Comparison of the efficacy and comfort of high-flow nasal cannula with different initial flow settings in patients with acute hypoxemic respiratory failure: a systematic review and network meta-analysis.

BACKGROUND: High-flow nasal cannula (HFNC) has been proven effective in improving patients with acute hypoxemic respiratory failure (AHRF), but a discussion of its use for initial flow settings still need to be provided. We aimed to compare the effectiveness and comfort evaluation of HFNC with different initial flow settings in patients with AHRF. METHODS: Studies published by October 10, 2022, were searched exhaustively in PubMed, Embase, Web of Science, Cochrane Library (CENTRAL), and the China National Knowledge Infrastructure (CNKI) database. Network meta-analysis (NMA) was performed with STATA 17.0 and R software (version 4.2.1). A Bayesian framework was applied for this NMA. Comparisons of competing models based on the deviance information criterion (DIC) were used to select the best model for NMA. The primary outcome is the intubation at day 28. Secondary outcomes included short-term and long-term mortality, comfort score, length of ICU or hospital stay, and 24-h PaO2/FiO2. RESULTS: This NMA included 23 randomized controlled trials (RCTs) with 5774 patients. With NIV as the control, the HFNC_high group was significantly associated with lower intubation rates (odds ratio [OR] 0.72 95% credible interval [CrI] 0.56 to 0.93; moderate quality evidence) and short-term mortality (OR 0.81 95% CrI 0.69 to 0.96; moderate quality evidence). Using HFNC_Moderate (Mod) group (mean difference [MD] - 1.98 95% CrI -3.98 to 0.01; very low quality evidence) as a comparator, the HFNC_Low group had a slight advantage in comfort scores but no statistically significant difference. Of all possible interventions, the HFNC_High group had the highest probability of being the best in reducing intubation rates (73.04%), short-term (82.74%) and long-term mortality (67.08%). While surface under the cumulative ranking curve value (SUCRA) indicated that the HFNC_Low group had the highest probability of being the best in terms of comfort scores. CONCLUSIONS: The high initial flow settings (50-60 L/min) performed better in decreasing the occurrence of intubation and mortality, albeit with poor comfort scores. Treatment of HFNC for AHRF patients ought to be initiated from moderate flow rates (30-40 L/min), and individualized flow settings can make HFNC more sensible in clinical practice.

High-flow nasal cannula versus noninvasive ventilation in patients with COVID-19: a systematic review and meta-analysis.

BACKGROUND: During the novel coronavirus disease 2019 (COVID-19) pandemic raging around the world, the effectiveness of respiratory support treatment has dominated people's field of vision. This study aimed to compare the effectiveness and value of high-flow nasal cannula (HFNC) with noninvasive ventilation (NIV) for COVID-19 patients. METHODS: A comprehensive systematic review via PubMed, Web of Science, Cochrane, Scopus, WHO database, China Biology Medicine Disc (SINOMED), and China National Knowledge Infrastructure (CNKI) databases was conducted, followed by meta-analysis. RevMan 5.4 was used to analyze the results and risk of bias. The primary outcome is the number of deaths at day 28. The secondary outcomes are the occurrence of invasive mechanical ventilation (IMV), the number of deaths (no time-limited), length of intensive care unit (ICU) and hospital stay, ventilator-free days, and oxygenation index [partial pressure of arterial oxygen (PaO2)/fraction of inhaled oxygen (FiO2)] at 24 h. RESULTS: In total, nine studies [one randomized controlled trial (RCT), seven retrospective studies, and one prospective study] totaling 1582 patients were enrolled in the meta-analysis. The results showed that the incidence of IMV, number of deaths (no time-limited), and length of ICU stay were not statistically significant in the HFNC group compared with the NIV group (ps = 0.71, 0.31, and 0.33, respectively). Whereas the HFNC group performed significant advantages in terms of the number of deaths at day 28, length of hospital stay and oxygenation index (p < 0.05). Only in the ventilator-free days did NIV show advantages over the HFNC group (p < 0.0001). CONCLUSION: For COVID-19 patients, the use of HFNC therapy is associated with the reduction of the number of deaths at day 28 and length of hospital stay, and can significantly improve oxygenation index (PaO2/FiO2) at 24 h. However, there was no favorable between the HFNC and NIV groups in the occurrence of IMV. NIV group was superior only in terms of ventilator-free days.

Comparison of tracheal intubation between sitting position and standing position in COVID-19 patients: A manikin study.

ABSTRACT: It is recommended to use visual laryngoscope for tracheal intubation in a Corona Virus Disease 2019 patient to keep the operator farther from the patient. How the position of the operator affects the distance in this setting is not ascertained. This manikin study compares the distances between the operator and the model and the intubation conditions when the operator is in sitting position and standing position, respectively.Thirty one anesthesiologists with minimum 3-years' work experiences participated in the study. The participant's posture was photographed when he performed tracheal intubation using UE visual laryngoscope in standing and sitting position, respectively. The shortest distance between the model's upper central incisor and operator's face screen (UF), the horizontal distance between the model's upper central incisor and the operator's face screen, the angle between the UF line and the vertical line of the model's upper central incisor were measured. The success rate of intubation, the duration of intubation procedure, the first-attempt success rate, the Cormack-Lehane grade, and operator comfort score were also recorded.When the operator performed the procedure in sitting position, the horizontal distance between the model's upper central incisor and the operator's face screen distance was significantly longer (9.5 [0.0-17.2] vs 24.3 [10.3-33.0], P ≤ .001) and the angle between the UF line and the vertical line of the model's upper central incisor angle was significantly larger (45.2 [16.3-75.5] vs 17.7 [0.0-38.9], P ≤ .001). There was no significant difference in UF distance when the operator changed the position. Cormack-Lehane grade was significantly improved when it was assessed using visual laryngoscope. Cormack-Lehane grade was not significantly different when the operator assessed it in sitting and standing position, respectively. No significant differences were found in the success rate, duration for intubation, first-attempt success rate, and operator comfort score.The operator is kept farther from the patient when he performs intubation procedure in sitting position. Meanwhile, it does not make the procedure more difficult or uncomfortable for the operator, though all the participants prefer to standing position.

Comparison of Repeated Video Display vs Combined Video Display and Live Demonstration as Training Methods to Healthcare Providers for Donning and Doffing Personal Protective Equipment: A Randomized Controlled Trial.

PURPOSE: The lack of training in personal protective equipment (PPE) donning and doffing is hindering the current fight against the COVID-19 worldwide. In order to enable medical staff to learn how to don and doff PPE faster and more effectively, we compared two training methods of PPE donning and doffing. METHODS: Participants in this study were 48 health care workers randomly divided into two groups. Group A watched a 10-minute demonstration (demo) video four times, while Group B watched the same 10-minute demo video twice and then watched a 10-minute live demo twice. The 40-minute learning time was the same for both groups. A 29-step examination was held after the training was completed. The examination scores of Groups A and B were recorded according to a checklist containing PPE donning and doffing steps . The time spent by the participants on PPE donning and doffing, their satisfaction with the training, and their confidence in donning and doffing PPE accurately were analyzed. RESULTS: The average score of Group B was higher than that Group A, with a mean (SD) of 94.92 (1.72) vs 86.63 (6.34), respectively (P<0.001). The average time spent by Group B was shorter than that spent by Group A, with a mean (SD) of 17.67 (1.01) vs 21.75 (1.82), respectively (P<0.001). The satisfaction and confidence of Group B were higher than those of Group A (P<0.001). CONCLUSION: Compared with repeated video display, combined video display and live demonstration are more suitable training methods for donning and doffing PPE.

Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations.

Tracheal intubation in coronavirus disease 2019 (COVID-19) patients creates a risk to physiologically compromised patients and to attending healthcare providers. Clinical information on airway management and expert recommendations in these patients are urgently needed. By analysing a two-centre retrospective observational case series from Wuhan, China, a panel of international airway management experts discussed the results and formulated consensus recommendations for the management of tracheal intubation in COVID-19 patients. Of 202 COVID-19 patients undergoing emergency tracheal intubation, most were males (n=136; 67.3%) and aged 65 yr or more (n=128; 63.4%). Most patients (n=152; 75.2%) were hypoxaemic (Sao2 <90%) before intubation. Personal protective equipment was worn by all intubating healthcare workers. Rapid sequence induction (RSI) or modified RSI was used with an intubation success rate of 89.1% on the first attempt and 100% overall. Hypoxaemia (Sao2 <90%) was common during intubation (n=148; 73.3%). Hypotension (arterial pressure <90/60 mm Hg) occurred in 36 (17.8%) patients during and 45 (22.3%) after intubation with cardiac arrest in four (2.0%). Pneumothorax occurred in 12 (5.9%) patients and death within 24 h in 21 (10.4%). Up to 14 days post-procedure, there was no evidence of cross infection in the anaesthesiologists who intubated the COVID-19 patients. Based on clinical information and expert recommendation, we propose detailed planning, strategy, and methods for tracheal intubation in COVID-19 patients.

Expert Recommendations for Tracheal Intubation in Critically ill Patients with Noval Coronavirus Disease 2019.

Coronavirus Disease 2019 (COVID-19), caused by a novel coronavirus (SARS-CoV-2), is a highly contagious disease. It firstly appeared in Wuhan, Hubei province of China in December 2019. During the next two months, it moved rapidly throughout China and spread to multiple countries through infected persons travelling by air. Most of the infected patients have mild symptoms including fever, fatigue and cough. But in severe cases, patients can progress rapidly and develop to the acute respiratory distress syndrome, septic shock, metabolic acidosis and coagulopathy. The new coronavirus was reported to spread via droplets, contact and natural aerosols from human-to-human. Therefore, high-risk aerosol-producing procedures such as endotracheal intubation may put the anesthesiologists at high risk of nosocomial infections. In fact, SARS-CoV-2 infection of anesthesiologists after endotracheal intubation for confirmed COVID-19 patients have been reported in hospitals in Wuhan. The expert panel of airway management in Chinese Society of Anaesthesiology has deliberated and drafted this recommendation, by which we hope to guide the performance of endotracheal intubation by frontline anesthesiologists and critical care physicians. During the airway management, enhanced droplet/airborne PPE should be applied to the health care providers. A good airway assessment before airway intervention is of vital importance. For patients with normal airway, awake intubation should be avoided and modified rapid sequence induction is strongly recommended. Sufficient muscle relaxant should be assured before intubation. For patients with difficult airway, good preparation of airway devices and detailed intubation plans should be made.