Clinical Consensus Recommendations Regarding Non-Invasive Respiratory Support in the Adult Patient with Acute Respiratory Failure Secondary to SARS-CoV-2 infection

Effect of Nebuliser and Patient Interface Type on Fugitive Medical Aerosol Emissions in Adult and Paediatric Patients

BACKGROUND

Open circuit aerosol therapy is associated with the potential for fugitive emissions of medical aerosol. Various nebulisers and interfaces are used in respiratory treatments, including the recent consideration of filtered interfaces. This study aims to quantify fugitive medical aerosols from various nebuliser types, in conjunction with different filtered and non-filtered interfaces.

METHODS

For both simulated adult and paediatric breathing, four nebuliser types were assessed including; a small volume jet nebuliser (SVN), a breath enhanced jet nebuliser (BEN), a breath actuated jet nebuliser (BAN) and a vibrating mesh nebuliser (VMN). A combination of different interfaces were used including filtered and unfiltered mouthpieces, as well as open, valved and filtered facemasks. Aerosol mass concentrations were measured using an Aerodynamic Particle Sizer at 0.8 m and 2.0 m. Additionally, inhaled dose was assessed.

RESULTS

Highest mass concentrations recorded were 214 (177, 262) µg m^-3 at 0.8 m over 45-minute run. The highest and lowest fugitive emissions were observed for the adult SVN facemask combination, and the adult BAN filtered mouthpiece combination respectively. Fugitive emissions decreased when using breath-actuated (BA) mode compared to continuous (CN) mode on the BAN for the adult and paediatric mouthpiece combination. Lower fugitive emissions were observed when a filtered facemask or mouthpiece was used, compared to unfiltered scenarios. For the simulated adult, highest and lowest inhaled dose were 45.1 (42.6, 45.6)% and 11.0 (10.1,11.9)% for the VMN and SVN respectively. For the simulated paediatric, highest and lowest inhaled dose were 44.0 (42.4, 44.8)% and 6.1 (5.9, 7.0)% for the VMN and BAN CN respectively. Potential inhalation exposure of albuterol was calculated to be up to 0.11 µg and 0.12 µg for a bystander and healthcare worker respectively.

CONCLUSION

This work demonstrates the need for filtered interfaces in clinical and homecare settings to minimise fugitive emissions and to reduce the risk of secondary exposure to care givers.

Principio de proporcionalidad terapéutica en la decisión de intubación orotraqueal y ventilación mecánica invasiva en paciente COVID-19 grave

En medicina cuando se aplica el principio de proporcionalidad terapéutica se valoran los medios empleados y el fin previsible en cada paciente. Y se distingue entre tratamientos proporcionados o desproporcionados, valorando el beneficio y utilidad. Entre ellos su aplicación en el paciente COVID-19 grave que requiere intubación orotraqueal y ventilación mecánica invasiva. En ocasiones nos puede generar el dilema ético de proceder a realizar dicho procedimiento y no encontrar beneficio alguno, sino al contrario generar sufrimiento, dolor y prolongación de su posible agonía. Teniendo el deber ético en estos casos de no abandonar sino acompañar a través de los cuidados paliativos, siempre informando al familiar sobre la decisión que se tome. El analizar este principio de proporcionalidad terapéutica y su aplicación en las unidades de cuidado intensivo requiere de una conciencia moral por parte del grupo que tiene la responsabilidad de la toma de la decisiòn y dirimir el dilema ético que se presente. Recordando que a los pacientes que requieran intubación orotraqueal se les deben ofrecer todas las medidas requeridas en ventilación mecánica invasiva y no invasiva para mejoría de la hipoxemia.

Se presenta un análisis y reflexión sobre el principio de proporcionalidad terapéutica y su fundamentación ética al igual que una revisión sistemática de la literatura médica relacionada con pacientes con COVID-19 en insuficiencia respiratoria aguda. Y se establecen unas consideraciones científicas y éticas a tener en cuenta en el paciente COVID-19. El principio de proporcionalidad terapéutica ante la decisión de intubación orotraqueal debe fundamentarse en un juicio de proporcionalidad, que garantice que se han hecho y utilizado todos los medios previsibles para evitar la intubación orotraqueal y como único fin útil para beneficiar al paciente será la ventilación mecánica invasiva.

[Severe SARS-CoV-2 infection: Clinical assessment and biomechanical functional evaluation one month after hospital discharge]

OBJECTIVE

To describe by an observational cross-sectional study the clinical and functional situation, at one month after hospital discharge, of patients admitted with COVID-19 in the hospital ICU between March and December 2020.

MATERIAL AND METHODS

59 patients were studied using different clinical scales and biomechanical analysis tests (hand dynamometry, fall risk assessment, gait and balance analysis).

RESULTS

At one month after discharge, patients reported persistent symptoms: dyspnea (47.5%), arthromyalgia (45%) and cough (22%). In the EQ-5D-5L questionnaire up to 73% of patients reported levels of anxiety or depression. 74.6% and 69.5% presented alterations in the strength of the right and left hand, respectively. The risk of falls in 38% of patients was moderate to very high. The somatosensory index remained within normal parameters, while the vestibular and, to a lesser extent, the visual indexes were altered. In gait, 81.4% of patients showed no abnormalities outside the normal range, with a normal average walking speed.

CONCLUSIONS

In the short term after severe COVID-19, patients have persistent symptomatology, anxiety/depression, impaired balance with increased risk of falls and loss of grip strength in both hands.

Noninvasive ventilation in patients with COVID-19 from the perspective of the risk of contamination: a narrative review

INTRODUCTION

noninvasive ventilation (NIV) can be a useful resource to treat acute respiratory failure (ARF), which occurs in patients with COVID-19. However, it is important to consider that there are still no clinical studies that have verified the safety of its use in increase of contamination.

AREAS COVERED

Given the potential benefits and simultaneous concerns over the use of NIV in patients with COVID-19, further inquiry is necessary to reach a clinical consensus and provide recommendations for safe use, avoiding contamination. In this context, this narrative review, which included articles published in the Embase, SciELO, PEDro, PubMed and Cochrane up to August 2021, is focused to evaluate available studies related to interfaces, types of circuits, recommended filters, cares for the environment and protective factors for NIV use in patients with COVID-19.

EXPERT OPINION

The studies analyzed recommend that the use of NIV can be safe: 1) with equipment that allows the use of the helmet as a safer interface; 2) with double circuit and antimicrobial filter in the expiratory branch; 3) in an environment that allows negative pressure, reducing the dispersion of aerosol particles in the environment; 4) the health team must use the recommended PPE to avoid contamination.

Role of respiratory intermediate care units during the SARS-CoV-2 pandemic

RATIONALE

The SARS-CoV2 pandemic increased exponentially the need for both Intensive (ICU) and Intermediate Care Units (RICU). The latter are of particular importance because they can play a dual role in critical and post-critical care of COVID-19 patients. Here, we describe the setup of 2 new RICUs in our institution to face the SARS-CoV-2 pandemic and discuss the clinical characteristics and outcomes of the patients attended.

METHODS

Retrospective analysis of the characteristics and outcomes of COVID-19 patients admitted to 2 new RICUs built specifically in our institution to face the first wave of the SARS-CoV-2 pandemic, from April 1 until May 30, 2020.

RESULTS

During this period, 106 COVID-19 patients were admitted to these 2 RICUs, 65 of them (61%) transferred from an ICU (step-down) and 41 (39%) from the ward or emergency room (step-up). Most of them (72%) were male and mean age was 66 ± 12 years. 31% of them required support with oxygen therapy via high-flow nasal cannula (HFNC) and 14% non-invasive ventilation (NIV). 42 of the 65 patients stepping down (65%) had a previous tracheostomy performed and most of them (74%) were successfully decannulated during their stay in the RICU. Length of stay was 7 [4-11] days. 90-day mortality was 19% being significantly higher in stepping up patients than in those transferred from the ICU (25 vs. 10% respectively; p < 0.001).

CONCLUSIONS

RICUs are a valuable hospital resource to respond to the challenges of the SARS-CoV-2 pandemic both to treat deteriorating and recovering COVID-19 patients.

Symptom clusters in COVID-19: A potential clinical prediction tool from the COVID Symptom Study app

As no one symptom can predict disease severity or the need for dedicated medical support in coronavirus disease 2019 (COVID-19), we asked whether documenting symptom time series over the first few days informs outcome. Unsupervised time series clustering over symptom presentation was performed on data collected from a training dataset of completed cases enlisted early from the COVID Symptom Study Smartphone application, yielding six distinct symptom presentations. Clustering was validated on an independent replication dataset between 1 and 28 May 2020. Using the first 5 days of symptom logging, the ROC-AUC (receiver operating characteristic - area under the curve) of need for respiratory support was 78.8%, substantially outperforming personal characteristics alone (ROC-AUC 69.5%). Such an approach could be used to monitor at-risk patients and predict medical resource requirements days before they are required.

[Spanish consensus document on diagnosis, stabilisation and treatment of pediatric multisystem inflammatory syndrome related to SARS-CoV-2 (SIM-PedS)]

A new paediatric multisystem inflammatory syndrome, linked to SARS-CoV-2, has been described. The clinical picture is variable and is associated with an active or recent infection due to SARS-CoV-2. A review of the existing literature by a multidisciplinary group of paediatric specialists is presented in this document. Later, they make recommendations on the stabilisation, diagnosis, and treatment of this syndrome.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Awake prone positioning does not reduce the risk of intubation in COVID-19 treated with high-flow nasal oxygen therapy: a multicenter, adjusted cohort study

Background

Awake prone positioning (awake-PP) in non-intubated coronavirus disease 2019 (COVID-19) patients could avoid endotracheal intubation, reduce the use of critical care resources, and improve survival. We aimed to examine whether the combination of high-flow nasal oxygen therapy (HFNO) with awake-PP prevents the need for intubation when compared to HFNO alone.

Methods

Prospective, multicenter, adjusted observational cohort study in consecutive COVID-19 patients with acute respiratory failure (ARF) receiving respiratory support with HFNO from 12 March to 9 June 2020. Patients were classified as HFNO with or without awake-PP. Logistic models were fitted to predict treatment at baseline using the following variables: age, sex, obesity, non-respiratory Sequential Organ Failure Assessment score, APACHE-II, C-reactive protein, days from symptoms onset to HFNO initiation, respiratory rate, and peripheral oxyhemoglobin saturation. We compared data on demographics, vital signs, laboratory markers, need for invasive mechanical ventilation, days to intubation, ICU length of stay, and ICU mortality between HFNO patients with and without awake-PP.

Results

A total of 1076 patients with COVID-19 ARF were admitted, of which 199 patients received HFNO and were analyzed. Fifty-five (27.6%) were pronated during HFNO; 60 (41%) and 22 (40%) patients from the HFNO and HFNO + awake-PP groups were intubated. The use of awake-PP as an adjunctive therapy to HFNO did not reduce the risk of intubation [RR 0.87 (95% CI 0.53–1.43), p = 0.60]. Patients treated with HFNO + awake-PP showed a trend for delay in intubation compared to HFNO alone [median 1 (interquartile range, IQR 1.0–2.5) vs 2 IQR 1.0–3.0] days (p = 0.055), but awake-PP did not affect 28-day mortality [RR 1.04 (95% CI 0.40–2.72), p = 0.92].

Conclusion

In patients with COVID-19 ARF treated with HFNO, the use of awake-PP did not reduce the need for intubation or affect mortality.

Neuroprotective immunity by essential nutrient "Choline" for the prevention of SARS CoV2 infections: An in silico study by molecular dynamics approach

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Prenatal Choline level protects the fetus's developing brain from effects of CoV2.

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Choline from many food supplements can protect the fetus from Coronavirus.

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Choline is used for treatment of many neurodegenerative diseases like Alzheimer.

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Natural Choline may regulate 3CL^pro protein’s viral replication.

Prenatal COVID infection is one of the worst affected and least attended aspects of the COVID-19 disease. Like other coronaviruses, CoV2 infection is anticipated to affect fetal development by maternal inflammatory response on the fetus and placenta. Studies showed that higher prenatal choline level in mother’s body can safeguard the developing brain of the fetus from the adverse effects of CoV2 infection. Choline is commonly used as food supplement. By virtual screening, molecular docking and molecular dynamics techniques, we have established a strong inhibitory possibility of choline for SARS 3CL^pro protease which may provide a lead for prenatal COVID-19 treatment.