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Harris TR, Bhutta ZA, Qureshi I, Kharma N, Raza T, Hssain AA, Pathare AS, D'Silva A, Khatib MY, Mohamedali MGH, Macineira IMG, Garcia Hernandez VR, Garcia JR, Thomas SH, Pathan SA. A randomised clinical trial of awake prone positioning in COVID-19 suspects with acute hypoxemic respiratory failure. Contemp Clin Trials Commun 2024; 39:101295. [PMID: 38689829 PMCID: PMC11059337 DOI: 10.1016/j.conctc.2024.101295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 02/22/2024] [Accepted: 03/27/2024] [Indexed: 05/02/2024] Open
Abstract
Background Awake prone position (APP) has been reported to improve oxygenation in patients with COVID-19 disease and to reduce the requirement for invasive mechanical ventilation for patients requiring support with high flow nasal cannula. There is conflicting data for patients requiring lower-level oxygen support. Research question Does APP reduce escalation of oxygen support in COVID-19 patients requiring supplementary oxygen?The primary outcome was defined as an escalation of oxygen support from simple supplementary oxygen (NP, HM, NRB) to NIV (CPAP or BiPAP), HFNC or IMV; OR from NIV (CPAP or BiPAP) or HFNC to IMV by day30. Study design Two center, prospective, non-blind, randomised controlled trial. Patients with confirmed or suspected COVID-19 pneumonia requiring ≥ 5 liters/min oxygen to maintain saturations ≥ 94 % were randomised to either APP or control group. The APP group received a 3-h APP session three times per day for three days. Results Between 9 May and July 13, 2021, 89 adults were screened and 61 enrolled, 31 to awake prone position and 30 controls. There was no difference in the primary outcome, 7 (22.6 %) patients randomised to APP and 9 (30.0 %) controls required escalation of oxygen support (OR 0.68 (0.22-2.14), P = 0.51). There were no differences in any secondary outcomes, in APP did not improve oxygenation. Interpretation In COVID-19 patients, the use of APP did not prevent escalation of oxygen support from supplementary to invasive or non-invasive ventilation or improve patient respiratory physiology. Trial registration NCT04853979 (clinicaltrials.gov).
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Affiliation(s)
- Tim R.E. Harris
- Corporate Department of Emergency Medicine, Hamad Medical Corporation, Qatar
- Queen Mary University London, United Kingdom
| | - Zain A. Bhutta
- Corporate Department of Emergency Medicine, Hamad Medical Corporation, Qatar
- Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Isma Qureshi
- Corporate Department of Emergency Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Nadir Kharma
- Corporate Department Medical Intensive Care, Hamad General Hospital, Doha, Qatar
- Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Tasleem Raza
- Corporate Department Medical Intensive Care, Hamad General Hospital, Doha, Qatar
| | - Ali Ait Hssain
- Corporate Department Medical Intensive Care, Hamad General Hospital, Doha, Qatar
| | - Ankush Suresh Pathare
- Corporate Department of Emergency Medicine, Hazm Mebaireek General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ashwin D'Silva
- Corporate Department of Emergency Medicine, Hazm Mebaireek General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Mohamad Yahya Khatib
- Corporate Medical Intensive Care, Head of Unit, Hazm Mebaireek General Hospital, Doha, Qatar
| | - Mohamed Gafar Hussein Mohamedali
- Corporate Department Internal Medicine, Head of Unit, Hazm Mebaireek General Hospital, Doha, Qatar
- Instructor in Clinical Medicine, Weill Cornell Medicine, Qatar
| | | | | | - Jorge Rosales Garcia
- Corporate Department Medical Intensive Care, The Cuban Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Stephen H. Thomas
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, MA, USA
- Queen Mary University London, United Kingdom
| | - Sameer A. Pathan
- Corporate Department of Emergency Medicine, Hamad Medical Corporation, Qatar
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Frick AE, Schiefer J, Maleczek M, Schwarz S, Benazzo A, Rath A, Kulu A, Hritcu R, Faybik P, Schaden E, Jaksch P, Tschernko E, Frommlet F, Markstaller K, Hoetzenecker K. The Effect of Prone Positioning After Lung Transplantation. Ann Thorac Surg 2024; 117:1045-1051. [PMID: 37150273 PMCID: PMC10162468 DOI: 10.1016/j.athoracsur.2023.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 03/19/2023] [Accepted: 04/10/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND Prone positioning has become a standard therapy in acute respiratory distress syndrome to improve oxygenation and decrease mortality. However, little is known about prone positioning in lung transplant recipients. This large, singe-center analysis investigated whether prone positioning improves gas exchange after lung transplantation. METHODS Clinical data of 583 patients were analyzed. Prone position was considered in case of impaired gas exchange Pao2/fraction of oxygen in inhaled air (<250), signs of edema after lung transplantation, and/or evidence of reperfusion injury. Patients with hemodynamic instability or active bleeding were not proned. Impact of prone positioning (n = 165) on gas exchange, early outcome and survival were determined and compared with patients in supine positioning (n = 418). RESULTS Patients in prone position were younger, more likely to have interstitial lung disease, and had a higher lung allocation score. Patients were proned for a median of 19 hours (interquartile range,15-26) hours). They had significantly lower Pao2/fraction of oxygen in inhaled air (227 ± 96 vs 303 ± 127 mm Hg, P = .004), and lower lung compliance (24.8 ± 9.1 mL/mbar vs 29.8 ± 9.7 mL/mbar, P < .001) immediately after lung transplantation. Both values significantly improved after prone positioning for 24 hours (Pao2/fraction of oxygen ratio: 331 ± 91 mm Hg; lung compliance: 31.7 ± 20.2 mL/mbar). Survival at 90 days was similar between the 2 groups (93% vs 96%, P = .105). CONCLUSIONS Prone positioning led to a significant improvement in lung compliance and oxygenation after lung transplantation. Prospective studies are needed to confirm the benefit of prone positioning in lung transplantation.
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Affiliation(s)
| | - Judith Schiefer
- Department of Anesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria
| | - Mathias Maleczek
- Department of Anesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria
| | - Stefan Schwarz
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Alberto Benazzo
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Anna Rath
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Askin Kulu
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Richard Hritcu
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Peter Faybik
- Department of Anesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria
| | - Eva Schaden
- Department of Anesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria
| | - Peter Jaksch
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Edda Tschernko
- Division of Cardiothoracic and Vascular Anesthesia, Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Florian Frommlet
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Klaus Markstaller
- Department of Anesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria
| | - Konrad Hoetzenecker
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria.
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Eti Aslan F, Çinar F, Hayat D. Evaluation of Pain During Endotracheal Aspiration in Intensive Care Patients Diagnosed with COVID-19. Pain Manag Nurs 2024; 25:e45-e49. [PMID: 37827865 DOI: 10.1016/j.pmn.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 08/08/2023] [Accepted: 08/10/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Endotracheal aspiration, a procedure that is particularly painful for intensive care patients, has received little attention in terms of pain evaluation specifically among intubated patients with COVID-19 in intensive care. AIM The study aims to assess the level of pain experienced by intubated intensive care patients diagnosed with COVID-19 during an endotracheal aspiration procedure. METHOD The study population was composed of patients admitted to the COVID-19 intensive care unit of the specified hospital between February and March 2021. Of the 56 patients admitted during that period, 47 were contacted and participated in the study. These 47 intubated and sedated patients were evaluated for 94 different expressions of pain during endotracheal aspiration twice a day before and during the procedure. Data were collected using the patient descriptive information form, the Non-Verbal Pain Scale for adults and data observation record form. RESULTS In the study, pain behavior was observed in 54.2% (n = 51) of the 94 observations. The patients were found to experience mild pain with an average score of 3.6 ± 1.07 on the Non-Verbal Pain Scale. The mean pain score before the procedure was found to be significantly different from the mean pain score during the procedure (p < .05), with an increase in pain during the procedure. During the procedure, 33.3% (n = 17) of the patients had a 10% decreased SpO2, and 29.4% (n = 15) had an increase in systolic blood pressure (>20), pulse (>20), and respiration (>10). Additionally, 21.5% (n = 11) of the patients experienced severe incompatibility with the ventilator, and 15.68% had muscle tension. CONCLUSIONS The study findings showed that nonverbal pain scores of sedated and intubated intensive care patients diagnosed with COVID-19 increased during endotracheal aspiration, accompanied by physiologic pain indicators. Effective pain management should be a priority for nurses. It is important to remember that patients with COVID-19 in the intensive care unit may experience pain while sedated and intubated. A holistic approach should be adopted for the evaluation and relief of pain in these patients. Intensive care nurses should consider physiologic and nonverbal behavioral pain indicators when evaluating pain in patients diagnosed with COVID-19.
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Affiliation(s)
- Fatma Eti Aslan
- Bahçeşehir University Faculty of Health Sciences, Istanbul, Turkey
| | - Fadime Çinar
- Nişantaşı University, Faculty of Health Sciences, Istanbul, Turkey.
| | - Deniz Hayat
- Kocaeli University Research and Application Hospital, Kocaeli, Turkey
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Takmak Ş, Karaçar Y, Karaçar Hİ, Küçükakça Çelik G. The effect of nature-based music intervention on adaptation and anxiety levels in patients with COVID-19 placed in the prone position: A randomized controlled trial. Intensive Crit Care Nurs 2023; 79:103496. [PMID: 37542800 DOI: 10.1016/j.iccn.2023.103496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 07/02/2023] [Accepted: 07/16/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVE To examine the effect of listening to nature-based music on anxiety, physiological parameters, and adjustment to the prone position in conscious and hypoxemic COVID-19 patients. DESIGN A single-blinded randomized control trial design. SETTING The study was conducted in the intensive care unit of a state hospital in Turkey. Sixty-four patients were randomized into an intervention group and a control group. METHODS A nature-based music intervention was applied in addition to routine care to the intervention group in the prone position, while the control group received routine care in the same position. The study outcomes included state-trait anxiety, physiological parameters, and prone time within 24 h. Measurements were performed in the supine position (Time: T0), in the 30th minute in the prone position (T1), and in the 30th minute of the supine position given following the prone position (T2). Data analysis included independent samples t-test in independent groups and repeated measures ANOVA in dependent groups. RESULTS State anxiety fell statistically significantly in the intervention group compared to that of the control group (39.1 ± 6.6 vs. 43.4 ± 7.9, p = 0.025). At T2, the heart rate of the intervention group did not increase, but it increased significantly in the control group compared to T0 and T1 values (87.8 ± 9.8 vs. 91.1 ± 10.8; p = 0.000). The oxygen saturation of the intervention group increased significantly compared to that of the control group (94.5 ± 2.3 vs. 93.4 ± 1.9, p = 0.035). The prone position time of the intervention group was significantly greater than that of the control group (11.5 ± 1.5 vs. 10.8 ± 1.1, p = 0.04). CONCLUSIONS It was found that nature-based music intervention applied to conscious and hypoxemic COVID-19 patients in the prone position improved anxiety and oxygen saturation and increased the prone position time. IMPLICATIONS FOR CLINICAL PRACTICE Listening to nature-based music in prone position may reduce anxiety in conscious patients with hypoxemic respiratory failure, it may increase adjustment to the prone position, and it may improve oxygenation and heart rate.
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Affiliation(s)
- Şenay Takmak
- Department of Nursing, Faculty of Health Science, Kütahya Health Science Universıty Kütahya, Turkey
| | - Yeliz Karaçar
- Department of Psychiatric Nursing, Faculty of Nursing, Akdeniz University, Antalya, Turkey.
| | | | - Gülden Küçükakça Çelik
- Department of Nursing, Faculty of Semra and Vefa Küçük Health Science, Nevşehir Hacı Bektaş University Nevşehir, Turkey
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Al Duhailib Z, Parhar KKS, Solverson K, Alhazzani W, Weatherald J. Awake prone position in patients with acute hypoxic respiratory failure: A narrative review. Respir Med Res 2023; 84:101037. [PMID: 37625375 DOI: 10.1016/j.resmer.2023.101037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 06/03/2023] [Accepted: 06/19/2023] [Indexed: 08/27/2023]
Affiliation(s)
- Zainab Al Duhailib
- Critical Care Medicine Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Ken Kuljit S Parhar
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, Canada; O'Brien Institute for Public Health and Libin Cardiovascular Institute, University of Calgary, Calgary, Canada
| | - Kevin Solverson
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, Canada; Department of Medicine, Division of Respirology, University of Calgary, Calgary, Canada
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; The Research Institute of St Joe's Hamilton, Hamilton, ON, Canada; Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Canada; Department of Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Jason Weatherald
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, Canada.
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Othman SY, El‐Menshawy AM, Mohamed AM. Effects of awake-prone positioning on oxygenation and physiological outcomes in non-intubated patients with COVID-19: A randomized controlled trial. Nurs Crit Care 2023; 28:1078-1086. [PMID: 35909384 PMCID: PMC9538049 DOI: 10.1111/nicc.12833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 07/12/2022] [Accepted: 07/14/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Prone positioning is a well-known supportive approach for increasing oxygenation and reducing mortality in non-COVID-19 patients with moderate to severe acute respiratory distress syndrome. However, studies highlighting the effects of proning in patients with COVID-19 are limited. AIM To investigate the effects of awake-prone positioning (APP) on oxygenation and physiological outcomes in non-intubated patients with COVID-19. STUDY DESIGN A randomized controlled trial was carried out with two parallel groups at 1:1 ratio. Adult awake non-intubated patients with confirmed COVID-19, non-rebreathing face mask or continuous positive airway pressure, PaO2 /FiO2 ratio ≤150 mmHg were randomly assigned to the APP group or control group. The control group was subjected to conventional positioning interventions. Outcome measures were PaO2 /FiO2 ratio, ROX index, PaO2 , PaCO2 , SaO2 , respiratory rate, blood pressure, and shock index. These parameters were recorded immediately before positioning, 10 min after patient positioning, and 1 h after patient positioning. RESULTS Of 115 patients assessed for eligibility, 82 were randomized to the APP group or control group (41 patients in each group). The use of APP for non-intubated patients with COVID-19 resulted in statistically significant improvements in oxygenation parameters, that is, SpO2 , PaO2 /FiO2 , ROX index, PaO2 , and SaO2 , at the three study time points (p = .000, .007, .000, .011, and .000 respectively). The SpO2 was increased to 92.15 ± 2.735 mmHg for the APP group versus 88.17 ± 4.847 for the control group after 1 h of patients' positioning. The PaO2 /FiO2 ratio increased in the APP group before proning compared with 1 h after proning (79.95 ± 22.508 vs. 98.91 ± 34.44) respectively. APP improved the SpO2 , PaO2 /FiO2 , ROX index, PaO2 , and SaO2 values for the APP group, representing an increase of 5.85%, 23.71%, 30.79%, 22.59%, and 5.26%, respectively. CONCLUSION Awake proning in non-intubated patients with COVID-19 showed marked improvement in oxygenation and physiological parameters. RELEVANCE TO CLINICAL PRACTICE This study provides evidence for critical care nurses to implement APP in non-intubated patients with COVID-19 to improve oxygenation and physiological parameters, as it was tolerated by most of the patients without serious adverse events.
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Jacquet-Lagrèze M, Riad Z, Portran P, Chesnel D, Schweizer R, Ferarris A, Jacquemet L, Ruste M, Fellahi JL. Hemodynamic Effects of Awake Prone Positioning With COVID-19 Acute Respiratory Failure. Respir Care 2023; 68:713-720. [PMID: 37225655 PMCID: PMC10208996 DOI: 10.4187/respcare.10597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
INTRODUCTION Awake prone positioning (PP) reduces need for intubation for patients with COVID-19 with acute respiratory failure. We investigated the hemodynamic effects of awake PP in non-ventilated subjects with COVID-19 acute respiratory failure. METHODS We conducted a single-center prospective cohort study. Adult hypoxemic subjects with COVID-19 not requiring invasive mechanical ventilation receiving at least one PP session were included. Hemodynamic assessment was done with transthoracic echocardiography before, during, and after a PP session. RESULTS Twenty-six subjects were included. We observed a significant and reversible increase in cardiac index (CI) during PP compared to supine position (SP): 3.0 ± 0.8 L/min/m2 in PP, 2.5 ± 0.6 L/min/m2 before PP (SP1), and 2.6 ± 0.5 L/min/m2 after PP (SP2, P < .001). A significant improvement in right ventricular (RV) systolic function was also evidenced during PP: The RV fractional area change was 36 ± 10% in SP1, 46 ± 10% during PP, and 35 ± 8% in SP2 (P < .001). There was no significant difference in PaO2 /FIO2 and breathing frequency. CONCLUSION CI and RV systolic function are improved by awake PP in non-ventilated subjects with COVID-19 with acute respiratory failure.
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Affiliation(s)
- Matthias Jacquet-Lagrèze
- Service d'anesthésie-réanimation, Hôpital cardiologique Louis Pradel, Hospices Civils de Lyon, Bron, France; Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France; and CarMeN Laboratory, Inserm UMR 1060, Université Claude Bernard Lyon 1, Lyon, France.
| | - Zakaria Riad
- Service d'anesthésie-réanimation, Hôpital cardiologique Louis Pradel, Hospices Civils de Lyon, Bron, France; and Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France
| | - Philippe Portran
- Service d'anesthésie-réanimation, Hôpital cardiologique Louis Pradel, Hospices Civils de Lyon, Bron, France
| | - Delphine Chesnel
- Service d'anesthésie-réanimation, Hôpital cardiologique Louis Pradel, Hospices Civils de Lyon, Bron, France
| | - Rémi Schweizer
- Service d'anesthésie-réanimation, Hôpital cardiologique Louis Pradel, Hospices Civils de Lyon, Bron, France
| | - Arnaud Ferarris
- Service d'anesthésie-réanimation, Hôpital cardiologique Louis Pradel, Hospices Civils de Lyon, Bron, France; and Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France
| | - Louis Jacquemet
- Service d'anesthésie-réanimation, Hôpital cardiologique Louis Pradel, Hospices Civils de Lyon, Bron, France
| | - Martin Ruste
- Service d'anesthésie-réanimation, Hôpital cardiologique Louis Pradel, Hospices Civils de Lyon, Bron, France; and Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France
| | - Jean-Luc Fellahi
- Service d'anesthésie-réanimation, Hôpital cardiologique Louis Pradel, Hospices Civils de Lyon, Bron, France; Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France; and CarMeN Laboratory, Inserm UMR 1060, Université Claude Bernard Lyon 1, Lyon, France
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Yarahmadi S, Ebrahimzadeh F, Mohamadipour F, Cheraghian T, Eskini M. Effect of Prone Position on Clinical Outcomes of Non-Intubated Patients with Covid-19: A Randomized Clinical Trial. Collegian 2022; 30:449-456. [PMID: 36591534 PMCID: PMC9792421 DOI: 10.1016/j.colegn.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 12/14/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022]
Abstract
Background Prone positioning (PP) is a well-known respiratory support approach. Limited data are available for the use of PP in non-intubated patients with COVID-19. Aim This study aims to investigate the effect of PP on the clinical outcomes of patients with COVID-19 pneumonia. Methods In This clinical trial, the participants in the PP group (n=41) were asked to lie comfortably in a prone position for 90 minutes. In the supine position (SP) group (n=41), the participants were asked to lie comfortably in a supine position for 90 minutes. Clinical data such as oxygen saturation, respiratory rate, the severity of dyspnea, mean arterial pressure, and pulse rate were assessed at 0 (immediately before), 30, 60, 90 minutes after the start of the intervention and 30 min after resuming the supine position. The participants in the PP group were then asked to intermittently stay in a prone position for a total of eight hours per 24 hours of hospitalization. The participants in the control group were asked to remain in their usual positions during the hospital stay. Finally, the length of hospital stay, intubation rate, and survival assessed. Findings Prone positioning was associated with significant improvement in oxygen saturation (P = 0.001), respiratory rate (P=0.004), the severity of dyspnea (P=0.014), and mean arterial pressure (P=0.027). There was no significant difference between the two groups in terms of pulse rate (P=0.890), hospital stay (P=0.994), intubation rate (P=0.324), and survival (P=0.091). Discussion Our results demonstrated that prone positioning showed marked improvement in some short-term clinical outcomes in non-intubated patients with COVID-19. Conclusion Prone positioning can be considered an inexpensive, accessible, and simple measure in awake non-intubated patients with COVID-19.
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Affiliation(s)
- Sajad Yarahmadi
- Social Determinants of Health Research Center, School of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorramabad, Iran,Student Research Committee, Semnan University of Medical Sciences, Semnan, Iran,Correspondence to: Environmental Health Research Center, School of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Farzad Ebrahimzadeh
- Nutritional Health Research Center, School of Health and Nutrition, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Fatemeh Mohamadipour
- Social Determinants of Health Research Center, School of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Tayebeh Cheraghian
- Cardiovascular Research Center, Shahid Rahimi Hospital, School of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Mahtab Eskini
- Social Determinants of Health Research Center, Shohadaye Ashayer Hospital, School of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorramabad, Iran
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Weatherald J, Parhar KKS, Al Duhailib Z, Chu DK, Granholm A, Solverson K, Lewis K, Møller MH, Alshahrani M, Belley-Cote E, Loroff N, Qian ET, Gatto CL, Rice TW, Niven D, Stelfox HT, Fiest K, Cook D, Arabi YM, Alhazzani W. Efficacy of awake prone positioning in patients with covid-19 related hypoxemic respiratory failure: systematic review and meta-analysis of randomized trials. BMJ 2022; 379:e071966. [PMID: 36740866 PMCID: PMC9727649 DOI: 10.1136/bmj-2022-071966] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine the efficacy and safety of awake prone positioning versus usual care in non-intubated adults with hypoxemic respiratory failure due to covid-19. DESIGN Systematic review with frequentist and bayesian meta-analyses. STUDY ELIGIBILITY Randomized trials comparing awake prone positioning versus usual care in adults with covid-19 related hypoxemic respiratory failure. Information sources were Medline, Embase, and the Cochrane Central Register of Controlled Trials from inception to 4 March 2022. DATA EXTRACTION AND SYNTHESIS Two reviewers independently extracted data and assessed risk of bias. Random effects meta-analyses were performed for the primary and secondary outcomes. Bayesian meta-analyses were performed for endotracheal intubation and mortality outcomes. GRADE certainty of evidence was assessed for outcomes. MAIN OUTCOME MEASURES The primary outcome was endotracheal intubation. Secondary outcomes were mortality, ventilator-free days, intensive care unit (ICU) and hospital length of stay, escalation of oxygen modality, change in oxygenation and respiratory rate, and adverse events. RESULTS 17 trials (2931 patients) met the eligibility criteria. 12 trials were at low risk of bias, three had some concerns, and two were at high risk. Awake prone positioning reduced the risk of endotracheal intubation compared with usual care (crude average 24.2% v 29.8%, relative risk 0.83, 95% confidence interval 0.73 to 0.94; high certainty). This translates to 55 fewer intubations per 1000 patients (95% confidence interval 87 to 19 fewer intubations). Awake prone positioning did not significantly affect secondary outcomes, including mortality (15.6% v 17.2%, relative risk 0.90, 0.76 to 1.07; high certainty), ventilator-free days (mean difference 0.97 days, 95% confidence interval -0.5 to 3.4; low certainty), ICU length of stay (-2.1 days, -4.5 to 0.4; low certainty), hospital length of stay (-0.09 days, -0.69 to 0.51; moderate certainty), and escalation of oxygen modality (21.4% v 23.0%, relative risk 1.04, 0.74 to 1.44; low certainty). Adverse events related to awake prone positioning were uncommon. Bayesian meta-analysis showed a high probability of benefit with awake prone positioning for endotracheal intubation (non-informative prior, mean relative risk 0.83, 95% credible interval 0.70 to 0.97; posterior probability for relative risk <0.95=96%) but lower probability for mortality (0.90, 0.73 to 1.13; <0.95=68%). CONCLUSIONS Awake prone positioning compared with usual care reduces the risk of endotracheal intubation in adults with hypoxemic respiratory failure due to covid-19 but probably has little to no effect on mortality or other outcomes. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42022314856.
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Affiliation(s)
- Jason Weatherald
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
- Department of Medicine, Division of Respirology, University of Calgary, Calgary, AB, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
- Contributed equally
| | - Ken Kuljit S Parhar
- Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB T2N 5A1, Canada
- O'Brien Institute for Public Health, Calgary, AB, Canada
- Contributed equally
| | - Zainab Al Duhailib
- Critical Care Medicine Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Derek K Chu
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- The Research Institute of St Joe's Hamilton, Hamilton, ON, Canada
| | - Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Kevin Solverson
- Department of Medicine, Division of Respirology, University of Calgary, Calgary, AB, Canada
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB T2N 5A1, Canada
| | - Kimberley Lewis
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Mohammed Alshahrani
- Department of Emergency and Critical Care, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Emilie Belley-Cote
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Nicole Loroff
- Knowledge Resource Service, Alberta Health Services, Edmonton, AB, Canada
| | - Edward T Qian
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cheryl L Gatto
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dan Niven
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB T2N 5A1, Canada
- O'Brien Institute for Public Health, Calgary, AB, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB T2N 5A1, Canada
- O'Brien Institute for Public Health, Calgary, AB, Canada
| | - Kirsten Fiest
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB T2N 5A1, Canada
- O'Brien Institute for Public Health, Calgary, AB, Canada
| | - Deborah Cook
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- The Research Institute of St Joe's Hamilton, Hamilton, ON, Canada
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, 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
- King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- The Research Institute of St Joe's Hamilton, Hamilton, ON, Canada
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
- Department of Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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10
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Sweeney DA, Malhotra A. Supportive Care in Patients with Critical Coronavirus Disease 2019. Infect Dis Clin North Am 2022; 36:777-789. [PMID: 36328636 PMCID: PMC9376305 DOI: 10.1016/j.idc.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Specific therapies for the treatment of coronavirus disease 2019 (COVID-19) have limited efficacy in the event a patient worsens clinically and requires admission to the intensive care unit (ICU). Thus, providing quality supportive care is essential to the overall management of patients with critical COVID-19. Patients with respiratory failure not requiring intubation should be supported with noninvasive positive pressure ventilation, continuous positive airway pressure, or high flow oxygenation. Use of these respiratory modalities may prevent patients from subsequently requiring intubation. Basic components of supportive care for the critically ill should be applied equally to patients with COVID-19 in the ICU.
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Affiliation(s)
- Daniel A Sweeney
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, Department of Medicine, University of California, San Diego, 9300 Campus Point Drive, La Jolla, CA 92037-7381, USA.
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, Department of Medicine, University of California, San Diego, 9300 Campus Point Drive, La Jolla, CA 92037-7381, USA
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11
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Chong WH, Saha BK, Tan CK. Clinical Outcomes of Routine Awake Prone Positioning in COVID-19 Patients: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Prague Med Rep 2022; 123:140-165. [PMID: 36107444 DOI: 10.14712/23362936.2022.14] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Before coronavirus disease 2019 (COVID-19) emerged, proning had been demonstrated to improve oxygenation in those with acute hypoxic respiratory failure and be performed in non-intensive care settings. This benefit was further exemplified by the COVID-19 pandemic, leading to awake prone positioning (APP). We assessed the efficacy of routine APP versus standard care in preventing death and invasive mechanical ventilation (IMV) in non-intubated hypoxic COVID-19 patients. PubMed, Cochrane Library, Scopus, and medRxiv databases were used from January 1st, 2020, to January 15th, 2022, to identify randomized controlled trials (RCTs). Routine APP group were encouraged to be self-prone, whereas the standard care group received care according to local clinical practice and allowed APP crossover as rescue therapy. We included eight COVID-19 RCTs assessing 809 APP vs. 822 standard care patients. APP group had less IMV requirement (26.5% vs. 30.9%; OR - odds ratio 0.77; P=0.03) than the standard care group, with subgroup analysis showing greater benefit (32.5% vs. 39.1%; OR 0.75; P=0.02) for those mainly requiring oxygen support of non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC). The time to IMV initiation was similar (mean 8.3 vs. 10.0 days; P=0.66) for patients requiring NIMV and HFNC. Patients mainly receiving supplemental oxygen and non-rebreather masks had improved oxygenation parameters, although not statistically significant. Other outcomes involving all-cause hospital mortality, hospital and ICU (intensive care unit) length of stay, and adverse events were comparable. APP appeared to be an important modality for reducing IMV requirements, especially in those requiring NIMV and HFNC.
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Affiliation(s)
- Woon Hean Chong
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, Singapore.
| | - Biplab K Saha
- Department of Pulmonary and Critical Care, Ozarks Medical Center, West Plains, USA
| | - Chee Keat Tan
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, Singapore
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12
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Douglas MJ, Bell BW, Kinney A, Pungitore SA, Toner BP. Early COVID-19 respiratory risk stratification using machine learning. Trauma Surg Acute Care Open 2022; 7:e000892. [PMID: 36111138 PMCID: PMC9438026 DOI: 10.1136/tsaco-2022-000892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 07/26/2022] [Indexed: 12/15/2022] Open
Abstract
Background COVID-19 has strained healthcare systems globally. In this and future pandemics, providers with limited critical care experience must distinguish between moderately ill patients and those who will require aggressive care, particularly endotracheal intubation. We sought to develop a machine learning-informed Early COVID-19 Respiratory Risk Stratification (ECoRRS) score to assist in triage, by providing a prediction of intubation within the next 48 hours based on objective clinical parameters. Methods Electronic health record data from 3447 COVID-19 hospitalizations, 20.7% including intubation, were extracted. 80% of these records were used as the derivation cohort. The validation cohort consisted of 20% of the total 3447 records. Multiple randomizations of the training and testing split were used to calculate confidence intervals. Data were binned into 4-hour blocks and labeled as cases of intubation or no intubation within the specified time frame. A LASSO (least absolute shrinkage and selection operator) regression model was tuned for sensitivity and sparsity. Results Six highly predictive parameters were identified, the most significant being fraction of inspired oxygen. The model achieved an area under the receiver operating characteristic curve of 0.789 (95% CI 0.785 to 0.812). At 90% sensitivity, the negative predictive value was 0.997. Discussion The ECoRRS score enables non-specialists to identify patients with COVID-19 at risk of intubation within 48 hours with minimal undertriage and enables health systems to forecast new COVID-19 ventilator needs up to 48 hours in advance. Level of evidence IV.
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Affiliation(s)
- Molly J Douglas
- Department of Surgery, University of Arizona, Tucson, Arizona, USA
- Program in Applied Mathematics, University of Arizona, Tucson, Arizona, USA
| | - Brian W Bell
- Program in Applied Mathematics, University of Arizona, Tucson, Arizona, USA
| | - Adrienne Kinney
- Program in Applied Mathematics, University of Arizona, Tucson, Arizona, USA
| | - Sarah A Pungitore
- Program in Applied Mathematics, University of Arizona, Tucson, Arizona, USA
| | - Brian P Toner
- Program in Applied Mathematics, University of Arizona, Tucson, Arizona, USA
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13
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Cosentini R, Groff P, Brambilla AM, Camajori Todeschini R, Gangitano G, Ingrassia S, Marino R, Nori F, Pagnozzi F, Panero F, Ferrari R. SIMEU position paper on non-invasive respiratory support in COVID-19 pneumonia. Intern Emerg Med 2022; 17:1175-1189. [PMID: 35103926 PMCID: PMC8803573 DOI: 10.1007/s11739-021-02906-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 12/06/2021] [Indexed: 12/19/2022]
Abstract
The rapid worldwide spread of the Coronavirus disease (COVID-19) crisis has put health systems under pressure to a level never experienced before, putting intensive care units in a position to fail to meet an exponentially growing demand. The main clinical feature of the disease is a progressive arterial hypoxemia which rapidly leads to ARDS which makes the use of intensive care and mechanical ventilation almost inevitable. The difficulty of health systems to guarantee a corresponding supply of resources in intensive care, together with the uncertain results reported in the literature with respect to patients who undergo early conventional ventilation, make the search for alternative methods of oxygenation and ventilation and potentially preventive of the need for tracheal intubation, such as non-invasive respiratory support techniques particularly valuable. In this context, the Emergency Department, located between the area outside the hospital and hospital ward and ICU, assumes the role of a crucial junction, due to the possibility of applying these techniques at a sufficiently early stage and being able to rapidly evaluate their effectiveness. This position paper describes the indications for the use of non-invasive respiratory support techniques in respiratory failure secondary to COVID-19-related pneumonia, formulated by the Non-invasive Ventilation Faculty of the Italian Society of Emergency Medicine (SIMEU) on the base of what is available in the literature and on the authors' direct experience. Rationale, literature, tips & tricks, resources, risks and expected results, and patient interaction will be discussed for each one of the escalating non-invasive respiratory techniques: standard oxygen, HFNCO, CPAP, NIPPV, and awake self-repositioning. The final chapter describes our suggested approach to the failing patient.
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Affiliation(s)
| | - Paolo Groff
- Pronto Soccorso e Osservazione Breve, Perugia, AO, Italy
| | | | | | | | - Stella Ingrassia
- Emergency Medicine Unit, Luigi Sacco Hospital, ASST FBF Sacco, Milan, Italy
| | - Roberta Marino
- Emergency Medicine, Sant'Andrea Hospital, Vercelli, Italy
| | - Francesca Nori
- Emergency Room, Emergency Care Unit, Santa Maria Della Scaletta Hospital, Imola, Italy
| | | | - Francesco Panero
- MECAU 2, Pronto Soccorso e Area Critica, ASL Città di Torino, Turin, Italy
| | - Rodolfo Ferrari
- Emergency Room, Emergency Care Unit, Santa Maria Della Scaletta Hospital, Imola, Italy
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14
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Koike T, Hamazaki N, Kuroiwa M, Kamiya K, Otsuka T, Sugimura K, Nishizawa Y, Sakai M, Miida K, Matsunaga A, Arai M. Detailed Changes in Oxygenation following Awake Prone Positioning for Non-Intubated Patients with COVID-19 and Hypoxemic Respiratory Failure—A Historical Cohort Study. Healthcare (Basel) 2022; 10:healthcare10061006. [PMID: 35742057 PMCID: PMC9222739 DOI: 10.3390/healthcare10061006] [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: 04/21/2022] [Revised: 05/24/2022] [Accepted: 05/27/2022] [Indexed: 12/04/2022] Open
Abstract
Few studies have reported on the effectiveness of awake prone therapy in the clinical course of coronavirus disease (COVID-19) patients. This study aimed to investigate the effects of awake prone therapy during spontaneous breathing on the improvement of oxygenation over 3 weeks for COVID-19 acute respiratory failure. Data of consecutive COVID-19 patients with lung disorder with a fraction of inspired oxygen (FIO2) ≥ 0.4 and without tracheal intubation were analyzed. We examined changes in SpO2/FIO2, ROX index ((SpO2/FIO2)/respiratory rate) and the seven-category ordinal scale after the initiation of FIO2 ≥ 0.4 and compared these changes between patients who did and did not receive prone therapy. Of 58 patients, 27 received awake prone therapy, while 31 did not. Trend relationships between time course and change in SpO2/FIO2 and ROX index were observed in both groups, although a significant interaction in the relationship was noted between prone therapy and change in SpO2/FIO2 and ROX index. The seven-category ordinal scale also revealed a trend relationship with time course in the prone therapy group. The awake prone therapy was significantly associated with a lower rate of tracheal intubation. In patients with COVID-19 pneumonia treated with FIO2 ≥ 0.4, awake prone therapy may improve oxygenation within two weeks.
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Affiliation(s)
- Tomotaka Koike
- Department of Intensive Care Center, Kitasato University Hospital, Sagamihara 252-0329, Japan;
| | - Nobuaki Hamazaki
- Department of Rehabilitation, Kitasato University Hospital, Sagamihara 252-0329, Japan; (N.H.); (K.M.)
| | - Masayuki Kuroiwa
- Department of Anesthesiology, School of Medicine, Kitasato University, Sagamihara 252-0373, Japan; (M.K.); (T.O.); (K.S.); (Y.N.); (M.S.)
| | - Kentaro Kamiya
- Department of Rehabilitation, School of Allied Health Sciences, Kitasato University, Sagamihara 252-0373, Japan;
- Correspondence: ; Tel.: +81-42-778-9693
| | - Tomohisa Otsuka
- Department of Anesthesiology, School of Medicine, Kitasato University, Sagamihara 252-0373, Japan; (M.K.); (T.O.); (K.S.); (Y.N.); (M.S.)
| | - Kosuke Sugimura
- Department of Anesthesiology, School of Medicine, Kitasato University, Sagamihara 252-0373, Japan; (M.K.); (T.O.); (K.S.); (Y.N.); (M.S.)
| | - Yoshiyuki Nishizawa
- Department of Anesthesiology, School of Medicine, Kitasato University, Sagamihara 252-0373, Japan; (M.K.); (T.O.); (K.S.); (Y.N.); (M.S.)
| | - Mayuko Sakai
- Department of Anesthesiology, School of Medicine, Kitasato University, Sagamihara 252-0373, Japan; (M.K.); (T.O.); (K.S.); (Y.N.); (M.S.)
| | - Kazumasa Miida
- Department of Rehabilitation, Kitasato University Hospital, Sagamihara 252-0329, Japan; (N.H.); (K.M.)
| | - Atsuhiko Matsunaga
- Department of Rehabilitation, School of Allied Health Sciences, Kitasato University, Sagamihara 252-0373, Japan;
| | - Masayasu Arai
- Division of Intensive Care Medicine, Department of Research and Development Center for New Medical Frontiers, School of Medicine, Kitasato University, Sagamihara 252-0373, Japan;
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15
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Musso G, Taliano C, Molinaro F, Fonti C, Veliaj D, Torti D, Paschetta E, Castagna E, Carbone G, Laudari L, Aseglio C, Zocca E, Chioni S, Giannone LC, Arabia F, Deiana C, Benato FM, Druetta M, Campagnola G, Borsari M, Mucci M, Rubatto T, Peyronel M, Tirabassi G. Early prolonged prone position in noninvasively ventilated patients with SARS-CoV-2-related moderate-to-severe hypoxemic respiratory failure: clinical outcomes and mechanisms for treatment response in the PRO-NIV study. Crit Care 2022; 26:118. [PMID: 35488356 PMCID: PMC9052189 DOI: 10.1186/s13054-022-03937-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 03/02/2022] [Indexed: 12/23/2022] Open
Abstract
Background Whether prone position (PP) improves clinical outcomes in COVID-19 pneumonia treated with noninvasive ventilation (NIV) is unknown. We evaluated the effect of early PP on 28-day NIV failure, intubation and death in noninvasively ventilated patients with moderate-to-severe acute hypoxemic respiratory failure due to COVID-19 pneumonia and explored physiological mechanisms underlying treatment response. Methods In this controlled non-randomized trial, 81 consecutive prospectively enrolled patients with COVID-19 pneumonia and moderate-to-severe (paO2/FiO2 ratio < 200) acute hypoxemic respiratory failure treated with early PP + NIV during Dec 2020–May 2021were compared with 162 consecutive patients with COVID-19 pneumonia matched for age, mortality risk, severity of illness and paO2/FiO2 ratio at admission, treated with conventional (supine) NIV during Apr 2020–Dec 2020 at HUMANITAS Gradenigo Subintensive Care Unit, after propensity score adjustment for multiple baseline and treatment-related variables to limit confounding. Lung ultrasonography (LUS) was performed at baseline and at day 5. Ventilatory parameters, physiological dead space indices (DSIs) and circulating inflammatory and procoagulative biomarkers were monitored during the initial 7 days. Results In the intention-to-treat analysis. NIV failure occurred in 14 (17%) of PP patients versus 70 (43%) of controls [HR = 0.32, 95% CI 0.21–0.50; p < 0.0001]; intubation in 8 (11%) of PP patients versus 44 (30%) of controls [HR = 0.31, 95% CI 0.18–0.55; p = 0.0012], death in 10 (12%) of PP patients versus 59 (36%) of controls [HR = 0.27, 95% CI 0.17–0.44; p < 0.0001]. The effect remained significant within different categories of severity of hypoxemia (paO2/FiO2 < 100 or paO2/FiO2 100–199 at admission). Adverse events were rare and evenly distributed. Compared with controls, PP therapy was associated with improved oxygenation and DSIs, reduced global LUS severity indices largely through enhanced reaeration of dorso-lateral lung regions, and an earlier decline in inflammatory markers and D-dimer. In multivariate analysis, day 1 CO2 response outperformed O2 response as a predictor of LUS changes, NIV failure, intubation and death.
Conclusion Early prolonged PP is safe and is associated with lower NIV failure, intubation and death rates in noninvasively ventilated patients with COVID-19-related moderate-to-severe hypoxemic respiratory failure. Early dead space reduction and reaeration of dorso-lateral lung regions predicted clinical outcomes in our study population.
Clinical trial registration ISRCTN23016116. Retrospectively registered on May 1, 2021. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03937-x.
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Affiliation(s)
- Giovanni Musso
- Emergency Medicine Department, HUMANITAS Gradenigo, C.so Regina Margherita 8, 10132, Turin, Italy.
| | - Claudio Taliano
- Emergency Medicine Department, HUMANITAS Gradenigo, C.so Regina Margherita 8, 10132, Turin, Italy
| | - Federica Molinaro
- Emergency Medicine Department, HUMANITAS Gradenigo, C.so Regina Margherita 8, 10132, Turin, Italy
| | - Caterina Fonti
- Emergency Medicine Department, HUMANITAS Gradenigo, C.so Regina Margherita 8, 10132, Turin, Italy
| | | | - Davide Torti
- Emergency Medicine Department, HUMANITAS Gradenigo, C.so Regina Margherita 8, 10132, Turin, Italy
| | - Elena Paschetta
- Emergency Medicine Department, HUMANITAS Gradenigo, C.so Regina Margherita 8, 10132, Turin, Italy
| | - Elisabetta Castagna
- Emergency Medicine Department, HUMANITAS Gradenigo, C.so Regina Margherita 8, 10132, Turin, Italy
| | - Giorgio Carbone
- Emergency Medicine Department, HUMANITAS Gradenigo, C.so Regina Margherita 8, 10132, Turin, Italy
| | - Luigi Laudari
- Intensive Care Unit, HUMANITAS Gradenigo, Turin, Italy
| | | | - Edoardo Zocca
- Intensive Care Unit, HUMANITAS Gradenigo, Turin, Italy
| | - Sonia Chioni
- Intensive Care Unit, HUMANITAS Gradenigo, Turin, Italy
| | | | | | - Cecilia Deiana
- Emergency Medicine Department, HUMANITAS Gradenigo, C.so Regina Margherita 8, 10132, Turin, Italy
| | | | - Marta Druetta
- Emergency Medicine Department, HUMANITAS Gradenigo, C.so Regina Margherita 8, 10132, Turin, Italy
| | | | | | - Martina Mucci
- Intensive Care Unit, HUMANITAS Gradenigo, Turin, Italy
| | | | - Mara Peyronel
- Emergency Medicine Department, HUMANITAS Gradenigo, C.so Regina Margherita 8, 10132, Turin, Italy
| | - Gloria Tirabassi
- Emergency Medicine Department, HUMANITAS Gradenigo, C.so Regina Margherita 8, 10132, Turin, Italy
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16
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Yildirim M, Halacli B, Pektezel MY, Er B, Geldigitti IT, Tok G, Ersoy EO, Topeli A. Comparison of critically ill COVID-19 and influenza patients with acute respiratory failure. Acute Crit Care 2022; 37:168-176. [PMID: 35280038 PMCID: PMC9184989 DOI: 10.4266/acc.2021.00920] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 08/27/2021] [Indexed: 01/08/2023] Open
Abstract
Background Coronavirus disease 2019 (COVID-19) is one of the biggest pandemic causing acute respiratory failure (ARF) in the last century. Seasonal influenza carries high mortality, as well. The aim of this study was to compare features and outcomes of critically-ill COVID-19 and influenza patients with ARF. Methods Patients with COVID-19 and influenza admitted to intensive care unit with ARF were retrospectively analyzed. Results Fifty-four COVID-19 and 55 influenza patients with ARF were studied. Patients with COVID-19 had 32% of hospital mortality, while those with influenza had 47% (P=0.09). Patients with influenza had higher Eastern Cooperative Oncology Group, Clinical Frailty Scale, Acute Physiology and Chronic Health Evaluation II and admission Sequential Organ Failure Assessment (SOFA) scores than COVID-19 patients (P<0.01). Secondary bacterial infection, admission acute kidney injury, procalcitonin level above 0.2 ng/ml were the independent factors distinguishing influenza from COVID-19 while prone positioning differentiated COVID-19 from influenza. Invasive mechanical ventilation (odds ratio [OR], 42.16; 95% confidence interval [CI], 9.45–187.97), admission SOFA score more than 4 (OR, 5.92; 95% CI, 1.85–18.92), malignancy (OR, 4.95; 95% CI, 1.13–21.60), and age more than 65 years (OR, 3.31; 95% CI, 0.99–11.03) were found to be independent risk factors for hospital mortality. Conclusions There were few differences in clinical features of critically-ill COVID-19 and influenza patients. Influenza cases had worse performance status and disease severity. There was no significant difference in hospital mortality rates between COVID-19 and influenza patients.
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Affiliation(s)
- Mehmet Yildirim
- Division of Intensive Care Medicine, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Burcin Halacli
- Division of Intensive Care Medicine, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Mehmet Yasir Pektezel
- Division of Intensive Care Medicine, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Berrin Er
- Division of Intensive Care Medicine, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ismail Tuna Geldigitti
- Division of Intensive Care Medicine, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Gulay Tok
- Division of Intensive Care Medicine, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ebru Ortac Ersoy
- Division of Intensive Care Medicine, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Arzu Topeli
- Division of Intensive Care Medicine, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
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17
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ASSESSMENT OF PROCEDURAL PAIN IN PATIENTS WITH COVID-19 IN THE INTENSIVE CARE UNIT. Pain Manag Nurs 2022; 23:596-601. [PMID: 35418331 PMCID: PMC8919865 DOI: 10.1016/j.pmn.2022.03.002] [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: 11/30/2021] [Revised: 03/02/2022] [Accepted: 03/07/2022] [Indexed: 01/08/2023]
Abstract
Aim The purpose of the study was to assess the level of procedural pain in patients treated in the COVID-19 intensive care unit, in a tertiary university hospital. Method We performed the procedural pain assessment of COVID-19 patients in this study, and 162 (93.6 %) of 173 hospitalized patients assessed during this period. While pain was assessed before, during, and at the 20th minute after endotracheal aspiration, wound care, and position change, which are procedural patient practices, the pain was assessed before, during, and up to the fourth hour after prone positioning, high-flow oxygen therapy (HFOT), and the non-invasive mechanical ventilation (NIMV) procedure. The Numerical Pain Scale was used for conscious patients in pain assessment, while the Behavioral Pain Scale and the Richmond Agitation-Sedation Scale were used for unconscious patients. Results Patients who underwent endotracheal aspiration, wound care, and positioning had higher pain levels during procedure than other time points. Patients in the prone position with HFOT and NIMV applied had the highest pain scores at fourth hour after procedure; this increase was statistically significant (p = .000, p < .05). Conclusions The study found that COVID-19 patients in the ICU had pain due to procedural practices and that the level of pain during the procedures was higher because endotracheal aspiration, wound care, and positioning were all short-term procedures. Moreover, prone positioning was found to be associated with pressure-related tissue damage, and patients' pain levels increased with the increasing duration of HFOT and NIMV procedure.
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18
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Abstract
Purpose/Aims Healthcare workers internationally continue to look for innovative ways to improve patient outcomes and optimize resource utilization during the coronavirus disease 2019 (COVID-19) pandemic. Proning awake, nonintubated patients has been suggested as a potential intervention in critical care. The aim of this study is to provide a multidisciplinary approach to safely perform awake self-prone positioning in the acute care setting. Design This is a prospective, descriptive study. Method Patients with COVID-19 were screened and enrolled within 48 hours of a positive test. After approval from the primary team, patients were provided education materials by a multidisciplinary team on the self-prone intervention. Visual cues were placed in the room. Patients were requested to maintain a diary of hours of prone positioning. Patients' baseline characteristics, admission vitals, daily oxygen requirements, and level of care were collected. Results Of 203 patients screened, 31 were enrolled. No pressure-related injury or catheter (intravenous or urinary) displacement was identified. Eighty-one percent of patients spent less than 8 hours a day in prone positioning. Among patients enrolled, none required invasive ventilation or died. Conclusions Awake self-proning can be performed safely in patients given a diagnosis of COVID-19 in the acute care setting with a multidisciplinary team.
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19
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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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20
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Abstract
The coronavirus disease 2019 (COVID-19) pandemic has posed unprecedented challenges in critical care medicine, including extreme demand for intensive care unit (ICU) resources and rapidly evolving understanding of a novel disease. Up to one-third of hospitalized patients with COVID-19 experience critical illness. The most common form of organ failure in COVID-19 critical illness is acute hypoxemic respiratory failure, which clinically presents as acute respiratory distress syndrome (ARDS) in three-quarters of ICU patients. Noninvasive respiratory support modalities are being used with increasing frequency given their potential to reduce the need for intubation. Determining optimal patient selection for and timing of intubation remains a challenge. Management of mechanically ventilated patients with COVID-19 largely mirrors that of non-COVID-19 ARDS. Organ failure is common and portends a poor prognosis. Mortality rates have improved over the course of the pandemic, likely owing to increasing disease familiarity, data-driven pharmacologics, and improved adherence to evidence-based critical care.
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Affiliation(s)
- Jennifer C Ginestra
- Division of Pulmonary, Allergy and Critical Care Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania 19104, USA; , , ,
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania 19104, USA
| | - Oscar J L Mitchell
- Division of Pulmonary, Allergy and Critical Care Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania 19104, USA; , , ,
- Center for Resuscitation Science, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - George L Anesi
- Division of Pulmonary, Allergy and Critical Care Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania 19104, USA; , , ,
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania 19104, USA
| | - Jason D Christie
- Division of Pulmonary, Allergy and Critical Care Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania 19104, USA; , , ,
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21
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Chicayban LM, Chicayban PB, Nunes PR, Soares GF, Carlos MJ. Evaluation of the response to prone positioning in awake patients with COVID-19. FISIOTERAPIA E PESQUISA 2022. [DOI: 10.1590/1809-2950/21018529012022en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT This study aims to evaluate the acute effects of the responses to prone positioning (PP) in awake patients with COVID-19. A prospective, single-centered study, using supplemental oxygen, was conducted with 32 awake patients with COVID-19. The response to PP was performed for 30 minutes. According to their tolerance, the patients were instructed to daily remain in PP. The variables for oxygen saturation (SpO2), heart rate, respiratory rate, ROX index and intensive care unit (ICU) admission rate were registered. In total, 25 patients (78.1%) responded to PP, with 13 (40.6%) showing persistent response and 12 (37.5%) showing transient response. Seven patients (21.9%) did not respond. Patients with persistent and transient responses increased SpO2 (p<0.001) and ROX index (p=0.001 and p<0.001, respectively), and reduced heart rate (p=0.01 and p=0.02, respectively), and respiratory rate (p=0.003 and p=0.001, respectively). The variables were similar in patients who did not respond to PP. The ICU admission rate of patients who had persistent or transient response, or did not respond was 30.8% (4/13), 41.7% (5/12), and 57.1% (4/7), respectively. The patients who responded to PP showed reduced heart and respiratory rates and increased ROX index, without interfering in the hospitalization rate.
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Affiliation(s)
| | | | - Paula Rangel Nunes
- Institutos Superiores de Ensino do Centro Educacional Nossa Senhora Auxiliadora, Brasil
| | | | - Marcelo Jesus Carlos
- Institutos Superiores de Ensino do Centro Educacional Nossa Senhora Auxiliadora, Brasil
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22
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Chicayban LM, Chicayban PB, Nunes PR, Soares GF, Carlos MJ. Avaliação da resposta à posição prona em pacientes acordados com COVID-19. FISIOTERAPIA E PESQUISA 2022. [DOI: 10.1590/1809-2950/21018529012022pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RESUMO O objetivo deste estudo foi avaliar os efeitos agudos dos tipos de resposta à posição prona (PP) em pacientes acordados com COVID-19. Realizou-se um estudo prospectivo, unicêntrico, com 32 pacientes acordados com COVID-19, e com uso de oxigênio suplementar. A resposta à posição prona foi feita durante 30 minutos. Após o teste, os pacientes foram orientados a permanecer na PP diariamente, de acordo com a tolerância de cada um. As variáveis saturação de oxigênio (SpO2), frequência cardíaca, frequência respiratória, índice ROX e taxa de internação na unidade de terapia intensiva (UTI) foram registradas. Um total de 25 pacientes (78,1%) responderam à PP, sendo que 13 (40,6%) apresentaram resposta persistente e 12 (37,5%) transitória. Sete pacientes (21,9%) não responderam. Os pacientes com respostas persistente e transitória tiveram aumento da SpO2 (p<0,001) e do índice ROX (p=0,001 e p<0,001, respectivamente), e redução das frequências cardíaca (p=0,01 e p=0,02, respectivamente) e respiratória (p=0,003 e p=0,001, respectivamente). Não houve diferença em nenhuma das variáveis nos pacientes que não responderam à PP. A taxa de internação na UTI dos pacientes que apresentaram resposta persistente, transitória ou que não responderam foi de 30,8% (4/13), 41,7% (5/12) e 57,1% (4/7), respectivamente. Conclui-se que os pacientes que responderam à PP apresentaram redução das frequências cardíaca e respiratória e aumento do índice ROX, sem interferir na taxa de internação.
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Affiliation(s)
| | | | - Paula Rangel Nunes
- Institutos Superiores de Ensino do Centro Educacional Nossa Senhora Auxiliadora, Brasil
| | | | - Marcelo Jesus Carlos
- Institutos Superiores de Ensino do Centro Educacional Nossa Senhora Auxiliadora, Brasil
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23
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AlMutiri AM, Alsulaimani S, Sabbagh AJ, Bajunaid KM, Tashkandi WA, Baeesa SS. Cervical Spinal Cord Injury During Prone Position Ventilation in the COVID-19 Pandemic. Cureus 2021; 13:e18958. [PMID: 34707947 PMCID: PMC8531578 DOI: 10.7759/cureus.18958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2021] [Indexed: 11/30/2022] Open
Abstract
The prone positioning of patients experiencing acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been proven effective in optimizing oxygenation and lung function. However, such patients may be at risk of developing complications due to the prolonged prone position in intensive critical care. A 45-year-old COVID-19 female, not known with cervical spine disease, presented with progressive severe COVID-19-related hypoxemia that required intensive care unit admission for pulmonary care. She was positioned prone and ventilated for several weeks. She developed a rapidly advanced decreased level of consciousness and flaccid quadriparesis. CT and MRI scans of the cervical spine revealed C4/C5 fracture-dislocation with spinal cord compression in asymptomatic ankylosing spondylitis and focal ossification of a posterior longitudinal ligament. In addition, the patient had severe ARDS-SARS-CoV-2 hemodynamic instability. Surgery was not performed due to her critical condition, and the patient died from multi-organ failure. Patients with underlying cervical spine disease or deformity can be subjected to hyperextension and develop fatigue (stress) spinal fracture, leading to spinal cord compression. To our knowledge, this is the first case of spontaneous cervical spine fracture dislocation in a COVID-19 patient after several weeks in prone position ventilation in ICU. Hence, our case report raises the awareness of the possibility of devastating spinal cord injuries in prone position ventilation during the COVID-19 pandemic and the need for early screening using plain X-rays of these patients for cervical spine disease.
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Affiliation(s)
| | | | | | | | - Wail A Tashkandi
- Critical Care Medicine, King Abdulaziz University Faculty of Medicine, Jeddah, SAU
| | - Saleh S Baeesa
- Surgery, King Abdulaziz University Faculty of Medicine, Jeddah, SAU
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24
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Dueñas-Castell C, Borre-Naranjo D, Rodelo D, Lora L, Almanza A, Coronell W, Rojas-Suarez J. Changes in Oxygenation and Clinical Outcomes with Awake Prone Positioning in Patients with Suspected COVID-19 In Low-Resource Settings: A Retrospective Cohort Study. J Intensive Care Med 2021; 36:1347-1353. [PMID: 34591700 DOI: 10.1177/08850666211049333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION This study aimed to describe the use of awake prone positioning (APP) and conventional oxygen therapy (COT) in patients with suspected coronavirus disease (COVID-19) and respiratory failure in a limited-resource setting. METHODS This was a retrospective cohort study of hospitalized patients aged ≥18 years old who were placed in an awake prone position due to hypoxemic respiratory failure and suspected COVID-19. The patients were selected from a tertiary center in Cartagena, Colombia, between March 1, 2020, and August 31, 2020. Demographic, clinical, and laboratory variables were collated, and all the variables were compared between the groups. RESULTS The median age of the participants was 63 (IQR, 48.8-73) years (survivors: 59 [IQR, 43.568] years vs. non-survivors: 70 [IQR, 63-78] years, P ≤ .001). Of the 1470 patients admitted for respiratory symptoms, 732 (49.8%) were hospitalized for more than 24 h, and 212 patients developed respiratory failure and required COT and APP (overall hospital mortality, 34% [73/212]). The mean rank difference in PaO2/FiO2 before and after APP was higher in the survivors than in the non-survivors (201.1-252.6, mean rank difference = 51.5, P = .001 vs. 134.1-172.4, mean rank difference = 38.28, P = .24, respectively). CONCLUSION While using COT in conjunction with APP can improve respiratory failure in patients with suspected COVID-19 in low-resource settings, persistent hypoxemia after APP can identify patients with higher mortality risk. More evidence is needed to establish the role of this strategy.
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Affiliation(s)
- Carmelo Dueñas-Castell
- Clínica Gestión Salud, Cartagena, Bolivar, Colombia
- Intensive Care and Obstetrics Research Group (GRICIO), 27986Universidad de Cartagena, Cartagena, Colombia
- Universidad Simón Bolívar, Barranquilla, Colombia
- Universidad Metropolitana, Barranquilla, Colombia
| | - Diana Borre-Naranjo
- Clínica Gestión Salud, Cartagena, Bolivar, Colombia
- Intensive Care and Obstetrics Research Group (GRICIO), 27986Universidad de Cartagena, Cartagena, Colombia
| | - Dairo Rodelo
- Universidad Simón Bolívar, Barranquilla, Colombia
| | - Leydis Lora
- Clínica Gestión Salud, Cartagena, Bolivar, Colombia
| | - Amilkar Almanza
- Clínica Gestión Salud, Cartagena, Bolivar, Colombia
- Intensive Care and Obstetrics Research Group (GRICIO), 27986Universidad de Cartagena, Cartagena, Colombia
| | - Wilfrido Coronell
- Intensive Care and Obstetrics Research Group (GRICIO), 27986Universidad de Cartagena, Cartagena, Colombia
| | - Jose Rojas-Suarez
- Clínica Gestión Salud, Cartagena, Bolivar, Colombia
- Intensive Care and Obstetrics Research Group (GRICIO), 27986Universidad de Cartagena, Cartagena, Colombia
- Universidad Simón Bolívar, Barranquilla, Colombia
- 204425Corporación Universitaria Rafael Núñez, Cartagena, Colombia
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25
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Joseph B, Mackinson LG, Sokol-Hessner L, Law AC, DeSanto-Madeya S. CE: A Prone Positioning Protocol for Awake, Nonintubated Patients with COVID-19. Am J Nurs 2021; 121:36-44. [PMID: 34510111 PMCID: PMC11044981 DOI: 10.1097/01.naj.0000794108.07908.54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
ABSTRACT Prone positioning of critically ill patients with acute respiratory distress syndrome is an accepted therapy done to improve oxygenation and promote weaning from mechanical ventilation. But there is limited information regarding its use outside of the ICU. At one Boston hospital, the influx of patients with suspected or confirmed COVID-19 strained its resources, requiring sweeping systems changes and inspiring innovations in clinical care. This article describes how an interdisciplinary team of clinicians developed a prone positioning protocol for use with awake, nonintubated, oxygen-dependent patients with suspected or confirmed COVID-19 on medical-surgical units, with the hope of hastening their recovery and avoiding deterioration and ICU transfer. A protocol implementation plan and staff educational materials were disseminated via the hospital incident command system and supported through daily leadership huddles. Patient eligibility criteria, including indications and contraindications, and a clear nursing procedure for the implementation of prone positioning with a given patient, were key elements. Nurses' feedback of their experiences with the protocol was elicited through an e-mailed survey. Nearly all respondents reported improvements in patients' oxygen saturation levels, while few respondents reported barriers to protocol implementation. The prone positioning protocol was found to be both feasible for and well tolerated by awake, nonintubated patients on medical-surgical units, and can serve as an example for other hospitals during this pandemic.
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Affiliation(s)
- Bridgid Joseph
- Bridgid Joseph is program director of the Emergency Cardiovascular Care Center at Beth Israel Deaconess Medical Center in Boston, where Lynn G. Mackinson is a nurse specialist in the Department of Cardiovascular Medicine, Lauge Sokol-Hessner is an attending physician in the Department of Hospital Medicine and the medical director of patient safety, and Anica C. Law is an attending physician in the Department of Pulmonary, Critical Care, and Sleep Medicine. Susan DeSanto-Madeya is the Miriam Weyker Endowed Chair for Palliative Care and an associate professor at the University of Rhode Island College of Nursing, Providence. Contact author: Bridgid Joseph, . The authors and planners have disclosed no potential conflicts of interest, financial or otherwise
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26
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Sweeney DA, Malhotra A. Coronavirus disease 2019 respiratory failure: what is the best supportive care for patients who require ICU admission? Curr Opin Crit Care 2021; 27:462-467. [PMID: 34310373 PMCID: PMC8452253 DOI: 10.1097/mcc.0000000000000863] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Currently, there is no cure for SARS-CoV-2 infection, yet hospital mortality rates for COVID-19 have improved over the course of the pandemic and may be due in part to improved supportive care in the ICU. This review highlights the evidence for and against various ICU supportive therapies for the treatment of critically ill patients with COVID-19. RECENT FINDINGS Early in the pandemic, there was great interest in novel ICU supportive care, both for the benefit of the patient, and the safety of clinicians. With a few exceptions (e.g. prone ventilation of nonintubated patients), clinicians abandoned most of these approaches (e.g. early intubation, avoidance of high flow or noninvasive ventilation). Standard critical care measures, especially for the treatment of severe viral respiratory infection including acute respiratory distress syndrome (ARDS) were applied to patients with COVID-19 with apparent success. SUMMARY In general, the COVID-19 pandemic reaffirmed the benefits of standard supportive care for respiratory failure and in particular, recent advances in ARDS treatment. Prone ventilation of nonintubated patients, an approach that was adopted early in the pandemic, is associated with improvement in oxygenation, but its impact on clinical outcome remains unclear. Otherwise, prone mechanical ventilation and avoidance of excessive tidal volumes, conservative fluid management, antibiotic stewardship and early evaluation for extracorporeal membrane oxygenation (ECMO) -- basic tenants of severe respiratory infections and ARDS care -- remain at the core of management of patients with severe COVID-19.
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Affiliation(s)
- Daniel A Sweeney
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California, San Diego, La Jolla, California, USA
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27
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Mendes JJ, Paiva JA, Gonzalez F, Mergulhão P, Froes F, Roncon R, Gouveia J. Update of the recommendations of the Sociedade Portuguesa de Cuidados Intensivos and the Infection and Sepsis Group for the approach to COVID-19 in Intensive Care Medicine. Rev Bras Ter Intensiva 2021; 33:487-536. [PMID: 35081236 PMCID: PMC8889599 DOI: 10.5935/0103-507x.0103-507x-rbti-20210080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 07/20/2021] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION The Sociedade Portuguesa de Cuidados Intensivos and the Infection and Sepsis Group have previously issued health service and management recommendations for critically ill patients with COVID-19. Due to the evolution of knowledge, the panel of experts was again convened to review the current evidence and issue updated recommendations. METHODS A national panel of experts who declared that they had no conflicts of interest regarding the development of the recommendations was assembled. Operational questions were developed based on the PICO methodology, and a rapid systematic review was conducted by consulting different bibliographic sources. The panel determined the direction and strength of the recommendations using two Delphi rounds, conducted in accordance with the principles of the GRADE system. A strong recommendation received the wording "is recommended", and a weak recommendation was written as "is suggested." RESULTS A total of 48 recommendations and 30 suggestions were issued, covering the following topics: diagnosis of SARS-CoV-2 infection, coinfection and superinfection; criteria for admission, cure and suspension of isolation; organization of services; personal protective equipment; and respiratory support and other specific therapies (antivirals, immunomodulators and anticoagulation). CONCLUSION These recommendations, specifically oriented to the Portuguese reality but that may also apply to Portuguese-speaking African countries and East Timor, aim to support health professionals in the management of critically ill patients with COVID-19. They will be continuously reviewed to reflect the progress of our understanding and the treatment of this pathology.
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Affiliation(s)
- João João Mendes
- Sociedade Portuguesa de Cuidados Intensivos - Lisboa,
Portugal
- Department of Intensive Care Medicine, Hospital Prof. Doutor
Fernando da Fonseca EPE - Lisboa, Portugal
| | - José Artur Paiva
- College of Specialties of Intensive Care Medicine, Ordem dos
Médicos- Lisboa, Portugal
- Infection and Sepsis Group - Lisboa, Portugal
- Department of Intensive Care Medicine, Centro Hospitalar
Universitário de São João EPE, Faculdade de Medicina da Universidade do Porto -
Porto, Portugal
| | - Filipe Gonzalez
- Sociedade Portuguesa de Cuidados Intensivos - Lisboa,
Portugal
- Department of Intensive Care Medicine, Hospital Garcia de Orta EPE -
Lisboa, Portugal
| | - Paulo Mergulhão
- Sociedade Portuguesa de Cuidados Intensivos - Lisboa,
Portugal
- Infection and Sepsis Group - Lisboa, Portugal
- Polyvalent Intensive Care Unit, Hospital Lusíadas Porto - Porto,
Portugal
| | - Filipe Froes
- Medical-Surgical Intensive Care Unit, Hospital de Pulido Valente,
Centro Hospitalar Universitário de Lisboa Norte EPE - Lisboa, Portugal
| | - Roberto Roncon
- Department of Intensive Care Medicine, Centro Hospitalar
Universitário de São João EPE, Faculdade de Medicina da Universidade do Porto -
Porto, Portugal
| | - João Gouveia
- Sociedade Portuguesa de Cuidados Intensivos - Lisboa,
Portugal
- Department of Intensive Care Medicine, Centro Hospitalar
Universitário de Lisboa Norte EPE - Lisboa, Portugal
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Kaur R, Vines DL, Mirza S, Elshafei A, Jackson JA, Harnois LJ, Weiss T, Scott JB, Trump MW, Mogri I, Cerda F, Alolaiwat AA, Miller AR, Klein AM, Oetting TW, Morris L, Heckart S, Capouch L, He H, Li J. Early versus late awake prone positioning in non-intubated patients with COVID-19. Crit Care 2021; 25:340. [PMID: 34535158 PMCID: PMC8446738 DOI: 10.1186/s13054-021-03761-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 09/04/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Awake prone positioning (APP) is widely used in the management of patients with coronavirus disease (COVID-19). The primary objective of this study was to compare the outcome of COVID-19 patients who received early versus late APP. METHODS Post hoc analysis of data collected for a randomized controlled trial (ClinicalTrials.gov NCT04325906). Adult patients with acute hypoxemic respiratory failure secondary to COVID-19 who received APP for at least one hour were included. Early prone positioning was defined as APP initiated within 24 h of high-flow nasal cannula (HFNC) start. Primary outcomes were 28-day mortality and intubation rate. RESULTS We included 125 patients (79 male) with a mean age of 62 years. Of them, 92 (73.6%) received early APP and 33 (26.4%) received late APP. Median time from HFNC initiation to APP was 2.25 (0.8-12.82) vs 36.35 (30.2-75.23) hours in the early and late APP group (p < 0.0001), respectively. Average APP duration was 5.07 (2.0-9.05) and 3.0 (1.09-5.64) hours per day in early and late APP group (p < 0.0001), respectively. The early APP group had lower mortality compared to the late APP group (26% vs 45%, p = 0.039), but no difference was found in intubation rate. Advanced age (OR 1.12 [95% CI 1.0-1.95], p = 0.001), intubation (OR 10.65 [95% CI 2.77-40.91], p = 0.001), longer time to initiate APP (OR 1.02 [95% CI 1.0-1.04], p = 0.047) and hydrocortisone use (OR 6.2 [95% CI 1.23-31.1], p = 0.027) were associated with increased mortality. CONCLUSIONS Early initiation (< 24 h of HFNC use) of APP in acute hypoxemic respiratory failure secondary to COVID-19 improves 28-day survival. Trial registration ClinicalTrials.gov NCT04325906.
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Affiliation(s)
- Ramandeep Kaur
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, 600 S Paulina St, Suite 765, Chicago, IL, USA
| | - David L Vines
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, 600 S Paulina St, Suite 765, Chicago, IL, USA
| | - Sara Mirza
- Division of Pulmonary, Critical Care, and Sleep Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Ahmad Elshafei
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, 600 S Paulina St, Suite 765, Chicago, IL, USA
| | - Julie A Jackson
- Department of Respiratory Care, Unity Point Health-Des Moines, Des Moines, IA, USA
| | - Lauren J Harnois
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, 600 S Paulina St, Suite 765, Chicago, IL, USA
| | - Tyler Weiss
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, 600 S Paulina St, Suite 765, Chicago, IL, USA
| | - J Brady Scott
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, 600 S Paulina St, Suite 765, Chicago, IL, USA
| | - Matthew W Trump
- The Iowa Clinic P.C. and Unity Point Health-Des Moines, Des Moines, IA, USA
| | - Idrees Mogri
- Pulmonary and Critical Care Medicine Division, Texas A&M School of Medicine, Baylor University Medical Center, Dallas, TX, USA
| | - Flor Cerda
- Nursing, MICU, Rush University Medical Center, Chicago, IL, USA
| | - Amnah A Alolaiwat
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, 600 S Paulina St, Suite 765, Chicago, IL, USA
| | - Amanda R Miller
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, 600 S Paulina St, Suite 765, Chicago, IL, USA
| | - Andrew M Klein
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, 600 S Paulina St, Suite 765, Chicago, IL, USA
| | - Trevor W Oetting
- Department of Respiratory Care, Unity Point Health-Des Moines, Des Moines, IA, USA
| | - Lindsey Morris
- Pulmonary and Critical Care Medicine Division, Texas A&M School of Medicine, Baylor University Medical Center, Dallas, TX, USA
| | - Scott Heckart
- Department of Respiratory Care, Unity Point Health-Des Moines, Des Moines, IA, USA
| | - Lindsay Capouch
- Department of Respiratory Care, Unity Point Health-Des Moines, Des Moines, IA, USA
| | - Hangyong He
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jie Li
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, 600 S Paulina St, Suite 765, Chicago, IL, USA.
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Akoumianaki E, Ischaki E, Karagiannis K, Sigala I, Zakyn-thinos S. The Role of Noninvasive Respiratory Management in Patients with Severe COVID-19 Pneumonia. J Pers Med 2021; 11:jpm11090884. [PMID: 34575661 PMCID: PMC8469068 DOI: 10.3390/jpm11090884] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 08/31/2021] [Indexed: 01/08/2023] Open
Abstract
Acute hypoxemic respiratory failure is the principal cause of hospitalization, invasive mechanical ventilation and death in severe COVID-19 infection. Nearly half of intubated patients with COVID-19 eventually die. High-Flow Nasal Oxygen (HFNO) and Noninvasive Ventilation (NIV) constitute valuable tools to avert endotracheal intubation in patients with severe COVID-19 pneumonia who do not respond to conventional oxygen treatment. Sparing Intensive Care Unit beds and reducing intubation-related complications may save lives in the pandemic era. The main drawback of HFNO and/or NIV is intubation delay. Cautious selection of patients with severe hypoxemia due to COVID-19 disease, close monitoring and appropriate employment and titration of HFNO and/or NIV can increase the rate of success and eliminate the risk of intubation delay. At the same time, all precautions to protect the healthcare personnel from viral transmission should be taken. In this review, we summarize the evidence supporting the application of HFNO and NIV in severe COVID-19 hypoxemic respiratory failure, analyse the risks associated with their use and provide a path for their proper implementation.
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Affiliation(s)
- Evangelia Akoumianaki
- Department of Intensive Care Unit, University Hospital of Heraklion, 71500 Crete, Greece
- Correspondence:
| | - Eleni Ischaki
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, 10676 Athens, Greece; (E.I.); (I.S.); (S.Z.-t.)
| | | | - Ioanna Sigala
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, 10676 Athens, Greece; (E.I.); (I.S.); (S.Z.-t.)
| | - Spyros Zakyn-thinos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, 10676 Athens, Greece; (E.I.); (I.S.); (S.Z.-t.)
- School of Medicine, National and Kapodistrian University of Athens, 10676 Athens, Greece
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Awake prone positioning in COVID-19: is tummy time ready for prime time? THE LANCET RESPIRATORY MEDICINE 2021; 9:1347-1349. [PMID: 34425072 PMCID: PMC8378831 DOI: 10.1016/s2213-2600(21)00368-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 08/03/2021] [Indexed: 01/04/2023]
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Affiliation(s)
- Maureen A Seckel
- Maureen A. Seckel is a critical care clinical nurse specialist and sepsis coordinator, ChristianaCare, Newark, Delaware
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Dickel S, Grimm C, Popp M, Struwe C, Sachkova A, Golinski M, Seeber C, Fichtner F, Heise D, Kranke P, Meissner W, Laudi S, Voigt-Radloff S, Meerpohl J, Moerer O. A Nationwide Cross-Sectional Online Survey on the Treatment of COVID-19-ARDS: High Variance in Standard of Care in German ICUs. J Clin Med 2021; 10:3363. [PMID: 34362146 PMCID: PMC8347152 DOI: 10.3390/jcm10153363] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/20/2021] [Accepted: 07/26/2021] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Coronavirus disease (COVID-19) has recently dominated scientific literature. Incomplete understanding and a lack of data concerning the pathophysiology, epidemiology, and optimal treatment of the disease has resulted in conflicting recommendations. Adherence to existing guidelines and actual treatment strategies have thus far not been studied systematically. We hypothesized that capturing the variance in care would lead to the discovery of aspects that need further research and-in case of proven benefits of interventions not being performed-better communication to care providers. METHODS This article is based on a quantitative and qualitative cross-sectional mixed-methods online survey among intensive-care physicians in Germany during the COVID-19 pandemic by the CEOsys (COVID-19 Evidence Ecosystem) network, endorsed by the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) conducted from December 3 to 31 December 2020. RESULTS We identified several areas of care with an especially high variance in treatment among hospitals in Germany. Crucially, 51.5% of the participating ICUs (n = 205) reported using intubation as a last resort for respiratory failure in COVID-19 patients, while 21.8% used intubation early after admission. Furthermore, 11.5% considered extracorporeal membrane oxygenation (ECMO) in awake patients. Finally, 72.3% of respondents used the ARDS-network-table to titrate positive end-expiratory-pressure (PEEP) levels, with 36.9% choosing the low-PEEP table and 41.8% the high-PEEP table. CONCLUSIONS We found that significant differences exist between reported treatment strategies and that adherence to published guidelines is variable. We describe necessary steps for future research based on our results highlighting significant clinical variability in care.
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Affiliation(s)
- Steffen Dickel
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Göttingen, 37085 Göttingen, Germany; (S.D.); (C.G.); (C.S.); (A.S.); (M.G.); (D.H.)
| | - Clemens Grimm
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Göttingen, 37085 Göttingen, Germany; (S.D.); (C.G.); (C.S.); (A.S.); (M.G.); (D.H.)
| | - Maria Popp
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, 97080 Wuerzburg, Germany; (M.P.); (P.K.)
| | - Claudia Struwe
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Göttingen, 37085 Göttingen, Germany; (S.D.); (C.G.); (C.S.); (A.S.); (M.G.); (D.H.)
| | - Alexandra Sachkova
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Göttingen, 37085 Göttingen, Germany; (S.D.); (C.G.); (C.S.); (A.S.); (M.G.); (D.H.)
| | - Martin Golinski
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Göttingen, 37085 Göttingen, Germany; (S.D.); (C.G.); (C.S.); (A.S.); (M.G.); (D.H.)
| | - Christian Seeber
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Leipzig, 04103 Leipzig, Germany; (C.S.); (F.F.); (S.L.)
| | - Falk Fichtner
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Leipzig, 04103 Leipzig, Germany; (C.S.); (F.F.); (S.L.)
| | - Daniel Heise
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Göttingen, 37085 Göttingen, Germany; (S.D.); (C.G.); (C.S.); (A.S.); (M.G.); (D.H.)
| | - Peter Kranke
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, 97080 Wuerzburg, Germany; (M.P.); (P.K.)
| | - Winfried Meissner
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Jena, 07743 Jena, Germany;
| | - Sven Laudi
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Leipzig, 04103 Leipzig, Germany; (C.S.); (F.F.); (S.L.)
| | - Sebastian Voigt-Radloff
- Institute for Evidence in Medicine, Faculty of Medicine and Medical Center, University of Freiburg, 79106 Freiburg, Germany; (S.V.-R.); (J.M.)
| | - Joerg Meerpohl
- Institute for Evidence in Medicine, Faculty of Medicine and Medical Center, University of Freiburg, 79106 Freiburg, Germany; (S.V.-R.); (J.M.)
- Cochrane Germany, Cochrane Germany Foundation, 79110 Freiburg, Germany
| | - Onnen Moerer
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Göttingen, 37085 Göttingen, Germany; (S.D.); (C.G.); (C.S.); (A.S.); (M.G.); (D.H.)
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Wang YC, Lu MC, Yang SF, Bien MY, Chen YF, Li YT. Respiratory care for the critical patients with 2019 novel coronavirus. Respir Med 2021; 186:106516. [PMID: 34218168 PMCID: PMC8215880 DOI: 10.1016/j.rmed.2021.106516] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 06/17/2021] [Accepted: 06/18/2021] [Indexed: 01/25/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is transmitted through respiratory droplets, aerosols and close contact. Cross infections occur because viruses spread rapidly among humans. Nineteen percent (19%) of the infected patients developed severe pneumonia and acute respiratory distress syndrome (ARDS). Hypoxemia usually occurs and patients may require oxygen therapy or mechanical ventilation (MV) support. In this article, recently published clinical experience and observational studies were reviewed. Corresponding respiratory therapy regarding different stages of infection is proposed. Infection control principles and respiratory strategies including oxygen therapy, non-invasive respiratory support (NIRS), intubation evaluation, equipment preparation, ventilator settings, special maneuvers comprise of the prone position (PP), recruitment maneuver (RM), extracorporeal membrane oxygenation (ECMO), weaning and extubation are summarized. Respiratory equipment and device disinfection recommendations are worked up. We expect this review article could be used as a reference by healthcare workers in patient care while minimizing the risk of environmental contamination.
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Affiliation(s)
- Yao-Chen Wang
- Division of Pulmonary Medicine, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, 402306, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, 402306, Taiwan.
| | - Min-Chi Lu
- Division of Infectious Diseases, Department of Internal Medicine, China Medical University Hospital, Taichung, 404332, Taiwan; Department of Microbiology and Immunology, School of Medicine, China Medical University, Taichung, 406040, Taiwan.
| | - Shun-Fa Yang
- Institute of Medicine, Chung San Medical University, Taichung, 402306, Taiwan; Department of Medical Research, Chung Shan Medical University Hospital, Taichung, 402306, Taiwan.
| | - Mauo-Ying Bien
- Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei, 116081, Taiwan; School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei, 110301, Taiwan.
| | - Yi-Fang Chen
- Division of Respiratory Therapy, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, 402306, Taiwan.
| | - Yia-Ting Li
- Institute of Medicine, Chung San Medical University, Taichung, 402306, Taiwan; Division of Respiratory Therapy, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, 402306, Taiwan.
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Vera M, Kattan E, Born P, Rivas E, Amthauer M, Nesvadba A, Lara B, Rao I, Espíndola E, Rojas L, Hernández G, Bugedo G, Castro R. Intubation timing as determinant of outcome in patients with acute respiratory distress syndrome by SARS-CoV-2 infection. J Crit Care 2021; 65:164-169. [PMID: 34166852 PMCID: PMC8216652 DOI: 10.1016/j.jcrc.2021.06.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/21/2021] [Accepted: 06/13/2021] [Indexed: 01/16/2023]
Abstract
Purpose To determine whether time-to-intubation was associated with higher ICU mortality in patients with COVID-19 on mechanical ventilation due to respiratory insufficiency. Materials and methods We conducted an observational, prospective, single-center study of patients with confirmed SARS-CoV-2 infection hospitalized with moderate to severe ARDS, connected to mechanical ventilation in the ICU between March 17 and July 31, 2020. We examined their general and clinical characteristics. Time-to-intubation was the time from hospital admission to endotracheal intubation. Results We included 183 consecutive patients; 28% were female, and median age was 62 years old. Eighty-eight patients (48%) were intubated before 48 h (early) and ninety-five (52%) after 48 h (late). Patients intubated early had similar admission PaO2/FiO2 ratio (123 vs 99; p = 0.179) but were younger (59 vs 64; p = 0.013) and had higher body mass index (30 vs 28; p = 0.006) compared to patients intubated late. Mortality was higher in patients intubated late (18% versus 43%), with admission PaO2/FiO2 ratio < 100 mmHg (OR 5.2; p = 0.011), of older age (OR 1.1; p = 0.001), and with previous use of ACE inhibitors (OR 4.8; p = 0.026). Conclusions In COVID-19 patients, late intubation, Pafi <100, older age, and previous ACE inhibitors use were associated with increased ICU mortality.
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Affiliation(s)
- Magdalena Vera
- Departamento de Medicina Intensiva, Pontificia Universidad Católica de Chile, Chile
| | - Eduardo Kattan
- Departamento de Medicina Intensiva, Pontificia Universidad Católica de Chile, Chile
| | - Pablo Born
- Departamento de Medicina Intensiva, Pontificia Universidad Católica de Chile, Chile
| | - Elizabeth Rivas
- Departamento de Medicina Intensiva, Pontificia Universidad Católica de Chile, Chile
| | - Macarena Amthauer
- Departamento de Medicina Intensiva, Pontificia Universidad Católica de Chile, Chile
| | - Annael Nesvadba
- Escuela de Medicina, Pontificia Universidad Católica de Chile, Chile
| | - Barbara Lara
- Sección Medicina de Urgencia, Departamento de Medicina Interna, Pontificia Universidad Católica de Chile, Chile
| | - Isabel Rao
- Sección Medicina de Urgencia, Departamento de Medicina Interna, Pontificia Universidad Católica de Chile, Chile
| | - Eduardo Espíndola
- Departamento de Medicina Intensiva, Pontificia Universidad Católica de Chile, Chile
| | - Luis Rojas
- Departamento de Medicina Interna, Pontificia Universidad Católica de Chile, Chile
| | - Glenn Hernández
- Departamento de Medicina Intensiva, Pontificia Universidad Católica de Chile, Chile
| | - Guillermo Bugedo
- Departamento de Medicina Intensiva, Pontificia Universidad Católica de Chile, Chile
| | - Ricardo Castro
- Departamento de Medicina Intensiva, Pontificia Universidad Católica de Chile, Chile.
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Loureiro-Amigo J, Suárez-Carantoña C, Oriol-Bermúdez I, Sánchez-Díaz C, Coloma-Conde A, Manzano-Espinosa L, Rubio-Rivas M, Otero-Perpiñá B, Jenaro MMFM, Coduras-Erdozain A, Garcia-Klepzig JL, Vargas-Parra D, Pesqueira-Fontán PM, Fiteni-Mera I, García-García GM, Jiménez-Torres J, Rodríguez-Cortés P, Costo-Muriel C, Arnalich-Fernández F, Artero A, Carrasco-Sánchez FJ, Escobar-Sevilla J, Alcalá-Pedrajas JN, Gómez-Huelgas R, Ramos-Rincón JM. Prone Position in COVID-19 Patients With Severe Acute Respiratory Distress Syndrome Receiving Conventional Oxygen Therapy: A Retrospective Study. Arch Bronconeumol 2021; 58:277-280. [PMID: 34121796 PMCID: PMC8180347 DOI: 10.1016/j.arbres.2021.05.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/17/2021] [Accepted: 05/19/2021] [Indexed: 12/15/2022]
Affiliation(s)
- Jose Loureiro-Amigo
- Infectious Diseases Unit - Internal Medicine Department, Moisès Broggi Hospital, Sant Joan Despí, Barcelona, Spain
| | - Cecilia Suárez-Carantoña
- Internal Medicine Department, Ramón y Cajal Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Isabel Oriol-Bermúdez
- Infectious Diseases Unit - Internal Medicine Department, Moisès Broggi Hospital, Sant Joan Despí, Barcelona, Spain
| | - Cristina Sánchez-Díaz
- Internal Medicine Department, Ramón y Cajal Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Ana Coloma-Conde
- Infectious Diseases Unit - Internal Medicine Department, Moisès Broggi Hospital, Sant Joan Despí, Barcelona, Spain
| | - Luis Manzano-Espinosa
- Internal Medicine Department, Ramón y Cajal Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain.,Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Manuel Rubio-Rivas
- Department of Internal Medicine, Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, Barcelona, Spain
| | | | | | | | | | - Derly Vargas-Parra
- Internal Medicine Department, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y Leon (SACYL), Valladolid, Spain
| | - Paula M Pesqueira-Fontán
- Internal Medicine Department, Complexo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | | | | | - José Jiménez-Torres
- Unidad de Gestión Clínica Medicina Interna, Lipids and Atherosclerosis Unit, Maimonides Institute for Biomedical Research in Córdoba, Reina Sofia University Hospital, University of Córdoba, Córdoba, Spain
| | | | - Clara Costo-Muriel
- Internal Medicine Department, Regional University Hospital of Málaga, Málaga, Spain
| | | | - Arturo Artero
- Internal Medicine Department, Dr. Peset University Hospital, Valencia, Spain
| | | | | | | | - Ricardo Gómez-Huelgas
- Internal Medicine Department, Regional University Hospital of Málaga, Biomedical Research Institute of Málaga (IBIMA), University of Málaga (UMA), Málaga, Spain
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Ogawa K, Asano K, Ikeda J, Fujii T. Non-invasive oxygenation strategies for respiratory failure with COVID-19: A concise narrative review of literature in pre and mid-COVID-19 era. Anaesth Crit Care Pain Med 2021; 40:100897. [PMID: 34087432 PMCID: PMC8168344 DOI: 10.1016/j.accpm.2021.100897] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/17/2021] [Accepted: 05/26/2021] [Indexed: 01/16/2023]
Abstract
The coronavirus disease 2019 (COVID-19) has spread globally and can cause a shortage of medical resources, in particular, mechanical ventilators. High-flow nasal cannula oxygen therapy (HFNC) and non-invasive positive pressure ventilation (NPPV) are frequently used for acute respiratory failure patients as alternatives to invasive mechanical ventilation. They are drawing attention because of a potential role to save mechanical ventilators. However, their effectiveness and risk of viral spread are unclear. The latest network meta-analysis of pre-COVID-19 trials reported that treatment with non-invasive oxygenation strategies was associated with improved survival when compared with conventional oxygen therapy. During the COVID-19 pandemic, a lot of clinical research on COVID-19 related acute respiratory failure has been reported. Several observational studies and small trials have suggested HFNC or NPPV as an alternative of standard oxygen therapy to manage COVID-19 related acute respiratory failure, provided that appropriate infection prevention is applied by health care workers to avoid risks of the virus transmission. Awake proning is an emerging strategy to optimise the management of patients with COVID-19 acute respiratory failure. However, the benefits of awake proning have yet to be assessed in properly designed clinical research. Although HFNC and NPPV are probably effective for acute respiratory failure, the safety data are mostly based on observational and experimental reports. As such, they should be implemented carefully if adequate personal protective equipment and negative pressure rooms are available.
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Affiliation(s)
- Kenta Ogawa
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan
| | - Kengo Asano
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan
| | - Junpei Ikeda
- Department of Clinical Engineering Technology, Jikei University Hospital, Tokyo, Japan
| | - Tomoko Fujii
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan.
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Kosar CM, White EM, Feifer RA, Blackman C, Gravenstein S, Panagiotou OA, McConeghy K, Mor V. COVID-19 Mortality Rates Among Nursing Home Residents Declined From March To November 2020. Health Aff (Millwood) 2021; 40:655-663. [PMID: 33705204 DOI: 10.1377/hlthaff.2020.02191] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Improved therapeutics and supportive care in hospitals have helped reduce mortality from COVID-19. However, there is limited evidence as to whether nursing home residents, who account for a disproportionate share of COVID-19 deaths and are often managed conservatively in the nursing home instead of being admitted to the hospital, have experienced similar mortality reductions. In this study we examined changes in thirty-day mortality rates between March and November 2020 among 12,271 nursing home residents with COVID-19. We found that adjusted mortality rates significantly declined from a high of 20.9 percent in early April to 11.2 percent in early November. Mortality risk declined for residents with both symptomatic and asymptomatic infections and for residents with both high and low clinical complexity. The mechanisms driving these trends are not entirely understood, but they may include improved clinical management within nursing homes, improved personal protective equipment supply and use, and genetic changes in the virus.
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Affiliation(s)
- Cyrus M Kosar
- Cyrus M. Kosar is a doctoral candidate in the Department of Health Services, Policy, and Practice, Brown University School of Public Health, in Providence, Rhode Island
| | - Elizabeth M White
- Elizabeth M. White is an investigator in the Center for Gerontology and Healthcare Research, Brown University School of Public Health
| | - Richard A Feifer
- Richard A. Feifer is the chief medical officer of Genesis Physician Services at Genesis HealthCare, in Kennett Square, Pennsylvania
| | - Carolyn Blackman
- Carolyn Blackman is the Northeast Region vice president for medical affairs of Genesis Physician Services at Genesis HealthCare
| | - Stefan Gravenstein
- Stefan Gravenstein is the director of the Division of Geriatrics and Palliative Medicine, Department of Medicine, Warren Alpert Medical School, Brown University, in Providence
| | - Orestis A Panagiotou
- Orestis A. Panagiotou is an assistant professor in the Department of Health Services, Policy, and Practice and the Center for Gerontology and Healthcare Research, Brown University School of Public Health
| | - Kevin McConeghy
- Kevin McConeghy is a doctoral student in the Department of Health Services, Policy, and Practice, Brown University School of Public Health
| | - Vincent Mor
- Vincent Mor is the Florence Pirce Grant University Professor in the Department of Health Services, Policy, and Practice and the Center for Gerontology and Healthcare Research, Brown University School of Public Health, and a research health scientist at the Providence Veterans Affairs Medical Center
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Surviving Sepsis Campaign Guidelines on the Management of Adults With Coronavirus Disease 2019 (COVID-19) in the ICU: First Update. Crit Care Med 2021; 49:e219-e234. [PMID: 33555780 DOI: 10.1097/ccm.0000000000004899] [Citation(s) in RCA: 239] [Impact Index Per Article: 79.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The coronavirus disease 2019 pandemic continues to affect millions worldwide. Given the rapidly growing evidence base, we implemented a living guideline model to provide guidance on the management of patients with severe or critical coronavirus disease 2019 in the ICU. METHODS The Surviving Sepsis Campaign Coronavirus Disease 2019 panel has expanded to include 43 experts from 14 countries; all panel members completed an electronic conflict-of-interest disclosure form. In this update, the panel addressed nine questions relevant to managing severe or critical coronavirus disease 2019 in the ICU. We used the World Health Organization's definition of severe and critical coronavirus disease 2019. The systematic reviews team searched the literature for relevant evidence, aiming to identify systematic reviews and clinical trials. When appropriate, we performed a random-effects meta-analysis to summarize treatment effects. We assessed the quality of the evidence using the Grading of Recommendations, Assessment, Development, and Evaluation approach, then used the evidence-to-decision framework to generate recommendations based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. RESULTS The Surviving Sepsis Campaign Coronavirus Diease 2019 panel issued nine statements (three new and six updated) related to ICU patients with severe or critical coronavirus disease 2019. For severe or critical coronavirus disease 2019, the panel strongly recommends using systemic corticosteroids and venous thromboprophylaxis but strongly recommends against using hydroxychloroquine. In addition, the panel suggests using dexamethasone (compared with other corticosteroids) and suggests against using convalescent plasma and therapeutic anticoagulation outside clinical trials. The Surviving Sepsis Campaign Coronavirus Diease 2019 panel suggests using remdesivir in nonventilated patients with severe coronavirus disease 2019 and suggests against starting remdesivir in patients with critical coronavirus disease 2019 outside clinical trials. Because of insufficient evidence, the panel did not issue a recommendation on the use of awake prone positioning. CONCLUSION The Surviving Sepsis Campaign Coronavirus Diease 2019 panel issued several recommendations to guide healthcare professionals caring for adults with critical or severe coronavirus disease 2019 in the ICU. Based on a living guideline model the recommendations will be updated as new evidence becomes available.
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Verma CV, Arora RD, Mistry HM, Kubal SV, Kolwankar NS, Patil PC, Dalvi AA, Vichare SA, Natesan A, Mangaonkar AN, Kanakia DD, Jere GS, Bansode KY, Patil MR, Sheth RD, Dudhavade SD, Mhatre SD, Patel SK, Mohite AG, Bhavsar AN, Alfonso JE, Syed MNA, Savla NP, Rajgond RN, Bute RA, Mane SM, Jaiswal SR, Parab VA, Kasbe AM, Joshi MA, Bharmal RN. Changes in Mode of Oxygen Delivery and Physiological Parameters with Physiotherapy in COVID-19 Patients: A Retrospective Study. Indian J Crit Care Med 2021; 25:317-321. [PMID: 33790514 PMCID: PMC7991778 DOI: 10.5005/jp-journals-10071-23763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background: Coronavirus disease (COVID-19) is an infectious disease caused by SARS-CoV-2, clinically presenting with common symptoms of fever, dry cough, and breathlessness within 14 days of exposure. Its severity ranges from mild to severe, latter manifesting into severe acute respiratory syndrome. As a part of multidisciplinary team, physiotherapy along with medical management was administered to patients with COVID-19 in an acute care setup. This retrospective study aims to explore various patient characteristics and will aid in identifying the impairments associated with the disease, giving a direction to the physiotherapy community in planning future management strategy to improve quality of life. Patients and methods: The present study is a unicentric study wherein prospective analysis of retrospective data of patients referred for physiotherapy from May 13 to July 31, 2020, was performed. (i) Characteristics of patients, (ii) associated comorbidities, (iii) hospital course since the time of admission to discharge, (iv) mode of oxygen delivery, (v) pre- and post-physiotherapy treatment values of oxygen saturation and heart rate, and (vi) physiotherapy treatment were recorded. The archived data were analyzed using the commercially available SPSS software version 24. Wilcoxon's matched pair test was used to compare pre- and post-treatment oxygen saturation and heart rate, and McNemar's test was used to compare mode of oxygen delivery and pre- and post-physiotherapy treatment. Results: Descriptive analysis of data showed a better outcome in terms of grade of dyspnea and rate of discharge on day 14 of physiotherapy treatment. Hence, a comparative analysis of day 1 and day 14 was performed for mode of oxygen delivery, oxygen saturation, and heart rate. A statistically significant improvement was observed in the heart rate (p = 0.001) and oxygen delivery (p = 0.000). However, no significant difference in the level of oxygen saturation was found (p = 0.6433). Conclusion: Physiotherapy treatment in conjunction with medical treatment can be effectively administered in patients with COVID-19 in acute care setup taking into consideration the health status and the hemodynamic stability of the patients. It emphasizes the role of physiotherapy in the alleviation of symptoms, facilitating early weaning and recovery enabling early discharge from the hospital. How to cite this article: Verma CV, Arora RD, Mistry HM, Kubal SV, Kolwankar NS, Patil PC, et al. Changes in Mode of Oxygen Delivery and Physiological Parameters with Physiotherapy in COVID-19 Patients: A Retrospective Study. Indian J Crit Care Med 2021;25(3):317-321.
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Affiliation(s)
- Chhaya V Verma
- Physiotherapy School and Centre, Topiwala National Medical College & BYL Nair Ch Hospital, Mumbai, Maharashtra, India
| | - Rachna D Arora
- Physiotherapy School and Centre, Topiwala National Medical College & BYL Nair Ch Hospital, Mumbai, Maharashtra, India
| | - Hetal M Mistry
- Physiotherapy School and Centre, Topiwala National Medical College & BYL Nair Ch Hospital, Mumbai, Maharashtra, India
| | - Swati V Kubal
- Physiotherapy School and Centre, Topiwala National Medical College & BYL Nair Ch Hospital, Mumbai, Maharashtra, India
| | - Nandini S Kolwankar
- Physiotherapy School and Centre, Topiwala National Medical College & BYL Nair Ch Hospital, Mumbai, Maharashtra, India
| | - Pranali C Patil
- Physiotherapy School and Centre, Topiwala National Medical College & BYL Nair Ch Hospital, Mumbai, Maharashtra, India
| | - Anushka A Dalvi
- Physiotherapy School and Centre, Topiwala National Medical College & BYL Nair Ch Hospital, Mumbai, Maharashtra, India
| | - Sonal A Vichare
- Physiotherapy School and Centre, Topiwala National Medical College & BYL Nair Ch Hospital, Mumbai, Maharashtra, India
| | - Akhila Natesan
- Physiotherapy School and Centre, Topiwala National Medical College & BYL Nair Ch Hospital, Mumbai, Maharashtra, India
| | - Anagha N Mangaonkar
- Physiotherapy School and Centre, Topiwala National Medical College & BYL Nair Ch Hospital, Mumbai, Maharashtra, India
| | - Dolly D Kanakia
- Physiotherapy School and Centre, Topiwala National Medical College & BYL Nair Ch Hospital, Mumbai, Maharashtra, India
| | - Gayatri S Jere
- Physiotherapy School and Centre, Topiwala National Medical College & BYL Nair Ch Hospital, Mumbai, Maharashtra, India
| | - Karan Y Bansode
- Physiotherapy School and Centre, Topiwala National Medical College & BYL Nair Ch Hospital, Mumbai, Maharashtra, India
| | - Madhura R Patil
- Physiotherapy School and Centre, Topiwala National Medical College & BYL Nair Ch Hospital, Mumbai, Maharashtra, India
| | - Rajvi D Sheth
- Physiotherapy School and Centre, Topiwala National Medical College & BYL Nair Ch Hospital, Mumbai, Maharashtra, India
| | - Sandhya D Dudhavade
- Physiotherapy School and Centre, Topiwala National Medical College & BYL Nair Ch Hospital, Mumbai, Maharashtra, India
| | - Sayali D Mhatre
- Physiotherapy School and Centre, Topiwala National Medical College & BYL Nair Ch Hospital, Mumbai, Maharashtra, India
| | - Suresh K Patel
- Physiotherapy School and Centre, Topiwala National Medical College & BYL Nair Ch Hospital, Mumbai, Maharashtra, India
| | - Akanksha G Mohite
- Physiotherapy School and Centre, Topiwala National Medical College & BYL Nair Ch Hospital, Mumbai, Maharashtra, India
| | - Ankita N Bhavsar
- Physiotherapy School and Centre, Topiwala National Medical College & BYL Nair Ch Hospital, Mumbai, Maharashtra, India
| | - Jessica E Alfonso
- Physiotherapy School and Centre, Topiwala National Medical College & BYL Nair Ch Hospital, Mumbai, Maharashtra, India
| | - Maryam NA Syed
- Physiotherapy School and Centre, Topiwala National Medical College & BYL Nair Ch Hospital, Mumbai, Maharashtra, India
| | - Nidhi P Savla
- Physiotherapy School and Centre, Topiwala National Medical College & BYL Nair Ch Hospital, Mumbai, Maharashtra, India
| | - Riya N Rajgond
- Physiotherapy School and Centre, Topiwala National Medical College & BYL Nair Ch Hospital, Mumbai, Maharashtra, India
| | - Rutuja A Bute
- Physiotherapy School and Centre, Topiwala National Medical College & BYL Nair Ch Hospital, Mumbai, Maharashtra, India
| | - Samiksha M Mane
- Physiotherapy School and Centre, Topiwala National Medical College & BYL Nair Ch Hospital, Mumbai, Maharashtra, India
| | - Shubham R Jaiswal
- Physiotherapy School and Centre, Topiwala National Medical College & BYL Nair Ch Hospital, Mumbai, Maharashtra, India
| | - Vibhawari A Parab
- Physiotherapy School and Centre, Topiwala National Medical College & BYL Nair Ch Hospital, Mumbai, Maharashtra, India
| | - Abhiram M Kasbe
- Department of Community Medicine, Topiwala National Medical College & BYL Nair Ch Hospital, Mumbai, Maharashtra, India
| | - Mohan A Joshi
- Department of General Surgery, Lokmanya Tilak Municipal Medical College and Lokmanya Tilak Municipal General Hospital, Mumbai, Maharashtra, India
| | - Ramesh N Bharmal
- Topiwala National Medical College & BYL Nair Ch Hospital, Mumbai, Maharashtra, India
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Pecho-Silva S, Navarro-Solsol AC, Panduro-Correa V, Rabaan AA, Bonilla-Aldana DK, Rodríguez-Morales AJ, Arteaga-Livias K. Non-recommended medical interventions and their possible harm in patients with COVID-19. Ther Adv Infect Dis 2021; 8:20499361211034070. [PMID: 35154700 PMCID: PMC8832330 DOI: 10.1177/20499361211034070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Samuel Pecho-Silva
- Facultad de Ciencias de la Salud, Universidad Científica
del Sur, Lima, Peru
- Pneumology Service, Hospital Nacional Edgardo Rebagliati
Martins, Lima, Peru
- Latin American Network of COVID-19 Research, Pereira,
Colombia
| | | | - Vicky Panduro-Correa
- Faculty of Medicine, Universidad Nacional Hermilio
Valdizán, Huánuco, Perú
- Hospital Regional Hermilio Valdizán Medrano, Huánuco,
Perú
| | - Ali A. Rabaan
- Molecular Diagnostic Laboratory, Johns Hopkins Aramco
Healthcare, Dhahran, Saudi Arabia
- Department of Public Health and Nutrition, The University
of Haripur, Haripur, Pakistan
| | - D. Katterine Bonilla-Aldana
- Latin American Network of COVID-19 Research, Pereira,
Colombia
- Semillero de Investigación en Zoonosis (SIZOO), Grupo de
Investigación GISCA, Fundacion Universitaria Autónoma de las Americas, Pereira,
Risaralda, Colombia
| | | | - Kovy Arteaga-Livias
- Facultad de Ciencias de la Salud, Universidad Científica
del Sur, Lima, Peru
- Latin American Network of COVID-19 Research, Pereira,
Colombia
- Faculty of Medicine, Universidad Nacional Hermilio
Valdizán, Huánuco, Perú
- Hospital II Huánuco, EsSalud. Huánuco, Perú
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Emergency Department Management of Severe Hypoxemic Respiratory Failure in Adults With COVID-19. J Emerg Med 2020; 60:729-742. [PMID: 33526308 PMCID: PMC7836534 DOI: 10.1016/j.jemermed.2020.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 11/14/2020] [Accepted: 12/13/2020] [Indexed: 01/19/2023]
Abstract
Background While emergency physicians are familiar with the management of hypoxemic respiratory failure, management of mechanical ventilation and advanced therapies for oxygenation in the emergency department have become essential during the coronavirus disease 2019 (COVID-19) pandemic. Objective We review the current evidence on hypoxemia in COVID-19 and place it in the context of known evidence-based management of hypoxemic respiratory failure in the emergency department. Discussion COVID-19 causes mortality primarily through the development of acute respiratory distress syndrome (ARDS), with hypoxemia arising from shunt, a mismatch of ventilation and perfusion. Management of patients developing ARDS should focus on mitigating derecruitment and avoiding volutrauma or barotrauma. Conclusions High flow nasal cannula and noninvasive positive pressure ventilation have a more limited role in COVID-19 because of the risk of aerosolization and minimal benefit in severe cases, but can be considered. Stable patients who can tolerate repositioning should be placed in a prone position while awake. Once intubated, patients should be managed with ventilation strategies appropriate for ARDS, including targeting lung-protective volumes and low pressures. Increasing positive end-expiratory pressure can be beneficial. Inhaled pulmonary vasodilators do not decrease mortality but may be given to improve refractory hypoxemia. Prone positioning of intubated patients is associated with a mortality reduction in ARDS and can be considered for patients with persistent hypoxemia. Neuromuscular blockade should also be administered in patients who remain dyssynchronous with the ventilator despite adequate sedation. Finally, patients with refractory severe hypoxemic respiratory failure in COVID-19 should be considered for venovenous extracorporeal membrane oxygenation.
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