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Westhoff M, Neumann P, Geiseler J, Bickenbach J, Arzt M, Bachmann M, Braune S, Delis S, Dellweg D, Dreher M, Dubb R, Fuchs H, Hämäläinen N, Heppner H, Kluge S, Kochanek M, Lepper PM, Meyer FJ, Neumann B, Putensen C, Schimandl D, Schönhofer B, Schreiter D, Walterspacher S, Windisch W. [Non-invasive Mechanical Ventilation in Acute Respiratory Failure. Clinical Practice Guidelines - on behalf of the German Society of Pneumology and Ventilatory Medicine]. Pneumologie 2024; 78:453-514. [PMID: 37832578 DOI: 10.1055/a-2148-3323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
The guideline update outlines the advantages as well as the limitations of NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications.Non-invasive ventilation (NIV) has a high value in therapy of hypercapnic acute respiratory failure, as it significantly reduces the length of ICU stay and hospitalization as well as mortality.Patients with cardiopulmonary edema and acute respiratory failure should be treated with continuous positive airway pressure (CPAP) and oxygen in addition to necessary cardiological interventions. This should be done already prehospital and in the emergency department.In case of other forms of acute hypoxaemic respiratory failure with only mild or moderately disturbed gas exchange (PaO2/FiO2 > 150 mmHg) there is no significant advantage or disadvantage compared to high flow nasal oxygen (HFNO). In severe forms of ARDS NIV is associated with high rates of treatment failure and mortality, especially in cases with NIV-failure and delayed intubation.NIV should be used for preoxygenation before intubation. In patients at risk, NIV is recommended to reduce extubation failure. In the weaning process from invasive ventilation NIV essentially reduces the risk of reintubation in hypercapnic patients. NIV is regarded useful within palliative care for reduction of dyspnea and improving quality of life, but here in concurrence to HFNO, which is regarded as more comfortable. Meanwhile NIV is also recommended in prehospital setting, especially in hypercapnic respiratory failure and pulmonary edema.With appropriate monitoring in an intensive care unit NIV can also be successfully applied in pediatric patients with acute respiratory insufficiency.
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Affiliation(s)
- Michael Westhoff
- Klinik für Pneumologie, Lungenklinik Hemer - Zentrum für Pneumologie und Thoraxchirurgie, Hemer
| | - Peter Neumann
- Abteilung für Klinische Anästhesiologie und Operative Intensivmedizin, Evangelisches Krankenhaus Göttingen-Weende gGmbH
| | - Jens Geiseler
- Medizinische Klinik IV - Pneumologie, Beatmungs- und Schlafmedizin, Paracelsus-Klinik Marl, Marl
| | - Johannes Bickenbach
- Klinik für Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen, Aachen
| | - Michael Arzt
- Schlafmedizinisches Zentrum der Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Regensburg
| | - Martin Bachmann
- Klinik für Atemwegs-, Lungen- und Thoraxmedizin, Beatmungszentrum Hamburg-Harburg, Asklepios Klinikum Harburg, Hamburg
| | - Stephan Braune
- IV. Medizinische Klinik: Akut-, Notfall- und Intensivmedizin, St. Franziskus-Hospital, Münster
| | - Sandra Delis
- Klinik für Pneumologie, Palliativmedizin und Geriatrie, Helios Klinikum Emil von Behring GmbH, Berlin
| | - Dominic Dellweg
- Klinik für Innere Medizin, Pneumologie und Gastroenterologie, Pius-Hospital Oldenburg, Universitätsmedizin Oldenburg
| | - Michael Dreher
- Klinik für Pneumologie und Internistische Intensivmedizin, Uniklinik RWTH Aachen
| | - Rolf Dubb
- Akademie der Kreiskliniken Reutlingen GmbH, Reutlingen
| | - Hans Fuchs
- Zentrum für Kinder- und Jugendmedizin, Neonatologie und pädiatrische Intensivmedizin, Universitätsklinikum Freiburg
| | | | - Hans Heppner
- Klinik für Geriatrie und Geriatrische Tagesklinik Klinikum Bayreuth, Medizincampus Oberfranken Friedrich-Alexander-Universität Erlangen-Nürnberg, Bayreuth
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Matthias Kochanek
- Klinik I für Innere Medizin, Hämatologie und Onkologie, Universitätsklinikum Köln, Köln
| | - Philipp M Lepper
- Klinik für Innere Medizin V - Pneumologie, Allergologie und Intensivmedizin, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg
| | - F Joachim Meyer
- Lungenzentrum München - Bogenhausen-Harlaching) München Klinik gGmbH, München
| | - Bernhard Neumann
- Klinik für Neurologie, Donauisar Klinikum Deggendorf, und Klinik für Neurologie der Universitätsklinik Regensburg am BKH Regensburg, Regensburg
| | - Christian Putensen
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Bonn
| | - Dorit Schimandl
- Klinik für Pneumologie, Beatmungszentrum, Zentralklinik Bad Berka GmbH, Bad Berka
| | - Bernd Schönhofer
- Klinik für Innere Medizin, Pneumologie und Intensivmedizin, Evangelisches Klinikum Bethel, Universitätsklinikum Ost Westphalen-Lippe, Bielefeld
| | | | - Stephan Walterspacher
- Medizinische Klinik - Sektion Pneumologie, Klinikum Konstanz und Lehrstuhl für Pneumologie, Universität Witten-Herdecke, Witten
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Lehrstuhl für Pneumologie Universität Witten/Herdecke, Köln
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2
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Bruni A, Battaglia C, Bosco V, Pelaia C, Neri G, Biamonte E, Manti F, Mollace A, Boscolo A, Morelli M, Navalesi P, Laganà D, Garofalo E, Longhini F. Complications during Veno-Venous Extracorporeal Membrane Oxygenation in COVID-19 and Non-COVID-19 Patients with Acute Respiratory Distress Syndrome. J Clin Med 2024; 13:2871. [PMID: 38792413 PMCID: PMC11122218 DOI: 10.3390/jcm13102871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 04/30/2024] [Accepted: 05/11/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Acute respiratory distress syndrome (ARDS) presents a significant challenge in critical care settings, characterized by compromised gas exchange, necessitating in the most severe cases interventions such as veno-venous extracorporeal membrane oxygenation (vv-ECMO) when conventional therapies fail. Critically ill ARDS patients on vv-ECMO may experience several complications. Limited data exist comparing complication rates between COVID-19 and non-COVID-19 ARDS patients undergoing vv-ECMO. This retrospective observational study aimed to assess and compare complications in these patient cohorts. Methods: We retrospectively analyzed the medical records of all patients receiving vv-ECMO for ARDS between March 2020 and March 2022. We recorded the baseline characteristics, the disease course and complication (barotrauma, bleeding, thrombosis) before and after ECMO cannulation, and clinical outcomes (mechanical ventilation and ECMO duration, intensive care unit, and hospital lengths of stay and mortalities). Data were compared between COVID-19 and non-COVID-19 patients. In addition, we compared survived and deceased patients. Results: Sixty-four patients were included. COVID-19 patients (n = 25) showed higher rates of pneumothorax (28% vs. 8%, p = 0.039) with subcutaneous emphysema (24% vs. 5%, p = 0.048) and longer non-invasive ventilation duration before vv-ECMO cannulation (2 [1; 4] vs. 0 [0; 1] days, p = <0.001), compared to non-COVID-19 patients (n = 39). However, complication rates and clinical outcomes post-vv-ECMO were similar between groups. Survival analysis revealed no significant differences in pre-vv-ECMO complications, but non-surviving patients had a trend toward higher complication rates and more pleural effusions post-vv-ECMO. Conclusions: COVID-19 patients on vv-ECMO exhibit higher pneumothorax rates with subcutaneous emphysema pre-cannulation; post-cannulation complications are comparable to non-COVID-19 patients.
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Affiliation(s)
- Andrea Bruni
- Department of Medical and Surgical Sciences, “Magna Graecia” University, 88100 Catanzaro, Italy; (A.B.); (V.B.); (C.P.); (G.N.); (D.L.); (F.L.)
| | - Caterina Battaglia
- Radiodiagnostic Institute, Dulbecco Hospital, 88100 Catanzaro, Italy; (C.B.); (F.M.); (A.M.)
| | - Vincenzo Bosco
- Department of Medical and Surgical Sciences, “Magna Graecia” University, 88100 Catanzaro, Italy; (A.B.); (V.B.); (C.P.); (G.N.); (D.L.); (F.L.)
| | - Corrado Pelaia
- Department of Medical and Surgical Sciences, “Magna Graecia” University, 88100 Catanzaro, Italy; (A.B.); (V.B.); (C.P.); (G.N.); (D.L.); (F.L.)
| | - Giuseppe Neri
- Department of Medical and Surgical Sciences, “Magna Graecia” University, 88100 Catanzaro, Italy; (A.B.); (V.B.); (C.P.); (G.N.); (D.L.); (F.L.)
| | - Eugenio Biamonte
- Institute of Anesthesia and Intensive Care, Dulbecco Hospital, 88100 Catanzaro, Italy;
| | - Francesco Manti
- Radiodiagnostic Institute, Dulbecco Hospital, 88100 Catanzaro, Italy; (C.B.); (F.M.); (A.M.)
| | - Annachiara Mollace
- Radiodiagnostic Institute, Dulbecco Hospital, 88100 Catanzaro, Italy; (C.B.); (F.M.); (A.M.)
| | - Annalisa Boscolo
- Department of Medicine (DIMED), University of Padua, 35131 Padua, Italy; (A.B.); (P.N.)
- Institute of Anesthesia and Intensive Care, Padua University Hospital, 35122 Padova, Italy
- Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, 35122 Padova, Italy
| | - Michele Morelli
- Department of Obstetrics and Gynecology, “Annunziata” Hospital, 87100 Cosenza, Italy;
| | - Paolo Navalesi
- Department of Medicine (DIMED), University of Padua, 35131 Padua, Italy; (A.B.); (P.N.)
- Institute of Anesthesia and Intensive Care, Padua University Hospital, 35122 Padova, Italy
| | - Domenico Laganà
- Department of Medical and Surgical Sciences, “Magna Graecia” University, 88100 Catanzaro, Italy; (A.B.); (V.B.); (C.P.); (G.N.); (D.L.); (F.L.)
| | - Eugenio Garofalo
- Department of Medical and Surgical Sciences, “Magna Graecia” University, 88100 Catanzaro, Italy; (A.B.); (V.B.); (C.P.); (G.N.); (D.L.); (F.L.)
| | - Federico Longhini
- Department of Medical and Surgical Sciences, “Magna Graecia” University, 88100 Catanzaro, Italy; (A.B.); (V.B.); (C.P.); (G.N.); (D.L.); (F.L.)
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3
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Fossali T, Locatelli M, Colombo R, Veronese A, Borghi B, Ballone E, Castelli A, Rech R, Catena E, Ottolina D. Awake pronation with helmet CPAP in early COVID-19 ARDS patients: effects on respiratory effort and distribution of ventilation assessed by EIT. Intern Emerg Med 2024:10.1007/s11739-024-03572-0. [PMID: 38532048 DOI: 10.1007/s11739-024-03572-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/27/2024] [Indexed: 03/28/2024]
Abstract
Prone positioning with continuous positive airway pressure (CPAP) is widely used for respiratory support in awake patients with COVID-19-associated acute respiratory failure. We aimed to assess the respiratory mechanics and distribution of ventilation in COVID-19-associated ARDS treated by CPAP in awake prone position. We studied 16 awake COVID-19 patients with moderate-to-severe ARDS. The study protocol consisted of a randomized sequence of supine and prone position with imposed positive end-expiratory pressure (PEEP) of 5 and 10 cmH2O delivered by helmet CPAP. Respiratory mechanics and distribution of ventilation were assessed through esophageal pressure (PES) and electrical impedance tomography (EIT). At the end of each 20-min phase, arterial blood gas analysis was performed, and PES swing and EIT tracings were recorded for the calculation of the respiratory mechanics and regional ventilation. The patient's position had no significant effects on respiratory mechanics. EIT analysis did not detect differences among global indices of ventilation. A significant proportion of pixels in the sternal region of interest showed an increase in compliance from the supine to prone position and PaO2/FIO2 increased accordingly. The best improvement of both PaO2/FIO2 and sternal compliance was obtained in the prone position with PEEP 10 cmH2O. In the studied subjects, prone positioning during CPAP treatment raised oxygenation without improvement of "protective" ventilation or global ventilatory inhomogeneity indices. Prone positioning with higher PEEP significantly increased the compliance of sternal regions.
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Affiliation(s)
- Tommaso Fossali
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Martina Locatelli
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Riccardo Colombo
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Alice Veronese
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Beatrice Borghi
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Elisabetta Ballone
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Antonio Castelli
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Roberto Rech
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Emanuele Catena
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Davide Ottolina
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy.
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4
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Pierucci P, de Candia ML, Marzullo A, Mele F, Introna F, Agrisani C, Ingoglia G, Gregoretti C, Carpagnano GE. The eye may be the spy of injury related to NIV interface and prone positioning. Pulmonology 2024; 30:192-194. [PMID: 35798639 PMCID: PMC9252870 DOI: 10.1016/j.pulmoe.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 05/05/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- P Pierucci
- A. Cardiothoracic Department, Respiratory and Critical Care Unit Bari Policlinic University Hospital, B. Section of Respiratory Diseases, Department of Basic Medical Science Neuroscience and Sense Organs, University of Bari 'Aldo Moro'
| | - M L de Candia
- A. Cardiothoracic Department, Respiratory and Critical Care Unit Bari Policlinic University Hospital, B. Section of Respiratory Diseases, Department of Basic Medical Science Neuroscience and Sense Organs, University of Bari 'Aldo Moro'.
| | - A Marzullo
- Pathology Division, Department of Emergency and Organ Transplantation, University of Bari
| | - F Mele
- Department of Interdisciplinary Medicine, Section of Legal Medicine, Policlinico di Bari Hospital, University of Bari, Italy
| | - F Introna
- Department of Interdisciplinary Medicine, Section of Legal Medicine, Policlinico di Bari Hospital, University of Bari, Italy
| | - C Agrisani
- Department of Interdisciplinary Medicine, Section of Legal Medicine, Policlinico di Bari Hospital, University of Bari, Italy
| | - G Ingoglia
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Department of Anesthesia Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo, Italy
| | - C Gregoretti
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University, of Palermo, Palermo, Italy; G. Giglio Fundation, Cefal, Palermo, Italy
| | - G E Carpagnano
- A. Cardiothoracic Department, Respiratory and Critical Care Unit Bari Policlinic University Hospital, B. Section of Respiratory Diseases, Department of Basic Medical Science Neuroscience and Sense Organs, University of Bari 'Aldo Moro'
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Chiappero C, Mattei A, Guidelli L, Millotti S, Ceccherini E, Oczkowski S, Scala R. Prone positioning during CPAP therapy in SARS-CoV-2 pneumonia: a concise clinical review. Ther Adv Respir Dis 2024; 18:17534666231219630. [PMID: 38159215 PMCID: PMC10757797 DOI: 10.1177/17534666231219630] [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: 07/03/2023] [Accepted: 11/23/2023] [Indexed: 01/03/2024] Open
Abstract
During the COVID-19 pandemic, the number of patients with hypoxemic acute respiratory failure (ARF) due to SARS-CoV-2 pneumonia threatened to overwhelm intensive care units. To reduce the need for invasive mechanical ventilation (IMV), clinicians tried noninvasive strategies to manage ARF, including the use of awake prone positioning (PP) with continuous positive airway pressure (CPAP). In this article, we review the patho-physiologic rationale, clinical effectiveness and practical issues of the use of PP during CPAP in non-intubated, spontaneously breathing patients affected by SARS-CoV-2 pneumonia with ARF. Use of PP during CPAP appears to be safe and feasible and may have a lower rate of adverse events compared to IMV. A better response to PP is observed among patients in early phases of acute respiratory distress syndrome. While PP during CPAP may improve oxygenation, the impact on the need for intubation and mortality remains unclear. It is possible to speculate on the role of PP during CPAP in terms of improvement of ventilation mechanics and reduction of strain stress.
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Affiliation(s)
- Chiara Chiappero
- Cardiovascular and Thoracic Department, Pneumology, AOU Città della Salute e della Scienza di Torino – Molinette hospital, c.so Bramante 88, Turin 10126, Italy
| | - Alessio Mattei
- Cardiovascular and Thoracic Department, Pneumology, AOU Città della Salute e della Scienza di Torino – Molinette hospital, Turin, Italy
| | - Luca Guidelli
- CardioThoraco-Neuro-Vascular Department, Pulmonology and RICU, S Donato Hospital USL Toscana Sudest, Arezzo, Italy
| | - Serena Millotti
- UOP RF Arezzo, Department of Healthcare technical professions, Rehabilitation and Prevention, USL Toscana Sudest, Arezzo, Italy
| | - Emiliano Ceccherini
- UOP RF Arezzo, Department of Healthcare technical professions, Rehabilitation and Prevention, USL Toscana Sudest, Arezzo, Italy
| | - Simon Oczkowski
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Raffaele Scala
- CardioThoraco-Neuro-Vascular Department, Pulmonology and RICU, S Donato Hospital USL Toscana Sudest, Arezzo, Italy
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Chiappero C, Misseri G, Mattei A, Ippolito M, Albera C, Pivetta E, Cortegiani A, Gregoretti C. Effectiveness and safety of a new helmet CPAP configuration allowing tidal volume monitoring in patients with COVID-19. Pulmonology 2023; 29 Suppl 4:S9-S17. [PMID: 34326019 PMCID: PMC8266523 DOI: 10.1016/j.pulmoe.2021.06.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/28/2021] [Accepted: 06/30/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND High generated tidal volumes (Vt) have been correlated with higher risk of self-induced lung injury and worse clinical outcome. This study aimed to evaluate the effectiveness and safety of a new helmet continuous positive airway pressure delivered (h-CPAP) configuration allowing Vt monitoring in patients affected by COVID-19. METHODS This prospective observational study was performed in the respiratory intermediate care unit of University Hospital in Turin, Italy, between March 24th, and June 15th, 2020. Included patients were treated with CPAP via a single-limb intentional leak configuration by a turbine-driven ventilator, provided with a dedicated patch. Effectiveness and safety of the configuration and healthcare workers safety were the outcomes of the study. MAIN FINDINGS Thirty-five patients were included in this study. Median age was 67 years (IQR 57-76 years), and 30 patients (85.7%) were men. Median value of overall leaks (intentional plus unintentional) was 68 L/min (IQR 63-75). Reliability of Vt measurements was 100%. An out of scale of Vt (above 50% compared to the previous values) was never recorded. Six patients (17.1%) needed more than two helmet replacements, due to leak test >10 l/min. Arm oedema and skin breakdowns were reported in sixteen (45.7%) and seven (20%) patients respectively. Among the 63 healthcare workers involved in the care of COVID-19 patients during the study only one was positive at RT-PCR nasopharyngeal swab testing. CONCLUSIONS The use of h-CPAP for treating COVID-19 in this configuration allowed for reliable Vt monitoring. Further studies evaluating this configuration in larger patients' cohorts are needed.
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Affiliation(s)
- C Chiappero
- Pneumology, Cardiovascular and Thoracic Department, AOU Città della Salute e della Scienza di Torino - Molinette hospital, Turin, Italy
| | | | - A Mattei
- Pneumology, Cardiovascular and Thoracic Department, AOU Città della Salute e della Scienza di Torino - Molinette hospital, Turin, Italy
| | - M Ippolito
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.). University of Palermo, Italy
| | - C Albera
- Pneumology, Cardiovascular and Thoracic Department, AOU Città della Salute e della Scienza di Torino - Molinette hospital, Turin, Italy; University of Turin, School of Medicine, Department of Medical Sciences, Italy
| | - E Pivetta
- Division of Emergency Medicine and High Dependency Unit, Department of General and Specialized Medicine, AOU Città della Salute e della Scienza di Torino - Molinette hospital, Turin, Italy
| | - A Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.). University of Palermo, Italy; Department of Anaesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo, Italy.
| | - C Gregoretti
- Fondazione "Giglio", Cefalù, Italy; Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.). University of Palermo, Italy
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7
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Reshia FAA, Salameh B, Alsadaan N, Alqahtani M, Ayed A, Kassabry MF, Abo Seada AI. Enhancing pulmonary function and arterial blood gas readings through immediate chest physiotherapy among extubated patients in ICU. J Int Med Res 2023; 51:3000605231208600. [PMID: 37929809 PMCID: PMC10683574 DOI: 10.1177/03000605231208600] [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: 05/19/2023] [Accepted: 10/02/2023] [Indexed: 11/07/2023] Open
Abstract
OBJECTIVE To examine the effect of immediate chest physiotherapy (ICPT) on pulmonary function and arterial blood gases among extubated patients. METHOD This prospective study enrolled patients aged 20-60 years who had been intubated for 48 h. They were randomly assigned to either a control or study group. The study group received ICPT by trained critical care nurses and physiotherapists, which included early mobilization, breathing exercises and airway clearance. The control group received standard nursing chest care (positioning, oral and endotracheal suctioning) without ICPT. Researchers evaluated participants using pulmonary function tests, arterial blood gas tests and mechanical ventilation parameters. RESULTS The study enrolled 70 patients. There were no significant differences in the sociodemographic characteristics and medical data before intubation between the two groups except for preparatory education. After extubation, the vital capacity was significantly higher in the study group compared with the control group. There were also significant differences between the two groups in other lung function tests and arterial blood gas tests. After extubation, the total lung capacity, functional residual capacity and residual volume were significantly higher in the study group compared with the control group. CONCLUSION The use of ICPT improved both pulmonary function and arterial blood gases.
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Affiliation(s)
- Fadia Ahmed Abdelkader Reshia
- Department of Medical and Surgical Nursing, College of Nursing, Jouf University, Sakaka, Saudi Arabia
- Department of Critical Care and Emergency Nursing, Faculty of Nursing, Mansoura University, Mansoura, Egypt
| | - Basma Salameh
- Department of Nursing, Arab American University, Jenin, Palestine
| | - Nourah Alsadaan
- Department of Nursing Administration and Education, College of Nursing, Jouf University, Sakaka, Saudi Arabia
| | - Mohammed Alqahtani
- Department of Nursing, College of Applied Medical Sciences, King Faisal University, Alahsa, Saudi Arabia
| | - Ahmad Ayed
- Department of Nursing, Arab American University, Jenin, Palestine
| | | | - Asmaa Ibrahem Abo Seada
- Department of Critical Care and Emergency Nursing, Faculty of Nursing, Mansoura University, Mansoura, Egypt
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8
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Piluso M, Ferrari C, Pagani S, Usai P, Raschi S, Parachini L, Oggionni E, Melacini C, D’Arcangelo F, Cattaneo R, Bonacina C, Bernareggi M, Bencini S, Nadalin M, Borelli M, Bellini R, Salandini MC, Scarpazza P. COVID-19 Acute Respiratory Distress Syndrome: Treatment with Helmet CPAP in Respiratory Intermediate Care Unit by Pulmonologists in the Three Italian Pandemic Waves. Adv Respir Med 2023; 91:383-396. [PMID: 37736976 PMCID: PMC10514851 DOI: 10.3390/arm91050030] [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: 08/08/2023] [Revised: 09/14/2023] [Accepted: 09/15/2023] [Indexed: 09/23/2023]
Abstract
COVID-19 Acute Respiratory Distress Syndrome (CARDS) is the most serious complication of COVID-19. The SARS-CoV-2 outbreaks rapidly saturated intensive care unit (ICU), forcing the application of non-invasive respiratory support (NIRS) in respiratory intermediate care unit (RICU). The primary aim of this study is to compare the patients' clinical characteristics and outcomes (Helmet-Continuous Positive Airway Pressure (H-CPAP) success/failure and survival/death). The secondary aim is to evaluate and detect the main predictors of H-CPAP success and survival/death. A total of 515 patients were enrolled in our observational prospective study based on CARDS developed in RICU during the three Italian pandemic waves. All selected patients were treated with H-CPAP. The worst ratio of arterial partial pressure of oxygen (PaO2) and fraction of inspired oxygen (FiO2) PaO2/FiO2 during H-CPAP stratified the subjects into mild, moderate and severe CARDS. H-CPAP success has increased during the three waves (62%, 69% and 77%, respectively) and the mortality rate has decreased (28%, 21% and 13%). H-CPAP success/failure and survival/death were related to the PaO2/FiO2 (worst score) ratio in H-CPAP and to steroids' administration. D-dimer at admission, FiO2 and positive end expiratory pressure (PEEP) were also associated with H-CPAP success. Our study suggests good outcomes with H-CPAP in CARDS in RICU. A widespread use of steroids could play a role.
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Affiliation(s)
- Martina Piluso
- Lung Unit, Cardiothoracic Vascular Department, Vimercate Hospital, 20871 Vimercate, Italy; (M.P.); (P.U.); (S.R.); (L.P.); (E.O.); (C.M.); (F.D.); (R.C.); (C.B.); (M.B.); (S.B.); (R.B.); (M.C.S.); (P.S.)
| | - Clarissa Ferrari
- Research and Clinical Trials Office, Poliambulanza Foundation Hospital, 25124 Brescia, Italy;
| | - Silvia Pagani
- Lung Unit, Cardiothoracic Vascular Department, Vimercate Hospital, 20871 Vimercate, Italy; (M.P.); (P.U.); (S.R.); (L.P.); (E.O.); (C.M.); (F.D.); (R.C.); (C.B.); (M.B.); (S.B.); (R.B.); (M.C.S.); (P.S.)
| | - Pierfranco Usai
- Lung Unit, Cardiothoracic Vascular Department, Vimercate Hospital, 20871 Vimercate, Italy; (M.P.); (P.U.); (S.R.); (L.P.); (E.O.); (C.M.); (F.D.); (R.C.); (C.B.); (M.B.); (S.B.); (R.B.); (M.C.S.); (P.S.)
| | - Stefania Raschi
- Lung Unit, Cardiothoracic Vascular Department, Vimercate Hospital, 20871 Vimercate, Italy; (M.P.); (P.U.); (S.R.); (L.P.); (E.O.); (C.M.); (F.D.); (R.C.); (C.B.); (M.B.); (S.B.); (R.B.); (M.C.S.); (P.S.)
| | - Luca Parachini
- Lung Unit, Cardiothoracic Vascular Department, Vimercate Hospital, 20871 Vimercate, Italy; (M.P.); (P.U.); (S.R.); (L.P.); (E.O.); (C.M.); (F.D.); (R.C.); (C.B.); (M.B.); (S.B.); (R.B.); (M.C.S.); (P.S.)
| | - Elisa Oggionni
- Lung Unit, Cardiothoracic Vascular Department, Vimercate Hospital, 20871 Vimercate, Italy; (M.P.); (P.U.); (S.R.); (L.P.); (E.O.); (C.M.); (F.D.); (R.C.); (C.B.); (M.B.); (S.B.); (R.B.); (M.C.S.); (P.S.)
| | - Chiara Melacini
- Lung Unit, Cardiothoracic Vascular Department, Vimercate Hospital, 20871 Vimercate, Italy; (M.P.); (P.U.); (S.R.); (L.P.); (E.O.); (C.M.); (F.D.); (R.C.); (C.B.); (M.B.); (S.B.); (R.B.); (M.C.S.); (P.S.)
| | - Francesca D’Arcangelo
- Lung Unit, Cardiothoracic Vascular Department, Vimercate Hospital, 20871 Vimercate, Italy; (M.P.); (P.U.); (S.R.); (L.P.); (E.O.); (C.M.); (F.D.); (R.C.); (C.B.); (M.B.); (S.B.); (R.B.); (M.C.S.); (P.S.)
| | - Roberta Cattaneo
- Lung Unit, Cardiothoracic Vascular Department, Vimercate Hospital, 20871 Vimercate, Italy; (M.P.); (P.U.); (S.R.); (L.P.); (E.O.); (C.M.); (F.D.); (R.C.); (C.B.); (M.B.); (S.B.); (R.B.); (M.C.S.); (P.S.)
| | - Cristiano Bonacina
- Lung Unit, Cardiothoracic Vascular Department, Vimercate Hospital, 20871 Vimercate, Italy; (M.P.); (P.U.); (S.R.); (L.P.); (E.O.); (C.M.); (F.D.); (R.C.); (C.B.); (M.B.); (S.B.); (R.B.); (M.C.S.); (P.S.)
| | - Monica Bernareggi
- Lung Unit, Cardiothoracic Vascular Department, Vimercate Hospital, 20871 Vimercate, Italy; (M.P.); (P.U.); (S.R.); (L.P.); (E.O.); (C.M.); (F.D.); (R.C.); (C.B.); (M.B.); (S.B.); (R.B.); (M.C.S.); (P.S.)
| | - Serena Bencini
- Lung Unit, Cardiothoracic Vascular Department, Vimercate Hospital, 20871 Vimercate, Italy; (M.P.); (P.U.); (S.R.); (L.P.); (E.O.); (C.M.); (F.D.); (R.C.); (C.B.); (M.B.); (S.B.); (R.B.); (M.C.S.); (P.S.)
| | - Marta Nadalin
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy; (M.N.); (M.B.)
- Cardiothoracic Vascular Department, Respiratory Unit, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
| | - Mara Borelli
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy; (M.N.); (M.B.)
- Cardiothoracic Vascular Department, Respiratory Unit, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
| | - Roberto Bellini
- Lung Unit, Cardiothoracic Vascular Department, Vimercate Hospital, 20871 Vimercate, Italy; (M.P.); (P.U.); (S.R.); (L.P.); (E.O.); (C.M.); (F.D.); (R.C.); (C.B.); (M.B.); (S.B.); (R.B.); (M.C.S.); (P.S.)
| | - Maria Chiara Salandini
- Lung Unit, Cardiothoracic Vascular Department, Vimercate Hospital, 20871 Vimercate, Italy; (M.P.); (P.U.); (S.R.); (L.P.); (E.O.); (C.M.); (F.D.); (R.C.); (C.B.); (M.B.); (S.B.); (R.B.); (M.C.S.); (P.S.)
| | - Paolo Scarpazza
- Lung Unit, Cardiothoracic Vascular Department, Vimercate Hospital, 20871 Vimercate, Italy; (M.P.); (P.U.); (S.R.); (L.P.); (E.O.); (C.M.); (F.D.); (R.C.); (C.B.); (M.B.); (S.B.); (R.B.); (M.C.S.); (P.S.)
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9
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Peng Q, Yang S, Zhang Y, Zhao W, Hu M, Meng B, Ni H, Min L, Yu J, Wang Y, Zhang L. Effects of awake prone position vs. usual care on acute hypoxemic respiratory failure in patients with COVID-19: A systematic review and meta-analysis of randomized controlled trials. Front Med (Lausanne) 2023; 10:1120837. [PMID: 37081841 PMCID: PMC10111056 DOI: 10.3389/fmed.2023.1120837] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 03/06/2023] [Indexed: 04/22/2023] Open
Abstract
Background Previous studies have shown that an awake prone position may be beneficial for the treatment of acute respiratory distress syndrome (ARDS) or acute hypoxic respiratory failure (AHRF) in patients with COVID-19, but the results are not consistent, especially in terms of oxygenation outcomes and intubation rate. This systematic review and meta-analysis assessed the effects of the awake prone position on AHRF in patients with COVID-19 with all randomized controlled trials (RCTs). Methods An extensive search of online databases, including MEDLINE, Embase, Web of Science, and Cochrane Central Register of Controlled Trials from 1 December 2019 to 30 October 2022, with no language restrictions was performed. This systematic review and meta-analysis are based on the PRISMA statement. We only included RCTs and used the Cochrane risk assessment tool for quality assessment. Results Fourteen RCTs fulfilled the selection criteria, and 3,290 patients were included. A meta-analysis found that patients in the awake prone position group had more significant improvement in the SpO2/FiO2 ratio [mean difference (MD): 29.76; 95% confidence interval (CI): 1.39-48.13; P = 0.001] compared with the usual care. The prone position also reduced the need for intubation [odd ratio (OR): 0.72; 95% CI: 0.61 to 0.84; P < 0.0001; I 2 = 0%]. There was no significant difference in mortality, hospital length of stay, incidence of intensive care unit (ICU) admission, and adverse events between the two groups. Conclusion The awake prone position was a promising intervention method, which is beneficial to improve the oxygenation of patients with ARDS or AHRF caused by COVID-19 and reduce the need for intubation. However, the awake prone position showed no obvious advantage in mortality, hospital length of stay, incidence of ICU admission, and adverse events. Systematic review registration International Prospective Register of Systematic Reviews (PROSPERO), identifier: CRD42022367885.
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Affiliation(s)
- Qing Peng
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Sheng Yang
- Department of Orthopedics, Graduate School of Dalian Medical University, Dalian, China
| | - Yu Zhang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Wenjie Zhao
- Department of Orthopedics, Graduate School of Dalian Medical University, Dalian, China
| | - Man Hu
- Department of Orthopedics, Graduate School of Dalian Medical University, Dalian, China
| | - Bo Meng
- Department of Orthopedics, Graduate School of Dalian Medical University, Dalian, China
| | - Huanhuan Ni
- Department of Anesthesiology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Lingfeng Min
- Department of Respiratory, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Jiangquan Yu
- Department of Critical Care Medicine, Clinical Medical College of Yangzhou University, Yangzhou, China
- *Correspondence: Jiangquan Yu
| | - Yongxiang Wang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China
- Yongxiang Wang
| | - Liang Zhang
- Department of Orthopedics, Regenerative Medicine Engineering Technology Research Center of Yangzhou, Yangzhou, China
- Liang Zhang
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10
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Accurso G, Vetrugno L, Pierucci P. Editorial: New advances in bedside assessment and monitoring of acute respiratory failure patients. Front Med (Lausanne) 2023; 10:1154289. [PMID: 36936218 PMCID: PMC10018187 DOI: 10.3389/fmed.2023.1154289] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 02/14/2023] [Indexed: 03/06/2023] Open
Affiliation(s)
- Giuseppe Accurso
- Department of Anaesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo, Italy
- *Correspondence: Giuseppe Accurso
| | - Luigi Vetrugno
- Department of Medical, Oral and Biotechnological Sciences University of Chieti-Pescara, Chieti, Italy
| | - Paola Pierucci
- Cardiothoracic Department, Respiratory and Critical Care Unit Bari Policlinico University Hospital, Bari, Italy
- Section of Respiratory Diseases, Department of Basic Medical Science Neuroscience and Sense Organs, University of Bari “Aldo Moro”, Bari, Italy
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11
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Pierucci P, Portacci A, Carpagnano GE, Banfi P, Crimi C, Misseri G, Gregoretti C. The right interface for the right patient in noninvasive ventilation: a systematic review. Expert Rev Respir Med 2022; 16:931-944. [PMID: 36093799 DOI: 10.1080/17476348.2022.2121706] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Research in the field of noninvasive ventilation (NIV) has contributed to the development of new NIV interfaces. However, interface tolerance plays a crucial role in determining the beneficial effects of NIV therapy. AREAS COVERED This systematic review explores the most significant scientific research on NIV interfaces, with a focus on the potential impact that their design might have on treatment adherence and clinical outcomes. The rationale on the choice of the right interface among the wide variety of devices that are currently available is discussed here. EXPERT OPINION The paradigm "The right mask for the right patient" seems to be difficult to achieve in real life. Ranging from acute to chronic settings, the gold standard should include the tailoring of NIV interfaces to patients' needs and preferences. However, such customization may be hampered by issues of economic nature. High production costs and the increasing demand represent consistent burdens and have to be considered when dealing with patient-tailored NIV interfaces. New research focusing on developing advanced and tailored NIV masks should be prioritized; indeed, interfaces should be designed according to the specific patient and clinical setting where they need to be used.
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Affiliation(s)
- Paola Pierucci
- A. Cardiothoracic Department, Respiratory and Critical care Unit Bari Policlinic University Hospital, B. Section of Respiratory Diseases, Dept. of Basic Medical Science Neuroscience and Sense Organs, University of Bari 'Aldo Moro'
| | - Andrea Portacci
- A. Cardiothoracic Department, Respiratory and Critical care Unit Bari Policlinic University Hospital, B. Section of Respiratory Diseases, Dept. of Basic Medical Science Neuroscience and Sense Organs, University of Bari 'Aldo Moro'
| | - Giovanna Elisiana Carpagnano
- A. Cardiothoracic Department, Respiratory and Critical care Unit Bari Policlinic University Hospital, B. Section of Respiratory Diseases, Dept. of Basic Medical Science Neuroscience and Sense Organs, University of Bari 'Aldo Moro'
| | - Paolo Banfi
- IRCCS Fondazione Don Carlo Gnocchi, Milano,Italy
| | - Claudia Crimi
- Respiratory Medicine Unit, "Policlinico-Vittorio Emanuele San Marco" University Hospital, Catania, Italy
| | | | - Cesare Gregoretti
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Italy and Fondazione Istituto "G.Giglio" Cefalù', Palermo, Italy
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12
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Polistina GE, Di Somma C, Flora M, Maraolo AE, Carannante N, Langella G, Mirizzi AI, Annunziata A, Fiorentino G. Respiratory Intensive Care Unit management and efficacy during the COVID-19 outbreak in Naples, Italy. Monaldi Arch Chest Dis 2022; 93. [PMID: 36062992 DOI: 10.4081/monaldi.2022.2358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 08/24/2022] [Indexed: 01/08/2023] Open
Abstract
The World Health Organization declared the Coronavirus Diseases 2019 (COVID-19) outbreak a global pandemic on March 11, 2020. COVID-19 had an impact on over 500 million people worldwide. According to the American Thoracic Society criteria, the respiratory spectrum of this disease ranges from mild illness to severe pneumonia, with the latter occurring in a not insignificant 15% of patients. A rapid increase in the incidence of COVID-19 pneumonia cases has been observed all over the world, resulting in a saturation of the Intensive Care Unit's capacity (ICUs). Because of this impressive outbreak, the ICU beds and invasive mechanical ventilators reached their capacity. Non-invasive supportive care has become an important option for keeping respiratory conditions under control. As a result, proper healthcare resource management was required to ensure adequate patient care. Respiratory Intensive Care Units (RICUs) have become a useful resource for managing complex patients due to a shortage of ICU capacity. This highlighted the importance of RICUs, where patients with moderate to severe respiratory failure can be treated with non-invasive respiratory support rather than being admitted to the ICU. The clinical outcomes and baseline characteristics of patients admitted to the RICU of Cotugno Hospital, a tertiary referral center in Naples (Italy), from January 2021 to October 2021 are described in this report.
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13
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Dantas AC, Costa ML, Silva ABD, Borges BEC, Araújo JNDM, Vitor AF. Eye Care Interventions in Critical/Surgical Patients in the Prone Position: Scoping Review. AQUICHAN 2022. [DOI: 10.5294/aqui.2022.22.3.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objectives: This study aimed to map evidence of eye care interventions in managing critical or surgical patients submitted to prone positions. Materials and method: This scoping review was prepared according to the Joanna Briggs Institute’s methodology, following the PRISMA-ScR criteria. A search was conducted from July to August 2020 in the SCOPUS, Web of Science, Science Direct, PubMed Central, CINAHL, and COCHRANE databases. The following research question was delimited: “What are the strategies and interventions used for eye care in the management of critical patients or surgical patients submitted to the prone position?” The sample consisted of 24 studies after applying the inclusion and exclusion criteria. Results: Eye care interventions in managing critical/surgical patients submitted to the prone position were eye examination, use of lubricants/specific ophthalmic solution, reverse Trendelenburg positioning, and protection with adhesive tape. Conclusions: This review allowed the understanding of eye care for critical/surgical patients in a prone position. Among the care presented, a large part is related to nursing since it is closer to patient care. The findings emphasize the need to implement patient safety policies with eye care as a priority.
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14
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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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15
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Cammarota G, Simonte R, De Robertis E. Comfort During Non-invasive Ventilation. Front Med (Lausanne) 2022; 9:874250. [PMID: 35402465 PMCID: PMC8988041 DOI: 10.3389/fmed.2022.874250] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 02/28/2022] [Indexed: 01/03/2023] Open
Abstract
Non-invasive ventilation (NIV) has been shown to be effective in avoiding intubation and improving survival in patients with acute hypoxemic respiratory failure (ARF) when compared to conventional oxygen therapy. However, NIV is associated with high failure rates due, in most cases, to patient discomfort. Therefore, increasing attention has been paid to all those interventions aimed at enhancing patient's tolerance to NIV. Several practical aspects have been considered to improve patient adaptation. In particular, the choice of the interface and the ventilatory setting adopted for NIV play a key role in the success of respiratory assistance. Among the different NIV interfaces, tolerance is poorest for the nasal and oronasal masks, while helmet appears to be better tolerated, resulting in longer use and lower NIV failure rates. The choice of fixing system also significantly affects patient comfort due to pain and possible pressure ulcers related to the device. The ventilatory setting adopted for NIV is associated with varying degrees of patient comfort: patients are more comfortable with pressure-support ventilation (PSV) than controlled ventilation. Furthermore, the use of electrical activity of the diaphragm (EADi)-driven ventilation has been demonstrated to improve patient comfort when compared to PSV, while reducing neural drive and effort. If non-pharmacological remedies fail, sedation can be employed to improve patient's tolerance to NIV. Sedation facilitates ventilation, reduces anxiety, promotes sleep, and modulates physiological responses to stress. Judicious use of sedation may be an option to increase the chances of success in some patients at risk for intubation because of NIV intolerance consequent to pain, discomfort, claustrophobia, or agitation. During the Coronavirus Disease-19 (COVID-19) pandemic, NIV has been extensively employed to face off the massive request for ventilatory assistance. Prone positioning in non-intubated awake COVID-19 patients may improve oxygenation, reduce work of breathing, and, possibly, prevent intubation. Despite these advantages, maintaining prone position can be particularly challenging because poor comfort has been described as the main cause of prone position discontinuation. In conclusion, comfort is one of the major determinants of NIV success. All the strategies aimed to increase comfort during NIV should be pursued.
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16
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Carpagnano GE, Pierucci P, Migliore G, Minicucci AM, Aricò M, Marra M, Carpagnano LF. Tailored Post-Acute Care Coordination for Survivors of Moderate to Severe COVID-19 Infection. J Am Med Dir Assoc 2021; 23:447-449. [PMID: 34995511 PMCID: PMC8677462 DOI: 10.1016/j.jamda.2021.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 12/02/2021] [Accepted: 12/11/2021] [Indexed: 11/09/2022]
Affiliation(s)
| | - Paola Pierucci
- Cardiothoracic Department, Respiratory and Critical Care Unit, Bari Policlinic University Hospital, Bari, Italy
| | | | | | | | - Maurizio Marra
- Hospital Health Direction Office, Bari Policlinic University Hospital, Bari, Italy
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De Cassai A, Longhini F, Romagnoli S, Cavaliere F, Caroleo A, Foti L, Furlani E, Gianoli S, Monteleone F, Saraco G, Villa G, Conti G, Navalesi P. Research on SARS-COV-2 pandemic: a narrative review focused on the Italian contribution. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2021. [PMCID: PMC8596088 DOI: 10.1186/s44158-021-00017-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Since late 2019, a severe acute respiratory syndrome, caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has spread with overwhelming speed causing over 214 million confirmed infections and more than 4.5 million deaths worldwide. In this framework, Italy had the second highest number of SARS-CoV-2 infections worldwide, and the largest number of deaths. A global effort of both the scientific community and governments has been undertaken to stem the pandemic. The aim of this paper is to perform a narrative review of the Italian contribution to the scientific literature regarding intensive care management of patients suffering from COVID-19, being one of the first western countries to face an outbreak of SARS-CoV-2 infection.
Main body
We performed a narrative review of the literature, dedicating particular attention and a dedicated paragraph to ventilatory support management, chest imaging findings, biomarkers, possible pharmacological interventions, bacterial superinfections, prognosis and non-clinical key aspects such as communication and interaction with relatives.
Conclusions
Many colleagues, nurses and patients died leaving their families alone. To all of them, we send our thoughts and dedicate these pages.
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Chilkoti GT, Mohta M, Saxena AK, Ahmad Z, Sharma CS. Awake Prone Positioning in the Management of COVID-19 Pneumonia: A Systematic Review. Indian J Crit Care Med 2021; 25:896-905. [PMID: 34733031 PMCID: PMC8559737 DOI: 10.5005/jp-journals-10071-23932] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Background: The aim was to investigate the efficacy of prone positioning (PP) in the management of coronavirus disease-2019 (COVID-19) pneumonia in various setups, with various modes of oxygen therapy and its optimal duration. Materials and methods: A systematic literature search was conducted from inception until May 15, 2021. Patients with a validated diagnosis of COVID-19 and receiving PP were included. Various factors, including intensive care unit (ICU) or non-ICU setup, mode of oxygen therapy, outcome, duration of proning, and limitations, were noted. Results: We retrieved 36 articles with a total of 1,385 patients for qualitative analysis. Out of 36 articles, there were 17 original articles, 09 case series, and 10 case reports. Out of 1,385 participants, 78.9% (n = 1,093) and 21.0% (n = 292) of patients were managed in ICU and non-ICU setup, respectively. Awake PP with high flow nasal cannula (HFNC) was found to be a promising technique; however, the result was inconclusive with helmet continuous positive airway pressure (CPAP). No study has evaluated the optimal duration of awake PP and the associated long-term outcomes. Conclusion: We encourage the use of early awake self-proning in the management of COVID19 disease. However, the evidence in terms of its use in non-ICU setup, the optimal duration of PP, and various oxygenation devices are insufficient, thereby mandating further well-designed multicentric studies to evaluate its efficacy as an adjunct in the management of COVID-19 pneumonia in context to the aforementioned factor. How to cite this article: Chilkoti GT, Mohta M, Saxena AK, Ahmad Z, Sharma CS. Awake Prone Positioning in the Management of COVID-19 Pneumonia: A Systematic Review. Indian J Crit Care Med 2021;25(8):896-905.
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Affiliation(s)
- Geetanjali T Chilkoti
- Department of Anaesthesiology, University College of Medical Sciences, New Delhi, India
| | - Medha Mohta
- Department of Anaesthesiology, University College of Medical Sciences, New Delhi, India
| | - Ashok K Saxena
- Department of Anaesthesiology, University College of Medical Sciences, New Delhi, India
| | - Zainab Ahmad
- Department of Anaesthesiology, University College of Medical Sciences, New Delhi, India
| | - Chhavi S Sharma
- Department of Anaesthesiology, University College of Medical Sciences, New Delhi, India
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19
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Lucchini A, Minotti D, Vanini S, Pegoraro F, Iannuzzi L, Isgrò S. The "Dolphin" Prone Position in Awake COVID-19 Patients. Dimens Crit Care Nurs 2021; 40:311-314. [PMID: 34606218 DOI: 10.1097/dcc.0000000000000505] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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20
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Bruni A, Garofalo E, Mazzitelli M, Voci CP, Puglisi A, Quirino A, Marascio N, Trecarichi EM, Matera G, Torti C, Longhini F. Multidisciplinary approach to a septic COVID-19 patient undergoing veno-venous extracorporeal membrane oxygenation and receiving thoracic surgery. Clin Case Rep 2021; 9:e04828. [PMID: 34631063 PMCID: PMC8489392 DOI: 10.1002/ccr3.4828] [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: 06/11/2021] [Revised: 08/23/2021] [Accepted: 08/30/2021] [Indexed: 11/06/2022] Open
Abstract
A multidisciplinary approach appears to be fundamental for the treatment of critically ill patients with COVID-19, improving clinical outcomes, even in the most severe cases. Such severe cases are advisable to be collegially discussed between intensivists, surgeons, infectious disease, and other physicians potentially involved.
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Affiliation(s)
- Andrea Bruni
- Anesthesia and Intensive Care Department of Medical and Surgical Sciences Magna Graecia University Catanzaro Italy
| | - Eugenio Garofalo
- Anesthesia and Intensive Care Department of Medical and Surgical Sciences Magna Graecia University Catanzaro Italy
| | - Maria Mazzitelli
- Infectious and Tropical Disease Unit Department of Medical and Surgical Sciences Magna Graecia University Catanzaro Italy
| | - Carlo P Voci
- Thoracic Surgery Department of Medical and Surgical Sciences Magna Graecia University Catanzaro Italy
| | - Armando Puglisi
- Thoracic Surgery Department of Medical and Surgical Sciences Magna Graecia University Catanzaro Italy
| | - Angela Quirino
- Clinical Microbiology Unit Department of Health Sciences Magna Graecia University Catanzaro Italy
| | - Nadia Marascio
- Clinical Microbiology Unit Department of Health Sciences Magna Graecia University Catanzaro Italy
| | - Enrico M Trecarichi
- Infectious and Tropical Disease Unit Department of Medical and Surgical Sciences Magna Graecia University Catanzaro Italy
| | - Giovanni Matera
- Clinical Microbiology Unit Department of Health Sciences Magna Graecia University Catanzaro Italy
| | - Carlo Torti
- Infectious and Tropical Disease Unit Department of Medical and Surgical Sciences Magna Graecia University Catanzaro Italy
| | - Federico Longhini
- Anesthesia and Intensive Care Department of Medical and Surgical Sciences Magna Graecia University Catanzaro Italy
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21
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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: 36] [Impact Index Per Article: 12.0] [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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22
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Arnal JM, Talmor D. Collective wisdom in a pandemic. Minerva Anestesiol 2021; 86:1132-1134. [PMID: 33228328 DOI: 10.23736/s0375-9393.20.15238-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
| | - Daniel Talmor
- Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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23
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Faraone A, Beltrame C, Crociani A, Carrai P, Lovicu E, Filetti S, Sbaragli S, Alessi C, Cameron Smith M, Angotti C, Fortini A. Effectiveness and safety of noninvasive positive pressure ventilation in the treatment of COVID-19-associated acute hypoxemic respiratory failure: a single center, non-ICU setting experience. Intern Emerg Med 2021; 16:1183-1190. [PMID: 33222116 PMCID: PMC7680552 DOI: 10.1007/s11739-020-02562-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 10/31/2020] [Indexed: 01/09/2023]
Abstract
The role of noninvasive positive pressure ventilation (NIPPV) in COVID-19 patients with acute hypoxemic respiratory failure (AHRF) is uncertain, as no direct evidence exists to support NIPPV use in such patients. We retrospectively assessed the effectiveness and safety of NIPPV in a cohort of COVID-19 patients consecutively admitted to the COVID-19 general wards of a medium-size Italian hospital, from March 6 to May 7, 2020. Healthcare workers (HCWs) caring for COVID-19 patients were monitored, undergoing nasopharyngeal swab for SARS-CoV-2 in case of onset of COVID-19 symptoms, and periodic SARS-CoV-2 screening serology. Overall, 50 patients (mean age 74.6 years) received NIPPV, of which 22 (44%) were successfully weaned, avoiding endotracheal intubation (ETI) and AHRF-related death. Due to limited life expectancy, 25 (50%) of 50 NIPPV-treated patients received a "do not intubate" (DNI) order. Among these, only 6 (24%) were weaned from NIPPV. Of the remaining 25 NIPPV-treated patients without treatment limitations, 16 (64%) were successfully weaned, 9 (36%) underwent delayed ETI and, of these, 3 (33.3%) died. NIPPV success was predicted by the use of corticosteroids (OR 15.4, CI 1.79-132.57, p 0.013) and the increase in the PaO2/FiO2 ratio measured 24-48 h after NIPPV initiation (OR 1.02, CI 1-1.03, p 0.015), while it was inversely correlated with the presence of a DNI order (OR 0.03, CI 0.001-0.57, p 0.020). During the study period, 2 of 124 (1.6%) HCWs caring for COVID-19 patients were diagnosed with SARS-CoV-2 infection. Apart from patients with limited life expectancy, NIPPV was effective in a substantially high percentage of patients with COVID-19-associated AHRF. The risk of SARS-CoV-2 infection among HCWs was low.
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Affiliation(s)
- Antonio Faraone
- Department of Internal Medicine, San Giovanni Di Dio Hospital, Via di Torregalli 3, 50143, Florence, Italy.
| | - Chiara Beltrame
- Department of Internal Medicine, San Giovanni Di Dio Hospital, Via di Torregalli 3, 50143, Florence, Italy
| | - Andrea Crociani
- Department of Internal Medicine, San Giovanni Di Dio Hospital, Via di Torregalli 3, 50143, Florence, Italy
| | - Paolo Carrai
- Department of Internal Medicine, San Giovanni Di Dio Hospital, Via di Torregalli 3, 50143, Florence, Italy
| | - Elena Lovicu
- Department of Internal Medicine, San Giovanni Di Dio Hospital, Via di Torregalli 3, 50143, Florence, Italy
| | - Simona Filetti
- Department of Internal Medicine, San Giovanni Di Dio Hospital, Via di Torregalli 3, 50143, Florence, Italy
| | - Serena Sbaragli
- Department of Internal Medicine, San Giovanni Di Dio Hospital, Via di Torregalli 3, 50143, Florence, Italy
| | - Chiara Alessi
- Department of Internal Medicine, San Giovanni Di Dio Hospital, Via di Torregalli 3, 50143, Florence, Italy
| | - Michela Cameron Smith
- Department of Internal Medicine, San Giovanni Di Dio Hospital, Via di Torregalli 3, 50143, Florence, Italy
| | - Chiara Angotti
- Department of Internal Medicine, San Giovanni Di Dio Hospital, Via di Torregalli 3, 50143, Florence, Italy
| | - Alberto Fortini
- Department of Internal Medicine, San Giovanni Di Dio Hospital, Via di Torregalli 3, 50143, Florence, Italy
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24
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Pierucci P, Ambrosino N, Di Lecce V, Dimitri M, Battaglia S, Boniello E, Portacci A, Resta O, Carpagnano GE. Prolonged Active Prone Positioning in Spontaneously Breathing Non-intubated Patients With COVID-19-Associated Hypoxemic Acute Respiratory Failure With PaO 2/FiO 2 >150. Front Med (Lausanne) 2021; 8:626321. [PMID: 34368174 PMCID: PMC8336785 DOI: 10.3389/fmed.2021.626321] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 06/09/2021] [Indexed: 11/22/2022] Open
Abstract
Background: The COVID-19 pandemic has led to new approaches to manage patients outside the ICU, including prone positioning in non-intubated patients. Objectives: To report the use of prolonged active prone positioning in spontaneously breathing patients with COVID-19-associated acute respiratory failure. Spontaneously breathing vs non-invasive respiratory support for COVID19 associated acute respiratory failure. Methods: Patients with PaO2/FiO2 > 150, with lung posterior consolidations as assessed by means of lung ultrasound, and chest x-ray were studied. Under continuous pulse oximetry (SpO2) monitoring, patients maintained active prone position. A PaO2/FiO2 < 150 was considered as treatment failure and patients had to be switched to non-invasive respiratory support. Retrospectively, data of 16 patients undergoing who refused proning and underwent non-invasive respiratory support were used as controls. The primary outcome was the proportion of patients maintaining prolonged prone position and discharged home. Secondary outcomes included improvement in oxygenation, hospital length of stay, and 6-month survival. Results: Three out of 16 (18.7%) patients did not tolerate the procedure. Three more patients showed a worsening in PaO2/FiO2 to <150 and required non-invasive support, two of whom finally needing endotracheal intubation. After 72 h, 10 out of 16 (62.5%) patients improved oxygenation [PaO2/FiO2: from 194.6 (42.1) to 304.7 (79.3.2) (p < 0.001)] and were discharged home. In the control group, three out of 16 failed, required invasive ventilatory support, and died within 1 month in ICU. Thirteen were successful and discharged home. Conclusion: In non-intubated spontaneously breathing COVID-19 patients with PaO2/FiO2 >150, active prolonged prone positioning was feasible and tolerated with significant improvement in oxygenation.
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Affiliation(s)
- Paola Pierucci
- A. Cardiothoracic Department, Respiratory and Critical Care Unit Bari Policlinic University Hospital, B. Section of Respiratory Diseases, Department of Basic Medical Science Neuroscience and Sense Organs, University of Bari 'Aldo Moro', Bari, Italy, University of Bari, Bari, Italy
| | - Nicolino Ambrosino
- Istituti Clinici Scientifici Maugeri Istituto di Ricovero e Cura a Carattere Scientifico Pneumologia Riabilitativa, Istituto di Montescano, Montescano, Italy
| | - Valentina Di Lecce
- A. Cardiothoracic Department, Respiratory and Critical Care Unit Bari Policlinic University Hospital, B. Section of Respiratory Diseases, Department of Basic Medical Science Neuroscience and Sense Organs, University of Bari 'Aldo Moro', Bari, Italy, University of Bari, Bari, Italy
| | - Michela Dimitri
- A. Cardiothoracic Department, Respiratory and Critical Care Unit Bari Policlinic University Hospital, B. Section of Respiratory Diseases, Department of Basic Medical Science Neuroscience and Sense Organs, University of Bari 'Aldo Moro', Bari, Italy, University of Bari, Bari, Italy
| | - Stefano Battaglia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Esterina Boniello
- A. Cardiothoracic Department, Respiratory and Critical Care Unit Bari Policlinic University Hospital, B. Section of Respiratory Diseases, Department of Basic Medical Science Neuroscience and Sense Organs, University of Bari 'Aldo Moro', Bari, Italy, University of Bari, Bari, Italy
| | - Andrea Portacci
- A. Cardiothoracic Department, Respiratory and Critical Care Unit Bari Policlinic University Hospital, B. Section of Respiratory Diseases, Department of Basic Medical Science Neuroscience and Sense Organs, University of Bari 'Aldo Moro', Bari, Italy, University of Bari, Bari, Italy
| | - Onofrio Resta
- A. Cardiothoracic Department, Respiratory and Critical Care Unit Bari Policlinic University Hospital, B. Section of Respiratory Diseases, Department of Basic Medical Science Neuroscience and Sense Organs, University of Bari 'Aldo Moro', Bari, Italy, University of Bari, Bari, Italy
| | - Giovanna Elisiana Carpagnano
- A. Cardiothoracic Department, Respiratory and Critical Care Unit Bari Policlinic University Hospital, B. Section of Respiratory Diseases, Department of Basic Medical Science Neuroscience and Sense Organs, University of Bari 'Aldo Moro', Bari, Italy, University of Bari, Bari, Italy
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25
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Winck JC, Scala R. Non-invasive respiratory support paths in hospitalized patients with COVID-19: proposal of an algorithm. Pulmonology 2021; 27:305-312. [PMID: 33516668 PMCID: PMC7816939 DOI: 10.1016/j.pulmoe.2020.12.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 12/13/2020] [Accepted: 12/17/2020] [Indexed: 02/06/2023] Open
Abstract
COVID-19 related Acute Respiratory Failure, may be successfully treated with Conventional Oxygen therapy, High Flow Nasal Cannula, Continuous Positive Airway Pressure or Bi-level Positive-Pressure ventilation. Despite the accumulated data in favor of the use of different Non-invasive Respiratory therapies in COVID-19 related Acute Respiratory Failure, it is not fully understood when start, escalate and de-escalate the best respiratory supportive option for the different timing of the disease. Based on the current published experience with Non-invasive Respiratory therapies in COVID-19 related Acute Respiratory Failure, we propose an algorithm in deciding when to start, when to stop and when to wean different NIRT. This strategy may help clinicians in better choosing NIRT during this second COVID-19 wave and beyond.
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Affiliation(s)
- J C Winck
- Facultyof Medicine-Porto University, Portugal.
| | - R Scala
- Pulmonology and Respiratory Intensive Care Unit, S Donato Hospital, Arezzo, Italy
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26
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Affiliation(s)
- Andrea Bruni
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Eugenio Garofalo
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Federico Longhini
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy.
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27
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Groff P, Ferrari R. Non-invasive respiratory support in the treatment of acute hypoxemic respiratory failure secondary to CoViD-19 related pneumonia. Eur J Intern Med 2021; 86:17-21. [PMID: 33676805 PMCID: PMC7906530 DOI: 10.1016/j.ejim.2021.02.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 01/29/2021] [Accepted: 02/17/2021] [Indexed: 01/15/2023]
Abstract
In the last 11 months, the SARS-CoV-2 pandemic has overwhelmed and disrupted the whole world in health, social and economic terms. We are progressively learning more and more about the epidemiological and clinical features that distinguish CoViD-19 from any previous experience in the emergency and critical care setting. Experiences are multiplying with regard to the use of non-invasive respiratory support techniques in the context of acute hypoxemic respiratory failure secondary to CoViD-19-related pneumonia. Doubts still far outweigh certainties, but a growing series of mostly monocentric and retrospective studies are becoming available as concrete decision-making and operational support for healthcare workers. In this review the available studies and experiences about non-invasive respiratory support in the treatment of Covid-19 related respiratory failure, mainly coming from outside the ICU setting, will be discussed.
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Affiliation(s)
- Paolo Groff
- Emergency Department, Santa Maria della Misericordia Hospital, Perugia, Italy.
| | - Rodolfo Ferrari
- Emergency Department, Santa Maria della Scaletta Hospital, Imola, Italy
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28
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Chalmers JD, Crichton ML, Goeminne PC, Cao B, Humbert M, Shteinberg M, Antoniou KM, Ulrik CS, Parks H, Wang C, Vandendriessche T, Qu J, Stolz D, Brightling C, Welte T, Aliberti S, Simonds AK, Tonia T, Roche N. Management of hospitalised adults with coronavirus disease 2019 (COVID-19): a European Respiratory Society living guideline. Eur Respir J 2021; 57:2100048. [PMID: 33692120 PMCID: PMC7947358 DOI: 10.1183/13993003.00048-2021] [Citation(s) in RCA: 118] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 02/23/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Hospitalised patients with coronavirus disease 2019 (COVID-19) as a result of SARS-CoV-2 infection have a high mortality rate and frequently require noninvasive respiratory support or invasive ventilation. Optimising and standardising management through evidence-based guidelines may improve quality of care and therefore patient outcomes. METHODS A task force from the European Respiratory Society and endorsed by the Chinese Thoracic Society identified priority interventions (pharmacological and non-pharmacological) for the initial version of this "living guideline" using the PICO (population, intervention, comparator, outcome) format. The GRADE approach was used for assessing the quality of evidence and strength of recommendations. Systematic literature reviews were performed, and data pooled by meta-analysis where possible. Evidence tables were presented and evidence to decision frameworks were used to formulate recommendations. RESULTS Based on the available evidence at the time of guideline development (20 February, 2021), the panel makes a strong recommendation in favour of the use of systemic corticosteroids in patients requiring supplementary oxygen or ventilatory support, and for the use of anticoagulation in hospitalised patients. The panel makes a conditional recommendation for interleukin (IL)-6 receptor antagonist monoclonal antibody treatment and high-flow nasal oxygen or continuous positive airway pressure in patients with hypoxaemic respiratory failure. The panel make strong recommendations against the use of hydroxychloroquine and lopinavir-ritonavir. Conditional recommendations are made against the use of azithromycin, hydroxychloroquine combined with azithromycin, colchicine, and remdesivir, in the latter case specifically in patients requiring invasive mechanical ventilation. No recommendation was made for remdesivir in patients requiring supplemental oxygen. Further recommendations for research are made. CONCLUSION The evidence base for management of COVID-19 now supports strong recommendations in favour and against specific interventions. These guidelines will be regularly updated as further evidence becomes available.
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Affiliation(s)
- James D Chalmers
- School of Medicine, University of Dundee, Dundee, UK
- J.D. Chalmers and N. Roche are task force co-chairs
| | | | - Pieter C Goeminne
- Department of Respiratory Medicine, AZ Nikolaas, Sint-Niklaas, Belgium
| | - Bin Cao
- Department of Respiratory and Critical Care Medicine, Clinical Microbiology and Infectious Disease Lab, China-Japan Friendship Hospital, National Center for Respiratory Medicine, Institute of Respiratory Medicine, Chinese Academy of Medical Science, National Clinical Research Center of Respiratory Diseases, Beijing, China
| | - Marc Humbert
- Service de Pneumologie et Soins Intensifs, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP); Université Paris-Saclay; Inserm UMR_S 999, Le Kremlin Bicêtre, France
| | - Michal Shteinberg
- Pulmonology institute and CF Center, Carmel Medical Center and the Technion-Israel Institute of Technology, Haifa, Israel
| | - Katerina M Antoniou
- Laboratory of Molecular and Cellular Pneumonology, Department of Respiratory Medicine, School of Medicine, University of Crete, Heraklion, Greece
| | - Charlotte Suppli Ulrik
- Department of Respiratory Medicine, Copenhagen University Hospital-Hvidovre Hospital, Hvidovre, Denmark
| | | | - Chen Wang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center of Respiratory Diseases, Beijing, China
| | | | - Jieming Qu
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Shanghai, China
- Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Daiana Stolz
- Clinic of Respiratory Medicine and Pulmonary Cell Research, University Hospital Basel, Basel, Switzerland
- Clinic of Respiratory Medicine, Medical Center - University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | - Tobias Welte
- Medizinische Hochschule Hannover, Direktor der Abteilung Pneumologie, Hannover, Germany
| | - Stefano Aliberti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- IRCCS Humanitas Research Hospital, Respiratory Unit, Rozzano, Italy
| | - Anita K Simonds
- Sleep and Ventilation Unit, Royal Brompton and Harefield Hospital, Guys and St Thomas NHS Foundation Trust, London, UK
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University Bern, Bern, Switzerland
| | - Nicolas Roche
- Respiratory Medicine, Cochin Hospital, APHP Centre-University of Paris, Cochin Institute (INSERM UMR1016), Paris, France
- J.D. Chalmers and N. Roche are task force co-chairs
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Calabrese F, Pezzuto F, Fortarezza F, Boscolo A, Lunardi F, Giraudo C, Cattelan A, Del Vecchio C, Lorenzoni G, Vedovelli L, Sella N, Rossato M, Rea F, Vettor R, Plebani M, Cozzi E, Crisanti A, Navalesi P, Gregori D. Machine learning-based analysis of alveolar and vascular injury in SARS-CoV-2 acute respiratory failure. J Pathol 2021; 254:173-184. [PMID: 33626204 PMCID: PMC8014445 DOI: 10.1002/path.5653] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/12/2021] [Accepted: 02/19/2021] [Indexed: 01/08/2023]
Abstract
Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) pneumopathy is characterized by a complex clinical picture and heterogeneous pathological lesions, both involving alveolar and vascular components. The severity and distribution of morphological lesions associated with SARS-CoV-2 and how they relate to clinical, laboratory, and radiological data have not yet been studied systematically. The main goals of the present study were to objectively identify pathological phenotypes and factors that, in addition to SARS-CoV-2, may influence their occurrence. Lungs from 26 patients who died from SARS-CoV-2 acute respiratory failure were comprehensively analysed. Robust machine learning techniques were implemented to obtain a global pathological score to distinguish phenotypes with prevalent vascular or alveolar injury. The score was then analysed to assess its possible correlation with clinical, laboratory, radiological, and tissue viral data. Furthermore, an exploratory random forest algorithm was developed to identify the most discriminative clinical characteristics at hospital admission that might predict pathological phenotypes of SARS-CoV-2. Vascular injury phenotype was observed in most cases being consistently present as pure form or in combination with alveolar injury. Phenotypes with more severe alveolar injury showed significantly more frequent tracheal intubation; longer invasive mechanical ventilation, illness duration, intensive care unit or hospital ward stay; and lower tissue viral quantity (p < 0.001). Furthermore, in this phenotype, superimposed infections, tumours, and aspiration pneumonia were also more frequent (p < 0.001). Random forest algorithm identified some clinical features at admission (body mass index, white blood cells, D-dimer, lymphocyte and platelet counts, fever, respiratory rate, and PaCO2 ) to stratify patients into different clinical clusters and potential pathological phenotypes (a web-app for score assessment has also been developed; https://r-ubesp.dctv.unipd.it/shiny/AVI-Score/). In SARS-CoV-2 positive patients, alveolar injury is often associated with other factors in addition to viral infection. Identifying phenotypical patterns at admission may enable a better stratification of patients, ultimately favouring the most appropriate management. © 2021 The Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.
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Affiliation(s)
- Fiorella Calabrese
- Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua Medical School, Padua, Italy
| | - Federica Pezzuto
- Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua Medical School, Padua, Italy
| | - Francesco Fortarezza
- Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua Medical School, Padua, Italy
| | - Annalisa Boscolo
- Department of Medicine, University of Padua Medical School, Padua, Italy
| | - Francesca Lunardi
- Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua Medical School, Padua, Italy
| | - Chiara Giraudo
- Department of Medicine, University of Padua Medical School, Padua, Italy
| | - Annamaria Cattelan
- Department of Medicine, University of Padua Medical School, Padua, Italy
| | - Claudia Del Vecchio
- Department of Molecular Medicine, University of Padua Medical School, Padua, Italy
| | - Giulia Lorenzoni
- Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua Medical School, Padua, Italy
| | - Luca Vedovelli
- Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua Medical School, Padua, Italy
| | - Nicolò Sella
- Department of Medicine, University of Padua Medical School, Padua, Italy
| | - Marco Rossato
- Department of Medicine, University of Padua Medical School, Padua, Italy
| | - Federico Rea
- Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua Medical School, Padua, Italy
| | - Roberto Vettor
- Department of Medicine, University of Padua Medical School, Padua, Italy
| | - Mario Plebani
- Department of Medicine, University of Padua Medical School, Padua, Italy
| | - Emanuele Cozzi
- Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua Medical School, Padua, Italy
| | - Andrea Crisanti
- Department of Molecular Medicine, University of Padua Medical School, Padua, Italy
| | - Paolo Navalesi
- Department of Medicine, University of Padua Medical School, Padua, Italy
| | - Dario Gregori
- Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua Medical School, Padua, Italy
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Tescione M, Vadalà E, Marano G, Bruni A, Garofalo E, Lavalle O, Longhini F, Battaglia E, Polimeni N, Labate D, Caracciolo S, Giordano F, Caracciolo M, Macheda S. Aggregometry and thromboelastography to identify the timing to trach a COVID-19 patient receiving both antiplatelet therapy and enoxaparin. Clin Case Rep 2021; 9:1049-1054. [PMID: 33768781 PMCID: PMC7981626 DOI: 10.1002/ccr3.3442] [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] [Received: 06/29/2020] [Revised: 09/16/2020] [Accepted: 10/04/2020] [Indexed: 01/08/2023] Open
Abstract
In COVID-19 patients receiving enoxaparin and antiplatelets therapy, aggregometry and thromboelastography might be considered an adjunctive tool to identify the time to perform procedures at risk of bleeding, such as tracheostomy.
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Affiliation(s)
- Marco Tescione
- Anesthesia and Intensive Care UnitGrande Ospedale MetropolitanoReggio CalabriaItaly
| | - Eugenio Vadalà
- Anesthesia and Intensive Care UnitGrande Ospedale MetropolitanoReggio CalabriaItaly
| | - Graziella Marano
- Anesthesia and Intensive Care UnitGrande Ospedale MetropolitanoReggio CalabriaItaly
| | - Andrea Bruni
- Anesthesia and Intensive CareDepartment of Medical and Surgical SciencesMagna Graecia UniversityCatanzaroItaly
| | - Eugenio Garofalo
- Anesthesia and Intensive CareDepartment of Medical and Surgical SciencesMagna Graecia UniversityCatanzaroItaly
| | - Ovidia Lavalle
- Anesthesia and Intensive CareDepartment of Medical and Surgical SciencesMagna Graecia UniversityCatanzaroItaly
| | - Federico Longhini
- Anesthesia and Intensive CareDepartment of Medical and Surgical SciencesMagna Graecia UniversityCatanzaroItaly
| | - Enzo Battaglia
- Anesthesia and Intensive Care UnitGrande Ospedale MetropolitanoReggio CalabriaItaly
| | - Nicola Polimeni
- Anesthesia and Intensive Care UnitGrande Ospedale MetropolitanoReggio CalabriaItaly
| | - Demetrio Labate
- Anesthesia and Intensive Care UnitGrande Ospedale MetropolitanoReggio CalabriaItaly
| | - Sarah Caracciolo
- Emergency and Acceptance DepartmentGrande Ospedale MetropolitanoReggio CalabriaItaly
| | - Francesco Giordano
- Anesthesia and Intensive Care UnitGrande Ospedale MetropolitanoReggio CalabriaItaly
| | - Massimo Caracciolo
- Anesthesia and Intensive Care UnitGrande Ospedale MetropolitanoReggio CalabriaItaly
| | - Sebastiano Macheda
- Anesthesia and Intensive Care UnitGrande Ospedale MetropolitanoReggio CalabriaItaly
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31
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Coppadoro A, Benini A, Fruscio R, Verga L, Mazzola P, Bellelli G, Carbone M, Mulinacci G, Soria A, Noè B, Beck E, Di Sciacca R, Ippolito D, Citerio G, Valsecchi MG, Biondi A, Pesci A, Bonfanti P, Gaudesi D, Bellani G, Foti G. Helmet CPAP to treat hypoxic pneumonia outside the ICU: an observational study during the COVID-19 outbreak. Crit Care 2021; 25:80. [PMID: 33627169 PMCID: PMC7903369 DOI: 10.1186/s13054-021-03502-y] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 02/10/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Respiratory failure due to COVID-19 pneumonia is associated with high mortality and may overwhelm health care systems, due to the surge of patients requiring advanced respiratory support. Shortage of intensive care unit (ICU) beds required many patients to be treated outside the ICU despite severe gas exchange impairment. Helmet is an effective interface to provide continuous positive airway pressure (CPAP) noninvasively. We report data about the usefulness of helmet CPAP during pandemic, either as treatment, a bridge to intubation or a rescue therapy for patients with care limitations (DNI). METHODS In this observational study we collected data regarding patients failing standard oxygen therapy (i.e., non-rebreathing mask) due to COVID-19 pneumonia treated with a free flow helmet CPAP system. Patients' data were recorded before, at initiation of CPAP treatment and once a day, thereafter. CPAP failure was defined as a composite outcome of intubation or death. RESULTS A total of 306 patients were included; 42% were deemed as DNI. Helmet CPAP treatment was successful in 69% of the full treatment and 28% of the DNI patients (P < 0.001). With helmet CPAP, PaO2/FiO2 ratio doubled from about 100 to 200 mmHg (P < 0.001); respiratory rate decreased from 28 [22-32] to 24 [20-29] breaths per minute, P < 0.001). C-reactive protein, time to oxygen mask failure, age, PaO2/FiO2 during CPAP, number of comorbidities were independently associated with CPAP failure. Helmet CPAP was maintained for 6 [3-9] days, almost continuously during the first two days. None of the full treatment patients died before intubation in the wards. CONCLUSIONS Helmet CPAP treatment is feasible for several days outside the ICU, despite persistent impairment in gas exchange. It was used, without escalating to intubation, in the majority of full treatment patients after standard oxygen therapy failed. DNI patients could benefit from helmet CPAP as rescue therapy to improve survival. TRIAL REGISTRATION NCT04424992.
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Affiliation(s)
- Andrea Coppadoro
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
| | - Annalisa Benini
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
| | - Robert Fruscio
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
- grid.7563.70000 0001 2174 1754Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB Italy
| | - Luisa Verga
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
| | - Paolo Mazzola
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
- grid.7563.70000 0001 2174 1754Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB Italy
| | - Giuseppe Bellelli
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
- grid.7563.70000 0001 2174 1754Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB Italy
| | - Marco Carbone
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
- grid.7563.70000 0001 2174 1754Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB Italy
| | - Giacomo Mulinacci
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
- grid.7563.70000 0001 2174 1754Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB Italy
| | - Alessandro Soria
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
| | - Beatrice Noè
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
- grid.7563.70000 0001 2174 1754Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB Italy
| | - Eduardo Beck
- grid.413643.70000 0004 1760 8047ASST Monza, Desio Hospital, Desio, Italy
| | - Riccardo Di Sciacca
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
| | - Davide Ippolito
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
| | - Giuseppe Citerio
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
- grid.7563.70000 0001 2174 1754Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB Italy
| | - Maria Grazia Valsecchi
- grid.7563.70000 0001 2174 1754Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB Italy
| | - Andrea Biondi
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
- grid.7563.70000 0001 2174 1754Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB Italy
| | - Alberto Pesci
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
- grid.7563.70000 0001 2174 1754Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB Italy
| | - Paolo Bonfanti
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
- grid.7563.70000 0001 2174 1754Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB Italy
| | - Davide Gaudesi
- grid.7563.70000 0001 2174 1754Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB Italy
| | - Giacomo Bellani
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
- grid.7563.70000 0001 2174 1754Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB Italy
| | - Giuseppe Foti
- grid.415025.70000 0004 1756 8604ASST Monza, San Gerardo Hospital, Monza, Italy
- grid.7563.70000 0001 2174 1754Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB Italy
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Kebapcı A, Kütük K, Eker E. Case study: An older COVID-19 patient in a Turkish intensive care unit with prolonged stay. Nurs Crit Care 2021; 27:628-634. [PMID: 33569898 PMCID: PMC8014747 DOI: 10.1111/nicc.12602] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 01/23/2021] [Accepted: 01/26/2021] [Indexed: 12/17/2022]
Abstract
This paper reports the presentation and management of an older female patient who was diagnosed with Coronavirus disease (COVID-19) and discharged from an intensive care unit (ICU) after prolonged hospitalization. The patient's COVID-19 test was negative; therefore, she was monitored in the COVID-19 general clinic with normal levels of oxygen saturation (SpO2 ). The patient had been taking Plaquenil for rheumatoid arthritis for a long time. Azithromycin was administered first, and then, the treatment continued with favipiravir according to the national treatment protocol in Turkey. On the third day in the COVID-19 general clinic, she was transferred to the ICU because of decreased saturation levels. Owing to worsening respiratory status and SpO2 <70%, the patient was intubated on the sixth day in the ICU, and every day, she was nursed in a prone position for >16 hours. We believe that the treatment and care activities under qualified and effective nursing care, such as providing appropriate respiratory support at the right time, early initiation and maintenance of anticoagulant therapy, long-term prone positioning, maintaining sufficient fluid resuscitation, and early commencement of balanced enteral nutrition, contributed to the successful discharge of the patient from the ICU. The patient was finally extubated on the 23rd day. Respiratory support was continued with oxygen administered at 2 lt/min through a nasal canula with SpO2 at 94%. We believe that by combining all these factors, the patient's results improved. She was discharged from the ICU after 25 days without any organ dysfunction. During the 25 days of care in the ICU, infectious disease protection and isolation rules were strictly adhered to, and personal protective equipment was worn.
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Affiliation(s)
- Ayda Kebapcı
- Koç University School of Nursing, Istanbul, Turkey
| | - Kübra Kütük
- Koç University Hospital, Adult Intensive Care Unit, Istanbul, Turkey
| | - Emine Eker
- Koç University Hospital, Adult Intensive Care Unit, Istanbul, Turkey
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33
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Amirfarzan H, Cereda M, Gaulton TG, Leissner KB, Cortegiani A, Schumann R, Gregoretti C. Use of Helmet CPAP in COVID-19 - A practical review. Pulmonology 2021; 27:413-422. [PMID: 33583765 PMCID: PMC7849604 DOI: 10.1016/j.pulmoe.2021.01.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/22/2021] [Accepted: 01/23/2021] [Indexed: 01/15/2023] Open
Abstract
Helmet CPAP (H-CPAP) has been recommended in many guidelines as a noninvasive respiratory support during COVID-19 pandemic in many countries around the world. It has the least amount of particle dispersion and air contamination among all noninvasive devices and may mitigate the ICU bed shortage during a COVID surge as well as a decreased need for intubation/mechanical ventilation. It can be attached to many oxygen delivery sources. The MaxVenturi setup is preferred as it allows for natural humidification, low noise burden, and easy transition to HFNC during breaks and it is the recommended transport set-up. The patients can safely be proned with the helmet. It can also be used to wean the patients from invasive mechanical ventilation. Our article reviews in depth the pathophysiology of COVID-19 ARDS, provides rationale of using H-CPAP, suggests a respiratory failure algorithm, guides through its setup and discusses the issues and concerns around using it.
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Affiliation(s)
- H Amirfarzan
- Tufts University School of Medicine, VA Boston Healthcare System, Anesthesiology and Perioperative Medicine, United States.
| | - M Cereda
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, 3400 Spruce St, Dulles Bldg, Floor 7, Philadelphia, PA 19104, United States.
| | - T G Gaulton
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, 3400 Spruce St, Dulles Bldg, Floor 7, Philadelphia, PA 19104, United States.
| | - K B Leissner
- Harvard Medical School, VA Boston Healthcare System, Anesthesiology and Perioperative Medicine, United States.
| | - A Cortegiani
- Departmentof Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Italy; Department of Anesthesia Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo, Italy.
| | - R Schumann
- Tufts University School of Medicine, VA Boston Healthcare System, Anesthesiology and Perioperative Medicine, United States.
| | - C Gregoretti
- Departmentof Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Italy; Fondazione 'Giglio', Cefalù, Italy.
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Stephani C, Herrmann P, Ritter CO, Lotz J, Saager L, Meissner K, Moerer O. Anatomic lung recruitment in the early phase of severe COVID-19-pneumonia. Pulmonology 2021; 27:345-347. [PMID: 33551267 PMCID: PMC7825885 DOI: 10.1016/j.pulmoe.2020.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/19/2020] [Accepted: 12/30/2020] [Indexed: 11/09/2022] Open
Affiliation(s)
- C Stephani
- Department for Anesthesiology, University Medical Center Göttingen, Robert-Koch-Strasse 40, 37075 Göttingen, Germany
| | - P Herrmann
- Department for Anesthesiology, University Medical Center Göttingen, Robert-Koch-Strasse 40, 37075 Göttingen, Germany
| | - C O Ritter
- Institute for Diagnostic and Interventional Radiology, University Medical Center Göttingen, Robert-Koch-Strasse 40, 37075 Göttingen, Germany
| | - J Lotz
- Institute for Diagnostic and Interventional Radiology, University Medical Center Göttingen, Robert-Koch-Strasse 40, 37075 Göttingen, Germany
| | - L Saager
- Department for Anesthesiology, University Medical Center Göttingen, Robert-Koch-Strasse 40, 37075 Göttingen, Germany
| | - K Meissner
- Department for Anesthesiology, University Medical Center Göttingen, Robert-Koch-Strasse 40, 37075 Göttingen, Germany
| | - O Moerer
- Department for Anesthesiology, University Medical Center Göttingen, Robert-Koch-Strasse 40, 37075 Göttingen, Germany.
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Tverring J, Åkesson A, Nielsen N. Helmet continuous positive airway pressure versus high-flow nasal cannula in COVID-19: a pragmatic randomised clinical trial (COVID HELMET). Trials 2020; 21:994. [PMID: 33272319 PMCID: PMC7711053 DOI: 10.1186/s13063-020-04863-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 11/03/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Patients with COVID-19 and hypoxaemia despite conventional low-flow oxygen therapy are often treated with high-flow nasal cannula (HFNC) in line with international guidelines. Oxygen delivery by helmet continuous positive airway pressure (CPAP) is a feasible option that enables a higher positive end-expiratory pressure (PEEP) and may theoretically reduce the need for intubation compared to HFNC but direct comparative evidence is lacking. METHODS We plan to perform an investigator-initiated, pragmatic, randomised trial at an intermediate-level COVID-19 cohort ward in Helsingborg Hospital, southern Sweden. We have estimated a required sample size of 120 patients randomised 1:1 to HFNC or Helmet CPAP to achieve 90% power to detect superiority at a 0.05 significance level regarding the primary outcome of ventilator free days (VFD) within 28 days using a Mann-Whitney U test. Patient recruitment is planned to being June 2020 and be completed in the first half of 2021. DISCUSSION We hypothesise that the use of Helmet CPAP will reduce the need for invasive mechanical ventilation compared to the use of HFNC without having a negative effect on survival. This could have important implications during the current COVID-19 epidemic. TRIAL REGISTRATION ClinicalTrials.gov NCT04395807 . Registered on 20 May 2020.
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Affiliation(s)
| | - Anna Åkesson
- Lunds universitet Medicinska fakulteten, Lund, Sweden
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36
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Donzelli M, Ippolito M, Catalisano G, Renda B, Tarantino F, Diquattro O, Cortegiani A. Prone positioning and convalescent plasma therapy in a critically ill pregnant woman with COVID-19. Clin Case Rep 2020; 8:3352-3358. [PMID: 33363933 PMCID: PMC7752326 DOI: 10.1002/ccr3.3426] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 09/30/2020] [Accepted: 10/04/2020] [Indexed: 12/15/2022] Open
Abstract
Prone positioning is feasible in pregnancy and may have contributed to the positive outcome in this case. Doctors should not be reluctant to move a patient to a prone position just because they are pregnant.
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Affiliation(s)
- Massimo Donzelli
- Unità Operativa di Anestesiae RianimazioneAzienda Ospedaliera Ospedali Riuniti (AOOR) P.O. CervelloPalermoItaly
| | - Mariachiara Ippolito
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.)University of PalermoPalermoItaly
| | - Giulia Catalisano
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.)University of PalermoPalermoItaly
| | - Baldassare Renda
- Unità Operativa di Anestesiae RianimazioneAzienda Ospedaliera Ospedali Riuniti (AOOR) P.O. CervelloPalermoItaly
| | - Francesco Tarantino
- Unità Operativa di Anestesiae RianimazioneAzienda Ospedaliera Ospedali Riuniti (AOOR) P.O. CervelloPalermoItaly
| | - Orazia Diquattro
- Unità Operativa di MicrobiologiaAzienda Ospedaliera Ospedali Riuniti (AOOR)PalermoItaly
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.)University of PalermoPalermoItaly
- Department of Anesthesia, Intensive Care and EmergencyPoliclinico Paolo GiacconeUniversity of PalermoPalermoItaly
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Islam MM, Mahmud S, Muhammad LJ, Islam MR, Nooruddin S, Ayon SI. Wearable Technology to Assist the Patients Infected with Novel Coronavirus (COVID-19). ACTA ACUST UNITED AC 2020; 1:320. [PMID: 33063058 PMCID: PMC7528718 DOI: 10.1007/s42979-020-00335-4] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 09/17/2020] [Indexed: 02/06/2023]
Abstract
Wearable technology plays a significant role in our daily life as well as in the healthcare industry. The recent coronavirus pandemic has taken the world’s healthcare systems by surprise. Although trials of possible vaccines are underway, it would take a long time before the vaccines are permitted for public use. Most of the government efforts are currently geared towards preventing the spread of the coronavirus and predicting probable hot zones. The essential and healthcare workers are the most vulnerable towards coronavirus infections due to their required proximity to potential coronavirus patients. Wearable technology can potentially assist in these regards by providing real-time remote monitoring, symptoms prediction, contact tracing, etc. The goal of this paper is to discuss the different existing wearable monitoring devices (respiration rate, heart rate, temperature, and oxygen saturation) and respiratory support systems (ventilators, CPAP devices, and oxygen therapy) which are frequently used to assist the coronavirus affected people. The devices are described based on the services they provide, their working procedures as well as comparative analysis of their merits and demerits with cost. A comparative discussion with probable future trends is also drawn to select the best technology for COVID-19 infected patients. It is envisaged that wearable technology is only capable of providing initial treatment that can reduce the spread of this pandemic.
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Affiliation(s)
- Md Milon Islam
- Department of Computer Science and Engineering, Khulna University of Engineering & Technology, Khulna, 9203 Bangladesh
| | - Saifuddin Mahmud
- Department of Computer Science, Kent State University, Kent, Ohio USA
| | - L J Muhammad
- Department of Mathematics and Computer Science, Faculty of Science, Federal University of Kashere, P.M.B. 0182, Gombe, Nigeria
| | - Md Rabiul Islam
- Department of Electrical and Electronic Engineering, Bangladesh Army University of Engineering and Technology, Natore, 6431 Bangladesh
| | - Sheikh Nooruddin
- Department of Computer Science and Engineering, Khulna University of Engineering & Technology, Khulna, 9203 Bangladesh
| | - Safial Islam Ayon
- Department of Computer Science and Engineering, Green University of Bangladesh, Dhaka, 1207 Bangladesh
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Moscarelli A, Iozzo P, Ippolito M, Catalisano G, Gregoretti C, Giarratano A, Baldi E, Cortegiani A. Cardiopulmonary resuscitation in prone position: A scoping review. Am J Emerg Med 2020; 38:2416-2424. [PMID: 33046293 PMCID: PMC7481259 DOI: 10.1016/j.ajem.2020.08.097] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/28/2020] [Accepted: 08/30/2020] [Indexed: 11/28/2022] Open
Abstract
Introduction The ongoing pandemic of COVID-19 brought to the fore prone positioning as treatment for patients with acute respiratory failure. With the increasing number of patients in prone position, both spontaneously breathing and mechanically ventilated, cardiac arrest in this position is more likely to occur. This scoping review aimed to summarize the available evidence on cardiopulmonary resuscitation in prone position (‘reverse CPR’) and knowledge or research gaps to be further evaluated. The protocol of this scoping review was prospectively registered on 10th May 2020 in Open Science Framework (https://osf.io/nfuh9). Methods We searched PubMed, EMBASE, MEDLINE and pre-print repositories (bioRxiv and medRxiv) for simulation, pre-clinical and clinical studies on reverse CPR until 31st May 2020. Results We included 1 study on manikins, 31 case reports (29 during surgery requiring prone position) and 2 nonrandomized studies describing reverse CPR. No studies were found regarding reverse CPR in patients with COVID-19. Conclusions Even if the algorithms provided by the guidelines on basic and advanced life support remain valid in cardiac arrest in prone position, differences exist in the methods of performing CPR. There is no clear evidence of superiority in terms of effectiveness of reverse compared to supine CPR in patients with cardiac arrest occurring in prone position. The quality of evidence is low and knowledge gaps (e.g. protocols, training of healthcare personnel, devices for skill acquisition) should be fulfilled by further research. Meanwhile, a case-by-case evaluation of patient and setting characteristics should guide the decision on how to start CPR in such cases. Prone positioning has been used in patients with COVID-19 An increasing number of cardiac arrests is expected to occur in prone position There is no clear evidence of superiority of reverse compared to supine cardiopulmonary resuscitation Knowledge gaps should be fulfilled by further research
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Affiliation(s)
- Alessandra Moscarelli
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Italy
| | - Pasquale Iozzo
- Department of Anesthesia, Intensive Care, and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
| | - Mariachiara Ippolito
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Italy
| | - Giulia Catalisano
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Italy
| | - Cesare Gregoretti
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Italy; Fondazione "Giglio" Cefalù, Palermo, Italy
| | - Antonino Giarratano
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Italy; Department of Anesthesia, Intensive Care, and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
| | - Enrico Baldi
- Cardiac Intensive Care Unit, Arrhythmia and Electrophysiology and Experimental Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Molecular Medicine, Section of Cardiology, University of Pavia, Pavia, Italy
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Italy; Department of Anesthesia, Intensive Care, and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy.
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Vitacca M, Migliori GB, Spanevello A, Melazzini MG, Ambrosino N, Ceriana P, Fanfulla F, Braghiroli A, Fracchia C, Balbi B. Management and outcomes of post-acute COVID-19 patients in Northern Italy. Eur J Intern Med 2020; 78:159-160. [PMID: 32532661 PMCID: PMC7283058 DOI: 10.1016/j.ejim.2020.06.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/01/2020] [Accepted: 06/04/2020] [Indexed: 12/25/2022]
Affiliation(s)
- Michele Vitacca
- Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation of the Institute of Lumezzane, Brescia, Italy.
| | - Giovanni Battista Migliori
- Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation of the Institute of Tradate, Varese, Italy
| | - Antonio Spanevello
- Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation of the Institute of Tradate, Varese, Italy; MACRO, University of Insubria, Tradate, Varese, Italy
| | | | - Nicolino Ambrosino
- Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation of the Institute of Montescano, Pavia, Italy
| | - Piero Ceriana
- Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation of the Institute of Pavia, Italy
| | - Francesco Fanfulla
- Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation of the Institute of Pavia, Italy
| | - Alberto Braghiroli
- Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation of the Institute of Veruno, Novara, Italy
| | - Claudio Fracchia
- Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation of the Institute of Montescano, Pavia, Italy
| | - Bruno Balbi
- Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation of the Institute of Veruno, Novara, Italy
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Bruni A, Garofalo E, Zuccalà V, Currò G, Torti C, Navarra G, De Sarro G, Navalesi P, Longhini F, Ammendola M. Histopathological findings in a COVID-19 patient affected by ischemic gangrenous cholecystitis. World J Emerg Surg 2020; 15:43. [PMID: 32615987 PMCID: PMC7330255 DOI: 10.1186/s13017-020-00320-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 06/14/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Since its first documentation, a novel coronavirus (SARS-CoV-2) infection has emerged worldwide, with the consequent declaration of a pandemic disease (COVID-19). Severe forms of acute respiratory failure can develop. In addition, SARS-CoV-2 may affect organs other than the lung, such as the liver, with frequent onset of late cholestasis. We here report the histological findings of a COVID-19 patient, affected by a tardive complication of acute ischemic and gangrenous cholecystitis with a perforated and relaxed gallbladder needing urgent surgery. CASE PRESENTATION A 59-year-old Caucasian male, affected by acute respiratory failure secondary to SARS-CoV-2 infection was admitted to our intensive care unit (ICU). Due to the severity of the disease, invasive mechanical ventilation was instituted and SARS-CoV-2 treatment (azithromycin 250 mg once-daily and hydroxychloroquine 200 mg trice-daily) started. Enoxaparin 8000 IU twice-daily was also administered subcutaneously. At day 8 of ICU admission, the clinical condition improved and patient was extubated. At day 32, patient revealed abdominal pain without signs of peritonism at examination, with increased inflammatory and cholestasis indexes at blood tests. At a first abdominal CT scan, perihepatic effusion and a relaxed gallbladder with dense content were detected. The surgeon decided to wait and see the evolution of clinical conditions. The day after, conditions further worsened and a laparotomic cholecystectomy was performed. A relaxed and perforated ischemic gangrenous gallbladder, with a local tissue inflammation and perihepatic fluid, was intraoperatively met. The gallbladder and a sample of omentum, adherent to the gallbladder, were also sent for histological examination. Hematoxylin-eosin-stained slides display inflammatory infiltration and endoluminal obliteration of vessels, with wall breakthrough, hemorrhagic infarction, and nerve hypertrophy of the gallbladder. The mucosa of the gallbladder appears also atrophic. Omentum vessels also appear largely thrombosed. Immunohistochemistry demonstrates an endothelial overexpression of medium-size vessels (anti-CD31), while not in micro-vessels, with a remarkable activity of macrophages (anti-CD68) and T helper lymphocytes (anti-CD4) against gallbladder vessels. All these findings define a histological diagnosis of vasculitis of the gallbladder. CONCLUSIONS Ischemic gangrenous cholecystitis can be a tardive complication of COVID-19, and it is characterized by a dysregulated host inflammatory response and thrombosis of medium-size vessels.
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Affiliation(s)
- Andrea Bruni
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Eugenio Garofalo
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Valeria Zuccalà
- Pathology Unit, "Pugliese-Ciaccio" Hospital, Viale Pio X°, 88100, Catanzaro, Italy
| | - Giuseppe Currò
- Digestive Surgery Unit, Department of Science of Health, "Magna Graecia" University, Catanzaro, Italy
- Surgical Oncology Division, Department of Human Pathology of Adult and Evolutive Age, University Hospital of Messina, Messina, Italy
| | - Carlo Torti
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Giuseppe Navarra
- Surgical Oncology Division, Department of Human Pathology of Adult and Evolutive Age, University Hospital of Messina, Messina, Italy
| | - Giovambattista De Sarro
- Clinical Pharmacology and Pharmacovigilance Unit, Department of Science of Health, "Magna Graecia" University, Catanzaro, Italy
| | - Paolo Navalesi
- Institute of Anesthesia and Intensive Care, Department of Medicine, University of Padua, Padua, Italy
| | - Federico Longhini
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy.
| | - Michele Ammendola
- Digestive Surgery Unit, Department of Science of Health, "Magna Graecia" University, Catanzaro, Italy
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