Associations of Awake Prone Positioning-Induced Changes in Physiology with Intubation: An International Prospective Observational Study in Patients with Acute Hypoxemic Respiratory Failure Related to COVID-19

INTRODUCTION

Awake prone positioning has the potential to improve oxygenation and decrease respiratory rate, potentially reducing the need for intubation in patients with acute hypoxemic respiratory failure. We investigated awake prone positioning-induced changes in oxygenation and respiratory rate, and the prognostic capacity for intubation in patients with COVID-19 pneumonia.

METHODS

International multicenter prospective observation study in critically ill adult patients with COVID-19 receiving supplemental oxygen. We collected data on oxygenation and respiratory rate at baseline, and at 1 h after being placed in prone positioning. The combined primary outcome was oxygenation and respiratory rate at 1 h. The secondary endpoint was treatment failure, defined as need for intubation within 24 h of start of awake prone positioning.

RESULTS

Between March 27th and November 2020, 101 patients were enrolled of which 99 were fully analyzable. Awake prone positioning lasted mean of 3 [2-4] h. In 77 patients (77.7%), awake prone positioning improved oxygenation, and in 37 patients (54.4%) it decreased respiratory rate. Twenty-nine patients (29.3%) were intubated within 24 h. An increase in SpO2/FiO2 of < 10 (OR 5.1, 95% CI 1.4-18.5, P = 0.01), a failure to increase PaO2/FiO2 to > 116 mmHg (OR 3.6, 95% CI 1.2-10.8, P = 0.02), and a decrease in respiratory rate of < 2 breaths/min (OR 3.6, 95% CI 1.3-9.5, P = 0.01) were independent variables associated with need for intubation. The AUC-ROC curve for intubation using a multivariable model was 0.73 (95% CI 0.62-0.84).

CONCLUSIONS

Awake prone positioning improves oxygenation in the majority of patients, and decreases respiratory rate in more than half of patients with acute hypoxemic respiratory failure caused by COVID-19. One in three patients need intubation within 24 h. Awake prone position-induced changes in oxygenation and respiratory rate have prognostic capacity for intubation within 24 h.

[Platypnea-orthodeoxia syndrome]

Platypnea-orthodeoxia syndrome (POS) is a rare clinical syndrome characterized by dyspnea (platypnea) and arterial desaturation (orthodeoxia) upon changing from a lying to a standing or sitting position. The underlying physiopathological mechanisms involved are complex. Hypoxemia is attributed to the mixing of deoxygenated venous blood with arterial blood through a shunt, which can be intracardiac, or extracardiac. Patent foramen ovale is the main cause of intracardiac shunting. The transthoracic bubble contrast echocardiogram with intravenous agited saline is the most important test in the diagnosis process. Management is specific to the underlying etiology.

Eight versus 28-point lung ultrasonography in moderate acute heart failure: a prospective comparative study

Lung ultrasonography (LUS) is an accurate method of estimating lung congestion but there is ongoing debate on the optimal number of scanning points. The aim of the present study was to compare the reproducibility (i.e. interobserver agreement) and the feasibility (i.e. time consumption) of the two most practiced protocols in patients hospitalized for acute heart failure (AHF). This prospective trial compared 8- and 28-point LUS protocols. Both were performed by an expert-novice pair of sonographers at admission and after 4 to 6 days on patients admitted for AHF. A structured bio-clinical evaluation was simultaneously carried out by the treating physician. The primary outcome was expert-novice interobserver agreement estimated by kappa statistics. Secondary outcomes included time spent on image acquisition and interpretation. During the study period, 43 patients underwent a total of 319 LUS exams. Expert-novice interobserver agreement was moderate at admission and substantial at follow-up for 8-point protocol (weighted kappa of 0.54 and 0.62, respectively) with no significant difference for 28-point protocol (weighted kappa of 0.51 and 0.41; P value for comparison 0.74 at admission and 0.13 at follow-up). The 8-point protocol required significantly less time for image acquisition at admission (mean time difference - 3.6 min for experts, - 5.1 min for novices) and interpretation (- 6.0 min for experts and - 6.3 min for novices; P value < 0.001 for all time comparisons). Similar differences were observed at follow-up. In conclusion, an 8-point LUS protocol was shown to be timesaving with similar reproducibility when compared with a 28-point protocol. It should be preferred for evaluating lung congestion in AHF inpatients.

Early Measurement of ROX Index in Intermediary Care Unit Is Associated with Mortality in Intubated COVID-19 Patients: A Retrospective Study

COVID-19 patients often present with rapidly progressing acute hypoxemic respiratory failure, requiring orotracheal intubation with different prognostic issues. However, ICU specialists lack predictive tools to stratify these patients. We conducted a single-center cross-sectional retrospective study to evaluate if the ROX index, measured under non-invasive oxygenation support, can predict ICU mortality in a COVID-19 intubated patient cohort. This study took place in the division of intensive care at the Geneva University Hospitals (Geneva, Switzerland). We included all consecutive adult patients treated by non-invasive oxygenation support and requiring intubation for acute respiratory failure due to COVID-19 between 9 September 2020 and 30 March 2021, corresponding to the second local surge of COVID-19 cases. Baseline demographic data, comorbidities, median ROX between H0 and H8, and clinical outcomes were collected. Overall, 82 patients were intubated after failing a non-invasive oxygenation procedure. Women represented 25.6% of the whole cohort. Median age and median BMI were 70 (60–75) years and 28 (25–33), respectively. Before intubation, the median ROX between H0 and H8 was 6.3 (5.0–8.2). In a multivariate analysis, the median ROX H0–H8 was associated with ICU mortality as a protective factor with an odds ratio (95% CI) = 0.77 (0.60–0.99); p < 0.05. In intubated COVID-19 patients treated initially by non-invasive oxygenation support for acute respiratory failure, the median ROX H0–H8 could be an interesting predictive factor associated with ICU mortality.

[Role of point-of-care ultrasonography in the management of heart failure]

Heart failure is a common disease and one of the main reasons of hospital admission. It is a rich research field, marked by regular novelties in the management of heart failure. In the last decades point-of-care ultrasonography has been more prominent in internal medicine, particularly for the management of heart failure. A structured training is required to acquire core competencies. In heart failure, this bedside tool includes focused lung, cardiac and vascular ultrasonography. The combination of these modalities raises diagnostic accuracy, reduce time to diagnosis in dyspneic patients and plays a role in adaptation of decongestive therapy.

[Internal medicine in 2020]

2020: annus horribilis for hospital medicine? The past year, notable because of the current pandemic, has had a profound impact on multiple aspects of medical practice. Just as all medical staff and the general population, hospital internists were put under immense strain in 2020. This year has more than ever reinforced our belief in the importance of keeping a critical and scientific eye on the mass of new studies and data produced every year. The internists of the HUG propose a critical review of selected recent publications that may influence our daily management of patients.

A comparison of two tools to screen potentially inappropriate medication in internal medicine patients

WHAT IS KNOWN

Potentially inappropriate medication (PIM) is an important issue for inpatient management; it has been associated with safety problems, such as increases in adverse drugs events, and with longer hospital stays and higher healthcare costs.

OBJECTIVE

To compare two PIM-screening tools-STOPP/START and PIM-Check-applied to internal medicine patients. A second objective was to compare the use of PIMs in readmitted and non-readmitted patients.

METHOD

A retrospective observational study, in the general internal medicine ward of a Swiss non-university hospital. We analysed a random sample of 50 patients, hospitalized in 2013, whose readmission within 30 days of discharge had been potentially preventable, and compared them to a sample of 50 sex- and age-matched patients who were not readmitted. PIMs were screened using the STOPP/START tool, developed for geriatric patients, and the PIM-Check tool, developed for internal medicine patients. The time needed to perform each patient's analysis was measured. A clinical pharmacist counted and evaluated each PIM detected, based on its clinical relevance to the individual patient's case. The rates of screened and validated PIMs involving readmitted and non-readmitted patients were compared.

RESULTS

Across the whole population, PIM-Check and STOPP/START detected 1348 and 537 PIMs, respectively, representing 13.5 and 5.4 PIMs/patient. Screening time was substantially shorter with PIM-Check than with STOPP/START (4 vs 10 minutes, respectively). The clinical pharmacist judged that 45% and 42% of the PIMs detected using PIM-Check and STOPP/START, respectively, were clinically relevant to individual patients' cases. No significant differences in the rates of detected and clinically relevant PIM were found between readmitted and non-readmitted patients.

WHAT IS NEW AND CONCLUSION

Internal medicine patients are frequently prescribed PIMs. PIM-Check's PIM detection rate was three times higher than STOPP/START's, and its screening time was shorter thanks to its electronic interface. Nearly half of the PIMs detected were judged to be non-clinically relevant, however, potentially overalerting the prescriber. These tools can, nevertheless, be considered useful in daily practice. Furthermore, the relevance of any PIM detected by these tools should always be carefully evaluated within the clinical context surrounding the individual patient.

[Ethics and the decision of cardiopulmonary resuscitation]

Following the guidelines of the Swiss Academy of Medical Science, most Swiss hospitals have implemented advanced directives that define what should be undertaken in case of cardiorespiratory arrest for every patient. This remains difficult to apply for physicians and difficult to understand for patients. From a medical perspective, some confusion occurs around medical directives. Difficulties include subjective misinterpretation of patient's quality of life, as well as decision making bias. In addition, patients overestimate the cardiopulmonary reanimation success rate, modify their choices with time and health status, and might lack their individual ability of discernment. Patient's autonomy must always be encouraged as long as it stays within the limits of medical indications.

[Atrial fibrillation and obstructive sleep apnea: a fortuitous association?]

Atrial fibrillation (AF) is a frequent arrhythmia and is associated with important morbidity and mortality. It is particularly frequent in patients with obstructive sleep apnea (OSA), occurring in 3 to 5% of these patients. Numerous studies show an association of these two pathologies, independently of classical cardiovascular risk factors and otherconfounders. A pathophysiological link between repeated apnea and cardiac modifications, inflammation and autonomic nervous system disequilibrium has also been demonstrated. The severity of OSA influences development of AF, and appears to make management more complicated. Success of catheter ablation of AF appears to be inferior in patients with OSA. Whilst more robust studies are required to better define the role of OSA in AF, the existing literature establishes a link between these two entities.