Effect of the Early Combination of Continuous Positive Airway Pressure and High-Flow Nasal Cannula on Mortality and Intubation Rates in Patients With COVID-19 and Acute Respiratory Distress Syndrome. The DUOCOVID Study.

INTRODUCTION: Non invasive respiratory support (NIRS) is useful for treating acute respiratory distress syndrome (ARDS) secondary to COVID-19, mainly in mild-moderate stages. Although continuous positive airway pressure (CPAP) seems superior to other NIRS, prolonged periods of use and poor adaptation may contribute to its failure. The combination of CPAP sessions and high-flow nasal cannula (HFNC) breaks could improve comfort and keep respiratory mechanics stable without reducing the benefits of positive airway pressure (PAP). Our study aimed to determine if HFNC+CPAP initiates early lower mortality and endotracheal intubation (ETI) rates. METHODS: Subjects were admitted to the intermediate respiratory care unit (IRCU) of a COVID-19 monographic hospital between January and September 2021. They were divided according to Early HFNC+CPAP (first 24h, EHC group) and Delayed HFNC+CPAP (after 24h, DHC group). Laboratory data, NIRS parameters, and the ETI and 30-day mortality rates were collected. A multivariate analysis was performed to identify the risk factors associated with these variables. RESULTS: The median age of the 760 included patients was 57 (IQR 47-66), who were mostly male (66.1%). The median Charlson Comorbidity Index was 2 (IQR 1-3) and 46.8% were obese. The median PaO2/FiO2 upon IRCU admission was 95 (IQR 76-126). The ETI rate in the EHC group was 34.5%, with 41.8% for the DHC group (p=0.045), while 30-day mortality was 8.2% and 15.5%, respectively (p=0.002). CONCLUSIONS: Particularly in the first 24h after IRCU admission, the HFNC+CPAP combination was associated with a reduction in the 30-day mortality and ETI rates in patients with ARDS secondary to COVID-19.

Enterovirus-Human-Rhinovirus Infection Leading to Acute Respiratory Distress Syndrome: A Case Report.

Enterovirus-human-rhinovirus (EV-HRV) is best known to cause the "common cold" and asthma exacerbations. Simple bronchitis and community-acquired pneumonia related to EV-HRV are also well documented. Scattered reports of rhinovirus causing acute respiratory distress syndrome (ARDS) have been published, yet the causality between recent SARS-CoV-2 pneumonia and severe ARDS secondary to EV-HRV has not been well defined. This case presents a 67-year-old male who was unvaccinated against SARS-CoV-2 with a past medical history of chronic obstructive pulmonary disease, who recently experienced a mild-to-moderate case of SARS-CoV-2 pneumonia, which was treated with dexamethasone and remdesivir. He was discharged to an inpatient psychiatric facility on as-needed oxygen via nasal cannula. Three weeks later, he experienced an episode of presyncope and was readmitted to the hospital. He then began to require increasing levels of supplemental oxygen via a high-flow nasal cannula. A real-time polymerase chain reaction respiratory pathogen panel was positive for EV-HRV. Computed tomography of the chest revealed extensive ground-glass opacities. Further workup for bacterial and fungal pneumonia was negative. Repeat SARS-CoV-2 testing was also negative. He required several days of supplemental oxygen via a high-flow nasal cannula. He received a short course of broad-spectrum antibiotics and a 10-day course of high-dose dexamethasone. Ultimately, he fully recovered, did not require further supplemental oxygen, and was discharged on room air.

Factors Associated With Non-invasive Oxygen Therapy Failure in COVID-19 Pneumonia: A Single Center, Retrospective Study in a Tertiary Hospital in North India.

BACKGROUND: Non-invasive oxygen therapy (NIT) consists of high-flow nasal oxygen (HFNO) and continuous positive airway pressure (CPAP). NIT is routinely being used for the management of acute respiratory failure secondary to coronavirus disease-2019 (COVID-19) with variable outcomes. However, previously published studies show that NIT failure might delay endotracheal intubation and invasive mechanical ventilation and results in worse outcomes in patients with hypoxemic respiratory failure. Early prediction of failure of NIT, will help in early decision-making in initiating invasive mechanical ventilation. We retrospectively studied the predictors for NIT failure in patients with moderate to severe COVID-19. METHODS: Adult patients (>18 years) admitted to the intensive care unit (ICU) with moderate to severe COVID-19 ARDS and received NIT [HFNO and CPAP non-invasive ventilation (NIV)] were included in this study. Baseline clinical and laboratory data were collected retrospectively from the electronic hospital information system. NIT failure was defined as the need for invasive mechanical ventilation after the initiation of NIT in the ICU. Univariate and multivariate logistic regression analyses were used to find out the possible predictors of NIT failure. RESULTS: Out of 254 patients admitted to ICU, 127 patients were initiated NIT at admission to ICU. During the course of the ICU stay, 33 (26%) patients subsequently required invasive mechanical ventilation (NIT failure). Respiratory rate-oxygenation index (ROX index) of <2.97 at two hours and <3.63 at six hours of ICU admission predicted NIT failure in our cohort of patients with a high positive predictive value. CONCLUSION: Patient selection is crucial for successful NIT in COVID-19. Application of ROX index measured in the first six hours of ICU admission helps in the identification of patients at risk of NIT failure with moderate to severe COVID-19 ARDS.

Increased use of high-flow nasal cannulas after the pandemic in bronchiolitis: a more severe disease or a changed physician's attitude?

After the SARS-CoV-2 pandemic, we noticed a marked increase in high-flow nasal cannula use for bronchiolitis. This study aims to report the percentage of children treated with high-flow nasal cannula (HFNC) in various seasons. The secondary outcomes were admissions for bronchiolitis, virological results, hospital burden, and NICU/PICU need. We conducted a retrospective study in four Italian hospitals, examining the medical records of all infants (< 12 months) hospitalized for bronchiolitis in the last four winter seasons (1 September-31 March 2018-2022). In the 2021-2022 winter season, 66% of admitted children received HFNC versus 23%, 38%, and 35% in the previous 3 years. A total of 876 patients were hospitalized in the study periods. In 2021-2022, 300 infants were hospitalized for bronchiolitis, 22 in 2020-2021, 259 in 2019-2020, and 295 in 2018-2019. The percentage of patients needing intensive care varied from 28.7% to 18%, 22%, and 15% in each of the four considered periods (p < 0.05). Seventy-seven percent of children received oxygen in the 2021-2022 winter; vs 50%, 63%, and 55% (p < 0.01) in the previous 3 years. NIV/CPAP was used in 23%, 9%, 16%, and 12%, respectively. In 2021-2020, 2% of patients were intubated; 0 in 2020-2021, 3% in 2019-2020, and 1% in 2018-2019. CONCLUSION: This study shows a marked increase in respiratory support and intensive care admissions this last winter. While these severity indexes were all driven by medical choices, more reliable indexes such as intubation rate and length of stay did not change. Therefore, we suggest that there is a more aggressive treatment attitude rather than a more severe disease. WHAT IS KNOWN: • COVID-19 pandemic deeply impacted bronchiolitis epidemiology, reducing hospitalizations to onetenth. In the 2021-2022 winter, bronchiolitis resurged to pre-pandemic numbers in Europe. WHAT IS NEW: • Bronchiolitis hospitalization rose much faster in the 2021-2022 winter period, peaking at a higher level. Respiratory supports and high-flow nasal cannula increased significantly compared to the pre-pandemic era.

A Puzzling Diagnosis of Cerebral Vein Thrombosis in a COVID-19-Vaccinated Patient.

Cerebral vein thrombosis (CVT) is a rare condition equivalent to deep vein thrombosis of the intracranial veins. Delayed diagnosis will result in severe and disabling complications. We report a case of a 59-year-old man with CVT with no significant past medical or surgical history. On admission, he reported right-sided numbness and weakness concerns, preceded by the sudden onset of bilateral vision loss and dysarthria. Magnetic resonance imaging and computed tomography scans confirmed the diagnosis of CVT. The most interesting relative risk factor was flying overseas twice a month for the last 10 years; each flight was longer than eight hours. Another possible contributing factor to our patient's condition was polycythemia, with a hemoglobin level of 19, but the most questionable and puzzling is the recent coronavirus disease 2019 (COVID-19) vaccination two months, eight months, and one year prior to admission. Our case highlights a rare COVID-19 vaccine-related CVT diagnosis and that close monitoring for new symptoms and signs is vital to prevent life-threatening complications, herniation, and hemorrhagic transformation.

Use of high flow nasal cannula as a modality of acute respiratory failure due to COVID-19

Oxygen (O2 ) therapy is the first-line therapy for acute respiratory distress with hypoxemia due to Coronavirus disease-2019 (COVID-19). High-flow nasal cannula (HFNC) therapy represents one of the O2 therapy alternative modalities. HFNC is a supportive O2 therapy device using a specially designed HFNC warmed and moisturizer, resulting in a stable flow rate. The physiological mechanisms of HFNC make its efficacy better than other O2 therapy applications. Management of COVID-19 focuses on preventing disease worsening, and HFNC can optimize the outcome of therapy. Further studies are necessary to evaluate the benefits of HFNC in hypoxemia management. It is also important to clarify its contraindications and factors associated with HFNC failure. [ FROM AUTHOR] Copyright of Gulhane Medical Journal is the property of Gulhane Military Medical Academy and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Outcomes of HFNC Use in COVID-19 Patients in Non-ICU Settings: A Single-center Experience.

How to cite this article: Aggarwal A, Arora U, Mittal A, Aggarwal A, Singh K, Ray A, et al.Outcomes of HFNC Use in COVID-19 Patients inNon-ICU Settings: A Single-center Experience. Indian J Crit Care Med 2022;26(4):528-530.

Predictors of high flow oxygen therapy failure in COVID-19-related severe hypoxemic respiratory failure.

Background: During COVID-19 pandemic, people who developed pneumonia and needed supplemental oxygen, where treated with low-flow oxygen therapy systems and non-invasive methods, including oxygen therapy using high flow nasal cannula (HFNC) and the application of bi-level or continuous positive airway pressure (BiPAP or CPAP). We aimed to investigate the outcomes of critical COVID-19 patients treated with HFNC and unveil predictors of HFNC failure. Methods: We retrospectively enrolled patients admitted to COVID-19 wards and treated with HFNC for COVID-19-related severe hypoxemic respiratory failure. The primary outcome of this study was treatment failure, such as the composite of intubation or death during hospital stay. The association between treatment failure and clinical features was evaluated using logistic regression models. Results: One hundred thirty-two patients with a median (IQR) PaO2/FiO2 ratio 96 (63-173) mmHg at HFNC initiation were studied. Overall, 45.4% of the patients were intubated. Hospital mortality was 31.8%. Treatment failure (intubation or death) occurred in 50.75% and after adjustment for age, gender, Charlson Comorbidity index (CCI) score and National Early Warning Score 2 (NEWS2) score on admission and PaO2/FiO2 ratio and acute respiratory distress syndrome (ARDS) severity at the time of HFNO initiation, it was significantly associated with the presence of dyspnea [adjusted OR 2.48 (95% CI: 1.01-6.12)], and higher Urea serum levels [adjusted OR 1.25 (95% CI: 1.03-1.51) mg/dL]. Conclusions: HFNC treatment was successful in almost half of the patients with severe COVID-19-related acute hypoxemic respiratory failure (AHRF). The presence of dyspnea and high serum Urea levels on admission are closely related to HFNC failure.

A Retrospective Study on Experience of High-flow Nasal Cannula Oxygen in Critically Ill COVID-19 Adult Patients Admitted to Intensive Care Unit.

BACKGROUND: The use of high-flow nasal cannula (HFNC) in coronavirus disease-2019 (COVID-19) patients is debated due to its uncertain benefits and risks of aerosol dispersion. This retrospective study was aimed to assess the outcome of treatment with HFNC therapy in adult COVID-19 patients with acute hypoxemic respiratory failure (AHRF) admitted in intensive care units (ICU) and to assess the factors affecting outcome. MATERIAL AND METHODS: We retrieved electronic medical records of all COVID-19 patients who received HFNC for respiratory support after failure to maintain adequate oxygenation with conventional oxygen devices, between June 1 and August 31, 2020. The data retrieved were statistically analyzed. RESULTS: A total number of 558 COVID-19 patients were admitted to ICUs, out of which 139 patients were identified to be on HFNC and 85 met the inclusion criteria for the study. The success rate of 48.2% with HFNC was observed in these patients. The patients recorded to experience HFNC success were of young age and having higher baseline oxygen saturation compared to those who had its failure. The ROX indices post-initiation were observed to be significantly higher in the success group (p ≤0.001). Awake-prone positioning while receiving HFNC was followed by around more patients in the success group (p <0.001). On multivariate logistic regression analysis, baseline oxygen saturation, awake-prone positioning, and number of days on HFNC were found to be independently affected outcome with HFNC. CONCLUSION: Almost half of the cases of moderate-to-severe COVID-19 pneumonia can be managed successfully with HFNC, without the need of mechanical ventilation. HOW TO CITE THIS ARTICLE: Kerai S, Singh R, Saxena KN, Desai SD, Bhalotra AR. A Retrospective Study on Experience of High-flow Nasal Cannula Oxygen in Critically Ill COVID-19 Adult Patients Admitted to Intensive Care Unit. Indian J Crit Care Med 2022;26(1):62-66.

Increased usage of the high flow nasal cannula in COVID-19 cases in Japan -from the online questionnaire survey by the Japanese Respiratory Society.

An online questionnaire survey was used to assess the application of noninvasive strategies in the management of COVID-19 patients. We found a marked increase in the proportion of facilities using high flow nasal cannula (HFNC) oxygen therapy successfully in the 3rd epidemic wave as compared to the 1st wave (49% vs. 12%) and rare reports of associated nosocomial infection in the medical personnel. Furthermore, the proportion of facilities using HFNC as first-line therapy for half or more than half of their patients who did not respond to conventional oxygen therapy increased from 9% in the first to 33% in the second survey. Conversely, the rate of mechanical ventilation with intubation usage following conventional oxygen therapy failure decreased from 62% to 54%. These changes could be due to the limited medical resources available during the larger 3rd wave coupled with increased internal reports on the success of HFNC.

Narrative review of practical aspects of aerosol delivery via high-flow nasal cannula.

Using high-flow nasal cannula (HFNC) as a "vehicle" to administer aerosolized medication has attracted clinicians' interest in recent years. In this paper, we summarize the current evidence to answer the common questions raised by clinicians about this new aerosol delivery route and best practices of administration. Benefits of trans-nasal aerosol delivery include increased comfort, ability to speak, eat, and drink for patients while meeting a range of oxygen requirements, particularly for those who need to inhale aerosolized medication for long periods. Aerosol administration via HFNC has been shown to be well tolerated by children and adults, with comparable or better delivery efficacy than other interfaces, ranging from 2-20%. In vitro and in vivo scintigraphy studies among pediatric and adult populations reported that the inhaled dose delivered via a vibrating mesh nebulizer is 2 to 3 fold greater than that via a jet nebulizer. For adults, placement of nebulizer at the inlet of humidifier increases inhaled dose while reducing rainout obstructing nasal prongs. When HFNC gas flow is set below patient inspiratory flow, aerosol deposition is higher than when the gas flow exceeds patient inspiratory flow; thus, if tolerated, titrating down HFNC gas flow during trans-nasal aerosol delivery, with close monitoring and the use of unit dose with high concentration are recommended. Trans-nasal pulmonary aerosol delivery has not been shown to increase bioaerosols generated by patients, but gas flow may disperse aerosols. Placement of a surgical or procedure mask over HFNC might reduce aerosol dispersion.

Extra Precautions while Caring for a Suspected COVID-19 Patient in an ICU beyond PPE and Hand Hygiene.

Since the diagnosis of the first case of COVID-19 in December 2019, there have been reports of several healthcare workers infected with COVID-19. It has changed the infection control practices of most ICUs all over the world. Prevention is better than cure is definitely proven true as there is no definite cure for COVID-19 yet. Personal protective equipment and hand hygiene are a must while handling any suspected COVID-19 patient. Apart from that, there are several other things, which should be followed in ICU and specifically while caring for a patient on ventilator. There are a large number of interventions done while treating any critically ill patient in ICU, which can generate aerosols and exaggerate spread of COVID-19, which include high-flow nasal cannula, NIV, nebulization, suctioning, bag and mask ventilation, endotracheal intubation, and bronchoscopy. We will be reviewing those things beyond PPE and hand hygiene along with the rationale of each of them, which can help to minimize the risk of exposure to healthcare workers and other patients in the surrounding. It will help not only to prevent COVID-19 transmission but also to reduce overall nosocomial infection rate. As per our knowledge, this will be the first paper reviewing innovative ideas to minimize the risk of infection in a comprehensive manner. How to cite this article: Shah V, Tyagi N, Trivedi D. Extra Precautions while Caring for a Suspected COVID-19 Patient in an ICU beyond PPE and Hand Hygiene. Indian J Crit Care Med 2021;25(3):331-336.

Management of COVID-19 in an adolescent demonstrates lasting effects of extreme prematurity on pulmonary function.

Extremely premature infants have demonstrated increased survival due to advancements in care. This population is at risk for decreased lung function that persists into adolescence. It is important for clinicians to consider this history when treating and assessing such patients who contract SARS-CoV-2 respiratory infection. A 17-year-old, former premature infant of 23 weeks gestation with BPD presented to the pediatric emergency department for evaluation of hypoxia and increased work of breathing in the setting of SARS-CoV-2 infection. He was managed aggressively with early noninvasive respiratory support, Remdesevir, systemic steroids, and convalescent plasma. Utilization of aggressive medical therapies early in the hospital course assisted in preventing intubation and mechanical ventilation for this patient. While there are studies examining the severity of SARS-CoV-2 infection in premature infants, there is a paucity of data on this vulnerable group as they age into adolescence. More studies are needed to assess the severity of illness and optimal management of this population.