ABSTRACT
Background: The COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has placed a significant demand on healthcare providers (HCPs) to provide respiratory support for patients with moderate to severe symptoms. Continuous Positive Airway Pressure (CPAP) non-invasive ventilation can help patients with moderate symptoms to avoid the need for invasive ventilation in intensive care. However, existing CPAP systems can be complex (and thus expensive) or require high levels of oxygen, limiting their use in resource-stretched environments. Technical Development + Testing: The LeVe ("Light") CPAP system was developed using principles of frugal innovation to produce a solution of low complexity and high resource efficiency. The LeVe system exploits the air flow dynamics of electric fan blowers which are inherently suited to delivery of positive pressure at appropriate flow rates for CPAP. Laboratory evaluation demonstrated that performance of the LeVe system was equivalent to other commercially available systems used to deliver CPAP, achieving a 10 cm H2O target pressure within 2.4% RMS error and 50-70% FiO2 dependent with 10 L/min oxygen from a commercial concentrator. Pilot Evaluation: The LeVe CPAP system was tested to evaluate safety and acceptability in a group of ten healthy volunteers at Mengo Hospital in Kampala, Uganda. The study demonstrated that the system can be used safely without inducing hypoxia or hypercapnia and that its use was well-tolerated by users, with no adverse events reported. Conclusions: To provide respiratory support for the high patient numbers associated with the COVID-19 pandemic, healthcare providers require resource efficient solutions. We have shown that this can be achieved through frugal engineering of a CPAP ventilation system, in a system which is safe for use and well-tolerated in healthy volunteers. This approach may also benefit other respiratory conditions which often go unaddressed in Low and Middle Income Countries (LMICs) for want of context-appropriate technology designed for the limited oxygen resources available.
ABSTRACT
Introduction and Objectives Traditionally at this unit, patients diagnosed with OSA have been initiated on CPAP at a face to face (F2F) appointment. Patients are followed up via telephone consultation at 4 weeks Abstract P23 Figure 1 with a virtual review of CPAP usage. During the Covid-19 pandemic this department adapted their practices to reduce F2F interactions. Patients were sent a CPAP machine via the post and a YouTube video link of how to use the CPAP. The aim of this study is to compare outcomes in symptoms and compliance between the patient groups to evaluate the effectiveness of a postal CPAP service. Methods Patients initiated on CPAP between September and November 2019 (F2F CPAP) were compared to patients initiated on CPAP between April and June 2020 (Postal CPAP). Data was obtained from the electronic records. Patients were only included in the study if all data regarding symptoms, Epworth score and compliance was complete. Results 346 patients were initiated on F2F CPAP between and 185 were sent postal CPAP during the said period. Of these, 191 (55%) and 59 (32%) respectively had full data recorded. Table 1 compares outcomes in symptom improvement and compliance between both groups. Common causes of missing data were unable to contact patient or extended trial. The majority of patients felt their symptoms were better on CPAP. There was no significant difference between the groups in terms of ESS improvement, hours used per night and percentage of nights used. Conclusions Overall, symptom improvement and compliance were similar in both groups. While it is possible that the outcomes were exaggerated as patients who did not respond well or were non-compliant were excluded as they were not contactable, however that is applicable to both groups & hence comparable. This study has huge implications for how the OSA CPAP service is run in future and supports a case that the initiation of CPAP can be done remotely via postal CPAP without impacting on patient outcomes, with fewer hospital visits, PPE use & clinic room utilization. Future studies should look at long term compliance in this group.
ABSTRACT
INTRODUCTION: Coronavirus disease-19 (COVID-19) is associated with a prothrombotic state and increased incidence of thromboembolic disease. Despite limited evidence, many ICUs have implemented increased prophylactic anticoagulation dosing protocols. However, anticoagulant medications increase the risk of bleeding and warrant additional monitoring. As a result, based on the Thromboembolism and Anticoagulant Therapy During the COVID-19 Pandemic: Interim Clinical Guidance from the Anticoagulation Forum, the study site increased doses of venous thromboembolism prophylaxis (VTEP) to a standard dose of enoxaparin 40 mg subcutaneous (subcut) Q12H for critically ill patients with COVID-19. For patients less than 60 kg, the dose was decreased to enoxaparin 30 mg subcut Q12H. Additionally, anti-Xa level monitoring was utilized to enhance monitoring for patients receiving enoxaparin. METHODS: This retrospective, observational study aimed to describe the anti-Xa level findings and enoxaparin dose adjustment needs. Patients with an estimated creatine clearance of less than 30 mL/min were excluded. Data collection included weight, serum creatinine, enoxaparin dose, anti-Xa levels, peak D-dimer, incidence of pulmonary emboli (PE), deep vein thrombosis (DVT), major bleeding, and minor bleeding, and ICU length of stay (LOS), hospital LOS, and mortality. Data below are presented as median (IQR). RESULTS: Seventeen adults were in the included and 76.5% (n=13) were started on enoxaparin 40 mg subcut Q12H. Twenty-three anti-Xa levels drawn at steady state. Of those, 82.6% (n=19) were within goal range, 8.7% (n=2) were below goal range, and 8.7% (n=2) were above goal range. Peak D-dimer was 2594 ng/mL (1575.5, 13086.3), two patients (10%) had a DVT, and no PEs were detected. Neither of the patients were receiving enoxaparin for VTEP at the time of the DVT. One patient (5%) had minor bleeding and no major bleeding was observed. The ICU LOS was 7 days (5, 15). Prior to the implementation of increased enoxaparin dosing, 4 anti-Xa levels were drawn for 4 patients on enoxaparin 40 mg subcut Q24H and 3 (75%) were below goal range. CONCLUSIONS: In conclusion, when utilizing increased doses of enoxaparin for VTEP, the majority of anti-Xa levels were within goal range and only 1 patient experienced minor bleeding.
ABSTRACT
Background: The COVID19 pandemic stopped most face to face (F2F) interventions like CPAP & NIV as they were deemed aerosol generating (AGP) and only telephone consultations continued. Prior to this we were performing 30 CPAP trials/week. We realised that without an alternative our patients will have to wait a long time for treatment. Methods: We sent CPAP machines by post with MirageFX nasal mask, a sizing gauge for full face mask along with a link to a Youtube video that we created simulating F2F trial. Patients received a phone call prior to sending the kit explaining what to expect & address any concerns. A pre-setup Airsense 10 machine with our standard CPAP booklet was sent and remote monitoring was enabled for a 4 week virtual review. We assessed patients' experience with this system and whether this could become the new normal. A survey questionnaire was sent to all patients. Most responses were on a 5 point Likert scale, 0 being very poor & 5 excellent. Results: We sent 171 CPAPs(ESS 12±5,ODI 32±22) between 27th April & 17th July 2020. 85(50%) responded to the (Table presented) survey. 95% felt able to set up the device successfully. 80% felt better or much better. Overall satisfaction score was 9/10 on a 10 point scale. 75% accessed the video. Table 1 shows the results. Conclusion: 95% patients could setup their devices through remote instructions without any F2F interaction. Initial phone call from the clinical team helped to address queries reducing future interactions. This new way of CPAP trial shows excellent patient satisfaction & less than half needed additional support. Most patients felt symptomatically better, suggesting good response to CPAP. Moving routine trials from F2F to postal had a significant impact in reducing waiting list, room utilizations, AGPs, PPE & man power usage. This reduced hospital visits during pandemic & allowed us to focus on more vulnerable patients. Currently we are sending 30 postal CPAPs/wk. If we have a second spike all F2F interactions might stop again hence we propose this as the standard practice limiting F2F CPAPs only in situations when this is not possible.