Predictors of high-flow nasal cannula failure in COVID-19 patients in a northern Peruvian hospital

OBJECTIVES

To determine predictors of high-flow nasal cannula (HFNC) failure in COVID-19 patients in a hospital in northern Peru.

METHODOLOGY

A retrospective cohort study was conducted during the months of March and May 2021. Data collection was based on a follow-up of 156 hospitalized patients with a diagnosis of COVID-19 who were users of HFNC. Epidemiological factors and clinical outcomes of treatment were analyzed from medical records. Epidemiological, analytical, and HFNC use-related characteristics were described using measures of absolute and relative frequencies, measures of central tendency, and dispersion. A multivariate Poisson regression analysis with robust variance and a 95% confidence interval was performed.

RESULTS

We found that age, SpO2/FiO2, work of breathing (WOB scale) at admission, degree of involvement, type of infiltrate on CT scan, lymphocytes, c-reactive protein, and D-dimer were significantly associated with failure of HFNC (p < 0.05). In addition, the WOB scale, PaO2/FiO2, SaO2/FiO2, and ROX index were variables that presented statistical significance (p < 0.0001). In the multivariate analysis model, a risk of failure of HFNC was determined with age > = 60 years [RRa 1.39 (1.05-1.85)] and PaO2/FiO2 score less than 100 [Rra 1.65 (0.99-2.76)].

CONCLUSIONS

Predictors to failure of HFNC are age older than 60 years and minimally significantly lower PaO2/FiO2 than 100.

Effects of high-flow nasal therapy on swallowing function: a scoping review

Background

High-flow nasal therapy is widely used in patients with respiratory failure in different clinical settings, but the effect of high-flow nasal therapy on respiratory-swallow coordination is unknown. Understanding this relationship is crucial, considering the necessity for patients to maintain adequate nutrition during daytime high-flow nasal therapy. This scoping review aims to synthesise available data on the effects of high-flow nasal therapy flow rates on swallowing function and the possible risk of aspiration during treatment, focusing on knowledge and evidence gaps.

Methods

PubMed, Scopus, Web of Science and Google Scholar databases were searched from inception to 30 May 2023 for studies reporting data on swallowing assessment in healthy adults or patients with acute or chronic respiratory failure receiving high-flow nasal therapy. Data on study design, patients' characteristics and quality outcomes were extracted.

Results

Eight studies were included, four including cohorts of healthy volunteers (n=148) and four including patients with acute or chronic respiratory failure (n=151). Study designs, patient populations and quality outcome measures were heterogeneous. Two studies indicated improvement while four articles showed impairment in swallowing function during high-flow nasal therapy; two studies showed that patients' overall clinical picture and underlying medical conditions influenced swallowing-breathing coordination rather than high-flow nasal therapy per se.

Conclusion

This scoping review found limited and controversial evidence on the impact of high-flow nasal therapy on swallowing function. Remarkably, methods for swallowing function assessment were quite heterogeneous. Additional research is required to test the effect of high-flow nasal therapy on respiratory-swallowing coordination.

Failure Prediction of High-Flow Nasal Cannula at the Conventional Oxygen Therapy Phase in the Emergency Department

INTRODUCTION

The use of high-flow nasal cannula (HFNC) in patients with acute hypoxemic respiratory failure has been increasing in the emergency department (ED). However, studies are lacking on the prediction of HFNC failure before therapy initiation in the ED. We investigated whether the existing indices, such as the ratio of pulse oximetry oxygen saturation/fraction of inspired oxygen to respiratory rate (ROX) and ratio of ROX index to heart rate (ROX-HR), can accurately predict HFNC failure at the conventional oxygen therapy phase in the ED.

METHODS

This retrospective single-center study included patients treated with HFNC in the ED. The ROX and ROX-HR indices were calculated before initiating HFNC. An estimated fraction of inspired oxygen was used for conventional oxygen therapy. We plotted each index's receiver operating characteristics curve and calculated the area under the curve (AUC) for diagnostic capacity. The optimal cutoff values were assessed using the Youden index. The primary outcome was HFNC failure, defined as intubation in the ED.

RESULTS

Among the 97 included patients, 25 (25.8%) failed HFNC therapy in the ED. The ROX and ROX-HR indices measured before initiating HFNC showed AUCs of 0.709 and 0.754, respectively. A ROX index of <5.614 and a ROX-HR index of <6.152 were associated with a high risk of intubation, even after correcting for confounding variables.

CONCLUSION

The ROX and ROX-HR indices measured before initiating HFNC provide a relatively fair predictive value of HFNC failure in the ED.

Efficiency of continuous positive airway pressure and high-flow nasal oxygen therapy in critically ill patients with COVID-19

OBJECTIVE

Critically ill patients with COVID-19 develop acute respiratory distress syndrome characterized by relatively well-preserved pulmonary compliance but severe hypoxemia. The challenge in managing such patients lies in optimizing oxygenation, which can be achieved through either high oxygen flow or noninvasive mechanical ventilation. This study was performed to compare the efficiency of two methods of noninvasive oxygen therapy: continuous positive airway pressure (CPAP) and high-flow nasal oxygen therapy (HFNO).

METHODS

This retrospective cohort study involved 668 patients hospitalized in the intensive care unit (ICU) of the "Sf. Apostol Andrei" Emergency Clinical Hospital, Galati, Romania from 1 April 2020 to 31 March 2021 (CPAP, n = 108; HFNO, n = 108).

RESULTS

Mortality was significantly lower in the CPAP and HFNO groups than in the group of patients who underwent intubation and mechanical ventilation after ICU admission. Mortality in the ICU was not significantly different between the CPAP and HFNO groups.

CONCLUSIONS

HFNO and CPAP represent efficient alternative therapies for patients with severe COVID-19 whose respiratory treatment has failed. Studies involving larger groups of patients are necessary to establish a personalized, more complex management modality for critically ill patients with COVID-19.

Effectiveness and safety of a new helmet CPAP configuration allowing tidal volume monitoring in patients with COVID-19

BACKGROUND

High generated tidal volumes (Vt) have been correlated with higher risk of self-induced lung injury and worse clinical outcome. This study aimed to evaluate the effectiveness and safety of a new helmet continuous positive airway pressure delivered (h-CPAP) configuration allowing Vt monitoring in patients affected by COVID-19.

METHODS

This prospective observational study was performed in the respiratory intermediate care unit of University Hospital in Turin, Italy, between March 24th, and June 15th, 2020. Included patients were treated with CPAP via a single-limb intentional leak configuration by a turbine-driven ventilator, provided with a dedicated patch. Effectiveness and safety of the configuration and healthcare workers safety were the outcomes of the study.

MAIN FINDINGS

Thirty-five patients were included in this study. Median age was 67 years (IQR 57-76 years), and 30 patients (85.7%) were men. Median value of overall leaks (intentional plus unintentional) was 68 L/min (IQR 63-75). Reliability of Vt measurements was 100%. An out of scale of Vt (above 50% compared to the previous values) was never recorded. Six patients (17.1%) needed more than two helmet replacements, due to leak test >10 l/min. Arm oedema and skin breakdowns were reported in sixteen (45.7%) and seven (20%) patients respectively. Among the 63 healthcare workers involved in the care of COVID-19 patients during the study only one was positive at RT-PCR nasopharyngeal swab testing.

CONCLUSIONS

The use of h-CPAP for treating COVID-19 in this configuration allowed for reliable Vt monitoring. Further studies evaluating this configuration in larger patients' cohorts are needed.

SARS-CoV-2 pneumonia and Eisenmenger's syndrome: doubling the challenge

Eisenmenger's syndrome (ES) is the most severe phenotype of pulmonary arterial hypertension secondary to congenital heart disease. In these cases, significant systemic-to-pulmonary (left-to-right) shunting triggers the development of pulmonary vascular disease and pulmonary hypertension. In cases of acute hypoxemic respiratory failure in patients with ES, high-flow nasal cannula (HFNC) oxygen therapy should be considered as a first-line approach in order to avoid pulmonary complications and right ventricular overload related to positive pressure ventilation. Here, we report a case of HFNC use in a patient with COVID-19 infection and ES.

High-Flow Nasal Therapy in Acute and Chronic Respiratory Failure: Past, Present, and Future

High-flow nasal therapy (HFNT) was introduced into clinical practice in the early 2000s as a form of noninvasive respiratory support (NIRS) [...]

High-flow nasal oxygen versus conventional oxygen therapy in patients with COVID-19 pneumonia and mild hypoxaemia: a randomised controlled trial

RATIONALE

In patients with COVID-19 pneumonia and mild hypoxaemia, the clinical benefit of high-flow nasal oxygen (HFNO) remains unclear. We aimed to examine whether HFNO compared with conventional oxygen therapy (COT) could prevent escalation of respiratory support in this patient population.

METHODS

In this multicentre, randomised, parallel-group, open-label trial, patients with COVID-19 pneumonia and peripheral oxygen saturation (SpO2) ≤92% who required oxygen therapy were randomised to HFNO or COT. The primary outcome was the rate of escalation of respiratory support (ie, continuous positive airway pressure, non-invasive ventilation or invasive mechanical ventilation) within 28 days. Among secondary outcomes, clinical recovery was defined as the improvement in oxygenation (SpO2 ≥96% with fractional inspired oxygen (FiO2) ≤30% or partial pressure of arterial carbon dioxide/FiO2 ratio >300 mm Hg).

RESULTS

Among 364 randomised patients, 55 (30.3%) of 181 patients assigned to HFNO and 70 (38.6%) of 181 patients assigned to COT underwent escalation of respiratory support, with no significant difference between groups (absolute risk difference -8.2% (95% CI -18% to +1.4%); RR 0.79 (95% CI 0.59 to 1.05); p=0.09). There was no significant difference in clinical recovery (69.1% vs 60.8%; absolute risk difference 8.2% (95% CI -1.5% to +18.0%), RR 1.14 (95% CI 0.98 to 1.32)), intensive care unit admission (7.7% vs 11.0%, absolute risk difference -3.3% (95% CI -9.3% to +2.6%)), and in hospital length of stay (11 (IQR 8-17) vs 11 (IQR 7-20) days, absolute risk difference -1.0% (95% CI -3.1% to +1.1%)).

CONCLUSIONS

Among patients with COVID-19 pneumonia and mild hypoxaemia, the use of HFNO did not significantly reduce the likelihood of escalation of respiratory support.

TRIAL REGISTRATION NUMBER

NCT04655638.

Lessons from COVID-19 in the management of acute respiratory failure

Accumulated evidence supports the efficacy of noninvasive respiratory support therapies in coronavirus disease 2019 (COVID-19)-related acute hypoxaemic respiratory failure, alleviating admissions to intensive care units. Noninvasive respiratory support strategies, including high-flow oxygen therapy, continuous positive airway pressure via mask or helmet and noninvasive ventilation, can be alternatives that may avoid the need for invasive ventilation. Alternating different noninvasive respiratory support therapies and introducing complementary interventions, like self-proning, may improve outcomes. Proper monitoring is warranted to ensure the efficacy of the techniques and to avoid complications while supporting transfer to the intensive care unit. This article reviews the latest evidence on noninvasive respiratory support therapies in COVID-19-related acute hypoxaemic respiratory failure.

How long is too long: A retrospective study evaluating the impact of the duration of noninvasive oxygenation support strategies (high flow nasal cannula & BiPAP) on mortality in invasive mechanically ventilated patients with COVID-19

BACKGROUND/AIM

We investigated the association of noninvasive oxygenation support [high flow nasal cannula (HFNC) and BiPAP], timing of invasive mechanical ventilation (IMV), and inpatient mortality among patients hospitalized with COVID-19.

METHODS

Retrospective chart review study of patients hospitalized with COVID-19 (ICD-10 code U07.1) and received IMV from March 2020-October 2021. Charlson comorbidity index (CCI) was calculated; Obesity defined as body mass index (BMI) ≥ 30 kg/m2; morbid obesity was BMI ≥ 40 kg/m2. Clinical parameters/vital signs recorded at time of admission.

RESULTS

709 COVID-19 patients underwent IMV, predominantly admitted from March-May 2020 (45%), average age 62±15 years, 67% male, 37% Hispanic, and 9% from group living settings. 44% had obesity, 11% had morbid obesity, 55% had type II diabetes, 75% had hypertension, and average CCI was 3.65 (SD = 3.11). Crude mortality rate was 56%. Close linear association of age with inpatient-mortality risk was found [OR (95% CI) = 1.35 (1.27-1.44) per 5 years, p<0.0001)]. Patients who died after IMV received noninvasive oxygenation support significantly longer: 5.3 (8.0) vs. 2.7 (SD 4.6) days; longer use was also independently associated with a higher risk of inpatient-mortality: OR = 3.1 (1.8-5.4) for 3-7 days, 7.2 (3.8-13.7) for ≥8 days (reference: 1-2 days) (p<0.0001). The association magnitude varied between age groups: 3-7 days duration (ref: 1-2 days), OR = 4.8 (1.9-12.1) in ≥65 years old vs. 2.1 (1.0-4.6) in <65 years old. Higher mortality risk was associated with higher CCI in patients ≥65 (P = 0.0082); among younger patients, obesity (OR = 1.8 (1.0-3.2) or morbid obesity (OR = 2.8;1.4-5.9) (p<0.05) were associated. No mortality association was found for sex or race.

CONCLUSION

Time spent on noninvasive oxygenation support [as defined by high flow nasal cannula (HFNC) and BiPAP] prior to IMV increased mortality risk. Research for the generalizability of our findings to other respiratory failure patient populations is needed.

Comment on Liu et al. Application of High-Flow Nasal Cannula in COVID-19: A Narrative Review. Life 2022, 12, 1419

We read the article "Application of High-Flow Nasal Cannula in COVID-19: A Narrative Review" by Liu and colleagues [...].

The right interface for the right patient in noninvasive ventilation: a systematic review

INTRODUCTION

Research in the field of noninvasive ventilation (NIV) has contributed to the development of new NIV interfaces. However, interface tolerance plays a crucial role in determining the beneficial effects of NIV therapy.

AREAS COVERED

This systematic review explores the most significant scientific research on NIV interfaces, with a focus on the potential impact that their design might have on treatment adherence and clinical outcomes. The rationale on the choice of the right interface among the wide variety of devices that are currently available is discussed here.

EXPERT OPINION

The paradigm "The right mask for the right patient" seems to be difficult to achieve in real life. Ranging from acute to chronic settings, the gold standard should include the tailoring of NIV interfaces to patients' needs and preferences. However, such customization may be hampered by issues of economic nature. High production costs and the increasing demand represent consistent burdens and have to be considered when dealing with patient-tailored NIV interfaces. New research focusing on developing advanced and tailored NIV masks should be prioritized; indeed, interfaces should be designed according to the specific patient and clinical setting where they need to be used.

Outcomes of COVID-19 Patients Admitted to the Intermediate Respiratory Care Unit: Non-Invasive Respiratory Therapy in a Sequential Protocol

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.

SIMEU position paper on non-invasive respiratory support in COVID-19 pneumonia

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.

Cardiac arrest and coronavirus disease 2019

PURPOSE OF REVIEW

The impact of the coronavirus disease 2019 (COVID-19) on the cardiovascular system has been highlighted since the very first weeks after the severe acute respiratory syndrome coronavirus 2 identification. We reviewed the influence of COVID-19 pandemic on cardiac arrest, both considering those occurred out of the hospital (OHCA) and in the hospital (IHCA).

RECENT FINDINGS

An increase in OHCA incidence occurred in different countries, especially in those regions most burdened by the COVID-19, as this seems to be bounded to the pandemic trend. A change of OHCA patients' characteristics, with an increase of the OHCA occurred at home, a decrease in bystander cardiopulmonary resuscitation and automated external defibrillator use before Emergency Medical Service (EMS) arrival and an increase in non-shockable rhythms, have been highlighted. A dramatic drop in the OHCA patients' survival was pointed out in almost all the countries, regardless of the high or low-incidence of COVID-19 cases. Concerning IHCA, a reduction in survival was highlighted in patients with COVID-19 who sustained a cardiac arrest.

SUMMARY

Cardiac arrest occurrence and survival were deeply affected by the pandemic. Informative campaigns to the population to call EMS in case of need and the re-allocation of the prehospital resources basing on the pandemic trend are needed to improve survival.

Observational study of changes in utilization and outcomes in mechanical ventilation in COVID-19

Background

The role of non-invasive ventilation (NIV) in severe COVID-19 remains a matter of debate. Therefore, the utilization and outcome of NIV in COVID-19 in an unbiased cohort was determined.

Aim

The aim was to provide a detailed account of hospitalized COVID-19 patients requiring non-invasive ventilation during their hospital stay. Furthermore, differences of patients treated with NIV between the first and second wave are explored.

Methods

Confirmed COVID-19 cases of claims data of the Local Health Care Funds with non-invasive and/or invasive mechanical ventilation (MV) in the spring and autumn pandemic period in 2020 were comparable analysed.

Results

Nationwide cohort of 17.023 cases (median/IQR age 71/61–80 years, 64% male) 7235 (42.5%) patients primarily received IMV without NIV, 4469 (26.3%) patients received NIV without subsequent intubation, and 3472 (20.4%) patients had NIV failure (NIV-F), defined by subsequent endotracheal intubation. The proportion of patients who received invasive MV decreased from 75% to 37% during the second period. Accordingly, the proportion of patients with NIV exclusively increased from 9% to 30%, and those failing NIV increased from 9% to 23%. Median length of hospital stay decreased from 26 to 21 days, and duration of MV decreased from 11.9 to 7.3 days. The NIV failure rate decreased from 49% to 43%. Overall mortality increased from 51% versus 54%. Mortality was 44% with NIV-only, 54% with IMV and 66% with NIV-F with mortality rates steadily increasing from 62% in early NIV-F (day 1) to 72% in late NIV-F (>4 days).

Conclusions

Utilization of NIV rapidly increased during the autumn period, which was associated with a reduced duration of MV, but not with overall mortality. High NIV-F rates are associated with increased mortality, particularly in late NIV-F.

Noninvasive ventilation in patients with COVID-19 from the perspective of the risk of contamination: a narrative review

INTRODUCTION

noninvasive ventilation (NIV) can be a useful resource to treat acute respiratory failure (ARF), which occurs in patients with COVID-19. However, it is important to consider that there are still no clinical studies that have verified the safety of its use in increase of contamination.

AREAS COVERED

Given the potential benefits and simultaneous concerns over the use of NIV in patients with COVID-19, further inquiry is necessary to reach a clinical consensus and provide recommendations for safe use, avoiding contamination. In this context, this narrative review, which included articles published in the Embase, SciELO, PEDro, PubMed and Cochrane up to August 2021, is focused to evaluate available studies related to interfaces, types of circuits, recommended filters, cares for the environment and protective factors for NIV use in patients with COVID-19.

EXPERT OPINION

The studies analyzed recommend that the use of NIV can be safe: 1) with equipment that allows the use of the helmet as a safer interface; 2) with double circuit and antimicrobial filter in the expiratory branch; 3) in an environment that allows negative pressure, reducing the dispersion of aerosol particles in the environment; 4) the health team must use the recommended PPE to avoid contamination.

Feasibility and Clinical Outcomes of a Step Up Noninvasive Respiratory Support Strategy in Patients with Severe COVID-19 Pneumonia

The best noninvasive respiratory strategy in patients with Coronavirus Disease 2019 (COVID-19) pneumonia is still discussed. We aimed at assessing the rate of endotracheal intubation (ETI) in patients treated with continuous positive airway pressure (CPAP) and noninvasive ventilation (NIV) if CPAP failed. Secondary outcomes were in-hospital mortality and in-hospital length of stay (LOS). A retrospective, observational, multicenter study was conducted in intermediate-high dependency respiratory units of two Italian university hospitals. Consecutive patients with COVID-19 treated with CPAP were enrolled. Thoraco-abdominal asynchrony or hemodynamic instability led to ETI. Patients showing SpO₂ ≤ 94%, respiratory rate ≥ 30 bpm or accessory muscle activation on CPAP received NIV. Respiratory distress and desaturation despite NIV eventually led to ETI. 156 patients were included. The overall rate of ETI was 30%, mortality 18% and median LOS 24 (17–32) days. Among patients that failed CPAP (n = 63), 28% were intubated, while the remaining 72% received NIV, of which 65% were intubated. Patients intubated after CPAP showed lower baseline PaO₂/FiO₂, lower lymphocyte counts and higher D-dimer values compared with patients intubated after CPAP + NIV. Mortality was 22% with CPAP + ETI, and 20% with CPAP + NIV + ETI. In the case of CPAP failure, a NIV trial appears feasible, does not deteriorate respiratory status and may reduce the need for ETI in COVID-19 patients.

Paradoxical role of oxygen in the treatment of patients with COVID-19

Dear Editor, Coronavirus disease-2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) was declared a pandemic by WHO on 11 March 2020 and has adversely affected human society and disrupted global health...

Usefulness of the HACOR score in predicting success of CPAP in COVID-19-related hypoxemia

Introduction

In COVID-19 associated hypoxemic acute respiratory failure (ARF) without mandatory indication for urgent endotracheal intubation, a trial of CPAP may be considered. We aimed to evaluate HACOR (heart rate, acidosis, consciousness, oxygenation, respiratory rate) score performance in these patients as predictor of CPAP failure.

Methods

Prospective observational multicentric study (three centers in different countries), including adult patients with SARS-CoV-2 pneumonia admitted to a respiratory intermediate care unit, presenting PaO₂/FiO₂ < 300 and PaCO₂ < 45 mmHg, who received CPAP. One hour after starting CPAP, HACOR was calculated.

Results

We enrolled 128 patients, mean age 61,7 years. Mean HACOR at 1 h after starting CPAP was 3,27 ± 3,84 and mean PaO₂/FiO₂ was 203,30 ± 92,21 mmHg; 35 patients (27,3 %) presented CPAP failure: 29 underwent oro-tracheal intubation and 6 died due to COVID-19 (all having a do-not-intubate order). HACOR accuracy for predicting CPAP failure was 82,03 %, while PaO₂/FiO2 accuracy was 81,25 %.

Conclusion

Although HACOR score had a good diagnostic performance in predicting CPAP failure in COVID-19-related ARF, PaO₂/FiO₂ has also shown to be a good predictor of failure.

Mortality in mechanically ventilated patients with COVID-19: a systematic review

Introduction: The use of mechanical ventilation associated with acute hypoxemic respiratory failure, the most common complication in critically ill COVID-19 patients, defines a high risk population that requires specific consideration of outcomes and treatment practices.Areas covered: This review evaluates existing information about mortality rates and effectiveness of antiviral, immune-modulating, and anticoagulation treatments in COVID-19 patients who received mechanical ventilation. The mortality rate and follow-up periods in patients receiving mechanical ventilation ranged widely. Antivirals, including remdesivir and convalescent plasma, have shown no definitive mortality benefit in this population despite positive results in other COVID-19 patients. Dexamethasone was associated with an absolute reduction in 28-day mortality by 12.3% (95% CI, 6.3 to 17.6), after adjusting for age. Reduced mortality has been demonstrated with tocilizumab use alongside corticosteroids. Evidence is inconclusive for therapeutic anticoagulation, and further studies are needed to determine the comparative benefit of prophylactic anticoagulation.Expert opinion: Significant variation and high mortality rates in mechanically ventilated patients necessitate more standardized outcome measurements, increased consideration of risk factors to reduce intubation, and improved treatment practices. Anticoagulation and dexamethasone should be incorporated in the treatment of patients receiving invasive mechanical ventilation, while more rigorous studies are required for other potential treatments.

The roles of noninvasive mechanical ventilation with helmet in patients with acute respiratory failure: A systematic review and meta-analysis

Objective

To compare the safety and effectiveness between helmet and face mask noninvasive mechanical ventilation (NIMV) in patients with acute respiratory failure (ARF).

Methods

English databases included PubMed, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science. Chinese databases involved Wanfang Data, China Knowledge Resource Integrated Database and Chinese Biological Medicine Database. Randomized controlled trials (RCTs) comparing helmet and face mask NIMV for patients with ARF were searched. Meta-analysis was performed using Review manager 5.1.0.

Results

Twelve trials with a total of 569 patients were eligible. Our meta-analysis showed that, comparing with face mask, helmet could significantly decrease the incidences of intolerance [risk ratio (RR) 0.19; 95% confidence interval (CI) 0.09−0.39], facial skin ulcer (RR 0.19; 95% CI 0.08−0.43) and aerophagia (RR 0.15; 95% CI 0.06−0.37), reduce respiratory rate [mean difference (MD) -3.10; 95% CI -4.85 to -1.34], intubation rate (RR 0.39; 95% CI 0.26−0.59) and hospital mortality (RR 0.62; 95% CI 0.39−0.99) in patients with ARF, and improve oxygenation index in patients with hypoxemic ARF (MD 55.23; 95% CI 31.37−79.09). However, subgroupanalysis for hypercapnic ARF revealed that PaCO₂ was significantly reduced in face mask group compared with helmet group (MD 5.34; 95% CI 3.41−7.27).

Conclusion

NIMV with helmet can improve the patient’s tolerance, reduce adverse events, increase oxygenation effect, and decrease intubation rate and hospital mortality comparing to face mask. However, the low number of patients from included studies may preclude strong conclusions. Large RCTs are still needed to provide more robust evidence.

Non-invasive respiratory support in the treatment of acute hypoxemic respiratory failure secondary to CoViD-19 related pneumonia

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.

Home Management of Patients with Moderate or Severe Respiratory Failure Secondary to COVID-19, Using Remote Monitoring and Oxygen with or without HFNC

BACKGROUND

Home treatment of patients affected by COVID-19 is still a matter of daily debate. During the clinical evolution of the disease, there are high risks of lung failure, which requires oxygen therapy. Here, we report our clinical experience with at-home treatment using high-flow nasal cannula in non-hospitalised patients with confirmed COVID-19.

PATIENTS AND METHODS

In this study, 18 patients with moderate-to-severe respiratory failure secondary to COVID-19 were monitored at home daily for temperature and SpO2 measurements. Other parameters such as saturation of peripheral oxygen (SpO2), SpO2/FiO2 (fraction of inspired oxygen), temperature, and lung performance were monitored periodically. Depending on oxygen requirements, the patients also received either standard oxygen via a face mask or, if higher FiO2 required, high-flow nasal cannula (HFNC).

RESULTS

All 18 patients had favourable outcomes and recovered from COVID-19. No death was recorded in this group.

CONCLUSION

Our clinical experience proves that high-flow nasal cannula oxygen therapy may be considered for at-home treatment of COVID-19 patients with moderate lung failure. This could be useful for further treatment during the pandemic and may also be considered in future epidemics.

Performance of EasyBreath Decathlon Snorkeling mask for delivering continuous positive airway pressure

During the COVID-19 pandemic, the need for noninvasive respiratory support devices has dramatically increased, sometimes exceeding hospital capacity. The full-face Decathlon snorkeling mask, EasyBreath (EB mask), has been adapted to deliver continuous positive airway pressure (CPAP) as an emergency respiratory interface. We aimed to assess the performance of this modified EB mask and to test its use during different gas mixture supplies. CPAP set at 5, 10, and 15 cmH₂O was delivered to 10 healthy volunteers with a high-flow system generator set at 40, 80, and 120 L min^-1 and with a turbine-driven ventilator during both spontaneous and loaded (resistor) breathing. Inspiratory CO₂ partial pressure (PiCO₂), pressure inside the mask, breathing pattern and electrical activity of the diaphragm (EAdi) were measured at all combinations of CPAP/flows delivered, with and without the resistor. Using the high-flow generator set at 40 L min^-1, the PiCO₂ significantly increased and the system was unable to maintain the target CPAP of 10 and 15 cmH₂O and a stable pressure within the respiratory cycle; conversely, the turbine-driven ventilator did. EAdi significantly increased with flow rates of 40 and 80 L min^-1 but not at 120 L min^-1 and with the turbine-driven ventilator. EB mask can be safely used to deliver CPAP only under strict constraints, using either a high-flow generator at a flow rate greater than 80 L min^-1, or a high-performance turbine-driven ventilator.

Personal protective equipment use by healthcare workers in intensive care unit during the early phase of COVID-19 pandemic in Italy: a secondary analysis of the PPE-SAFE survey

BACKGROUND

Italy was the first Western country to be heavily affected by COVID-19. Healthcare workers (HCWs) were exposed to a high risk of occupational infection, partially due to insufficient personal protective equipment (PPE) supplies. This study aimed to describe the practices, availability, training, confidence in PPE use and the adverse effects due to extended PPE use, as reported by HCWs in Italy. We also aimed to provide a comparison between Italian data and those from other countries.

METHODS

This study was a secondary analysis of a previously published international study, the PPE-SAFE Survey, conducted in April 2020. Data were analysed from the original study database.

RESULTS

We analysed the responses from 380 healthcare workers based in Italy, out of the 2711 respondents to the international survey. Among the Italian respondents, FFP2 and FFP3 respirators or equivalent were the most used masks for routine tasks (respectively 188/380, 50%; and 163/380, 43%). The median time of wearing PPE without taking a break was 5 h [interquartile range (IQR) 4-6], with statistically significant difference from other countries [median 4 h (IQR 2-5) p < 0.0001]. In Italy, 249 out of 380 (65%) HCWs had never performed a formal fit test for a N95 mask or equivalent and 91/380 (24%) never had a partner for donning and doffing procedures. Most of the respondents (299/380, 79%) had received formal training in PPE use at any time.

CONCLUSION

Most of the surveyed Italian HCWs reported working at above usual capacity, long shifts with PPE without breaks and routine use in intensive care unit of aerosol protection (e.g. FFP2/FFP3), hazmat suits and face shields/visors. The correct adherence to safety procedures (e.g. donning/doffing in pairs, performing fit test) has substantial scope for improvement in the future.

Continuous Positive Airway Pressure (CPAP) face-mask ventilation is an easy and cheap option to manage a massive influx of patients presenting acute respiratory failure during the SARS-CoV-2 outbreak: A retrospective cohort study

INTRODUCTION

Because of the COVID-19 pandemic, intensive care units (ICU) can be overwhelmed by the number of hypoxemic patients.

MATERIAL AND METHODS

This single centre retrospective observational cohort study took place in a French hospital where the number of patients exceeded the ICU capacity despite an increase from 18 to 32 beds. Because of this, 59 (37%) of the 159 patients requiring ICU care were referred to other hospitals. From 27th March to 23rd April, consecutive patients who had respiratory failure or were unable to maintain an SpO2 > 90%, despite receiving 10-15 l/min of oxygen with a non-rebreather mask, were treated by continuous positive airway pressure (CPAP) unless the ICU physician judged that immediate intubation was indicated. We describe the characteristics, clinical course, and outcomes of these patients. The main outcome under study was CPAP discontinuation.

RESULTS

CPAP was initiated in 49 patients and performed out of ICU in 41 (84%). Median age was 65 years (IQR = 54-71) and 36 (73%) were men. Median respiratory rate before CPAP was 36 (30-40) and median SpO2 was 92% (90-95) under 10 to 15 L/min oxygen flow. Median duration of CPAP was 3 days (IQR = 1-5). Reasons for discontinuation of CPAP were: intubation in 25 (51%), improvement in 16 (33%), poor tolerance in 6 (12%) and death in 2 (4%) patients. A decision not to intubate had been taken for 8 patients, including the 2 who died while on CPAP. Two patients underwent less than one hour CPAP for poor tolerance. In the end, 15 (38%) out of 39 evaluable patients recovered with only CPAP whereas 24 (62%) were intubated.

CONCLUSIONS

CPAP is feasible in a non-ICU environment in the context of massive influx of patients. In our cohort up to 1/3 of the patients presenting with acute respiratory failure recovered without intubation.