Awake pronation with helmet continuous positive airway pressure for COVID-19 acute respiratory distress syndrome patients outside the ICU: A case series

OBJECTIVE

Continuous positive airway pressure (CPAP) is an important therapeutic tool in COVID-19 acute respiratory distress syndrome (ARDS) since it improves oxygenation, reduces respiratory rate and can prevent intubation and intensive care unit (ICU) admission. CPAP during pronation has seldom been described and never during sedation.

DESIGN

Case series.

SETTING

High dependency unit of San Carlo University Hospital (Potenza, Italy).

PATIENTS

Eleven consecutive patients with COVID-19 ARDS.

INTERVENTION

Helmet CPAP in prone position after failing a CPAP trial in the supine position.

MAIN VARIABLE OF INTEREST

Data collection at baseline and then after 24, 48 and 72h of pronation. We measured PaO₂/FIO₂, pH, lactate, PaCO₂, SpO₂, respiratory rate and the status of the patients at 28-day follow up.

RESULTS

Patients were treated with helmet CPAP for a mean±SD of 7±2.7 days. Prone positioning was feasible in all patients, but in 7 of them dexmedetomidine improved comfort. PaO₂/FIO₂ improved from 107.5±20.8 before starting pronation to 244.4±106.2 after 72h (p<.001). We also observed a significantly increase in Sp0₂ from 90.6±2.3 to 96±3.1 (p<.001) and a decrease in respiratory rate from 27.6±4.3 to 20.1±4.7 (p=.004). No difference was observed in PaCO₂ or pH. At 28 days two patients died after ICU admission, one was discharged in the main ward after ICU admission and eight were discharged home after being successfully managed outside the ICU.

CONCLUSIONS

Helmet CPAP during pronation was feasible and safe in COVID-19 ARDS managed outside the ICU and sedation with dexmedetomidine safely improved comfort. We recorded an increase in PaO₂/FIO₂, SpO₂ and a reduction in respiratory rate.

Accurate detection of atrial fibrillation using a smartphone remains uncertain: a systematic review and meta-analysis

Introduction

Early diagnosis of atrial fibrillation (AF) is essential to reduce complications such as stroke, and improve patient quality of life. Novel screening techniques using smartphone camera photoplethysmography (PPG) can be used for AF detection, but their clinical applicability remains unclear.

Purpose

To assess the diagnostic accuracy of smartphone PPG compared to conventional ECG for AF detection.

Methods

We performed a systematic review of MEDLINE, EMBASE, Cochrane library, and other databases (1980-October 2019), including any study or abstract where smartphone finger-tip PPG was compared with a reference ECG (1, 3 or 12-lead). Outcomes were sensitivity (SE), specificity (SP), positive and negative predictive value (PPV; NPV) and overall accuracy. Bivariate hierarchical random effects meta-analysis was performed for studies with confidence intervals for SE and SP, and funnel plots were used to identify publication bias. Study quality was assessed using the established QUADAS-2 tool by two independent graders.

Results

1350 publications were screened, of which 17 studies were included in the systematic review (7 full text publications and 10 abstracts), providing 21 comparisons of accuracy for AF detection. Most studies were based in secondary care and small (range n=33 to 1095), with a total of 5469 participants including 1384 with AF. Only 4 studies were multicentre. Smartphone applications used were Cardiio Rhythm, Fibricheck, Preventicus and Heartbeats, with 7 studies not specifying the tool used. Overall SE and SP for AF detection were high, ranging from 76 to 100%, and 85 to 100% respectively. PPV ranged from 54 to 100% and NPV from 77 to 100%, with overall accuracy between 61 and 99%. The meta-analysis included 12 comparisons from 10 studies (n=2714; 936 with AF). The pooled SE was 93% (95% CI 90–96%) and SP 97% (95% CI 95–99%); Figure 1A. QUADAS-2 assessment demonstrated poor quality of studies overall, with a high or unclear risk of bias in at least one domain for all studies. There was clear evidence of publication bias; Figure 1B.

Conclusions

PPG offers the potential for large scale, non-invasive, patient-led screening of AF. However, current evidence is limited to biased, low quality studies often with unrealistic results for AF detection. These are insufficient to advise clinicians on the true value of current smartphone PPG technology.

Figure 1. Meta-analysis & publication bias

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): BigData@Heart EU/EFPIA IMI 116074.

Awake pronation with helmet continuous positive airway pressure for COVID-19 acute respiratory distress syndrome patients outside the ICU: A case series

OBJECTIVE

Continuous positive airway pressure (CPAP) is an important therapeutic tool in COVID-19 acute respiratory distress syndrome (ARDS) since it improves oxygenation, reduces respiratory rate and can prevent intubation and intensive care unit (ICU) admission. CPAP during pronation has seldom been described and never during sedation.

DESIGN

Case series.

SETTING

High dependency unit of San Carlo University Hospital (Potenza, Italy).

PATIENTS

Eleven consecutive patients with COVID-19 ARDS.

INTERVENTION

Helmet CPAP in prone position after failing a CPAP trial in the supine position.

MAIN VARIABLE OF INTEREST

Data collection at baseline and then after 24, 48 and 72h of pronation. We measured PaO2/FIO2, pH, lactate, PaCO2, SpO2, respiratory rate and the status of the patients at 28-day follow up.

RESULTS

Patients were treated with helmet CPAP for a mean±SD of 7±2.7 days. Prone positioning was feasible in all patients, but in 7 of them dexmedetomidine improved comfort. PaO2/FIO2 improved from 107.5±20.8 before starting pronation to 244.4±106.2 after 72h (p<.001). We also observed a significantly increase in Sp02 from 90.6±2.3 to 96±3.1 (p<.001) and a decrease in respiratory rate from 27.6±4.3 to 20.1±4.7 (p=.004). No difference was observed in PaCO2 or pH. At 28 days two patients died after ICU admission, one was discharged in the main ward after ICU admission and eight were discharged home after being successfully managed outside the ICU.

CONCLUSIONS

Helmet CPAP during pronation was feasible and safe in COVID-19 ARDS managed outside the ICU and sedation with dexmedetomidine safely improved comfort. We recorded an increase in PaO2/FIO2, SpO2 and a reduction in respiratory rate.

Investigating the importance of the local food environment for fruit and vegetable intake in older men and women in 20 UK towns: a cross-sectional analysis of two national cohorts using novel methods

BACKGROUND

Local neighbourhood environments can influence dietary behavior. There is limited evidence focused on older people who are likely to have greater dependence on local areas and may suffer functional limitations that amplify any neighbourhood impact.

METHODS

Using multi-level ordinal regression analysis we investigated the association between multiple dimensions of neighbourhood food environments (captured by fine-detail, foot-based environmental audits and secondary data) and self-reported frequency of fruit and vegetable intake. The study was a cross-sectional analysis nested within two nationally representative cohorts in the UK: the British Regional Heart Study and the British Women's Heart and Health Study. Main exposures of interest were density of food retail outlets selling fruits and vegetables, the density of fast food outlets and a novel measure of diversity of the food retail environment.

RESULTS

A total of 1124 men and 883 women, aged 69 - 92 years, living in 20 British towns were included in the analysis. There was strong evidence of an association between area income deprivation and fruit and vegetable consumption, with study members in the most deprived areas estimated to have 27% (95% CI: 7, 42) lower odds of being in a higher fruit and vegetable consumption category relative to those in the least deprived areas. We found no consistent evidence for an association between fruit and vegetable consumption and a range of other food environment domains, including density of shops selling fruits and vegetables, density of premises selling fast food, the area food retail diversity, area walkability, transport accessibility, or the local food marketing environment. For example, individuals living in areas with greatest fruit and vegetable outlet density had 2% (95% CI: -22, 21) lower odds of being in a higher fruit and vegetable consumption category relative to those in areas with no shops.

CONCLUSIONS

Although small effect sizes in environment-diet relationships cannot be discounted, this study suggests that older people are less influenced by physical characteristics of neighbourhood food environments than is suggested in the literature. The association between area income deprivation and diet may be capturing an important social aspect of neighbourhoods that influence food intake in older adults and warrants further research.

[Captopril and hydrochlorothiazide combined in the treatment of mild-to-moderate hypertension. Evaluation of sugar and lipid metabolism in a long-term study]

Ten hypertensive patients (I-IIWHO) were treated for a period of three months with captopril 50 mg + hydrochlorothiazide 25 mg once or twice daily, with the aim of evaluating the antihypertensive effectiveness of this association and the lack of influences on lipid and mainly glucose metabolism. Blood pressure and heart rate were evaluated every month, while chemical tests were performed at the beginning and at the end of the trial. Besides before and after treatment were studied blood glucose and insulin levels during oral glucose tolerance test, at times 0, 15', 30', 60', 90', 120', 180'. Our data show that captopril combined with hydrochlorothiazide has a good antihypertensive action, and doesn't alter lipid and glucose metabolism either after oral glucose tolerance test.

[Problems in the treatment of the hypertensive diabetic patient]

Hypertension is much more common among diabetics than non-diabetics and particular care must be taken in treating both chronic pathologies. It is in fact vital to consider the effect antihypertensive drugs may have on diabetes and its complications. Hence the choice of anti-hypertensive drug for a patient with diabetes mellitus must be preceded by a careful study of the metabolic effects of that drug. An attempt is made to assess the interference by antihypertensive agents with glucose metabolism and to identify an appropriate treatment protocol for the patient with both arterial hypertension and diabetes mellitus.

[Hypertension therapy in the elderly. Our experience with converting enzyme inhibitors]

Arterial hypertension shows, in the elderly, particular features and special problems connected with its pharmacological treatment. In our work ten patients, aged between 65-75, suffering from essential hypertension, were examined for eight weeks. At the end of this period, we observed a significant reduction of systolic and diastolic pressure, heart rate being unchanged. We didn't observe any significant change in the metabolic parameters considered (uricemia, creatininemia, triglycerides and cholesterol). No patient had to interrupt the treatment as a consequence of side effects. According to our data, we can affirm that Captopril reduces arterial pressure gradually and doesn't cause orthostatic hypotension, being thus very useful in the elderly.