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Minerva Anestesiol ; 2022 Nov 30.
Article in English | MEDLINE | ID: covidwho-2228767


BACKGROUND: The optimal first-line noninvasive respiratory support (NIRS) to improve outcome in patients affected by COVID-19 pneumonia admitted to ICU is still debated. METHODS: We conducted a retrospective study in 7 French ICUs, including all adults admitted between July and December 2020 with documented SARS-CoV-2 acute respiratory failure (PaO2/FiO2 <300 mmHg), and treated with either high-flow nasal therapy (HFNT) alone, noninvasive ventilation alone or in combination with HFNT (NIV), or continuous positive airway pressure alone or in combination with HFNT (CPAP). The primary outcome was NIRS failure at day 28, defined as the need for endotracheal intubation (ETI) or death without ETI. RESULTS: Among the 355 patients included, 160 (45%) were treated with HFNT alone, 115 (32%) with NIV and 80 (23%) with CPAP. The primary outcome occurred in 65 (41%), 69 (60%), and 25 (31%) patients among those treated with HFNT alone, NIV, and CPAP, respectively (P<0.001). After univariate analysis, patients treated with CPAP had a trend for a lower incidence of the primary outcome, whereas patients treated with NIV had a significant higher incidence of the primary outcome, both compared to those treated with HFNT alone (unadjusted Hazard ratio 0.67; 95% CI [0.42-1.06], and 1.58; 95% CI [1.12-2.22]; P=0.09 and 0.008, respectively). CONCLUSIONS: Among ICU patients admitted for severe COVID-19 pneumonia and managed with NIRS, the outcome seems to differ according to the initial chosen strategy. Prospective randomized controlled studies are warranted to identify the optimal strategy.

Crit Care Explor ; 4(12): e0805, 2022 Dec.
Article in English | MEDLINE | ID: covidwho-2190842


To determine the effect of the awake prone position (APP) on gas exchange and the work of breathing in spontaneously breathing patients with COVID-19-associated acute hypoxemic respiratory failure (AHRF) supported by high-flow nasal oxygen. DESIGN: Prospective randomized physiologic crossover multicenter trial. SETTINGS: Four ICUs in Marseille, France. PATIENTS: Seventeen patients with laboratory-confirmed COVID-19 pneumonia and Pao2/Fio2 less than or equal to 300 mm Hg while treated with high-flow nasal cannula oxygen therapy. INTERVENTIONS: Periods of APP and semirecumbent position (SRP) were randomly applied for 2 hours and separated by a 2-hour washout period. MEASUREMENTS AND MAIN RESULTS: Arterial blood gases, end-tidal CO2. and esophageal pressure were recorded prior to and at the end of each period. Inspiratory muscle effort was assessed by measuring the esophageal pressure swing (∆PES) and the simplified esophageal pressure-time product (sPTPES). The other endpoints included physiologic dead space to tidal volume ratio (VD/VT) and the transpulmonary pressure swing. The APP increased the Pao2/Fio2 from 84 Torr (61-137 Torr) to 208 Torr (114-226 Torr) (p = 0.0007) and decreased both the VD/VT and the respiratory rate from 0.54 (0.47-0.57) to 0.49 (0.45-0.53) (p = 0.012) and from 26 breaths/min (21-30 breaths/min) to 21 breaths/min (19-22 breaths/min), respectively (p = 0.002). These variables remained unchanged during the SRP. The ∆PES and sPTPES per breath were unaffected by the position. However, the APP reduced the sPTPES per minute from 225 cm H2O.s.m-1 (176-332 cm H2O.s.m-1) to 174 cm H2O.s.m-1 (161-254 cm H2O.s.m-1) (p = 0.049). CONCLUSIONS: In spontaneously breathing patients with COVID-19-associated AHRF supported by high-flow nasal oxygen, the APP improves oxygenation and reduces the physiologic dead space, respiratory rate, and work of breathing per minute.