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Alhazzani W, Parhar KKS, Weatherald J, Al Duhailib Z, Alshahrani M, Al-Fares A, Buabbas S, Cherian SV, Munshi L, Fan E, Al-Hameed F, Chalabi J, Rahmatullah AA, Duan E, Tsang JLY, Lewis K, Lauzier F, Centofanti J, Rochwerg B, Culgin S, Nelson K, Abdukahil SA, Fiest KM, Stelfox HT, Tlayjeh H, Meade MO, Perri D, Solverson K, Niven DJ, Lim R, Møller MH, Belley-Cote E, Thabane L, Tamim H, Cook DJ, Arabi YM. Effect of Awake Prone Positioning on Endotracheal Intubation in Patients With COVID-19 and Acute Respiratory Failure: A Randomized Clinical Trial. JAMA 2022; 327:2104-2113. [PMID: 35569448 PMCID: PMC9108999 DOI: 10.1001/jama.2022.7993] [Citation(s) in RCA: 58] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE The efficacy and safety of prone positioning is unclear in nonintubated patients with acute hypoxemia and COVID-19. OBJECTIVE To evaluate the efficacy and adverse events of prone positioning in nonintubated adult patients with acute hypoxemia and COVID-19. DESIGN, SETTING, AND PARTICIPANTS Pragmatic, unblinded randomized clinical trial conducted at 21 hospitals in Canada, Kuwait, Saudi Arabia, and the US. Eligible adult patients with COVID-19 were not intubated and required oxygen (≥40%) or noninvasive ventilation. A total of 400 patients were enrolled between May 19, 2020, and May 18, 2021, and final follow-up was completed in July 2021. INTERVENTION Patients were randomized to awake prone positioning (n = 205) or usual care without prone positioning (control; n = 195). MAIN OUTCOMES AND MEASURES The primary outcome was endotracheal intubation within 30 days of randomization. The secondary outcomes included mortality at 60 days, days free from invasive mechanical ventilation or noninvasive ventilation at 30 days, days free from the intensive care unit or hospital at 60 days, adverse events, and serious adverse events. RESULTS Among the 400 patients who were randomized (mean age, 57.6 years [SD, 12.83 years]; 117 [29.3%] were women), all (100%) completed the trial. In the first 4 days after randomization, the median duration of prone positioning was 4.8 h/d (IQR, 1.8 to 8.0 h/d) in the awake prone positioning group vs 0 h/d (IQR, 0 to 0 h/d) in the control group. By day 30, 70 of 205 patients (34.1%) in the prone positioning group were intubated vs 79 of 195 patients (40.5%) in the control group (hazard ratio, 0.81 [95% CI, 0.59 to 1.12], P = .20; absolute difference, -6.37% [95% CI, -15.83% to 3.10%]). Prone positioning did not significantly reduce mortality at 60 days (hazard ratio, 0.93 [95% CI, 0.62 to 1.40], P = .54; absolute difference, -1.15% [95% CI, -9.40% to 7.10%]) and had no significant effect on days free from invasive mechanical ventilation or noninvasive ventilation at 30 days or on days free from the intensive care unit or hospital at 60 days. There were no serious adverse events in either group. In the awake prone positioning group, 21 patients (10%) experienced adverse events and the most frequently reported were musculoskeletal pain or discomfort from prone positioning (13 of 205 patients [6.34%]) and desaturation (2 of 205 patients [0.98%]). There were no reported adverse events in the control group. CONCLUSIONS AND RELEVANCE In patients with acute hypoxemic respiratory failure from COVID-19, prone positioning, compared with usual care without prone positioning, did not significantly reduce endotracheal intubation at 30 days. However, the effect size for the primary study outcome was imprecise and does not exclude a clinically important benefit. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04350723.
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Affiliation(s)
- Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Research Institute of St Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Ken Kuljit S. Parhar
- Department of Critical Care Medicine, Alberta Health Services and University of Calgary, Calgary, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute for Public Health, Calgary, Alberta, Canada
| | - Jason Weatherald
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute for Public Health, Calgary, Alberta, Canada
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Zainab Al Duhailib
- Critical Care Medicine Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Mohammed Alshahrani
- Department of Emergency and Critical Care, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Abdulrahman Al-Fares
- Department of Anesthesia, Critical Care Medicine, and Pain Medicine, Al Amiri Hospital, Kuwait City, Kuwait
| | - Sarah Buabbas
- Department of Anesthesia, Critical Care Medicine, and Pain Medicine, Jaber Al-Ahmad Al-Sabah Hospital, Kuwait City, Kuwait
| | - Sujith V. Cherian
- Department of Internal Medicine, Divisions of Critical Care, Pulmonary, and Sleep Medicine, University of Texas Health-McGovern Medical School, Houston
| | - Laveena Munshi
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Fahad Al-Hameed
- Department of Intensive Care, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Jamal Chalabi
- Intensive Care Department, Ministry of National Guard Health Affairs, Al Ahsa, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Al Ahsa, Saudi Arabia
| | - Amera A. Rahmatullah
- Critical Care Medicine Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Erick Duan
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Research Institute of St Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
- Division of Critical Care, Niagara Health, St Catharines, Ontario, Canada
| | - Jennifer L. Y. Tsang
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care, Niagara Health, St Catharines, Ontario, Canada
| | - Kimberley Lewis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Research Institute of St Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
| | - François Lauzier
- Department of Medicine, Université Laval, Québec City, Québec, Canada
- Department of Anesthesiology and Critical Care, Division of Critical Care, Université Laval, Québec City, Québec, Canada
| | - John Centofanti
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Sarah Culgin
- Research Institute of St Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Katlynne Nelson
- Research Institute of St Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Sheryl Ann Abdukahil
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Kirsten M. Fiest
- Department of Critical Care Medicine, Alberta Health Services and University of Calgary, Calgary, Canada
- Department of Community Health Sciences and O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
- Department of Psychiatry and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Henry T. Stelfox
- Department of Critical Care Medicine, Alberta Health Services and University of Calgary, Calgary, Canada
- Department of Community Health Sciences and O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Haytham Tlayjeh
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Maureen O. Meade
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Dan Perri
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Research Institute of St Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Kevin Solverson
- Department of Critical Care Medicine, Alberta Health Services and University of Calgary, Calgary, Canada
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Daniel J. Niven
- Department of Critical Care Medicine, Alberta Health Services and University of Calgary, Calgary, Canada
| | - Rachel Lim
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Emilie Belley-Cote
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Research Institute of St Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Hani Tamim
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Department of Emergency Medicine, American University of Beirut, Beirut, Lebanon
| | - Deborah J. Cook
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Research Institute of St Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Yaseen M. Arabi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
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Klompas M, Branson R, Cawcutt K, Crist M, Eichenwald EC, Greene LR, Lee G, Maragakis LL, Powell K, Priebe GP, Speck K, Yokoe DS, Berenholtz SM. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2022; 43:687-713. [PMID: 35589091 PMCID: PMC10903147 DOI: 10.1017/ice.2022.88] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
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Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Richard Branson
- Department of Surgery, University of Cincinnati Medicine, Cincinnati, Ohio
| | - Kelly Cawcutt
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Matthew Crist
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eric C Eichenwald
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Linda R Greene
- Highland Hospital, University of Rochester, Rochester, New York
| | - Grace Lee
- Stanford University School of Medicine, Palo Alto, California
| | - Lisa L Maragakis
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Krista Powell
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gregory P Priebe
- Department of Anesthesiology, Critical Care and Pain Medicine; Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and Harvard Medical School, Boston, Massachusetts
| | - Kathleen Speck
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah S Yokoe
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Sean M Berenholtz
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy & Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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153
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Qian ET, Gatto CL, Amusina O, Dear ML, Hiser W, Buie R, Kripalani S, Harrell FE, Freundlich RE, Gao Y, Gong W, Hennessy C, Grooms J, Mattingly M, Bellam SK, Burke J, Zakaria A, Vasilevskis EE, Billings FT, Pulley JM, Bernard GR, Lindsell CJ, Rice TW. Assessment of Awake Prone Positioning in Hospitalized Adults With COVID-19: A Nonrandomized Controlled Trial. JAMA Intern Med 2022; 182:612-621. [PMID: 35435937 PMCID: PMC9016608 DOI: 10.1001/jamainternmed.2022.1070] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE Awake prone positioning may improve hypoxemia among patients with COVID-19, but whether it is associated with improved clinical outcomes remains unknown. OBJECTIVE To determine whether the recommendation of awake prone positioning is associated with improved outcomes among patients with COVID-19-related hypoxemia who have not received mechanical ventilation. DESIGN, SETTING, AND PARTICIPANTS This pragmatic nonrandomized controlled trial was conducted at 2 academic medical centers (Vanderbilt University Medical Center and NorthShore University HealthSystem) during the COVID-19 pandemic. A total of 501 adult patients with COVID-19-associated hypoxemia who had not received mechanical ventilation were enrolled from May 13 to December 11, 2020. INTERVENTIONS Patients were assigned 1:1 to receive either the practitioner-recommended awake prone positioning intervention (intervention group) or usual care (usual care group). MAIN OUTCOMES AND MEASURES Primary outcome analyses were performed using a bayesian proportional odds model with covariate adjustment for clinical severity ranking based on the World Health Organization ordinal outcome scale, which was modified to highlight the worst level of hypoxemia on study day 5. RESULTS A total of 501 patients (mean [SD] age, 61.0 [15.3] years; 284 [56.7%] were male; and most [417 (83.2%)] were self-reported non-Hispanic or non-Latinx) were included. Baseline severity was comparable between the intervention vs usual care groups, with 170 patients (65.9%) vs 162 patients (66.7%) receiving oxygen via standard low-flow nasal cannula, 71 patients (27.5%) vs 62 patients (25.5%) receiving oxygen via high-flow nasal cannula, and 16 patients (6.2%) vs 19 patients (7.8%) receiving noninvasive positive-pressure ventilation. Nursing observations estimated that patients in the intervention group spent a median of 4.2 hours (IQR, 1.8-6.7 hours) in the prone position per day compared with 0 hours (IQR, 0-0.7 hours) per day in the usual care group. On study day 5, the bayesian posterior probability of the intervention group having worse outcomes than the usual care group on the modified World Health Organization ordinal outcome scale was 0.998 (posterior median adjusted odds ratio [aOR], 1.63; 95% credibility interval [CrI], 1.16-2.31). However, on study days 14 and 28, the posterior probabilities of harm were 0.874 (aOR, 1.29; 95% CrI, 0.84-1.99) and 0.673 (aOR, 1.12; 95% CrI, 0.67-1.86), respectively. Exploratory outcomes (progression to mechanical ventilation, length of stay, and 28-day mortality) did not differ between groups. CONCLUSIONS AND RELEVANCE In this nonrandomized controlled trial, prone positioning offered no observed clinical benefit among patients with COVID-19-associated hypoxemia who had not received mechanical ventilation. Moreover, there was substantial evidence of worsened clinical outcomes at study day 5 among patients recommended to receive the awake prone positioning intervention, suggesting potential harm. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04359797.
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Affiliation(s)
- Edward Tang Qian
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cheryl L Gatto
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Olga Amusina
- Critical Care Services, NorthShore University HealthSystem, Evanston, Illinois.,Department of Biobehavioral Nursing Science, University of Illinois, Chicago, College of Nursing, Chicago
| | - Mary Lynn Dear
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - William Hiser
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Reagan Buie
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sunil Kripalani
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Frank E Harrell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Robert E Freundlich
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yue Gao
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Wu Gong
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Cassandra Hennessy
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Jillann Grooms
- School of Nursing and Health Sciences, North Park University, Chicago, Illinois
| | - Megan Mattingly
- Critical Care Services, NorthShore University HealthSystem, Evanston, Illinois
| | - Shashi K Bellam
- Division of Pulmonary and Critical Care, Department of Medicine, NorthShore University HealthSystem, Evanston, Illinois
| | - Jessica Burke
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Arwa Zakaria
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Eduard E Vasilevskis
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Frederic T Billings
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jill M Pulley
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gordon R Bernard
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher J Lindsell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Todd W Rice
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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154
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Sottile PD, Albert RK, Moss M. Prone Positioning for Nonintubated Patients With COVID-19-Potential Dangers of Extrapolation and Intermediate Outcome Variables. JAMA Intern Med 2022; 182:622-623. [PMID: 35435933 DOI: 10.1001/jamainternmed.2022.1086] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Peter D Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora
| | - Richard K Albert
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora
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155
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Li J, Luo J, Pavlov I, Perez Y, Tan W, Roca O, Tavernier E, Kharat A, McNicholas B, Ibarra-Estrada M, Vines DL, Bosch NA, Rampon G, Simpson SQ, Walkey AJ, Fralick M, Verma A, Razak F, Harris T, Laffey JG, Guerin C, Ehrmann S, Li J, Luo J, Pavlov I, Perez Y, Tan W, Roca O, Tavernier E, Kharat A, McNicholas B, Ibarra-Estrada M, Vines D, Bosch NA, Rampon G, Simpson SQ, Walkey AJ, Fralick M, Verma A, Razak F, Harris T, Laffey JG, Guerin C, Ehrmann S, Mirza S, Xue L, Pavord ID, Plamondon P, Jayaraman D, Shahin J, Dahine J, Kulenkamp A, Pacheco A. Awake prone positioning for non-intubated patients with COVID-19-related acute hypoxaemic respiratory failure: a systematic review and meta-analysis. THE LANCET RESPIRATORY MEDICINE 2022; 10:573-583. [PMID: 35305308 PMCID: PMC8926412 DOI: 10.1016/s2213-2600(22)00043-1] [Citation(s) in RCA: 75] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/14/2022] [Accepted: 01/17/2022] [Indexed: 12/12/2022]
Abstract
Background Awake prone positioning has been broadly utilised for non-intubated patients with COVID-19-related acute hypoxaemic respiratory failure, but the results from published randomised controlled trials (RCTs) in the past year are contradictory. We aimed to systematically synthesise the outcomes associated with awake prone positioning, and evaluate these outcomes in relevant subpopulations. Methods In this systematic review and meta-analysis, two independent groups of researchers searched MEDLINE, Embase, PubMed, Web of Science, Scopus, MedRxiv, BioRxiv, and ClinicalTrials.gov for RCTs and observational studies (with a control group) of awake prone positioning in patients with COVID-19-related acute hypoxaemic respiratory failure published in English from Jan 1, 2020, to Nov 8, 2021. We excluded trials that included patients intubated before or at enrolment, paediatric patients (ie, younger than 18 years), or trials that did not include the supine position in the control group. The same two independent groups screened studies, extracted the summary data from published reports, and assessed the risk of bias. We used a random-effects meta-analysis to pool individual studies. We used the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty and quality of the evidence. The primary outcome was the reported cumulative intubation risk across RCTs, and effect estimates were calculated as risk ratios (RR;95% CI). The analysis was primarily conducted on RCTs, and observational studies were used for sensitivity analyses. No serious adverse events associated with awake prone positioning were reported. The study protocol was prospectively registered with PROSPERO, CRD42021271285. Findings A total of 1243 studies were identified, we assessed 138 full-text articles and received the aggregated results of three unpublished RCTs; therefore, after exclusions, 29 studies were included in the study. Ten were RCTs (1985 patients) and 19 were observational studies (2669 patients). In ten RCTs, awake prone positioning compared with the supine position significantly reduced the need for intubation in the overall population (RR 0·84 [95% CI 0·72–0·97]). A reduced need for intubation was shown among patients who received advanced respiratory support (ie, high-flow nasal cannula or non-invasive ventilation) at enrolment (RR 0·83 [0·71–0·97]) and in intensive care unit (ICU) settings (RR 0·83 [0·71–0·97]) but not in patients receiving conventional oxygen therapy (RR 0·87 [0·45–1·69]) or in non-ICU settings (RR 0·88 [0·44–1·76]). No obvious risk of bias and publication bias was found among the included RCTs for the primary outcome. Interpretation In patients with COVID-19-related acute hypoxaemic respiratory failure, awake prone positioning reduced the need for intubation, particularly among those requiring advanced respiratory support and those in ICU settings. Awake prone positioning should be used in patients who have acute hypoxaemic respiratory failure due to COVID-19 and require advanced respiratory support or are treated in the ICU. Funding OpenAI, Rice Foundation, National Institute for Health Research, and Oxford Biomedical Research Centre.
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156
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Shekar K, Ling RR. The pandemic and the great awakening in the management of acute hypoxaemic respiratory failure. THE LANCET RESPIRATORY MEDICINE 2022; 10:527-529. [PMID: 35305307 PMCID: PMC8926406 DOI: 10.1016/s2213-2600(22)00051-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Kiran Shekar
- Adult Intensive Care Services, Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, QLD 4032, Australia; Queensland University of Technology, Brisbane, QLD, Australia; University of Queensland, Brisbane and Bond University, Gold Coast, QLD, Australia.
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
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157
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Guérin C, Cour M, Argaud L. Prone Positioning and Neuromuscular Blocking Agents as Adjunctive Therapies in Mechanically Ventilated Patients with Acute Respiratory Distress Syndrome. Semin Respir Crit Care Med 2022; 43:453-460. [DOI: 10.1055/s-0042-1744304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AbstractNeuromuscular blocking agents (NMBAs) and prone position (PP) are two major adjunctive therapies that can improve outcome in moderate-to-severe acute respiratory distress syndrome. NMBA should be used once lung-protective mechanical ventilation has been set, for 48 hours or less and as a continuous intravenous infusion. PP should be used as early as possible for long sessions; in COVID-19 its use has exploded. In nonintubated patients, PP might reduce the rate of intubation but not mortality. The goal of this article is to perform a narrative review on the pathophysiological rationale, the clinical effects, and the clinical use and recommendations of both NMBA and PP.
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Affiliation(s)
- Claude Guérin
- Médecine Intensive Réanimation, Hôpital Edouard Herriot, Lyon, France
- Faculté de Médecine Lyon-Est, Université de Lyon, Lyon, France
- INSERM 955 CNRS 7200, Institut Mondor de Recherches Biomédicales, Créteil, France
| | - Martin Cour
- Médecine Intensive Réanimation, Hôpital Edouard Herriot, Lyon, France
- Faculté de Médecine Lyon-Est, Université de Lyon, Lyon, France
| | - Laurent Argaud
- Médecine Intensive Réanimation, Hôpital Edouard Herriot, Lyon, France
- Faculté de Médecine Lyon-Est, Université de Lyon, Lyon, France
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158
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Granados-Bolivar ME, Quesada-Caballero M, Suleiman-Martos N, Romero-Béjar JL, Albendín-García L, Cañadas-De la Fuente GA, Caballero-Vázquez A. Evolution of Acute Respiratory Distress Syndrome in Emergency and Critical Care: Therapeutic Management before and during the Pandemic Situation. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:726. [PMID: 35743989 PMCID: PMC9229826 DOI: 10.3390/medicina58060726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/23/2022] [Accepted: 05/25/2022] [Indexed: 11/23/2022]
Abstract
Background and Objectives: Acute respiratory distress syndrome is a life-threatening lung condition that prevents enough oxygen from getting to the lungs and blood. The causes can be varied, although since the COVID-19 pandemic began there have been many cases related to this virus. The management and evolution of ARDS in emergency situations in the last 5 years was analyzed. Materials and Methods: A systematic review was carried out in the PubMed and Scopus databases. Using the descriptors Medical Subject Headings (MeSH), the search equation was: "Emergency health service AND acute respiratory distress syndrome". The search was conducted in December 2021. Quantitative primary studies on the care of patients with ARDS in an emergency setting published in the last 5 years were included. Results: In the initial management, adherence to standard treatment with continuous positive airway pressure (CPAP) is recommended. The use of extracorporeal membrane reduces the intensity of mechanical ventilation or as rescue therapy in acute respiratory distress syndrome (ARDS). The prone position in both intubated and non-intubated patients with severe ARDS is associated with a better survival of these patients, therefore, it is very useful in these moments of pandemic crisis. Lack of resources forces triage decisions about which patients are most likely to survive to start mechanical ventilation and this reflects the realities of intensive care and emergency care in a resource-limited setting. Conclusions: adequate prehospital management of ARDS and in emergency situations can improve the prognosis of patients. The therapeutic options in atypical ARDS due to COVID-19 do not seem to vary substantially from conventional ARDS.
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Affiliation(s)
- Monserrat E. Granados-Bolivar
- Iznalloz Health Center, Granada Metropolitan District, Andalusian Health Service, Calle Virgen de la Consolación, 12, 18015 Granada, Spain;
| | - Miguel Quesada-Caballero
- Albayda La Cruz Health Center, Granada Metropolitan District, Andalusian Health Service, Calle Virgen de la Consolación, 12, 18015 Granada, Spain;
| | - Nora Suleiman-Martos
- Faculty of Health Sciences, University of Granada, Campus Universitario de Ceuta, C/Cortadura del Valle SN, 51001 Ceuta, Spain;
| | - José L. Romero-Béjar
- Statistics and Operational Research Department, University of Granada, Avda. Fuentenueva S/N, 18071 Granada, Spain
| | - Luis Albendín-García
- Casería de Montijo Health Center, Granada Metropolitan District, Andalusian Health Service, Calle Virgen de la Consolación, 12, 18015 Granada, Spain;
| | | | - Alberto Caballero-Vázquez
- Diagnostic Lung Cancer Unit, Broncopleural Techniques and Interventional Pulmonology Departament, Hospital Universitario Virgen de las Nieves, 18014 Granada, Spain;
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159
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Yarnell CJ, Sklar MC. Noninvasive Respiratory Strategies and Intubation or Mortality Among Patients With Acute Hypoxemic Respiratory Failure Due to COVID-19. JAMA 2022; 327:2023. [PMID: 35608589 DOI: 10.1001/jama.2022.5276] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Christopher J Yarnell
- University Health Network and Sinai Health Systems, University of Toronto, Toronto, Ontario, Canada
| | - Michael C Sklar
- St Michael's Hospital Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
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160
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Niehues P, Wegner FK, Wolfes J, Willy K, Ellermann C, Vollenberg R, Reinecke H, Rosenow F, Lepper J, Sackarnd J, Eckardt L. Incidence and predictors of cardiac arrhythmias in patients with COVID-19 induced ARDS. J Cardiol 2022; 80:298-302. [PMID: 35589465 PMCID: PMC9108971 DOI: 10.1016/j.jjcc.2022.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/12/2022] [Accepted: 04/18/2022] [Indexed: 12/15/2022]
Abstract
Introduction Recent studies suggest cardiac involvement with an increased incidence of arrhythmias in the setting of coronavirus disease 2019 (COVID-19). The aim of this study was to evaluate the risk of potentially lethal arrhythmias and atrial fibrillation in patients with COVID-19-induced acute respiratory distress syndrome (ARDS) and to elicit possible predictors of arrhythmia occurrence. Methods and results A total of 107 patients (82 male, mean age 60 ± 12 years, median body mass index 28 kg/m2) treated for COVID-19-induced ARDS in a large tertiary university hospital intensive care unit between March 2020 and February 2021 were retrospectively analyzed. Eighty-four patients (79%) had at least moderate ARDS, 88 patients (83%) were mechanically ventilated, 35 patients (33%) received vvECMO. Forty-three patients (40%) died during their hospital stay. Twelve patients (11%) showed potentially lethal arrhythmias (six ventricular tachycardia, six significant bradycardia). Atrial fibrillation occurred in 27 patients (25%). In a multivariate logistic regression analysis, duration of hospitalization was associated with the occurrence of potentially lethal arrhythmias (p = 0.006). There was no association between possible predictive factors and the occurrence of atrial fibrillation. Invasive ventilation, antipsychotics, and the QTc interval were independently associated with acute in-hospital mortality, but this was not arrhythmia-driven as there was no association between the occurrence of arrhythmias and mortality. Conclusion In this relatively young population with COVID-19-induced ARDS, the incidence of potentially lethal arrhythmias was low. While overall mortality was high in these severely affected patients, cardiac involvement and arrhythmia occurrence was not a significant driver of mortality.
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Affiliation(s)
- Philipp Niehues
- Department of Cardiology II - Electrophysiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany
| | - Felix K Wegner
- Department of Cardiology II - Electrophysiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany.
| | - Julian Wolfes
- Department of Cardiology II - Electrophysiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany
| | - Kevin Willy
- Department of Cardiology II - Electrophysiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany
| | - Christian Ellermann
- Department of Cardiology II - Electrophysiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany
| | - Richard Vollenberg
- Department of Medicine B for Gastroenterology, Hepatology, Endocrinology and Clinical Infectiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany
| | - Holger Reinecke
- Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany
| | - Felix Rosenow
- Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany
| | - Johannes Lepper
- Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany
| | - Jan Sackarnd
- Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany
| | - Lars Eckardt
- Department of Cardiology II - Electrophysiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany
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161
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Gershengorn HB, Pavlov I, Perez Y, Tavernier E, Ibarra-Estrada M, Vines D, McNicholas B, Roca O, Ehrmann S, Laffey JG, Li J. High-Flow Nasal Cannula Failure Odds Is Largely Independent of Duration of Use in COVID-19. Am J Respir Crit Care Med 2022; 205:1240-1243. [PMID: 35176213 PMCID: PMC9872798 DOI: 10.1164/rccm.202111-2509le] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Affiliation(s)
- Hayley B. Gershengorn
- University of Miami Miller School of MedicineMiami, Florida
- Albert Einstein College of MedicineBronx, New York
| | | | - Yonatan Perez
- FCRIN Research NetworkTours, France
- Université de ToursTours, France
| | | | | | | | - Bairbre McNicholas
- Galway University HospitalsGalway, Ireland
- HRB Galway Clinical Research FacilityGalway, Ireland
- National University of IrelandGalway, Ireland
| | - Oriol Roca
- Hospital Universitari Vall d’HebronBarcelona, Spain
- Instituto de Salud Carlos IIIMadrid, Spain
| | - Stephan Ehrmann
- FCRIN Research NetworkTours, France
- Université de ToursTours, France
| | - John G. Laffey
- Galway University HospitalsGalway, Ireland
- HRB Galway Clinical Research FacilityGalway, Ireland
- National University of IrelandGalway, Ireland
| | - Jie Li
- Rush UniversityChicago, Illinois
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162
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Smith LM, Glauser JM. Managing Severe Hypoxic Respiratory Failure in COVID-19. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2022; 10:31-35. [PMID: 35572208 PMCID: PMC9091541 DOI: 10.1007/s40138-022-00245-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2022] [Indexed: 12/11/2022]
Abstract
Purpose of Review Adult respiratory distress syndrome is a life-threatening complication from severe COVID-19 infection resulting in severe hypoxic respiratory failure. Strategies at improving oxygenation have evolved over the course of the pandemic. Recent Findings Although non-invasive respiratory support reduces the need for intubation, a significant number of patients with COVID-19 progress to invasive mechanical ventilation. Once intubated, a lung protective ventilation strategy should be employed that limits tidal volumes to 6 ml/kg of predicted body weight and employs sufficient positive end-expiratory pressure to maximize oxygen delivery while minimizing the fraction of inspired oxygen. Intermittent prone positioning is effective at improving survival, and there is a growing body of evidence that it can be safely performed in spontaneously breathing patients to reduce the need for invasive mechanical ventilation. Inhaled pulmonary vasodilators have not been shown to improve survival or cost-effectiveness in COVID-19 and should be used selectively. Summary Finally, the best outcomes are likely achieved at centers with experience at severe ARDS management and protocols for escalation of care.
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Affiliation(s)
- Lane M. Smith
- Division of Critical Care Medicine, Department of Anesthesiology, University of Michigan Health System, 4172 Cardiovascular Center, 1500 East Medical Center Dr., SPC 5861, Ann Arbor, MI 48109-5861 USA
| | - Jonathan M. Glauser
- Department of Emergency Medicine, MetroHealth System and Case Western Reserve University, Cleveland, OH 44109 USA
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163
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Tran TNA, Wikle NB, Yang F, Inam H, Leighow S, Gentilesco B, Chan P, Albert E, Strong ER, Pritchard JR, Hanage WP, Hanks EM, Crawford FW, Boni MF. SARS-CoV-2 Attack Rate and Population Immunity in Southern New England, March 2020 to May 2021. JAMA Netw Open 2022; 5:e2214171. [PMID: 35616938 PMCID: PMC9136627 DOI: 10.1001/jamanetworkopen.2022.14171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/09/2022] [Indexed: 12/15/2022] Open
Abstract
Importance In emergency epidemic and pandemic settings, public health agencies need to be able to measure the population-level attack rate, defined as the total percentage of the population infected thus far. During vaccination campaigns in such settings, public health agencies need to be able to assess how much the vaccination campaign is contributing to population immunity; specifically, the proportion of vaccines being administered to individuals who are already seropositive must be estimated. Objective To estimate population-level immunity to SARS-CoV-2 through May 31, 2021, in Rhode Island, Massachusetts, and Connecticut. Design, Setting, and Participants This observational case series assessed cases, hospitalizations, intensive care unit occupancy, ventilator occupancy, and deaths from March 1, 2020, to May 31, 2021, in Rhode Island, Massachusetts, and Connecticut. Data were analyzed from July 2021 to November 2021. Exposures COVID-19-positive test result reported to state department of health. Main Outcomes and Measures The main outcomes were statistical estimates, from a bayesian inference framework, of the percentage of individuals as of May 31, 2021, who were (1) previously infected and vaccinated, (2) previously uninfected and vaccinated, and (3) previously infected but not vaccinated. Results At the state level, there were a total of 1 160 435 confirmed COVID-19 cases in Rhode Island, Massachusetts, and Connecticut. The median age among individuals with confirmed COVID-19 was 38 years. In autumn 2020, SARS-CoV-2 population immunity (equal to the attack rate at that point) in these states was less than 15%, setting the stage for a large epidemic wave during winter 2020 to 2021. Population immunity estimates for May 31, 2021, were 73.4% (95% credible interval [CrI], 72.9%-74.1%) for Rhode Island, 64.1% (95% CrI, 64.0%-64.4%) for Connecticut, and 66.3% (95% CrI, 65.9%-66.9%) for Massachusetts, indicating that more than 33% of residents in these states were fully susceptible to infection when the Delta variant began spreading in July 2021. Despite high vaccine coverage in these states, population immunity in summer 2021 was lower than planned owing to an estimated 34.1% (95% CrI, 32.9%-35.2%) of vaccines in Rhode Island, 24.6% (95% CrI, 24.3%-25.1%) of vaccines in Connecticut, and 27.6% (95% CrI, 26.8%-28.6%) of vaccines in Massachusetts being distributed to individuals who were already seropositive. Conclusions and Relevance These findings suggest that future emergency-setting vaccination planning may have to prioritize high vaccine coverage over optimized vaccine distribution to ensure that sufficient levels of population immunity are reached during the course of an ongoing epidemic or pandemic.
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Affiliation(s)
- Thu Nguyen-Anh Tran
- Center for Infectious Disease Dynamics, Department of Biology, Pennsylvania State University, University Park
| | - Nathan B. Wikle
- Center for Infectious Disease Dynamics, Department of Statistics, Pennsylvania State University, University Park
| | - Fuhan Yang
- Center for Infectious Disease Dynamics, Department of Biology, Pennsylvania State University, University Park
| | - Haider Inam
- Center for Infectious Disease Dynamics, Department of Bioengineering, Pennsylvania State University, University Park
| | - Scott Leighow
- Center for Infectious Disease Dynamics, Department of Bioengineering, Pennsylvania State University, University Park
| | | | - Philip Chan
- Department of Medicine, Brown University, Providence, Rhode Island
| | - Emmy Albert
- Department of Physics, Pennsylvania State University, University Park
| | - Emily R. Strong
- Center for Infectious Disease Dynamics, Department of Statistics, Pennsylvania State University, University Park
| | - Justin R. Pritchard
- Center for Infectious Disease Dynamics, Department of Bioengineering, Pennsylvania State University, University Park
| | - William P. Hanage
- Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Ephraim M. Hanks
- Center for Infectious Disease Dynamics, Department of Statistics, Pennsylvania State University, University Park
| | - Forrest W. Crawford
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
- Department of Statistics and Data Science, Yale University, New Haven, Connecticut
| | - Maciej F. Boni
- Center for Infectious Disease Dynamics, Department of Biology, Pennsylvania State University, University Park
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164
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Shikano K, Sakao S, Inaba Y, Taniguchi T, Saito G, Naito A, Abe M, Kasai H, Yahaba M, Kawasaki T, Shigeta A, Ikari J, Sugiura T, Kawasaki Y, Igari H, Suzuki T. Tolerability of prone positioning in non-intubated patients with hypoxaemia due to COVID-19-related pneumonia. Respirology 2022; 27:370-371. [PMID: 35253312 PMCID: PMC9115325 DOI: 10.1111/resp.14238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 02/23/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Kohei Shikano
- Department of Respirology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Seiichiro Sakao
- Department of Respirology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Yosuke Inaba
- Biostatistics Section, Clinical Research CenterChiba University HospitalChibaJapan
| | | | - Go Saito
- Department of Respirology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Akira Naito
- Department of Respirology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Mitsuhiro Abe
- Department of Respirology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Hajime Kasai
- Department of Respirology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Misuzu Yahaba
- Department of Infectious DiseasesChiba University HospitalChibaJapan
| | - Takeshi Kawasaki
- Department of Respirology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Ayako Shigeta
- Department of Respirology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Jun Ikari
- Department of Respirology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Toshihiko Sugiura
- Department of Respirology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Yohei Kawasaki
- Biostatistics Section, Clinical Research CenterChiba University HospitalChibaJapan
- Faculty of NursingJapanese Red Cross College of NursingTokyoJapan
| | - Hidetoshi Igari
- Department of Infectious DiseasesChiba University HospitalChibaJapan
| | - Takuji Suzuki
- Department of Respirology, Graduate School of MedicineChiba UniversityChibaJapan
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165
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Budweiser S. Bauchlage senkt Intubationsrate bei wachen COVID-19-Patienten auf Intensivstation. PNEUMO NEWS 2022; 14:19-20. [PMID: 35531058 PMCID: PMC9060839 DOI: 10.1007/s15033-022-2823-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Stephan Budweiser
- Medizinische Klinik III, RoMed Klinikum Rosenheim, Pettenkoferstr. 10, 83022 Rosenheim, Deutschland
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166
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Schroeder I, Irlbeck M, Zoller M. [Noninvasive respiratory support and invasive ventilation in COVID‑19 : Where do we stand today?]. Anaesthesist 2022; 71:333-339. [PMID: 35397669 PMCID: PMC8994638 DOI: 10.1007/s00101-022-01114-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2022] [Indexed: 12/23/2022]
Abstract
The controversy surrounding ventilation in coronavirus disease 2019 (COVID-19) continues. Early in the pandemic it was postulated that the high intensive care unit (ICU) mortality may have been due to too early intubation. As the pandemic progressed recommendations changed and the use of noninvasive respiratory support (NIRS) increased; however, this did not result in a clear reduction in ICU mortality. Furthermore, large studies on optimal ventilation in COVID-19 are lacking. This review article summarizes the pathophysiological basis, the current state of the science and the impact of different treatment modalities on the outcome. Potential factors that could undermine the benefits of noninvasive respiratory support are discussed. The authors attempt to provide guidance in answering the difficult question of when is the right time to intubate?
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Affiliation(s)
- Ines Schroeder
- Klinik für Anästhesiologie, LMU Klinikum, Marchioninistraße 15, 81377, München, Deutschland.
| | - Michael Irlbeck
- Klinik für Anästhesiologie, LMU Klinikum, Marchioninistraße 15, 81377, München, Deutschland
| | - Michael Zoller
- Klinik für Anästhesiologie, LMU Klinikum, Marchioninistraße 15, 81377, München, Deutschland
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167
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Abstract
Pregnant women with covid-19 are at greater risk of severe disease than their non-pregnant peers, and yet they are frequently denied investigations or treatments because of unfounded concerns about risk to the fetus. The basic principles of diagnosing and managing covid-19 are the same as for non-pregnant patients, and a multidisciplinary, expert team approach is essential to ensure optimal care. During pregnancy, treatment with corticosteroids should be modified to use non-fluorinated glucocorticoids. Il-6 inhibitors and monoclonal antibodies, together with specific antiviral therapies, may also be considered. Prophylaxis against venous thromboembolism is important. Women may require respiratory support with oxygen, non-invasive ventilation, ventilation in a prone position (either awake or during invasive ventilation), intubation and ventilation, and extracorporeal membrane oxygenation (ECMO). Pregnancy is not a contraindication for any of these supportive therapies, and the criteria for providing them are the same as in the general population. Decisions regarding timing, place, and mode of delivery should be taken with a multidisciplinary team including obstetricians, physicians, anesthetists, and intensivists experienced in the care of covid-19 in pregnancy. Ideally these decisions should take place in consultation with centers that have experience and expertise in all these specialties.
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Affiliation(s)
- Melanie Nana
- Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Kenneth Hodson
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | | | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, UK
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168
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Brioni M, Meli A, Grasselli G. Mechanical Ventilation for COVID-19 Patients. Semin Respir Crit Care Med 2022; 43:405-416. [PMID: 35439831 DOI: 10.1055/s-0042-1744305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Non-invasive ventilation (NIV) or invasive mechanical ventilation (MV) is frequently needed in patients with acute hypoxemic respiratory failure due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. While NIV can be delivered in hospital wards and nonintensive care environments, intubated patients require intensive care unit (ICU) admission and support. Thus, the lack of ICU beds generated by the pandemic has often forced the use of NIV in severely hypoxemic patients treated outside the ICU. In this context, awake prone positioning has been widely adopted to ameliorate oxygenation during noninvasive respiratory support. Still, the incidence of NIV failure and the role of patient self-induced lung injury on hospital outcomes of COVID-19 subjects need to be elucidated. On the other hand, endotracheal intubation is indicated when gas exchange deterioration, muscular exhaustion, and/or neurological impairment ensue. Yet, the best timing for intubation in COVID-19 is still widely debated, as it is the safest use of neuromuscular blocking agents. Not differently from other types of acute respiratory distress syndrome, the aim of MV during COVID-19 is to provide adequate gas exchange while avoiding ventilator-induced lung injury. At the same time, the use of rescue therapies is advocated when standard care is unable to guarantee sufficient organ support. Nevertheless, the general shortage of health care resources experienced during SARS-CoV-2 pandemic might affect the utilization of high-cost, highly specialized, and long-term supports. In this article, we describe the state-of-the-art of NIV and MV setting and their usage for acute hypoxemic respiratory failure of COVID-19 patients.
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Affiliation(s)
- Matteo Brioni
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Meli
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Grasselli
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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169
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Frat JP, Le Pape S, Coudroy R, Thille AW. Noninvasive Oxygenation in Patients with Acute Respiratory Failure: Current Perspectives. Int J Gen Med 2022; 15:3121-3132. [PMID: 35418775 PMCID: PMC9000535 DOI: 10.2147/ijgm.s294906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 02/22/2022] [Indexed: 01/16/2023] Open
Abstract
Purpose of Review High-flow nasal oxygen and noninvasive ventilation are two alternative strategies to standard oxygen in the management of acute respiratory failure. Discussion Although high-flow nasal oxygen has gained major popularity in ICUs due to its simplicity of application, good comfort for patients, efficiency in improving oxygenation and promising results in patients with acute hypoxemic respiratory failure, further large clinical trials are needed to confirm its superiority over standard oxygen. Non-invasive ventilation may have deleterious effects, especially in patients exerting strong inspiratory efforts, and no current recommendations support its use in this setting. Protective non-invasive ventilation using higher levels of positive-end expiratory pressure, more prolonged sessions and other interfaces such as the helmet may have beneficial physiological effects leading to it being proposed as alternative to high-flow nasal oxygen in acute hypoxemic respiratory failure. By contrast, non-invasive ventilation is the first-line strategy of oxygenation in patients with acute exacerbation of chronic lung disease, while high-flow nasal oxygen could be an alternative to non-invasive ventilation after partial reversal of respiratory acidosis. Questions remain about the target populations and non-invasive oxygen strategy representing the best alternative to standard oxygen in acute hypoxemic respiratory failure. As concerns acute on-chronic-respiratory failure, the place of high-flow nasal oxygen remains to be evaluated.
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Affiliation(s)
- Jean-Pierre Frat
- Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers, France
- Centre d’Investigation Clinique 1402 ALIVE, INSERM, Université de Poitiers, Poitiers, France
| | - Sylvain Le Pape
- Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers, France
| | - Rémi Coudroy
- Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers, France
- Centre d’Investigation Clinique 1402 ALIVE, INSERM, Université de Poitiers, Poitiers, France
| | - Arnaud W Thille
- Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers, France
- Centre d’Investigation Clinique 1402 ALIVE, INSERM, Université de Poitiers, Poitiers, France
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170
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Beran A, Mhanna M, Srour O, Ayesh H, Sajdeya O, Ghazaleh S, Mhanna A, Ghazaleh D, Khokher W, Maqsood A, Assaly R. Effect of Prone Positioning on Clinical Outcomes of Non-Intubated Subjects With COVID-19. Respir Care 2022; 67:471-479. [PMID: 34753813 PMCID: PMC9994005 DOI: 10.4187/respcare.09362] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Awake prone positioning (APP) has been recently proposed as an adjunctive treatment for non-intubated coronavirus disease 2019 (COVID-19) patients requiring oxygen therapy to improve oxygenation and reduce the risk of intubation. However, the magnitude of the effect of APP on clinical outcomes in these patients remains uncertain. We performed a comparative systematic review and meta-analysis to evaluate the effectiveness of APP to improve the clinical outcomes in non-intubated subjects with COVID-19. METHODS The primary outcomes were the need for endotracheal intubation and mortality. The secondary outcome was hospital length of stay. Pooled risk ratio (RR) and mean difference with the corresponding 95% CI were obtained by the Mantel-Haenszel method within a random-effect model. RESULTS A total of 14 studies (5 randomized controlled trials [RCTs] and 9 observational studies) involving 3,324 subjects (1,495 received APP and 1,829 did not) were included. There was a significant reduction in the mortality rate in APP group compared to control (RR 0.68 [95% CI 0.51-0.90]; P = .008, I2 = 52%) with no significant effect on intubation (RR 0.85 [95% CI 0.66-1.08]; P = .17, I2 = 63%) or hospital length of stay (mean difference -3.09 d [95% CI-10.14-3.96]; P = .39, I2 = 97%). Subgroup analysis of RCTs showed significant reduction in intubation rate (RR 0.83 [95% CI 0.72-0.97]; P = .02, I2 = 0%). CONCLUSIONS APP has the potential to reduce the in-hospital mortality rate in COVID-19 subjects with hypoxemia without a significant effect on the need for intubation or length of hospital stay. However, there was a significant decrease in the need for intubation on subgroup analysis of RCTs. More large-scale trials with a standardized protocol for prone positioning are needed to better evaluate its effectiveness in this select population.
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Affiliation(s)
- Azizullah Beran
- Department of Internal Medicine, University of Toledo, Toledo, Ohio.
| | - Mohammed Mhanna
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | - Omar Srour
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | - Hazem Ayesh
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | - Omar Sajdeya
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | - Sami Ghazaleh
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | | | | | - Waleed Khokher
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | - Aadil Maqsood
- Department of Pulmonary and Critical Care Medicine, University of Toledo, Toledo, Ohio
| | - Ragheb Assaly
- Department of Pulmonary and Critical Care Medicine, University of Toledo, Toledo, Ohio
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Brady WJ, Chavez S, Gottlieb M, Liang SY, Carius B, Koyfman A, Long B. Clinical update on COVID-19 for the emergency clinician: Cardiac arrest in the out-of-hospital and in-hospital settings. Am J Emerg Med 2022; 57:114-123. [PMID: 35561501 PMCID: PMC9045864 DOI: 10.1016/j.ajem.2022.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/05/2022] [Accepted: 04/20/2022] [Indexed: 01/08/2023] Open
Abstract
Introduction Coronavirus disease of 2019 (COVID-19) has resulted in millions of cases worldwide. As the pandemic has progressed, the understanding of this disease has evolved. Its impact on the health and welfare of the human population is significant; its impact on the delivery of healthcare is also considerable. Objective This article is another paper in a series addressing COVID-19-related updates to emergency clinicians on the management of COVID-19 patients with cardiac arrest. Discussion COVID-19 has resulted in significant morbidity and mortality worldwide. From a global perspective, as of February 23, 2022, 435 million infections have been noted with 5.9 million deaths (1.4%). Current data suggest an increase in the occurrence of cardiac arrest, both in the outpatient and inpatient settings, with corresponding reductions in most survival metrics. The frequency of out-of-hospital lay provider initial care has decreased while non-shockable initial cardiac arrest rhythms have increased. While many interventions, including chest compressions, are aerosol-generating procedures, the risk of contagion to healthcare personnel is low, assuming appropriate personal protective equipment is used; vaccination with boosting provides further protection against contagion for the healthcare personnel involved in cardiac arrest resuscitation. The burden of the COVID-19 pandemic on the delivery of cardiac arrest care is considerable and, despite multiple efforts, has adversely impacted the chain of survival. Conclusion This review provides a focused update of cardiac arrest in the setting of COVID-19 for emergency clinicians.
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Maslove DM, Sibley S, Boyd JG, Goligher EC, Munshi L, Bogoch II, Rochwerg B. Complications of Critical COVID-19: Diagnostic and Therapeutic Considerations for the Mechanically Ventilated Patient. Chest 2022; 161:989-998. [PMID: 34655568 PMCID: PMC8511547 DOI: 10.1016/j.chest.2021.10.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 09/04/2021] [Accepted: 10/06/2021] [Indexed: 01/31/2023] Open
Abstract
Patients admitted to the ICU with critical COVID-19 often require prolonged periods of mechanical ventilation. Difficulty weaning, lack of progress, and clinical deterioration are commonly encountered. These conditions should prompt a thorough evaluation for persistent or untreated manifestations of COVID-19, as well as complications from COVID-19 and its various treatments. Inflammation may persist and lead to fibroproliferative changes in the lungs. Infectious complications may arise including bacterial superinfection in the earlier stages of disease. Use of immunosuppressants may lead to the dissemination of latent infections, and to opportunistic infections. Venous thromboembolic disease is common, as are certain neurologic manifestations of COVID-19 including delirium and stroke. High levels of ventilatory support may lead to ventilator-induced injury to the lungs and diaphragm. We present diagnostic and therapeutic considerations for the mechanically ventilated patient with COVID-19 who shows persistent or worsening signs of critical illness, and we offer an approach to treating this complex but common scenario.
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Affiliation(s)
- David M. Maslove
- Department of Critical Care Medicine, Queen’s University, Kingston, ON, Canada,Kingston Health Sciences Centre, Kingston, ON, Canada,CORRESPONDENCE TO: David M. Maslove, MD
| | - Stephanie Sibley
- Department of Critical Care Medicine, Queen’s University, Kingston, ON, Canada,Kingston Health Sciences Centre, Kingston, ON, Canada
| | - J. Gordon Boyd
- Department of Critical Care Medicine, Queen’s University, Kingston, ON, Canada,Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Ewan C. Goligher
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada,University Health Network, Toronto, ON, Canada
| | - Laveena Munshi
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada,Sinai Health System, Toronto, ON, Canada
| | - Isaac I. Bogoch
- University Health Network, Toronto, ON, Canada,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, ON, Canada,Juravinski Hospital, Hamilton, ON, Canada
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173
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Karageorgos V, Proklou A, Vaporidi K. Lung and diaphragm protective ventilation: a synthesis of recent data. Expert Rev Respir Med 2022; 16:375-390. [PMID: 35354361 DOI: 10.1080/17476348.2022.2060824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION : To adhere to the Hippocratic Oath, to "first, do no harm", we need to make every effort to minimize the adverse effects of mechanical ventilation. Our understanding of the mechanisms of ventilator-induced lung injury (VILI) and ventilator-induced diaphragm dysfunction (VIDD) has increased in recent years. Research focuses now on methods to monitor lung stress and inhomogeneity and targets we should aim for when setting the ventilator. In parallel, efforts to promote early assisted ventilation to prevent VIDD have revealed new challenges, such as titrating inspiratory effort and synchronizing the mechanical with the patients' spontaneous breaths, while at the same time adhering to lung-protective targets. AREAS COVERED This is a narrative review of the key mechanisms contributing to VILI and VIDD and the methods currently available to evaluate and mitigate the risk of lung and diaphragm injury. EXPERT OPINION Implementing lung and diaphragm protective ventilation requires individualizing the ventilator settings, and this can only be accomplished by exploiting in everyday clinical practice the tools available to monitor lung stress and inhomogeneity, inspiratory effort, and patient-ventilator interaction.
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Affiliation(s)
- Vlasios Karageorgos
- Department of Intensive Care, University Hospital of Heraklion and University of Crete Medical School, Greece
| | - Athanasia Proklou
- Department of Intensive Care, University Hospital of Heraklion and University of Crete Medical School, Greece
| | - Katerina Vaporidi
- Department of Intensive Care, University Hospital of Heraklion and University of Crete Medical School, Greece
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174
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Ibarra-Estrada M, Li J, Pavlov I, Perez Y, Roca O, Tavernier E, McNicholas B, Vines D, Marín-Rosales M, Vargas-Obieta A, García-Salcido R, Aguirre-Díaz SA, López-Pulgarín JA, Chávez-Peña Q, Mijangos-Méndez JC, Aguirre-Avalos G, Ehrmann S, Laffey JG. Factors for success of awake prone positioning in patients with COVID-19-induced acute hypoxemic respiratory failure: analysis of a randomized controlled trial. Crit Care 2022; 26:84. [PMID: 35346319 PMCID: PMC8958810 DOI: 10.1186/s13054-022-03950-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 03/14/2022] [Indexed: 12/26/2022] Open
Abstract
Background Awake prone positioning (APP) improves oxygenation in coronavirus disease (COVID-19) patients and, when successful, may decrease the risk of intubation. However, factors associated with APP success remain unknown. In this secondary analysis, we aimed to assess whether APP can reduce intubation rate in patients with COVID-19 and to focus on the factors associated with success.
Methods In this multicenter randomized controlled trial, conducted in three high-acuity units, we randomly assigned patients with COVID-19-induced acute hypoxemic respiratory failure (AHRF) requiring high-flow nasal cannula (HFNC) oxygen to APP or standard care. Primary outcome was intubation rate at 28 days. Multivariate analyses were performed to identify the predictors associated to treatment success (survival without intubation).
Results Among 430 patients randomized, 216 were assigned to APP and 214 to standard care. The APP group had a lower intubation rate (30% vs 43%, relative risk [RR] 0.70; CI95 0.54–0.90, P = 0.006) and shorter hospital length of stay (11 interquartile range [IQR, 9–14] vs 13 [IQR, 10–17] days, P = 0.001). A respiratory rate ≤ 25 bpm at enrollment, an increase in ROX index > 1.25 after first APP session, APP duration > 8 h/day, and a decrease in lung ultrasound score ≥ 2 within the first 3 days were significantly associated with treatment success for APP. Conclusion In patients with COVID-19-induced AHRF treated by HFNC, APP reduced intubation rate and improved treatment success. A longer APP duration is associated with APP success, while the increase in ROX index and decrease in lung ultrasound score after APP can also help identify patients most likely to benefit. Trial registration: This study was retrospectively registered in ClinicalTrials.gov at July 20, 2021. Identification number NCT04477655. https://clinicaltrials.gov/ct2/show/NCT04477655?term=PRO-CARF&draw=2&rank=1 Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03950-0.
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Ball L, Silva PL, Giacobbe DR, Bassetti M, Zubieta-Calleja GR, Rocco PRM, Pelosi P. Understanding the pathophysiology of typical acute respiratory distress syndrome and severe COVID-19. Expert Rev Respir Med 2022; 16:437-446. [PMID: 35341424 PMCID: PMC9115784 DOI: 10.1080/17476348.2022.2057300] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction Typical acute respiratory distress syndrome (ARDS) and severe coronavirus-19 (COVID-19) pneumonia share complex pathophysiology, a high mortality rate, and an unmet need for efficient therapeutics. Areas covered This review discusses the current advances in understanding the pathophysiologic mechanisms underlying typical ARDS and severe COVID-19 pneumonia, highlighting specific aspects of COVID-19-related acute hypoxemic respiratory failure that require attention. Two models have been proposed to describe the mechanisms of respiratory failure associated with typical ARDS and severe COVID-19 pneumonia. Expert opinion ARDS is defined as a syndrome rather than a distinct pathologic entity. There is great heterogeneity regarding the pathophysiologic, clinical, radiologic, and biological phenotypes in patients with ARDS, challenging clinicians, and scientists to discover new therapies. COVID-19 has been described as a cause of pulmonary ARDS and has reopened many questions regarding the pathophysiology of ARDS itself. COVID-19 lung injury involves direct viral epithelial cell damage and thrombotic and inflammatory reactions. There are some differences between ARDS and COVID-19 lung injury in aspects of aeration distribution, perfusion, and pulmonary vascular responses.
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Affiliation(s)
- Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,Anesthesia and Intensive Care, Ospedale Policlinico San Martino, IRCCS per l'Oncologia e le Neuroscienze, Genoa, Italy
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Daniele Roberto Giacobbe
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.,Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS per l'Oncologia e le Neuroscienze, Genoa, Italy
| | - Matteo Bassetti
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.,Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS per l'Oncologia e le Neuroscienze, Genoa, Italy
| | | | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,Anesthesia and Intensive Care, Ospedale Policlinico San Martino, IRCCS per l'Oncologia e le Neuroscienze, Genoa, Italy
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Kharat A, Ribeiro C, Er B, Fisser C, López-Padilla D, Chatzivasiloglou F, Heunks LMA, Patout M, D'Cruz RF. ERS International Congress, Virtual 2021: Highlights from the Respiratory Intensive Care Assembly Early Career Members. ERJ Open Res 2022; 8:00016-2022. [PMID: 35615411 PMCID: PMC9124870 DOI: 10.1183/23120541.00016-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/10/2022] [Indexed: 11/19/2022] Open
Abstract
Early Career Members of Assembly 2 (Respiratory Intensive Care) attended the European Respiratory Society International Congress through a virtual platform in 2021. Sessions of interest to our assembly members included symposia on the implications of acute respiratory distress syndrome phenotyping on diagnosis and treatment, safe applications of noninvasive ventilation in hypoxaemic respiratory failure, and new developments in mechanical ventilation and weaning, and a guidelines session on applying high-flow therapy in acute respiratory failure. These sessions are summarised in this article. Early Career Members of @ERSAssembly2 attended the #ERSCongress 2021, and reported on symposia on ARDS phenotyping, noninvasive ventilation in hypoxic respiratory failure, ventilator weaning and high-flow therapy in acute respiratory failurehttps://bit.ly/3D68r50
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177
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Cammarota G, Simonte R, De Robertis E. Comfort During Non-invasive Ventilation. Front Med (Lausanne) 2022; 9:874250. [PMID: 35402465 PMCID: PMC8988041 DOI: 10.3389/fmed.2022.874250] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 02/28/2022] [Indexed: 01/03/2023] Open
Abstract
Non-invasive ventilation (NIV) has been shown to be effective in avoiding intubation and improving survival in patients with acute hypoxemic respiratory failure (ARF) when compared to conventional oxygen therapy. However, NIV is associated with high failure rates due, in most cases, to patient discomfort. Therefore, increasing attention has been paid to all those interventions aimed at enhancing patient's tolerance to NIV. Several practical aspects have been considered to improve patient adaptation. In particular, the choice of the interface and the ventilatory setting adopted for NIV play a key role in the success of respiratory assistance. Among the different NIV interfaces, tolerance is poorest for the nasal and oronasal masks, while helmet appears to be better tolerated, resulting in longer use and lower NIV failure rates. The choice of fixing system also significantly affects patient comfort due to pain and possible pressure ulcers related to the device. The ventilatory setting adopted for NIV is associated with varying degrees of patient comfort: patients are more comfortable with pressure-support ventilation (PSV) than controlled ventilation. Furthermore, the use of electrical activity of the diaphragm (EADi)-driven ventilation has been demonstrated to improve patient comfort when compared to PSV, while reducing neural drive and effort. If non-pharmacological remedies fail, sedation can be employed to improve patient's tolerance to NIV. Sedation facilitates ventilation, reduces anxiety, promotes sleep, and modulates physiological responses to stress. Judicious use of sedation may be an option to increase the chances of success in some patients at risk for intubation because of NIV intolerance consequent to pain, discomfort, claustrophobia, or agitation. During the Coronavirus Disease-19 (COVID-19) pandemic, NIV has been extensively employed to face off the massive request for ventilatory assistance. Prone positioning in non-intubated awake COVID-19 patients may improve oxygenation, reduce work of breathing, and, possibly, prevent intubation. Despite these advantages, maintaining prone position can be particularly challenging because poor comfort has been described as the main cause of prone position discontinuation. In conclusion, comfort is one of the major determinants of NIV success. All the strategies aimed to increase comfort during NIV should be pursued.
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178
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Fralick M, Colacci M, Munshi L, Venus K, Fidler L, Hussein H, Britto K, Fowler R, da Costa BR, Dhalla I, Dunbar-Yaffe R, Branfield Day L, MacMillan TE, Zipursky J, Carpenter T, Tang T, Cooke A, Hensel R, Bregger M, Gordon A, Worndl E, Go S, Mandelzweig K, Castellucci LA, Tamming D, Razak F, Verma AA. Prone positioning of patients with moderate hypoxaemia due to covid-19: multicentre pragmatic randomised trial (COVID-PRONE). BMJ 2022; 376:e068585. [PMID: 35321918 PMCID: PMC8941343 DOI: 10.1136/bmj-2021-068585] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To assess the effectiveness of prone positioning to reduce the risk of death or respiratory failure in non-critically ill patients admitted to hospital with covid-19. DESIGN Multicentre pragmatic randomised clinical trial. SETTING 15 hospitals in Canada and the United States from May 2020 until May 2021. PARTICIPANTS Eligible patients had a laboratory confirmed or a clinically highly suspected diagnosis of covid-19, needed supplemental oxygen (up to 50% fraction of inspired oxygen), and were able to independently lie prone with verbal instruction. Of the 570 patients who were assessed for eligibility, 257 were randomised and 248 were included in the analysis. INTERVENTION Patients were randomised 1:1 to prone positioning (that is, instructing a patient to lie on their stomach while they are in bed) or standard of care (that is, no instruction to adopt prone position). MAIN OUTCOME MEASURES The primary outcome was a composite of in-hospital death, mechanical ventilation, or worsening respiratory failure defined as needing at least 60% fraction of inspired oxygen for at least 24 hours. Secondary outcomes included the change in the ratio of oxygen saturation to fraction of inspired oxygen. RESULTS The trial was stopped early on the basis of futility for the pre-specified primary outcome. The median time from hospital admission until randomisation was 1 day, the median age of patients was 56 (interquartile range 45-65) years, 89 (36%) patients were female, and 222 (90%) were receiving oxygen via nasal prongs at the time of randomisation. The median time spent prone in the first 72 hours was 6 (1.5-12.8) hours in total for the prone arm compared with 0 (0-2) hours in the control arm. The risk of the primary outcome was similar between the prone group (18 (14%) events) and the standard care group (17 (14%) events) (odds ratio 0.92, 95% confidence interval 0.44 to 1.92). The change in the ratio of oxygen saturation to fraction of inspired oxygen after 72 hours was similar for patients randomised to prone positioning and standard of care. CONCLUSION Among non-critically ill patients with hypoxaemia who were admitted to hospital with covid-19, a multifaceted intervention to increase prone positioning did not improve outcomes. However, wide confidence intervals preclude definitively ruling out benefit or harm. Adherence to prone positioning was poor, despite multiple efforts to increase it. Subsequent trials of prone positioning should aim to develop strategies to improve adherence to awake prone positioning. STUDY REGISTRATION ClinicalTrials.gov NCT04383613.
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Affiliation(s)
- Michael Fralick
- Division of General Internal Medicine, Sinai Health, Toronto, ON, Canada
| | - Michael Colacci
- General Internal Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Laveena Munshi
- Mount Sinai Hospital, Interdepartmental Division of Critical Care Medicine, Toronto, ON, Canada
| | - Kevin Venus
- University Health Network, Division of General Internal Medicine and Geriatrics, Toronto, ON, Canada
| | - Lee Fidler
- Division of Respirology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Haseena Hussein
- Department of Medicine, William Osler Health System, Brampton, ON, Canada
| | - Karen Britto
- Department of Medicine, William Osler Health System, Brampton, ON, Canada
| | - Rob Fowler
- University Health Network, Interdepartmental Division of Critical Care Medicine, Toronto, ON, Canada
| | - Bruno R da Costa
- The Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
| | - Irfan Dhalla
- Division of General Internal Medicine, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Richard Dunbar-Yaffe
- Division of General Internal Medicine and Geriatrics, Sinai Health System and University Health Network, Toronto, ON, Canada
| | - Leora Branfield Day
- General Internal Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Thomas E MacMillan
- University Health Network, Division of General Internal Medicine and Geriatrics, Toronto, ON, Canada
| | - Jonathan Zipursky
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Travis Carpenter
- Division of General Internal Medicine, St Joseph's Health Centre, Unity Health Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Terence Tang
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
| | - Amanda Cooke
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Rachel Hensel
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Melissa Bregger
- Department of Medicine, Division of Hospital Medicine, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Alexis Gordon
- Department of Medicine, Scarborough Health Network, Scarborough, ON, Canada
| | - Erin Worndl
- Department of Medicine, Scarborough Health Network, Scarborough, ON, Canada
| | - Stephanie Go
- Department of Medicine, Humber River Hospital, Toronto, ON, Canada
| | | | - Lana A Castellucci
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, ON, Canada
| | | | - Fahad Razak
- Division of General Internal Medicine, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Contributed equally
| | - Amol A Verma
- Division of General Internal Medicine, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Contributed equally
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Barker J, Koeckerling D, Mudalige NL, Oyefeso O, Pan D. Awake prone positioning for patients with covid-19. BMJ 2022; 376:o632. [PMID: 35321937 DOI: 10.1136/bmj.o632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Joseph Barker
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Department of Cardiology, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - David Koeckerling
- Division of Angiology, Swiss Cardiovascular Center, Bern University Hospital, University of Bern, Switzerland
| | | | | | - Daniel Pan
- Department of Respiratory Sciences, University of Leicester, Leicester, UK
- Department of Infectious Diseases and HIV Medicine, Hospitals of Leicester NHS Trust, Leicester, UK
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180
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Elmer N, Liebl ME, Schwedtke C, Drebinger D, Reißhauer A. [Acute rehabilitation after COVID-19 infection : A selected case series]. Z Rheumatol 2022; 81:386-392. [PMID: 35318531 PMCID: PMC8939397 DOI: 10.1007/s00393-022-01178-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND While the first wave of the coronavirus disease 2019 (COVID-19) pandemic mainly affected the old, currently younger patients also become infected and hospitalized. After severe and critical COVID-19 infections and also after surviving acute phase symptoms, these patients often show symptoms (e.g. exertional dyspnea), organ damage (e.g. of the lungs, the cardiovascular system) as well as psychological impairments. OBJECTIVE The severe courses after critical cases of COVID-19 represent challenges for rehabilitation and require more than ever rehabilitative treatment approaches even in acute hospitals. METHODS This article presents a selected case series of patients with a typical constellation of pre-existing conditions due to immunosuppression plus critical course of COVID-19 and indications for acute rehabilitation. RESULTS This case series depicts the long duration of hospitalization with high numbers of hours on ventilation in the intensive care unit. At the time of transfer to acute rehabilitation these patients are immobile and have severe limitations in all activities of daily life, so that an inpatient rehabilitation in an acute hospital is indicated and the usual means of continuation of rehabilitation were not feasible. The sequelae of lying prone and complications, such as exertional desaturation in the early stage of convalescence are detected in the acute phase of early rehabilitation. CONCLUSION After severe COVID-19 infections new challenges for rehabilitation are to be expected, so that rehabilitative treatment approaches with an interdisciplinary early rehabilitation in an acute hospital are urgently needed. Finally, acute rehabilitation not only enables a seamless treatment chain for these patients but also the flow of patients from the intensive care unit to ensure the functioning of local infrastructures.
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Affiliation(s)
- Nancy Elmer
- Physikalische Medizin und Rehabilitation, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Deutschland.
| | - Max Emanuel Liebl
- Physikalische Medizin und Rehabilitation, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Deutschland
| | - Christine Schwedtke
- Physikalische Medizin und Rehabilitation, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Deutschland
| | - Daniel Drebinger
- Physikalische Medizin und Rehabilitation, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Deutschland
| | - Anett Reißhauer
- Physikalische Medizin und Rehabilitation, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Deutschland
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Prone Position Minimizes the Exacerbation of Effort-dependent Lung Injury: Exploring the Mechanism in Pigs and Evaluating Injury in Rabbits. Anesthesiology 2022; 136:779-791. [PMID: 35303058 DOI: 10.1097/aln.0000000000004165] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Vigorous spontaneous effort can potentially worsen lung injury. This study hypothesized that the prone position would diminish a maldistribution of lung stress and inflation after diaphragmatic contraction and reduce spontaneous effort, resulting in less lung injury. METHODS A severe acute respiratory distress syndrome model was established by depleting surfactant and injurious mechanical ventilation in 6 male pigs ("mechanism" protocol) and 12 male rabbits ("lung injury" protocol). In the mechanism protocol, regional inspiratory negative pleural pressure swing (intrabronchial balloon manometry) and the corresponding lung inflation (electrical impedance tomography) were measured with a combination of position (supine or prone) and positive end-expiratory pressure (high or low) matching the intensity of spontaneous effort. In the lung injury protocol, the intensities of spontaneous effort (esophageal manometry) and regional lung injury were compared in the supine position versus prone position. RESULTS The mechanism protocol (pigs) found that in the prone position, there was no ventral-to-dorsal gradient in negative pleural pressure swing after diaphragmatic contraction, irrespective of the positive end-expiratory pressure level (-10.3 ± 3.3 cm H2O vs. -11.7 ± 2.4 cm H2O at low positive end-expiratory pressure, P = 0.115; -10.4 ± 3.4 cm H2O vs. -10.8 ± 2.3 cm H2O at high positive end-expiratory pressure, P = 0.715), achieving homogeneous inflation. In the supine position, however, spontaneous effort during low positive end-expiratory pressure had the largest ventral-to-dorsal gradient in negative pleural pressure swing (-9.8 ± 2.9 cm H2O vs. -18.1 ± 4.0 cm H2O, P < 0.001), causing dorsal overdistension. Higher positive end-expiratory pressure in the supine position reduced a ventral-to-dorsal gradient in negative pleural pressure swing, but it remained (-9.9 ± 2.8 cm H2O vs. -13.3 ± 2.3 cm H2O, P < 0.001). The lung injury protocol (rabbits) found that in the prone position, spontaneous effort was milder and lung injury was less without regional difference (lung myeloperoxidase activity in ventral vs. dorsal lung, 74.0 ± 30.9 μm · min-1 · mg-1 protein vs. 61.0 ± 23.0 μm · min-1 · mg-1 protein, P = 0.951). In the supine position, stronger spontaneous effort increased dorsal lung injury (lung myeloperoxidase activity in ventral vs. dorsal lung, 67.5 ± 38.1 μm · min-1 · mg-1 protein vs. 167.7 ± 65.5 μm · min-1 · mg-1 protein, P = 0.003). CONCLUSIONS Prone position, independent of positive end-expiratory pressure levels, diminishes a maldistribution of lung stress and inflation imposed by spontaneous effort and mitigates spontaneous effort, resulting in less effort-dependent lung injury. EDITOR’S PERSPECTIVE
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182
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Li J, Pavlov I, Ehrmann S. High-Flow Oxygen vs Conventional Oxygen and Invasive Mechanical Ventilation and Clinical Recovery in Patients With Severe COVID-19. JAMA 2022; 327:1092. [PMID: 35289885 DOI: 10.1001/jama.2022.1154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Jie Li
- Department of Respiratory Care, Rush University, Chicago, Illinois
| | - Ivan Pavlov
- Department of Emergency Medicine, Hôpital de Verdun, Montréal, Québec, Canada
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183
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Ospina-Tascón GA, Martínez D, Gempeler A. High-Flow Oxygen vs Conventional Oxygen and Invasive Mechanical Ventilation and Clinical Recovery in Patients With Severe COVID-19-Reply. JAMA 2022; 327:1092-1093. [PMID: 35289882 DOI: 10.1001/jama.2022.1157] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Diana Martínez
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia
| | - Andrés Gempeler
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia
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184
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Chieng D, Kistler PM. The Authors' Reply. JACC Clin Electrophysiol 2022; 8:385. [PMID: 35331437 PMCID: PMC8936025 DOI: 10.1016/j.jacep.2022.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 01/29/2022] [Indexed: 11/26/2022]
Affiliation(s)
| | - Peter M. Kistler
- Baker Heart and Diabetes Research Institute, 55 Commercial Road, Melbourne 3004, Australia
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185
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Padrão EMH, Rahhal H, Valente FS, Besen BAMP. Methodological issues in meta-analyses of observational studies: the need for attention to the details. Br J Anaesth 2022; 128:e303-e305. [PMID: 35248355 PMCID: PMC8890671 DOI: 10.1016/j.bja.2022.01.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/26/2022] [Accepted: 01/31/2022] [Indexed: 01/03/2023] Open
Affiliation(s)
| | - Hassan Rahhal
- Universidade de São Paulo, Departamento de Clínica Médica, São Paulo, Brazil
| | - Fernando S Valente
- Universidade de São Paulo, Departamento de Clínica Médica, São Paulo, Brazil
| | - Bruno A M P Besen
- Universidade de São Paulo, Departamento de Clínica Médica, São Paulo, Brazil
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186
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Kataria V, Ryman K, Tsai-Nguyen G, Wakwaya Y, Modrykamien A. Evaluation of aerosolized epoprostenol for hypoxemia in non-intubated patients with coronavirus disease 2019. Hosp Pract (1995) 2022; 50:118-123. [PMID: 35212586 PMCID: PMC8935453 DOI: 10.1080/21548331.2022.2047310] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Objectives Patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) frequently present with a febrile illness that may progress to pneumonia and hypoxic respiratory failure. Aerosolized epoprostenol (aEPO) has been evaluated in patients with acute respiratory distress syndrome and refractory hypoxemia. A paucity of literature has assessed the impact of aEPO in patients with SARS-CoV-2 receiving oxygen support with high flow nasal cannula (HFNC). The objective of this study was to evaluate whether aEPO added to HFNC prevents intubation and/or prolong time to intubation compared to controls only treated with HFNC, guided by oxygen saturation goals. Methods This was a single-center, retrospective study of adult patients infected with coronavirus 2019 (COVID-19) and admitted to the medical intensive care unit. A total of 60 patients were included. Thirty patients were included in the treatment, and 30 in the control group, respectively. Among patients included in the treatment group, response to therapy was assessed. The need for mechanical ventilation and hospital mortality between responders vs. non-responders was evaluated. Results The primary outcome of mechanical ventilation was not statistically different between groups. Time from HFNC initiation to intubation was significantly prolonged in the treatment group compared to the control group (5.7 days vs. 2.3 days, P = 0.001). There was no statistically significant difference between groups in mortality or length of stay. Patients deemed responders to aEPO had a lower rate of mechanical ventilation (50% vs 88%, P = 0.025) and mortality (21% vs 63%, P = 0.024), compared with non-responders. Conclusion The utilization of aEPO in COVID-19 patients treated with HFNC is not associated with a reduction in the rate of mechanical ventilation. Nevertheless, the application of this strategy may prolong the time to invasive mechanical ventilation, without affecting other clinical outcomes.
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Affiliation(s)
- Vivek Kataria
- Department of Pharmacy, Baylor University Medical Center, Dallas, TX, USA
| | - Klayton Ryman
- Department of Pharmacy, Baylor University Medical Center, Dallas, TX, USA
| | - Ginger Tsai-Nguyen
- Department of Critical Care-Medical Intensive Care Unit, Baylor University Medical Center, Dallas, TX, USA
| | - Yosafe Wakwaya
- Department of Critical Care-Medical Intensive Care Unit, Baylor University Medical Center, Dallas, TX, USA
| | - Ariel Modrykamien
- Department of Critical Care-Medical Intensive Care Unit, Baylor University Medical Center, Dallas, TX, USA
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187
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Windisch W, Schönhofer B. [Development and progress in mechanical ventilation]. DER PNEUMOLOGE 2022; 19:83-91. [PMID: 35228843 PMCID: PMC8865494 DOI: 10.1007/s10405-021-00425-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/05/2021] [Indexed: 11/06/2022]
Abstract
Mechanical ventilation comprises two important sectors: 1) the acute application in intensive care medicine and 2) long-term mechanical ventilation, i.e. home mechanical ventilation. Today, based on increasing scientific evidence the approach to mechanical ventilation is highly sophisticated and this is true for both sectors. For this reason, several guidelines have been established in Germany with specific emphasis on mechanical ventilation. In addition, the current development of mechanical ventilation in Germany is influenced by the corona pandemic and also by the economization of the healthcare system. Notably, home mechanical ventilation is steadily increasing, while intensive care unit (ICU) capacities are currently decreasing. The current article focuses on these developments.
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Affiliation(s)
- Wolfram Windisch
- Lungenklinik Merheim, Kliniken der Stadt Köln gGmbH, Ostmerheimer Str. 200, 51109 Köln, Deutschland
- Lehrstuhl für Pneumologie, Universität Witten/Herdecke, Witten, Deutschland
| | - Bernd Schönhofer
- Klinik für Innere Medizin, Pneumologie und Intensivmedizin, Evangelisches Klinikum Bethel, Bielefeld, Deutschland
- Universitätsklinikum Ostwestphalen Lippe (OWL), Universität Bielefeld, Bielefeld, Deutschland
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188
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Proning in COVID-19 Acute Respiratory Distress Syndrome: Role of Paralytics. Crit Care Explor 2022; 4:e0646. [PMID: 35211685 PMCID: PMC8863123 DOI: 10.1097/cce.0000000000000646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES: Although proning is beneficial to acute respiratory distress syndrome, impressions vary about its efficacy. Some providers believe that paralysis is required to facilitate proning. We studied impact of paralysis on prone-induced gas exchange improvements and provider attitudes regarding paralytics. DESIGN: Observational. SETTING: University of California San Diego. PATIENTS: Intubated COVID acute respiratory distress syndrome patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: 1) Changes in Pao2:Fio2 and Spo2:Fio2 ratios before and after proning with and without paralytics, 2) adverse events during proning with and without paralytics, and 3) nurse and physician attitudes about efficacy/safety of proning with and without paralytics. Gas-exchange improvement with proning was similar with and without paralytics (with no serious adverse events). Survey results showed similar attitudes between nurses and physicians about proning efficacy but differing attitudes about the need for paralytics with proning. CONCLUSIONS: Findings support use of proning and may help in design of randomized trials to assess paralytics in acute respiratory distress syndrome management.
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189
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Chen L, Zhang Y, Li Y, Song C, Lin F, Pan P. The Application of Awake-Prone Positioning Among Non-intubated Patients With COVID-19-Related ARDS: A Narrative Review. Front Med (Lausanne) 2022; 9:817689. [PMID: 35198575 PMCID: PMC8858818 DOI: 10.3389/fmed.2022.817689] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 01/10/2022] [Indexed: 01/03/2023] Open
Abstract
The coronavirus disease (COVID-19) pandemic has significantly increased the number of patients with acute respiratory distress syndrome (ARDS), necessitating respiratory support. This strain on intensive care unit (ICU) resources forces clinicians to limit the use of mechanical ventilation by seeking novel therapeutic strategies. Awake-prone positioning appears to be a safe and tolerable intervention for non-intubated patients with hypoxemic respiratory failure. Meanwhile, several observational studies and meta-analyses have reported the early use of prone positioning in awake patients with COVID-19-related ARDS (C-ARDS) for improving oxygenation levels and preventing ICU transfers. Indeed, some international guidelines have recommended the early application of awake-prone positioning in patients with hypoxemic respiratory failure attributable to C-ARDS. However, its effectiveness in reducing intubation rate, mortality, applied timing, and optimal duration is unclear. High-quality evidence of awake-prone positioning for hypoxemic patients with COVID-19 is still lacking. Therefore, this article provides an update on the current state of published literature about the physiological rationale, effect, timing, duration, and populations that might benefit from awake proning. Moreover, the risks and adverse effects of awake-prone positioning were also investigated. This work will guide future studies and aid clinicians in deciding on better treatment plans.
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Affiliation(s)
- Lingli Chen
- Center of Respiratory Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Yan Zhang
- Hunan Engineering Research Center for Intelligent Diagnosis and Treatment of Respiratory Disease, Changsha, China
| | - Yi Li
- National Key Clinical Specialty, Branch of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, Changsha, China
| | - Chao Song
- Department of Infection Control Center, Xiangya Hospital, Central South University, Changsha, China
| | - Fengyu Lin
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, China
| | - Pinhua Pan
- Center of Respiratory Medicine, Xiangya Hospital, Central South University, Changsha, China
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190
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Pavlov I, Estrada MI, Perez Y, Ehrmann S, Li J. In Reply to Mancilla-Galindo et al. Respir Care 2022; 67:281. [PMID: 35078904 PMCID: PMC9993951 DOI: 10.4187/respcare.09802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Ivan Pavlov
- Department of Emergency MedicineHôpital de VerdunMontréal, Québec
| | | | - Yonatan Perez
- Médecine Intensive Réanimation, CIC INSERM 1415 CRICSTriggerSEP research networkCHRU Tours, Tours
| | - Stephan Ehrmann
- Médecine Intensive Réanimation, CIC INSERM 1415 CRICSTriggerSEP research networkCHRU Tours, Tours, FranceINSERM, Centre d'étude des pathologies respiratoiresU1100, Université de ToursTours, France
| | - Jie Li
- Department of Cardiopulmonary SciencesDivision of Respiratory CareRush UniversityChicago, Illinois
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191
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Piciucchi S, Ravaglia C, Vizzuso A, Giampalma E, Poletti V. Awake prone positioning for COVID-19 acute respiratory failure: imaging and histological background. THE LANCET RESPIRATORY MEDICINE 2022; 10:e14. [PMID: 35120610 PMCID: PMC8806195 DOI: 10.1016/s2213-2600(21)00554-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 12/09/2021] [Indexed: 10/26/2022]
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192
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Pacheco-Reyes A, Garcia-de-Acilu M, Roca O. Decúbito prono más allá del paciente intubado: ¿tiene sentido? Med Intensiva 2022. [DOI: 10.1016/j.medin.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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193
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Fazzini B, Page A, Pearse R, Puthucheary Z. Prone positioning for non-intubated spontaneously breathing patients with acute hypoxaemic respiratory failure: a systematic review and meta-analysis. Br J Anaesth 2022; 128:352-362. [PMID: 34774295 PMCID: PMC8514681 DOI: 10.1016/j.bja.2021.09.031] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/06/2021] [Accepted: 09/23/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Prone positioning in non-intubated spontaneously breathing patients is becoming widely applied in practice alongside noninvasive respiratory support. This systematic review and meta-analysis evaluates the effect, timing, and populations that might benefit from awake proning regarding oxygenation, mortality, and tracheal intubation compared with supine position in hypoxaemic acute respiratory failure. METHODS We conducted a systematic literature search of PubMed/MEDLINE, Cochrane Library, Embase, CINAHL, and BMJ Best Practice until August 2021 (International Prospective Register of Systematic Reviews [PROSPERO] registration: CRD42021250322). Studies included comprise least-wise 20 adult patients with hypoxaemic respiratory failure secondary to acute respiratory distress syndrome or coronavirus disease (COVID-19). Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and study quality was assessed using the Newcastle-Ottawa Scale and the Cochrane risk-of-bias tool. RESULTS Fourteen studies fulfilled the selection criteria and 2352 patients were included; of those patients, 99% (n=2332/2352) had COVID-19. Amongst 1041 (44%) patients who were placed in the prone position, 1021 were SARS-CoV-2 positive. The meta-analysis revealed significant improvement in the PaO2/FiO2 ratio (mean difference -23.10; 95% confidence interval [CI]: -34.80 to 11.39; P=0.0001; I2=26%) after prone positioning. In patients with COVID-19, lower mortality was found in the group placed in the prone position (150/771 prone vs 391/1457 supine; odds ratio [OR] 0.51; 95% CI: 0.32-0.80; P=0.003; I2=48%), but the tracheal intubation rate was unchanged (284/824 prone vs 616/1271 supine; OR 0.72; 95% CI: 0.43-1.22; P=0.220; I2=75%). Overall proning was tolerated for a median of 4 h (inter-quartile range: 2-16). CONCLUSIONS Prone positioning can improve oxygenation amongst non-intubated patients with acute hypoxaemic respiratory failure when applied for at least 4 h over repeated daily episodes. Awake proning appears safe, but the effect on tracheal intubation rate and survival remains uncertain.
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Affiliation(s)
- Brigitta Fazzini
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, UK.
| | - Alexandria Page
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Rupert Pearse
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, UK; William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Zudin Puthucheary
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, UK; William Harvey Research Institute, Queen Mary University of London, London, UK
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194
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Abstract
PURPOSE OF REVIEW Prone position has been widely used in the COVID-19 pandemic, with an extension of its use in patients with spontaneous breathing ('awake prone'). We herein propose a review of the current literature on prone position in mechanical ventilation and while spontaneous breathing in patients with COVID-19 pneumonia or COVID-19 ARDS. RECENT FINDINGS A literature search retrieved 70 studies separating whether patient was intubated (24 studies) or nonintubated (46 studies). The outcomes analyzed were intubation rate, mortality and respiratory response to prone. In nonintubated patient receiving prone position, the main finding was mortality reduction in ICU and outside ICU setting. SUMMARY The final results of the several randomized control trials completed or ongoing are needed to confirm the trend of these results. In intubated patients, observational studies showed that responders to prone in terms of oxygenation had a better survival than nonresponders.
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Affiliation(s)
- Aileen Kharat
- Service de Pneumologie, Hôpitaux Universitaires de Genève
- Université de Médecine de Genève, Switzerland
| | - Marie Simon
- Médecine Intensive-Réanimation, Hôpital Edouard Herriot, Lyon
| | - Claude Guérin
- Médecine Intensive-Réanimation, Hôpital Edouard Herriot, Lyon
- Université de Lyon, Lyon
- Institut Mondor de Recherches Biomédicales, INSERM 955, CNRS 7200, Créteil, France
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195
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196
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Strategies for monitoring and predicting failure to high-flow nasal cannula therapy in the ED. Am J Emerg Med 2022; 57:183-184. [PMID: 35058084 DOI: 10.1016/j.ajem.2021.12.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 12/21/2021] [Indexed: 12/25/2022] Open
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197
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Schmid B, Griesel M, Fischer AL, Romero CS, Metzendorf MI, Weibel S, Fichtner F. Awake Prone Positioning, High-Flow Nasal Oxygen and Non-Invasive Ventilation as Non-Invasive Respiratory Strategies in COVID-19 Acute Respiratory Failure: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11020391. [PMID: 35054084 PMCID: PMC8782004 DOI: 10.3390/jcm11020391] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/07/2022] [Accepted: 01/10/2022] [Indexed: 01/10/2023] Open
Abstract
Background: Acute respiratory failure is the most important organ dysfunction of COVID-19 patients. While non-invasive ventilation (NIV) and high-flow nasal cannula (HFNC) oxygen are frequently used, efficacy and safety remain uncertain. Benefits and harms of awake prone positioning (APP) in COVID-19 patients are unknown. Methods: We searched for randomized controlled trials (RCTs) comparing HFNC vs. NIV and APP vs. standard care. We meta-analyzed data for mortality, intubation rate, and safety. Results: Five RCTs (2182 patients) were identified. While it remains uncertain whether HFNC compared to NIV alters mortality (RR: 0.92, 95% CI 0.65–1.33), HFNC may increase rate of intubation or death (composite endpoint; RR 1.22, 1.03–1.45). We do not know if HFNC alters risk for harm. APP compared to standard care probably decreases intubation rate (RR 0.83, 0.71–0.96) but may have little or no effect on mortality (RR: 1.08, 0.51–2.31). Conclusions: Certainty of evidence is moderate to very low. There is no compelling evidence for either HFNC or NIV, but both carry substantial risk for harm. The use of APP probably has benefits although mortality appears unaffected.
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Affiliation(s)
- Benedikt Schmid
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, 97080 Wuerzburg, Germany; (B.S.); (S.W.)
| | - Mirko Griesel
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Services, 04103 Leipzig, Germany; (M.G.); (A.-L.F.)
| | - Anna-Lena Fischer
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Services, 04103 Leipzig, Germany; (M.G.); (A.-L.F.)
| | - Carolina S. Romero
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, General University Hospital, 46014 Valencia, Spain;
| | - Maria-Inti Metzendorf
- Cochrane Metabolic and Endocrine Disorders Group, Institute of General Practice, Medical Faculty of the Heinrich-Heine-University Düsseldorf, 40225 Duesseldorf, Germany;
| | - Stephanie Weibel
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, 97080 Wuerzburg, Germany; (B.S.); (S.W.)
| | - Falk Fichtner
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Services, 04103 Leipzig, Germany; (M.G.); (A.-L.F.)
- Correspondence: ; Tel.: +49-341-97-10709
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198
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Pearce AK, McGuire WC, Malhotra A. Lung and chest wall mechanics in COVID-19 acute respiratory distress syndrome. J Thorac Dis 2022; 13:6214-6216. [PMID: 34992801 PMCID: PMC8662500 DOI: 10.21037/jtd-21-1567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 10/20/2021] [Indexed: 12/12/2022]
Affiliation(s)
- Alex K Pearce
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, University of California, San Diego, CA, USA
| | - W Cameron McGuire
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, University of California, San Diego, CA, USA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, University of California, San Diego, CA, USA
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199
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Esperatti M, Busico M, Fuentes NA, Gallardo A, Osatnik J, Vitali A, Wasinger EG, Olmos M, Quintana J, Saavedra SN, Lagazio AI, Andrada FJ, Kakisu H, Romano NE, Matarrese A, Mogadouro MA, Mast G, Moreno CN, Niquin GDR, Barbaresi V, Bruhn Cruz A, Ferreyro BL, Torres A. Impact of exposure time in awake prone positioning on clinical outcomes of patients with COVID-19-related acute respiratory failure treated with high-flow nasal oxygen: a multicenter cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2022; 26:16. [PMID: 34996496 PMCID: PMC8740872 DOI: 10.1186/s13054-021-03881-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 12/23/2021] [Indexed: 12/15/2022]
Abstract
Background In patients with COVID-19-related acute respiratory failure (ARF), awake prone positioning (AW-PP) reduces the need for intubation in patients treated with high-flow nasal oxygen (HFNO). However, the effects of different exposure times on clinical outcomes remain unclear. We evaluated the effect of AW-PP on the risk of endotracheal intubation and in-hospital mortality in patients with COVID-19-related ARF treated with HFNO and analyzed the effects of different exposure times to AW-PP. Methods This multicenter prospective cohort study in six ICUs of 6 centers in Argentine consecutively included patients > 18 years of age with confirmed COVID-19-related ARF requiring HFNO from June 2020 to January 2021. In the primary analysis, the main exposure was awake prone positioning for at least 6 h/day, compared to non-prone positioning (NON-PP). In the sensitivity analysis, exposure was based on the number of hours receiving AW-PP. Inverse probability weighting–propensity score (IPW-PS) was used to adjust the conditional probability of treatment assignment. The primary outcome was endotracheal intubation (ETI); and the secondary outcome was hospital mortality. Results During the study period, 580 patients were screened and 335 were included; 187 (56%) tolerated AW-PP for [median (p25–75)] 12 (9–16) h/day and 148 (44%) served as controls. The IPW–propensity analysis showed standardized differences < 0.1 in all the variables assessed. After adjusting for other confounders, the OR (95% CI) for ETI in the AW-PP group was 0.36 (0.2–0.7), with a progressive reduction in OR as the exposure to AW-PP increased. The adjusted OR (95% CI) for hospital mortality in the AW-PP group ≥ 6 h/day was 0.47 (0.19–1.31). The exposure to prone positioning ≥ 8 h/d resulted in a further reduction in OR [0.37 (0.17–0.8)]. Conclusion In the study population, AW-PP for ≥ 6 h/day reduced the risk of endotracheal intubation, and exposure ≥ 8 h/d reduced the risk of hospital mortality. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03881-2.
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Affiliation(s)
- Mariano Esperatti
- Intensive Care Unit, Hospital Privado de Comunidad, Mar del Plata, Argentina.,Escuela Superior de Medicina, Universidad Nacional de Mar del Plata, Mar del Plata, Argentina
| | - Marina Busico
- Intensive Care Unit, Clínica Olivos SMG, Av. Maipú 1660, B1602 ABQ, Olivos, Provincia de Buenos Aires, Argentina. .,Sociedad Argentina de Terapia Intensiva, Buenos Aires, Argentina.
| | - Nora Angélica Fuentes
- Intensive Care Unit, Hospital Privado de Comunidad, Mar del Plata, Argentina.,Escuela Superior de Medicina, Universidad Nacional de Mar del Plata, Mar del Plata, Argentina
| | - Adrian Gallardo
- Intensive Care Unit, Sanatorio Clínica Modelo de Morón, Morón, Buenos Aires, Argentina.,Universidad de Morón, Morón, Buenos Aires, Argentina
| | - Javier Osatnik
- Intensive Care Unit, Hospital Aleman, Ciudad Autónoma de Buenos Aires, Argentina.,Universidad del Salvador, Buenos Aires, Argentina
| | - Alejandra Vitali
- Intensive Care Unit, Sanatorio de La Trinidad Palermo, Ciudad Autónoma de Buenos Aires, Argentina
| | - Elizabeth Gisele Wasinger
- Intensive Care Unit, Hospital Universitario Austral, Pilar, Buenos Aires, Argentina.,Universidad Austral, Pilar, Buenos Aires, Argentina
| | - Matías Olmos
- Intensive Care Unit, Hospital Privado de Comunidad, Mar del Plata, Argentina
| | - Jorgelina Quintana
- Intensive Care Unit, Clínica Olivos SMG, Av. Maipú 1660, B1602 ABQ, Olivos, Provincia de Buenos Aires, Argentina
| | | | - Ana Inés Lagazio
- Intensive Care Unit, Sanatorio de La Trinidad Palermo, Ciudad Autónoma de Buenos Aires, Argentina
| | - Facundo Juan Andrada
- Intensive Care Unit, Hospital Universitario Austral, Pilar, Buenos Aires, Argentina.,Universidad Austral, Pilar, Buenos Aires, Argentina
| | - Hiromi Kakisu
- Intensive Care Unit, Hospital Privado de Comunidad, Mar del Plata, Argentina
| | - Nahuel Esteban Romano
- Intensive Care Unit, Clínica Olivos SMG, Av. Maipú 1660, B1602 ABQ, Olivos, Provincia de Buenos Aires, Argentina
| | - Agustin Matarrese
- Intensive Care Unit, Hospital Aleman, Ciudad Autónoma de Buenos Aires, Argentina
| | | | - Giuliana Mast
- Intensive Care Unit, Hospital Universitario Austral, Pilar, Buenos Aires, Argentina.,Universidad Austral, Pilar, Buenos Aires, Argentina
| | | | | | - Veronica Barbaresi
- Intensive Care Unit, Hospital Privado de Comunidad, Mar del Plata, Argentina
| | - Alejandro Bruhn Cruz
- Departement of Intensive Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Bruno Leonel Ferreyro
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Antoni Torres
- Pulmonary Department, Hospital Clinic, Universitat de Barcelona, IDIBAPS, CIBERES, Barcelona, Spain
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Luján M, Sayas J, Mediano O, Egea C. Non-invasive Respiratory Support in COVID-19: A Narrative Review. Front Med (Lausanne) 2022; 8:788190. [PMID: 35059415 PMCID: PMC8763700 DOI: 10.3389/fmed.2021.788190] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/30/2021] [Indexed: 12/20/2022] Open
Abstract
Acute respiratory failure secondary to COVID-19 pneumonia may require a variety of non-pharmacological strategies in addition to oxygen therapy to avoid endotracheal intubation. The response to all these strategies, which include high nasal flow, continuous positive pressure, non-invasive ventilation, or even prone positioning in awake patients, can be highly variable depending on the predominant phenotypic involvement. Deciding when to replace conventional oxygen therapy with non-invasive respiratory support, which to choose, the role of combined methods, definitions, and attitudes toward treatment failure, and improved case improvement procedures are directly relevant clinical questions for the daily care of critically ill COVID-19 patients. The experience accumulated after more than a year of the pandemic should lead to developing recommendations that give answers to all these questions.
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Affiliation(s)
- Manel Luján
- Pneumology Service, Hospital Universitari Parc Taulí, Sabadell, Spain
- Centro de Investigacion Biomédica en Red (CIBERES), Madrid, Spain
| | - Javier Sayas
- Pneumology Service, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Olga Mediano
- Pneumology Department, Hospital Universitario de Guadalajara, Guadalajara, Spain
| | - Carlos Egea
- Centro de Investigacion Biomédica en Red (CIBERES), Madrid, Spain
- Hospital Universitario de Araba, Universidad País Vasco, Vitoria Gasteiz, Spain
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