Noninvasive Ventilatory Support for Covid-19-Induced Ards

INTRODUCTION: Guidelines advocate caution against the use of non-invasive ventilatory (NIV) support in the management of de novo hypoxemic respiratory failure, especially acute respiratory distress syndrome (ARDS). However, NIV support was used extensively during the COVID-19 pandemic. We hypothesized that the use of NIV, especially bi-level positive airway support (BiPAP), is associated with adverse outcomes in COVID-19 induced ARDS, as it may delay intubation and expose patients to harmful effects of ventilation induced lung injury. METHOD(S): This is a retrospective, single-center study of adult patients admitted to a tertiary medical center's ICUs with COVID-19 induced respiratory failure between March- September 2020 who required BiPAP support. We excluded patients who were using BiPAP at home prior to admission or required BiPAP after extubation. NIV failure is defined as the need for intubation after a trial of BiPAP. RESULT(S): A total of 35 patients (out of 129) fulfilled the criteria for inclusion in the study. The mean (standard deviation, SD) age was 63.5 (13.8) years, and the majority were Caucasian men (60%). The mean (SD) BMI was 35.4 (9.6) kg/m2, and the mean (SD) APACHE II score was 16 (6.4). 18 out of 35 patients (51%) had NIV failure. Patients who failed BiPAP support had increased ICU and hospital mortality compared to those who did not require intubation after BiPAP therapy (66.6% vs. 11.7% and 72.2% vs. 17.6%, respectively;P< 0.001). ICU and hospital lengths of stay were also higher for the patients with NIV failure (17 vs. 3.4 days and 23.5 vs. 13.1 days, respectively;P< 0.001). CONCLUSION(S): NIV failure was associated with adverse clinical outcomes in the management of COVID-19 induced ARDS.

Case Series of Pneumomediastinum and Subcutaneous Emphysema in COVID-19 Patients

Spontaneous pneumomediastinum has been reported in association with COVID-19. Pneumomediastinum could remain elusive until computed tomogra- phy is performed. Hence, we need to be vigilant even though it generally has a benign clinical course. We presented four confirmed COVID-19 cases with typical ground glass opacity on chest radiograph. All four had the computed tomography that re- vealed pneumomediastinum, pneumothorax and subcutaneous emphysema. Only one patient had pneumomediastinum after intubation. Pneumomediastinum is a devastating finding which should be picked up as early as possible and must be excluded in COVID patients whom deteriorate quickly, as adequate time may pass before any viable intervention can be done to expedite the patients' recovery. Copyright © 2022 Tehran University of Medical Sciences.