Utility of Bain’s Circuit to Deliver Respiratory Support in a Resource‑Limited Setting during the COVID‑19 Pandemic

Introduction:Patients with COVID pneumonia, who did not respond to high‑flow oxygen by nonrebreathing mask (NRBM), needed additional support to deliver oxygen with pressure. We present our innovation to use Bain’s circuit to deliver continuous positive airway pressure (CPAP) along with 100% oxygen in patients with COVID‑19 when there was a shortage of respiratory support equipment. Materials and Methods: It is a retrospective observational study conducted at two high‑volume, government‑designated, tertiary level COVID centers of Northern India, during May and June 2021. After taking informed consent from all patients included in the study, a nonventilated noninvasive ventilation (NIV) mask was used as the interface between Bain’s circuit and the patient for making a tight seal. Vital parameters were recorded on admission, before putting the patient on Bain’s circuit, at 30 min, and 6 h after the initiation of Bain’s circuit. Results: Forty‑five patients were enrolled in this study. There was a significant reduction in the work of breathing after the application of Bain’s circuit. Vital parameters show improvement of the condition. Sensorium also showed a significant improvement after the application of Bain’s circuit. Overall, 40% of patients who received Bain’s circuit were weaned off to oxygen by NRBM, 31.1% of patients were bridged to NIV, and 28.9% of patients got intubated. Conclusion: The aim of presenting our experience is to generate interest regarding innovations in the face of crisis which may not be perfect but are practical for the situation. We do not recommend the use of Bain’s circuit to provide NIV support under normal circumstances. Further studies are needed to support the use of Bain’s circuit with modifications as a CPAP/NIV delivering device in selected patients.

Impacto del decúbito prono en el síndrome de insuficiencia respiratoria aguda en pacientes con COVID-19 bajo ventilación mecánica invasiva / Impact of prone position on acute respiratory distress syndrome in patients with COVID-19 under invasive mechanical ventilation / Impacto de la posição prona na síndrome da insuficiência respiratória aguda em pacientes com COVID-19 sob ventilação mecânica invasiva

Resumen: A finales del año 2019 surgió una nueva especie de coronavirus con la capacidad de producir enfermedad en humanos, conocida como SARS-CoV-2 y definiéndose la enfermedad como COVID-19. A partir de marzo del 2020 se comenzaron a presentar casos de neumonía por SARS-CoV-2 en el Hospital Español de México, algunos de estos pacientes desarrollaron la enfermedad grave requiriendo ventilación mecánica invasiva. Se realizó el estudio de una serie de casos, de tipo descriptivo, transversal, retrolectivo y analítico, desde mayo de 2020 hasta agosto de 2020, en pacientes ingresados en el área de terapia intensiva COVID en dicho hospital. Se obtuvo una muestra de 42 pacientes, 32 (76%) hombres y 10 (24%) mujeres, con neumonía severa por SARS-CoV-2 e hipoxemia refractaria con un cuadro de síndrome de insuficiencia respiratoria aguda (SIRA) moderado (PaO2/FiO2 < 200) a severo (PaO2/FiO2 < 100), los cuales necesitaron ventilación mecánica invasiva y por hipoxemia refractaria al menos un evento de decúbito prono. La duración mínima de cada episodio de prono fue al menos de 24 horas, teniendo como mínimo un evento de decúbito prono y como máximo siete eventos, con un promedio global de 2.7 eventos de decúbito prono. El tiempo máximo prono por evento fue de 36 horas continuas, teniendo un promedio de 30.1 horas en decúbito prono. Se logró establecer que los pacientes en decúbito prono presentaron una mejoría respecto al índice de oxigenación (PaO2/FiO2) con una p < 0.01, a diferencia de otros indicadores de oxigenación tales como PaO2 y PaCO2, donde no se encontró suficiente evidencia respecto a ser predictor sobre mortalidad y gravedad.

Abstract: At the end of 2019, a new species of coronavirus identified as SARS-CoV-2 emerged, with the ability to cause disease in humans, defined as COVID-19. As of March 2020, cases of SARS-CoV-2 pneumonia began to appear at the Hospital Español de México, some of these patients developed severe disease requiring invasive mechanical ventilation. A descriptive, cross-sectional, retrolective and analytical study of cases was conducted from May to August 2020, in patients admitted to the COVID intensive care area at said hospital. A sample of 42 patients was obtained, 32 (76%) men and 10 (24%) women, with severe pneumonia due to SARS-CoV-2 and refractory hypoxemia with a picture of acute respiratory insufficiency syndrome (SIRA) from moderate (PaO2/FiO2 < 200) to severe (PaO2/FiO2 < 100), which required invasive mechanical ventilation and for refractory hypoxemia at least one event in the prone position. The minimum duration of each prone episode was at least 24 hours, with a minimum of one decubitus and prone events and a maximum of seven events, with a global average of 2.7 prone events. The maximum prone time per event was 36 continuous hours, with an average of 30.1 hours in the prone position. It was possible to establish that patients in the prone position presented an improvement regarding the oxygenation index (PaO2/FiO2) with a p < 0.01, unlike other characteristics such as PaO2 and PaCO2, where not enough evidence was found with regard to being a predictor of mortality and gravity.

Resumo: No final de 2019, surgiu uma nova espécie de Coronavírus com capacidade de causar doença em humanos, identificando-se como COVID-19 e definindo a doença como SARS-CoV-2. Em março de 2020, casos de pneumonia por SARS-CoV-2 começaram a aparecer no Hospital Español de México, alguns desses pacientes desenvolveram doença grave que requereram ventilação mecânica invasiva. Uma série de casos descritivos, transversais, retroletivos e analíticos foi realizada de maio de 2020 a agosto de 2020 em pacientes internados na área de terapia intensiva COVID do Hospital Español de México. Uma amostra de 42 pacientes, 32 (76%) homens e 10 (24%) mulheres, com pneumonia grave por SARS-CoV-2 e hipoxemia refratária com síndrome de insuficiência respiratória aguda (SIRA) moderada (PaO2/FiO2 < 200) a grave (PaO2/FiO2 < 100), que exigiu ventilação mecânica invasiva e devido à hipoxemia refratária pelo menos um evento em decúbito prono. A duração mínima de cada episódio na posição prona foi menor a 24 horas, tendo como mínimo de 1 evento decúbito e prona e como máximo de 7 eventos, com uma média global de 2.7 eventos em decúbito prona. O tempo máximo em prona por evento foi de 36 horas contínuas, com média de 30.1 horas na posição prona. Foi possível estabelecer que os pacientes em decúbito prona apresentaram melhora em relação ao índice de oxigenação (PaO2/FiO2) com p < 0.01, ao contrário de outros indicadores de oxigenação como PaO2 e PaCO2, não foram encontradas evidências suficientes de ser um preditor de mortalidade e gravidade.