ABSTRACT
Background: To review the efficacy of long-term non-invasive ventilation (LTV) with virtual follow-up, using assistive technologies and remote monitoring. Objective(s): Compliance greater than 4 hours, correction of hypercapnia and improvements in sleep and quality of life (QoL) were the objectives in improving patient outcome. Method(s): We conducted a retrospective cohort study including patients established on LTV over an 18 month period from the start of the pandemic. Initiation of LTV was established as an inpatient (n= 17;35%), outpatient (n= 28;57%) or from the patient's home (n= 4;8%) and follow-up was by telephone, video consultation or from the patient's own home. LTV was considered successful if compliance achieved was > 4 hours using remote monitoring, corrected hypercapnia (tCO2 < 6.5Kpa) and patient-reported improvements in sleep and QoL. Result(s): Forty-nine patients were included. LTV was initiated for: neuromuscular disease (n=19;39%), obesity hypoventilation or overlap (n=12;24%), chronic obstructive pulmonary disease (n=11;22%) and chest wall deformity (n=6;14%). Compliance > 4 hours was achieved in 69% with effective correction of hypercapnia (tCO2 < 6.5Kpa) in 67% and reported improved sleep and QoL at 63%. Overall success in all 3 objectives was 61%. Patient preference for future follow-up was 45% requesting face-to-face consultations and 33% to continue remotely. A proportion of the most vulnerable (14%) would prefer to be seen at home. Conclusion(s): Successful LTV can be achieved with remote compliance data and transcutaneous carbon dioxide monitoring to support virtual clinics. Patient preference for face-to-face consultations remains important in overall satisfaction.
ABSTRACT
Introduction: Awake prone positioning (APP) may reduce ventilation-perfusion mismatch in the context of acute respiratory distress syndrome. The Intensive Care Society recommends its use in COVID-19 to improve oxygenation and reduce risk of progression to invasive mechanical ventilation. This audit project measured the use of APP on an Acute Respiratory Care Unit (ARCU). Method(s): Observations and patient outcomes were recorded for non-intubated patients where a clinical decision had been made to prone. The activPALTM accelerometer was used as an objective measure of APP (prone or lateral-lie positioning). Analysis was performed using STATA v16. Result(s): Between September 2020 and February 2021, 19 individuals with a median age of 68 years were included. 74% were male. In the first 48 hours, 747 person-hours of data were recorded, with 358 person-hours spent in APP. Eight individuals spent at least 50% of their first 48 hours in APP. Lateral lie was better tolerated than full prone positioning, with a median (interquartile range, IQR) of 11.6 (8.0, 20.2) hours spent in lateral lie and median (IQR) of 1.6 (0.5, 8.3) hours spent fully proned in the first 48 hours. Median (interquartile range, IQR) improvement from baseline in respiratory rate/oxygenation (ROX) index at 48 hours was +1.65 (0.90, 1.89). Median (IQR) ROX index at 12 hours for individuals not in APP was 4.80 (3.04, 8.51) and 10.41 (9.09, 11.42) for individuals who were fully proned. Nine individuals were admitted to intensive care, 13 survived to discharge. Conclusion(s): Accelerometry is an objective method to measure time spent in APP and showed that lateral lie was preferred to full prone position in this cohort. Trends suggest possible improvement in ROX, although numbers were small.
ABSTRACT
Introduction: The ISARIC4C score1 and APACHE II score are used widely to predict mortality in critically ill patients with COVID-19 pneumonitis. These scores, however, do not predict response to specific treatments. Non-invasive respiratory support (NRS) in the form of CPAP/NIV/HFNC has been extensively used to treat COVID-19 pneumonitis. ROX index2 (SpO2/FiO2/Respiratory Rate) is used to predict failure of HFNC in treatment of Acute Hypoxaemic Respiratory Failure and ARDS. However, there are limited data on its efficacy to predict NRS failure in COVID-19 infection. Objective: Whether ROX index can be used to predict response to NRS in both patients for escalation to mechanical ventilation and those where NRS is ceiling of care. Methods: A retrospective study of individuals, SARSCOV-2 positive by RT-PCR, admitted to the ICU and requiring CPAP/NIV/HFNC, in a single centre between October 2020 to January 2021. Respiratory parameters were obtained at initiation of NRS followed by 2, 6 and 12 hours post initiation. NRS failure was defined as the need for mechanical ventilation in those for escalation of support or death in those where NRS was set as ceiling of care. Results: Data (Table 1) for 104 patients (70 men) were analysed. The mean age and BMI were 58.0 years and 31.4kg/m2, respectively, mean Respiratory Rate was 31 and mean SpO2/FiO2 of 144 on admission. In 10 out of 104 NRS was set as ceiling of care. Most patients were treated with CPAP/NIV, and they often used HFNC for breaks and while eating and drinking. Of the 62 patients that failed NRS, 10 had NRS as ceiling of care and a further 10 died without receiving mechanical ventilation. 42 patients underwent mechanical ventilation. 70 were discharged and 34 (32.7%) died in hospital. Baseline and 12 hour ROX index was not significantly different but the mean change between 0 and 12 hour ROX (2.2, 95% CI 0.99 to 3.46;p=0.0005) was significantly higher in those with NRS success. NRS success was predicted by a ROX index value of >5(OR 2.59, 95% CI 1.15-5.85;p= 0.01) and improvement in ROX score by >1 at 12 hours (OR 3.25, 95% CI 1.43 to 7.4;p=0.025). Conclusion: There was a significantly higher increase in ROX index at 12 hours in those with NRS success. A 12 hour ROX index of > 5 or an improvement by >1 are good predictors of success. Patients where NRS failed were older, had higher APACHE II and slightly higher ISARIC-4C score as expected. Discussion: This was a real life study where patients were treated with a combination of CPAP/NIV and HFNC as opposed to just HFNC or CPAP. The advantage of ROX index over P/F ratio is that arterial blood gases are not needed. It can be scored easily by routinely collected vital observations. A large number of patients are likely to be treated outside critical care in light of results from RECOVERY-RS trial3. In these settings, ROX index could be a useful tool for escalation to critical care or planning for symptom palliation as appropriate.
ABSTRACT
Background: Shielding for clinically vulnerable members of the population during the COVID-19 pandemic has had significant impacts on healthcare delivery. This study investigates whether shielding reduces hospital admissions amongst patients requiring long term ventilation (LTV) and whether there may be a role for shielding and adopting other hygiene methods every winter to reduce hospital admissions. Methods: 603 LTV patients in two large centres completed a questionnaire about shielding and COVID-19 symptoms during the lockdown. A comparative retrospective study of hospital admissions for acute hypercapnic respiratory failure requiring non-invasive ventilation (NIV) between the periods March-June 2019 and March - June 2020 during the peak of the COVID-19 pandemic, was also carried out. Results: 522(88.57%) of the 603 patients reported observing strict adherence to shielding whilst the remaining 81(13.43%) observed isolation precautions to various degrees. 30 (4.98%) reported having developed COVID-19 symptoms with just 2 (0.33%) testing positive but none required invasive ventilation and there were no deaths. Admissions requiring acute NIV in 2019 was 39(6.47%) compared to 9(1.49%) during the 2020 COVID19 peak. Conclusion: Compared to 2019, there was a drop in the number of admissions in patients requiring acute NIV during lock-down. COVID 19 incidence was also low in this shielded cohort. These suggest a case can be made for advocating shielding every winter for LTV patients and potentially for all patients with chronic respiratory disease. Widespread use of masks and improved hand hygiene could also help reduce spread of other viral illnesses like influenza which account for a significant number of admissions in (Figure presented) patients with chronic respiratory conditions over the winter months. Adopting a blanket strategy to shield all patients with chronic respiratory illness during winter is probably impractical. A stratify-and-shield policy requiring an adaptive social distancing strategy to keep the load on critical care services within manageable limits1 has been advocated. We anticipate our findings will generate exciting debate for and against shielding our most clinically vulnerable respiratory patients during winter.