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Ramirez GA, Bozzolo EP, Gobbi A, Castelli E, Centurioni C, DI Meo M, Della Torre E, DI Scala F, Morgillo A, Marinosci A, Miglio M, Scarpellini P, Tassan Din C, Castiglioni B, Oltolini C, Ripa M, DI Terlizzi G, DA Prat V, Damanti S, Scotti R, DI Lucca G, Baiardo Redaelli M, Plumari VP, Moizo E, Carcó F, Silvani P, DE Cobelli F, Landoni G, Tresoldi M. Outcomes of non-invasive ventilation as the ceiling of treatment in patients with COVID-19. Panminerva Med 2021; 64:506-516. [PMID: 33860653 DOI: 10.23736/s0031-0808.21.04280-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Non-invasive mechanical ventilation (NIV) is effective for symptom relief and respiratory support in patients with respiratory insufficiency, severe comorbidities and no indication to intubation. Experience with NIV as the ceiling of treatment in severely compromised novel coronavirus disease (COVID-19) patients is lacking. METHODS We evaluated 159 patients with COVID-19-related acute respiratory syndrome (ARDS), 38 of whom with NIV as the ceiling of treatment, admitted to an ordinary ward and treated with continuous positive airway pressure (CPAP) and respiratory physiotherapy. Treatment failure and death were correlated with clinical and laboratory parameters in the whole cohort and in patients with NIV as the ceiling of treatment. RESULTS Patients who had NIV as the ceiling of treatment were elderly, with a low BMI and a high burden of comorbidities, showed clinical and laboratory signs of multi-organ insufficiency on admission and of rapidly deteriorating vital signs during the first week of treatment. NIV failure occurred overall in 77 (48%) patients, and 27/38 patients with NIV as the ceiling of treatment died. Congestive heart failure, chronic benign haematological diseases and inability/refusal to receive respiratory physiotherapy were independently associated to NIV failure and mortality. Need for increased positive end-expiratory pressures and low platelets were associated with NIV failure. Death was associated to cerebrovascular disease, need for CPAP cycles longer than 12h and, in the subgroup of patients with NIV as the ceiling of treatment, was heralded by vital sign deterioration within 48 h. CONCLUSIONS NIV and physiotherapy are a viable treatment option for patients with severe COVID-19 and severe comorbidities.
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Affiliation(s)
- Giuseppe A Ramirez
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy - .,Vita-Salute San Raffaele University, Milan, Italy -
| | - Enrica P Bozzolo
- Unit of General Medicine and Advanced Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Agnese Gobbi
- Vita-Salute San Raffaele University, Milan, Italy.,Unit of General Medicine and Advanced Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Elena Castelli
- Cardiothoracic Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Clarissa Centurioni
- Vita-Salute San Raffaele University, Milan, Italy.,Unit of General Medicine and Advanced Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mattia DI Meo
- Cardiothoracic Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Emanuel Della Torre
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Flavia DI Scala
- Vita-Salute San Raffaele University, Milan, Italy.,Unit of General Medicine and Advanced Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Anna Morgillo
- Vita-Salute San Raffaele University, Milan, Italy.,Unit of General Medicine and Advanced Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Marinosci
- Unit of General Medicine and Advanced Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Paolo Scarpellini
- Unit of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Chiara Tassan Din
- Unit of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Barbara Castiglioni
- Unit of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Chiara Oltolini
- Unit of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Ripa
- Unit of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gaetano DI Terlizzi
- Unit of General Medicine and Advanced Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Valentina DA Prat
- Unit of General Medicine and Advanced Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sarah Damanti
- Unit of General Medicine and Advanced Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Raffaella Scotti
- Unit of General Medicine and Advanced Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giuseppe DI Lucca
- Unit of General Medicine and Advanced Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Martina Baiardo Redaelli
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Valentina P Plumari
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Elena Moizo
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Carcó
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Silvani
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Giovanni Landoni
- Vita-Salute San Raffaele University, Milan, Italy.,Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Moreno Tresoldi
- Unit of General Medicine and Advanced Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Cabrini L, Baiardo Redaelli M, Filippini M, Fominskiy E, Pasin L, Pintaudi M, Plumari VP, Putzu A, Votta CD, Pallanch O, Ball L, Landoni G, Pelosi P, Zangrillo A. Tracheal intubation in patients at risk for cervical spinal cord injury: A systematic review. Acta Anaesthesiol Scand 2020; 64:443-454. [PMID: 31837227 DOI: 10.1111/aas.13532] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 11/21/2019] [Accepted: 12/03/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Tracheal intubation in patients at risk for secondary spinal cord injury is potentially difficult and risky. OBJECTIVES To compare tracheal intubation techniques in adult patients at risk for secondary cervical spinal cord injury undergoing surgery. Primary outcome was first-attempt failure rate. Secondary outcomes were time to successful intubation and procedure complications. DESIGN Systematic review and meta-analysis of randomized controlled trials (RCTs) with trial sequential analysis (TSA). DATA SOURCES Databases searched up to July 2019. ELIGIBILITY Randomized controlled trials comparing different intubation techniques. RESULTS We included 18 trials enrolling 1972 patients. Four studies used the "awake" approach, but no study compared awake versus non-awake techniques. In remaining 14 RCTs, intubation was performed under general anesthesia. First-attempt failure rate was similar when comparing direct laryngoscopy or fiberoptic bronchoscopy versus other techniques. A better first-attempt failure rate was found with videolaryngoscopy and when pooling all the fiberoptic techniques together. All these results appeared not significant at TSA, suggesting inconclusive evidence. Intubating lighted stylet allowed faster intubation. Postoperative neurological complications were 0.34% (no significant difference among techniques). No life-threatening adverse event was reported; mild local complications were common (19.5%). The certainty of evidence was low to very low mainly due to high imprecision and indirectness. CONCLUSIONS Videolaryngoscopy and fiberoptic-assisted techniques might be associated with higher first-attempt failure rate over controls. However, low to very low certainty of evidence does not allow firm conclusions on the best tracheal intubation in patients at risk for cervical spinal cord injury.
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Affiliation(s)
- Luca Cabrini
- Department of Anesthesia and Intensive Care IRCCS San Raffaele Scientific Institute Milan Italy
- Università Vita‐Salute San Raffaele Milan Italy
| | | | - Martina Filippini
- Department of Anesthesia and Intensive Care IRCCS San Raffaele Scientific Institute Milan Italy
| | - Evgeny Fominskiy
- Department of Anesthesia and Intensive Care IRCCS San Raffaele Scientific Institute Milan Italy
| | - Laura Pasin
- Department of Anesthesia and Intensive Care Padua Italy
| | - Margherita Pintaudi
- Department of Anesthesia and Intensive Care IRCCS San Raffaele Scientific Institute Milan Italy
| | - Valentina P. Plumari
- Department of Anesthesia and Intensive Care IRCCS San Raffaele Scientific Institute Milan Italy
| | - Alessandro Putzu
- Division of Anesthesiology Department of Anesthesiology, Pharmacology, Intensive Care and Emergency Medicine Geneva University Hospitals Geneva Switzerland
| | - Carmine D. Votta
- Department of Anesthesia and Intensive Care IRCCS San Raffaele Scientific Institute Milan Italy
| | - Ottavia Pallanch
- Department of Anesthesia and Intensive Care IRCCS San Raffaele Scientific Institute Milan Italy
| | - Lorenzo Ball
- Anesthesia and Intensive Care San Martino Policlinico Hospital IRCCS for Oncology and Neurosciences Genoa Italy
- Department of Surgical Sciences and Integrated Diagnostics University of Genoa Genoa Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care IRCCS San Raffaele Scientific Institute Milan Italy
- Università Vita‐Salute San Raffaele Milan Italy
| | - Paolo Pelosi
- Anesthesia and Intensive Care San Martino Policlinico Hospital IRCCS for Oncology and Neurosciences Genoa Italy
- Department of Surgical Sciences and Integrated Diagnostics University of Genoa Genoa Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care IRCCS San Raffaele Scientific Institute Milan Italy
- Università Vita‐Salute San Raffaele Milan Italy
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Cabrini L, Plumari VP, Nobile L, Olper L, Pasin L, Bocchino S, Landoni G, Beretta L, Zangrillo A. Non-invasive ventilation in cardiac surgery: a concise review. Heart Lung Vessel 2013; 5:137-41. [PMID: 24364004 PMCID: PMC3848671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Mild to severe respiratory dysfunction is still a common issue after cardiac surgery. Postoperative respiratory complications are associated with prolonged hospitalization and worse survival. In this high-risk surgery, non-invasive ventilation could have relevant positive effects. The present narrative concise review aims to summarize available data on the role of non-invasive ventilation before and after cardiac surgery. Non-invasive ventilation exerts its main effects on the pulmonary and on the cardiovascular systems. Non-invasive ventilation can be applied to prevent acute respiratory failure; it can also be prescribed as a curative tool to treat an established postoperative acute respiratory failure. Non-invasive ventilation could also be applied to wean patients from mechanical ventilation. When applied as a preventive tool, the main scope is the prevention of pneumonia by resolving or preventing atelectasis. So far, limited (but encouraging) data are available: its routine use in all patients to prevent postoperative acute respiratory failure cannot be recommended. Non-invasive ventilation to treat postoperative acute respiratory failure has been evaluated more extensively. A failure rate from 10 to 55% was reported. Safety appears preserved, with no relevant hemodynamic complication reported. Non-invasive ventilation has also been applied during percutaneous aortic valve implant in patients unable to lie supine due to severe respiratory limitation and orthopnea. In conclusion, non-invasive ventilation has the potential to be very useful before and after cardiac surgery. So far, results are promising but available data are limited. Training and experience are essential to obtain positive results and to avoid complications.
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