Airway Management During Mechanical Ventilation: COVID-19

The disease caused by the new SARS-CoV-2 can elicit a violent, dysregulated host immune response that can lead to severe results in most of these older patients as ARDS, multiple-organ failure, and death. Acute respiratory distress syndrome (ARDS) is defined as hypoxemia secondary to a rapid onset of non-cardiogenic pulmonary edema. The airway management in a patient with COVID-19 should be carried out considering several aspects. Once it is decided to intubate the patient, use a rapid induction sequence. When signs of respiratory distress are associated with severe hypoxemia, patients should be managed as soon as possible according to the pulmonary phenotypes;however, management of mechanical ventilation must be personalized;if possible, use low tidal volume with 6 mL/kg of predicted body weight. There is no consensus regarding the best PEEP value;several guidelines recommended keeping Pplat 30 cmH2O in patients with ARDS. There are no available studies that describe the clinical evolution of COVID-19 patients ventilated in the prone position;intermittent doses of neuromuscular blocking agents to facilitate lung-protective ventilation, and tracheostomy, remain necessary in some patients with COVID-19. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Hipoxemia severa durante ECMO veno-venoso: a propósito de un caso clínico

Resumen La membrana de oxigenación extracorpórea (ECMO) brinda un soporte vital en casos de falla respiratoria aguda severa y refractaria al manejo convencional. A pesar de la mejoría de la sobrevida en pacientes seleccionados con SDRA severo, durante el soporte no es infrecuente eventos de hipoxemia severa, para lo cual es necesario identificar las causas e intervenir prontamente en el paciente y en el circuito del ECMO. La recirculación, el disbalance aporte consumo de oxígeno, la falla del oxigenador y la disminución de la función pulmonar residual son las principales causas de la hipoxemia severa aun durante el ECMO. Se describe el caso de un paciente obeso con SDRA severo y refractario por SARS-CoV-2 con necesidad de soporte ECMO, el cual durante su evolución presentó episodios de hipoxemia severa aun en ECMO, por lo que fueron necesarias múltiples intervenciones tanto en el circuito como en el paciente para solventar esta complicación. Este artículo presenta un caso clínico, una revisión de la literatura, y un algoritmo diagnóstico y terapéutico para una oportuna resolución de la hipoxemia severa en ECMO. Extracorporeal membrane oxygenation (ECMO) provides life support in cases of severe acute respiratory failure refractory to conventional management. Despite the improvement in survival in selected patients with severe ARDS, events of severe hypoxemia are not uncommon during support, for which it is necessary to identify the causes and promptly intervene in the patient and in the ECMO circuit. Recirculation, oxygen consumption imbalance, oxygenator failure, and decreased residual lung function are the main causes of severe hypoxemia even during ECMO. A case of an obese patient with severe ARDS and refractory to SARS CoV-2 in need of ECMO support is described, who during his evolution presented episodes of severe hypoxemia even on ECMO, for which multiple interventions were necessary both in the circuit and in the patient to solve this complication. This article presents a clinical case, a review of the literature, and a diagnostic and therapeutic algorithm for timely resolution of severe hypoxemia on ECMO.

¿Prono en ventilación espontánea? Un problema de inducción: una revisión panorámica

Resumen Introducción El prono en ventilación espontánea no es una estrategia reciente, y pese a los muchos años que lleva intentando consolidarse, no ha podido demostrar ser de real utilidad. Durante la reciente pandemia, el prono en ventilación espontánea resurgió como una alternativa práctica y simple, aunque muy cuestionada por su débil nivel de evidencia. Con el tiempo y la experiencia generada, de a poco fue relegada a convertirse únicamente en una atractiva hipótesis. Objetivo Este estudio busca analizar los potenciales beneficios del prono en ventilación espontánea en pacientes con hipoxemia producida por SARS-CoV-2. Método Se realizó una revisión panorámica de los estudios más relevantes publicados en las bases de datos MEDLINE, Embase y Scopus hasta el 20 de diciembre de 2021. Resultados Tras el escrutinio se eligieron para el análisis: 4 estudios observacionales, un ensayo clínico aleatorizado y 3 revisiones sistemáticas. Conclusiones Mediante análisis estadísticos concluimos que el prono en ventilación espontánea, si bien podría retrasar la intubación, no mejoraba la sobrevida de los sujetos hipoxémicos por neumonía viral causada por coronavirus tipo 2. 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.

Retour d'expérience des six évacuations sanitaires aériennes collectives MoRPHEE durant la pandémie de Covid-19

Après son apparition en Chine à la fin de 2019, l'épidémie de coronavirus 2019 (Covid-19) a rapidement provoqué le risque d'une saturation des ressources en soins intensifs dans chaque pays touché. La répartition de la maladie entre les différents territoires est hétérogène. Le transport interhospitalier sur longue distance de patients atteints de Covid-19 dans le but de limiter la pression sur les unités de soins intensifs au niveau national ou international n'a pas encore été décrit. L'objectif de cet article était de fournir des données descriptives des six missions d'évacuation aéromédicale collective (Evasan) de patients atteints de Covid-19 réalisées en Europe et sur le territoire national français les 18, 21, 24, 27, 31 mars et 3 avril 2020 grâce au dispositif MoRPHEE. Trente-six patients souffrant de syndrome de détresse respiratoire aiguë (SDRA) ont été évacués durant six missions d'évacuations sanitaires collectives. Le SDRA était modéré (rapport PaO2/FiO2 > 100 et ≤ 200) chez 24 patients et léger (rapport PaO2/FiO2 > 200 et ≤ 300) chez 12 patients. La durée médiane de la ventilation mécanique en soins intensifs avant le transport était de quatre jours (interquartile [IQ] : 3‒5). Le rapport médian PaO2/FiO2 était de 180 mmHg (IQ : 156‒202). Le débit médian de perfusion de noradrénaline était de 0,08 μg/kg par min. Aucune complication mettant en jeu le pronostic vital n'a été signalée. En conclusion, l'évacuation sanitaire aérienne collective de patients gravement malades de Covid-19 est une solution contribuant à contrôler le niveau de saturation du système de soins au niveau national ou international.Alternate : Since its emergence in China in late 2019, the coronavirus disease 2019 (COVID-19) outbreak has rapidly posed the risk of critical care resources overload in every affected country. The distribution of the disease among the territories is heterogeneous. Long-range inter-hospital transport of critically ill COVID-19 patients as a way to mitigate the localised pressure from overloaded intensive care units at a national or international level has not been reported yet. The aim of this article was to provide descriptive data about the six collective aeromedical evacuation of COVID- 19 patients performed within Europe and French national territory on March 18, 21, 24, 27, 31 and April 3, 2020. Thirty-six patients with acute respiratory distress syndrome (ARDS) were transported aboard six aeromedical evacuation missions. ARDS was moderate (PaO2/FiO2 ratio > 100 and ≤ 200) in 24 patients and mild (PaO2/FiO2 ratio > 200 and ≤ 300) in 12 patients. The median duration of mechanical ventilation in ICU before transportation was 4 days [Interquartile (IQ): 3–5]. The median PaO2/FiO2 ratio was 180 mmHg (IQ: 156–202). The median norepinephrine infusion rate was 0.08 μg/kg/min. No life-threatening event was reported. Collective aeromedical evacuation of COVID-19 critically ill patients could provide a reliable solution to help control the burden of the disease at a national or international level. Future works may evaluate the global safety and effectiveness of aeromedical evacuations in this context.

Critical patients COVID-19 has changed the management and outcomes in the ICU after 1 year of the pandemic? A multicenter, prospective, observational study.

OBJECTIVE: To compare the clinical characteristics, treatments, and evolution of critical patients with COVID-19 pneumonia treated in Intensive Care Units (ICU) after one year of pandemic. METHODOLOGY: Multicenter, prospective study, which included critical COVID-19 patients in 9 ICUs in northwestern Spain. The clinical characteristics, treatments, and evolution of patients admitted to the ICU during the months of March-April 2020 (period 1) were compared with patients admitted in January-February 2021 (period 2). RESULTS: 337 patients were included (98 in period 1 and 239 in period 2). In period 2, fewer patients required invasive mechanical ventilation (IMV) (65% vs 84%, p < 0.001), using high-flow nasal cannulas (CNAF) more frequently (70% vs 7%, p < 0.001), ventilation non-invasive mechanical (NIMV) (40% vs 14%, p < 0.001), corticosteroids (100% vs 96%, p = 0.007) and prone position in both awake (42% vs 28%, p = 0.012), and intubated patients (67% vs 54%, p = 0.034). The days of IMV, ICU stay and hospital stay were lower in period 2. Mortality was similar in the two periods studied (16% vs 17%). CONCLUSIONS: After 1 year of pandemic, we observed that in patients admitted to the ICU, CNAF, NIMV, use of the prone position, and corticosteroids have been used more frequently, reducing the number of patients in IMV, and the length of stay in the ICU and hospital stay. Mortality was similar in the two study periods.

Correlación entre el aumento del dímero D en sangre con el espacio muerto en pacientes con COVID 19 y síndrome de dificultad respiratoria aguda (SDRA)

Resumen Introducción: Desde diciembre de 2019, un número de casos de neumonía por Síndrome Respiratorio Agudo Severo (SARS) COV2/COVID-19 en Wuhan China se identificaron como causa de insuficiencia respiratoria aguda y se propagaron por el mundo a gran velocidad. Debido al gran nùmero de casos y la necesidad de entender más esta condición, surge la necesidad de identificar herramientas que gradúen la intensidad y el pronóstico vital de los pacientes. El objetivo de este estudio es determinar la relación entre el espacio muerto medido por capnografía volumétrica o por ventilatory ratio y el aumento de los niveles de dímero D en pacientes con diagnóstico de neumonía por COVID-19 y que cumplan los criterios de Berlín para Síndrome de Dificultad Respiratoria Aguda (SDRA). Materiales y métodos: Se realizó un estudio observacional de una cohorte prospectiva, monocéntrico, sobre el uso de dímero D y la correlación con el espacio muerto. Se incluyeron adultos mayores de 18 años con diagnóstico de neumonía por COVID-19 y SDRA hospitalizados en las unidades de cuidados intensivos del Hospital Santa Clara en Bogotá, Colombia, desde agosto de 2020 hasta julio de 2021. Resultados: El estudio incluyó 67 pacientes, con diagnóstico de SARS-CoV-2 confirmado en todos ellos, no se encontró asociación entre dímero D y espacio muerto en el día 1 y 3 de hospitalización en la UCI. Conclusión: El dímero D no se correlaciona con el aumento del espacio muerto en nuestro estudio y tampoco se asoció con los desenlaces clínicos relevantes en los pacientes con SDRA. Introduction: Since December 2019, a number of cases of COV2 / COVID-19 severe acute respiratory syndrome (SARS) pneumonia in Wuhan China have been identified as a cause of acute respiratory failure and have spread around the world at high speed. Due to the large number of cases and the need to better understand this condition, tools are required to grade the intensity and vital prognosis of patients. The objective of this study is to determine the relationship between the dead space measured by volumetric capnography or ventilatory ratio and the increase in D-dimer levels in patients diagnosed with COVID-19 pneumonia and who meet the Berlin criteria for Acute Respiratory Distress Syndrome (ARDS). Materials and methods: A single-centre observational study of a prospective cohort on the use of D-dimer and the correlation with dead space. Adults older than 18 years with a diagnosis of pneumonia due to COVID-19 and ARDS hospitalized in the intensive care units of Hospital Santa Clara in Bogotá, Colombia, from August 2020 to July 2021 were included. Results: The study included 67 patients, all with a confirmed SARS-CoV-2 diagnosis, no association was found between D-dimer and dead space on day 1 and 3 of hospitalization in the ICU. Conclusions: D-dimer was not correlated with increased dead space in our study and was not associated with relevant outcomes in patients with ARDS.

Quality of life and persistent symptoms after hospitalization for COVID-19. A prospective observational study comparing ICU with non-ICU patients.

BACKGROUND: Hospitalized COVID-19 patients are prone to develop persistent symptoms and to show reduced quality of life following hospital admission. METHODS: Prospective cohort study of COVID-19 patients admitted to a hospital from March 1 to April 30, 2020. The primary outcome was to compare health related quality of life and persistent symptoms six months after hospital admission, of COVID-19 patients who required ICU admission with those who did not. RESULTS: Among the 242 patients hospitalized during the defined period of time, 44 (18.2%) needed ICU admission. Forty (16.5%) patients died during hospital admission. Two hundred and two (83.5%) patients were discharged alive from the hospital. At six months, 183 (75.6%) patients completed the questionnaires (32 ICU patients and 151 non ICU patients). Ninety-six (52.4%) reported decreased quality of life and 143 (78.1%) described persistent symptoms. More ICU patients showed worsening of their quality of life (71.9% vs 43.7%, P=0.004). There were no differences in the proportion of patients with persistent symptoms between ICU and non ICU patients (87.5% vs 76.2%, P=0.159). ICU patients showed more frequently dyspnea on exertion (78.1% vs 47.7%, P=0.02), dyspnea on light exertion (37.5% vs 4.6%, P<0.001), and asthenia (56.3 vs 29.1, P=0.003). CONCLUSIONS: Survivors of COVID-19 needing hospitalization had persistent symptoms and a decline in the quality of life. ICU patients referred a large decrease of their quality of life compared with non ICU patients.

Neumomediastino en pacientes con COVID-19: Una serie de 10 casos

Resumen En la actualidad la enfermedad por Coronavirus 2019 (COVID-19) es un problema de salud pública que ha causado más de 100.000 muertes en Colombia y alrededor de 4,13 millones de muertes en todo el mundo. El síndrome de Distress Respiratorio Agudo (SDRA) secundario a esta infección viral, puede llevar a un serie de complicaciones como el neumomediastino, este es poco frecuente pero potencialmente mortal y se encuentra relacionado con la ventilación mecánica. Presentamos una serie de casos de 10 pacientes que ingresaron a la unidad de cuidados intensivos con requerimiento de ventilación mecánica invasiva y que desarrollaron neumomediastino. La serie de casos más grande reportada hasta el momento. Coronavirus disease 2019 (COVID-19) is a current public health problem that has caused more than 100,000 deaths in Colombia and around 4.13 million deaths worldwide. The acute respiratory distress syndrome (ARDS) secondary to this viral infection can lead to a series of complications such as pneumomediastinum, which is rare but potentially fatal and is related to mechanical ventilation. We present a case series of 10 patients who were admitted to the intensive care unit requiring invasive mechanical ventilation and developed pneumomediastinum. Largest case series reported to date

[Place of biomarkers in the renutrition of patients with serious Covid-19 infection: discussion around a clinical case]. / Place des biomarqueurs dans la renutrition des patients ayant une infection grave à Covid-19 : discussion autour d'un cas clinique.

Covid-19 infection is a potentially serious disease. Overweight, obesity, and diabetes are comorbidities frequently found in the severe form of the disease. Appropriate nutritional management of the patient is an integral part of care. We will discuss the renutrition of a 76-year-old, obese (BMI = 35kg/m2), malnourished patient, according to the 2021 Haute Autorité de santé criteria, with Covid-19 infection, admitted to the intensive care unit at the Bordeaux University Hospital for an acute respiratory distress syndrome. Adaptation of nutritional intakes was achieved by clinical and biological monitoring. A refeeding syndrome was treated on the first day of hospitalization in the intensive care unit. After thiamine supplementation and when kalemia and phosphatemia have been normalized, renutrition was started. Parenteral nutrition as a complement to oral nutrition was used. Parenteral nutrition was well tolerated; recommended caloric and protein intakes were achieved by the fourth day of hospitalization. The clinical evolution was favorable. In conclusion, patients with Covid-19 infection should be considered malnourished when admitted to the intensive care unit. Macro and micronutrient intakes adapted to metabolically stressed patients are essential. Biological monitoring including monitoring of ionogram, phosphate, uremia, creatinine, liver function tests and blood glucose is essential in the nutritional management of patients with serious Covid-19 infection.

Awake pronation with helmet continuous positive airway pressure for COVID-19 acute respiratory distress syndrome patients outside the ICU: A case series.

OBJECTIVE: Continuous positive airway pressure (CPAP) is an important therapeutic tool in COVID-19 acute respiratory distress syndrome (ARDS) since it improves oxygenation, reduces respiratory rate and can prevent intubation and intensive care unit (ICU) admission. CPAP during pronation has seldom been described and never during sedation. DESIGN: Case series. SETTING: High dependency unit of San Carlo University Hospital (Potenza, Italy). PATIENTS: Eleven consecutive patients with COVID-19 ARDS. INTERVENTION: Helmet CPAP in prone position after failing a CPAP trial in the supine position. MAIN VARIABLE OF INTEREST: Data collection at baseline and then after 24, 48 and 72h of pronation. We measured PaO2/FIO2, pH, lactate, PaCO2, SpO2, respiratory rate and the status of the patients at 28-day follow up. RESULTS: Patients were treated with helmet CPAP for a mean±SD of 7±2.7 days. Prone positioning was feasible in all patients, but in 7 of them dexmedetomidine improved comfort. PaO2/FIO2 improved from 107.5±20.8 before starting pronation to 244.4±106.2 after 72h (p<.001). We also observed a significantly increase in Sp02 from 90.6±2.3 to 96±3.1 (p<.001) and a decrease in respiratory rate from 27.6±4.3 to 20.1±4.7 (p=.004). No difference was observed in PaCO2 or pH. At 28 days two patients died after ICU admission, one was discharged in the main ward after ICU admission and eight were discharged home after being successfully managed outside the ICU. CONCLUSIONS: Helmet CPAP during pronation was feasible and safe in COVID-19 ARDS managed outside the ICU and sedation with dexmedetomidine safely improved comfort. We recorded an increase in PaO2/FIO2, SpO2 and a reduction in respiratory rate.

Acute respiratory distress syndrome due to COVID-19. Clinical and prognostic features from a medical Critical Care Unit in Valencia, Spain.

OBJECTIVE: Information from critically ill coronavirus disease 2019 (COVID-19) patients is limited and in many cases coming from health systems approaches different from the national public systems existing in most countries in Europe. Besides, patient follow-up remains incomplete in many publications. Our aim is to characterize acute respiratory distress syndrome (ARDS) patients admitted to a medical critical care unit (MCCU) in a referral hospital in Spain. DESIGN: Retrospective case series of consecutive ARDS COVID-19 patients admitted and treated in our MCCU. SETTING: 36-bed MCCU in referral tertiary hospital. PATIENTS AND PARTICIPANTS: SARS-CoV-2 infection confirmed by real-time reverse transcriptase-polymerase chain reaction (RT-PCR) assay of nasal/pharyngeal swabs. INTERVENTIONS: None MAIN VARIABLES OF INTEREST: Demographic and clinical data were collected, including data on clinical management, respiratory failure, and patient mortality. RESULTS: Forty-four ARDS COVID-19 patients were included in the study. Median age was 61.50 (53.25 - 67) years and most of the patients were male (72.7%). Hypertension and dyslipidemia were the most frequent co-morbidities (52.3 and 36.4% respectively). Steroids (1mg/Kg/day) and tocilizumab were administered in almost all patients (95.5%). 77.3% of the patients needed invasive mechanical ventilation for a median of 16 days [11-28]. Prone position ventilation was performed in 33 patients (97%) for a median of 3 sessions [2-5] per patient. Nosocomial infection was diagnosed in 13 patients (29.5%). Tracheostomy was performed in ten patients (29.4%). At study closing all patients had been discharged from the CCU and only two (4.5%) remained in hospital ward. MCCU length of stay was 18 days [10-27]. Mortality at study closing was 20.5% (n 9); 26.5% among ventilated patients. CONCLUSIONS: The seven-week period in which our MCCU was exclusively dedicated to COVID-19 patients has been challenging. Despite the severity of the patients and the high need for invasive mechanical ventilation, mortality was 20.5%.

Early prone positioning therapy for patients with mild COVID-19 disease.

OBJECTIVE: In December 2019, Wuhan, China, experienced an outbreak of coronavirus disease 2019 (COVID-19). Some patients admitted to our hospital were treated with early prone positioning (PP). Here, we analyzed its clinical significance. METHODS: This was a retrospective observational study. We defined the early PP group as mild COVID-19 patients who were placed into a prone position within 24h of admission; others served as the control group. We recorded basic data and outcomes of early PP and compared the results to those of controls. RESULTS: After 1 day of treatment, oxygenation was greater in the early PP group than in the control group (P/F: 421.6±39.74 vs. 382.1±38.84mmHg [1mmHg=0.133kPa], p<0.01). And early PP group spent less total time in prone position (11.1±4.17 vs. 16.9±5.20 days, p<0.01), and required shorter hospitalization duration (12.2±4.49 vs. 23.2±4.83 days, p<0.001). CONCLUSIONS: Early PP treatment can improve hypoxia and shorten the prone position time and hospitalization duration in mild COVID-19 patients. It is a potential clinically applicable intervention.

[COVID-19 and mechanical circulatory support]. / COVID-19 et assistance circulatoire.

Extracorporeal membrane oxygenation (ECMO) is mainly used as a rescue therapy in COVID-19 patients with severe acute respiratory distress syndrome (ARDS). More rarely, COVID-19 can be complicated by hemodynamic failure due to fulminant myocarditis or massive pulmonary embolism necessitating the implantation of venous-arterial ECMO. The management of ECMO during the COVID-19 pandemic is challenging due to some specificities related to the disease characteristics, such as the management of anticoagulation in patients with a hypercoagulable state and an increased risk of venous thromboembolism. In large retrospective cohorts, survival of ECMO-rescued COVID-19 patients with ADRS was reported to be similar to that reported in previous studies on ECMO support for severe ARDS. Full consideration of ECMO candidacy is crucial for appropriate allocation of resources.

Critically ill COVID-19 patients attended by anesthesiologists in northwestern Spain: a multicenter prospective observational study. / Pacientes críticos COVID-19 atendidos por anestesiólogos en el Noroeste de España: estudio multicéntrico, prospectivo, observacional.

BACKGROUND AND OBJECTIVES: There are limited information on outcome, complications and treatments of critically ill COVID-19 patients requiring admission to an intensive care unit (ICU). The aim of this study is to describe the clinical ICU course, treatments used, complications and outcomes, of critically ill COVID-19 patients admitted in seven ICU in Galicia region during the 2020 March-April pandemic peak. METHODS: Between March 21 and April 19, 2020, we evaluated critically ill COVID-19 patients admitted to the ICU of Anesthesia of seven hospitals in Galicia, northwestern Spain. Outcome, complications, and treatments were monitored until May 6, 2020, the final date of follow-up. RESULTS: A total of 97 critically ill COVID-19 patients were included. During ICU stay, mechanical ventilation became necessary in 80 (82.5%) patients, and tracheostomy in 22 (22.7%) patients. Prone position was used frequently in both intubated (67.5%) and awake (27.8%) patients. Medications consisted of antivirals agents (92.7%), corticosteroids (93.8%), tocilizumab (57.7%), and intermediate or high doses of anticoagulants (83.5%). The most frequent complications were ICU-acquired infection (52.6%), thrombosis events (16.5%), and reintubation (9.3%). After a median follow-up of 42 (34-45) days, 15 patients (15.5%) deceased, 73 patients (75.2%) had been discharged from ICU, and nine patients (9.3%) were still in the ICU. CONCLUSIONS: A high proportion of our critically ill COVID-19 patients required mechanical ventilation, prone positioning, antiviral medication, corticosteroids, and anticoagulants. ICU complications were frequent, mainly infections and thrombotic events. We had a relatively low mortality of 15,5%.