70 A review of end of life care of patients on high flow nasal cannula at the royal victoria infirmary, newcastle upon Tyne

BackgroundHigh flow nasal cannula (HFNC) has a role in managing chronic and acute respiratory failure. Many published reports suggest that HFNC decreases breathing frequency and work of breathing and reduces needs of escalation of respiratory support in patients with diverse underlying diseases. These properties may provide beneficial symptom control where reversibility of the condition is not possible.MethodOur aim was to evaluate end of life care delivered in patients who received HFNC in their terminal admission. These patients were identified via database kept by Critical Care Outreach Nurses from December 2019 - February 2020. Data was collected retrospectively from electronic notes.Results33 patient notes were reviewed (mean age= 77.2 years (15 female, 18 Male)). A majority (24) were admitted from home, with the remainder from nursing or residential care. Initiation of HFNC happened throughout the hospital (Emergency Department and admission unit= 14, Respiratory unit= 8, other medical wards= 6, Non-medical wards= 5). The primary indication for commencing HFNC was pneumonias (15), with an average duration of 7.24 days. 15 patients weaned off HFNC, 11 died with HFNC in situ, 4 did not tolerate treatment, 2 were discharged to community for end of life care and 1 was intubated. Regarding the recognition and management of the dying patient: 31 were recognised to be dying by medical teams and of these, 29 had documented discussions regarding end of life care with patient or relatives. 27 patients were referred to Palliative Care for specialist advice and 27 were prescribed anticipatory medications for symptom management.ConclusionThere was clear evidence of good symptom management and onward referral to Specialist Palliative Care for patients who were treated with HFNC during their final admission. However, we are limited by reviewing retrospective documentation and the likely change in practice given the Covid-19 pandemic.

The variation of FiO2 with circuit type and peak inspiratory flow rate during non-invasive respiratory support using domiciliary ventilators and its significance during the COVID-19 pandemic.

Background: The COVID-19 pandemic has resulted in increased admissions with respiratory failure and there have been reports of oxygen failure and shortages of machines to deliver ventilation and Continuous Positive Airway Pressure (CPAP). Domiciliary ventilators which entrain room air have been widely used during the pandemic. Poor outcomes reported with non-invasive respiratory support using ventilators which lack an oxygen blender could be related to an unreliable Fraction of inspired O2 (FiO2). Additionally, with concerns about oxygen failure, the variety of ventilator circuits used as well as differing peak inspiratory flow rates (PIFR) could impact on the FiO2 delivered during therapy with domiciliary ventilators. Methods: In a series of bench tests, we tested the effect of choice of circuit and different PIFR on the FiO2 achieved during simulation of ventilation and CPAP therapy using domiciliary ventilators. Results: FiO2 was highly dependent upon the type of circuit used with circuits with an active exhalation valve achieving similar FiO2 at lower oxygen flow rates than circuits using an exhalation port. During CPAP therapy, high PIFR resulted in significantly lower FiO2 than low PIFR. Conclusions: This study has implications for oxygen usage as well as delivery of non-invasive respiratory support during therapy with domiciliary ventilators when these are used during the second wave of COVID-19.

Case Report: Renal potassium wasting in SARS-CoV-2 infection.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is associated with many potentially fatal complications. Renal involvement in various forms is common in addition to serum electrolyte disturbances. Early reports suggest that hypokalaemia may frequent those with SARS-CoV-2 infection and various aetiological factors may cause this electrolyte disturbance. A Chinese retrospective study has demonstrated renal potassium wasting in patients infected with SARS-CoV-2, however, it is not known if these patients were receiving diuretic therapy which may be a contributing factor. This case report illustrates an example of renal potassium wasting in SARS-CoV-2 infection in the absence of diuretics and extra-renal mechanisms with important lessons learned.

Improved survival following ward-based non-invasive pressure support for severe hypoxia in a cohort of frail patients with COVID-19: retrospective analysis from a UK teaching hospital.

Since the outbreak of COVID-19 in China in December 2019, a pandemic has rapidly developed on a scale that has overwhelmed health services in a number of countries. COVID-19 has the potential to lead to severe hypoxia; this is usually the cause of death if it occurs. In a substantial number of patients, adequate arterial oxygenation cannot be achieved with supplementary oxygen therapy alone. To date, there has been no clear guideline endorsement of ward-based non-invasive pressure support (NIPS) for severely hypoxic patients who are deemed unlikely to benefit from invasive ventilation. We established a ward-based NIPS service for COVID-19 PCR-positive patients, with severe hypoxia, and in whom escalation to critical care for invasive ventilation was not deemed appropriate. A retrospective analysis of survival in these patients was undertaken. Twenty-eight patients were included. Ward-based NIPS for severe hypoxia was associated with a 50% survival in this cohort. This compares favourably with Intensive Care National Audit and Research Centre survival data following invasive ventilation in a less frail, less comorbid and younger population. These results suggest that ward-based NIPS should be considered as a treatment option in an integrated escalation strategy in all units managing respiratory failure secondary to COVID-19.