Oxygen therapy limiting peripheral oxygen saturation to 89-93% is associated with a better survival prognosis for critically ill COVID-19 patients at high altitudes.

Patients admitted to the Intensive Care Unit (ICU) with acute hypoxemic respiratory failure automatically receive oxygen therapy to improve inspiratory oxygen fraction (FiO2). Supplemental oxygen is the most prescribed drug for critically ill patients regardless of altitude of residence. In high altitude dwellers (i.e. in La Paz [≈3,400 m] and El Alto [≈4,150 m] in Bolivia), a peripheral oxygen saturation (SatpO2) of 89-95% and an arterial partial pressure of oxygen (PaO2) of 50-67 mmHg (lower as altitude rises), are considered normal values ​​for arterial blood. Consequently, it has been suggested that limiting oxygen therapy to maintain SatpO2 around normoxia may help avoid episodes of hypoxemia, hyperoxemia, intermittent hypoxemia, and ultimately, mortality. In this study, we evaluated the impact of oxygen therapy on the mortality of critically ill COVID-19 patients who permanently live at high altitudes. A multicenter cross-sectional descriptive observational study was performed on 100 patients admitted to the ICU at the "Clinica Los Andes" (in La Paz city) and "Agramont" and "Del Norte" Hospitals (in El Alto city). Our results show that: 1) as expected, fatal cases were detected only in patients who required intubation and connection to invasive mechanical ventilation as a last resort to overcome their life-threatening desaturation; 2) among intubated patients, prolonged periods in normoxia are associated with survival, prolonged periods in hypoxemia are associated with death, and time spent in hyperoxemia shows no association with survival or mortality; 3) the oxygenation limits required to effectively support the intubated patients' survival in the ICU are between 89% and 93%; 4) among intubated patients with similar periods of normoxemic oxygenation, those with better SOFA scores survive; and 5) a lower frequency of observable reoxygenation events is not associated with survival. In conclusion, our findings indicate that high-altitude patients entering an ICU at altitudes of 3,400 - 4,150 m should undergo oxygen therapy to maintain oxygenation levels between 89 and 93 %.

Validity of ROX index in prediction of risk of intubation in patients with COVID-19 pneumonia.

INTRODUCTION: One important concern during the management of COVID-19 pneumonia patients with acute hypoxemic respiratory failure is early anticipation of the need for intubation. ROX is an index that can help in identification of patients with low and those with high risk of intubation. So, this study was planned to validate the diagnostic accuracy of the ROX index for prediction of COVID-19 pneumonia outcome (the need for intubation) and, in addition, to underline the significant association of the ROX index with clinical, radiological, demographic data. MATERIAL AND METHODS: Sixty-nine RT-PCR positive COVID-19 patients were enrolled. The following data were collected: medical history, clinical classification of COVID-19 infection, the ROX index measured daily and the outcome assessment. RESULTS: All patients with severe COVID-19 infection (100%) were intubated (50% of them on the 3rd day of admission), but only 38% of patients with moderate COVID-19 infection required intubation (all of them on the 3rd day of admission). The ROX index on the 1st day of admission was significantly associated with the presence of comorbidities, COVID-19 clinical classification, CT findings and intubation (p ≤ 0.001 for each of them). Regression analysis showed that sex and ROX.1 are the only significant independent predictors of intubation [AOR (95% CI): 16.9 (2.4- 117), 0.77 (0.69-0.86)], respectively. Cut-off point of the ROX index on the 1st day of admission was ≤ 25.26 (90.2% of sensitivity and 75% of specificity). CONCLUSIONS: ROX is a simple noninvasive promising tool for predicting discontinuation of high-flow oxygen therapy and could be used in the assessment of progress and the risk of intubation in COVID-19 patients with pneumonia.

A narrative review of hydrogen-oxygen mixture for medical purpose and the inhaler thereof.

Recent development regarding mixture of H2 (concentration of ~66%) with O2 (concentration of ~34%) for medical purpose, such as treatment of coronavirus disease-19 (COVID-19) patients, is introduced. Furthermore, the design principles of a hydrogen inhaler which generates mixture of hydrogen (~66%) with oxygen (~34%) for medical purpose are proposed. With the installation of the liquid blocking module and flame arresters, the air pathway of the hydrogen inhaler is divided by multiple isolation zones to prevent any unexpected explosion propagating from one zone to the other. An integrated filtering/cycling module is utilized to purify the impurity, and cool down the temperature of the electrolytic module to reduce the risk of the explosion. Moreover, a nebulizer is provided to selectively atomize the water into vapor which is then mixed with the filtered hydrogen-oxygen mix gas, such that the static electricity of a substance hardly occurs to reduce the risk of the explosion. Furthermore, hydrogen concentration detector is installed to reduce the risk of hydrogen leakage. Result shows that the hydrogen inhaler implementing the aforesaid design rules could effectively inhibit the explosion, even ignition at the outset of the hydrogen inhaler which outputs hydrogen-oxygen gas (approximately 66% hydrogen: 34% oxygen).

Understanding Clinicians' Perceived Barriers and Facilitators to Optimal Use of Acute Oxygen Therapy in Adults.

Background: Supplemental oxygen is commonly administered to patients in acute care. It may cause harm when used inappropriately. Guidelines recommend prescription of acute oxygen, yet adherence is poor. We aimed to identify barriers and facilitators to practicing in accordance with the evidence-based Thoracic Society of Australia and New Zealand (TSANZ) oxygen guideline, and to determine the beliefs and attitudes relating to acute oxygen therapy. Methods: A national cross-sectional survey was conducted. The survey consisted of 3 sections: (1) introduction and participant characteristics; (2) opinion/beliefs, knowledge and actions about oxygen therapy and other drugs; and (3) barriers and facilitators to use of the TSANZ guideline. Convenience sampling was employed. A paper-based survey was distributed at the TSANZ Annual Scientific Meeting. An online survey was emailed to the TSANZ membership and to John Hunter Hospital's clinical staff. Results: Responses were received from 133 clinicians: 52.6% nurses, 30.1% doctors, and 17.3% other clinicians. Over a third (37.7%) were unaware/unsure of the oxygen guideline's existence. Most (79.8%) believe that oxygen is a drug and should be treated as one. Most (92.4%) stated they only administered it based on clinical need. For four hypothetical cases, there was only one where the majority of participants identified the optimal oxygen saturation. A number of barriers and facilitators were identified when asked about practicing in accordance with the TSANZ guideline. Lack of oxygen equipment, getting doctors to prescribe oxygen and oxygen being treated differently to other drugs were seen as barriers. The guideline itself and multiple clinician characteristics were considered facilitators. Conclusion: There is discordance between clinicians' beliefs and actions regarding the administration of oxygen therapy and knowledge gaps about optimal oxygen therapy in acute care. Identified barriers and facilitators should be considered when developing evidence-based guidelines to improve dissemination and knowledge exchange.

Respiratory support in patients with COVID-19 (outside intensive care unit). A position paper of the Respiratory Support and Chronic Care Group of the French Society of Respiratory Diseases.

With first cases noted towards the end of 2019 in China, COVID-19 infection was rapidly become a devastating pandemic. Even if most patients present with a mild to moderate form of the disease, the estimated prevalence of COVID-19-related severe acute respiratory failure (ARF) is 15-20% and 2-12% needed intubation and mechanical ventilation. In addition to mechanical ventilation some other techniques of respiratory support could be used in some forms of COVID-19 related ARF. This position paper of the Respiratory Support and Chronic Care Group of the French Society of Respiratory Diseases is intended to help respiratory clinicians involved in care of COVID-19 pandemic in the rational use of non-invasive techniques such as oxygen therapy, CPAP, non-invasive ventilation and high flow oxygen therapy in managing patients outside intensive care unit (ICU). The aims are: (1) to focus both on the place of each technique and in describing practical tips (types of devices and circuit assemblies) aimed to limit the risk of caregivers when using those techniques at high risk spreading of viral particles; (2) to propose a step-by-step strategy to manage ARF outside ICU.

Clinical outcome of standardized oxygen therapy nursing strategy in COVID-19.

BACKGROUND: Novel coronavirus pneumonia (COVID-19) has become a global pandemic. However, a technical standard for oxygen therapy nursing, as well as how this would improve clinical outcomes and symptoms, is yet to be explored. METHODS: From February 9, 2020, to March 31, 2020, 58 patients of confirmed COVID-19 were admitted to the 20th ward of the Eastern Branch, Renmin Hospital of Wuhan University. Fifteen patients who did not receive oxygen therapy and 13 patients who were transferred from other hospitals were excluded. The rest of the 30 patients that received standardized oxygen therapy in our unit were included in the study. Baseline characteristics, symptoms, and finger pulse oxygen saturation were collected during hospitalization. RESULTS: Clinical outcomes of the 30 patients were as follows: 27 patients (90.00%) were cured and discharged; 3 patients (10.00%) who continued to stay in hospital were stabilized with symptoms relieved. The fingertip oxygen saturation was 94.80%±3.49% at ICU admission and 97.8%±1.27% when transferred out of ICU after standardized oxygen therapy (P<0.005). The symptoms of dyspnea, fatigue, and muscle aches of the patients were improved when transferred out of ICU, compared with their condition when admitted to ICU (P<0.05). CONCLUSIONS: The standardized oxygen therapy nursing strategy for patients with COVID-19 emphasizes the nursing measurement, which focuses on the patient's oxygenation. It is led by nurses and starts oxygen therapy at an earlier stage. It not only improves the clinical outcomes of critical patients but also effectively reduces the infection risk of medical staff while emphasizing nursing quality management.

Modified Anesthesia Protocol for Electroconvulsive Therapy Permits Reduction in Aerosol-Generating Bag-Mask Ventilation during the COVID-19 Pandemic.

INTRODUCTION: Electroconvulsive therapy (ECT) is a critical procedure in psychiatric treatment, but as typically delivered involves the use of bag-mask ventilation (BMV), which during the COVID-19 pandemic exposes patients and treatment staff to potentially infectious aerosols. OBJECTIVE: To demonstrate the utility of a modified anesthesia protocol for ECT utilizing preoxygenation by facemask and withholding the use of BMV for only those patients who desaturate during the apneic period. METHODS: This chart review study analyzes patients who were treated with ECT using both the traditional and modified anesthesia protocols. RESULTS: A total of 106 patients were analyzed, of whom 51 (48.1%) required BMV using the new protocol. Of clinical factors, only patient BMI was significantly associated with the requirement for BMV. Mean seizure duration reduced from 52.0 ± 22.4 to 46.6 ± 17.1 s, but seizure duration was adequate in all cases. No acute physical, respiratory, or psychiatric complications occurred during treatment. CONCLUSIONS: A modified anesthesia protocol reduces the use of BMV by more than 50%, while retaining adequate seizure duration.