences of COVID-19. Just one study dealt with rehabilitation interventions regarding COVID-19, and two discussed reorganization of rehabilitative services.

CONCLUSIONS

The most recently published COVID-19 research focuses more on describing the clinical presentations and the natural history of the pathology, rather than rehabilitation interventions or service delivery. Studies with high levels of evidence regarding the efficacy of interventions, long-term monitoring, or new organization models remain lacking.

Nutrition Support During Prone Positioning: An Old Technique Reawakened by COVID-19

Acute respiratory distress syndrome (ARDS) is a complex disease characterized by inflammation, resulting in diffuse alveolar damage, proliferation, and fibrosis, and carries a high mortality rate. Recently, the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has overwhelmed healthcare systems worldwide, as many patients have required hospitalization for the management of respiratory failure similar in nature to ARDS. In addition to lung-protective ventilation strategies aimed to maintain an oxygen saturation >90%, a ratio of partial pressure of oxygen to fraction of inspired oxygen >200, a pH of 7.25-7.40, and a plateau pressure <35 cm H₂ O, prone positioning has emerged as an effective treatment strategy for severe ARDS by improving oxygenation and secretion clearance. Although early nutrition assessment and intervention are recommended for acutely and critically ill patients, rotational therapy may present challenges in providing this care. Here, we will describe the pathophysiology of ARDS and the rationale for use of prone positioning and review the considerations and challenges of providing nutrition therapy for patients in the prone position.

COVID-19 respiratory support in the emergency department setting

Introduction

Severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2), which causes the coronavirus disease 2019 (COVID-19), may result in severe complications, multiorgan dysfunction, acute respiratory failure, and death. SARS-CoV-2 is highly contagious and places healthcare workers at significant risk, especially during aerosol-generating procedures, including airway management.

Objective

This narrative review outlines the underlying respiratory pathophysiology of patients with COVID-19 and discusses approaches to airway management in the emergency department (ED) based on current literature.

Discussion

Patients presenting with SARS-CoV-2 infection are at high risk for acute respiratory failure requiring airway management. Among hospitalized patients, 10–20% require intensive care unit admission, and 3–10% require intubation and mechanical ventilation. While providing respiratory support for these patients, proper infection control measures, including adherence to personal protective equipment policies, are necessary to prevent nosocomial transmission to healthcare workers. A structured approach to respiratory failure in these patients includes the use of exogenous oxygen via nasal cannula or non-rebreather, as well as titrated high-flow nasal cannula and non-invasive ventilation. This review offers several guiding principles and resources designed to be adapted in conjunction with local workplace policies for patients requiring respiratory support.

Conclusions

While the fundamental principles of acute respiratory failure management are similar between COVID-19 and non-COVID-19 patients, there are some notable differences, including a focus on provider safety. This review provides an approach to airway management and respiratory support in the patient with COVID-19.

Conscious Proning or Mixed Positioning for Improving Oxygenation-COVID-19 Brings Many Changes!

How to cite this article: Garg R. Conscious Proning or Mixed Positioning for Improving Oxygenation-COVID-19 Brings Many Changes! Indian J Crit Care Med 2020;24(10):893-894.

Best Practice Recommendations for Point-of-Care Lung Ultrasound in Patients with Suspected COVID-19

BACKGROUND

Lung point-of-care ultrasound (POCUS) is a critical tool for evaluating patients with dyspnea in the emergency department (ED), including patients with suspected coronavirus disease (COVID)-19. However, given the threat of nosocomial disease spread, the use of ultrasound is no longer risk free.

OBJECTIVE

Here, we review the lung POCUS findings in patients with COVID-19. In doing so we present a scanning protocol for lung POCUS in COVID-19 that maximizes clinical utility and provider safety.

DISCUSSION

In COVID-19 lung, POCUS findings are predominantly located in the posterior and lateral lung zones bilaterally. A six-zone scanning protocol that prioritizes obtaining images in these locations optimizes provider positioning, and minimizes time spent scanning, which can reduce risk to health care workers performing POCUS.

CONCLUSIONS

Lung POCUS can offer valuable clinical data when evaluating patients with COVID-19. Scanning protocols such as that presented here, which target clinical utility and decreased nosocomial disease spread, must be prioritized.

Use of Dexmedetomidine in Early Prone Positioning Combined With High-Flow Nasal Cannula and Non-Invasive Positive Pressure Ventilation in a COVID-19 Positive Patient

As the COVID-19 pandemic continues to manifest in our society, we still lack evidence-based treatment guidelines. Current treatment for COVID-19 pneumonia has been modeled from currently established guidelines such as that of acute respiratory distress syndrome (ARDS). COVID-19 pneumonia, also known as SARS-CoV-2, is characterized by severe hypoxia and near-normal respiratory system compliance with a time-related presentation. Dexmedetomidine is a centrally acting alpha-2 receptor agonist that promotes sedative and anxiolytic effects without the risk of respiratory depression and can provide cooperative or semi-rousable sedation. Patients who are developing ARDS secondary to COVID-19 pneumonia have been treated with self-proning intervals in combination with supplementation of oxygenation via high-flow nasal cannula (HFNC) or non-invasive positive pressure ventilation (NIPPV); however, a few patients have poor tolerance to the devices, leading to poor compliance and eventual worsening respiratory symptoms leading to intubation. In the current case report, we detail how a patient was able to successfully be self-proned with proper tolerance to HFNC and NIPPV while using dexmedetomidine, leading to discharge without the need for further oxygen supplementation at home.

A Rationale for Use of High Flow Nasal Cannula for Select Patients With Suspected or Confirmed Severe Acute Respiratory Syndrome Coronavirus-2 Infection

Infection with the novel 2019 coronavirus (SARS-CoV-2) is associated with the development of a viral pneumonia with severe hypoxemia and respiratory failure. In many cases these patients will require mechanical ventilation; but in others the severity of disease is significantly less and may not need invasive support. High flow nasal cannula (HFNC) is a widely used modality of delivering high concentrations of oxygen and airflow to patients with hypoxemic respiratory failure, but its use in patients with SARS-CoV-2 is poorly described. Concerns with use of HFNC have arisen including aerosolization of viral particles to healthcare workers (HCW) to delaying intubation and potentially worsening of outcomes. However, use of HFNC in other coronavirus pandemics and previous experimental evidence suggest HFNC is low risk and may be effective in select patients infected with SARS-CoV-2. With the significant increase in resource utilization in care of patients with SARS-CoV-2, identification of those that may benefit from HFNC allowing allocation of ventilators to those more critically ill is of significant importance. In this manuscript, we review pertinent literature regarding the use of HFNC in the current SARS-CoV-2 pandemic and address many concerns regarding its use.

Tolerability and safety of awake prone positioning COVID-19 patients with severe hypoxemic respiratory failure

PURPOSE

Prone positioning of non-intubated patients with coronavirus disease (COVID-19) and hypoxemic respiratory failure may prevent intubation and improve outcomes. Nevertheless, there are limited data on its feasibility, safety, and physiologic effects. The objective of our study was to assess the tolerability and safety of awake prone positioning in COVID-19 patients with hypoxemic respiratory failure.

METHODS

This historical cohort study was performed across four hospitals in Calgary, Canada. Included patients had suspected COVID-19 and hypoxic respiratory failure requiring intensive care unit (ICU) consultation, and underwent awake prone positioning. The duration, frequency, tolerability, and adverse events from prone positioning were recorded. Respiratory parameters were assessed before, during, and after prone positioning. The primary outcome was the tolerability and safety of prone positioning.

RESULTS

Seventeen patients (n = 12 ICU, n = 5 hospital ward) were included between April and May 2020. The median (range) number of prone positioning days was 1 (1-7) and the median number of sessions was 2 (1-6) per day. The duration of prone positioning was 75 (30-480) min, and the peripheral oxygen saturation was 91% (84-95) supine and 98% (92-100) prone. Limitations to prone position duration were pain/general discomfort (47%) and delirium (6%); 47% of patients had no limitations. Seven patients (41%) required intubation and two patients (12%) died.

CONCLUSIONS

In a small sample, prone positioning non-intubated COVID-19 patients with severe hypoxemia was safe; however, many patients did not tolerate prolonged durations. Although patients had improved oxygenation and respiratory rate in the prone position, many still required intubation. Future studies are required to determine methods to improve the tolerability of awake prone positioning and whether there is an impact on clinical outcomes.

The pathophysiology of 'happy' hypoxemia in COVID-19

The novel coronavirus disease 2019 (COVID-19) pandemic is a global crisis, challenging healthcare systems worldwide. Many patients present with a remarkable disconnect in rest between profound hypoxemia yet without proportional signs of respiratory distress (i.e. happy hypoxemia) and rapid deterioration can occur. This particular clinical presentation in COVID-19 patients contrasts with the experience of physicians usually treating critically ill patients in respiratory failure and ensuring timely referral to the intensive care unit can, therefore, be challenging. A thorough understanding of the pathophysiological determinants of respiratory drive and hypoxemia may promote a more complete comprehension of a patient's clinical presentation and management. Preserved oxygen saturation despite low partial pressure of oxygen in arterial blood samples occur, due to leftward shift of the oxyhemoglobin dissociation curve induced by hypoxemia-driven hyperventilation as well as possible direct viral interactions with hemoglobin. Ventilation-perfusion mismatch, ranging from shunts to alveolar dead space ventilation, is the central hallmark and offers various therapeutic targets.

COVID-19 disease: Non-Invasive Ventilation and high frequency nasal oxygenation

Severe COVID-19 causes significant numbers of patients to develop respiratory symptoms that require increasing interventions. Initially, the treatment for severe respiratory failure included early intubation and invasive ventilation, as this was deemed preferable to be more effective than Non-Invasive Ventilation (NIV). However, emerging evidence has shown that NIV may have a more significant and positive role than initially thought. NIV includes Continuous Positive Airway Pressure (CPAP) and Bi-Level Positive Airway Pressure (BiPAP). CPAP is the method of choice with the use of BiPAP for those with complex respiratory conditions who contract COVID-19. The use of High Flow Nasal Oxygen (HFNO) remains contentious with different perspectives in how this modality can be used to treat respiratory failure in COVID-19.

Current thinking suggests that NIV and HFNO may be an appropriate bridging adjunct in the early part of the disease progress and may prevent the need for intubation or invasive ventilation. Patients requiring NIV or HFNO may be nursed in locations outside of the critical care unit. Therefore, this article reviews the different types of NIV and HFNO, indications and the nursing care.

Can Hyperperfusion of Nonaerated Lung Explain COVID-19 Hypoxia?

Early stages of the novel coronavirus disease (COVID-19) have been associated with 'silent hypoxia' and poor oxygenation despite relatively small fractions of afflicted lung. Although it has been speculated that such paradoxical findings may be explained by impairment of hypoxic pulmonary vasoconstriction in infected lungs regions, no studies have confirmed this hypothesis nor determined whether such extreme degrees of perfusion redistribution are physiologically plausible. Here, we present a mathematical model which provides evidence that the extreme amount of pulmonary shunt observed in patients with early COVID-19 is not plausible without hyperperfusion of the relatively small fraction of injured lung, with three-fold increases in regional perfusion to afflicted regions. Although underlying perfusion heterogeneity (e.g., due to gravity or pulmonary emboli) exacerbated existing shunt in the model, the reported severity of hypoxia in early COVID-19 patients could not be replicated without considerable reduction of vascular resistance in nonoxygenated regions.

Prone positioning to improve oxygenation and relieve respiratory symptoms in awake, spontaneously breathing non-intubated patients with COVID-19 pneumonia

Emergency departments are facing an unprecedented challenge in dealing with patients who have coronavirus disease 2019 (COVID-19). The massive number of cases evolving to respiratory failure are leading to a rapid depletion of medical resources such as respiratory support equipment, which is more critical in low- and middle-income countries. In this context, any therapeutic and oxygenation support strategy that conserves medical resources should be welcomed. Prone positioning is a well-known ventilatory support strategy to improve oxygenation levels. Self-proning can be used in the management of selected patients with COVID-19 pneumonia. Here, we describe our experience with two COVID-19-positive patients who were admitted with respiratory failure. The patients were successfully managed with self-proning and noninvasive oxygenation without the need for intubation.

Awake Proning: Current Evidence and Practical Considerations

Prone positioning has been shown to improve oxygenation for decades. However, proning in awake, non-intubated patients gained acceptance in the last few months since the onset of coronavirus (COVID-19) pandemic. To overcome the shortage of ventilators, to decrease the overwhelming burden on intensive care beds in the pandemic era, and also as invasive ventilation was associated with poor outcomes, proning of awake, spontaneously breathing patients gathered momentum. Being an intervention with minimal risk and requiring minimum assistance, it is now a globally accepted therapy to improve oxygenation in acute hypoxemic respiratory failure in COVID-19 patients. We thus reviewed the literature of awake proning in non-intubated patients and described a safe protocol to practice the same. How to cite this article: Sodhi K, Chanchalani G. Awake Proning: Current Evidence and Practical Considerations. Indian J Crit Care Med 2020;24(12):1236-1241.