Effects of prone position in acute respiratory distress syndrome secondary to COVID-19: experience in a high complexity hospital

Introduction: The use of protective mechanical ventilation and prone position was recommended for the management of moderate to severe acute respiratory distress syndrome (ARDS) due to COVID-19, as a result of its reported utility on oxygenation and mortality. Our objective is to describe gasometric and mechanical behavior in subjects with ARDS due to COVID-19 managed with protective mechanical ventilation and prone position in a high complexity hospital. Method: Observational study. Subjects ≥18 years of age with ARDS due to COVID-19 were included. Protective mechanical ventilation was started from the first connection to invasive ventilation, while the prone position started with PaO2/FIO2 150. Follow-up was performed during and after the prone position. A descriptive analysis of baseline characteristics and comparison of means between groups was performed using the Dunn and Friedman test. Statistical significance corresponds to p 0.05 in all analyses. Results: 74 subjects were studied, 58% correspond to men with a mean age of 60 years. There is evidence of a significant increase in arterial oxygenation assessed by PaO2 (76 to 98 mmHg, p 0.05) and PaO2/FIO2 (100 to 161, p 0.05) during the first hour of treatment, with stability of values beyond 48 hours after supination. Pulmonary mechanics values remain constant within the established protection range (p = 0,18). Conclusion: The strategy of protective mechanical ventilation and prone position for 48 or more hours, in subjects with moderate to severe ARDS due to COVID-19, improves and maintains arterial oxygenation up to 48 hours after supination. © 2023

Omicron driven ECMO in a vaccinated critically ill patient

Objectives: Reporting a case of a COVID-19 vaccinated patient admitted to our intensive care unit with severe acute respiratory failure due to SARSCoV2 - Omicron variant, rapidly deteriorating requiring intubation, prone ventilation, and ECMO support. Method(s): A 62 years old Caucasian male was admitted in ICU for rapidly deranging respiratory failure and fever which occurred over the previous 24h. The patient received two doses of SARS-CoV2 vaccine (Oxford, AstraZeneca), the last one over five months before onset of symptoms. The patient was admitted to the intensive care unit (ICU) with tachypnea, low peripheral saturation (80%), elevated serum creatinine (2.4 mg/dl), and mild obesity (BMI 34,6). Pressure support ventilation trial (2 hours) failed carryng out to orotracheal intubation and protective ventilation. Worsening of respiratory exchanges (5 th day from the admission) required a rescue prone ventilation cycle, in the meantime an indication was given to the placement of veno-venous ECMO. The cannulation site was femoro-femoral and the configuration used was Vivc25- Va21, according to the current ELSO nomenclature;ECMO flow was progressively increased until a peripheral saturation of 95% was obtained. Result(s): The patient passed out after 2 month of extracorporeal support with no sign of recovery of pulmonary and renal function. Conclusion(s): Unlike evidences showing a lower symptomatic engagement of the Omicron variant SARSCoV2 positive patients, we have witnessed a rapid and massive pulmonary involvement. The short time that passed from the onset of symptoms and the rapid decay of respiratory function required rapid escalation of the intensity of care up to extracorporeal support. The patient showed previous pathologies that can lead to suspicion of a loss of immune coverage given by the vaccine, in addition to the long time elapsed since the last dose. (Figure Presented).

Analysis of Quality Metrics Relating to the Intubation of Covid-19 patients on a General ICU

Introduction: Most modern healthcare systems are striving to improve patient outcomes in an evidence-based manner. Increasingly, performance metrics are seen as key tools for accurately measuring and improving patient outcomes and healthcare value.1 However, in order to achieve better outcomes, process measures need to be identified. Process measures are evidence-based, best practices metrics that can be measured and thus, used to identify if outcomes are being met. Good process measures can improve patient outcomes by reducing the amount of variation in care delivery. During the Covid-19 pandemic, vast quantities of data were generated while managing ARDS (Acute Respiratory Distress Syndrome) on the ICU. Furthermore, there was as a concomitant evolution of treatment strategies, which made it exceedingly difficult to identify processes that were actually improving patient outcomes. Objective(s): The aim of our quality improvement project was to promote standardised high quality care for intubated Covid-19 patients by identifying potential quality indicators and trends in their management. It is our intention to expand on this work to report metrics on all severe acute respiratory failure patients. Method(s): 15 process metrics surrounding the early care of intubated of Covid-19 patients were selected via a consultant led review process and a literature review in an effort to identify markers of quality surrounding intubation on our ITU. The variables selected included: - P/F ratio 24 hours pre-intubation, CPAP (continuous positive airway pressure) duration prior to intubation, Recording intubation location, Enhanced thromboprophylaxis prescribed, Permissive hypercapnia, Driving pressure documented, prone position and paralysis initiated if P/F ratio was less than 20 kPa, Echo post intubation. Result(s): Data surrounding the intubation of Covid-19 patients was collected over an 11 week period between September and November 2021. The data was collected in a standardised fashion from patient notes and nursing notes, then stored in an excel file. Our data showed more than half the patients admitted were either intubated on the ward or immediately following arrival onto our ICU, possible indicating a delay in admitting Covid-19 patients. Our data also demonstrated heterogeneity of duration in CPAP prior to intubation which may also indicate delayed intubation for these patients.2 Conclusion(s): Our data demonstrated a reasonable degree of heterogeneity in our approach to the early care of intubated Covid-19 Patients. Areas of concern highlighted were the number of patients intubated on the ward or immediately upon arrival to ITU, rather than admitting prior to deterioration (most likely due to bed pressure) and variation in post intubation respiratory sampling between invasive and non-invasive broncheoalveolar lavage. Ongoing PDSA (plan-do-study-act) cycling are in progress to refine the data collection processes and reporting for all severe acute respiratory failure patients.

Determinants of death in patients with COVID-19 pneumonia treated with venovenous extracorporeal membrane oxygenation support

Objectives: Death from SARS-CoV-2 pneumonia resulted from progressive respiratory failure in most patients. Whenever accessible, venovenous extracorporeal membrane oxygenation (VVECMO) was implemented to rescue patients with refractory hypoxemia. Reported mortality in this population reached values from 20 to 50 percent, but the direct causes of death were not so widely acknowledged. The aim of our study was to characterize mortality in patients treated with VVECMO support. Method(s): Retrospective review of a prospectively collected database in an ECMO referral centre. All patients with diagnosis of SARS-CoV-2 infection treated with VVECMO support were included. Survivors and nonsurvivors were compared using t-student and chi2 methods. A Cox regression analysis was performed to identify predictors of mortality at admission. Result(s): Ninety-three patients were included (29% female). Median age was 54+/-12 years, mean SOFA was 5.7+/-2.9 and SAPS II was 35.6+/-13.6. Hospital mortality was 24.7%. Main causes of death were septic shock in 39.1% (9 patients), irreversible lung fibrosis 30.4% (7 patients) and catastrophic hemorrhage in 4.3% (4 patients). End-of-life care measures (withdrawal or withholding) were adopted in 65.2% of non-survivals. Patients who died were older (55 vs 48 years, p<0.05), had longer disease course (19 vs 15.3 days, p<0.05), longer invasive mechanical ventilation course before cannulation (8.5 vs 5 days, p<0.05), lower static lung compliance (25.5 vs 31.8 mL/cmH2O, p<0.05) and were ventilated with lower PEEP (8 vs 10 cmH2O, p<0.05) on cannulation. On a Cox-regression model, only prone ventilation before cannulation (HR 9,7;CI 95% 1,4- 68,6;p<0.05) and SAPS II (HR 1.04;CI 95% 1,001- 1,083;p<0.05) predicted mortality. Conclusion(s): Mortality in patients with severe SARSCoV-2 pneumonia treated with VVECMO was exceedingly low in our study, when compared with other series. Only one-third died from progressive lung disease, which suggests that protocol improvement can further reduce mortality.

Experience achieved after implementation of the Veno-Venous ExtraCorporeal Membrane Oxygenation(ECMO) retrieval program in the region of Madrid (Spain). Hospital Universitario 12 de Octubre

Objectives: The objetive of this study is to describe the cases trasferred to an ECMO referral;s centre (Hospital Universitario 12 de Octubre, Madrid (Spain)), to investigate characteristics before ECMO and while the patient was on ECMO, to analyse the presence or not of complications secondary to transfer and cannulation and finally to analyse the ICU outcome. Method(s): This is a Prospective study done from November 1st, 2020 to December 31st, 2022. The cases were accepted either for emergency ECMO cannulation in the hospital of origin and retrieval or for conventional transfer. We analysed basic decriptive variables such as male proportion, age, IMC and etiology of ARDS and variables before ECMO such as prone position, duration of non-invasive ventilation, invasive ventilation and ICU leght of stay before ECMO. We recorded ELSO, SOFA and APACHE Severity Scores. We also analysed several variables on ECMO: if prone position on ECMO was done, median days of ECMO and succesfull weaning from ECMO. We also recorded whether there were complications or not in the transfer and cannulation. Finally ICU survival was examined. Result(s): 31 cases were accepted. 22 (71 %) were male. 29 cases were accepted for emergency ECMO cannulation. Median age was 47 years and IMC 31.1. The etiology of SDRA was COVID 19 infection in 23 cases (74% cases). Lenght of non invasive and invasive ventilation before ECMO were 4 days and 3 days respectively and lenght of ICU admission before ECMO was 2 days. Prone position was 1 day and 2 prone sessions were done before ECMO. Severity scores: APACHE 10 , SOFA 4 , ELSO 3 . On ECMO Prone position was done on 15 cases(48.4%) . Median days on ECMO were 13.5 days. Succesfull weaning from ECMO were achieved on 20 cases(61%), 2 cases remain on ECMO. No complications were seen on transfer or cannulation. ICU Survivors were 16(51.6%). Conclusion(s): After 2 years of experience on ECMO retrieval in the region of Madrid ECMO availability was achieved. Our results are similar than ELSO mortality.

The application experience of focused ultrasound heart examination in patients with COVID-19 in Prone-position.

Aim of the study. To study the experience of using focused transthoracic echocardiography in patients with COVID-19 in prone position (fEchoPr) in intensive care units (ICU). Materials and methods. The retrospective observational study included 53 patients (period from 15 April to 31 December 2020). Inclusion criteria: confirmed diagnosis of COVID-19, availability of fEchoPr data, outcome certainty (discharge/death). We analyzed electronic medical records. The fEchoPr was performed in patients in the prone position with a bolster under the left side of the chest and left arm raised ('swimmer's position'). We assessed the systolic function of the right ventricle (RV) (tricuspid annular plane systolic excursion (TAPSE)), RV size, RV/LV ratio, systolic function of the left ventricle (LV) (left ventricular outflow tract velocity time integral. (LVOT VTI)), and pulmonary hypertension (PH) (tricuspid regurgitation peak gradient (PGTR). Depending on the results, the patients were divided into 2 groups: informative (+fEchoPr) and non-informative (-fEchoPr) examinations. Results. There was no statistically significant difference in the groups (+fEcho n = 35 vs -fEcho n = 18) by age (65.6 +/- 15.3 vs 60.2 +/- 15.8, p > 0.05), by gender (male: 23 (65.7%) vs 14 (77.8%), p > 0.05), by body mass index (31.3 +/- 5.3 kg/m2 vs 29.5 +/- 5.4 kg/m2, p > 0.05), by mechanical ventilation support (24 (68.6%) vs 17 (94.4%), p = 0.074), by NEWS scale indicators (6.9 +/- 3.7 vs 8.5 +/- 3.5 points), by mortality (82.8% vs 94.4%, p > 0.05). Correlation analysis revealed a moderate inverse relationship between being on mechanical ventilation and the informative value of the study (Spearman's r = -0.30 at p = 0.033). In the +fEchoPr group, the correct measurement of TAPSE and RV/LV was carried out in 100%: a decrease in RV systolic function was recorded in 5 patients (14%), expansion of the RV in 13 patients (37%). Signs of PH were detected in 11 patients (31%), PGTR could not be measured in 10 patients (28%). LV systolic dysfunction was detected in 7 patients (20%). No pathology was detected in 16 patients (46%). One patient was diagnosed with infective endocarditis of native mitral valve, which was later confirmed by autopsy. Conclusion. In 66% of cases, fEchoPr examinations were informative, especially in terms of assessing the state of the right heart. fEchoPr examination is an affordable, valid and reproducible method to assess and monitor the state of the heart in ICU patients.Copyright © 2021 VIDAR Publishing House. All Rights Reserved.

Ultrasound-guided central venous access for patients in the Intensive Care Unit in prone position: report of three cases.

The prone position is extensively used to improve oxygenation in patients with severe acute respiratory distress syndrome caused by SARS-CoV-2 pneumonia. Occasionally, these patients exhibit cardiac and respiratory functions so severely compromised they cannot tolerate lying in the supine position, not even for the time required to insert a central venous catheter. The authors describe three cases of successful ultrasound-guided internal jugular vein cannulation in prone position. The alternative approach here described enables greater safety and well-being for the patient, reduces the number of episodes of decompensation, and risk of tracheal extubation and loss of in-situ vascular lines.

Exploring the learning needs of clinicians in Belgium and Sweden regarding prone positioning and skin damage prevention: A qualitative study.

INTRODUCTION: During the coronavirus pandemic (COVID -19), the use of prone positioning in critically ill patients with acute respiratory distress syndrome (ARDS) increased substantially. As a result, clinicians had to (re)learn how to treat the patient in the prone position while preventing adverse events such as pressure ulcers, skin tears and moisture-associated skin damage. AIM: The purpose of the study was to determine participants' learning needs related to patients in the prone position and the prevention of skin damage, such as pressure ulcers, and what they perceived as a positive or negative learning experience. DESIGN: This study used a qualitative methodological framework and employed an exploratory design. PARTICIPANTS: A purposive sample of clinicians (n = 20) with direct or indirect work experience with prone ventilated patients was recruited in Belgium and Sweden. METHODS: Individual semi-structured interviews were conducted in Belgium and Sweden between February and August 2022. Data were analysed thematically using an inductive approach. The COREQ guideline was utilised to comprehensively report on the study. FINDINGS: Two themes were identified: 'Adapting to a crisis' and 'How to learn', with the latter having two subthemes: 'balancing theory and practice' and 'co-creating knowledge'. Unexpected circumstances necessitated a personal adaption, a change in learning methods and a pragmatic adaptation of protocols, equipment and working procedures. Participants recognised a multifaceted educational approach which would contribute to a positive learning experience regarding prone positioning and skin damage prevention. The importance of poising theoretical teaching with practical hands-on training was highlighted with an emphasis on interaction, discussion, and networking between peers. CONCLUSIONS: The study findings highlight learning approaches which may help inform the development of befitting educational resources for clinicians. Prone therapy for ARDS patients is not limited to the pandemic. Therefore, educational efforts should continue to ensure patient safety in this important area.

Prone positioning for mechanically ventilated patients with coronavirus disease 2019: the experience of an Irish regional hospital intensive care unit.

BACKGROUND: The benefits of prone positioning in acute respiratory distress syndrome (ARDS) have been known for many years. While some controversy exists regarding whether coronavirus disease 2019 (COVID-19) pneumonia should be treated with the same therapeutic strategies as for non-COVID ARDS, the Surviving Sepsis Campaign still provide a weak recommendation to utilise prone positioning in this setting. AIMS: The aims of this study are to ascertain if prone positioning improves oxygenation significantly in mechanically ventilated patients with severe COVID-19 ARDS and to describe the feasibility of frequent prone positioning in an Irish regional hospital intensive care unit (ICU) with limited prior experience. METHODS: In this retrospective, observational cohort study, we investigate if the PaO2/FiO2 ratio and ventilatory ratio improve during and following prone positioning, and whether this improvement correlates with patient baseline characteristics or survival. RESULTS: Between March 2020 and 2021, 12 patients underwent prone positioning while mechanically ventilated for severe COVID ARDS. Sixty-six percent were male, mean age 60.9 (± 10.5), mean BMI 33.5 (± 6.74) and median APACHE II score on admission to ICU was 10.5 (7.25-16.3). Further, 83% were proned within 24 h of being intubated due to refractory hypoxaemia. PaO2/FiO2 ratio improved from 11.6 kPa (9.80-13.8) to 15.80 kPa (13.1-19.6) while prone, p < 0.0001. CONCLUSIONS: We found prone positioning to be a safe method of significantly improving oxygenation in mechanically ventilated patients with severe COVID-19 ARDS. We did not find a relationship between patient baseline characteristics nor illness severity and degree of PaO2/FiO2 ratio improvement, nor did we find a relationship between degree of PaO2/FiO2 ratio improvement and survival.

Evaluation of the efficiency and complications of the consecutive proning in COVID-19 ICU: a retrospective study.

PURPOSE: We aimed to evaluate and compare the efficacy and complications of three consecutive prone positions (PP) in COVID-19 ICU. MATERIALS AND METHOD: Patients with ARDS and placed in PP for 3 times (PP1, PP2, PP3) consecutively were included. Arterial blood gases (ABG), partial pressure of arterial oxygen/fraction of inspired oxygen (PaO2/FiO2) ratios, partial pressure of carbondioxide (PaCO2), PEEP, and FiO2 were recorded before (bPP), during (dPP), and after (aPP) every prone positioning. Eye, skin, nerve, and tube complications related to PP were collected. RESULTS: In all positions, PaO2 value during PP was significantly higher than PaO2 before and after prone position (p = 0.001). PaO2 values were similar in all (PP1, PP2, PP3) bPP arterial blood gases. We found difference in PaO2 values during prone position between the first (PP1) and second proning (PP2). When each prone was evaluated within itself, PaO2/FiO2 increases after proning compared to before proning. PaO2/FiO2 during PP were higher compared to before proning ones. PaO2/FiO2 during PP1 was significantly higher compared to during PP3 (p = 0.005). In PP3, PEEP values bPP, dPP, and aPP were significantly higher than PEEP values after the second prone (p = 0.02, p = 0.001, p = 0.01). In the third prone, PaCO2 levels were higher than in PP1 and PP2. There were eye complications in 13, tube-related complications in 10, skin complications in 30, and nerve damage in 1 patient. CONCLUSION: We believe that a more careful decision should be made after the second prone position in patients who have to be placed in sequential prone position.

Prone Position Ventilation in Severe ARDS due to COVID-19: Comparison between Prolonged and Intermittent Strategies.

Ventilation in a prone position (PP) for 12 to 16 h per day improves survival in ARDS. However, the optimal duration of the intervention is unknown. We performed a prospective observational study to compare the efficacy and safety of a prolonged PP protocol with conventional prone ventilation in COVID-19-associated ARDS. Prone position was undertaken if P/F < 150 with FiO2 > 0.6 and PEEP > 10 cm H2O. Oxygenation parameters and respiratory mechanics were recorded before the first PP cycle, at the end of the PP cycle and 4 h after supination. We included 63 consecutive intubated patients with a mean age of 63.5 years. Of them, 37 (58.7%) underwent prolonged prone position (PPP group) and 26 (41.3%) standard prone position (SPP group). The median cycle duration for the SPP group was 20 h and for the PPP group 46 h (p < 0.001). No significant differences in oxygenation, respiratory mechanics, number of PP cycles and rate of complications were observed between groups. The 28-day survival was 78.4% in the PPP group versus 65.4% in the SPP group (p = 0.253). Extending the duration of PP was as safe and efficacious as conventional PP, but did not confer any survival benefit in a cohort of patients with severe ARDS due to COVID-19.

Hemodynamic Effects of Awake Prone Positioning With COVID-19 Acute Respiratory Failure.

INTRODUCTION: Awake prone positioning (PP) reduces need for intubation for patients with COVID-19 with acute respiratory failure. We investigated the hemodynamic effects of awake PP in non-ventilated subjects with COVID-19 acute respiratory failure. METHODS: We conducted a single-center prospective cohort study. Adult hypoxemic subjects with COVID-19 not requiring invasive mechanical ventilation receiving at least one PP session were included. Hemodynamic assessment was done with transthoracic echocardiography before, during, and after a PP session. RESULTS: Twenty-six subjects were included. We observed a significant and reversible increase in cardiac index (CI) during PP compared to supine position (SP): 3.0 ± 0.8 L/min/m2 in PP, 2.5 ± 0.6 L/min/m2 before PP (SP1), and 2.6 ± 0.5 L/min/m2 after PP (SP2, P < .001). A significant improvement in right ventricular (RV) systolic function was also evidenced during PP: The RV fractional area change was 36 ± 10% in SP1, 46 ± 10% during PP, and 35 ± 8% in SP2 (P < .001). There was no significant difference in PaO2 /FIO2 and breathing frequency. CONCLUSION: CI and RV systolic function are improved by awake PP in non-ventilated subjects with COVID-19 with acute respiratory failure.

Factors Associated With Prolonged Ventilation in Patients Receiving Prone Positioning Protocol With Muscle Relaxants for Severe COVID-19 Pneumonia.

BACKGROUND: Prone positioning and neuromuscular blocking agents (NMBAs) are frequently used to treat severe respiratory failure from COVID-19 pneumonia. Prone positioning has shown to improve mortality, whereas NMBAs are used to prevent ventilator asynchrony and reduce patient self-inflicted lung injury. However, despite the use of lung-protective strategies, high death rates in this patient population have been reported. METHODS: We retrospectively examined the factors affecting prolonged mechanical ventilation in patients receiving prone positioning plus muscle relaxants. The medical records of 170 patients were reviewed. Subjects were divided into 2 groups according to ventilator-free days (VFDs) at day 28. Whereas subjects with VFDs < 18 d were defined as prolonged mechanical ventilation, subjects with VFDs ≥18 d were defined as short-term mechanical ventilation. Subjects' baseline status, status at ICU admission, therapy before ICU admission, and treatment in the ICU were studied. RESULTS: Under the proning protocol for COVID-19, the mortality rate in our facility was 11.2%. The prognosis may be improved by avoiding lung injury in the early stages of mechanical ventilation. According to multifactorial logistic regression analysis, persistent SARS-CoV-2 viral shedding in blood (P = .027), higher daily corticosteroid use before ICU admission (P = .007), delayed recovery of lymphocyte count (P < .001), and higher maximal fibrinogen degradation products (P = .039) were associated with prolonged mechanical ventilation. A significant relationship was found between daily corticosteroid use before admission and VFDs by squared regression analysis (y = -0.00008522x2 + 0.01338x + 12.8; x: daily corticosteroids dosage before admission [prednisolone mg/d]; y: VFDs/28 d, R2 = 0.047, P = .02). The peak point of the regression curve was 13.4 d at 78.5 mg/d of the equivalent prednisolone dose, which corresponded to the longest VFDs. CONCLUSIONS: Persistent SARS-CoV-2 viral shedding in blood, high corticosteroid dose from the onset of symptoms to ICU admission, slow recovery of lymphocyte counts, and high levels of fibrinogen degradation products after admission were associated with prolonged mechanical ventilation in subjects with severe COVID-19 pneumonia.

A critical care follow-up service evaluation: Acquired peripheral nerve injury after admission with COVID-19 respiratory disease.

Anticipated sequelae of critical care admission for COVID-19 disease remain unclear. Our Edinburgh-based critical care follow-up service identified patterns with nerve injury in 13 of 35 patients who attended following a critical care admission between 15/03/2020 and 25/12/2020. This included 7 cases of meralgia parasthetica, 1 brachial plexopathy, 2 common peroneal neuropathies and 3 ulnar neuropathies. All cases of upper limb neuropathy and foot drop occurred in patients in whom prone positioning was used, with meralgia parasthetica occurring additionally in patients who remained supine.

Erratum: Effects of awake prone position vs. usual care on acute hypoxemic respiratory failure in patients with COVID-19: a systematic review and meta-analysis of randomized controlled trials.

[This corrects the article DOI: 10.3389/fmed.2023.1120837.].

Prone position in spontaneous ventilation? An induction problem: A scoping review

Intoduction: Prone position in spontaneous ventilation is not a recent strategy, and despite the many years it has been trying to consolidate, it has not been able to prove to be of real utility. During the recent pandemic, prone spontaneous ventilation re-emerged as a practical and simple alternative, although it was highly questioned due to its weak level of evidence. With time and experience, it was gradually relegated to become only an attractive hypothesis. Objective: This study aims to analyze the potential benefits of prone position in spontaneous ventilation in patients with hypoxemia caused by SARS-CoV-2. Methods: A panoramic review of the most relevant studies published in the MEDLINE, Embase and Scopus databases up to December 20, 2021 was performed. Results: After screening, 4 observational studies, 1 randomized clinical trial, and 3 systematic reviews were selected for analysis. Conclusions: By statistical analysis we concluded that prone position in spontaneous ventilation, although it could delay intubation, did not improve survival in hypoxemic subjects with viral pneumonia caused by coronavirus type 2. © 2023 Asociación Colombiana de Medicina Crítica y Cuidado lntensivo

Respiratory Therapy and Proning

The novel SARS coronavirus-2 (SARS-CoV-2) is responsible for COVID-19 which primarily affects the respiratory tract, particularly the lungs, of infected patients. The COVID-19 pandemic resulted in a large number of hospitalized patients with respiratory failure reaching the level of acute respiratory distress syndrome (ARDS). ARDS requires prolonged respiratory care. Critically ill patients can frequently progress to decompensation and death. Respiratory therapy is therefore important in response to such a health crisis as COVID-19, to improve patient care and ultimately prevent mortality. Modern respiratory care science has shown that proning can improve oxygenation of patients with ARDS. Planning and preparation for a viral respiratory health crisis require a strategy and system to prone patients effectively and safely. In this two-part chapter, perspectives are presented on respiratory therapy and proning during the pandemic. The experience of respiratory therapy at the SBH Health System during the COVID-19 crisis surge in Spring 2020 presents rich lessons to be learned about health crisis planning, preparation, and management with respect to respiratory therapy. © SBH Health System 2022.

Evaluating the Impact of Nutrition Support on Clinical Outcomes in Critically Ill Patients With COVID-19: A Retrospective Study

Background: Patients with COVID-19 experience prolonged ICU stays. The rate of malnutrition in hospitalized patients remains controversial as well as the appropriate nutrition therapy for these patients. The purpose of the study was to evaluate the impact of nutrition support on clinical outcomes in critically ill patients with COVID-19. Method(s): This was a retrospective chart review involving 48 adults, critically ill patients admitted with confirmed SARS-CoV-2 infection. Data extracted included demographic, anthropometric, medical history, biochemical tests, medications, nutrition support protocol, clinical outcomes, length of stay, and ventilator status. We tested associations between aspects of nutrition support (such as early versus delayed feeding, adequacy, and patient positioning) and clinical outcomes (ICU length of stay, weight status, malnutrition status, refeeding syndrome, and ventilator days) using Chi-square, and t-tests, with significance established at the level of p <= 0.05. Result(s): Thirty-eight percent (18) of the patients met the criteria for malnutrition using the Global Leadership Initiative on Malnutrition (GLIM) tool. Approximately 83% of these patients did not have a documented diagnosis of malnutrition in the electronic medical record. More than half of the patients in the study (58.3%) were placed in prone position as part of their treatment and only 7% of these had documented signs of feeding intolerance. None of the patients were switched to total parenteral nutrition (TPN). Only 37% of the patients received adequate protein within the first week of nutrition support while 98% had adequate or exceeded caloric needs. There was no difference in percent weight loss among patients who received inadequate protein compared to those who had adequate protein. Inadequate protein intake was associated with shorter ICU stays (p = 0.04) and fewer ventilator days (p = 0.01) compared to those with adequate protein. Patients who received inadequate or exceeded their calories needs also had shorter ICU stays and fewer ventilator days (p > 0.05). In the context of this study, shorter ICU stays translated into fewer days of life, as 98% of the studied population died before ICU discharge. There were no associations between early nutrition support and selected biochemical parameters. Conclusion(s): The rate of malnutrition was remarkable and largely undocumented. Most patients did not meet the minimum estimated protein needs. Studies with larger sample sizes are needed to examine appropriate protein needs and the effect of nutrition support in patients with COVID-19. Diagnosing and documenting malnutrition warrants heightened attention.

Role of Point-of-Care Ultrasound in the Management of Mechanical Ventilation

Ultrasound (US) became an essential tool in the hands of the intensivist and is now recommended both for procedural guidance and diagnostic purposes. Point-of-care ultrasound (POCUS) is an immediately available and repeatable, non-irradiating bedside tool integrating the clinical examination. Recent years were characterized by a growing interest in the fields of lung ultrasound (LUS) and diaphragm ultrasound (DUS). The combination of these two ultrasound techniques with critical care echocardiography (CCE) may integrate the classical approach to mechanically ventilated patients, both for monitoring and diagnostic purposes, finally contributing to the titration of mechanical ventilation and to the management of respiratory disease. Lung, diaphragm, and cardiac US provide significant information to improve the management of the critical patient under mechanical ventilation, from the initial assessment, through the ventilation setting (like PEEP) and its complication diagnosis (like pneumothorax, atelectasis), until the weaning process. LUS is of particular help in COVID-19 patients. It is potentially able to distinguish between the two phenotypes (type H and type L) of COVID-19, based on the different signs and patterns and also the assessment of prone positioning effects and lung recruitment maneuvers in these patients. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.