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Gondhalekar VB, Gandomi A, Gilman SL, Hajizadeh N, Hasan ZM, Bank MA, Rolston DM, Cohen A, Li T, Nishikimi M, Narasimhan M, Becker L, Jafari D. Should Transport Ventilators Be Used in Times of Crisis? The Use of Emergency Authorized Nonconventional Ventilators Is Associated With Mortality Among Patients With COVID-19 Acute Respiratory Distress Syndrome. Crit Care Med 2024; 52:1021-1031. [PMID: 38563609 DOI: 10.1097/ccm.0000000000006252] [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: 04/04/2024]
Abstract
OBJECTIVES Nonconventional ventilators (NCVs), defined here as transport ventilators and certain noninvasive positive pressure devices, were used extensively as crisis-time ventilators for intubated patients with COVID-19. We assessed whether there was an association between the use of NCV and higher mortality, independent of other factors. DESIGN This is a multicenter retrospective observational study. SETTING The sample was recruited from a single healthcare system in New York. The recruitment period spanned from March 1, 2020, to April 30, 2020. PATIENTS The sample includes patients who were intubated for COVID-19 acute respiratory distress syndrome (ARDS). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was 28-day in-hospital mortality. Multivariable logistic regression was used to derive the odds of mortality among patients managed exclusively with NCV throughout their ventilation period compared with the remainder of the sample while adjusting for other factors. A secondary analysis was also done, in which the mortality of a subset of the sample exclusively ventilated with NCV was compared with that of a propensity score-matched subset of the control group. Exclusive use of NCV was associated with a higher 28-day in-hospital mortality while adjusting for confounders in the regression analysis (odds ratio, 1.41; 95% CI [1.07-1.86]). In the propensity score matching analysis, the mortality of patients exclusively ventilated with NCV was 68.9%, and that of the control was 60.7% ( p = 0.02). CONCLUSIONS Use of NCV was associated with increased mortality among patients with COVID-19 ARDS. More lives may be saved during future ventilator shortages if more full-feature ICU ventilators, rather than NCVs, are reserved in national and local stockpiles.
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Affiliation(s)
- Vikram B Gondhalekar
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Amir Gandomi
- Department of Information Systems and Business Analytics, Frank G. Zarb School of Business, Hofstra University, Manhasset, NY
- Institute of Health System Science, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY
| | - Sarah L Gilman
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Negin Hajizadeh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Zubair M Hasan
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Matthew A Bank
- Division of Acute Care Surgery, Department of Surgery, South Shore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Bayshore, NY
| | - Daniel M Rolston
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Allison Cohen
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Timmy Li
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Mitsuaki Nishikimi
- Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
- Laboratory of Critical Care Physiology, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY
| | - Mangala Narasimhan
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Lance Becker
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
- Laboratory of Critical Care Physiology, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY
| | - Daniel Jafari
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
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Arias-Sanchez PP, Wendel-Garcia PD, Tirapé-Castro HA, Cobos J, Jaramillo-Aguilar SX, Peñaloza-Tinoco AM, Jaramillo-Aguilar DS, Martinez A, Holguín-Carvajal JP, Cabrera E, Roche-Campo F, Aguirre-Bermeo H. Use of a gas-operated ventilator as a noninvasive bridging respiratory therapy in critically Ill COVID-19 patients in a middle-income country. Intern Emerg Med 2024:10.1007/s11739-024-03681-w. [PMID: 38940989 DOI: 10.1007/s11739-024-03681-w] [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: 08/26/2023] [Accepted: 06/14/2024] [Indexed: 06/29/2024]
Abstract
During the COVID-19 pandemic, there was a notable undersupply of respiratory support devices, especially in low- and middle-income countries. As a result, many hospitals turned to alternative respiratory therapies, including the use of gas-operated ventilators (GOV). The aim of this study was to describe the use of GOV as a noninvasive bridging respiratory therapy in critically ill COVID-19 patients and to compare clinical outcomes achieved with this device to conventional respiratory therapies. Retrospective cohort analysis of critically ill COVID-19 patients during the first local wave of the pandemic. The final analysis included 204 patients grouped according to the type of respiratory therapy received in the first 24 h, as follows: conventional oxygen therapy (COT), n = 28 (14%); GOV, n = 72 (35%); noninvasive ventilation (NIV), n = 49 (24%); invasive mechanical ventilation (IMV), n = 55 (27%). In 72, GOV served as noninvasive bridging respiratory therapy in 42 (58%) of these patients. In the other 30 patients (42%), 20 (28%) presented clinical improvement and were discharged; 10 (14%) died. In the COT and GOV groups, 68% and 39%, respectively, progressed to intubation (P ≤ 0.001). Clinical outcomes in the GOV and NIV groups were similar (no statistically significant differences). GOV was successfully used as a noninvasive bridging respiratory therapy in more than half of patients. Clinical outcomes in the GOV group were comparable to those of the NIV group. These findings support the use of GOV as an emergency, noninvasive bridging respiratory therapy in medical crises when alternative approaches to the standard of care may be justifiable.
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Affiliation(s)
- Pedro P Arias-Sanchez
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Intensive Care Unit, Hospital Vicente Corral Moscoso, Cuenca, Ecuador
| | - Pedro D Wendel-Garcia
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | | | - Johanna Cobos
- Intensive Care Unit, Hospital Vicente Corral Moscoso, Cuenca, Ecuador
| | | | | | | | - Alberto Martinez
- Emergency Department, Hospital Vicente Corral Moscoso, Cuenca, Ecuador
| | | | - Enrique Cabrera
- Intensive Care Unit, Hospital Vicente Corral Moscoso, Cuenca, Ecuador
| | - Ferran Roche-Campo
- Intensive Care Unit, Hospital Verge de la Cinta de Tortosa, Tarragona, Spain
- The Pere Virgili Institute for Health Research (IISPV), Tarragona, Spain
| | - Hernan Aguirre-Bermeo
- Intensive Care Unit, Hospital Vicente Corral Moscoso, Cuenca, Ecuador.
- Faculty of Medicine, Universidad de Cuenca, Cuenca, Ecuador.
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Chalkias A, Huang Y, Ismail A, Pantazopoulos I, Papagiannakis N, Bitterman B, Anderson E, Catalan T, Erne GK, Tilley CR, Alaka A, Amadi KM, Presswalla F, Blakely P, Bernal-Morell E, Cebreiros López I, Eugen-Olsen J, García de Guadiana Romualdo L, Giamarellos-Bourboulis EJ, Loosen SH, Reiser J, Tacke F, Skoulakis A, Laou E, Banerjee M, Pop-Busui R, Hayek SS. Intubation Decision Based on Illness Severity and Mortality in COVID-19: An International Study. Crit Care Med 2024; 52:930-941. [PMID: 38391282 DOI: 10.1097/ccm.0000000000006229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
OBJECTIVES To evaluate the impact of intubation timing, guided by severity criteria, on mortality in critically ill COVID-19 patients, amidst existing uncertainties regarding optimal intubation practices. DESIGN Prospective, multicenter, observational study conducted from February 1, 2020, to November 1, 2022. SETTING Ten academic institutions in the United States and Europe. PATIENTS Adults (≥ 18 yr old) confirmed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and hospitalized specifically for COVID-19, requiring intubation postadmission. Exclusion criteria included patients hospitalized for non-COVID-19 reasons despite a positive SARS-CoV-2 test. INTERVENTIONS Early invasive mechanical ventilation (EIMV) was defined as intubation in patients with less severe organ dysfunction (Sequential Organ Failure Assessment [SOFA] < 7 or Pa o2 /F io2 ratio > 250), whereas late invasive mechanical ventilation (LIMV) was defined as intubation in patients with SOFA greater than or equal to 7 and Pa o2 /F io2 ratio less than or equal to 250. MEASUREMENTS AND MAIN RESULTS The primary outcome was mortality within 30 days of hospital admission. Among 4464 patients, 854 (19.1%) required mechanical ventilation (mean age 60 yr, 61.7% male, 19.3% Black). Of those, 621 (72.7%) were categorized in the EIMV group and 233 (27.3%) in the LIMV group. Death within 30 days after admission occurred in 278 patients (42.2%) in the EIMV and 88 patients (46.6%) in the LIMV group ( p = 0.28). An inverse probability-of-treatment weighting analysis revealed a statistically significant association with mortality, with patients in the EIMV group being 32% less likely to die either within 30 days of admission (adjusted hazard ratio [HR] 0.68; 95% CI, 0.52-0.90; p = 0.008) or within 30 days after intubation irrespective of its timing from admission (adjusted HR 0.70; 95% CI, 0.51-0.90; p = 0.006). CONCLUSIONS In severe COVID-19 cases, an early intubation strategy, guided by specific severity criteria, is associated with a reduced risk of death. These findings underscore the importance of timely intervention based on objective severity assessments.
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Affiliation(s)
- Athanasios Chalkias
- Institute for Translational Medicine and Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Outcomes Research Consortium, Cleveland, OH
| | - Yiyuan Huang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Anis Ismail
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | | | | | - Brayden Bitterman
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Elizabeth Anderson
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Tonimarie Catalan
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Grace K Erne
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Caroline R Tilley
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Abiola Alaka
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Kingsley M Amadi
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Feriel Presswalla
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Pennelope Blakely
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Enrique Bernal-Morell
- Infectious Diseases Unit, Department of Internal Medicine, Hospital General Universitario Reina Sofía, Murcia, Spain
| | - Iria Cebreiros López
- Department of Laboratory Medicine, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Jesper Eugen-Olsen
- Department of Clinical Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | | | | | - Sven H Loosen
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Jochen Reiser
- Department of Medicine, Rush University Medical Center, Chicago, IL
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Campus Charité Mitte and Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Eleni Laou
- Faculty of Medicine, University of Thessaly, Larisa, Greece
| | - Mousumi Banerjee
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Salim S Hayek
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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Grotberg JC, Kraft BD, Sullivan M, Pawale AA, Kotkar KD, Masood MF. Advanced Respiratory Support Days as a Novel Marker of Mortality in COVID-19 Acute Respiratory Distress Syndrome Requiring Extracorporeal Membrane Oxygenation. ASAIO J 2024; 70:427-435. [PMID: 38295398 PMCID: PMC11062834 DOI: 10.1097/mat.0000000000002119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024] Open
Abstract
Emerging evidence suggests prolonged use of noninvasive respiratory support may increase mortality of patients with coronavirus disease 2019 (COVID-19)-associated acute respiratory distress syndrome who require extracorporeal membrane oxygenation (ECMO). Using a database of adults receiving ECMO for COVID-19, we calculated survival curves and multivariable Cox regression to determine the risk of death associated with pre-ECMO use of high-flow nasal oxygen (HFNO), noninvasive ventilation (NIV), and invasive mechanical ventilation (IMV) days. We investigated the performance of a novel variable, advanced respiratory support days (composite of HFNO, NIV, and IMV days), on Respiratory ECMO Survival Prediction (RESP) score. Subjects (N = 146) with increasing advanced respiratory support days (<5, 5-9, and ≥10) had a stepwise increase in 90 day mortality (32.2%, 57.7%, and 75.4%, respectively; p = 0.002). Ninety-day mortality was significantly higher in subjects (N = 121) receiving NIV >4 days (81.8% vs. 52.4%, p < 0.001). Each additional pre-ECMO advanced respiratory support day increased the odds of right ventricular failure (odds ratio [OR]: 1.066, 95% confidence interval [CI]: 1.002-1.135) and in-hospital mortality (1.17, 95% CI: 1.08-1.27). Substituting advanced respiratory support days for IMV days improved RESP score mortality prediction (area under the curve (AUC) or: 0.64 vs. 0.71). Pre-ECMO advanced respiratory support days were associated with increased 90 day mortality compared with IMV days alone. Adjusting the RESP score for advanced respiratory support days improved mortality prediction.
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Affiliation(s)
- John C. Grotberg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Bryan D. Kraft
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Mary Sullivan
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Amit A. Pawale
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Kunal D. Kotkar
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Muhammad F. Masood
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
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Kummer RL, Marini JJ. The Respiratory Mechanics of COVID-19 Acute Respiratory Distress Syndrome-Lessons Learned? J Clin Med 2024; 13:1833. [PMID: 38610598 PMCID: PMC11012401 DOI: 10.3390/jcm13071833] [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: 01/31/2024] [Revised: 03/13/2024] [Accepted: 03/18/2024] [Indexed: 04/14/2024] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a well-defined clinical entity characterized by the acute onset of diffuse pulmonary injury and hypoxemia not explained by fluid overload. The COVID-19 pandemic brought about an unprecedented volume of patients with ARDS and challenged our understanding and clinical approach to treatment of this clinical syndrome. Unique to COVID-19 ARDS is the disruption and dysregulation of the pulmonary vascular compartment caused by the SARS-CoV-2 virus, which is a significant cause of hypoxemia in these patients. As a result, gas exchange does not necessarily correlate with respiratory system compliance and mechanics in COVID-19 ARDS as it does with other etiologies. The purpose of this review is to relate the mechanics of COVID-19 ARDS to its underlying pathophysiologic mechanisms and outline the lessons we have learned in the management of this clinic syndrome.
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Affiliation(s)
- Rebecca L. Kummer
- Department of Pulmonary and Critical Care Medicine, University of Minnesota School of Medicine, Minneapolis, MN 55455, USA
| | - John J. Marini
- Department of Pulmonary and Critical Care Medicine, Regions Hospital, St. Paul, MN 55101, USA
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6
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Adzic-Vukicevic T, Markovic D, Reljic A, Brkovic V. What did we learn about tocilizumab use against COVID-19? A single-center observational study from an intensive care unit in Serbia. Front Med (Lausanne) 2023; 10:1253135. [PMID: 38034537 PMCID: PMC10683091 DOI: 10.3389/fmed.2023.1253135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/24/2023] [Indexed: 12/02/2023] Open
Abstract
Background Selection of effective and safe therapy for management of patients with coronavirus disease is challenging. Tocilizumab (TZB) has emerged as a potential treatment option for COVID-19. Several aspects regarding Tocilizumab treatment remain uncertain, such as the optimal timing for its administration and the safety profile, including the potential risk of infections. The aim of the study is to present the clinical characteristics of patients with COVID-19 following the application of Tocilizumab. Methods This is a retrospective analysis of 121 patients with severe forms of COVID-19 previously treated with Tocilizumab was conducted. All patients were admitted to intensive care units (ICUs). Results Of 121 patients, the majority were men 72 (59.5%) with a median age at presentation of 65 ± 13 years. Only 9 (7.43%) patients were without comorbidities, while the other 112 (92.55%) had two or more comorbidities. Almost all of the 120 patients (99.2%) needed oxygen therapy, such as nasal cannulas in 110 (90.9%) patients, high flow nasal catheter (HFNC) in 4 (3.3%) patients, and continuous positive airway pressure (CPAP) in 5 (4.1%) patients while 1 patient was intubated at the time of hospital admission. The average time from Tocilizumab application to admission to the ICU was 3 days. During clinical deterioration, almost half 57 (47.1%) of the patients were intubated, and 52 (82.5%) of these intubated patients (p < 0.001) had lethal outcomes. The most significant predictors for a lethal outcome according to multivariate analysis were diabetes mellitus (p < 0.001) followed by a subsequent elevation in C-reactive protein levels (CRP; p < 0.002) and ferritin (p < 0.013) after Tocilizumab application. Bloodstream infections were found in 20 (16.5%) patients, most frequently with Gram-negative pathogens like Acinetobacter spp. as in 12 (18.6%) patients, Klebsiella spp. in 6 (8%) patients, and Pseudomonas spp. in 2 (3.2%) patients. Urine culture isolates were found in 9 (7.43%) patients, with Candida spp. being most frequently isolated in 7 (5.8%) patients, followed by Klebsiella spp. and Pseudomonas spp. in 1 patient each (0.8%). Significantly lower survival was seen in patients with proven infection. Conclusion The benefit of tocilizumab was not found in our study. The high mortality rate among intubated patients after Tocilizumab use suggests appropriate patient selection and monitoring and emphasizes the risk of superinfections. Diabetes mellitus, increased levels of CRP, and ferritin were identified as the most significant predictors of poor outcomes in contrast to increased levels of IL-6.
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Affiliation(s)
- Tatjana Adzic-Vukicevic
- Clinic of Pulmonology, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Dejan Markovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic for Anesthesiology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Aleksandar Reljic
- Covid Hospital Batajnica, University Clinical Center of Serbia, Belgrade, Serbia
| | - Voin Brkovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic for Nephrology, University Clinical Center of Serbia, Belgrade, Serbia
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Bajto P, Saric I, Bugarin JD, Delic N, Dosenovic S, Ilic D, Stipic SS, Duplancic B, Saric L. Barotrauma in patients with severe coronavirus disease 2019-retrospective observational study. J Thorac Dis 2023; 15:5297-5306. [PMID: 37969263 PMCID: PMC10636462 DOI: 10.21037/jtd-23-677] [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: 04/23/2023] [Accepted: 08/18/2023] [Indexed: 11/17/2023]
Abstract
Background Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. Although it is known that the COVID-19 acute respiratory distress syndrome (ARDS) is associated with higher incidence of pulmonary barotrauma, unique mechanisms causing the aforementioned complication are still to be investigated. The goal of this research was to investigate the incidence of barotrauma among COVID-19 patients treated in the intensive care unit (ICU) and to examine different clinical outcomes among those subjects. Methods This retrospective observational cohort study included adult COVID-19 patients admitted to ICU from September 1, 2020, to February 28, 2022. All admitted subjects received invasive respiratory support. Subjects were divided into two groups based on occurrence of pulmonary barotrauma. Data were collected from available electronical medical records. Results In the study period, a total of 900 subjects met inclusion criteria. Pulmonary barotrauma occurred in 88 (9.8%) of them. Subcutaneous emphysema developed in 73 (83%), pneumomediastinum in 68 (77.3%) and pneumothorax in 54 (61.4%) subjects. A small group of subjects developed less common complications like pneumoperitoneum (8 subjects, 9.1%) and pneumopericardium (2 subjects, 2.3%). Survival rate was higher in control than in barotrauma group [396 (48.8%) vs. 22 (25.0%), P<0.05]. There was also a significant difference between two groups in PaO2/FiO2 ratio on admission, duration of non-invasive respiratory support before mechanical ventilation, duration of mechanical ventilation and duration of ICU and hospital stay, all in favour of control group. Conclusions Development of barotrauma in patients with severe forms of COVID-19 disease and in need of respiratory support is associated with longer ICU and hospital stay as well as lower survival rates at hospital discharge. Further efforts are needed in understanding mechanism in developing barotrauma and finding new prevention and treatment options.
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Affiliation(s)
- Petra Bajto
- Department of Anesthesiology, Reanimatology and Intensive Care, University Hospital Split, Split, Croatia
| | - Ivana Saric
- Department of Anesthesiology, Reanimatology and Intensive Care, University Hospital Split, Split, Croatia
| | - Josipa Domazet Bugarin
- Department of Anesthesiology, Reanimatology and Intensive Care, University Hospital Split, Split, Croatia
| | - Nikola Delic
- Department of Anesthesiology, Reanimatology and Intensive Care, University Hospital Split, Split, Croatia
| | - Svjetlana Dosenovic
- Department of Anesthesiology, Reanimatology and Intensive Care, University Hospital Split, Split, Croatia
| | - Darko Ilic
- Department of Anesthesiology, Reanimatology and Intensive Care, University Hospital Split, Split, Croatia
| | - Sanda Stojanovic Stipic
- Department of Anesthesiology, Reanimatology and Intensive Care, University Hospital Split, Split, Croatia
| | - Bozidar Duplancic
- Department of Anesthesiology, Reanimatology and Intensive Care, University Hospital Split, Split, Croatia
| | - Lenko Saric
- Department of Anesthesiology, Reanimatology and Intensive Care, University Hospital Split, Split, Croatia
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8
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Green A, Rachoin JS, Schorr C, Dellinger P, Casey JD, Park I, Gupta S, Baron RM, Shaefi S, Hunter K, Leaf DE. Timing of invasive mechanical ventilation and death in critically ill adults with COVID-19: A multicenter cohort study. PLoS One 2023; 18:e0285748. [PMID: 37379286 PMCID: PMC10306211 DOI: 10.1371/journal.pone.0285748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 05/02/2023] [Indexed: 06/30/2023] Open
Abstract
PURPOSE To investigate if the timing of initiation of invasive mechanical ventilation (IMV) for critically ill patients with COVID-19 is associated with mortality. MATERIALS AND METHODS The data for this study were derived from a multicenter cohort study of critically ill adults with COVID-19 admitted to ICUs at 68 hospitals across the US from March 1 to July 1, 2020. We examined the association between early (ICU days 1-2) versus late (ICU days 3-7) initiation of IMV and time-to-death. Patients were followed until the first of hospital discharge, death, or 90 days. We adjusted for confounding using a multivariable Cox model. RESULTS Among the 1879 patients included in this analysis (1199 male [63.8%]; median age, 63 [IQR, 53-72] years), 1526 (81.2%) initiated IMV early and 353 (18.8%) initiated IMV late. A total of 644 of the 1526 patients (42.2%) in the early IMV group died, and 180 of the 353 (51.0%) in the late IMV group died (adjusted HR 0.77 [95% CI, 0.65-0.93]). CONCLUSIONS In critically ill adults with respiratory failure from COVID-19, early compared to late initiation of IMV is associated with reduced mortality.
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Affiliation(s)
- Adam Green
- Cooper University Health Care and Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - Jean-Sebastien Rachoin
- Cooper University Health Care and Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - Christa Schorr
- Cooper University Health Care and Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - Phil Dellinger
- Cooper University Health Care and Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - Jonathan D. Casey
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Isabel Park
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Shruti Gupta
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Rebecca M. Baron
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States of America
| | - Krystal Hunter
- Cooper University Health Care and Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - David E. Leaf
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
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Chaudhari P, Singh PK, Govindagoudar M, Sharma V, Saxena P, Ahuja A, Lalwani L, Chaudhry D. Utility and timing of the respiratory rate-oxygenation index in the prediction of high-flow oxygen therapy failure in acute hypoxemic respiratory failure of infective etiology: a prospective observational study. Monaldi Arch Chest Dis 2023; 94. [PMID: 37194448 DOI: 10.4081/monaldi.2023.2509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 05/04/2023] [Indexed: 05/18/2023] Open
Abstract
During and following the COVID-19 pandemic, the world has witnessed a surge in high-flow oxygen therapy (HFOT) use. The ability to provide high oxygenation levels with remarkable comfort levels has been the grounds for the same. Despite the advantages, delays in intubation leading to poor overall outcomes have been noticed in subgroups of patients on HFOT. The respiratory rate-oxygenation (ROX) index has been proposed to be a useful indicator to predict HFOT success. In this study, we have examined the utility of the ROX index prospectively in cases of acute hypoxemic respiratory failure (AHRF) due to infective etiologies. A total of 70 participants were screened, and 55 were recruited for the study. The majority of participants were males (56.4%), with diabetes mellitus being the most common comorbidity (29.1%). The mean age of the study subjects was 46.27±15.6 years. COVID-19 (70.9%) was the most common etiology for AHRF, followed by scrub typhus (21.8%). 19 (34.5%) experienced HFOT failure, and 9 (16.4%) subjects died during the study period. Demographic characteristics did not differ between either of the two groups (HFOT success versus failure and survived group versus expired group). The ROX index was significantly different between the HFOT success versus failure group at baseline, 2, 4, 6, 12, and 24 hours. The best cut-offs of the ROX index at baseline and 2 hours were 4.4 (sensitivity 91.7%, specificity 86.7%) and 4.3 (sensitivity 94.4% and specificity 86.7%), respectively. The ROX index was found to be an efficient tool in predicting HFOT failure in cases of AHRF with infective etiology.
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Affiliation(s)
- Pramod Chaudhari
- Department of Pulmonary and Critical Care Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana.
| | - Pawan Kumar Singh
- Department of Pulmonary and Critical Care Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana.
| | - Manjunath Govindagoudar
- Department of Pulmonary and Critical Care Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana.
| | - Vinod Sharma
- Department of Pulmonary and Critical Care Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana.
| | - Puneet Saxena
- Respiratory Medicine, Research and Referral Army Hospital, New Delhi.
| | - Aman Ahuja
- Department of Pulmonary and Critical Care Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana.
| | - Lokesh Lalwani
- Respiratory Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana.
| | - Dhruva Chaudhry
- Respiratory Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana.
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10
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Manrique S, Claverias L, Magret M, Masclans JR, Bodi M, Trefler S, Canadell L, Díaz E, Sole-Violan J, Bisbal-Andrés E, Natera RG, Moreno AA, Vallverdu M, Ballesteros JC, Socias L, Vidal FG, Sancho S, Martin-Loeches I, Rodriguez A. Timing of intubation and ICU mortality in COVID-19 patients: a retrospective analysis of 4198 critically ill patients during the first and second waves. BMC Anesthesiol 2023; 23:140. [PMID: 37106321 PMCID: PMC10133910 DOI: 10.1186/s12871-023-02081-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 04/06/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND The optimal time to intubate patients with SARS-CoV-2 pneumonia has not been adequately determined. While the use of non-invasive respiratory support before invasive mechanical ventilation might cause patient-self-induced lung injury and worsen the prognosis, non-invasive ventilation (NIV) is frequently used to avoid intubation of patients with acute respiratory failure (ARF). We hypothesized that delayed intubation is associated with a high risk of mortality in COVID-19 patients. METHODS This is a secondary analysis of prospectively collected data from adult patients with ARF due to COVID-19 admitted to 73 intensive care units (ICUs) between February 2020 and March 2021. Intubation was classified according to the timing of intubation. To assess the relationship between early versus late intubation and mortality, we excluded patients with ICU length of stay (LOS) < 7 days to avoid the immortal time bias and we did a propensity score and a cox regression analysis. RESULTS We included 4,198 patients [median age, 63 (54‒71) years; 71% male; median SOFA (Sequential Organ Failure Assessment) score, 4 (3‒7); median APACHE (Acute Physiology and Chronic Health Evaluation) score, 13 (10‒18)], and median PaO2/FiO2 (arterial oxygen pressure/ inspired oxygen fraction), 131 (100‒190)]; intubation was considered very early in 2024 (48%) patients, early in 928 (22%), and late in 441 (10%). ICU mortality was 30% and median ICU stay was 14 (7‒28) days. Mortality was higher in the "late group" than in the "early group" (37 vs. 32%, p < 0.05). The implementation of an early intubation approach was found to be an independent protective risk factor for mortality (HR 0.6; 95%CI 0.5‒0.7). CONCLUSIONS Early intubation within the first 24 h of ICU admission in patients with COVID-19 pneumonia was found to be an independent protective risk factor of mortality. TRIAL REGISTRATION The study was registered at Clinical-Trials.gov (NCT04948242) (01/07/2021).
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Affiliation(s)
- Sara Manrique
- Critical Care Department - Hospital Universitario de Tarragona Joan XXIII, Mallafre Guasch 4, Tarragona, 43005, Spain.
- Rovira i Virgili University, Tarragona, Spain.
| | - Laura Claverias
- Critical Care Department - Hospital Universitario de Tarragona Joan XXIII, Mallafre Guasch 4, Tarragona, 43005, Spain
| | - Mónica Magret
- Critical Care Department - Hospital Universitario de Tarragona Joan XXIII, Mallafre Guasch 4, Tarragona, 43005, Spain
- URV/IISPV, Tarragona, Spain
| | | | - María Bodi
- Critical Care Department - Hospital Universitario de Tarragona Joan XXIII, Mallafre Guasch 4, Tarragona, 43005, Spain
- URV/IISPV, Tarragona, Spain
| | - Sandra Trefler
- Critical Care Department - Hospital Universitario de Tarragona Joan XXIII, Mallafre Guasch 4, Tarragona, 43005, Spain
- URV/IISPV, Tarragona, Spain
| | - Laura Canadell
- URV/IISPV, Tarragona, Spain
- Pharmacy Department - Hospital Universitario de Tarragona Joan XXIII, Tarragona, Spain
| | - Emili Díaz
- Critical Care Department - Hospital Parc Tauli, Sabadell, Spain
| | - Jordi Sole-Violan
- Critical Care Department - Hospital Dr. Negrin, Las Palmas de Gran Canaria, Spain
- Universidad Fernando Pessoa- Canarias, Las Palmas, Spain
| | | | | | | | | | | | - Lorenzo Socias
- Critical Care Department Hospital - Hospital Son Llatzer, Palma de Mallorca, Spain
| | | | - Susana Sancho
- Critical Care Department Hospital -Hospital Universitari i Politènic la Fe, Valencia, Spain
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland
| | - Alejandro Rodriguez
- Critical Care Department - Hospital Universitario de Tarragona Joan XXIII, Mallafre Guasch 4, Tarragona, 43005, Spain
- URV/IISPV, Tarragona, Spain
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11
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Yamamoto R, Yamamoto A, Masaoka T, Homma K, Matsuoka T, Takemura R, Wada M, Sasaki J. Early symptoms preceding post-infectious irritable bowel syndrome following COVID-19: a retrospective observational study incorporating daily gastrointestinal symptoms. BMC Gastroenterol 2023; 23:108. [PMID: 37020263 PMCID: PMC10075174 DOI: 10.1186/s12876-023-02746-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/27/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Intestinal microinflammation with immune dysfunction due to severe acute respiratory syndrome coronavirus 2 reportedly precipitates post-infectious irritable bowel syndrome. This study aimed to elucidate potential risk factors for subsequent development of irritable bowel syndrome, hypothesizing that it is associated with specific symptoms or patient backgrounds. METHODS This single-center retrospective observational study (2020-2021) included adults with confirmed coronavirus disease requiring hospital admission and was conducted using real-world data retrieved from a hospital information system. Patient characteristics and detailed gastrointestinal symptoms were obtained and compared between patients with and without coronavirus disease-induced irritable bowel syndrome. Multivariate logistic models were used to validate the risk of developing irritable bowel syndrome. Moreover, daily gastrointestinal symptoms during hospitalization were examined in patients with irritable bowel syndrome. RESULTS Among the 571 eligible patients, 12 (2.1%) were diagnosed with irritable bowel syndrome following coronavirus disease. While nausea and diarrhea during hospitalization, elevated white blood cell count on admission, and intensive care unit admission were associated with the development of irritable bowel syndrome, nausea and diarrhea were identified as risk factors for its development following coronavirus disease, as revealed by the adjusted analyses (odds ratio, 4.00 [1.01-15.84] and 5.64 [1.21-26.31], respectively). Half of the patients with irritable bowel syndrome had both diarrhea and constipation until discharge, and constipation was frequently followed by diarrhea. CONCLUSIONS While irritable bowel syndrome was rarely diagnosed following coronavirus disease, nausea and diarrhea during hospitalization precede the early signs of irritable bowel syndrome following coronavirus disease.
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Affiliation(s)
- Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Asako Yamamoto
- Clinical and Translational Research Center, Keio University Hospital, Tokyo, Japan
| | - Tatsuhiro Masaoka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan.
- Department of Gastroenterology and Hepatology, International University of Health and Welfare Mita Hospital, Tokyo, Japan.
| | - Koichiro Homma
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tadashi Matsuoka
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Ryo Takemura
- Clinical and Translational Research Center, Keio University Hospital, Tokyo, Japan
| | - Michihiko Wada
- Clinical and Translational Research Center, Keio University Hospital, Tokyo, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
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12
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Yu PT, Chen CH, Wang CJ, Kuo KC, Wu JC, Chung HP, Chen YT, Tang YH, Chang WK, Lin CY, Wu CL. Predicting the successful application of high-flow nasal oxygen cannula in patients with COVID-19 respiratory failure: a retrospective analysis. Expert Rev Respir Med 2023; 17:319-328. [PMID: 37002880 DOI: 10.1080/17476348.2023.2199157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
Abstract
BACKGROUND The right time of high-flow nasal cannulas (HFNCs) application in COVID-19 patients with acute respiratory failure remains uncertain. RESEARCH DESIGN AND METHODS In this retrospective study, COVID-19-infected adult patients with hypoxemic respiratory failure were enrolled. Their baseline epidemiological data and respiratory failure related parameters, including the Ventilation in COVID-19 Estimation (VICE), and the ratio of oxygen saturation (ROX index), were recorded. The primary outcome measured was the 28-day mortality. RESULTS A total of 69 patients were enrolled. Fifty-four (78%) patients who intubated and received invasive mechanical ventilatory (MV) support on day 1 were enrolled in the MV group. The remaining fifteen (22%) patients received HFNC initially (HFNC group), in which, ten (66%) patients were not intubated during hospitalization were belong to HFNC-success group and five (33%) of these patients were intubated later due to disease progression were attributed to HFNC-failure group. Compared with those in the MV group, those in the HFNC group had a lower mortality rate (6.7% vs. 40.7%, p = 0.0138). There were no differences in baseline characteristics among the two groups; however, the HFNC group had a lower VICE score (0.105 [0.049-0.269] vs. 0.260 [0.126-0.693], p = 0.0092) and higher ROX index (5.3 [5.1-10.7] vs. 4.3 [3.9-4.9], p = 0.0007) than the MV group. The ROX index was higher in the HFNC success group immediately before (p = 0.0136) and up to 12 hours of HFNC therapy than in the HFNC failure group. CONCLUSIONS Early intubation may be considered in patients with a higher VICE score or a lower ROX index. The ROX score during HFNCs use can provide an early warning sign of treatment failure. Further investigations are warranted to confirm these results.
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Affiliation(s)
- Ping-Tsung Yu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Chao-Hsien Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Chieh-Jen Wang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Kuan-Chih Kuo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Jou-Chun Wu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Hsin-Pei Chung
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Yen-Ting Chen
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Yen-Hsiang Tang
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
- Department of Critical Care Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Wen-Kuei Chang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Chang-Yi Lin
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Chien-Liang Wu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
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13
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Abstract
The timing of initiating mechanical ventilation in patients with acute respiratory distress syndrome due to COVID-19 remains controversial. At the outset of the pandemic, "very early" intubation was recommended in patients requiring oxygen flows above 6 L per minute but was followed closely thereafter by avoidance of invasive mechanical ventilation (IMV) due to a perceived (yet over-estimated) risk of mortality after intubation. While the use of noninvasive methods of oxygen delivery, such as high-flow nasal oxygen (HFNO) or noninvasive positive pressure ventilation (NIV), can avert the need for mechanical ventilation in some, accumulating evidence suggests delayed intubation is also associated with an increased mortality in a subset of COVID-19 patients. Close monitoring is necessary in COVID-19 patients on HFNO or NIV to identify signs of noninvasive failure and ensure appropriate provision of IMV.
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14
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Sanfilippo F, Dean Gopalan P, Hasanin A. The COVID-19 pandemic: A gateway between one world and the next! Anaesth Crit Care Pain Med 2022; 41:101131. [PMID: 35878869 PMCID: PMC9306261 DOI: 10.1016/j.accpm.2022.101131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 07/20/2022] [Indexed: 11/24/2022]
Affiliation(s)
- Filippo Sanfilippo
- Department of Anaesthesia and Intensive Care, A.O.U. Policlinico-San Marco, Catania, Italy.
| | - P Dean Gopalan
- Discipline of Anaesthesiology and Critical Care, University of KwaZulu Natal, Durban, South Africa
| | - Ahmed Hasanin
- Department of Anaesthesia and critical care medicine, Cairo University, Cairo, Egypt
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