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Bosso G, Sansone G, Papillo M, Giaquinto A, Orefice S, Allegorico E, Serra C, Minerva V, Mercurio V, Cannavacciuolo F, Dello Vicario F, Porta G, Pagano A, Numis FG. Lung ultrasound-guided PEEP titration in COVID-19 patients treated with CPAP. J Basic Clin Physiol Pharmacol 2023; 34:677-682. [PMID: 37463298 DOI: 10.1515/jbcpp-2023-0165] [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: 07/01/2023] [Accepted: 07/06/2023] [Indexed: 07/20/2023]
Abstract
OBJECTIVES An increasing number of COVID-19 patients were treated with continuous positive airways pressure (CPAP). To evaluate the clinical effects of personalized positive end-expiratory pressure (PEEP) compared to standard fixed PEEP in COVID-19 patients requiring CPAP. METHODS This is a single center, prospective, randomized clinical study. Sixty-three COVID-19 patients with hypoxemic respiratory failure and bilateral pneumonia were randomized in two Groups: Group A received CPAP with fixed PEEP of 10 cm H2O, Group B performed the "PEEP trial", that consists in the evaluation of best PEEP defined as the PEEP value that precedes the echographic appearance of "lung pulse" determining a PaO2/FiO2 increase. Primary outcome was composite in-hospital mortality + intubation, secondary outcome was the percentage increase of PaO2/FiO2. As safety indicator, the incidence of pneumothorax was collected. RESULTS Thirty-two patients were enrolled in Group A and 31 in Group B. The two groups were comparable for clinical characteristics and laboratory parameters. The primary outcome occurred in 36 (57.1 %) patients: 23 (71.8 %) in Group A and 13 (41.9 %) in Group B (p<0.01). Mortality was higher in Group A (53.1 vs. 19.3 %, p<0.01), while intubation rate was comparable between groups. Group B showed a higher PaO2/FiO2 increase than Group A (34.9 vs. 13.1 %, p<0.01). Five cases of pneumothorax were reported in Group A, none in Group B. CONCLUSIONS Lung ultrasound-guided PEEP trial is associated with lower mortality in COVID-19 patients treated with CPAP. Identifying the best PEEP is useful to increase oxygenation and reduce the incidence of complications.
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Affiliation(s)
- Giorgio Bosso
- Department of Emergency Medicine, COVID Care Unit, Santa Maria delle Grazie Hospital, Pozzuoli, Naples, Italy
| | - Gennaro Sansone
- Department of Emergency Medicine, COVID Care Unit, Santa Maria delle Grazie Hospital, Pozzuoli, Naples, Italy
| | - Martina Papillo
- Department of Emergency Medicine, COVID Care Unit, Santa Maria delle Grazie Hospital, Pozzuoli, Naples, Italy
| | - Alessandro Giaquinto
- Department of Emergency Medicine, COVID Care Unit, Santa Maria delle Grazie Hospital, Pozzuoli, Naples, Italy
| | - Silvia Orefice
- Department of Emergency Medicine, COVID Care Unit, Santa Maria delle Grazie Hospital, Pozzuoli, Naples, Italy
| | - Enrico Allegorico
- Department of Emergency Medicine, COVID Care Unit, Santa Maria delle Grazie Hospital, Pozzuoli, Naples, Italy
| | - Claudia Serra
- Department of Emergency Medicine, COVID Care Unit, Santa Maria delle Grazie Hospital, Pozzuoli, Naples, Italy
| | - Valentina Minerva
- Department of Emergency Medicine, COVID Care Unit, Santa Maria delle Grazie Hospital, Pozzuoli, Naples, Italy
| | - Valentina Mercurio
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | | | - Ferdinando Dello Vicario
- Department of Emergency Medicine, COVID Care Unit, Santa Maria delle Grazie Hospital, Pozzuoli, Naples, Italy
| | - Giovanni Porta
- Department of Emergency Medicine, COVID Care Unit, Santa Maria delle Grazie Hospital, Pozzuoli, Naples, Italy
| | - Antonio Pagano
- Department of Emergency Medicine, COVID Care Unit, Santa Maria delle Grazie Hospital, Pozzuoli, Naples, Italy
| | - Fabio Giuliano Numis
- Department of Emergency Medicine, COVID Care Unit, Santa Maria delle Grazie Hospital, Pozzuoli, Naples, Italy
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Patil VP, Rajput A. Finding Cost-effective Solutions: Need of the Hour. Indian J Crit Care Med 2022; 26:1163-1164. [PMID: 36873594 PMCID: PMC9983655 DOI: 10.5005/jp-journals-10071-24358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 10/21/2022] [Indexed: 11/06/2022] Open
Abstract
How to cite this article: Patil VP, Rajput A. Finding Cost-effective Solutions: Need of the Hour. Indian J Crit Care Med 2022;26(11):1163-1164.
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Affiliation(s)
- Vijaya Prakash Patil
- Department of Anaesthesia, Critical Care and Pain, Division of Clinical Anaesthesia, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Abhishek Rajput
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India
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Carrillo-Aleman L, Carrasco-Gónzalez E, Araújo MJ, Guia M, Alonso-Fernández N, Renedo-Villarroya A, López-Gómez L, Higon-Cañigral A, Sanchez-Nieto JM, Carrillo-Alcaraz A. Is hypocapnia a risk factor for non-invasive ventilation failure in cardiogenic acute pulmonary edema? J Crit Care 2022; 69:153991. [DOI: 10.1016/j.jcrc.2022.153991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 01/02/2022] [Accepted: 01/14/2022] [Indexed: 11/26/2022]
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Bosso G, Mercurio V, Diab N, Pagano A, Porta G, Allegorico E, Serra C, Guiotto G, Numis FG, Tocchetti CG, Schiraldi F. Time-weighted lactate as a predictor of adverse outcome in acute heart failure. ESC Heart Fail 2020; 8:539-545. [PMID: 33231918 PMCID: PMC7835560 DOI: 10.1002/ehf2.13112] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 10/16/2020] [Accepted: 10/29/2020] [Indexed: 12/28/2022] Open
Abstract
Aims The role of dynamic changes in lactate concentrations on prognosis in acute heart failure has been poorly investigated. The aim of this study was to explore the predictive value of 24 h time‐weighted lactate (LACTW) in patients with acute heart failure. Methods and results Ninety‐six consecutive acute heart failure patients presenting to the Emergency Department of San Paolo Hospital, Naples, Italy, were prospectively enrolled. Arterial blood lactate was measured at admission and during the following 24 h at random time intervals. LACTW was obtained by the sum of the average lactate values among consecutive time points multiplied by the intervals between consecutive time points and dividing the sum by the total time (24 h). The outcome was a composite of need of admission to the intensive care unit, hospitalization duration >7 days, or intra‐hospital death. Admission lactate, maximum measured lactate, and LACTW were collected. Univariate and multivariate Cox regression analysis was applied to determine the hazard ratio (HR) of developing the outcome. Forty‐three patients experienced the pre‐specified outcome. In sex‐adjusted and age‐adjusted multivariable analysis, LACTW predicted the outcome occurrence (HR: 1.51, 95% confidence interval: 1.24, 1.84, P < 0.001). Risk stratification analysis based on LACTW tertiles demonstrated a gradual increase in risk of developing the outcome (HR: 17.32, 95% confidence interval: 2.30, 130.23, P = 0.006) for the highest LACTW tertile. Conclusions In acute heart failure patients, 24 h LACTW had a significant independent predictive value for adverse intra‐hospital outcome. LACTW could be a useful index at identifying high‐risk patients who may require a more aggressive treatment during hospitalization.
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Affiliation(s)
- Giorgio Bosso
- Department of Emergency Medicine, Santa Maria delle Grazie Hospital, Pozzuoli, Italy
| | - Valentina Mercurio
- Department of Translational Medical Sciences, Federico II University, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Nermin Diab
- Department of Respirology, University of Toronto, Toronto, Ontario, Canada
| | - Antonio Pagano
- Department of Emergency Medicine, Santa Maria delle Grazie Hospital, Pozzuoli, Italy
| | - Giovanni Porta
- Department of Emergency Medicine, Santa Maria delle Grazie Hospital, Pozzuoli, Italy
| | - Enrico Allegorico
- Department of Emergency Medicine, Santa Maria delle Grazie Hospital, Pozzuoli, Italy
| | - Claudia Serra
- Department of Emergency Medicine, Santa Maria delle Grazie Hospital, Pozzuoli, Italy
| | | | - Fabio Giuliano Numis
- Department of Emergency Medicine, Santa Maria delle Grazie Hospital, Pozzuoli, Italy
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences, Federico II University, Via Sergio Pansini 5, 80131, Naples, Italy
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Pagano A, Porta G, Bosso G, Allegorico E, Serra C, Dello Vicario F, Minerva V, Russo T, Altruda C, Arbo P, Mercurio V, Numis FG. Non-invasive CPAP in mild and moderate ARDS secondary to SARS-CoV-2. Respir Physiol Neurobiol 2020; 280:103489. [PMID: 32629100 PMCID: PMC7332943 DOI: 10.1016/j.resp.2020.103489] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 06/23/2020] [Accepted: 07/01/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND During the COVID-19 outbreak, a very high number of infected patients developed pneumonia and many of them complicated with acute respiratory distress syndrome. The optimal management of respiratory failure and the role of lung ultrasound imaging in the evaluation of efficacy of treatment are unknown. METHODS In March 2020 we treated 18 patients with mild and moderate ARDS secondary to SARS-CoV-2 with non-invasive continuous positive airway pressure therapy (NI-CPAP). All patients underwent lung ultrasound imaging to verify the entity of lung recruitment after NI-CPAP initiation. RESULTS After one hour of treatment we observed a significant improvement in PaO2/FiO2 ratio in 10 patients. Notably, only 50 % of them reached an effective improvement in lung aeration detectable with lung ultrasound. In the other 50 % or patients the improvement in PaO2/FiO2 might be related to blood redistribution and reverse of hypoxic vasoconstriction. CONCLUSION NI- CPAP is a valid therapeutic option in mild and moderate ARDS secondary SARS-CoV-2. Lung recruitment detected by means of lung ultrasound is a relevant but not the exclusive mechanism that underlies the therapeutic efficacy of NI-CPAP in this clinical setting.
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Affiliation(s)
- A Pagano
- Emergency Department, Santa Maria delle Grazie Hospital Naples, ASL Napoli 2 Nord, Italy.
| | - G Porta
- Emergency Department, Santa Maria delle Grazie Hospital Naples, ASL Napoli 2 Nord, Italy
| | - G Bosso
- Emergency Department, Santa Maria delle Grazie Hospital Naples, ASL Napoli 2 Nord, Italy
| | - E Allegorico
- Emergency Department, Santa Maria delle Grazie Hospital Naples, ASL Napoli 2 Nord, Italy
| | - C Serra
- Emergency Department, Santa Maria delle Grazie Hospital Naples, ASL Napoli 2 Nord, Italy
| | - F Dello Vicario
- Emergency Department, Santa Maria delle Grazie Hospital Naples, ASL Napoli 2 Nord, Italy
| | - V Minerva
- Emergency Department, Santa Maria delle Grazie Hospital Naples, ASL Napoli 2 Nord, Italy
| | - T Russo
- Emergency Department, Santa Maria delle Grazie Hospital Naples, ASL Napoli 2 Nord, Italy
| | - C Altruda
- Emergency Department, Santa Maria delle Grazie Hospital Naples, ASL Napoli 2 Nord, Italy
| | - P Arbo
- Emergency Department, Santa Maria delle Grazie Hospital Naples, ASL Napoli 2 Nord, Italy
| | | | - F G Numis
- Emergency Department, Santa Maria delle Grazie Hospital Naples, ASL Napoli 2 Nord, Italy
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Berbenetz N, Wang Y, Brown J, Godfrey C, Ahmad M, Vital FMR, Lambiase P, Banerjee A, Bakhai A, Chong M. Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema. Cochrane Database Syst Rev 2019; 4:CD005351. [PMID: 30950507 PMCID: PMC6449889 DOI: 10.1002/14651858.cd005351.pub4] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Non-invasive positive pressure ventilation (NPPV) has been used to treat respiratory distress due to acute cardiogenic pulmonary oedema (ACPE). We performed a systematic review and meta-analysis update on NPPV for adults presenting with ACPE. OBJECTIVES To evaluate the safety and effectiveness of NPPV compared to standard medical care (SMC) for adults with ACPE. The primary outcome was hospital mortality. Important secondary outcomes were endotracheal intubation, treatment intolerance, hospital and intensive care unit length of stay, rates of acute myocardial infarction, and adverse event rates. SEARCH METHODS We searched CENTRAL (CRS Web, 20 September 2018), MEDLINE (Ovid, 1946 to 19 September 2018), Embase (Ovid, 1974 to 19 September 2018), CINAHL Plus (EBSCO, 1937 to 19 September 2018), LILACS, WHO ICTRP, and clinicaltrials.gov. We also reviewed reference lists of included studies. We applied no language restrictions. SELECTION CRITERIA We included blinded or unblinded randomised controlled trials in adults with ACPE. Participants had to be randomised to NPPV (continuous positive airway pressure (CPAP) or bilevel NPPV) plus standard medical care (SMC) compared with SMC alone. DATA COLLECTION AND ANALYSIS Two review authors independently screened and selected articles for inclusion. We extracted data with a standardised data collection form. We evaluated the risks of bias of each study using the Cochrane 'Risk of bias' tool. We assessed evidence quality for each outcome using the GRADE recommendations. MAIN RESULTS We included 24 studies (2664 participants) of adult participants (older than 18 years of age) with respiratory distress due to ACPE, not requiring immediate mechanical ventilation. People with ACPE presented either to an Emergency Department or were inpatients. ACPE treatment was provided in an intensive care or Emergency Department setting. There was a median follow-up of 13 days for hospital mortality, one day for endotracheal intubation, and three days for acute myocardial infarction. Compared with SMC, NPPV may reduce hospital mortality (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.51 to 0.82; participants = 2484; studies = 21; I2 = 6%; low quality of evidence) with a number needed to treat for an additional beneficial outcome (NNTB) of 17 (NNTB 12 to 32). NPPV probably reduces endotracheal intubation rates (RR 0.49, 95% CI 0.38 to 0.62; participants = 2449; studies = 20; I2 = 0%; moderate quality of evidence) with a NNTB of 13 (NNTB 11 to 18). There is probably little or no difference in acute myocardial infarction (AMI) incidence with NPPV compared to SMC for ACPE (RR 1.03, 95% CI 0.91 to 1.16; participants = 1313; studies = 5; I2 = 0%; moderate quality of evidence). We are uncertain as to whether NPPV increases hospital length of stay (mean difference (MD) -0.31 days, 95% CI -1.23 to 0.61; participants = 1714; studies = 11; I2 = 55%; very low quality of evidence). Adverse events were generally similar between NPPV and SMC groups, but evidence was of low quality. AUTHORS' CONCLUSIONS Our review provides support for continued clinical application of NPPV for ACPE, to improve outcomes such as hospital mortality and intubation rates. NPPV is a safe intervention with similar adverse event rates to SMC alone. Additional research is needed to determine if specific subgroups of people with ACPE have greater benefit of NPPV compared to SMC. Future research should explore the benefit of NPPV for ACPE patients with hypercapnia.
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Affiliation(s)
| | - Yongjun Wang
- Schulich School of Medicine & Dentistry, Western UniversityKresge Building, Rm. K1LondonONCanada
| | | | | | - Mahmood Ahmad
- Royal Free Hospital, Royal Free London NHS Foundation TrustCardiology DepartmentLondonUK
| | - Flávia MR Vital
- Cochrane Brazil Minas GeraisAv. Cristiano Ferreira Varella, 555MuriaéMinas GeraisBrazil36888‐233
| | - Pier Lambiase
- The Heart Hospital, University College London HospitalsCentre for Cardiology in the Young16‐18 Westmoreland Street,LondonUKW1G 8PH
| | - Amitava Banerjee
- University College LondonInstitute of Health Informatics ResearchLondonUK
| | - Ameet Bakhai
- Royal Free London NHS Foundation TrustBarnet General Hospital Cardiology DepartmentBarnet General HospitalThames House, Wellhouse LaneBarnetEnfieldUKEN5 3DJ
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Briones Claudett KH, Grunauer M. Pressure support ventilation vs continuous positive airway pressure for treating of acute cardiogenic pulmonary edema. Comment. Respir Physiol Neurobiol 2019; 259:176-177. [DOI: 10.1016/j.resp.2018.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 08/11/2018] [Accepted: 08/14/2018] [Indexed: 10/28/2022]
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