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Pisciotta W, Passannante A, Arina P, Alotaibi K, Ambler G, Arulkumaran N. High-flow nasal oxygen versus conventional oxygen therapy and noninvasive ventilation in COVID-19 respiratory failure: a systematic review and network meta-analysis of randomised controlled trials. Br J Anaesth 2024; 132:936-944. [PMID: 38307776 PMCID: PMC11103093 DOI: 10.1016/j.bja.2023.12.022] [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: 09/28/2023] [Revised: 11/17/2023] [Accepted: 12/18/2023] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND Noninvasive methods of respiratory support, including noninvasive ventilation (NIV), continuous positive airway pressure (CPAP), and high-flow nasal oxygen (HFNO), are potential strategies to prevent progression to requirement for invasive mechanical ventilation in acute hypoxaemic respiratory failure. The COVID-19 pandemic provided an opportunity to understand the utility of noninvasive respiratory support among a homogeneous cohort of patients with contemporary management of acute respiratory distress syndrome. We performed a network meta-analysis of studies evaluating the efficacy of NIV (including CPAP) and HFNO, compared with conventional oxygen therapy (COT), in patients with COVID-19. METHODS PubMed, Embase, and the Cochrane library were searched in May 2023. Standard random-effects meta-analysis was used first to estimate all direct pairwise associations and the results from all studies were combined using frequentist network meta-analysis. Primary outcome was treatment failure, defined as discontinuation of HFNO, NIV, or COT despite progressive disease. Secondary outcome was mortality. RESULTS We included data from eight RCTs with 2302 patients, (756 [33%] assigned to COT, 371 [16%] to NIV, and 1175 [51%] to HFNO). The odds of treatment failure were similar for NIV (P=0.33) and HFNO (P=0.25), and both were similar to that for COT (reference category). The odds of mortality were similar for all three treatments (odds ratio for NIV vs COT: 1.06 [0.46-2.44] and HFNO vs COT: 0.97 [0.57-1.65]). CONCLUSIONS Noninvasive ventilation, high-flow nasal oxygen, and conventional oxygen therapy are comparable with regards to treatment failure and mortality in COVID-19-associated acute respiratory failure. PROSPERO REGISTRATION CRD42023426495.
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Affiliation(s)
- Walter Pisciotta
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK
| | - Alberto Passannante
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK
| | - Pietro Arina
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK
| | - Khalid Alotaibi
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - Nishkantha Arulkumaran
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK.
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Beurton A, Kooistra EJ, De Jong A, Schiffl H, Jourdain M, Garcia B, Vimpère D, Jaber S, Pickkers P, Papazian L. Specific and Non-specific Aspects and Future Challenges of ICU Care Among COVID-19 Patients with Obesity: A Narrative Review. Curr Obes Rep 2024:10.1007/s13679-024-00562-3. [PMID: 38573465 DOI: 10.1007/s13679-024-00562-3] [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] [Accepted: 03/16/2024] [Indexed: 04/05/2024]
Abstract
PURPOSE OF REVIEW Since the end of 2019, the coronavirus disease 2019 (COVID-19) pandemic has infected nearly 800 million people and caused almost seven million deaths. Obesity was quickly identified as a risk factor for severe COVID-19, ICU admission, acute respiratory distress syndrome, organ support including mechanical ventilation and prolonged length of stay. The relationship among obesity; COVID-19; and respiratory, thrombotic, and renal complications upon admission to the ICU is unclear. RECENT FINDINGS The predominant effect of a hyperinflammatory status or a cytokine storm has been suggested in patients with obesity, but more recent studies have challenged this hypothesis. Numerous studies have also shown increased mortality among critically ill patients with obesity and COVID-19, casting doubt on the obesity paradox, with survival advantages with overweight and mild obesity being reported in other ICU syndromes. Finally, it is now clear that the increase in the global prevalence of overweight and obesity is a major public health issue that must be accompanied by a transformation of our ICUs, both in terms of equipment and human resources. Research must also focus more on these patients to improve their care. In this review, we focused on the central role of obesity in critically ill patients during this pandemic, highlighting its specificities during their stay in the ICU, identifying the lessons we have learned, and identifying areas for future research as well as the future challenges for ICU activity.
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Affiliation(s)
- Alexandra Beurton
- Department of Intensive Care, Hôpital Tenon, APHP, Paris, France.
- UMR_S 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, INSERM, Sorbonne Université, Paris, France.
| | - Emma J Kooistra
- Department of Intensive Care Medicine, Radboud University Medical Center, 6500HB, Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases, Radboud University Medical Center, 6500HB, Nijmegen, The Netherlands
| | - Audrey De Jong
- Anesthesia and Critical Care Department, Saint Eloi Teaching Hospital, University Montpellier 1, Montpellier, France
- Phymed Exp INSERM U1046, CNRS UMR 9214, Montpellier, France
| | - Helmut Schiffl
- Division of Nephrology, Department of Internal Medicine IV, University Hospital LMU Munich, Munich, Germany
| | - Mercedes Jourdain
- CHU Lille, Univ-Lille, INSERM UMR 1190, ICU Department, F-59037, Lille, France
| | - Bruno Garcia
- CHU Lille, Univ-Lille, INSERM UMR 1190, ICU Department, F-59037, Lille, France
| | - Damien Vimpère
- Anesthesia and Critical Care Department, Hôpital Necker, APHP, Paris, France
| | - Samir Jaber
- Anesthesia and Critical Care Department, Saint Eloi Teaching Hospital, University Montpellier 1, Montpellier, France
- Phymed Exp INSERM U1046, CNRS UMR 9214, Montpellier, France
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, 6500HB, Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases, Radboud University Medical Center, 6500HB, Nijmegen, The Netherlands
| | - Laurent Papazian
- Intensive Care Unit, Centre Hospitalier de Bastia, Bastia, Corsica, France
- Aix-Marseille University, Marseille, France
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Rucci JM, Law AC, Bolesta S, Quinn EK, Garcia MA, Gajic O, Boman K, Yus S, Goodspeed VM, Kumar V, Kashyap R, Walkey AJ. Variation in Sedative and Analgesic Use During the COVID-19 Pandemic and Associated Outcomes. CHEST CRITICAL CARE 2024; 2:100047. [PMID: 38576856 PMCID: PMC10994221 DOI: 10.1016/j.chstcc.2024.100047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
BACKGROUND Providing analgesia and sedation is an essential component of caring for many mechanically ventilated patients. The selection of analgesic and sedative medications during the COVID-19 pandemic, and the impact of these sedation practices on patient outcomes, remain incompletely characterized. RESEARCH QUESTION What were the hospital patterns of analgesic and sedative use for patients with COVID-19 who received mechanical ventilation (MV), and what differences in clinical patient outcomes were observed across prevailing sedation practices? STUDY DESIGN AND METHODS We conducted an observational cohort study of hospitalized adults who received MV for COVID-19 from February 2020 through April 2021 within the Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS) COVID-19 Registry. To describe common sedation practices, we used hierarchical clustering to group hospitals based on the percentage of patients who received various analgesic and sedative medications. We then used multivariable regression models to evaluate the association between hospital analgesia and sedation cluster and duration of MV (with a placement of death [POD] approach to account for competing risks). RESULTS We identified 1,313 adults across 35 hospitals admitted with COVID-19 who received MV. Two clusters of analgesia and sedation practices were identified. Cluster 1 hospitals generally administered opioids and propofol with occasional use of additional sedatives (eg, benzodiazepines, alpha-agonists, and ketamine); cluster 2 hospitals predominantly used opioids and benzodiazepines without other sedatives. As compared with patients in cluster 2, patients admitted to cluster 1 hospitals underwent a shorter adjusted median duration of MV with POD (β-estimate, -5.9; 95% CI, -11.2 to -0.6; P = .03). INTERPRETATION Patients who received MV for COVID-19 in hospitals that prioritized opioids and propofol for analgesia and sedation experienced shorter adjusted median duration of MV with POD as compared with patients who received MV in hospitals that primarily used opioids and benzodiazepines.
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Affiliation(s)
- Justin M Rucci
- Pulmonary Center, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine
- Center for Healhcare Organization and Implementation Research, VA Boston Healthcare System
| | - Anica C Law
- Pulmonary Center, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine
| | - Scott Bolesta
- Department of Pharmacy Practice, Nesbitt School of Pharmacy, Wilkes University, Wilkes-Barre, PA
| | - Emily K Quinn
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, University of Massachusetts Chan School of Medicine, Worcester MA
| | - Michael A Garcia
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington Medicine Valley Medical Center, Renton, WA
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Karen Boman
- Society of Critical Care Medicine, Mount Prospect, IL
| | - Santiago Yus
- Department of Intensive Care Medicine, La Paz University Hospital, Madrid, Spain
| | - Valerie M Goodspeed
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, University of Massachusetts Chan School of Medicine, Worcester MA
| | | | - Rahul Kashyap
- Department of Anesthesia and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Allan J Walkey
- Division of Health Systems Science, Department of Medicine, University of Massachusetts Chan School of Medicine, Worcester MA
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Michelson AP, Lyons PG, Nguyen NM, Reynolds D, McDonald R, McEvoy CA, Despotovic V, Brody SL, Kollef MH, Kraft BD. Use of Inhaled Epoprostenol in Patients With COVID-19 Receiving Humidified, High-Flow Nasal Oxygen Is Associated With Progressive Respiratory Failure. CHEST CRITICAL CARE 2023; 1:100019. [PMID: 38516615 PMCID: PMC10956404 DOI: 10.1016/j.chstcc.2023.100019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
BACKGROUND The clinical benefit of using inhaled epoprostenol (iEpo) through a humidified high-flow nasal cannula (HHFNC) remains unknown for patients with COVID-19. RESEARCH QUESTION Can iEpo prevent respiratory deterioration for patients with positive SARS-CoV-2 findings receiving HHFNC? STUDY DESIGN AND METHODS This multicenter retrospective cohort analysis included patients aged 18 years or older with COVID-19 pneumonia who required HHFNC treatment. Patients who received iEpo were propensity score matched to patients who did not receive iEpo. The primary outcome was time to mechanical ventilation or death without mechanical ventilation and was assessed using Kaplan-Meier curves and Cox proportional hazard ratios. The effects of residual confounding were assessed using a multilevel analysis, and a secondary analysis adjusted for outcome propensity also was performed in a multivariable model that included the entire (unmatched) patient cohort. RESULTS Among 954 patients with positive SARS-CoV-2 findings receiving HHFNC therapy, 133 patients (13.9%) received iEpo. After propensity score matching, the median number of days until the composite outcome was similar between treatment groups (iEpo: 5.0 days [interquartile range, 2.0-10.0 days] vs no-iEpo: 6.5 days [interquartile range, 2.0-11.0 days]; P = .26), but patients who received iEpo were more likely to meet the composite outcome in the propensity score-matched, multilevel, and multivariable unmatched analyses (hazard ratio, 2.08 [95% CI, 1.73-2.50]; OR, 4.72 [95% CI, 3.01-7.41]; and OR, 1.35 [95% CI, 1.23-1.49]; respectively). INTERPRETATION In patients with COVID-19 receiving HHFNC therapy, use of iEpo was associated with the need for invasive mechanical ventilation.
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Affiliation(s)
- Andrew P Michelson
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO.; Department of Medicine, the Institute for Informatics, Washington University School of Medicine, Saint Louis, MO
| | - Patrick G Lyons
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Nguyet M Nguyen
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Daniel Reynolds
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Rachel McDonald
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Colleen A McEvoy
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Vladimir Despotovic
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Steven L Brody
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Bryan D Kraft
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO
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Taghboulit NEI, Andrejak C, Mahjoub Y, Toublanc B, Mayeux I, Delomez J, Mercier M, Leriche P, Maizel J, Dupont H, Jounieaux V, Basille D. Long-term survival comparison between the first and second waves among 265 critical COVID-19 patients admitted to the ICU: A retrospective cohort study. Respir Med Res 2023; 84:101057. [PMID: 37918184 DOI: 10.1016/j.resmer.2023.101057] [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: 05/10/2023] [Revised: 09/28/2023] [Accepted: 10/02/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUD Management of severe COVID-19 patients admitted to ICU considerably evolved during the first months of the pandemic. It is unclear, however, whether these changes improved long-term survival of these critically ill patients. METHODS We conducted a retrospective cohort study in adults with COVID-19 pneumonia admitted to a French ICU between February 2020 and January 2021, a timeframe that covered the first two waves of the pandemic. Primary outcome was to compare long-term survival between the first and second waves. Survival predictor were identified using a Cox proportional-hazards model. RESULTS We included 265 patients in the cohort: 140 (52.8 %) and 125 (47.2 %) belonging to the first and second waves, respectively. Baseline characteristics of the patients were similar between the two waves. During W2, use of early corticotherapy increased (86.4% vs. 17.8 %; p <0.001), as well as high-flow oxygen therapy use (68.5% vs. 37.4 %; p<0.001). Need for invasive mechanical ventilation decreased (49.6% vs. 72.9 %; p <0.001) and ICU length of stay was shorter (11 [6-22] vs 19 [8-32]days; p = 0.008). ICU mortality was 32.8 % without significant difference between waves. Survival analysis revealed that 3 variables were independently associated with a worse long-term prognosis: a higher SAPS II score (1.05 [1.04-1.06]; p<0.001), a higher age (1.05 [1.01-1.08]; p = 0.005) and admission during W2 (2.22 [1.15-4.28]; p = 0.017). DISCUSSION Despite substantial changes on management of severe COVID-19 patients, we observed a decreased long-term survival among patients admitted during the second wave. We also noted a shorter ICU length of stay.
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Affiliation(s)
- Nour-El-Imane Taghboulit
- Department of Respiratory Disease and Critical Care Unit, University Hospital Centre Amiens-Picardie, Amiens, France 1, Rue du Professeur Christian Cabrol 80054 Amiens-Cedex, France
| | - Claire Andrejak
- Department of Respiratory Disease and Critical Care Unit, University Hospital Centre Amiens-Picardie, Amiens, France 1, Rue du Professeur Christian Cabrol 80054 Amiens-Cedex, France; AGIR Unit - UR4294, University Picardie Jules Verne, 1, rue des Louvels, 80037 Amiens Cedex 1, France; RECIF Unit, University Picardie Jules Verne, 1, rue des Louvels, 80037 Amiens Cedex 1, France
| | - Yazine Mahjoub
- Department of Anesthesiology and Critical Care Medicine, University Hospital Centre Amiens-Picardie, Amiens, France 1, Rue du Professeur Christian Cabrol 80054 Amiens-Cedex, France
| | - Bénédicte Toublanc
- Department of Respiratory Disease and Critical Care Unit, University Hospital Centre Amiens-Picardie, Amiens, France 1, Rue du Professeur Christian Cabrol 80054 Amiens-Cedex, France
| | - Isabelle Mayeux
- Department of Respiratory Disease and Critical Care Unit, University Hospital Centre Amiens-Picardie, Amiens, France 1, Rue du Professeur Christian Cabrol 80054 Amiens-Cedex, France
| | - Julia Delomez
- Department of Respiratory Disease and Critical Care Unit, University Hospital Centre Amiens-Picardie, Amiens, France 1, Rue du Professeur Christian Cabrol 80054 Amiens-Cedex, France
| | - Marie Mercier
- Department of Respiratory Disease and Critical Care Unit, University Hospital Centre Amiens-Picardie, Amiens, France 1, Rue du Professeur Christian Cabrol 80054 Amiens-Cedex, France
| | - Pauline Leriche
- Department of Respiratory Disease and Critical Care Unit, University Hospital Centre Amiens-Picardie, Amiens, France 1, Rue du Professeur Christian Cabrol 80054 Amiens-Cedex, France
| | - Julien Maizel
- Intensive Care Department, University Hospital Centre Amiens-Picardie, Amiens, France 1, Rue du Professeur Christian Cabrol 80054 Amiens-Cedex, France
| | - Hervé Dupont
- Department of Anesthesiology and Critical Care Medicine, University Hospital Centre Amiens-Picardie, Amiens, France 1, Rue du Professeur Christian Cabrol 80054 Amiens-Cedex, France
| | - Vincent Jounieaux
- Department of Respiratory Disease and Critical Care Unit, University Hospital Centre Amiens-Picardie, Amiens, France 1, Rue du Professeur Christian Cabrol 80054 Amiens-Cedex, France; AGIR Unit - UR4294, University Picardie Jules Verne, 1, rue des Louvels, 80037 Amiens Cedex 1, France
| | - Damien Basille
- Department of Respiratory Disease and Critical Care Unit, University Hospital Centre Amiens-Picardie, Amiens, France 1, Rue du Professeur Christian Cabrol 80054 Amiens-Cedex, France; AGIR Unit - UR4294, University Picardie Jules Verne, 1, rue des Louvels, 80037 Amiens Cedex 1, France; RECIF Unit, University Picardie Jules Verne, 1, rue des Louvels, 80037 Amiens Cedex 1, France.
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Keshavjee S, Jivraj NK, Tejpal A, Sklar MC. Non-invasive support for the hypoxaemic patient. Br J Hosp Med (Lond) 2023; 84:1-10. [PMID: 36708347 DOI: 10.12968/hmed.2022.0420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Optimisation of oxygenation strategies in patients with hypoxaemic respiratory failure is a top priority for acute care physicians, as hypoxaemic respiratory failure is one of the leading causes of admission. Various oxygenation methods range from non-invasive face masks to high flow nasal cannulae, which have advantages and disadvantages for this heterogeneous patient group. Focus has turned toward examining the benefits of non-invasive ventilation, as this was heavily researched in resource-limited settings during the COVID-19 pandemic. The oxygenation strategy should be determined on an individualised basis for patients, and with new evidence from the COVID-19 pandemic, providers may now consider placing further emphasis on non-invasive approaches. As non-invasive ventilation continues to be used in increasing frequency, new methods of monitoring patient response, including when to escalate ventilation strategy, will need to be validated.
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Affiliation(s)
- Sara Keshavjee
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Naheed K Jivraj
- Interdepartmental Division of Critical Care Medicine and Department of Anesthesia, University of Toronto, Toronto, ON, Canada
| | - Ambika Tejpal
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Michael C Sklar
- Interdepartmental Division of Critical Care Medicine and Department of Anesthesia, University of Toronto, Toronto, ON, Canada
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