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Pepe F, Fabiani G, Cogozzo C, Mazzilli V, Villanti M, Pini R, Innocenti F. HACOR score to predict NIV failure in patients with COVID-related hypoxemic respiratory failure managed in the ordinary ward and in the critical care setting. Intern Emerg Med 2024:10.1007/s11739-024-03628-1. [PMID: 38739206 DOI: 10.1007/s11739-024-03628-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/24/2024] [Indexed: 05/14/2024]
Abstract
We evaluated the prevalence of non-invasive ventilation (NIV) failure among patients with COVID-19-related pneumonia, managed in the ordinary ward and in the HDU/ICU and we tested the prognostic role of the HACOR score in those different settings. This is a retrospective study, conducted in the University-Hospital Careggi. We included all subjects with COVID-19 and ARF requiring NIV between March 2020 and May 2021, respectively managed in the ordinary ward (G1) and in the critical care setting (G2). Clinical parameters, HACOR and SOFA score were evaluated at Day 0 and after 1, 2 and 5 days of treatment. The primary outcome was NIV failure. 13% G1 patients and 40% G2 patients underwent endotracheal intubation (ETI). NIV was successful in 60% G1 AND 43% G2 patients (p < 0.001). In G1, compared to those with successful NIV, patients who underwent ETI, had a higher HACOR since the baseline evaluation (T0: 6 [5-6] vs 5 [3-6]; T1: 6 [5-6] vs 5 [3-6], all p < 0.05). An HACOR score > 5 was associated with an increased prevalence of ETI independent to an advanced age and a SOFA score > 5 both in G1 (T1: RR 4.87, 95% CI 1.462-16.275; T5: 3.630, 95% CI 0.979-13.462) and G2 (T0: 1.76, 95% CI 0.906-3.422; T1: 3.38, 95% CI 1.386-8.265). Among patients with COVID-related-ARF, NIV could be managed in the ordinary ward in a consistent proportion of patients and, among them, an HACOR score > 5 was independently associated with increased NIV failure from the earliest evaluations.
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Affiliation(s)
- Francesco Pepe
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Ginevra Fabiani
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Carolina Cogozzo
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Valerio Mazzilli
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Maurizio Villanti
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Riccardo Pini
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Francesca Innocenti
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy.
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Brusić J, Grubešić A, Jarić F, Vučković T, Lekić A, Šustić A, Protić A. Use of CPAP Ventilation in Non-ICU Wards May Influence Outcomes in Patients with Severe Respiratory COVID-19. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:582. [PMID: 38674228 PMCID: PMC11052437 DOI: 10.3390/medicina60040582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 03/22/2024] [Accepted: 03/27/2024] [Indexed: 04/28/2024]
Abstract
Background and Objectives: The COVID-19 disease has significantly burdened the healthcare system, including all units of severe patient treatment. Non-intensive care units were established to rationalize the capacity within the Intensive Care Unit (ICU) and to create a unit where patients with Acute Respiratory Distress Syndrome (ARDS) could be treated with non-invasive Continuous Positive Air Pressure (CPAP) outside the ICU. This unicentric retrospective study aimed to assess the efficacy of NIV Treatment in Patients of the fourth pandemic wave and how its application affects the frequency and mortality of ICU-treated patients at University Hospital Rijeka compared to earlier waves of the COVID-19 pandemic. Furthermore, the study showcases the effect of the Patient/Nurse ratio (P/N ratio) on overall mortality in the ICU. Materials and Methods: The study was conducted on two groups of patients with respiratory insufficiency in the second and third pandemic waves, treated in the COVID Respiratory Centre (CRC) (153 patients). We also reviewed a cohort of patients from the fourth pandemic wave who were initially hospitalized in a COVID-6 non-intensive unit from 1 October 2021 to 1 November 2022 (102 patients), and some of them escalated to CRC. Results: The introduction of the CPAP non-invasive ventilation method as a means of hypoxic respiratory failure treatment in non-intensive care units has decreased the strain, overall number of admissions, and CRC patient mortality. The overall fourth wave mortality was 29.4%, compared to the 58.2% overall mortality of the second and third waves. Conclusions: As a result, this has decreased CRC patient admissions and, by itself, overall mortality.
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Affiliation(s)
- Josip Brusić
- Department of Anesthesiology, Intensive Care and Pain Treatment, Clinical Hospital Center Rijeka, Krešimirova 42, 51 000 Rijeka, Croatia; (J.B.); (A.P.)
- Department of Nursing, Faculty of Health Studies, University of Rijeka, Viktora Cara Emina 5, 51000 Rijeka, Croatia
| | - Aron Grubešić
- Department of Hematology, Clinical Hospital Center Rijeka, Krešimirova 42, 51000 Rijeka, Croatia
- Department of Internal Medicine, Faculty of Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia
| | - Filip Jarić
- Faculty of Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia; (F.J.); (T.V.)
| | - Tin Vučković
- Faculty of Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia; (F.J.); (T.V.)
| | - Andrica Lekić
- Department of Basic Medical Sciences, Faculty of Health Studies, University of Rijeka, Viktora Cara Emina 5, 51000 Rijeka, Croatia;
| | - Alan Šustić
- Department of Anesthesiology, Intensive Care and Pain Treatment, Clinical Hospital Center Rijeka, Krešimirova 42, 51 000 Rijeka, Croatia; (J.B.); (A.P.)
- Department of Nursing, Faculty of Health Studies, University of Rijeka, Viktora Cara Emina 5, 51000 Rijeka, Croatia
- Department of Anesthesiology, Reanimatology, Emergency and Intensive Medicine, Faculty of Medicine, University of Rijeka, Tome Strižića 3, 51000 Rijeka, Croatia
| | - Alen Protić
- Department of Anesthesiology, Intensive Care and Pain Treatment, Clinical Hospital Center Rijeka, Krešimirova 42, 51 000 Rijeka, Croatia; (J.B.); (A.P.)
- Department of Nursing, Faculty of Health Studies, University of Rijeka, Viktora Cara Emina 5, 51000 Rijeka, Croatia
- Department of Anesthesiology, Reanimatology, Emergency and Intensive Medicine, Faculty of Medicine, University of Rijeka, Tome Strižića 3, 51000 Rijeka, Croatia
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Wenzel D, Bleazard L, Pepper CJ, Wilson E, Faull C. Non-invasive advanced respiratory support in end-of-life care and symptom management: systematic review. BMJ Support Palliat Care 2024; 13:e547-e553. [PMID: 36229167 DOI: 10.1136/spcare-2022-003905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 09/13/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To narrate the canon of knowledge around symptom control at end of life for patients using, or having recently used, non-invasive advanced respiratory support (NARS) at end of life for respiratory failure. METHODS A systematic review forming a narrative synthesis from a wide range of sample papers from Medline, Embase, CINAHL, Emcare, Cochrane and OpenGrey databases. A secondary search of grey literature was also performed with hand searching reference lists and author citations. The review was undertaken using the ENTREQ checklist for quality. RESULTS In total, 22 studies were included in the synthesis and four themes were generated: NARS as a buoy (NARS can represent hope and relief from the symptoms of respiratory failure), NARS as an anchor (NARS brings significant treatment burden), Impact on Staff (uncertainty over the balance of benefit and burden as well as complex patient care drives distress among staff providing care) and the Process of Withdrawal (withdrawal of therapy felt to be futile exists as discrete event in patient care but is otherwise poorly defined). CONCLUSION NARS represents a complex interplay of hope, symptom control, unnaturally prolonged death and treatment burden. The literature captures the breadth of these issues, but further, detailed, research is required in almost every aspect of practice around end-of-life care and NARS-especially how to manage symptoms at the end of life.
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Affiliation(s)
- David Wenzel
- Palliative Care, University Hospitals of Leicester NHS Trust, Leicester, Leicester, UK
- Palliative Care, LOROS Hospice, Leicester, UK
| | - Lucy Bleazard
- School of Health Sciences, University of Leicester, Leicester, UK
| | - Coral Jayne Pepper
- Library and Information Service, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Eleanor Wilson
- School of Health Sciences, University of Nottingham, Nottingham, UK
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Westhoff M, Neumann P, Geiseler J, Bickenbach J, Arzt M, Bachmann M, Braune S, Delis S, Dellweg D, Dreher M, Dubb R, Fuchs H, Hämäläinen N, Heppner H, Kluge S, Kochanek M, Lepper PM, Meyer FJ, Neumann B, Putensen C, Schimandl D, Schönhofer B, Schreiter D, Walterspacher S, Windisch W. [Non-invasive Mechanical Ventilation in Acute Respiratory Failure. Clinical Practice Guidelines - on behalf of the German Society of Pneumology and Ventilatory Medicine]. Pneumologie 2023. [PMID: 37832578 DOI: 10.1055/a-2148-3323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
The guideline update outlines the advantages as well as the limitations of NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications.Non-invasive ventilation (NIV) has a high value in therapy of hypercapnic acute respiratory failure, as it significantly reduces the length of ICU stay and hospitalization as well as mortality.Patients with cardiopulmonary edema and acute respiratory failure should be treated with continuous positive airway pressure (CPAP) and oxygen in addition to necessary cardiological interventions. This should be done already prehospital and in the emergency department.In case of other forms of acute hypoxaemic respiratory failure with only mild or moderately disturbed gas exchange (PaO2/FiO2 > 150 mmHg) there is no significant advantage or disadvantage compared to high flow nasal oxygen (HFNO). In severe forms of ARDS NIV is associated with high rates of treatment failure and mortality, especially in cases with NIV-failure and delayed intubation.NIV should be used for preoxygenation before intubation. In patients at risk, NIV is recommended to reduce extubation failure. In the weaning process from invasive ventilation NIV essentially reduces the risk of reintubation in hypercapnic patients. NIV is regarded useful within palliative care for reduction of dyspnea and improving quality of life, but here in concurrence to HFNO, which is regarded as more comfortable. Meanwhile NIV is also recommended in prehospital setting, especially in hypercapnic respiratory failure and pulmonary edema.With appropriate monitoring in an intensive care unit NIV can also be successfully applied in pediatric patients with acute respiratory insufficiency.
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Affiliation(s)
- Michael Westhoff
- Klinik für Pneumologie, Lungenklinik Hemer - Zentrum für Pneumologie und Thoraxchirurgie, Hemer
| | - Peter Neumann
- Abteilung für Klinische Anästhesiologie und Operative Intensivmedizin, Evangelisches Krankenhaus Göttingen-Weende gGmbH
| | - Jens Geiseler
- Medizinische Klinik IV - Pneumologie, Beatmungs- und Schlafmedizin, Paracelsus-Klinik Marl, Marl
| | - Johannes Bickenbach
- Klinik für Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen, Aachen
| | - Michael Arzt
- Schlafmedizinisches Zentrum der Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Regensburg
| | - Martin Bachmann
- Klinik für Atemwegs-, Lungen- und Thoraxmedizin, Beatmungszentrum Hamburg-Harburg, Asklepios Klinikum Harburg, Hamburg
| | - Stephan Braune
- IV. Medizinische Klinik: Akut-, Notfall- und Intensivmedizin, St. Franziskus-Hospital, Münster
| | - Sandra Delis
- Klinik für Pneumologie, Palliativmedizin und Geriatrie, Helios Klinikum Emil von Behring GmbH, Berlin
| | - Dominic Dellweg
- Klinik für Innere Medizin, Pneumologie und Gastroenterologie, Pius-Hospital Oldenburg, Universitätsmedizin Oldenburg
| | - Michael Dreher
- Klinik für Pneumologie und Internistische Intensivmedizin, Uniklinik RWTH Aachen
| | - Rolf Dubb
- Akademie der Kreiskliniken Reutlingen GmbH, Reutlingen
| | - Hans Fuchs
- Zentrum für Kinder- und Jugendmedizin, Neonatologie und pädiatrische Intensivmedizin, Universitätsklinikum Freiburg
| | | | - Hans Heppner
- Klinik für Geriatrie und Geriatrische Tagesklinik Klinikum Bayreuth, Medizincampus Oberfranken Friedrich-Alexander-Universität Erlangen-Nürnberg, Bayreuth
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Matthias Kochanek
- Klinik I für Innere Medizin, Hämatologie und Onkologie, Universitätsklinikum Köln, Köln
| | - Philipp M Lepper
- Klinik für Innere Medizin V - Pneumologie, Allergologie und Intensivmedizin, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg
| | - F Joachim Meyer
- Lungenzentrum München - Bogenhausen-Harlaching) München Klinik gGmbH, München
| | - Bernhard Neumann
- Klinik für Neurologie, Donauisar Klinikum Deggendorf, und Klinik für Neurologie der Universitätsklinik Regensburg am BKH Regensburg, Regensburg
| | - Christian Putensen
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Bonn
| | - Dorit Schimandl
- Klinik für Pneumologie, Beatmungszentrum, Zentralklinik Bad Berka GmbH, Bad Berka
| | - Bernd Schönhofer
- Klinik für Innere Medizin, Pneumologie und Intensivmedizin, Evangelisches Klinikum Bethel, Universitätsklinikum Ost Westphalen-Lippe, Bielefeld
| | | | - Stephan Walterspacher
- Medizinische Klinik - Sektion Pneumologie, Klinikum Konstanz und Lehrstuhl für Pneumologie, Universität Witten-Herdecke, Witten
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Lehrstuhl für Pneumologie Universität Witten/Herdecke, Köln
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Nikbin R, Beydokhti TB, Moghaddam KB, Rohandeh Z. Comparison of the effect of Continuous Positive Airway Pressure (CPAP) and Bi-Level Positive Airway Pressure (BiPAP) on hemodynamic parameters in Covid-19 patients: A clinical trial. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2023; 12:178. [PMID: 37404940 PMCID: PMC10317288 DOI: 10.4103/jehp.jehp_36_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 02/21/2023] [Indexed: 07/06/2023]
Abstract
BACKGROUND The most prevalent clinical sign for COVID-19 patients are respiratory diseases such that the criteria for clinical screening and care of the patients in most countries, including Iran, are based on the three primary symptoms, i.e., fever, cough, shortness of breath, or difficulty breathing. The purpose of the current study was to compare the effect of continuous positive airway pressure and bi-level positive airway pressure on hemodynamic parameters in COVID-19 patients. MATERIALS AND METHODS It was a clinical trial conducted on 46 COVID-19 patients admitted to Imam Hassan Hospital in Bojnourd in 2022. This study included patients selected through convenient sampling and then through Permuted block randomization, who were assigned to continuous positive airway pressure (CPAP), and Bi-Level Positive Airway Pressure (BiPAP) groups. Patients were compared in terms of the severity of their COVID-19 disease in both groups and were divided equally in each disease severity. After determining their type of respiratory aid use, the patient's hemodynamic status (systolic blood pressure, diastolic blood pressure, pulse, arterial oxygen saturation, and temperature) was examined beforehand, immediately after 1 hour, 6 hours, and then daily up to 3 days of CPAP/BiPAP at a specific time. Data collection tools were demographic data questionnaires and information on patients' diseases. A checklist was also used to record the main variables of the research. The collected data were put into SPSS software version 19. To analyze the data, the Kolmogorov-Smirnov normality test was used to evaluate the normality of quantitative variables. As a result, it was found that the data had a normal distribution. Repeated measures of ANOVA and independent t-tests were employed to compare quantitative variables in the two groups at different times. In this study, a significance level of 0.05 was considered. RESULTS There was a significant difference in terms of systolic blood pressure, diastolic blood pressure, respiration rate, pulse rate, oxygen saturation, and temperature in the two groups of patients at 1 day, 2 days, and 3 days after use (P < 0.05). CONCLUSION The results displayed better performance of CPAP than BiPAP in the parameters of systolic blood pressure, diastolic blood pressure, respiration rate, pulse rate, oxygen saturation, and temperature in COVID-19 patients. Therefore, in necessary cases, it is recommended to use a CPAP mask.
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Affiliation(s)
- Razieh Nikbin
- School of Nursing, Gonabad University of Medical Sciences, Gonabad, Iran
| | - Tahereh Baloochi Beydokhti
- Department of Medical Emergencies, School of Nursing, Nursing Research Center, Gonabad University of Medical Sciences, Gonabad, Iran
| | - Kokab Basiri Moghaddam
- School of Nursing, Department of Operating Room Technology, Nursing Research Center, Gonabad University of Medical Sciences, Gonabad, Iran
| | - Zohreh Rohandeh
- Department of Anesthesiology and ICU, The Head of the Hospital, Bentolhoda Hospital, ICU Department, North Khorasan Medical University, Iran
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Morishita M, Hojo M. Treatment options for patients with severe COVID-19. Glob Health Med 2023; 5:99-105. [PMID: 37128231 PMCID: PMC10130548 DOI: 10.35772/ghm.2023.01024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/04/2023] [Accepted: 04/06/2023] [Indexed: 05/03/2023]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has affected the world for over 3 years. Treatment options have improved substantially during this period, including antiviral drugs, antibody drugs, immune-based agents, and vaccination. While these improvements have reduced mortality rates in patients with COVID-19, some patients still develop severe illness. In this review, we aimed to provide an overview of treatments for patients with severe COVID-19 from study reports and clinical experience. We discussed the treatments from two perspectives: respiratory care and drug treatments. In the respiratory care section, we discussed the usefulness of high-flow nasal cannula therapy and non-invasive ventilation as an alternative to invasive ventilation. In the drug treatments section, we focused on three classes for severe COVID-19 treatment: antiviral drugs, immune-based agents, and anticoagulation therapy. We did not discuss antibody drugs and vaccination, as they are not used for severe COVID-19 treatment.
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Affiliation(s)
| | - Masayuki Hojo
- Address correspondence to:Masayuki Hojo, Department of Respiratory Medicine, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan.
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Adi O, Fong CP, Keong YY, Apoo FN, Roslan NL. Helmet CPAP in the emergency department: A narrative review. Am J Emerg Med 2023; 67:112-119. [PMID: 36870251 DOI: 10.1016/j.ajem.2023.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/13/2023] [Accepted: 02/21/2023] [Indexed: 02/27/2023] Open
Abstract
BACKGROUND The choice of correct interface for the right patient is crucial for the success of non-invasive ventilation (NIV) therapy. Helmet CPAP is a type of interface used to deliver NIV. Helmet CPAP improves oxygenation by keeping the airway open throughout the breathing cycle with positive end-expiratory pressure (PEEP). OBJECTIVE This narrative review describes the technical aspects and clinical indications of helmet continuous positive airway pressure (CPAP). In addition, we explore the advantages and challenges faced using this device at the Emergency Department (ED). DISCUSSION Helmet CPAP is tolerable than other NIV interfaces, provides a good seal and has good airway stability. During Covid-19 pandemic, there are evidences it reduced the risk of aerosolization. The potential clinical benefit of helmet CPAP is demonstrated in acute cardiogenic pulmonary oedema (ACPO), Covid-19 pneumonia, immunocompromised patient, acute chest trauma and palliative patient. Compare to conventional oxygen therapy, helmet CPAP had been shown to reduce intubation rate and decrease mortality. CONCLUSION Helmet CPAP is one of the potential NIV interface in patients with acute respiratory failure presenting to the emergency department. It is better tolerated for prolonged usage, reduced intubation rate, improved respiratory parameters, and offers protection against aerosolization in infectious diseases.
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Affiliation(s)
- Osman Adi
- Resuscitation & Emergency Critical Care Unit (RECCU), Trauma & Emergency Department, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia.
| | - Chan Pei Fong
- Resuscitation & Emergency Critical Care Unit (RECCU), Trauma & Emergency Department, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia
| | - Yip Yat Keong
- Resuscitation & Emergency Critical Care Unit (RECCU), Trauma & Emergency Department, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia
| | - Farah Nuradhwa Apoo
- Resuscitation & Emergency Critical Care Unit (RECCU), Trauma & Emergency Department, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia
| | - Nurul Liana Roslan
- Resuscitation & Emergency Critical Care Unit (RECCU), Trauma & Emergency Department, Hospital Kuala Lumpur, Malaysia
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Sedda L, Ashish A, Unsworth A, Martindale J, Sundar R, Farrier M. Comparison of COVID-19 survival in relation to CPAP length of treatment and by comorbidity and transmission setting (community or hospital acquired) in a medium-sized UK hospital in 2020: a retrospective study. BMJ Open 2022; 12:e060994. [PMID: 36414291 PMCID: PMC9684282 DOI: 10.1136/bmjopen-2022-060994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To estimate continuous positive airway pressure (CPAP) length of treatment effect on survival of hospitalised COVID-19 patients in a medium-sized UK Hospital, and how this effect changes according to the patient's comorbidity and COVID-19 route of acquisition (community or nosocomial) during the two waves in 2020. SETTING The acute inpatient unit in Wrightington, Wigan and Leigh Teaching Hospitals National Health Service (NHS) Foundation Trust (WWL), a medium-sized NHS Trust in north-west of England. DESIGN Retrospective cohort of all confirmed COVID-19 patients admitted in WWL during 2020. PARTICIPANTS 1830 patients (568 first wave, 1262 s wave) with antigen confirmed COVID-19 disease and severe acute respiratory syndrome admitted between 17 March 2020 (first confirmed COVID-19 case) and 31 December 2020. OUTCOME MEASURE COVID-19 survival rate in all patients and survival rate in potentially hospital-acquired COVID-19 (PHA) patients were modelled using a predictor set which include comorbidities (eg, obesity, diabetes, chronic ischaemic heart disease (IHD), chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD)), wave, age, sex and care home residency, and interventions (remdesivir, dexamethasone, CPAP, intensive care unit (ICU), intubation). Secondary outcome measure was CPAP length, which was modelled using the same predictors of the survival rate. RESULTS Mortality rate in the second wave was significantly lower than in the first wave (43.4% vs 28.1%, p<0.001), although for PHA COVID-19 patients mortality did not reduce, remaining at very high levels independently of wave and CPAP length. For all cohort, statistical modelling identified CPAP length (HR 95% CI 0.86 to 0.96) and women (HR 95% CI 0.71 to 0.81) were associated with improved survival, while being older age (HR 95% CI 1.02 to 1.03) admitted from care homes (HR 95% CI 2.22 to 2.39), IHD (HR 95% CI 1.13 to 1.24), CKD (HR 95% CI 1.14 to 1.25), obesity (HR 95% CI 1.18 to 1.28) and COPD-emphysema (HR 95% CI 1.18 to 1.57) were associated with reduced survival. Despite the detrimental effect of comorbidities, patients with CKD (95% CI 16% to 30% improvement in survival), IHD (95% CI 1% to 10% improvement in survival) and asthma (95% CI 8% to 30% improvement in survival) benefitted most from CPAP length, while no significant survival difference was found for obese and patients with diabetes. CONCLUSIONS The experience of an Acute Trust during the COVID-19 outbreak of 2020 is documented and indicates the importance of care home and hospitals in disease acquisition. Death rates fell between the first and second wave only for community-acquired COVID-19 patients. The fall was associated to CPAP length, especially for some comorbidities. While uncovering some risk and protective factors of mortality in COVID-19 studies, the study also unravels how little is known about PHA COVID-19 and the interaction between CPAP and some comorbidities.
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Affiliation(s)
- Luigi Sedda
- Lancaster Ecology and Epidemiology Group, Lancaster University, Lancaster, UK
| | - Abdul Ashish
- Wrightington Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Alison Unsworth
- Wrightington Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Jane Martindale
- Wrightington Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Ramachandaran Sundar
- Department of Respiratory Medicine, Wrightington Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Martin Farrier
- Paediatrics, Wrightington Wigan and Leigh NHS Foundation Trust, Wigan, UK
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Innocenti F, Lazzari C, Paolucci E, De Paris A, Lagomarsini A, Guerra F, Alleonato P, Casalini L, Buggea M, Caldi F, Zanobetti M, Pieralli F, Guazzini G, Lastraioli L, Luise F, Milia A, Sammicheli L, Maddaluni L, Lavorini F, Pini R. Role of prognostic scores in predicting in-hospital mortality and failure of non-invasive ventilation in adults with COVID-19. Intern Emerg Med 2022; 17:2367-2377. [PMID: 35918627 PMCID: PMC9345392 DOI: 10.1007/s11739-022-03058-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 07/18/2022] [Indexed: 12/04/2022]
Abstract
We tested the prognostic performance of different scores for the identification of subjects with acute respiratory failure by COVID-19, at risk of in-hospital mortality and NIV failure. We conducted a retrospective study, in the Medical High-Dependency Unit of the University-Hospital Careggi. We included all subjects with COVID-19 and ARF requiring non-invasive ventilation (NIV) between March 2020 and January 2021. Clinical parameters, the HACOR score (Heart rate, Acidosis, Consciousness, Oxygenation, Respiratory Rate) and ROX index ((SpO2/FiO2)/respiratory rate) were collected 3 (-3) and 1 day (-1) before the NIV initiation, the first day of treatment (Day0) and after 1 (+1), 2 (+2), 5 (+5), 8 (+8) and 11 (+11) of treatment. The primary outcomes were in-hospital mortality and NIV failure. We included 135 subjects, mean age 69±13 years, 69% male. Patients, who needed mechanical ventilation, showed a higher HACOR score (Day0: 6 [5-7] vs 6 [6-7], p=.057; Day+2: 6 [6-6] vs 6 [4-6], p=.013) and a lower ROX index (Day0: 4.2±2.3 vs 5.1±2.3, p=.055; Day+2: 4.4±1.2.vs 5.5±1.3, p=.001) than those with successful NIV. An HACOR score >5 was more frequent among nonsurvivors (Day0: 82% vs 58%; Day2: 82% vs 48%, all p<0.01) and it was associated with in-hospital mortality (Day0: RR 5.88, 95%CI 2.01-17.22; Day2: RR 4.33, 95%CI 1.64-11.41) independent to age and Charlson index. In conclusion, in subjects treated with NIV for ARF caused by COVID19, respiratory parameters collected after the beginning of NIV allowed to identify those at risk of an adverse outcome. An HACOR score >5 was independently associated with increased mortality rate.
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Affiliation(s)
- Francesca Innocenti
- High-Dependency Unit, Emergency Department, Careggi University-Hospital, Lg. Brambilla 3, 50134, Florence, Italy.
| | - Cristian Lazzari
- High-Dependency Unit, Emergency Department, Careggi University-Hospital, Lg. Brambilla 3, 50134, Florence, Italy
| | - Elisa Paolucci
- High-Dependency Unit, Emergency Department, Careggi University-Hospital, Lg. Brambilla 3, 50134, Florence, Italy
| | - Anna De Paris
- High-Dependency Unit, Emergency Department, Careggi University-Hospital, Lg. Brambilla 3, 50134, Florence, Italy
| | - Alessia Lagomarsini
- High-Dependency Unit, Emergency Department, Careggi University-Hospital, Lg. Brambilla 3, 50134, Florence, Italy
| | - Federica Guerra
- High-Dependency Unit, Emergency Department, Careggi University-Hospital, Lg. Brambilla 3, 50134, Florence, Italy
| | - Patrizia Alleonato
- High-Dependency Unit, Emergency Department, Careggi University-Hospital, Lg. Brambilla 3, 50134, Florence, Italy
| | - Lisa Casalini
- High-Dependency Unit, Emergency Department, Careggi University-Hospital, Lg. Brambilla 3, 50134, Florence, Italy
| | - Michele Buggea
- High-Dependency Unit, Emergency Department, Careggi University-Hospital, Lg. Brambilla 3, 50134, Florence, Italy
| | - Francesca Caldi
- High-Dependency Unit, Emergency Department, Careggi University-Hospital, Lg. Brambilla 3, 50134, Florence, Italy
| | - Maurizio Zanobetti
- High-Dependency Unit, Emergency Department, Careggi University-Hospital, Lg. Brambilla 3, 50134, Florence, Italy
| | - Filippo Pieralli
- Intermediate Care Unit, Careggi University-Hospital, Florence, Italy
| | - Giulia Guazzini
- Intermediate Care Unit, Careggi University-Hospital, Florence, Italy
| | - Lisa Lastraioli
- Intermediate Care Unit, Careggi University-Hospital, Florence, Italy
| | - Fabio Luise
- Intermediate Care Unit, Careggi University-Hospital, Florence, Italy
| | - Alessandro Milia
- Intermediate Care Unit, Careggi University-Hospital, Florence, Italy
| | - Lucia Sammicheli
- Intermediate Care Unit, Careggi University-Hospital, Florence, Italy
| | - Lucia Maddaluni
- High-Dependency Unit, Emergency Department, Careggi University-Hospital, Lg. Brambilla 3, 50134, Florence, Italy
| | - Federico Lavorini
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Riccardo Pini
- High-Dependency Unit, Emergency Department, Careggi University-Hospital, Lg. Brambilla 3, 50134, Florence, Italy
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
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Innocenti F, De Paris A, Lagomarsini A, Pelagatti L, Casalini L, Gianno A, Montuori M, Bernardini P, Caldi F, Tassinari I, Pini R. Stratification of patients admitted for SARS-CoV2 infection: prognostic scores in the first and second wave of the pandemic. Intern Emerg Med 2022; 17:2093-2101. [PMID: 35733074 PMCID: PMC9216296 DOI: 10.1007/s11739-022-03016-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 05/23/2022] [Indexed: 01/08/2023]
Abstract
To test the prognostic performance of different scores, both specifically designed for patients with COVID-19 and generic, in predicting in-hospital mortality and the need for mechanical ventilation (MV). We retrospectively collected clinical data of patients admitted to the Emergency Department of the University Hospital AOU Careggi, Florence, Italy, between February 2020 and January 2021, with a confirmed infection by SARS-CoV2. We calculated the following scores: Sequential Organ Failure Assessment (SOFA) score, CALL score, 4C Mortality score, QUICK score, CURB-65 and MuLBSTA score. The end-points were in-hospital mortality and the need for MV. We included 1208 patients, mean age 60 ± 17 years, 57% male sex. Compared to survivors, non-survivors showed significantly higher values of all the prognostic scores (4C: 13 [10-15] vs 8 [4-10]; CALL: 11 [10-12] vs 9 [7-11]; QUICK: 4 [1-6] vs 0 [0-3]; SOFA: 5 [4-6] vs 4 [4-5]; CURB: 2 [1-3] vs 1 [0-1]; MuLBSTA: 11 [9-13] vs 9 [7-11], all p < 0.001). Discriminative ability evaluated by the Receiver Operating Curve analysis showed the following values of the Area under the Curve: 0.83 for 4C, 0.74 for CALL, 0.70 for QUICK, 0.68 for SOFA, 0.76 for CURB and 0.64 for MuLBSTA. The mortality rate significantly increased in increasing quartiles of 4C and CALL score (respectively, 2, 8, 24 and 54% for the 4C score and 1, 17, 33 and 68% for the CALL score, both p < 0.001). 4C and CALL score allowed an early and good prognostic stratification of patients admitted for pneumonia induced by SARS-CoV2.
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Affiliation(s)
- F Innocenti
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Lg. Brambilla 3, 50134, Florence, Firenze, Italy.
| | - A De Paris
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Lg. Brambilla 3, 50134, Florence, Firenze, Italy
| | - A Lagomarsini
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Lg. Brambilla 3, 50134, Florence, Firenze, Italy
| | - L Pelagatti
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Lg. Brambilla 3, 50134, Florence, Firenze, Italy
| | - L Casalini
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Lg. Brambilla 3, 50134, Florence, Firenze, Italy
| | - A Gianno
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Lg. Brambilla 3, 50134, Florence, Firenze, Italy
| | - M Montuori
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Lg. Brambilla 3, 50134, Florence, Firenze, Italy
| | - P Bernardini
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Lg. Brambilla 3, 50134, Florence, Firenze, Italy
| | - F Caldi
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Lg. Brambilla 3, 50134, Florence, Firenze, Italy
| | - I Tassinari
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Lg. Brambilla 3, 50134, Florence, Firenze, Italy
| | - R Pini
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Lg. Brambilla 3, 50134, Florence, Firenze, Italy
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Gasa M, Ruiz-Albert Y, Cordoba-Izquierdo A, Sarasate M, Cuevas E, Suarez-Cuartin G, Méndez L, Alfaro-Álvarez JC, Sabater-Riera J, Pérez-Fernández XL, Molina-Molina M, Santos S. Outcomes of COVID-19 Patients Admitted to the Intermediate Respiratory Care Unit: Non-Invasive Respiratory Therapy in a Sequential Protocol. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10772. [PMID: 36078488 PMCID: PMC9518070 DOI: 10.3390/ijerph191710772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/22/2022] [Accepted: 08/24/2022] [Indexed: 06/15/2023]
Abstract
The intermediate respiratory care units (IRCUs) have a pivotal role managing escalation and de-escalation between the general wards and the intensive care units (ICUs). Since the COVID-19 pandemic began, the early detection of patients that could improve on non-invasive respiratory therapies (NRTs) in IRCUs without invasive approaches is crucial to ensure proper medical management and optimize limiting ICU resources. The aim of this study was to assess factors associated with survival, ICU admission and intubation likelihood in COVID-19 patients admitted to IRCUs. Observational retrospective study in consecutive patients admitted to the IRCU of a tertiary hospital from March 2020 to April 2021. Inclusion criteria: hypoxemic respiratory failure (SpO2 ≤ 94% and/or respiratory rate ≥ 25 rpm with FiO2 > 50% supplementary oxygen) due to acute COVID-19 infection. Demographic, comorbidities, clinical and analytical data, and medical and NRT data were collected at IRCU admission. Multivariate logistic regression models assessed factors associated with survival, ICU admission, and intubation. From 679 patients, 79 patients (12%) had an order to not do intubation. From the remaining 600 (88%), 81% survived, 41% needed ICU admission and 37% required intubation. In the IRCU, 51% required non-invasive ventilation (NIV group) and 49% did not (non-NIV group). Older age and lack of corticosteroid treatment were associated with higher mortality and intubation risk in the scheme, which could be more beneficial in severe forms. Initial NIV does not always mean worse outcomes.
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Affiliation(s)
- Mercè Gasa
- Respiratory Department, Bellvitge Biomedical Research Institute (IDIBELL), Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain; (Y.R.-A.); (A.C.-I.); (M.S.); (E.C.); (G.S.-C.); (L.M.); (M.M.-M.)
- Department of Medicine, Campus Bellvitge, Universitat de Barcelona, 08907 L’Hospitalet de Llobregat, Spain
| | - Yolanda Ruiz-Albert
- Respiratory Department, Bellvitge Biomedical Research Institute (IDIBELL), Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain; (Y.R.-A.); (A.C.-I.); (M.S.); (E.C.); (G.S.-C.); (L.M.); (M.M.-M.)
| | - Ana Cordoba-Izquierdo
- Respiratory Department, Bellvitge Biomedical Research Institute (IDIBELL), Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain; (Y.R.-A.); (A.C.-I.); (M.S.); (E.C.); (G.S.-C.); (L.M.); (M.M.-M.)
| | - Mikel Sarasate
- Respiratory Department, Bellvitge Biomedical Research Institute (IDIBELL), Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain; (Y.R.-A.); (A.C.-I.); (M.S.); (E.C.); (G.S.-C.); (L.M.); (M.M.-M.)
| | - Ester Cuevas
- Respiratory Department, Bellvitge Biomedical Research Institute (IDIBELL), Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain; (Y.R.-A.); (A.C.-I.); (M.S.); (E.C.); (G.S.-C.); (L.M.); (M.M.-M.)
| | - Guillermo Suarez-Cuartin
- Respiratory Department, Bellvitge Biomedical Research Institute (IDIBELL), Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain; (Y.R.-A.); (A.C.-I.); (M.S.); (E.C.); (G.S.-C.); (L.M.); (M.M.-M.)
| | - Lidia Méndez
- Respiratory Department, Bellvitge Biomedical Research Institute (IDIBELL), Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain; (Y.R.-A.); (A.C.-I.); (M.S.); (E.C.); (G.S.-C.); (L.M.); (M.M.-M.)
| | | | - Joan Sabater-Riera
- Critical Care Department, Bellvitge Biomedical Research Institute (IDIBELL), Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain; (J.S.-R.); (X.L.P.-F.)
| | - Xosé L. Pérez-Fernández
- Critical Care Department, Bellvitge Biomedical Research Institute (IDIBELL), Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain; (J.S.-R.); (X.L.P.-F.)
| | - María Molina-Molina
- Respiratory Department, Bellvitge Biomedical Research Institute (IDIBELL), Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain; (Y.R.-A.); (A.C.-I.); (M.S.); (E.C.); (G.S.-C.); (L.M.); (M.M.-M.)
- Department of Medicine, Campus Bellvitge, Universitat de Barcelona, 08907 L’Hospitalet de Llobregat, Spain
| | - Salud Santos
- Respiratory Department, Bellvitge Biomedical Research Institute (IDIBELL), Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain; (Y.R.-A.); (A.C.-I.); (M.S.); (E.C.); (G.S.-C.); (L.M.); (M.M.-M.)
- Department of Medicine, Campus Bellvitge, Universitat de Barcelona, 08907 L’Hospitalet de Llobregat, Spain
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Exploiting Bacteria for Improving Hypoxemia of COVID-19 Patients. Biomedicines 2022; 10:biomedicines10081851. [PMID: 36009399 PMCID: PMC9405060 DOI: 10.3390/biomedicines10081851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/27/2022] [Accepted: 07/28/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Although useful in the time-race against COVID-19, CPAP cannot provide oxygen over the physiological limits imposed by severe pulmonary impairments. In previous studies, we reported that the administration of the SLAB51 probiotics reduced risk of developing respiratory failure in severe COVID-19 patients through the activation of oxygen sparing mechanisms providing additional oxygen to organs critical for survival. Methods: This “real life” study is a retrospective analysis of SARS-CoV-2 infected patients with hypoxaemic acute respiratory failure secondary to COVID-19 pneumonia undergoing CPAP treatment. A group of patients managed with ad interim routinely used therapy (RUT) were compared to a second group treated with RUT associated with SLAB51 oral bacteriotherapy (OB). Results: At baseline, patients receiving SLAB51 showed significantly lower blood oxygenation than controls. An opposite condition was observed after 3 days of treatment, despite the significantly reduced amount of oxygen received by patients taking SLAB51. At 7 days, a lower prevalence of COVID-19 patients needing CPAP in the group taking probiotics was observed. The administration of SLAB51 is a complementary approach for ameliorating oxygenation conditions at the systemic level. Conclusion: This study proves that probiotic administration results in an additional boost in alleviating hypoxic conditions, permitting to limit on the use of CPAP and its contraindications.
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Cosentini R, Groff P, Brambilla AM, Camajori Todeschini R, Gangitano G, Ingrassia S, Marino R, Nori F, Pagnozzi F, Panero F, Ferrari R. SIMEU position paper on non-invasive respiratory support in COVID-19 pneumonia. Intern Emerg Med 2022; 17:1175-1189. [PMID: 35103926 PMCID: PMC8803573 DOI: 10.1007/s11739-021-02906-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 12/06/2021] [Indexed: 12/19/2022]
Abstract
The rapid worldwide spread of the Coronavirus disease (COVID-19) crisis has put health systems under pressure to a level never experienced before, putting intensive care units in a position to fail to meet an exponentially growing demand. The main clinical feature of the disease is a progressive arterial hypoxemia which rapidly leads to ARDS which makes the use of intensive care and mechanical ventilation almost inevitable. The difficulty of health systems to guarantee a corresponding supply of resources in intensive care, together with the uncertain results reported in the literature with respect to patients who undergo early conventional ventilation, make the search for alternative methods of oxygenation and ventilation and potentially preventive of the need for tracheal intubation, such as non-invasive respiratory support techniques particularly valuable. In this context, the Emergency Department, located between the area outside the hospital and hospital ward and ICU, assumes the role of a crucial junction, due to the possibility of applying these techniques at a sufficiently early stage and being able to rapidly evaluate their effectiveness. This position paper describes the indications for the use of non-invasive respiratory support techniques in respiratory failure secondary to COVID-19-related pneumonia, formulated by the Non-invasive Ventilation Faculty of the Italian Society of Emergency Medicine (SIMEU) on the base of what is available in the literature and on the authors' direct experience. Rationale, literature, tips & tricks, resources, risks and expected results, and patient interaction will be discussed for each one of the escalating non-invasive respiratory techniques: standard oxygen, HFNCO, CPAP, NIPPV, and awake self-repositioning. The final chapter describes our suggested approach to the failing patient.
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Affiliation(s)
| | - Paolo Groff
- Pronto Soccorso e Osservazione Breve, Perugia, AO, Italy
| | | | | | | | - Stella Ingrassia
- Emergency Medicine Unit, Luigi Sacco Hospital, ASST FBF Sacco, Milan, Italy
| | - Roberta Marino
- Emergency Medicine, Sant'Andrea Hospital, Vercelli, Italy
| | - Francesca Nori
- Emergency Room, Emergency Care Unit, Santa Maria Della Scaletta Hospital, Imola, Italy
| | | | - Francesco Panero
- MECAU 2, Pronto Soccorso e Area Critica, ASL Città di Torino, Turin, Italy
| | - Rodolfo Ferrari
- Emergency Room, Emergency Care Unit, Santa Maria Della Scaletta Hospital, Imola, Italy
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Hussain Khan Z, Maki Aldulaimi A, Varpaei HA, Mohammadi M. Various Aspects of Non-Invasive Ventilation in COVID-19 Patients: A Narrative Review. IRANIAN JOURNAL OF MEDICAL SCIENCES 2022; 47:194-209. [PMID: 35634520 PMCID: PMC9126903 DOI: 10.30476/ijms.2021.91753.2291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 09/21/2021] [Accepted: 10/01/2021] [Indexed: 01/08/2023]
Abstract
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.
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Affiliation(s)
- Zahid Hussain Khan
- Department of Anesthesiology and Critical Care, Imam Khomeini Medical Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmed Maki Aldulaimi
- Al-furat Al-awsat Hospital, Al-furat Al-awsat Technical University, Health and Medical Technical College, Department of Anesthesia and Critical Care, Kufa, Iraq
| | - Hesam Aldin Varpaei
- Department of Nursing and Midwifery, School of Nursing, Islamic Azad University Tehran Medical Sciences, Tehran, Iran
| | - Mostafa Mohammadi
- Department of Anesthesiology and Critical Care, Tehran University of Medical Sciences, Tehran. Iran
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15
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Winck JC, Moreira J. Non-invasive respiratory support for COVID-19-related acute respiratory failure. Chin Med J (Engl) 2022; 135:416-418. [PMID: 34759223 PMCID: PMC8869568 DOI: 10.1097/cm9.0000000000001832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- João Carlos Winck
- Department of Medicine, Faculty of Medicine-Porto University, Porto 4200-319, Portugal
| | - Joaquim Moreira
- Unidade Local de Saúde do Alto Minho, Viana do Castelo, Portugal
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Weerakkody S, Arina P, Glenister J, Cottrell S, Boscaini-Gilroy G, Singer M, Montgomery HE. Non-invasive respiratory support in the management of acute COVID-19 pneumonia: considerations for clinical practice and priorities for research. THE LANCET. RESPIRATORY MEDICINE 2022; 10:199-213. [PMID: 34767767 PMCID: PMC8577844 DOI: 10.1016/s2213-2600(21)00414-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 09/07/2021] [Accepted: 09/07/2021] [Indexed: 01/03/2023]
Abstract
Non-invasive respiratory support (NIRS) has increasingly been used in the management of COVID-19-associated acute respiratory failure, but questions remain about the utility, safety, and outcome benefit of NIRS strategies. We identified two randomised controlled trials and 83 observational studies, compromising 13 931 patients, that examined the effects of NIRS modalities-high-flow nasal oxygen, continuous positive airway pressure, and bilevel positive airway pressure-on patients with COVID-19. Of 5120 patients who were candidates for full treatment escalation, 1880 (37%) progressed to invasive mechanical ventilation and 3658 of 4669 (78%) survived to study end. Survival was 30% among the 1050 patients for whom NIRS was the stated ceiling of treatment. The two randomised controlled trials indicate superiority of non-invasive ventilation over high-flow nasal oxygen in reducing the need for intubation. Reported complication rates were low. Overall, the studies indicate that NIRS in patients with COVID-19 is safe, improves resource utilisation, and might be associated with better outcomes. To guide clinical decision making, prospective, randomised studies are needed to address timing of intervention, optimal use of NIRS modalities-alone or in combination-and validation of tools such as oxygenation indices, response to a trial of NIRS, and inflammatory markers as predictors of treatment success.
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Affiliation(s)
- Sampath Weerakkody
- Centre for Human Health and Performance, Institute of Sport, Exercise and Health, Division of Medicine, University College London, London, UK.
| | - Pietro Arina
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK,University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Sam Cottrell
- Digital Publishing, Office for National Statistics, Fareham, Hampshire, UK
| | | | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK,University College London Hospitals NHS Foundation Trust, London, UK
| | - Hugh E Montgomery
- Centre for Human Health and Performance, Institute of Sport, Exercise and Health, Division of Medicine, University College London, London, UK,The Whittington Health NHS Foundation Trust, London, UK
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Menga LS, Berardi C, Ruggiero E, Grieco DL, Antonelli M. Noninvasive respiratory support for acute respiratory failure due to COVID-19. Curr Opin Crit Care 2022; 28:25-50. [PMID: 34694240 PMCID: PMC8711305 DOI: 10.1097/mcc.0000000000000902] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW Noninvasive respiratory support has been widely applied during the COVID-19 pandemic. We provide a narrative review on the benefits and possible harms of noninvasive respiratory support for COVID-19 respiratory failure. RECENT FINDINGS Maintenance of spontaneous breathing by means of noninvasive respiratory support in hypoxemic patients with vigorous spontaneous effort carries the risk of patient self-induced lung injury: the benefit of averting intubation in successful patients should be balanced with the harms of a worse outcome in patients who are intubated after failing a trial of noninvasive support.The risk of noninvasive treatment failure is greater in patients with the most severe oxygenation impairment (PaO2/FiO2 < 200 mmHg).High-flow nasal oxygen (HFNO) is the most widely applied intervention in COVID-19 patients with hypoxemic respiratory failure. Also, noninvasive ventilation (NIV) and continuous positive airway pressure delivered with different interfaces have been used with variable success rates. A single randomized trial showed lower need for intubation in patients receiving helmet NIV with specific settings, compared to HFNO alone.Prone positioning is recommended for moderate-to-severe acute respiratory distress syndrome patients on invasive ventilation. Awake prone position has been frequently applied in COVID-19 patients: one randomized trial showed improved oxygenation and lower intubation rate in patients receiving 6-h sessions of awake prone positioning, as compared to conventional management. SUMMARY Noninvasive respiratory support and awake prone position are tools possibly capable of averting endotracheal intubation in COVID-19 patients; carefully monitoring during any treatment is warranted to avoid delays in endotracheal intubation, especially in patients with PaO2/FiO2 < 200 mmHg.
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Affiliation(s)
- Luca S. Menga
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Cecilia Berardi
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Ersilia Ruggiero
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Domenico Luca Grieco
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Massimo Antonelli
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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18
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Madekurozwa M, Bonneuil WV, Frattolin J, Watson DJ, Moore AC, Stevens MM, Moore J, Mathiszig-Lee J, van Batenburg-Sherwood J. A Novel Ventilator Design for COVID-19 and Resource-Limited Settings. FRONTIERS IN MEDICAL TECHNOLOGY 2022; 3:707826. [PMID: 35047946 PMCID: PMC8757831 DOI: 10.3389/fmedt.2021.707826] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 09/07/2021] [Indexed: 11/13/2022] Open
Abstract
There has existed a severe ventilator deficit in much of the world for many years, due in part to the high cost and complexity of traditional ICU ventilators. This was highlighted and exacerbated by the emergence of the COVID-19 pandemic, during which the increase in ventilator production rapidly overran the global supply chains for components. In response, we propose a new approach to ventilator design that meets the performance requirements for COVID-19 patients, while using components that minimise interference with the existing ventilator supply chains. The majority of current ventilator designs use proportional valves and flow sensors, which remain in short supply over a year into the pandemic. In the proposed design, the core components are on-off valves. Unlike proportional valves, on-off valves are widely available, but accurate control of ventilation using on-off valves is not straightforward. Our proposed solution combines four on-off valves, a two-litre reservoir, an oxygen sensor and two pressure sensors. Benchtop testing of a prototype was performed with a commercially available flow analyser and test lungs. We investigated the accuracy and precision of the prototype using both compressed gas supplies and a portable oxygen concentrator, and demonstrated the long-term durability over 15 days. The precision and accuracy of ventilation parameters were within the ranges specified in international guidelines in all tests. A numerical model of the system was developed and validated against experimental data. The model was used to determine usable ranges of valve flow coefficients to increase supply chain flexibility. This new design provides the performance necessary for the majority of patients that require ventilation. Applications include COVID-19 as well as pneumonia, influenza, and tuberculosis, which remain major causes of mortality in low and middle income countries. The robustness, energy efficiency, ease of maintenance, price and availability of on-off valves are all advantageous over proportional valves. As a result, the proposed ventilator design will cost significantly less to manufacture and maintain than current market designs and has the potential to increase global ventilator availability.
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Affiliation(s)
- Michael Madekurozwa
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Willy V Bonneuil
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Jennifer Frattolin
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Daniel J Watson
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Axel C Moore
- Department of Materials, Department of Bioengineering and Institute of Biomedical Engineering, Imperial College London, London, United Kingdom
| | - Molly M Stevens
- Department of Materials, Department of Bioengineering and Institute of Biomedical Engineering, Imperial College London, London, United Kingdom
| | - James Moore
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Jakob Mathiszig-Lee
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom.,Department of Anaesthetics and Perioperative Medicine, Royal Marsden Hospital, London, United Kingdom
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19
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Jha OK, Kumar S, Mehra S, Sircar M, Gupta R. Helmet NIV in Acute Hypoxemic Respiratory Failure due to COVID-19: Change in PaO 2/FiO 2 Ratio a Predictor of Success. Indian J Crit Care Med 2021; 25:1137-1146. [PMID: 34916746 PMCID: PMC8645804 DOI: 10.5005/jp-journals-10071-23992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
In acute respiratory failure due to severe coronavirus disease 2019 (COVID-19) pneumonia, mechanical ventilation remains challenging and may result in high mortality. The use of noninvasive ventilation (NIV) may delay required invasive ventilation, increase adverse outcomes, and have a potential aerosol risk to caregivers. Data of 30 patients were collected from patient files and analyzed. Twenty-one (70%) patients were weaned successfully after helmet-NIV support (NIV success group), and invasive mechanical ventilation was required in 9 (30%) patients (NIV failure group) of which 8 (26.7%) patients died. In NIV success vs failure patients, the mean baseline PaO2/FiO2 ratio (PFR) (147.2 ± 57.9 vs 156.8 ± 59.0 mm Hg; p = 0.683) and PFR before initiation of helmet (132.3 ± 46.9 vs 121.6 ± 32.7 mm Hg; p = 0.541) were comparable. The NIV success group demonstrated a progressive improvement in PFR in comparison with the failure group at 2 hours (158.8 ± 56.1 vs 118.7 ± 40.7 mm Hg; p = 0.063) and 24 hours (PFR-24) (204.4 ± 94.3 vs 121.3 ± 32.6; p = 0.016). As predictor variables, PFR-24 and change (delta) in PFR at 24 hours from baseline or helmet initiation (dPFR-24) were significantly associated with NIV success in univariate analysis but similar significance could not be reflected in multivariate analysis perhaps due to a small sample size of the study. The PFR-24 cutoff of 161 mm Hg and dPFR-24 cutoff of -1.44 mm Hg discriminate NIV success and failure groups with the area under curve (confidence interval) of 0.78 (0.62-0.95); p = 0.015 and 0.74 (0.55-0.93); p = 0.039, respectively. Helmet interface NIV may be a safe and effective tool for the management of patients with severe COVID-19 pneumonia with acute respiratory failure. More studies are needed to further evaluate the role of helmet NIV especially in patients with initial PFR <150 mm Hg to define PFR/dPFR cutoff at the earliest time point for prediction of helmet-NIV success. How to cite this article Jha OK, Kumar S, Mehra S, Sircar M, Gupta R. Helmet NIV in Acute Hypoxemic Respiratory Failure due to COVID-19: Change in PaO2/FiO2 Ratio a Predictor of Success. Indian J Crit Care Med 2021;25(10):1137-1146.
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Affiliation(s)
- Onkar K Jha
- Department of Pulmonology and Critical Care, Fortis Hospital, Noida, Uttar Pradesh, India
| | - Sunny Kumar
- Department of Pulmonology and Critical Care, Fortis Hospital, Noida, Uttar Pradesh, India
| | - Saurabh Mehra
- Department of Pulmonology and Critical Care, Fortis Hospital, Noida, Uttar Pradesh, India
| | - Mrinal Sircar
- Department of Pulmonology and Critical Care, Fortis Hospital, Noida, Uttar Pradesh, India
| | - Rajesh Gupta
- Department of Pulmonology and Critical Care, Fortis Hospital, Noida, Uttar Pradesh, India
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20
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Nadeem I, Jordon L, Rasool MU, Mahdi N, Kumar R, Rehman Z, Tilley CJ, Kang S, Rai A, Lok S, McMillan A. Role of advanced respiratory support in acute respiratory failure in clinically frail patients with COVID-19. Future Microbiol 2021; 17:89-97. [PMID: 34915735 PMCID: PMC8734119 DOI: 10.2217/fmb-2021-0226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background: The main aim of this study was to assess the efficacy of advanced respiratory support (ARS) for acute respiratory failure in do-not-attempt cardiopulmonary resuscitation order (DNACPR) COVID-19 patients. Methods: In this single-center study, the impact of different types of ARS modality, PaO2/FiO2 (PF) ratio, clinical frailty score (CFS) and 4C score on mortality was evaluated. Results: There was no significant difference in age, type of ARS modality, PF ratio and 4C scores between those who died and those who survived. Overall survival rates/hospital discharge of patients still requiring ARS at 5 and 7 days post admission were 20 and 17%, respectively. Conclusion: Our study showed that ARS can be a useful tool in frail, elderly and high-risk COVID-19 patients irrespective of high 4C mortality score.
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Affiliation(s)
- Iftikhar Nadeem
- Department of Respiratory Medicine, East & North Hertfordshire NHS Trust, Stevenage, UK
| | - Louise Jordon
- Department of Respiratory Medicine, East & North Hertfordshire NHS Trust, Stevenage, UK
| | - Masood Ur Rasool
- Department of Respiratory Medicine, Norfolk & Norwich University Hospital NHS Trust, Norwich, UK
| | - Noor Mahdi
- Department of Respiratory Medicine, East & North Hertfordshire NHS Trust, Stevenage, UK
| | - Ritesh Kumar
- Department of Respiratory Medicine, East & North Hertfordshire NHS Trust, Stevenage, UK
| | - Zahra Rehman
- Department of Internal Medicine, East & North Hertfordshire NHS Trust, Stevenage, UK
| | - Craig J Tilley
- Department of Internal Medicine, East & North Hertfordshire NHS Trust, Stevenage, UK
| | - Simran Kang
- Department of Internal Medicine, East & North Hertfordshire NHS Trust, Stevenage, UK
| | - Amrita Rai
- Department of Internal Medicine, East & North Hertfordshire NHS Trust, Stevenage, UK
| | - She Lok
- Department of Respiratory Medicine, East & North Hertfordshire NHS Trust, Stevenage, UK
| | - Alison McMillan
- Department of Respiratory Medicine, East & North Hertfordshire NHS Trust, Stevenage, UK
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21
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Bonnesen B, Jensen JUS, Jeschke KN, Mathioudakis AG, Corlateanu A, Hansen EF, Weinreich UM, Hilberg O, Sivapalan P. Management of COVID-19-Associated Acute Respiratory Failure with Alternatives to Invasive Mechanical Ventilation: High-Flow Oxygen, Continuous Positive Airway Pressure, and Noninvasive Ventilation. Diagnostics (Basel) 2021. [DOI: doi.org/10.3390/diagnostics11122259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Patients admitted to hospital with coronavirus disease 2019 (COVID-19) may develop acute respiratory failure (ARF) with compromised gas exchange. These patients require oxygen and possibly ventilatory support, which can be delivered via different devices. Initially, oxygen therapy will often be administered through a conventional binasal oxygen catheter or air-entrainment mask. However, when higher rates of oxygen flow are needed, patients are often stepped up to high-flow nasal cannula oxygen therapy (HFNC), continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), or invasive mechanical ventilation (IMV). BiPAP, CPAP, and HFNC may be beneficial alternatives to IMV for COVID-19-associated ARF. Current evidence suggests that when nasal catheter oxygen therapy is insufficient for adequate oxygenation of patients with COVID-19-associated ARF, CPAP should be provided for prolonged periods. Subsequent escalation to IMV may be implemented if necessary.
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22
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Bonnesen B, Jensen JUS, Jeschke KN, Mathioudakis AG, Corlateanu A, Hansen EF, Weinreich UM, Hilberg O, Sivapalan P. Management of COVID-19-Associated Acute Respiratory Failure with Alternatives to Invasive Mechanical Ventilation: High-Flow Oxygen, Continuous Positive Airway Pressure, and Noninvasive Ventilation. Diagnostics (Basel) 2021; 11:diagnostics11122259. [PMID: 34943496 PMCID: PMC8700515 DOI: 10.3390/diagnostics11122259] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 11/28/2021] [Accepted: 12/01/2021] [Indexed: 02/05/2023] Open
Abstract
Patients admitted to hospital with coronavirus disease 2019 (COVID-19) may develop acute respiratory failure (ARF) with compromised gas exchange. These patients require oxygen and possibly ventilatory support, which can be delivered via different devices. Initially, oxygen therapy will often be administered through a conventional binasal oxygen catheter or air-entrainment mask. However, when higher rates of oxygen flow are needed, patients are often stepped up to high-flow nasal cannula oxygen therapy (HFNC), continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), or invasive mechanical ventilation (IMV). BiPAP, CPAP, and HFNC may be beneficial alternatives to IMV for COVID-19-associated ARF. Current evidence suggests that when nasal catheter oxygen therapy is insufficient for adequate oxygenation of patients with COVID-19-associated ARF, CPAP should be provided for prolonged periods. Subsequent escalation to IMV may be implemented if necessary.
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Affiliation(s)
- Barbara Bonnesen
- Department of Medicine, Section of Respiratory Medicine, Herlev and Gentofte Hospital, University of Copenhagen, 2200 Copenhagen, Denmark; (B.B.); (J.-U.S.J.)
| | - Jens-Ulrik Stæhr Jensen
- Department of Medicine, Section of Respiratory Medicine, Herlev and Gentofte Hospital, University of Copenhagen, 2200 Copenhagen, Denmark; (B.B.); (J.-U.S.J.)
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Klaus Nielsen Jeschke
- Department of Respiratory Medicine, Copenhagen University Hospital-Hvidovre, 2650 Hvidovre, Denmark; (K.N.J.); (E.F.H.)
| | - Alexander G. Mathioudakis
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester M23 9LT, UK;
- North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester M23 9LT, UK
| | - Alexandru Corlateanu
- Department of Respiratory Medicine, State University of Medicine and Pharmacy “Nicolae Testemitanu”, 2004 Chisinau, Moldova;
| | - Ejvind Frausing Hansen
- Department of Respiratory Medicine, Copenhagen University Hospital-Hvidovre, 2650 Hvidovre, Denmark; (K.N.J.); (E.F.H.)
| | - Ulla Møller Weinreich
- Department of Respiratory Medicine, Aalborg University Hospital, University of Aalborg, 9100 Aalborg, Denmark;
- The Clinical Institute, Aalborg University, 9220 Aalborg, Denmark
| | - Ole Hilberg
- Department of Medicine, Little Belt Hospital, 7100 Vejle, Denmark;
- Department of Regional Health Research, University of Southern Denmark, 5000 Odense, Denmark
| | - Pradeesh Sivapalan
- Department of Medicine, Section of Respiratory Medicine, Herlev and Gentofte Hospital, University of Copenhagen, 2200 Copenhagen, Denmark; (B.B.); (J.-U.S.J.)
- Correspondence: ; Tel.: +45-298-806-01
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23
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Bassetti M, Giacobbe DR, Bruzzi P, Barisione E, Centanni S, Castaldo N, Corcione S, De Rosa FG, Di Marco F, Gori A, Gramegna A, Granata G, Gratarola A, Maraolo AE, Mikulska M, Lombardi A, Pea F, Petrosillo N, Radovanovic D, Santus P, Signori A, Sozio E, Tagliabue E, Tascini C, Vancheri C, Vena A, Viale P, Blasi F. Clinical Management of Adult Patients with COVID-19 Outside Intensive Care Units: Guidelines from the Italian Society of Anti-Infective Therapy (SITA) and the Italian Society of Pulmonology (SIP). Infect Dis Ther 2021; 10:1837-1885. [PMID: 34328629 PMCID: PMC8323092 DOI: 10.1007/s40121-021-00487-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 06/15/2021] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION The Italian Society of Anti-Infective Therapy (SITA) and the Italian Society of Pulmonology (SIP) constituted an expert panel for developing evidence-based guidance for the clinical management of adult patients with coronavirus disease 2019 (COVID-19) outside intensive care units. METHODS Ten systematic literature searches were performed to answer ten different key questions. The retrieved evidence was graded according to the Grading of Recommendations Assessment, Development, and Evaluation methodology (GRADE). RESULTS AND CONCLUSION The literature searches mostly assessed the available evidence on the management of COVID-19 patients in terms of antiviral, anticoagulant, anti-inflammatory, immunomodulatory, and continuous positive airway pressure (CPAP)/non-invasive ventilation (NIV) treatment. Most evidence was deemed as of low certainty, and in some cases, recommendations could not be developed according to the GRADE system (best practice recommendations were provided in similar situations). The use of neutralizing monoclonal antibodies may be considered for outpatients at risk of disease progression. For inpatients, favorable recommendations were provided for anticoagulant prophylaxis and systemic steroids administration, although with low certainty of evidence. Favorable recommendations, with very low/low certainty of evidence, were also provided for, in specific situations, remdesivir, alone or in combination with baricitinib, and tocilizumab. The presence of many best practice recommendations testified to the need for further investigations by means of randomized controlled trials, whenever possible, with some possible future research directions stemming from the results of the ten systematic reviews.
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Affiliation(s)
- Matteo Bassetti
- Infectious Diseases Unit, Ospedale Policlinico San Martino-IRCCS, L.go R. Benzi, 10, 16132, Genoa, Italy.
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.
| | - Daniele Roberto Giacobbe
- Infectious Diseases Unit, Ospedale Policlinico San Martino-IRCCS, L.go R. Benzi, 10, 16132, Genoa, Italy.
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.
| | - Paolo Bruzzi
- Clinical Epidemiology Unit, Ospedale Policlinico San Martino-IRCCS, Genoa, Italy
| | - Emanuela Barisione
- Interventional Pulmonology, Ospedale Policlinico San Martino-IRCCS, Genoa, Italy
| | - Stefano Centanni
- Department of Health Sciences, University of Milan, Respiratory Unit, ASST Santi Paolo e Carlo, Milan, Italy
| | - Nadia Castaldo
- Infectious Diseases Clinic, Santa Maria Misericordia Hospital, Udine, Italy
| | - Silvia Corcione
- Department of Medical Sciences, Infectious Diseases, University of Turin, Turin, Italy
- Tufts University School of Medicine, Boston, MA, USA
| | | | - Fabiano Di Marco
- Department of Health Sciences, University of Milan, Respiratory Unit, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Andrea Gori
- Infectious Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Centre for Multidisciplinary Research in Health Science (MACH), University of Milan, Milan, Italy
| | - Andrea Gramegna
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Department, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy
| | - Guido Granata
- Clinical and Research Department for Infectious Diseases, National Institute for Infectious Diseases L. Spallanzani, IRCCS, Rome, Italy
| | - Angelo Gratarola
- Department of Emergency and Urgency, San Martino Policlinico Hospital, IRCCS, Genoa, Italy
| | | | - Malgorzata Mikulska
- Infectious Diseases Unit, Ospedale Policlinico San Martino-IRCCS, L.go R. Benzi, 10, 16132, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Andrea Lombardi
- Infectious Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
- SSD Clinical Pharmacology Unit, University Hospital, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Nicola Petrosillo
- Clinical and Research Department for Infectious Diseases, National Institute for Infectious Diseases L. Spallanzani, IRCCS, Rome, Italy
- Infection Control and Infectious Disease Service, University Hospital "Campus-Biomedico", Rome, Italy
| | - Dejan Radovanovic
- Division of Respiratory Diseases, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Pierachille Santus
- Division of Respiratory Diseases, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Milan, Italy
- Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Milan, Italy
| | - Alessio Signori
- Department of Health Sciences, Section of Biostatistics, University of Genoa, Genoa, Italy
| | - Emanuela Sozio
- Infectious Diseases Clinic, Santa Maria Misericordia Hospital, Udine, Italy
| | - Elena Tagliabue
- Interventional Pulmonology, Ospedale Policlinico San Martino-IRCCS, Genoa, Italy
| | - Carlo Tascini
- Infectious Diseases Clinic, Santa Maria Misericordia Hospital, Udine, Italy
| | - Carlo Vancheri
- Regional Referral Centre for Rare Lung Diseases-University Hospital "Policlinico G. Rodolico", Catania, Italy
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Antonio Vena
- Infectious Diseases Unit, Ospedale Policlinico San Martino-IRCCS, L.go R. Benzi, 10, 16132, Genoa, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
- Infectious Diseases Unit, University Hospital IRCCS Policlinico Sant'Orsola, Bologna, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Department, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy
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D'Amore J, Meigher S, Patterson E, Sanapala S, Tarr M, Leisman D, Jones M, Moskovitz JB, Offenbacher J, Sperling J. Intubation outcomes and practice trends during the initial New York SARS-COV-19 surge at an academic, level 1 trauma, urban emergency department. J Am Coll Emerg Physicians Open 2021; 2:e12563. [PMID: 34853833 PMCID: PMC8612629 DOI: 10.1002/emp2.12563] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/02/2021] [Accepted: 08/30/2021] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES The goal of this study was to describe outcomes and associated characteristics of patients who were intubated during the initial (3/2020-4/2020) New York City surge of the severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic, during which time we were confronted by an unknown and unprecedented respiratory distress syndrome with extremely high degrees of morbidity and mortality. Our secondary aim was to analyze our physician's rapidly evolving approaches to COVID-19 airway management. METHODS A retrospective cohort analysis of all patients intubated at two emergency departments (EDs) for COVID-19 suspected respiratory failure. In addition, a survey was done to analyze clinician airway management trends and attitudes as they evolved during that period. RESULTS Ninety-five patients met inclusion criteria for the study. Primary outcomes looked at the spectrum of mortality outcomes ranging from died on arrival (DOA) to the ED, died in the ED (DED), died an inpatient (DIH), and survival to discharge. Overall mortalitywas 71.6% with an average age of 62.7 years. Female sex, as a demographic, was associated with higher rates of survival to discharge at 42.3% when compared to males at 23.2% (P < 0.001). Mean age was 70.8 years DOA, 65.6 years DED, 62.9 years DIH, and 60.0 years for survivors (P = 0.0037). Initial lactate levels were 8.15 mmol/L DED, 3.56 mmol/L DIH, and 2.61 mmol/L survivors (P < 0.0001). Initial creatinine levels were 3.38 mg/dL DED, 1.94 mg/dL DIH, and 1.77 mg/dL survivors (P = 0.0073). D-dimer levels were 7520.5 ng/mL DED, 5932.4 ng/mL DIH, and 1133.9 ng/mL survivors (P = 0.0045). Physician survey respondents reported high levels (69%) of laryngeal edema and prolonged post intubation hypoxia (>50% of time) and >80% remained concerned for their safety. There was a dramatic shift from early (73% of time) to late intubation strategies (67% of time) or non-invasive approaches (28% of time) as the first surge of the pandemic evolved. CONCLUSION Our findings demonstrate that several demographic, clinical and laboratory parameters correlated with mortality in our cohort of patients intubated during the initial phase of the COVID-19 pandemic. These included male sex, advanced age, high levels of initial lactic acidosis, elevated D-dimer, and chronic kidney disease/acute kidney injury. In contrast, presenting respiratory characteristics were not correlated with mortality. In addition, our findings demonstrate that physician attitudes and strategies related to COVID-19 airway management evolved significantly and rapidly over the initial phase of the pandemic.
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Affiliation(s)
- Jason D'Amore
- Department of Emergency Medicine at the Jacobi Medical CenterAlbert Einstein College of MedicineBronxNew YorkUSA
| | - Stephen Meigher
- Department of Emergency Medicine at the Jacobi and Montefiore Medical CentersAlbert Einstein College of MedicineBronxNew YorkUSA
| | - Elizabeth Patterson
- Department of Emergency Medicine at the Jacobi and Montefiore Medical CentersAlbert Einstein College of MedicineBronxNew YorkUSA
| | - Sowmya Sanapala
- Department of Emergency Medicine at the Jacobi and Montefiore Medical CentersAlbert Einstein College of MedicineBronxNew YorkUSA
| | - Michael Tarr
- Department of Emergency Medicine at the Jacobi and Montefiore Medical CentersAlbert Einstein College of MedicineBronxNew YorkUSA
| | - Dan Leisman
- Icahn Mount Sinai School of MedicineNew YorkNew YorkUSA
| | - Michael Jones
- Department of Emergency Medicine at the Jacobi and Montefiore Medical CentersAlbert Einstein College of MedicineBronxNew YorkUSA
| | - Joshua B Moskovitz
- Department of Emergency Medicine at the Jacobi Medical CenterAlbert Einstein College of MedicineBronxNew YorkUSA
| | - Joseph Offenbacher
- Department of Emergency Medicine at the Jacobi and Montefiore Medical CentersAlbert Einstein College of MedicineBronxNew YorkUSA
| | - Jeremy Sperling
- Department of Emergency Medicine at the Jacobi Medical CenterAlbert Einstein College of MedicineBronxNew YorkUSA
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25
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Masa JF, Patout M, Scala R, Winck JC. Reorganizing the respiratory high dependency unit for pandemics. Expert Rev Respir Med 2021; 15:1505-1515. [PMID: 34720022 DOI: 10.1080/17476348.2021.1997596] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Respiratory high dependency units (RHDUs) set up in European countries in the last decade are based on being a transitional step between the intensive care units (ICUs) and the conventional hospital ward in terms of staffing, level of monitoring, and patients' severity. In the pre-COVID-19 era, its main use has been the treatment of hypercapnic acute-on-chronic respiratory failure with noninvasive respiratory support, and more recently, for hypoxemic acute respiratory failure. AREAS COVERED We searched the following databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, limited to the terms: COVID-19 and RHDU, Respiratory Intermediate care Unit, acute respiratory distress syndrome (ARDS), noninvasive ventilation (NIV), high flow nasal cannula (HFNC), prone position, and monitoring. In this review, we summarize RHDU´s dual purpose: on the one hand, to decrease the number of admissions into ICU, and on the other hand, early discharges of patients from ICU with prolonged admissions due to the need of care or laborious weaning from invasive mechanical ventilation. Although this dual purpose of RHDUs has contributed to decrease the overload of the ICUs during the pandemic, the hundreds of patients admitted in hospitals, with approximately 20%-30% needing critical care, has exceeded the forecasts of many hospitals. EXPERT OPINION It seems clear that a reorganization and optimization of the care of patients with severe COVID-19 is necessary, minimizing admissions to the ICU and facilitating an early discharge. During the pandemic, several hospitals have spontaneously created new RHDUs or extended preexisting RHDUs or up-graded respiratory wards in order to receive less sick patients requiring lower levels of monitoring and nurse-to-patient ratios. This article reviews under a European expert perspective this topic and proposes an adaptation and optimization of the RHDUs to meet the emergent needs caused by the pandemic emphasizing the role of the expert application of noninvasive respiratory therapies in preventing intubation and ICU access.
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Affiliation(s)
- Juan Fernando Masa
- San Pedro De Alcantara Hospital, Cáceres, Spain.,Ciber De Enfermedades Respiratorias (Ciberes), Madrid, Spain.,Instituto Universitario De Investigación Biosanitaria De Extremadura (Inube), Spain
| | - Maxime Patout
- 1. Ap-hp, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Service Des Pathologies Du Sommeil (Département R3S), Paris, France.,Sorbonne Université, Inserm, UMRS1158 Neurophysiologie Respiratoire Expérimentale Et Clinique, Paris, France
| | - Raffaele Scala
- Pulmonology and Respiratory Intensive Care Unit. Cardiovascular-thoracic-metabolic Department. Usl Toscana Sudest. San Donato Hospital, Arezzo, Italy
| | - Joao Carlos Winck
- Faculdade De Medicina Da Universidade Do Porto, Centro De Reabilitação Do Norte (Chvng), Vila Nova De Gaia, Portugal
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Long-term survival of mechanically ventilated patients with severe COVID-19: an observational cohort study. Ann Intensive Care 2021; 11:143. [PMID: 34601646 PMCID: PMC8487336 DOI: 10.1186/s13613-021-00929-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 09/16/2021] [Indexed: 12/28/2022] Open
Abstract
Background Information is lacking regarding long-term survival and predictive factors for mortality in patients with acute hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19) and undergoing invasive mechanical ventilation. We aimed to estimate 180-day mortality of patients with COVID-19 requiring invasive ventilation, and to develop a predictive model for long-term mortality. Methods Retrospective, multicentre, national cohort study between March 8 and April 30, 2020 in 16 intensive care units (ICU) in Spain. Participants were consecutive adults who received invasive mechanical ventilation for COVID-19. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection detected in positive testing of a nasopharyngeal sample and confirmed by real time reverse-transcriptase polymerase chain reaction (rt-PCR). The primary outcomes was 180-day survival after hospital admission. Secondary outcomes were length of ICU and hospital stay, and ICU and in-hospital mortality. A predictive model was developed to estimate the probability of 180-day mortality. Results 868 patients were included (median age, 64 years [interquartile range [IQR], 56–71 years]; 72% male). Severity at ICU admission, estimated by SAPS3, was 56 points [IQR 50–63]. Prior to intubation, 26% received some type of noninvasive respiratory support. The unadjusted overall 180-day survival rates was 59% (95% CI 56–62%). The predictive factors measured during ICU stay, and associated with 180-day mortality were: age [Odds Ratio [OR] per 1-year increase 1.051, 95% CI 1.033–1.068)), SAPS3 (OR per 1-point increase 1.027, 95% CI 1.011–1.044), diabetes (OR 1.546, 95% CI 1.085–2.204), neutrophils to lymphocytes ratio (OR per 1-unit increase 1.008, 95% CI 1.001–1.016), failed attempt of noninvasive positive pressure ventilation prior to orotracheal intubation (OR 1.878 (95% CI 1.124–3.140), use of selective digestive decontamination strategy during ICU stay (OR 0.590 (95% CI 0.358–0.972) and administration of low dosage of corticosteroids (methylprednisolone 1 mg/kg) (OR 2.042 (95% CI 1.205–3.460). Conclusion The long-term survival of mechanically ventilated patients with severe COVID-19 reaches more than 50% and may help to provide individualized risk stratification and potential treatments. Trial registration: ClinicalTrials.gov Identifier: NCT04379258. Registered 10 April 2020 (retrospectively registered) Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00929-y.
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Nightingale R, Lewis J, Monsell KR, Jones L, Smith C, Kundu S, Bond H, Burhan H, Fletcher T, Blanchard T, Beadsworth M, Hampshire P, Gautam M, Todd S, Jones G, Aston S. CPAP delivered outside critical care during the second wave of COVID-19: outcomes from a UK respiratory surge unit. BMJ Open Respir Res 2021; 8:8/1/e000907. [PMID: 34521649 PMCID: PMC8441225 DOI: 10.1136/bmjresp-2021-000907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 08/07/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND NHS England recommends non-invasive continuous positive airway pressure (CPAP) as a possible treatment for type 1 respiratory failure associated with COVID-19 pneumonitis, either to avoid intubation or as a ceiling of care. However, data assessing this strategy are sparse, especially for the use of CPAP as a ceiling of care, and particularly when delivered outside of a traditional critical care environment. We describe a cohort of patients from Liverpool, UK, who received CPAP on a dedicated respiratory surge unit at the start of the second wave of the COVID-19 pandemic in UK. METHODS Retrospective cohort analysis of consecutive patients receiving CPAP for the treatment of respiratory failure secondary to COVID-19 on the respiratory surge unit at the Royal Liverpool Hospital, Liverpool, UK from 21 September until 30 November 2020. RESULTS 88 patients were included in the analysis. 56/88 (64%) were deemed suitable for escalation to invasive mechanical ventilation (IMV) and received CPAP as a trial; 32/88 (36%) received CPAP as a ceiling of care. Median age was 63 years (IQR: 56-74) and 58/88 (66%) were men. Median SpO2/FiO2 immediately prior to CPAP initiation was 95 (92-152). Among patients for escalation to IMV, the median time on CPAP was 6 days (IQR 4-7) and survival at day 30 was 84% (47/56) with 14/56 (25%) escalated to IMV. Of those patients for whom CPAP was ceiling of care, the median duration of CPAP was 9 days (IQR 7-11) and 18/32 (56%) survived to day 30. Pulmonary barotrauma occurred in 9% of the cohort. There were no associations found on multivariant analysis that were associated with all-cause 30-day mortality. CONCLUSIONS With adequate planning and resource redistribution, CPAP may be delivered effectively outside of a traditional critical care setting for the treatment of respiratory failure due to COVID-19. Clinicians delivering CPAP to patients with COVID-19 pneumonitis should be alert to the dangers of pulmonary barotrauma. Among patients who are for escalation of care, the use of CPAP may avoid the need for IMV in some patients. Our data support the NHS England recommendation to consider CPAP as a ceiling of care.
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Affiliation(s)
- Rebecca Nightingale
- Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK .,Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Joseph Lewis
- Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.,Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.,Institute of Infection, Veterinary and Ecological Sciences, Univeristy of Liverpool, Liverpool, UK
| | - Katelyn Rhiannon Monsell
- Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Lewis Jones
- Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Christopher Smith
- Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Shantanu Kundu
- School of Medicine, Univeristy of Liverpool, Liverpool, UK
| | - Helena Bond
- Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Hassan Burhan
- Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.,Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Tom Fletcher
- Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.,Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Thomas Blanchard
- Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.,Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.,Institute of Infection, Veterinary and Ecological Sciences, Univeristy of Liverpool, Liverpool, UK
| | - Michael Beadsworth
- Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.,Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Peter Hampshire
- Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Manish Gautam
- Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Stacy Todd
- Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Gareth Jones
- Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Stephen Aston
- Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.,Institute of Infection, Veterinary and Ecological Sciences, Univeristy of Liverpool, Liverpool, UK
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Coppadoro A, Zago E, Pavan F, Foti G, Bellani G. The use of head helmets to deliver noninvasive ventilatory support: a comprehensive review of technical aspects and clinical findings. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:327. [PMID: 34496927 PMCID: PMC8424168 DOI: 10.1186/s13054-021-03746-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/20/2021] [Indexed: 11/14/2022]
Abstract
A helmet, comprising a transparent hood and a soft collar, surrounding the patient’s head can be used to deliver noninvasive ventilatory support, both as continuous positive airway pressure and noninvasive positive pressure ventilation (NPPV), the latter providing active support for inspiration. In this review, we summarize the technical aspects relevant to this device, particularly how to prevent CO2 rebreathing and improve patient–ventilator synchrony during NPPV. Clinical studies describe the application of helmets in cardiogenic pulmonary oedema, pneumonia, COVID-19, postextubation and immune suppression. A section is dedicated to paediatric use. In summary, helmet therapy can be used safely and effectively to provide NIV during hypoxemic respiratory failure, improving oxygenation and possibly leading to better patient-centred outcomes than other interfaces.
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Affiliation(s)
| | - Elisabetta Zago
- ASST Monza, San Gerardo Hospital, Monza, Italy.,Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB, Italy
| | - Fabio Pavan
- ASST Monza, San Gerardo Hospital, Monza, Italy.,Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB, Italy
| | - Giuseppe Foti
- ASST Monza, San Gerardo Hospital, Monza, Italy.,Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB, Italy
| | - Giacomo Bellani
- ASST Monza, San Gerardo Hospital, Monza, Italy. .,Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB, Italy.
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29
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Akoumianaki E, Ischaki E, Karagiannis K, Sigala I, Zakyn-thinos S. The Role of Noninvasive Respiratory Management in Patients with Severe COVID-19 Pneumonia. J Pers Med 2021; 11:jpm11090884. [PMID: 34575661 PMCID: PMC8469068 DOI: 10.3390/jpm11090884] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 08/31/2021] [Indexed: 01/08/2023] Open
Abstract
Acute hypoxemic respiratory failure is the principal cause of hospitalization, invasive mechanical ventilation and death in severe COVID-19 infection. Nearly half of intubated patients with COVID-19 eventually die. High-Flow Nasal Oxygen (HFNO) and Noninvasive Ventilation (NIV) constitute valuable tools to avert endotracheal intubation in patients with severe COVID-19 pneumonia who do not respond to conventional oxygen treatment. Sparing Intensive Care Unit beds and reducing intubation-related complications may save lives in the pandemic era. The main drawback of HFNO and/or NIV is intubation delay. Cautious selection of patients with severe hypoxemia due to COVID-19 disease, close monitoring and appropriate employment and titration of HFNO and/or NIV can increase the rate of success and eliminate the risk of intubation delay. At the same time, all precautions to protect the healthcare personnel from viral transmission should be taken. In this review, we summarize the evidence supporting the application of HFNO and NIV in severe COVID-19 hypoxemic respiratory failure, analyse the risks associated with their use and provide a path for their proper implementation.
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Affiliation(s)
- Evangelia Akoumianaki
- Department of Intensive Care Unit, University Hospital of Heraklion, 71500 Crete, Greece
- Correspondence:
| | - Eleni Ischaki
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, 10676 Athens, Greece; (E.I.); (I.S.); (S.Z.-t.)
| | | | - Ioanna Sigala
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, 10676 Athens, Greece; (E.I.); (I.S.); (S.Z.-t.)
| | - Spyros Zakyn-thinos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, 10676 Athens, Greece; (E.I.); (I.S.); (S.Z.-t.)
- School of Medicine, National and Kapodistrian University of Athens, 10676 Athens, Greece
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30
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Banai A, Taieb P, Furie N, Hochstadt A, Merdler I, Sapir O, Granot Y, Lupu L, Ghantous E, Borohovitz A, Gal-Oz A, Ingbir M, Arbel Y, Banai S, Topilsky Y, Lichter Y, Szekely Y. COVID-19, a tale of two peaks: patients' characteristics, treatments, and clinical outcomes. Intern Emerg Med 2021; 16:1629-1639. [PMID: 33797029 PMCID: PMC8016151 DOI: 10.1007/s11739-021-02711-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 01/21/2021] [Indexed: 12/27/2022]
Abstract
Coronavirus 2019 disease (COVID-19) continues to challenge healthcare systems globally as many countries are currently experiencing an increase in the morbidity and mortality. Compare baseline characteristics, clinical presentation, treatments, and clinical outcomes of patients admitted during the second peak to those admitted during the first peak. Retrospective analysis of 258 COVID-19 patients consecutively admitted to the Tel Aviv Medical Center, of which, 131 during the first peak (March 21-May 30, 2020) and 127 during the second peak (May 31-July 16, 2020). First and second peak patients did not differ in baseline characteristics and clinical presentation at admission. Treatment with dexamethasone, full-dose anticoagulation, tocilizumab, remdesivir, and convalescent plasma transfusion were significantly more frequent during the second peak, as well as regimens combining 3-4 COVID-19-directed drugs. Compared to the first peak, 30-day mortality and invasive mechanical ventilation rates as well as adjusted risk were significantly lower during the second peak (10.2%, vs 19.8% vs p = 0.028, adjusted HR 0.39, 95% CI 0.19-0.79, p = 0.009 and 8.8% vs 19.3%, p = 0.002, adjusted HR 0.29, 95% CI 0.13-0.64, p = 0.002; respectively). Rates of 30-day mortality and invasive mechanical ventilation, as well as adjusted risks, were lower in the second peak of the COVID-19 pandemic among hospitalized patients. The change in treatment strategy and the experienced gained during the first peak may have contributed to the improved outcomes.
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Affiliation(s)
- Ariel Banai
- Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Philippe Taieb
- Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nadav Furie
- Sheba Medical Center, Tel Hashomer, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aviram Hochstadt
- Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ilan Merdler
- Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Orly Sapir
- Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yoav Granot
- Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Lior Lupu
- Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Eihab Ghantous
- Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ariel Borohovitz
- Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Amir Gal-Oz
- Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Merav Ingbir
- Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yaron Arbel
- Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Shmuel Banai
- Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yan Topilsky
- Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yael Lichter
- Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yishay Szekely
- Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
- Department of Cardiology, Tel Aviv Sourasky Medical Center, 6 Weizmann St., 64239, Tel Aviv, Israel.
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31
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Greco S, Fabbri N, Bella A, Bonsi B, Parini S, Rocchi C, Giaccari S, Gavioli M, Passaro A, Feo CV. COVID-19 inpatients with gastrointestinal onset: sex and care needs' differences in the district of Ferrara, Italy. BMC Infect Dis 2021; 21:739. [PMID: 34344331 PMCID: PMC8329637 DOI: 10.1186/s12879-021-06476-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 07/27/2021] [Indexed: 02/08/2023] Open
Abstract
Background COVID-19 is characterized by interstitial pneumonia, but a presentation of the disease with digestive symptoms only may occur. This work was aimed at evaluating: (1) the prevalence of presentation with digestive symptoms only in our cohort of COVID-19 inpatients; (2) differences between patients with and without gastrointestinal onset; (3) differences among males and females with gastrointestinal presentation; (4) outcomes of the groups of subjects with and without gastrointestinal onset. Method We retrospectively divided the patients hospitalized with COVID-19 into two groups: (1) the one with digestive symptoms (DSG) and (2) the other without digestive symptoms (NDSG). We compared the subjects of DSG with those of NDSG and males with females in the DSG group only, in terms of demographics (age, sex), inflammation and organ damage indexes, length of stay, in-hospital and 100-day mortality. Results The prevalence of gastrointestinal symptoms at presentation was 12.5%. The DSG group showed a prevalence of females, and these tended to a shorter hospital stay; DSG patients were younger and with a higher load of comorbidities, but no differences concerning inflammation and organ damage indexes, need for intensification of care, in-hospital and 100-day mortality were detected. Among DSG patients, males were younger than females, more comorbid, with higher serum CRP and showed a longer length of hospital stay. Survival functions of DSG patients, in general, are more favourable than those of NDSG if adjusted for sex, age and comorbidities. Conclusions (1) The prevalence of gastrointestinal presentation among hospitalized COVID-19 patients was 12.5%; (2) DSG patients were on average younger, more comorbid and with a prevalence of females, with a shorter hospital stay; (3) in the DSG group, males had a higher Charlson Comorbidity Score and needed a longer hospital stay; (4) DSG subjects seem to survive longer than those of the NDSG group. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06476-y.
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Affiliation(s)
- Salvatore Greco
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy - Via Luigi Borsari, 46, 44121, Ferrara, Emilia Romagna, Italy
| | - Nicolò Fabbri
- Department of General Surgery, Azienda Unità Sanitaria Locale Di Ferrara, Ospedale del Delta, via Valle Oppio, 2, Lagosanto, 44023, Ferrara, Emilia Romagna, Italy
| | - Alessandro Bella
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy - Via Luigi Borsari, 46, 44121, Ferrara, Emilia Romagna, Italy
| | - Beatrice Bonsi
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy - Via Luigi Borsari, 46, 44121, Ferrara, Emilia Romagna, Italy
| | - Stefano Parini
- Medical Department, Azienda Unità Sanitaria Locale Di Ferrara, Ospedale del Delta, via Valle Oppio, 2, Lagosanto, 44023, Ferrara, Emilia Romagna, Italy
| | - Cindy Rocchi
- Medical Department, Azienda Unità Sanitaria Locale Di Ferrara, Ospedale del Delta, via Valle Oppio, 2, Lagosanto, 44023, Ferrara, Emilia Romagna, Italy
| | - Sara Giaccari
- Medical Department, Azienda Unità Sanitaria Locale Di Ferrara, Ospedale del Delta, via Valle Oppio, 2, Lagosanto, 44023, Ferrara, Emilia Romagna, Italy
| | - Manuel Gavioli
- Medical Department, Azienda Unità Sanitaria Locale Di Ferrara, Ospedale del Delta, via Valle Oppio, 2, Lagosanto, 44023, Ferrara, Emilia Romagna, Italy
| | - Angelina Passaro
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy - Via Luigi Borsari, 46, 44121, Ferrara, Emilia Romagna, Italy. .,Medical Department, University Hospital of Ferrara Arcispedale Sant'Anna, Via Aldo Moro, 8, 44124, Ferrara, Emilia Romagna, Italy. .,Department of Translational Medicine and Medical Department, University of Ferrara, University Hospital of Ferrara Arcispedale Sant'Anna, Via Aldo Moro, 8, 44124, Ferrara, Emilia Romagna, Italy.
| | - Carlo V Feo
- Department of General Surgery, Azienda Unità Sanitaria Locale Di Ferrara, Ospedale del Delta, via Valle Oppio, 2, Lagosanto, 44023, Ferrara, Emilia Romagna, Italy
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32
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Cammarota G, Esposito T, Azzolina D, Cosentini R, Menzella F, Aliberti S, Coppadoro A, Bellani G, Foti G, Grasselli G, Cecconi M, Pesenti A, Vitacca M, Lawton T, Ranieri VM, Di Domenico SL, Resta O, Gidaro A, Potalivo A, Nardi G, Brusasco C, Tesoro S, Navalesi P, Vaschetto R, De Robertis E. Noninvasive respiratory support outside the intensive care unit for acute respiratory failure related to coronavirus-19 disease: a systematic review and meta-analysis. Crit Care 2021; 25:268. [PMID: 34330320 PMCID: PMC8324455 DOI: 10.1186/s13054-021-03697-0] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/21/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Noninvasive respiratory support (NIRS) has been diffusely employed outside the intensive care unit (ICU) to face the high request of ventilatory support due to the massive influx of patients with acute respiratory failure (ARF) caused by coronavirus-19 disease (COVID-19). We sought to summarize the evidence on clinically relevant outcomes in COVID-19 patients supported by NIV outside the ICU. METHODS We searched PUBMED®, EMBASE®, and the Cochrane Controlled Clinical trials register, along with medRxiv and bioRxiv repositories for pre-prints, for observational studies and randomized controlled trials, from inception to the end of February 2021. Two authors independently selected the investigations according to the following criteria: (1) observational study or randomized clinical trials enrolling ≥ 50 hospitalized patients undergoing NIRS outside the ICU, (2) laboratory-confirmed COVID-19, and (3) at least the intra-hospital mortality reported. Preferred Reporting Items for Systematic reviews and Meta-analysis guidelines were followed. Data extraction was independently performed by two authors to assess: investigation features, demographics and clinical characteristics, treatments employed, NIRS regulations, and clinical outcomes. Methodological index for nonrandomized studies tool was applied to determine the quality of the enrolled studies. The primary outcome was to assess the overall intra-hospital mortality of patients under NIRS outside the ICU. The secondary outcomes included the proportions intra-hospital mortalities of patients who underwent invasive mechanical ventilation following NIRS failure and of those with 'do-not-intubate' (DNI) orders. RESULTS Seventeen investigations (14 peer-reviewed and 3 pre-prints) were included with a low risk of bias and a high heterogeneity, for a total of 3377 patients. The overall intra-hospital mortality of patients receiving NIRS outside the ICU was 36% [30-41%]. 26% [21-30%] of the patients failed NIRS and required intubation, with an intra-hospital mortality rising to 45% [36-54%]. 23% [15-32%] of the patients received DNI orders with an intra-hospital mortality of 72% [65-78%]. Oxygenation on admission was the main source of between-study heterogeneity. CONCLUSIONS During COVID-19 outbreak, delivering NIRS outside the ICU revealed as a feasible strategy to cope with the massive demand of ventilatory assistance. REGISTRATION PROSPERO, https://www.crd.york.ac.uk/prospero/ , CRD42020224788, December 11, 2020.
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Affiliation(s)
- Gianmaria Cammarota
- Department of Medicine and Surgery, University of Perugia, Piazza Università 1, 06123, Perugia, Italy.
| | - Teresa Esposito
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | - Danila Azzolina
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | | | - Francesco Menzella
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS Di Reggio Emilia, Reggio Emilia, Italy
| | - Stefano Aliberti
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | | | - Giacomo Bellani
- ASST Monza, San Gerardo Hospital, Monza, Italy
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Giuseppe Foti
- ASST Monza, San Gerardo Hospital, Monza, Italy
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Giacomo Grasselli
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Antonio Pesenti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Michele Vitacca
- Respiratory Rehabilitation Unit Lumezzane, ICS Maugeri IRCCS, Brescia, Italy
| | - Tom Lawton
- Department of Anesthesia and Critical Care, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - V Marco Ranieri
- Anesthesia and Intensive Care Medicine, Policlinico Di Sant'Orsola, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | | | - Onofrio Resta
- Cardiothoracic Department, Respiratory Unit, University Hospital, Bari, Italy
| | - Antonio Gidaro
- Department of Biomedical and Clinical Sciences Luigi Sacco, University of Milan, Ospedale Luigi Sacco, Milan, Italy
| | - Antonella Potalivo
- Department of Anesthesia and Intensive Care, Infermi Hospital, AUSL Della Romagna, Rimini, Italy
| | - Giuseppe Nardi
- Department of Anesthesia and Intensive Care, Infermi Hospital, AUSL Della Romagna, Rimini, Italy
| | - Claudia Brusasco
- Anesthesia and Intensive Care Unit, E.O. Ospedali Galliera, Genoa, Italy
| | - Simonetta Tesoro
- Department of Medicine and Surgery, University of Perugia, Piazza Università 1, 06123, Perugia, Italy
| | - Paolo Navalesi
- Department of Medicine-DIMED, Università Di Padova, Padua, Italy
| | - Rosanna Vaschetto
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | - Edoardo De Robertis
- Department of Medicine and Surgery, University of Perugia, Piazza Università 1, 06123, Perugia, Italy
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Pavlov I, He H, McNicholas B, Perez Y, Tavernier E, Trump MW, Jackson JA, Zhang W, Rubin DS, Spiegel T, Hung A, Estrada MÁI, Roca O, Vines DL, Cosgrave D, Mirza S, Laffey JG, Rice TW, Ehrmann S, Li J. Awake Prone Positioning in Non-Intubated Patients With Acute Hypoxemic Respiratory Failure Due to COVID-19. Respir Care 2021; 67:102-114. [PMID: 34234032 DOI: 10.4187/respcare.09191] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- Ivan Pavlov
- Department of Emergency Medicine, Hôpital de Verdun, Montréal, Québec, Canada
| | - Hangyong He
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Bairbre McNicholas
- Anaesthesia and Intensive Care Medicine, School of Medicine, National University of Ireland Galway and Department of Anaesthesia, University Hospital Galway, Saolta Hospital Group, Galway, Ireland
| | - Yonatan Perez
- Médecine Intensive Réanimation, CIC INSERM 1415, CRICS-TriggerSEP research network, CHRU Tours, Tours, France and INSERM, Centre d'étude des pathologies respiratoires, U1100, Université de Tours, Tours, France
| | - Elsa Tavernier
- INSERM 1246-SPHERE, Universities of Tours and Nantes, Tours, France; Clinical Investigation Center, INSERM 1415, CHRU Tours, Tours, France
| | - Matthew W Trump
- Department Pulmonary and Critical Care Medicine, The Iowa Clinic, West Des Moines, Iowa
| | - Julie A Jackson
- Department of Respiratory Therapy, UnityPoint Health, Des Moines, Iowa
| | - Wei Zhang
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital, Second Military Medical University, Shanghai, China
| | - Daniel S Rubin
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
| | - Thomas Spiegel
- Section of Emergency Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Anthony Hung
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Miguel Ángel Ibarra Estrada
- Intensive Care Unit, Hospital Civil Fray Antonio Alcalde, Universidad de Guadalajara. Guadalajara, Jalisco, Mexico
| | - Oriol Roca
- Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Barcelona, Spain; Ciber Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - David L Vines
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, Illinois
| | - David Cosgrave
- Anaesthesia and Intensive Care Medicine, School of Medicine, National University of Ireland Galway and Department of Anaesthesia, University Hospital Galway, Saolta Hospital Group, Galway, Ireland
| | - Sara Mirza
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, National University of Ireland Galway and Department of Anaesthesia, University Hospital Galway, Saolta Hospital Group, Galway, Ireland
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Stephan Ehrmann
- Médecine Intensive Réanimation, CIC INSERM 1415, CRICS-TriggerSEP research network, CHRU Tours, Tours, France and INSERM, Centre d'étude des pathologies respiratoires, U1100, Université de Tours, Tours, France.
| | - Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, Illinois.
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Landry SA, Barr JJ, MacDonald MI, Subedi D, Mansfield D, Hamilton GS, Edwards BA, Joosten SA. Viable virus aerosol propagation by positive airway pressure circuit leak and mitigation with a ventilated patient hood. Eur Respir J 2021; 57:13993003.03666-2020. [PMID: 33303543 DOI: 10.1183/13993003.03666-2020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 11/24/2020] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Nosocomial transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been a major feature of the COVID-19 pandemic. Evidence suggests patients can auto-emit aerosols containing viable viruses; these aerosols could be further propagated when patients undergo certain treatments, including continuous positive airway pressure (PAP) therapy. Our aim was to assess 1) the degree of viable virus propagated from PAP circuit mask leak and 2) the efficacy of a ventilated plastic canopy to mitigate virus propagation. METHODS Bacteriophage phiX174 (108 copies·mL-1) was nebulised into a custom PAP circuit. Mask leak was systematically varied at the mask interface. Plates containing Escherichia coli host quantified viable virus (via plaque forming unit) settling on surfaces around the room. The efficacy of a low-cost ventilated headboard created from a tarpaulin hood and a high-efficiency particulate air (HEPA) filter was tested. RESULTS Mask leak was associated with virus contamination in a dose-dependent manner (χ2=58.24, df=4, p<0.001). Moderate mask leak (≥21 L·min-1) was associated with virus counts equivalent to using PAP with a vented mask. The highest frequency of viruses was detected on surfaces <1 m away; however, viable viruses were recorded up to 3.86 m from the source. A plastic hood with HEPA filtration significantly reduced viable viruses on all plates. HEPA exchange rates ≥170 m3·h-1 eradicated all evidence of virus contamination. CONCLUSIONS Mask leak from PAP may be a major source of environmental contamination and nosocomial spread of infectious respiratory diseases. Subclinical mask leak levels should be treated as an infectious risk. Low-cost patient hoods with HEPA filtration are an effective countermeasure.
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Affiliation(s)
- Shane A Landry
- Dept of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, Australia
| | - Jeremy J Barr
- School of Biological Sciences, Monash University, Clayton, Australia
| | | | - Dinesh Subedi
- School of Biological Sciences, Monash University, Clayton, Australia
| | - Darren Mansfield
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Australia.,School of Clinical Sciences, Monash University, Melbourne, Australia.,Monash Partners - Epworth, Victoria, Australia
| | - Garun S Hamilton
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Australia.,School of Clinical Sciences, Monash University, Melbourne, Australia.,Monash Partners - Epworth, Victoria, Australia
| | - Bradley A Edwards
- Dept of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, Australia.,Turner Institute for Brain and Mental Health, Monash University, Melbourne, Australia
| | - Simon A Joosten
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Australia.,School of Clinical Sciences, Monash University, Melbourne, Australia.,Monash Partners - Epworth, Victoria, Australia
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35
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Gabrielli M, Valletta F, Franceschi F. Barotrauma during non-invasive ventilation for acute respiratory distress syndrome caused by COVID-19: a balance between risks and benefits. Br J Hosp Med (Lond) 2021; 82:1-9. [PMID: 34191558 DOI: 10.12968/hmed.2021.0109] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Ventilatory support is vital for the management of severe forms of COVID-19. Non-invasive ventilation is often used in patients who do not meet criteria for intubation or when invasive ventilation is not available, especially in a pandemic when resources are limited. Despite non-invasive ventilation providing effective respiratory support for some forms of acute respiratory failure, data about its effectiveness in patients with viral-related pneumonia are inconclusive. Acute respiratory distress syndrome caused by severe acute respiratory syndrome-coronavirus 2 infection causes life-threatening respiratory failure, weakening the lung parenchyma and increasing the risk of barotrauma. Pulmonary barotrauma results from positive pressure ventilation leading to elevated transalveolar pressure, and in turn to alveolar rupture and leakage of air into the extra-alveolar tissue. This article reviews the literature regarding the use of non-invasive ventilation in patients with acute respiratory failure associated with COVID-19 and other epidemic or pandemic viral infections and the related risk of barotrauma.
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Affiliation(s)
- M Gabrielli
- Department of Emergency, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - F Valletta
- Department of Emergency, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - F Franceschi
- Department of Emergency, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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36
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Ogawa K, Asano K, Ikeda J, Fujii T. Non-invasive oxygenation strategies for respiratory failure with COVID-19: A concise narrative review of literature in pre and mid-COVID-19 era. Anaesth Crit Care Pain Med 2021; 40:100897. [PMID: 34087432 PMCID: PMC8168344 DOI: 10.1016/j.accpm.2021.100897] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/17/2021] [Accepted: 05/26/2021] [Indexed: 01/16/2023]
Abstract
The coronavirus disease 2019 (COVID-19) has spread globally and can cause a shortage of medical resources, in particular, mechanical ventilators. High-flow nasal cannula oxygen therapy (HFNC) and non-invasive positive pressure ventilation (NPPV) are frequently used for acute respiratory failure patients as alternatives to invasive mechanical ventilation. They are drawing attention because of a potential role to save mechanical ventilators. However, their effectiveness and risk of viral spread are unclear. The latest network meta-analysis of pre-COVID-19 trials reported that treatment with non-invasive oxygenation strategies was associated with improved survival when compared with conventional oxygen therapy. During the COVID-19 pandemic, a lot of clinical research on COVID-19 related acute respiratory failure has been reported. Several observational studies and small trials have suggested HFNC or NPPV as an alternative of standard oxygen therapy to manage COVID-19 related acute respiratory failure, provided that appropriate infection prevention is applied by health care workers to avoid risks of the virus transmission. Awake proning is an emerging strategy to optimise the management of patients with COVID-19 acute respiratory failure. However, the benefits of awake proning have yet to be assessed in properly designed clinical research. Although HFNC and NPPV are probably effective for acute respiratory failure, the safety data are mostly based on observational and experimental reports. As such, they should be implemented carefully if adequate personal protective equipment and negative pressure rooms are available.
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Affiliation(s)
- Kenta Ogawa
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan
| | - Kengo Asano
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan
| | - Junpei Ikeda
- Department of Clinical Engineering Technology, Jikei University Hospital, Tokyo, Japan
| | - Tomoko Fujii
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan.
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Rezoagli E, Magliocca A, Bellani G, Pesenti A, Grasselli G. Development of a Critical Care Response - Experiences from Italy During the Coronavirus Disease 2019 Pandemic. Anesthesiol Clin 2021; 39:265-284. [PMID: 34024430 PMCID: PMC7879060 DOI: 10.1016/j.anclin.2021.02.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Italy was the first western country facing an outbreak of coronavirus disease 2019 (COVID-19). The first Italian patient diagnosed with COVID-19 was admitted, on Feb. 20, 2020, to the intensive care unit (ICU) in Codogno (Lodi, Lombardy, Italy), and the number of reported positive cases increased to 36 in the next 24 hours, and then exponentially for 18 days. This triggered a response that resulted in a massive surge in ICU bed capacity. The COVID19 Lombardy Network organized a structured logistic response and provided scientific evidence to highlight information on COVID-19 associated respiratory failure.
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Affiliation(s)
- Emanuele Rezoagli
- Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore, 48, Monza 20900, Italy,Department of Emergency and Intensive Care, San Gerardo Hospital, Via G. B. Pergolesi, 33, Monza 20900, Italy,Corresponding author. Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, Monza (MB) 20900, Italy
| | - Aurora Magliocca
- Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore, 48, Monza 20900, Italy
| | - Giacomo Bellani
- Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore, 48, Monza 20900, Italy,Department of Emergency and Intensive Care, San Gerardo Hospital, Via G. B. Pergolesi, 33, Monza 20900, Italy
| | - Antonio Pesenti
- Department of Pathophysiology and Transplantation, University of Milan, Via Francesco Sforza 35, Milano 20122, Italy,Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via della Commenda, 10, Milano 20122, Italy
| | - Giacomo Grasselli
- Department of Pathophysiology and Transplantation, University of Milan, Via Francesco Sforza 35, Milano 20122, Italy,Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via della Commenda, 10, Milano 20122, Italy
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38
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Radovanovic D, Coppola S, Franceschi E, Gervasoni F, Duscio E, Chiumello DA, Santus P. Mortality and clinical outcomes in patients with COVID-19 pneumonia treated with non-invasive respiratory support: A rapid review. J Crit Care 2021; 65:1-8. [PMID: 34052780 PMCID: PMC8137355 DOI: 10.1016/j.jcrc.2021.05.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 04/23/2021] [Accepted: 05/15/2021] [Indexed: 01/08/2023]
Abstract
Introduction and aim Non-invasive ventilation (NIV) and continuous positive airway pressure (CPAP) have been widely employed to treat acute respiratory failure secondary to COVID-19 pneumonia, but their role in terms of efficacy and safety are still debated. The aim of this review was to analyse mortality and intubation rates in COVID-19 patients treated with NIV/CPAP. Methods Rapid review methodology was applied to include all the studies published since December-2019 until November-2020 with available data on in-hospital mortality in COVID-19 patients treated with NIV or CPAP. Results 23 manuscripts were included (4776 patients, 66% males, 46% with hypertension). 46% of patients received non-invasive respiratory support, of which 48.4% with CPAP, 46% with NIV, and 4% with either CPAP or NIV. Non-invasive respiratory support failed in 47.7% of patients, of which 26.5% were intubated and 40.9% died. In-hospital mortality was higher in patients treated with NIV compared with CPAP (35.1% vs. 22.2%). Complications were under-reported, but mostly not related to CPAP/NIV treatment. Conclusion CPAP and NIV appear equally and frequently applied in patients with COVID-19 pneumonia, but associated with high mortality. Robust evidence is urgently needed to confirm the clinical efficacy of non-invasive respiratory support in COVID-19-related ARDS.
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Affiliation(s)
- Dejan Radovanovic
- Division of Respiratory Diseases, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74, 20157 Milano, Italy
| | - Silvia Coppola
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy
| | - Elisa Franceschi
- Division of Respiratory Diseases, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74, 20157 Milano, Italy; Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Milano, Italy
| | - Fabrizio Gervasoni
- Rehabilitation Unit, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74, 20157 Milano, Italy
| | - Eleonora Duscio
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Davide Alberto Chiumello
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy; Coordinated Research Center on Respiratory Failure, University of Milan, Milan, Italy.
| | - Pierachille Santus
- Division of Respiratory Diseases, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74, 20157 Milano, Italy; Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Milano, Italy
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Avari H, Hiebert RJ, Ryzynski AA, Levy A, Nardi J, Kanji-Jaffer H, Kiiza P, Pinto R, Plenderleith SW, Fowler RA, Mbareche H, Mubareka S. Quantitative Assessment of Viral Dispersion Associated with Respiratory Support Devices in a Simulated Critical Care Environment. Am J Respir Crit Care Med 2021; 203:1112-1118. [PMID: 33534659 PMCID: PMC8314904 DOI: 10.1164/rccm.202008-3070oc] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Rationale: Patients with severe coronavirus disease (COVID-19) require supplemental oxygen and ventilatory support. It is unclear whether some respiratory support devices may increase the dispersion of infectious bioaerosols and thereby place healthcare workers at increased risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).Objectives: To quantitatively compare viral dispersion from invasive and noninvasive respiratory support modalities.Methods: This study used a simulated ICU room with a breathing-patient simulator exhaling nebulized bacteriophages from the lower respiratory tract with various respiratory support modalities: invasive ventilation (through an endotracheal tube with an inflated cuff connected to a mechanical ventilator), helmet ventilation with a positive end-expiratory pressure (PEEP) valve, noninvasive bilevel positive-pressure ventilation, nonrebreather face masks, high-flow nasal oxygen (HFNO), and nasal prongs.Measurements and Main Results: Invasive ventilation and helmet ventilation with a PEEP valve were associated with the lowest bacteriophage concentrations in the air, and HFNO and nasal prongs were associated with the highest concentrations. At the intubating position, bacteriophage concentrations associated with HFNO (2.66 × 104 plaque-forming units [PFU]/L of air sampled), nasal prongs (1.60 × 104 PFU/L of air sampled), nonrebreather face masks (7.87 × 102 PFU/L of air sampled), and bilevel positive airway pressure (1.91 × 102 PFU/L of air sampled) were significantly higher than those associated with invasive ventilation (P < 0.05 for each). The difference between bacteriophage concentrations associated with helmet ventilation with a PEEP valve (4.29 × 10-1 PFU/L of air sampled) and bacteriophage concentrations associated with invasive ventilation was not statistically significant.Conclusions: These findings highlight the potential differential risk of dispersing virus among respiratory support devices and the importance of appropriate infection prevention and control practices and personal protective equipment for healthcare workers when caring for patients with transmissible respiratory viral infections such as SARS-CoV-2.
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Affiliation(s)
- Hamed Avari
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Ryan J Hiebert
- Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada; and
| | - Agnes A Ryzynski
- Sunnybrook Research Institute, Toronto, Ontario, Canada.,Practice Based Research and Innovation
| | - Ariela Levy
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Julie Nardi
- Respiratory Therapy, Tory Trauma Program, and
| | | | - Peter Kiiza
- Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Robert A Fowler
- Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Hamza Mbareche
- Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada; and
| | - Samira Mubareka
- Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada; and
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40
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Das UN. Bioactive lipid-based therapeutic approach to COVID-19 and other similar infections. Arch Med Sci 2021; 19:1327-1359. [PMID: 37732033 PMCID: PMC10507771 DOI: 10.5114/aoms/135703] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 04/11/2021] [Indexed: 09/22/2023] Open
Abstract
COVID-19 is caused by SARS-CoV-2 infection. Epithelial and T, NK, and other immunocytes release bioactive lipids especially arachidonic acid (AA) in response to microbial infections to inactivate them and upregulate the immune system. COVID-19 (coronavirus) and other enveloped viruses including severe acute respiratory syndrome (SARS-CoV-1 of 2002-2003) and Middle East respiratory syndrome (MERS; 2012-ongoing) and hepatitis B and C (HBV and HCV) can be inactivated by AA, γ-linolenic acid (GLA, dihomo-GLA (DGLA), eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), which are precursors to several eicosanoids. Prostaglandin E1, lipoxin A4, resolvins, protectins and maresins enhance phagocytosis of macrophages and leukocytes to clear debris from the site(s) of infection and injury, enhance microbial clearance and wound healing to restore homeostasis. Bioactive lipids modulate the generation of M1 and M2 macrophages and the activity of other immunocytes. Mesenchymal and adipose tissue-derived stem cells secrete LXA4 and other bioactive lipids to bring about their beneficial actions in COVID-19. Bioactive lipids regulate vasomotor tone, inflammation, thrombosis, immune response, inactivate enveloped viruses, regulate T cell proliferation and secretion of cytokines, stem cell survival, proliferation and differentiation, and leukocyte and macrophage functions, JAK kinase activity and neutrophil extracellular traps and thus, have a critical role in COVID-19.
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Affiliation(s)
- Undurti N. Das
- UND Life Sciences, Battle Ground, WA, USA
- Department of Medicine, Omega Hospitals, Gachibowli, Hyderabad, India
- International Research Centre, Biotechnologies of the third Millennium, ITMO University, Saint-Petersburg, Russia
- Department of Biotechnology, Indian Institute of Technology-Hyderabad, Telangana, India
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41
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Kofod LM, Nielsen Jeschke K, Kristensen MT, Krogh-Madsen R, Monefeldt Albek C, Hansen EF. COVID-19 and acute respiratory failure treated with CPAP. Eur Clin Respir J 2021; 8:1910191. [PMID: 33889343 PMCID: PMC8043540 DOI: 10.1080/20018525.2021.1910191] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 03/24/2021] [Indexed: 01/15/2023] Open
Abstract
Introduction: Patients admitted with COVID-19 often have severe hypoxemic respiratory insufficiency and it can be difficult to maintain adequate oxygenation with oxygen supplementation alone. There is a physiological rationale for the use of Continuous Positive Airway Pressure (CPAP), and CPAP could keep some patients off mechanical ventilation. We aimed to examine the physiological response to CPAP and the outcome of this treatment. Methods: Data from all patients admitted with COVID-19 and treated with CPAP, from March to July 2020 were collected retrospectively. CPAP was initiated on a medical ward when oxygen supplementation exceeded 10 liters/min to maintain oxygen saturation (SpO2) ≥92%. CPAP was administered with full face masks on a continuous basis until stable improvement in oxygenation or until intubation or death. Results: CPAP was initiated in 53 patients (35 men, 18 women) with a median (IQR) age of 68 (57-78) years. Nine patients were not able to tolerate the CPAP treatment. Median duration for the 44 patients receiving CPAP was 3 (2-6) days. The PaO2/FiO2 ratio was severely reduced to an average of 101 mmHg at initiation of treatment. A positive response of CPAP was seen on respiratory rate (p = 0.002) and on oxygenation (p < 0.001). Of the 44 patients receiving CPAP, 12 (27%) avoided intubation,13 (29%) were intubated, and 19 (43%) died. Of the patients with a ceiling of treatment in the ward (26 of 53) only 2 survived. Older age and high initial oxygen demand predicted treatment failure. Discussion: CPAP seems to have positive effect on oxygenation and respiratory rate in most patients with severe respiratory failure caused by COVID-19. Treatment with CPAP to severely hypoxemic patients in a medical ward is possible, but the prognosis for especially elderly patients with high oxygen requirement and with a ceiling of treatment in the ward is poor.
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Affiliation(s)
- Linette Marie Kofod
- Department of Physio- and Occupational Therapy, Copenhagen University Hospital- Hvidovre&Physical Medicine and Rehabilitation Research – Copenhagen, Denmark
| | | | - Morten Tange Kristensen
- Department of Physio- and Occupational Therapy, Copenhagen University Hospital- Hvidovre&Physical Medicine and Rehabilitation Research – Copenhagen, Denmark
- Department of Orthopaedic Surgery, Copenhagen University Hospital – Hvidovre & Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Rikke Krogh-Madsen
- Department of Infectious Diseases, Copenhagen University Hospital – Hvidovre, Denmark
| | - Carsten Monefeldt Albek
- Department of Anaesthesiology an Intensive Care, Copenhagen University Hospital - Hvidovre & University of Copenhagen, Denmark
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42
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Winck JC, Scala R. Non Invasive Respiratory Support Therapies in COVID-19 Related Acute Respiratory Failure: Looking at the Neglected Issues. Arch Bronconeumol 2021; 57:9-10. [PMID: 34629630 PMCID: PMC7927576 DOI: 10.1016/j.arbres.2021.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
| | - Raffaele Scala
- Pulmonology and Respiratory Intensive Care Unit, S Donato Hospital, Arezzo, Italy
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43
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Groff P, Ferrari R. Non-invasive respiratory support in the treatment of acute hypoxemic respiratory failure secondary to CoViD-19 related pneumonia. Eur J Intern Med 2021; 86:17-21. [PMID: 33676805 PMCID: PMC7906530 DOI: 10.1016/j.ejim.2021.02.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 01/29/2021] [Accepted: 02/17/2021] [Indexed: 01/15/2023]
Abstract
In the last 11 months, the SARS-CoV-2 pandemic has overwhelmed and disrupted the whole world in health, social and economic terms. We are progressively learning more and more about the epidemiological and clinical features that distinguish CoViD-19 from any previous experience in the emergency and critical care setting. Experiences are multiplying with regard to the use of non-invasive respiratory support techniques in the context of acute hypoxemic respiratory failure secondary to CoViD-19-related pneumonia. Doubts still far outweigh certainties, but a growing series of mostly monocentric and retrospective studies are becoming available as concrete decision-making and operational support for healthcare workers. In this review the available studies and experiences about non-invasive respiratory support in the treatment of Covid-19 related respiratory failure, mainly coming from outside the ICU setting, will be discussed.
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Affiliation(s)
- Paolo Groff
- Emergency Department, Santa Maria della Misericordia Hospital, Perugia, Italy.
| | - Rodolfo Ferrari
- Emergency Department, Santa Maria della Scaletta Hospital, Imola, Italy
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44
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Stratifying pulmonary embolism risk in COVID-19 pneumonia in the Emergency Department: the Bergamo Emergency Room pulmonary embolism risk in COVID-19 score - a pilot study. Eur J Emerg Med 2021; 28:158-161. [PMID: 33674519 DOI: 10.1097/mej.0000000000000768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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45
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Kulkarni AR, Athavale AM, Sahni A, Sukhal S, Saini A, Itteera M, Zhukovsky S, Vernik J, Abraham M, Joshi A, Amarah A, Ruiz J, Hart PD, Kulkarni H. Deep learning model to predict the need for mechanical ventilation using chest X-ray images in hospitalised patients with COVID-19. BMJ INNOVATIONS 2021; 7:261-270. [PMID: 34192015 PMCID: PMC7931213 DOI: 10.1136/bmjinnov-2020-000593] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/18/2021] [Accepted: 02/13/2021] [Indexed: 01/28/2023]
Abstract
OBJECTIVES There exists a wide gap in the availability of mechanical ventilator devices and their acute need in the context of the COVID-19 pandemic. An initial triaging method that accurately identifies the need for mechanical ventilation in hospitalised patients with COVID-19 is needed. We aimed to investigate if a potentially deteriorating clinical course in hospitalised patients with COVID-19 can be detected using all X-ray images taken during hospitalisation. METHODS We exploited the well-established DenseNet121 deep learning architecture for this purpose on 663 X-ray images acquired from 528 hospitalised patients with COVID-19. Two Pulmonary and Critical Care experts blindly and independently evaluated the same X-ray images for the purpose of validation. RESULTS We found that our deep learning model predicted the need for mechanical ventilation with a high accuracy, sensitivity and specificity (90.06%, 86.34% and 84.38%, respectively). This prediction was done approximately 3 days ahead of the actual intubation event. Our model also outperformed two Pulmonary and Critical Care experts who evaluated the same X-ray images and provided an incremental accuracy of 7.24%-13.25%. CONCLUSIONS Our deep learning model accurately predicted the need for mechanical ventilation early during hospitalisation of patients with COVID-19. Until effective preventive or treatment measures become widely available for patients with COVID-19, prognostic stratification as provided by our model is likely to be highly valuable.
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Affiliation(s)
- Anoop R Kulkarni
- Innotomy Consulting, Bengaluru, India
- Lata Medical Research Foundation, Nagpur, India
| | - Ambarish M Athavale
- Department of Medicine, Division of Nephrology, Cook County Hospital, Chicago, Illinois, USA
| | - Ashima Sahni
- Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, USA
| | - Shashvat Sukhal
- Department of Medicine, Division of Pulmonary and Critical Care, Cook County Hospital, Chicago, Illinois, USA
| | - Abhimanyu Saini
- Department of Medicine, Division of Cardiology, Cook County Hospital, Chicago, Illinois, USA
| | - Mathew Itteera
- Department of Medicine, Division of Nephrology, Cook County Hospital, Chicago, Illinois, USA
| | - Sara Zhukovsky
- Rush Medical College, Rush University Medical Center, Chicago, Illinois, USA
| | - Jane Vernik
- Department of Medicine, Division of Nephrology, Cook County Hospital, Chicago, Illinois, USA
| | - Mohan Abraham
- Department of Medicine, Division of Nephrology, Cook County Hospital, Chicago, Illinois, USA
| | - Amit Joshi
- Department of Medicine, Division of Nephrology, Cook County Hospital, Chicago, Illinois, USA
| | - Amatur Amarah
- Department of Medicine, Division of Nephrology, Cook County Hospital, Chicago, Illinois, USA
| | - Juan Ruiz
- Department of Medicine, Division of Nephrology, Cook County Hospital, Chicago, Illinois, USA
| | - Peter D Hart
- Department of Medicine, Division of Nephrology, Cook County Hospital, Chicago, Illinois, USA
| | - Hemant Kulkarni
- Lata Medical Research Foundation, Nagpur, India
- M&H Research LLC, San Antonio, Texas, USA
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Robinson RE, Nightingale R, Frost F, Green T, Jones G, Nwosu N, Hampshire P, Brown D, Beadsworth M, Aston S, Gillespie A, Clark M, Fletcher T, Haslam N, Burhan H, Gautam M. The rapid development and deployment of a new multidisciplinary CPAP service outside of a critical care environment during the early stages of the COVID-19 pandemic. Future Healthc J 2021; 8:e156-e159. [PMID: 33791498 DOI: 10.7861/fhj.2020-0167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
The COVID-19 pandemic has led to a dramatic increase in patients presenting with type 1 respiratory failure. In order to protect our limited critical care capacity, we rapidly developed a new ward-based inpatient continuous positive airway pressure (CPAP) service with direct input from the respiratory, infectious diseases and critical care teams. Close collaboration between these specialties and new innovative solutions were required to facilitate this. CPAP equipment (normally reserved for domiciliary care) was adapted to reduce the pressure on our strained oxygen infrastructure. Side rooms on the infectious diseases ward were swiftly converted into new negative pressure areas using temporary installed ventilatory equipment, reducing the viral aerosol risk for staff. Novel patient monitoring solutions were used to protect staff while also ensuring patient safety. Staff training and specialist oversight was organised within days. The resulting service was successful, with over half (17/26 (65%)) of patients avoiding invasive ventilation.
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Affiliation(s)
- Ryan E Robinson
- Royal Liverpool Hospital, Liverpool, UK and Liverpool School of Tropical Medicine, Liverpool, UK
| | - Rebecca Nightingale
- Royal Liverpool Hospital, Liverpool, UK and Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Tom Green
- Royal Liverpool Hospital, Liverpool, UK
| | | | | | | | | | - Michael Beadsworth
- Royal Liverpool Hospital, Liverpool, UK and Liverpool School of Tropical Medicine, Liverpool, UK
| | - Stephen Aston
- Royal Liverpool Hospital, Liverpool, UK and Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | - Tom Fletcher
- Royal Liverpool Hospital, Liverpool, UK and Liverpool School of Tropical Medicine, Liverpool, UK
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Attaway AH, Scheraga RG, Bhimraj A, Biehl M, Hatipoğlu U. Severe covid-19 pneumonia: pathogenesis and clinical management. BMJ 2021; 372:n436. [PMID: 33692022 DOI: 10.1136/bmj.n436] [Citation(s) in RCA: 177] [Impact Index Per Article: 59.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Severe covid-19 pneumonia has posed critical challenges for the research and medical communities. Older age, male sex, and comorbidities increase the risk for severe disease. For people hospitalized with covid-19, 15-30% will go on to develop covid-19 associated acute respiratory distress syndrome (CARDS). Autopsy studies of patients who died of severe SARS CoV-2 infection reveal presence of diffuse alveolar damage consistent with ARDS but with a higher thrombus burden in pulmonary capillaries. When used appropriately, high flow nasal cannula (HFNC) may allow CARDS patients to avoid intubation, and does not increase risk for disease transmission. During invasive mechanical ventilation, low tidal volume ventilation and positive end expiratory pressure (PEEP) titration to optimize oxygenation are recommended. Dexamethasone treatment improves mortality for the treatment of severe and critical covid-19, while remdesivir may have modest benefit in time to recovery in patients with severe disease but shows no statistically significant benefit in mortality or other clinical outcomes. Covid-19 survivors, especially patients with ARDS, are at high risk for long term physical and mental impairments, and an interdisciplinary approach is essential for critical illness recovery.
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Affiliation(s)
- Amy H Attaway
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rachel G Scheraga
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Inflammation and Immunity, Cleveland Clinic, Cleveland, Ohio, USA
| | - Adarsh Bhimraj
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michelle Biehl
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Umur Hatipoğlu
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Coppadoro A, Benini A, Fruscio R, Verga L, Mazzola P, Bellelli G, Carbone M, Mulinacci G, Soria A, Noè B, Beck E, Di Sciacca R, Ippolito D, Citerio G, Valsecchi MG, Biondi A, Pesci A, Bonfanti P, Gaudesi D, Bellani G, Foti G. Helmet CPAP to treat hypoxic pneumonia outside the ICU: an observational study during the COVID-19 outbreak. Crit Care 2021; 25:80. [PMID: 33627169 PMCID: PMC7903369 DOI: 10.1186/s13054-021-03502-y] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 02/10/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Respiratory failure due to COVID-19 pneumonia is associated with high mortality and may overwhelm health care systems, due to the surge of patients requiring advanced respiratory support. Shortage of intensive care unit (ICU) beds required many patients to be treated outside the ICU despite severe gas exchange impairment. Helmet is an effective interface to provide continuous positive airway pressure (CPAP) noninvasively. We report data about the usefulness of helmet CPAP during pandemic, either as treatment, a bridge to intubation or a rescue therapy for patients with care limitations (DNI). METHODS In this observational study we collected data regarding patients failing standard oxygen therapy (i.e., non-rebreathing mask) due to COVID-19 pneumonia treated with a free flow helmet CPAP system. Patients' data were recorded before, at initiation of CPAP treatment and once a day, thereafter. CPAP failure was defined as a composite outcome of intubation or death. RESULTS A total of 306 patients were included; 42% were deemed as DNI. Helmet CPAP treatment was successful in 69% of the full treatment and 28% of the DNI patients (P < 0.001). With helmet CPAP, PaO2/FiO2 ratio doubled from about 100 to 200 mmHg (P < 0.001); respiratory rate decreased from 28 [22-32] to 24 [20-29] breaths per minute, P < 0.001). C-reactive protein, time to oxygen mask failure, age, PaO2/FiO2 during CPAP, number of comorbidities were independently associated with CPAP failure. Helmet CPAP was maintained for 6 [3-9] days, almost continuously during the first two days. None of the full treatment patients died before intubation in the wards. CONCLUSIONS Helmet CPAP treatment is feasible for several days outside the ICU, despite persistent impairment in gas exchange. It was used, without escalating to intubation, in the majority of full treatment patients after standard oxygen therapy failed. DNI patients could benefit from helmet CPAP as rescue therapy to improve survival. TRIAL REGISTRATION NCT04424992.
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Affiliation(s)
- Andrea Coppadoro
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
| | - Annalisa Benini
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
| | - Robert Fruscio
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
- grid.7563.70000 0001 2174 1754Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB Italy
| | - Luisa Verga
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
| | - Paolo Mazzola
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
- grid.7563.70000 0001 2174 1754Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB Italy
| | - Giuseppe Bellelli
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
- grid.7563.70000 0001 2174 1754Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB Italy
| | - Marco Carbone
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
- grid.7563.70000 0001 2174 1754Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB Italy
| | - Giacomo Mulinacci
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
- grid.7563.70000 0001 2174 1754Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB Italy
| | - Alessandro Soria
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
| | - Beatrice Noè
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
- grid.7563.70000 0001 2174 1754Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB Italy
| | - Eduardo Beck
- grid.413643.70000 0004 1760 8047ASST Monza, Desio Hospital, Desio, Italy
| | - Riccardo Di Sciacca
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
| | - Davide Ippolito
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
| | - Giuseppe Citerio
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
- grid.7563.70000 0001 2174 1754Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB Italy
| | - Maria Grazia Valsecchi
- grid.7563.70000 0001 2174 1754Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB Italy
| | - Andrea Biondi
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
- grid.7563.70000 0001 2174 1754Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB Italy
| | - Alberto Pesci
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
- grid.7563.70000 0001 2174 1754Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB Italy
| | - Paolo Bonfanti
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
- grid.7563.70000 0001 2174 1754Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB Italy
| | - Davide Gaudesi
- grid.7563.70000 0001 2174 1754Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB Italy
| | - Giacomo Bellani
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
- grid.7563.70000 0001 2174 1754Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB Italy
| | - Giuseppe Foti
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
- grid.7563.70000 0001 2174 1754Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB Italy
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Paglia S, Nattino G, Occhipinti F, Sala L, Targetti E, Cortellaro F, Cosentini R, Costantino G, Fichtner F, Mancarella M, Marinaro C, Sorlini C, Bertolini G, Acquistapace G, Agostinis M, Bonzi M, Brena N, Caruso S, Mascolo M, Massabò D, Scrignoli F. The Quick Walk Test: A Noninvasive Test to Assess the Risk of Mechanical Ventilation During COVID-19 Outbreaks. Acad Emerg Med 2021; 28:244-247. [PMID: 33249678 PMCID: PMC7753836 DOI: 10.1111/acem.14180] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 11/21/2020] [Accepted: 11/23/2020] [Indexed: 01/20/2023]
Affiliation(s)
| | - Giovanni Nattino
- the Laboratory of Clinical Epidemiology Department of Public Health Istituto di Ricerche Farmacologiche Mario Negri IRCCS Ranica (BG)Italy
| | - Federica Occhipinti
- the Laboratory of Clinical Epidemiology Department of Public Health Istituto di Ricerche Farmacologiche Mario Negri IRCCS Ranica (BG)Italy
| | - Luca Sala
- the Laboratory of Clinical Epidemiology Department of Public Health Istituto di Ricerche Farmacologiche Mario Negri IRCCS Ranica (BG)Italy
| | - Elena Targetti
- the Laboratory of Clinical Epidemiology Department of Public Health Istituto di Ricerche Farmacologiche Mario Negri IRCCS Ranica (BG)Italy
| | | | - Roberto Cosentini
- Emergency Department and Medicine ASST Papa Giovanni XXIII Bergamo (BG)Italy
| | - Giorgio Costantino
- Pronto Soccorso e Medicina d’Urgenza Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico MilanoItaly
- and the Università degli Studi di Milano Milano (MI) Italy
| | | | - Marta Mancarella
- Pronto Soccorso e Medicina d’Urgenza Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico MilanoItaly
| | - Claudia Marinaro
- Emergency Department and Medicine ASST Papa Giovanni XXIII Bergamo (BG)Italy
| | - Cristina Sorlini
- Accident and Emergency Services ASST Santi Paolo e Carlo Milano (MI)Italy
| | - Guido Bertolini
- the Laboratory of Clinical Epidemiology Department of Public Health Istituto di Ricerche Farmacologiche Mario Negri IRCCS Ranica (BG)Italy
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Abstract
Bergamo province was badly hit by the coronavirus disease 2019 (COVID-19) epidemic. We organised a public-funded, multidisciplinary follow-up programme for COVID-19 patients discharged from the emergency department or from the inpatient wards of ‘Papa Giovanni XXIII’ Hospital, the largest public hospital in the area. As of 31 July, the first 767 patients had completed the first post-discharge multidisciplinary assessment. Patients entered our programme at a median time of 81 days after discharge. Among them, 51.4% still complained of symptoms, most commonly fatigue and exertional dyspnoea, and 30.5% were still experiencing post-traumatic psychological consequences. Impaired lung diffusion was found in 19%. Seventeen per cent had D-dimer values two times above the threshold for diagnosis of pulmonary embolism (two unexpected and clinically silent pulmonary thrombosis were discovered by investigating striking D-dimer elevation). Survivors of COVID-19 exhibit a complex array of symptoms, whose common underlying pathology, if any, has still to be elucidated: a multidisciplinary approach is fundamental, to address the different problems and to look for effective solutions.
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