COVID-19 pandemic and non invasive respiratory management: Every Goliath needs a David. An evidence based evaluation of problems

Time course of exercise capacity in patients recovering from COVID-19-associated pneumonia

Objective:

High prevalences of muscle weakness and impaired physical performance in hospitalized patients recovering from COVID-19-associated pneumonia have been reported. Our objective was to determine whether the level of exercise capacity after discharge would affect long-term functional outcomes in these patients.

Methods:

From three to five weeks after discharge from acute care hospitals (T₀), patients underwent a six-minute walk test (6MWT) and were divided into two groups according to the distance walked in percentage of predicted values: <75% group and ≥75% group. At T₀ and three months later (T₁), patients completed the Short Physical Performance Battery and the Euro Quality of Life Visual Analogue Scale, and pulmonary function and respiratory muscle function were assessed. In addition, a repeat 6MWT was also performed at T₁.

Results:

At T₀, 6MWD values and Short Physical Performance Battery scores were lower in the <75% group than in the ≥75% group. No differences were found in the Euro Quality of Life Visual Analogue Scale scores, pulmonary function variables, respiratory muscle function variables, length of hospital stay, or previous treatment. At T₁, both groups improved their exercise capacity, but only the subjects in the <75% group showed significant improvements in dyspnea and lower extremity function. Exercise capacity and functional status values returned to predicted values in all of the patients in both groups.

Conclusions:

Four weeks after discharge, COVID-19 survivors with exercise limitation showed no significant differences in physiological or clinical characteristics or in perceived health status when compared with patients without exercise limitation. Three months later, those patients recovered their exercise capacity.

Non-invasive respiratory support paths in hospitalized patients with COVID-19: proposal of an algorithm

COVID-19 related Acute Respiratory Failure, may be successfully treated with Conventional Oxygen therapy, High Flow Nasal Cannula, Continuous Positive Airway Pressure or Bi-level Positive-Pressure ventilation. Despite the accumulated data in favor of the use of different Non-invasive Respiratory therapies in COVID-19 related Acute Respiratory Failure, it is not fully understood when start, escalate and de-escalate the best respiratory supportive option for the different timing of the disease. Based on the current published experience with Non-invasive Respiratory therapies in COVID-19 related Acute Respiratory Failure, we propose an algorithm in deciding when to start, when to stop and when to wean different NIRT. This strategy may help clinicians in better choosing NIRT during this second COVID-19 wave and beyond.

Management of SARS-CoV-2 pneumonia in intensive care unit: An observational retrospective study comparing two bundles

Purpose

To compare the effects of two therapeutic bundles of management in SARS-CoV2 ICU patients.

Materials and methods

Our retrospective, observational study was performed in a university ICU from March to June 2020 (first wave) and from September 2020 to January 2021 (second wave). In first wave, patients received bundle 1 including early invasive ventilation, hydroxychloroquine, cefotaxime and azithromycin. In second wave, bundle 2 included non-invasive oxygenation support and dexamethasone. The main outcome was in-hospital mortality. Secondary outcomes included ICU and hospital length of stay, ICU supportive therapies, viral clearance and antimicrobial resistance emergence.

Results

129 patients with SARS-CoV-2 pneumonia were admitted to our ICU. Thirty-five were treated according to bundle 1 and 76 to bundle 2. In-hospital mortality was similar in the two groups (23%, p = 1). The hospital (p = 0.003) and ICU (p = 0.01) length of stay and ventilator-free days at 28 days (p = 0.03) were significantly reduced in bundle 2. Increasing age, vasopressor use and PaO₂/FiO₂ ratio < 125 were associated with in-hospital mortality.

Conclusion

Within the limitations of our study, changes in therapeutic bundles for SARS-Cov-2 ICU patients might have no effect on in-hospital mortality but were associated with less exposure to mechanical ventilation and reduced hospital length of stay.

Noninvasive Ventilatory Support of Patients with COVID-19 outside the Intensive Care Units (WARd-COVID)

Rationale: Treatment with noninvasive ventilation (NIV) in coronavirus disease (COVID-19) is frequent. Shortage of intensive care unit (ICU) beds led clinicians to deliver NIV also outside ICUs. Data about the use of NIV in COVID-19 is limited.

Objectives: To describe the prevalence and clinical characteristics of patients with COVID-19 treated with NIV outside the ICUs. To investigate the factors associated with NIV failure (need for intubation or death).

Methods: In this prospective, single-day observational study, we enrolled adult patients with COVID-19 who were treated with NIV outside the ICU from 31 hospitals in Lombardy, Italy.

Results: We collected data on demographic and clinical characteristics, ventilatory management, and patient outcomes. Of 8,753 patients with COVID-19 present in the hospitals on the study day, 909 (10%) were receiving NIV outside the ICU. A majority of patients (778/909; 85%) patients were treated with continuous positive airway pressure (CPAP), which was delivered by helmet in 617 (68%) patients. NIV failed in 300 patients (37.6%), whereas 498 (62.4%) patients were discharged alive without intubation. Overall mortality was 25%. NIV failure occurred in 152/284 (53%) patients with an arterial oxygen pressure (Pa_O2)/fraction of inspired oxygen (Fi_O2) ratio <150 mm Hg. Higher C-reactive protein and lower Pa_O2/Fi_O2 and platelet counts were independently associated with increased risk of NIV failure.

Conclusions: The use of NIV outside the ICUs was common in COVID-19, with a predominant use of helmet CPAP, with a rate of success >60% and close to 75% in full-treatment patients. C-reactive protein, Pa_O2/Fi_O2, and platelet counts were independently associated with increased risk of NIV failure.

Clinical trial registered with ClinicalTrials.gov (NCT04382235).

Adult Pulmonary Intensive and Intermediate Care Units: The Italian Thoracic Society (ITS-AIPO) Position Paper

The imbalance between the prevalence of patients with acute respiratory failure (ARF) and acute-on-chronic respiratory failure and the number of intensive care unit (ICU) beds requires new solutions. The increasing use of non-invasive respiratory tools to support patients at earlier stages of ARF and the increased expertise of non-ICU clinicians in other types of supportive care have led to the development of adult pulmonary intensive care units (PICUs) and pulmonary intermediate care units (PIMCUs). As in other European countries, Italian PICUs and PIMCUs provide an intermediate level of care as the setting designed for managing ARF patients without severe non-pulmonary dysfunction. The PICUs and PIMCUs may also act as step-down units for weaning patients from prolonged mechanical ventilation and for discharging patients still requiring ventilatory support at home. These units may play an important role in the on-going coronavirus disease 2019 pandemic. This position paper promoted by the Italian Thoracic Society (ITS-AIPO) describes the models, facilities, staff, equipment, and operating methods of PICUs and PIMCUs.

Modeling of aerosol transmission of airborne pathogens in ICU rooms of COVID-19 patients with acute respiratory failure

The COVID-19 pandemic has generated many concerns about cross-contamination risks, particularly in hospital settings and Intensive Care Units (ICU). Virus-laden aerosols produced by infected patients can propagate throughout ventilated rooms and put medical personnel entering them at risk. Experimental results found with a schlieren optical method have shown that the air flows generated by a cough and normal breathing were modified by the oxygenation technique used, especially when using High Flow Nasal Canulae, increasing the shedding of potentially infectious airborne particles. This study also uses a 3D Computational Fluid Dynamics model based on a Lattice Boltzmann Method to simulate the air flows as well as the movement of numerous airborne particles produced by a patient's cough within an ICU room under negative pressure. The effects of different mitigation scenarii on the amount of aerosols potentially containing SARS-CoV-2 that are extracted through the ventilation system are investigated. Numerical results indicate that adequate bed orientation and additional air treatment unit positioning can increase by 40% the number of particles extracted and decrease by 25% the amount of particles deposited on surfaces 45s after shedding. This approach could help lay the grounds for a more comprehensive way to tackle contamination risks in hospitals, as the model can be seen as a proof of concept and be adapted to any room configuration.

Barotrauma during non-invasive ventilation for acute respiratory distress syndrome caused by COVID-19: a balance between risks and benefits

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.

The Considerations and Controversies in Using High-Flow Nasal Oxygen with Self-Prone Positioning in SARS-CoV-2 COVID-19 Disease

Evidence exists for the use of high-flow nasal oxygen (HFNO) in the general critical care population for acute hypoxemic respiratory failure. There is discord between guidelines for hypoxemia management in COVID-19. Both noninvasive management and intubation present risk to patients and staff and potentially overwhelm hospital mechanical ventilator capacity. The use of HFNO has been particularly controversial in the UK, with oxygen infrastructure failure. We discuss our experience of managing COVID-19 with HFNO and awake self-prone positioning. We focus upon the less-usual case of an eighteen-year-old female to illustrate the type of patient where HFNO may be used when perhaps earlier intubation once was. It is important to consider the wider implications of intubation. We have used HFNO as a bridge to intubation or as definitive management. As we await clinical trial evidence, HFNO with self-prone positioning has a role in COVID-19 for certain patients. Response parameters must be set and reviewed, oxygen infrastructure considered, and potential staff droplet exposure minimised.

Noninvasive Ventilation in Patients With COVID-19-Related Acute Hypoxemic Respiratory Failure: A Retrospective Cohort Study

Introduction: Noninvasive ventilation (NIV) has been used to alleviate hypoxemia and dyspnea, but there is no consensus on the application of NIV in patients with coronavirus disease 2019 (COVID-19). Some staff use NIV as the rescue therapy which might lead to the adverse outcomes. This study was to identify early factors associated with intubation to help the medical staff select appropriate patients for receiving NIV treatment.

Methods: Patients with laboratory-confirmed COVID-19 who were treated with NIV in emergency department or ICU of the Third People's Hospital (the only designated hospital for treating COVID-19 in Shenzhen) between January 1 and August 31, 2020, were retrospectively analyzed.

Results: Thirty-nine patients with COVID-19 treated with NIV were included; of them, 16 (41%) received endotracheal intubation and 3 (8%) died. Significant differences were observed between intubated and non-intubated patients in PaO₂/FiO₂ before NIV initiation, hospitalization duration, NIV as the rescue therapy, and PaO₂/FiO₂ of ≤200 mmHg after 1–2 h of NIV initiation. Notably, 1–2 h after NIV initiation, a PaO₂/FiO₂ of ≤200 mmHg (odds ratio [OR], 9.35; 95% confidence interval [CI], 1.84–47.62; P = 0.007) and NIV as the rescue therapy (OR, 5.43; 95% CI, 1.09–27.12; P = 0.039) were the risk factors for intubation.

Conclusions: In patients with COVID-19-related acute hypoxemic respiratory failure receiving NIV, close attention should be paid to PaO₂/FiO₂ after 1–2 h of NIV initiation. Also, using NIV as rescue therapy should draw our awareness that it might delay escalation of respiratory support and lead to adverse outcomes.

COVID-19 Pneumonia and ROX index: Time to set a new threshold for patients admitted outside the ICU

High flow nasal cannula (HFNC) is used to treat acute hypoxemic respiratory failure (AHRF) even outside the ICU and the ROX index (pulse oximetry/fraction of inspired oxygen/respiratory rate) may predict HFNC failure.

Objective

The purpose of this investigation was therefore to verify whether the ROX index is an accurate predictor of HFNC failure for COVID-19 patients treated outside the intensive care unit (ICU) and to evaluate the validity of the previously suggested threshold.

Design

Multicenter study. Retrospective observational analysis of prospectively collected data.

Setting

3 centres specialized in non-invasive respiratory support (Buenos Aires, Argentina; Bolzano and Treviso, Italy). Patients treated outside the ICU were analysed

Measurements

The variables to calculate the ROX index were collected during the first day of therapy at 2, 6, 12 and 24 hours and then recorded every 24 hours. HFNC failure was defined as escalation of respiratory support to invasive mechanical ventilation (IMV) or death.

Main results

A total of 35 (29%) patients failed HFNC and required intubation. ROC analysis identified the 12-hour ROX index as the best predictor of intubation with an AUC of 0.7916[CI 95% 0.6905-0.8927] and the best threshold to be 5.99[Specificity 96% Sensitivity 62%]. In the survival analysis, a ROX value <5.99 was associated with an increased risk of failure (p = 0008 log – rank test). The threshold of 4,9 identified by Roca as the best predictor in non-COVID patients, was not able to discriminate between success and failure (p = 0.4 log-rank test) in our patients.

Conclusions

ROX index may be useful in guiding the clinicians in their decision to intubate patients, especially in patients with moderate ARF, treated therefore outside the ICU. Indeed, it also demonstrates a different threshold value than reported for non-COVID patients, possibly related to the different mechanisms of hypoxia.

Evaluation of the effectiveness and safety of adding ivermectin to treatment in severe COVID-19 patients

Background and objectives

An effective treatment option is not yet available for SARS-CoV2, which causes the COVID-19 pandemic and whose effects are felt more and more every day. Ivermectin is among the drugs whose effectiveness in treatment has been investigated. In this study; it was aimed to investigate the presence of gene mutations that alter ivermectin metabolism and cause toxic effects in patients with severe COVID-19 pneumonia, and to evaluate the effectiveness and safety of ivermectin use in the treatment of patients without mutation.

Materials and methods

Patients with severe COVID19 pneumonia were included in the study, which was planned as a prospective, randomized, controlled, single-blind phase 3 study. Two groups, the study group and the control group, took part in the study. Ivermectin 200 mcg/kg/day for 5 days in the form of a solution prepared for enteral use added to the reference treatment protocol -hydroxychloroquine + favipiravir + azithromycin- of patients included in the study group. Patients in the control group were given only reference treatment with 3 other drugs without ivermectin. The presence of mutations was investigated by performing sequence analysis in the mdr1/abcab1 gene with the Sanger method in patients included in the study group according to randomization. Patients with mutations were excluded from the study and ivermectin treatment was not continued. Patients were followed for 5 days after treatment. At the end of the treatment and follow-up period, clinical response and changes in laboratory parameters were evaluated.

Results

A total of 66 patients, 36 in the study group and 30 in the control group were included in the study. Mutations affecting ivermectin metabolism was detected in genetic tests of six (16.7%) patients in the study group and they were excluded from the study. At the end of the 5-day follow-up period, the rate of clinical improvement was 73.3% (22/30) in the study group and was 53.3% (16/30) in the control group (p = 0.10). At the end of the study, mortality developed in 6 patients (20%) in the study group and in 9 (30%) patients in the control group (p = 0.37). At the end of the follow-up period, the average peripheral capillary oxygen saturation (SpO2) values of the study and control groups were found to be 93.5 and 93.0%, respectively. Partial pressure of oxygen (PaO2)/FiO2 ratios were determined as 236.3 ± 85.7 and 220.8 ± 127.3 in the study and control groups, respectively. While the blood lymphocyte count was higher in the study group compared to the control group (1698 ± 1438 and 1256 ± 710, respectively) at the end of the follow-up period (p = 0.24); reduction in serum C-reactive protein (CRP), ferritin and D-dimer levels was more pronounced in the study group (p = 0.02, p = 0.005 and p = 0.03, respectively).

Conclusions

According to the findings obtained, ivermectin can provide an increase in clinical recovery, improvement in prognostic laboratory parameters and a decrease in mortality rates even when used in patients with severe COVID-19. Consequently, ivermectin should be considered as an alternative drug that can be used in the treatment of COVID-19 disease or as an additional option to existing protocols.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06104-9.

Evaluation of the effectiveness and safety of adding ivermectin to treatment in severe COVID-19 patients

BACKGROUND AND OBJECTIVES

An effective treatment option is not yet available for SARS-CoV2, which causes the COVID-19 pandemic and whose effects are felt more and more every day. Ivermectin is among the drugs whose effectiveness in treatment has been investigated. In this study; it was aimed to investigate the presence of gene mutations that alter ivermectin metabolism and cause toxic effects in patients with severe COVID-19 pneumonia, and to evaluate the effectiveness and safety of ivermectin use in the treatment of patients without mutation.

MATERIALS AND METHODS

Patients with severe COVID19 pneumonia were included in the study, which was planned as a prospective, randomized, controlled, single-blind phase 3 study. Two groups, the study group and the control group, took part in the study. Ivermectin 200 mcg/kg/day for 5 days in the form of a solution prepared for enteral use added to the reference treatment protocol -hydroxychloroquine + favipiravir + azithromycin- of patients included in the study group. Patients in the control group were given only reference treatment with 3 other drugs without ivermectin. The presence of mutations was investigated by performing sequence analysis in the mdr1/abcab1 gene with the Sanger method in patients included in the study group according to randomization. Patients with mutations were excluded from the study and ivermectin treatment was not continued. Patients were followed for 5 days after treatment. At the end of the treatment and follow-up period, clinical response and changes in laboratory parameters were evaluated.

RESULTS

A total of 66 patients, 36 in the study group and 30 in the control group were included in the study. Mutations affecting ivermectin metabolism was detected in genetic tests of six (16.7%) patients in the study group and they were excluded from the study. At the end of the 5-day follow-up period, the rate of clinical improvement was 73.3% (22/30) in the study group and was 53.3% (16/30) in the control group (p = 0.10). At the end of the study, mortality developed in 6 patients (20%) in the study group and in 9 (30%) patients in the control group (p = 0.37). At the end of the follow-up period, the average peripheral capillary oxygen saturation (SpO2) values of the study and control groups were found to be 93.5 and 93.0%, respectively. Partial pressure of oxygen (PaO2)/FiO2 ratios were determined as 236.3 ± 85.7 and 220.8 ± 127.3 in the study and control groups, respectively. While the blood lymphocyte count was higher in the study group compared to the control group (1698 ± 1438 and 1256 ± 710, respectively) at the end of the follow-up period (p = 0.24); reduction in serum C-reactive protein (CRP), ferritin and D-dimer levels was more pronounced in the study group (p = 0.02, p = 0.005 and p = 0.03, respectively).

CONCLUSIONS

According to the findings obtained, ivermectin can provide an increase in clinical recovery, improvement in prognostic laboratory parameters and a decrease in mortality rates even when used in patients with severe COVID-19. Consequently, ivermectin should be considered as an alternative drug that can be used in the treatment of COVID-19 disease or as an additional option to existing protocols.

Evolving changes in mortality of 13,301 critically ill adult patients with COVID-19 over 8 months

PURPOSE

Clinical characteristics and management of COVID-19 patients have evolved during the pandemic, potentially changing their outcomes. We analyzed the associations of changes in mortality rates with clinical profiles and respiratory support strategies in COVID-19 critically ill patients.

METHODS

A multicenter cohort of RT-PCR-confirmed COVID-19 patients admitted at 126 Brazilian intensive care units between February 27^th and October 28^th, 2020. Assessing temporal changes in deaths, we identified distinct time periods. We evaluated the association of characteristics and respiratory support strategies with 60-day in-hospital mortality using random-effects multivariable Cox regression with inverse probability weighting.

RESULTS

Among the 13,301 confirmed-COVID-19 patients, 60-day in-hospital mortality was 13%. Across four time periods identified, younger patients were progressively more common, non-invasive respiratory support was increasingly used, and the 60-day in-hospital mortality decreased in the last two periods. 4188 patients received advanced respiratory support (non-invasive or invasive), from which 42% underwent only invasive mechanical ventilation, 37% only non-invasive respiratory support and 21% failed non-invasive support and were intubated. After adjusting for organ dysfunction scores and premorbid conditions, we found that younger age, absence of frailty and the use of non-invasive respiratory support (NIRS) as first support strategy were independently associated with improved survival (hazard ratio for NIRS first [95% confidence interval], 0.59 [0.54-0.65], p < 0.001).

CONCLUSION

Age and mortality rates have declined over the first 8 months of the pandemic. The use of NIRS as the first respiratory support measure was associated with survival, but causal inference is limited by the observational nature of our data.

Personal protective equipment for reducing the risk of COVID-19 infection among health care workers involved in emergency trauma surgery during the pandemic: An umbrella review

BACKGROUND

Health care facilities in low- and middle-income countries are inadequately resourced to adhere to current COVID-19 prevention recommendations. Recommendations for surgical emergency trauma care measures need to be adequately informed by available evidence and adapt to particular settings. To inform future recommendations, we set to summarize the effects of different personal protective equipment (PPE) on the risk of COVID-19 infection in health personnel caring for trauma surgery patients.

METHODS

We conducted an umbrella review using Living Overview of Evidence platform for COVID-19, which performs regular automated searches in MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and more than 30 other sources. Systematic reviews of experimental and observational studies assessing the efficacy of PPE were included. Indirect evidence from other health care settings was also considered. Risk of bias was assessed with the AMSTAR II tool (Assessing the Methodological Quality of Systematic Reviews, Ottawa, ON, Canada), and the Grading of Recommendations, Assessment, Development, and Evaluation approach for grading the certainty of the evidence is reported (registered in International Prospective Register of Systematic Reviews, CRD42020198267).

RESULTS

Eighteen studies that fulfilled the selection criteria were included. There is high certainty that the use of N95 respirators and surgical masks is associated with a reduced risk of COVID-19 when compared with no mask use. In moderate- to high-risk environments, N95 respirators are associated with a further reduction in risk of COVID-19 infection compared with surgical masks. Eye protection also reduces the risk of contagion in this setting. Decontamination of masks and respirators with ultraviolet germicidal irradiation, vaporous hydrogen peroxide, or dry heat is effective and does not affect PPE performance or fit.

CONCLUSION

The use of PPE drastically reduces the risk of COVID-19 compared with no mask use in health care workers. N95 and equivalent respirators provide more protection than surgical masks. Decontamination and reuse appear feasible to overcome PPE shortages and enhance the allocation of limited resources. These effects are applicable to emergency trauma care and should inform future recommendations.

LEVEL OF EVIDENCE

Review, level II.

Pulmonary Rehabilitation in Patients Recovering from COVID-19

BACKGROUND

In hospitalized patients recovering from the SARS-coronavirus-2 disease 19 (COVID-19), high prevalence of muscle weakness and physical performance impairment has been observed.

OBJECTIVES

The aim of this study was to evaluate the effectiveness of pulmonary rehabilitation in these subjects in a real-life setting.

METHODS

Retrospective data analysis of patients recovering from COVID-19, including those requiring assisted ventilation or oxygen therapy, consecutively admitted to an in-patient pulmonary rehabilitation program between April 1 and August 15, 2020. Short Physical Performance Battery (SPPB: primary outcome), Barthel Index (BI), and six-min walking distance were assessed as outcome measures.

RESULTS

Data of 140 patients were analyzed. After rehabilitation, patients showed improvements in SPPB {from: (median [IQR]) 0.5 (0-7) to 7 (4-10), p < 0.001} and BI (from 55 [30-90] to 95 [65-100], p < 0.001), as well as in other assessed outcome measures. The proportion of patients unable at admission to stand, rise from a chair and walk was significantly reduced (p < 0.00).

CONCLUSIONS

Pulmonary rehabilitation is possible and effective in patients recovering from COVID-19. Our findings may be useful to guide clinicians taking care of patients surviving COVID-19 infection.

Early awake proning in critical and severe COVID-19 patients undergoing noninvasive respiratory support: A retrospective multicenter cohort study

BACKGROUND/MATERIALS AND METHODS

This retrospective cohort study was conducted in two teaching hospitals over a 3-month period (March 2010-June 2020) comparing severe and critical COVID-19 patients admitted to Respiratory Intensive Care Unit for non-invasive respiratory support (NRS) and subjected to awake prone position (PP) with those receiving standard care (SC). Primary outcome was endotracheal intubation (ETI) rate. In-hospital mortality, time to ETI, tracheostomy, length of RICU and hospital stay served as secondary outcomes. Risk factors associated to ETI among PP patients were also investigated.

RESULTS

A total of 114 patients were included, 76 in the SC and 38 in the PP group. Unadjusted Kaplan-Meier estimates showed greater effect of PP compared to SC on ETI rate (HR = 0.45 95% CI [0.2-0.9], p = 0.02) even after adjustment for baseline confounders (HR = 0.59 95% CI [0.3-0.94], p = 0.03). After stratification according to non-invasive respiratory support, PP showed greater significant benefit for those on High Flow Nasal Cannulae (HR = 0.34 95% CI [0.12-0.84], p = 0.04). Compared to SC, PP patients also showed a favorable difference in terms of days free from respiratory support, length of RICU and hospital stay while mortality and tracheostomy rate were not significantly different.

CONCLUSIONS

Prone positioning in awake and spontaneously breathing Covid-19 patients is feasible and associated with a reduction of intubation rate, especially in those patients undergoing HFNC. Although our results are intriguing, further randomized controlled trials are needed to answer all the open questions remaining pending about the real efficacy of PP in this setting.

High-Flow Nasal Cannula, a Boon or a Bane for COVID-19 Patients? An Evidence-Based Review

PURPOSE OF REVIEW

This review instantiates the efficacy and safety of HFNC in the context of COVID-19 pandemic.

RECENT FINDINGS

Globally, the healthcare system is facing an unprecedented crisis of resources due to the 2019 novel coronavirus disease (COVID-19) pandemic. Fever, cough, dyspnea, myalgia, fatigue, and pneumonia are the most common symptoms associated with it. The incidence of invasive mechanical ventilation in ICU patients ranges from 29.1 to 89.9%. Supplemental oxygen therapy is the main stay treatment for managing hypoxemic respiratory failure. The high-flow nasal cannula (HFNC) is a novel non-invasive strategy for better oxygenation and ventilation in critically ill patients. In this grim scenario, a reduction in mechanical ventilation by means of HFNC is of prime interest.

SUMMARY

HFNC is considered an aerosol-generating intervention with the risk of viral aerosolization with a concern of potential nosocomial transmission of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). However, there is no consensus regarding the use of HFNC in novel coronavirus-infected pneumonia (NCIP). HFNC seems to be an effective and safe treatment modality in acute respiratory failure with optimal settings and selection of ideal patients.

Patient's treatment burden related to care coordination in the field of respiratory diseases

The management of respiratory diseases requires various levels of care: multidisciplinary teams, educational and behavioural interventions, self-management and home-based technical support are vital to ensure adequate care management. However, it is often difficult to access these networks due to fragmentation of patient care and treatment burden. Care coordination aims to ensure patients have a central role and that there is continuity of care among various levels and professionals involved. Moreover, the coronavirus disease pandemic has caused strain on the global healthcare system, with care coordination becoming increasingly important in increasing the resilience of health systems, supporting healthcare professionals and ensuring the right treatment and adequate level of care for these patients.

Spontaneous pneumomediastinum in Covid-19 : a case of complete resolution despite invasive positive pressure ventilation

We present the case of a 65-year-old patient who was admitted to the intensive care unit (ICU) due to Covid-19 respiratory failure. During his hospital stay, he developed a spontaneous pneumomediastinum (SP). To date, there have been few reports of SP associated with Covid-19 and even less is known about the impact of positive pressure ventilation on these patients. Our patient was first treated with high-flow nasal cannula oxygen therapy (HFNC). Because of further respiratory deterioration, he was supported with non-invasive ventilation (NIV). Later, he required intubation and ventilation with invasive positive pressure ventilation. Despite this, a complete spontaneous resolution of the pneumomediastinum was observed 13 days after the initial diagnosis.

Nasal high flow oxygen in acute respiratory failure

Thermo-humidified nasal high flow (NHF) oxygen therapy is increasingly used in the management of respiratory failure. This therapy has recently gained attention as an alternative non-invasive respiratory support in several clinical scenarios, including acute and chronic settings. NHF enhances the patient's comfort and tolerance when compared with standard oxygen by supplying a heated and humidified mixture of air and oxygen at flows up to 60L/min. It can be delivered through different devices. Although few studies have compared the clinical effects of different NHF systems, the purpose of this paper is to describe the major benefits of NHF and to provide a quick guide on how to implement this therapy in daily practice. We have also included a brief description of the most frequently used NHF systems.

Clinical Characteristics and Outcome of Patients With Severe COVID-19 Pneumonia at a Public Sector Hospital in Karachi, Pakistan

INTRODUCTION

In Pakistan, the first case of COVID-19 was reported in February of 2020, cases peaked in June, and by January 2021, approximately 500,000 confirmed cases and over 10,000 deaths have been reported. There is a lack of data in Pakistan of the demographics, clinical characteristics, and outcome of patients with COVID-19 pneumonia, particularly those with severe illness, which we aim to assess.

METHODS

This is a single-centered, observational study conducted at the COVID unit of the Shaheed Mohtarma Benazir Bhutto Institute of Trauma in Karachi, Pakistan. A manual medical record review of patients admitted from April 24, 2020 to August 24, 2020 was conducted, and all patients with polymerase chain reaction (PCR) positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) with moderate, severe, and critical COVID-19 pneumonia were included.

RESULTS

Of 299 patients, the median age was 60 years (50-65). Males accounted for 221 (73.9%). Most common symptoms were shortness of breath seen in 270 (90.3%) and fever in 225 (75.3%) patients. Diabetes mellitus (51.2%) and hypertension (50.3%) were the predominant co-morbidities. COVID disease was categorized on admission as moderate in 68 (22.7%), severe in 151 (50.5%), and critical in 80 (26.8%) patients. Survival analysis was done in 252 patients, all of whom received steroids, while tocilizumab was administered to 111 (44%) patients. Hundred (39.7%) patients received non-invasive ventilation (NIV), while 57 (22.6%) were placed on mechanical ventilation. Overall, 95 (37.7%) patients died. Factors associated with mortality included older age with those above 60 years more likely to die (odds ratio [OR]: 1.925; 95% CI: 1.148-3.228; pvalue: 0.009), presence of co-morbidities (OR 1.843; 95% CI: 0.983-3.456; p value: 0.070), development of cytokine release syndrome (CRS) (73 [56.2%] vs 57 [43.8%], p value: <0.001), acute kidney injury (31 [81.6%] vs 7 [18.4%], p value: <0.001), cardiac complications (12 [75%] vs 4 [25%], p value: 0.002), and sepsis (29 [87.9%] vs 4 [12.1%], p value: <0.001). Non-survivors were more likely to develop acute respiratory distress syndrome (ARDS), having been placed on NIV and mechanical ventilation. Laboratory parameters at final outcome found that in non-survivors, median total leukocyte count, C-reactive protein (CRP), neutrophil lymphocyte ratio (NLR), and lactate dehydrogenase (LDH) were higher, while absolute lymphocyte count and platelet counts were lower which were found to be statistically significant compared to survivors.

CONCLUSION

In this study of patients with severe COVID-19 pneumonia at a public sector hospital in Karachi, Pakistan, most were males, and the average age was 60 years. Mortality was high, and associated factors included older age, presence of comorbid conditions, and the development of ARDS, CRS, and sepsis.

Use of Helmet CPAP in COVID-19 - A practical review

Helmet CPAP (H-CPAP) has been recommended in many guidelines as a noninvasive respiratory support during COVID-19 pandemic in many countries around the world. It has the least amount of particle dispersion and air contamination among all noninvasive devices and may mitigate the ICU bed shortage during a COVID surge as well as a decreased need for intubation/mechanical ventilation. It can be attached to many oxygen delivery sources. The MaxVenturi setup is preferred as it allows for natural humidification, low noise burden, and easy transition to HFNC during breaks and it is the recommended transport set-up. The patients can safely be proned with the helmet. It can also be used to wean the patients from invasive mechanical ventilation. Our article reviews in depth the pathophysiology of COVID-19 ARDS, provides rationale of using H-CPAP, suggests a respiratory failure algorithm, guides through its setup and discusses the issues and concerns around using it.

Ventilation of coronavirus disease 2019 patients

PURPOSE OF REVIEW

To summarize the current knowledge of pathophysiology and ventilatory management of acute respiratory failure in COVID-19.

RECENT FINDINGS

Early reports suggested that COVID-19 is an 'atypical ARDS' with profound hypoxemia with normal respiratory system compliance (Crs). Contrarily, several more populated analyses showed that COVID-19 ARDS has pathophysiological features similar to non-COVID-19 ARDS, with reduced Crs, and high heterogeneity of respiratory mechanics, hypoxemia severity, and lung recruitability. There is no evidence supporting COVID-19-specific ventilatory settings, and the vast amount of available literature suggests that evidence-based, lung-protective ventilation (i.e. tidal volume ≤6 ml/kg, plateau pressure ≤30 cmH2O) should be enforced in all mechanically ventilated patients with COVID-19 ARDS. Mild and moderate COVID-19 can be managed outside of ICUs by noninvasive ventilation in dedicated respiratory units, and no evidence support an early vs. late intubation strategy. Despite widely employed, there is no evidence supporting the efficacy of rescue therapies, such as pronation, inhaled vasodilators, or extracorporeal membrane oxygenation.

SUMMARY

Given the lack of evidence-based specific ventilatory strategies and a large amount of literature showing pathophysiological features similar to non-COVID-19 ARDS, evidence-based lung-protective ventilatory strategies should be pursued in all patients with COVID-19 ARDS.

Tuberculosis, COVID-19 and hospital admission: Consensus on pros and cons based on a review of the evidence

The scientific debate on the criteria guiding hospitalization of tuberculosis (TB) and COVID-19 patients is ongoing. The aim of this review is to present the available evidence on admission for TB and TB/COVID-19 patients and discuss the criteria guiding hospitalization. Furthermore, recommendations are made as derived from recently published World Health Organization documents, based on Global Tuberculosis Network (GTN) expert opinion. The core published documents and guidelines on the topic have been reviewed. The proportion of new TB cases admitted to hospital ranges between 50% and 100% while for multidrug-resistant (MDR) TB patients it ranges between 85 and 100% globally. For TB patients with COVID-19 the proportion of cases admitted is 58%, probably reflecting different scenarios related to the diagnosis of COVID-19 before, after or at the same time of the active TB episode. The hospital length of stay for drug-susceptible TB ranges from 20 to 60 days in most of countries, ranging from a mean of 10 days (USA) to around 90 days in the Russian Federation. Hospitalization is longer for MDR-TB (50-180 days). The most frequently stated reasons for recommending hospital admission include: severe TB, infection control concerns, co-morbidities and drug adverse events which cannot be managed at out-patient level. The review also provides suggestions on hospital requirements for safe admissions as well as patient discharge criteria, while underlining the relevance of patient-centred care through community/home-based care.

Predictors of intubation in COVID-19 patients treated with out-of-ICU continuous positive airway pressure

BACKGROUND

As delayed intubation may worsen the outcome of coronavirus disease 2019 (COVID-19) patients treated with continuous positive airway pressure (CPAP), we sought to determine COVID-specific early predictors of CPAP failure.

METHODS

In this observational retrospective multicentre study, we included all COVID-19 patients treated with out-of-ICU CPAP, candidates for intubation in case of CPAP failure. From these patients, we collected demographic and clinical data.

RESULTS

A total of 397 COVID-19 patients were treated with CPAP for respiratory failure, with the therapeutic goal of providing intubation in case of CPAP failure. Univariable analysis showed that, age, lactate dehydrogenase (LDH) and white cell counts were all significantly lower in patients with successful CPAP treatment compared to those failing it and undergoing subsequent intubation. The percentage changes between baseline and CPAP application in the ratio of partial pressure arterial oxygen (PaO₂) and fraction of inspired oxygen (FiO₂), PaO_2, respiratory rate and ROX index were higher in patients experiencing successful CPAP compared to those failing it. FiO₂ and male gender were also significantly associated with intubation. Multivariable analysis adjusting for age, gender, Charlson comorbidity index, percentage change in PaO₂/FiO₂ or PaO₂ and FiO₂ separately, lactate, white blood cell count, LDH and C-reactive protein levels led to an area under the curve of 0.818 and confirmed that age, LDH and percentage increase in PaO₂/FiO₂ are predictors of intubation.

CONCLUSIONS

In COVID-19 patients requiring CPAP, age, LDH and percentage change in PaO₂/FiO₂ after starting CPAP are predictors of intubation.

Measures of physical performance in COVID-19 patients: a mapping review

BACKGROUND AND OBJECTIVE

There is evidence of short- and long-term impairment of physical performance in patients with COVID-19 infection, but a verification of measures of physical impairment in this condition is lacking. We reviewed the measures used to assess physical performance in these patients. Secondary targets were measures of exercise or daily life activities induced symptoms.

METHODS

Medline, CINAHL, and Pedro databases were searched from January 2020 to February 2021 for articles in the English language. Two investigators independently conducted the search, screened all titles and/or abstracts based on the inclusion criteria and independently scored the studies. The quality of the studies was evaluated by two reviewers according to the NIH quality assessment tool for observational cohort and cross-sectional studies. Discrepancies were resolved through consensus.

RESULTS

Out of 156 potentially relevant articles, 31 observational studies (8 cross-sectional), 1 randomized controlled trial, and 1 protocol were included. The quality of most of the 31 evaluable studies was judged as low (11 studies) or fair (14 studies). Sample sizes of the studies ranged from 14 to 20,889 patients. among the 28 reported measures, Barthel Index (42.4% of studies), Six-Minute Walking Distance Test (36.4%), Short Physical Performance Battery (21.2%) and 1-Minute Sit-to-Stand (12.1%) were the most used. Fifteen% and 36% of studies reported exercise induced desaturation and dyspnoea when performing the assessments, respectively. Other exercise induced symptoms were fatigue and pain. Studies reported wide ranges of impairment in physical performance as compared to "reference" values (range of mean or median reported values vs "reference values": 11-77 vs 100 points for Barthel Index; 11-22 vs 22-37 repetitions/min for 1m-STS; 0.5-7.9 vs 11.4 ± 1.3 points for SPPB; and 45-223 vs 380-782 m for 6MWT respectively).

CONCLUSION

This review found that a wide variety of functional status tests have been used, making comparisons difficult between studies. These measures show impairment in physical performance in COVID-19 patients. However, the quality of most of the studies was judged as low or fair.

Outcomes of an intermediate respiratory care unit in the COVID-19 pandemic

BACKGROUND

15% of COVID-19 patients develop severe pneumonia. Non-invasive mechanical ventilation and high-flow nasal cannula can reduce the rate of endotracheal intubation in adult respiratory distress syndrome, although failure rate is high.

OBJECTIVE

To describe the rate of endotracheal intubation, the effectiveness of treatment, complications and mortality in patients with severe respiratory failure due to COVID-19.

METHODS

Prospective cohort study in a first-level hospital in Madrid. Patients with a positive polymerase chain reaction for SARS-CoV-2 and admitted to the Intermediate Respiratory Care Unit with tachypnea, use of accessory musculature or SpO2 <92% despite FiO2> 0.5 were included. Intubation rate, medical complications, and 28-day mortality were recorded. Statistical analysis through association studies, logistic and Cox regression models and survival analysis was performed.

RESULTS

Seventy patients were included. 37.1% required endotracheal intubation, 58.6% suffered medical complications and 24.3% died. Prone positioning was independently associated with lower need for endotracheal intubation (OR 0.05; 95% CI 0.005 to 0.54, p = 0.001). The adjusted HR for death at 28 days in the group of patients requiring endotracheal intubation was 5.4 (95% CI 1.51 to 19.5; p = 0.009).

CONCLUSIONS

The rate of endotracheal intubation in patients with severe respiratory failure from COVID-19 was 37.1%. Complications and mortality were lower in patients in whom endotracheal intubation could be avoided. Prone positioning could reduce the need for endotracheal intubation.

Diagnosis and Management of Acute Respiratory Distress Syndrome in a Time of COVID-19

Acute respiratory distress syndrome (ARDS) remains a serious illness with significant morbidity and mortality, characterized by hypoxemic respiratory failure most commonly due to pneumonia, sepsis, and aspiration. Early and accurate diagnosis of ARDS depends upon clinical suspicion and chest imaging. Coronavirus disease 2019 (COVID-19) is an important novel cause of ARDS with a distinct time course, imaging and laboratory features from the time of SARS-CoV-2 infection to hypoxemic respiratory failure, which may allow diagnosis and management prior to or at earlier stages of ARDS. Treatment of ARDS remains largely supportive, and consists of incremental respiratory support (high flow nasal oxygen, non-invasive respiratory support, and invasive mechanical ventilation), and avoidance of iatrogenic complications, all of which improve clinical outcomes. COVID-19-associated ARDS is largely similar to other causes of ARDS with respect to pathology and respiratory physiology, and as such, COVID-19 patients with hypoxemic respiratory failure should typically be managed as other patients with ARDS. Non-invasive respiratory support may be beneficial in avoiding intubation in COVID-19 respiratory failure including mild ARDS, especially under conditions of resource constraints or to avoid overwhelming critical care resources. Compared to other causes of ARDS, medical therapies may improve outcomes in COVID-19-associated ARDS, such as dexamethasone and remdesivir. Future improved clinical outcomes in ARDS of all causes depends upon individual patient physiological and biological endotyping in order to improve accuracy and timeliness of diagnosis as well as optimal targeting of future therapies in the right patient at the right time in their disease.

Update on the diagnosis and management of COVID-19 in pediatric patients

Coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), became a pandemic in March 2020, affecting millions of people worldwide. However, COVID-19 in pediatric patients represents 1-5% of all cases, and the risk for developing severe disease and critical illness is much lower in children with COVID-19 than in adults. Multisystem inflammatory syndrome in children (MIS-C), a possible complication of COVID-19, has been described as a hyperinflammatory condition with multiorgan involvement similar to that in Kawasaki disease or toxic shock syndrome in children with evidence of SARS-CoV-2 infection. This review presents an update on the diagnostic methods for COVID-19, including reverse-transcriptase polymerase chain reaction (RT-PCR) tests, serology tests, and imaging, and summarizes the current recommendations for the management of the disease. Particular emphasis is placed on respiratory support, which includes noninvasive ventilation and invasive mechanical ventilation strategies according to lung compliance and pattern of lung injury. Pharmacological treatment, including pathogen-targeted drugs and host-directed therapies, has been addressed. The diagnostic criteria and management of MIS-C are also summarized.

ResUHUrge: A Low Cost and Fully Functional Ventilator Indicated for Application in COVID-19 Patients

Although the cure for the SARS-CoV-2 virus (COVID-19) will come in the form of pharmaceutical solutions and/or a vaccine, one of the only ways to face it at present is to guarantee the best quality of health for patients, so that they can overcome the disease on their own. Therefore, and considering that COVID-19 generally causes damage to the respiratory system (in the form of lung infection), it is essential to ensure the best pulmonary ventilation for the patient. However, depending on the severity of the disease and the health condition of the patient, the situation can become critical when the patient has respiratory distress or becomes unable to breathe on his/her own. In that case, the ventilator becomes the lifeline of the patient. This device must keep patients stable until, on their own or with the help of medications, they manage to overcome the lung infection. However, with thousands or hundreds of thousands of infected patients, no country has enough ventilators. If this situation has become critical in the Global North, it has turned disastrous in developing countries, where ventilators are even more scarce. This article shows the race against time of a multidisciplinary research team at the University of Huelva, UHU, southwest of Spain, to develop an inexpensive, multifunctional, and easy-to-manufacture ventilator, which has been named ResUHUrge. The device meets all medical requirements and is developed with open-source hardware and software.

The role of 3D printing during COVID-19 pandemic: a review

The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has spread through more than 180 countries, leading to diverse health systems overload around the world. Because of the high number of patients and the supply chain disruption, it generated a shortage of medical devices and personal protective equipment. In this context, initiatives from the additive manufacturing community emerged to fight the lack of devices. Diverse designs were produced and are currently being used in hospitals by patients and health workers. However, as some devices must follow strict standards, these products may not fulfill these standards. Therefore, to ensure the user's health, there is a need for understanding each device, their usage, and standards. This study reviews the use of additive manufacturing during COVID-19 pandemic. It gathers the source of several 3D printed devices such as face shields, face masks, valves, nasopharyngeal swabs, and others, discussing their use and regulatory issues. In this regard, the major drawbacks of the technology, addressed for the next pandemic scenario, are highlighted. Finally, some insights of the future of additive manufacturing during emergency are given and discussed.

Global Current Practices of Ventilatory Support Management in COVID-19 Patients: An International Survey

BACKGROUND

As the global outbreak of COVID-19 continues to ravage the world, it is important to understand how frontline clinicians manage ventilatory support and the various limiting factors.

METHODS

An online survey composed of 32 questions was developed and validated by an international expert panel.

RESULTS

Overall, 502 respondents from 40 countries across six continents completed the survey. The mean number (±SD) of ICU beds was 64 ± 84. The most popular initial diagnostic tools used for treatment initiation were arterial blood gas (48%) and clinical presentation (37.5%), while the national COVID-19 guidelines were the most used (61.2%). High flow nasal cannula (HFNC) (53.8%), non-invasive ventilation (NIV) (47%), and invasive mechanical ventilation (IMV) (92%) were mostly used for mild, moderate, and severe COVID-19 cases, respectively. However, only 38.8%, 56.6% and 82.9% of the respondents had standard protocols for HFNC, NIV, and IMV, respectively. The most frequently used modes of IMV and NIV were volume control (VC) (36.1%) and continuous positive airway pressure/pressure support (CPAP/PS) (40.6%). About 54% of the respondents did not adhere to the recommended, regular ventilator check interval. The majority of the respondents (85.7%) used proning with IMV, with 48.4% using it for 12-16 hours, and 46.2% had tried awake proning in combination with HFNC or NIV. Increased staff workload (45.02%), lack of trained staff (44.22%) and shortage of personal protective equipment (PPE) (42.63%) were the main barriers to COVID-19 management.

CONCLUSION

Our results show that general clinical practices involving ventilatory support were highly heterogeneous, with limited use of standard protocols and most frontline clinicians depending on isolated and varied management guidelines. We found increased staff workload, lack of trained staff and shortage of PPE to be the main limiting factors affecting global COVID-19 ventilatory support management.

3D-printed valves to assist noninvasive ventilation procedures during the COVID-19 pandemic: a case study

Aim: To produce valves to be used with full-face snorkeling masks for noninvasive ventilation (NIV) procedure during the coronavirus disease 2019 (COVID-19) pandemic. Materials & methods: ISINNOVA’s Charlotte valves for full-face snorkeling masks used for NIV procedures were redesigned, produced by selective laser sintering additive manufacturing, and submitted to air leakage tests. Results: The final model assembly did not present air leakage during the NIV procedure on human models, minimizing risks of air contamination. Conclusion: This study shows the feasibility of using additive manufactured valves with snorkel facial masks to support health systems during COVID-19 and possible future pandemics.

Oxygen therapy via high flow nasal cannula in severe respiratory failure caused by Sars-Cov-2 infection: a real-life observational study

The worldwide spread of coronavirus disease 2019 (COVID-19), caused by the new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was declared a pandemic by the World Health Organization (WHO) in March 2020. According to clinical studies carried out in China and Italy, most patients experience mild or moderate symptoms; about a fifth of subjects develop a severe and critical disease, and may suffer from interstitial pneumonia, possibly associated with acute respiratory distress syndrome (ARDS) and death.

In patients who develop respiratory failure, timely conventional oxygen therapy through nasal catheter plays a crucial role, but it can be used only in mild forms. Continuous positive airway pressure (CPAP) support or non-invasive mechanical ventilation (NIV) are uncomfortable, and require significant man–machine cooperation. Herein we describe our experience of five patients with COVID-19, who were treated with high-flow nasal cannula (HFNC) after failure of CPAP or NIV, and discuss the role of HFNC in COVID-19 patients. Our findings suggest that HFNC can be used successfully in selected patients with COVID-19-related ARDS.

The reviews of this paper are available via the supplemental material section.

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.

Severity of respiratory failure at admission and in-hospital mortality in patients with COVID-19: a prospective observational multicentre study

OBJECTIVES

COVID-19 causes lung parenchymal and endothelial damage that lead to hypoxic acute respiratory failure (hARF). The influence of hARF severity on patients' outcomes is still poorly understood.

DESIGN

Observational, prospective, multicentre study.

SETTING

Three academic hospitals in Milan (Italy) involving three respiratory high dependency units and three general wards.

PARTICIPANTS

Consecutive adult hospitalised patients with a virologically confirmed diagnosis of COVID-19. Patients aged <18 years or unable to provide informed consent were excluded.

INTERVENTIONS

Anthropometrical, clinical characteristics and blood biomarkers were assessed within the first 24 hours from admission. hARF was graded as follows: severe (partial pressure of oxygen to fraction of inspired oxygen ratio (PaO2/FiO2) <100 mm Hg); moderate (PaO2/FiO2 101-200 mm Hg); mild (PaO2/FiO2 201-300 mm Hg) and normal (PaO2/FiO2 >300 mm Hg).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the assessment of clinical characteristics and in-hospital mortality based on the severity of respiratory failure. Secondary outcomes were intubation rate and application of continuous positive airway pressure during hospital stay.

RESULTS

412 patients were enrolled (280 males, 68%). Median (IQR) age was 66 (55-76) years with a PaO2/FiO2 at admission of 262 (140-343) mm Hg. 50.2% had a cardiovascular disease. Prevalence of mild, moderate and severe hARF was 24.4%, 21.9% and 15.5%, respectively. In-hospital mortality proportionally increased with increasing impairment of gas exchange (p<0.001). The only independent risk factors for mortality were age ≥65 years (HR 3.41; 95% CI 2.00 to 5.78, p<0.0001), PaO2/FiO2 ratio ≤200 mm Hg (HR 3.57; 95% CI 2.20 to 5.77, p<0.0001) and respiratory failure at admission (HR 3.58; 95% CI 1.05 to 12.18, p=0.04).

CONCLUSIONS

A moderate-to-severe impairment in PaO2/FiO2 was independently associated with a threefold increase in risk of in-hospital mortality. Severity of respiratory failure is useful to identify patients at higher risk of mortality.

TRIAL REGISTRATION NUMBER

NCT04307459.

Decreased Mortality in Patients With Severe Bronchospasm Associated With SARS-CoV-2: An Alternative to Invasive Mechanical Ventilation

The number of patients with acute episodes of severe bronchospasm needing intubation and ventilatory support has increased rapidly during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) coronavirus disease 2019 (COVID-19) pandemic. Although medical consensus upholds the use of ventilatory support in this pathology, its survival benefits remain unclear. To improve the outcomes and survival rates, a bundle of early respiratory therapy with a pharmacological rescue regimen was provided to four patients with bronchospasm secondary to COVID-19. This therapeutic approach successfully delayed the need for invasive mechanical ventilation for 48 hours and decreased the mortality rate in all cases.

Case Report: Opportunities for Treatment of Severe COVID-19 Patients-Lessons From a Death Case

With the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, the incidence of coronavirus disease (COVID-19) increases each day. To date, there is no specific anti-SARS-CoV-2 drug. The usual approach to treating COVID-19 is treating its symptoms. However, this approach is limited by the different conditions of each area. We treated a 57-year-old man who was initially diagnosed with a severe type of the infection, but he progressed to a critical condition and eventually died. We learned valuable lessons from this case. The first lesson is the need to use immediate invasive mechanical ventilation if there is no obvious improvement after using non-invasive ventilation for several hours, which directly affects the prognosis. Another lesson is the risk involved in transferring severe COVID-19 patients. In the process of transfer, various threats may be encountered at any time. Thus, accurate assessment of the patient's condition and strict medical conditions are highly required. During the patient's 25-day treatment, we performed cardiopulmonary resuscitation twice. Currently, many patients require invasive mechanical ventilation and transfer to a superior hospital. We hope our findings will provide some advice and help for treating severe and critical COVID-19 cases.

Sleep medicine and COVID-19. Has a new era begun?

Since late December 2019, COVID-19, the disease caused by the novel coronavirus, SARS-CoV-2, has spread rapidly around the world, causing unprecedented changes in provided health care services. Patients diagnosed with sleep-disordered breathing (SDB) are subject to a higher risk of worse outcomes from COVID-19, due to the high prevalence of coexistent comorbidities. Additionally, treatment with positive airway treatment devices (PAP) can be challenging because of PAP-induced droplets and aerosol. In this context, sleep medicine practices are entering a new era and need to adapt rapidly to these circumstances, so as to provide the best care for patients with SDB. Novel approaches, such as telemedicine, may play an important role in the management of patients with SDB during the COVID-19 pandemic.

Intensive care management of patients with COVID-19

The COVID-19 pandemic originated in China in December 2019 and has since then, swept across the world. The last Influenza pandemic of 1918 happened before the advent of modern medicine. We have come a long way since then. But the pandemic has still caught us unprepared in many quarters. The review focuses on the management of critically ill COVID-19 patients and the various challenges faced by intensivists.

Modified Barrier Enclosure for Noninvasive Respiratory Support in COVID-19 Outbreak

Aim

To develop a device that can reduce the exposure of aerosols to healthcare workers (HCWs) who are working in coronavirus disease-2019 (COVID-19) critical units.

Background

Barrier enclosure has recently been proposed for use during intubations where the risk of aerosolization is high. In COVID-19 outbreak, use of noninvasive respiratory support is increasing. But at the same time, it is associated with high risk of aerosol generation, leading to infections among HCWs. We have made a modification in the intubation box and hence expanded its use with an aim to reduce COVID-19 exposure.

Technique

Vacuum suction tubing was attached to wall mount, and the other end of tubing was fixed, using adhesive surgical tapes, to the inside of the roof of barrier enclosure. Keeping the vacuum suction switched-on inside the box created a negative pressure while overall air flow is into the box from outside. This led us to believe that aerosols if generated are not contaminating patient's vicinity. Currently, we are using barrier enclosure boxes on all patients who are on noninvasive support (noninvasive ventilation or high-flow oxygen therapy).

Conclusion and clinical significance

We believe that adding barrier enclosure with the above-mentioned negative-pressure modification will provide an opportunity to use noninvasive support widely, while at the same time, HCW's exposure to aerosols will be reduced.

How to cite this article

Kumar P, Chaudhry D, Lalwani LK, Singh PK. Modified Barrier Enclosure for Noninvasive Respiratory Support in COVID-19 Outbreak. Indian J Crit Care Med 2020;24(9):835-837.