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1.
Acute Crit Care ; 36(2): 143-150, 2021 May.
Article in English | MEDLINE | ID: covidwho-1289166

ABSTRACT

BACKGROUND: Evidence prior to the coronavirus disease 2019 (COVID-19) pandemic suggested that, compared with conventional ventilation strategies, airway pressure release ventilation (APRV) can improve oxygenation and reduce mortality in patients with acute respiratory distress syndrome. We aimed to assess the association between APRV use and clinical outcomes among adult patients receiving mechanical ventilation for COVID-19 and hypothesized that APRV use would be associated with improved survival compared with conventional ventilation. METHODS: A total of 25 patients with COVID-19 pneumonitis was admitted to intensive care units (ICUs) for invasive ventilation in Perth, Western Australia, between February and May 2020. Eleven of these patients received APRV. The primary outcome was survival to day 90. Secondary outcomes were ventilation-free survival days to day 90, mechanical complications from ventilation, and number of days ventilated. RESULTS: Patients who received APRV had a lower probability of survival than did those on other forms of ventilation (hazard ratio, 0.17; 95% confidence interval, 0.03-0.89; P=0.036). This finding was independent of indices of severity of illness to predict the use of APRV. Patients who received APRV also had fewer ventilator-free survival days up to 90 days after initiation of ventilation compared to patients who did not receive APRV, and survivors who received APRV had fewer ventilator-free days than survivors who received other forms of ventilation. There were no differences in mechanical complications according to mode of ventilation. CONCLUSIONS: Based on the findings of this study, we urge caution with the use of APRV in COVID-19.

3.
Acute Crit Care ; 36(2): 143-150, 2021 May.
Article in English | MEDLINE | ID: covidwho-1215557

ABSTRACT

BACKGROUND: Evidence prior to the coronavirus disease 2019 (COVID-19) pandemic suggested that, compared with conventional ventilation strategies, airway pressure release ventilation (APRV) can improve oxygenation and reduce mortality in patients with acute respiratory distress syndrome. We aimed to assess the association between APRV use and clinical outcomes among adult patients receiving mechanical ventilation for COVID-19 and hypothesized that APRV use would be associated with improved survival compared with conventional ventilation. METHODS: A total of 25 patients with COVID-19 pneumonitis was admitted to intensive care units (ICUs) for invasive ventilation in Perth, Western Australia, between February and May 2020. Eleven of these patients received APRV. The primary outcome was survival to day 90. Secondary outcomes were ventilation-free survival days to day 90, mechanical complications from ventilation, and number of days ventilated. RESULTS: Patients who received APRV had a lower probability of survival than did those on other forms of ventilation (hazard ratio, 0.17; 95% confidence interval, 0.03-0.89; P=0.036). This finding was independent of indices of severity of illness to predict the use of APRV. Patients who received APRV also had fewer ventilator-free survival days up to 90 days after initiation of ventilation compared to patients who did not receive APRV, and survivors who received APRV had fewer ventilator-free days than survivors who received other forms of ventilation. There were no differences in mechanical complications according to mode of ventilation. CONCLUSIONS: Based on the findings of this study, we urge caution with the use of APRV in COVID-19.

4.
Patient ; 14(3): 319-330, 2021 05.
Article in English | MEDLINE | ID: covidwho-1117440

ABSTRACT

BACKGROUND AND OBJECTIVE: During the COVID-19 pandemic, resources in intensive care units (ICUs) have the potential to be inadequate to treat all those who might benefit. Therefore, it is paramount to identify the views of the community regarding how to allocate such resources. This study aims to quantify Australian community preferences for ventilation allocation. METHODS: A discrete choice experiment was designed and administrated to an adult Australian online panel. Each survey respondent answered 12 choice sets from a total design of 120. Each choice set placed the respondent in the role of hypothetical decision maker, prioritising care between two patients. Conditional logit, mixed logit regression and latent class analysis were used to analyse the data. Additionally, we asked a series of attitudinal questions about different methods of making such decisions in practice, focusing on who should be responsible. RESULTS: A total of 1050 community members completed the survey and responded to each choice. Dimensions considered most important were age, likely effectiveness, smoking status, whether the person has dependents, whether they are a healthcare worker, and whether they have a disability or not. Estimating marginal rates of substitution between patient characteristics and chance of survival if ventilated yielded values of up to 30 percentage points if the patient was 70 years old relative to being 30. However, respondents typically said they would prefer such decisions to be made by medical professionals. CONCLUSION: This study demonstrated the preferences of the community to allocation of ventilators during the COVID-19 pandemic. The use of such information should be treated with some caution as the underlying reason for such preferences are unclear, and respondents themselves preferred the decision to be made by others.


Subject(s)
COVID-19/epidemiology , Choice Behavior , Health Care Rationing/methods , Ventilators, Mechanical , Adolescent , Adult , Age Factors , Aged , Australia/epidemiology , Female , Humans , Intensive Care Units , Male , Middle Aged , Pandemics , Quality-Adjusted Life Years , SARS-CoV-2 , Smoking/epidemiology , Socioeconomic Factors , Young Adult
5.
Breathe (Sheff) ; 16(2): 200062, 2020 Jun.
Article in English | MEDLINE | ID: covidwho-886500

ABSTRACT

The patient and family perspective on the appropriateness of intensive care unit (ICU) treatments involves preferences, values and social constructs beyond medical criteria. The clinician's perception of inappropriateness is more reliant on clinical judgment. Earlier consultation with families before ICU admission and patient education on the outcomes of life-sustaining therapies may help reconcile these provider-patient disagreements. However, global emergencies like COVID-19 change the usual paradigm of end-of-life care, as it is a new disease with only scarce predictive information about it. Pandemics can also bring about the burdensome predicament of doctors having to make unwanted choices of rationing access to the ICU when demand for otherwise life-saving resources exceeds supply. Evidence-based prognostic checklists may guide treatment triage but the principles of shared decision-making are unchanged. Yet, they need to be altered with respect to COVID-19, defining likely outcomes and likelihood of benefit for the patient, and clarifying their willingness to take on the risks inherent to being in an ICU for 2 weeks for those eligible. For patients who are admitted during the prodrome of COVID-19 disease, or those who deteriorate in the second week, clinicians have some lead time in hospital to have appropriate discussions about ceilings of treatments offered based on severity. KEY POINTS: The patient and family perspective on inappropriateness of intensive care at the end of life often differs from the clinician's opinion due to the nonmedical frame of mind.To improve satisfaction with communication on treatment goals, consultation on patient values and inclusion of social constructs in addition to clinical prediction is a good start to reconcile differences between physician and health service users' viewpoints.During pandemics, where health systems may collapse, different admission criteria driven by the need to ration services may be warranted. EDUCATIONAL AIMS: To explore the extent to which older patients and their families are involved in decisions about appropriateness of intensive care admission or treatmentsTo understand how patients or their families define inappropriate intensive care admission or treatmentsTo reflect on the implications of decision to admit or not to admit to the intensive care unit in the face of acute resource shortages during a pandemic.

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