Indications for Intubation in COVID-19

Intubation and invasive mechanical ventilation are often unavoidable in most severe cases of COVID-19 pneumonia;however, deciding the optimum timing and best practices of intubation is challenging. The decision to proceed with intubation should be based on an integrated patient evaluation and not limited to the assessment of the severity of hypoxemia alone. Intubation is a maneuver exposing the operator to a high risk of contamination, therefore adequate personal protection equipment is mandatory. Benefits of intubation over noninvasive respiratory support include reduction or suppression of the respiratory drive, reduction of the basal metabolism and allowance of maintaining protective mechanical ventilation. On the other hand, risks are related to the need for sedation, the presence of an artificial airway and exposure to mechanical ventilation, which may result in overlapping ventilator-associated bacterial pneumonia and ventilator-induced lung injury. Balancing between risks and benefits of intubation in this context is challenging and the optimum timing of intubation remains largely an open question. This chapter discusses the clinical, technical, and safety aspects that deserve to be considered when considering intubation in patients with severe COVID-19-related acute respiratory failure. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Influence of different protection levels of PPE on nurses' physical fatigue during the COVID-19 pandemic.

BACKGROUND: The continuous spread of COVID-19 globally has led to busier medical practices and nurses are having to provide medical services to patients while suffering from high levels of fatigue. OBJECTIVE: This study experimentally investigated the influence of different levels of personal protection equipment (PPE) on nurses' physical fatigue. METHODS: We collected data from 12 participants by simulating a series of nursing tasks. The participants wore one of three different protection levels of PPE, and data recording their heart rate (HR), oral temperature, task completion time, and subjective fatigue were collected. Following this, relationship models between subjective fatigue and objective fatigue indices was established using multiple linear regression analysis. RESULTS: By analyzing the variation trends of single indices of HR, oral temperature, task completion time, and subjective fatigue, it was found that the higher the level of protection levels of PPE worn by the participants, the higher the degree of fatigue experienced by them. In addition, taking subjective fatigue variation as the dependent variable and objective fatigue indices as independent variables, relationship models of the three different protection levels of PPE were established. CONCLUSIONS: The results confirmed the influence of different protection levels of PPE on nurses' physical fatigue levels. They also provide a basis for medical administrators to monitor the degree of fatigue experienced by nurses, attempt to arrange nurses' work content accordingly, and schedule suitably to combat and manage recorded increases in fatigue.

The source control effect of personal protection equipment and physical barrier on short-range airborne transmission.

In order to control the spread of Covid-19, authorities provide various prevention guidelines and recommendations for health workers and the public. Personal protection equipment (PPE) and physical barrier are the most widely applied prevention measures in practice due to their affordability and ease of implementation. This study aims to investigate the effect of PPE and physical barriers on mitigating the short-range airborne transmission between two people in a ventilated environment. Four types of PPE (surgical mask, two types of face shield, and mouth visor), and two different sizes of the physical barrier were tested in a controlled environment with two life-size breathing thermal manikins. The PPE was worn by the source manikin to test the efficiency of source control. The measurement results revealed that the principles of PPE on preventing short-range droplet and airborne transmission are different. Instead of filtering the fine droplet nuclei, they mainly redirect the virus-laden exhalation jet and avoid the exhaled flow entering the target's inhalation region. Physical barriers can block the spreading of droplet nuclei and create a good micro environment at short distances between persons. However, special attention should be paid to arranging the physical barrier and operating the ventilation system to avoid the stagnant zone where the contaminant accumulates.

Investigating the Effective Factors of Using Personal Protective Equipment from the Perspective of Nurses Caring for COVID-19 Patients: A Cross-Sectional Study.

Considering the importance of appropriate personal protective equipment (PPE) for preventing COVID-19 transmission, the aim of this study was to investigate the factors affecting the use of PPE from the perspective of the nurses caring for COVID-19 patients. This descriptive cross-sectional study surveyed 240 nurses working in the central COVID-19 hospitals of Arak, Iran. Nurses were enrolled in the study by a convenience sampling method. The data collection tool was a validated questionnaire. Data were analyzed by SPSS 16 software using descriptive statistics, analysis of variance (ANOVA), and independent sample t-test. Environmental (4.24 ± 0.45), personal (4.16 ± 0.42), and organizational (4.04 ± 0.50) factors all contribute significantly to nursing attitudes about PPE use (p < 0.05). The average score, combining all identified factors, was 4.15 ± 0.31. The most influential factor contributing to appropriate use of PPE was environmental, while the least impactful parameters were related to rules and regulations. Environmental factors have the greatest impact on the use of PPE from the perspective of the nurses caring for patients with COVID-19. Managers and healthcare organizations should provide appropriate and adequate PPE to nurses, educate them on proper use, and monitor the process to resolve barriers.

Effectiveness of germicidal ultraviolet light to inactivate coronaviruses on personal protective equipment to reduce nosocomial transmission.

OBJECTIVE: To circumvent the need for rationing personal protective equipment (PPE), we explored whether germicidal ultraviolet light (GUV) could be used to inactivate human coronaviruses on PPE, enabling safe reuse. DESIGN: We performed a laboratory study to assess the ability of 2 commercially available portable GUV devices to inactivate 2 common cold coronaviruses (HCoV-229E and HCoV-OC43) and severe acute respiratory syndrome coronavirus virus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), on the surface of whole N95 respirators and coupons cut from those respirators. We experimentally contaminated N95 respirators with coronavirus cultures and then assessed viral inactivation after GUV exposure by plaque assay, the median tissue culture infectious dose (TCID50) assay, and quantitative reverse-transcriptase polymerase chain reaction (RT-PCR). RESULTS: We found that GUV could efficiently inactivate coronaviruses on the surface of N95 masks, with an average reduction in viral titers of 5-log for HCoV-229E, 3-log for HCoV-OC43, and 5-log for SARS-CoV-2. In addition, the GUV susceptibility of HCoV-229E was similar on coupons and whole N95 respirators. CONCLUSIONS: We demonstrate that diverse human coronaviruses, including SARS-CoV-2, are susceptible to GUV inactivation, and 2 scalable portable GUV devices were effective in inactivating coronaviruses on N95 respirators. Thus, GUV treatment with commercially scalable devices may be an effective method to decontaminate PPE, allowing their safe reuse.

Precautionary Measures: Performing ERCP on a Patient With Juxtapapillary Duodenal Diverticula (JPDD)-Related Biliary Stone After COVID-19 Lockdown Restriction Lifted in Wuhan, China.

On April 8, 2020, after nearly 3 months of battling against the outbreak of COVID-19, Wuhan, where the pandemic began, began easing lockdown restrictions. However, given that asymptomatic carriers could continue to lead to transmission of COVID-19 during the very early stages, the endoscopists have taken precautions and conduct risk assessments to perform endoscopic intervention in this transition stage. Here, we have reported an urgent ERCP in a patient with acute pancreatitis secondary to JPDD-related biliary stone. Based on our experiences, the objective is to provide practical suggestions for the safe resumption of ERCP procedures in the setting of the COVID-19 pandemic with specific focus on patient risk assessment, personal protection equipment (PPE), and dress code modalities, all of which have been implemented in our hospital to reduce the risk of viral transmission.

Legal Implications of Personal Protective Equipment Use When Treating Patients for COVID-19 (SARS-CoV-2).

Front-line health care personnel, including anaesthetists, otolaryngologists, and other health professionals dealing with acute cases of coronavirus, face a high risk of infection and thus mortality. The scientific evidence establishes that to protect them, hospital protocols should require that wearing of the highest levels of personal protective equipment (PPE) be available for doctors and nurses performing aerosol-generating procedures, such as intubation, sputum induction, open suctioning of airways, bronchoscopy, etc. of COVID-19 patients. Although several international bodies have issued recommendations for a very high-level PPE to be used when these procedures are undertaken, the current PPE guidelines in Australia have tended to be more relaxed, and hospital authorities relying on them might not comply with legal obligations to their employee health care workers. Failure to provide high-level PPE in many hospitals is of concern for a large number of health care workers; this article examines the scientific literature on the topic and provides a legal perspective on hospital authorities' possible liability in negligence.

Powered Air Purifying Respirator (PAPR) restores the N95 face mask induced cerebral hemodynamic alterations among Healthcare Workers during COVID-19 Outbreak.

BACKGROUND AND AIM: COVID-19 pandemic has resulted in an unprecedented increased usage of Personal protective equipment (PPE) by healthcare-workers. PPE usage causes headache in majority of users. We evaluated changes in cerebral hemodynamics among healthcare-workers using PPE. METHODS: Frontline healthcare-workers donning PPE at our tertiary center were included. Demographics, co-morbidities and blood-pressure were recorded. Transcranial Doppler (TCD) monitoring of middle cerebral artery was performed with 2-MHz probe. Mean flow velocity (MFV) and pulsatility index (PI) were recorded at baseline, after donning N95 respirator-mask, and after donning powered air-purifying respirator (PAPR), when indicated. End-tidal carbon-dioxide (ET-CO2) pressure was recorded for participants donning PAPR in addition to the N95 respirator-mask. RESULTS: A total of 154 healthcare-workers (mean age 29 ± 12 years, 67% women) were included. Migraine was the commonest co-morbidity in 38 (25%) individuals while 123 (80%) developed de-novo headache due to N95 mask. Donning of N95 respirator-mask resulted in significant increase in MFV (4.4 ± 10.4 cm/s, p < 0.001) and decrease in PI (0.13 ± 0.12; p < 0.001) while ET-CO2 increased by 3.1 ± 1.2 mmHg (p < 0.001). TCD monitoring in 24 (16%) participants donning PAPR and N95 respirator mask together showed normalization of PI, accompanied by normalization of ET-CO2 values within 5-min. Combined use of N95 respirator-mask and PAPR was more comfortable as compared to N95 respirator-mask alone. CONCLUSION: Use of N95 respirator-mask results in significant alterations in cerebral hemodynamics. However, these effects are mitigated by the use of additional PAPR. We recommend the use of PAPR together with the N95 mask for healthcare-workers doing longer duties in the hospital wards.

Beyond the PPE shortage: Improperly fitting personal protective equipment and COVID-19 transmission among health care professionals.

Background: Personal protective equipment (PPE) use is required when caring for COVID-19 patients. Proper mask fitting is essential in prevention of infectious agent transmission at hospital setting.Methods and Results: We describe three cases of health care professionals (HCP) in a COVID-19 designated ward with positive SARS-CoV-2 RT-PCR results, and were found to have improperly fitted masks.Conclusion: These cases of improperly fitting masks in HCP may have contributed to their eventual COVID-19 infection. These cases raise the important issue of PPE fitting. Abbreviations: Personal Protective Equipment (PPE), Health Care Professional (HCP), Real-time PCR (RT-PCR).

Headaches Associated With Personal Protective Equipment - A Cross-Sectional Study Among Frontline Healthcare Workers During COVID-19.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is an emerging infectious disease of pandemic proportions. Healthcare workers in Singapore working in high-risk areas were mandated to wear personal protective equipment (PPE) such as N95 face mask and protective eyewear while attending to patients. OBJECTIVES: We sought to determine the risk factors associated with the development of de novo PPE-associated headaches as well as the perceived impact of these headaches on their personal health and work performance. The impact of COVID-19 on pre-existing headache disorders was also investigated. METHODS: This is a cross-sectional study among healthcare workers at our tertiary institution who were working in high-risk hospital areas during COVID-19. All respondents completed a self-administered questionnaire. RESULTS: A total of 158 healthcare workers participated in the study. Majority [126/158 (77.8%)] were aged 21-35 years. Participants included nurses [102/158 (64.6%)], doctors [51/158 (32.3%)], and paramedical staff [5/158 (3.2%)]. Pre-existing primary headache diagnosis was present in about a third [46/158 (29.1%)] of respondents. Those based at the emergency department had higher average daily duration of combined PPE exposure compared to those working in isolation wards [7.0 (SD 2.2) vs 5.2 (SD 2.4) hours, P < .0001] or medical ICU [7.0 (SD 2.2) vs 2.2 (SD 0.41) hours, P < .0001]. Out of 158 respondents, 128 (81.0%) respondents developed de novo PPE-associated headaches. A pre-existing primary headache diagnosis (OR = 4.20, 95% CI 1.48-15.40; P = .030) and combined PPE usage for >4 hours per day (OR 3.91, 95% CI 1.35-11.31; P = .012) were independently associated with de novo PPE-associated headaches. Since COVID-19 outbreak, 42/46 (91.3%) of respondents with pre-existing headache diagnosis either "agreed" or "strongly agreed" that the increased PPE usage had affected the control of their background headaches, which affected their level of work performance. CONCLUSION: Most healthcare workers develop de novo PPE-associated headaches or exacerbation of their pre-existing headache disorders.