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BACKGROUND: Prone positioning improves oxygenation in patients with acute respiratory distress syndrome (ARDS) secondary to COVID-19. However, its haemodynamic effects are poorly understood. OBJECTIVES: The objective of this study was to investigate the acute haemodynamic changes associated with prone position in mechanically ventilated patients with COVID-19 ARDS. The primary objective was to describe changes in cardiac index with prone position. The secondary objectives were to describe changes in mean arterial pressure, FiO2, PaO2/FiO2 ratio, and oxygen delivery (DO2) with prone position. METHODS: We performed this cohort-embedded study in an Australian intensive care unit, between September and November 2021. We included adult patients with severe COVID-19 ARDS, requiring mechanical ventilation and prone positioning for respiratory failure. We placed patients in the prone position for 16 h per session. Using pulse contour technology, we collected haemodynamic data every 5 min for 2 h in the supine position and for 2 h in the prone position consecutively. RESULTS: We studied 18 patients. Cardiac index, stroke volume index, and mean arterial pressure increased significantly in the prone position compared to supine position. The mean cardiac index was higher in the prone group than in the supine group by 0.44 L/min/m2 (95% confidence interval, 0.24 to 0.63) (P < 0.001). FiO2 requirement decreased significantly in the prone position (P < 0.001), with a significant increase in PaO2/FiO2 ratio (P < 0.001). DO2 also increased significantly in the prone position, from a median DO2 of 597 mls O2/min (interquartile range, 504 to 931) in the supine position to 743 mls O2/min (interquartile range, 604 to 1075) in the prone position (P < 0.001). CONCLUSION: Prone position increased the cardiac index, mean arterial pressure, and DO2 in invasively ventilated patients with COVID-19 ARDS. These changes may contribute to improved tissue oxygenation and improved outcomes observed in trials of prone positioning.
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An introduction to articles published within the issue is presented on topics including the effects of physiotherapy on hemodynamics, gas exchange and cerebral physiology in ventilated subjects, an evaluation of four mechanical insufflation-exsufflation (MI-E) devices, and a session of intermittent intrapulmonary deflation technique and positive expiratory pressure therapy in chronic obstructive pulmonary disease (COPD) patients.
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This commentary refers to the article "A Recirculation System to Reduce the Consumption of Oxygen During CPAP" by A. Coppadoro, L. Paratico, G. Bellani and colleagues, that was published within the issue. Topics discussed include oxygen therapy during the COVID-19 pandemic, partial rebreathing, and oxygen conservation and efficient use of limited oxygen supplies.
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SESSION TITLE: Trainees: Mental Well-Being and Performance SESSION TYPE: Original Investigations PRESENTED ON: 10/16/22 10:30 am - 11:30 am PURPOSE: With the COVID-19 pandemic and hospital surges, our institution’s house staff was responsible for a significantly increased volume of critically ill patients while balancing residency training. In August 2020, a needs assessment survey was distributed among categorical Internal Medicine (IM) and Internal Medicine/Pediatrics (Med-Peds) residents. The results indicated low comfort levels in the evaluation of decompensating patients and in leading rapid response teams (RRTs). A grassroots initiative was started by two residents and a resuscitation nursing coordinator to address this need. Here, we describe the design and implementation of a resident-led simulation and clinical skills-based curriculum aimed at improving residents’ comfort in leading RRTs. METHODS: From August to September 2021, 56 senior level IM and Med-Peds residents attended a three-hour resuscitation workshop. A mixed educational format with high fidelity simulations, hands-on skills and small group debriefing discussions was implemented. Five scenarios were developed from retrospective hospital-wide RRT data;ventricular tachycardia (VT), supraventricular tachycardia (SVT), ventricular fibrillation, symptomatic bradycardia, and respiratory distress. Skills training included defibrillator use, transcutaneous pacing, adenosine administration, intraosseous line placement and low- and high-flow oxygen delivery devices. Participants were asked to complete a pre- and post-workshop questionnaire. The survey consisted of 7 questions about their comfort level on a 5-point Likert scale. A two-sample t-test was used to assess for difference in mean scores. RESULTS: Residents’ comfort level scores improved significantly in the following: from 3.49 to 4.36 (P< 0.0001) in the initial evaluation of an RRT patient, from 3.14 to 3.84 (P= 0.0026) in regard to thinking quickly during an emergency, and from 2.88 to 4.00 (P< 0.0001) in leading a RRT. There was also a global increase in comfort level scores with the scenarios: “VT” (P=0.0003), “SVT” (P< 0.0001), “symptomatic bradycardia” (P< 0.0001), and “respiratory distress” (P= 0.0324). CONCLUSIONS: Residents’ comfort levels as code leaders encountering various RRT scenarios significantly improved after our three-hour high-fidelity simulation and clinical skills workshop. CLINICAL IMPLICATIONS: Despite the challenges of COVID-19 group gathering restrictions and hospital surges, this training course became a well-received educational project to improve the effectiveness of resident-led RRTs. In response to its success, a pilot two-year curriculum involving more diverse RRT scenarios is currently being launched. The curriculum includes three workshop sessions per year for a multidisciplinary team of residents, pharmacy residents, and nurses aimed at improving code leader effectiveness and teamwork dynamics. DISCLOSURES: No relevant relationships by Tanja Barac No relevant relationships by Christie Brillante No relevant relationships by Lily Cheng No relevant relationships by Paul Cooper no disclosure on file for Cristina Diaz Pabon;No relevant relationships by Shaveta Khosla
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Access to therapeutic oxygen in low-resource settings remains a significant global problem. Solar powered oxygen (SPO2) delivery is a reliable and cost-effective solution. We followed implementation research methodology to gather data on engineering parameters (remote monitoring), nurse training (before and after knowledge questionnaire), patients treated with SPO2 (descriptive case series), and qualitative user feedback (focus group discussions). In January 2021, SPO2 was installed at Hanano General Hospital in Dusamareb, Galmudug State, Somalia, in a conflict-affected region. Daily photovoltaic cell output (median 8.0 kWh, interquartile range (IQR) 2.6-14) exceeded the electrical load from up to three oxygen concentrators (median 5.0 kWh, IQR 0.90-12). Over the first six months after implementation, 114 patients (age 1 day to 89 years, 54% female) were treated for hypoxaemic illnesses, including COVID-19, pneumonia, neonatal asphyxia, asthma, and trauma. Qualitative end user feedback highlighted SPO2 acceptability. Violent conflict was identified as a contextual factor affecting local oxygen needs. We provide the preliminary findings of this implementation research study and describe the feasibility, fidelity, rapid adoption, usefulness, and acceptability of SPO2 in a low-resource setting characterized by violent conflict during the COVID-19 pandemic. Our findings demonstrated the lifesaving feasibility of SPO2 in volatile settings.
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COVID-19 , Pandemics , Feasibility Studies , Female , Humans , Infant , Infant, Newborn , Male , Oxygen , SomaliaABSTRACT
Background: Severe Coronavirus Disease 2019 (COVID-19) can develop pneumonia with severe complications. The Oxygen Efficient Respiratory Aid (OxEraTM) device has been granted SAPHRA approval for emergency COVID-19 pandemic use. The device has the potential to be used widely in the healthcare sector due to its efficient oxygen supply and adjustable wall positive expiratory pressure (PEP). Objectives: We assessed whether the OxEraTM device was safe to use in a healthy adult volunteer population. Our primary objective was to ensure there was no asphyxiation, as assessed by changes observed from baseline End Tidal Carbon Dioxide (ETCO2) exceeding 6.3 mmHg and above the 45 mmHg threshold. We also monitored changes in vital organ signs and assessed the pain and comfort of the participant at various intervals with changes in PEPs. Methods: This was an experimental safety study of the OxEraTM Device on 30 healthy participants at the ICU training centre of Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa. Each participant had basic vital-signs, ETCO2, and Oxygen saturation percentages (SpO2%) taken at baseline until the end of 2 h. In the first 20 min, the PEP was increased by 5 cmH20 until 20 min, then continued for the rest of the time on a PEP of 5 cmH20. At each interval, vital signs, subjective comfort, pain, and visual scores were measured. Results: Thirty healthy participants were enrolled. There was no significant difference in ETCO2 from baseline until 2 h. No participant experienced an increase in measured ETCO2 greater than 45 mmHg and no increase in ETCO2 from baseline was greater than 6.3 mmHg. The median increase in ETCO2 over the study period was 2 mmHg. There were no significant changes in respiratory rate and blood pressure. The heart rate decreased significantly (73-68 bpm). The VAS and comfort score had a significant increase over the 2 h from baseline of 0-2 at maximum; however, the PAS scores showed no significant increase. Conclusion: Overall the OxEraTM device achieved the safety endpoints set out. There was no sign of asphyxiation and there were appropriate physiological responses to changes in PEP once applied. The comfort of the mask did worsen over the 2 h; however, the scores were minimally worse on PEP application but improved once-off PEP. No adverse event was recorded at all.
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Background: In the wake of rise in COVID patients in the country, world is experiencing an acute shortage of mechanical ventilators and medical oxygen to an extent that many hypoxic patients are not able to get oxygen support. The need of the hour is a more efficient Oxygen Delivery device which can be easily accessible to most of remote health setups that are devoid of ICU beds or Ventilators. Moreover with the growing Oxygen Crisis, we also need devices that can help in Oxygen conservation. Objective: To assess the efficiency of bains circuit compared to NRBM in covid -19 patients awaiting NIV support based on SpO2 and PaO2. Methodology: Prospective study conducted on patients presenting with moderate to severe COVID 19 Disease. The study subjects will be randomly assigned to the experimental group. Baseline data (spO2 levels, PaO2 levels) will be collected, the experimental group will be Oxygenated via NRBM then shifted to Bains Circuit on same oxygen flow rates. SpO2 and PaO2 levels will be compared in the same group. Also, the total Oxygen consumption by each patient of same group will be compared.Assuming acute shortage of Oxygen, ventilator beds and ICU beds in most parts of India, the use of Bains Circuit, if proven efficient over NRBM can be a major help to most of the rural and low resource setups. It can be a useful device for transportation of severely hypoxic patients to higher DCHCs. Results: A common trend was seen in patients maintaining sufficient respiratory efforts but reduced SpO2 on NRBM, as soon as shifted on Bain's circuit (connected via a BiPaP mask), a sudden jump in SpO2 and PaO2 (approx. 15-20%) was seen at same oxygen flow rates. Conclusion: As we anticipate 3rd wave of Covid 19, keeping Bain's circuit as choice for oxygen therapy can be a lifesaving alternative for patients awaiting non invasive ventilator support.
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The demand for oxygen delivery systems has continued to rise in recent years. Oxygen is still a valuable resource in the event of a calamity. With the COVID-19 epidemic still raging, the oxygen delivery system is on the verge of failing. The strategic management of oxygen supply is a priority at this time. Hospitals have ample liquid oxygen supplies and compressed gas oxygen cylinders to last many days, but the pandemic's enormous intake of patients is putting a strain on these resources. As a result, an AI system has been proposed in which users can find oxygen supplies in a very efficient manner using chatbots and voice assistants from dealers and hospitals. This application will alleviate the difficulties faced by illiterates with language incompetence, visually impaired users, and the elderly in obtaining assistance. The planned method will make oxygen readily available to individuals of all ages and backgrounds. So, deaths due to oxygen supply will be reduced. © 2022 IEEE.
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COVID-19/complications , Oxygen/metabolism , Adult , Aged , Female , Humans , Male , Middle Aged , Oxygen Consumption , Perioperative Care , Young AdultABSTRACT
Patient 60 years old, a teacher working from home, got infected from her husband. The husband was an asymptomatic. Symptoms were loss of taste and smell, fever, weakness, nausea, vomiting, diarrhea, blurred vision. Hemodynamic parameters-BP 90/60 mm Hg, HR-99 bpm. Her regular HR was 55-60 bpm. Due to the overloading of hospitals, there was a queue for hospitalization at home. She was receiving the treatment of a family doctor. On the 9th day, her condition became worst. CT-scan picture showed 20% of lung lesions. Hemodynamic parameters were-BP 80/50 mm Hg, HR-115 beats. Due to of progressive dehydration, the high temperature lasted for 12 days. In anamnesis she has a drug allergy, chronic hypertension with left anterior bundle branch block because of suffering with rheumatic heart disease from the childhood. Any kind of liquid per oral caused immediate nausea and vomiting. Saturation was 74. We had to start i/v therapy at home in order to stop severe dehydration and high fever. Mobile oxygen delivery devices were used to monitor saturation. With that treatment during the day, the saturation indicator was 92. But at night, when the saturation went down below 86, the device, by means of an audible alert, gave a signal to connect oxygen. BP dropped to 70/50 mm Hg, HR-120 bpm. The patient also received factor XA inhibitor, antibiotic therapy, antiviral therapy, vitamins C and D. After these measures, she felt better, but could not take liquid on her own, as it still caused nausea. On the 14th day, a place was vacated in one of the hospitals and she was hospitalized. In the hospital, she spent another 10 days, the hemodynamics returned to normal and the second CT-scan showed 5% of the lungs damage. She was discharged of her own free will. For 1.5 months after that, she still felt severe weakness and was unable to work.
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Background: Coronavirus disease (COVID-19) is an infectious disease caused by SARS-CoV-2, clinically presenting with common symptoms of fever, dry cough, and breathlessness within 14 days of exposure. Its severity ranges from mild to severe, latter manifesting into severe acute respiratory syndrome. As a part of multidisciplinary team, physiotherapy along with medical management was administered to patients with COVID-19 in an acute care setup. This retrospective study aims to explore various patient characteristics and will aid in identifying the impairments associated with the disease, giving a direction to the physiotherapy community in planning future management strategy to improve quality of life. Patients and methods: The present study is a unicentric study wherein prospective analysis of retrospective data of patients referred for physiotherapy from May 13 to July 31, 2020, was performed. (i) Characteristics of patients, (ii) associated comorbidities, (iii) hospital course since the time of admission to discharge, (iv) mode of oxygen delivery, (v) pre- and post-physiotherapy treatment values of oxygen saturation and heart rate, and (vi) physiotherapy treatment were recorded. The archived data were analyzed using the commercially available SPSS software version 24. Wilcoxon's matched pair test was used to compare pre- and post-treatment oxygen saturation and heart rate, and McNemar's test was used to compare mode of oxygen delivery and pre- and post-physiotherapy treatment. Results: Descriptive analysis of data showed a better outcome in terms of grade of dyspnea and rate of discharge on day 14 of physiotherapy treatment. Hence, a comparative analysis of day 1 and day 14 was performed for mode of oxygen delivery, oxygen saturation, and heart rate. A statistically significant improvement was observed in the heart rate (p = 0.001) and oxygen delivery (p = 0.000). However, no significant difference in the level of oxygen saturation was found (p = 0.6433). Conclusion: Physiotherapy treatment in conjunction with medical treatment can be effectively administered in patients with COVID-19 in acute care setup taking into consideration the health status and the hemodynamic stability of the patients. It emphasizes the role of physiotherapy in the alleviation of symptoms, facilitating early weaning and recovery enabling early discharge from the hospital. How to cite this article: Verma CV, Arora RD, Mistry HM, Kubal SV, Kolwankar NS, Patil PC, et al. Changes in Mode of Oxygen Delivery and Physiological Parameters with Physiotherapy in COVID-19 Patients: A Retrospective Study. Indian J Crit Care Med 2021;25(3):317-321.
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INTRODUCTION: Efforts to meet increased oxygen demands in COVID-19 patients are a priority in averting mechanical ventilation (MV), associated with high mortality approaching 76.4-97.2%. Novel methods of oxygen delivery could mitigate that risk. Oxygen hoods/helmets may improve: O2-saturation (SaO2), reduce in-hospital mechanical ventilation and mortality rates, and reduce length of hospitalization in hypoxic Covid-19 patients failing on conventional high-flow oxygen delivery systems. METHODS: DesignProspective Controlled Cohort Study. SettingSingle Center. ParticipantsAll patients admitted with a diagnosis of COVID-19 were reviewed and 136/347 patients met inclusion criteria. Study period3/6/2020 to 5/1/2020. 136 participants completed the study with known status for all outcome measures. Intervention or exposureOxygen hoods/helmets as compared to conventional high-flow oxygen delivery systems. MAIN OUTCOME(S) AND MEASURE(S): 1) Pre and post change in oxygen saturation (SaO2). 2) In-hospital Mechanical Ventilation (MV). 3) In-hospital Mortality. 4) Length of hospitalization. RESULTS: 136 patients including 58-intervention and 78-control patients were studied. Age, gender, and other demographics/prognostic indicators were comparable between cohorts. Oxygen hoods averted imminent or immediate intubation/MV in all 58 COVID-19 patients failing on conventional high-flow oxygen delivery systems with a mean improvement in SaO2 of 8.8%, p < 0.001. MV rates were observed to be higher in the control 37/78 (47.4%) as compared to the intervention cohort 23/58 (39.7%), a difference of 7.7%, a 27% risk reduction, not statistically significant, OR 95%CI 0.73 (0.37-1.5). Mortality rates were observed higher in the control 54/78 (69.2%) as compared to the intervention cohort 36/58 (62.1%), a difference of 7.1%, a 27% risk reduction, not statistically significant OR 95%CI 0.73 (0.36-1.5). CONCLUSION: Oxygen hoods demonstrate improvement in SaO2 for patients failing on conventional high-flow oxygen-delivery systems and prevented imminent mechanical ventilation. In-hospital mechanical ventilation and mortality rates were reduced with the use of oxygen hoods but not found to be statistically significant. The oxygen hood is a safe, effective oxygen-delivery system which may reduce intubation/MV and mortality rates. Their use should be considered in treating hypoxic COVID-19 patients. Further research is warranted. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04407260.